Journal of Research in Medical and Dental Science

2022, Volume 10, Issue 2, Page No: 83-89

Copyright CC BY-NC 4.0
Available Online at: www.jrmds.in
eISSN No. 2347-2367: pISSN No. 2347-2545

Association of Anterior Implant Placement and Advancement of Flap

Santhosh Bala S1, Abhinav RP1*, Subhasree R2, Thiyaneswaran N2

1
Department of Oral and Maxillofacial Surgery, Saveetha Dental College and Hospitals, Saveetha Institute of
Medical and Technical Sciences, Saveetha University, India
2
Department of Implantology, Saveetha Dental College and Hospitals Saveetha Institute of Medical and
Technical Sciences, Saveetha University

ABSTRACT
Introduction: Implant osseointegration is defined as direct contact between the implant surface and the bone as
measured under a light microscope. When enough bone volume surrounds the full surface of the implant, it has a better
chance of surviving. Bone grafting may be required to ensure enough osseous support. This can happen at a variety
of times, including after extraction for socket augmentation and in a staged or simultaneous approach with implant
placement for ridge augmentation. Flap reflection is required for access to determine bone morphology, quantity,
quality, and key anatomical features during bone grafting procedures. The flap characteristics and the outcomes of
regenerative operations may be influenced by a variety of incision patterns and reflection approaches. The aim of this
study is to determine the association of anterior implants and flap advancement.
Materials and methods: In this retrospective study, the data was collected from the hospital database and further
analysis was done and the results were tabulated. A statistical analysis of the collected data regarding the necessity of
flap advancement during anterior implant placement
Results: The sample size was found to be 2,116. 16.19% were in the age group 18-30 years, 39.88% were in the age
group 30-50 years, 40.39% were in the age 50-70 years and 3.56% were in the age group 70-90 years. 67.08% of
the cases were males and 32.92% were females. 28.29% of the cases needed flap advancement, while 71.71% of the
cases did not require flap advancement. 61.74% of the cases were maxillary anterior and 38.26% of the cases were
mandibular anterior.
Discussion: In the current study, it can be concluded that there is no significant association between anterior implant
placements. It is not dependent on the site of the implant. Previous study conducted by Zazou et al. concluded that flap
advancement can be used in mandibular posteriors, especially if ridge augmentation is needed. In cases of anterior
implant placements, Flap advancement is usually not needed. But a true association cannot be made between the
implant site and necessity for flap advancement, as flap advancement is decided based on various factors mentioned
above.
Conclusion: Thus, it can be concluded that there is no association between anterior implant placement and flap
advancement. Flap advancement is decided based on various factors, but the implant site alone is not determinative
of the need for advancement of flap.
Key words: Anterior implants, Flap advancement, Osseointegration, Innovative treatment

HOW TO CITE THIS ARTICLE: Santhosh Bala S, Abhinav RP, Subhasree R, Thiyaneswaran N, Association of Anterior Implant Placement and
Advancement of Flap, J Res Med Dent Sci, 2022, 10 (2):83-89.

Corresponding author: Suhaas Pradhyumna Y between the implant surface and the bone as measured
e-mail: [email protected] under a light microscope. When enough bone volume
surrounds the full surface of the implant, it has a better
Received: 09-Jan-2022, Manuscript No. JRMDS-22-51428;
chance of surviving. Bone grafting may be required to
Editor assigned: 11-Jan-2022, PreQC No. JRMDS-22-51428 (PQ); ensure enough osseous support. This can happen at
Reviewed: 25-Jan-2022, QC No. JRMDS-22-51428; a variety of times, including after extraction for socket
Revised: 28-Jan-2022, Manuscript No. JRMDS-22-51428 (R); augmentation and in a staged or simultaneous approach
with implant placement for ridge augmentation. Flap
Published: 04-Feb-2022
reflection is required for access to determine bone
morphology, quantity, quality, and key anatomical
INTRODUCTION
features during bone grafting procedures. The flap
Implant osseointegration is defined as direct contact characteristics and the outcomes of regenerative

