|Year : 2020 | Volume
| Issue : 3 | Page : 131-140
Impact of photobiomodulation on the osseointegration around dental implants in fresh extraction socket: a 1-year split-mouth clinical trial
Yasser M El Makaky1, Emad F Essa2, Rafic R Pedar2, Ayman M El Makaky BDS, MSc, PhD 3
1 Department of Oral Medicine and Periodontology, Faculty of Dentistry, Tanta University, Tanta, Egypt
2 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tanta University, Tanta, Egypt
3 Department of Physical Therapy for Surgery, Faculty of Physical Therapy, South Valley University, Qena, Egypt
|Date of Submission||16-Feb-2020|
|Date of Acceptance||03-Mar-2020|
|Date of Web Publication||30-Oct-2020|
Ayman M El Makaky
Department of Oral Medicine and Periodontology, Faculty of Dentistry, Tanta University, Tanta 43353
Source of Support: None, Conflict of Interest: None
Low-level laser therapy (LLLT) is a noninvasive technique that stimulates osteoblastic activity and enhances tissue healing. The goal of this trial was to assess the efficacy of LLLT on the osseointegration of implants placed on fresh extraction sockets.
Patients and methods
A 1-year split-mouth controlled clinical study was conducted on 40 dental implants inserted immediately in 20 patients. Implants were randomly divided into two groups. Eight sessions of LLLT (a 660 nm aluminum gallium indium phosphide) were used to irradiate the test group implants during the first 2 weeks. A similar process was done for the control group implants using a laser headpiece that was adjusted in 'off' mode. Osseointegration was assessed by recording implant stability in addition to clinical and radiographical evaluations.
The statistical tests showed that there were no significant differences in the mean values of the primary outcome (implant stability measured by Periotest) between the test and control implants over time. Besides, no significant differences were observed between the study groups regarding the secondary outcomes which include marginal bone loss, probing depth, gingival index, modified plaque index, bleeding index, and pain on visual analog scale.
LLLT using a 660 nm aluminum gallium indium phosphide laser during the first 2 weeks following the immediate implantation in posterior mandible regions expressed no statistically significant impact on the osseointegration.
Keywords: fresh extraction sockets, implant stability, low-level laser, osseointegration
|How to cite this article:|
El Makaky YM, Essa EF, Pedar RR, El Makaky AM. Impact of photobiomodulation on the osseointegration around dental implants in fresh extraction socket: a 1-year split-mouth clinical trial. Tanta Dent J 2020;17:131-40
|How to cite this URL:|
El Makaky YM, Essa EF, Pedar RR, El Makaky AM. Impact of photobiomodulation on the osseointegration around dental implants in fresh extraction socket: a 1-year split-mouth clinical trial. Tanta Dent J [serial online] 2020 [cited 2020 Nov 27];17:131-40. Available from: http://www.tmj.eg.net/text.asp?2020/17/3/131/299636
| Introduction|| |
The use of dental implants represents a successful option for the rehabilitation of missing dentition. According to the preliminary protocols, the healing time after insertion of screw-type implants takes 3–4 months which prolongs to 5–6 months in areas having more cancellous bone such as posterior mandible and maxilla.
In view of the advances in techniques, designs, and materials of dental implants, patients desire treatment plans with fewer surgical procedures and shorter recovery time. Dental implantation in a fresh extracted socket allows the utilizing of the remaining bone, removes a surgical step, considered as a conservative approach plus other advantages including satisfactory aesthetic outcomes as wished by the patients, and reduction of overall treatment time before insertion of final rehabilitation.
