Previously Published

Review analysis & evaluation

Flapless Dental Implant Surgery may Improve Hard and Soft Tissue Outcomes

Article Title and Bibliographic Information

SUMMARY

A 1-year prospective clinical study of soft tissue conditions and marginal bone changes around dental implants after apless implant surgery. Jeong S-M, Choi B-H, Kim J, Xuan F, Lee D-H, Mo DY, et al. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:41-6.
Reviewer

Subjects
Two hundred forty-one patients (108 men, 133 women, age range 19-73 years, mean age 54 years) were recruited from a single clinic at the Wonju College of Medicine, Yonsei University, Seoul, South Korea. Patients were included who needed single tooth replacements or partial-arch or full-arch reconstruction. A total of 432 implants were placed; most patients (50%) received single implants, and 31% received 2 implants, 14% re ceived 3 implants, and 5% received 4 or more implants. Most implants (42%) were placed in the mandibular rst molar position. Patients were systemically healthy with good periodontal health, al though patients with mild to moderate gingivitis were included. Patients re quiring ridge augmentation or bone grafts were excluded.

Richard Oliver, BDS, BSc, PhD, FDSRCPS, FDS(OS)RCPS

Purpose/Question

To evaluate the soft tissue and marginal bone levels after 1 year around dental implants placed using apless surgery
Source of Funding

Key Exposure/Study Factor

All patients had Osstem GSII bone level implants placed under local anes thetic. Access through the soft tissues was achieved using a 3-mm tissue punch over the crestal bone site. The implant osteotomy was performed through this soft tissue access. A range of sizes of implants was used (3.5-, 4.0-, 4.5-, or 5.0-mm diameter), with lengths ranging from 8.5 to 15.0 mm. A 1-stage surgical procedure was used with healing abutments con nected to the implant xtures. The surgery was performed by experienced senior clinicians. Restoration of the implants was undertaken at 3 to 4 months after surgery by restorative dentists using screw-retained metal-ceramic or metal-resin prostheses.

Korea Science and Engineering Foundation (KOSEF) funded by the Korean Government
Type of Study Design

Case series

Level of Evidence

level 3

Other evidence

Strength of Recommendation Grade Consensus, disease-oriented C  evidence, usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening.

Main Outcome Measure

Gingival soft tissues were evaluatedby a single clinician at 12 months after the surgical placement. The following were measured: probing pocket depth, gingival index, bleeding on probing, and the presence or absence of kerati nized mucosa around the implants. The thickness of the soft tissue overlying the bone at the osteotomy site was also measured at the time of surgery. The crestal bone levels were assessed using digitized images at 8 mag nication of conventional intraoral dental radiographs taken at baseline, postoperatively, and 12 months later. Measurements were made at the mesial and distal aspects of the implant xture and the mean per case was calculated. Two assessors who were blinded to the methods of the intervention undertook the measurements.

Reviewer: Richard Oliver, BDS, BSc, PhD, FDSRCPS, FDS(OS)RCPS, Specialist in Oral Surgery, RED (Research and Education in Dentistry), 10 Longbow Close, Harlescott Lane, Shrewsbury SY1 3GZ, United Kingdom E-mail: Richard.oliver@redonline.org Originally Published in: J Evid Base Dent Pract 2011;11:206207 1532-3382/$36.00 2011 Elsevier Inc. All rights reserved. doi: 10.1016/j.jebdp.2011.09.002

Main Results
At 1 year, the mean pocket probing depth was 2.1 mm (SD 0.7), bleeding on probing index was 0.1 (SD 0.3), and the average gingival index score was 0.1 (SD 0.3). Keratinized mucosa was absent around the buccal gingival surface in only 6implants.

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Journal of evidence-based dental practice Special IssuePeriodontal and Implant Treatment

There was a 100% survival of the implants, and with maximal crestal bone loss recorded at 1.1 mm, according to Albrektsson et als success criteria,1 a 100% success rate. The mean marginal bone loss was 0.3 mm (SD 0.4 mm, range 0.0 to 1.1 mm), with 125 implants exhibit ing no bone loss. There was no signicant difference in bone loss between those cases with thick (3 mm) com pared with those with thinner (<3mm) overlying mucosa.

