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Systematic Review Paper
Dental Implants
Is flapless implant surgerya viable option in posteriormaxilla?
A reviewN.Doan, Z. Du, R. Crawford, P. Reher, Y. Xiao: Is flapless
implant surgery a viableoptionin posteriormaxilla?A review. Int.J.
OralMaxillofac.Surg. 2012;41:10641071.# 2012 International
Association of Oral and Maxillofacial Surgeons. Published
byElsevier Ltd. All rights reserved.
N. Doan1, Z. Du1,2, R. Crawford1,P. Reher3, Y. Xiao1
1Institute of Health and BiomedicalInnovation, Queensland
University ofTechnology, Brisbane, Australia; 2School andHospital
of Stomatology, Fujian MedicalUniversity, Fuzhou, China; 3School
ofDentistry and Oral Health, Griffith University,Gold Coast,
Australia
Abstract. This article reviews the literature on the outcome of
flapless surgery fordental implants in the posterior maxilla. The
literature search was carried out inusing the keywords: flapless,
dental implants and maxilla. A hand search andMedline search were
carried out on studiespublishedbetween 1971 and 2011. Theauthors
included research involving a minimum of 15 dental implants with a
follow-up period of 1 year, an outcome measurement of implant
survival, but excludedstudies involving multiple simultaneous
interventions, and studies with missingdata. The Cochrane approach
for cohort studies and Oxford Centre for Evidence-Based Medicine
were applied. Of the 56publishedpapers selected, 14papers on
theflapless technique showed high overall implant survival rates.
The prospectivestudies yielded 97.01% (95% CI: 90.7299.0) while
retrospective studies or caseseries illustrated 95.08% (95% CI:
91.097.93) survival. The average ofintraoperative complications was
6.55% using the flapless procedure. The limiteddata obtained showed
that flapless surgery in posterior maxilla areas could be aviable
and predictable treatment method for implant placement. Flapless
surgerytends to be more applicable in this area of the mouth.
Further long-term clinicalcontrolled studies are needed.
Key words: dental implants; flapless surgery;complications;
maxilla; survival; success; effi-cacy; effectiveness; guided
surgery; review.
Accepted for publication 8 June 2012Available online 9 July
2012
The introduction of osseointegration in1977 by Branemark et al.1
revolutionizedoral rehabilitation in partially and fullyedentulous
patients. This concept wasbased on the utilization of a
mucoperios-teal flap. The flap was designed for thevisualization of
underlying bone byreflecting the alveolar crest soft tissuefor
placement and closure with sutureon completion of theprocedure.
This con-cept implies that implants should be cov-ered by soft
tissue to warrant primarystabilization and decrease infection as
a
standard of care. For many practitioners,the flap technique has
remained the main-stay of implant surgery as it allows
bettervisualization, particularly in areas ofinadequate bone
quantity, and it permitsthe manipulation of soft tissue in
aestheticregions. Despite their popularity, flaptechniques have
disadvantages includinggingival recession,bone resorption
aroundnatural teeth,2,3 soft tissue deficiency fromflap raising,
and negative implant aestheticoutcomes, especially in the anterior
max-illa.4
Over the last three decades, there havebeen many modifications
to implant flapdesign, including the flapless surgicaltechnique. In
contrast to the flap techni-que, implant flapless surgery does
notrequire reflection of a mucoperiosteal flapwhile perforating the
alveolar mucosa andbone. Therefore, flapless surgery gener-ates
less postoperative bleeding, less dis-comfort for the patient,
surgery time isshorter, and healing time is reduced. Thepatients
heal with minor, or no, swel-ling.5,6 The flapless technique uses
rotary
Int. J. Oral Maxillofac. Surg. 2012; 41:
10641071http://dx.doi.org/10.1016/j.ijom.2012.06.002, available
online at http://www.sciencedirect.com
0901-5027/0901064+ 08 $36.00/0 # 2012 International Association
of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All
rights reserved.
