Journal of Periodontology; Copyright 2014 DOI: 10.1902/jop.2014.

140355

Comparison of Crestal Bone Loss Around Dental Implants

Placed in Healed Sites Using Flapped and Flapless
Techniques: A Systematic Review
†
Fahim Vohra,* Abdul Aziz Al-Khuraif, Khalid Almas,‡ Fawad Javed§

* Department of Prosthetic Dental Sciences, College of Dentistry, King Saud

University, Riyadh, Saudi Arabia.

† College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia.

‡ Department of Periodontology, College of Dentistry, University of Dammam,

Dammam, Saudi Arabia.

§ Eng. Abdullah Bugshan Research Chair for Growth Factors and Bone Regeneration,
3D Imaging and Biomechanical Laboratory, College of Applied Medical Sciences,
King Saud University, Riyadh, Saudi Arabia.
Objective: The aim of the present systematic review was to compare the crestal bone loss
(CBL) around dental implants placed in healed sites using flapped and flapless surgical techniques.
Methods: The addressed focused question was “Does flapped and flapless surgical technique
influence CBL around dental implants placed in healed sites? Databases were searched from 1975 up
to and including May 2014 using different combinations of the following keywords: "crestal bone
loss"; "dental implant"; "surgery"; "flap"; and "flapless". Unpublished data, experimental studies,
letters to the editor, review articles, case reports, commentaries and articles published in languages
other than English, were excluded. In all studies, the test group comprised of implants placed using
flapless surgery and in the control group, implants were placed after reflection of a full thickness
mucoperiosteal flap.
Results: Nine clinical studies were included. In six studies, CBL around implants was
comparable among the test and control groups. In three studies, implants in the test group showed
significantly less CBL as compared to the control group. In one study, CBL was significantly higher in
the test group than the control group.
Conclusion: Crestal bone loss around dental implants placed in healed sites using flapped and
flapless techniques is comparable.

KEY WORDS:
alveolar bone loss; surgical flap; dental implants.
A traditional implant placement protocol involves exposure of the alveolar ridge using
a full thickness mucoperiosteal flap, following which implants are placed in bone and
the flaps repositioned using sutures.1, 2 Flap elevation facilitates visibility and access
at the operating site and is considered advantageous in the esthetic zone since flaps
can be repositioned to desired locations.3 However, reflection of mucoperiosteal flap
compromises the vascular supply of bone, which may lead to crestal bone loss (CBL)
and long-term esthetic complications.3-5
Studies6-8 have shown that a flapless procedure during implant placement has a
positive effect on alveolar bone remodeling process. For example, in the study by
Sunitha and Sapthagiri7, 40 patients selected for conventional implant therapy were
assigned to two treatment groups, flapped and flapless respectively. The amount of
CBL was measured at baseline and up to two years after implant placement using
conventional two-dimensional radiographs. The results showed that CBL was

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Journal of Periodontology; Copyright 2014 DOI: 10.1902/jop.2014.140355

significantly higher around implants placed after flapped surgery as compared to

flapless implants.7 Similar results were reported by Tsoukaki et al.8, Job et al.6
and Tonetti and Schmid9. An explanation in this regard may be derived from the
fact that using a flapless approach during implant placement preserves the periosteal
vascular supply to bone thereby minimizing the possibility of future CBL. However,
controversial results have also been reported. In the studies by Froum et al.10 and De
Bruyn et al.11 CBL around implants placed in healed sites using flapped and flapless
surgery were comparable.
To our knowledge from indexed literature, there is one recently published
systematic review which compared the effect of flapped and flapless surgical
techniques on CBL around dental implants.12 The results showed that the implant
survival and radiographic CBL among flapped and flapless interventions were
comparable. It is however noteworthy that studies on both immediate and
conventionally placed implants were included in this systematic review.12 In addition,
in one study bone augmentation procedures were also performed.13 It has been
reported, as compared to implants placed in healed sites using flapless technique, a
significant correlation exists between crestal bone loss and flapless immediate
implants.12 This suggests that factors such as implant placement protocol (immediate
or conventional) and surgical technique (flapped, flapless and/or bone augmentation
procedures) influence the overall CBL around implants. Therefore, it is speculated
that a systematic review primarily focusing on implants placed in either healed sites
or fresh extraction sockets would clearly show the influence of flapped and flapless
surgical technique on CBL.
With this background, the aim of the present systematic review was to compare
CBL around dental implants placed in healed sites using flapped and flapless surgical
techniques.

