Dental implant placement with flapless and flapped technique: A systematic review.

  • Rojin Asadollahi Department of oral and maxillofacial surgery, Azad university of Isfahan, Isfahan, Iran.
  • Meysam Mohammadi khah Department of Oral and Maxillofacial Surgery, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
  • Niknaz Yahyazadehfar Department of Prosthodontics, Shahed University, Tehran, Iran.
  • Farnaz Kouhestani Department of Periodontics, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
  • Zahra Tehrani Department of Orthodontics, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran.


Aim: This study was aimed to systematically review and compare implant treatment outcome including success and survival rates, marginal bone loss and post-operative pain between flapped and flapless techniques of implant insertion. Material and Methods: An internet search was performed in PubMed and Cochrane Library in June 2018 using relevant keywords limited to human studies and English language. Clinical studies evaluating the survival rate, marginal bone loss (MBL) and rate of complications between flapped and flapless techniques for implant insertion were included. The review process was performed by two reviewers and the relevant data was extracted from the included studies. Data was compared in a qualitative manner. Results: Electronic search resulted in 1872 studies out of which 32 (21 RCTs) were selected based on the inclusion and exclusion criteria including 1528 patients and 3047 implants. No significant difference was found between success and survival rate of implants using two techniques except for one study that reported higher success rate in flapless group. Twelve studies reported higher MBL in the flapped groups while two studies showed higher MBL in the flapless group. Less pain following flapless technique was reported in 9 studies. One study, however, showed more pain in flapless technique. Conclusion: Implant survival rate using flapped and flapless technique is comparable. Also, MBL using flapless technique is similar or less than flapped technique. Concerning post-operative complications, flapless technique would probably have less post-operative pain.

Author Biography

Rojin Asadollahi, Department of oral and maxillofacial surgery, Azad university of Isfahan, Isfahan, Iran.
Interim Editor -in- Chief


1. Ormianer Z, Palti A. Long-term clinical evaluation of tapered multi-threaded implants: results and influences of potential risk factors. J Oral Implantol. 2006;32(6):300–7.
2. Jokstad A, Braegger U, Brunski JB, Carr AB, Naert I, Wennerberg A. Quality of dental implants. Int Dent J. 2003;53(6 Suppl 2):409–43.
3. Behnia H, Motamedian SR, Kiani MT, Morad G, Khojasteh A. Accuracy and reliability of cone beam computed tomographic measurements of the bone labial and palatal to the maxillary anterior teeth. Int J Oral Maxillofac Implants. 2015;30(6):1249–55.
4. Morad G, Behnia H, Motamedian SR, Shahab S, Gholamin P, Khosraviani K, Nowzari H, Khojasteh A. Thickness of labial alveolar bone overlying healthy maxillary and mandibular anterior teeth. J Craniofac Surg. 2014;25(6):1985–91.
5. Vohra F, Al-Kheraif AA, Almas K, Javed F. Comparison of crestal bone loss around dental implants placed in healed sites using flapped and flapless techniques: a systematic review. . J Periodontol. 2015;86(2):185–91.
6. Khojasteh A, Motamedian SR, Sharifzadeh N, Zadeh HH. The influence of initial alveolar ridge defect morphology on the outcome of implants in augmented atrophic posterior mandible: an exploratory retrospective study. Clin Oral Implants Res. 2017;28(10):e208–17.
7. Khojasteh A, Hassani A, Motamedian SR, Saadat S, Alikhasi M. Cortical Bone Augmentation Versus Nerve Lateralization for Treatment of Atrophic Posterior Mandible: A Retrospective Study and Review of Literature. Clin Implant Dent Relat Res. 2016;18(2):342–59.
8. Hosseinpour S, Ghazizadeh Ahsaie M, Rezai Rad M, Baghani MT, Motamedian SR, Khojasteh A. Application of selected scaffolds for bone tissue engineering: a systematic review. Oral Maxillofac Surg. 2017;21(2):109–29.
9. Motamedian SR, Tabatabaei FS, Akhlaghi F, Torshabi M, Gholamin P, Khojasteh A. Response of Dental Pulp Stem Cells to Synthetic, Allograft, and Xenograft Bone Scaffolds. Int J Periodontics Restorative Dent. 2017;37(1):49–59.
10. Eroglu CN, Ertugrul AS, Eskitascioglu M, Eskitascioglu G. Changes in the surface of bone and acid-etched and sandblasted implants following implantation and removal. Eur J Dent. 2016;10(1):77–81.
11. Cecchinato D, Lops D, Salvi GE, Sanz M. A prospective, randomized, controlled study using OsseoSpeed™ implants placed in maxillary fresh extraction socket: soft tissues response. Clin Oral Implants Res. 2015;26(1):20–7.
