J Oral Maxillofac Surg

65:20-32, 2007, Suppl 1

Guidelines for Flapless Surgery

Anthony G. Sclar, DMD*

With the introduction of in-office cone beam computed tomography (CT), improved access to conven-
tional CT scanning, and dental implant treatment planning software allowing on-the-spot 3-dimensional
evaluations of potential implant sites, the use of “flapless” implant surgery has gained popularity among
surgeons. Although the flapless approach was initially suggested for and embraced by novice implant
surgeons, the successful use of this approach often requires advanced clinical experience and surgical
judgment. This article reviews the advantages and disadvantages of and indications and contraindications
for flapless dental implant surgery, with special emphasis on requirements for establishing or maintaining
long-term health and stability of the peri-implant soft tissues. Prerequisites for surgeons wishing to use
the flapless tissue punch approach in dental implant surgery are outlined and put into perspective
relative to conventional open-flap surgery techniques and other minimally invasive procedures currently
used in implant surgery. Procedures for single- and multiple-tooth applications are illustrated.
© 2007 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 65:20-32, 2007, Suppl 1

Some of the earliest applications of the “flapless”
approach in dental implant surgery involved innova-
tive site preservation techniques developed for imme-
diate or delayed implant placement after tooth extrac-
tion in areas of high esthetic concern. The rationale
for the flapless approach in these case scenarios was
to isolate the implant and/or grafted socket from the
oral cavity obtaining an inclusive guided bone regen-
eration effect while preserving circulation and es-
thetic soft tissue contours.1 This was a radical depar-
ture from the then strongly supported concept of
isolating implants placed into fresh extraction sockets
with a barrier membrane and primary flap closure.2 In
addition, mounting clinical experience demonstrated
that esthetic hard tissue contours were also main-
tained by using minimally traumatic extraction tech-
niques and slow substitution bone graft materials.
This approach yielded predictable results even in the
most challenging case scenarios with multiple contigu-
ous implants placed in areas of high esthetic concern
(Fig 1).
With the introduction of in-office cone beam com-
puted tomography (CT), improved access to conven-
tional CT scanning, and new dental implant treatment
*Director, Clinical Research and Postgraduate Dental Implant
Surgery, Department of Oral and Maxillofacial Surgery, College of
Dental Medicine, Nova Southeastern University, Fort Lauderdale,
FL.
Address correspondence and reprint requests to Dr Sclar: South
Florida OMS, 7600 Red Road, Suite 101, Miami, FL 33143; e-mail:
anthonysclar@aol.com
© 2007 American Association of Oral and Maxillofacial Surgeons
0278-2391/07/6507-0104$32.00/0
doi:10.1016/j.joms.2007.03.017
planning software allowing 3-dimensional evaluation
of potential implant sites, the use of flapless surgery
for implant placement has been gaining popularity
among implant surgeons. In its simplest form, flapless
surgery involves using a tissue punch device to gain
access to the alveolar ridge for implant placement or
abutment connection (Fig 2). Although the flapless
approach was initially suggested for and embraced by
novice implant surgeons, the successful use of this
approach often requires advanced clinical experience
and surgical judgment.
Although flapless implant surgery has numerous
advantages, including preservation of circulation, soft
tissue architecture, and hard tissue volume at the site;
decreased surgical time; improved patient comfort;
and accelerated recuperation, allowing the patient to
resume normal oral hygiene procedures immediately
after, the approach does have some drawbacks. Some
of these include the surgeon’s inability to visualize
anatomic landmarks and vital structures, the potential
for thermal damage secondary to reduced access for
external irrigation during osteotomy preparation, the
increased risk of malposed angle or depth of implant
placement, a decreased ability to contour osseous
topography when needed to facilitate restorative pro-
cedures and to optimize soft tissue contours, and,
most importantly, the surgeon’s inability to manipu-
late soft tissues to ensure circumferential adaptation
of adequate dimensions of keratinized gingival tissues
around emerging implant structures.
As such, there are certain prerequisites for sur-
geons wishing to use the flapless approach for im-
plant placement and uncovering procedures. These
include in-depth knowledge of the criteria for optimal
flap designs used in dental implant surgery, as well as
the clinical goals for surgical management of peri-

