Flapless implant surgery: an experimental study

Seung-Mi Jeong, DDS, PhD,a Byung-Ho Choi, DDS, PhD,b Jingxu Li, DDS,c
Han-Sung Kim, PhD,d Chang-Yong Ko,e Jae-Hyung Jung, DDS,f Hyeon-Jung Lee, DDS,f
Seoung-Ho Lee, DDS, PhD,g and Wilfried Engelke, MD, DDS, PhD,h Wonju and Seoul,
South Korea, and Göttingen, Germany
YONSEI UNIVERSITY AND GEORG-AUGUST UNIVERSITY

Objective. The purpose of this study was to examine the effect of flapless implant surgery on crestal bone loss and
osseointegration in a canine mandible model.
Study design. In 6 mongrel dogs, bilateral, edentulated, flat alveolar ridges were created in the mandible. After 3
months of healing, 2 implants in each side were placed by either flap or flapless procedures. After a healing period of
8 weeks, microcomputerized tomography at the implantation site was performed. Osseointegration was calculated as
percentage of implant surface in contact with bone. Additionally, bone height was measured in the peri-implant bone.
Results. The mean osseointegration was greater at flapless sites (70.4%) than at sites with flaps (59.5%) (P ⬍ .05). The
mean peri-implant bone height was greater at flapless sites (10.1 mm) than at sites with flaps (9.0 mm) (P ⬍ .05).
Conclusion. Flapless surgery can achieve results superior to surgery with reflected flaps. The specific improvements of
this technique include enhanced osseointegration of dental implants and increased bone height. (Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2007;104:24-8)

When soft tissue flaps are reflected during dental im- examine the effect of flapless implant surgery on crestal
plant surgery, bone resorption of varying degrees al- bone loss and osseointegration in a canine mandible
most always occurs in the crestal area of the alveolar model.
bone.1,2 Flapless implant surgery may be useful, there-
fore, for minimizing bone resorption. In general, clini- MATERIALS AND METHODS
cians have described flapless implant surgery as a pre- Animal model
dictable procedure,3,4 but such reports include clinical Six adult female mongrel dogs, each weighing more
observations without well defined parameters for suc- than 15 kg (range 15-20 kg), were used in this exper-
cess or proper controls. In an attempt to provide more iment. The protocol was approved by the Animal Care
rigorous data, the present study was undertaken to and Use Committee of Yonsei Medical Center, Seoul,
Korea.
Supported by a research grant from Yonsei University Wonju College
of Medicine (YUWCM 2006-11). Edentulated flat ridge induction
a
Assistant Professor, Department of Dentistry, Yonsei University All surgical procedures were performed under sys-
Wonju College of Medicine, Wonju.
b
Professor, Department of Oral and Maxillofacial Surgery, College of
temic (5 mg/kg ketamine and 2 mg/kg IM xylazine) and
Dentistry, Yonsei University, Seoul. local (2% lidocaine with 1:80,000 epinephrine) anes-
c
Research Assistant, Department of Dentistry, Yonsei University thesia. All mandibular premolars were removed to es-
Wonju College of Medicine, Wonju. tablish space for implants. After 1 month of healing,
d
Associate Professor, Department of Biomedical Engineering. Col- bilateral flat alveolar ridges were surgically produced.
lege of Health Science, Institute of Medical Engineering, Yonsei
University, Wonju.
Briefly, a mucoperiosteal flap was raised to expose the
e
Graduate, Department of Biomedical Engineering. College of Health alveolar bone. Burs were then used to flatten the alve-
Science, Institute of Medical Engineering, Yonsei University, Wonju. olar crest under sterile saline irrigation so that an ap-
f
Graduate, Department of Oral and Maxillofacial Surgery, College of propriate width of bone would be available for implant
Dentistry, Yonsei University. placement. The mucoperiosteal flap was replaced and
g
Associate Professor, Department of Periodontology, Ewha Women’s
University.
sutured, and the resulting edentulated flat alveolar ridge
h
Professor, Department of Oral Surgery, School of Dentistry, Georg- was allowed to heal for 3 months.
August University, Göttingen, Germany.
Received for publication Aug 21, 2006; returned for revision Oct 2, Implantation procedure
2006; accepted for publication Nov 9, 2006.
1079-2104/$ - see front matter
Two dental implants (length 10 mm, diameter 4.1
© 2007 Mosby, Inc. All rights reserved. mm; Osstem, Seoul, Korea) were placed within the
doi:10.1016/j.tripleo.2006.11.034 edentulated ridge in each side of the mandible (Fig. 1).

