Flap Versus Flapless Implant Placement: Recommendations?

Dr. LK, a general dentist, asks:
I am a general dentist in a medium sized city on the East Coast of the United States. There is a lot of competition in my area. I have been placing my own implants for about 10 years. I am just learning how to use CBVT scans [Cone Beam Volumetric Tomographic scans] to plan the placement of implants. I use a surgical guide stent and I lay a Full Thickness or Partial Thickness Flap for all my cases, depending on the nature of the placement and surgery. Some of the specialists and general dentists here are doing flapless surgical placement. This seems to result in less trauma and more rapid healing. I would like to get some feedback from users. How reliable is this method? You are depending on your CBVT scan and accuracy of your surgical guide stent. I really worry about not being able to actually see and feel the bone. What do you recommend?

10 thoughts on “Flap Versus Flapless Implant Placement: Recommendations?

  1. Your concerns are correct.
    i use flapless surgery when I know everything about a site. Examples:
    1. I was the one who took out the tooth
    2. I know that buccal/lingual/palatal walls are intact
    3. A grafted extraction site vs a non-grafted one
    4. No grafting will be necessary (except for a summer’s sinus lift)
    5. There is adequate attached / keratinized tissue that will remain after a tissue punch
    I have been amazed at how quickly patients heal with flapless procedures. Preserving the blood supply, especially in anterior esthetic cases, is of huge short and long term benefit. However,
    you will never be surpised with open flap surgery, and you should never be criticised for raising flaps. Vision is everything, despite CBCT and surgical guides.
    I have seen flapless surgery disasters, and I have created flapless surgery disasters and had to fix them. Like all techniques, there is a learning curve.
    Start with an easy case and an easy patient. If you are uncomfortable, it usually means that you are not ready for the technique or you patient is not a good candidate.
    Stay carefull, sleep well.

  2. This has been a dilema since the day I started Placing Implants. I think it depends upon the case and the Implant syestem we use. Both Flap and Flapless has its own advantages and disadvantages. Healing time is less in case of Flapless. The principle blood supply to the bone is from the periostium and soft tissue. Anytime you reflect periostium and insert an implant at the cellular level you struggle or you starve the individual cells of bone. You also block the venous return, which decreases the acidity and increases the toxicity. Implants done transmucosal flapless bone level is better preserved and healing is faster. you also have matured vascularised cortical bone surrounding the Implant. I mostly use flapless in one piece Immediate loading implants like KOS. Patients are very happy, less trauma.
    Regarding raising Flap advantage is you get to see the bone and feel it. Placement is more precise.

  3. I think you should do flapless in all cases. Raising a flap results in pain and swelling and loss of blood supply. In cases where there is limited bone, I recommend you place a small diameter implant flapless. The smallest diameter you can go down to is 1.8 mm, even for molars. I have been doing this for 2 years and haven’t had a single failure yet.

  4. I aggre mostly with Dr. Smith. I have been doing flap surgery for 11 years and flapless for 10 years. 99% of my ases are all flapless. It’s the only way to go if you have the experience and are good at placing implants. If you want to compete with the guys doing cbvt scans, stents etc. that increase the cost of placing immplants for your patients, then learn to use your eyes and fingers to evaluate the bone anatomy, thickness, angle and a simple panoramic radiograph for the length of the implant possible. Pretty soon we will not have to touch a patient to place an implant because someone will have invented an expensive machimne to do it for you…which is fine if you have a line of patients standing at your office door waiting to have you place an implant. (I haven’t met that operator yet!)
    One of the things you want to make sure of is that you place the implant down into the bone sufficiently to cover the major threads of the implant… you get better soft tissue healing that way. Patients with flapless procedures have NO posterative facial swelling. You don’t need to us any sutureing, either (in most cases) which in my case takes longer to do than to place the implant!
    I place a healing abutment immediately so I don’t have to any second stage surgery to worry about…tissues are ready in a couple of months for impression and crown fabrication.
    Under size the osteotomy site so as to torque the implant in to the bone. With mechanical retention, you can usually restore in a matter of weeks! (I dare you to challenge me on this one! I just love being a prosthodontist that places ALL of my patients implants!)

  5. Hi
    I think you should go for flapless surgery only when you get enough bone width and intact buccal & lingal cortical bone plates. Definitely the trauma to the patient is minimum and healing is fast and better than flap surgeries. If you have any doubt even during surgery then just raise the flap to avoid any post-operative complications.