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Santhosh Bala S, et al. J Res Med Dent Sci, 2022, 10 (2):83-89

operations may be influenced by a variety of incision from an apical aspect to produce a pedicle and unfolding
patterns and reflection approaches [1]. it over the graft site, resulting in full-thickness buccal
and palatal flaps. The buccal flap is restored over the
Flap designs based on the need for flap advancement
expanded tissue and single interrupted sutures are used
are categorized into 3 types- Mild flap advancement,
to close the wound [8]. Lingual pedicle uses a rotational
moderate flap advancement and major flap advancement.
split-thickness connective tissue pedicle from the palate
Mild flap advancement is employed when the flap should
to boost flap length for primary soft tissue closure over
be advanced 1-3 mm. When a buccal plate defect likely
grafted extraction sites or insufficient ridges, similar
to result in implant fenestration is present, Aesthetic
to the vascularized periosteal membrane. At the most
buccal flap approach was advocated for immediate
apical extent of the vertical releasing incisions, the
implantation in the aesthetic zone. This flap is very useful
buccal flap design comprises horizontal incisions of 3 to
when existing alveolar bone loss, thin tissue biotype, or a
4 mm up to 6 to 10 mm in length. In a case series, this flap
combination of the two causes flap reflection recession,
maintained soft tissue covering for 6 months in 98.8%
papilla height loss, and unsatisfactory aesthetics. It
of the 173 sites [9]. Coronally positioned palatal sliding
involves creating a full-thickness flap with a horizontal
flap is used to enlarge the zone of keratinized tissue and
incision 3 mm apical to the free gingival margin in
offer primary coverage of barrier membranes during
keratinized tissue, followed by two vertical releasing
implant implantation and simultaneous grafting, split-
incisions extending past the MGJ. Before or after the
thickness planes of palatal tissue are created from a full-
atraumatic evacuation of the hopeless tooth, the flap
thickness flap to allow for sliding and rotation similar to
might be performed [2]. The flap is replaced, and the
a garage door (10). Like a free gingival graft donor site,
vertical and horizontal incisions are sutured together
the underlying de-epithelialized palatal tissue will re-
to reduce stress. The implant should be temporised
epithelialize [10,11].
as soon as possible to maximise soft tissue support
[3]. Mucogingival pouch flap is used when aesthetic Major flap advancement is employed when the
considerations are low. This procedure is also used to advancement needed is 7mm or greater. Hockey stick
graft a buccal dehiscence or fenestration defect after flap was proposed by Tinti and Parma-Benfenati to
implant placement. Additional flap extension is achieved accommodate extensive vertical ridge augmentation
by periosteal scoring incisions (for additional 2–3 mm around implants. The vertical incisions of the full-
advancement) after flap reflection and grafting with the thickness buccal flap have "hockey stick"–shaped
SBA technique and a collagen membrane [4]. Periosteal apical extensions. These incisions are often known as
pocket flap is suitable for staged GBR before implant "cutback" incisions [12]. The lingual flap reflection
insertion and is proposed for horizontal augmentation requires the mylohyoid muscle being raised while
of knife-edge ridges. The periosteal pocket promotes important structures in the mouth's floor are contained
graft containment as well as stability. The coronal and protected [13]. A coronally positioned palatal flap
section of the graft is covered with a collagen membrane. is employed in the maxilla. The periosteum (as well as
Horizontal mattress suturing is done in two steps muscle fibres in the mandible) is separated from the
through the lingual flap, each time engaging the buccal flaps' outer, mucosal component. Horizontal mattress
periosteal and mucosal layers independently [5]. Lateral “U-stitches'' spaced 3 mm apart from the “first line of
incision technique provides targeted horizontal ridge closure,” which is followed by simple interrupted sutures
augmentation. When compared to crestal incisions, the [14]. Remote flap is used for horizontal or vertical ridge
combined flap design is said to reduce soft tissue issues. augmentation. This flap is a version of Tinti and Parma-
For space preservation, tenting screws can be used with a Benfenati's "Hockey stick" flap design. Extending the
bone graft and a nonresorbable, fixed ePTFE membrane. flap 5 mm beyond the graft site in edentulous areas is
For tension-free primary closure, a horizontal mattress one modification (compared with 3 mm). Sutures are
and simple interrupted sutures are employed [6]. put in place using a horizontal mattress and simple
interrupted sutures [15]. Double flap was created for
Moderate flap advancement techniques are used for
GBR in the posterior jaw, both vertically and horizontally.
when advancement needed is 4-6 mm. Buccal pedicle
The design of a mid crestal horizontal incision with a
flap/graft design is utilised for socket preservation or
single vertical incision at the mesial aspect of the flap
rapid implant insertion to allow for soft tissue covering
was based on anatomical considerations in order to
while avoiding a disparity in the MGJ, vestibule loss, and
protect blood flow to the avascular crestal section of the
limited keratinized tissue, all of which can occur if the
edentulous ridge while avoiding essential structures.
flap is overextended. Instead, a pedicle or free gingival
The mucosal and periosteal flaps are lifted and sutured
graft method uses buccal keratinized gingiva from a
independently, just as the periosteal pocket flap [16].
neighbouring tooth as the donor for soft tissue covering
To generate a twofold partial thickness buccal flap and
over the membrane. Any graft that is left over can be used
a coronal positioned palatal sliding flap, Multilayered
to restore the donor location [7]. Vascularised periosteal
approach employs plastic and microsurgery concepts [17].
membrane is used to perform primary closure over
grafted sockets. It is possible to utilise an absorbable Our team has extensive knowledge and research
membrane or not. The additional flap extension is experience that has translated into high quality
performed by internally splitting the palatal flap in half publications [18–37]. The aim of this study is to

