J Bagh College Dentistry Vol. 31(4), December 2019 Flap and Flapless 6 Evaluation of Crestal Bone Resorption around Dental Implants in Flapped and Flapless Surgical Techniques Depending on Cone Beam CT Scan (Comparative Study) Mustafa Abdul Hussein Al Najjar B.D.S.(1) Sahar Shakir Al- Adili B.D.S., M.Sc.(2) ABSTRACT Background: The long term survival of dental implants is evaluated by the amount of crestal bone loss around the implants. Some initial loss of bone around dental implants is generally expected. There is reason to believe that reflecting a mucoperiosteal flap promotes crestal bone loss in the initial phase after an implant has been inserted. The surgical placement of a dental implant fixture is constantly changing and in recent years, there has been some interest in developing techniques that minimize the invasive nature of the procedure, with flapless implant surgery being advocated. The purpose of this study was to compare the radiographic level of the peri- implant bone after implant placement between traditional flapped surgery and flapless approach depending on CBCT during 24 weeks healing period. Materials and Methods: A total of 25 Iraqi patients with an age range of 20-60 years who received 46 implants were randomly divided into two groups: a control group which involved 27 implants inserted by conventional flapped surgical approach and a study group which involved 19 implants inserted by flapless surgical approach. The bone level was measured by CBCT for each implant at buccal and palata/lingual sides at two times, immediately after implant placement (base line data), and after 24 weeks healing period. Results: There was no significant difference between study (flapless) and control (flapped) groups in the mean of total crestal bone resorption for buccal and palatal side after 24 weeks from implant placement (P= 0.393 for buccal side and P= 0.214 for palatal side). There was highly significant difference between buccal and palatal side regarding crestal bone loss around implants (P = 0.001) Conclusions: Bone resoption around dental implants placed with conventional flap surgery compared to flapless surgery does not seem to be influenced during the healing period before implant loading. (Received: 16/2/2019; Accepted: 17/3/2019) INTRODUCTION Osseointegrated dental implants are usually placed with a flap approach, which is based on soft tissue flap reflection and repositioning with suture after implant placement. This traditional approach has several drawbacks: decreased supraperiosteal blood supply due to flap elevation procedures, which can theoretically lead to bone loss; patient discomfort, which includes pain, bleeding, edema, and a longer surgical time (1, 2). The objective of modern implant treatment involves not only the successful osseointegration of the dental implant but furthermore an esthetic and functional restoration. The implant is required to be surrounded by stable peri-implant tissue levels that are in harmony with the existing dentition. Stable bone levels at or close to the implant margin (shoulder) are among the factors used to consider implant treatment successful (3, 4). Successful prosthetic reconstruction by dental implant mainly depends on the preservation of peri-implant bone (5, 6). In recent years, flapless surgery is increasingly becoming a routine clinical procedure, and has been reported to have a predictable outcome with high success rate. 1. Baghdad Health Directorate – Al- Rusafa, Ministry of health. 