The prognosis of dental implants be based on successful osseointegration, and many attempts have used to increase this procedure, one of these was the exposure to low-level laser (LLL). Low-level laser therapy (LLLT) is a noninvasive adjunctive treatment modality that utilizes light-emitting diodes or low-power (low-level) lasers and is known to increase bone healing. Clinically, LLL has been used for the treatment of many conditions based primarily on its capability to stimulate molecular and biochemical processes that take place during tissue repair, resulting in increased collagen synthesis and enhancement of epithelial and fibroblast proliferation, which can increase the healing procedure. Moreover, its impacts are associated with normalization of hormone function, restoration of nerve function following trauma, increased possibility of bone repair and remodeling, regulation of the immunity, attenuation of pain, and decreasing of inflammation and edema [6–9].
The main prerequisite for implant loading is to obtain adequate primary stability of implant at the time of placement. While, the time of implant loading and the time it can resist masticatory forces were determined by its secondary stability. In dentistry, the experimental studies have been found a positive impact of LLL on bone healing and osseointegration,, and in cases of rehabilitation using implant-supported prostheses to increase the osseointegration process, this adjuvant treatment tool has become a well-accepted. However, clinical trials on its influence on implant stability and osseointegration are limited,,,. Therefore, the aim of this study was to evaluate the effect of photobiomodulation (PBM) on osseointegration of immediately placed implants clinically and radiographically.
| Patients and Methods|| |
Patients and study design
A prospective, controlled, and randomized clinical study with 12 months follow-up period was planned. Patients in this trial were selected from Tanta University, Faculty of Dentistry between February 2017 and March 2018. All participants signed informed consent compatible with the Declaration of Helsinki and were aware of study objectives, surgical procedures and were instructed about the follow-up evaluations, postoperative care, and alternative treatment choices obtainable to them.
Using split-mouth technique, a total number of 40 implants (IMPLA System; Schutz Dental, Rosbach, Germany) were immediately placed bilaterally in the posterior mandible of the 20 patients who were referred to the Department of Oral and Maxillofacial Surgery with proper indications. In this clinical study, two dental implants with a length of 13–14.5 mm and a diameter of 4.5–5.3 mm were inserted immediately following the extraction of hopeless teeth in each patient. Indications for tooth extraction included tooth fracture and endodontic treatment failure. Implants were allocated randomly into two parallel groups with allocation ratio 1:1; a test group (consisted of 20 fresh sockets were implanted immediately with an endosseous implant and treated with LLL) or control group (included 20 immediately placed dental implants without LLL treatment) using computer-generated random numbers. A convenient sampling technique was applied (i.e. selection of those who fit the inclusion criteria).
The patients were selected in this trial under the subsequent inclusion criteria: bilateral hopeless mandibular molars; age 18 years or older; the presence of four-bony wall sockets at the implant sites; adequate amount of bone width (≥8.0 mm), and height (≥14.5 mm over the mandibular canal) at implant sites; nodehiscence or fenestrations in sockets wall; healthy individuals with no systemic diseases; no signs of acute infection at implant sites; cooperative patients with good oral hygiene; nonsmokers; no history of craniofacial radiotherapy; healthy periodontium; no history of bisphosphonate medication; nor history of chemotherapy.
- Thorough medical and dental history was gathered for each patient
- A detailed intra and extraoral examinations were performed for all patients
- Each participant was examined with a panoramic radiography, diagnostic casts and cone-beam computed tomographic scans to assess the anatomic conditions
- Profound scaling and root planning were done for all eligible patients
- All patients were instructed to take Augmentin (Amoxicillin 875 mg and clavulanic potassium 125 mg; GlaxoSmithKline, Cairo, Egypt) 1 g tablet one hour before immediate implantation and continues for 7 days twice daily (no one in this trial was sensitive to Penicillin), Chlorhexidine Gluconate 0.12% mouth rinse (Peridex oral rinse, 3 M; ESPE, Saint Paul, Minnesota, USA) 1 minute preoperative and then two times daily for 2 weeks, and Ibuprofen 400 mg tablet (Brufen 400 mg tablet; Mylan Products Ltd, Potters Bar, Herts, UK) 3–4 times daily when needed.
