12 a clinico – radiographic clinico radiographic4j.pdf · apical area was prepared for the...

ABSTRACT: Background: Replacement of lost natural teeth by osseointegrated implant has represented

the most revolutionary advancement in restorative dentistry. For implant placement surgically flap

technique is commonly used in day today practice but very few cases have been done with minimal

invasive flapless techniques, which offers several advantages over flap technique including less

postoperative bleeding, less discomfort, minimized crestal bone loss, and shorter surgery and recovery

time.

Aims and objectives: ?To evaluate and compare the bone level and soft tissue changes around implants

using conventional radiography in flap and flapless technique.

Materials and Method: A study comprised of 14 implants wherein 7 were placed using flap technique and

other using flapless technique. Clinical assessment by measuring the plaque accumulation, bleeding on

probing and probing depth along with radiographic evaluation for the marginal bone loss were carried out

at baseline, 1 month, 3 months, 6 months was carried out and compared for both the techniques.

Results: Both with-flap (Group I) and flapless (Group II) during the six months follow up, changes in soft

and hard tissue was statistically significant with flap approach when compared to flapless approach.

Conclusion: Both the techniques showed clinical and radiographical changes but the flapless technique

showed a lesser reduction. Therefore, the flapless technique can be considered as a better alternative

treatment approach for placement of implants

1 2 1Dhinsa Gurpreet, Senior Lecturer , Saimbi CS, Professor , Tandon Pradeep, Professor , 3 3 4Saha Sonali Reader , Dhinsa Kavita, Reader , Karki Rishiraj Singh, Senior Lecturer ,

1 Department of Periodontology, Career Post Graduate Institute of Dental Sciences & Hospital, 2Lucknow, India, Department of Periodontology, Universal College of Medical Sciences, Bhairahawa,

3Nepal, Department of Pedodontics and Preventive Dentistry, Sardar Patel Post Graduate Institute of 4Dental and Medical Sciences, Lucknow, Department of Periodontology, Eklavya Dental College &

Hospital, Kotputli, Rajasthan, India

Professor,

INTRODUCTION: The idea of replacing missing tooth with

an artificial substitute has been an important part of dentistry.

In earlier times, missing teeth and its supporting structures

have been replaced with dentures or bridges but these

conventional methods had certain limitations like difficulties

in eating, speech and stability. Hence, the clinical

replacement of lost natural teeth by osseointegrated implant

has represented the most revolutionary advancement in

restorative dentistry.1 For implant placement surgically flap

technique is commonly used in day today practice but very

few cases have been done with minimal invasive flapless

techniques as which has several advantages over flap

technique including less postoperative bleeding, less

discomfort, minimized crestal bone loss, and shorter surgery

and recovery time.2 Consequently, the present study was

undertaken to evaluate and compare the hard and soft tissue

A CLINICO – RADIOGRAPHIC COMPARATIVE

EVALUATION OF HARD AND SOFT TISSUE

CHANGES AROUND IMPLANTS PLACED BY FLAP

AND FLAPLESS TECHNIQUE: AN IN VIVO STUDY

Journal of Dental Sciences

University

University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 67

University J Dent Scie 2018; Vol. 4, Issue 1

Research Article

Keywords:-

Keywords: Flap, Flapless,

Implant, Osseo integration,

Minimally Invasive

Conflict of interest: Nil

No conflicts of interest : Nil

changes around the implant placed by flap and flapless

technique.

Material & Methodology

A standardized implant integration protocol for each site

included the principles of subject selection, site evaluation

and grouping, proper planning. Pre-operative preparation,

optimal implant placement and implant specified provisional

and definitive restoration was accomplished.

Study Design

The study comprised of 7 patients aged from 20 to 60 years

were selected for implant placement.

A) Surgical stent:

An alginate impression was taken of the edentulous site and a

positive replica was made of dental stone model (cast). An

acrylic tooth was placed on the edentulous site of the surgical

template, stimulating the missing tooth. A hole was then

drilled through the central fossa of the acrylic tooth in case of

the posterior missing teeth and on the centre of cingulum for

anterior missing tooth. The hole was then widened which

helped in guiding the lance drill during osteotomy for

marking the optimal location on the alveolar crest in order to

verify the implant position during placement.

b) Radiographic Stent:

A metallic ball of a known diameter was embedded in the

acrylic at the edentulous site. The patient is asked to wear the

radiographic stent and orthopantomogram is taken. The

percentage magnification in ball is then calculated which

gives an overall magnification at the planned implant site as

well. The actual amount of bone is then known.

