ISSN: 2320-5407 Int. J. Adv. Res.

11(04), 1386-1394

Journal Homepage: -www.journalijar.com

Article DOI:10.21474/IJAR01/16801
DOI URL: http://dx.doi.org/10.21474/IJAR01/16801

RESEARCH ARTICLE
COMPARATIVE EVALUATION OF INITIAL CRESTAL BONE LOSS AROUND DENTAL IMPLANTS
USING FLAPLESS OR FLAP METHOD: AN IN VIVO STUDY

Dr. Leena Tomer1, Dr. Chandani2, Dr. Puja Maity2, Dr. Amruthasree V.2, Dr. Vikas Sharma2, Dr. Swati
Tyagi2 and Dr. Pravender Kumar2
1. HOD & Professor, Department of Prosthodontics, Crown & Bridge and Implantology, Divya Jyoti College of
Dental Sciences & Research.
2. Post Graduate student, Department of Prosthodontics, Crown & Bridge and Implantology, Divya Jyoti College
of Dental Sciences & Research.
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Purpose:The objective of this study was to compare the effect of
Received: 28 February 2023 flapless implant insertion on initial bone loss with that of conventional
Final Accepted: 31 March 2023 placement after elevation of a mucoperiosteal flap.
Published: April 2023 Materials and Methods:Total of 20 implants were replaced in the
edentulous area within the mouth randomly categorized under two
Keywords:-
Dental Implants, Flapless Implant groups which differ in flap or flapless surgical placement. Group
Insertion, Initial Bone Loss, 1(n=10) Patients with dental implants using flap method. Group 2
Transgingival Healing, Transmucosal (n=10) Patients with dental implants using flapless method. To assess
Healing
changes in the peri-implant bone level, the height of the mesial and
distal peri-implant bone was measuredwith digital radiograph taken at
the time of implant placement and 3month and 6month afterward.
Results: The crestal bone loss on mesial side and distal side was higher
in the flap elevation methods at baseline, 3month and 6month as
compared to the flapless methods and the difference was statistically
significant at the 3month.
Conclusion: Within the limitations of this study, it can beconcluded
that flapless implant surgery results in lesser lossof marginal bone and
also results in better patient comfort;however, proper patient selection
and technique is essentialfor a successful flapless implant surgery.

Copy Right, IJAR, 2023,. All rights reserved.

……………………………………………………………………………………………………....
Introduction:-
Although the conventional treatment for replacement of lost teeth has been partial or full dentures, the need for
fixed, esthetic and functional restoration makes dental implants a reliable alternative.1

Thetraditional method for placement of implant involves elevation of full thickness mucoperiosteal flap approach
which allows the clinician to directly visualize the alveolar bone and assess bone morphology of the ridge. 2When
soft tissue flaps are reflected for implant placement, blood supply from the soft tissue to the bone is disrupted, thus
leaving poorly vascularized bone without a part of its vascular supply, promoting bone resorption during the initial
healing phase almost at crestal region. 3

Corresponding Author:- Dr. Leena Tomer

Address:- HOD & Professor, Department of Prosthodontics, Crown & Bridge and 1386
Implantology, Divya Jyoti College of Dental Sciences & Research.
ISSN: 2320-5407 Int. J. Adv. Res. 11(04), 1386-1394

To overcome the limitations, the concept of flapless implant surgery has been introduced by Lederman. 4With a
flapless approach, intact periosteum is left on the buccal and lingual aspects of the ridge which maintains a better
blood supply to the site, reducing the likelihood of bone resorption. 5Reduced surgery time, less patient discomfort
and prevention of esthetic complications such as loss of interdental papillae has been reported using this technique. 6

Despite the above advantages, the flapless technique also has several potential shortcomings. These include the
inability of the surgeon to visualize anatomical landmarks and vital structures, an inability to ideally visualize the
vertical endpoint of the implant placement (too shallow/too deep) and inability to manipulate the circumferential soft
tissues to ensure the ideal dimensions of keratinized mucosa around the implant.7

The introduction of cone beam computed tomography, improved access to conventional CT scanning and new
dental implant treatment planning software allowsdetermination of underlying osseous anatomy prior to the implant
placement and three-dimensional placement in the alveolus.8

Null hypothesis for the present study states that clinically and radiographically there is no difference in soft and hard
tissue changes at different time intervals around implants placed with flap technique and flapless technique.

