ITI World Symposium, Geneva, April 15-17, 2010 ITI Research Competition A new technique for flapless implant

surgery Presenter: Manuele Leoni, Modena, Italy leoni.manuele@libero.it Co-Authors: Pio Bertani, Piero Zoppi, Paolo Generali Introduction Flapless surgery for implant placement has been gaining popularity among implant surgeons1. Flapless implant surgery has numerous advantages, including the preservation of circulation, soft tissue architecture, and hard tissue volume at the site, as well as decreased surgical time, improved patient comfort, and accelerated recovery2. Various methods exist for gaining access to the alveolar ridge. The use of a tissue punch has been proposed3, whereas other made a hole in the gingival tissue using drills instead of a tissue punch4. Drilling through the mucosa without removing a core of soft tissue may simultaneously cut the gingival tissue and the bone. This method could result in large ragged wounds, increasing the risk of impaired healing and significant scarring and entrapment of soft tissues in the implant site1. A study1 supports the use of a tissue punch slightly narrower than the implant itself to obtain better perimplant tissue healing around flapless implants. Although flapless implant surgery has numerous advantages, the approach also has some drawbacks, including the inability to save the keratinized mucosa. In regions were the amount of keratinized tissue is deficient, use of gingival punch is not indicated5. Aim of this study is show a novel technique for flapless implant surgery, using dedicated rotary devices, designed to save keratinized mucosa. Patients and methods Eleven consecutive patients were enrolled for this study, 8 F, 3 M, 35-72 yo, mean 62. Inclusion criteria were patient age>18, willing and able to give informed consent, willing to participate in the study, absence of systemic or local controindication for implant placement; 2) Treatment plan that included implant positioning on both side of maxilla or mandible; 3) Abundant bone (>7mm width, >12 mm height, measured by CT scans) 4) presence of a band of keratinized mucosa larger than 5 mm. Exclusion criteria were patients with uncontrolled diabetes and those on oral or IV bisphosphonates, history of alcoholism or drug abuse, uncontrolled metabolic disease, transplant patient on immunosuppressant therapy, uncompensated systemic disease, mental illness, received radiation therapy to surgical site, pregnancy. Surgery was performed with hand punch 4 mm in diameter on one side (Gima SpA, Gessate, MI, Italy), while on the other the new devices (Surgical Kit for non-invasive implant surgery, Avimatic Srl, Bagnolo Cremasco, CR, Italy) were used. The tested surgical kit was made of three rotary instruments, 1) Disc Blade 2) Cup Blade 3) Flat blade. The sides were choosen using a random technique (Random number generator, Graphpad, www graphpad.com). Tissue Level 4.1 or 4.8 Straumann Implants were used, 10 or 12 mm of lenght (Straumann AG, Basel, Switzerland). Clinical data were collected before, during and after surgery, at 1 week, 1 month and 3 months recall before placement of final prosthesis, and included patients discomfort, surgical time, radiographic appearance, quality and quantity of keratinized mucosa, probing depth and bleeding on probing. Results All patients completed the study. 28 implants were placed, 15 with the tested device and 13 with tissue punch. The results were analyzed using non-parametric statistics (Mann-Whitney test Graphpad InStat) and showed that, 3 months after surgery the experimental sites had significant more keratinized mucosa than control sites. Probing depth, bleeding on probing, surgical time, x-ray evaluation and patient discomfort did not show significant differences. Discussion Based upon data of this study, the tested devices look promising for flapless surgical implant positioning. The use of these rotary blades allow the surgeon to save almost all the keratinized tissue, and even to move it slightly in the preferred position. The section of all fibrous tissue before osteotomy could prevent entrapment of soft tissues in the implant site. Conclusion The tested devices could be useful in minimally invasive implant surgery. Further studies are needed in order to evaluate their possible use, even in presence of a band of keratinized tissue smaller than implant diameter.

Patient n11. M.L., 35 yo F, 36 & 46, 2 Straumann Standard Implant 4.8x10 mm WN

Tested rotary devices

References 1) Lee DH, Choi BH, Jeong SM, Xuan F, Kim HR, Mo DY: Effects of soft tissue punch size on the healing of peri-implant tissue in flapless implant surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109: 525-530 2) Sclar AG. Guidelines for flapless surgery. J Oral Maxillofac Surg 2007;65:20-32. 3) Campelo LD, Camara JRD. Flapless implant surgery: a 10-year clinical retrospective analysis. Int J Oral Maxillofac Implants 2002;17:271-6. 4) Becker W, Goldstein M, Becker BE, Sennerby L, Kois D, Hujoel P. Minimally invasive flapless implant placement: follow-up results from a multicenter study. J Periodontol 2009;80:347-52. 5) Rotter BE: Emergence profile consideration for implant surgery. Oral Maxillofacial Surg Clin North Am 8; 413,1996.

P value is 0,0158, considered significant.