Flapless Technique Research Articles

Platelet-Rich Fibrin (PRF) in Implants Dentistry in Combination with New Bone Regenerative Flapless Technique: Evolution of the Technique and Final Results.

Most common techniques for alveolar bone augmentation are guided bone regeneration (GBR) and autologous bone grafting. GBR studies demonstrated long-term reabsorption using heterologous bone graft. A general consensus has been achieved in implant surgery for a minimal amount of 2 mm of healthy bone around the implant.A current height loss of about 3-4 mm will result in proper deeper implant insertion when alveolar bone expansion is not planned because of the dome shape of the alveolar crest. To manage this situation a split crest technique has been proposed for alveolar bone expansion and the implants’ insertion in one stage surgery. Platelet-rich fibrin (PRF) is a healing biomaterial with a great potential for bone and soft tissue regeneration without inflammatory reactions, and may be used alone or in combination with bone grafts, promoting hemostasis, bone growth, and maturation.AimThe aim of this study was to demonstrate the clinical effectiveness of PRF combined with a new split crest flapless modified technique in 5 patients vs. 5 control patients.Materials and methodsTen patients with horizontal alveolar crests deficiency were treated in this study, divided into 2 groups: Group 1 (test) of 5 patients treated by the flapless split crest new procedure; Group 2 (control) of 5 patients treated by traditional technique with deeper insertion of smaller implants without split crest. The follow-up was performed with x-ray orthopantomography and intraoral radiographs at T0 (before surgery), T1 (operation time), T2 (3 months) and T3 (6 months) post-operation.ResultsAll cases were successful; there were no problems at surgery and post-operative times. All implants succeeded osteointegration and all patients underwent uneventful prosthetic rehabilitation. Mean height bone loss was 1 mm, measured as bone-implant most coronal contact (Δ-BIC), and occurred at immediate T2 post-operative time (3 months). No alveolar bone height loss was detected at implant insertion time, which was instead identified in the control group because of deeper implant insertion.ConclusionThis modified split crest technique combined with PRF appears to be reliable, safe, and to improve the clinical outcome of patients with horizontal alveolar crests deficiency compared to traditional implanting techniques by avoiding alveolar height-loss related to deeper insertion of smaller implants.

Acute infection and numbness following dental implant placement using the flapless technique

Background: Acute onset of infection and numbness arising after dental implant placement are rare but not uncommon complications. Studies have reported that 4–10% of patients receiving dental implants develop postoperative infections which hamper osteointegration and leads to implant failure. Objective: The aim of this article is to report the incidence of a postoperative right submandibular swelling and right mental region numbness occurring 48 h post implant placement using a flapless technique. The patient noticed swelling of the right submandibular region 2 days after implant placement, which was associated with excruciating pain and fever. The swelling gradually increased in size despite the administration of oral antibiotic with pus seen discharging around the vicinity of implant when palpated. Pus swab revealed the isolation of Streptococcus parasanguinis, Neisseria spp. and Klebsiella spp. The sensation of pain at the implant site and submandibular region overwhelmed the numbness felt at the right mental region, which was caused by the implant impinging onto the inferior alveolar nerve. However, numbness became prominent and persisted after controlling the infection and removing the offending implant. Conclusion: A rare case of acute infection that presented as a submandibular swelling coupled with the sensation of numbness at the right mental region after implant placement is presented. These symptoms lead to detrimental quality of life for the patient at one-month post-explantation.

Bone Height Changes of the Mandibular Edentulous Ridge in Screw Retained Versus Telescopic Restorations for Completely Edentulous Patients.

AIM:This study was established to evaluate the amount of bone height changes in the posterior mandibular area of edentulous patients receiving screw-retained prostheses versus removable telescopic implant overdentures.MATERIAL AND METHODS:Every patient received four inter-foraminal implants regarding the mandibular arch and four anterior implants for the maxillary arch, computer guided surgical guides were planned for the insertion of the implants accurately with a flapless technique. Panoramic radiographs were made immediately, six months and twelve months after the prostheses` use proportional area and vertical measurements were applied to determine changes in the bone height of the posterior mandibular edentulous area.RESULTS:After twelve months, a statistically non-significant amount of bone resorption was reported for both groups.CONCLUSION:Up to the limitations of this study both treatment options the screw retained and telescopic overdenture can be used for rehabilitation of completely edentulous patients. These cases must be followed for a longer period to have a definite answer regarding their efficiency in the long run.

