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Impact of different flap approaches on the outcome of dental implant surgeries–

A review.

Article in Journal of Orofacial Research · December 2023

DOI: 10.5281/zenodo.10425733

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Journal of Orofacial Rehabilitation Flap approaches during implant surgeries

Impact of different flap approaches on the outcome of dental implant

surgeries – A review.
Yash Singh1, Akash Raj Sharma1, Deepanshu Sharma1, M. Shalini2, Sakshi Sahni3, Kanchan
Shukla4.
1Assistant Professor, Department of Prosthodontics & Crown & Bridge, Subharti Dental College & Hospital, Meerut.
2Postgraduate Student, Department of Prosthodontics, AIIMS Bathinda, Punjab.
3Junior Resident, Department of prosthodontics and crown & bridge, Saraswati dental college & hospital, Lucknow, UP
4Private Practitioner, Meerut.

ABSTRACT
Objective: This paper reviews the impact of different flap approaches in dental implant surgeries, focusing
on their influence on outcomes and the principles guiding their use.
Background: Implant dentistry aims to restore aesthetics and functionality in edentulous patients through
osseointegrated implants. Flap elevation during implant placement enhances visibility of landmarks but
may lead to complications like morbidity, discomfort, and tissue loss. Various flap designs and principles
are employed to address these challenges.
Methods: The review analyzes diverse flap designs, principles, and their implications in implant dentistry,
emphasizing their impact on esthetics, bone preservation, and surgical outcomes.
Results: Different flap approaches like flapless, vestibular incision, papilla sparing, and others are assessed
in terms of their advantages, limitations, and impact on soft tissue aesthetics, bone resorption, and surgical
success. Principles guiding flap design and management for esthetic implant therapy are also outlined.
Conclusion: Preserving inter-dental papilla through appropriate flap designs is crucial in preventing bone
denudation and subsequent resorption post-implant placement. Adhering to principles and employing
suitable techniques ensures consistent and favorable esthetic outcomes in dental implant surgeries.
Application: This review highlights the significance of flap approaches in implant dentistry, offering
insights into optimizing surgical techniques and promoting patient-centered outcomes, contributing to
enhanced esthetic and functional restoration.

Keywords: Bone density, flaps, implant surgery, implants, surgical techniques.

Address of correspondence: Dr. Akash Raj Sharma, Department of Prosthodontics & Crown & Bridge, Subharti Dental College
& Hospital, Swami Vivekanand Subharti University Meerut.
Email address: - itsdocakash@gmail.com Phone no: 7376017017. DOI: 10.5281/zenodo.10425733
Submitted: 27-Oct-2023 Revised: 15-Nov-2023 Accepted: 27-Nov-2023 Published: 25-Dec-2023
Bibliographic details: Journal of Orofacial Rehabilitation Vol. 3(3), Dec 2023, pp. 40-49.

Introduction that expedite treatment, such as flapless or

The current preferred method for minimally invasive surgical procedures
rehabilitating missing teeth involves dental coupled with immediate placement and
implants, lauded for their functional and loading.[2] However, the long-term success of
aesthetic advantages and boasting high implants hinges on various primary and
survival rates. The field of implant dentistry secondary factors, including surgical aspects
has transitioned from traditional flap therapy that can lead to marginal bone loss and,
to a more esthetically driven discipline, ultimately, late implant failure.[3] The surgical
propelled by advancements in material technique employed significantly impacts
sciences and a deeper understanding of implant survival, with the conventional
occlusion.[1] Consequently, there has been a approach involving flap elevation for
quest among clinicians to adopt techniques

