Peri-implant Outcomes with

Laser vs Nanosurface Treatment of Early Loaded

Implant-Retaining Mandibular Overdentures
Salah Hegazy, BDS, MSc, PhD1/Nesreen Elmekawy, BDS, MSc, PhD1/Radwa M. K. Emera, BDS, MSc, PhD2

Purpose: To compare peri-implant changes seen with two early loading protocols for modifying surface
treatment of dental implants—one modifying the collar portion (Laser-Lok implant) and the other modifying
the implant surface (nanosurface-treated implant). Materials and Methods: Thirty-six completely edentulous
patients were chosen for this research. Conventional complete dentures were constructed for all patients.
Two implants were used for each patient corresponding to mandibular canines. The patients were classified
into two groups. Eighteen patients in group 1 received 36 laser-collar–treated implants; 18 patients in group
2 received 36 nanosurface–treated implants. The implants were early loaded 2 weeks after implant insertion.
The peri-implant outcome was evaluated using the following variables: (1) modified Plaque Index, (2) modified
Bleeding Index, (3) probing depth, (4) implant mobility using the Periotest instrument, and (5) marginal bone
loss as recorded at the time of the overdenture insertion and 6 and 12 months after insertion. Results: At all
times of the study, the differences between the groups were not significant with regard to peri-implant tissue
changes around implants. Conclusion: Both the laser collar– and nanosurface–treated dental implants
showed the same peri-implant tissue changes with the early loading protocol. This study found that both early
loading protocols are reliable, with good implant stability. Int J Oral Maxillofac Implants 2016;31:424–430.
doi: 10.11607/jomi.3805

Keywords: implant early loading, mandibular overdentures, peri-implant outcome

T he fixation between dental implant surfaces and

the residual alveolar ridge should be considered
a precondition for the long-range success of implant-
hydroxyapatite plasma spray5 as well as subtractive
methods such as acid etching,6 acid etching associ-
ated with sandblasting using either aluminum oxide
supported prostheses.1 Numerous techniques of or titanium dixode,7 and laser ablation.8–10
surface treatments have been fully considered and Surface characteristics play an important role in
applied to modulate biologic surface properties, there- the osseointegration between the surfaces of the
by improving the mechanism of osseointegration.1,2 implant and the alveolar bone of the host. Coarse-
The evolution of implant surface treatment objec- ness modification of the surface has been shown to
tives includes the improvement of clinical efficiency promote bone-to-implant contact and modulate the
and hastening the healing of bone, thus allowing clinical efficiency of implants. The surface coarseness
early or immediate protocols of loading as well as the with nanometer formatting and chemistry play a role
growth of alveolar bone.1 in the osseointegration between implant surfaces and
As described by Faeda et al,3 the surface character- tissue proteins and cells. The micromechanical features
istics of titanium implants had been altered by addi- affect the secondary integration process. A nanoscale,
tive methods using materials such as titanium4 and textured surface topography augments the energy
of the surfaces, which increases cell-surface adhe-
sion and hastens fibrin binding, matrix proteins, and
1 Associate Professor of Removable Prosthodontics, Faculty of growth and differentiation factors. Nanotopography,
Dentistry, Mansoura University, Mansoura, Egypt.
2 Assistant Professor of Removable Prosthodontics, Faculty of
with cell behavior modulation, affects the cell migra-
Dentistry, Mansoura University, Mansoura, Egypt. tion process and also influences cell proliferation and
differentiation. Thereby, these surfaces confirm the
Correspondence to: Dr Salah A. F. Hegazy, Department of process of osseointegration by expediting wound
Prosthodontics, Faculty of Dentistry, Mansoura University, healing after placement of the implant.11
Mansoura, Egypt. Email: [email protected]
Laser-Lok microchannels are formed by a comput-
©2016 by Quintessence Publishing Co Inc. er-controlled laser ablation technique that innovates