Investigations:

Complete Haemogram including Hb%, TLC, DLC, PCV,

bleeding time and clotting time was done to evaluate the

fitness of the patient for stage I surgery or implant placement.

Surgical procedure:

A) Flap Design

B) Flapless Design

A. Flap Design (Figure 1- 3)

After achieving adequate local anaesthesia, crestal incisions

were placed on the edentulous site with no. 15 B.P. blade. The

crestal incisions were extended to the mid buccal and mid

lingual crevices of adjacent tooth. Full thickness flaps were

elevated using periosteal elevator. Drilling of the osteotomy

site was done according to the manufacturer instructions. The

apical area was prepared for the placement of implant. Bone

drilling was performed at revolutionary rates recommended

by Branemark i.e.1000-1500 Rpm.3 To minimize trauma to

bone, drilling was performed at low speeds, the area was

profusely irrigated with chilled saline solution, to avoid

overheating and thus necrosis of alveolar bone and drills were

used in progressively increasingly diameters. The depth and

angulations were checked continuously with the help of depth

gauge paralleling pins which has depth markings. Once, the

depth and angulation of the osteotomy was confirmed, use of

subsequent drills for final osteotomy preparation capable of

accepting the fixture dimension was accomplished. The

implant site was generously irrigated with sterile saline to

ensure no debris or bone chip left at the base or attached to the

vertical walls of the osteotomy site following preparation.

Implant placement: (Figure 4-5)

Implants of decided dimension were placed at a speed of 20-

30 rpm. During implant placement care was taken for the

angulation of placement. After completion of implant site

preparation titanium implants were then placed with the collar

of the implant at the level of the bone crest on the labial aspect.

All implants were placed with primary stability and were

completely housed within the implant osteotomy.

Suturing of the flap

The flap margins were then repositioned and sutured tension

free by applying simple interrupted and /or simple mattress

lock sutures with a 3, 0 braided silk suture for 7-10 days.

B. Flapless Design :

Before surgery, alginate impression and cast fabrications

were carried out for all patients. Over the model, surgical

stents, size customized to implant drills, were made in each

case from the cast using the technique described by Shotwell

et al.(2005).4 Ideal implant angulation was determined on the

cast using a dental surveyor. The proposed implant site was

marked and drilled in the cast using a bench-top drill press and

drill bits matching the ascending size of surgical drills. By

sequentially placing drill blanks matched to the diameter of

the holes prepared in the cast, surgical stent is fabricated using

soft cure acrylic resin. Soft tissue of the proposed implant site

was ink-marked, guided by surgical stent, and punched with a

4 mm tissue punch (Figure 6).

After tissue punch was made, soft tissue thickness was

measured using a University of North Carolina (UNC) probe.

Implant osteotomy and placement were performed using the

size-customized implant drill guides, according to the

manufacturer's surgical protocol (Figure 7). A periapical

radiograph was taken during the osteotomy to ensure proper

angulation and length of the proposed implant site. All

patients received a root-form endosseous implant via flapless

surgery.



Post Surgical Follow up:

The patients were called up for the post-operative checkup

after 24hrs. In case of patients done under flap technique,

sutures were removed seven days after surgery. Regular

follow up of all patients were done at 1st day, 7 days, 15 days,

1st month, 3rd month and 6th month there on and required

investigations were done whenever needed.

SECOND STAGE SURGERY: Three-four months after

implant placement second stage surgery was initiated. Mid

crestal incision was placed and flap was reflected. Cover

screw was removed and gingival former was placed for a

period of 15days. This resulted in formation of gingival cuff

or gingival collar. Gingival former was removed with the help

of 0.50 hex driver, abutment was placed over implant and

screw was tightened. Impressions were made using addition

silicone impression material with a closed tray technique. The

impression was sen to the dental laboratory for the fabrication

of porcelen fused to metal prosthesis. The miled abutment

was placed in the dental implant and abutment screw or

prosthesis screw was tightened. Cementation of prosthesis

was done and patient was kept on a follow up of 1st month, 3rd

month and 6th month for evaluation of parameters.