Materials and Method:-

This study was conductedfrom time period of February’21 to March’22 in the Department of Prosthodontics &
Implantology, DJ College of Dental Sciences & Research Modinagar (IEC NO.- DJC/IEC/2020/38). Those
patients presented with missing tooth and choose the option of restoration with implant support were selected and
written consent from each patient was taken in the prescribed form. The inclusion criteria for patient selection
include good periodontal status, adequate bone height and width, acceptance of the conditions of the study and
exclusion criteria includeparafunctional habits, immunocompromised medical condition, irradiation in the head or
neck region, myocardial infarction within 6 months, uncontrolled diabetes mellitus, blood dyscariasis,
neuromuscular disorders, smoking, pregnancy.

Total of 20 implants were replaced in the edentulous area within the mouth randomly categorized under two
groups which differ in flap or flapless surgical placement.

Surgical Procedure
In flap group,a midcrestal incision was made on the edentulous site along with sulcular incision on the mesial and/or
distal aspects of the adjacent teeth and a full thickness flapwas elevated andin flapless group, a round tissue punch
was used to remove the soft tissue overlying the underlying bone.All implants were placed equicrestally and primary
stability was achieved. Cover screw was placed over the implant and the surgical site was sutured using 3-0 non
resorbable sutures. Post operative RVG was taken to verify the correct angulation/placement.Patients were given
both verbal and written instructions about post-operative care for operative site and were prescribed antibiotics and
non-steroidal anti-inflammatory agents for 5 days to combat any post-operative discomfort.

Fig 1:- Flap Group; a. Preoperative site for implant placement (36), b. Full thickness flap elevation, c. Site after
implant placement.

1387
ISSN: 2320-5407 Int. J. Adv. Res. 11(04), 1386-1394

Fig 2:- Flapless Group; a. Preoperative site for implant placement (46), b. Exposed underlying bone after soft tissue
removal, c. Site after implant placement.

Clinical Examination
All implant sites were evaluated for bleeding index and probing depth at 3month and 6month.

Bleeding index is an indicator of sulcus health. The most common bleeding gingival index used for implants is the
SULCUS BLEEDING INDEX and was followed in this study.It was assessed at 4 sites around each implant i.e., on
the buccal, lingual, mesial and distal surfaces of the implant by using the blunt end of the plastic probe. By adding
the implant scores together & dividing by the number of teeth examined, an individual score can be obtained.

Probing depth reveals tissue consistency, bleeding and exudates. Ideal implant sulcus should be maintained at less
than 5 mm. Titanium /plastic instrument i.e., plastic probe was used to evaluate the probing depth at different time
intervals to evaluate the success of implants (i.e., at 3month and 6month).

Radiographic Examination
All patients were subjected to radiographic examination of the implant site with RVG (Sidexis software) using
paralleling technique to evaluate the bone loss at the interval of baseline, 3month,6month in which a line was traced
from the most upper point adjacent to the implant on the crest of alveolar bone to implant shoulder as the reference
point. This helps to assess the amount of bone loss over follow-up periods.

Fig 3:- RVG showing implant site 36 on follow up period a. baseline, b. 3month, c. 6month.

1388
ISSN: 2320-5407 Int. J. Adv. Res. 11(04), 1386-1394

Fig 4:- RVG showing implant site 46 on follow up period a. baseline, b. 3month, c. 6month.

Statistical Analysis
The Statistical software IBM SPSS statistics 20.0 (IBM Corporation, Armonk, NY, USA) was used for the analyses
of the data and Microsoft word and Excel were used to generate graphs, tables etc.

Descriptive and inferential statistical analyses were carried out in the present study. Results on continuous
measurements were presented on Mean  SD. Level of significance was fixed at p=0.05 and any value less than or
equal to 0.05 was considered to be statistically significant.