20
ANTHONY G. SCLAR 21

FIGURE 1. Replacement of failing maxillary incisors with multiple adjacent implants using a flapless approach. A and B, Preoperative radiographs
demonstrating maxillary incisors with unfavorable root morphology and moderate horizontal bone loss. C, Three adjacent 1-piece nonsubmerged
implants (Straumann USA, Andover, MA) were placed with the Bio-Col ridge preservation technique immediately after flapless tooth removal
facilitated by the use of periotomes. D and E, Postoperative radiographs documenting ideal placement of 3 adjacent implants and the lack of
sufficient surgical and restorative dimension to allow placement of a fourth implant. (Figure 1 continued on next page.)
Anthony G. Sclar. Guidelines for Flapless Surgery. J Oral Maxillofac Surg 2007.
22 GUIDELINES FOR FLAPLESS SURGERY

FIGURE 1 (cont’d). F, Three-month postoperative view showing that

the flapless approach combined with the early tissue molding provided
by Esthetic Plus abutments (Straumann USA, Andover, MA) resulted in
preservation of esthetic soft tissue volume and contours. The implant sites
are ready for provisional restoration. G, One year postdelivery of final
restoration (18 months postimplant placement) demonstrates that under
specific circumstances, multiple adjacent implants can be successfully
used in areas of high esthetic concern.
Anthony G. Sclar. Guidelines for Flapless Surgery. J Oral Maxillofac
Surg 2007.

implant soft tissues. The surgeon should also be
knowledgeable regarding the indications and tech-
niques (soft tissue surgical maneuvers) commonly re-
quired for successful management of peri-implant soft
tissues during conventional open flap surgery. Finally,
the surgeon should be familiar with other available
minimally invasive techniques that incorporate abbre-
viated incisions and flaps, as well as pouch and tunnel
dissections, because these approaches may be more
beneficial than the flapless tissue punch approach in
many clinical scenarios.
A firm grasp of the information just outlined, com-
bined with clinical experience, will allow the implant
surgeon to put flapless surgery in proper perspective
relative to conventional open-flap surgery and other
minimally invasive approaches. To begin with, the
surgeon should be familiar with the following criteria
for optimal flap designs used in dental implant sur-
gery: 1) preserve circulation and alveolar ridge topog-
raphy; 2) provide access for required implant instru-
mentation; 3) allow identification of vital structures;
4) provide access for modifying osseous contours
and/or local bone harvest when indicated; 5) provide
for closure away from submerged fixture installation
or augmentation sites; 6) minimize postsurgical bac-
terial contamination; 7) facilitate flap elevation, re-
traction, and wound closure; and 8) aid in achieving
circumferential adaptation of good-quality tissues
around emerging implant structures.3 Although
Brånemark et al4 originally advocated using flaps in-
corporating vestibular incisions, buccal flaps initiated
with pericrestal incisions have been shown to pro-
ANTHONY G. SCLAR
FIGURE 2. Tissue punch devices for flapless implant surgery. Hand-
held punch (Uni-Punch; Premier Medical, King of Prussia, PA) and
rotary tissue punch (Salvin Dental Specialties, Charlotte, NC) devices
are available in multiple diameters corresponding to commonly avail-
able implant diameters.
Anthony G. Sclar. Guidelines for Flapless Surgery. J Oral Maxil-
lofac Surg 2007.
vide a practical and effective approach to implant
placement, abutment connection, and ancillary graft-
ing procedures.3 Typically, the buccal flap is outlined
by a pericrestal incision and 1 or more vertical releas-