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

BackgroundDental 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.ObjectivesThe aim of this systematic review was to evaluate the clinical parameters following implant surgery in healed sites, using two procedures: flapped vs. flapless surgery.Material and MethodsA 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.ResultsTen 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.ConclusionsThe 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. Key words: Clinical parameters, gingival recession, probing depth, dental implants, flap, flapless.

THE AMOUNT OF THE KERATINIZED TISSUE ON TRANS-MUCOSAL TECHNIQUE VERSUS PUNCH TECHNIQUE IN FLAPLESS IMPLANT SURGERY

The aim : Of this study is to show which technique can be enhance the amount of keratinized tissue width (KTW) to improve the soft tissue profile after flapless implant placement.. Materials: A 14 patients (6 women and 8 men) aged between 25-70 years with mean value (47.5 years) were enrolled in this study. First group consisted of seven patients in which implants were inserted through trans-mucosal flapless technique, while the second group consisted of seven patients in which implants were inserted via punch flapless technique then the normal flapless surgical protocol for implant insertion was used and implant was covered by healing cap screw. KTW measured immediately before and after the surgery and at the time of the prosthetic finalization (3-4 months) for maxillary anterior and premolar regions.. Results: KTW at 1-2 mm (before) can be effectively increased, while no significant effect at 5 mm can expected. For the punch technique the mean value of KTW of 1-2 mm showed significant increase at 3-4 months postoperative ..

A Retrospective Survival Study of Trabecular Tantalum Implants Immediately Placed in Posterior Extraction Sockets Using a Flapless Technique.

A retrospective review of patient records was conducted in a single private practice to evaluate the efficacy of immediately placing a novel implant design in posterior jaw locations using a flapless technique. Forty-two patients (22 males, 20 females) with a mean (SD) age of 60.2 (7.6) years (range = 31-68) presented with 1-2 nonrestorable molar (maxillary = 14; mandibular = 8) or premolar (maxillary = 20; mandibular = 1) teeth compromised by periodontal disease, endodontic failure, root resorption, root fracture, or severe caries. Most patients (78.6%) had moderate (66.7%) or severe (11.9%) periodontitis. Other comorbidities included smoking (14.3%) and controlled diabetes mellitus (11.9%). After atraumatic extraction, teeth were immediately replaced with a total of 44 trabecular tantalum implants (Trabecular Metal Implants, Zimmer Biomet Dental) (diameter = 3.7-4.7 mm; length = 10-13 mm). Sites requiring augmentation were treated with 3 types of small-particle (250-1000 μm), mineralized, solvent-dehydrated, allografts (Puros) based on location: cortical for crestal sinus grafts, cancellous for peri-implant voids in thick tissue biotypes, or cortical-cancellous (70:30) mix for peri-implant voids in thin tissue biotypes. Cortical particulate was used when slower resorption would help maintain graft volume for esthetics or implant support. Grafts were covered with resorbable bovine pericardium membranes (CopiOs, Zimmer Biomet). Cumulative implant survival and success rates were 97.7%, respectively, with a mean (±SD) follow-up time of 25.0 ± 12.1 months (range = 4-48). One asymptomatic implant failed to osseointegrate. Within the limitations of this study, implants achieved outcomes comparable to conventionally placed and restored single-tooth implants in anterior jaw locations.

Flap Designs for Implant-Related Surgical Procedures: A Review.

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. 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." 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. 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).

A Comparative Study between Flapped and Flapless Surgical Techniques in Dental Implant Stability According to Resonance Frequency Analysis

