title: Histologic evaluation of implants following flapless and flapped surgery: a study in canines.
abstract: BACKGROUND
  Flapless surgery requires penetration of the alveolar mucosa and bone without reflection of mucoperiosteal flaps. Do these techniques force gingival tissue or foreign materials into osteotomies? If so, do such tissues or materials interfere with osseointegration? A proof-of-principle study using a canine model attempted to answer these questions.
  
  
  METHODS
  Five young adult Hound Labrador mongrel dogs received implants with a moderately roughened surface by anodic oxidation using flapless or conventional one-stage (control) surgery in contralateral jaw quadrants. The implants were placed into the osteotomies, and the international stability quotient (ISQ) was recorded using resonance frequency analysis. These measurements were repeated following a 3-month healing interval when the animals were euthanized, and implants and surrounding tissues were retrieved and processed for histologic analysis.
  
  
  RESULTS
  The implants were stable upon insertion and demonstrated increased stability at 3 months without significant differences between surgical protocols. The histologic evaluation showed high bone-implant contact (flapless surgery: 54.7% +/- 8.4%; control: 52.2% +/- 13.0%; P >0.05) without evidence of gingival tissue or foreign body inclusions. There were no significant differences in marginal bone levels between the surgical protocols. Post-insertion and at 3 months, ISQ values depended on the amount of torque delivered. Immediately post-insertion, for every 1-unit increase in torque value, the ISQ increased by 0.3 (95% confidence interval: 0.1 to 0.4; P = 0.0043). Three months postoperatively, for every one-unit increase in torque the ISQ value decreased 0.2 (95% confidence interval: -0.4 to -0.1; P = 0.0012). The effect of torque on ISQ values was independent of treatment effects and remained significant after adjustment for treatment.
  
  
  CONCLUSIONS
  The results suggest that implants placed without flap reflection remain stable and exhibit clinically relevant osseointegration similar to when implants are placed with flapped procedures. Greater torque at implant placement resulted in less implant stability at 3 months.
authors.affiliation: University of Southern California School of Dentistry, Los Angeles, CA, USA. branebill@comcast.net
authors.forename: William
authors.initials: W
authors.lastname: Becker
authors.forename: Ulf M E
authors.initials: UM
authors.lastname: Wikesjö
authors.forename: Lars
authors.initials: L
authors.lastname: Sennerby
authors.forename: Mohammed
authors.initials: M
authors.lastname: Qahash
authors.forename: Philippe
authors.initials: P
authors.lastname: Hujoel
authors.forename: Moshe
authors.initials: M
authors.lastname: Goldstein
authors.forename: Ilser
authors.initials: I
authors.lastname: Turkyilmaz
mesh_terms: D000539:Alveolar Process / Q000473:pathology / Q000601:surgery; D000818:Animals; D015519:Bone Density / Q000502:physiology; D015921:Dental Implants; D004285:Dogs; D005547:Foreign Bodies / Q000473:pathology; D005881:Gingiva / Q000473:pathology / Q000601:surgery; D008297:Male; D008334:Mandible / Q000473:pathology / Q000601:surgery*; D023421:Models, Animal; D009061:Mouth Mucosa / Q000473:pathology / Q000601:surgery; D016348:Osseointegration / Q000502:physiology; D010027:Osteotomy / Q000379:methods*; D013499:Surface Properties; D013524:Surgical Flaps; D013997:Time Factors; D019415:Torque; D014945:Wound Healing / Q000502:physiology
chemical_list: D015921:Dental Implants