What is flapless implant surgery?
In conventional implant surgery the gum is opened. Cleveland Clinic describes the sequence: the surgeon makes an incision in the gum, creates a small hole in the jawbone, places the implant and closes the incision with stitches. Cambridge University Hospitals (CUH) puts it similarly: the gum is cut and pushed back to expose the bone. The piece of gum that is lifted is called a “flap” in dental terminology.
In flapless implant surgery the gum is not lifted. By the definition used in the meta-analysis by Chrcanovic and colleagues (2014), the implant is placed into the bone through the gum without raising a flap. It does not work entirely without an opening, however: a small, implant-sized opening is made in the gum.
How this approach relates to a surgical guide is covered in a separate section of our guide to guided implant surgery; the standard procedure with an incision is explained in our guide to how dental implant surgery is done.
What conditions does flapless surgery need?
Without lifting the gum, the dentist does not see the bone directly. The conditions therefore have to be known precisely before surgery. The sources name above all:
- Sufficiently wide and tall bone: the bone has to surround the implant on all sides. Chrcanovic and colleagues report that some authors recommend a bone width of at least 7 mm.
- Enough firm gum: the pale pink gum firmly attached to the bone is called keratinised or attached gingiva. The meta-analysis regards patients with enough attached gum and bone volume at the implant site as suitable.
- No bone grafting needed: Romandini and colleagues recommend limiting the flapless approach to cases without bone grafting.
- Three-dimensional imaging: according to Brodala’s review for the 2009 ITI consensus conference, a good outcome requires advanced imaging, clinical training and surgical judgement. How these measurements are taken is explained in our guide to CBCT scans before dental implants.
Is it an option for everyone?
No. Flapless surgery is an option for selected patients with suitable conditions. The 2012 Cochrane review also limits its finding that the flapless approach does not reduce success to “carefully selected patients”.
In these situations the gum is usually lifted:
| Situation | Reason |
|---|---|
| Narrow bone, bone grafting in the same appointment | The bone has to be visible to place the graft material |
| Sinus lift with a lateral window in the upper jaw | The window is made in the bone after lifting the gum |
| Very little attached gum at the implant site | The flap allows the gum to be repositioned around the implant |
| Unclear bone shape or undercuts on the CBCT scan | Working blind raises the risk of perforating the bone wall |
Chrcanovic and colleagues note that in some studies the flapless approach was used only in favourable conditions, so the good results cannot be transferred to everyone. What bone grafting or a sinus lift means for your trip is covered in our guides to bone grafts before implants and the sinus lift.
What are the advantages of flapless surgery?
The Cochrane review (Esposito and colleagues, 2012) analysed two randomised trials with 56 patients comparing placement with and without a flap. After the flapless approach, pain and swelling were lower; the authors rate the evidence as weak, however, because of the two small trials.
In the review by Romandini and colleagues on guided flapless placement, surgery time was on average about 24 minutes shorter than with a flap. Chrcanovic and colleagues list less tissue trauma, shorter procedures, faster healing and more comfort as the claimed advantages.
Where are the limits and risks?
The main limitation is that the bone cannot be seen. Chrcanovic and colleagues call the flapless approach a “blind” technique: because the actual shape of the bone is not visible, the thin bone wall towards the cheek or tongue can be perforated unintentionally during drilling, with possible aesthetic consequences or implant loss. The same authors name further points:
- Cooling water reaches the drill hole less well, so the bone may heat up more.
- Flapless implants tend to be placed deeper than with a flap.
In Brodala’s review, the rate of complications during surgery in the studies that reported it was 3.8 percent of procedures, including perforations of the cheek-side or tongue-side bone wall. With a flap such a problem is seen directly and corrected in the same appointment; without an incision it may become necessary to lift the gum during surgery after all.
How does the approach relate to a surgical guide?
Flapless surgery can be done freehand or with a custom-made surgical guide. The 2013 ITI consensus statement records that guided placement is possible with and without a flap; a guide therefore does not automatically mean flapless surgery, and vice versa. The guide ties the direction of the implant to the plan and makes working without sight of the bone easier, but it does not remove the risks: Chrcanovic and colleagues warn that a guide can give a “false sense of security” about perforations of the bone wall.
The systematic review by Turkyilmaz and colleagues (2023) compared both approaches for guided implants across 57 studies. Survival was 97.4 percent without a flap and 95.8 percent with one, with no significant difference. Mean bone loss was 0.96 mm without and 0.49 mm with a flap; the authors see a slight advantage for the flapped approach in terms of bone level.
What does the research say overall?
| Source | What was studied? | Key finding |
|---|---|---|
| Brodala, ITI review (2009) | Clinical studies 1966 to 2008; mean follow-up 19 months | In prospective studies around 98.6 percent of implants survived |
| Cochrane, Esposito and colleagues (2012) | 2 randomised trials, 56 patients | Less pain and swelling; weak evidence |
| Chrcanovic and colleagues (2014) | 23 studies, 3,496 implants | Implant loss 3.09 percent without and 1.73 percent with a flap; no difference in bone loss or infections |
| Turkyilmaz and colleagues (2023) | Guided implants, 57 studies | No difference in survival; bone level slightly better with a flap |
Chrcanovic and colleagues consider the higher loss with the flapless approach statistically significant, but urge cautious interpretation because of the high risk of bias in most studies. In short: for suitable patients flapless surgery is a reasonable option, but there is no robust evidence that it is better than the flapped approach in the long term.
What should you look out for if you want flapless surgery?
- Ask whether the width and height of your bone on the CBCT scan are sufficient for the approach.
- Ask whether there is enough attached gum at the implant site.
- Clarify whether bone grafting or a sinus lift will be needed in the same appointment.
- Discuss beforehand that the gum may have to be lifted after all if there are unexpected findings during surgery.
- Follow the aftercare instructions just as carefully regardless of the approach; what applies in the first week is in our guide to the first week after dental implants.
For international patients the flapless approach changes nothing about the number of trips: the healing period stays the same, and the final teeth follow on the second trip. How the trips are planned is explained on our page on dental treatment in Türkiye.
How is the approach decided at Rönesans?
Bone height and width are assessed in three dimensions with the CBCT scanner at our clinic. Whether a flapless approach is an option for you is assessed by your dentist after the examination and the scan; the use of a surgical guide is also decided only then. If there is not enough bone, we carry out bone grafting and sinus lifts at the clinic, and in that case the gum is lifted.
Our dentists draw up your treatment plan together, and before treatment starts you receive in writing which procedure is planned at which tooth and what it costs. We answer planning questions in English on WhatsApp at +90 532 363 49 54. The stages of treatment are on our dental implants page.