Background: Recent implant surgical approach aims to cause less trauma, invasiveness and pain as much as possible and to reduce patient and surgeon discomfort, time of surgery and time needed for functional implant loading. Flapless surgical techniques considered recently as one of the most popular techniques that may achieve these aims especially enhancing osseointegration and subsequently implant stability within less time than the traditional flapped surgical technique. So this study aimed to make a comparison between flapped and flapless surgical techniques in resulted implant stability according to resonance frequency analysis RFA and in duration of surgical operation. Materials and methods: A total of 26 patients with 41 implants (one implant in the study group failed so it was excluded from the statistical analysis) were randomized into two groups: control group which involved 20 implants inserted by conventional flapped surgical approach and study group which involved 20 implants inserted by flapless surgical approach. Estimation of alveolar bone was done for study group by bone (ridge) mapping procedure. Duration of surgical operation for each implant, Implant stability was measured at three time intervals (at surgery, two months and three months after surgery). Results: After three months interval of surgery the mean implant stability of the study (flapless) group achieved significant higher implant stability than control (flapped) group (P< 0.05) and the difference in measured implant stability was (5.05) implant stability quotient(ISQ). The time of surgical operation for implants in the study group significantly was less than that of control group (P< 0.01). Conclusions:implants placed with flapless surgical technique can produce high implant stability in shorter time and consume prominently shorter time for surgical operation compared to those placed with conventional flapped technique.

A 3-Year Prospective Cohort Study on 132 Calcium Phosphate–Blasted Implants: Flap vs Flapless Technique

To evaluate the survival rate and marginal bone loss (MBL) of a calcium phosphate-blasted titanium implant inserted by a flap or flapless technique and to study the morphochemical characteristics of the implant surface. Sixty out of 85 patients who received one or more implants were selected as eligible for this prospective longitudinal cohort clinical study. Titanium implants (n = 132) were placed in human healthy subjects using either a flap or flapless technique, selected on the basis of the best practice. The survival rate and MBL were evaluated after 3 months (preloading stress-free healing period) and after 6, 12, 24, and 36 months in relation to implant diameter, location, sex, and smoking habits. Surface morphochemical analyses were performed by environmental scanning electron microscopy connected with energy-dispersive x-ray (ESEM/EDX). The overall survival rate was 97.72%. After 3 and 36 months, MBL was 0.36 ± 0.66 mm and 1.09 ± 1.10 mm for the flapless group and 0.29 ± 0.51 mm and 1.03 ± 0.92 mm for the flap group. MBL showed a statistically significant increase with time (P = .0001), and differences were found at all times since 6 months. No statistical differences between the flapless and flap groups and sex were observed at any time, while MBL was significantly higher in the maxillary versus mandibular location (6, 12, and 24 months) and in smokers versus nonsmokers (6 months). Higher MBL in both groups was found for a smaller diameter (3.5 mm) than larger diameter (4.1, 5 mm). The surface showed a Ti-Al-V alloy displaying a uniform nanotexture. The implant system showed a high survival rate and markedly lower MBL considering the limits for acceptable progression. Flapless and flap techniques demonstrated similar results of MBL at the preloading healing period and at the 6 months to 3 years postloading periods. Both surgical procedures induced an early MBL during the preloading stress-free period. Implant diameter, mandibular/maxillary location, preloading stress-free period, and smoking habits affect MBL more than the type of surgery after both short- and long-term follow-up.

Influence of immediate/delayed implant placement and implant platform on the peri-implant bone formation.

To determinate the influence of the timing and position of the implant placement, as well as the presence and absence of a buccal gap, associated with different implant platforms on bone formation around implants. In a first surgical stage, two premolars in one side of the mandibular arch of 07 mongrel dogs were extracted. After a 120-day healing period, a second-stage surgery was performed, in which a full flap was raised and two implants were installed. At this same stage, two contralateral premolars were extracted and two immediate implants were placed into the fresh sockets, through the "palatal approach technique" without flap elevation, totaling four implants per animal. The 28 installed implants constituted groups according to the timing (Immediate or delayed) of placement and the type of surface treatment. After 4months, samples were collected and histomorphometric analysis was performed to determinate buccal surface BIC, lingual surface BIC, total BIC, buccal area, and lingual area of all implants. Kruskal-Wallis and pared Wilcoxon (P<0.05) tests were performed for statistical analysis. After 4-month healing period, the groups of immediate implants presented better BIC scores, mainly on the buccal surface. Data also suggest better bone area formation around the implants of these same groups. Concerning the type of implant platform, better results were found using Morse taper. The flapless technique with "palatal approach," Morse taper implants, and immediate implant placement all have favorable influence on the bone formation around the implants.

Implant Dentistry: Monitoring of Bacteria Along the Transmucosal Passage of the Healing Screw in Absence of Functional Load.

