Open Journal of Stomatology, 2013, 3, 298-305 OJST
doi:10.4236/ojst.2013.35050 Published Online August 2013 (http://www.scirp.org/journal/ojst/)
Short-term postoperative discomfort in patients receiving
flapless contra open implant surgery
Alexander Aizenberg1, Jesper Jansson1, Peter Abrahamsson2
1Department of Oral and Maxillofacial Surgery and Oral Medicine, Faculty of Odontology, Malmö University, Malmö, Sweden
2Maxillofacial Unit, Halmstad Hospital, Halmstad, Sweden
Email: alex@alinks.se, jesper.jansson@gmail.com, peter.abrahamsson@regionhalland.se
Received 11 May 2013; revised 12 June 2013; accepted 10 July 2013
Copyright © 2013 Alexander Aizenberg et al. This is an open access article distributed under the Creative Commons Attribu-
tion License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
ABSTRACT
Purpose: The aim of this pilot study was to evaluate
subjective and objective findings on short-term post-
operative discomfort in patients receiving flapless
implant surgery compared to traditional open flap
surgery. Materials and Methods: A two-centre, pro-
spective survey study was conducted, using a custom-
ized questionnaire. Between December 2010 and Jan-
uary 2012, 20 patients were consecutively included.
Eleven received conventional open-flap surgery and
nine received flapless surgery. Inflammatory signs,
analgesic consumption and sleeping difficulties were
evaluated up to seven days postoperatively. A clinical
examination was made one week postoperatively. Re-
sults: Significantly less experienced swelling was noted
24 hours after flapless surgery compared to open flap
surgery for patients receiving four implants or more,
and at three days postoperatively for patients receiv-
ing single implants. No difference concerning sleeping
difficulties, pain or analgesic consumption was found.
Clinical examination one week postoperatively showed
no differences in wound gaps, redness of the mucosa,
or presence of pus between the groups. Conclusions:
In conclusion, flapless surgery seems to have a limited
effect on postoperative comfort and short-term post-
operative signs of soft tissue healing compared to
open flap surgery. There is a need for larger random-
ized trials for evaluating differences in postoperative
discomfort between the two surgical techniques.
Keywords: Postoperative Discomfort; Flapless Surgery;
Guided Implant Surgery
1. INTRODUCTION
To enable the insertion of a dental implant, open flap
surgery has been a standard technique. Conventional im-
plant surgery involves transmucosal incision and reflec-
tion of a mucoperiosteal flap, followed by preparation of
an implant socket in the alveolar bone. A dental implant
can then be inserted and the flap can be sutured back into
its original position [1]. However, this method can lead
to some post-operative discomforts. Both physical and
mental strains are commonly associated with conventional
implant surgery [2-4]. Inflammatory signs such as pain,
swelling and bleeding are normally seen postoperatively
[5].
An alternative to a conventional flap elevation is the
minimally invasive, flapless approach. Clinical studies
have revealed that implants can be successfully placed
with a flapless technique [6-9]. The treatment time and
patient discomforts are reduced compared to traditional
implant surgery [8,10,11]. Blood supply to the perio-
steum is preserved and sutures become superfluous [5,12,
13]. A histological study has shown significantly higher
amount of blood vessels in the peri-implant mucosa three
months after insertion of a dental implant in flapless sur-
gery compared to flap elevation. Furthermore, no signs
of inflammation in the mucosa surrounding such im-
plants were seen [14].
Flapless surgery is an advanced technique that requires
considerable surgical experience and extensive knowl-
edge of the underlying tissue anatomy [15]. The main dis-
advantages are the inability to visualize anatomic land-
marks, increased risk of misplaced implants, risk of over
heating and the impossibility to manipulate the soft tis-
sue [5,15].
To overcome some of the problems encountered in
flapless surgery, a 3D planning software [16], based on a
cone beam computed tomography (CBCT) or regular
computed tomography (CT) scan, has been developed.
This method has been defined as computer-assisted sur-
gery and includes the use of a surgical template [5,17].
Published Online August 2013 in SciRes. http://www.scirp.org/journal/ojst
A. Aizenberg et al. / Open Journal of Stomatology 3 (2013) 298-305 299
Current studies on computer-assisted surgery show a
high level of implant survival (91% - 100%) after 12 - 60
months [18], but there are no long-term follow-ups [17].