http://dx.doi.org/10.1016/j.ijom.2012.06.002http://dx.doi.org/10.1016/j.ijom.2012.06.002http://dx.doi.org/10.1016/j.ijom.2012.06.002http://dx.doi.org/10.1016/j.ijom.2012.06.002http://dx.doi.org/10.1016/j.ijom.2012.06.002
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burs or a tissue punch to gain access tobone without flap
elevation, so the vascu-lar supply and surrounding soft tissue
arewellpreserved. The flapless technique hasbeen well established
in immediate extrac-tion and site preservation with
minimalcomplication.7 With the advance of flap-less surgery, the
traditional flap method is
being challenged because it is being per-ceived as
unnecessary.Traditionally, flapless surgery has been
regarded as having multiple limitationssuch as: poor control of
precise drillingdepth due to difficulty in observing thedrilling
direction of the alveolar bone;inability to preserve keratinized
gingivawith a tissue punch perforation; and poorability to assess
the implant point of entrydue to the lack of direct vision of
therecipient bone. Therefore, it is difficult tocorrect
intraoperative peri-implant defects.This implies that flapless
surgery is mainly
used
for
cases
where
there
is
sufficientquantity and quality of bone, as well as adecent
quantity of keratinized gingiva.8
Maxilla posterior areas can satisfy theseflapless surgery
requirements.Reviewing publications on animal stu-
dies aids understanding of flapless surgeryandhelps to improve
theflapless technique.For example, the biological width
long-itudinal dimension at the buccal aspectwere higher in the flap
group than in theflapless group in minipigs9; flapless sur-gical
implantation into freshly extractedsockets did not aid in the
avoidance of
alveolar bone
resorption
and
had
no
influ-ence in the dimensional differences of thealveolar process
after tooth extraction incontrasted to the traditional
implantplace-ment using mucoperiosteal flaps10; andflapless implant
surgery can be utilizedfor the placement dental implants, andthe
application of a tissue punch larger thanthe diameter of the
implants is not recom-mended, as it can endanger the result of
theimplantation process.11
The posterior maxilla is defined as theback part of the upper
jaw, anteriorlyboundedby the upper canine teeth,poster-iorly by the
maxillary tuberosities,bucallyby buccal mucosa and medially by
thepalate. The supporting alveolar bone inthis area is usually wide
enough forimplant placement, particularly in themolar
region.Following tooth loss, resorption has
been shown to adhere to a predictablepattern: the alveolar
labial aspect of theridge is the main site of resorption,
whichdiminishes first in width then in height.1214 The posterior
maxilla has differentanatomy and bone quality, and
distinctivebuccal andpalatal resorptionpatterns.12,15
When the maxillabecomes edentulous, itsshape changes according
to the extent ofresorption. The cortical bone in the max-illa
becomes thinner and more porousposteriorly in an agedpopulation.16
Usingcomputed tomography, trabecular bonedensity varies markedly
with potentialimplant site in the anterior
(516 132 Hounsfield units, HU) andposterior (332 136 HU)
regions, whichmay compromise the clinical outcome ofdental implants
in the posterior maxilla.Fuh et al.17 indicated that female
maxillaeshowed a smaller amount and a lowerdensity of cancellous
bone than male max-illae.The literature reveals limited and
con-
flicting information concerning dentalimplant treatment in poor
quality boneof the posterior maxilla. Although thereis a slightly
lower osseointegration suc-cess rate, poor quality bone is not
an
absolute
contraindication
for
dentalimplant treatment.1821 The anatomicaland structural
features of the posteriormaxilla, such aspoor quality and
quantitybone due to its proximity to the maxillarysinus, may
compromise the clinical out-come of dental implants.In recent
years, the advance of three
dimensional (3D) dental imaging, particu-larly cone beam
computed tomography(CBCT), and the associated planning soft-ware,
used in conjunction with computergenerated surgical guides, has
allowedmore efficient results when using flapless
techniques.
This
has
turned
flapless
implantsurgery into a predictable procedure withhigh success
rates if patients are appropri-ately selected and an appropriate
width ofbone is available for implant placement.2,22
These studies mainly focus on anteriorareas, in order to improve
aesthetic results,to shorten in surgery time, and to
decreasemorbidity after surgery. Few studies focuson the posterior
areas, especially posteriormaxilla areas. There are some benefits
forflapless surgery in this area, including: lessaesthetic demand;
bone resorption patternresulting in wider width and less
undercut;and minimal concern about nerve damage.Therefore, flapless
surgery appears to havemore applications in the posterior
maxillathan in anyother area.Thedifficulties in theposteriormaxilla
are: lessbone density; thepositionof thesinus;and thedifficult
accessto the mouth. The posterior maxilla hasbeen described as the
most difficult andproblematic intraoral area confronting theimplant
practitioner, which may influencethe results of flapless
surgery.This article reviews the contemporary
literature relating to the outcome (effi-ciency and
effectiveness) and surgical
challenges of flapless dental implant sur-gery in theposterior
maxilla and indicatesthat flapless implant surgery is an
accep-table technique in the posterior maxilla.
