Case Report DOI: 10.

17354/cr/2016/187

Flapless Surgery Followed by Immediate Loading of

Implant: A Blissful Combination of New Era
Robinson K Job1, S Lylajam2, R Ravichandran2, K Harshakumar2
Post Graduate Student, Department of Prosthodontics, Government Dental College, Thiruvananthapuram, Kerala, India, 2Professor, Department of
1

Prosthodontics, Government Dental College, Thiruvananthapuram, Kerala, India

Esthetic challenges are inevitable during placement of the implant in the maxillary anterior region. This is because of the fact that tooth
loss leads to bone resorption and collapse of gingival architecture, which eventually leads to compromise in esthetics and inadequacy of
bone for implant placement. There are two established methods of implant placement. One method involves placement of the implant after
reflecting the mucoperiosteal flap and another one without the flap. Conventionally, implants are allowed to osseointegrate for a period of
3-5 months before the commencement of prosthetic phase.1 However, nowadays, immediate loading of implants with the flapless approach
is gaining popularity as the flapless approach is having a lot of merits. The successful placement of an implant for immediate loading and its
provisional restoration requires the careful consideration of many clinical entities and treatment steps. It is critical to understand about the
factors which can be controlled and which cannot be controlled. A flapless, immediate procedure when done successfully provides a viable
treatment option for patients as it reduces treatment time and leads to enhanced esthetic outcomes. Our challenge is to provide this service
without compromising the long-term result. This case report describes a simple procedure of replacing a missing tooth by flapless surgery
followed by immediate loading of the implant.

Keywords: Flapless surgery, implant, prosthesis

INTRODUCTION implants in case of submerged healing, and no need to use

Loss of tooth in the esthetic zone is a traumatic experience.
According to the traditional protocols, 3-4 months of healing
period are required for the consolidation of the extraction
socket.1 Taking into account the prosthetic treatment,
patients frequently are required to wait up to 6 months for
replacement of a lost tooth.
The two-stage surgical procedure for implant placement
with delayed implant loading has been the most documented
approach to implant therapy. Similar results have been
reported with the one-stage surgical procedure. The
adoption of immediate loading protocol delivers obvious
benefits to the patient when compared to conventional
implant treatment.
Among these are the reduction of treatment time and
discomfort, no need for a second surgery to uncover
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a removable prosthesis to avoid temporary periods without
teeth.2 The reduced treatment time achieved with immediate
early loading is an obvious advantage for the patient.
Nowadays, the flapless surgery followed by immediate
loading is becoming more popular. Decreasing patient
discomfort and reducing treatment time, while achieving
high predictability and an excellent esthetic outcome, are
the main goals of this treatment procedure.3
CASE REPORT
A 33-year-old, apparently healthy male patient reported to
the Department of Prosthodontics, with a chief complaint
of missing an anterior tooth. Various treatment plans were
presented to the patient appropriate to his needs and
preferences for fixed rehabilitation. Treatment options
discussed included implant-supported restoration as well as
a tooth-supported prosthesis. After discussing the options,
the treatment modality of an implant-supported prosthesis
was decided on (Figure 1).

Month of Submission : 12-2015 Intraoral examination revealed missing 21, which was lost
Month of Peer Review : 01-2016 six months back following trauma. All the criteria for flapless
Month of Acceptance : 01-2016 surgery followed by immediate loading of the implant were
Month of Publishing : 02-2016
satisfied. These criteria for flapless surgery include: (1)
www.ijsscr.com
Presence of adequate keratinized tissue and (2) Presence of

Corresponding Author:
Dr. Robinson K Job, Department of Prosthodontics, Government Dental College, Thiruvananthapuram - 695 011, Kerala, India.
E-mail: robinsonkjob@gmail.com

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 Job, et al.: Flapless Surgery Followed by Immediate Loading of Implant: A Blissful Combination of New Era

increased bone width (at least 4.5 mm). One disadvantage

of the procedure was that it was difficult to ensure that
the implant was positioned in the center of crestal bone as
visibility was an apparent challenge (Figure 2).

The requirements of immediate loading are (1) good quality

(Types I or II) bone; (2) possibility of placing an implant
that is 12-16 mm long; (3) Keratinized soft tissue which is
adequate in amount; (4) the ability to protect the healing
Figure 1: Pre-operative
implants from excessive occlusal forces; and (5) Primary
stability of 45 Ncm at the time of implant placement.

Maxillary and mandibular diagnostic impressions were

made in irreversible hydrocolloid impression material. The
impressions were poured in Type III dental stone, and the
cast was duplicated for bone mapping. One pair of the cast
was used for diagnostic mounting. Digital panoramic and
periapical radiographs were used to evaluate the implant
site. Radiographs were analyzed for any bone deformities,
retained root stumps, or any other pathology. Radiographs
and bone mapping were employed in the selection of the
size of implants (Figure 3).
Figure 2: Flapless approach
Bone mapping was done to assess the bone width, ridge,
contour, and soft tissue thickness. In the middle of the
edentulous area, a line was drawn. An acrylic stent was
fabricated, and three holes were drilled on buccal and
lingual aspects of the edentulous area corresponding to the
line on the cast which will have equal distance from the crest
of the ridge both buccally as well as lingually or palatally.
The cast was sectioned along the line. The stent was
disinfected in betadine solution. The area was anesthetized
by local infiltration using 2% lignocaine with adrenaline.
The stent was tried in patient’s mouth. Endodontic file with
rubber stops was pierced through the hole until it contacted
the bone while the stent was in place. The file was removed Figure 3: Sequential drilling
and transferred to the sectioned cast in the cross-sectional
area of the ridge. The procedure was repeated for other
points so that when all the points are connected the outline
of the ridge contour and thickness of the soft tissue were
obtained (Figure 4).

