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Year : 2019  |  Volume : 30  |  Issue : 4  |  Page : 600-611
Survival rate of dental implant placement by conventional or flapless surgery in controlled type 2 diabetes mellitus patients: A systematic review

1 Department of Biochemistry, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Prosthodontics, FODS, King George's Medical University, Lucknow, Uttar Pradesh, India
3 Department of Prosthodontics, ESIC Dental College, New Delhi, India

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Date of Submission27-Oct-2017
Date of Decision07-Feb-2018
Date of Acceptance23-Jun-2018
Date of Web Publication18-Nov-2019


Introduction: Dental implant may serve as a choice of treatment for replacement of missing tooth in diabetic patients with their well-controlled glycemic index. To minimize postoperative complications, dental surgical procedures comprises mainly two types, namely conventional and flapless surgery. Objective: The aim of this review is to find the survival rate of the dental implant when placed with either of the technique, that is, conventional or flapless in patients with controlled Type 2 diabetes mellitus from published studies. Materials and Methods: A total of 14 studies were included from PubMed database related to the survival rate of dental implant placement by conventional or flapless surgery among patients with controlled diabetes mellitus. The cumulative mean of dental implant survival rate by conventional and flapless techniques calculated from included studies is 94.2% and 92.3%, respectively. Conclusion: The survival rate of dental implant placement by conventional and flapless techniques is similar. As few studies on flapless technique are available, therefore researchers in future should explore its advantages and disadvantages.

Keywords: Conventional surgery, dental implant, flapless surgery, glycated hemoglobin, survival rate, type 2 diabetes

How to cite this article:
Singh K, Rao J, Afsheen T, Tiwari B. Survival rate of dental implant placement by conventional or flapless surgery in controlled type 2 diabetes mellitus patients: A systematic review. Indian J Dent Res 2019;30:600-11

How to cite this URL:
Singh K, Rao J, Afsheen T, Tiwari B. Survival rate of dental implant placement by conventional or flapless surgery in controlled type 2 diabetes mellitus patients: A systematic review. Indian J Dent Res [serial online] 2019 [cited 2023 May 29];30:600-11. Available from:

   Introduction Top

In modern dentistry, missing teeth is a matter of indifference as its best alternative available is dental implant which is highly successful, long-lasting, comfortable, and also function like natural tooth. Dental implants made up of titanium have a unique property to fuse with the living bone called as “osteophilic property (osseo-bone, philic-loving)” thus becoming a part of the jawbone.[1] Studies are going on in the field of dental implantology to achieve higher success rate for the patients seeking the surgery thus providing a better quality of life.

Diabetes mellitus, a systematic disorder, was once considered as a contraindication to the use of dental implant therapy, it has been associated with comorbidities, including increased susceptibility to infection, impaired wound healing, and dental abscess. As known, diabetes mellitus is a metabolic disorder that affects the processing of glucose by the body. Type 2 diabetes mellitus is a condition in which body fails to utilize the insulin in sufficient amount to obtain energy for living cells and affects almost every part of the body. Individuals with controlled blood glucose level can reduce the risk of developing complications caused due to Type 2 diabetes mellitus.[2] It is among one of four priority non-communicable diseases (NCDs) targeted by world leaders in Political Declaration on the Prevention and Control of NCDs.[3] WHO estimated that globally, 422 million adults aged over 18 years were living with diabetes in the year 2014.[4] With increasing awareness of diabetes, people have learned to manage its complications by improving their lifestyles such as diet, regular exercise, and follow-ups, yet wound healing is a major part of the concern. To diagnose, diabetes mellitus, guidelines recommended by the American Diabetes Association (ADA), is given in [Figure 1].[5]
Figure 1: Diagnostic criteria for diabetes mellitus recommended by the American Diabetes Association

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Glycated hemoglobin (HbA1c), a well-known marker for monitoring glycemic control, also now used as a diagnostic marker when estimated by the National Glycohemoglobin Standardization Program (NGSP) certified method. ADA recommends HbA1c range of 4.0%–5.7% as nondiabetic and value ≥6.5% as diagnostic cutoff for diabetes. To decrease the risk of microvascular and macrovascular complications, ADA recommends diabetic patients to maintain HbA1c below 7%.[6],[7]

