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Survival Rate of Dental Implant Placement by Conventional or Flapless

Surgery in Controlled Type 2 Diabetes Mellitus Patients: A Systematic Review

Article  in  Indian Journal of Dental Research · August 2019

DOI: 10.4103/ijdr.IJDR_606_17

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Issue 04 . July-August 2019 . Volume 30

Indian Journal of Dental Research • Volume 30 • Issue 4 •

Indian Journal of Dental Research

July-August 2019 • Pages 329-482

Official Publication of
Indian
Society
for
Dental
Research
www.isdrindia.com
International Association for Dental Research - Indian Division
www.iadr.com
 Systematic Review

Survival Rate of Dental Implant Placement by Conventional or Flapless

Surgery in Controlled Type 2 Diabetes Mellitus Patients: A Systematic
Review

Abstract Kalpana Singh,

Introduction: Dental implant may serve as a choice of treatment for replacement of missing tooth in Jitendra Rao1,
diabetic patients with their well‑controlled glycemic index. To minimize postoperative complications, Tuba Afsheen1,
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 Bhawna Tiwari2
either of the technique, that is, conventional or flapless in patients with controlled Type  2 diabetes Department of Biochemistry,
mellitus from published studies. Materials and Methods: A total of 14 studies were included from King George’s Medical
University, 1Department
PubMed database related to the survival rate of dental implant placement by conventional or flapless of Prosthodontics, FODS,
surgery among patients with controlled diabetes mellitus. The cumulative mean of dental implant King George’s Medical
survival rate by conventional and flapless techniques calculated from included studies is 94.2% and University, Lucknow, Uttar
92.3%, respectively. Conclusion: The survival rate of dental implant placement by conventional and Pradesh, 2Department of
flapless techniques is similar. As few studies on flapless technique are available, therefore researchers Prosthodontics, ESIC Dental
in future should explore its advantages and disadvantages. College, New Delhi, India

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

Introduction in which body fails to utilize the insulin

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
This is an open access journal, and articles are
distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially,
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licensed under the identical terms.
For reprints contact: reprints@medknow.com
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 Address for correspondence:
Dr. Jitendra Rao,
year 2014.[4] With increasing awareness of
Department of Prosthodontics,
diabetes, people have learned to manage FODS, King George’s
its complications by improving their Medical University, Lucknow,
lifestyles such as diet, regular exercise, and Uttar Pradesh, India.
follow‑ups, yet wound healing is a major E‑mail: drjit123@rediffmail.com
part of the concern. To diagnose, diabetes
mellitus, guidelines recommended by the Received : 27-10-2017
American Diabetes Association  (ADA), is Revised : 07-02-2018
given in Figure 1.[5] Accepted : 23-06-2018
Published : 18-11-2019
Glycated hemoglobin  (HbA1c), a
well‑known marker for monitoring Access this article online
glycemic control, also now used as a Website: www.ijdr.in
diagnostic marker when estimated by the DOI: 10.4103/ijdr.IJDR_606_17
National Glycohemoglobin Standardization Quick Response Code:
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.

600 © 2019 Indian Journal of Dental Research | Published by Wolters Kluwer - Medknow
 Singh, et al.: A systematic review of dental implant success outcome in conventional or flapless surgery in patient with type 2 DM
Figure 1: Diagnostic criteria for diabetes mellitus recommended by the
American Diabetes Association
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
Indian Journal of Dental Research | Volume 30 | Issue 4 | July-August 2019 
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
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].
601
 Singh, et al.: A systematic review of dental implant success outcome in conventional or flapless surgery in patient with type 2 DM
Figure 2: Flowchart representing the process of selection of studies
included in the review
Results
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.
Discussion
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 Figures 1 and 3.
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
602
Figure 3: Total percentage of dental implant placed in diabetic and
nondiabetic participants in the studies considered for review of literature
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
Indian Journal of Dental Research | Volume 30 | Issue 4 | July-August 2019
 Table 1: Observations of the studies included in the present systematic review
Authors Number Average age Average HbA1c (%) Blood sugar level Type of Number of Follow‑up Observations
of subjects (years) duration of surgery implants visits
enrolled diabetes (years) placed (months)
Eskow et al., 24 type 2 NA NA Poorly NA Conventional 131 24 Survival rates at 1st and 2nd
2016 diabetic controlled year were 98.6% and 96.6%,
patients HbA1c respectively,
(8%‑12%) 4 patients lost to follow‑up
29% of patients suffered with peri
implant mucositis: a common
complication
Complications were not directly
related with HbA1c levels
Nobre et al., 70 diabetic 59 NA NA Diagnosis of Conventional 352 60 Patients were divided into two
2016 patients diabetes groups: CVD 38 patients and
FBS ≥7.0 mmol/l non‑CVD 32 patients
(126 mg/dl) 7 patients (10%) were lost to
2 h PP ≥11.1 follow‑up (1 in CVD and 6 in
mmol/l (200 mg/dl) non‑CVD)
1 prosthesis failed in non‑CVD,
rendering 97.4% survival rate
compared to 100% in CVD