ing incisions located at the mesial and distal extent of
the site. The surgeon simply adjusts the position and
bevel of the pericrestal incision to accommodate for
submerged or nonsubmerged implant placement and
abutment connection procedures.
The implant surgeon also must be familiar with the
clinical goals and guidelines for surgical management
of peri-implant soft tissues. The clinical goal of this
surgical management is to establish an adequate zone,
approximately 3 mm in apicocoronal dimension
(width), of attached nonmobile, preferably keratin-
ized, soft tissue that is circumferentially adapted to
the transmucosal implant structures.3 Doing so pro-
vides the epithelial and connective tissue elements
needed for soft tissue integration and the develop-
ment of circumferential biological width without sac-
rificing the underlying peri-implant supporting bone.5
Although long-term success is possible with less than
23
the recommended 3 mm of keratinized tissue sur-
rounding an implant restoration, predictability is far
greater with the recommended amount, because the
tissues are better able to withstand the trauma of
prosthetic procedures, abutment connection, and re-
connection; the forces of mastication and oral hy-
giene maintenance; and the mechanical challenges
presented by removable implant prosthesis secured
by resilient prosthetic attachments.
Nevertheless, it is also important for the surgeon to
recognize that tissue thickness plays a significant role
in surgical decision making with regard to the selec-
tion of appropriate soft tissue surgical maneuvers dur-
ing implant surgery and determination of when soft
tissue augmentation is needed to prevent progressive
tissue recession. Long-term clinical observations indi-
cate that ideal tissue thickness is somewhere between
2.5 and 3 mm, and that the presence of adequate soft
tissue thickness greatly contributes to the mainte-
nance of a stable peri-implant soft tissue environment.
In addition, the combination of adequate soft tissue
thickness and apicocoronal dimension of keratinized
tissue surrounding an implant restoration helps resist
recession, protects peri-implant crestal bone levels,
and provides esthetic masking of underlying metal
components. Furthermore, at the ideal tissue thick-
ness, a reduction in the apicocoronal width of kera-
tinized tissue may become acceptable. Finally, in ar-
eas of high esthetic concern, along with the
objectives outlined earlier, preservation or recon-
struction of esthetic soft tissue contours is required to
ensure that the peri-implant gingival tissues are in
harmony with the soft tissues surrounding the adja-
cent natural dentition in terms of form, color, and
surface texture. In many cases, this requires greater
apicocoronal dimensions of keratinized gingival tis-
sues than recommended earlier.
Another prerequisite for implant surgeons desiring
to perform flapless implant surgery includes aware-
ness of the indications and the surgical technique
(soft tissue surgical maneuvers) commonly used for
successful management of peri-implant tissues.3
When placing a nonsubmerged implant or performing
abutment connection to a submerged implant, opti-
mal flap design dictates locating the pericrestal inci-
sion such that approximately 3 mm of good-quality
keratinized tissue remains on the oral aspect of the
emerging implant structures. Then the apicocoronal
dimension (width) of the keratinized gingival remain-
ing on the elevated buccal flap guides the surgeon in
selecting the appropriate surgical maneuver for that
particular site, keeping in mind the need to obtain a
circumferential adaptation of approximately 3 mm of
keratinized tissue surrounding the emerging implant
(Table 1).
24 GUIDELINES FOR FLAPLESS SURGERY