To assess the changes in bacterial profile along the transmucosal path of healing screws placed immediately after insertion of two-piece endosseus implants during the 4-month osseointegration phase, in absence of functional load. Two site-specific samples were collected at the peri-implant mucosa of the healing screws of 80 two-piece implants, for a total of 640 samples. Implants placement was performed following a single protocol with flapless technique, in order to limit bacterial contamination of the surgical site. Identical healing screws (5 mm diameter/4 mm height) were used for each of the 80 implants. During the 4 months of the study, the patients followed a standard oral care regimen with no special hygiene maneuvers at the collection sites. The present research documents that during the 4-month period prior to application of function load the bacterial profile of all sites exhibited a clear prevalence of cocci at the interface between implant neck and osteoalveolar crest margin. A potentially pathogenic bacterial flora developed only along the peri-implant transmucosal path.

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.

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. The study used five domestic pigs. Implants were inserted 9weeks 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 2weeks, 1, 3, 6 and 12months 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. 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 12months compared with the conventional flap group. 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.

A retrospective evaluation of aesthetic outcomes for single-tooth implants in the anterior maxilla.

To investigate objective and patient-centred aesthetic outcomes for single-tooth implants in the anterior maxilla. Ninety-eight patients (21 men and 77 women) with a mean age of 51.2 ± 3.8 years were included in this retrospective study. A total of 98 maxillary anterior single-tooth implant crowns with a mean functional time of 68.1 months (range 12-245) were evaluated. Aesthetic outcomes were measured by PES and WES. Statistical analysis was performed using the Mood's median and stepwise logistic regression with backward elimination to assess the effect of patient demographics, clinical parameters and surgical methods on aesthetic outcome (P < 0.05). The median PES was 11 and 94% of implants were deemed aesthetically acceptable. The median WES was 9 and 98% of implants were deemed aesthetically acceptable. The PES was positively influenced by the use of a connective tissue graft (CTG), adding 1 to the score (P = 0.002) and negatively influenced by membrane use (P = 0.026). Flapless techniques employed as part of an immediate implant placement protocol yielded better outcomes compared to flapped sites (P = 0.017). Immediate implant placement demonstrated greater variability in outcomes compared to early implant placement. Satisfactory objective and patient-reported aesthetic outcomes were achieved with dental implants replacing missing single teeth in the anterior maxilla. The use of CTG improved the aesthetic outcome mainly by increasing the alveolar process contour. Less variation in outcomes was observed with early (type 2) placement compared to immediate (type 1 placement).

Massive Lingual and Sublingual Haematoma following Postextractive Flapless Implant Placement in the Anterior Mandible

Dental implants placement in the anterior mandible with flap or flapless technique is a routine procedure and is considered to be safe. However, serious life-threatening complications may occur. We report the first case of massive lingual and sublingual haematoma following postextractive implant placement in the anterior mandible with flapless technique. A 45-year-old female patient underwent placement of four immediately postextractive implants in the anterior mandible using flapless technique. During the procedure, the patient referred intense acute pain and worsening sign of airway obstruction, dysphagia, dyspnea, and speech difficulties. Bimanual compression of the mouth floor, lingual surface of the mandible, and submental skin was maintained for approximately 25 minutes in order to stop the bleeding. Computerized tomography highlighted the massive lingual and sublingual haematoma. The symptoms and signs had almost completely resolved in the next 48 hours. The prevention of these complications is mandatory with clinical and CT analyses, in order to highlight mandibular atrophy and to select carefully the correct length and angulation of bone drilling and to keep more attention to the flapless technique considering the elevation of a lingual mucoperiosteal flap to access the mandibular contour intraoperatively and to protect the sublingual soft tissues and vasculature in high risk cases.

Tissue stability of implants placed in fresh extraction sockets: a 5-year prospective single-cohort study.