Student t tests (two tailed, paired and unpaired) were used to find the significance of study parameters on continuous
scale within and between two groups (Intra and Intergroup analysis). Repeated measures Analysis of variance (RM -
ANOVA) was used to find the significance of study parameters within the group at different time intervals (Intra
group analysis).

Results:-
Table 1:- Comparison of bleeding index values in terms of {Mean (SD)} at different time intervals among both the
groups using unpaired t test.
Bleeding index Group N Mean Std. Deviation t value p value
Flap elevation 10 .8000 .15811
3 months 0.612 0.548
Flapless 10 .7500 .20412
Flap elevation 10 .6250 .17678
6 months 0.739 0.470
Flapless 10 .5750 .12076
(p < 0.05 - Significant*, p < 0.001 - Highly significant**)

1389
ISSN: 2320-5407 Int. J. Adv. Res. 11(04), 1386-1394

Graph 1:- Comparison of bleeding index values in terms of {Mean (SD)} at different time intervals among both the
groups using unpaired t test.

0.9

0.8
3 months 6 months

0.7

0.6
Mean (SD)

0.5

0.4 0.8
0.75

0.3 0.625
0.575

0.2

0.1

0
Flap elevation Flapless

Table 2:- Comparison of probing index values in terms of {Mean (SD)} at different time intervals among both the
groups using unpaired t test.
Probing index Group N Mean Std. Deviation t value p value
3 months Average Flap elevation 10 3.4250 .28988 2.621 0.017*
Flapless 10 3.1375 .19049
3 months Average Flap elevation 10 3.4250 .28988 2.621 0.017*
Flapless 10 3.1375 .19049
(p < 0.05 - Significant*, p < 0.001 - Highly significant**)

1390
ISSN: 2320-5407 Int. J. Adv. Res. 11(04), 1386-1394

Graph 2:- Comparison of probing index values in terms of {Mean (SD)} at different time intervals among both the
groups using unpaired t test.
3.5

3 months
3.4
6 months
3.3

3.2
Mean (SD)

3.1

3 3.425

2.9 3.1875
3.1375

2.8
2.875
2.7

2.6
Flap elevation Flapless

Table 3:- Comparison of bone loss values in terms of {Mean (SD)} at different time intervals among both the
groups using unpaired t test.
Bone loss Group N Mean Std. Deviation t value p value
Flap elevation 10 .5300 .11595
3 months Mesial 5.522 <0.001**
Flapless 10 .2900 .07379
Flap elevation 10 .5600 .12649
3 months Distal 5.422 <0.001**
Flapless 10 .2800 .10328
Flap elevation 10 .9400 .16465
6 months Mesial 0.647 0.526
Flapless 10 .9000 .10541
Flap elevation 10 .7400 .20111
6 months Distal 1.152 0.264
Flapless 10 .6500 .14337
(p < 0.05 - Significant*, p < 0.001 - Highly significant**)

1391
ISSN: 2320-5407 Int. J. Adv. Res. 11(04), 1386-1394

Graph 3:- Comparison of bone loss values in terms of {Mean (SD)} at different time intervals among both the
groups using unpaired t test
Mesial Bone Loss
1
0.9 Baseline
0.8 3 months
0.7 6 months
Mean (SD)

0.6
0.5
0.94 0.9
0.4
0.3
0.53
0.2
0.24 0.29
0.1 0.2
0
Flap elevation Flapless

Distal Bone Loss

0.8

0.7 Baseline

0.6 3 months

0.5 6 months
Mean (SD)

0.4
0.74
0.65
0.3
0.56

0.2
0.28
0.1 0.22
0.17

0
Flap elevation Flapless
1. The bleeding index scores based on the Sulcular Bleeding Index were higher in the flap elevation groups at
3month and 6month as compared to the flapless method group but the difference was statistically non -
significant. (Table 1, Graph 1).
2. The probing depth was higher in the flap elevation method as compared to the flapless method at the3month
and 6month. The difference between the groups was statistically significant at 3month and 6month. (Table 2,
Graph 2).

1392
ISSN: 2320-5407 Int. J. Adv. Res. 11(04), 1386-1394

3. The crestal bone loss on mesial side and distal side was higher in the flap elevation methods at Baseline,
3month and 6month as compared to the flapless methods and the difference was statistically significant at the
3month. (Table 3, Graph 3).