2. Assist. Professor, Department of Oral and Maxillofacial Surgery, College of Dentistry University of Baghdad. Corresponding author Mustafa Abdul Hussein Al Najjar, mustafaalnajjar17@gmail.com This is facilitated by modern radiographic technologies and dental implant treatment planning software to perform three-dimensional evaluation of bone volume at anticipated implant sites (7). Flapless surgery has several theoretical advantages. From a patient point of view, it shortens the surgical time, decreases discomfort by reducing swelling and pain and accelerates post- surgical healing. Moreover, the blood vessels of hard and soft tissues around the implant site are preserved. Some studies state that this less traumatic surgery implies reduced bone resorption (8). Nevertheless, flapless surgery has some risks due to the limitations of exposure in the surgical site. A reported risk is buccal or lingual cortical plate perforation. Therefore, the technique requires advanced clinical experience, and surgical judgement for appropriate case selection (patients with sufficient alveolar three dimensional bone and adequate keratinized gingiva) (9). Several studies report on bone resorption and ridge alterations after implant placement in humans (10) and animals (11, 12). Many studies in animals assess that leaving the periosteum in place with flapless implant surgery clearly decreases the bony resorption rate (13, 14), and according to some authors, the flapless procedure is superior to flap implant procedures for maintaining original mucosal shape surrounding implants (15). J Bagh College Dentistry Vol. 31(4), December 2019 Flap and Flapless 7 Therefore, it can be speculated that similar events may occur in humans after implant surgery. Imaging may aid in evaluating implant therapy outcomes, such as peri implant bone defects and level and bone to implant interface (16, 17). Recently, cone beam computed tomography (CBCT) has been heavily marketed for implant- based oral rehabilitation procedures, mainly for treatment planning (18). Nevertheless, some studies have used the method for assessment of the marginal peri-implant bone level and thickness, primarily of the buccal bone, and outcome of regenerative procedures (19, 20, 21). This study aimed to compare the radiographic level of the peri- implant bone after implant placement between traditional flapped surgery and flapless approach depending on CBCT during 24 weeks healing period. The working hypothesis is that using flapless technique decrease crestal bone resoption around dental implant. MATERIALS AND METHODS This clinical randomized prospective study was conducted from December 2017 to November 2018, it included 25 Iraqi patients who received 46 implants with an age range of 20-60 years. The patients were randomly divided into two groups: a control group which involved 27 implants inserted by conventional flapped surgical approach and study group which involved 19 implants inserted by flapless surgical approach. Preoperative clinical and radiographic assessment were done for all patients. One implant system was utilized in the study (Nucleoss Co., Turkey). Inclusion Criteria 1. Patients had to be at least 18 years of age 2. Implants to be placed at least 6 months after teeth extraction (healed sites). 3. Only those patients who did not need any soft or hard tissue augmentation. 4. A minimum distance of 2 mm to adjacent anatomical structures (mandibular canal, maxillary sinus, mental foramen, and adjacent teeth). 5. The Presence of attached non-mobile soft tissue at least 1.5 mm in thickness above the crest of bone in the area receiving the implant, as measured by reamer and stopper. 6. The presence of adequate bone width at least 5 mm, 3 mm apical to crest measured by bone caliper after measurement of soft tissue above the crest, no need for bone augmentation procedures. 7. Patients with good oral hygiene. Exclusion Criteria 1. Insufficient keratinized tissue above the implant site (less than 2 mm above the ridge crest). 2. Insufficient bone width (less than 5 mm, 3 mm apical to crest). 3. Presence of any pathological condition adjacent to proposed implant site or at the implant zone. 4. Any medical conditions that could not withstand implant surgery or conditions that would interfere with normal healing mechanism including uncontrolled diabetes, osteoporosis, psychosis, current pregnancy at the time of surgical procedures. 5. Heavy smokers (more than 20 cigarette per day) 6. Patients with history of head and neck radiotherapy or chemotherapy over the past 5 years. 7. History or clinical evidence of para-functional habits such as bruxism and clenching. 