DEC 2023 VOL 3 ISSUE 3 40

Journal of Orofacial Rehabilitation Flap approaches during implant surgeries

improved visualization and optimal implant flap design is contingent upon a

positioning.[4] comprehensive evaluation of the individual
Over the past three decades, modifications to clinical circumstances to optimize the
conventional surgical techniques have outcomes of the implant procedure. In
incorporated aesthetic considerations, situations where a tension-free closure is
particularly in critical aesthetic zones. When essential, a vertical releasing incision is
faced with limited bone quality, elevating a frequently integrated.[3] Gomez-Roman et al.
mucoperiosteal flap aids in visual assessment highlighted the significance of employing a
of bone morphology and quality, ensuring limited flap design for single-tooth implants,
maximum bone-to-implant contact and as it helps prevent potential loss of the papillae
achieving primary stability during implant and reduces interproximal crestal bone loss.
placement.[5] Furthermore, flap elevation Attaining favorable esthetic outcomes
facilitates proper visualization, potentially consistently relies on the utilization of
reducing the risk of complications like appropriate surgical techniques and
dehiscence and fenestration, thus minimizing principles.[8,9]
associated discomfort and morbidity. Studies
dating back to the 1970s have indicated a link Type of flap reflection:
between flap elevation and adverse effects like A comprehensive comprehension of the
gingival recession and bone resorption around intended procedure is crucial when planning
natural teeth.[6] Post surgical tissue loss for implant surgery to determine the necessary
resulting from flap elevation has been type of flap reflection. Two commonly
documented, impacting the aesthetic performed flap reflections in implant surgery
outcomes of implants, particularly along the include the full-thickness mucoperiosteal and
margins of anterior teeth.[7] partial-thickness mucosal flap reflections
(Figure 1). In clinical scenarios where an
Flap design: ample amount of underlying hard and soft
Thoroughly assessing the clinical scenario to tissue is available, the routine choice is a full
determine the most suitable flap design is a thickness mucoperiosteal flap. Conversely,
crucial element in achieving success in each when simultaneous augmentation of both hard
specific case. During implant surgery, a range and soft tissues is necessary, a combination of
of flap designs are at the surgeon's disposal. full-thickness and split-thickness flap
Factors that significantly influence flap design reflections is often employed.[8]
encompass the location of the implant site,
identification of anatomical structures, Principles of flap design in dental
necessity for soft or hard tissue grafting, as implantology [10]
well as the number of implants intended for • Principle 1: Utilizing new scalpel blades
placement, among others. In instances where and sharp periosteal elevators is crucial for
an ample amount of keratinized tissue and making precise incisions and effectively
appropriate ridge dimensions are present, a elevating flaps, ensuring the preservation
flapless or less invasive flap approach may be of mucosal viability. Clear, precise
considered suitable. Conversely, cases incisions are imperative to prevent
involving substantial vertical and/or unnecessary retraction, while elevating the
horizontal ridge deficiencies may necessitate a flap necessitates adept and flawless use of
more extensive flap elevation to facilitate a dedicated periosteal elevator.
manipulation of either hard or soft tissue as • Principle 2: Optimal visibility of the
required. The selection of the most appropriate operative site is paramount during surgical

DEC 2023 VOL 3 ISSUE 3 41

Journal of Orofacial Rehabilitation Flap approaches during implant surgeries

procedures. Some recommendations • Principle 10: It is also essential to ensure

suggest making the incision longer than that all wounds have clean edges, which
strictly necessary to expose the operative will facilitate closure and optimize healing
area, thereby enhancing visibility of the by primary intention.
bone. It is important to note that longer • Principle 11: Permitting the raising of a
incisions do not necessarily impede full mucoperiosteal flap ensures that it has
healing; in fact, they tend to heal at a a good vascular supply. Insufficient blood
similar rate to shorter incisions. supply compromises the survival of the
• Principle 3: The periosteum serves as the non-reflected tissue, which can lead to
major vascular supply to the bone; necrosis as well as the potential for a
therefore, at most, only a minimal amount, deleterious aesthetic result. The choice of
if any, of the periosteum should be flap design should allow for maintenance
removed. of optimal and sufficient blood supply to
• Principle 4: If papillae are involved, they all parts of the mobilized tissues as well as
should not be bisected but elevated in total. the soft tissues in the surrounding area.
• Principle 5: If the implant procedure is to • Principle 12: Flap blood perfusion must
involve the alveolar ridge, the incision be maintained up to the point at which the
should be made at the crest within the linea ratio of length to the width of the parallel
alba. pedicle flap equals 2:1. The length/width
• Principle 6: If tension-relieving incisions ratio requirement usually favors a slight
are required to avoid stretching or tearing trapezoidal shape of the flap.
the tissues, these incisions should be made • Principle 13: The tissue flap must be kept
obliquely to ensure broad-based flaps. moist at all times to help avoid shrinkage
• Principle 7: Flexibility in positioning the and dehydration of the tissue. With
surgical guide4 must be provided. prolonged duration of the surgical
• Principle 8: Ensuring adequate procedure, the involved tissues are at risk
identification of critical anatomical of drying out, especially when a high
landmarks is imperative in surgical degree of hemostasis has been achieved.
procedures. Evaluating, protecting, and • Principle 14: The goal is always to
preserving the location and trajectory of minimize scarring and avoid vestibular
blood vessels and nerves throughout the flattening.
surgical process is crucial. Beyond a • Principle 15: It is imperative to provide
general understanding of these structures, for closure away from the submerged
precise awareness of their specific fixture installation or augmentation site.
locations, such as the mental foramina and • Principle 16: As with any operative
incisal canal, is essential. This detailed technique, the minimization of
knowledge is an integral aspect of postsurgical bacterial contamination
preoperative planning, safeguarding improves outcome and decreases
against inadvertent damage to vital morbidity.
structures during the procedure. • Principle 17: Minimal tension during re-
• Principle 9: Identification of the contours approximation and after suturing is
of the adjacent teeth, as well as the important to avoid impairment of the
concavities or protrusions on the surface of circulation at the wound margins.
the bone, is essential and will facilitate Shrinkage of the reflected tissue with
implant placement.