The accuracy of the available systems has not yet been
perfected [18]. An in vitro study has shown an increased
heat generation during drilling when a surgical template
is used [19].
There is a need of further research in post-operative
comfort associated with flapless and computer guided
implant surgery [17]. Computer-assisted surgery is still
considered to be an experimental treatment and consti-
tutes an increased cost for the patient. It is therefore de-
sirable to further investigate what the benefits are at a
patient level.
The aim of this pilot study was to evaluate subjective
and objective findings on short-term postoperative dis-
comfort in patients receiving flapless implant surgery
compared to traditional open surgery. The working hy-
pothesis was that using flapless technique leads to less
short-term postoperative discomfort.
2. METHODS
2.1. Study Design
The study took place from December 2010 to January
2012 at the maxillofacial unit at the Halland Hospital,
Halmstad, and in a private clinic specialized in implant
dentistry, located in Ytterby, Sweden. One surgeon was
an experienced maxillofacial specialist and the other was
an experienced DDS with high level of knowledge in
implant dentistry.
Patients scheduled for flapless implant surgery who
met the inclusion/exclusion criteria (Table 1) were asked
to participate in the study. These patients were matched
with patients referred for conventional open flap implant
Table 1. Inclusion and exclusion criteria.
Inclusion Exclusion
Patient 18 years Implant treatment of the mandible
Implant treatment is
necessary Direct placement of implant
Patient consent available Bone augmentation needed
Pregnancy
Immunocompromised patient
Bleeding disorders
Drug or alcohol abuse
Radiation of head/neck-region
Psychiatric disease
Uncontrolled diabetes
Completed cytostatic treatment
Bisphosphonate treatment
treatment. They were matched in number of implants and
position of implants. Taking part in the study was com-
pletely voluntary, anonymous and did not affect the
choice of treatment. Informed consent was obtained from
all participants. The patient selection was consecutive.
The ethical board at the Faculty of Odontology, Malmö
University, issued ethical approval.
A total of 20 patients were included in the study (mean
age 56.9 years, SD 18.75). Six patients (mean age 51.8
years, SD 19.64) received single implants installed with
conventional technique and five (mean age 40.8 years,
SD 16.45) received single implants installed with flapless
technique. Five patients (mean age 68.0 years, SD 8.43)
received four implants or more installed with conven-
tional technique and four (mean age 71.0 years, SD
13.21) received four implants or more installed with
flapless technique. No significant differences regarding
gender and age were seen between the groups.
2.2. Surgical Methods
Computer-assisted implant surgery in this study included
the following steps:
A clinical and radiographic examination was made;
including panoramic X-ray to ensure the anatomical and
pathophysiological conditions of the jaws. Impressions
for study casts were taken together with a stable index. A
dental technician manufactured working models that
were used to make a diagnostic tooth set-up. When the
tooth set-up was accepted, a radiographic guide in clear
acrylic was made. This guide was provided with ra-
diopaque reference markers. A double CT-scan protocol
was used. First the patient was scanned with the radio-
logical guide and index in place. Thereafter, the guide
alone was scanned. In the planning software the two
scans were overlaid to distinguish soft tissue from the
guide material, as they have similar radio-density. Data
from the scan was processed in the planning software.
Virtual implants were then placed with consideration to
anatomical structures as well as depth, angulation and
position of the fixture.
The surgical guide was manufactured in hard acrylic
with sleeves for the implant drills. The guide was posi-
tioned using the original index and stabilized with the
help of anchor pins. In this stage, the operator transferred
the planned implant position, depth and angle from the
software to the actual mouth. To penetrate the mucosa a
tissue punch was used.
In this study NobelClinicanTM solution (Nobel Biocare,
Yorba Linda, CA) was used for planning and planning
conducted by the operating surgeon. A tissue punch was
used for all flapless incisions.
In the open flap surgery group a mucoperiosteal flap
was raised to expose the alveolar bone. The implant
sockets were prepared and implants installed in accor-
Copyright © 2013 SciRes. OJST
A. Aizenberg et al. / Open Journal of Stomatology 3 (2013) 298-305
Copyright © 2013 SciRes.