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 Hegazy et al

a series of microgrooved surfaces to optimally cog the

Table 1 Baseline Patient Characteristics
orientation of attached cells. An implant with this collar
has the possibility of attaching to connective tissue. If Laser-Lok NanoTite group
group (n = 18) (n = 18)
attachment is possible, these microgrooved surfaces
Characteristic Mean SD Mean SD
frustrate apical migration of the epithelial attachment
and prevent the loss of crestal bone.12 Age (y) 63.3 5.01 61.9 6.69
A high degree of primary implant stability seems to Sex (M/F) 12/6 12/6
be one of the prerequisites for success in an early or Mandibular bone 21.1 2.12 22.60 2.14
immediate loading procedure. Implant surface proper- height in the canine
region (mm)
ties may play an important part in the success of this
procedure.13 Period of mandibular 8.0 4.4 7.2 3.9
edentulism (y)
The purpose of this research was to compare the
health of peri-implant tissue around implants treated Number of previous 2.9 1.2 3.0 1.4
with a laser surface modification versus those treated mandibular dentures
with a nanosurface modification. SD = standard deviation.

radiograph), mandibular edentulism, and the number

MATERIALS AND METHODS of existing mandibular dentures. The patients were then
earmarked to two groups of equal size (according to
Patient Cohort type of implant surface treatment): Group 1, in which
Thirty-six completely edentulous patients (24 men and 18 patients received 36 laser-collar–treated implants
12 women) were selected for the study. Their age range (Laser-Lok implants, BioHorizons) and Group 2, in which
was from 47 to 78 years, and they were selected from 18 patients received 36 nanosurface–treated implants
the Prosthodontic Department outpatient clinic, Faculty (NanoTite implants, Biomet 3i). Table 1 summarizes the
of Dentistry, Mansoura University, Mansoura, Egypt. The attributes of the patients in every group.
number of patients was chosen according to Elsyad et
al,14 in which they compared the peri-implant outcome Surgical and Prosthetic Procedures
between two groups of implant-retained mandibular For all patients, maxillary and mandibular conventional
overdentures. It was predetermined that a sample size complete dentures were constructed according to the
of 18 patients for each group (anticipated dropout rate: lingualized concept of occlusion. The same surgeon and
20%) was a prerequisite to provide 80% power. A type prosthodontist performed all the surgical and prosthet-
1 error of 0.05, with a difference of 1 mm (standard ic procedures (SH, NE). All laboratory steps were carried
deviation: 0.53 mm) in peri-implant bone loss between out by the same dental technician under the supervi-
groups would be considered statistically significant. sion of the study prosthodontists. A mandibular denture
The inclusion criteria for patient enrollment were: duplicate was constructed with clear acrylic resin and
mandibular edentulism for at least 1 year; type II or III metal radiopaque indication at the anticipated implant
interforaminal edentulous ridge covered by sanitary location to be utilized as a radiographic template that
mucosa according to the classification proposed by was transformed to a surgical template by connect-
Lekholm and Zarb15; good general condition; and class ing metal tubes (of 4.5-mm diameter) at suggested
III to V resorption of the mandible according to Cawood implant sites.
and Howell,16 which is a minimum bone height of All surgeries were accomplished with the admin-
13 mm in the interforaminal area. The exclusion criteria istration of local anesthesia and an antibiotic (2 g of
included the following: systemic diseases contraindicat- amoxicillin 1 hour before surgery). An incision on the
ing implant surgery, metabolic bone disease, smoking crest of the mandible was done amid the mental foram-
habits, and previous tumors or irradiation at the head ina. The mucoperiosteum was elevated, and the bone
and neck region. The study protocol and objectives was softly drilled to plan osteotomy positions for the
were explained to all participants before obtaining inserts. Each patient received two implants (12 × 4 mm,
signed informed consent. The research was organized Laser-Lok implants in group 1 and NanoTite implants in
according to the principles of the Helsinki Declaration group 2) at the mandibular canine area; the insertion
(2013 version). torques were ≥ 35 Ncm. Integration of the implants was
Patients were randomly allocated to their treatment done by the oral surgeon (according to the manufac-
group by a computerized balanced randomization turer’s recommendation for each implant system), who
to ensure pretreatment comparability of the groups was not blinded to implant types used in each group.
with regard to age, sex, mandibular interforaminal Healing abutments were linked to the implants after
bone height (measured in a preoperative panoramic surgery, and the mucoperiosteal flap was cautiously

