SOFT TISSUE AND MARGINAL BONE CHANGES AROUND DENTAL IMPLANTS FOLLOWING

FLAPLESS AND CONVENTIONAL METHOD- A COMPARATIVE CLINICAL AND RADIOGRAPHIC

STUDY BETWEEN STAGE I AND STAGE II SURGERY

Abstract

Background and objectives:

The aim of this study was to compare the effects of implants placed with a flapless procedure and conventional
surgical procedure on soft tissue condition and marginal bone changes around dental implants evaluated clinically
and radiographically between stage I and stage II surgeries.

Methodology:

20 partially edentulous patients were selected, and according to the randomized procedure implants were placed
with flapless or by conventional method by giving incision and flap elevation. Implants of the conventional group
were placed after a midcrestal incision and full thickness flap elevation. Flaps were closed with single suture.
Implants were placed load free for 4 months in mandibles and maxillae. The prosthetic procedure remains same for
both the groups.

Results:

Reduction in crestal bone height was seen in both conventional and flapless method. On comparison of crestal bone
loss, the flapless method showed lesser reduction as determined by radiographs. The other clinical parameters used
for the study i.e. Gingival index, bleeding on probing, and probing depth were insignificant while comparing the two
methods.

Interpretation and conclusion:

The flapless implant surgery is a predictable procedure. In addition, it is advantageous for preserving crestal bone
and mucosal health surrounding dental implants. And the flapless method of implant placement may increase the
success rate.

Keywords:

Dental implants, bone loss, gingival index, bleeding on probing, probing depth, flapless, conventional.

Page 1
 Introduction

Present day dental treatment not only directed at enhancing function and esthetic results but also aims at
achieving patient comfort with optimum satisfaction. In this developing world as the days are passing newer and
finer techniques are being developed so as to achieve better results that are less invasive, in other words more
conservative in the nature. Implant dentistry is nonetheless behind when advances are concerned, we have seen the
inclination towards minimal invasive implant techniques, to yield better esthetics as well as improved results, taking
care of patient discomfort. Of the various minimal invasive techniques .Flapless techniques are gaining popularity
over the conventional full thickness flap reflection techniques. Successful single-tooth implant treatment requires
buccal bone sufficiently thick to avoid any implant dehiscence. 1, 2
The dental literature has documented that the
more invasive the surgical procedure, the higher the likelihood of loss of alveolar bone and soft tissue, including the
dental papilla.3, 4

The increase in the use of this method can be attributed to improvements in the radiologic techniques and
also availability of dental implant treatment planning software, as clinicians can now acquire 3-dimensional images
of potential implant sites before surgery. Three-dimensional imaging techniques such as computerized tomography
are indeed effective aid in assessing the bone dimensions at implant site but are expensive. 5 In view of this clinicians
use the clinical method for assessing edentulous ridges transversely is ridge mapping, in which sharp-beaked
calipers are used to measure the facio-lingual width of the residual bony ridge at the proposed implant site. Partially
used by the dentists in the developing countries which is cost effective.6 The two stage surgical protocol established
by Branemark et. al to accomplish osseointegration consisted of several pre-requisites, such as: obtaining and
maintaining a soft tissue covering over the implant for 3 to 6 months, and maintaining the non loaded implant
environment.7

In recent years, flapless implant surgery has been reported to have a predictable outcome with a high
success rate, as long as patients are properly selected with sufficient width of bone available for implant placement.
Other studies have shown that exclusion of the mucoperiosteal flap can prevent the potential postoperative bone
resorption8. Additionally, most crestal bone loss occurs in the early phase after implant placement. Therefore, the
purpose of the present study is to evaluate the soft tissue conditions and marginal bone changes around dental
implants after flapless and conventional implant placement between stage I and stage II surgery.

In the early 1970s, studies demonstrated a correlation between flap elevation and gingival recession, as well
as bone resorption around natural teeth. Furthermore, there has been a report of postsurgical tissue loss from flap
elevation, implying that the use of flap surgery for implant placement may negatively influence implant esthetic
outcomes, especially in the anterior maxilla.9

Page 2
 Materials And Methods

SOURCE OF DATA:

The study was carried out at the Department of Oral implantology, The oxford dental college and hospital,
Bangalore.
Patients were selected from the outpatient department of The Oxford dental college with missing teeth requiring
dental implants for rehabilitation.
Total sample size of 20 with 10 requaring conventional technique and 10 with flapless technique.
Methods of collection of data

Routine pre-surgical protocol was followed for each patient. The site of flapless placement of the implant
was selected on basis of the bone dimension determined by bone mapping and sufficient keratinized gingiva. A
round punch of tissue was removed with tissue punch and through this punch the implant was placed for flapless
procedure and for conventional method crestal incision was given.