12. Khorsand A, Rasouli-Ghahroudi AA, Naddafpour N, Shayesteh YS, Khojasteh A. Effect of Microthread Design on Marginal Bone Level Around Dental Implants Placed in Fresh Extraction Sockets. Implant Dent. 2016;25(1):90–6.
13. Stoupel J, Lee CT, Glick J, Sanz-Miralles E, Chiuzan C, Papapanou PN. Immediate implant placement and provisionalization in the aesthetic zone using a flapless or a flap-involving approach: a randomized controlled trial. J Clin Periodontol. 2016;43(12):1171–9.
14. Costich ER, Ramfjord SP. Healing after partial denudation of the alveolar process. J Periodontol. 1968;39(3):127–34. [PubMed]
15. Campelo LD, Camara JR. Flapless implant surgery: a 10-year clinical retrospective analysis. Int J Oral Maxillofac Implants. 2002;17(2):271–6.
16. Cosyn J, Sabzevar MM, De Bruyn H. Predictors of inter-proximal and midfacial recession following single implant treatment in the anterior maxilla: a multivariate analysis. J Clin Periodontol. 2012;39(9):895–903.
17. Chen ST, Darby IB, Reynolds EC, Clement JC. Immediate implant placement postextraction without flap elevation. J Periodontol. 2009;80(1):163–72.
18. Elaskary A. Fundamentals of Esthetic Dentistry. 2th Ed. Wiley-Blackwell; 2008.
19. Scala R, Ghensi P, Cucchi A, Pistoia E. Postextraction implant placement with immediate provisionalisation and finalisation, using a simplified technique: technical notes and a case report. Open Dent J. 2012:164–9.
20. Brodala N. Flapless surgery and its effect on dental implant outcomes. Int J Oral Maxillofac Implants. 2009;24(Suppl):118–25.
21. Doan NV, Du Z, Reher P, Xiao Y. Flapless dental implant surgery: a retrospective study of 1,241 consecutive implants. Int J Oral Maxillofac Implants. 2014;29(3):650–8.
22. Moraschini V, Velloso G, Luz D, Barboza EP. Implant survival rates, marginal bone level changes, and complications in full-mouth rehabilitation with flapless computer-guided surgery: a systematic review and meta-analysis. Int J Oral Maxillofac Surg. 2015;44(7):892–901.
23. Sunitha RV, Ramakrishnan T, Kumar S, Emmadi P. Soft tissue preservation and crestal bone loss around single-tooth implants. J Oral Implantol. 2008;34(4):223–9.
24. Becker W, Goldstein M, Becker BE, Sennerby L. Minimally invasive flapless implant surgery: a prospective multicenter study. Clin Implant Dent Relat Res. 2005;7(Suppl 1):S21–7.
25. Job S, Bhat V, Naidu EM. In vivo evaluation of crestal bone heights following implant placement with 'flapless' and 'with-flap' techniques in sites of immediately loaded implants. Indian J Dent Res. 2008;19(4):320–5.
26. Tsoukaki M, Kalpidis CD, Sakellari D, Tsalikis L, Mikrogiorgis G, Konstantinidis A. Clinical, radiographic, microbiological, and immunological outcomes of flapped vs. flapless dental implants: a prospective randomized controlled clinical trial. Clin Oral Implants Res. 2013;24(9):969–76.
27. Jeong SM, Choi BH, Kim J, Xuan F, Lee DH, Mo DY, Lee CU. A 1-year prospective clinical study of soft tissue conditions and marginal bone changes around dental implants after flapless implant surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;111(1):41–6.
28. Jeong SM, Choi BH, Li J, Ahn KM, Lee SH, Xuan F. Bone healing around implants following flap and mini-flap surgeries: a radiographic evaluation between stage I and stage II surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;105(3):293–6.
29. Becker W, Goldstein M, Becker BE, Sennerby L, Kois D, Hujoel P. Minimally invasive flapless implant placement: follow-up results from a multicenter study. J Periodontol. 2009;80(2):347–52.
30. Ozan O, Turkyilmaz I, Yilmaz B. A preliminary report of patients treated with early loaded implants using computerized tomography-guided surgical stents: flapless versus conventional flapped surgery. J Oral Rehabil. 2007;34(11):835–40.
31. Al-Juboori MJ, Bin Abdulrahaman S, Jassan A. Comparison of flapless and conventional flap and the effect on crestal bone resorption during a 12-week healing period. Dent Implantol Update. 2012;23(2):9–16.