8. Patients with active periodontitis. 9. Any dehiscence or fenestration of alveolar bone happened during the operation of implant placement. Surgical Procedures Flap Procedure (Control Group) After anaesthetization with Lidocaine 2% by infiltration technique, a three sided flap (extensive flap design) or two sided flap was made initiated via paracrestal incision with palatal bias for better visibility, preserving a wider band of keratinized attached gingiva for more solid wound closure and avoiding wound dehiscence as seen in Fig (1). Full thickness mucoperiosteal flap reflection to expose crestal and buccal alveolar bone using periosteal elevator. The implant bed was prepared by the conventional drilling procedure. The predetermined dental implant size installed in its position. Soft tissue closure was achieved with 3/0 black silk non absorbable suture (simple interrupted technique). J Bagh College Dentistry Vol. 31(4), December 2019 Flap and Flapless 8 Figure 1: Placement of dental implants through the palatal bias incision Flapless Procedure (Study Group) After anaesthetization with Lidocaine 2% by infiltration technique, the soft tissue punch was used with speed 400-600 rpm to remove the soft tissue and expose the bone in which the implant to be driven in as seen in Fig (2). Figure 2: Mucosa was punched by tissue punch. The drilling procedure was started by pilot drill, Fig. (3), then the parallelism and angulation of drilling holes checked with parallel pins, Fig. (4) Figure 3: Drilling with pilot drill. Figure 4: Parallel pin to verify proposed implant angulation. followed by sequential stepped drilling until reaching the appropriate final drill size according to manufacturer instructions. The predetermined dental implant size installed in its position, Fig. (5), and the margin of implant checked by periodontal probe to ensure that it was with the level of the surrounding bone followed by subjoining the cover screw into the fixture, Fig. (6). Then a single 3/0 black silk suture was used to preserve blood clot above the implant area. J Bagh College Dentistry Vol. 31(4), December 2019 Flap and Flapless 9 Figure 5: Installation of dental implant in its position. Figure 6: Fixtures after placement in prepared sockets with cover screws. After six months the patients re-attended for second stage surgery and placement of healing abutments for about (10-14) days, Fig. (7), then the patients were referred for prosthesis fabrication, Fig. (8). Figure 7: Healing abutment connection after six months. Figure 8: Final prosthesis was fixed in patient's mouth. Data Collection and post-operative Radiological Assessment All patients in both surgical groups were informed to take CBCT (time 1) in the same day or at the second day of surgery to assess the position of the implants within the bone; the relation of the implant/s to the other dentition, vital structures and the relation of the implant to the crestal bone level in 3 planes. Data were collected first at the seventh day after surgery (first follow up). Determination of bone level immediately that represents as base line data for each implant in both group on two sides, buccal side and palata/lingual side, firstly a vertical line was drawn at the center with the long axis of the dental implant passing through the notch of the cover screw which represent a reference point, then another horizontal line was drawn at the top of implant to determine its level with the crestal bone, also another two vertical lines along the buccal and palatal/lingual sides of implant were drawn where from these lines about 1mm the bone level was measured on each side of implant if the bone thickness was enough (such as implants placed in posterior area) or about 0.5 mm if the bone was thin (such as implants placed in anterior region), Fig. (9 A) All the patients were investigated by CBCT (time 2) after 24 weeks post-operatively with the same relations of (time 1), also assessment of osseointegration, survival and early failure rate with the aid of Alberktson criteria of success (implant immobility, no