Computer Guided Template-Based Dental Implant

electronic computer contributed Template-Based Dental ImplantAbstractThe introduction of enters to dentistry has overhauled more(prenominal) edentulous unhurried of ofs to take a crap a more reliable serviceable and dainty preference to fixed and removable prosthetic appliances. The best 3-dimensional smudge of the institutes secures the outdo function and esthetic of the final restoration and at the same cadence bars the biomechanical complications and failure that might take business office consequent to the wrong location of the inserts. The aim of this bulge out is to bring out the sizeableness of placing the embeds in the optimal three-D position. Computer guided template- ground engraft posture yield be discussed as a precise and foreseeable tool in the grooming and in the exe loveion of the constitute posture. The bearing is to enable the situation of the found in a way that secures the highest certain success with the least complicati ons. Materials and Methods Out of 350 down burdened relevant articles only 161 articles were chosen and referenced. The excluded articles were either written in languages another(prenominal) than English, descriptive of new-sprung(prenominal) fabrication methods of functional guides, single shimmy reports or data-establish d wiz on small try on sizeless than 5. Results Most of the revised papers be scale series or observational studies done on animals or cadavers. Even the dictatorial reviews were found on those articles. Computerized tomography (CT) and interactive software programs are proven to be important for unblemished handling plan. The accuracy of delegatering the handling plan just by the aid of CAD/CAM fabricated functional guide to the patient mouth are reported to be more certain than uninvolved ease up engraft side especially in the compromised cases. Conclusion The execute books highlighted the higher predictability, accuracy and precision of computer guided template based embed placement over conventional free hit placement precisely supporting strong evidence is lacking. Good controlled clinical studies with long full term follow up is infallible in this regard. For the clock being and with the reported high success of conventional free go on infix placement, it seems that free hand graft placement seems to be predictable at least in the hands of experts or with the uncompromised cases.IntroductionIn the 19th century many aspects of life were affected by the industrial revolution, especially in sciences and manufacturing. Dentistry was not an exception of this. that, it was in the squeamish era when the basis of modern dental care was first set. A self-aggrandising number of the evolutions in dentistry were just modifications of industrial constructs. most of such(prenominal) developments were impossible forrader the introduction and intention of electricity, which led to the invention of more compl ex mathematical operation equipments Gelbier S, 2005. Another very important development took place as a consequence of the invention and the use of computers in the various fields of dentistry Schleyer Titus K.L., 1999.Computer guided implant placement is one of the aspects that shows how dentistry has got use to the computer and its science Azari A. and Nikzad S. 2008.In fact, it is true that the cash pass on in dentistry and the increased public awareness public of the importance of keeping their teeth healthy arrive led to the decreased relative frequency of edentulism. Such declination varies not only among disparate countries but as well among the different geographic neighbourhoods within the same country and among the different groups of con stratum of different cultural and social backgrounds. However, it is predicted that in the next fewer decades, in that location organise be very low proportions of edentulism in seniorly persons (over 65 years). Teeth lea ving increases with age, this means that in the future day edentulism will continue at later stages in life Lang NP muser F. 2007 Lang N.P. De Bruyn H., 2009. In such situations and in addition to the lifelike delays in the healing of elder individuals Goodson 3rd WH Hunt TK 1979 the patients at that age will be nearly properly affected by co-morbidities and unfavorable ageing conditions want osteoporosis, uncontrolled diabetes mellitus, hypothyroidism and chronic renal disease which are among the diseases that negatively affect the get up feature and consequently implant success. Some older age relate diseases like putting surfaceinsonism, Alzheimer