Int. J. Oral Maxillofac. Surg. 2012; 41: 10641071 http://dx.doi.org/10.1016/j.ijom.2012.06.002, available online at http://www.sciencedirect.

com

Systematic Review Paper Dental Implants

Is apless implant surgery a viable option in posterior maxilla? A review

N. Doan, Z. Du, R. Crawford, P. Reher, Y. Xiao: Is apless implant surgery a viable option in posterior maxilla? A review. Int. J. Oral Maxillofac. Surg. 2012; 41: 10641071. # 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. This article reviews the literature on the outcome of apless surgery for dental implants in the posterior maxilla. The literature search was carried out in using the keywords: apless, dental implants and maxilla. A hand search and Medline search were carried out on studies published between 1971 and 2011. The authors included research involving a minimum of 15 dental implants with a followup period of 1 year, an outcome measurement of implant survival, but excluded studies involving multiple simultaneous interventions, and studies with missing data. The Cochrane approach for cohort studies and Oxford Centre for EvidenceBased Medicine were applied. Of the 56 published papers selected, 14 papers on the apless technique showed high overall implant survival rates. The prospective studies yielded 97.01% (95% CI: 90.7299.0) while retrospective studies or case series illustrated 95.08% (95% CI: 91.097.93) survival. The average of intraoperative complications was 6.55% using the apless procedure. The limited data obtained showed that apless surgery in posterior maxilla areas could be a viable and predictable treatment method for implant placement. Flapless surgery tends to be more applicable in this area of the mouth. Further long-term clinical controlled studies are needed.

N. Doan1, Z. Du1,2, R. Crawford1, P. Reher3, Y. Xiao1

Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia; 2School and Hospital of Stomatology, Fujian Medical University, Fuzhou, China; 3School of Dentistry and Oral Health, Grifth University, Gold Coast, Australia
1

Key words: dental implants; apless surgery; complications; maxilla; survival; success; efcacy; effectiveness; guided surgery; review. Accepted for publication 8 June 2012 Available online 9 July 2012

The introduction of osseointegration in nemark et al.1 revolutionized 1977 by Bra oral rehabilitation in partially and fully edentulous patients. This concept was based on the utilization of a mucoperiosteal ap. The ap was designed for the visualization of underlying bone by reecting the alveolar crest soft tissue for placement and closure with suture on completion of the procedure. This concept implies that implants should be covered by soft tissue to warrant primary stabilization and decrease infection as a
0901-5027/0901064 + 08 $36.00/0

standard of care. For many practitioners, the ap technique has remained the mainstay of implant surgery as it allows better visualization, particularly in areas of inadequate bone quantity, and it permits the manipulation of soft tissue in aesthetic regions. Despite their popularity, ap techniques have disadvantages including gingival recession, bone resorption around natural teeth,2,3 soft tissue deciency from ap raising, and negative implant aesthetic outcomes, especially in the anterior maxilla.4

Over the last three decades, there have been many modications to implant ap design, including the apless surgical technique. In contrast to the ap technique, implant apless surgery does not require reection of a mucoperiosteal ap while perforating the alveolar mucosa and bone. Therefore, apless surgery generates less postoperative bleeding, less discomfort for the patient, surgery time is shorter, and healing time is reduced. The patients heal with minor, or no, swelling.5,6 The apless technique uses rotary

