Flapless and fully guided implant placement has the potential to maximize efficacy outcomes and at the same time to minimize surgical invasiveness. The aim of the current systematic review was to answer the following PICO question: “In adult human subjects undergoing dental implant placement (P), is minimally invasive flapless computer-aided fully guided (either dynamic or static computer-aided implant placement (sCAIP)) (I) superior to flapped conventional (free-handed implant placement (FHIP) or cast-based/drill partially guided implant placement (dPGIP)) surgery (C), in terms of efficacy, patient morbidity, long-term prognosis, and costs (O)?” Randomized clinical trials (RCTs) fulfilling specific inclusion criteria established to answer the PICO question were included. Two review authors independently searched for eligible studies, screened the titles and abstracts, performed full-text analysis, extracted the data from the published reports, and performed the risk of bias assessment. In cases of disagreement, a third review author took the final decision during ad hoc consensus meetings. The study results were summarized using random effects meta-analyses, which were based (wherever possible) on individual patient data (IPD). A total of 10 manuscripts reporting on five RCTs, involving a total of 124 participants and 449 implants, and comparing flapless sCAIP with flapped FHIP/cast-based partially guided implant placement (cPGIP), were included. There was no RCT analyzing flapless dynamic computer-aided implant placement (dCAIP) or flapped dPGIP. Intergroup meta-analyses indicated less depth deviation (difference in means (MD) = −0.28 mm; 95% confidence interval (CI): −0.59 to 0.03; moderate certainty), angular deviation (MD = −3.88 degrees; 95% CI: −7.00 to −0.77; high certainty), coronal (MD = −0.6 mm; 95% CI: −1.21 to 0.01; low certainty) and apical (MD = −0.75 mm; 95% CI: −1.43 to −0.07; moderate certainty) three-dimensional bodily deviations, postoperative pain (MD = −17.09 mm on the visual analogue scale (VAS); 95% CI: −33.38 to −0.80; low certainty), postoperative swelling (MD = −6.59 mm on the VAS; 95% CI: −19.03 to 5.85; very low certainty), intraoperative discomfort (MD = −9.36 mm on the VAS; 95% CI: −17.10 to −1.61) and surgery duration (MD = −24.28 minutes; 95% CI: −28.62 to −19.95) in flapless sCAIP than in flapped FHIP/cPGIP. Despite being more accurate than flapped FHIP/cPGIP, flapless sCAIP still resulted in deviations with respect to the planned position (intragroup meta-analytic means: 0.76 mm in depth, 2.57 degrees in angular, 1.43 mm in coronal, and 1.68 in apical three-dimensional bodily position). Moreover, flapless sCAIP presented a 12% group-specific intraoperative complication rate, resulting in an inability to place the implant with this protocol in 7% of cases. Evidence regarding more clinically relevant outcomes of efficacy (implant survival and success, prosthetically and biologically correct positioning), long-term prognosis, and costs, is currently scarce. When the objective is to guarantee minimal invasiveness at implant placement, clinicians could consider the use of flapless sCAIP. A proper case selection and consideration of a safety margin are, however, suggested.

中文翻译：

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牙种植体植入的微创性：无翻瓣全引导手术的系统评价和荟萃分析

无翻瓣和完全引导的种植体植入有可能最大限度地提高疗效，同时最大限度地减少手术侵入性。当前系统评价的目的是回答以下 PICO 问题：“在接受牙种植体植入 (P) 的成人受试者中，是微创无翻瓣计算机辅助完全引导（动态或静态计算机辅助种植体植入 (sCAIP)） ) (I) 在疗效、患者发病率、长期预后和成本（O）？” 纳入了满足为回答 PICO 问题而制定的特定纳入标准的随机临床试验 (RCT)。两位综述作者独立检索符合条件的研究，筛选标题和摘要，进行全文分析，从已发表的报告中提取数据，并进行偏倚风险评估。如果出现分歧，第三位综述作者在临时共识会议上做出最终决定。研究结果使用随机效应荟萃分析进行总结，该分析（尽可能）基于个体患者数据（IPD）。总共包括 10 份手稿，涉及 5 项随机对照试验，总共涉及 124 名受试者和 449 个种植体，并对无翻瓣 sCAIP 与翻瓣 FHIP/基于石膏的部分引导种植体植入 (cPGIP) 进行了比较。没有随机对照试验分析无翻瓣动态计算机辅助种植体植入 (dCAIP) 或翻瓣 dPGIP。组间荟萃分析表明深度偏差较小（平均值差值 (MD) = -0.28 mm；95% 置信区间 (CI)：-0.59 至 0.03；中等确定性）、角度偏差（MD = -3.88 度；95% CI： -7.00 至 -0.77；高确定性）、冠状（MD = -0.6 mm；95% CI：-1.21 至 0.01；低确定性）和心尖（MD = -0.75 mm；95% CI：-1.43 至 -0.07；中度）确定性）三维身体偏差、术后疼痛（视觉模拟量表（VAS）上的 MD = -17.09 mm；95% CI：-33.38 至 -0.80；低确定性）、术后肿胀（VAS 上的 MD = -6.59 mm） ；95% CI：-19.03 至 5.85；非常低确定性）、术中不适（VAS 上的 MD = -9.36 毫米；95% CI：-17.10 至 -1.61）和手术持续时间（MD = -24.28 分钟；95% CI） ：-28.62 至 -19.95）在无瓣 sCAIP 中比在有瓣 FHIP/cPGIP 中。尽管比翻瓣 FHIP/cPGIP 更准确，但无翻瓣 sCAIP 仍然会导致相对于计划位置的偏差（组内荟萃分析平均值：深度 0.76 毫米，角度 2.57 度，冠状 1.43 毫米，心尖三角 1.68 度）。维度身体位置）。此外，无翻瓣 sCAIP 的特定群体术中并发症发生率为 12%，导致 7% 的病例无法采用该方案放置种植体。有关更多临床相关功效结果的证据（种植体存活和成功、修复体和生物学上的正确定位），目前缺乏长期预后和费用。当目标是保证种植体植入时的微创时，临床医生可以考虑使用无瓣 sCAIP。然而，建议选择适当的案例并考虑安全裕度。