An In-Vivo Comparative Study of the Soft Tissue Response and Esthetics of the Titanium Implant with Titanium Collar by Flapless and Conventional Flap Technique.

Background: These days, patients want quick results for tooth replacement and esthetic results. However, there is no direct correlation between the achievement of osseointegration and the outcome of successful treatment always. It is vital to sustaining peri-implant soft tissue health for extensive tenure success of the implant. Aim: The purpose of this trial was to determine, estimate, and compare the soft tissue retort and esthetics of the titanium implants with titanium collar at periodic intervals by flapless and conventional flap technique before and after prosthesis placement.
Results: The difference in soft tissue indices namely, gingival index, plaque index, and the modified sulcular bleeding index was insignificant between the two implants placed by flapless and open flap technique 2. There was a significant difference amid the probing depths of the two implants after 3 months of prosthesis positioning where the implant placed by flapless technique showed lesser values as compared to the implant placed by the open flap technique 3. The esthetics of the soft tissues surrounding the titanium implant with titanium collar, when compared, presented a significant difference between the two techniques of implant placement.
Conclusion: In conclusion, in recent advancements in dentistry, the flapless technique is becoming prominent because of procedure of minimally invasive surgery in implantology. There are advantages of early re-epithelialization and less inflammation around the soft tissue of the implant in the flapless procedure, provided that the prospective for the establishment of a fully functioning along with aesthetically desirable peri-implant soft tissue collar. The flapless technique accomplishes high degrees of gratification by the patients by shortening the surgery time and minimum invasion to both bone and soft tissue. Copyright:

INTRODUCTION

In the surgical protocol of dental implant placement, it was observed that dental implants that were placed followed by reflecting flaps demonstrate some bone resorption. All through the initial phase of healing, bone resorption of varying degrees virtually constantly ensue in the crestal region.[1] A dental implant is placed without reflecting a flap through the mucosal tissue in a flapless[2] procedure. The flapless procedure results in patient comfort and early soft tissue healing because it causes less trauma and less time consumption equated to the open-flap technique. It has the advantages of adjustment of the provisional appliance immediately due to less postoperative bleeding and swelling.[12345] A major disadvantage of flapless surgery is that in this procedure we cannot raise mucogingival tissue, so we cannot observe the underlying available bone true topography. We should consider the advantages and disadvantages of both surgical techniques and a study should be done to know the appropriate effect of flap vs. flapless techniques[4] on crestal bone loss and soft tissue changes for the long-term success of implant prosthesis because the amount and the quality of bone are critical aspects. Hence, the goal of the current trial was to assess the soft tissue[567891011121314] conditions and marginal bone changes all around dental implants followed by flapless surgery.

METHODOLOGY

Ten clinically healthy, partially edentulous patients with at least two or more teeth missing in the same arch and willing to participate in the trial were selected from the outpatient department of the Patna Dental College and Hospital, Patna. Both flapless and conventional flap techniques for implants to be compared were placed in the same patient so that subjective bias can be eliminated. Two groups were made for comparison, in one group, the implant was placed by flapless technique, in the second group, the implant was placed by the conventional flap technique, and soft tissue response and esthetics were compared. All surgeries were performed under aseptic conditions, local anesthesia was achieved by infiltrating 2% lignocaine containing 1:100,000 adrenaline. The site of osteotomy was marked with the help of a round bur. Sequential drilling was performed with the help of osteotomy drills of surgical kit and physiodispenser in a sequential manner. Profuse irrigation with cold normal saline was used to minimize bone damage due to overheating. This was the same for both techniques. After osteotomy, the selected implant was placed slowly, with the hand torque-ratchet. The implant was placed such that the implant body was totally submerged in the bone and the smooth collar lay supracrestally and was allowed to merge with the gingival, leaving the head exposed to the oral cavity. The cover screw was tightened on the implant with the hex driver. This was the same for flapless and conventional flap techniques. Follow-up after 1 week: Patients were called after 1 week for suture removal at the site of implant placed by the conventional flap technique. Follow-up was done after 6 weeks and 3 months of implant placement. As the whole dimension of the soft tissue interface to titanium, that is, “biological width” was recognized subsequently after 6 weeks subsequent to surgery, the implants were evaluated for the soft tissue response by recording gingival index score, plaque index score, and modified sulcular bleeding index score on both sides of the implant placed by flapless and conventional flap techniques with the help of periowise periodontal probe. Descriptive statistics, as well as mean value and standard deviation, were utilized using the SPSS (version 18.0) software for Windows (SPSS Inc., Chicago II, USA).

