Three-Year Outcome of Fixed Partial Rehabilitations Supported by Implants Inserted with Flap or Flapless Surgical Techniques

Comparative evaluation of circumferential crestal bone loss after 1 year of implant placement with flapless versus flap surgery using surgical template after immediate loading in the posterior mandibular region using cone-beam computed tomography: A randomized controlled trial

Aim

The study was aimed to evaluate circumferential crestal bone level after one year of implant placement with flapless versus flap surgery using surgical template after immediate loading in the posterior mandibular region using CBCT.

Setting and Design

The study was designed as a Randomized controlled trial.

Material and Methods

32 implants were placed in single edentulous spaces in the mandibular posterior region after random allocation into two groups: Flap surgery (Group A) and Flapless surgery (Group B). Virtual implant planning was performed using Blue Sky Bio software, and static CBCT guided 3D printed surgical templates were fabricated for all participants of both the groups. Immediate non-functional temporization was performed. Circumferential crestal bone levels were assessed after surgery and one-year follow-up using CBCT and XELIS software. Vertical bone loss (VBL) and horizontal bone loss (HBL) was assessed on four sides: buccal, lingual, mesial and distal.

Statistical Analysis Used

Data was analyzed using Statistical Package for Social Sciences IBM Corp. Released 2017, IBM SPSS Statistics for Windows, Version 25.0. (Armonk, NY: IBM Corp.) and Graph Pad Prism 7.0 version. The level of significance was chosen <0.05. Chi square test was performed to assess the difference in the age in the two groups. Mann-Whitney U test was performed to compare the two groups for outcome measure. Graphically, quantile-quantile (Q-Q) plot was made using mean and standard deviation for normality verification of data.

Results

100% survival rate and patient compliance was observed along the one-year follow-up duration. By using Mann-Whitney U test, statistically significant difference was found in the vertical bone loss among participants of Flap surgery (Group A) and Flapless surgery (Group B) on all the four sides after one year of implant placement. However, significant results were not obtained for the difference in the horizontal bone level.

Conclusion

Within the limitations of this study, vertical bone loss measured circumferentially was more positively correlated with the implants placed with flap surgery compared to flapless surgery after immediate loading in the posterior mandibular region after one year.

Comparative evaluation of crestal bone level by flapless and flap techniques for implant placement: Systematic review and meta-analysis

Aim

:To compare the crestal bone level of flapless technique of dental implant placement with the flap technique.

Setting and Design

This Systematic review and Meta-analysis was conducted according to the Preferred Reporting Items For Systematic Review and Meta-Analyses (PRISMA) Guidelines and registered with PROSPERO.

Materials and Methods

Electronic search of Medline and Google scholar databases for articles from 2010 till March 2020 was performed. Studies comparing the crestal bone level with both the techniques were included. After the collection of data, the risk of bias was assessed for each study.

Statistical Analysis Used

Meta-analysis was executed using RevMan 5 software version 5.3.

Results

23 studies were included. Statistically significant difference in crestal bone level was found between flapless and flap surgery with mean difference of -0.14 (flapless placement versus flap surgery; 95% CI: -0.24 to -0.03; P = 0.01FNx01). The difference in crestal bone level between the 2 groups was not statistically significant with a mean difference of -0.05(Guided flapless placement versus flap surgery; 95% CI: -0.10 to 0.00; P=0.06). Meta-analysis of the freehand flapless surgery with flap surgery generated a mean difference of -0.20 which was found to be statistically significant (Freehand flapless placement versus flap surgery; 95% CI: -0.37 to -0.03; P=0.02FNx01).

Conclusions

Flapless placement of implant can positively influence crestal bone loss in comparison with conventional flap technique.

Long-term clinical performance of flapless implant surgery compared to the conventional approach with flap elevation: A systematic review and meta-analysis

BACKGROUND

The conventional implant approach involves flap elevation, which may result in increased soft tissue and bone loss and postoperative morbidity. The flapless surgical technique, aided by three-dimensional medical imaging equipment, is regarded as a possible alternative to the conventional approach to alleviate the above issues. Several studies have been performed regarding the role of flapless implant surgery. However, the results are inconsistent and there is no robust synthesis of long-term evidence to better inform surgeons regarding which type of surgical technique is more beneficial to the long-term prognosis of patients in need of implant insertion.

AIM

To compare the long-term clinical performance after flapless implant surgery to that after the conventional approach with flap elevation.