tail affect the ability to perform adequate viva hygiene and this whitethorn lead to inflammation and mug up sacking virtually implants Roberts WE. et al.1992 Elsubeihi ES. Zarb GA. 2002 Marder MZ. 2004.For this, dental professionals need to develop their skills and to use new techniques that offer the patients with the safest, entire results and the least morbidity and to be able to manage such elder patients and their unfavorable conditions which some condemnations whitethorn preclude the placement of the implants Lang NP Muller F, 2007 Lang N.P. De Bruyn H., 2009.Back groundTraditionally, lost teeth were replaced by removable partial(p) dentures RPD, fixed partial dentures FPD and fulfil dentures in cases of full edentulism Bragger U et al 2005. Since the introduction of implants to dentistry by Branemark1977, many of the edentulous patients have been able to have more reliable functional and esthetic alternative to fixed and removable prosthetic appliancesLang N.P. De Bruyn H., 2009. The increasing Demand for implant carry restorations in the last few decades resulted in the need for new improve techniques to ensure the most proper implant position to restore the patient properly Ganz S.D,2001 .Historically the implants were placed where there is work up Kopp et al 2003. They were c onsidered self-made when integration is achieved Branemark et al.1977. However, as the functional and esthetic demands of the patients have increased importantly the success of implant- back up restorations is no more only related to the level of implant integration in the fig out but also to the proper positioning of the implants and concomitant prosthetic outcome Lal et al.2006. For this proper interference readiness has manufacture mandatory. The master(prenominal) goal of the handling plan is to place the implants in the optimal position as dictated by function and esthetics of the authorised restoration. This in turn avoids the biomechanical complications and failure that might take place subsequent to the wrong positioning of the implants Garber DA Belser UC. 1995 Kopp et al. 2003 Park et al. 2009.The aim of this project is to highlight the importance of placing the implants in the optimal three-D position. Computer guided template-based implant placement will be disc ussed as a precise and predictable tool in the prep and in the execution of the implant placement.The objectiveis to enable the placement of the implant in a way that secures the highest predictable success with the least complications.Materials and MethodsMultiple searches have been made through attainment Direct and Google Scholar. The following key words were employ with different combinations systematic review, computer-guided, computer-assisted, image-guided, robots, dental implants, complications, treatment planning, radiography, computerized tomography, accuracy, bustleless operating room, zygomatic implant, deck out parsimony, augmentation volume, immediate loading, free hand surgery, Steriolithographic templates. As the topic of computer guided implant placement is a modern topic the selected articles were limited to the articles published from the year 2000 up to 2010. However some older but relevant articles were hand searched, selected and referenced. Almost 350 ar ticles were set to be relevant to the different points to be covered in the project were downloaded after reading their abstracts it was found that many of them were either clinical case series and reports or experi amiable studies made on animals or cadavers, many of the systematic reviews were found but again nearly all of them were based on the mentioned articles. The articles of single case reports and the experimental studies with very small sample less than five size were excluded. Also, the articles that focus on the fabrication of new surgical guides were excluded. Articles in languages other than English are excluded too. Only 161 were selected and referenced in this project.ResultsMost of the revised articles concerning the accuracy of CAD/CAM template based implant placement are case series or experimental studies done on animals or cadavers. Even the systematic reviews were based on those articles. Based on the revised articles computerized tomography (CT) and interact ive software programs are proven to be important for close treatment planning. The accuracy of transferring the treatment plan precisely by the aid of CAD/CAM fabricated surgical guide to the patient mouth are reported to be more predictable than free hand implant placement especially in the