Bone mapping (Ridge mapping)

Bone mapping or ridge mapping can be used to measure bone width present at the desired site of implant
placement. It is easy to expertise in this technique and doesn't require unnecessary radiation to exposure or any
specialized instrument. First the cast is prepared after the impression of the desired site. The sectioning of the cast is
done at the midpoint of desired edentulous area as shown in figure. Three points are marked on the cast on buccal
aspect, similarly followed by marking on the lingual aspect. These points are replicated intraoraly in patients mouth. After
anesthetizing the desired site of implant placement, using endodontic file with stopper, the gingival tissue is penetrated on
buccal as well as lingual aspect so as to reach the bone and this is replicated over the diagnostic cast .
Pre operative and post operative evaluations were done by clinical and radiographic
means.

It included:

Clinical photographs
Study Models
Orthopantomogram
Intraoral Periapical Radiographs

All patients were followed for 4 months after implant placement.

PROCEDURE OF IMPLANT PLACEMENT

Page 3
Surgical procedure:

After patient selection according to inclusion criteria, dimensions of implant were selected after removing
radiographic errors and on basis of bone mapping. A surgical stent was prepared and tried in patients mouth. Local
anaesthesia (Lignocaine with 1:200,000 Adrenaline) was administered to block the regional nerve supply and aid
heamostasis. For the conventional method, crestal incision was given and surgical site was exposed. The process of implant
osteotomy was begun with the punch cut by using pilot drill through the hole in the stent, to accurately reproduce the
angulation. The stent was removed and the osteotomy was carried to the desired depth. The angulation was checked
once again with the paralleling pin both clinically and radiographically and any discrepancy found was corrected
subsequently. The osteotomy was then diametrically enlarged to desired width.

While for Flapless method a punch of tissue was removed with the help of disposable soft tissue punch from the
planned site of implant placement. Before drilling, the soft tissue thickness was measured at the implant site using a
periodontal probe which was followed by sequential drilling to get a final osteotomy to accommodate implant.

All of the patients received endosseous implants 3.3, 3.5, 4.0, 4.5, or 5.0 mm in diameter and 10-13 mm in
length via flapless and conventional surgery. After completion of the osteotomy, the implant is carried from the
packaging to the site using the disposable carrier provided by the manufacturer. It is screwed in and tightened using
the hardware provided in the surgical kit.

All these steps are done under constant internal and external irrigation. After placement of implant the
closure of the site was done with silk 3-0 suture in case of conventional method, and, for the flapless method a healing
abutment was placed instead of cover screw and no sutures were placed.

After implant placement and suturing, each patient received 500mg of amoxycillin thrice daily for 5 days. 600mg of
lbuprofen as and when required and a 0.2% chlorhexidine mouthwash to be used twice daily for 2weeks. Patients who
received implants via conventional method were recalled after 7 days for suture removal.

4 months letter second stage surgery was carried out for both flapless and conventional groups .In flapless group
abutment was placed where as in the case of conventional group gingival collar was placed. Subsequently patients are
referred to the prosthodontics department for further steps.

Post operative clinical evaluation

For each patient, a clinical evaluation was performed 4 months after the implant insertion. Which involved
measuring the

1. Probing pocket depth,

2. Gingival index (GI),

3. Bleeding on probing (BOP)

Page 4
4. Radiographic evaluation

1. Probing pocket depth:

Pocket depths were measured using Williams periodontal probe with a probing force of 0.2 N. The probe
was calibrated for a 0.2N probing force. The mean pocket probing depth for each implant site was obtained from
average of the measurements taken at 4 different sites around the implant.

2. Gingival index:

The Gingival Index (Le and Silness, 1963) was used for the assessment of gingival health and to record
qualitative changes in the gingiva. Scores are measured for the marginal and interproximal tissues separately on the
score of 0 to 3. The bleeding is assessed by probing gently along the wall of soft tissue of the implant placed. The
scores of the four areas of the implant can be summed up and divided by four to give the GI for the implant.

3. Bleeding on probing:

In the present study modified gingival index was used for evaluating the bleeding. This index scores gingival
inflammation from 0-3 on the facial, palatal, mesial and distal surfaces of the implant. The scores are based on
presence or absence of bleeding on probing and are awarded.

