Title Flapless and Conventional Flap Approaches to Implant Placement Provide Similar Esthetic Results
Clinical Question In systemically healthy patients seeking single implant placement in the esthetic zone, does a flapless implant surgery protocol provide a better esthetic outcome than a conventional flap approach, focusing on mid-facial recession?
Clinical Bottom Line For patients requiring a single implant in the esthetic zone, a flapless surgical protocol provides a similar esthetic outcome with regard to mid-facial recession as compared to the conventional flap approach. This is supported by two randomized controlled trials in which a flapless approach did not result in a significant difference in mid-facial recession compared to the conventional flap approach. A flapless approach should only be considered by skilled surgeons in anatomically appropriate patients.
Best Evidence  
PubMed ID Author / Year Patient Group Study type
(level of evidence)
27501953Stoupel/201639 adults needing single implant in the esthetic zoneRandomized Controlled Trial
Key resultsCompared to the pre-surgical baseline, the mean mid-buccal recession in the flapless group at 3 months was 0.28mm vs 0.48mm in the flap-involving group (p=0.18). At 6 months, the mean mid-buccal recession in the flapless group was 0.19mm vs 0.40mm in the flap-involving group (p=0.13). At 12 months, the mean mid-buccal recession in the flapless group was 0.22mm vs. 0.42mm in the flap-involving group (p=0.18). None of these differences were statistically significant. Compared to the post-surgical baseline, at 3 months the mid-buccal gingival margin migrated coronally -0.22mm in the flapless group vs receded 0.2mm in the flap-involving group (p=0.01). At 6 months, the flapless group continued to migrate coronally to -0.25mm vs receding 0.13mm in the flap-involving group (p=0.04). These differences were statistically significant.
23347348Bashutski/201324 adults missing a single tooth in the esthetic zoneRandomized Controlled Trial
Key resultsImmediately following implant placement, the mean mid-buccal gingival margin between the flap group and flapless group was significantly different with an average of 2.17mm in the flap group and 1.17mm in the flapless group (p=0.01). However, prior to surgery and 3 to 15 months post-surgery, there were no significant differences between groups. After 15 months, there was no statistically significant difference in the position of the gingival margin between the two groups.
Evidence Search (flapless[All Fields] AND implant[All Fields] AND ("esthetics"[MeSH Terms] OR "esthetics"[All Fields])) AND ((Randomized Controlled Trial[ptyp] OR Meta-Analysis[ptyp] OR systematic[sb]) AND "humans"[MeSH Terms])
Comments on
The Evidence
Validity: Both studies included were single-center, randomized controlled trials with extensive inclusion and exclusion criteria. Subjects were followed and accurately reported on throughout the studies. All measurements were completed by a single blinded examiner. However, there was significant heterogeneity in the surgical protocols used between the two studies. Bashutski et al. (2013) chose subjects who were already edentulous at the replacement site, placed implants using a surgical guide, and restored the implants 3 months later. Stoupel et al. (2016) extracted the teeth and immediately placed and provisionalized the implant without a guide. Perspective: Based on these RCTs, both flap and flapless procedures resulted in similar esthetic outcomes, specifically mid-facial recession. However, when evaluation of the alveolar ridge anatomy indicates a potential for fenestration or dehiscence of the buccal plate, a flap approach is preferred in order to allow buccal augmentation. Finally, a surgical guide may be helpful when using a flapless approach in order to allow proper placement of the implant in a more predictable position within the alveolar bone.
Applicability When replacing a tooth in the anterior maxilla, preserving esthetics is of key importance. A flapless approach may reduce post-operative swelling and discomfort; however it seems there is no advantage over the conventional flap approach when it comes to improving esthetics long term. Furthermore, a flapless approach does not allow access to the buccal plate to repair possible perforations, dehiscences or fenestrations. One must consider each patient individually when deciding which surgical approach to use given their anatomical structure. More long-term studies with larger sample sizes must be done in order to verify these results.
Specialty (General Dentistry) (Oral Surgery) (Periodontics) (Prosthodontics)
Keywords Flapless implant esthetics
ID# 3401
Date of submission 11/26/2019
E-mail loughridge@uthscsa.edu
Author Nathan Loughridge, DDS
Co-author(s) Jacob Zellner, DMD
Co-author(s) e-mail zellner@uthscsa.edu
Faculty mentor Angela Palaiologou Gallis, DDS, MS
Faculty mentor e-mail palaiologoua@uthscsa.edu
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
None available
Comments and Evidence-Based Updates on the CAT
None available