Discussion:-
In the present study, the Bleeding Index was recorded using the index described by Mombelli A et al.9The bleeding
index scores based on the Sulcular Bleeding Index were higher in the flap elevation groups at 3month and 6month as
compared to the flapless method group but the difference was statistically non - significant. The result of the present
study is in accordance with the study conducted by Rajpal et al10whoshowed thatthe mean modified bleeding index
was higher for the flap technique than the flapless technique from baseline to 6 months, and it was
statisticallysignificant at different periods.

The Probing depth was higher in the flap elevation method as compared to the flapless method at the 3rd month
and 6th month. The difference between the groups was statistically significant at 3month and 6month. According to
the study of Vikhe DM11 et al, peri-implant probing depth up to 3 mm around implants was considered “healthy.” In
our study, at all time periods, the peri-implant probing depth was between 1-3 mm, indicating that the implant
mucosa was kept in a healthy condition from the beginning of the present study.

The bone loss on mesial side and distal side was higher in the flap elevation methods at 3month and 6month as
compared to the flapless methods and the difference was statistically significant at the 3month.According to Singh P
et al12 crestal bone loss of upto 1mm during first year of implant service and thereafter annual bone loss of 0.1 mm,
has been accepted.

Shibu et al13 found that flapless implant surgery has improved crestal bone levels and osseointegration compared
with the conventional technique. A study by Abdul-Saheb et al14 concluded that the flapless implant placement
ensures less bone level reduction when compared with the flap technique. The findings of the present study
demonstrate that the mean bone loss was less after flapless implant surgery and that no implants failed to
osseointegrate. The lower rate of crestal bone loss in the present study may be due to use of a tissue punch that was
narrower than the implant itself. Another explanation for the high success rate may be that when flaps are not
reflected, the periosteum is preserved, which may help to optimize the healing of the peri-implant tissue. Therefore,
the flapless technique can be considered as a better treatment approach for the placement of implants. Shamsan et
al15 reported that mean crestal bone loss was less in flapless technique than inthe conventional flap group. Job et
al16 and Divakar et al17concluded that flapless implant surgery results in lesser loss of marginal bone and results in
better patient comfort when compared with the flap technique, provided that proper patient selection is essential for
carrying out flapless implant surgery. Cannizzaro et al18reported that peri-implant crestal bone loss in both flap and
flapless techniques had no statistically significant differences at baseline and 1 year after loaded. Becker et al19 also
noted non-significant bone loss around implants placed with flapless technique until 2 years. De Bruyn et al20
observed that there was a significant difference in bone loss between flap and flapless groups.

Gomez and Roman21 supported the results of the present study by reporting that whenever it comes to marginal
bone, higher bone loss rates usually occur with widely mobilized surgical flap sites where the interdental bone in the
proximity to the implant is denuded from the periosteum thus affecting the nutrition of the bone and papillae, thus
resulting in unpredictable degree of resorption of the interproximal marginal bone.

Crestal bone loss not just depends upon the flap or flapless technique of implant placement but there are numerous
other factors which plays an important role in crestal bone loss. However, further trials involving a larger sample
size, longer follow-up period, comparative evaluation and more standardization and protocols are necessary before
this implant placement protocol can be decisively declared superior to the conventional flap procedure.

Conclusion:-
According to the results of thisstudy, the null hypothesis for the present study was partially accepted as
radiographically bone loss on mesial side and distal side was higher in the flap elevation methods at 3month and
6month as compared to the flapless methods and the difference was statistically significant at the 3month.