Materials and methods
A search for English publications was
carried out using Medline to search dentaljournals from 1971 to
2011. Major dentalimplant journals covering oral and max-illofacial
surgery, dental implant,prostho-dontics, and periodontics, for a
similarperiod, were searched by hand to findrelevant references.
The reference searchwas conducted using a mixture of thefollowing
keywords: dental implants,flapless surgery, complications,
maxilla,survival, success, efficacy, effectiveness,guided surgery,
review.Clinicalhuman studies published inEng-
lish in the last 40 years between 1971 and
2011 obtained
through
the
Medline
or
thehand search were categorized by studytypes (case
report,preclinical, cohort, con-trol clinical trial, review and
meta-analy-sis), and subjects (human versus animal).This review
includedonly human studies ofthe posterior maxilla with 15 or
moreimplants; expert and clinical opinion pub-lications were
excluded. In order to applythe best available evidence gained from
thescientific method to clinical decision mak-ing, the Oxford
Centre for Evidence-BasedMedicine4 was used to weigh the level
ofevidence in clinical studies.
In this
review,
conventional
implantsurgery refers to flap surgical techniquesthat require
elevation of a mucoperiostealflap for thepurpose of implant surgery
andimplant placement. Flapless implant sur-gery is defined as a
surgical techniqueutilized toprepare the implant drilling sitefor
surgicalplacement of the implant with-out the need to raise a
mucoperiosteal flap.The information was organized into a
system of comparison in a table formatsimilar to that
suggestedby Brodala4 con-taining type of study, number of
partici-pants, dropouts, follow-up time, mean age,implant case,
outcomes (survival), com-plications and failures. It was assumed
thatthese patients had no adverse medicalconditions.
Statistical data management
The data retrieved from the selectedpaperswas managed according
to the followingmethods. The mean values of the survivalrates were
case weighted to have an evendistribution. Ideally, one would limit
thesample to studies that use KaplanMeiermethods to estimate
survival and include
Flapless implant surgery in posterior maxilla 1065
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the results of the few studies that meet thenew inclusion
criteria.Owing to the limitednumber of publications available,
retro-spective studies were included in thereview. To improve the
validity of thesestudies, Oxford Centre for Evidence-BasedMedicines
2001 classification of levels ofevidence were used. The studies
were orga-
nized, reported, and stratifiedby the levelsof evidence.
Results
Medline search results
The Medline search found 56 articles, 19were deemed to meet the
inclusion cri-teria. Of these, five systemic reviews wereexcluded
as they did not involve clinicalstudies (Fig. 1). Using Oxford
Centre forEvidence-Based Medicines 2001 classi-fication, of the 14
remaining papers(Tables 13), six were level 2prospectivecohort
studies, five were retrospective, onewas a non-randomized trial,
and therewere two case studies (level 4) that looked
1066 Doan et al.
Medline search (Pubmed)
through database(n=56)
Records excluded according
to the criteria
(n = 37)
Full-text articles
assessed for eligibility(n = 19) Full-text articles
excluded,
with no clinical data
(n = 5)
Number of studies
included after screening
(n = 14)
Full papers included in
this study(n = 14)
Articles via hand-searched
journals relative to dental
implant(n=0)
Fig. 1. Flowchart of article selection for review.
Table 1. Demographics of studies.