CLINICAL PARAMETERS: Patients were evaluated with

the following clinical parameters at baseline, 1 month, 3

months and 6 months.

1. Bleeding on probing- evaluated by Bleeding Index

of Mombelli et al. (1987).5 Bleeding on probing elicited after

the insertion of a probe into the sulcus used to assess peri-

implant tissue conditions around implants. It was used to

examine the health status of sulcular epithelium with scores

ranging from 0-3.

2. Plaque accumulation- measured with the help of

modified plaque index of Mombelli et al. (1987).5 The

original plaque index has been slightly modified to assist

formation around implants with the help of probe and

recorded as the scores given below.

3. Probing Depth : It was measured in millimeters with

a plastic periodontal probe on mesial, distal, buccal and

lingual surfaces of the implant.

RADIOGRAPHIC PARAMETERS: Intra oral Periapical

radiographs were taken for all the implant sites of selected

subjects at 1st, 3rdand 6th month's interval to assess marginal

bone loss. The marginal bone height of each fixture was

measured mesially and distally by using the fixture threads as

an internal dimensional reference with the help of a

millimetric grid.

All the recorded clinical and radiographic parameters were

entered in the standard proforma drawn for this study and was

subjected to statistical analysis.

STATISTICAL ANALYSIS : The data was analyzed using

Statistical Package for Social Sciences (SPSS) version 15.0.

Chi-square test was used to compare the categorical data. As

the sample size was small, hence a non-parametric evaluation

plan was adopted. Mean differences were compared using

Mann Whitney U test. Within group differences at different

time intervals were assessed using Wilcoxon Signed Rank

test. The confidence level of the study was kept at 95%, hence

a "p" value less than 0.05 indicated a statistically significant

difference.

RESULTS : The hard and the soft tissues around implant was

evaluated and compared at four different time points,

baseline, 1, 3, 6 months after implant placement on both the

proximal aspects (mesial and distal) for both techniques

separately. No dropouts were registered during the follow up

of the study

At baseline and 1st month no significant difference between

two groups was observed for any of the parameters.

At three months interval as compared to Group I, for all the

clinical variables, the mean value of Group II was lower,

however the difference was significant statistically only for

pocket depth (p=0.004)



At six months interval as compared to Group I, for all the

clinical variables, the mean value of Group II was lower,

however the difference was significant statistically only for

bleeding on probing and pocket depth (p<0.05).

At the entire three intervals the mean crestal bone changes

were lower in Group II as compared to Group I but the

difference was not significant statistically (p>0.05) at any

time interval.

DISCUSSION : Long-term success and failures of various

techniques depend upon a traumatic surgical procedure,

primary implant stability and finally the amount and quality

of bone surrounding the implant.6 Single tooth implant can be

placed either using flap or flapless techniques. To minimize

the possibility of postoperative peri-implant tissue loss and to

overcome the challenge of soft tissue management during or

after surgery, the concept of flapless implant surgery has been

introduced as studied by Campelo & Camara (2002). 7

The rationale for choosing a submerged, countersunk surgical

approach and delayed loading period in our study was to

reduce and minimize the risk of bacterial infection, to prevent

apical migration of the oral epithelium along the body of the

implant, and to reduce and minimize the risk of early implant

loading during bone remodelling as premature micro motion

will repeatedly disrupt the normal osseous modelling

processes leading to fibrous tissue encapsulation rather than

on direct bone apposition around the implant. 8,9

The ultimate goal of implant surgery is a properly positioned

and properly supported restoration. For exact surgical

placement of the implant, pre-placement surgical stents were

utilized. These surgical stents were prepared from transparent

material which covered enough adjacent teeth to be stable and

rigid when positioned, as also used in a study by Pal et al.