MATERIALS AND METHODS

Focused Question
The addressed focused question was "Does flapped and flapless surgical technique
influence CBL around dental implants placed in healed sites?”

Eligibility Criteria
The following eligibility criteria were imposed: (a) original studies; (b)
clinical studies; (c) intervention: CBL around dental implants placed in healed sites
using flapped and flapless techniques; (d) presence of a test group (implants placed
using flapless surgery) and a control group (implants placed using conventional full
thickness mucoperiosteal flaps) in healed sites (e) articles published only in English
language. Letters to the Editor, case reports, commentaries, review articles and
unpublished articles were excluded.

Search Strategy
PubMed/Medline (National Library of Medicine, Bethesda, Maryland), Google-
Scholar, EMBASE and ISI Web of Knowledge databases were searched from 1975 up
to and including May 2014 using different combinations of the following key words:
“ crestal bone loss”, “ dental implant ”, “ surgery”, “flap” and “flapless”. Titles and
abstracts of studies that fulfilled the eligibility criteria were individually assessed by

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Journal of Periodontology; Copyright 2014 DOI: 10.1902/jop.2014.140355

the authors (FV, AK, KA and FJ) and checked for agreement. Full text of the relevant
studies were then independently read and assessed with reference to the selection
protocol. As a next step, reference lists of original and review studies were hand
searched to identify any articles that could have been missed during the initial search.
Any disagreements regarding study selection were resolved by discussion (Figure 1).
The initial search yielded 36 studies. Twenty-six studies, which did not fulfill our
eligibility criteria were excluded (see supplementary Appendix 1 in the online Journal
of Periodontology). In total, 10 studies6-8, 10, 11, 14-18 were included and processed for
data extraction.

RESULTS
General Characteristics of the Studies
All studies6-8, 10, 11, 14-18 had a prospective design and were performed either at
universities and health care centers. The total number of patients ranged between 6
and 60 individuals. Seven studies7, 8, 11, 15-18 reported the mean age of study
participants, which was between 39.2 years and 61 years (age range 20 to 79). Nine
studies7, 8, 10, 11, 14-18 reported the number of female participants, which ranged between
7 and 35 individuals (Table 1). In the study by Katsoulis et al.15 and De Bruyn et al.11,
3 and 10 smokers respectively were included. In all studies6-8, 10, 11, 14-18 CBL was
measured using standardized two-dimensional radiographs. In four studies10, 11, 15, 16 it
remained unclear whether or not soft tissue biotype was assessed prior to implant
placement.

Surgical Technique and Implant Related Characteristics

In all studies,6-8, 10, 11, 14-18 rough surfaced titanium implants were placed in healed
sites, with diameters and lengths ranging between 3.3 mm-5mm and 7mm-18 mm
respectively. The number of implants placed ranged between 10 and 195. In four
studies,7, 11, 14, 17 implants were placed in both arches. In three studies15, 16, 18 all
implants were placed in the maxilla. In three studies,6, 8, 10 location of implants was
not reported. Five studies11, 14, 15, 17, 18, reported the implant insertion torque, which
ranged between 20Ncm-35Ncm. Immediate and conventional loading was performed
in three6, 16, 17 and four7, 10, 11, 18 studies respectively. In three studies8, 14, 15 implant
loading was not performed (Table 1). The follow up period ranged from 6 weeks up
to 48 months.
In 5 studies10, 11, 14-16 CBL was comparable around implants placed using flapped
and flapless techniques. In 4 studies6-8, 18 implants placed using flapless techniques
showed significantly less CBL compared to those placed using flapped technique. In
the study by Malo et al.17 implants placed using flapless techniques showed
significantly higher CBL than those placed using flapped surgery.