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determine the association of anterior implants and flap south Indians. The necessary data such as age, gender,
advancement. implant site, necessity of flap advancement, etc. was
recorded. Incomplete patient data was excluded. Data
MATERIAL AND METHODS was recorded in Microsoft Excel and exported to the
statistical package of social science for Windows (SPSS)
This retrospective study examined the records of and subjected to statistical analysis. Chi Square test was
patients from 01 June 2019 to 31st March 2021 who used for comparison of groups.
visited Saveetha Dental College and Hospitals. Ethical
approval was taken from the institutional review board. RESULTS
The study population included patients who underwent
implant placement in anterior sites. The study sample The sample size was found to be 2,116. The patients
included both male and female gender, predominantly were split into 4 age groups. 16.19% were in the age

Figure 1: Bar chart depicting the population distribution in age. 16.19% were in the age group 18-30 years, 39.88% were in the age group 30-
50 years, 40.39% were in the age 50-70 years and 3.56% were in the age group 70-90 years.

Figure 2: Bar chart depicting the population distribution in gender. 67.08% were males and 32.92% were females.

Figure 3: Bar chart depicting the percentage distribution on whether flap advancement was needed. 28.29% of the cases needed flap
advancement, while 71.71% of the cases did not require flap advancement.

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Figure 4: Bar chart depicting the percentage distribution of implant sites. 61.74% of the cases were maxillary anterior and 38.26% of the cases
were mandibular anterior.

Figure 5: Bar chart depicting the association between Gender and requirement of flap advancement. X axis represents Gender, and Y axis
represents Number of cases. Chi square test was done and the association was not found to be statistically significant. Pearson’s Chi value:
2.319, df: 2, p-value= 0.314 (p>0.05). Hence, not statistically significant.

Figure 6: Bar chart depicting the association between Age and requirement of flap advancement. X axis represents Age, and Y axis represents
the number of cases. Chi square test was done and the association was not found to be statistically significant. Pearson’s Chi value: 13.152, df:
8, p-value= 0.107 (p>0.05). Hence, not statistically significant.

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Figure 7: Bar chart depicting the association between the implant site and requirement of flap advancement. X axis represents implant site,
and Y axis represents Number of cases. Chi square test was done and the association was not found to be statistically significant. Pearson’s Chi
value: 9.689, df: 6, p-value=0.219 (p>0.05). Hence, not statistically significant.

group 18-30 years, 39.88% were in the age group 30-50 Flap sloughing can occur as a result of a disruption in
years, 40.39% were in the age 50-70 years and 3.56% blood flow, resulting in tissue necrosis; therefore, careful
were in the age group 70-90 years (Figure 1). 67.08% of flap management is critical during periosteal release to
the cases were males and 32.92% were females (Figure avoid excessive flap thinning or perforation. Damage
2). 28.29% of the cases needed flap advancement, while to vascular and neurologic tissues are two further
71.71% of the cases did not require flap advancement surgical consequences. Membrane contamination and
(Figure 3). 61.74% of the cases were maxillary anteriors infection, with or without bacterial contamination,
and 38.26% of the cases were mandibular anterior are not uncommon, particularly with nonresorbable
(Figure 4). The correlation between Gender and membranes [40]. Exposed bone graft particles and
requirement of flap advancement was not found to be fixation are also prevalent. When doing a treatment
statistically significant, meaning there is no correlation like ridge augmentation, it's typical to underprepare
between gender and requirement of flap advancement the flap, which leads to tensionless closure failure.
(Figure 5). The correlation between Age and requirement Primary closure will not be achieved if the tissue is not
of flap advancement was not found to be statistically adequately released, and excessive force on the sutures
significant, meaning there is no correlation between will be required to seal the wound. Suture necrosis and
age and requirement of flap advancement (Figure 6). dehiscence along the suture line are possible outcomes.
The correlation between implant site and requirement To eliminate this problem, it's best to prepare the flap for
of flap advancement was not found to be statistically advancement before putting bone grafts and barriers in
significant, meaning there is no correlation between place. The extent to which the tissue must be advanced is
the site of implant placement and requirement of flap determined by the amount of the predicted enlargement
advancement (Figure 7). in breadth and height. The buccal flap should be allowed
to move 3 to 5 millimetres. The failure to provide
DISCUSSION tensionless closure is the most common cause of wound
dehiscence. Infection, stress from opposing teeth,
In the current study, it can be concluded that there is discomfort from a removable prosthesis, and hematoma
no significant association between anterior implant formation are all possible causes of a dehiscence. A
placements. It is not dependent on the site of the implant. dehiscence might occur if a patient brushes on the sutures
Previous study conducted by Zazou et al. concluded that too soon. The chances of a successful augmentation are
flap advancement can be used in mandibular posteriors, diminished if a dehiscence occurs. Attempting to restore
especially if ridge augmentation is needed. This is used a dehiscence is not a good idea. The clinician should
in Guided Bone Regeneration (GBR) [38]. The necessity allow it to cure naturally.
for flap advancement has to be correlated with their pros
The viability of a flap is dependent on the flow of
and cons. Many studies have reported complications
oxygenated blood to the flap's leading edges. As the
with advancement of flap. Complications have been
distance from the feeding artery or arteriole rises, blood
documented in up to 25% of horizontal and 45.5 percent
perfusion through the vascular plexuses diminishes 41].
of vertical bone augmentation surgeries; as a result,
The distal tip of an advancement flap is most vulnerable
various authors have established classification and
to necrosis because it has fewer blood vessels and is
management strategies for these complications [39].
farthest from the feeding artery or arteriole, and the

