Comparison of general and aesthetic effects between flapless and flap techniques in dental implantation: a meta-analysis of randomized controlled trials

Effects of flapless and flapped implantations on soft tissue: a systematic review and Meta-analysis

OBJECTIVES

This study aimed to systematically compare the effects of flapless and flapped implantations on the surrounding soft tissues of dental implants.

METHODS

Nine databases were searched, including PubMed, Embase, Cochrane Library, Web of Science, Clinical Trials, OpenGrey, OpenDoar, Scopus, and Ovid, from January 1, 2013, to August 27, 2023. Randomized controlled trials comparing flapless implantation with flapped implantation for restoration of missing teeth were included. Meta-analysis was conducted on studies that met the inclusion criteria by using RevMan 5.3 and Stata 14.0.

RESULTS

A total of 1 245 articles were retrieved, and 17 studies were ultimately included. The results of Meta-analysis showed that flapless implantation resulted in better healing of the soft tissues around the dental implants than flapped implantation. Moreover, flapless implantation showed superior changes in implant success rate [mean difference (MD)=1.06, 95% confidence interval (CI) (1.02, 1.10), P=0.004], the width of keratinized gingival changes [MD=0.10, 95%CI (0.00, 0.20), P=0.04], and probing depth [MD=-0.60, 95%CI (-0.67, -0.53), P<0.000 01], with statistically significant differences. The final combined results of modified plaque index [standardized mean difference (SMD)=-0.41, 95%CI (-0.81, 0.00), P=0.05] and modified sulcus bleeding index [SMD=-0.44, 95%CI (-0.78, -0.10), P=0.01] showed superiority over flapped implantation. The papillary presence index was higher in the flapless implantation group than in the flapped implantation group. No statistically significant differences were observed in plaque index and gingival indices changes between the two groups.

CONCLUSIONS

Flapless implantation can achieve higher implant success rate, smaller changes in the width of keratinized gingival, and smaller probing depths than flapped implantation. It also has advantages in terms of modified plaque index, modified sulcus bleeding index, and papillary presence index.

Evaluation of clinical and serological responses after full-mouth implantation in single-visit versus multiple-session surgery

Background

This research aimed to evaluate the clinical characteristics of pain and wound healing and serological inflammatory markers after full-mouth implantation in one session compared to several sessions.

Methods

A single-masked clinical trial was conducted on 20 patients (n=10) receiving full-mouth implants. Patients were randomly divided into two groups. The first group was operated under general anesthesia in one session and the second group in multi-sessions. Inflammation level was evaluated through white blood cell (WBC) and serum C-reactive protein (CRP) before and after surgery by a blood test. Pain and early wound healing (EHS) assessment was conducted after surgery with VAS and EHS indicators, respectively. Serological and clinical parameters were compared by repeated-measures ANOVA and Sidak and Man-Whitney U tests, respectively, using SPSS 20.

Results

The CRP level 48 hours postoperatively was not different in the two groups; however, seven days after treatment, it was higher in the multi-session group than in the single-session approach. The WBC was not different between the two groups at evaluated intervals. Serum levels of WBC and CRP increased 48 hours postoperatively and decreased seven days later. EHS showed no difference between the two groups at the three investigated intervals. The amount of VAS 24 and 48 hours and 7 days postoperatively was higher in multi-session surgery than in the one-session approach. In both groups, VAS was not different at 24 and 48 hours postoperatively and decreased over seven days.

Conclusion

Full-mouth implant surgery under general anesthesia in one session caused less inflammation and pain postoperatively while presenting the same wound-healing process as the multi-session surgery.

Avoiding errors and complications related to immediate implant placement in the esthetic area with a mucogingival approach

Immediate implant placement is considered the treatment of choice for single tooth replacement in the esthetic area. However, this treatment is associated with several critical drawbacks related to the inadequate assessment/management of the soft and hard peri-implant tissues and their subsequent remodeling, resulting in peri-implant soft-tissue defects that can lead to impaired esthetic outcomes in time. We describe in detail how the mucogingival approach to immediate implant placement ensures a standard result regardless of the baseline soft-hard tissue situation. Fully guided implant placement guarantees an adequate three-dimensional implant placement, the flap design makes it possible to perform bone augmentation with complete visibility of the area being treated, allows soft tissue augmentation with proper fixation of the connective tissue graft, and the placement of an immediate provisional ensures stabilization of the peri-implant tissues throughout the healing period.

Clinical Observation of Flapless Implantation in the Posterior Tooth Area under the Guidance of the Fully Guided Template

Objective

Compared with the conventional flap implantation, the postoperative effect of flapless implantation of a single posterior tooth under the guidance of the fully guided template was observed.

Materials and Methods

67 cases were divided into the template group (n = 35) and the flap group (n = 32) according to the wishes and actual situation of the patients. In the template group, the fully guided template was made by rapid prototyping technology, and the flapless implantation was performed under the guidance of the template in the posterior tooth area. The flap group underwent routine flap implantation. After the operation, the template group took CBCT (cone beam computed tomography) again and fitted it with that before the operation. Neck deviation, apical deviation, depth deviation, and axial angle deviation in buccolingual and mesiodistal directions were measured to observe the accuracy of the fully guided template. At the same time, the postoperative reactions of the two surgical methods were compared by recording the operation time, pain degree 24 hours after the operation, swelling degree 72 hours after the operation, and postoperative satisfaction of patients.

Results

Whether in buccolingual or mesiodistal directions, the maximum values of neck deviation, apical deviation, and depth deviation were less than 2 mm. The axial angle deviation was 0.07°∼5.93° in the buccolingual direction and 0°∼4.12° in the mesiodistal direction. The guiding effect of the template was relatively reliable, and the implantation site and depth were well controlled. Although there were small deviations, the accuracy of the template could meet the clinical needs. The operation time and the VAS (visual analogue scale) score 24 hours after the operation in the template group were lower than those in the flap group (P < 0.05), and the swelling degree rating 72 hours after the operation and postoperative satisfaction of the patients were better than those in the flap group (P < 0.05).

Conclusion

Compared with the conventional flap implantation, the flapless implantation in the posterior tooth area under the guidance of the fully guided template could improve the accuracy of the operation, shorten the operation time, and reduce the degree of postoperative pain and swelling, which had a certain positive clinical significance.