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American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
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American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

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Comparative Evaluation of the Effect of Low Level Laser Therapy Versus No Adjunctive Therapy on Crestal Bone Levels Around Endosseous Intraoral Implants – A Split Mouth Study

Sharma Manek*, Mukherjee Manish, Singh Harjeet, KR Krishnaprasad, SP Saravanan, Rai Rahul

Department of Periodontology, Army Dental Centre, New Delhi, India

Abstract: Aim: To evaluate the role of Low-Level Laser Therapy (LLLT) on the early phases of intraoral endosseous implant healing. Material & Method: It was a randomized split-mouth pilot study. Patients visiting with the chief complaint of missing teeth were asked to participate. The partially edentulous sites were divided into two groups where: Group A: Received no further treatment following endosseous implant (no LLLT/ control group). Group B: Received LLLT therapy immediately following osteotomy before implant placement and then repeated after 48 hrs,7th day, 14th day after placement of implant. (Received LLLT / test group). Results: Crestal bone levels were evaluated at baseline and at 6 months interval using CBCT. From the findings, it can be summarized that statistically significant, differences in crestal bone levels at 6 months post-operatively among the groups was seen with less bone loss around sites which received LLLT. Conclusion: It can be concluded from the study that use of low-level laser did show additional benefits in terms of post-surgical crestal bone level measured at different sites.

Keywords: Low level laser therapy , bone regeneration, crestal bone loss, photobiomodulation

Received November 22, 2024; Revised December 24, 2024; Accepted December 30, 2024

Citation: Sharma Manek, Mukherjee Manish, Singh Harjeet, KR Krishnaprasad, SP Saravanan, Rai Rahul, Comparative Evaluation of the Effect of Low Level Laser Therapy Versus No Adjunctive Therapy on Crestal Bone Levels Around Endosseous Intraoral Implants – A Split Mouth Study. International Journal of Dental Sciences and Research, 13 (1). 1-10. January 2025. doi:10.12691/ijdsr-13-1-1

1. Introduction

LASER is an acronym for ‘Light Amplification by the Stimulated Emission of Radiation’ [1]. It was first introduced in dentistry by Ralph H. Stern and Reidar Sognnaes in 1965, who used a ruby laser. However, it could not be successfully utilized in clinical scenarios due to undesirable and uncontrolled increase in tissue temperature. The first successful application of lasers was reported by Terry Myers in 1989 [2].

Since then, laser technology has benefited most dental specialties, including operative dentistry, implantology, periodontics, paediatric dentistry, and oral surgery [1]. The absorption characteristics of the irradiated tissue play a major role in determining how the laser beam affects the target tissue. The tissue optics and biomolecule absorption spectra determine how well laser irradiation can influence the target molecules. The temperature rises as a result of this energy transfer. Four potential interactions between a laser's energy and a target tissue are possible: reflection, transmission, scattering, and absorption. Depending on the amount of water in the tissues, light energy absorption results in photochemical reactions [1].

Low Level Laser Therapy

Low level laser therapy (LLLT) is defined as treatment that uses lasers that have low enough energy outputs so that the temperature of the tissue being treated does not rise above normal body temperature (36.5° C). The effects are biostimulatory in nature [3]. The precise mechanism of the biostimulation is believed to be attributed to the respiratory chain enzymes, or cytochromes, within mitochondria or endogenous porphyrins in the cell that act as the energy absorbing chromophores. Respiratory chain enzymes form high energy phosphate bonds in ATP that are used to drive cell metabolism [4].

Laser biostimulation is known to induce osteogenesis and aid in bone healing. It has been successfully used to improve healing post-extraction and bone fractures and to accelerate orthodontic tooth movement. The stimulating impact of biostimulation on bone is connected to proliferation of fibroblasts and osteoblasts during mesenchymal development. Studies have shown that biostimulation may improve bone collagen fiber density. Increased tissue vascularization releases mediators, which stimulate bone matrix production and expedite bone healing. Thus, it is possible to use laser biostimulation and bone metabolism to enhance osseointegration of dental implants in low-density bones [5].

