Flapless Implant Surgery

Dr. Berg asks:
I am a general dentist placing many of my dental implants. I have recently read about and taken some courses in flapless implant placement using a surgical template.

In addition, I have discussed this technique with some of the other GPā€™s I know who are placing dental implants, and they have told me that there is very little pain from flapless procedures as compared to laying a full thickness flap. In their view, because there is very little pain involved with the flapless procedures, more patients are accepting dental implants. I was wondering what others thought about this topic. Would flapless implant placement increase the acceptance of dental implant treatment plans with my patients? What are the pros and cons here? Thanks.

49 thoughts on “Flapless Implant Surgery

  1. Mark Spatzner says:

    Flapless surgical implant therapy is a technique that was not developed in order to ‘sell’ more dentistry. It is a treatment modality that allows the blood supply to remain uncompromised especially on the thin fragile facial/buccal bone plate as well as to the interproximal bony peaks. It is not an easier procedure as one has to take into account the anatomy and undercuts that could be perforated. Bone grafting and GBR are still utilised if an osseous defect is present which is more technically demanding without an open flap. WRT the comment regarding discomfort following implant therapy, my experience in placing implants for over 18 years has convinced me that implant therapy is one of the least painful procedures that I perform as a Periodontist. Prudence and experience will determine whether one opens a flap; the patient acceptance issue has been already solved if he/she is in the chair anesthetized.

  2. Mark Boulcott says:

    Mini implants such as MIDI or Osteotech favour the flapless approach as do several ‘punch a hole and screw’ systems. But all systems suppose you know what you are ‘screwing’ into and that the topography of the bone is known, that there are no boney defects and that you know exactly where you are going (say after a CT scan, and computer designed guides eg nobel guide). In any other circumstances you may encounter problems that could have legal repercussions later.

  3. satish joshi says:

    yes flapless surgery lessens the pain and discomfort to patient , no question about it.
    and it requires less time as there is no flap relection or suturing.
    BUT as Dr.Boulcott has mentioned you must be knowing topography of ridge pecisely.with the use of proper diagnostic tools or you will end up with part of your implant lying in soft tissues,
    particularly in case of ridges covered with thick mucosal tissues giving false impression of width.
    Also some times it is difficult to do precise ostrotomy height as soft tissues will hinder proper reading of height marks on drills.
    Also on grafted sites or recent extraction sites you do not know what is the conditon of osseous crest.
    It is better to open the flap and visulise the tissues first hand, rather doing a blind surgery unless you are sure fo topography.
    Be careful in ant maxillary region.
    It is an excellent modality when you want to use osteotomes for ridge expansion as blood supply and periosteum are not disturbed.

  4. satish joshi says:

    one more thing to think about,
    If you are short of keratinised tissues it is better to save tissues with flap rather than punch in flapless surgery,and/or with palatal insision keratinised tissue zone can be increased.

  5. Bob Horowitz says:

    As usual, I totally agree with Don Callan (one of the true workhorses of the Periodontal community). There is usually minimal to no postoperative swelling and pain after “conventional” implant placement. Flapless implant surgery enables the “surgeon” or “operator” to remove keratinized tissue necessary for aesthetic support of the final implant-supported restoration. Additionally, even if a CT scan is utilized preoperatively, there is the possibility of perforation with no ability to perform osseous regeneration.

  6. Dr. Dennis Nimchuk says:

    Once in a while there is the perfect circumstance where an abudance of bone volume and of keratinized attached gingiva exists. In these rare circumstances you almost cannot go wrong in implant placement without raising a flap. However, it has been my experience that in the overwhelming majority of cases such conditions seldom exist unless it is a situation where root removal and implant placement can be done simultaneously. The reality is that overall, you will perform a better quality service if you flap all but the most perfect of sites. Patients, if given the option, will always elect for quality and predictability compared to convenience and risk.