Indian Journal of Dental Research | Volume 30 | Issue 4 | July-August 2019 

10 implants failed in 7 patients
8 implants failure in 5 patients with
CVD (86.7% survival rate)
2 implants failure in 2 patients
without CVD (93.8% survival rate)
Mean survival rate: 97.2%
Yadav et al., 76 controlled Flapless: 57 Flapless: 6.91 <7% NA Conventional 76 36 Dental implants were placed by
2016 type 2 Conventional: Conventional: and flapless Conventional: delayed loading (4 months)
diabetic 54 6.55 40 Mesial and distal bone loss
patients from 0, 6, and 12 months were
Flapless: 36
grouped calculated
into two
In both type surgery significant
depending
increase in mesial and distal crestal
on type of
bone loss was observed at 12
surgery
months
In between two types of surgery
similar mesial and distal crestal
Singh, et al.: A systematic review of dental implant success outcome in conventional or flapless surgery in patient with type 2 DM

bone loss after 6 and 12 months

Loss to follow‑up

603
Contd...
 Table 1: Contd...

604
Authors Number Average age Average HbA1c (%) Blood sugar level Type of Number of Follow‑up Observations
of subjects (years) duration of surgery implants visits
enrolled diabetes (years) placed (months)
Conventional ‑ 2
Flapless ‑ 5
Survival rate
Conventional ‑ 95.2%
Flapless ‑ 92.3%
Mean ‑ 94.2%
Gomez‑Moreno 67 type 2 59 NA Group 1 (<6) NA Conventional 67 36 21 patients in group I, 24 in group
et al., 2015 diabetic Group 2 II, 11 patients in group III and IV
patients (6.1‑8) Probing depth, bleeding on probing,
Group 1: 21 Group 3 marginal bone loss were observed
Group 2: 24 (8.1‑10) Marginal bone loss increased with
Group 3: 11 Group 4 increase in HbA1c level
Group 4: 11 (>10.1) Bleeding on probing showed
statistically significant differences
between groups (mean level varied
with group and time)
Probing depth values were too
low and statistically no difference
between groups were observed
Implant therapies can be
predictable with controlled
glycemic level
Erdogan et al., 24 patients NA NA NA NA Conventional 43 12 Success rate of 95% and 100% in
2015 divided Diabetic: 22 diabetic and nondiabetic subjects
equally into CBCT findings, RFA values, and
Nondiabetic:
2 groups wound‑healing paramater’s were
21
of type 2 taken to assess success rate
diabetic and
nondiabetic
Oates et al., 117 patients 64 NA Nondiabetic: FBS in nondiabetic: Conventional 234 12 7 patients lost to follow‑up
2014 Nondiabetic: <5.9% <100 mg/dl Survival rates at 1 year were 93%,
50 Well 92.6%, and 95% in nondiabetic,
Well controlled well controlled, and poorly
controlled: HbA1c: 6‑8% controlled patients, respectively
47 Poor control Overall implant survival rate was
Singh, et al.: A systematic review of dental implant success outcome in conventional or flapless surgery in patient with type 2 DM

Poorly HbA1c: 94%

controlled : 20 ≥8.1%

Indian Journal of Dental Research | Volume 30 | Issue 4 | July-August 2019

Contd...
 Table 1: Contd...
Authors Number Average age Average HbA1c (%) Blood sugar level Type of Number of Follow‑up Observations
of subjects (years) duration of surgery implants visits
enrolled diabetes (years) placed (months)
Wu DY et al., 248 patients NA NA NA A Conventional 1190 96 Patients with periodontal disease
2011 with type 2 and flapless and diabetes were included
diabetes 0.5% (6 implants) were lost during
first 6 months of healing
Overall survival rate at 1, 5, and
8 years were 98.4%, 95.3%, and
89.2%
Tawil et al., 90 subjects 64.7 NA Well NA Conventional 499 144 Overall survival in diabetic
2008 45 controlled Diabetic: 255 patients was 97.2%
nondiabetic <7% Overall survival rate in nondiabetic
Nondiabetic:
45 type 2 Fairly 244 was 98.8%
diabetes controlled No difference was found
7%‑9% between 2 groups based on HbA1c
levels
Peri‑implant bone loss was found
similar between diabetic and
nondiabetic patients
Scott et al., 35 subjects Nondiabetic: NA Nondiabetic NA Conventional 50 4 I phase
2007 45 HbA1c ‑ <6%