compromised cases.DiscussionComplications associated with wrong(p) implant positioningMarginal bead loss and consequent mechanical and esthetic problemsThe coefficient of correlation of marginal bone loss and improper positioning of the implant is reported in the literature. The wrong angulation of the implant is usually compensated by the use of angled abutments, in this situation the load carried by the implant is mostly off- axis vertebra, such unfavorable load leads to the bone destruction around the implant and other mechanical complications like screw loosening, fracture and/or implant fracture Chun-Li Lin et al., 2005 Saab X. E. et al 2007.The improper placement labially, will lead t o thin labial bone and subsequent bone loss and gum recessionBuser D. et al. 2004, lingually, in addition to the turn of lingula bone it results in emergence problems as seen with extend-lap restorations. Such restorations are demanding to maintain and consequent inflammation and bone loss is unavoidable Tarnow DP. 1995 Belser UC. et al. 1998. The placement of the implant too close to the adjacent tooth can cause resorption of the inter-proximal alveolar crest Esposito M. et al. 1993 Thilander B. et al. 1999. If the implant is placed too far apically development extensive countersinking, the polished implant collar will come into physical contact with the bone and this in turn induces bone resorption because polished scratch does not integrate Buser D. et al. 1991a Hmmerle et al. 1996, also the micro gap will come closer to bone and unnecessary bone loss will take place. Disuse atrophy due to subnormal mechanical arousal is another explanation for bone loss around polished i mplant neck or crest modulous Al-Sayyed, A. et al. 1994 Vidyasagar L. Apse P. 2004.Nerve impairment neutered sensation of the lower lip as a result of modest alveolar nerve injury is one of the serious complications of mandibular implant osteotomies Bartling et a. 1999 Vazquez L. et al. 2007.This is especially if the magnification factor on the panoramic radiograph is misinterpreted Vazquez L. et al. 2007.The injury of the mental nerve can also lead to the same symptoms the mental foramen is an important landmark during surgical procedures in the lower premolar ambit. it is usually located at the apex of the second mandibular premolar or between apices of thetwo premolars. However, in some cases its location can metamorphose from the mandibular canine to the first molar. Unfortunately, The foramen may not have the appearance _or_ semblance on conventional two dimensional radiographs, in this condition a computerized tomography (CT) scans are important as they are more exact for the detection of the mental foramen than conventional radiographs Bartling et a. 1999 , Greenstein Tarnow, 2006.Lingual bundlethough it is rare complication, the wrong implant placement in the lower call downbone may lead to the perforation of lingual cortex with a great possibility of lingual bundle injury with a subsequent fatal bleeding and haematoma formation. Under the effect of profuse bleeding and as a result of the progressive expansion of the lingual, sublingual, sub- mandibular, and sub-mental hematomas the tongue and the floor of the mouth can be displaced leading to the rapid and complete obstruction of the airway Mordenfeld A et al. 1997 and Kalpidis Setayesh , 2004.de bouncyisation of the adjacent teethIn addition to the risk of losing the inter-proximal bone Esposito M. et al. 1993 Thilander B. et al. 1999 the placement of the implants in close proximity to the adjacent teeth may lead to the loss of the teeth vitality especially if the roots are injure durin g drilling for implant placement Jemt T. Pettersson P. 1993 Rubenstein J.E. Taylor T.D. 1997 Goodacre CJ. et al. 1999 Schwartz-Arad D. et al. 2004.Other possible rare but serious complicationsSome other rare complications can take place due to poor treatment plan and wrong implant placement like perforation of nasal and sinus floor Nahlieli O. et al 2008,injury of the submandibular and/or sublingual salivary glands Nahlieli O. et al 2008,mandibular fracture especially in osteoporotic and atrophied mandible Raghoebar G.M. et al.2000 Meijer H.J.A. et al. 2003.Criteria of optimal implant positionThe ideally placed implant should be surrounded by uniform bone volume and minginess this provides the implant with a good superfluous support against the multi directional long term loading. A minimum of more than 1 mm bone thickness is recommended to keep around the body of the implants Nancy L.C., 1993. In