The term osseointegration was used to create a fully integrated bond between jaw bone and titanium. Weiss theory states that there is a fibro-osseous ligament formed between the implant and the bone which can be considered as the equivalent to periodontal ligament of natural tooth.[8] Quality and quantity of the loading bone provide primary mechanical stability and promote a strong interaction between bone and implant over the time through osseointegration. Today, approximately 4.5 lakh osseointegrated dental implants are being placed every year, with an expectation of 95% success rate (in the case of single tooth replacement with an implant supported crown), with minimum risks and associated complications.[9] It is well known that the prevalence of tooth loss is much higher in diabetic patients as compared with nondiabetic individuals. The ultimate replacement for missing tooth is dental implant in modern dental practice apart from conventional prosthodontic procedures such as fixed partial denture and removable dentures. Earlier dental implant was said to be a contraindication for diabetic patients but due to the advancement in technology; it is considered as an alternative choice of treatment with nearly no risk of complication in patients with well-controlled diabetes mellitus.

Dental implant surgery can be performed by two ways either by conventional flapped (open) surgical procedure or flapless procedure. Conventional flapped technique is considered as the standard surgical procedure for placing a dental implant. During placement of dental implant through conventional surgery, elevation of flap (open flap) is usually preferred to visualize the recipient site clearly. The flapless implant procedure came into practice during the last part of the 20th century. The idea of flapless technique has been designed to reduce postoperative peri-implant tissue loss, pain, and swelling. Few other advantages of the flapless surgery include quick postoperative healing, patient's comfort, lesser surgical procedure, and reduced complications after the surgery.[10] Furthermore, bones can be remodeled in short duration as the bone remains covered by periosteum during surgery in flapless type.[11] A recent randomized, controlled trial revealed that minimal invasive flapless technique might serve as a choice of method for dental implant placement in terms of less pain, and healing after surgery as compared to conventional technique.[12] Studies are available in which researchers/clinicians focused on drawbacks of the flapless surgery, that is, there may be deviation in position of the implant while placement or the implant can be inserted in inclined position or there may be perforation of cortical plates as this technique is said to be a “blind” procedure.[11] Furthermore, the actual drilling area for obtaining stable position should be accurately known in flapless procedure.[13] Flapless surgery requires skilled surgeon to reduce the risk of contamination and to avoid the deposition of epithelial and connective cells from oral mucosa in the bone during surgery.[11]

Dental implant and diabetes may not be a poor combination for better outcome in individuals with their diabetes well under control. In diabetic patients with their well-controlled glycemic index, dental implant may serve as a choice of treatment for replacement of missing tooth. Patients with uncontrolled diabetes may find difficulty during implant surgery and also have more chance of developing infection after surgery. It is well known that diabetic patients are more susceptible to develop complications after implant surgical procedure as compared to nondiabetic individuals; therefore, minimal and conservative surgical procedure is recommended. Flapless surgical procedure may serve as a better option over conventional surgery with advantage of less patient's discomfort, less postoperative inflammation and swelling, shorter surgery and recovery time, and minimal crestal bone loss.

The aim of this review of literature is to find out the survival rate of dental implant placement in patients with well-controlled, moderately or poorly controlled diabetes mellitus from the published studies along with the factors included assessing the implant stability. We also want to find out the type of technique, i. e., conventional and flapless used for dental implant placement in diabetic patients, measure used to assess the glycemic control, and duration of follow-up visit.

   Materials and Methods Top

PubMed database was considered as search engine for the studies conducted from 2000 to 2016. The criteria to explore the suitable articles for the study were related to survival dental implant, dental implant and diabetes, dental implant and controlled diabetes, dental implant success and diabetes, and blood sugar level and dental implant. We included clinical controlled trials, retrospective/prospective cohort studies, and case-control studies written in English [Figure 2].
Figure 2: Flowchart representing the process of selection of studies included in the review

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   Results Top

A total of 14 studies were found fulfilling the criteria related to the dental implants in patients with controlled diabetes mellitus to review, details of which are given in [Table 1].
Table 1: Observations of the studies included in the present systematic review

