Quit flapping your gums
Featured Products Promotional FeaturesPosted by: Dental Design 16th November 2024
Many factors affect the outcome of dental implant treatment, making it important – albeit difficult – to control an abundance of elements that ensure immediate and long-term success. Slight deviations in implant angulation or depth could change the success of a treatment drastically, hence the need for predictable, reproducible dental implant placement strategies.
Guided surgeries have become favourable to many clinicians, and where a more accurate and beneficial result could be achieved, its current strengths must be explored.
They are also a potential aid to the problem of “minimally invasive” dentistry, which is championed in an attempt to improve the patient recovery process and avoid excessive treatment interventions. Understanding how guided implant surgery supports this is important for all dental professionals operating in this realm of care.
Battling convention
A guided placement workflow creates the opportunity to explore a flapless and therefore minimally invasive treatment approach.
Conventional surgery involves a crestal incision and the raising of a mucoperiosteal flap.[i] This allows for improved visualisation of the surgical site and access to the alveolar bone, meaning clinicians can identify and protect anatomical landmarks.
However, this approach is inherently invasive. With additional surgery performed on the soft tissue, suturing is necessary, and a degree of morbidity and discomfort is expected.[ii] It has also been shown that flap reflection is associated with gingival recession and bone resorption around natural teeth.ii Statistically significant results for marginal bone loss around dental implants where a conventional flap technique has been employed are reported in the literature.ii
New guided surgical techniques have allowed clinicians to implement flapless treatments in appropriate cases. With the development of computed tomography (CT) and cone beam CT (CBCT) scans, clinicians now have the ability to analyse and plan around the existing anatomical structures with great accuracy.[iii] Where sufficient bone quantity has been identified, a flapless technique may be employed. The planning process means clinicians can work with the anatomy, identifying the most optimal locations for implant placement – especially helpful as an alternative solution when working with severe atrophy of the residual alveolar bone.[iv]
A flapless approach has been suggested to improve healing time of the soft tissue, minimally interfere with the blood supply (which also results in a reduction of bleeding), and develop a shortened surgical time.[v]
The literature has found that flapless implant surgery provides comparable implant survival rates and complication rates to a conventional approach, making it a viable alternative without compromising care.[vi] There are debates about the efficacy of a guided approach. Some researchers suggest that freehand placement could lead to a threefold higher failure rate,[vii] others believe there is no significant difference at all – but it should be noted that this aspect may be influenced by the experience of the presiding clinician.v A guided approach can be especially useful when dental professionals are expanding into new personal territories of implant care.
Ultimately unavoidable
There are cases where a flap must be raised to give a dental implant the greatest opportunity for long-term stability. When the site features resorbed or weakened bone structure, tissue augmentation may be the only viable solution that a dental professional can recommend and carry out. Luckily, the use of prosthetically-driven implant placement means clinicians can still benefit from the use of guided care.
By choosing a guided workflow, clinicians can identify the need for augmentation procedures in the planning stages,[viii] and remain confident in the predictability of the final outcome. A guide design can be fabricated with considerations for an implant being placed concurrently with hard/soft tissue augmentation, or revisited once grafts have had time to begin the healing process.
A flap will, of course, need to be raised for augmentation techniques to be used so that clinicians can access the treatment site. In these cases, clinicians can use the planning process to determine that increased soft tissue recovery is an unavoidable necessity in order to facilitate long-term implant stability and health.
Developing skills
No matter the case presented to clinicians, choosing to implement guided surgical and augmentation techniques is only possible when a dental professional is appropriately trained and confident in their abilities.[ix] The Postgraduate Diploma in Advanced Techniques in Implant Dentistry from One to One Implant Education can equip clinicians with the skills and knowledge to tackle complex cases, and develop their knowledge of guided surgical interventions. The course explores hard and soft tissue augmentation, ensuring dental professionals can effectively and reliably provide care for a wide variety of patients, and use the techniques upon their return to the practice.
Guided surgery can provide a variety of benefits to the dental professional. Whilst it may not guarantee a flapless workflow and its associated recovery benefits, it can establish processes that help clinicians design the best possible approach in each given situation.
To reserve your place or to find out more, please visit
https://121implanteducation.co.uk or call 020 7486 0000.