Radiographic evaluation:

Mean marginal bone loss was assessed radiographically using the standard Intraoral Periapical Radiographs. The
distance between the observed crestal bone level and implant-abutment interface was measured at the mesial and distal
implant surfaces and the mean marginal bone loss level was calculated. In some cases, a magnification error may exist.
In such cases, the length (mm) of the implant, and the distance between the observed crestal bone and implant-abutment
interface was measured on the radiographs. The actual implant length is known based on manufacturing standards. To
adjust the measurements for magnification error, the following equation was used to determine the corrected crestal bone
levels.

Corrected crestal bone loss = measured crestal bone loss x actual implant length

Measured implant length

Prosthodontic Protocol:

Impression for temporary prosthesis was made with alginate and cast was poured with implant analog. Final prosthesis was
delivered at the end of 5 months. Final prosthesis was kept in centric contact with no excursive contacts.

Page 5
 Results

20 patients, reporting to the Dept of oral implantology, The Oxford dental college and hospital, desiring
replacement of missing teeth who have satisfied the specified inclusion criteria. 25 single tooth implants were placed
totally in 20 patients. 10 patients received the implants via conventional method and 10 patients via flapless method.
Among the 20 patients, 70 %( n=14) were male and 30 %( n=6) were female. The mean age of the patients was
29.4 years (range 22years -36 years). Of the 33 implants placed, 18 implants placed via conventional method and 15
via flapless method. In all the cases, implants of dimensions ranging from 3.3mm- 5mm in width and 10mm- 13mm
in length were used. To assess the outcomes of conventionally placed implants and implants placed via flapless
method, we have focused our follow up on 3 clinical and 1 radiographic parameters: namely, Probing depth,
Gingival index (GI), Bleeding on probing (BOP) and Radiographic evaluation respectively. The values were
recorded over follow up appointments scheduled at 4 th month of post implant placement surgery.

In the study the statistically significant result was seen between the conventional and flapless method with respect to
the bone loss at 4th month. It showed that bone loss at the 4 th month is significantly higher in conventional method as
compared to flapless method. . Conventional method showed 0.6mm 0.22 SD bone loss while flapless method
showed 0.34mm 0.10 SD. There were no significant differences observed between two methods (Conventional
and Flapless method) with respect to gingival index scores, probing depth and bleeding on probing at 4th month.
The mean probing depth recorded in the study for conventional method was 2.27mm 0.34 SD and for the flapless
method it was 2.03mm0.17 SD. There was no significant difference between two methods (Conventional and
Flapless method) with respect to probing depth at 4th month. There is no significant difference seen between two
methods (Conventional and Flapless method) with respect to bleeding on probing. The mean bleeding on probing for
conventional group is 0.23 0.18 SD and for the flapless method it was 0.210.18 SD. The mean gingival index
score was 0.230.18 SD for the conventional group and for the flapless method it was 0.200.23 SD. The results
showed that there was no significant difference seen between the two groups with respect to the gingival index
score.

Discussion

Maintaining the soft tissue health and bone height following implant placement has been a challenge for the
restorative dentist .With the conventional flap elevation technique, an extended flap is needed to visualize the bone
sufficiently in order to avoid perforation of critical anatomical structures. Flap elevation ensures that some
anatomical landmarks such as foramina, lingual undercuts or maxillary sinuses are clearly identified and protected.
When the amount of available bone is limited, flap elevation will facilitate the implant placement. However flaps are
associated with some degree of morbidity and discomfort and require suturing. Avoiding the surgical flap can have
advantages for soft tissue healing and patient comfort Despite the long-standing and successful use of this traditional
flap approach for the surgical placement of dental implants, this technique has been associated with several
disadvantages. Chief among these is a loss of alveolar crest bone due to decreased supraperiosteal blood supply
because of raising the tissue flap during the surgical procedure. 10 Additional concerns include perioperative blood

Page 6
loss and hemorrhage, esthetically displeasing soft tissue recession (including papillae), pain and discomfort for the
patient.11-13 To overcome these disadvantages, alternative methods to the flap approach have been sought in recent
years. There have been reports that the flapless implant surgery is a predictable procedure with high success rates if
patients are appropriately selected and an appropriate width of bone is available for implant placement. 7,14 Flapless
surgery has numerous advantages, including preservation of the vessels around the implants, maintenance of the
original mucosal form around the implants15 and retention of hard tissue volume at the surgical site16. This method
also shortens the length of the surgery, improves patient comfort, and accelerates recovery.

