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Flapless Implant Surgery
Dr. Berg asks:
I am a general dentist placing many of my dental implants. I have recently read about and taken some courses in flapless implant placement using a surgical template.
In addition, I have discussed this technique with some of the other GP’s I know who are placing dental implants, and they have told me that there is very little pain from flapless procedures as compared to laying a full thickness flap. In their view, because there is very little pain involved with the flapless procedures, more patients are accepting dental implants. I was wondering what others thought about this topic. Would flapless implant placement increase the acceptance of dental implant treatment plans with my patients? What are the pros and cons here? Thanks.
August 8, 2006 in Techniques and Procedures | Permalink
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Comments
Would you let someone do this on you or one of you children?? Flapless surgery is about selling more implants.
Posted by: Don Callan | Aug 8, 2006 1:41:18 PM
Flapless surgical implant therapy is a technique that was not developed in order to 'sell' more dentistry. It is a treatment modality that allows the blood supply to remain uncompromised especially on the thin fragile facial/buccal bone plate as well as to the interproximal bony peaks. It is not an easier procedure as one has to take into account the anatomy and undercuts that could be perforated. Bone grafting and GBR are still utilised if an osseous defect is present which is more technically demanding without an open flap. WRT the comment regarding discomfort following implant therapy, my experience in placing implants for over 18 years has convinced me that implant therapy is one of the least painful procedures that I perform as a Periodontist. Prudence and experience will determine whether one opens a flap; the patient acceptance issue has been already solved if he/she is in the chair anesthetized.
Posted by: Mark Spatzner | Aug 8, 2006 2:07:00 PM
Mini implants such as MIDI or Osteotech favour the flapless approach as do several 'punch a hole and screw' systems. But all systems suppose you know what you are 'screwing' into and that the topography of the bone is known, that there are no boney defects and that you know exactly where you are going (say after a CT scan, and computer designed guides eg nobel guide). In any other circumstances you may encounter problems that could have legal repercussions later.
Posted by: Mark Boulcott | Aug 8, 2006 2:11:01 PM
yes flapless surgery lessens the pain and discomfort to patient , no question about it.
and it requires less time as there is no flap relection or suturing.
BUT as Dr.Boulcott has mentioned you must be knowing topography of ridge pecisely.with the use of proper diagnostic tools or you will end up with part of your implant lying in soft tissues,
particularly in case of ridges covered with thick mucosal tissues giving false impression of width.
Also some times it is difficult to do precise ostrotomy height as soft tissues will hinder proper reading of height marks on drills.
Also on grafted sites or recent extraction sites you do not know what is the conditon of osseous crest.
It is better to open the flap and visulise the tissues first hand, rather doing a blind surgery unless you are sure fo topography.
Be careful in ant maxillary region.
It is an excellent modality when you want to use osteotomes for ridge expansion as blood supply and periosteum are not disturbed.
Posted by: satish joshi | Aug 8, 2006 2:43:47 PM
one more thing to think about,
If you are short of keratinised tissues it is better to save tissues with flap rather than punch in flapless surgery,and/or with palatal insision keratinised tissue zone can be increased.
Posted by: satish joshi | Aug 8, 2006 2:54:37 PM
As usual, I totally agree with Don Callan (one of the true workhorses of the Periodontal community). There is usually minimal to no postoperative swelling and pain after "conventional" implant placement. Flapless implant surgery enables the "surgeon" or "operator" to remove keratinized tissue necessary for aesthetic support of the final implant-supported restoration. Additionally, even if a CT scan is utilized preoperatively, there is the possibility of perforation with no ability to perform osseous regeneration.
Posted by: Bob Horowitz | Aug 8, 2006 7:59:13 PM
Once in a while there is the perfect circumstance where an abudance of bone volume and of keratinized attached gingiva exists. In these rare circumstances you almost cannot go wrong in implant placement without raising a flap. However, it has been my experience that in the overwhelming majority of cases such conditions seldom exist unless it is a situation where root removal and implant placement can be done simultaneously. The reality is that overall, you will perform a better quality service if you flap all but the most perfect of sites. Patients, if given the option, will always elect for quality and predictability compared to convenience and risk.
Posted by: Dr. Dennis Nimchuk | Aug 8, 2006 11:03:51 PM
Just placed two implants, #8, and #9 as a flappless procedure today. Perfect procedure with perfect placement. No miracle, though! At time of extraction, a graft was used to maintain the socket. In addition, it took me placing several hundreds of implants until I got to a point of reasunable comfort with this technique sensitive procedure. It is much more difficult to do a flappless implant with perfect placement (unless one is dealing with a big, thick ridge, and lots of keratinized gingiva. I agree with the comments above. If there is a doubt in my mind... I flap it. I actually found out that the biggest pain reduction measure has been converting to digital radiography, which allows me to check my placement and complete procedures rapidely. In short, learn the trade, not the tricks of the trade.