Several materials have been used for ridge preservation after tooth extraction. This 5-year prospective single-cohort study is aimed at evaluating the success rate, marginal bone level (MBL), soft tissue stability, and subjective patient evaluation of implants placed in fresh extraction sockets with the use of a flapless technique and a xenograft to treat the peri-implant bone defect. Patients requiring a single implant in fresh extraction sockets were selected. After flapless extraction and implant insertion, the peri-implant bone defect was grafted with porcine bone. Collagen membrane was used to stabilize the graft. Four months later, a second surgery and prosthetic procedures were performed. Clinical parameters (width of keratinized gingiva [WKG], facial soft tissue level [FST], papilla index, plaque index, and bleeding on probing) were measured, and periapical radiographs were taken at the time of implant placement (baseline) and then at 1, 3, and 5 years thereafter. Image analysis software was applied to measure changes in the marginal bone level (ΔMBL). Additionally, patient satisfaction regarding the implant treatment was evaluated. All analyses were collected and measured by an independent, trained observer. Together with descriptive statistics, for each of the outcome variables, pairwise comparisons were performed using the Wilcoxon signed-rank test for matched samples. The level of statistical significance was set at 0.01 for all analyses. Forty-seven consecutive patients were treated, with an implant survival rate at 5 years of 95.7%. ΔMBL showed statistically significant differences: mean values were -0.68 ± 0.39, -0.94 ± 0.44, and -1.08 ± 0.43 mm at the 1, 3, and 5-year follow-up, respectively. Changes in WKG (ΔWKG) and FST (ΔFST) decreased from the 1-year point of the survey (0.80 ± 0.79 and 0.71 ± 0.73 mm for ΔWKG and ΔFST, respectively) to the last follow-up check at 5 years (0.67 ± 0.74 and 0.56 ± 0.69 mm for ΔWKG and ΔFST, respectively), with no significant differences. The papilla indexes showed significant differences among the baseline and all the other time points. Concerning patient satisfaction, at the last survey time point, 74% ± 11.8% of patients were satisfied regarding the overall implant treatment, 73.0% ± 11.1% gave a favorable opinion regarding the appearance of the peri-implant soft tissues, and 80.5% ± 11.3% judged positively the finished appearance of the implant crown. No significant differences were obtained among the three follow-up times. The data of the present study suggest that the placement of a dental implant by means of a flapless technique in a fresh extraction socket filled with slowly resorbable graft biomaterial and with a delayed prosthetic restoration shows positive final esthetic outcomes. At the 5-year point of the survey, the changes in the bone level were minimal. Moreover, both midfacial tissue and the papillae maintained the early increase recorded before the first year of the follow-up.

Histopathological comparative analysis of peri-implant soft tissue response after dental implant placement with flap and flapless surgical technique. Experimental study in pigs.

The aim of this study was comparing the effect of flapless vs. flap technique of implant placement on inflammation degree of peri-implant soft tissue, through histopathological analysis. The experiment was conducted on five domestic pigs. Nine weeks after tooth extraction, implants were installed. Each animal received six implants in mandible. According to split-mouth design, randomly one side was used for flapless technique using mini-incision, while on the other side, flap was raised. After 7, 14, 21, 28, and 90 days, the experimental animals were sacrificed. Samples for histopathological analyzes were taken from the buccal side of peri-implant mucosa next to the neck of implants, from three levels. The degree of inflammatory response in the peri-implant soft tissue was estimated through ordinal scores from 0 to 3. In the flap group Score 3 indicating high degree of inflammation was present from day 7 to day 21, in contrast to flapless group where Score 3 was not recorded during the entire follow-up. Three months after implantation, there were no signs of inflammation neither around flap nor around flapless implants. Flapless surgical implantation technique using mini-incision decreases peri-implant soft tissue inflammatory reaction compared with flap surgery.

Flapless versus conventional flapped dental implant surgery: a meta-analysis.

The aim of this study was to test the null hypothesis of no difference in the implant failure rates, postoperative infection, and marginal bone loss for patients being rehabilitated by dental implants being inserted by a flapless surgical procedure versus the open flap technique, against the alternative hypothesis of a difference. An electronic search without time or language restrictions was undertaken in March 2014. Eligibility criteria included clinical human studies, either randomized or not. The search strategy resulted in 23 publications. The I2 statistic was used to express the percentage of the total variation across studies due to heterogeneity. The inverse variance method was used for random-effects model or fixed-effects model, when indicated. The estimates of relative effect were expressed in risk ratio (RR) and mean difference (MD) in millimeters. Sixteen studies were judged to be at high risk of bias, whereas two studies were considered of moderate risk of bias, and five studies of low risk of bias. The funnel plots indicated absence of publication bias for the three outcomes analyzed. The test for overall effect showed that the difference between the procedures (flapless vs. open flap surgery) significantly affect the implant failure rates (P = 0.03), with a RR of 1.75 (95% CI 1.07–2.86). However, a sensitivity analysis revealed differences when studies of high and low risk of bias were pooled separately. Thus, the results must be interpreted carefully. No apparent significant effects of flapless technique on the occurrence of postoperative infection (P = 0.96; RR 0.96, 95% CI 0.23–4.03) or on the marginal bone loss (P = 0.16; MD −0.07 mm, 95% CI −0.16–0.03) were observed.