32. Van de Velde T, Sennerby L, De Bruyn H. The clinical and radiographic outcome of implants placed in the posterior maxilla with a guided flapless approach and immediately restored with a provisional rehabilitation: a randomized clinical trial. Clin Oral Implants Res. 2010;21(11):1223–33.
33. Cannizzaro G, Felice P, Leone M, Checchi V, Esposito M. Flapless versus open flap implant surgery in partially edentulous patients subjected to immediate loading: 1-year results from a split-mouth randomised controlled trial. Eur J Oral Implantol. 2011;4(3):177–88.
34. Fortin T, Bosson JL, Isidori M, Blanchet E. Effect of flapless surgery on pain experienced in implant placement using an image-guided system. Int J Oral Maxillofac Implants. 2006;21(2):298–304.
35. Cannizzaro G, Leone M, Consolo U, Ferri V, Esposito M. Immediate functional loading of implants placed with flapless surgery versus conventional implants in partially edentulous patients: a 3-year randomized controlled clinical trial. Int J Oral Maxillofac Implants. 2008;23(5):867–75.
36. Lin GH, Chan HL, Bashutski JD, Oh TJ, Wang HL. The effect of flapless surgery on implant survival and marginal bone level: a systematic review and meta-analysis. J Periodontol. 2014;85(5):e91–103.
37. Chrcanovic BR, Albrektsson T, Wennerberg A. Flapless versus conventional flapped dental implant surgery: a meta-analysis. PLoS One. 2014;9(6):e100624.
38. Tehranchi A, Motamedian SR, Saedi S, Kabiri S, Shidfar S. Correlation between frontal sinus dimensions and cephalometric indices: A cross-sectional study. Eur J Dent. 2017;11(1):64–70.
39. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Ann Intern Med. 2009;151(4):W65–94.
40. Oh TJ, Shotwell JL, Billy EJ, Wang HL. Effect of flapless implant surgery on soft tissue profile: a randomized controlled clinical trial. J Periodontol. 2006;77(5):874–82.
41. Nikzad S, Azari A. Custom-made radiographic template, computed tomography, and computer-assisted flapless surgery for treatment planning in partial edentulous patients: a prospective 12-month study. J Oral Maxillofac Surg. 2010;68(6):1353–9.
42. Lindeboom JA, van Wijk AJ. A comparison of two implant techniques on patient-based outcome measures: a report of flapless vs. conventional flapped implant placement. Clin Oral Implants Res. 2010;21(4):366–70.
43. Froum SJ, Cho SC, Elian N, Romanos G, Jalbout Z, Natour M, Norman R, Neri D, Tarnow DP. Survival rate of one-piece dental implants placed with a flapless or flap protocol--a randomized, controlled study: 12-month results. Int J Periodontics Restorative Dent. 2011;31(6):591–601.
44. Parmigiani-Izquierdo JM, Sánchez-Pérez A, Cabaña-Muñoz ME. A pilot study of postoperative pain felt after two implant surgery techniques: a randomized blinded prospective clinical study. Int J Oral Maxillofac Implants. 2013;28(5):1305–10.
45. Sunitha RV, Sapthagiri E. Flapless implant surgery: a 2-year follow-up study of 40 implants. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;116(4):e237–43.
46. Bashutski JD, Wang HL, Rudek I, Moreno I, Koticha T, Oh TJ. Effect of flapless surgery on single-tooth implants in the esthetic zone: a randomized clinical trial. J Periodontol. 2013;84(12):1747–54.
47. Meizi E, Meir M, Laster Z. New-design dental implants: a 1-year prospective clinical study of 344 consecutively placed implants comparing immediate loading versus delayed loading and flapless versus full-thickness flap. Int J Oral Maxillofac Implants. 2014;29(1):e14–21.
48. Pozzi A, Tallarico M, Marchetti M, Scarfò B, Esposito M. Computer-guided versus free-hand placement of immediately loaded dental implants: 1-year post-loading results of a multicentre randomised controlled trial. Eur J Oral Implantol. 2014;7(3):229–42.
49. Maló P, de Araújo Nobre M, Lopes A. Three-Year Outcome of Fixed Partial Rehabilitations Supported by Implants Inserted with Flap or Flapless Surgical Techniques. J Prosthodont. 2016;25(5):357–63.
50. Maier FM. Initial Crestal Bone Loss After Implant Placement with Flapped or Flapless Surgery-A Prospective Cohort Study. Int J Oral Maxillofac Implants. 2016;31(4):876–83.
51. Pisoni L, Ordesi P, Siervo P, Bianchi AE, Persia M, Siervo S. Flapless Versus Traditional Dental Implant Surgery: Long-Term Evaluation of Crestal Bone Resorption. J Oral Maxillofac Surg. 2016;74(7):1354–9.