DISCUSSION
The present study was based on the hypothesis that implants placed in healed sites
using flapless technique undergo significantly less CBL as compared to those placed
using conventional surgical flap procedures. An explanation in this regard may be
derived from the fact that as compared to flapped surgical procedures, flapless surgery
allows minimum disruption of peri-implant tissues thereby reducing changes in
crestal bone levels, probing depth and inflammation.19 In addition, flapless surgery

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Journal of Periodontology; Copyright 2014 DOI: 10.1902/jop.2014.140355

has also been reported to preserve circulation of the peri-implant tissues and
accelerate recuperation, thereby allowing the patient to resume regular oral hygiene
maintenance procedure immediately after implant placement.7 The findings of the
present systematic review are comparable to those reported in the study by Lin et al
12
. However, Lin et al.12 included studies on implants placed in healed sites, fresh
extraction sockets and augmented sites. Therefore, the present systematic review was
performed using strict eligibility criteria to assess CBL around dental implants placed
in healed sites using flapped and flapless surgical procedures.
Interestingly, 50% studies10, 11, 14-16 included in the present systematic review
showed that CBL was comparable among implants placed either using flapped or
flapless surgical technique. It is possible that additional factors, which may have
influenced crestal bone levels were over-looked in the studies that fulfilled our
eligibility criteria. For example, it is well-known that regular oral hygiene
maintenance plays an essential role in the overall success of periodontal surgical
interventions.20, 21 Although 211, 16 out of these 5 studies10, 11, 14-16 clearly stated that
oral hygiene status was satisfactory in their study populations; it is speculated that all
patients in these studies had acceptable pre and post-operative oral hygiene statuses.
This could have yielded comparable results in terms of CBL among the groups.
Likewise, studies22, 23 have also shown that CBL is significantly higher in smokers as
compared to non-smokers. Among the studies10, 11, 14-16 showing comparable CBL
among flapped and flapless implants, in only one study 16 all participants were non-
smokers. In studies by Katsoulis et al.15 and De Bruyn et al.11 nearly 7% and 20% of
the population, respectively comprised of smokers. However, the group allocation
(flapped and flapless) of smokers remained unclear. It is possible that the comparable
outcomes reported in these studies11, 15 could have been influenced by the distribution
of smokers within their respective study groups. Moreover, clinical experience and
skills of the surgeon are considered a prerequisite in the overall treatment success 3, 24,
25
. In 60% of these studies11, 15, 16, surgical procedures were performed by a single
skilled operator. Therefore, the operator’s skills seem to be an additional factor that
governed CBL around dental implants regardless of the surgical techniques (flapped
or flapless) used in these studies10, 11, 14-16. Furthermore, peri-implant soft-tissue
biotype, implant abutment interface, depth of implant placement (crestal or sub-
crestal) and occlusal loading are additional factors that could have biased the results
of the studies included in the present review.26-29 It is noteworthy that none of the
studies included in this review addressed the relationship of crestal bone levels with
implant-abutment interface, depth of implant placement and occlusal loading
independent of the surgical technique used (flapped or flapless). Also, in 410, 11, 15, 16
studies, it remained unclear whether the soft tissue biotype prior to implant placement
was investigated.
A limitation of the studies included in the present review6-8, 10, 11, 14-18 is that all
study participants were presumably healthy individuals. It is well-known that
periodontal inflammatory conditions are worse in immunocompromised patients
(such as patients with poorly controlled diabetes and pre-diabetes) and elderly patients
as compared to systemically healthy and younger individuals.30-33 It may therefore be
speculated that the outcomes of implant surgical procedures (regardless of the
technique used) are compromised in immunosuppressed and elderly individuals as
compared to systemically healthy counterparts. However, further studies are needed
in this regard.

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Journal of Periodontology; Copyright 2014 DOI: 10.1902/jop.2014.140355

CONCLUSION
Within the limits of the present systematic review crestal bone loss around dental
implants placed in healed sites using flapped and flapless techniques is comparable.