The Effect of Flapless Surgery on Implant Survival and Marginal Bone Level: A Systematic Review and Meta‐Analysis

The clinical outcomes of implants placed using the flapless approach have not yet been systematically investigated. Hence, the present systematic review and meta-analysis aims to study the effect of the flapless technique on implant survival rates (SRs) and marginal bone levels (MBLs) compared with the conventional flap approach. An electronic search of five databases (from 1990 to March 2013), including PubMed, Ovid (MEDLINE), EMBASE, Web of Science, and Cochrane Central, and a hand search of peer-reviewed journals for relevant articles were performed. Human clinical trials with data on comparison of SR and changes in MBL between the flapless and conventional flap procedures, with at least five implants in each study group and a follow-up period of at least 6 months, were included. Twelve studies, including seven randomized controlled trials (RCTs), one cohort study, one pilot study, and three retrospective case-controlled trials (CCTs), were included. The SR of each study was recorded, weighted mean difference (WMD) and confidence interval (CI) were calculated, and meta-analyses were performed for changes in MBL. The average SR is 97.0% (range, 90% to 100%) for the flapless procedure and 98.6% (range, 91.67% to 100%) for the flap procedure. Meta-analysis for the comparison of SR among selected studies presented a similar outcome (risk ratio = 0.99, 95% CI = 0.97 to 1.01, P = 0.30) for both interventions. Mean differences of MBL were retrieved from five RCTs and two retrospective CCTs and subsequently pooled into meta-analyses; however, none of the comparisons showed statistical significance. For RCTs, the WMD was 0.07, with a 95% CI of -0.05 to 0.20 (P = 0.26). For retrospective CCTs, the WMD was 0.23, with a 95% CI of -0.58 to 1.05 (P = 0.58). For the combined analysis, the WMD was 0.03, with a 95% CI of -0.11 to 0.18 (P = 0.67). The comparison of SR presented a low to moderate heterogeneity, but MBL presented a considerable heterogeneity among studies. This systematic review revealed that the SRs and radiographic marginal bone loss of flapless intervention were comparable with the flap surgery approach.

Open‐Flap Versus Flapless Esthetic Crown Lengthening: 12‐Month Clinical Outcomes of a Randomized Controlled Clinical Trial

Excessive gingival display (EGD) has a negative impact on a pleasant smile. Minimally invasive therapeutic modalities have become the standard treatment in many dentistry fields. Therefore, the aim of this study is to compare the clinical outcomes of open-flap (OF) and minimally invasive flapless (FL) esthetic crown lengthening (ECL) for the treatment of EGD. A split-mouth randomized controlled trial was conducted in 28 patients presenting with EGD. Contralateral quadrants received ECL using OF or FL techniques. Clinical parameters were evaluated at baseline and 3, 6, and 12 months post-surgery. The local levels of receptor activator of nuclear factor-κB ligand (RANKL) and osteoprotegerin (OPG) were assessed by enzyme-linked immunosorbent assay at baseline and 3 months. Patients' perceptions regarding morbidity and esthetic appearance were also evaluated. Periodontal tissue dimensions were obtained by computed tomography at baseline and correlated with the changes in the gingival margin (GM). Patients reported low morbidity and high satisfaction with esthetic appearance for both procedures (P >0.05). RANKL and OPG concentrations were increased in the OF group at 3 months (P <0.05). Probing depths were reduced for both groups at all time points, compared with baseline (P <0.05). There were no differences between groups for GM reduction at any time point (P >0.05). FL and OF surgeries produced stable and similar clinical results up to 12 months. FL ECL may be a predictable alternative approach for the treatment of EGD.