# 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Flapless implant surgery in posterior maxilla

burs or a tissue punch to gain access to bone without ap elevation, so the vascular supply and surrounding soft tissue are well preserved. The apless technique has been well established in immediate extraction and site preservation with minimal complication.7 With the advance of apless surgery, the traditional ap method is being challenged because it is being perceived as unnecessary. Traditionally, apless surgery has been regarded as having multiple limitations such as: poor control of precise drilling depth due to difculty in observing the drilling direction of the alveolar bone; inability to preserve keratinized gingiva with a tissue punch perforation; and poor ability to assess the implant point of entry due to the lack of direct vision of the recipient bone. Therefore, it is difcult to correct intraoperative peri-implant defects. This implies that apless surgery is mainly used for cases where there is sufcient quantity and quality of bone, as well as a decent quantity of keratinized gingiva.8 Maxilla posterior areas can satisfy these apless surgery requirements. Reviewing publications on animal studies aids understanding of apless surgery and helps to improve the apless technique. For example, the biological width longitudinal dimension at the buccal aspect were higher in the ap group than in the apless group in minipigs9; apless surgical implantation into freshly extracted sockets did not aid in the avoidance of alveolar bone resorption and had no inuence in the dimensional differences of the alveolar process after tooth extraction in contrasted to the traditional implant placement using mucoperiosteal aps10; and apless implant surgery can be utilized for the placement dental implants, and the application of a tissue punch larger than the diameter of the implants is not recommended, as it can endanger the result of the implantation process.11 The posterior maxilla is dened as the back part of the upper jaw, anteriorly bounded by the upper canine teeth, posteriorly by the maxillary tuberosities, bucally by buccal mucosa and medially by the palate. The supporting alveolar bone in this area is usually wide enough for implant placement, particularly in the molar region. Following tooth loss, resorption has been shown to adhere to a predictable pattern: the alveolar labial aspect of the ridge is the main site of resorption, which diminishes rst in width then in height.12 14 The posterior maxilla has different anatomy and bone quality, and distinctive buccal and palatal resorption patterns.12,15 When the maxilla becomes edentulous, its shape changes according to the extent of resorption. The cortical bone in the maxilla becomes thinner and more porous posteriorly in an aged population.16 Using computed tomography, trabecular bone density varies markedly with potential implant site in the anterior (516 132 Hounseld units, HU) and posterior (332 136 HU) regions, which may compromise the clinical outcome of dental implants in the posterior maxilla. Fuh et al.17 indicated that female maxillae showed a smaller amount and a lower density of cancellous bone than male maxillae. The literature reveals limited and conicting information concerning dental implant treatment in poor quality bone of the posterior maxilla. Although there is a slightly lower osseointegration success rate, poor quality bone is not an absolute contraindication for dental implant treatment.1821 The anatomical and structural features of the posterior maxilla, such as poor quality and quantity bone due to its proximity to the maxillary sinus, may compromise the clinical outcome of dental implants. In recent years, the advance of three dimensional (3D) dental imaging, particularly cone beam computed tomography (CBCT), and the associated planning software, used in conjunction with computer generated surgical guides, has allowed more efcient results when using apless techniques. This has turned apless implant surgery into a predictable procedure with high success rates if patients are appropriately selected and an appropriate width of bone is available for implant placement.2,22 These studies mainly focus on anterior areas, in order to improve aesthetic results, to shorten in surgery time, and to decrease morbidity after surgery. Few studies focus on the posterior areas, especially posterior maxilla areas. There are some benets for apless surgery in this area, including: less aesthetic demand; bone resorption pattern resulting in wider width and less undercut; and minimal concern about nerve damage. Therefore, apless surgery appears to have more applications in the posterior maxilla than in any other area. The difculties in the posterior maxilla are: less bone density; the position of the sinus; and the difcult access to the mouth. The posterior maxilla has been described as the most difcult and problematic intraoral area confronting the implant practitioner, which may inuence the results of apless surgery. This article reviews the contemporary literature relating to the outcome (efciency and effectiveness) and surgical

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challenges of apless dental implant surgery in the posterior maxilla and indicates that apless implant surgery is an acceptable technique in the posterior maxilla.
Materials and methods

