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FLAPLESS AND TRADITIONAL DENTAL IMPLANT SURGERY An Open , Retrospective Comparative Study Paul Rousseau(JOMS Sep.2010,68:2299-2306) :

FLAPLESS AND TRADITIONAL DENTAL IMPLANT SURGERY An Open , Retrospective Comparative Study Paul Rousseau(JOMS Sep.2010,68:2299-2306 ) Moderator: Dr.Chaitanya Kothari Presented By: Dr. Shahid Khan

INTRODUCTION:

Dental implant ( endosteal ) is an alloplastic material surgically inserted into residual bony ridge primarily to serve as a prosthodontic foundation. Implants are used to : Replace missing teeth Rebuild the craniofacial skeleton Provide anchorage during orthodontic treatment Help new bone formation in distraction osteogenesis Osseointegration is defined as a relationship where bone is in direct contact with the implant, without any intermediate connective tissue. (Branemark 1952) INTRODUCTION

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Traditionally dental implantation is performed by a flap approach that involves soft tissue reflection and suturing after implant placement. To this end, flapless surgical approaches have been developed that can provide function, esthetics and comfort with minimally invasive surgeries. Flapless Single-stage approach is suitable for pt. with sufficient bone height volume, density adequate keratinsed gingiva.

METHODS AND MATERIALS:

Patients : 218 patients requiring 377 implants were treated in this study. 93 men & 125 women Mean pt. age 23-85 yrs All patients who required dental implantation and who made the criteria for implantation. Patients were, pre or intra operatively, assigned to the FL or TR treatment group. Exclusion criteria : patients’ with uncontrolled local or general diseases. METHODS AND MATERIALS

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Site selection for implantation: Width of keratinized gingival crest - min. width of 2mm had to remain on the buccal side after crestal circular incision Bone was evaluated from periapical radiographs.

IMPLANTS :

IMPLANTS All implants used were of the straumann dental implants system ( insitut straumann,basel,switzerland). Diameter of implant 3.3,4.1,4.8mm Wide neck diameter 6.5mm Regular neck diameter 4.8mm Narrow neck diameter 3.5mm Length of implant- 8,10,12,14 mm

EXAMINATION SCHEDULE:

The distance between the mesial and distal implant shoulder and the first visible bone-implant contact(DIB) assessed at the time of implantation. Patients were recalled at 4weeks after implantation for assessment of implant mobility . 1 st follow up visit 2 to 3 months after implantation. 2 nd follow up visit 2 years after implantation. EXAMINATION SCHEDULE

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Surgical Procedure Flapless Method Flap Method

SUCCESS CRITERIA:

Primary success criteria : absence of -mobility radiolucency pain infection Secondary success criteria: change in DIB. SUCCESS CRITERIA

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DATA COLLECTION: At the time of surgery - indication for implantation, -implant details: position,diameter,length and type of implant. Parameter measured at the time of surgery -stability of implant, bone quality. Parameter at first and 2 nd visit - mobility, radiolucency, complications such as infection or pain

STATISTICAL ANALYSIS:

COMPARATIVE With in group comparisons were examined with the wilcoxon signed rank test or Friedman test. Comparisons were assessed with - 2-sided tests - P less than 0.05 indicated statistical significance P values of 0.05 to less than 0.1 were predefined to indicate a trend. STATISTICAL ANALYSIS

RESULTS :

The FL method was applied to 174 implants in 121 patients The TR method was applied to 203 implants in 98 patients At first visit : implantation was retained successful in 171/174(98.3%) implants with the FL method 200/203(98.5%) with the TR method. Success rate remained constant until 2 nd visit. RESULTS

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Changes in bone level mean increase in DIB is significantly greater FL group compared with the TR group. This changes until 2 nd visit were more pronounced in the FL compared with TR group FL group No. of cases Total 3 Pain 1 Detachment of healing cap 2 TR group Total 3 Pain 2 Infection 1

DISCUSSION ::

The flap surgery and TR dental implant surgery were associated with high success rates above 98% In this study 377 implants are placed in 218 patients outcome in terms of efficacy and safety did not differ significantly between implants placed with the FL and TR approach DISCUSSION :

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Patients in the FL group presented with lower DIB at the time of implant placement compared with those in the TR group . Patients in the FL group exhibited significantly greater increases in DIB from implant placement to visit 1and 2 compared with patients in the TR group

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Due to blind instalation in FL technique the implant is deeply placed than with the TR technique. Therefore a portion of the transmucosal ( supracrestal ) part of the implant is slightly below the crestal bone level Because the coronal part of the implant is smooth titanium , rearrangement of bone around the neck of the implant is normal.

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After healing and loading, the bone level reaches beyond the rough titanium surface. In TR technique the implant is installed directly under visual control at the right crestal bone position.

RELATED STUDIES::

1.) Single mandibular 1 st molar implants with flapless guided surgery and immediate function: Preliminary Clinical And Radiographic Results Of A Prospective Study (J Prosthet Dent 2007:97;S3-S14) To develop a standardized method for mandibular single molar replacement.51 implants were placed in 46 patients with guided flapless surgery and loaded with abutments. All implants were stable & successful in function after 1yr providing a 100% survival rate RELATED STUDIES:

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2). A comparison of two implant techniques on pt based outcome measures: a report of flapless vs conventional flapped implant placement In this study 96 implants were successfully placed in 16 pt’s with edentulous maxilla by using 2 stage flapless implant surgery Pt’s in the flapless group had to endure more than patients in the flap group

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3). Flapless implant surgery- a 10 year clinical retrospective analysis. Int J Oral Maxillofac Implants 2002 Campelo and Camera, in this retrospective analysis of FL implant surgery,also reported a 100% success rate for the placement of 91 implants.

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4). Minimally invasive flapless implant surgery: A prospective multi centre study. (Clini. Implant Dent Related Research 7:S21, 2005) Beakers et al reported a success rate of 98.7% at 2 years after implantation for 79 implants in 57 patients who were treated with the FL approach.

CONCLUSION::

Based on pre- or intraoperative decision making, patients eligible for FL surgery can benefit from a less straining procedure without affecting the success rate of dental implant surgery. FL approach is a predictable procedure when pt selection and surgical procedure are appropriate. CONCLUSION:

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