1393
ISSN: 2320-5407 Int. J. Adv. Res. 11(04), 1386-1394

References:-
1. C. A. A. Lemos, F. R. Verri, R. S. Cruz, J. M. L. Gomes, D. M. dos Santos, M. C. Goiato, E. P. Pellizzer:
Comparison between flapless and open-flap implant placement: a systematic review and meta-analysis, Int. J.
Oral Maxillofac. Surg. 2020; 49: 1220– 1231.
2. Al-juboori. Flap procedures for implant related surgical procedures: A review. Implant dentistry 2016;25:845-
54.
3. Job S, Bhat V. An insight into flapless implant placement technique. J Indian Prosthodont Soc 2008;8:140-3.
4. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on
the presence or absence of the interproximal dental papilla. J Periodontol1992;63:995-6.
5. Asadollahi R, Khan M, Yahyazadehfar N, Kaouhestani, Tehrani Z. Dental implant placement with flapless and
flapped technique: A systemic review. J Oral Res 2018;7:324-35.
6. Brodala N. Flapless surgery and its effect on dental implant outcomes. Int J Oral Maxillofac Implants 2009;24
Suppl:118-25.
7. Brodala N. Flapless surgery and its effect on dental implant outcomes. Int J Oral Maxillofac Implants 2009;24
Suppl:118-25.
8. Fortin T, Bosson JL, Isidori M, Blanchet E. Effect of flapless surgery on pain experienced in implant placement
using an image-guided system. Int J Oral Maxillofac Implants 2006;21:298–304.
9. Mombelli A, Van Oosten MAC, Schürch E, Lang NP. The microbiota associated with successful or failing
osseointegrated titanium implants. Oral Microbiol Immunol 1987;2:145–51.
10. Rajpal J, Gupta KK, Tandon P, Srivastava A, Chandra C. Assessment of hard and soft tissue changes around
implants: a clinico-radiographic in vivo study. J Dent Implant 2014;4:126-34.
11. Vikhe DM, Tambe SD, Mascarenhas R, Bawane S, Jadhav R, Kathariya R. Assessment of Crestal Bone Loss
Surrounding the Implant before Prosthetic Loading of Dental Implant Systems: A Pilot Study. Journal of
International Oral Health. 2016 Dec 1;8(12):1110.
12. Singh P, Garge H G, Parmar V S, Viswambaran M, Goswami M M. Evaluation of implant stability and crestal
bone loss around the implant prior to prosthetic loading: A six month study. J Indian Prosthodont Soc
2006;6:33-7.
13. Job S, Bhat V, Naidu EM. In vivo evaluation of crestal bone heights following implant placement with flapless
and with flap techniques in sites of immediately loaded implants. Indian J Dent Res 2008;19:320-3.
14. Abdul-Saheb A, Abdul-Saheb R, Fatihallah A. Comparison Between Flapped and Flapless Implant Techniques
by Measuring Crestal Bone Level: A Prospective Radiographical Trial. Iraqi Dent. J. 2015; 37(2):51-55.
15. Shamsan YA, Eldibany RM, Halawani GN, Fahmy RA. Flapless versus conventional flap approach for dental
implant placement in the maxillary esthetic zone. Alex Dent J 2018;43:80-5.
16. Job S, Bhat V, Naidu EM. In vivo evaluation of crestal bone heights following implant placement with flapless
and with flap techniques in sites of immediately loaded implants. Indian J Dent Res 2008;19:320-3.
17. Divakar TK, Arularasan SG, Baskaran M, Packiaraj I, Kumar ND. Clinical evaluation of placement of implant
by flapless technique over conventional flap technique. J Maxillofac Oral Surg 2019;11:301-19.
18. Cannizzaro G, Felice P, Leone M, Checchi V, Esposito M. Flapless versus open flap implant surgery in partially
edentulous patients subjected to immediate loading: 1-year results from a split-mouth randomised controlled
trial. Eur J Oral Implantol. 2011 Autumn;4(3):177-88.
19. Becker W, Goldstein M, Becker BE, Sennerby L. Minimally Invasive Flapless Implant Surgery:A Prospective
Multicenter Study. Clin Implant Dent Relat Res 2005;7:21-7.
20. Bruyn D, Atashkadeh M, Cosyn J, Velde TV. Clinical outcome and bone preservation of single Ti Unite
implants installed with flapless or flap surgery. Clin Implant Dent Relat Res 2009;13:175-83.
21. Gomez-Roman G. Influence of flap design on peri-implant interproximal crestal bone loss around single-tooth
implants. Int J Oral Maxillofac Implants 2001;16:61–67.

1394