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portion of the flap sutured under the greatest tension 4. Greenstein G, Greenstein B, Cavallaro J, et al. Flap
because the tension from the closure causes compressive advancement: Practical techniques to attain tension free
forces on blood vessels [42]. primary closure. J Periodontol 2009; 80:4-15.

Hence, it is understandable why clinicians debate on 5. Simion M, Dahlin C, Trisi P, et al. Qualitative and
whether flap advancement is needed. But, it can be quantitative comparative study on different filling
concluded that while many studies have shown the materials used in bone tissue regeneration: a controlled
clinical study. Int J Periodontics Restorative Dent 1994; 14.
clinical outcome with flap advancement, it is more
frequently indicated in complicated implant placements 6. Wang HL, Boyapati L. “PASS” principles for predictable
(like ridge augmentation). In cases of anterior implant bone regeneration. Implant Dent 2006; 15:8-17.
placements, Flap advancement is usually not needed. 7. Melcher AH. On the repair potential of periodontal
But a true association cannot be made between the tissues. J Periodontol 1976; 47:256-260.
implant site and necessity for flap advancement, as
flap advancement is decided based on various factors 8. Fu JH, Wang HL. Horizontal bone augmentation. The
mentioned above. decision tree. Int J Periodontics Restorative Dent 2011; 31.
9. Nevins M, Mellonig JT. Nevins M, et al. The advantages
CONCLUSION of localized ridge augmentation prior to implant
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Thus, it can be concluded that there is no association Dent 1994; 14.
between anterior implant placement and flap
10. Kalaivani N, Arun M, Abhinav RP, et al. Requirement of
advancement. Flap advancement is decided based
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determinative of the need for advancement of flap.
11. Buser D, Dula K, Hirt HP, et al. Lateral ridge augmentation
using autografts and barrier membranes: A clinical
ACKNOWLEDGEMENT
study with 40 partially edentulous patients. J Oral
The authors are thankful to Saveetha Dental College for Maxillofac Surg 1996; 54:420-432.
providing a platform to express our knowledge. 12. Gopal TM, Subhashree R, Nesappan T. et al. Association
of gingival Biotype and soft tissue healing one week
AUTHOR CONTRIBUTIONS after implant placement. J Long Term Effects Med
implants 2020; 30.
Santhosh Bala contributed to data collection, analysis
13. von Arx T, Kurt B. Implant placement and simultaneous
and interpretation and drafting of the article. Abhinav ridge augmentation using autogenous bone and a micro
RP, Subhashree, Thiyaneswaran contributed to the titanium mesh. A prospective clinical study with 20
critical revision of the article. implants. Clin oral Implants Res 1999; 10:24-33.
14. Vergara JA, Quiñones CR, Nasjleti CE, et al. Vascular
CONFLICT OF INTEREST
response to guided tissue regeneration procedures
No potential conflict of interest relevant to this article using nonresorbable and bioabsorbable membranes in
was reported. dogs. J Periodontol 1997; 68:217-224.
15. Park SH, Lee KW, Oh TJ, et al. Effect of absorbable
SOURCE OF FUNDING membranes on sandwich bone augmentation. Clin Oral
Implants Res 2008; 19:32-41.
The present study was supported by Saveetha Dental
16. Fu JH, Oh TJ, Benavides E, et al. A randomized clinical
College, Saveetha Institute of Medical and Technical trial evaluating the efficacy of the sandwich bone
Sciences, Saveetha University, India. augmentation technique in increasing buccal bone
thickness during implant placement surgery. I. Clinical
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