No. Authors
Study designand OxfordEvidencebased level
No. ofPatients
No.dropouts
Remainingimplantsafter
dropouts
No. ofterminalevents
Agerange(years)
Meanage
(years)
Follow-upperiod(months)
Successrate (%)
Meansurvivalrate (%)
1 Rocci et al.5 Prospectivecohort (level 2)
46 0 97 9 2477 51 36 91(prostheticload)94
(splint)
90.72
2 Becker et al.23 Prospectivecohort (level 2)
57 0 79 1 2486 NR 24 98.7 98.7
3 van Steenbergheet al.8
Prospectivecohort (level 2)
27 3 164 NR 3489 63 12 NR NR
4 Fortin et al.24 Prospectivecomparativecohort (level 2)
60 0 152 NR 1982 NR 6 days NR NR
5 Cannizzaro et al.25 Prospectivecohort (level 2)
35 0 202 2 3970 56.6 12 99 99
6 Malo et al.26 Prospectivecohort (level 2)
23 0 92 0 NR NR 21 98 (max)97(Md)
98
7 Campelo andCamara27
Retrospectivestudy (level 4)
377 18 770 37 2783 54.7 60 (1) 97.4(2) 100
95.25
8 Sanna et al.28 Retrospective
study (level 4)30 4 183 9 3874 56 36 98.9 (non-
smoker)81.2(smoker)
91.5
9 Sennerby et al.29 Retrospectivestudy (level 4)
43 0 117 6 NR 50 18 94.87 94.87
10 Katsoulis et al.30 Retrospectivestudy (level 4)
28 0 112 NR NR NR NR NR NR
11 Pomares Puig31 Retrospectivestudy (level 4)
195 0 194 4 3584 59.5 12 07.95 97.95
12 Oh et al.32 Non randomizedtrial (level 4)
24 0 24 NR 2572 45 6 NR NR
13 Merli et al.33 Case series(level 4)
13 0 89 5 NR NR 8 NR NR
14 Ozan et al.34 Case series
(level 4)5 0 14 1 NR NR 14 98.3 98.3
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at implant success and survival rate andother clinical
variables. Of these, 10 wereshort-term studies (6 days) that
evaluatedintraoperative complications such as mor-bidity and
comfort (level 2). The onlylong-term clinical study (level 2) was
aretrospective cohort study. The most com-mon features encountered
in these studieswere the use of guided surgical techniquesduring
the course of their treatment plan-
ning. The differences in study designswere either treatment in a
single locationor multiple locations in the maxilla.
Implant survival rate
Life time analysis was calculated usingKaplanMeier methods to
estimate survi-val.37 The obtained survival data werethen case
weighed. In a long term study
of implant outcomes27 of 778patients and2040 implants over a
mean studyperiod of19 months, the results indicated a fairlyhigh
survival rate. Theprospective studiesyielded 97.01% (95% CI:
90.7299.0)while retrospective or case series evalua-tion showed
95.08% survival (95% CI:91.097.93). These results illustrated
clin-ical efficacy with prospective studies andclinical
effectiveness, respectively.
Flapless implant surgery in posterior maxilla 1067
Table 2. Study types and results.
No. Authors
No.singletooth
Partialedentulism
Completeedentulism
Maxillaand
implants
Mandibleand
implants Result I Result II
1 Becker et al.23 NR NR NR 47 32 No significant changes in PD,BI
from 1 to 6.5 months
Bone loss = 0.07 mmdetected by X-rays was notsignificant
2 Campelo and
Camara27
NR NR NR 282 488 Overall implant failure: 37
(4.8%) over 10 years
Analgesics were not used:
90%3 Cannizzaro et al.25 0 0 33 33 0 Reported pain: none
slight
(79%), moderate severe(21%)
Swelling post surgically:none slight (58%),moderate severe
42%
4 Fortin et al.24 NR NR NR NR NR Reported pain (VAS):significant
less and of shorterPain duration found inflapless group,
significant lessuse of analgesics with flaplesstechnique
NR
5 Malo et al.35,36 0 0 23 18 5 Overall implantsurvival = 98%;
maxilla97%; mandible 100%
Bone loss detected by X-rays = 1.9 mm at 12 mo
6 Oh et al.32 24 0 0 24 0 Tendency for Papillary Index(PPI) to
increase over 6months
No differences in ML, PD,mPI, mBI, WKM
7 Ozan et al.34 NR NR NR Yes Yes Total of 5 out of 5
implantssurvived at average 9 months
NR
8 Rocci et al.5 27 70 0 97 0 Implant cumulative survivalrate:
91% at 36 months
9 Sanna et al.28 0 0 30 26 4 Bone loss detected by X-raysat 4
years: 2.64 mm smokers;1.3 mm nonsmokers
Implant cumulative survivalrate 91.5% over 66 months
10 Sennerby et al.29 18 99 0 45 72 53% of implants had > 2
mmradiographic bone loss at;>3 mm radiographic boneloss at 37%
implants
NR
11 van Steenbergheet al.