24
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Volume 104, Number 1
Fig. 1. Clinical feature after implant placement. A, Implant
placed without a flap. B, Implant placed with a flap.
The implants in each side were randomly assigned to 1
of the following 2 surgical techniques: 1) implantation
after making a 5-mm-wide circumferential incision in
the gingiva at the center of the implant site (flapless
group); 2) implantation after elevating a mucoperiosteal
flap to expose the alveolar ridge (flap group). Care was
taken during this procedure to place the 2 implants at
the same height and to avoid perforation of the cortical
plates, both lingual and buccal. Abutments were con-
nected to the implants, and the implants were not sub-
merged. Antibiotic therapy was administered 1 hour
before surgery and once daily for 2 days after surgery.
Microcomputerized tomography
Animals were killed 8 weeks after implantation, and
bone blocks containing the implants were excised. Re-
sected bone specimens were fixed for 48 h in 10%
buffered formalin and then stored in 70% ethanol. A
morphometric study, using microcomputerized tomog-
raphy (microCT) (Skyscan 1076; Skyscan, Antwerpen,
Belgium), was used to quantify the bone around the
implants. Microtomographic slices were acquired at
each 35-␮m interval, and computerized 3-dimensional
(3D) reconstruction was performed by accumulating
traces of each implant, following the method described
by Akagawa et al.5 These settings have been recently
used for accurate analysis of titanium implant os-
seointegration.6 Osseointegration was calculated as
percentage of implant surface in contact with bone.
Additionally, bone height in the peri-implant bone was
measured as the distance between the alveolar crest and
the bottom surface of the implant.
Statistical analysis
Wilcoxon signed rank test for paired samples was
used to calculate statistical differences between the
groups.
Jeong et al. 25
Fig. 2. Photograph of the mandible showing bone loss around
the implants. A, flapless site; B, flap site.
Table I. Parameters (mean values and standard devia-
tion) of bone-to-implant contact and bone height
around dental implants when placed either without or
with a flap
Flapless group Flap group P values
Bone-implant contact (%) 70.4 ⫾ 6.3 59.5 ⫾ 6.3 ⬍.05
Bone height (mm) 10.1 ⫾ 0.5 9.0 ⫾ 0.7 ⬍.05
RESULTS
Healing after implant placement was uneventful in
all animals. Upon gross examination, the bone around
the implants was more abundant at flapless sites than at
flap sites (Fig. 2). The results of microCT image anal-
ysis are presented in Table I. Average bone height was
greater in the flapless group (10.1 ⫾ 0.5 mm) than in
the flap group (9.0 ⫾ 0.7 mm) (P ⬍ .05) (Fig. 3).
Average osseointegration was significantly greater in
the flapless group (70.4 ⫾ 6.3%) than in the flap group
(59.5 ⫾ 6.3%) (P ⬍ .05) (Fig. 4). The flapless group
had significantly better vertical alveolar ridge height
and more bone/implant contact than the flap group.
DISCUSSION
In recent years, there have been reports that flapless
implant surgery is a predictable procedure with high
success rates if patients are appropriately selected and
an appropriate width of bone is available for implant
placement.3,4 The aim of the present study was to
examine the effect of flapless implant surgery on crestal
bone loss and osseointegration compared with flap im-
plant surgery. The study showed that when implants
were placed without flap elevation, both the amount of
osseointegration and bone height around the implants
were significantly greater than in implants placed with
flap elevation. This enhancement is probably due to the
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26 Jeong et al. July 2007

Fig. 3. Three-dimensional microCT showing the bone (yellow) around the implants (gray). A, Implant placed without a flap.
B, Implant placed with a flap. Buccal, buccal side of the alveolus; lingual, lingual side of the alveolus.
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Volume 104, Number 1
Fig. 4. Three-dimensional microCT overview of the bone-to-
implant contact area (red) around the implant surface (gray).
A, Implant placed without a flap. B, Implant placed with a
flap.
Jeong et al. 27
preservation of bone vascularization. When teeth are
present, blood is supplied to the bone from 3 different
paths: the periodontal ligament, the connective tissue
above the periosteum, and inside the bone. When a
tooth is lost, the blood supply from the periodontal
ligament disappears, and blood is supplied only from
soft tissue and bone. Cortical bone is poorly vascularized
in contrast to marrow bone. When soft tissue flaps are
reflected for implant placement, the blood supply from the
soft tissue to the bone (supraperiosteal blood supply) is
also removed, leaving only poorly vascularized cortical
bone without a part of its vascular supply, ultimately
prompting bone resorption during the initial healing
phase.7-9 The preservation of bone vascularization when
no flaps are reflected may help optimize bone regeneration
around implants, as suggested by the improved osseointe-
gration we observed after flapless surgery.
According to the Branemark protocol, an incision in
the mucosa or the mucobuccal fold was made, and then
a flap was reflected to expose the underlying bone. The
implants were placed, and the flap was sutured back in
place.10,11 The rationale for this method is to keep the
incision line away from the implants, thereby possibly
preventing infection.12 In the present study, however,
peri-implantitis did not occur in the flapless group.
Most studies have histologically evaluated the
bone structure around the implant. It is well recog-
nized, however, that partial evaluation of some sec-
tions is not sufficient for overall evaluation of the
bone structure. This study attempted to evaluate the
3D bone structure around the implants, using mi-
croCT. In 1989, Feldkamp et al.13 introduced an
x-ray microCT system to create 3D images. More re-
cent developments have allowed the creation of higher-
resolution 3D images and quantitative measurements of
the trabecular bone structure.14 MicroCT was validated
as a method for 3D assessment and analysis of cancel-
lous bone by Muller et al.15 in 1998, who compared the
morphometric results of conventional histomorphom-
etry to microCT scans. Those authors demonstrated the
strength of 3D representation of trabecular bone archi-
tecture compared with conventional 2D histology and
found excellent correlation of the indices assessed. Re-
cent studies have proposed the application of microCT
to dental implant research.16,17 In the present study,
microCT was used to perform a detailed quantitative
analysis of the entire implantation site.
To our knowledge, this is the first report to provide
controlled experimental data concerning the influence
of flapless implant surgery on osseointegration and the
height of newly formed bone around implants. Flapless
implant surgery improved both the osseointegration of
dental implants and the bone height around implants
after surgery. Our data, therefore, support the concept

28 Jeong et al.
that flapless implant surgery may be more effective
than surgery with flap reflection in improving implant
anchorage.
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Reprint requests:
Prof. Byung-Ho Choi
Dept. of Oral and Maxillofacial Surgery
College of Dentistry, Yonsei University
Seoul, South Korea
hoibh@yonsei.ac.kr