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Hegazy et al

Fig 1  Locator abutments were torqued Fig 2   The metal housings with attached Fig 3  Maxillary complete denture and
into the implants. black processing inserts were fixed intra- mandibular overdenture were inserted
orally to the fitting surface of mandibular intraorally.
denture.

adapted around the abutments by interrupted sutures. 2. Modified Bleeding Index (MBI): Bleeding
The old dentures were fitted to the abutment with tis- was specified on probing as stated by the
sue-conditioning material. A soft diet was prescribed modifications of Mombelli and Lang18 from the
to the patients, who were also instructed to wash with first procedure of Loe and Silness19 and ranked
0.12% chlorhexidine mouthwash three times per day from 0 to 3 as follows: 0 = no bleeding when
for 2 weeks. periodontal probe is passed along the gingival
Two weeks after implant placement, locator abut- margin adjacent to the implant, 1 = isolated
ments were torqued to 30 Ncm as described by Payne bleeding spots visible, 2 = blood forms a confluent
et al17 for early loading (Fig 1). The new mandibular red line on margin, 3 = heavy bleeding.
dentures were relieved opposite the locator attachment 3. Peri-implant probing depth (PD): This was
sites. The metal housings with black processing inserts measured along the border of the gingival margin
were attached intraorally to the mandibular denture and tip of the graduated plastic periodontal probe
intaglio surface with autopolymerized acrylic resin dur- (Vivacare TPS Probe, Ivoclar Vivadent). It was
ing function (Fig 2). After complete curing of the acrylic assessed to the nearest 0.5 mm.
resin, the denture was removed, and the transforming 4. Implant mobility: The Periotest instrument
inserts were discarded. The surplus acrylic resin was (Siemens) was used to evaluate implant mobility
cleared, and the denture was completed before the at the implant placement time and in subsequent
definitive plastic male inserts were used according to visits using the Periotest value (PTV).20,21 The
the required retention. All prosthetic steps for the two measurements were made at the abutment
groups were completed by the same prosthodontist, level with the rod held perpendicular to the
who was not blinded. After delivery of the maxillary longitudinal axis of the implants. Measurements
complete denture and mandibular implant overdenture were taken until two duplicate values were
(Fig 3), patients were instructed in the plaque control registered. The PTV scale ranged from –8 to
protocol, which was reinforced during ensuing reviews +50. The smaller the value level, the higher
(every 3 months). the stability/damping impact of the measured
implant. All readings ranged from –8 to 9, which
Peri-implant Outcome Measures means zero mobility.
The following implant-related outcomes were recorded, 5. Marginal bone loss (MBL): Periapical calibrated
at the time of the overdenture insertion (T0) and at digital radiographs were obtained to determine
6 (T6) and 12 (T12) months after insertion: the changes of the marginal bone level after
loading. The long screw of the impression coping
1. Modified Plaque Index (MPI): The existence of was used to fix the film holder (Rinn XCP, Dentsply
plaque was estimated by the MPI, and ranked Rinn) in the internal hex of the implants after
from 0 to 3 as follows: 0 = plaque not detected, locator abutments were removed. This was done
1 = plaque observed only by a probe running for the standardization of radiographic film
over the smooth marginal surface of the implant, placement in relation to the radiation during
2 = plaque is visible unaided, 3 = amplitude of subsequent film exposures.14 The bone margin
soft tissue. level around implants was assessed by image