80 0 27 27 0 Bone loss 1.2 mm detectedby
X-rays at 12 monthsNR
12 Pomares Puig31 0 0 30 128 67 4 implants out of 195 failed in3
patients during the healing
period:
2
in
the
maxilla
and
2in the mandible. 3 of themwere replaced successfully
After 1 year of loading, therewere no dropouts and no
failure
of
the
definitiveprosthesis 12
13 Katsouliset al.30 0 0 40 184 0 28 patients (70%)
withsufficientbone and 4 implantseach (112 implants); 12patients
each have 6 implants(72 implants)
6 had insufficient bone toplace any implant and 6 havecombined
sufficient bone andinsufficient bone
14 Merli et al.31 0 0 28 112 0 13 consecutive patients
withatrophic maxillae weretreated with 89 implants (68implants per
patient)
5 implants failed in 4patients.1 patient dropped out. 8months
after loading, allprostheses were successful.11 out of 12patients
reportedtheir quality of life andlifestyle had improved
PD =probing depth; BI =bleeding index; ML = attachment level,
mPI = modified plaque index; mBI = modified bleeding index; AUC =
area
under curve; WKM = width of keratinized mucosa; NR = not
reported (modified from Brodala4).
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1068 Doan et al.
Table 3. Complication and failures.
No. of complications
No. AuthorsIntraoperativecomplication
Postoperativecomplication
No. offailedimplants Biological Technical Aesthetics
1 Becker et al.23 NR NR 1 0 NR NR2 Campelo and Camara27
36perforation (21
fenestrations
15deshisences)
NR 37 NR NR NR
3 Cannizzaro et al.25 1 perforation 1treatment aborted
NR 2 5 (no. ofintermittentpain = 1,hyperplastictissue = 1,
peri-implantmucositis = 1,peri-implant peri-implantitis =
2);all
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Three studies30,31,33 used flaplessmethod in conjunction with
navigated sur-gical protocols, and the authors reportedsurvival
rates ranging from 87.3% to97.8%. The authors concluded that
thenavigated surgical technique might notbe appropriate for all
types of bone mor-phology, but could be a viable and pre-
dictable treatment modality. Somecomplications arose during
treatment, sothe technique could be sensitive to theoperators
experience and a learning curveis required.
Post-surgical trauma discomfort
The level of intraoperative flapless surgi-cal trauma was found
to be mini-mal.26,35,36 In the majority of thesestudies objective
short-term evaluationof postoperative complications were
verylimited or often omitted. One study was a
comparative
prospective
non-randomizedpilot study25 of patients morbidity (suchas pain
and facial swelling) from 1 to 7days postoperatively using a visual
analo-gue scale (VAS) following either a flap orflapless surgical
technique. The authorsused 3D imaging to plan the proceduresand
questionnaires were used to recordfeedback. All patients in the
study hadan edentulous maxilla and each receivedsix implants. The
authors found that theflapless surgery decreased the level
ofpainand postoperative swelling significantly(p
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implants. Upper posterior implants weregrouped under the heading
of maxilla andimplants, and only two studies31,35,36 illu-strated
the success rates between maxillaand mandible (Table 2). Thus the
overallresults of implants placed in the posteriormaxilla using the
flapless technique are notclearly defined in these selected
studies.
One major limitation in thispaper is thatthe flapless surgical
procedures forimplant placement were used in variousclinical
settings. Even though there werereports on the use of navigation
and 3Dguided surgery in standard surgicalproce-dures, there was no
clear indication on theuse of a surgical stent or guide.Correct
application of flapless surgery
can help to lessen the morbidity and oper-ating time,
especially, in the posteriormaxilla. With inadequate planning
andimproper placement, flapless surgeryusually results in
unsatisfactory outcomes
due
to
inappropriate
implant
position.