  7. Zev Kaufman, D.D.S. says:

    Just placed two implants, #8, and #9 as a flappless procedure today. Perfect procedure with perfect placement. No miracle, though! At time of extraction, a graft was used to maintain the socket. In addition, it took me placing several hundreds of implants until I got to a point of reasunable comfort with this technique sensitive procedure. It is much more difficult to do a flappless implant with perfect placement (unless one is dealing with a big, thick ridge, and lots of keratinized gingiva. I agree with the comments above. If there is a doubt in my mind… I flap it. I actually found out that the biggest pain reduction measure has been converting to digital radiography, which allows me to check my placement and complete procedures rapidely. In short, learn the trade, not the tricks of the trade.

  8. Anonymous says:

    This discussion has two arms. One is about selling and the other is about the science of implant dentistry. I wont dignify the former.

    Flapless surgery does have its place, just like every protocol in periodontics and dentistry. Like everything else pick your cases and situations. That is the diagnostic skills associated with implant surgery. If one goes flapless you must be prepared to change the approach if circustances require it.

    To me the best and really true indication for this approach is in the maxillary incisor region when a tooth has failed due to a root fracture, restorability issues, post failure, or endodontic reasons. Here the tooth is removed, the socet carefully and throughly debrided, the fixture is installed, socket and buccal plate region grafted and the provisional placed out of occlsuion in all excursions. The flapless approach maximizes the soft tissue healing. This appraoch many times is more taxing than a conventional appraoch.

    One final perspective. I recently heard Dr. Myron Nevins present. Dr. Nevins is a past recipeint of the American Acadamey of Periodontology’s Master Clinician Award. His comments on flapless implant placement are very telling(paraphrased). He stated that he has done surgery all day for his entire professional career and that he does not have a comfort level with this type of procedure.

  9. Albert Hall says:

    Pros: Less trauma,maintainace of bllod supply and epithelial attachment

    Cons: you need to have experience and it does not come with the software itself….unfortunately!

    Conclusion: You might have more patients for implants in the “winner cases”

  10. Kevin Keogh says:

    Dear Doctors: I had an implant placed about a year ago and my wonderful surgeon placed a membrane over the site where he extracted a fractured root canaled tooth.
    Unfortunately after abutment placement, I started experiencing nerve like pain and numbness. Recently I found out through a flap surgery that the membrane never hardened and the implant broke through bone. Do you think this might be causing my pain. Also I will lose my adjacent tooth which is healthy if implant is removed. Thank you for your advice.

  11. satish joshi says:

    Hi Bob,
    Guys Bob Horowitz is skilled clinician, excellent educator and outstanding orator.
    he lectures locally and nationally.
    try to attend his lecture on regeneration.(RIDGE AUGMENTATION)

  12. Anonymous says:

    I had to change from planned flapless to flap when I encountered an extremely narrow upper premolar ridge covered by thick fibrous tissue. The radiographs showed good bone height but of course disguised the thin narrow bone crest. obviously a CT would have warned me

  13. satish joshi says:

    that is exactly what i meant.some times that very good looking ridge may not be that good after all.particularly in ant.maxilla some times soft tissues thckness may be 4 to 5 mm. and also there may be some labial concavities which can be missed easily, especially in lateral incisors and 2nd maxillary pre molars.
    but if you know topography of ridge and if you have nice wide bony ridge with nice thin soft tissues. it is a goog technique.

  14. Anonymous says:

    Kevin: My implant was not placed properly and is protruding through my jaw bone also. I noticed the gum above the good teeth next to the implant is quite red and swollen. This is after three years and I am just now having pain. I noticed no professionals have advised you on what to do. I think it best to take a chance and have implants removed. We may lose bone and good teeth but may end up without pain which would be a blessing. You are not alone. There are a lot of people having problems with implants out there. Good luck!