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 Hegazy et al

Table 2 Comparison of Plaque Scores, Bleeding Scores, and Probing Depths Between Groups
at Different Observation Times
Group/Time T0 T6 T12 P
Plaque scores
Group 1/M (Min–Max) 0.00 (0.00–0.00) 1.00 (0.00–0.200) 1.00 (0.00–1.00) .004*
Group 2/M (Min–Max) 0.00 (0.00–0.00) 1.00 (0.00–2.00) 1.00 (0.00–2.00) .006*
Mann-Whitney test (P) 1.00 .76 .54
Bleeding scores
Group 1/M (Min–Max) 1.00 (1.00–3.00) 0.00 (0.00–1.00) 0.00 (0.00–0.00) .00*
Group 2/M (Min–Max) 1.00 (0.00–2.00) 0.00(0.00–1.00) 0.00 (0.00–0.00) .00*
Mann-Whitney test (P) .65 .54 1.00
Probing depth
Group 1/ M (Min–Max) 1.00 (0.5–1.5) 2.5 (1.5–3.00) 2.4 (1.00–3.00) .002*
Group 2/M (Min–Max) 1.00 (0.5–1.5) 2.3 (1.5–3.00) 2.3 (1.00–3.00) .001*
Mann-Whitney test (P) .44 .58 .69
T0 = At the time of overdenture insertion; T6 = 6 months after overdenture insertion; T12 = 12 months after overdenture insertion; Group
1 = Laser-Lok group; Group 2 = NanoTite group; M = median, min = minimum; max = maximum.
*Significant at .05 with the Friedman test.

analysis software (Autocad 2006, version Z 54.10, RESULTS

Autodesk), which compensated for radiographic
magnification.22 The distance measured from the The analysis could not be carried out for two patients
implant neck (point A) to the most coronal point in group 1 who were unable to regularly attend the
where the bone seemed to be in contact with the evaluation process because of severe illness. Another
implant (point B) indicated the bone level (Fig patient in the same group was unavailable for follow-
4). Calculation of MBL was done by subtracting up. In group 2, one patient died after 6 months, and
congruent bone levels around the implant at T0, analysis could not be completed for two patients who
from bone levels around the implant at T6 and moved from the area. Thus, 30 patients (15 in every
T12. MBL was measured in millimeters at the group) were available for the evaluation (dropout rate,
mesial and distal surface of every implant (the 16%). No implant failure occurred throughout the
mean values were used in the statistical analysis). study period; therefore, the 1-year implant survival
rate was 100% in the two groups. A comparison of pre-
Statistical Analysis treatment variables listed in Table 1 found insignificant
Recorded data were analyzed with SPSS version differences between both groups.
18 (SPSS). The Shapiro-Wilk test was used to determine Descriptive statistics of MPI, MBL, and PD for group
the normal distribution of data. Nonparametric data 1 (Laser-Lok implants) and group 2 (NanoTite implants)
(MPI, MBL, and PD) were presented using median val- at different observation times are presented in Table
ues (minimum to maximum), whereas parametric data 2. MPI, MBL, and PD increased significantly in both
(PTV and MBL) were demonstrated as mean ± standard groups over time (Freidman test, P < .05; Table 2).
deviation. For nonparametric data, the Mann-Whitney Multiple comparisons (Wilcoxon signed rank test) of
test was used to compare the groups, the Friedman test MPI, MBL, and PD between two observation periods
was utilized to compare data at the various observa- for each group are represented in Table 3. At all obser-
tion periods within the group, and the Wilcoxon signed vation times (T0, T6, and T12), the changes in MPI,
rank test was utilized to compare two observation MBL, and PD between both groups were insignificant
periods within the same group. For parametric data, (Mann-Whitney test, P > .05; Table 2).
the authors utilized the independent t test for com- Figure 5 represents the mean PTVs for the two groups
parison between both groups, a general linear model at various observation periods. Multivariate analysis
(multivariate analysis) to compare various follow-up with reiterated measures demonstrated a significant
periods in the group itself, and the paired sample t test difference in PTVs at different observation times; the
to compare follow-up observation periods within the PTV decreased significantly with the progression of
group itself. P was considered to be significant at .05 or time (P = .001). Multiple comparisons of PTV (paired
less, using 95% confidence intervals. sample t test) between two observation periods for each