Flapless implant surgery is thought to be a procedure with many limitations, including the inability to save
the keratinized mucosa because a tissue punch removes some of this tissue; lack of proper drilling depth assessment
as it is difficult to see lines on the drill at the bone crest, inability to assess the location of the implant due to lack of
visualization of the bone; and inability to correct peri-implant defects as they are not exposed during surgery. As a
result, guidelines on the flapless procedure were that it should be used only when the bone has abundant width and
when the mucosal tissue has sufficient amounts of keratinization. 14 In the present clinical study a total of 20 patients
out of which 10 patients received implants via conventional method and another 10 received via flapless method out
of which 70 %(n=14) were male and 30%(n=6) were female with the mean age 29.4 years (range 22years -36 years)
Of the 33 teeth replaced, 18 implants placed via conventional method and 15 implants placed via flapless The tissue
punch that was used for the flapless technique had a diameter of 5mm which was slightly bigger than the implant
selected for the placement. Flapless technique was used only for those cases where sufficient bone width was
present as determined by ridge mapping along with the subsequent quantity of keratinized mucosa.

The clinical parameters that were taken into the consideration were probing depth, gingival index, bleeding on
probing and the radiographic marginal bone loss. The probing depth measurement is one of the most important
parameters for clinical characterization of the implant condition (Behneke et al. 2002)17. It is of central importance
also because of the similarity of the tissues surrounding teeth and implants, the value measured is related to
marginal bone loss .For natural dentition, a probing depth of 1 to 3 mm is considered to be physiological, though
around implants the healthy or pathological values vary. A probing depth of 1.5 to 3.5 mm was found to be optimal.
The values found in this study showed no significant difference between two groups regarding pocket depth.18

The Gingival Index (Le and Silness, 1963) is used for the assessment of the gingival health. It was
created for the assessment of the gingival condition and records qualitative changes in the gingival. The gingival
index is based on two of the characteristics signs of inflammation swelling and redness. An important sign is
bleeding. The bleeding is assessed by probing gently along the wall of soft tissue of the gingival sulcus. 19 The
sensitivity and reproducibility is good provided the examiner's knowledge of periodontal biology and pathology is
optimal (Le, 1967).

It is observed that an excellent peri-implant mucosal health in the present sample after flapless implant
surgery, as confirmed by low GI and BOP index scores. Scoring of the gingival index in the present study shows no
significant difference in both the groups. Lekholm and colleagues found no correlation between bleeding on probing

Page 7
and histologic, microbiologic, or radiographic changes around implants20. These authors hypothesized that bleeding
could have been caused by inappropriate force transmission from the periodontal probe tip to the peri-implant soft
tissues. These preliminary findings were confirmed in an animal study. Conversely, findings from animal
experiments yielded completely different results. Healthy sites were characterized by absence of bleeding (0%),
whereas both peri implant mucositis and peri-implantitis sites showed substantially increased bleeding on probing
(67% and 91%, respectively). The reason for these results might be attributed to the different probing forces applied
by the various investigators. These findings were in conformity with the present study where absence of bleeding on
probing had a high negative predictive value, thus serving as a predictor for stable peri-implant conditions.
Radiographic bone level was measured by comparing the periapical radiographs obtained immediately after
the implant placement and with those obtained at the second stage. Bone level was measured on mesial and distal
aspect from a fixed reference point i.e. the implant/abutment junction, to the crestal bone.
Recently, in a controlled retrospective study Rousseau (2010) has demonstrated the correct indication
range, the success of minimally invasive transgingival implantation is the same as that of the classical protocol:
minimally invasive, 98.3 %; conventional, 98.5 %. Nevertheless investigations of the peri-implant soft tissue
following minimally invasive surgery are rare: and 241 patients have been followed up over a period of four to 12
months .The present study demonstrated the same results, with no significant difference seen between conventional
and flapless method regarding soft tissue conditions.21