  15. Dr.chin Lim says:

    Hi, I’ve done severeral flapless mini implant and conventional procedure. I think as for experience you have to have proper case selection. When in doubt open a flap.I think its a risky procedure but the patient love it because of no complicated instruction for suturing involved. As I said case selection is the key.

  16. Gcc says:

    I placed two flapless impalnts for congenitally missing maxillary laterals.Spaces were created orthodontically.Patient’s temporary RPD were used as surgical guide.Patient was extreamly happy about the result.I feel case selection is important key .Then it is an important adjunt to the implant treatment modalities.

  17. Matt-Implant rep says:

    I witness flapless implant procedures on a daily basis performed by OMFS. I have never seen a complication or failure in regards to flapless implant placement. No worries…

  18. Barry P. Levin, D.M.D. says:

    The literature on flapless implant surgery is sparse, to put it mildly. Respected organizations such as the ITI still consider flapless surgery as experimental in over 95% of the cases. A well-trained periodontist or OMFS should have little problem raising and replacing a mucoperiosteal flap. The “simple” implant surgery usually has very little post-op pain associated with it. It is also rare that a proper implant placement leaves a thick (2-3mm)amount of circumferential bone (especially buccal) in place. As of today, I am unaware of any predictable means for augmenting this buccal plate with a flapless procedure. Additionally, it is rare that a patient presents with a healthy site without ridge-resorption warranting augmentation to facilitate proper placement.

    The flapless procedure is mainly advocated by implant companies trying to sell more implants by marketing these procedures as easy and painless. This is mostly-appealing to non-trained surgeons. A surgeon who has completed an accredited residency in perio or maxillofacial surgery can usually see through the sale pitch. The long-term results are not in yet. Those who feel the procedure is always safe have not seen enough to realize how difficult these misadventures can be to correct. It is creating a sub-specialty for the specialists. Can somebody find a prospective study longer than 6 months supporting this technique.

    We have to look past the sales pitch and remember we are doctors. The patient’s best interest should come before profits. If we don’t remember this, we will eventually fall like our medical colleagues, who now are untrusted and slaves to insurance carriers and malpractice attorneys.

  19. Andrej Meniga says:

    In my opinion, the only drawback of flapless surgery is that it can not be preformed if residual bone or soft tissue needs grafting. In all other cases using guided surgery upon CT planning made flap surgery obsolete šŸ™‚

  20. Wayne O'Roark, DDS says:

    With over 30 years of implantology and 5000+ implants, flapless surgery is just another revival of older techniques. Be prepared to raise a flap if any question about the anatomy and topography of the underlying bone. In the mandible, keep in mind the flair of the lingual mandible so you do not perforate the inferior border, maxillary incisive fossa. The maxillary buccal angulation may cause you to perforate the buccal plate superior to the ridge. It is just another option not a panacea.

    It is amazing how thin, bucco-palatally the maxillary bone can be with very large ridge form consisting of mostly thick mucosa.

    I have also noted increased bleeding immediately postoperatively, for a short time versus the flap with which I get almost none. I still prefer the flap but worry about interrupting the blood supply to the cortical bone. If you are in and out quickly, I do not think this is a big problem, however. I wonder how much of the crestal bone loss seen by POX is actually from this interruption of a thin residual crestal bone’s blood supply.

  21. Dr. KFC says:

    The whole surgical world is moving towards minimal invasive procedures. I believe flapless surgery or transmucosal placement or just making an incision big enough to do the osteotomy is the natural and sensible progression in implant surgery provided no extensive bone grafting is required. Popular rhetoric that it is blind is untrue. It is partially-blind because we have the benefit of models, bone-mapping, Xrays and imaging techniques that give us a pretty good idea of the bone morphology especially when you can eyeball it in vivo albeit covered with a layer of mucosa. Added on to the tactile palpating remote sensing of our supersensitive finger tips, we actually can “see” quite well without flapping and compromising the integrity of surrounding tissues. Flapless unless choiceless is the way to go.

