Narrative review regarding the applicability, accuracy, and clinical outcome of flapless implant surgery with or without computer guidance

Abstract

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.

Accuracy of Guided Implant Surgery in the Edentulous Jaw Using Desktop 3D-Printed Mucosal Supported Guides

“…The use of a guided surgery for implant placement has been extensively investigated in the past decades, resulting in several systematic reviews [1][2][3][4][5]. Guided implant surgery is the first step in a full digital workflow for implant rehabilitation, and simplifies flapless surgery, which reduces treatment time, causes less postoperative discomfort for the patient and ensures a more predictable implant placement [6].…”

“…Differences between the virtual and actual implant position are unavoidable and will result in deviations of the implant angulation and displacement of the coronal and apical aspect of the implant [5,11]. Usually, the deviations are smallest at the coronal aspect, close to the surgical guide, where guidance is best.…”

“…Usually, the deviations are smallest at the coronal aspect, close to the surgical guide, where guidance is best. Angular and coronal deviation increase with increasing distance from the point of entry [5]. According to a systematic review, mucosa-supported guides resulted in maximal mean deviations of 2.19 mm at the apical aspect, 1.68 mm at the coronal aspect and 4.67 degrees in angulation [1].…”

Effect of Desktop Scanning Protocol on Accuracy of Guided Implant Placement in Completely Edentulous Patients

“…(3) Moreover, accuracy of the guide is also dependent on implant site location, whether the patient being completely or partially edentulous, the type of tissue support for the guide and the amount of surgical restriction offered by it. (4)(5)(6) Surgical guides for partially edentulous patients were found to be more accurate than completely edentulous patients. Furthermore, surgical guides supported by posterior teeth compared to anterior teeth, showed a higher level of accuracy.…”

In vitro evaluation of bioburden, three‐dimensional stability, and accuracy of surgical templates without metallic sleeves after routinely infection control activities

“…One of the most common mythbusters about guided surgery is that a surgical template always leads to a flapless surgery. Advancement in digital technologies may encourage the concept of minimally invasive surgery, making flapless approach more reliable 13 . Nevertheless, flapless approach also presents several limitations, besides the well‐known limited vision.…”