A search for English publications was carried out using Medline to search dental journals from 1971 to 2011. Major dental implant journals covering oral and maxillofacial surgery, dental implant, prosthodontics, and periodontics, for a similar period, were searched by hand to nd relevant references. The reference search was conducted using a mixture of the following keywords: dental implants, apless surgery, complications, maxilla, survival, success, efcacy, effectiveness, guided surgery, review. Clinical human studies published in English in the last 40 years between 1971 and 2011 obtained through the Medline or the hand search were categorized by study types (case report, preclinical, cohort, control clinical trial, review and meta-analysis), and subjects (human versus animal). This review included only human studies of the posterior maxilla with 15 or more implants; expert and clinical opinion publications were excluded. In order to apply the best available evidence gained from the scientic method to clinical decision making, the Oxford Centre for Evidence-Based Medicine4 was used to weigh the level of evidence in clinical studies. In this review, conventional implant surgery refers to ap surgical techniques that require elevation of a mucoperiosteal ap for the purpose of implant surgery and implant placement. Flapless implant surgery is dened as a surgical technique utilized to prepare the implant drilling site for surgical placement of the implant without the need to raise a mucoperiosteal ap. The information was organized into a system of comparison in a table format similar to that suggested by Brodala4 containing type of study, number of participants, dropouts, follow-up time, mean age, implant case, outcomes (survival), complications and failures. It was assumed that these patients had no adverse medical conditions.
Statistical data management

The data retrieved from the selected papers was managed according to the following methods. The mean values of the survival rates were case weighted to have an even distribution. Ideally, one would limit the sample to studies that use KaplanMeier methods to estimate survival and include

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Medline search (Pubmed) through database (n = 56) Records excluded according to the criteria (n = 37) Full-text articles assessed for eligibility (n = 19)

Full-text articles excluded, with no clinical data (n = 5)

the results of the few studies that meet the new inclusion criteria. Owing to the limited number of publications available, retrospective studies were included in the review. To improve the validity of these studies, Oxford Centre for Evidence-Based Medicines 2001 classication of levels of evidence were used. The studies were organized, reported, and stratied by the levels of evidence.

Number of studies included after screening (n = 14)

Results
Articles via hand-searched journals relative to dental implant
(n = 0)

Medline search results

Full papers included in this study (n = 14)

Fig. 1. Flowchart of article selection for review.

The Medline search found 56 articles, 19 were deemed to meet the inclusion criteria. Of these, ve systemic reviews were excluded as they did not involve clinical studies (Fig. 1). Using Oxford Centre for Evidence-Based Medicines 2001 classication, of the 14 remaining papers (Tables 13), six were level 2 prospective cohort studies, ve were retrospective, one was a non-randomized trial, and there were two case studies (level 4) that looked

Table 1. Demographics of studies. Study design and Oxford Evidence based level Prospective cohort (level 2) No. drop outs 0 Remaining implants after dropouts 97 No. of terminal events 9 Age range (years) 2477 Mean age (years) 51 Follow-up period (months) 36 Mean survival rate (%) 90.72

No. 1

Authors Rocci et al.5

No. of Patients 46

Success rate (%) 91 (prosthetic load) 94 (splint) 98.7 NR NR 99 98 (max) 97(Md) (1) 97.4 (2) 100 98.9 (nonsmoker) 81.2 (smoker) 94.87 NR 07.95 NR NR 98.3

2 3 4 5 6 7 8

Becker et al.23 van Steenberghe et al.8 Fortin et al.24 Cannizzaro et al.25 Malo et al.
26

Campelo and Camara27 Sanna et al.28

Prospective cohort (level 2) Prospective cohort (level 2) Prospective comparative cohort (level 2) Prospective cohort (level 2) Prospective cohort (level 2) Retrospective study (level 4) Retrospective study (level 4) Retrospective study (level 4) Retrospective study (level 4) Retrospective study (level 4) Non randomized trial (level 4) Case series (level 4) Case series (level 4)

57 27 60 35 23 377 30

0 3 0 0 0 18 4

79 164 152 202 92 770 183

1 NR NR 2 0 37 9

2486 3489 1982 3970 NR 2783 3874

NR 63 NR 56.6 NR 54.7 56

24 12 6 days 12 21 60 36

98.7 NR NR 99 98 95.25 91.5

9 10 11 12 13 14

Sennerby et al.29 Katsoulis et al.30 Pomares Puig31 Oh et al.32 Merli et al.

