Quality and quantity of soft tissues can be maintained and protected by implement- ing proper flap design during the surgical procedure. Proper technique will offer different advantages while imposing some restrictions. Dentists need to make a sound decision on which design to apply to achieve the desired goals of a specific procedure. Flap design plays an essential role in providing proper access while maintaining the soft tissues’ integrity. This will result in proper outcomes both aes- thetically and functionally.
Any flap design should fulfill the basic flap requirement and provide the following [42]:
1. Optimal visualization.
2. Problem-free expansion of the soft tissues.
3. Mobilization of the overlying soft tissue to cover the surgical field.
4. No placement over bony defects or cavities.
5. Sufficient vascularization of soft tissue.
6. Minimum esthetic impairment and good tissue covering.
Regardless of the flap design, the healing process will result in scaring forma- tion, which impacts esthetic and functional outcomes. Blood supply in the surgical area must be maintained at a sufficient level during different surgical stages. Kleinheinz et al. in 2005 described the proper incisions during flap reflection to minimize blood supply interruption at the surgical site in order to prevent complica- tions, as shown in Fig. 4.10a–c. An avascular mid-crestal incision seems to be the ideal choice in the edentulous area and to restrict the application of a vertical releas- ing incision to the anterior end of the flap. Blood vessels run from the posterior to anterior area. Positioning the vertical incision anteriorly will prevent blood supply interruption. A trapezoid flap should be avoided if adequate access can be achieved by anterior vertical releasing incision only. The color of gingival tissues depends on the blood vessels and tissues’ keratinization; less keratinization and more blood ves- sels will yield more red color and vice versa [43].
During the surgical phase, implants can be placed utilizing either the flapped or flapless surgical approach. A flapped technique provides a better soft tissue emer- gence profile as it allows the surgeon to place the soft tissue in the proper desired contour [44]. A flapless technique is a minimally invasive approach that helps main- tain blood supply and avoid interruption of blood flow to the surgical site while providing limited access to the surgical site. The flapped technique provides better visibility through a full-thickness mucoperiosteal flap. The full-thickness flap helps protect and identify anatomical landmarks [45] with the disadvantage of causing blood supply interruption to the surgical field. Blood supply interruption will lead to crestal bone resorption and some long-term esthetic and functional complications. The flapped technique is still the approach of choice in case bone augmentation is indicated to compensate for hard tissue deficiencies.
Flap Technique
Figure 4.11 shows a patient with missing tooth #26. Due to the inadequacy of interdental space shown in Fig. 4.11, the patient has undergone orthodontic treatment to provide enough space for proper implant-supported crown restoration to prevent space loss. 
After completing the course of orthodontic treatment, as shown in Figs. 4.12 and 4.13, the patient presented to pursue implant placement. A treatment plan was developed with immediate loading of the implant as a space maintainer to guard against space loss. In addition, this approach allows the patient not to use a retainer after orthodontic treatment. Implementing the Kleinheinz flap design as shown in Fig. 4.14, an implant was placed with hard tissue augmentation and immediate load- ing in the same surgical session (Figs. 4.15, 4.16, 4.17, 4.18, and 4.19). Five-year follow-up evaluation (Figs. 4.20 and 4.21) show stable functional and esthetic out- comes, both clinically and radiographically.
Flapless Technique
A patient with a missing mandibular anterior dentition presented for implant placement. The treatment consists of replacing missing dentitions with implant-supported fixed partial dentures.
Utilizing the flapless technique provides intact mucoperiosteum, which offers advantages such as less bleeding, less postoperative pain, rapid postoperative heal- ing, and less surgical time [46–48]. Disadvantages include the possibility of hard tissue perforation and/or fenestration due to lack of visibility, which may also cause anatomical landmark threats [49]. The flapless technique should be restricted to cases with anticipated adequate width and height of bone and soft tissues. Figures 4.22, 4.23, 4.24, and 4.25 show extraction of hopeless teeth #22–27 fol- lowed by bone augmentation and implant placement in the area of missing teeth #22 and 27. Figures 4.26 and 4.27 show implant-supported fixed partial dentures replac- ing extracted teeth #22–27.
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