ACKNOWLEDGEMENT
The authors would like to extend their appreciation to the Research Centre, College of Applied Medical
Sciences and the Deanship of Scientific Research at King Saud University for funding this research.

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17. Malo P, Nobre M. Flap vs. flapless surgical techniques at immediate implant function in
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Correspondence: Dr. Fahim Vohra. Department of Prosthetic Dental Sciences,

College of Dentistry, King Saud University, P.O.Box 60169, Riyadh 11545, Saudi
Arabia. Tel: +966 53 291 1056 Email: fahimvohra@yahoo.com
Submitted June 14, 2014; accepted for publication August 26, 2014.

Figure 1 –
Study selection criteria

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Journal of Periodontology; Copyright 2014 DOI: 10.1902/jop.2014.140355

Table 1:
Characteristics of the studies that fulfilled the eligibility criteria.
Authors et No. of Mean age Females Study groups Total no. Implant Implant Loading Follow- Outcome
al. Patients in years (n) of dimensions surface protocol Up
(n) (range) Implants (Width-Length)
(n) (in mm)
Job et al.6 6 NA NA FG: 5 implants were placed 10 3,8/10-15 Rough Immediate, 12 weeks Bone loss was
(35-55) FLG: 5 implants were non- significantly higher in
placed functional FG as compared to FLG.
Sunitha and 40 39.2 (25- 15 FG: 20 Implants were 40 3.7-4.8/ 13-16 Up to 24 FLG showed
Sapthagiri7 62) placed months significantly less CBL
FLG: 20 Implants were NA Convention than FG
placed al
Tsoukaki et 20 FG: 46.4 11 FG: 15 Implants were 30 3.5-4 / NA NA Up to 12 CBL was higher in FG
al.8 placed weeks than FLG
FLG: 47.4 FLG: 15 Implants were Unloaded
(30-62) placed
Froum et al.10 60 NA 35 FG: 30 implants were 60 4.3-5.0/10-16 Rough Convention 12 Bone loss was
placed al months comparable between FG
FLG: 30 implants were and FLG
placed
*
DeBruyn et 49 53 (20-79) 27 Group 1: Implants placed 53 3.3-5.0/7-18 Rough Convention Up to 48 Both group 1 and group
al.11 with flap technique al months 2 showed a mean bone
*
Group 2: Implants placed loss of 1.35mm
with flapless technique
†
Al-Juboori et 10 NA 7 FG: 11 implants were 22 4.1-4.8 / 10 Rough Unloaded Up to 12 No significant difference
al.14 placed weeks was seen in CBL
†
(27-62) FLG: 11 Implants were between the two groups.
placed
Katsoulis et 40 61 (47-78) 16 FG: 110 implants placed in 195 3.5-4.3/ 10-13 NA Unloaded Up to 36 Both FG and FLG
al.15 23 patients with FT months showed a mean bone
FLG: 85 implants in 17 loss of 1.5mm
patients with FLT

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Journal of Periodontology; Copyright 2014 DOI: 10.1902/jop.2014.140355

Van de Velde 14 55.7 (39- 10 FG: 34 implants were 70 4.1-4.8/ 8-12 Rough FG: Up to 18 Both FG and FLG
et al.16 75) placed Delayed months showed a mean bone
FLG: 36 implants were FLG: loss of 1.9mm
placed Immediate
Malo et al.17 41 45.5 (19- 22 FG: 40 Implants were 72 4.0/ 10-15 Rough Immediate 12 FLG showed more
79) placed months marginal bone loss than
FLG: 32 Implants were FG
placed
Bashutski et 24 FG: 52.8 14 FG: 12 Implants were 24 3.5-4/NA Rough Convention 15 FLG showed
al.18 (27-78) placed al months significantly less CBL
FLG: 52.8 FLG: 12 implants were than FG
(22-76) placed
†
* Number of implants assessed in the group was not reported Number of implants assessed in the group was not reported
NA: not available FG: Implants inserted using flap technique FLG: Implants inserted using flapless technique
CBL: crest bone loss

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Journal of Periodontology; Copyright 2014 DOI: 10.1902/jop.2014.140355