300
2.3. Postoperative Evaluation
dance to the manufacturers drill protocol. After implant
installation the flap was sutured using Vicryl 4-0 sutures
(Ethicon Inc., Somerville, NJ). Patients that agreed to take part in the study received a
multiple-choice form. They were asked to evaluate sub-
jective post-operative discomfort and sleeping difficul-
ties 24 hours, three days and seven days postoperatively.
Consumption of analgesics was recorded at the same
intervals. A numerical rating scale (NRS) was used to
evaluate pain (Figure 1).
Surgery was conducted using local anaesthesia (Xylo-
cain® Dental Adrenalin, Dentsply Pharmaceutical). Pre-
scription-free NSAID and Paracetamol were used for
postoperative pain relief when needed. All patients in the
trial received antibiotics per os according to the clinics
standardized protocol.
Questionnaire
1. I am a: Woman Man
2. I was born 19_______
3. Did you experience swelling in the operated area 24 hour s after surgery?
No, not at all
Some swelling
A lot of swelling
4. Did you experience bleeding from the operated area 24 hours after surgery?
No, not at all
Some bleeding
A lot of bleeding
5. Rate your pain 24 hours after the procedure:
6. Did you use any pain killers 24 hours after surgery?
Yes
No
Amount:___________
Type:______________
7. Did you experience difficulty sleeping 24 hours after surgery?
No, not at all
Some sleeping
difficulties
Severe sleeping
difficulties
Thank you for participating!
0 1 2 3 456789 10
No
pain
Worst
pain
imaginable
Figure 1. Questionnaire used by patient at 24 hours, three and seven days postoperatively in accordance.
OJST
A. Aizenberg et al. / Open Journal of Stomatology 3 (2013) 298-305 301
All patients were examined 1 week postoperatively by
the operating surgeon according to a standardized form
(Figure 2). Patient and dentist forms were matched using
a code system.
2.4. Statistical Methods
Statistical analysis was conducted using SPSS 20.0
(SPSS, Inc., Chicago, IL). Due to the small sample size
Fishersexac t test was used for categorical variables and
a non-parametric statistical hypothesis test (Mann-Whit-
ney U-test) for numerical variables. Level of significance
was set at p < 0.05.
3. RESULTS
3.1. Single Implants
No significant difference in experienced postoperative
Dentist form
This form is filled out by the dentist at the examination one week after surgery. Enter the
number from the patient questionnaire in the upper right corner.
1. Which method was used for implant surgery? Open flap Flapless
2. Which jaw was treated? Maxilla Mandible Both
3. How many fixtures were installed?
Single implant
2-3 fixtures
More than 4 fixtures
4. In which positions were the fixtures placed?_____________________________
_
________________________________________________________________________
_
________________________________________________________________________
5. Which type of antibiotic was used and what dose?
Type:________________
Dose:________________
No antibiotics
6. Wound gaps?
<1 mm
1-2 mm
> 2 mm
7. Redness of the mucosa?
Less than 25 % of the
surgical area
25-50 % of the
surgical area
More than 50 % of the
surgical area
8. Presence of pus in the surgical area?
Yes
No
Figure 2. Form filled out by dentist one week postoperatively.
Copyright © 2013 SciRes. OJST
A. Aizenberg et al. / Open Journal of Stomatology 3 (2013) 298-305
302
swelling was reported between the groups at 24 hours
and seven days after installation but at three days a sig-
nificant difference was noted (p < 0.05, Table 2). No
differences in NRS scores for pain were seen at any in-
terval (Table 3). After 24 hours 2/6 patients in the open
flap surgery group and 1/5 patients in the flapless surgery
group reported some bleeding. Three and seven days
postoperatively no bleeding was reported in any of the
groups. No significant differences were seen.
After 24 hours 5/6 patients in the open flap surgery
group and 2/5 in the flapless group consumed analgesics.
After three days none of the patients consumed analge-
sics. No significant difference was seen between the
groups.
Two out of five patients in the flapless group reported
some sleeping difficulties after 24 hours, but none after
three and seven days. In the open flap group 1/6 patients
reported some sleeping difficulties at 24 hours, after
three days 1/6 patients reported some sleeping difficul-
ties and at seven days no patients experienced any sleep-
ing difficulties. No statistical difference was found at any
interval. No correlation between level of pain and sleep-
ing difficulties was seen. Two patients reported paresthe-
sia seven days after surgery and both had single implants
installed in the anterior region using flap elevation.
