23 December 2020

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Which is the best solution between open flap and flapless technique placement of dental implants?

Giulia Palandrani

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The use of dental implants in the rehabilitation of partially or totally edentulous patients is a routine procedure with very high and predictable success rates . Despite this, the placement of a dental implant is a biologically aggressive surgical procedure, which causes a postoperative inflammatory process associated with resorption of the peri-implant bone.

Postoperative discomfort due to flap elevation led to the development of minimally invasive techniques for implant placement in which the mucoperiosteal flap is not elevated (flapless) . These techniques achieve a reduction in surgical time, a better preservation of soft and hard tissues, a decrease in postoperative inflammation, bleeding and pain, and a shorter recovery time. 

However, these minimally invasive techniques also have drawbacks, there is a greater difficulty in achieving sufficient bone cooling during bone cutting, and remodeling of the bone crest or manipulation of the soft tissues in the emergent area of the implants cannot be performed. 

The objective of the present study is to compare the immediate postoperative period of participants rehabilitated with dental implants placed with a conventional technique or with a minimally invasive technique, without a mucoperiosteal flap elevation (flapless). 

Material and Methods
A prospective, randomized, pilot study was conducted, 35 patients ( ASA I or II) partially or totally edentulous were divided in two groups, in Group A (G_A) the implants were placed using a standard technique with flap elevation; and in Group B (G_B) they were placed using a flapless technique, accessing the bone with a round mucosal punch of the same diameter as that of the implant to be placed . All participants were premedicated with 2 g of amoxicillin or 600 mgr of clindamycin. After surgery all participants were prescribed antibiotic therapy with amoxicillin 1 g/8 h for 5 days or clindamycin 300 mg/8 h. Ibuprofen 600 mg/8 h for pain control (maximum of 3 tablets per day) as well as mouth wash with chlorhexidine and chitosan 24 h after the surgery for a period of 14 days was also prescribed. 

Results 
35 participants with a total of 74 implants were operated, 5 participants assigned to group B had to be discarded from the analysis due to intraoperative complications in which the flap had to be elevated to rectify the implant placement. 

Finally, 30 participants (18 men and 12 women) with a mean age of 48 years (range 36–68) were included in the data analysis with a total of 48 implants . 

 One implant (2.0%) failed in the G_A group in a non- smoker male patient before prosthetic loading due to mobility and pain at 3 months’ follow-up 

In five implants, two of the G_A and three of the G_B, there was a bone loss of > 4 mm at 15 days’ follow-up. 

In the 17 unitary implants (9 in G_A and 8 in G_B) the mean surgical time is reduced by approximately half for G_B as compared to G_A (48 min vs. 82 min). Surgeries in participants who needed a greater number of implants demonstrated quite similar operating times between G_A and G_B.

Participants reported less postoperative pain in G_B (at 24 h, 7 and 15 days); consequently there was less consumption of analgesics (at 24 h and 7 days).

The oral hygiene index has been shown to be better in the flapless surgery group. Some patients have a tendency to avoid brushing due to fear of developing problems with the sutures. Moreover in this study, participants with open flap and sutures reported more pain, resulting in a tendency to avoid thorough hygienic measures. 

Conclusions

Participants operated for implant placement using the flapless technique  undergo a better postoperative period, measured using objective and subjective parameters. 

Both techniques show high success rates, but to perform  flapless technique patients must be properly selected and the surgeon must be qualified to resolve the surgery using flap elevation. 

For additional information: Open flap versus flapless placement of dental implants. A randomized controlled pilot trial .