RESULTS

In total, 20 two-piece, one-stage implants were implanted in the trial, including 20 titanium implants with titanium collars (Osstem, SSIII) implants, 10 flapless implants, and 10 traditional flap implants. At each interval of time period examined, the results disclosed no statistically significant difference (P > 0.05, n = 10) between the two groups. After each follow-up, implants implanted using the open-flap technique had a higher gingival index score than implants placed using the flapless technique. At each interval of time period examined, the results disclosed no statistically significant difference (P > 0.05, n = 10) amid the two groups [Table 1]. After respective follow-up, the plaque index score for implants placed utilizing the open-flap approach increased in comparison to implants placed utilizing the flapless technique. The value of this score grew from 6 weeks to 1 month following implant placement in each group but reduced once the prosthesis was placed and oral hygiene instructions were reinforced. After each interval of time, the values for implants placed by the open-flap method were higher than those for implants implanted by the flapless method. Because the implant surface is in close touch with the adjacent mucosa, implants can be cleaned quickly after the flapless implant operation. Early plaque management is perilous for maintaining the health of the peri-implant mucosa. At each interval of time period examined, the results revealed no statistically significant difference (P > 0.05, n = 10) between the two groups (P > 0.05, n = 10) [Table 2]. Following each follow-up, an increase in the modified sulcular bleeding index score was observed with implants placed using the open-flap technique compared to implants placed using the flapless technique, which then dropped slightly after prosthesis insertion. After 1 month and 3 months of prosthesis placement, probing depth around both implants was assessed on buccal, lingual, mesial, and distal aspects, with the average value of all surfaces recorded and compared using a calibrated plastic periodontal probe (periowise). After 1 month of prosthesis placement, there was no statistically significant difference (P > 0.05, n = 10) between the two groups. However, after 3 months of prosthesis installation, there was a significant difference (P < 0.05, n = 10) in probing depth between implants placed using the open-flap approach and implants implanted using the flapless technique. When comparing implants implanted using the open-flap approach to implants implanted using the flapless technique, a higher probing depth was seen. The average of the recordings given by both skilled and untrained observers was used to obtain the mean values of the aesthetic scores. The mean values of the Visual Analog Scale (VAS) were calculated for both the flapless and open-flap implants. The difference in aesthetic scores is substantial (P = 0.05, n = 10), with the flapless technique's average score of 7.62 being greater than the open-flap technique's average score of 6.85. In most cases, the soft tissue around the implant placed using the flapless technique adapted better than the implant placed using the open-flap technique. After flapless implant surgery, excellent peri-implant mucosal health was present, as evidenced by low Gingival index (GI) and Bleeding on probing (BOP) index scores.

Table 1

Mean comparison of gingival index

	Flapless technique (n=10)		Open-flap technique (n=10)		Sig. (P)
	Mean	Std. deviation	Mean	Std. deviation
Gingival index (at 6th week of implant placement)	0.83	0.58	1.03	0.65	0.477
Gingival index (at the 3rd month of implant placement)	0.90	0.53	1.18	0.68	0.325
Gingival index (after 1 month of prosthesis)	0.93	0.60	1.15	0.57	0.401
Gingival index (after 3 months of prosthesis)	1.03	0.66	1.20	0.57	0.535

(P>0.05=insignificant; P<0.05=significant)

Table 2

Mean comparison of periodontal pocket depth

	Group	Flapless technique (n=10)		Open-flap technique (n=10)		Sig. (P)
		Mean	Std. deviation	Mean	Std. deviation
Periodontal pocket depth (after 1 month of prosthesis)	2.68	0.47	3.08	0.44	0.066
Periodontal pocket depth (after 3 months of prosthesis)	2.90	0.29	3.53	0.69	0.017

(P>0.05=insignificant; P<0.05=significant)

DISCUSSION

For placement of the implant-supported fixed prosthesis, proper positioning of implants and very good conditions of soft and hard tissues are required for a successful treatment.[9] According to Fransson et al.,[10] there is progressive bone loss of 28% over a period of 5 years at least after implant placement. There is bacterial proliferation or colonization, which causes peri-implantitis in the transmucosal section of the implant site, this is the reason soft tissue response is important for implant survival. This study was aimed to compare the soft tissue response and esthetics of titanium implant with titanium collar by flapless and conventional flap techniques. The average period of the study was around 12 months. Both implants were two-piece and one-stage, non-submerged implants. One-stage implants have several advantages;[11] considering the BOP as an important criterion for the measurement of peri-implant tissue health. The results showed insignificant differences in the peri-implant parameters namely gingival index, plaque index, and modified sulcular bleeding index. The values were, however, slightly more in the implants placed by the open-flap technique. In the presented study, the gingival esthetics were compared through visual observation rating it on a scale of 0 to 10 (Visual Analog Scale).[123456789] The results of the present study showed a significant difference between the average esthetic scores of two implant designs. The average score of implant placed by flapless technique was higher than the implant placed by the open-flap technique. The contour of soft tissue and emergence profile of prosthesis was natural in appearance around the implant placed by flapless technique. The flapless surgical protocol shows limited information on long-term outcomes compared to conventional flap surgical protocol. Until now, published papers have reported the outcome only up to 18 months.[12345] There were certain other limitations associated with the study. The course of the investigation was a short time period and hence long-term clinical parameters are important diagnostic tools to analyze the success of any implant. The sample size was also limited.

CONCLUSION

The subsequent inferences were depicted within the confines of the trial are that the difference in soft tissue indices, namely, gingival index, plaque index, and the modified sulcular bleeding index was insignificant amid the two implants placed by flapless and open-flap technique. There was a significant difference amongst the probing depths of the two implants after 3 months of prosthesis placement where the implant placed by the flapless technique showed lesser values as compared to the implant placed by the open-flap technique. The esthetics of the soft tissues surrounding the titanium implant with titanium collar, when compared, presented a significant difference amongst the two techniques of implant placement. The average score of esthetics under VAS was greater with the implant placed by the flapless technique as compared to the open-flap technique.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.