Table 1. GUIDELINES FOR SELECTING SOFT TISSUE

SURGICAL MANEUVERS
Width of Keratinized
Gingiva Present on
Buccal Flap Margin
sutures, typically resulting in exposure of alveolar
bone distal or mesial to the site. Closure at the areas
of bone exposure is obtained through mucosal ad-
vancement, or, in some cases, a protective dressing
Indicated Surgical Maneuver

5 to 6 mm Resective contouring
4 to 5 mm Papilla regeneration (Palacci)
3 to 4 mm Lateral flap advancement
Anthony G. Sclar. Guidelines for Flapless Surgery. J Oral Maxil-
lofac Surg 2007.

Resective contouring (gingivectomy) is indicated

when the apicocoronal dimension of keratinized gin-
gival remaining on the buccal flap adjacent to the
implant site is 5 to 6 mm (Fig 3). Typically, the
surgeon begins by passively aligning the flap adjacent
to implant abutment at 1 end of the surgical site and
uses a low-profile scalpel (eg, a 15c blade) to perform
the resection. The flap is then secured mesial and
distal to that abutment with interrupted sutures. Next
the surgeon evaluates the width of tissue at the adja-
cent sites and, if indicated, sequentially performs the
resective contouring maneuver at each site and se-
cures the flap to obtain circumferential tissue adapta-
tion around the remaining abutments (Figs 3B,C).
The papilla regeneration technique, as originally
described by Palacci,6 is indicated when 4 to 5 mm of
keratinized tissue remains on the buccal flap margin
adjacent to the implant site in question. This tech-
nique is very useful for obtaining circumferential clo-
sure of good-quality tissue around the emerging im-
plant structures (Fig 4A). The use of this technique
also promotes the formation of an interimplant papilla
when adequate bone support is present and ideal
spacing between implants has been achieved. In a
fashion similar to the resection maneuver, the sur-
geon passively aligns the flap adjacent to the implant
abutment and places light pressure near the flap mar-
gin with his or her finger tip after, then uses a low-
profile blade to create a pedicle in the margin of the
flap in such a fashion to allow passive rotation into
the adjacent interdental or interimplant space (Fig
4B). The flap is then secured with figure-8 or simple
interrupted sutures in a fashion that avoids tension in FIGURE 3. Resective contouring. A, When apicocoronal dimension
of keratinized tissue remaining on the buccal flap is between 5 and 6
the pedicle, which could embarrass its circulation mm, the resective contouring maneuver is used to obtain circumferen-
causing necrosis (Fig 4C). tial tissue closure around the emerging implant neck or abutment. After
Lateral flap advancement is the indicated surgical outlining the flap, tissue is taken from the top of the ridge and moved
in a buccal direction. B, A 15c scalpel is used to precisely perform the
maneuver when only 3 to 4 mm of keratinized gingivectomy adjacent to the emerging implant neck, after which the
tissue width remains on the buccal flap (Fig 5A). To tissue is adapted around the abutment and, if appropriate, the resec-
benefit from this soft tissue maneuver, the peri- tion is repeated sequentially adjacent to each implant site. C, The
contoured flap is then apically repositioned and secured around each
crestal incision must be extended well beyond the emerging implant with sutures placed in the interimplant areas. (Re-
area of implantation, to allow lateral advancement printed with permission.3)
of keratinized tissue into the implant site (Figs Anthony G. Sclar. Guidelines for Flapless Surgery. J Oral Maxil-
5A,B). The flap is then secured with interrupted lofac Surg 2007.
ANTHONY G. SCLAR
FIGURE 4. Papilla regeneration. A, When apicocoronal dimension
of keratinized tissue remaining on the buccal flap is between 4 and 5
mm, the papilla regeneration maneuver is indicated to obtain circum-
ferential tissue closure around the emerging implant neck or abutment.
After outlining the flap, tissue is taken from the top of the ridge and
moved in a buccal direction. Pedicles that correspond to the interim-
plant spaces are then created in the margin of the flap using a
low-profile scalpel. B, The pedicles are then rotated into the interim-
plant space. A “reverse cutback” facilitates passive rotation of the
pedicle without embarrassing its circulation. C, After adapting the flap,
figure-8 or interrupted sutures are used to obtain circumferential tissue
closure around the emerging implants. (Reprinted with permission.3)
Anthony G. Sclar. Guidelines for Flapless Surgery. J Oral Maxil-
lofac Surg 2007.
is applied in this area (Fig 5C). In Kennedy Class III
situations, the flap is extended through split-thick-
ness dissection to allow advancement of a portion
of the keratinized tissue present around the adja-
25
FIGURE 5. Lateral flap advancement. A, When the apicocoronal
dimension of keratinized tissue remaining on the buccal flap is be-
tween 3 and 4 mm, resective maneuvers may result in less than the
ideal soft tissue dimensions required to establish a stable hard and soft
tissue peri-implant environment. Instead, the lateral flap advancement
maneuver is used to obtain circumferential tissue closure around the
permucosal implant components. After outlining a flap that extends
well beyond the planned implant surgery site, tissue is taken from the
top of the ridge and moved in a buccal direction. B and C, The
resultant flap is apically repositioned and adapted around the emerg-
ing implant structures and, in most instances, the closure begins at the
anterior most implant and progresses distally with sutures placed in the
interimplant areas. As a consequence, the keratinized tissues are
advanced into the implant surgery site from adjacent areas. (Reprinted
with permission.3)
Anthony G. Sclar. Guidelines for Flapless Surgery. J Oral Maxil-
lofac Surg 2007.
26 GUIDELINES FOR FLAPLESS SURGERY

FIGURE 6. The U-shaped peninsula flap. This flap provides the advantages of tissue preservation and patient comfort associated with the flapless
tissue punch approach with enhanced visualization of osseous anatomy during implant surgeries. (Reprinted with permission.3)
Anthony G. Sclar. Guidelines for Flapless Surgery. J Oral Maxillofac Surg 2007.

cent natural dentition into the implant site without keratinized tissue is present around the adjacent
encroaching on the marginal gingival tissues. Pre- dentition to allow for this.
operative assessment allows the surgeon to deter- When the apicocoronal dimension of keratinized
mine whether sufficient apicocoronal dimension of tissue surrounding an implant restoration is or will be