The stent was fabricated on the sectioned cast following

bone mapping. The favorable area in the ridge contour of
the sectioned cast is drilled corresponding to the pilot drill
insertion. The sections were kept in position and metal
rod of 2 mm (equivalent to pilot drill) diameter is secured
in the drilled area. The rod was stabilized with wax. The
metallic sleeve was put over the rod, which acts as a guide
during drilling. The auto polymerizing acrylic resin was Figure 4: Implant placement
adapted over the area including one tooth on the both sides
of the edentulous area. The stent was kept in disinfectant of systemic abnormalities. Titanium root form implants of
solution for minimum of 12 h before surgery. Routine dimension 3.3 mm × 16 mm were selected based on bone
blood investigation was carried out to rule out any kind mapping and radiographs (Figure 5).

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 Job, et al.: Flapless Surgery Followed by Immediate Loading of Implant: A Blissful Combination of New Era

The routine presurgical protocol was strictly followed for

the patient. Draping, scrubbing with betadine solution
was done extraorally. The patient was made to rinse the
mouth with 0.2% chlorhexidine mouthwash to reduce the
oral microbial count. The areas were anesthetized by local
infiltration using 2% lignocaine with 1:200000 adrenaline.
Adequate anesthesia was ensured by subjective and
objective evaluation. After marking the site using a surgical
stent, the circular bit of tissue was removed using no. 15
BP blade. Initial penetration through cortical bone was
achieved with round bur. Incremental drilling was done
using progressively larger drill sizes starting from 2.5 mm.
A recommended drill speed of 1000 rpm was selected for
all drills. The preparation was done carefully progressing
over 1 mm every 5 s under copious saline irrigation. The Figure 5: Milled abutment in position
depth gauge was used intermittently to ensure the required
depth. Once the required depth of the osteotomy was
achieved, the implant was mounted on a carrier and was
placed onto the prepared site. It was then slowly driven to
its final position using a torque wrench. An implant level
impression was made using an open tray impression post.
An implant analog was attached, and the cast was poured.
The straight abutment was then prepared on the cast to
achieve adequate clearance. A metal-ceramic restoration
was fabricated over the abutment. The abutment was then
removed from the analog and was attached to the implant
by fastening abutment screw. The metal-ceramic restoration Figure 6: Post-operative
was cemented on the abutment using glass ionomer cement
(Figure 6). hygiene procedures immediately.5 Furthermore, there is
no need of any sutures after implant surgery when the
DISCUSSION flapless technique is employed which seems to be patient
friendly.6 Moreover, the patient is obtaining the prosthesis
Patients lose teeth partially or completely because of soon after implant surgery which is considered as the
multiple factors such as dental caries, periodontal disease, major advantage of the immediate loading technique.7
and accidental trauma. Replacement of missing teeth is Always primary stability of 45 Ncm at the time of implant
important for the patient’s general and oral health as well placement is the minimum requirement for implant to be
as for his social well-being. Over the last few decades, the immediately loaded.8
utilization of bone-anchored dental implants has become
an established treatment method in the replacement CONCLUSION
of missing teeth.4 In the conventional method, implant
placement is done after raising the flap, and prosthetic This article describes a case report in which anterior missing
phase is begun after 3-6 months. However, nowadays, tooth is restored by the implant-supported prosthesis. In this
the flapless surgery and immediate loading protocol are case, implant placement is done by the flapless approach
gaining popularity as it’s a faster technique and post- and immediate loading of the implant was carried out.
operative complication is comparatively less due to the The flapless approach is having certain advantages such as
fact that periosteal blood supply is not compromised. maintaining better blood supply to site,9 reduced likelihood
Leaving the periosteum intact on the facial and palatal/ of resorption, maintains the soft tissue architecture and
lingual aspects of the ridge maintains a better blood hard tissue volume at the site, decreases the surgical time,
supply to the site, reducing the likelihood of resorption. and accelerates recuperation. Whenever primary stability
In addition to preservation of blood circulation, flapless of 45 Ncm can be achieved, the implant can be loaded
implant surgery maintains the soft tissue architecture immediately10 which helps the patient to obtain prosthesis
and hard tissue volume at the site, decreases the surgical soon. Anyway, flapless technique followed by immediate
time and accelerates recuperation. It reduces patient loading protocol is a fabulous combination if patient
morbidity, allowing the patient to resume normal oral selection is done properly.

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 Job, et al.: Flapless Surgery Followed by Immediate Loading of Implant: A Blissful Combination of New Era

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