Table 2. Swelling.
Method Swelling 24 h Swelling 3 days Swelling 7 days
Flapless
[n = 5]
None = 40%
[n = 2]
Some = 60%
[n = 3]
A lot = 0%
[n = 0]
None = 100%
[n = 5]
Some = 0%
[n = 0]
A lot = 0%
[n = 0]
None = 100%
[n = 5]
Some = 0%
[n = 0]
A lot = 0%
[n = 0]
Open flap
[n = 6]
None = 0%
[n = 0]
Some = 66.7%
[n = 4]
A lot = 33.3%
[n = 2]
None = 16.7%
[n = 1]
Some = 83.3%
[n = 5]
A lot = 0%
[n = 0]
None = 83.3%
[n = 5]
Some = 16.7%
[n = 1]
A lot = 0%
[n = 0]
p-value 0.212 0.015 1.0
Experienced swelling at different intervals for patients receiving single
implants.
Table 3. Pain.
Method Pain 24 h Pain 3 days Pain 7 days
Flapless [n = 5] 1 [0-4] 0 [0-2] 0 [0-2]
Open flap [n = 6] 3 [0-7] 0 [0-2] 0 [0-1]
p-value 0.404 0.840 0.521
Median values for pain [NRS] at different intervals [min-max] for patients
receiving single implants.
3.2. Four Implants or More
Significant difference between the groups in experienced
swelling was reported at 24 hours but not at three or
seven days (p < 0.05, Table 4). One out of five patients
in the open flap group experienced bleeding at 24 hours
and at three days. No significant differences were seen
between the groups. No differences in NRS scores for
pain were seen at any interval (Table 5). After 24 hours
4/5 patients in the open flap surgery group and 2/4 in the
flapless group consumed analgesics. After three days
none of the patients consumed analgesics. Two out of
five patients in the open surgery group reported some
sleeping difficulties after 24 hours, 1/5 after three days
but none after seven days. In the flapless group none of
the patients reported sleeping difficulties. No paresthesia
was reported at seven days.
3.3. Clinical Examination
Clinical examination one week postoperatively showed
no statistical differences in wound gaps, redness of the
mucosa or presence of pus between any groups. The ma-
jority of the patients had redness of the mucosa <25% of
the operated area, wound gaps <1 mm and none had
presence of pus.
Table 4. Swelling.
Method Swelling 24 hSwelling 3 days Swelling 7 days
Flapless
[n = 4]
None = 50%
[n = 2]
Some = 50%
[n = 2]
A lot = 0%
[n = 0]
None = 75%
[n = 3]
Some = 25%
[n = 1]
A lot = 0%
[n = 0]
None = 75%
[n = 3]
Some = 25%
[n = 1]
A lot = 0%
[n = 0]
Open flap
[n = 5]
None = 0%
[n = 0]
Some = 20%
[n = 1]
A lot = 80%
[n = 4]
None = 0%
[n = 0]
Some = 60%
[n = 3]
A lot = 40%
[n = 4]
None = 100%
[n = 5]
Some = 0%
[n = 0]
A lot = 0%
[n = 0]
p-value 0.048 0.079 0.264
Experienced swelling at different intervals for patients receiving 4 im-
plants.
Table 5. Pain.
Method Pain 24 h Pain 3 days Pain 7 days
Flapless
[n = 4] 1 [0-3] 1 [0-2] 0 [0-2]
Open flap
[n = 5] 4 [1-5] 2 [0-5] 0 [0-1]
p-value 0.59 0.592 0.737
Median values for pain [NRS] at different intervals [min-max] for patients
receiving 4 implants.
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A. Aizenberg et al. / Open Journal of Stomatology 3 (2013) 298-305 303
4. DISCUSSION
In this study a tendency to short-term benefits in postop-
erative comfort was seen in the flapless surgery group as
swelling was significantly less reported in this group. No
significant differences could be seen regarding pain or
analgesic consumption. These latter findings do not cor-
relate with results reported by Fortin et al., [20] where
the patients receiving flapless surgery experienced less
pain up to two days and consumed less analgesic up to
three days, and Nkenke et al. [21] who found a signifi-
cant reduction in pain and swelling for patients receiving
flapless surgery up to seven days postoperatively. Swell-
ing, in that study, was measured with an optical 3D im-
age system. Different ways to register pain (VAS-scale in
the two studies above and NRS in this study) as well as
different statistical tests make comparison of the results
somewhat uncertain. It cannot be excluded that the small
sample size in the present study could have an influence
on the divergent findings compared to other studies.