  6. I personally take a case specific approach to flapless versus open approaches or even guided approaches. For example, what I have found, primarily from the school of hard knocks, is that having a very very accurate and detailed dental history is absolutely the most important aspect when determining the need for flapless surgery in the maxillary anterior region. If there has been blunt trauma, surgical trauma, multiple endodontic procedures, apical surgery, external or internal resorption – these are some predictors that suggest an increased possibility for vascularity issues and the need for flapless surgery. These cases I try to do guided and flapless. Nevertheless, even with a flapless approach, I stil have seen cases melt.

    Another situation where I’ll go guided and flapless is if I need to place multiple implants, say in an edentulous maxilla case or any case where I’m really concerned about parallelism (even with angled abutments, lol). It’s just easier, IMHO.

    If I’m in a situation where I’m concerned about nerve impingement, I’l go guided and flapless.

    Actually, if you go guided, theoretically there’s really no reason to raise a flap right?

    Well, not always. I have found using the Materialize stents you need to be very careful. If your virtual surgery shows very very little space between the cortices, don’t thing you can use a guide to split hairs…it won’t work. The tolerances of these systems really do need you to have at the very least 1/2 to 1 mm at a minimum of distance between the implant and cortical plate. These systems are accurate, but they are NOT precise.

    Just a few indications in my private Idaho. The biggest is in relation to the anterior aesthetic zone and concerns about risk of periosteal stripping and bone loss. On the other hand, if I have a big wide ridge in the mandible with gobs of height, I go flapless and don’t use a guide either. So really it’s kinda dependent on the situation. In my book, never say never, and never say always.

    I would say, be very careful about the use of guides in the posterior quadrants. Always CHECK your vertical height to see if a tall burr will work. Been quasi-burned on that before. Lastly, on guided distal extention or edentulouse guided cases, ALWAYS use a guide that has been generated using a properly rendered CBCT for direct bone contact. Distal extention cases will have “wiggle room” that will make it hard to anchor precisely and get the proper orientation.

  7. These are all excellent observations. Take them into consideration and follow what you feel comfortable with. Don’t let fear hold you back, unless you are not sure of yourself. I have found that taking everything one step at a time and doing each one thoroughly and following correct surgical criteria will prove to be the best path to follow. Today, I had to extract a failing endodontic lower left 1st molar. I had the patient premedicated with amoxicillin, 500 MG twice daily for two days preop. I sectioned the molar prior to extraction to minimize trauma to the alveolus. I had a choice of placing my 6MM x 16MM Tapered Screw Vent implant immediately in either the mesial canal space (which was filled with granulation tissue), the septum, or the distal canal. I opted for the healthy distal canal. I made sure I removed all unhealthy tissue from the mesial socket, and prepared the distal socket at the same time that I “shaped” the distal wall of the septum. I prepared the site up to one half of the diameter of the next to last bur in the sequence. I placed the implant with the ratchet untill I achieved >90% maximum torque, replaced the autogenous bone which I mixed with 30% Osteogen (mostly for radiographic contrast), placed a covering of Biomend, a healing cuff (not a surgical healing screw), and sutured with Vicryl to keep everything in place, plus 2 more days of antibiotic coverage. For added security, I covered everything with Barricaid for removal in a week’s time. This is standard practice for me in these failing tooth cases. In 6 weeks time I will impression and finish the case with a PFM crown in occlusion! Patients love it and so do I.

  8. The idea of flapless surgery seems good.
    No mp flap raising better blood supply/less pain etc etc
    Even with ct based guides (way more accurate than a ride mapped guide) how do you know your platform is where you want it? How do you also know whether there is a dehisence/fenestration ? you don’t!
    Unless you have a really wide ridge 5mm plus then avoid!
    I have placed flaplessly and have encountered problems!
    Good luck

  9. When placing an implant it is critical to know how much crestal bone you have around the implant at time of placement. Relying on radiography to confirm crestal width may be ok prior to placement, but is no guarantee that at time of placement the implant will be placed in exactly the guided position as shown on the radiograph.
    There is no substitute for seeing the actual bone at placement, and with conservative flapping technique, there is in my hands no difference with post surgery healing or pain. In fact there are some papers which show that a flapless approach is in fact more traumatic from a patient’s perspective. Certainly, if the implant is not placed adequately due to blind surgery, then from everyone’s perspective this approach is unacceptable. Certainly as has been mentioned previously, when there is no question of crestal bone width and volume, a flapless approach may be acceptable, otherwise my advice is conservative flapped approach and save the anguish.

  10. I have had excellent results “threading the needle” going guided flapless using my I-CAT and Keystone Guide.
    I routinely take a quick 8 second post-op scan to verify implant placement.
    I like what Jim has done in a molar immediate placement.
    I tried those big molar implants from megagen a while back, they work by using a trephine to core the interseptal bone to place implant and graft using the morselized core that is removed. Difficult for me and slow–so I abandoned those implants.
    Sincerely,
    William Reeves DDS PC

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