Conclusions
The authors concluded that a apless surgical procedure for dental implant placement is advantageous for preserv ing crestal bone and mucosal health, and that this tech nique increases the success rate of dental implants.

participants (30 in each group), it fol lowed patients only up to 6 days and concentrated on immediate postoperative outcomes (pain and swelling). The other trial7 actually compared immediately loaded implants placed using apless surgery with conventionally placed implants loaded 3 to 4 months later (40 patients, 20 in group); although a number of outcomes were as sessed, the most signicant difference in outcomes was postoperative pain reduction in the apless group. When both trials were combined in a meta-analysis, a sig nicant difference in postoperative pain was demon strated in favor of the apless group (relative risk 1.78, 95% condence interval 1.04 to 3.03). There still remains a paucity of high-level evidence for many of the longer-term outcomes for apless surgery. This article by Jeong et al4 should be interpreted with caution, as a noncontrolled series of cases that did not appear to follow the current best practice of using computer-guided surgery. Their apparent high success rate in this instance is admirable and could be a result of well-selected patients or skilled surgeons. As was high lighted recently by Esposito8 for implant research in general, but is particularly applicable for this question, fu ture studies should concentrate more on pragmatic patientrelated outcomes (quality of life, complications, aesthetics) with less emphasis on small differences in outcomes that ultimately have little impact on the patient (marginal bone levels, bleeding on probing).

COMMENTARY AND ANALYSIS

Endosseous dental implants have become a dependable and predictable method of replacing missing teeth to greatly enhance patients quality of life. This has been achieved through developments and convergence in im plant design and renements of techniques. Dentists are striving to further improve the entire patient journey through implant treatmentminimizing the peri-and postsurgical discomfort, maximizing aesthetics, and im proving the long-term success of the implants. Flapless implant surgery appears to be one way this can be aided2; however, although simplifying the surgical exposure for the patient, undertaking the placement of dental im plants essentially blinded to the status and morphology of the underlying bone is somewhat risky and requires ad equate treatment planning and operator skill. To aid the surgeon placing the implant either conven tionally or using apless surgery, computerized 3-dimensional scans (CTorcone-beamCT)can beunder taken of the patients jawbone, from which the anatomy can be clearly visualized and accurate drilling guides/ stents can be generated. This is commonly referred to as computer-guided surgery. Even with these complex and costly aids, in addition to the higher radiation dose for the patient, this requires a higher skill level and can still result in complications and failures when placements are performed aplessly. Indeed, a recent International Team for Implantology consensus paper recommended that apless surgery should be performed only by skilled and experienced surgeons with the use of this computer ized 3-dimensional treatment planning.3 There is no indi cation in this study by Jeong et al4 that such imaging was obtained before placement, so it is somewhat surprising that the authors chose to use this essentially unguided technique but obtained the results published here. The most recent Cochrane review5 included 2 random ized controlled trials6,7 that compared ap elevation with apless surgery for implant placement. One trial6 was judged to have a high risk of bias; despite having a reason able number of

REFERENCES
1. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term ef cacy of currently used dental implants: a review and proposed crite ria of success. Int J Oral Maxillofac Implants 1986;1(1):11-25. Brodala N. Flapless surgery and its effect on dental implant outcomes. Int J Oral Maxillofac Implants 2009;24(Suppl):118-25. Hammerle CH, Stone P, Jung RE, Kapos T, Brodala N. Consensus statements and recommended clinical procedures regarding computer-assisted implant dentistry. Int J Oral Maxillofac Implants 2009;24(Suppl):126-31. Jeong SM, Choi BH, Kim J, Xuan F, Lee DH, Mo DY, et al. A 1-year pro spective clinical study of soft tissue conditions and marginal bone changes around dental implants after apless implant surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111(1):41-6. Esposito M, Grusovin MG, Maghaireh H, Coulthard P, Worthington HV. Interventions for replacing missing teeth: manage ment of soft tissues for dental implants. Cochrane Database Syst Rev 2008;(4):CD006697. Fortin T, Bosson JL, Isidori M, Blanchet E. Effect of apless surgery on pain experienced in implant placement using an image-guided sys tem. Int J Oral Maxillofac Implants 2006;21(2):298-304. Cannizzaro G, Leone M, Consolo U, Ferri V, Esposito M. Immediate functional loading of implants placed with apless surgery versus con ventional implants in partially edentulous patients: a 3-year random ized controlled clinical trial. Int J Oral Maxillofac Implants 2008;23(5):867-75. Esposito M. Updated guidelines for authors. Eur J Oral Implantol 2010;3(3):183.

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