Theimplant clinician should use measures thatreduce
complications in flapless surgeryincluding the use of advanced 3D
dentalimaging such as CBCT and the associatedplanning software,
used in conjunctionwith computer generated surgical guides.These
have allowed better pre-treatmentplanning for flapless techniques
making itmore efficient and avoiding hidden unfa-vourable
anatomical and pathological pit-falls. This has made flapless
implantsurgery a predictable procedure with highsuccess rates
provided patients are
selected
appropriately
and
an
appropriatebone quantity and quality is available forimplant
placement.20,19 Thorough treat-ment planning and operator
experienceare important in reducing complications.As with any new
technological advance,
theuser has to go through a studyperiod toperfect the
technology. This usually bringsan understanding of nuances that
must becomprehended to reduce complications.For instance, there
isadanger inmisreadingCT information or incorrectly placing
sur-gical stents in implant surgery, which cancause irretrievable
damage. It is importantthat the implantologist should understandall
the aspects of the new technology, anduseit at abasic stage prior
to advancing intocomplex scenarios such as guided implantplacement.
The implant practitioner shouldbe diligent, adaptable, and cautious
withnew techniques and technology, to safe-guard against unforeseen
complications inimplant dentistry.During the compilation of this
review,
consideration was given to authorbias andother sources of bias
(such as conflicts ofinterest) in the selected studies. TheCochrane
review approach was used for
the appraisal of the validity of studiesinvolved. This paper
stressed the possibi-lity ofbias in their outcomes, inparticularthe
chance that they will overestimate orunderestimate the actual
interventionpower. Furthermore, the authors wereaware of
study-specific matters that maycause concern about thepossibility
ofbias,
and attempted to express judgementsabout these. Several tools
are availablefor evaluating the procedural value ofclinical trial
studies. The utilization ofmeasures producing a summary score isnot
recommended. Instead, this studyemployed the Cochrane
Collaborationrecommended specific tool for assessingthe risk of
bias in each included study.This comprises ajudgement and a
supportfor the finding for each entry in a risk ofbias table, where
each entry addresses aspecific feature of the study. The judge-ment
for each item encompasses evaluat-
ing
the
risk
of
bias
as
low
risk,
highrisk, or unclear risk, with the lattergroup representing
deficiency of data ordoubt over the potential for bias. Forexample,
the prosthetic implant loadingprotocols differed vastly in the 14
studies,as loading couldbe immediate, delayed, orconventional.
Taking into account theseissues, in conjunction with additional
con-founding factors, it implies that the out-come of any
particular procedure is not100% clear or has unclear risk. This
meansthat it is best to consider the above men-tioned factors prior
to extrapolating any
clinical
outcomes.
In
order
to
evaluate
thevalues of the flapless approach correctly,the researcher
would require more studiesof comparable loading procedures
thatfairly relate conventional approach tothe flapless technique.In
conclusion, the current data obtained
from posterior maxilla areas showed thatflapless surgery could
be a viable andpredictable treatment method for implantplacement,
indicating efficacy and clinicaleffectiveness. The available
short-termand long-term results reported in thisreview illustrate
that the flapless approach,initially endorsed for inexperienced
clin-icians, requires extra skill andpre-surgicalpreparation than
initially thought. Theflapless approach requires greater knowl-edge
and skill than the conventional sur-gical techniques. In the light
of modernadvancements in digital imaging and com-puter guided
surgery, the above require-ment is no longer mandatory.
Cautionshould be exercised in using flapless sur-gery to minimize
complications and mis-haps. This implies that the
implantpractitioners must be willing to learnand adapt to new
technology.
Being diligent and cautious with newtechnique and technology
aremeasures thatcould help to safeguard against
unwantedcomplications in flapless implant surgery,including those
implantsplaced in thepos-terior maxilla. The application of
flaplessimplant surgical technique in everyday pro-cedure should be
limited to experienced
surgeons, and it is not endorsed for inex-perienced
clinicians.
Funding
ITI Foundation for the dental implantproject.
Competing interests
There is no conflict of interest. Theprojectis purely scientific
and there is no com-mercial interest.
Ethical approval
Human Ethical Committee, QueenslandUniversity of Technology and
FujianMedical University
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Address:Yin XiaoInstitute ofHealth
andBiomedicalInnovationQueensland University of TechnologyKelvin
Grove CampusBrisbaneQld 4059AustraliaTel: +61 7 3138 6240; Fax: +61
7 3138 6030E-mail: [email protected]
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