Few studies have evaluated effect of laser biostimulation effects on crestal bone levels around endosseous intraoral implants but with inconclusive results and explanation. There is a need to evaluate the effects of low-level laser therapy on crestal bone levels around endosseous implants taking radiological parameters.

1.2. Aim

The primary purpose of this study was to evaluate the role of Low Level Laser Therapy on the early phases of intraoral endosseous implant healing.

1.3. Objectives

To evaluate crestal bone level around endosseous implants that followed Low Level Laser treatment after implant placement.

To evaluate crestal bone level around endosseous implants that received no further adjunctive treatment.

2. Material and Methods

2.1. Clinical Data

The study was conducted on patients visiting the central out-patient department of Army Dental Centre (Research & Referral), Army Hospital, Delhi Cantonment. The ethical clearance was obtained from the institutional review board of the Army Dental Centre prior to the start of the study. Sample size was kept as 10 patients (20 surgical sites) as this being a pilot study. The present study was a randomized split mouth study. Subjects visiting the department of Periodontology with a chief complaint of missing teeth were asked to participate in the present study based on the inclusion and exclusion criteria.

2.2. Inclusion and Exclusion Criteria

The patients were included if they met the following criteria:

• Subjects of 20-60 yrs age group

• Subjects requiring dental implants to restore missing dentition with adequate bone height and width apical to the alveolus to ensure implant stability.

• Split mouth edentulous space in maxilla/mandible indicated for implant placement.

• Patients willing for recall visits.

Exclusion criteria:

• Implant site that was previously grafted.

• Presence of uncontrolled diabetes mellitus, immune diseases, or other systemic conditions contraindicating the procedure

• Parafunctional habits

• Smoking

• Poor oral hygiene

• Insufficient bone volume

2.3. Sample Size Randomization

According to the criteria enumerated above, 10 patients were recruited for the study. Each recruited patient was explained about the surgical procedure and possible discomforts, risks and complications. Patients were informed of their participation in a randomized trial, about the study design and schedule in detail. Informed consent was obtained from the patients who participated in the study. The partially edentulous sites will be divided into two groups where:

• Group A: Received no further treatment following endosseous implant (no Low Level Laser Therapy/ control group)

• Group B: Receive Low Level Laser Therapy immediately following osteotomy prior to implant placement and then repeated after 48 hrs,7th day, 14th day after placement of implant. (Received Low Level Laser Therapy / test group)

Randomization was carried out by the flip of a coin for both the sites selected as well as the procedure. A detailed history, clinical examination, haematological investigations and CBCT analysis were carried out prior to the surgical procedure. Upper and lower jaw impressions were made, and casts prepared. Patients with adequate ridge form and shape were subjected for a CBCT (NewTom). A detailed space analysis was done based on the data obtained by CBCT and crestal bone levels were measured.

2.4. Surgical Procedure

The procedure was carried out using aseptic techniques under local anesthesia. The patient was asked to rinse the mouth with 15ml of 0.12% chlorhexidine solution for 1 minute and spit out the solution. Once the subjective signs of local anesthesia were confirmed, mid-crestal incisions along with adjacent sulcular incisions were made at the implant recipient site and a mucoperiosteal flap was elevated (Figure 9 and Figure 1). After evaluating the ridge clinically and correlating it with CBCT scans, sequential osteotomy sites were prepared (Figure 1) with copious saline irrigation. LLLT was given using a 980 nm diode laser with 400 microns fiber diameter and 0.5 Watt power at 6 sites adjacent to osteotomy (Figure 1) in noncontact mode for the duration of 9 sec per site dissipating a total of 35 J of energy. LLLT was again given using the same protocol after 48 hrs, 7th day, and 14th day after placement of the implant. The application points were divided into six points in the regions in the immediate vicinity of the surgical site. Flaps were sutured using 4-0 black silk interrupted sutures (Figure 1). All patients were prescribed a similar set of post-operative instructions and analgesics. Sutures were removed after 1 week (Figure 1) and patients were recalled after 48 hrs, 7th post-operative day and 14th post-operative day for low-level laser application. Thereafter subjects were recalled once in two months for follow-up. Radiological evaluation using the CBCT software of the crestal bone levels was done at 4 sites ie buccal, lingual/palatal, mesial and distal sites around the implants at baseline immediately following endosseous implant placement and at 24 weeks intervals (Figure 1, Figure 1, Figure 1, and Figure 2). The platform of the implant served as the reference point to assess the crestal bone margin levels.