METHODS

PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and grey literature databases were searched from inception to 23 September 2019. Randomised controlled trials (RCTs) and cohort studies comparing the long-term clinical performance after flapless implant surgery to that after the conventional approach over a follow-up of three years or more were included. Meta-analyses were conducted to estimate the odds ratios (ORs) or mean differences (MDs) and their 95% confidence intervals (CIs) between the long-term implant survival rate, marginal bone loss, and complication rate of the flapless and conventional groups. Subgroup analyses were carried out to account for the possible effects of the guided or free-hand method during flapless surgery.

RESULTS

Ten articles, including four RCTs and six cohort studies, satisfied the eligibility criteria and nine of them were included in the meta-analysis. There was no significant difference between the long-term implant survival rate [OR = 1.30, 95%CI (0.37, 4.54), P = 0.68], marginal bone loss [MD = 0.01, 95%CI (-0.42, 0.44), P = 0.97], and complication rate [OR = 1.44, 95%CI (0.77, 2.68), P = 0.25] after flapless implant surgery and the conventional approach. Moreover, subgroup analyses revealed that there was no statistically significant difference between the implant survival rate [guided: OR = 1.52, 95%CI (0.19, 12.35), P = 0.70]; free-hand: n = 1, could not be estimated), marginal bone loss [guided: MD = 0.22, 95%CI (-0.14, 0.59), P = 0.23; free-hand: MD = -0.27, 95%CI (-1.10, 0.57), P = 0.53], or complication rate [guided: OR = 1.16, 95%CI (0.52, 2.63), P = 0.71; free-hand: OR = 1.75, 95%CI (0.66, 4.63), P = 0.26] in the flapless and conventional groups either with use of the surgical guide or by the free-hand method.

CONCLUSION

The flapless surgery and conventional approach had comparable clinical performance over three years or more. The guided or free-hand technique does not significantly affect the long-term outcomes of flapless surgery.

Comparison between flapless and open-flap implant placement: a systematic review and meta-analysis

No consensus has been reached regarding the influence of the flapless and open-flap surgical techniques on the placement of dental implants. This systematic review compared the effects of flapless implant placement and implant placement with elevation of the mucoperiosteal flap in terms of marginal bone loss, implant survival rate and complications rates. This review followed PRISMA guidelines and was registered in PROSPERO with the registration number CRD42017071475. Two independent reviewers performed a comprehensive search of the PubMed/MEDLINE, Scopus, and Cochrane Library databases for studies published until December 2017. The search identified 559 references. After a detailed review, 24 studies were assessed for eligibility. A total of 1025 patients who had received a total of 1873 dental implants were included. There were no significant differences between the flapless and open-flap surgical techniques in terms of implant survival rates (P=0.34; risk ratio (RR): 1.36; confidence interval (CI): 0.72-2.56), marginal bone loss (P=0.23; MD: -0.20; CI: -0.52-0.13), or complication rates (P=0.67; RR: 1.10; CI: 0.70-1.73). The current meta-analysis showed that the implant survival rate, marginal bone levels, and complications of flapless surgery were similar to those of open-flap surgery over a mean follow-up period of 21.62 months.

Comparison Between a Computer-Aided Surgical Template and the Free-Hand Method: A Systematic Review and Meta-Analysis

BACKGROUND

During implantation planning, dentists should be able to make an informed decision regarding whether to use an implant template to assist the surgery.

PURPOSE

The aim of this meta-analysis was to assess the results of implantation with or without an implant template based on the accuracy, survival rate, and other considerations.

MATERIALS AND METHODS

In January 2018, a systematic review was undertaken for randomized controlled trials and retrospective and prospective cohort studies with relevance to implant accuracy and the survival rate between the implant template and free-hand method. The odds ratios (ORs) of the survival rate and the mean difference of accuracy deviation from the selected papers were estimated by meta-analysis.

RESULTS

Of the 362 screened articles, 6 studies were included in the meta-analysis. Comparison of the survival rate of implant surgery with or without an implant template revealed no significant result (OR = 1.71, 95% confidence interval [CI] 0.65-4.51). Significant differences in accuracy were observed in angular (mean difference = -5.45 degrees, 95% CI -0.66 to -4.24 degrees) and apical deviation (mean difference = -0.83 mm, 95% CI -1.12 to -0.54).

CONCLUSIONS

With the technology of computer-aided surgical template, implant placement can be more accurate than free-hand operation. No significant difference is observed in the survival rate between template and free-hand.