DEC 2023 VOL 3 ISSUE 3 42

Journal of Orofacial Rehabilitation Flap approaches during implant surgeries

wound dehiscence will ultimately lead to • Principle 25: Atraumatic wound handling
increased scar formation. avoids tension and pressure to the flap that
• Principle 18: Tissue trauma, such as may lead to impaired blood flow and
stretching, tearing, or distortion, should be interrupted lymph drainage.
avoided through appropriate and careful • Principle 26: Controlling intraoperative
reflection and manipulation of tissue flap. bleeding (adequate hemostasis) is
Excessive trauma from retraction may necessary to avoid the possibility of
cause increased swelling and delay hematoma formation, another causative
healing. factor in delayed wound healing.
• Principle 19: The integrity of the • Principle 27: Practitioners should strive to
periosteum should be maintained eliminate the formation of any dead space
throughout. The periosteum will serve as a in which fluids might collect after wound
barrier against the connective tissue cells closure1.
so that these cells cannot invade the bone • Principle 28: The use of proper suture
cavity during the healing process and materials with an atraumatic needle must
prevent a complete bone fill. be practiced. Further, practitioners must
• Principle 20: Providers should avoid have exceptional surgical knotting and
oblique relieving incisions over prominent suture selection techniques.
root surfaces because recession may result • Principle 29: Avoid any local or external
if there is an underlying bony dehiscence. pressure on the wound during the healing
• Principle 21: In cases of reduced quantity period. Educate patients about the
of keratinized tissue, it is beneficial to importance of postoperative care.
position the crestal incision toward the • Principle 30: In situations involving non-
palatal aspect, the area where more submerged implants, it is recommended to
keratinized tissue as it extends onto the reposition the flap edge upward
palatal mucosa. postoperatively. This is aimed at
• Principle 22: When employing graft preventing excessive growth of the
materials or membranes during gingiva above the healing cap or cover
procedures, it is advisable to incorporate screw. Achieving this involves orienting
relieving incisions at a minimum of one the connective tissue (periosteum) toward
tooth proximal to the augmentation area. the healing cap rather than positioning the
Principle 23 emphasizes that in situations epithelium in that direction.
where uncertainty arises regarding the
necessity to expose anatomical structures The advantages and disadvantages of various
like the incisive nerve, or when flap designs have been enumerated in Table
augmentation techniques might be no. 1.
necessary, opting for a wider flap design
that includes the papillae becomes
obligatory. Flap design and management
• Principle 24: For larger implant sites that considerations for esthetic implant
are 8 mm and larger, choose a mesiodistal therapy[11]:
crestal incision of 5-6 mm to allow for
nonreflection of papillary tissue. For sites The planning and execution of incisions
that are less than or equal to 7 mm within the esthetic zone should adhere to
mesiodistally, there is a need to reflect the biological principles and consider the desired
papillae. esthetic outcome. Various incision and flap