33

43 28 195 24 13 5

0 0 0 0 0 0

117 112 194 24 89 14

6 NR 4 NR 5 1

NR NR 3584 2572 NR NR

50 NR 59.5 45 NR NR

18 NR 12 6 8 14

94.87 NR 97.95 NR NR 98.3

Ozan et al.34

Flapless implant surgery in posterior maxilla

Table 2. Study types and results. Maxilla Mandible No. and and single Partial Complete tooth edentulism edentulism implants implants NR NR 0 NR NR NR 0 NR NR NR 33 NR 47 282 33 NR 32 488 0 NR

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No. 1 2 3 4

Authors Becker et al.23 Campelo and Camara27 Cannizzaro et al.25 Fortin et al.24

Result I

Result II

5 6 7 8 9 10

Malo et al.35,36 Oh et al.32 Ozan et al.34 Rocci et al.5 Sanna et al.28 Sennerby et al.29

0 24 NR 27 0 18

0 0 NR 70 0 99

23 0 NR 0 30 0

18 24 Yes 97 26 45

5 0 Yes 0 4 72

11 12

van Steenberghe et al.8 Pomares Puig31

0 0

0 0

27 30

27 128

0 67

13

Katsouliset al.30

40

184

14

Merli et al.31

28

112

No signicant changes in PD, Bone loss = 0.07 mm BI from 1 to 6.5 months detected by X-rays was not signicant Overall implant failure: 37 Analgesics were not used: (4.8%) over 10 years 90% Reported pain: none slight Swelling post surgically: (79%), moderate severe none slight (58%), (21%) moderate severe 42% Reported pain (VAS): NR signicant less and of shorter Pain duration found in apless group, signicant less use of analgesics with apless technique Bone loss detected by XOverall implant survival = 98%; maxilla rays = 1.9 mm at 12 mo 97%; mandible 100% Tendency for Papillary Index No differences in ML, PD, (PPI) to increase over 6 mPI, mBI, WKM months Total of 5 out of 5 implants NR survived at average 9 months Implant cumulative survival rate: 91% at 36 months Bone loss detected by X-rays Implant cumulative survival at 4 years: 2.64 mm smokers; rate 91.5% over 66 months 1.3 mm nonsmokers 53% of implants had > 2 mm NR radiographic bone loss at; >3 mm radiographic bone loss at 37% implants Bone loss 1.2 mm detected by NR X-rays at 12 months 4 implants out of 195 failed in After 1 year of loading, there 3 patients during the healing were no dropouts and no period: 2 in the maxilla and 2 failure of the denitive in the mandible. 3 of them prosthesis 12 were replaced successfully 28 patients (70%) with 6 had insufcient bone to sufcient bone and 4 implants place any implant and 6 have each (112 implants); 12 combined sufcient bone and patients each have 6 implants insufcient bone (72 implants) 13 consecutive patients with 5 implants failed in 4 patients. atrophic maxillae were 1 patient dropped out. 8 treated with 89 implants (68 months after loading, all implants per patient) prostheses were successful. 11 out of 12 patients reported their quality of life and lifestyle had improved

PD = probing depth; BI = bleeding index; ML = attachment level, mPI = modied plaque index; mBI = modied bleeding index; AUC = area under curve; WKM = width of keratinized mucosa; NR = not reported (modied from Brodala4).

at implant success and survival rate and other clinical variables. Of these, 10 were short-term studies (6 days) that evaluated intraoperative complications such as morbidity and comfort (level 2). The only long-term clinical study (level 2) was a retrospective cohort study. The most common features encountered in these studies were the use of guided surgical techniques during the course of their treatment plan-

ning. The differences in study designs were either treatment in a single location or multiple locations in the maxilla.
Implant survival rate

Life time analysis was calculated using KaplanMeier methods to estimate survival.37 The obtained survival data were then case weighed. In a long term study

of implant outcomes27 of 778 patients and 2040 implants over a mean study period of 19 months, the results indicated a fairly high survival rate. The prospective studies yielded 97.01% (95% CI: 90.7299.0) while retrospective or case series evaluation showed 95.08% survival (95% CI: 91.097.93). These results illustrated clinical efcacy with prospective studies and clinical effectiveness, respectively.