Indian Journal of Dental Research | Volume 30 | Issue 4 | July-August 2019 

10 Nondiabetic: 22 patients
nondiabetic Diabetic: 66 Well 12 Nondiabetic patients ‑ 10 patients
25 type 2 controlled Diabetic: 38 Well glycemic
diabetes HbA1c:
controlled ‑ 9 patients
6%‑8%
Moderately controlled ‑ 3 patients
Moderately
controlled II phase
HbA1c: 13 patients with Type 2 diabetes
8.1%‑10% Well controlled ‑ 1 patient
Poorly Moderately controlled ‑ 9 patients
controlled
Poorly controlled ‑ 3 patients
HbA1c:
>10% Baseline HbA1c level was used
Follow‑up 4 months
Outcome
Implant success (clinical mobility,
peri‑implant radiolucency, pain,
etc.,) ‑ all implants were clinically
Singh, et al.: A systematic review of dental implant success outcome in conventional or flapless surgery in patient with type 2 DM

integrated (100% success rate)

605
Contd...
 Table 1: Contd...

606
Authors Number Average age Average HbA1c (%) Blood sugar level Type of Number of Follow‑up Observations
of subjects (years) duration of surgery implants visits
enrolled diabetes (years) placed (months)
Complications were observed as
2 implant in different patients
had rotational movement at
2 weeks (HbA1c 8.3% at baseline)
1 implant with gingival
inflammation with partially
submerged healing cap after
2 weeks (HbA1c 7.4% at baseline)
Huang et al., 21 patients NA NA Well NA Conventional 53 36 Survival rate was 90.4%
2004 with type 2 glycemic
diabetes controlled
mellitus
Peled et al., 41 type 2 Patients were NA NA According to ADA, Conventional 141 60 Each patient completed a
2003 diabetic divided into fasting plasma questionnaire related to level of
patients two groups glucose level <140 satisfaction and improvement of
according mg/dl and PP function
to age, i.e., <200 mg/dL was Criteria for success were stability in
over 65 years maintained implant and no symptoms of pain,
and under inflammation, purulent discharge,
65 years radiolucency and loss of no>1 mm
bone around the implant in 1 year
Success rate was 97.3% and 94.4%
after 1 and 5 years of follow‑up
No correlation was found between
failed implants and glucose level
Patients with well controlled type 2
diabetes had good success rate
Morris et al., 663 patients NA NA NA NA Conventional 2887 36 2632 (91%) were placed in
2000 with both nondiabetic patients
types of 255 (8.8%) were placed in type 2
diabetes diabetic patients
Type 2 patients have significantly
more failure rate (P=0.020)
Use of antibiotic following implant
surgery resulted in 2.5% survival
in nondiabetic patients and 9.1%
Singh, et al.: A systematic review of dental implant success outcome in conventional or flapless surgery in patient with type 2 DM

improvement in type 2 diabetic

patients

Indian Journal of Dental Research | Volume 30 | Issue 4 | July-August 2019

Contd...
 Table 1: Contd...
Authors Number Average age Average HbA1c (%) Blood sugar level Type of Number of Follow‑up Observations
of subjects (years) duration of surgery implants visits
enrolled diabetes (years) placed (months)
Use of antibiotic before surgery
improved the survival rate by 4.5%
in nondiabetic and 10.5% in type 2
diabetic patients
Use of HA coated implants
improved the survival by 13.2% in
type 2 diabetic patients
Fiorellini et al., 40 diabetic NA NA NA NA Conventional 215 78 Out of these 24 failure occurred
2000 patients within the 1st year of loading
Success rate for maxilla and
mandible were 85.5% and 85.7%,
respectively
Success rate for anterior and
posterior regions were 83.5% and
85.6%, respectively

