Flapless placement works well in immediate extraction sites but one has to verify that the buccal plate is intact. This can be done with an instrument in the socket. if the buccal plate is intact the key is to direct the osteotomy towards the palatal with no contact of the implant with the coronal aspect of the buccal wall so that resorption doesnt occur. If the plate is not present in all or part of the buccal it should be flapped to assess and grafting will need to be done if you can get primary stability of the fixture.

In sites that have been missing a tooth and have healed gingival crest you should after anesthetic is placed probe thru the buccal tissue to "map" the bone and determine how thick the ridge is. if its determined its think enough then one can expose the crest by either a small crestal incision and then spread it to see the boney crest or use a tissue punch (if you have enough attached gingiva) then the site can be started with a pilot drill and use osteotomes from there to expand the site and make the bone denser.

Flapless is more technique sensitive and should be attempted after one has experience doing flapped approaches and one has to be ready to flap in some cases if things are not going well.

Bottom line its more important to see the bone and make sure of proper placement for long term success then doing it flapless.

Perhaps I have a slightly different take on this subject. First of all, I am in agreement with those that have posted on this subject. However, I think that there certainly is a place for this approach. We would all agree that experience is important. A flapless approach should not be seen as a short cut for beginners that are not comfortable laying flaps and manipulating tissue in their sleep ;o)

On the other hand, the experienced implant surgeon should have no problem determining the cases that meet the criteria of this approach. Some of the criteria are the dimensions of the recipient site, the morphology of the bone in that site, the ease of placement even if a flap is laid, etc. Most is in the first one, the dimension of the recipient site and the ability to determine it without a flap (an absolute must).

So, lets take a site that meets the criteria of being more than adequate dimensions, a morphology that is compatible with the desired implant position, and good healthy gingiva surrounding the site. In a situation like this a flapless approach in the experienced hands becomes almost a no-brainer. While a CT is helpful and certainly gives the maximum amount of information, many can be done with only a panorex.. the third dimension determined by bone sounding and morphology detection (more on that below). In a situation like this, this is how it is done:

Once local anesthesia is accomplished, the a 3 dimensional evaluation of the site can be determined: a) the thickness of the tissue can be determined by bone sounding. b) the morphology of the area and medial and lateral borders of the bone can be determined by evaluating subperiosteally with a periodontal probe.. skittering along the bone to determine the angulation of these borders (probes can be left in place as guides during initial drilling and/or checked throughout the osteotomy procedure). c) the location of vital structures may be noted on x/ray or CT.

Once these parameters are determined to allow placement of the implant in the correct prosthetic position, it becomes a quick and easy procedure to complete the osteotomies and fixture placement. One more thing, make sure that the area is decontaminated by chlorhexidine (Peridex or Hibicleans) prior to penetration with the implant fixture.. (this makes sense but I know of no observations of problems with osseointegration if this is not done). One more thing; it is important to assess the position of the top of the implant as it relates to the osseous crest, but this can be easily done with a probe to sound for the crest.. It can also be evaluated with an intra-op x-ray with a depth-probe in place. (not to be confused with a depth-charge... ;o)

So, what is the benefit? Primarily the ease and quickness of the procedure, and the very limited discomfort for the patient. Can this be done as a routine procedure? Yes as long as the criteria is met.

I had a conversation with Bob Lamb of the IDEA teaching facility a few weeks ago. He places almost ALL of his implants this way, and I believe he teaches the technique there as well.. I seem to recall Bob saying that he has not laid a flap for an implant in a long time!

I hope this helps!

Michael

Dear Dr Smith:

Monitor the central, don't panic. But remember that prevention is the key to avoiding complications. ALWAYS check your position after the first drill with a radiograph when ever there is a question. If you are VERY concerned during the initial placement, only drill 1/2 way to depth (or whatever you are comfortable with) and then check.. it is easy to redirect at this point.

Whether flapless or not, direction can be thrown off by crown position, so always check in the beginning. My recommendation, and I would expect it to be the recommendation of others as well, is to not attempt flapless approach until much experience is gained. But the flapless part of this might not be the problem.. direction can be off with or without a flap.

But, monitor the central and make sure that it is vital. Any indication otherwise, provide endodontic care. Next time, prevent by intra-op evaluation.

I am glad that you glean something useful from the posts...

Success rate with flapless is no different than traditional placement. Since osseointegration is related to methods of ostectomy, implant surfaces, etc., whether you place it with a flap or not has no bearing on integration, therefore no difference in success rate of osseointegration.

However, success as determined by position of the fixture from a prosthetic perspective might vary if one does not plan the case and instrument it appropriately. But that is up to the clinician placing the implant and would be the same whether a flap is laid or not..Given the above, there is no difference in success rate.

A very important aspect of this, as has been mentioned by others, is that you know exactly where you are, the volume and dimensions of the bone, and you must have no doubt of this if a flapless approach is provided. There is no excuse to exit the bony housing by accident, so there must be no doubt as to where you are at all times. IF, however, you find yourself in doubt or realize you have penetrated the border of the bone (cortical plate) into the tissue area, do not hesitate to lay a flap and graft the area and use a membrane.

Truly, a complete set of surgical skills are necessary in order to provide competent and safe implant surgery and one must be ready to initiate creative, well thought out alternatives to any event that may occur during any surgery at any time. Always establish a clear 3 dimensional image in your mind utilizing whatever methods you choose. With that, it becomes routine... without that, you may get bit!

Excellent comments, SL.... I could not agree more. In esthetic areas, it is important to fabricate a custom tissue controlling abutment and there are several ways to do this, the one you mentioned being one, a custom made abutment being another (can be done by adding composite for the shape required, pre op is way easier).

Non esthetic sites are easy. I would suggest considering very carefully what SL has said.

Michael