  22. Robert J. Miller says:

    Flapless surgery can be performed as confidently as traditional flap surgery. But it requires an extra protocol to ensure it’s success. First you need a volumetric scan (CT, cone beam DVT)preferably with a barium sulfate scan guide. You can then fabricate a guided surgery template or use a surgical nvaigation device (RoboDent) for implant placement. As long as there is an adequate band of attached gingiva and sufficient bone volume, there really is no good reason NOT to use flapless surgery. Healing is faster, patients are more comfortable, and there is less crestal bone remodeling. It is my preferred modality whenever possible. The problems occur when you skip these steps and cannot accurately judge your axial orientation during implant placement. In these cases, use a flap.

  23. Dr. KFC says:

    A volumetric scan is ideal but need not be essential provided you know your anatomy and make full use of whatever low tech but economical techniques that are available like what had been described. In many parts of the world, we may not have the scan and use of it may put it out of reach of almost everyone except the very affluent; not to mention a computer fabricated surgical stent.
    As it is many who need implants cannot afford them. Optimal technology suitable for the context especially the economy of the local people should be used together with a large dose of common sense.
    Dental implants are the best replacement of lost teeth. As such we should strive to bring its extraordinary life-changing benefits to as many people as possible. Having said that, we should continue to develop more and more accurate means, hightech or otherwise in order to place implants better and faster and more affordably.

  24. Ron Horne says:

    All comments duly noted. Flapless implant placements have worked very well for me over the last 8-10 years. But they are not always easy and require more pre op preparation. Good imaging is essential to understand the 3D bone morphology and anatomy of vital structures. I perform a model surgery and rigid stent fabrication in every case (Nobel Guided or Higginbottom type). The model surgery is performed through a thin stent representation of the prosthetic needs. The depth of the osteotomy is more difficult to judge and as the osteotomy is performed must be measured at the bone and soft tissue levels. Ridge expansion and sinus tap-up procedures are performed through the stent. If the osteotomy results in a significant dehiscence (very small ones may best be left alone), the area can be accessed and augmented through a keyhole approach with bone or materials of choice and PRP, and the gingival collar will remain undisturbed. If keritinized gingiva is at a minimum, I make a crestal incision to preserve the attached gingiva, but still do not raise a flap. The flapless procedure best preserves blood supply to the labial plate, and makes for the most predictable relationship between the implant/restorative margin and the gingival margin . And they are less painful postoperatively.

  25. Dr. Gerald Rudick, Montreal says:

    All the above comments have a lot of merit and are true.
    Flapless surgery is most appealing, but we are entering into the bone as a blind person enters a room. Blind people seem to have an extra sense in that they almost have a built in radar system to keep them away from structures ( most of the time), but they use their sense of feel through a cane.

    When doing a flapless implant placement, try to use Osteotomes initially, or after a pilot hole is drilled to guide your entery.Use the narrowist
    Osteotome as a feeler ( like a cane) by shifting it buccally, lingually, mesially, and distally, while placing your thumb and index finger on either side of the ridge…….if you feel some movement under your finger tips, then, it would be best to open a flap.

    If you feel nothing, then proceed with osteotomes or ridge expansion tools without drilling, because you will manipulate the bone, and not pierce it.

    Gerald Rudick dds Montreal

  26. hersheydmd says:

    There are not that many things we have control over. However, decrease the size of the flap and decrease the length of time the bone is exposed to air and you will decrease the amount of post-op pain meds you have to prescribe. Granted, in most cases post-op pain is not that much of a problem in implant dentistry. Still, striving for shorter surgeries and minimally invasive techniques, can’t be a bad thing, as long as you use the proper tools (i.e. accurate computer generated guides)