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   Discussion Top

A number of patients varied from 21, in which 53 dental implants were placed, while in another study, 663 patients were enrolled, in which 2887 dental implants were placed.[14],[15] Total implants placed in 14 studies were 6116, of which 3207 (52.44%) in diabetic patients and 2909 (47.56%) in nondiabetics as shown in [Figure 1] and [Figure 3].
Figure 3: Total percentage of dental implant placed in diabetic and nondiabetic participants in the studies considered for review of literature

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Dental implant and types of diabetes mellitus

Data obtained from the included studies revealed that in 10 studies patients with Type 2 diabetes mellitus were used as subject and in remaining four studies both Type 1 and 2 diabetic patients were taken for dental implant treatment. It may be because patients with Type 2 diabetes are easily available for enrolment in the research as it is more prevalent.

Dental implant and duration of diabetes mellitus

Two studies reported the duration of diabetes mellitus in patients enrolled for implant surgery.[16],[17] As the duration of diabetes increases, the risk of both microvascular and macrovascular complications also increases which can adversely affect the dental implant survival rate. Hence, duration of diabetes is an important factor to predict the outcome in the patient undergoing dental implant surgery and must be taken into consideration in diabetic patient.

Dental implant and glycemic control

HbA1c a well-known prognostic marker of glycemic control in diabetic patients, nowadays also considered a diagnostic marker when analyzed by NGSP certified method. HbA1c is used to monitor the glycemic control as it predicts an average blood glucose level of previous 2–3 months and also patient preparation is not required. Six studies had not mentioned the baseline HbA1c levels in enrolled diabetic patients which may be because of the most common disadvantage of HbA1c that it is not a cost-effective method and requires technical skill.

Two studies followed the guidelines recommended by ADA and considered HbA1c cutoff below 7% as well-controlled glycemic index in diabetes mellitus.[16],[18] While in another study, patients of Type 2 diabetes were grouped into four according to their HbA1c level and considered HbA1c of <6% as well controlled.[19] A prospective cohort study included Type 2 diabetic patients and categorized them as well controlled having HbA1c level between 6% and 8% and poorly controlled with HbA1c ≥8.1%.[20] They also enrolled nondiabetic individuals having HbA1c <5.9%. While in a pilot study, individuals with HbA1c level below 6% were reported as nondiabetic and Type 2 diabetic patients were classified into well controlled (HbA1c: 6%–8%), moderately (HbA1c 8.1%–10%), and poorly controlled (HbA1c >10%) diabetes.[21] Type 2 diabetic patients with their blood sugar level under well control were selected in a clinical study, but the baseline value of HbA1c was not available.[14] Similarly, Olson (2000) measured HbA1c level at baseline and classified patients as normal, 2% above normal, and >2% above normal, but the HbA1c cutoff considered normal was not mentioned.[17] A recent study conducted on patients having Type 2 diabetes mellitus defined poorly controlled glycemic index with HbA1c level between 8% and 12%; however, well-controlled group was not included in their research.[22] While two studies maintained the level of fasting blood sugar <140 mg/dl and postprandial <200 mg/dl, criterion defined by ADA for diabetic patients, but in both, HbA1c was not considered as a marker for glycemic control.[23],[24]

Method to monitor the average blood glucose level varied, most of the studies used HbA1c while fewer studies maintained the fasting and postprandial blood sugar cutoff defined by ADA. Although it is well established that dental implant can be placed safely with similar outcome in well-controlled diabetic patient as in healthy individuals,[25] HbA1c cutoff used to define the diabetic patients as well controlled varied from study to study. Thus, the HbA1c cutoff value for well-controlled diabetes of <7% recommended by ADA [6] should be followed universally by clinicians and researchers. During follow-up period, maintaining good glycemic control will prevent the failure of dental implant in diabetic patient; hence, HbA1c should be monitored along with antidiabetic therapy after the surgery.