addition, the implant ideally should be placed in the geometric centre of the cro wn this reduces the off axis loading and prevents many of the biomechanical complications and its subsequent poor esthetic outcomes Galanis C.C et al. 2005 2007.Implant tooth outmatchA minimum of 1- 1.5 mm distance between the implant climb and the adjacent teeth needs to be respected Buser D. et al 2004. However, a 3 mm distance between the implant and an adjacent natural tooth is recommended to minimize the potential for damage to the supporting structures of the natural teeth Adell et al, 1986 hobo et al, 1989.Implant to implant distanceTo avoid bone resorption center(a) the adjacent implants a minimum of 3 mm inter-implant distance is recommended do-nothing et al, 1989 Traini et al. 2007.Implant to vital structure distanceTo avoid nerve injury during implant surgery in the mandible, some guidelines should be considered with respect to substantiating the position of the mandibular and/ or the mental foramen and to validate the front end of the prefrontal loop of the menta l nerve. These guidelines implyd leaving a 2 mm as safety device zone between the implant and the nerve. one time the safety zone is identified, implants can be placed safely and before the placement of any implant anterior to the mental foramen that is deeper than the safety zone, the mental foramen must(prenominal)iness(prenominal) be explored to verify the possibility that an anterior loop is there Buser Von Arx 2000, Greenstein Tarnow, 2006. In consideration of the risk of surgical complications during implant placement, bone grafting or other surgical procedures where risk is anticipated, a CT examination should routinely be performed before any surgical approach Ganz S.D,2001 Scaravilli MS, et al 2009 Naitoh et al. 2010.To reduce the probability of such serious complication, some preventive bankers bills should be taken before, during, and after implant placement in the anterior part of the mandible, among such measures are the awareness of the regional arterial anatom y, proper treatment planning through radiographic and clinical valuation of the osseous morphology, and the right angulation and length of the selected implant and finally the skill of the sawbones Kalpidis Setayesh , 2004.Dental CT is a valuable tool for the sound judgement of jaw bone anatomy and can easily demonstrate the occurrence, position, diameter and course of the lingual vascular distribution channels of the mandible for this, a CT examination should routinely be performed before any surgical procedure to the anterior region of the mandible to verify the presence of the mandibular lingual vascular canal MLVC and to evaluate the lingual cortical bone thickness and assiduousness to avoid perforations and the life threatening bleeding Scaravilli MS, et al 2009 Naitoh et al. 2010.Distribution of the implants in edentulous jawsIdeal implant distribution and placement is faultfinding in format to secure the optimal mechanical and esthetic outcome of the definitive restora tions as well as enabling the patients to maintain proper hygiene. The placement of the implants in the inter-proximal positions may cause problems from an aesthetic, mechanical and hygiene perspective Jivarj S., 2006. Also, the antero-posterior distribution of the implants should forgo equal distribution of load over a capacious heavens with minimal cantilever length Adell R et al. 1990 Palmqvist S et al 1994 Jivarj S., 2006. When quaternate implants are placed to retain a prosthetic appliance symmetricalness between the implants should be secured otherwise the unfavorable off-axis loading will not be avoidable Arfai N.K. Kiat-amnuay S. 2007. In the case of implant and tissue supported overdentures both implant placement and distribution become critical where the Implants have to be placed so that when a bar is constructed it has a clean line connection between the implants and does not encroach on the palatal/lingual denture bearing area. The distribution of implants shoul d also be in the way so that adequate space is lendable for the clip Jivarj S., 2006. When more force from the opposing occlusion- on the implants are anticipated more implants should be placed to share the load Jivarj S., 2006.Treatment planningUntil recently the main concern was directed to the surgical aspect of implant placement Ganz S.D, 2001. The implants were plotted to be placed where the bone is found Kopp et al 2003. The esthetic and functional outcome of the final prosthesis was not much considered Ganz S.D, 2001. The new plan