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Hegazy et al

Table 3 Multiple Comparisons of Plaque Scores, Bleeding Scores,

and Probing Depths Between Different Observation Times
for Each Group D C
A
T0–T6 T0–T12 T6–T12
Plaque scores B B
Group 1 0.011* 0.008* 0.37
Group 2 0.014* 0.014* 1.00
Bleeding scores
Group 1 0.57 0.004* 0.15
Group 2 0.72 0.006* 0.31
Probing depth
Group 1 0.008* 0.012* 0.67 Fig 4  The distance was mea-
sured from the implant neck
Group 2 0.005* 0.011* 0.76
(point A) to the most coronal point
T0 = at time of overdenture insertion, T6 = 6 months after overdenture insertion, T12 = 12 months where the bone appeared to be
after overdenture insertion; Group 1 = Laser-Lok group; Group 2 = NanoTite group. in contact with the implant (point
*P value is significant at .05; all P values were determined using the Wilcoxon signed rank test. B). Points C and D represent the
crest of the ridge.

Table 4 Multiple Comparisons of Implant Mobility and Marginal Bone

Loss Between Different Observation Times for Each Group
T0–T6 T0–T12 T6–T12
Implant mobility
Group 1 0.048* 0.015* 0.047*
Group 2 0.049* 0.022* 0.018*
Marginal bone loss
Group 1 – – 0.00*
Group 2 – – 0.00*
T0 = at the time of overdenture insertion; T6 = 6 months after overdenture insertion; T12 = 12
months after overdenture insertion; Group 1 = Laser-Lok group; Group 2 = NanoTite group;
– = no measurements of marginal bone loss were taken at this point in the study.
*P value is significant at .05; all P values were determined using the paired sample t test.

group are given in Table 4. Differences in PTV between the implant surface. The roughness and composition
the groups at the different observation times were of the implant surface represent an important part in
not statistically significant (independent sample t test, osseointegration and in implant-tissue interaction.
P > .05; Fig 5). Several methods of surface manipulation have aimed
Figure 6 shows the mean MBL for both groups to enhance the osseointegration of dental implants.
at various observation periods. The MBL was sig- The results of the present study show that the
nificantly higher at T12 (group 1, 1.45 ± 0.31; group 2, differences between laser collar– and nanosurface–
1.51 ± 0.34) compared with T6 (group 1, 1.19 ± 0.17; treated implants were statistically insignificant with
group 2, 1.26 ± 0.20) for both groups (paired sample t test, regard to the criteria of PD, MBI, mobility of the dental
P = .00; Table 4). There was an insignificant difference implants, and MBL at different observation periods of
in MBL between the two groups at various observation the study.
periods (independent sample t test, P > .05; Fig 6). This indicates that although the surface treatment
The amount of bone loss observed was consistent used for enhancing the collar portion of the Laser-Lok
with peri-implant tissue stability observed at 12 months, implant is different from that used for modifying the
and the bone loss did not cause any implant mobility. surface of the nanosurface–treated implant, both
of these treatments had similar results in this early
loading protocol.
DISCUSSION This finding is in agreement with that of Men-
donça et al,23 who stated that the dental implant
The osseointegration quality and rate of dental nanofeatures are able to be coordinated in a system-
implants are interconnected to the characteristics of atic (isotropic) or unsystematic (anisotropic) manner,

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 Hegazy et al

Laser-collar­–treated implants Laser-collar–treated implants

Nanosurface-treated implants Nanosurface-treated implants
0.00

1.45 ± 0.31

1.51 ± 0.34
2.00

–3.89 ± 0.44

–3.71 ± 0.21

–4.33 ± 0.67

–4.13 ± 0.52

–4.58 ± 0.61

–4.37 ± 0.60
–1.00

1.19 ± 0.17

1.26 ± 0.20
1.80
–2.00
1.60
–3.00
PTV

1.40

MBL
–4.00
1.20
–5.00
1.00
P = .26 P = .47 P = .45
–6.00
0.80 P = .42 P = .69
T0 T6 T12
T6 T12
Observation
Error bars: 95% CI Observation

Fig 5   Comparison of Periotest values (PTVs) between groups at Fig 6   Comparison of marginal bone loss (MBL) between groups
different observation times. Data are mean ± standard deviation at different observation times. Data are mean ± standard devia-
values. *Independent sample t test. CI = confidence interval; T0 tion values. *Independent sample t test. CI = confidence inter-
= at the time of overdenture insertion; T6 = 6 months after over- val; T6 = 6 months after overdenture insertion; T12 = 12 months
denture insertion; T12 = 12 months after overdenture insertion. after overdenture insertion.