Survival rate of dental implant in well controlled, moderately, or poorly controlled diabetes mellitus

Survival rate varied from 85.7% to 100% among the studies included [Table 1]. Hundred percent survival rate was observed in well-controlled diabetes, uncontrolled diabetes, and nondiabetic individuals while in a cohort study survival rate of 92.6%, 95%, and 93% was reported in well-controlled, poorly controlled patients, and nondiabetic individuals respectively with an overall survival rate of 94%.[20],[21] In patients with well-controlled diabetes, survival rate of 94.2% and 90.4% were observed.[14],[16] Two studies compared survival rate among diabetic patients with nondiabetic patients.[18],[26] They found survival rate of 95% and 97.2% among diabetic patients as compared to 100% and 98.8% in nondiabetic individuals. Survival rate was 94.4% in diabetic patients with fasting plasma glucose <140 mg/dl and postprandial <200 mg/dl.[24] Furthermore, they had not found any correlation between the failed implants and blood glucose level. In a recent study, survival rate of 97.6% was observed in poorly controlled diabetic patients.[22] Overall survival rate of 85.7% was observed in diabetic patients over a period of 6.5 years follow-up in a retrospective study.[27] One study reported the survival rate of 93.8% in diabetic patients without cardiovascular diseases (CVD) as compared to 86.7% in diabetic patients with CVD.[23] Another study observed survival rate of 94.3% in diabetic patients with periodontal diseases.[28] In one study, better outcome of dental implant was reported in well-controlled diabetic patients, though data of survival rate were not available.[20] Thus, we can conclude that no difference in dental implant survival rate was observed from published studies among diabetic patients with well-controlled, moderately, or poorly controlled glycemic index and nondiabetic individuals.

Survival rate of dental implant in diabetic patients by conventional and flapless surgical procedure

As there was only one study in our search that compared the conventional versus flapless type of surgery, while in remaining 12 studies conventional technique was used for dental implant placement, we cannot compare the two types of techniques [Table 2]. One study opted both techniques for dental implant placement with overall survival rate of 94.3%, but data for comparing the two surgical procedures were not available.[28] However, the cumulative mean of dental implant survival rate by conventional and flapless techniques calculated from 11 studies is 94.2% and 92.3%, respectively, as shown in [Figure 4]. Thus, with this data, it can be concluded that the two techniques are similar in terms of survival rate. More studies are required to compare conventional and flapless procedures in diabetic patients [Figure 4].
Table 2: Survival rate of dental implant placement by conventional and flapless technique

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Figure 4: Mean survival rate of dental implants by conventional and flapless technique

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Report of a meta-analysis revealed that while placing dental implants, open flapped procedure is usually considered a better option when compared with flapless procedure, as surgical area can be easily visualized.[13] In case of limited amount of bones present, risk of bone fenestrations or perforations can be reduced by elevation of flap which is an advantage of conventional procedure.[29] While another study found that conventional flapped surgical procedure requires more time for the surgery, causes discomfort by complications such as pain, swelling, and inflammation.[30]

Duration of follow-up visit in dental implant patient

In all the selected studies duration of follow-up visit varied from 4 months to 144 months as shown in [Figure 5]. Although no correlation between the survival rate of dental implant in diabetic patients and follow-up visits was observed from the available data, most of the implant failure occurred within short duration after the surgery [Table 1]. Guidelines regarding the number and interval of follow-up visit must be framed out for better outcome of dental implants in diabetic patients [Figure 5].
Figure 5: Duration of follow-up visit in studies included for the review

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Factors affecting dental implant survival

Success rate/survival rate of dental implant depends on the short-term and long-term outcomes of the surgery. Factors such as pain, swelling, inflammation, peri-implantitis, and implant mobility are assessed for the short-term outcome, that is, 3 months after implant placement. Assessment of long-term follow-up is done by measuring marginal or crestal bone loss, bleeding on probing, and probing depth.