Following administering local anesthesia via the Inferior alveolar nerve block technique using 2%Mepivacaine hydrochloride with 1:20000 Levonordefrin (Alexandria Co. for Pharmaceuticals and Chemical Industries; Alexandria, Egypt), a horizontal Intrasulcular incision was done to displace a full- thickness buccal mucoperiosteal flap. The teeth to be extracted ( first molar/second molar) as shown in [Figure 1] were sectioned for atraumatic extraction, then the extraction sockets were carefully debrided and irrigated with sterile saline solution to remove residual granulation tissue. Socket walls were examined using a curette to detect any dehiscence or fenestrations and to be sure that the cortical plates were intact after tooth removal. Preparation of implant site was initiated by pilot drill (2 mm) which locate the pathway for fixture insertion with 1200–1500 rpm speed under copious saline irrigation, then a sequentially enlarged series of gradually increasing drills for an implant bed preparation with a diameter ranged between 4.5–5.3 mm and a length of 12–14 mm were carried out according to the manufacturer's instructions as shown in [Figure 2].
The placement torque ranged between 30 and 35 Ncm, the implant was then screwed inside the bone (implant osteotomy) by hand-driven screw and tightened using a ratchet wrench. To obtain primary stability the fixture was inserted at least 3–5 mm apical to the base of socket as shown in [Figure 3]. All implants in both groups were inserted utilizing the non-submerged technique as shown in [Figure 4]. Finally, the healing abutment was screwed as shown in [Figure 5], then the mucoperiosteal flap sutured using 3.0 silk sutures. After implant insertion, they were randomly allocated to either the test group or the control group.
After 7 days, sutures were removed and patients were checked weekly during the first month after surgery then monthly till the end of the study. All participants were given oral hygiene instructions. Patients were instructed to stay away from any forms of mechanical trauma at the implant sites mainly for 1 month after surgery. After three months healing abutment was removed and final abutment was screwed and tightened with 30 Ncm torque as shown in [Figure 6]. Employing transfer technique for impression the final restorations (Porcelain-fused-to-metal) were manufactured and were cemented as shown in [Figure 7]. No temporary prosthesis was made.
It was previously known as LLL. PBM works primarily on cytochrome c oxidase (in mitochondria) which is one of the extremely important chromophores to reduce oxidative stress and increase ATP production. The intracellular downstream influences and a cascade of mitochondrial lead to reduced inflammation and enhanced tissue healing. A 660 nm aluminum gallium indium phosphide (AlGaInP) (Thor Photomedicine Ltd, Chesham, UK) was used by a laser therapist in this study. Laser safety glasses were utilized by both clinician and patients, and all safety measures were followed. The following laser parameters were used; output power of 75 mW, wavelength of 660 nm, 0.245 W/cm2 power density, a spot size of 0.260 cm2, continuous-wave mode, and exposure time of 40 s with energy density (0.980 J/cm2). The laser probe was used in contact mode, gently touching the buccal and lingual tissues at the implant site and was moved in a slow circular shape to guarantee full irradiation of the target area with 5.12 J total energy per se ssion.
PBM therapy was carried out immediately after implant placement then repeated every 2 days for 2 weeks as in [Figure 8]. The implants in the test group were subjected to eight sessions with a total dose of 40.96 J. All dental implants in the control group were exposed to the same irradiation protocol and laser safety measures carried out on those in the test group but with a laser handpiece in 'off' mode.
For each implant in this trial, the following peri-implant parameters were monitored at 3, 6, and 12 months after the immediate implantation by the same periodontist using a graduated plastic probe (UNC 12; Hu-Friedy, Chicago, Illinois, USA) at four sites per each implant; mesial, buccal, distal, and lingual then the arithmetic mean for these values were used for each implant in statistical analysis:
- The probing depth (PD) was measured from peri-implant gingival margin to bottom of the pocket and was assessed to the nearest 0.5 mm
- Gingival index (GI) has been used for assessment of gingival inflammation and it has good reproducibility and sensitivity. Its score ranges from 0 (healthy gingiva) to 3 (severe inflammation)
- Modified plaque index (MPI) was monitored at first visually, and then by a probe with index values range from 0 (no plaque) to 3 (severe plaque accumulation)
- Bleeding index (BI); four sites around each implant were probed and after 15 s the number of bleeding sites was recorded and was divided by the total count of probed sites to obtain BI as a percent.