DEC 2023 VOL 3 ISSUE 3 43

Journal of Orofacial Rehabilitation Flap approaches during implant surgeries

designs have been identified for implant and predictable soft tissue aesthetics, a crestal
implant-related surgeries in this zone, bone height of 5.0 mm or less is deemed
including flapless, vestibular incision, papilla necessary. After extraction, buccal bone
sparing, envelope, triangular, and trapezoidal resorption results in substantial vertical
techniques. Proper surgical planning requires reduction of the buccal crest. Immediate
time and a multidisciplinary approach, implants placed with a flapless technique do
ensuring comprehensive treatment planning not prevent alveolar bone resorption and show
and appropriate case selection for each no impact on dimensional changes of the
technique to minimize complications. extraction socket over time compared to those
Specifically tailored incision planning should placed with a flap. Both flapless and flap
be conducted with a focus on the desired implant placement techniques exhibit high
esthetic result. Emphasizing patient-driven success rates; however, a flapless protocol, by
outcomes through diagnostic mock-ups or avoiding potential scars and trauma to
esthetic try-ins during the initial stages of supracrestal gingival fibers, may offer
therapy aids in treatment planning. Utilizing a superior esthetic outcomes in certain clinical
multidisciplinary approach and prioritizing scenarios. Flap designs based on need for flap
biologically predictable results for each advancement is shown in the figure 1.
surgery is essential. Employing a flapless or
vestibular incision technique, when suitable, Conclusion
minimizes anterior maxillary surgical
interventions critical for predictable esthetic
Preserving inter-dental papilla through
outcomes. Therefore, prior to any surgical
different flap designs is crucial, as it aids in
procedure, thorough consultation involving a
preventing the denudation of interproximal
discussion of expected outcomes and
bone near adjacent teeth from the periosteum.
treatment options is imperative with the
This preservation plays a vital role in averting
patient and treatment team.
deleterious effects on bone nutrition,
consequently leading to reduced resorption
Guidelines for implant placement advocate for
following dental implant placement. By
the implant-abutment interface to be
adhering to these principles and employing
positioned 3 mm apically and 2 mm palatally
appropriate surgical techniques, consistent
to the gingival zenith at the alveolar bone
and favorable esthetic outcomes can be
crest. These guidelines consider the biologic
reliably achieved.
width along the abutment and the stability of
thicker buccal tissue following implant
placement. In surgical contexts, a flapless References
approach is often favored to maintain soft
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single implants placed using a flapless Mendonca MR, Pellizzer EP. Short dental
approach exhibit less soft tissue recession implants versus standard dental implants
compared to those placed using a flap placed in the posterior jaws: A systematic
approach. Preserving supracrestal gingival review and meta-analysis. J Dent
fibers has been linked to predicting 2016;47:8–17.
postsurgical attachment levels. A direct
correlation exists between crestal bone height 2. Ledermann P. Complete denture provision
and the stability of soft tissue indicators of atrophic problem mandible with aid of
influencing esthetic success.[12-18] For cbs implants. Quintessenz. 1977;28:221-6.

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3. Chrcanovic BR, Albrektsson T, 11. Hutchens LH, Beauchamp SD, McLeod

Wennerberg A. Reasons for failures of SH, Stern JK. Considerations for incision
oral implants. J Oral Rehabil and flap design with implant therapy in the
2014;41(6):443–76. esthetic zone. Implant dentistry. 2018 Jun
1;27(3):381-7.
4. Cannizzaro G, Felice P, Leone M, Checchi
V, Esposito M. Flapless versus open flap 12. Sharma AR, Saxena D, Saran S, Raj R.
im-plant surgery in partially edentulous Maxillary submerged implants: from error
patients subjected to immediate loading: to innovation. Int J of All Res Edu & Sci
1-year results from a split-mouth Methods Jun. 2022 Jun;10(6):1612-8.
randomised controlled trial. Eur J Oral
Implantol 2011;4 (3):177–88. 13. Sha RK, Kumar S, Bhayana R, Shill M.
5. Adell R, Lekholm U, Röckler B, Sharma AR Full Mouth Reconstruction-
Brånemark PI. A 15-year study of Malo I, mplant Bridge: A Case Report. Int.
osseointegrated implants in the treatment J Sci Res July. 2020;9(11):1.
of the edentulous jaw. Int J Oral Surg
1981;10:387–416. 14. Deb S, Ranjan R, Kumar B, Sharma AR,
Noorani MK, Kumari A. Comparative
6. Albrektsson T, Brånemark PI, Hansson Analysis of Osseointegration With or
HA, Lindström J. Osseointegrated Without PRF (Platelet Rich Fibrin) In Oral
titanium implants. Requirements for Implantology- A Randomized Prospective
ensuring a long-lasting, direct bone-to- Clinical Study. Int. J Sci Res Nov.
implant anchorage in man. Acta Orthop 2020;9(11).
Scand 1981;52:155–170.
15. Sharma AR, Rawat P, Gupta U, Tomar S,
7. Wood DL, Hoag PM,Donnenfeld OW, Tyagi M, Shukla K. Occlusion
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Periodontol 1972;43:141–144.
16. Sharma AR, Singh K, Gupta RK, Gupta U.
8. Ho CC, Attia D, Liu J. Flap Design and Clinical success of the fiber reinforced
Management for Implant Placement. composite fixed partial denture (frc fpd) in
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2021 Sep 17:145-54. missing teeth in anterior region. An
original study. Journal of Pharmaceutical
9. Gomez-Roman G. Influence of flap design Negative Results. 2023 Jan 1:1856-66.
on peri-implant interproximal crestal bone
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Jun;23:41-4. Study of Serum Glycosylated Hemoglobin

