Do Implant Surgical Guides Allow an Adequate Zone of Keratinized Tissue for Flapless Surgery?

J Oral Maxillofac Surg. 2018 Dec;76(12):2540-2550. doi: 10.1016/j.joms.2018.07.006. Epub 2018 Jul 19.

Deeb JG1, Bencharit S2, Loschiavo CA3, Yeung M4, Laskin D5, Deeb GR6.



A major advantage of guided implant surgery using 3-dimensionally printed guides is the ability to perform accurate flapless surgery. A drawback of a flapless technique is the inability to manipulate soft tissue to ensure sufficient gingiva around the implant. The purpose of this study was to determine how often flapless surgery using surgical guides results in less than 2 mm of keratinized tissue surrounding the implant.


This retrospective analysis included 27 maxillary and 27 mandibular implant sites that underwent treatment planning for implant-guided surgery using 3Shape Implant Studio (3Shape, Copenhagen, Denmark). Intraoral scan images were used to measure the width of the keratinized tissue on the buccal aspect of each implant site in both arches and the lingual aspect in the mandibular arch. Three examiners measured the amount of buccal and lingual keratinized tissue in millimeters at each implant site. Analysis of variance (P < .05) and correlation coefficients were used to determine statistically significant differences in keratinized tissue among sites.


No statistically significant difference was found either between the widths of buccal keratinized tissue in the maxillary anterior (4.06 ± 1.42 mm) and posterior (4.93 ± 2.54 mm) areas (P = .293) or between the amounts of buccal and lingual keratinized tissue in the mandible (P = .995). The keratinized tissue width in the maxillary buccal area was significantly different (4.48 ± 2.04 mm) from that in the mandibular posterior buccal (1.98 ± 1.41 mm) and lingual (1.98 ± 1.23 mm) areas (P < .001). Over 77% of maxillary implant sites had greater than 3 mm of gingiva, and just over 20% had sufficient gingiva in the mandible.


Adequate keratinized tissue was found in most of the planned maxillary implant sites, whereas most of the mandibular posterior implant sites had inadequate keratinized tissue. Therefore, elevation of a flap to preserve and reposition existing keratinized tissue around implants should be considered when planning to use tooth-borne surgical guides in the posterior mandible.

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