of prosthetically driven treatment planning and implant placement requires careful military rank of the surgical site. In addition, it must relate the three-D location of the future prosthetic restoration to the optimal 3-D implant position. This position must be discussed and agreed on between the restorative dentist and the dental operating surgeon Garber DA Belser UC, 1995, Kopp et al 2003 Park et al. 2009.In the early eld dentists who wer e believing in this concept prosthetic driven were mostly dependant on conventional radiography, wax-up prostheses and/or surgical templates made on the dangerous stony surfaces of the study casts, and to overcome the problem of transferring the plan to the operative site, customized radiographic and surgical templates have become an integral part of treatment (Becker CM Kaiser DA. 2000, Almog DM et al.2001. Very soon later, it was found that the hard surface of casts is not equal to the soft tissue surface of the oral cavity, and this method may not be as accurate as necessary for treatment purposes. Additionally, it was established that templates fabricated on the study cast without knowledge of the precise anatomy below the surface cannot be considered reliable Lal K. et al. 2006 and Widmann G collect JR 2006.The traditional tools for the treatment planning of dental implants include detailed clinical examination, panoramic, cephalometric and peri-apical x-ray films, diagnos tic wax-up and articulated study models. Other diagnostic aid may include photography and ridgepolepole purpose technique for the estimation of the implant bone sites. Advanced diagnostic tools such as tomography, digital radiography, and CT scan film allow for a more accurate pre-surgical evaluation sites Traxler M. 1992, Tyndall D. A. et al. 2000, Flanagan D. 2001, Ganz S.D,2001, Perez A.M. et al 2005, Guerrero M. E. 2006, Chen Lung-Cheng 2008, Loubele M. et al 2008. assume modelsAccurately mount casts are critical in assessing prosthetic and inter-occlusal space limitations. Spatial constraints must be considered as a matter of practicality Jivraj S et al 2006. Study casts are also valuable tool to evaluate occlusion Hayasaki et al. 2005 and to help in the treatment planning through diagnostic wax- up Katsoulis J. et al. 2008. Moreover, radiographic and surgical templates can be constructed out of such study models Lal K.et al. 2006 Katsoulis J. et al. 2008 Rubio-Serrano M. et al 2008.Bone soundingNo doubt that the direct measurement DM of the ridge size is the most accurate diagnostic tool. However, treatment planning especially in the big cases calls for collecting information before surgery. This saves time and money, avoids the unexpected complicated surgeries like harvesting bone for ridge augmentation and increases the predictability of the treatment. When ridge mapping RM is compared to direct measurement DM of the ridge size and to running(a) tomography LT cone beam computerized tomography CBCT ridge mapping RM seems to be the most reliable pre- operative clinical method to determine the ridge size Perez L.A. 2005 Chen L.C. 2008., linear tomography is reported to underestimate the ridge size Perez L.A. 2005 while cone beam computerized tomography is reported to overreckoning the ridge measurements Chen L.C. 2008.However, ridge mapping is not only an incursive procedure but also a difficult to use in the cases of shallow labial and/or li ngual vestibules. Additionally, in ridge mapping the actual position of the inferior alveolar nerve cannot be confirm Perez L.A. 2005 Chen L.C. 2008.Conventional two dimensional radiographyActually, conventional 2-D radiography panoramic, cephalometric and intraoral views, which is widely used for the treatment planning, has important diagnostic limitations, such as magnification and distortion, setting errors and position artifacts Tyndall D.A. Brooks S.L. 2000 White SC et al, 2001. Moreover, these 2-D radiographs do not show lingual anatomy or provide complete three dimensional (3-D) information about the dental arch Nikzad and Azari. 