Adell R et. al. have argued that it is important to avoid contamination of the implant surface by bacteria and
biologic molecules (including saliva and foreign bodies) during the surgical insertion of implants. 22 However
Esposito et al. contradicted the above observation and reported that clinical observations and experimental evidence
failed to indicate any soft tissue contactrelated causes for implant failures.23 Present study produced similar results
to those of Esposito et al. in the process of osseointegration despite potential contamination caused by the small
puncture. Flapless implant surgical procedure offers clinicians the possibility of placing implants in less time,
without extensive flap exposure, and with less bleeding and postoperative discomfort. 24,25 The findings of the
present study demonstrated that there is significant difference in crestal bone loss and soft tissues between 2 groups
of implant placement. Conventional method showed 0.6mm 0.22 SD bone loss while flapless method showed
0.34mm 0.10 SD. The finding with data previously reported from animal Experiments showed that no significant
differences were shown in the marginal bone level between the 2 surgical procedures.
The mean probing depth recorded in the study for conventional method was 2.27mm 0.34 SD and for the
flapless method it was 2.03mm0.17 SD. There was no significant difference between two methods (Conventional
and Flapless method) with respect to probing depth at 4th month. There is no significant difference seen between
two methods (Conventional and Flapless) with respect to bleeding on probing. The mean bleeding on probing for
conventional group is 0.23 0.18 SD and for the flapless method it was 0.210.18 SD.

The mean gingival index score was 0.230.18 SD for the conventional group and for the flapless method it
was 0.200.23 SD. The results showed that there was no significant difference seen between the two groups with
respect to the gingival index score. These results suggest that the flapless procedure is sufficiently safe and that flap

Page 8
elevation can be avoided in placing implants. This low frequency of both early failures and progressive bone loss in
the flapless group agrees with findings from previous studies showing that flapless implant surgical procedure is a
predictable procedure with a high success rate.

One explanation for this observation may be that when no flaps are reflected, the preservation of the
periosteum may help to optimize the healing of the peri-implant tissue.26,27 In comparing the conventional and
flapless procedures in this study, the difference in the amount of peri implant bone level changes observed during
the healing process between the stage I and stage II are statistically significant. During this period, significantly
higher rates of crestal bone resorption have been reported and were compared at the rate of other post loading
periods. For this reason, this study was undertaken to evaluate postoperative changes in the early phase between
implant placement and implant exposure (3 to 4 months later).

Although it is important to consider the final bone level that is established around functionally loaded
implants following exposure, success during the early postoperative period is likely to translate into long-term
success. Further investigations of the effects of conventional and flapless implant surgeries on soft tissue conditions
and crestal bone changes around dental implants in the late postoperative period are needed to determine whether the
success rates in this study are indicative of long-term success.

Conclusion

The present study was carried out to compare the effects of implants placed with a flapless and flap
elevation technique to evaluate the soft tissue conditions and marginal bone changes around implants placed
between stage I and stage II surgeries. In the present study total of 20 patients were selected out of which 10 patients
received implants via conventional method and 10 via flapless method. The clinical and radiographic follow up was
done for 4 months. At the second stage of implant placement the results showed that crestal bone loss was
comparably lower in flapless as compared to conventional method. But the soft tissue conditions i.e. gingival index,
bleeding on probing and probing depth showed no significant difference between both the groups. The data obtained
suggests that flapless surgery appears to be a plausible treatment modality for implant placement, demonstrating
both efficacy and clinical effectiveness. An analysis of the data obtained during the course of this study, coupled and
compared with data obtained while reviewing literature, suggests that flapless implant surgery is a predictable
procedure. In addition, it is advantageous for preserving crestal bone and mucosal health surrounding dental
implants. Reduction in crestal bone height was seen in both conventional and flapless method. On comparison of
crestal bone loss, the flapless method showed a statistically significant reduction in bone loss as determined by
radiographs. The other clinical parameters used for the study i.e. gingival index, bleeding on probing and probing
depth were statistically insignificant while comparing the two methods. Findings of this study support the view that
the clinical use of flapless implant surgery increases the success rate of the implant procedure.

Page 9
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Tables and Graphs

Table I: Distribution of male and females in two methods (Conventional and Flapless method)

Gender Conventional percentage Flapless percentage Total Percentage

method method

Male 8 80.00% 6 60.00% 14 70.00%

Female 2 20.00% 4 40.00% 6 30.00%

Total 10 100.00% 10 100.00% 20 100.00%

Table II : Mean and SD age of male and females in two methods (Conventional and Flapless method)

Gender Conventional method Flapless method Total

Mean SD Mean SD Mean SD

Male 30.50 2.20 30.17 4.26 30.36 3.10

Female 30.50 7.78 25.50 6.66 27.17 6.74

Total 30.50 3.24 28.30 5.54 29.40 4.56

Table III: Comparison of two methods (Conventional and Flapless method) with respect to mean number of
implants placed by t test