Posted by: Zev Kaufman, D.D.S. | Aug 9, 2006 12:29:03 AM
This discussion has two arms. One is about selling and the other is about the science of implant dentistry. I wont dignify the former.
Flapless surgery does have its place, just like every protocol in periodontics and dentistry. Like everything else pick your cases and situations. That is the diagnostic skills associated with implant surgery. If one goes flapless you must be prepared to change the approach if circustances require it.
To me the best and really true indication for this approach is in the maxillary incisor region when a tooth has failed due to a root fracture, restorability issues, post failure, or endodontic reasons. Here the tooth is removed, the socet carefully and throughly debrided, the fixture is installed, socket and buccal plate region grafted and the provisional placed out of occlsuion in all excursions. The flapless approach maximizes the soft tissue healing. This appraoch many times is more taxing than a conventional appraoch.
One final perspective. I recently heard Dr. Myron Nevins present. Dr. Nevins is a past recipeint of the American Acadamey of Periodontology's Master Clinician Award. His comments on flapless implant placement are very telling(paraphrased). He stated that he has done surgery all day for his entire professional career and that he does not have a comfort level with this type of procedure.
Posted by: | Aug 9, 2006 3:54:27 AM
Pros: Less trauma,maintainace of bllod supply and epithelial attachment
Cons: you need to have experience and it does not come with the software itself....unfortunately!
Conclusion: You might have more patients for implants in the "winner cases"
Posted by: Albert Hall | Aug 9, 2006 12:03:14 PM
Dear Doctors: I had an implant placed about a year ago and my wonderful surgeon placed a membrane over the site where he extracted a fractured root canaled tooth.
Unfortunately after abutment placement, I started experiencing nerve like pain and numbness. Recently I found out through a flap surgery that the membrane never hardened and the implant broke through bone. Do you think this might be causing my pain. Also I will lose my adjacent tooth which is healthy if implant is removed. Thank you for your advice.
Posted by: Kevin Keogh | Aug 9, 2006 12:37:58 PM
Hi Bob,
Guys Bob Horowitz is skilled clinician, excellent educator and outstanding orator.
he lectures locally and nationally.
try to attend his lecture on regeneration.(RIDGE AUGMENTATION)
Posted by: satish joshi | Aug 9, 2006 2:57:32 PM
I had to change from planned flapless to flap when I encountered an extremely narrow upper premolar ridge covered by thick fibrous tissue. The radiographs showed good bone height but of course disguised the thin narrow bone crest. obviously a CT would have warned me
Posted by: | Aug 11, 2006 4:47:25 AM
that is exactly what i meant.some times that very good looking ridge may not be that good after all.particularly in ant.maxilla some times soft tissues thckness may be 4 to 5 mm. and also there may be some labial concavities which can be missed easily, especially in lateral incisors and 2nd maxillary pre molars.
but if you know topography of ridge and if you have nice wide bony ridge with nice thin soft tissues. it is a goog technique.
Posted by: satish joshi | Aug 11, 2006 8:38:59 AM
Kevin: My implant was not placed properly and is protruding through my jaw bone also. I noticed the gum above the good teeth next to the implant is quite red and swollen. This is after three years and I am just now having pain. I noticed no professionals have advised you on what to do. I think it best to take a chance and have implants removed. We may lose bone and good teeth but may end up without pain which would be a blessing. You are not alone. There are a lot of people having problems with implants out there. Good luck!
Posted by: | Aug 13, 2006 4:30:50 PM
Hi, I've done severeral flapless mini implant and conventional procedure. I think as for experience you have to have proper case selection. When in doubt open a flap.I think its a risky procedure but the patient love it because of no complicated instruction for suturing involved. As I said case selection is the key.
Posted by: Dr.chin Lim | Aug 15, 2006 6:20:31 PM
Bob, I agree you about Don Callan. He does knows about bone and implants. Look as his new work.
JPS
Posted by: JPS | Aug 18, 2006 6:37:47 AM
I placed two flapless impalnts for congenitally missing maxillary laterals.Spaces were created orthodontically.Patient's temporary RPD were used as surgical guide.Patient was extreamly happy about the result.I feel case selection is important key .Then it is an important adjunt to the implant treatment modalities.
Posted by: Gcc | Dec 28, 2006 12:15:57 AM
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