Intraexaminer calibration was done to compute the standard error of measurement. For PD the intraexaminer variability was ranged from 0.22 to 0.24 mm. Implant failure was evaluated by using the success criteria of Albrektsson et al..
Implant survival and failure: The clinical and radiographic examinations were carried out for all implants in both groups at every follow-up session. All remaining implants were assessed to be survived implants in spite of clinical and radiographic signs. If the fixture was mobile or removed, the implant was recorded as a failure.
Implant success and complications were assessed at 3, 6, and 12 months postimplantation using criteria that were proposed by Buser et al. as follows; no implant mobility, no persistent complaints, no peri-implant radiolucency, no peri-implant inflammation, and an implant is in surgical site.
Visual analog scale (VAS): it was utilized for subjective pain evaluation. All the participants were instructed to assess the pain on each implant separately postoperative and at 1, 3, 5, and 7 days following surgery, using VAS scale as follow; 0 (no pain), 1–3 (low pain), 4–6 (moderate pain), and 7–10 (high pain).
The implants stability was assessed in this trial by a Periotest device (Siemens, Bensheim, Germany) immediately after surgery, 6, and 12 months following implant insertion. It has been recommended by Giovanni and Niklaus to detect the initial implant mobility and measure horizontal displacement. The Periotest value (PTV) depends on a digital scale extend from −8 to +50, the low PTVs readings mean high implant stability.
Radiographic examinations were carried out postoperatively on the day of surgery (baseline), at the delivery of the final restorations at 3 months, and 12 months after the implant insertion. All the radiographs were obtained by using the long cone technique with a custom-made bite block mounted on Rinn system (Dentsply, FriadentSchweiz, Nidau, Switzerland). The linear space between the implant shoulder and the most coronal bone to implant contact was assessed on the distal and mesial sides of each implant as in [Figure 9] and the mean value of these measurements was used in statistical analysis for each implant. This distance was known as marginal bone loss (MBL). Fixture diameter was utilized for internal calibration to permit the actual recording of MBL in millimeters. The differences in MBL between baseline radiographs and final radiographs were utilized for data analysis.
|Figure 9: Baseline of linear space between the implant shoulder and the most coronal bone to implant contact.|
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The assessments of all study outcomes (primary and secondary) were done in a double-blind method since neither researcher (who not participated in PBM treatment) nor patients were knowing of treatment allocation.
Statistical evaluation and study outcomes
The primary outcome in this trial was the changes in implant stability from baseline to 12 months. While the secondary outcomes were the changes in peri-implant parameters, VAS for pain, and MBL at the different follow-up sessions. Numerical data were displayed as the mean and SD. Independent sample t-test was utilized to compare the outcomes between the two groups while repeated measure analysis of variance was done to compare between the three or more readings followed by Bonferroni test to compare between every two readings for statistically significant results, and paired t-test was used to compare outcomes at different two follow-up times intragroup. All statistical tests were performed at a 5% level of significance by mean of a statistical tools package (SPSS version 19; IBM, Armonk, New York, USA).
| Results|| |
Twenty eligible patients (11 females and 9 males) were recruited in this clinical trial. They received a total of 40 immediate implants that were inserted bilaterally into posterior mandibular regions with a 1-year total follow-up period. During this observation interval, all the implants and their prostheses were stable with no prosthodontic or biologic complications as assessed by a radiographic and clinical examination at each follow-up session. Regarding success criteria of Albrektsson et al., and Buser et al., for osseointegration and criteria for Implant survival and failure suggested by Buser et al., all 40 implants remained in the surgical site, resulting in a 100% cumulative implant success and survival rate.