FIGURE 7. Abbreviated flap-pouch procedure. A, An abbreviated flap is outlined by incisions that are beveled toward the center of the site that end at
the mucogingival junction. B, After subperiosteal elevation of the abbreviated flap, surgical access and visualization are enhanced by extending the
dissection further apically (pouch dissection), allowing a guided bone regeneration procedure to be performed to repair a fenestration defect. C, The
beveled portions of the flap are precisely readapted and simple interrupted sutures are used for closure at both lateral incisor sites. D, By combining an
abbreviated flap with a subperiosteal pouch, an ideal esthetic result was obtained. This minimally invasive approach provided access for performing the
guided bone regeneration procedure without extensive flap elevation that can result in flap retraction and soft tissue shrinkage. The papillary sparing beveled
incisions resulted in inconspicuous incision lines and maintenance of scalloped soft tissue architecture. (Reprinted with permission.3)
Anthony G. Sclar. Guidelines for Flapless Surgery. J Oral Maxillofac Surg 2007.
ANTHONY G. SCLAR 27

FIGURE 8. Use of minimally invasive procedures for esthetic implant replacement of fractured central incisor and repair of associated labial bone
and soft tissue recession defects. A, Preoperative frontal view demonstrated tissue inflammation and discoloration resulting from tooth fracture and
tooth mobility. Soft tissue shrinkage is expected after tooth removal despite use of ridge preservation. B, Preoperative radiograph demonstrating
widened periodontal ligament space and apical radiolucency. C, Types of labial bone defect after tooth removal. Whereas labial bone defects
whose widths are one third the width of the site or less have a favorable prognosis of regeneration when site preservation procedures are performed,
those wider than one third of the width of the site have an unfavorable prognosis despite site preservation. The defect in this case had a favorable
morphology. (Reprinted with permission.8) D, A pouch procedure was used to dissect a subperiosteal plane extending 2 mm beyond the periphery
of the defect. An absorbable collagen membrane (Bio-Gide; Osteohealth, Oceanside, NY) was carefully positioned within the pouch after which
Bio-Oss anorganic bovine bone mineral was condensed in the extraction socket. This creates a “tenting” effect of the periosteum overlying the labial
bone defect. The membrane was folded over the occlusal portion of the porous bovine mineral graft and an absorbable collagen dressing (CollaPlug;
Zimmer Dental, Carlsbad, CA) was placed to further isolate the site, support the supraosseous soft tissues, and to promote rapid connective tissue
ingrowth and epithelialization of the site. Iso-butyl cyanoacrylate tissue cement (IsoDent; Ellman International, Oceanside, NY) was then placed over
the collagen dressing to render the site impervious to oral liquids. (Figure 8 continued on next page.)
Anthony G. Sclar. Guidelines for Flapless Surgery. J Oral Maxillofac Surg 2007.

less than 3 mm, the surgeon should consider using
soft tissue augmentation procedures to provide for
long-term stability. The propensity for progressive
peri-implant soft tissue recession is multiplied when
inadequate tissue thickness is combined with reduced
keratinized tissue width at a particular site.
Along with having in-depth knowledge of the clin-
ical goals, guidelines, and surgical techniques used for
successful management of peri-implant soft tissues,
the implant surgeon also should be familiar with other
minimally invasive approaches for implant placement,
exposure, and grafting, such as U-shaped peninsula
flaps (Fig 6), abbreviated trapezoidal flaps, and pouch
or tunnel dissections, which can have advantages
comparable to those of the flapless tissue punch ap-
proach with improved access and visualization (Figs
28 GUIDELINES FOR FLAPLESS SURGERY

FIGURE 8 (cont’d). E, The postextraction site preservation radiograph.