2008 . These limitations make the 2-d radiography is less than optimal tool for the diagnosis and treatment planning of dental implants where according to recommendations provided by The American Academy of Oral and maxillofacial Radiology (AAMOR), The aim of the preoperative dental implant treatment planning is to place the optimum number and si ze of implants to secure the best prosthetic outcome. This can be achieved only if a thorough knowledge of the patients bony anatomy in 3- dimensions is provided in the radiographic examination .Proper treatment planning requires that the clinician evaluate the suitability of the remaining bone for placement of implants. The clinician must determine if there is enough upper side, density, width of bone, and an appropriate axis of penchant for a successful prosthetic outcome Tyndall D.A. Brooks S.L 2000 White SC et al, 2001.CT scanningAlthough Computerized Tomography CT scans have been used in the medical field since 1973 it was not before 1987 when this new engine room became available for dental purpose Ganz S.D, 2001. In implant dentistry Computerized Tomography CT scan is one of the most important diagnostic tools which significantly amend the clinicians ability to diagnose and to put accurate treatment plan because it helps in viewing the anatomy and dental related anomalie s of the jaws Dula K. et al. 1994 Abrahams JJ Berger SB,1998 AbrahamsJ.J. Hayt M.W.,1999 Lal K. et al. 2006and in the proper option of implant size and angulation and this in turn helps to avoid injury of critical structures such as the mandibular canal or maxillary sinus Ganz S.D,2001 Scaravilli MS, et al 2009 Naitoh et al. 2010.Moreover the CT scan allows the visualization of the scanned jaw bone in a series of cross sectional, axial and panoramic views .This makes the planning of implant placement more precise in relation to the bone and future prosthesis especially when the a radiographic template scano-guide is used during scanningLal K.et al. 2006 Rubio-Serrano M. et al 2008 .However CT scan by itself is nothing but series of axial and coronal 2-D images and the clinician needs to integrate such images in his mind to gain the desired information in 3-D Gillespie J.E. Isherwood I.1986. synergetic software programsThe present development of clinical computer applications all ows the clinicians to obtain 3-D models to plan virtually real situations Rubio-Serrano M. et al 2008.Interactive computer software is now increasingly used as a tool for implant diagnosis, planning and treatment execution. Firstly, it is used in connection with visualize techniques, such as computerized tomography (CT) or magnetic resonance imaging (MRI) Hassfeld S, Mhling J 2001. Secondly, it is used for the construction of surgical templates carrying the information necessary to transfer that planning to the mouth of the patient. In most of the cases, this procedure is based on stereolithographic models Ewers R . et al 2005 Ganz S.D. 2005 , Schneider D. et al 2009 . There are different commercialized soft ware programs are available, such as Implametric, SimPlant Ganz S.D. 2005 Parel SM Triplett RG 2004, Nobel Guide Rocci A et al. 2003, med3D Engelke W Capobianco M. 2005, etc. Most of the programs display an axial cut and a panoramic cut with multiple bucco-lingual cuts p arasagittal and reformatted 3-D image Parel SM Triplett RG 2004. In the 3D image, bony structures are visualized with the possibility of incorporating other anatomical structures or even soft tissues Schneider D. et al 2009.Bone densityOne of the good tools in the software programs is the ability to evaluate the bone density quality during the analysis of CT data. The importance of bone quality density for the success of dental implants is agreed on in the literature Jemt T, Lekholm U 1995 Esposito M et al 1998 Shahlaie et al 2003 Park et al 2008.As suggested by Lindh et al.1996 Site-specific measurements are important, not only for a general prediction of treatment prognosis but also in the evaluation of how long of an legal separation between first- and second-stage surgical procedure and loading is needed Friberg B et al 1991,1995a 1995b. Moreover, to have accurate preoperative measurements of the bone density helps in avoiding the placement of the implants in the areas of p oor quality Norton M.R. and Gamble C. 2001 Shahlaie et al 2003.The strong correlation between the average CT number and the concentration of hydroxyapatite in bone is reported Maki et al 1997, and the quantitative CT in Hounsfield units HU are veritable as a valuable supplement to the subjective bone density classification defined by Lekholm and Zarb 1985. The Hounsfield index is a standardized racing shell for reporting the reconstructed CT values. It is a measure of the attenuation coefficient which varies among different tissues, it is based on the density of air (-1000),water (0) and dense bone(1000) Shapurian T. et al. 2006. Misch CE 1993 verbalize that the bone density measurements using CT scan is more accurate than radiographic assessment. And he classified bones into 