peri-implant radiolucency, asymptomatic), and checking for any complication that may have occurred. Determination of crestal bone level after 24 weeks was done with the same method in (time 1) and the difference was calculated which represented bone loss that was shown as a shadow in the area, Fig. (9 B). In order to view the same J Bagh College Dentistry Vol. 31(4), December 2019 Flap and Flapless 10 section in the CBCT and to avoid any error that may affect the result in reading the section, the notch of the cover screw is used as a reference point. Figure (9): CBCT (oblique view) for the same posterior DI placed with flapped procedure. (A) Immediate post-operative CBCT illustrating the buccal side bone level of DI (arrows) in relation to the horizontal line. (B) 24 weeks post-operative CBCT illustrating the difference in bone level (arrow) that presented as shadow. Statistical Analysis The data were analyzed using Statistical Package for Social Sciences (SPSS) version 25. The data presented as mean, standard deviation and ranges. Categorical data presented by frequencies and percentages. Independent t-test and Analysis of variances (ANOVA) (two tailed) was used to compare the continuous variables among study groups accordingly. Z-test was used to evaluate the difference in proportions between flapped and flapless cases regarding survival rate. A level of P – value less than 0.05 was considered significant. RESULTS There was no significant difference between study (flapless) and control (flapped) groups in the mean of total crestal bone resorption for buccal and palatal sides after 24 weeks from implant placement (P= 0.393 for buccal side and P= 0.214 for palatal side), Table (1). There was highly significant differences between buccal and palatal sides regarding crestal bone loss around implants measured by CBCT after 24 weeks from implants placement for both flapped and flapless surgical techniques (P = 0.001), table (2). Table 1: Comparison according to total mean bone loss in buccal and palatal sides between two surgical groups. Sides Total Bone Loss in Surgical Groups P- Value Flapped Group Mean ± SD Flapless Group Mean ± SD Buccal Side 0.5 ± 0.43 0.39 ± 0.35 0.393 Palatal Side 0.13 ± 0.18 0.06 ± 0.14 0.214 Values are expressed in mean ± SD Table 2: Comparison between Total Resorption of Buccal and Palatal sides Group Total Bone loss of Buccal and Palatal Sides P- Value Buccal side Mean ± SD Palatal side Mean ± SD Flapped group 0.5 ± 0.43 0.13 ± 0.18 0.001 Flapless group 0.39± 0.35 0.06 ± 0.14 0.001 Values are expressed in mean ± SD DISCUSSION According to our data flapless surgery cannot fully avoid bone resoption this was true with all implants placed by flapless technique in this study as they were evaluated by CBCT. This agree with a study done by Nickenig et al. (2010) (22) , they found that the mean crestal bone loss of (0. 5 mm) for implants placed with flapless surgery after a healing period determined radiographicaly using digital panoramic radiographs. So it possible to say that gentle flap raising does not hamper bone healing around dental implants in humans. Based on the results obtained from this study, the choice of type of surgical approach does not affect peri-implant bone resorption. Our data on bone resoption are in line with the majority of data in the literature, Lin et al. (2014) (23) reported no significant reduction of marginal bone resorption with flapless technique, also studies showed that crestal bone loss was comparable among implants placed either using flapped or flapless surgical technique (24, 25). The findings of this study disagree with Tsoukaki et al. (2013) (8) who reported that no bone resoption around flapless implants and (Job et al., J Bagh College Dentistry Vol. 31(4), December 2019 Flap and Flapless 11 2008) (26) who reported a significantly lower resoption around implants in flapless group. In this study, there was significant difference between total mean of buccal and palatal aspects (P = 0.001) for both flapped and flapless group. There was obvious that bone resoption