During the past years a rapid progress was seen in the field of three-dimensional analysis using the digital volume tomography (DVT) and computer-based planning in dental implant patients. The resulting increase in accuracy of visualization of the operation field prior to surgery allowed for a reduction in the invasiveness of the intervention by minimization of the amount of flap elevation. Flapless surgery seems to be a new promising technique, which reduced post operative pain and swelling. In a recent minipig study of our group it was shown that flapless surgery results in a significantly increased expression of epithelial adhesion molecules, like laminin or integrin, in the sulcular epithelium. Furthermore, in the supracrestal connective tissue a more dense collagen architecture is detectable. As a consequence the implant seems less prone to infection, which is demonstrated by a reduced amount of inflammatory cells as well as vessels in the supracrestal connective tissue 12 weeks post insertion. However, insertion using the flapless approach also calls for minimally invasive techniques of augmentation. In those cases crestal sinus floor elevation using the osteotome technique as well as endoscopic guidance might provide a new and interesting option.