52. Prati C, Zamparini F, Scialabba VS, Gatto MR, Piattelli A, Montebugnoli L, Gandolfi MG. A 3-Year Prospective Cohort Study on 132 Calcium Phosphate-Blasted Implants: Flap vs Flapless Technique. Int J Oral Maxillofac Implants. 2016;31(2):413–23.
53. Wang F, Huang W, Zhang Z, Wang H, Monje A, Wu Y. Minimally invasive flapless vs. flapped approach for single implant placement: a 2-year randomized controlled clinical trial. Clin Oral Implants Res. 2017;28(6):757–64.
54. Froum SJ, Khouly I. Survival Rates and Bone and Soft Tissue Level Changes Around One-Piece Dental Implants Placed with a Flapless or Flap Protocol: 8.5-Year Results. Int J Periodontics Restorative Dent. 2017;37(3):327–37.
55. Bömicke W, Gabbert O, Koob A, Krisam J, Rammelsberg P. Comparison of immediately loaded flapless-placed one-piece implants and flapped-placed conventionally loaded two-piece implants, both fitted with all-ceramic single crowns, in the posterior mandible: 3-year results from a randomised controlled pilot trial. Eur J Oral Implantol. 2017;10(2):179–95.
56. Jané-Salas E, Roselló-LLabrés X, Jané-Pallí E, Mishra S, Ayuso-Montero R, López-López J. Open flap versus flapless placement of dental implants. A randomized controlled pilot trial. Odontology. 2008;106(3):340–8.
57. Kumar D, Sivaram G, Shivakumar B, Kumar T. Comparative evaluation of soft and hard tissue changes following endosseous implant placement using flap and flapless techniques in the posterior edentulous areas of the mandible-a randomized controlled trial. Oral Maxillofac Surg. 2018:[Epub ahead of print].
58. Tallarico M, Esposito M, Xhanari E, Caneva M, Meloni SM. Computer-guided vs freehand placement of immediately loaded dental implants: 5-year postloading results of a randomised controlled trial. Eur J Oral Implantol. 2018;11(2):203–13.
59. Berdougo M, Fortin T, Blanchet E, Isidori M, Bosson JL. Flapless implant surgery using an image-guided system. A 1- to 4-year retrospective multicenter comparative clinical study. Clin Implant Dent Relat Res. 2010;12(2):142–52.
60. Bhat V, Bangawala MR. Immediate implant placement without flap elevation - A review. NUJHS. 2014;4(3):131–7.
61. al-Ansari BH, Morris RR. Placement of dental implants without flap surgery: a clinical report. Int J Oral Maxillofac Implants. 1998;13(6):861–5.
62. Eslamipour F, Motamedian SR, Bagheri F. Ibuprofen and Low-level Laser Therapy for Pain Control during Fixed Orthodontic Therapy: A Systematic Review of Randomized Controlled Trials and Meta-analysis. J Contemp Dent Pract. 2017;18(6):527–33.
63. Chen ST, Wilson TG Jr, Hämmerle CH. Immediate or early placement of implants following tooth extraction: review of biologic basis, clinical procedures, and outcomes. Int J Oral Maxillofac Implants. 2004;19 Suppl:12–25.
64. Chen ST, Darby IB, Reynolds EC, Clement JC. Immediate implant placement postextraction without flap elevation. J Periodontol. 2009;80(1):163–72.
65. Serino G, Turri A, Lang NP. Maintenance therapy in patients following the surgical treatment of peri-implantitis: a 5-year follow-up study. Clin Oral Implants Res. 2015;26(8):950–6.
66. Vervaeke S, Collaert B, Vandeweghe S, Cosyn J, Deschepper E, De Bruyn H. The effect of smoking on survival and bone loss of implants with a fluoride-modified surface: a 2-year retrospective analysis of 1106 implants placed in daily practice. J Prosthet Dent. 2007;97(6):331–9.
67. Sanna AM, Molly L, van Steenberghe D. Immediately loaded CAD-CAM manufactured fixed complete dentures using flapless implant placement procedures: a cohort study of consecutive patients. J Prosthet Dent. 2007;97(6):331–9.
68. Cushen SE, Turkyilmaz I. Impact of operator experience on the accuracy of implant placement with stereolithographic surgical templates: an in vitro study. J Prosthet Dent. 2013;109(4):248–54.
How to Cite
ASADOLLAHI, Rojin et al. Dental implant placement with flapless and flapped technique: A systematic review.. Journal of Oral Research, [S.l.], v. 7, n. 7, p. 264-275, aug. 2018. ISSN 0719-2479. Available at: <>. Date accessed: 25 apr. 2019. doi:


dental implants; surgical flaps; survival rate; postoperative complications.