in buccal side much more than palatal / lingual side in both groups. Also bone resoption in buccal side was a little higher in maxilla than mandible and anteriorly more than posteriorly for the flapped group, while for flapless group was nearly the same. The data from this study can be accounted for the following reasons: According to anterior maxilla the bone loss in buccal/facial side was higher than palatal side in both flapped and flapless groups, this may be related to the thinner facial plate that leading to more bone resoption after implant placement. This was supported by EL Nahass & Naiem. (2015) (27), who reported that in the incisor region, the buccal bone plate around a tooth was thinner than 1 mm in 86% of the cases as demonstrated by Computerized tomography. For posterior maxilla and mandible in flapless group also the bone loss was higher in buccal side than palatal/lingual side, there was no clear interpretation for this result but after evaluation of the buccal plates for implants placed with flapless procedures, we noticed that most of them were thinner than palatal/lingual plates, this may be either they were initially thin or implant were deviated slightly towards buccal side during placement which made them more thin. It however noteworthy that thin buccal plates lost more bone than thick buccal plates. The deviation of implants supported by a study done by Van de Velde et al. (2008)(28) performed an in vitro model study to analyze deviations in the position and inclination of implants placed with flapless surgery compared with the ideal, virtual planned position and they concluded that location of implants installed with a flapless approach differed significantly from the ideal position. The findings were supported or in line with a hypothesis reported by (Teughels et al., 2009; Merheb et al., 2015) (29) (30), stated that a thin buccal plate is less resistant to the different types of trauma an implant can endure and would therefore be more prone to resoption and buccal implant exposition. According to posterior maxilla and mandible in flapped group the buccal bone loss was higher than palatal/lingual bone, this may be related to the flap elevation during surgical procedure on the buccal side and subsequent trauma that occurred more buccally rather than palatal/ lingual sides where there was no flap elevation. This was supported and in accordance with the fundamental studies reported by Merheb et al. (2015) (30), who stated that flap elevation lead to a bone resoption from the surgical trauma of up to 0.4 mm. Conclusions: Bone resoption around dental implants placed with conventional flap surgery compared to flapless surgery does not seem to be influenced during the healing period before implant loading. Bone resoption in buccal side facing dental implants compared to palatal side seems to be influenced in conventional flap and flapless surgery. REFERENCES 1. Kim JI, Choi BH, Li J, Xuan F, Jeong SM. Blood vessels of the peri-implant mucosa: a comparison between flap and flapless procedures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.2009; 1;107(4):508-12. 2. Lei Q, Chen J, Jiang J, Fu X, Lin H, Cai Z. Comparison of soft tissue healing around implants in beagle dogs: flap surgery versus flapless surgery. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013; 1;115(3):e21-7. 3. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of currently used dental implants: a review and proposed criteria of success. Int j oral maxillofac implants. 1986;1(1):11-25. 4. Weber HP, Crohin CC, Fiorellini JP. A 5‐year prospective clinical and radiographic study of non‐ submerged dental implants. Clin Oral Implants Res. 2000; 11(2):144-53. 5. Guirado JL, Yuguero MR, Zamora GP, Barrio EM. Immediate provisionalization on a new implant design for esthetic restoration and preserving crestal bone. Implant Dentistry. 2007; 1;16(2):155-64. 6. Hürzeler M, Fickl S, Zuhr O, Wachtel HC. 2007. Peri- implant bone level around implants with platform- switched abutments: Preliminary data from a prospective study. J Oral Maxillofac Surg. 65 7 Suppl 1:33-9. 