title: A model study on flapless implant placement by clinicians with a different experience level in implant surgery.
abstract: BACKGROUND
  Some implant companies advocate that flapless surgery is easy to perform and beneficial for aesthetics and patients morbidity. However, studies objectively analyzing the position in the bone of implants installed with this approach are lacking. This in vitro model study was performed to analyse deviations in position and inclination of implants placed with flapless surgery compared with the ideally planned position and to examine whether the outcome is affected by experience level.
  
  
  METHODS
  Identical radio-opaque resin models were developed with a silicon lining mimicking the soft tissues and six edentulous single tooth spaces. Eighteen clinicians (six periodontists, six general dentists and six students) drilled four implant sites each (Straumann AG, Basel, Switzerland) with a flapless approach. Corresponding CT-scan images of the models were available. A virtual implant program (Simplant, Materialise NV, Leuven, Belgium) was used to plan the ideal position and to compare this with the implant angulation and position of the test implants.
  
  
  RESULTS
  There were no significant differences between the experience groups for all parameters except for global deviations between dentist and students, angle deviations between dentists and students and horizontal deviations between specialists and students. In incisor sites, specialists and students deviated significantly more in global deviation and depth than dentists. In premolar and molar sites, there were no significant differences except for horizontal deviations between specialists and dentists in molar sites. As a consequence of the malpositioning, perforations were seen in 59.7% (43/72) of the implant occasions when the artificial mucosa was removed from the model.
  
  
  CONCLUSIONS
  The three-dimensional location of implants installed with flapless approach differs significantly from the ideal, although neighbouring teeth were present and maximal radiographical information was available. Within the limitations of this in vitro model study it seems necessary to point out that these deviations would in a clinical situation lead to complications such as loss of implant stability, aesthetical and phonetical consequences. The outcome is not influenced by the level of experience with implant surgery. This points out that more precise measurements of soft tissue in situ or additional use of guiding systems are recommendable.
authors.affiliation: Department of Periodontology and Oral Implantology, University of Ghent, Ghent, Belgium. Tommie.vandevelde@telenet.be
authors.forename: Tommie
authors.initials: T
authors.lastname: Van de Velde
authors.forename: Fadi
authors.initials: F
authors.lastname: Glor
authors.forename: Hugo
authors.initials: H
authors.lastname: De Bruyn
mesh_terms: D000539:Alveolar Process / Q000293:injuries; D002983:Clinical Competence; D003198:Computer Simulation; D003758:Dental Implantation, Endosseous / Q000009:adverse effects* / Q000379:methods*; D019232:Dental Restoration Failure; D003815:Dentists; D008953:Models, Anatomic; D003765:Models, Dental; D010517:Periodontics; D013335:Students, Dental; D013524:Surgical Flaps; D013529:Surgical Wound Dehiscence / Q000209:etiology; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014584:User-Computer Interface