Figure 1. Layout of trolley for surgery

Figure 2. Physio dispenser

Figure 3. Implant Kit

Figure 4. 980 nm Diode Laser Device

Figure 5. Dental Implants

Figure 6. CBCT Machine

Figure 7. Space evaluation M-D

Figure 8. Intraocclusal space evaluation

Figure 9. Incision design

Figure 10. Flap reflection

Figure 11. Implant placement

Figure 12. LLLT

Figure 13. Suturing

Figure 14. 1 week post operative

Figure 15. Pre operative RVG

Figure 16. After implant placement

Figure 17. Crestal bone levels at baseline Group A

Figure 18. Crestal bone levels after 6 months Group A

Figure 19. Crestal bone levels at baseline GROUP B

Figure 20. Crestal bone level at 6 months Group B

3. Results

The aim of the present study was to evaluate the effects of LLLT on crestal bone levels around endosseous implants taking radiological parameters. All the subjects that received the intended treatment had completed the study protocol and requisite follow-up period. All the study parameters were recorded and tabulated for both groups by a single observer during the course of the study. The data obtained was statistically analyzed using SYSTAT 13 software, USA. Paired t-test, unpaired t-test and post-hoc analysis using Bonferroni correction was done so as to minimize Type-I errors.

Table 1. Demographic data

Table 1 depicts demographic data of 10 subjects that include age, gender, and sites selected, that were randomly divided into two groups viz group A & group B. There were 6 males and 4 females in the study group with age range of 28 to 56 years. 9 patients presented with bilaterally missing mandibular first molars and 1 patient with bilaterally missing maxillary first molar. The test and control sites were divided by the toss of a coin.

Table 2. Crestal bone levels in Group A (Conventional) at baseline & 6 months

Crestal bone levels were evaluated from mesial, distal, buccal, and lingual/ palatal sites at baseline and 6 months postoperatively (Table 2, Table 3, Table 4). The statistical significance was measured at p < 0.05.

Table 3. Crestal bone levels in Group B (test) at baseline & 6 months

The mean difference of crestal bone levels between mesial surface Group A at Baseline and at 6 months was found to be statistically significant (t=-8.397; p=0.00). The mean difference of crestal bone levels between distal surface group A at Baseline and at 6 months was found to be statistically significant (t=-6.474; p=0.00). The mean difference of crestal bone level between buccal surface group A at baseline and at 6 months was found to be statistically significant (t=-7.536; p=0.00). The mean difference of crestal bone level between lingual surface group A at baseline and at 6 months was found to be statistically significant (t=-11.271; p=0.00) Table 5.

Table 4. Mean Crestal bone levels in both groups at baseline & 6 months

Table 5. Intragroup comparison (Group B) of difference of mean at baseline and at 6 months at various sites

In Group B while comparing mean crestal bone levels at baseline (0.32) and 6 months (1.190) for mesial surface, the difference was found to be statistically significant (t=-11.221; p=0.00) Graph 1. While comparing mean crestal bone levels at baseline (0.30) and 6 months (1.190) for distal surface, the difference was found to be statistically significant (t=-15.706; p=0.00). [Graph 2] While comparing mean crestal bone levels at baseline (0.39) and 6 months (1.030) for buccal surface in Group B, the difference was found to be statistically significant (t=-14.154; p=0.00) [Graph 3]. While comparing mean crestal bone levels at baseline (0.39) and 6 months (1.090) for lingual surface in Group B, the difference was found to be statistically significant (t=-12.550; p=0.00) Table 6, Graph 4.