F, Four months after tooth removal, flapless implant placement was facili-
tated using a rotary tissue punch. Sharp dissection was used to create a
supraperiosteal pouch, which served as a recipient site for a subepithelial
connective tissue graft harvested from the maxillary tuberosity. G, H, and
I, Smile, close-up frontal, and radiograph of the implant restoration 18
months after delivery of the final restoration. Flapless tooth extraction and
delayed implant placement combined with minimally invasive pouch ap-
proaches for repair of the favorable labial bone defect and subsequent
soft tissue reconstruction yielded an excellent esthetic result in this case of
high esthetic concern.
Anthony G. Sclar. Guidelines for Flapless Surgery. J Oral Maxillofac
Surg 2007.
ANTHONY G. SCLAR
FIGURE 9. Application of 4-MHz radio surgery in minimally invasive
dental implant surgery. The 4-MHz radio surgery technology (Surgi-
tron; Ellman International, Oceanside, NY) allows the surgeon to
perform incisions with minimal heat dissipation and cellular alteration.
Very fine incisions can be precisely located adjacent to implant abut-
ments without the risk of unanticipated soft tissue recession. The rela-
tively bloodless surgical field achieved using this instrumentation pro-
vides a tremendous advantage for surgeons performing minimally
invasive dental implant surgery.
Anthony G. Sclar. Guidelines for Flapless Surgery. J Oral Maxil-
lofac Surg 2007.
7, 8).3 Furthermore, the surgeon should consider us-
ing instrumentation that minimizes tissue trauma and
helps preserve soft tissue volume, which is in concert
with the underlying concept of minimally invasive
surgery. High-frequency (4 MHz) radio surgery instru-
mentation allows the implant surgeon to maintain a
relatively “bloodless” field during minimally invasive
procedures, thus maximizing intraoperative visibility
29
(Fig 9). This provides a significant intraoperative ad-
vantage for surgeons performing implant surgery and
adjunctive procedures through the minimally invasive
approaches described earlier. In addition, this tech-
nology allows the surgeon to perform very fine inci-
sions in precise locations with negligible lateral tissue
damage, resulting in maximum tissue preservation at
the site.7
Finally, armed with the necessary prerequisites out-
lined earlier, the surgeon can take full advantage of
the flapless approach in dental implant surgery. The
flapless (tissue punch) approach is indicated when
the surgeon has confidence that the underlying osse-
ous anatomy is ideal relative to the planned implant
diameter and 3-dimensional placement in the alveo-
lus. Typically, this is determined by clinical and radio-
graphic evaluation, aided by analysis of articulated
dental study models. Nevertheless, interactive CT
treatment planning is of great benefit for evaluating
osseous ridge morphology in a significant percentage
of cases. In cases where site preservation is per-
formed at the time of tooth removal, the surgeon
should closely observe and document the dimensions
of the remaining alveolar housing and the morphol-
ogy of any socket wall defects. This information will
allow the surgeon to decide whether a flapless ap-
proach will be feasible for subsequent implant place-
ment in most cases when delayed implant placement
is planned after the tooth extraction.
Most importantly, as outlined earlier, the surgeon
also must be able to determine whether an ade-
quate volume of good-quality soft tissues will re-
main surrounding the emerging implant structures
for optimal function and esthetics. To minimize soft
tissue complications that can jeopardize the long-
term success of an implant restoration, the quan-
tity, quality, and position of the existing keratinized
tissues relative to the planned implant emergence
should be evaluated before surgery.3 This evalua-
tion is facilitated by a preoperative try-in of the
surgical template, allowing the surgeon to deter-
mine whether adequate apicocoronal width of ke-
ratinized tissue will remain after a tissue punch
procedure to establish a stable peri-implant soft
tissue environment, as discussed earlier. To make
this determination, the implant surgeon must be
familiar with the criteria for optimal flap designs
used for implant placement and exposure as out-
lined earlier (Fig 10). When these criteria are not
met, the flapless approach is contraindicated (Fig
11). Finally, when unexpected intraoperative find-
ings necessitate additional access or visualization,
the surgeon must be prepared for the appropriate
course of action (Fig 12).
30 GUIDELINES FOR FLAPLESS SURGERY

FIGURE 10. Application of the flapless approach for implant replacement of a failing mandibular molar. A, Preoperative radiograph of a failing
mandibular molar. The patient had experienced continued sensitivity after completing endodontic therapy over a 2-year period. Note the
radiolucency in the interradicular area indicating a chronic inflammatory process most likely associated with bacterial ingress. B, Three months
postextraction with site preservation with the Bio-Col technique, the location and apicocoronal dimension of keratinized tissue at the site is ideal for
placement of the implant through a flapless approach. C, One week post-flapless implant placement. Peri-implant tissue health is ideal, and the
papillary and col anatomy have been preserved. Note that adequate apicocoronal dimension of keratinized tissue surrounds the implant despite the
tissue punch procedure. Accelerated healing and improved postoperative oral hygiene are evident. D and E, Clinical and radiographic views 1 year
postdelivery of the final restoration. The flapless approach for tooth extraction, site preservation, and subsequent implant placement preserved the
hard and soft tissue ridge contours facilitating the delivery of an implant restoration that is functional, self-cleansing, and esthetically pleasing. Note
the complete resolution of preexisting radiolucency and maintenance of ideal crestal bone levels.
Anthony G. Sclar. Guidelines for Flapless Surgery. J Oral Maxillofac Surg 2007.
ANTHONY G. SCLAR 31