(2010). 10

The protocol of dental implants has undergone many

advances since the beginning of usage. In this respect, the

temperature rise within the alveolar bone during osteotomy

preparation is the one critical factor that affects the primary

healing capability of alveolar bone. The studies have

indicated that the success of endosteal implants depends on

the primary healing capability of alveolar bone. Huang et al.

(2010) in their study stated that the temperature over 47°C for

1 min causes 'heat necrosis' in the bone and without irrigation,

drill temperatures above 100°C are reached within seconds

during the osteotomy preparation.11

In addition to temperature rise, excessive pressure to the bone

may cause pressure necrosis and increase the devital zone of

bone around the implant during healing. According to the

surgical guidelines given by Misch (2008) torque value up to

35 N-cm is considered safe with most threaded implant

designs. Thus, once the implant site was ready for implant

insertion, the selected implant was rotated to a torque of

approximately 35 N-cm while threading into position.12

A large number of varying criteria; for implant success have

been published over the last 25 years with each being a better

reflection of the continually evolving science of

Implantology. Be it be the most widely accepted criteria given

by Albrektsson et al. (1986) 13 or Zarb et al. (1989) 14, no

single set of criteria could address the entire implant system in

each and every patient while attempting to judge the success

rate of an implant.

Taking into consideration all the criteria given in various

literatures, a set of four (three clinical and one radiographic)

criteria for assessment of hard and the soft tissue changes

taking place around our implant, which would further analyze

the success and survival rate of the implant.15

Although implants are fundamentally different from natural

teeth in that they do not decay, have no dental pulps to

function as early indicators of disease and have no periodontal

membrane but implants placed in the oral cavity represent

artificial surfaces colonized by bacteria from saliva and

ecologic niches such as periodontal pockets, tonsils, and

crypts of the tongue. Also, experimental and human studies

have provided evidence that formation and development of a

microbial biofilm represents an important etiologic factor in

the pathogenesis of peri-implant disease. It is thus appropriate

to apply periodontal parameters to the perimplant tissues and

monitor their condition in a similar manner as the periodontal

tissues.15

Plaque is considered an important etiological factor in peri-

implantitis. Significant relationships have been shown

between the modified plaque - index and several

microbiological features of subgingival plaque on implants.

Mombelli et al. (1987) modified the original Plaque-Index

introduced by Sillness and Loe to assess biofilm formation in



the marginal area around implants. So, the Modified Plaque-

Index did the evaluation of plaque in our study.5, 16

The results of plaque assessment shows that there was an

increase in plaque accumulation from baseline to 1st, 3rd, 6th

month in both the groups whereas on comparing both groups

plaque index were higher in group I as compared to group II at

all time intervals. This could be attributed to plaque control by

the patient and the repeated reinforcements of oral hygiene

measures given to the patient by the clinician. The change in

plaque index at different periods remained statistically the

same, which were similar to the earlier studies conducted by

Oh et al. (2006), Esposito et al. (2007).17, 18

With regard to mucosa around the implant, diagnostic

accuracy of bleeding on probing (BOP) appears to be a better

predictor. In case of a peri-implant sites absence of bleeding

on probing is considered healthy and stable. Thus, periodic

recording of this parameter with light probing force (0.2-

0.25N) can be recommended to measure peri-implant soft

tissue conditions. Therefore, bleeding on probing was

measured using Mombelli et al., (1987) index.5

The results of the study shows that the scores increased in the

1st and 6th month but decreased 3rd month from baseline in

group I and group II. This could be due to the fact that after

loading the implant, hygiene could not be well maintained in

the sub gingival regions but later when the repeated

reinforcement of oral hygiene measures were given to the

patient the inflammation subsided and so did Bleeding on

Probing. As compared to Group I, for all the clinical variables,

the mean value of Group II was lower, however the difference

was statistically significant only for bleeding on probing

(p<0.05) in 6th month.

However, the reduction was not statistically significant

(p>0.05) i.e. the change in bleeding index at different periods

remains statistically the same, which were in accordance with

the earlier studies conducted by Cooper et al. (2001), Camelo

& Camara (2002) and Becker et al. (2009). 19, 7, 20

In a study by Bauman (1992), probing proved to be the most

accurate means of detecting peri-implant destruction. He

suggested using radiographic and probing measurements

together to facilitate the accuracy and variability of

comprehensive peri-implant assessment. Investigators have

debated the diagnostic and prognostic value of crevicular

probing depth. Because the epithelial attachment adheres

only weakly, some would consider probing to be invasive,

allowing penetration of the probe close to the bony crest.

