Guidelines and Pitfalls of Minimally Invasive and “Flapless” Dental Implant Surgery

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The flapless approach in implant surgery originated with the emergence of innovative site preservation techniques for immediate placement of implants following tooth extraction in areas of high esthetic concern. The rationale for the flapless approach in these case scenarios was to isolate the implant and grafted socket from the oral cavity, obtaining an inclusive guided bone regeneration effect while preserving circulation and esthetic soft tissue contours. This was a radical departure from the then strongly supported concept of isolating implants placed into fresh extraction sockets with a barrier membrane and primary flap closure.

Recently, the use of flapless surgery for implant placement has gained popularity. Although this approach was initially recommended for novice implant surgeons, successful use of the flapless approach actually requires advanced clinical experience and surgical judgment in many clinical case scenarios. While flapless implant surgery has numerous advantages including improved patient comfort and recuperation, decreased surgical time, and the ability to resume normal hygiene procedures immediately following surgery, there are pitfalls. These drawbacks include: inability to visualize anatomic landmarks, thermal damage secondary to inadequate irrigation during osteotomy preparation, malposed angle or depth of implant placement, and inability to appropriately contour osseous topography to facilitate restorative procedures. The implant surgeon should be aware that there are several minimally invasive approaches to implant placement and grafting procedures such as “U” shaped peninsula flaps, abbreviated trapezoidal flaps, and pouch or tunnel dissections which can provide similar advantages with improved access and visualization.

Furthermore, the flapless approach is only indicated when the surgeon has confidence that the underlying osseous anatomy is ideal relative to the planned implant diameter and three dimensional placement in the alveolus. Typically, this is determined by clinical and radiographic evaluation aided by analysis of articulated dental study models. Nevertheless, interactive CT treatment planning is necessary and of great benefit in a significant percentage of cases. Although often overlooked, another prerequisite for the use of flapless dental implant surgery, is the determination of whether an adequate volume of good quality soft tissues will remain surrounding the emerging implant structures to satisfy biologic width requirements thereby promoting optimal long term function and esthetics. In order to make this determination, the implant surgeon must be familiar with the criteria for optimal flap design for implant placement and exposure surgery. When the above criteria are not met, the flapless approach is contraindicated and conventional open flap procedures with appropriate soft tissue surgical maneuvers should be employed to obtain a stable peri-implant soft tissue environment. Finally, when unexpected intraoperative findings necessitate additional access or visualization, the surgeon must be prepared for the appropriate course of action.

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References 

1. Sclar AG. Preserving Alveolar Ridge Anatomy Following Tooth Removal in Conjunction with immediate Implant Placement: The Bio-Col Technique. Atlas of the Oral and Maxillofacial Surgery Clinics of North America. 1999;7(2):September
2. Lazzarra RJ. Immediate Implant Placement Into Extraction Sites: Surgical and Restorative Advantages. Int J Periodont Rest Dent. 1989;9:333–343
3. Sclar AG. Surgical Techniques for Management of Peri-implant Soft Tissues, in Soft Tissue and Esthetic Considerations in Implant Therapy, Quintessence. 2003;