Table 6. Intragroup comparison (Group A) of difference of mean at baseline and at 6 months at various site

An intergroup analysis for crestal bone loss was also done using unpaired t test. While comparing mean crestal bone levels for Gp A and Gp B at baseline, the mean difference was found to be statistically non-significant (t= 1.222 and p value of 0.253) Table 7, Table 8 & Graph 5.

Table 7. Inter group mean at baseline

While comparing mean crestal bone levels for Gp A and Gp B at 6 months, the mean difference was found to be statistically significant (t= 2.851 and p value of 0.019) Table 8, Table 9 & Graph 6.

Table 8. Inter group mean difference at baseline

From the findings in the present study, it can be summarized that statistically significant crestal bone loss at 6 months post-operatively among the groups is seen. These findings warrant further studies with a large sample size and with a longer study duration to investigate the effect of low-level laser therapy on crestal bone loss after placement of implant.

Table 9. Mean of both the groups at 6 months

Table 10. Difference of means of both groups at 6 months

Graph 1. Intra Group comparison of baseline and 6 months at distal site in group B

Graph 2. Intra Group comparison of baseline and 6 months at mesial site in group B

Graph 3. Intra Group comparison of baseline and 6 months at buccal site in group B

Graph 4. Intra Group comparison of baseline and 6 months at buccal site in group B

Graph 5. Unpaired T-Test between GR-A & GR-B at baseline (µ VALUE)

Graph 6. Unpaired T-test between GR-A & GR-B at 06 months (µ Value)

4. Discussion

The long-term endurance and durability of dental implants are highly reliant on the integration between implant surface and oral tissues. Preservation of bone support around the dental implant predicts their long-term clinical success. As per Albrektsson’s criteria for successful implants, the crestal bone remodeling should be less than 2.0 mm in the first year after implant placement and less than 0.2mm each year thereafter [6].

The use of LLLT has been proposed as an approach for accelerating and improving the bone tissue healing process. LASER light irradiation has been used in the medical field with great success because of its biostimulatory effects. LASER has conducive effects on wound healing, fibroblast proliferation, and collagen synthesis. Moreover, LLLT shows an increase in mitochondrial respiration and adenosine triphosphate (ATP) synthesis. Bone irradiated mainly with infrared wavelengths shows improved osteoblastic proliferation, collagen deposition, and new bone formation when compared to non-irradiated bone [7].

Early crestal bone loss depends mainly on the trauma caused due to surgery during the placement of implant which includes excessive reflection of the periosteal flaps, prolonged exposure of the osteotomy site to the external environment and due to more pressure applied on the bone during the placement of implant. [8] Considering this, the implant placement was done as atraumatically as possible in all the subjects. Continuous efforts have been made to reduce the peri-implant crestal bone loss [8].

Cochran et al demonstrated that clinically significant remodeling of the marginal bone will take place resulting in bone level alterations during the first 6 months after implant placement. During this time, the remodeling may be affected by several other important events, such as the preparation of the implant osteotomy site, resulting in the interruption of the vascular supply, suture removal, placement of the provisional restoration, and during placement of the final prosthesis which will result in the disruption of the peri-implant tissues and periosteum, resulting in a net crestal bone loss where osteoclastic activity outweighs the osteoblastic activity [9]. Enkling et al and various other researchers have also proved that significant bone remodeling and crestal bone level alteration occur during the first few months [10]. Similarly, the early longitudinal studies of Adell et al. established that the majority of bone loss occurred during the healing and remodeling periods or within the first year of loading; very little bone loss occurs thereafter [11]. Albrektsson et al. proposed that an acceptable criterion for implant success was a mean crestal bone loss of less than 1.6 mm during the first post-surgical year. They also suggested a maintenance phase yearly crestal bone loss of 0.05mm to 0.13mm [6].