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Table 3. Complication and failures. No. of complications Intraoperative complication NR 36 perforation (21 fenestrations 15 deshisences) 1 perforation 1 treatment aborted Postoperative complication NR NR NR No. of failed implants 1 37 2 0 NR 5 (no. of intermittent pain = 1, hyperplastic tissue = 1, periimplant mucositis = 1, peri-implant periimplantitis = 2); all < 10 months and resolved NR 0 NR

No. 1 2 3

Authors Becker et al.23 Campelo and Camara27 Cannizzaro et al.25

Biological NR NR

Technical

Aesthetics NR NR NR

10 (not related to apless placement)

4 5 6

Fortin et al.24 Malo et al.26 Oh et al.32

NR NR NR

NR 0 NR

0 2 3

NR 8 (fracture of acrylic denture) NR

NR NR 2 (patient subjective; patient chose to have prosthetic redone) NR NR NR NR

7 8 9 10

Ozan et al.34 Rocci et al.5 Sanna et al.28 Sennerby et al.29

NR NR NR NR

NR NR NR NR

NR 9 9 6

11

Van Steenberghe et al.8

NR

Marginal stula (1) resolved

NR NR NR 6 (same failed; immediate NR loading with apless) 4 (inamed hyperplastic gingiva)

NR NR NR NR

12

Pomares Puig31

3 patients had surgical templates fracture during implantation

13

Katsoulis et al.30

NR

4 implants out of 195 failed in three patients during the healing period: 2 in the, and 2 in the mandible. 3 of them were replaced successfully NR

4 failed but only 3 successfully replaced. 3 patients have to be treated with antibiotics.

4 (2 occlusal material fracture, resolved 1 screw loosening, 1 patient decided to change for different prosthesis) One patient, a new impression had to be taken to t the provisional prosthesis

NR

NR

14

Merli et al.33

Two aps had to be elevated in two patients. One template fractured during surgery

One patient dropped out, due to nancial reasons, with the provisional prosthesis still in function

5 implants failed in 4 patients

21 of 28 patients had exhibited a combination of sufcient or insufcient bone Two aps had to be elevated in two patients

NR

NR

One template fractured during surgery

NR

Flapless implant surgery in posterior maxilla

Three studies30,31,33 used apless method in conjunction with navigated surgical protocols, and the authors reported survival rates ranging from 87.3% to 97.8%. The authors concluded that the navigated surgical technique might not be appropriate for all types of bone morphology, but could be a viable and predictable treatment modality. Some complications arose during treatment, so the technique could be sensitive to the operators experience and a learning curve is required.
Post-surgical trauma discomfort

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The level of intraoperative apless surgical trauma was found to be minimal.26,35,36 In the majority of these studies objective short-term evaluation of postoperative complications were very limited or often omitted. One study was a comparative prospective non-randomized pilot study25 of patients morbidity (such as pain and facial swelling) from 1 to 7 days postoperatively using a visual analogue scale (VAS) following either a ap or apless surgical technique. The authors used 3D imaging to plan the procedures and questionnaires were used to record feedback. All patients in the study had an edentulous maxilla and each received six implants. The authors found that the apless surgery decreased the level of pain and postoperative swelling signicantly (p < 0.05). In a similar study using VAS as an assessing tool, the researchers24 evaluated the level of postsurgical discomfort from day 1 to day 6 and the use of painkillers in ap and apless techniques. The patients in the apless group experienced signicantly reduced pain and used fewer painkillers than the ap group (p < 0.01).
Peri-implant bone loss

loss. All the implants used in the studies were immediately loaded, and two studies did not use guided surgery. Sanna et al.28 evaluated annual bone loss in seven non-smokers and 13 smokers after apless implant placement using guided surgery. The authors did not report any substantial differences with regard to the mean marginal bone levels between the two groups at baseline and after a 1 year follow-up: non-smokers baseline 0.1 mm (SD 0.5 mm), 1 year 0.8 mm (SD 1.1 mm); and smokers baseline 0.1 mm (SD 0.4 mm), 1 year 1.1 mm (SD 1.4 mm). In a study of 109 Noble Biocare1 one piece implants, using a apless technique, the authors29 showed a mean marginal bone loss of 3 mm (SD 1.4). Of these, 14% experienced greater than 3 mm and 27% had more than 2 mm of bone loss. The authors found more bone loss in dental implants placed with apless than with ap techniques. The poor result yielded above was attributed to the attempt by the authors to increase efcacy and effectiveness by using one-piece implants, apless technique and immediate loading.
Postoperative soft tissue responses

