Flap versus Flapless Immediate Implants with Bone Augmentation: A Novel Study

ABSTRACT

Background:

This study aimed to equate implants placed using a traditional flap elevation technique with implants placed using a flapless process regarding bone healing and success in clinical conditions.

Materials and Methods:

Sixty subjects were included in this research work. The participants were randomly divided into two groups. Patients in group A underwent implant placement with the flap elevation technique. Similarly, group B patients underwent implant placement without flap reflection. Parameters such as plaque index, wound healing index, crestal bone loss, and radiograph were considered to estimate the effectiveness of the two techniques.

Results:

Plaque indexes were improved in both groups. The modified gingival index also improved in all the phases of healing. The flapless method showed a better crestal bone.

Conclusion:

It can be concluded that this study showed that with the right augmentation techniques, implants could be successfully performed immediate extraction sockets, both with and without elevation of the mucoperiosteal flap.

INTRODUCTION

After Branemark developed dental implants in 1952, the field of implantology underwent a major change. Since then, newer procedures have been developed, and implant dentistry has constantly changed. It has recently advanced to greater levels with the use of rapid implant placement following extraction, which not only improves aesthetic results but also helps to maintain both soft and hard tissues.[1] In a particular clinical situation, a surgeon must frequently decide whether or not to raise a gingival flap. The best possible aesthetic results in the aesthetic zone can be achieved by carefully choosing a flap design.[2]

There are several potential benefits of flapless surgery, including (1) a decrease in patient-level complications, such as pain and swelling; (2) a decrease in intraoperative bleeding; (3) a decrease in the length of the procedure and the requirement for sutures; (4) the preservation of all types of tissues; and (5) maintaining the blood supply.[3] Nevertheless, the flapless approach still offers several potential drawbacks despite these benefits.[4] The negative point includes the operator’s inability to see the important landmarks directly, a vague possibility of thermal trauma to bone due to lack of direct irrigation, and decreased accessibility to bony contours.[5]

This study aimed to compare the technique of implants inserted using a flapless approach into freshly extracted sockets to implants inserted using a flap elevation procedure in terms of clinical performance and bone healing.

MATERIALS AND METHODS

Sixty patients were enrolled in a study with informed permission that was divided into two groups and adhered to the protocol’s inclusion and exclusion criteria. Sixty implants in total were inserted. Before the implant placement began, the patients’ full medical history was properly recorded. The following were the study’s inclusion requirements: age range of greater than 20; availability of the patient to adhere to the follow-up timeline; American Society of Anesthesiologists (ASA) I and ASA 117 in a healthy patient; patients who maintain proper oral care (verified by plaque index and modified gingival index) adequate adherence from the patient; and patients who are stable enough neurologically and hemodynamically to endure an extensive surgical treatment; the study only included single-rooted front teeth and premolars, and they contained at least 3 millimeters of bone beyond the root apex. Tooth/teeth have been recommended for extraction because of periodontal disease, endodontic failures, caries, or root fractures. Patients not fit for implant placement and not willing for study were excluded.

Surgical technique

All of the selected patients underwent a full mouth oral prophylaxis after receiving detailed instructions regarding plaque control measures. Patients who met the inclusion criteria were called back after a week. A standardized grid was used to take intraoral periapical radiographs and a Cone beam computed tomography (CBCT) of the area.

After these evaluations, all of the patients had undergone oral prophylaxis and were given oral hygiene instructions. Under aseptic conditions, the same surgeon performed all the implant surgeries. The cases were arbitrarily assigned to the control or test group. A mucoperiosteal flap was raised through intrasulcular and vertical incisions at the places in group A.

After that, the implants were inserted at the predetermined depth at sites that had been prepared using the standard drill provided by the manufacturer.

Group A’s immediate implant sites were transplanted with a bioactive glass (PerioGlas™). This graft was covered with a resorbable collagen membrane (CollaGuide™), and primary soft tissue closure was achieved. On the sites in group B, no incisions or flap elevations were carried out before placing the implants. The soft tissue edges were sutured. Primary closure for soft tissues was not carried out for the test sites. Following the procedure, a follow-up was conducted six months later, and clinical parameters were assessed to compare the outcomes.

RESULTS

Each group consisted of 30 patients. Group A distance implant-bone (DIB) scores were 2.80 ± 0.57 and 1.90 ± 0.42 at baseline and six months, respectively, with a variance of -0.90 and a P value of 0.001 in comparison. Consequently, from baseline to six months, a gradual decline in DIB is observed. Additionally, it showed significant results (P value >0.05) [Table 1]. Distance from implant shoulder to creastal bone (DIC) score in group A from baseline to six months was significant. Consequently, from baseline to six months, DIC declines gradually. Additionally, it was statistically significant because the P value was less than 0.05.

