Flapless Dental Implantation using Cortex Implants

Flapless Dental Implantation
using Cortex Implants
By Dr. Meir Mamraev DMD LLB
We Prove It Every Day
The following case study discusses the flapless implant surgery approach using the Cortex implant package
and surgical kit. This article will depict the background for this technique as well as the potential advantages
and disadvantages of the procedure.
The first studies of the flapless implant procedures began to appear in the last parts of the twentieth century
after Lederman1 introduced the technique in 1977. A comprehensive study was conducted in 2002 by Campelo
& Camara2, who evaluated retrospectively 770 implants placed with a flapless approach over a period of 10
years. The cumulative success rate for implants placed using a flapless one-stage surgical technique after a 10year period improved from 74.1% for implants placed in the 1990’s to roughly a 100% from year 2000 onwards.
This remarkable change can be largely attributed to the changes and technological advancements made in the
surface of the various implants used in the procedure as well as the implants shapes.
The advantages illustrated and discussed in this case study were presented initially by Dr. Becker3 in 2005
and consist of the following: Reduced surgical procedure time; Minimal changes in crestal bone levels; Probing
depth and inflammation; Minimized perceived bleeding; Lessened post-operative discomfort. In recent years, the
popularity of the flapless technique gained due to the introduction of CT scans and tomography technological
advancements, enabling doctors the possibility to use more accurate guiding methods in order to achieve
accurate implant placement.
A study conducted in 2006 by Ghent University4 showed that there were no real differences in perforation
or dehiscence of the crestal bone by either novice doctors or professional periodontics, corroborating the
assumption that the flapless technique was in fact a reliable and easy to use method. The arising conclusion
form the study showed that the key element of procedural success was the familiarity with the bone structure
and anatomy.
A later study performed in 2009 by Goldstein & Becker5 published a 4 year follow-up result showing 98.7%
survival rate. Goldstein & Becker concluded that flapless surgery was in fact a procedure with high implant
predictability due to insignificant crestal bone loss for up to 4 years, and that proper diagnosis and treatment
planning are key factors in achieving predictable outcomes. However, they asserted that the procedure actually
required advanced clinical judgment and surgical experience and that surgeons performing the flapless
procedure should also be familiar with other minimally invasive techniques such as minimal incisions and flaps,
pouch techniques and tunnel dissections.
Apart from familiarity with the structure, anatomy and indications of the intended implantation site, a
surgeon performing the surgery should be aware of the management of peri-implant soft tissues. Ideal tissue
thickness is should be between 2.5mm and 3mm. This contributes to the maintenance of a stable peri-implant
soft tissue environment. The combination of adequate soft tissue thickness and apicocoronal dimension of
keratinized tissue help resist recession, protects peri-implant crestal bone levels, and provides esthetic masking
of underlying metal components.
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Cortex Dental Industries Ltd.
The advantages of the flapless procedure
The natural tooth has three sources of blood supply
including: pulp, periost and bone. As the implant placed
in the bone does not have pulp left are only two sources
of blood supply – the periost and bone. Periostal flap
elevation, results in of roughly 80% of the remaining blood
supply. This may result in some deficiency in blood supply
to the implant area and bone necrosis.
The preservation of soft tissue architecture
If a surgeon does not raise a flap after extraction he is left with complete integrity of the papillae architecture
that may be preserved with a direct placement of the implant to the extraction site even in cases where immediate
loading is performed, as can be seen in the following pictures where Cortex implants are used for fixed restoration.
Preservation of hard tissue volumeat the site
Especially in cases of implantation after extraction, when a flap is raised, it is possible that small pieces of the bucal
plate might be dislocated when it is relatively thin. As can be seen in the pictures below, refraining from raising a
flap can help preserve the site its initial structure thus protecting the delicate and thin layer of bone plate and, if
necessary, perform bone augmentation around emerging implant structure.
Cortex Dental Industries Ltd.
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Time Consumption and patient discomfort
Statistics show that the use of the flapless approach decreases surgery time by a factor of two, from an average of
28 minutes (±13 minutes) to roughly 15 minutes. In addition, statistics show that when using a flapless approach a
dramatic decrease in post-operative discomfort is present. Fewer prescriptionsfor analgesic were required and the
amounts of drugs consumed by patients were substantially lower and for shorter periods of time.
Accelerated recuperation and resumption of
normal hygiene
On the day of surgery
Two weeks post-op
As a result of a less traumatic procedure to the soft tissue, without flap elevation, a significantly better soft tissue
recuperation and better result is noticed when a flapless technique is utilized.
The absence of incisions and sutures post-surgery allows the patient to resume a better hygiene regime sooner and
with less discomfort. This is mostly due to the fact that most patients tend to resume brushing of the implant area
faster when pain levels are lower.
On the day of surgery
Two weeks post-op
Precautions and Disadvantages
There are some notable disadvantages surgeons should consider before opting for the flapless approach. The first is
the inability to visualize anatomic landmarks and vital structures that may exist beneath the surface. Such structures
may include under-cuts in the mandible, maxillary sinuses or under-cuts in the pre-maxilla.