Indian Journal of Dental Research | Volume 30 | Issue 4 | July-August 2019 

Cumulative survival rate was
85.7% after 6.5 years of follow‑up
Olson et al., 89 type 2 62 8.7 Baseline FBS Conventional 178 101 90% survival rate was observed
2000 diabetic Normal ‑ 32 Mean: 154 mg/dl Significant relationship was found
patients patients between implant length and its
Up to 2% success/failure
above Duration of diabetes affects
normal ‑ 34 implant survival
patients
>2% above
normal ‑ 21
patients
Data missing
for 2 patients
CVD: Cardiovascular diseases, CBCT: Cone‑beam computed tomography, CVD: Cardiovascular diseases, FBS: Fasting blood sugar, RFA: Resonance frequency analysis, HbA1c: Hemoglobin
A1c, NA: Not available, ADA: American Diabetes Association
Singh, et al.: A systematic review of dental implant success outcome in conventional or flapless surgery in patient with type 2 DM

607
 Singh, et al.: A systematic review of dental implant success outcome in conventional or flapless surgery in patient with type 2 DM

implant can be placed safely with similar outcome in Table 2: Survival rate of dental implant placement by
well‑controlled diabetic patient as in healthy individuals,[25] conventional and flapless technique
HbA1c cutoff used to define the diabetic patients as Authors Number of implants Survival rate (%)
well controlled varied from study to study. Thus, the in diabetic patients
HbA1c cutoff value for well‑controlled diabetes of  <7% Conventional Flapless Conventional Flapless
recommended by ADA[6] should be followed universally Eskow et al., 131 ‑ 97.6 ‑
by clinicians and researchers. During follow‑up period, 2016
maintaining good glycemic control will prevent the failure Nobre et al., 352 ‑ 97.2 ‑
of dental implant in diabetic patient; hence, HbA1c should 2016
be monitored along with antidiabetic therapy after the Yadav et al., 40 36 95.2 92.3
surgery. 2016
Erdogan et al., 22 ‑ 95 ‑
Survival rate of dental implant in well controlled, 2015
moderately, or poorly controlled diabetes mellitus Oates et al., 234 ‑ 94 ‑
Survival rate varied from  85.7% to 100%  among the 2014
studies included  [Table  1]. Hundred percent survival rate Tawil et al., 255 ‑ 97.2 ‑
2008
was observed in well‑controlled diabetes, uncontrolled
Scott et al., 38 ‑ 100 ‑
diabetes, and nondiabetic individuals while in a cohort
2007
study survival rate of 92.6%, 95%, and 93% was reported in
Huang et al., 53 ‑ 90.4 ‑
well‑controlled, poorly controlled patients, and nondiabetic 2004
individuals respectively with an overall survival rate Peled et al., 141 ‑ 94.4 ‑
of 94%.[20,21] In patients with well‑controlled diabetes, 2003
survival rate of 94.2% and 90.4% were observed.[14,16] Two Fiorellini et al., 215 ‑ 85.7 ‑
studies compared survival rate among diabetic patients 2000
with nondiabetic patients.[18,26] They found survival rate Olson et al., 178 ‑ 90 ‑
of 95% and 97.2% among diabetic patients as compared 2000
to 100% and 98.8% in nondiabetic individuals. Survival Average mean 150.8 36 94.2 92.3
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, Figure 4: Mean survival rate of dental implants by conventional and flapless
technique
or poorly controlled glycemic index and nondiabetic
individuals.
but data for comparing the two surgical procedures
Survival rate of dental implant in diabetic patients by
were not available.[28] However, the cumulative mean of
conventional and flapless surgical procedure
dental implant survival rate by conventional and flapless
As there was only one study in our search that compared techniques calculated from 11 studies is 94.2% and 92.3%,
the conventional versus flapless type of surgery, while in respectively, as shown in Figure  4. Thus, with this data,
remaining 12 studies conventional technique was used for it can be concluded that the two techniques are similar
dental implant placement, we cannot compare the two types in terms of survival rate. More studies are required to
of techniques [Table 2]. One study opted both techniques for compare conventional and flapless procedures in diabetic
dental implant placement with overall survival rate of 94.3%, patients [Figure 4].

608 Indian Journal of Dental Research | Volume 30 | Issue 4 | July-August 2019

 Singh, et al.: A systematic review of dental implant success outcome in conventional or flapless surgery in patient with type 2 DM
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].
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
Figure 5: Duration of follow-up visit in studies included for the review
Indian Journal of Dental Research | Volume 30 | Issue 4 | July-August 2019 
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
609
 Singh, et al.: A systematic review of dental implant success outcome in conventional or flapless surgery in patient with type 2 DM
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
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.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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