[Table 1] showed a comparison of PD among study groups at the different follow-up periods. In the test group, the mean value of PD was insignificantly increased from measurement at 3 months to subsequent measurements at 6 and 12 months postoperative, respectively. The same observation was reported within the control group where the mean value of PD showed insignificant increase throughout the different follow-up visits. The differences between the study groups at all follow-up periods did not reach statistical significance.
[Table 2] demonstrated changes in a gingival index between study groups throughout the trial period. In both study groups, the mean values of the gingival index were insignificant increasing with a time throughout the duration of trial without any significant difference between study groups (all P > 0.05).
[Table 3] depicted the distribution of mean values of MPI among the study population. There were no significant differences observed between the test and control implants regarding MPI during the study period (all P > 0.05). In the test group, implants demonstrated slightly insignificant changes of MPI from first reading at 3 months to the followings readings at 6 and 12 months. The same findings were reported in the control group concerning MPI readings.
The comparisons of BI throughout follow up periods between study groups were exhibited in [Table 4]. The mean value of BI at 3, 6, and 12 months was found to be insignificantly (P > 0.05) higher in the control group compared to the test group. The changes in the mean values of PTVs among study implants were described in [Table 5]. The differences between control and test implants at all periods of measurements were not statistically significant. There were significant increases in the implant stability for all implants in both groups between the baseline reading and subsequent readings at 6 and 12 months following surgery, as assessed by the repeated measure analysis of variance test followed by the Bonferroni test.
In this study, all implants in both groups showed insignificant MBL during a 1-year follow-up period as shown in [Figure 10]. However, there were no significant differences between test and control implants regarding MBL during this period [Table 6]. Patients were evaluated postoperatively and on days 1, 3, 5, and 7 to monitor pain. No statistically significant differences were observed between the two groups at all-time intervals. All implants in both groups showed a significant increase in pain sensation from baseline (immediately postoperative) to the day 1 where it represented highest pain value then exhibited a significant reduction in pain during the subsequent follow-up visits [Table 7].
|Table 6: The mean marginal bone loss in the study groups over time groups|
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|Table 7: The visual analog scale scores at different periods of follow up|
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| Discussion|| |
Implant therapy with different types of fixed dental restorations has proven to be a predictable option for restoring failing or missing teeth, and satisfactory long-term outcomes have been revealed for the use of endosseous implants by more than 30 years of experimental and clinical data. Immediate implant insertion in fresh extraction sockets provide potential benefits for both patients and clinicians, decrease the treatment duration, and may result in enhanced patient satisfaction. Osseointegration is a vital prerequisite for successful dental implant and numerous studies have evaluated the effectiveness of biophysical and biological adjuncts to accelerate bone healing to the implant surface. Previous studies have revealed the positive impacts of LLLT on bone healing,. However, still, little data exist concerning these outcomes on implant osseointegration.
This split-mouth clinical trial was aimed to investigate PBM effect on implant stability and implant osseointegration using a 660 nm Aluminum gallium indium phosphide laser with 5.12 J total energy per se ssion by means of Periotest besides, the clinical, and radiographic analysis. In agreement with Raghavendra et al. who reported that LLL application using a wavelength of 600–1100 nm (optical window) causes a deeper tissue penetration and therefore elicit a wide cell-light response. Arndt-Schultz's curve presents the dose-dependent impacts of LLLT. It proposed that a low stimulus enhances the physiologic activity, moderate stimuli slow down the response, and strong stimuli stop the activity. This indicates that the application of insufficient low dose causing no biological response. While the usage of too much energy results in a suppressive impact. The employment of energy with a 1–10 J/cm2 range is optimal to elicit an optimal biological effect. In accord with these findings in the present study total energy per se ssion of 5.12 J was used allowed increasing implant osseointegration and stability.