However, probing does provide a means for assessing clinical

attachment loss over time, which may be an indicator of a

failing implant. Probing should be avoided during the first 3

months after abutment connection so that progressive healing

is not disturbed.21

Probing depths alone may not accurately reflect peri-implant

bone loss (attachment-loss) if a concomitant gingival

recession parallels the bone resorption. The location of the

fixed reference point should be recorded on the patient's chart.

It is recommended that sulcular probing around metal

implants be accomplished with available periodontal probes

of similar metal or plastic. This will prevent scratching and

electrochemical interaction between dissimilar metals, which

could be detrimental to the biocompatibility of the implant.

So, the probing technique in the present study was in

accordance with the above-mentioned method. We used a

plastic probe for probing. The implant shoulder was taken as

the reference point and the probe was gently directed parallel

the long axis of the implant, between the mucosa. The probing

depth was measured from the gingival margin to the apical

advancement of the probe's tip on the four aspects around each

implant (to the nearest 0.5 mm) (mesial, distal, buccal and

lingual). The probing depths were measured at baseline, 1st,

3rd and 6th months from loading and the analysis was done.

The results of peri-implant probing depths shows that the

probing depth has increased from baseline to 1st, 3rd and 6th

months in both groups. All the tables showed that there was an

increase in pocket depth scores from baseline to 1st to 3rd to

6th month in both the groups. As compared to Group I, for all

the clinical variables, the mean value of Group II was lower,

however the difference was significant statistically for pocket

depth (p<0.05), which were accordance to the early studies

conducted by Velde et al. (2007) and Sclar (2008). 22, 23

According to Salvi (2004), probing depth of approximately

3mm can be detected around successful implants. In our study

although values for probing depth have increased

significantly in pool of patients, the values stayed within

physiologic level of 3mm throughout the entire observation

period, so healthy peri-implant conditions prevailed. 24

Long-term preservation of crestal bone height around

osseointegrated implants is often used as primary success

criteria for different implant systems. Originally, a mean

crestal bone loss > 1.5 mm during the first year after loading

and > 0.2 mm/year thereafter had been proposed as one of the

major success criteria. 13

The results of our study showed that there was increase in

marginal mean bone level at distal and mesial location at



every month 1st, 3rd & 6th month in both the groups. This

may be due to difficulty in maintaining proper oral hygiene.

(Bragger et al.1997). 25 From the baseline to the 1st, 3rd, &

6th month distal location had a higher bone loss in group I as

compared to group II. All the three interval the mean crestal

bone changes were lower in group II as compared to group I

but the difference was not significant statistically (p>0.05)

which were similar to early studies conducted by Wood et al.

(1972), Sclar (2007), Job & Bhat (2008). 26, 27

CONCLUSION

Our study clearly demonstrates that in both with-flap (Group

I) and flapless (Group II) during the six months follow up,

changes in soft and hard tissue was statistically significant

with flap approach when compared to flapless approach. Also

in-group of patients with no periodontal disease the survival

rate of two-stage, countersunk, submerged implants in the

edentulous sites is 100% during a follow-up period of 6

months. Possible explanations may be proper case selection,

diagnosis, aseptic method of surgery, maintenance of good

oral hygiene during follow up period. In order to increase our

understanding, studies need to be conducted with longer

duration and a larger sample size.

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CORRESPONDING AUTHOR:

Dr. Gurpreet Dhinsa

Department of Periodontology

Career Post Graduate Institute of Dental Sciences & Hospital,

Lucknow, India.

Mobile No. 9839130943

Email: [email protected].

Figure 1: Full thickness Flap was raised

Figure 2: Prepared Osteotomy Site

Fig.3: Marking the Depth using Pilot Drill

Fig.4 Tightening of Implant using Ratchet

Figure 5: Cover Screw Tightened over Implant

Figure 6: Tissue Punch

Figure 7: Implant Placed on the prepared osteotomy site



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