  27. Dr. Mehdi Jafari says:

    Flapless implant surgery has certainly improved both the osseointegration of dental implants and the bone height around implants after surgery. Some investigators have reported that flapless implant surgery is a predictable procedure with high success rates if patients are appropriately selected and an appropriate width of bone is available for implant placement. Their studies have showed that when implants were placed without flap elevation, both the amount of osseointegration and bone height around the implants were significantly greater than in implants placed with flap elevation. The cause seems to be due to the preservation of bone vascularization. In dentate jawbone, blood supply to the teeth is from three different origins: the periodontal ligament, the connective tissue adjacent to the periosteum, and the bone itself. When there is no tooth, there will be no blood supply from the periodontal ligament, and blood is supplied only from two other sources. When soft tissue flaps are reflected, the blood supply from the soft tissue to the bone (supraperiosteal blood supply) is also removed, leaving only poorly vascularized cortical bone without a part of its vascular supply, ultimately prompting bone resorption during the initial healing phase. The preservation of bone vascularization when no flaps are reflected may help optimize bone regeneration around implants. It is now strongly believed by some authors that flapless placement of implants cannot be successfully fulfilled in all the regions of the jawbones and taking advantage of the new 3-D computerized navigation technologies, will certainly add to its excellence.

  28. Robert J. Miller says:

    Mehdi; At face value, I agree with the statements you have made. However, with respect to some of the older studies, the cause and effect of the biologic changes are suspect. Of course there is vascularity from the periodontal ligament. But histologically, I believe that the greater effect is from perfusion rather than direct blood supply. When we reflect periosteum from cortical bone, we see the relative LACK of bleeding as compared to preparation of the osteotomy. This belies a difference in vacularization as is classically taught. I also firmly believe that crestal bone remodeling is not mediated from a short term interuption of blood flow, but rather the inflammatory changes that take place post-operatively. The production of inflammatory modifiers (i.e. matrix metalloproteanases) have an osteopromotive effect on osteoclasts resulting in crestal bone loss. Flapless surgery mitigates the inflammatory response and therefore reduces early bone loss. With regard to earlier posts, one must differentiate between flapless surgery in the healed site and that of extraction/immediate placement. I usually require CBCT scans for my healed sites so that I can use active or passive navigated implant placement. However, I rarely use CBCT when an extraction site is present because I can visualize bone anatomy and bone sound if I am not sure.

  29. al in dallas says:

    I follow Dr callen’s teaching, and I truely believe there are so few cases out there are ideal for flapless implant surgery.
    If all you place is flapless implants? How many do you place a month? It is scary to hear someone claim they place 20-30 implants a month, and they are all flapless.

  30. Dr. M says:

    I’ve never been to a flapless surgery course, so know nothing of what they teach; but about 12 or so years ago I began inserting selected implants without a flap. I use a tissue punch no more than 0.5mm larger than the diameter of the planned implant. The tissue plug is easily removed with a curette or periosteal after it is incised. The ridge must be “fat” with plenty of attached mucosa. There must be adequate landmarks (usually adjoining teeth) to easily locate the mucosal plug and therefore the center of the implant. After that, usually smooth sailing. Bleeding is minimal. Pain is minimal. Mucosal healing is rapid. Most usually done in my office for mandibular bicuspids and molars, a few maxillary bi’s and molars. All in all about 20% to 25% of the time. When in doubt about bone or anything else, I lay a flap.

  31. chaim wexler says:

    Once again we have a classic battle between the forces of simplification in our field and those that would keep it difficult. We have seen this many times already with digital xrays,rotary endo, invisalign and CEREC. It should be more than obvious to everyone that simplification always wins out.

    Flapless implant placement will win out because its simpler and more accessible to the generalists who comprise the vast majority of practitioners. I personally have done this for six years almost exclusively starting with mini implants and using similar techniques to place conventional size fixtures. Sure one needs a bit of training and careful angulation and placement. Arguably, one can do that more carefully if one does not have to manage a flap and can use an isolite. If it works well for some people than it can work well for all. The addition of ct/cone beam based splints will further open up the field.