7. Sclar AG. Guidelines for flapless surgery. J Oral Maxillofac Surg. 2007; 1;65(7):20-32. 8. Tsoukaki M, Kalpidis CD, Sakellari D, Tsalikis L, Mikrogiorgis G, Konstantinidis A. Clinical, radiographic, microbiological, and immunological outcomes of flapped vs. flapless dental implants: a prospective randomized controlled clinical trial. Clin Oral Implants Res. 2013; 24(9):969-76. 9. Campelo LD, Camara JR. Flapless implant surgery: a 10- year clinical retrospective analysis. Int J Oral Maxillofac Implants. 2002; 1;17(2). 10. Matarasso S, Salvi GE, Iorio Siciliano V, Cafiero C, Blasi A, Lang NP. Dimensional ridge alterations following immediate implant placement in molar extraction sites: a six‐month prospective cohort study with surgical re‐entry. Clin Oral Implants Res. 2009; 20(10):1092-8. 11. Blanco J, Liñares A, Pérez J, Muñoz F. Ridge alterations following flapless immediate implant placement with or without immediate loading. Part II: a histometric study in the Beagle dog. J Clin Periodontol. 2011; 38(8):762-70. J Bagh College Dentistry Vol. 31(4), December 2019 Flap and Flapless 12 12. Calvo‐Guirado JL, Gomez Moreno G, Aguilar‐ Salvatierra A, Mate Sanchez de Val JE, Abboud M, Nemcovsky CE. Bone remodeling at implants with different configurations and placed immediately at different depth into extraction sockets. Experimental study in dogs. Clin Oral Implants Res. 2015; 26(5):507-15. 13. Jeong SM, Choi BH, Li J, Kim HS, Ko CY, Jung JH, Lee HJ, Lee SH, Engelke W. Flapless implant surgery: an experimental study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007; 1;104(1):24-8. 14. You TM, Choi BH, Li J, Xuan F, Jeong SM, Jang SO. Morphogenesis of the peri-implant mucosa: a comparison between flap and flapless procedures in the canine mandible. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009; 1;107(1):66-70. 15. Lee DH, Choi BH, Jeong SM, Xuan F, Kim HR. Effects of flapless implant surgery on soft tissue profiles: a prospective clinical study. Clin Implant Dent Relat Res. 2011; 13(4):324-9. 16. Reddy MS, Wang IC. Radiographic determinants of implant performance. Adv Dent Res. 1999; 13(1):136- 45. 17. Tyndall DA, Price JB, Tetradis S, Ganz SD, Hildebolt C, Scarfe WC. Position statement of the American Academy of Oral and Maxillofacial Radiology on selection criteria for the use of radiology in dental implantology with emphasis on cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012; 1;113(6):817-26. 18. Benavides, E., Rios, H.F., Ganz, S.D., An, C.H., Resnik, R., Reardon, G.T., Feldman, S.J., Mah, J.K., Hatcher, D., Kim, M.J., Sohn, D.S., Palti, A., Perel, M.L., Judy, K.W., Misch, C.E. & Wang, H.L. Use of cone beam computed tomography in implant dentistry: the International Congress of Oral Implantologists consensus report. Implant Dent. 2012; 21: 78–86. 19. Fienitz T, Schwarz F, Ritter L, Dreiseidler T, Becker J, Rothamel D. Accuracy of cone beam computed tomography in assessing peri‐implant bone defect regeneration: a histologically controlled study in dogs. Clin Oral Implants Res. 2012; 23(7):882-7. 20. Vera C, De Kok IJ, Chen W, Reside G, Tyndall D, Cooper LF. Evaluation of post-implant buccal bone resorption using cone beam computed tomography: a clinical pilot study. Int J Oral Maxillofac Implant. 2012; 1;27(5). 21. Schropp L, Wenzel A, Spin‐Neto R, Stavropoulos A. Fate of the buccal bone at implants placed early, delayed, or late after tooth extraction analyzed by cone beam CT: 10‐year results from a randomized, controlled, clinical study. Clin Oral Implants Res. 2015; 26(5):492-500. 22. Nickenig H-J, Wichmann M, Schlegel KA, Nkenke E, Eitner S. Radiographic evaluation of marginal bone levels during healing period, adjacent to parallel-screw cylinder implants inserted in the posterior zone of the jaws, placed with flapless surgery. Clin. Oral Impl.Res. 21, 2010; I 386-I393. 23. Lin GH, Chan HL, Bashutski JD, Oh TJ, Wang HL. The effect of flapless surgery on implant survival and marginal bone level: a systematic review and meta‐ analysis. J Periodontol. 2014; 85(5):e91-103. 