FIGURE 11. Determining whether flapless surgery is indicated for implant placement. A, Preoperative try-in of surgical template indicated that
the flapless approach was contraindicated at the first molar implant site. Nevertheless, during surgery, a round bur was used to mark the center of
the implant osteotomy by penetrating through the soft tissues at the ridge crest before elevation of the abbreviated flap seen here. B, The location
of the soft tissue puncture clearly demonstrates that the use of a 6-mm tissue punch would have excised all the keratinized tissue buccal to the emerging
first molar implant. Note that a tissue punch approach would have been feasible for the second molar site. C, In this case, ideal tissue thickness
allowed the use of a variation of the papilla regeneration maneuver. The pedicles were created in the lingual flap and passively rotated into the
interimplant space. D, A simple interrupted suture was used to secure the abbreviated buccal flap mesial and distal to the emerging first molar implant
and a horizontal mattress suture was used to secure the lingual pedicles in the interimplant space without embarrassing their circulation. Note the
6-mm margin of apicocoronal keratinized tissue present on the buccal flap adjacent to the second molar implant. E, Resective contouring was
performed at the second molar site with a 15c blade, and a simple interrupted suture was used to secure the flap distal to the second molar implant.
F, Three-year follow-up clinical photograph demonstrating a stable and self-cleansing peri-implant soft tissues environment as a result of appropriate
flap design and use of surgical maneuvers to create scalloped soft tissue contours that resist collection of food debris.
Anthony G. Sclar. Guidelines for Flapless Surgery. J Oral Maxillofac Surg 2007.
32 GUIDELINES FOR FLAPLESS SURGERY

FIGURE 12. Use of minimally invasive tunnel dissection to provide access for repair of an osseous fenestration defect occurring unexpectedly during
flapless implant placement. A, Occlusal view of flapless placement of implant (Prevail; 3i Biomet, Palm Beach Gardens, FL) after use of a rotary tissue
punch and a series of twist and profile drills. Unexpectedly, a fenestration defect was detected by palpation over the apical aspect of the surgical
site. B and C, A full-thickness vertical incision was performed 5 mm mesial to the fenestration defect and a subperiosteal tunnel was made 5 mm
distal to the defect. Grafting was accomplished through this minimally invasive approach using autogenous bone and porous bone mineral (Bio-Oss;
Osteohealth, Shirley, NY). The resorbable barrier membrane (Ossix Plus; 3i Biomet) shown in this photograph was introduced into the tunnel and
stabilized by absorbing blood at the site with light pressure held over the graft site for 10 minutes. Interrupted sutures were then used for closure. D,
Postoperative periapical radiograph demonstrates ideal implant positions as per surgical guide. Seating of abutments through the tissue punch access
is facilitated by the integrated platform-switching feature of the implants used in this case (Prevail; 3i Biomet). E, Postoperative cone beam CT
cross-sectional image (I-Cat Vision Software; Imaging Sciences International, Hatfield, PA) of the grafted defect indicating successful augmentation
of the defect and surrounding thin buccal plate visualized through the subperiosteal tunnel.
Anthony G. Sclar. Guidelines for Flapless Surgery. J Oral Maxillofac Surg 2007.

References 4. Branemark P-I, Zarb GA, Albrektsson T: Tissue-Integrated Pros-

1. Sclar AG: Preserving alveolar ridge anatomy following tooth
removal in conjunction with immediate implant placement: The
Bio-Col technique. Atlas Oral Maxillofac Surg Clin North Am
7:39, 1999
2. Lazzara RJ: Immediate implant placement into extraction sites:
Surgical and restorative advantages. Int J Periodont Rest Dent
9:333, 1989
3. Sclar AG: Surgical techniques for management of peri-implant
soft tissues, in Bywaters LC (ed): Soft Tissue and Esthetic Con-
siderations in Implant Therapy. Chicago, IL, Quintessence,
2003, p 43
theses: Osteointegration in Clinical Dentistry. Chicago, IL, Quin-
tessence, 1985, p 211
5. Berglundh T, Lindhe J: Dimension of the peri-implant mucosa:
Biologic width revisited. J Clin Periodontol 23:971, 1996
6. Palacci P, Ericsson I, Engstrand P, et al: Optimal Implant Posi-
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