    Two things upset me in this discussion. The insinuation that companies are pandering by offering and encouraging this technique and the sly hint that legal ramifications will ensue if a non specialists attempts these techniques.

    Companies that sell dental products are in the business of widening the appeal of their goods. So its no surprise they will seize upon positive trends and sell them. That is what they should be doing. Specialists have a vested interest in keeping things complex and murky. In time, specialists will return to their proper roles of handling the most difficult cases and leave the 60 to 80 percent of the implant placements in the hands of generalists. This will tend to keep prices lower and more accesible to the patient population

    As far as legal ramifications, it is unfortunate that some dentists may feel a need to make an alliance with our only known natural predator..the lawyer. If one feels that lawyers are there to protect the population than one has never been involved in litigation. The predator has only one imperative..to eat. Litigation is more a game of “gotya” than about policing the profession. Dentists shoould not run their careers based on fear of being sued. Suits will happen anyway and most often not in correlation to any misdeeds done by a practitioner

  32. sdddds says:

    As an Oral and Maxillofacial Surgeon, who also had some training in General Surgery, a maxim that was repeatedly emphasized was:

    Small incision = small brain

    Experience agrees. I concur with Al in Dallas – there are very few indications for flapless implant placement.

  33. Bill Pace DDS says:

    Someone correct me if I am wrong,Isn’t the McBurney incision small?Sometimes you need small incisions sometimes large ones.As for pain some people have large pain with small procedures some have no pain with large procedures.

  34. anupam says:

    The motive is to place the implant at the right place and in a manner that it makes the surrounding hard and soft tissue like it.The points to take into consideration is the junction of the implant and the tissue.The more atraumatic the placement of the implant better it will be accomodated by the bone and soft tissue.Flapless procedures is a thought by the surgeon to achieve it.Flapless procedures should be restricted to cases needing immediate loading,anteriors.With the dentascan it is possible to know the thickness of gingiva of the operating site and so the exposed threads can be prevented.Angulation of the FINISHED TOOTH is some thing all the time to be kept in mind during surgery.In my view,doing a flapless is a challenge,like launching a satellite,any degree of change of angulation,the purpose is lost.

  35. Dr. Mehdi Jafari says:

    I teach oral and maxillofacial surgery at both under- and postgraduate levels but, some statements here sound very astonishing to me. While the whole world of surgery and medicine is galloping towards endoscopic less invasive techniques, we are reminded of certain 19th century quoting like “BIG SURGEONS MAKE BIG INCISIONS”. Minimally invasive procedures are designed to maximize patient comfort by avoiding traumatic injury to the tissues. Treatment modalities for plating of orbital and codylar fractures, antral explorations, bronchoscopic procedures, laparoscopic removal of tissues (and e.g. billiary stones), transurethral approaches and so on, are all indicating a rapid shifting towards less aggressive, noninvasive methods. The role of diagnosis technology and computer aided surgery is very relevant, and, magniļ¬cation technology with the assistance of computer technology, work together to provide more precise treatments and offer to the patients a less painful experience. Ideal positioning of implants will require three-dimensional orientation and accuracy for mandibular canal or maxillary sinus proximity, zygoma and pterygoid implant placement, angulated root of neighboring teeth or aesthetic. The technology of computerized navigation has been developed in medicine for brain, ENT, orthopedic surgery. We have borrowed the concept of Minimally Invasive Surgery (MIS) from other medical ļ¬elds, as it has its greatest implications on the field of implant surgery. MIS involves smaller and more accurate incisions, using magniļ¬cation systems and microsurgery instruments. But MIS also requires fewer operations, which implies a very precise planning and a combination of surgical techniques aiming at several objectives simultaneously, or even at ļ¬‚apless surgery. Flapless insertion of dental implants prevents complications arising from soft-tissue elevation such as infection, dehiscence and necrosis, and provides dental implant success rates equal to conventional techniques (Becker et al. 2005). In the anterior mandible, the flapless technique requires surgical guidance for optimal tilt of drilling to avoid injury to underlying anatomical structures during preparation of the implant socket. Computer-assisted surgery is known to enhance safety in dental implantology while being compatible with all aspects of implant surgery including flapless technique (Casap et al. 2005).

