Flapless or Flap Protocol?

When placing dental implants, a flap is traditionally elevated to better visualize the implant recipient site. When a limited amount of bone is available, a flap elevation reduces the risk of bone fenestrations or perforations [1]. The concept of flapless implant surgery has been introduced for the patients with sufficient keratinized gingival tissue and bone volume in the implant recipient site.

In a flapless procedure, a dental implant is installed through the mucosal tissues without reflecting a flap. The alleged reasons to choose the flapless technique are to minimize the possibility of postoperative peri-implant tissue loss and to overcome the challenge of soft tissue management during or after surgery [2]. Other alleged advantages of the flapless implant surgery include less traumatic surgery, decreased operative time, rapid postsurgical healing, fewer postoperative complications and increased patient comfort [3], [4].

But which approach achieves better long-term clinical results? A recent study, investigated this issue, by measuring marginal bone changes and peri-implant conditions 8.5 years after placement of one-piece implants with an anodically oxidized surface (AOS) using a flapless or flap protocol.[5]

The conclusion:

Similar mean levels of probing pocket depth (PPD) were found in flap and flapless groups (mean [SD] = 2.4 [0.3] and 2.2 [0.4] mm, respectively [P = .18]), as well as similar rates of presence of bleeding on probing (22.8% vs 17.9%, respectively). Papilla levels increased during the first year after implant loading. However, there was little additional change between 1.5 and 8.5 years. A total of eight fractured porcelain crowns and three crown loosenings were reported. One-piece implants with an AOS showed high survival rates and stable marginal bone and periimplant soft tissue levels regardless of whether a flapless or flap protocol was used.[5]

In your practical experience have you see a difference in clinical outcomes between a flapless or flap protocol?

1. Ozan O, Turkyilmaz I, Yilmaz B (2007) A preliminary report of patients treated with early loaded implants using computerized tomography-guided surgical stents: flapless versus conventional flapped surgery. J Oral Rehabil 34: 835–840. [PubMed]

2. Rocci A, Martignoni M, Gottlow J (2003) Immediate loading in the maxilla using flapless surgery, implants placed in predetermined positions, and prefabricated provisional restorations: a retrospective 3-year clinical study. Clin Implant Dent Relat Res 5(Suppl ()) 29–36. [PubMed]

3. Arisan V, Karabuda CZ, Ozdemir T (2010) Implant surgery using bone- and mucosa-supported stereolithographic guides in totally edentulous jaws: surgical and post-operative outcomes of computer-aided vs. standard techniques. Clin Oral Implants Res 21: 980–988. [PubMed]

4. Sunitha RV, Sapthagiri E (2013) Flapless implant surgery: a 2-year follow-up study of 40 implants. Oral Surg Oral Med Oral Pathol Oral Radiol 116: e237–e243. [PubMed]

5. Survival Rates and Bone and Soft Tissue Level Changes Around One-Piece Dental Implants Placed with a Flapless or Flap Protocol: 8.5-Year Results.., Int J Periodontics Restorative Dent. 2017 May/Jun; Froum SJ et al.

5 thoughts on “Flapless or Flap Protocol?

  1. Eric Ruckert, DDS says:

    I use flaps, my associate does not. I have less than one percent failure, he has 8%. I would bet longevity is longer with flap procedures. When I flap a ridge to place an implant, I SEE what the bone is like in 3D. Many times I need to add a small amount of bone for a crater or deficiency I cannot feel on exam or see on XR. I can make the area perfect. My patients with a flap get two sutures, and go right back to work from the office. Why try to cut corners? By the way, I feel the same about placing healing collars at the first surgery. Why? The uncovering procedure is only 5 minutes, and I do not have to worry about chewing on the healing collar, or a path for bugs to get to the implant while healing. I do not charge for uncovering.
    Hurrying is market driven or patient driven. I’d rather have my success rate. Patients always go along when explained to .

    • Peter Fairbairn says:

      Makes sense to me …..benefits with both methods , we saw increased failure without flaps as well , but just an opinion

    • Kent E. White, DDS says:

      Well said…in many ways. I value my direct vision, feel and intuitive guide, via the flap. I have also expanded my incision/technique approaches , as performed/taught by many of you.
      Metaphor- The tools have to stay sharp and the tool box should always be growing, for us. “Just because you don’t or choose not to see it, doesn’t mean it’s not there. ” Kent. Happy/Thankful, Memorial Day!

  2. Ex Prof Dr Phulphagar says:

    Both techniques have their place !whenever there is doubt about bone anatomy a flap should be preferred . The comfort of flapless should not be tempting whenever bone contours are unfavourable!


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