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Levels and Periodontal Therapy in

Smokers and Non-Smokers with Chronic
Periodontitis Patient Running Title: Effect
of Non-Surgical Periodontal Therapy in
Non-Diabetic Patients. European
Chemical Bulletin 12(1):5063-71.

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Journal of Orofacial Rehabilitation Flap approaches during implant surgeries

TABLES

Table No. 1

DESIGN ADVANTAGES LIMITATION DIAGRAM

• Minimal surgery • Simultaneous bone
• Minimal postoperative grafting is not possible
Punch Flap
pain/discomfort • Minimal exposure to
•Suitable for one-stage the bone for thickness
evaluation
surgery •Require sufficient
keratinized mucosa

Half punch One-stage implant surgery Minimal exposure to

the bone for thickness
with possible
evaluation
simultaneous bone
grafting

Mid crestal incision • This flap can be used for • Requires sufficient
both one- and two-stage buccal and palatal
implant surgery tissues
• Buccal and
palatal/lingual bone
grafting is possible

Palatal/lingual • Suitable in cases when

there is less buccal tissues
crestal incision
available to raise full
thickness flap.
• Bone grafting can be
performed buccally or
palatally/lingually.
• Suitable for both one-
and two-stage implant
surgery

Mesial papilla • Good aesthetic results • Not suitable if bone

• Minimal surgery and grafting is required
preservation flap
soft tissue manipulation • Used for the second
stage of implant
surgery to help get
maximum aesthetic
results by preserving
the papilla

DEC 2023 VOL 3 ISSUE 3 47

Journal of Orofacial Rehabilitation Flap approaches during implant surgeries

Distal papilla preserve the

distal side of the defect to
preservation
allow bone grafting.

Double papilla • More aesthetic results • Vascularity may be

• Suitable for the second compromised in the
preservation
stage of implant surgery narrow space.
where the mobilization of
a good amount of tissues
may be required.

Book flap • Wide exposure allows • Bone devitalization

observing the undercut and subsequent
lingually or buccally remodeling resorption
• Easy to lean and in narrow ridge
perform alveoloplasty • Less predictable
• Easy to perform bone outcomes
cutting and splitting.
Triangular flap • Adequate • Limited access
visibility • Increased
• Less tension on tension when
closure grafting
Easy to modify • Potential for
bone loss and
recession
Increased disruption of
blood supply
Trapezoidal flap • Good visibility • Potential for
• Tension free bone loss and
closure recession
• Good access to • Increased
additional sites disruption of
blood supply
Vestibular incision • Less invasive • Limited
• No disruption of Access
papillae • Low visibility

DEC 2023 VOL 3 ISSUE 3 48

 Journal of Orofacial Rehabilitation Flap approaches during implant surgeries

FIGURE

Figure 1: Principles for achieving passive flap extension. This figure categorises the
surgical flap designs based on the amount of flap advancement that may be achieved by
each technique, shown in the boxes on each axis. The authors recommendation for each
category based on experience, are highlighted in yellow. The centre of the triangle lists
determining factors which are key principles that determine the degree of flap advancement
and success of the guided bone regeneration (GBR) procedure. “Other modifying factors”
also may have an effect on flap advancement.

DEC 2023 VOL 3 ISSUE 3 49

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