  36. Joseph W.Como OMS says:

    I would like to help answer the two patients who have asked questions about their personal treatment. I recommend you see the Doctor who placed the implants along with the Doctor who restored them ( placing crowns on them.) It is very difficult to give an opinion on treatment that was rendered by someone else, their is no harm in going back to your Doctor and speaking to them . All professionals want to help their patients, so I am sorry I can not give an opinion as to what is going on with your specific case, I did read your articles and my opinion is going back to your Doctor, have an open communication with them get all the facts then make your decision as to what the best choice for your oral health would be. I hope this was helpfull,

  37. wizzies says:

    I was wondering, Dr Jafari, how you place implants endoscopically? I would be interested in the literature on this. I would also love to place implants under real-time MRI guidance. Many of these “advanced” diagnostic techniques are wonderful to write papers on, but are impractical in the real world. Especially when it comes to placement of a single implant. Tech-heavy procedures such as “Teeth In an Hour” are now being backed off of, as failure rates approach 50%. Some of these cases involve minimal flap size, but maximal radiation. Most of the time, a simple radiograph, with a flap large enough to view the bony contours, is the optimal choice. Frankly, I am waiting for robotic implant placement, with a robot I can control with my iPhone from a beachchair.

  38. wizzies says:

    Oops, I hit submit by accident. To continue : Many of the techniques described are useful for instances where accessability/visibility are limited, or where cosmetics are an issue. No one would argue that of course it is preferable on many grounds to use a minimally invasive technique for intra-antral, intra-abdominal or intra-cranial surgery when possible, or in areas such as the face where incisions must remain hidden or lawyers will not. But with dental implants, these considerations are rarely of consequence. And am I to understand that use of a minimally invasive technique (versus an open technique) by definition means that more planning and more careful incisions are used? Flapless surgery prevents infections?
    Look, there are instances where flapless or minimally invasive surgery can be performed – these have been discussed above, i.e., plentiful attached gingiva, wide alveolar ridge, nerve or sinus far enough away.
    But for the average implant placement case, one could obtain both a CT scan and an MRI, have a 3-D model fabricated, mount models with a facebow, have a custom-made screw-retained computer-generated splint, operate with both loopes and microscope, use fiberoptic lighting, operate in a filtered ventilation controlled room, and still put the threads through the buccal plate. Why not take a look?

  39. Dr. Mehdi Jafari says:

    Sir, I never claimed that I place my implants endoscopically. But if you kindly pay enough attention to the former comments, you will see a very strange statement, I quote” SMALL INCISION=SMALL BRAIN. I felt that if this equation is true, then many big shots in many disciplines of surgery and medicine may already have small brains and they have got to do something about it. Have a nice weekend.

  40. Albert Zickmann says:

    In my hands flapless surgery has worked extremely well in thousands of sites. I do more than 90% of my placements flapless or with a minor modification when there is a lack of keratinized tissue. The modification is that I make a small crestal incision instead of removing a circular portion of the gingiva and then reflect the tissue in such a way that it rests on the implant (one stage) just like with a flap but with a minimal reflection.
    The reward is significantly less discomfort and faster healing possibly because of maintenance of vascular supply to the bone. The key is to map the bone ahead of the surgery to identify bone topography, either by probing with an anesthetic needle (for single sites) or by imaging techniques such as CT scans or tomograms.

    This technique is great in experienced hands and I would not recommend it to a clinician who has done less about hundred procedures.