Methods n Mean SD t-value P-value

Conventional method 18 1.80 0.92 0.7093 0.4872

Flapless method 15 1.50 0.97

Table IV: Comparison of two methods (Conventional and Flapless method) with respect to Bone loss at 4th month
(mm) by t test

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Methods n Mean SD t-value P-value

Conventional method 10 0.60 0.22 3.4179 0.0031*

Flapless method 10 0.34 0.10

*p<0.05

Table V: Comparison of two methods (Conventional and Flapless method) with respect to gingival index scores at
4th month by Mann-Whitney U test

Methods n Mean SD Sum of U-value Z-value P-value

ranks

Conventional method 10 0.23 0.18 109.50

Flapless method 10 0.20 0.23 100.50 45.50 -0.3402 0.7337

Table VI: Comparison of two methods (Conventional and Flapless method) with respect to probing depth at 4th
month by t test

Methods n Mean SD t-value P-value

Conventional method 10 2.27 0.34 1.9954 0.0614

Flapless method 10 2.03 0.17

Table VII: Comparison of two methods (Conventional and Flapless method) with respect to bleeding on probing at
4th month by t test

Methods n Mean SD t-value P-value

Conventional method 10 0.23 0.18 0.5721 0.5743

Flapless method 10 0.18 0.21

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Table VIII: Correlation among different parameters by Karl Pearsons correlation coefficient in conventional
method

Variable No. of Bone loss - GI - 4th PD - 4th Bleeding on

implants 4th month month month (mm) probing - 4th
placed (mm) month

No. of implants placed -

Bone loss - 4th month (mm) r=0.6406* -

GI - 4th month r=0.4588 r=0.6292 -

PD - 4th month (mm) r=-0.3413 r=-0.7249* r=-0.6332* -

Bleeding on probing - 4th month r=0.4588 r=0.6292 r=0.9999* r=-0.6332* -

*p<0.05

Table IX: Correlation among different parameters by Karl Pearsons correlation coefficient in Flapless method

Variable No. of Bone loss - GI - 4th PD - 4th Bleeding on

implants 4th month month month (mm) probing - 4th
placed (mm) month

No. of implants placed -

Bone loss - 4th month (mm) r=0.0622 -

GI - 4th month r=-0.1244 r=0.1435 -

PD - 4th month (mm) r=-0.5035 r=-0.1774 r=-0.0994 -

Bleeding on probing - 4th month r=-0.2083 r=0.0200 r=0.9400* r=0.1506 -

*p<0.05

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14
 Figure: Distribution of male and females in two methods (Conventional
and Flapless method)

100.0
90.0 80.0
80.0
70.0 60.0
Percentage

60.0
50.0 40.0
40.0
30.0
20.0
20.0
10.0
0.0
Conventional method Flapless method

Male Female

Figure:Comparison of mean age of male and females in two methods

(Conventional and Flapless method)
35.00
30.50 30.50 30.50 30.17
28.30
30.00 25.50
25.00
Mean value

20.00

15.00

10.00

5.00

0.00
Conventional method Flapless method

Male Female Total

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15
 Figure:Comparison of two methods (Conventional and Flapless
method) with respect to mean number of implants placed
2.00 1.80
1.75 1.50
1.50
Mean value

1.25 0.97
0.92
1.00
0.75
0.50
0.25
0.00
Conventional method Flapless method
Mean SD

Figure:Comparison of two methods (Conventional and Flapless

method) with respect to Bone loss at 4th month (mm)
0.80

0.60
0.60
Mean value

0.40 0.34

0.22
0.20 0.10

0.00
Conventional method Flapless method

Mean SD

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16
 Figure:Comparison of two methods (Conventional and Flapless
method) with respect to gingival index scores at 4th month

0.30

0.23 0.23
0.25
0.20
0.18
Mean value

0.20

0.15

0.10

0.05

0.00
Conventional method Flapless method
Mean SD

Figure:Comparison of two methods (Conventional and Flapless

method) with respect to pocket depth at 4th month

2.75
2.50 2.27
2.25 2.03
2.00
Mean value

1.75
1.50
1.25
1.00
0.75
0.34
0.50 0.17
0.25
0.00
Conventional method Flapless method
Mean SD

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17
 Figure:Comparison of two methods (Conventional and Flapless
method) with respect to bleeding on probing at 4th month

0.25 0.23
0.21

0.20 0.18 0.18

Mean value

0.15

0.10

0.05

0.00
Conventional method Flapless method
Mean SD

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18