Author bios:
Dr Fazeela Khan-Osborne is the founding clinician of the FACE dental implant multi-disciplinary team for the One To One Dental Clinic based on Harley Street, London. She has always had a passion and special interest in implant dentistry, particularly in surgical and restorative full arch rehabilitation of the maxilla. She has been involved in developing treatment modalities for peri-implantitis within clinical practice.
Dr Khan-Osborne is also the Founding Course Lead for the One To One Education Programme, now in its 20th year. As a former Lead Tutor on the Diploma in Implant Dentistry course at the Royal College of Surgeons (England), she lectures worldwide on implant dentistry and is an active full member of the Association of Dental Implantology, the British Academy of Aesthetic Dentistry and the International Congress of Oral Implantologists.
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Nikolas is a Senior Implant and Restorative Surgeon in private clinics in London and Edinburgh. His special interest and main qualifications are in Oral Surgery and Oral Implantology, while he has vast experience in all areas of Aesthetic Dentistry. He has been a practising Dental Surgeon since 2005 after graduating from the prestigious Military Academy Medical School at the University of Thessaloniki, Greece.
Nikolas started his training in the Oral and Maxillofacial Surgery Department of the 401 Military Hospital in Athens, Greece. As a military officer, he then went on to serve as a team leader in a field hospital in Kabul, Afghanistan – an experience, which shaped his commitment and dedication to his chosen field. On returning to Greece, he furthered his training completing a Postgraduate Diploma in Oral Implantology from the University of Athens, Greece and a Master of Science Degree in Oral Surgery/Implantology from Göethe University of Frankfurt, Germany. He recently obtained an Advanced Surgical Master Curriculum in Regenerative Implant Dentistry next to Dr Istvan Urban in Budapest, Hungary. Nikolas is lecturing about Dental Implants and Regenerative Dentistry, and he is holding a program for introducing and mentoring dentists in Implant Dentistry. He is a Member of the Association of Dental Implantology and the International Team for Implantology.
[i] Yadav, M. K., Verma, U. P., Parikh, H., & Dixit, M. (2018). Minimally invasive transgingival implant therapy: A literature review. National journal of maxillofacial surgery, 9(2), 117-122.
[ii] Shamsan, Y. A., Eldibany, R. M., El Halawani, G. N., & Fahmy, R. A. (2018). Flapless versus conventional flap approch for dental implant placement in the maxillary esthetic zone. Alexandria Dental Journal, 43(2), 80-85.
[iii] La Monaca, G., Pranno, N., Annibali, S., Di Carlo, S., Pompa, G., & Cristalli, M. P. (2022). Immediate flapless full‐arch rehabilitation of edentulous jaws on 4 or 6 implants according to the prosthetic‐driven planning and guided implant surgery: A retrospective study on clinical and radiographic outcomes up to 10 years of follow‐up. Clinical Implant Dentistry and Related Research, 24(6), 831-844.
[iv] Pommer, B., Busenlechner, D., Fürhauser, R., Watzek, G., Mailath-Pokorny, G., & Haas, R. (2016). Trends in techniques to avoid bone augmentation surgery: Application of short implants, narrow-diameter implants and guided surgery. Journal of Cranio-Maxillofacial Surgery, 44(10), 1630-1634.
[v] Romero-Ruiz, M. M., Mosquera-Perez, R., Gutierrez-Perez, J. L., & Torres-Lagares, D. (2015). Flapless implant surgery: A review of the literature and 3 case reports. Journal of clinical and experimental dentistry, 7(1), e146.
[vi] Cai, H., Liang, X., Sun, D. Y., & Chen, J. Y. (2020). Long-term clinical performance of flapless implant surgery compared to the conventional approach with flap elevation: A systematic review and meta-analysis. World journal of clinical cases, 8(6), 1087.
[vii] Abdelhay, N., Prasad, S., & Gibson, M. P. (2021). Failure rates associated with guided versus non-guided dental implant placement: a systematic review and meta-analysis. BDJ open, 7(1), 31.
[viii] Schubert, O., Schweiger, J., Stimmelmayr, M., Nold, E., & Güth, J. F. (2019). Digital implant planning and guided implant surgery–workflow and reliability. British dental journal, 226(2), 101-108.
[ix] General Dental Council, (2019). Standards for the dental team. (Online) Available at: https://www.gdc-uk.org/standards-guidance/standards-and-guidance/standards-for-the-dental-team [Accessed August 2024]