  41. Bruce Knecht says:

    I have done quite a few “flapless” implant placements in the past and have to my shagrin seen the buccal exposure of the smooth colar of the implant body. luckily, I did not do this technique in the anterior. I have gone back to flapping. In can recontour the bone and truely visualize the crestas well as the occasionaly buccal depressions that are usally covered by the thickened aveolar tissue. I think that it is safer and more predictable to flap than not. Great dialogue by Dr Miller on bone healing!

  42. prof.Dr.Dr.Hossam Barghash says:

    may be my comment is late that is why I’ll make it more general. I think to judge on any technique we have to understand all the aspects of the technique then by knowing the advantages & disadvantages we start to write what are the indication & contraindication of such technique, this evaluation well be based on the final benefit the patient get froma all aspects. talking about falpless implant surgery we cann’t be totally aganist or with because ther is nothing absoult, but to use it of course you must be aware of all aspects of soft & hard tissue planning,I wouldn’t recommend it for docrores who are new in the field simply cos there well be,misuse & misudge .

  43. Karen Harding says:

    I had a flapless implant on my left upper lateral incisor in November of
    2007. About two months after the implant, I began to have drainage in the area around the implant. The drainage changes from thin to slightly thick. There is no pain, but it is extremely annoying. I have returned to the surgeon twice. He has taken xrays and told me there is nothing wrong. I have also consulted with my regular dentist. We tried antibiotics, but there was no change. She says the only thing she can think to do is remove the implant.
    My doctor has referred me to an ENT. I have an appointment with her in June.

  44. bijoy says:

    recently placed a n implant in upper 1st premolar area. The implant motor malfunctioned and was unable to either drive the implant to place nor retrieve it’.finally had to use the torque wrench to drive the implant to place for the final three threads. IMPLANT STABILITY WAS GREATER THAN 35 N.

  45. Mike Davis says:

    In my practice as a periodontist I seldom do flapless implant placement. In delayed placement cases the posterior mandible is the only situation where I go flapless. The tissue is thin so it is obvious where the bone is and if the ridge is very wide I feel comfortable not visualizing the bone. I always have to see the bone in the maxilla due to the thick palatal tissue. This makes the ridge width too unpredictable. Usually I have to be very careful in drilling my osteotomies even when I can visualize the bone in the maxilla. As far as immediate implant placement goes it is almost the opposite. I do flapless procedures in the maxillary anterior whenever I can get the tooth out without raising a flap. I see no benefit in not reflecting a flap elsewhere in the dentition for immediately placed implants

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Socket grafting with Collagen Dressing and Bond Apatite

This video demonstrates socket grafting with just bond apatite and a collagen wound dressing.[...]

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Dental Implant for Lower Right Second Molar

This video shows implant placement on the lower right second molar.[...]

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Saving a Bridge with Periodontal Therapy

This video shows a case involving a 48-year-old male who was referred for periodontal treatment[...]

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Immediate Loading Full Arch

This video shows a case of Immediate loading of a full arch with simultaneous guided[...]

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Apically Repositioned Flap Technique Around Implants

The apically positioned flap is a commonly used surgical approach, that may help the long[...]

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Digitally Planned Bone Augmentation and Immediate Implantation

This video shows a case using the Ring technique to provide bone augmentation along with[...]

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AnyRidge Implants: Replacement of Upper Left Molars

This video shows the replacement of maxillary upper left molars with Megagen AnyRidge Implants.[...]

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Guided Implant Surgery & Immediate Temporisation

This video demonstrates the placement of a missing pre-molar using computer-guided surgery and immediate temporization.[...]

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Implantoplasty to Treat Peri-implantitis

This video shows the use of the Implantoplasty technique to treat peri-implantits. Granulation tissue and[...]


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Placement of Implant Using EZ Devices

This video demonstrates the placement of a dental implant in the upper jaw using the[...]

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BonePen: Improve Positioning of Implants

A short video demonstrating close up the use of the BonePen Kit, a set of[...]

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