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Cortex Dental Industries Ltd.
An additional disadvantage with using the surgical guides is the potential risk of thermal damage secondary to
reduced access for external irrigation during osteotomy preparation. In some cases it is advised to use internal
irrigation for this specific reason.
Another disadvantage is the possible perforation of the bucal plate as
a result of malposed angle. If that occurs, it is advised that the doctor
discontinue the flapless approach and raise a flap, or use a pouch or
tunnel techniques in order to remedy the situation.
Another issue that should be addressed is that a flapless technique
decreased ability of making a contour of osseous topography allowing
the detection of various bone defects around the implant emergence. Like advised earlier, in cases where such defects
are either suspected or found during the procedure, it is advised to raise a flap and facilitate a restorative procedure.
When the implant site not allow to obtain a circumferential adaptation of approximately 3 mm of keratinized tissue
surrounding the emerging implant, flapless approach should not to be done, and flap elevation or other minimally
invasive procedure in order to make an apical re-positioning of the flap should be performed.
Case Study - Application of the free-hand
flapless approach
The following is a step by step depiction
of a flapless approach technique use with a
set of Cortex implants and tools. As evident
in the pre-op scans, the subject is a 35 year
old healthy male with reasonably good bone
topography for implantation.
The CT scan shows that there is adequate
width and height for the flapless procedure.
In this case soft tissue punching was with
a surgical bur. A Cortex pilot drill was used
next according to the desired length of the
implant, established pre-op in the treatment
plan.
Cortex Dental Industries Ltd.
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It is highly important to check with a depth probe in the osteotomy site the integrity of the bone along the
osteotomy preparation. If at this part of the procedure one can recognize signs of perforation, one should abandon
the flapless technique and raise a flap or utilize pouch or tunnel techniques.
After the initial preparation an additional drills was used as shown for the placement of a Cortex Dynamix 4.2 mm
implant.
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12
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Cortex Dental Industries Ltd.
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If the torque of insertion of the implant is above 40N/cm, measurable by a surgical torque wrench, Cortex implants
are especially suitable for immediate loading. However, in this case since the site is posterior and there was no
requirement for aesthetic considerations, the abutment was left in place and was covered with a plastic healing cap
that is conveniently included in the Cortex PREMIUM package of the implant.
As can be seen below, the combination of the flapless approach and the Cortex implant system provide exceptional
results.
Two weeks post-op X-ray
Two weeks post-op site condition
Final Restoration
Cortex Dental Industries Ltd.
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References:
1. Ledermann, Ph.D. (1977) Vollprothetische Versorgung des atrophierten Problem–UnterkiefersmitHilfe von CBS
Implantaten. Quintessenz 12: 21–26).
2. Campelo, L.D. & Camara, J.R. (2002) Flapless implant surgery: a 10-year clinical retrospective analysis. International
Journal of Oral & Maxillofacial Implants 17: 271–276
3. Becker, W., Goldstein, M., Becker, B.E. & Sen- nerby, L. (2005) Minimally invasive flapless implant surgery: a prospective
multicenter study. Clinical Implant Dentistry and Related Research 7 (Suppl. 1): S21–S27.
4. Van de Velde T, Glor F, De Bruyn H. A model study on flapless implant placement by clinicians with a different experience
level in implant surgery. Clin. Oral Impl. Res. 19, 2008; 66–72
5. Becker W, Goldstein M, Becker BE, Sennerby L, Kois D, Hujoel P (February 2009). "Minimally invasive flapless implant
placement: follow-up results from a multicenter study". Journal of Periodontology 80 (2): 347–52
6. Anthony G. Sclar, DMD Guidelines for Flapless 2007 American Association of Oral and Maxillofacial Surgeons
7. Lazzara RJ: Immediate implant placement into extraction sites: Surgical and restorative advantages. Int J Periodont Rest
Dent 9:333, 1989.
8. Andersen, E., Haanæs, H.R. & Knutsen, B.M. (2002) Immediate loading of single-tooth ITI implants in the anterior maxilla:
a prospective 5-year pilot study. Clinical Oral Implants Research 13: 281–287
9. Casap, N., Tarazi, E., Wexler, A., Sonnenfeld, U. & Lustmann, J. (2005) Intraoperative computerized navigation for flapless
implant surgery and immediate loading in the edentulous mandible. International Journal of Oral & Maxillofacial
Implants 20: 92–98.
10. Berglundh T, Lindhe J: Dimension of the peri-implant mucosa: Biologic width revisited. J ClinPeriodontol 23:971, 1996
11. Ledermann, Ph.D. (1977) VollprothetischeVersorgung des atrophierten Problem–UnterkiefersmitHilfe von CBS
Design & Concept by StudioGE.com
AC-FMEIR Rev-01
Implantaten. Quintessenz 12: 21–26).