Table 1.

Intergroup comparison between groups A and B (independent t-test)

Group characteristics	n	Mean	Std. deviation	Std. error mean	Mean difference	P	Significance
Plaque index baseline
A	30	0.564	0.18	0.082	-0.036	0.766	NS
B	30	0.600	0.19	0.083
Plaque index 3 months
A	30	0.634	0.18	0.081	-0.034	0.763	NS
B	30	0.668	0.16	0.073
Plaque index abutment placement
A	30	0.702	0.22	0.098	-0.050	0.686	NS
B	30	0.752	0.15	0.068
Modified gingival index baseline
A	30	0.598	0.19	0.083	-0.032	0.727	NS
B	30	0.630	0.07	0.031
Modified gingival index 3 months
A	30	0.672	0.21	0.093	-0.040	0.698	NS
B	30	0.712	0.08	0.034
Modified gingival index abutment placement
A	30	0.742	0.22	0.098	-0.048	0.656	NS
B	30	0.790	0.08	0.034
1-week early wound healing index
A	30	3.200	0.45	0.200	0.200	0.347	NS
B	30	3.000	0.00	0.000
2-week early wound healing index
A	30	2.200	0.45	0.200	0.200	0.608	NS
B	30	2.000	0.71	0.316
4-week early wound healing index
A	30	1.400	0.55	0.245	0.200	0.545	NS
B	30	1.200	0.45	0.200
DIB baseline
A	30	2.800	0.57	0.255	-0.400	0.299	NS
B	30	3.200	0.57	0.255
DIB abutment placement
A	30	1.900	0.42	0.187	-0.600	0.074	NS
B	30	2.500	0.50	0.224
DIC baseline
A	30	1.600	0.55	0.245	0.200	0.580	NS
B	30	1.400	0.55	0.245
DIC abutment placement
A	30	0.000	0.00	0.000	0.000	NP	NP
B	30	0.000	0.00	0.000

NP=P was not measured as both groups’ standard deviations were 0

The intergroup comparison of the plaque index was statistically significant [Table 1]. All of Buser’s criteria results measured at the baseline, three months, and during abutment placement were negative. DIC gradually reduced from baseline to six months and was statistically significant (P value <0.05) [Table 1]. The DIB score in group B was significant from baseline to six months, and consequently, from baseline to six months, a gradual decline in DIB is observed [Table 1].

DISCUSSION

The field of implant dentistry has advanced significantly over the past 20 years, giving doctors access to many previously unthinkable alternatives for tooth rehabilitation. Immediate implants are considered a clinically predictable treatment that prevents post-tooth extraction bone resorption.[6]

It has recently advanced to new levels with the immediate placement of implants following extraction, which not only produces better aesthetic results but also maintains the soft and hard tissues.[7] Not only has implant insertion without elevation of the mucoperiosteal flap been acknowledged as a successful operation, but it also has been shown to lessen patient discomfort and postoperative edema.

In a related study, Shibu J et al.[8] and associates placed implants in patients by both conventional and flapless surgery and stated that, after three months, the level of bone in the flapless procedures was stable while it significantly decreased in the conventional flap procedure.

Flap reflection may cause postoperative soft tissue loss, suggesting that using a flap during implant placement may have a negative impact on the results in terms of aesthetics. According to a study by C E English[9] a minimal incision can be used to place a flapless implant. This flapless method has very little surgical stress, which considerably reduces postoperative pain and suffering.

The use of a minimally invasive or flapless approach to carefully extract a damaged tooth may provide an opportunity for immediate implant placement. According to Schultz[10] the idea of an osteogenic “jumping distance” attributes a major physiologic relevance to the separation between an implant and the surrounding alveolar wall.

Stefan Fickl[11] and Suaid[12] showed that the loss of bone height was two times more significant in the flap elevation group.

Also, flapless implant procedures show improved vascularized peri-implant mucosa, which will result in adequate blood supply and therefore lead to higher resistance to inflammation and bacterial invasion.[13,14]

According to Seung-Mi Jeong[15] flapless implant surgery results in better osseointegration of dental implants and the bone height around implants after surgery, and flapless implant surgery may be more effective than surgery with flap reflection in improving implant anchorage.

CONCLUSION

Within the constraints of this study, it can be said that this research demonstrated that augmentation procedures could successfully place implants in freshly extracted sockets with or without elevation of the mucoperiosteal flap. Flapless implantation offers a number of benefits, including shorter recovery times, reduced surgical hemorrhage, preservation of both soft and hard tissues, and patient comfort.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.