usually depending on the method of manufacture. Laser-Lok microchannels include a succession of

The dental implant topographies are usually charac- cell-sized circumferential channels of 0.7 μm, which
teristically anisotropic. Isotropic characteristics, such are produced by laser ablation technology, to form
as nanogrooves or nanopits, are produced by optical an implant surface with microchannels that are opti-
methods that cannot be used with screw-shaped mally sized to fasten and organize the fibroblasts
dental implants. together with osteoblasts. Also, repeating nanostruc-
When these concepts are applied, the implant tures increase the implant surface area and permit
surface is embellished with features of nanometer- collagen microfibrils to interdigitate to the implant
scale, which causes new physicochemical behavior surface treated by the laser. The Laser-Lok surface has
or biochemical events. to be effective for soft tissue attachment.24
The NanoTite implant incorporates the complex Furthermore, Laser-Lok surface treatment showed
architecture at the nanoscale, thus forming a bone- a tissue reaction that implicates the suppression of
bonding surface. Bone bonding is achieved by increas- epithelial downgrowth and the engagement of con-
ing the complexity of the surface topography by adding nective tissue (unlike Sharpey fibers).12,26 This attach-
nanoscale calcium phosphate crystals by a discrete ment achieves osseointegration around the implant
crystalline deposition process on the osseotite dual that reserves and preserves crestal bone health. The
acid–etched surface, which is established at a submi- Laser-Lok experience has been demonstrated in post-
cron scale. The crystal deposits are approximately 20 to market research to be more helpful in reducing bone
100 nm, and the shear strength of crystal attachments loss than other implant designs.27–30
to the osseotite surface exceeds the minimum shear Locator attachments provide dual retention for
strength value of 34.5 MPa. The nanoscale discrete mandibular overdentures. They display great durability
crystalline deposition process increases by 200%.24 and long-lasting effectiveness for more than 60,000
This nanotopography has many benefits: (1) it insertion cycles; also, they require low maintenance.31
reduces the healing time in half; (2) it improves The locator implant overdenture is indicated when
osseointegration; and (3) the dental implant surface the ridge is adequate and the prosthesis will be primar-
increased by 40% compared with the dental implant ily tissue borne with the implants providing retention.
surface treated by acid etching with microtomogra- The locator system revealed better soft tissue scores
phy. The implant surface with 560-nm nanonodules because sanitary maintenance is easier, thus decreas-
produces 3.1 times more osseointegration than the ing the possibility of chronic inflammation around
acid-etched implant surface.25 implants, which may affect peri-implant changes.32

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Hegazy et al

CONCLUSIONS 14. Elsyad MA, Al-Mahdy YF, Fouad MM. Marginal bone loss adjacent
to conventional and immediate loaded two implants supporting a
ball-retained mandibular overdenture: A 3-year randomized clinical
Both laser collar– and nanosurface–treated dental trial. Clin Oral Implants Res 2012;23:496–503.
implants showed the same peri-implant tissue changes 15. Lekholm U, Zarb GA. Patient selection and preparation. In: Bråne-
in this early loading protocol. Both types were found to mark PI, Zarb GA, Albrektsson T (eds). Tissue Integrated Prostheses:
Osseointegration in Clinical Dentistry. Chicago: Quintessence,
be reliable, with good implant stability. 1985:199–210.
16. Cawood JI, Howell RA. A classification of the edentulous jaws. Int J
Oral Maxillofac Surg 1988;17:232–236.
17. Payne AG, Tawse-Smith A, Thompson WM, Kumara R. Early func-
ACKNOWLEDGMENTS tional loading of unsplinted roughened surface implants with
mandibular overdentures 2 weeks after surgery. Clin Implant Dent
The authors reported no conflicts of interest related to this study. Relat Res 2003;5:143–153.
18. Mombelli A, Lang NP. The diagnosis and treatment of peri-implanti-
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19. Loe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and
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