5 categories according to density D1 bone had density above 1250 HU D2 = 850-1250 HU D3 = 350-850 HU D4 = 150-350 HU and D5, below150 HU. For this, the use of CT scanning and interactive software programs is considered as a viable and accurate method to measure bone density Norton M.R. and Gamble C. 2001 Shahlaie et al 2003.Recently, efforts in the oral imaging field have focused on developing tools that accurately and automatically measure bone density by measurements of x-ray absorption de Oliveira R. C. G. et al. 2008. thank to such efforts, now the CT images in DICOM Digital Imaging and communications in Medicine format contain the necessary data of bone density which enables the different software programs can measure it Norton M.R. and Gamble C. 2001 Park et al 2008.Bone graft volumeAccurate evaluation of the 3-D bone volume before surgery is another advantage of the use of soft ware programs in the treatment planning in implant dentistry. The lack of enough bone volume frequently precludes the conventional implant placement. In this condition the bone volume needs to be better by different augmentation techniques and /or materials Esposito M. et al, 2008.The detailed informati on about the needed bone volume before surgery is of much help in determining the best donor site Krennmair G. et al 2006 Verdugo F. et al 2009 and can help in estimating the amount and costs of the xenographic bone substitute required for the augmentation surgeryClavero J. Lundgren S. 2003. Moreover, knowing the needed bone volume in advance helps in minimizing the duration of the surgery and this in turn minimizes the chances of complications and reduces the expenses for the patients Cricchio G. Lundgren S.2003. The computerized tomography CT can produce series of accurate cross sectional images and by the aid of soft ware programs like Simplant Materialise, Leuven, Belgium the 3-D volume of area to be augmented can be calculated Hatano N. et al. 2004 Krennmair G. et al. 2006.Flapless implant surgeryPredictable flapless implant surgery is one of the fruits of the application of modern technology like CT scan, interactive software programs and CAD/CAM fabricated surgical guides Sclar A.G. 2007. Minimal invasive surgery techniques are applied to a wide variety of interventions. The main aim is to reduce the costs of the treatment and patient healing time Rubio-Serrano M et al 2008 Valente F. et al 2009.The traditional implant protocol set by Branemark requires a duration of a few months for osseointegration of the endosseous implants before the connection of definitive dental prostheses Adell R. et al 1981 Branemark PI 1983 Lindquist LW et al 1996. When compared with the surgical phases, implant prosthesis fabrication is relatively time down Rodrigues AH et al, 2003.When implants are placed without flap elevation, both the amount of osseointegration and bone height around the implants are significantly greater than in implants placed with flap elevation. This enhancement is most probably due to the preservation of bone vascularization Pennel B.M. et al 1967 Wilderman M.N et al. 1970 Jeong S-M et al 2007. Moreover, the small sized punched mucosa lead to sm all, clean, unlikable wounds are known to heal quickly with little scar formation, whereas large open wounds heal slowly and with significant scarring Mathes S.J.,2006 Lee D-H et al. 2009.18 D.C. Sabiston and H.K. Lyerly, Textbook of previous(prenominal) termsurgery,next term Saunders, The biological basis of modern surgical practice. Philadelphia (1997) p. 207-20.Recently, the use of flapless surgery for implant placement has become popular. This can be attributed to its numerous advantages that include improved patient comfort and healing, decreased surgical time, and the ability to add up normal hygiene procedures immediately following surgery. However, the flapless approach is only indicated when the surgeon is confident that the underlying osseous anatomy is ideal relative to the intend implant size and its 3-D position in the alveolus. If this is not the case many problems may arise like injury of the unseen vital structures, thermal damage secondary to inadequate irrigat ion during osteotomy preparation, malposed angle or depth of implant placement, and inability to appropriately contour osseous topography to relieve restorative procedures Sclar A.G. 2007 Van De Velde T. et al. 2007. For this, the use of the conventional flapless implant placement should be limited to clinicians with advanced clinical experience and good surgical assessment Sclar A.G. 2007.By no