X-ray assessment of peri-implant alveolar bone loss over 12 months varied from 0.7 mm to 2.6 mm in six studies.8,26 Of the included studies, the peri-implant bone was assessed using different techniques including peri-apical X-rays, panoramic radiography, CBCT, and radiographic fractal analysis. Minimal bone changes over a short time can be monitored using digital intra-oral radiography. Radiographic fractal analysis did not appear to match histological fractal analysis, and CBCT was not consistent for bone density measures, but might have potential in structural investigation of the trabecular bone.38 Periapical and panoramic X-rays were the main methods used to detect bone

The effect of apless surgery on soft tissue changes was well demonstrated in a study23 of 79 implants using a apless technique and delayed loading where baseline probing depths up to 1 month after insertion of nal prostheses, were recorded. The results showed no signicant differences between the baseline (2.2 mm, SD 0.9) and up to 1 month (2.3 mm, SD 0.8). A long term study would be required. Other soft tissue changes via the apless approach were investigated by a short term study,32 in which 25 patients were randomly assigned to the immediate (baseline) or the delayed loading group (after 4 months). The assessing parameters were modied plaque index, modied bleeding index, probing depths, and keratinized gingiva width. No signicant changes were observed at two time lines (base line and at 6 months). Longer study is required to validate the results.
Complications

postoperative complications include technical, biological and aesthetic complications. Technical complications include mechanical failures, biological encompass problems with osseointegration, pain, infections, and aesthetic refer to poor gingival appearance and unattractive prostheses. Intraoperative complications using the apless method were reported in the ve included studies.25,27 These complications range from perforations of bony plates to poor primary stability. One of the ve studies21 reported 3.8% complications occurred during surgical procedures which required the clinician to abandon or submerge the implant in these situations. In a 10-year study,27 770 dental implants were placed via apless techniques, in edentulous and partially edentulous patients. The diagnostic imaging technique used was CT or two-dimensional radiography. Although surgical stents were used routinely, guided surgical stents were not mentioned. The authors reported 21 fenestrations where the proposed treatment was changed to implant guided bone regeneration. In 15 instances of dehiscence, the authors either chose a different implant location or aborted the procedure, and resumed implant placement 3 months later after proper wound healing. Of the 16 studies included, only four reported perforation as a complication. As such, the complication report should be viewed with care.
Discussion

The overlapping denition of complication within the context of this study is dened as unfavourable outcomes requiring chair-side assistance intra-operatively or postoperatively. Intraoperative complications range from perforations of bony plates to poor primary stability whereas

As with any type of implant surgery, the complications associated with the apless technique might be intraoperative, postoperative, or delayed (Table 3). Of these, immediate postoperative complications related to the apless approach were found in two studies25,27 which were minimal in comparison with the ap technique. These studies indicated 3.8% intraoperative surgical complications related to perforation of the buccal or lingual bony plates. The bulk of the complications were found in ve studies.8,22,2931 In most studies there was no information about the presence or absence of perforations. Therefore the effect that perforations may have on implant survival or complications is not clearly outlined. The postoperative and delayed complications seem to be similar to those of the conventional approach. Most papers reported in which jaw the implant was placed but did not specify the exact location of the