24. Froum SJ, Cho SC, Elian N, et al. Survival rate of one- piece dental implants placed with a flapless or flap protocol, a randomized, controlled study: 12-month results. Int J Periodontics Restorative Dent 2011; 31: 591-601. 25. De Bruyn H, Atashkadeh M, Cosyn J, et al. Clinical outcome and bone preservation of single TiUnite implants installed with flapless or flap surgery. Clin Implant Dent Relat Res 2011; 13: 175-183. 26. Job S, Bhat V, Naidu EM. In vivo evaluation of crestal bone heights following implant placement with'flapless' and'with-flap'techniques in sites of immediately loaded implants. Indian J Dent Res. 2008; 1;19(4):320. 27. El Nahass H, N. Naiem S. Analysis of the dimensions of the labial bone wall in the anterior maxilla: a cone‐ beam computed tomography study. Clin. Oral Impl.Res. 2015; 26(4):e57-61. 28. Van de Velde T, Glor F, De Bruyn H. A model study on flapless implant placement by clinicians with a different experience level in implant surgery. Clin. Oral Impl.Res. 2008; 19(1):66-72. 29. Teughels W, Merheb J, Quirynen M. Critical horizontal dimensions of interproximal and buccal bone around implants for optimal aesthetic outcomes: a systematic review. Clin. Oral Impl.Res. 2009; 20:134-45. 30. Merhab J, Vercruyssen M, Couke W, Beckers L, Teughels W, Quirynen M. The fate of buccal bone around dental implants. A 12-month postloading follow-up study. Clin. Oral Impl. Res. 00, 2015, 1-6. J Bagh College Dentistry Vol. 31(4), December 2019 Flap and Flapless 13 الخالصة من خالل تقييم كمية فقدان العظم السنخي الحافي حول زراعة األسنان تعد بمثابة جذور االسنان االصطناعية حيث يتم تقييم بقائها على المدى الطويل خلفية الدراسة: ضع الجراحي لزراعة االسنان زرعة السن. هناك سبب لألعتقاد بأن رفع السدلة الجراحية يعزز من فقدان العظم في المراحل األولية بعد ادخال الغرسة. يتغير الو حة الالسديلة, أن استخدام بشكل مستمر وفي السنوات االخيرة كان هناك بعض االهتمام بتطوير التقنيات التي تقلل من طبيعة األجراء الجراحي مع تزايد عملية الجرا ن منصة الغرسة وبداية الغرسة مع العظم يمكن أن يكون مفيدا جدا التصوير الشعاعي المقطعي المخروطي لقياس حجم العظم حول الغرسات السنية واالرتفاع بي ومهما لمراقبة األنسجة العظمية للحفاظ على طول عمر الزرعة وجمالية األسنان االصطناعية المدعمة بالزرعات. ة( والجراحة )الالسديلة( اعتمادا على التصوير الشعاعي لمقارنة المستوى الشعاعي للعظم المحيط بالزرعة بين عملية الجراحة التقليدية )السديل أهداف الدراسة: أسبوع(. أيضا الجراء مقارنة عامة بين كل من التقنيات فيما يتعلق بمدة العملية الجراحية. 24المقطعي المخروطي خالل فترة الشفاء ) مريضا عراقيا 25وان ما مجموعه ,2018الى تشرين الثاني/نوفمبر 2017 أجريت هذه الدراسة االستباقية السريرية من كانون االول/ديسمبر المواد وأساليب العمل: سنة. فشلت عملية زرع واحدة في المجموعة الضابطة لذلك تم استبعادها من التحليل االحصائي بأستثناء تحليل 60و 20عملية زرع تتراوح اعمارهم بين 47مع عملية زرع يتم ادخال الزرعات عن طريق الجراحة 27ية في مجموعتين: المجموعة الضابطة التي تضمنت معدالت البقاء والفشل. تم اختيارالمرضى بصورة عشوائ عملية زرع تم ادخال الزرعات عن طريق الجراحة )الالسديلة( حيث تم اجراء تقييم سريري وشعاعي قبل الجراحة 19التقليدية )السديلة( ومجموعة الدراسة تضمنت , تركيا( Nucleossء تقدير العظم السنخي لمجموعة الدراسة عن طريق التخطيط العظمي, تم استخدام نظام زرع واحد في الدراسة )شركةلجميع المرضى وتم اجرا Carestream CS 8100 3D)وتم قياس مستوى العظم )الخسارة( ومدة العملية لكل زرعة. قياس مستوى العظم تم بواسطة التصوير الشعاعي المخروطي بجهاز Health Inc., France) ( 24في الجانب الخدي والجانب الحنكي مرتين لكل زرعة, فور وضع الزرعة وبعد فترة الشفاء .)اسبوع ( للجانب الخدي P= 0.393) لم يكن هناك فرق معنوي بين مجموعة الدراسة ومجموعة الضبط في متوسط اجمال فقدان العظم في الجانب الخدي والحنكي النتائج: قياسها ( للجانب الحنكي. كانت هناك فروق ذات داللة احصائية كبيرة بين الجانب الخدي والحنكي فيما يتعلق بفقدان العظم حول الزرعات التي تم P=0.214)و اعة السن في مجموعة (. وفقا لوقت العملية, استهلكت زر P=0.001) اسبوع من وضع الزرعات لكل من التقنيات الجراحية 24بواسطة التصوير الشعاعي بعد . P=0.001)) الدراسة حوالي ثلث الوقت الالزم لزراعة المجموعة الضابطة مع فرق كبير للغاية فاء قبل تحميل ال يبدو ان فقدان العظم حول الغرسات السنية الموضوعة بطريقة الجراحة )السديلة( مقارنة بالجراحة )الالسديلة( قد تاثر خالل فترة الش األستنتاجات: الزرعة.