In our study we too found statistically significant difference on all surfaces of crestal bone in both the groups which shows crestal bone loss. Our findings are comparable to those of Block et al, who put 22 implants, of which 3 were implanted immediately after the excision of a single-rooted tooth with a human mineralized cancellous bone complement and the rest were placed in tooth sockets maintained with an allograft (human mineralized cancellous bone). The radiological measurements at 4 months after the implant placement revealed an average bone loss of 0.51 ± 0.41 mm at the mesial level and 0.48 ± 0.53 mm at the distal level [12].

LLLT also known as laser photo biostimulation, is a kind of phototherapy that employs monochromatic and coherent light to promote healing. LLLT may be seen as a useful adjuvant for promoting early healing. LLLT has been proven to control inflammation, promote cell proliferation, and improve bone repair [13]. This study endeavoured to evaluate and compare Low-Level Laser Therapy's efficacy on the amount of crestal bone loss around dental implants. Group A's treatment comprised osteotomy site without irradiation with LLLT preparation and Group B comprises irradiation with low-level laser after osteotomy site preparation.

The irradiations performed with 980 nm diode laser in the present study were based on the positive effects of LLLT on alveolar bone sockets at the level of deeper as well as superficial tissue as demonstrated by Park and Kang. Histological observations and gene expression analyses revealed that 980 nm diode laser irradiations resulted in a reduction of inflammatory cells and accelerated bone regeneration with the proliferation of fibroblasts and osteoblasts [14].

In reference to table and graphs at the time of implant placement, radiographic marginal bone level around implants was similar between the two groups. Following a healing period of 6 months, the crestal bone loss was statistically significant between the two implant groups , and the clinical data suggested that less crestal bone resorption had occurred around irradiated implants.

Lopes et al [18] through Raman spectroscopy also showed a significant difference in the concentration of calcium hydroxyapatite in irradiated group as compared to control group. Mandic et al using a split-mouth design, too achieved higher stability of irradiated implants than nonirradiated ones in 12 patients. However, the outcomes indicated that the difference was not significant until the fifth postoperative week, similar to the results seen in our study [15].

Exposure time and intensity in the current study were in accordance with a systematic review by Prados-Frutos et al that reported stronger biomodulatory effects with exposure timing ranging from 30 to 120 seconds [16]. In the present study, an overall exposure time of approximately 54 seconds was divided across six application sites to 09 seconds for each site. Four LLLT sessions were administered with first irradiation therapy applied directly on bone immediately following osteotomy and then on the mucosa at subsequent time points after implant placement. The laser hand piece was held close to the implant site and greater penetration depth of near infrared laser prevented reflection of the laser energy irradiated into the tissues. Furthermore, irradiations were performed during first 2 weeks following osteotomy. According to Gerbi et al [17] and Pinheiro et al [18] the effects of LLLT are more pronounced during the early stages of bone healing and not detec Table 3 days after osteotomy. It can be attributed to the fact that during the early stages of bone healing, the cellular component is more prominent and more prone to be affected by LLLT. There were few limitations in the study as well. No long term follow up was done and no evaluation of effects of implant loading is mentioned.

Although the results obtained in the present study are encouraging a multicentre study with a larger sample size and longer follow-up is warranted to validate the results obtained in the present study. Further exploration of this technology by employing different implant systems and characteristics, different bone conditions, different LLLT parameters, and different lengths of follow-up period would be of great value.

5. Conclusion

To conclude, with-in limitations of this study, the application of low-level laser irradiation around dental implants reduced the crestal bone resorption during the early phases of bone regeneration. The low energy density combined with 0.5 W powers using a 980 nm diode laser has reported favourable outcomes in the present study. The results concluded a more enhanced crestal bone level in the irradiated group, emphasizing the effects of photobiomodulation. However, further research evaluating crestal bone levels involving larger sample size for longer duration are required to better study the effects of LLLT on crestal bone levels around implants.

Conflict of Interest

The authors report there are no conflict of interests.

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