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the appraisal of the validity of studies involved. This paper stressed the possibility of bias in their outcomes, in particular the chance that they will overestimate or underestimate the actual intervention power. Furthermore, the authors were aware of study-specic matters that may cause concern about the possibility of bias, and attempted to express judgements about these. Several tools are available for evaluating the procedural value of clinical trial studies. The utilization of measures producing a summary score is not recommended. Instead, this study employed the Cochrane Collaboration recommended specic tool for assessing the risk of bias in each included study. This comprises a judgement and a support for the nding for each entry in a risk of bias table, where each entry addresses a specic feature of the study. The judgement for each item encompasses evaluating the risk of bias as low risk, high risk, or unclear risk, with the latter group representing deciency of data or doubt over the potential for bias. For example, the prosthetic implant loading protocols differed vastly in the 14 studies, as loading could be immediate, delayed, or conventional. Taking into account these issues, in conjunction with additional confounding factors, it implies that the outcome of any particular procedure is not 100% clear or has unclear risk. This means that it is best to consider the above mentioned factors prior to extrapolating any clinical outcomes. In order to evaluate the values of the apless approach correctly, the researcher would require more studies of comparable loading procedures that fairly relate conventional approach to the apless technique. In conclusion, the current data obtained from posterior maxilla areas showed that apless surgery could be a viable and predictable treatment method for implant placement, indicating efcacy and clinical effectiveness. The available short-term and long-term results reported in this review illustrate that the apless approach, initially endorsed for inexperienced clinicians, requires extra skill and pre-surgical preparation than initially thought. The apless approach requires greater knowledge and skill than the conventional surgical techniques. In the light of modern advancements in digital imaging and computer guided surgery, the above requirement is no longer mandatory. Caution should be exercised in using apless surgery to minimize complications and mishaps. This implies that the implant practitioners must be willing to learn and adapt to new technology. Being diligent and cautious with new technique and technology are measures that could help to safeguard against unwanted complications in apless implant surgery, including those implants placed in the posterior maxilla. The application of apless implant surgical technique in everyday procedure should be limited to experienced surgeons, and it is not endorsed for inexperienced clinicians.
Funding

implants. Upper posterior implants were grouped under the heading of maxilla and implants, and only two studies31,35,36 illustrated the success rates between maxilla and mandible (Table 2). Thus the overall results of implants placed in the posterior maxilla using the apless technique are not clearly dened in these selected studies. One major limitation in this paper is that the apless surgical procedures for implant placement were used in various clinical settings. Even though there were reports on the use of navigation and 3D guided surgery in standard surgical procedures, there was no clear indication on the use of a surgical stent or guide. Correct application of apless surgery can help to lessen the morbidity and operating time, especially, in the posterior maxilla. With inadequate planning and improper placement, apless surgery usually results in unsatisfactory outcomes due to inappropriate implant position. The implant clinician should use measures that reduce complications in apless surgery including the use of advanced 3D dental imaging such as CBCT and the associated planning software, used in conjunction with computer generated surgical guides. These have allowed better pre-treatment planning for apless techniques making it more efcient and avoiding hidden unfavourable anatomical and pathological pitfalls. This has made apless implant surgery a predictable procedure with high success rates provided patients are selected appropriately and an appropriate bone quantity and quality is available for implant placement.20,19 Thorough treatment planning and operator experience are important in reducing complications. As with any new technological advance, the user has to go through a study period to perfect the technology. This usually brings an understanding of nuances that must be comprehended to reduce complications. For instance, there is a danger in misreading CT information or incorrectly placing surgical stents in implant surgery, which can cause irretrievable damage. It is important that the implantologist should understand all the aspects of the new technology, and use it at a basic stage prior to advancing into complex scenarios such as guided implant placement. The implant practitioner should be diligent, adaptable, and cautious with new techniques and technology, to safeguard against unforeseen complications in implant dentistry. During the compilation of this review, consideration was given to author bias and other sources of bias (such as conicts of interest) in the selected studies. The Cochrane review approach was used for

ITI Foundation for the dental implant project.

Competing interests

There is no conict of interest. The project is purely scientic and there is no commercial interest.
Ethical approval

Human Ethical Committee, Queensland University of Technology and Fujian Medical University
References
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Flapless implant surgery in posterior maxilla

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Address: Yin Xiao Institute of Health and Biomedical Innovation Queensland University of Technology Kelvin Grove Campus Brisbane Qld 4059 Australia Tel: +61 7 3138 6240; Fax: +61 7 3138 6030 E-mail: yin.xiao@qut.edu.au