Background The advent of computer‐guided surgery removed the need for complex surgical interventions such as extensive flap elevations, second stage implant exposure, and complications usually associated with conventional protocols. Purpose (a) Analyze available literature reporting on applicability, accuracy, clinical outcome of flapless surgery with or without computer guidance. (b) Evaluate quality of studies, in terms of scientific level of evidence and ethical committee approval. Materials and methods A PUBMED search was performed in July 2018. A first search was based on a general search string limited to “Dental Implants” and “flapless surgery.” A second search focused on accuracy of computer‐guided surgery using search string “Surgery, Computer‐Assisted” or “guided surgery,” and “Dental implants.” The following inclusion criteria were applied: (a) studies in English; (b) human studies (excluding cadaver); (c) systematic reviews; (d) systematic reviews with meta‐analysis. Reviews not mentioning accuracy were excluded in search 2. Results Nine reviews included in total. Implant survival ranged between 89% and 100%. Early surgical and prosthetic complications reported in 9.1% to 36.4% of reviewed papers. Tooth‐supported guides show more accuracy than bone or mucosa‐supported guides. Fully guided surgery yields higher accuracy, with lower values for horizontal coronal, horizontal apical and angular deviation (1.00, 1.23, and 3.13°mm, respectively) than those placed with half guided surgery (1.44, 1.91, and 4.30 mm, respectively). Thirty‐four of 71 human studies included in nine reviews, mentioned ethical committee approval or compliance with Declaration of Helsinki. Conclusions Guided flapless surgery is comparable to free‐hand surgery in terms of implant survival, marginal bone remodeling, and peri‐implant variables. Clinicians advised to take care in all steps of the protocol, and include safety margins around virtually planned implants. Regarding compliance with research ethics, we should question whether scientific reports of clinical trials performed without an ethical umbrella are trustworthy. Compliance of ethics standards is imperative for submitted research papers.

(1) Long-term data on maxillary implant overdentures (IODs) are scarce. This case series evaluated three types of IODs supported by six, four or three implants (Anyridge®, Mega’Gen Implant Co., Ltd., Daegu, South-Korea), after 3–5 years in function. (2) A total of 31 patients, with 132 implants, were non-randomly allocated based on available bone or financial limitations. IOD-6 received a telescopic overdenture; IOD-4 a bar; and IOD-3, non-connected implants with locator abutments. Implant survival, bone level changes, probing pocket depth (PPD), plaque index, bleeding on probing (BOP), and technical, biological and aesthetic complications were registered. Impact of suprastructures on bone loss and PPD was analyzed using mixed-effect linear regression models. Differences between groups were analyzed using the ANOVA test for BOP, and Kruskal Wallis test for complications. (3) In total, 23 patients participated in the follow-up (9 female, 14 male), with average age of 62.2 years; 7, 11 and 5 patients in IOD-6, IOD-4 and IOD-3, respectively. Implant survival after 4.4 years on average, was 98% in total; 100%, 97.8% and 93.3% for IOD-6, IOD-4 and IOD-3, respectively. Mean bone loss corresponded to 0.68 mm (SD 1.06, range −4.57–1.51), 0.39 mm (SD 1.06, range −3.6–2.43), and 1.42 mm (SD 1.68, range −5.11–0.74) for IOD-6, IOD-4 and IOD-3, respectively. A statistically significant difference was seen in bone level when comparing IOD-6 to IOD-3 (p = 0.044), and IOD-4 to IOD-3 (p = 0.018). Mean PPD was 3.8 mm (SD: 0.69; range 2.5–5.3), 3.5 mm (SD 0.59; range 2.33–5), and 3.2 mm (SD 0.56; range 2–4) for IOD-6, IOD-4 and IOD-3, respectively, and differed significantly between IOD-6 and IOD-3 (p = 0.029). Incidence of peri-implantitis was 1%. No differences were seen for complications between groups. (4) Maxillary IOD supported by four to six implants is the most reliable treatment regarding implant survival and peri-implant health. More research is needed in the clinical outcomes, in particular the peri-implant health, and complications of maxillary IODs, especially with a reduced number of implants.

Free-handed flapless implant surgery for single implants with neighboring teeth is a predictable long-term treatment provided when there is sufficient bone volume.

(1) Although the accuracy of static computer-aided implant surgery (sCAIP) is well reported, information on its long-term effect on peri-implant health and complications is scarce. (2) Twenty-six patients initially treated were recalled. Implant survival, radiographic bone level, peri-implant health, and complications were registered. A multilevel regression model was applied to study the relationship between the research variables. (3) Sixteen patients participated in this study (average age 58.5 years; range 27.8–73.8). The mean follow-up time was 9.1 years (range 7.3–11.3). Two implants failed, resulting in a survival rate of 97.1%. The mean bone level change corresponded to a loss of 0.63 mm (SD 1.90) for the whole group, 0.17 mm (SD 1.46), and 0.91 mm (SD 2.09) for tooth- and mucosa-supported guides, respectively. The mean PPD for the total group was 4.24 mm (SD 1.25), and 3.79 mm (SD 0.97) and 4.51 mm (SD 1.33) for the tooth- and mucosa-supported guides, respectively. Four implants (6.3%) were diagnosed with peri-implantitis. Coronal deviation was slightly associated with having a negative impact on bone level at follow-up, but this was not statistically significant. Seven patients (43.8%) experienced technical complications. Biological complications were seen in 3/16 patients (18.75%). (4) SCAIP may contribute to more predictable implant placement; the long-term clinical outcome is similar to conventional nonguided surgery.

Background: Long-term follow-up of single implants and crowns is scarce, especially when inserted using flapless surgery. Aim: Evaluate survival, peri-implantitis incidence, and technical/biologic complications of solitary implants/crowns after 10–12 years of function. Material and methods: 49 patients with 53 single implants, initially operated with a one-stage flap (F) or flapless (FL) surgery and delayed loading, were recalled. Implant survival, radiographic bone-level changes compared to baseline, peri-implant health, and soft tissue aesthetics were registered. Differences in implant level between and within groups were statistically tested using the Mann–Whitney U-Test and Wilcoxon Signed Ranks Test, respectively. Results: 36 patients with 40 implants were reassessed, yielding 100% implant and 97.5% crown survival. The bone loss in F (n = 19) was 0.56 mm (SD 0.89; range −0.9–2.02) and −0.85 mm (SD 0.98; range −2.84–0.53) in FL (n = 21), indicative of bone gain in FL (p = 0.003), the latter due to a difference at baseline but bone-level was comparable (p = 0.126). Groups were comparable for probing pocket depth (PPD); (3.32 vs. 3.19 mm), Bleeding Index (BI); (0.15 vs. 0.22), and gingival recession; (0.38 vs. 0.17 mm). According to international criteria, the peri-implantitis incidence was 0%, but 32.5% of the implants/crowns experienced biological or technical complications irrespective of surgical technique. Conclusions: Solitary implants and crowns show good long-term clinical outcomes and peri-implant health. Flapless surgery is a good alternative to conventional in straightforward cases with sufficient bone volume and proper treatment planning.