It should also be noted that pain could arise from fac-
tors not associated with the surgical method itself, such
as surgical time and the patients’ fear, stress and anxiety
levels [20]. In third molar surgery extended operating
time is correlated to increased postoperative pain [21-23]
and complications such as paresthesia [24,25]; this might
also be valid for implant surgery. In the present study
surgical time was not measured, but increased amount of
installed implants could be expected to result in extended
surgical time. Despite this, pain levels were not signifi-
cantly higher in patients receiving four implants or more
compared to those receiving a single implant. An expla-
nation might be the observation by Lindeboom et al. that
no gain in time was measured when computer-assisted,
flapless surgery was used [26].
Clinical examination one week postoperatively show-
ed no statistical difference in wound gap, redness of the
mucosa or presence of pus between groups and the ob-
served changes were discrete, indicating that the advan-
tage of flapless surgery contra open flap surgery for this
reason can be questioned.
Patients in this study were allocated into the different
groups as they were referred to the clinics. Patients re-
ferred for flapless surgery formed one group and patients
referred for conventional surgery formed the other group.
Patients in both groups were matched according to im-
plant position and number of implants. It would have
been desirable to randomize the patients into the two
different groups. However, as the patients had to pay an
additional cost for (computer-assisted) flapless surgery
and not all patients were willing to do this, a randomiza-
tion was not possible to perform.
In this study 20 patients participated. The low number
of individuals can be contributed to the novelty of this
treatment method and the higher cost of flapless implant
surgery in combination with computer guided surgery.
Still, significant differences were found in some areas. It
would be desirable to increase the sample size to be able
to detect smaller differences and obtain more reliable
results.
Two patients in the open flap surgery group [single
implant] reported paresthesia one week post-operatively.
Temporary paresthesia has been shown to be a relatively
common complication following implant surgery, espe-
cially in the mandible [27,28]. It can result from poor
flap design, performing terminal block of the inferior
alveolar nerve and during osteotomy preparation [27].
The paresthesia is often reversible and the incidence re-
ported varies between 6.5% - 36% [28-30]. The sensation
often returns within four months and beyond [29]. The
use of computer assisted implant surgery in combination
with flapless technique may reduce the risk of nerve in-
jury. It is not possible to know if the paresthesias re-
ported in this study are reversible since the follow up
time was limited to one week.
All patients in this study received antibiotics never-
theless there is currently no consensus regarding the use
of antibiotics in implant dentistry [31] and there are no
studies that evaluate the effect of antibiotics on postop-
erative discomfort in implant surgery. In third molar sur-
gery postoperative pain was not reduced when using an-
tibiotics [32,33].
This study shows that the main advantage of using
flapless surgery is less postoperative swelling. This is to
be expected since flapless surgery is less traumatizing to
the soft tissue. No other benefits were found on a patient
level. Still, maintaining blood supply to the periosteum is
a major benefit since it potentially minimizes the risk of
loosing bone height. The major disadvantages of flapless
implant surgery can be avoided by using a computer as-
sisted approach, yet this method also has some weak-
nesses. These include risk of overheating and inability to
visualize anatomical landmarks. Computer assisted im-
plant surgery is also an expensive treatment.
5. CONCLUSION
This pilot study indicates that flapless surgery compared
to open flap surgery can lead to less postoperative swell-
ing while no difference is seen regarding pain or post-
operative bleeding. However, randomized studies based
on larger sample sizes with focus on quality of life ef-
fects, including a cost-benefit analysis are required be-
cause of the considerably increased cost for the patient
receiving flapless surgery.
6. ACKNOWLEDGEMENTS
We would like to thank Per-Erik Isberg and Björn Söderfeldt for valu-
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A. Aizenberg et al. / Open Journal of Stomatology 3 (2013) 298-305
304
able help with questionnaire design and statistical analysis.
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