Peri-implant mucositis was the most common cause of dental implant failure in diabetic patient as observed in a controlled clinical trial.[22] Recently, in a randomized clinical trial, mesial and distal crestal bone loss at 6th and 12th months after implant placement was observed and compared with baseline values in Type 2 diabetic patients with well-controlled blood sugar levels.[16] In both flapless and conventional techniques, crestal bone loss increased significantly at the 6th and 12th months. No statistically significant difference in crestal bone loss was found in both surgical procedures, that is, flapless and conventional. In other study, long-term outcome was observed by assessing marginal bone loss, bleeding on probing, and probing depth at 3 years in diabetic patients.[19] Similarly, peri-implant bone loss was assessed by measuring plaque index, bleeding on probing, and probing depth in both diabetic and nondiabetic individuals.[18] Clinical mobility, pain, infection, inflammation, swelling in association of surgical area, and peri-implant radiolucency were observed as short-term factors for assessing the survival rate of dental implant in diabetic patients.[21] From their findings, it was proved that with poor HbA1c level loss of marginal bone is more because of altered bone metabolism in patients with uncontrolled diabetes. They found that in two implants rotational movement occurred after two weeks of surgery and in one implant they found gingival inflammation with partially submerged healing cap after two weeks. In all the three cases HbA1c level at the time of surgery were >7.3%. Criteria to assess success rate in a clinical study were pain, inflammation, purulent discharge, radiolucency, and loss of >1 mm bone around the implant at 1-year follow-up.[24] Length of dental implant was also considered as a significant factor affecting its survival in a prospective study.[17] In a prospective cohort study, implant stability by resonance frequency measurements was assessed and it was found that after four months of dental implant placement, implant stability decreased in Type 2 diabetic patients with HbA1c ≥8%.[20] While in another study, cone-beam computed tomography, resonance frequency analysis findings, and wound-healing parameters were assessed at 12 months to find out the survival outcome of dental implant in diabetic patients.[26] The use of antibiotic before and after the implant surgery improves the survival rate in diabetic patient as observed in one of the study included in this review.[15]

With the variations observed in included studies, we would like to suggest that factors may be categorized into short-term and long-term as both are equally important and must be measured carefully at defined time intervals for assessing the outcome of dental implant placement in diabetic patients. Furthermore, both conventional and flapless procedures have their own advantages and disadvantages, dental surgeons should select the procedure for placing dental implant depending on systemic and local factors.

Dental implant failure due to poor glycemic control in patients with diabetes mellitus

Diabetes mellitus is one of the common systemic diseases, once thought to be negative factor for dental implant surgery and its high failure rate because of poor wound healing and altered bone metabolism in diabetic patients. Due to elevated levels of blood glucose, nonenzymatic glycation of proteins results in the formation of advanced glycation end products (AGE's).[31] Advanced glycation of proteins alters the permeability of endothelium, release inflammatory cytokines, and growth factors, alters the anti-thrombotic properties of endothelium, and increases the expression of adhesion molecules and chemokines, thereby leading to microvascular complications, for example, poor circulation and delayed wound healing.[32] All these factors may increase the chance of implant failure in diabetic individuals with poor glycemic control.

Bone quality is an essential factor in implant success which may be compromised in diabetic, especially patients with uncontrolled diabetes mellitus. AGE's directly inhibit proliferation and differentiation of bone cells, thereby altering the bone metabolism.[33],[34] Elevated blood glucose level decreases the number of osteoblasts and its maturation leading to impaired osteoid mineralization.[35] Osteoclasts are required for resorptive phase of bone remodeling and this activity is inhibited in Type 2 diabetes mellitus. Normally, enzymatic cross-linkages formed by lysine hydroxylase and lysyl oxidase provide tensile strength to the bone.[36] Hyperglycemia causes nonenzymatic advanced glycation of collagen in bone, a well-established factor for poor “bone quality” in diabetics. Bone fragility increases due to nonenzymatic formation of pentosin and carboxymethyl-lysine in collagen fibers as cross-linked and noncross linked types of advanced glycation products in diabetics.[37]

Due to these complications, dental implant surgery was once thought to be contraindicated in diabetic patients. There is now literature available which shows that dental implants can be safely used in diabetic patients with good glycemic control, but the implant failure rate increases in patients with poorly controlled diabetes because of the reasons mentioned above.

   Conclusion Top

Similar survival rate of dental implant placement by conventional and flapless surgery was observed which explains why flapless technique is much the same as the often preferred conventional technique. Until date, very little data is available on flapless technique; therefore, researchers/clinicians are recommended to explore more, especially among diabetic patients, which will add to the information in existing literature.

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Correspondence Address:
Dr. Jitendra Rao
Department of Prosthodontics, FODS, King George's Medical University, Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdr.IJDR_606_17

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2]

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