In this study, laser application was performed using tissue probe with the continuous mode in contact with mucosa at two points (on a facial and a lingual side of the implant) and setting the exposure time at 40 s per point. These were in agreement with a previous study reporting that the powerful biomodulatory effects can be achieved with exposure time from 30 to 120 s. This was also in consistent with Torkzaban et al. and Matys et al. who studied the effect of LLL on implant stability. The cell components are predominant during primary phases of bone healing so that, they are less susceptible to LLLT. In the primary cell-rich phase, the count of osteoblasts increases and during this phase, laser therapy can effectively enhance cell proliferation. Increased number of cells causes greater deposition of bone matrix and its maturation and calcification. Accordingly, in this trial, LLL was irradiated in the first 2 weeks, which appears to be an appropriate protocol regarding interval and duration according to Gomes et al.. In-vitro studies, the positive and direct impacts of LLLT on bone regeneration and osteoblasts appear to be well proven,. Therefore, clinical studies are required to investigate the effectiveness of LLLT in vivo.
In this controlled study, the inclusions criteria for implant site were in agreement with Liu et al. who used the following criteria as indications for immediate implantation: no acute infection at the fresh extraction site; intact bony walls; good oral hygiene; and adequate volume of native bone to obtain primary stability.
Periotest was utilized to assess implant stability by measurement of the damping characteristics, on a scale ranging from –8 to +50. The more negative values indicating the more the implant stability. In addition, it is capable of giving valuable data regarding the favorable or unfavorable bony changes around the implant, and also information concerning the time for implant loading. It can be considered as an objective clinical method to assess the stability of bone-implant contact. In this study, Periotest was used to assess the implant stability immediately postimplantation (primary stability) and at 12 months after implantation (secondary stability), the main outcome was that LLLT with 660 nm AlGaInP laser did not significantly enhance implant stability according to the mean PTVs obtained by Periotest measurements. The same findings have been observed in other previous studies; Torkzaban et al. who study the influence of LLLT using 940 nm diode laser on the implant stability by means of Osstell Mentor; Morales et al. who reported that the using of 830 nm wavelength diode laser did not significantly increase implant stability; Mandić et al. utilized 637 nm wavelength LLLT in their clinical trial but did not observe any significant positive effect; and Jawad et al. concluded that although during the primary phase of healing LLLT may raise the count of osteogenic cells, but it has no significant influence on implant stability. But Mayer et al. in an experimental study, monitored significant differences in percent of newly formed bone volume and implant stability quotients following application of 830 nm wavelength diode laser therapy with 50 mW output power. In addition, Matys et al. who reported that implants irradiated with a diode laser at 635 nm wavelength were showed significantly greater bone density and secondary stability in comparison to control implants.
MBL is a vital indicator of peri-implant health. It can reflect survival and esthetic result as the peri-implant bone loss may motivate pocket formation which is considered unfavorable for the long-term peri-implant tissue health. Using periapical radiographs for measurements of MBL are accepted in general as a reliable technique to measure bone levels around the implant from the insertion to years thereafter. In this study, radiographic measurements at the proximal surfaces showed statistically insignificant differences in MBL around the laser-irradiated implants and the control implants. This outcome was in inconsistency with observations of the other studies; Renno et al. concluded that laser irradiation at an 830 nm wavelength produced a significant elevation in the proliferation of osteoblasts; Fávaro-Pípi et al. stated that the LLLT application had significant positive impacts on bone healing; in another trial, laser therapy resulted in significantly enhance fracture repair procedure by providing increased bone density and callus volume; and Sella et al. reported that LLL application to fractured rat femurs enhanced the volume of bone tissue in the area of the fracture.
In the present 12-month split-mouth clinical trial, all patients were recalled after implantation surgery on days 1, 3, 5, and 7 for assessment of pain, study result revealed that there was an insignificant difference between test and control implants on VAS scale. Besides, the secondary outcomes (MPI, BI, PD, and GI) were evaluated at 3, 6, and 12 months postimplantation and showed no significant differences between the studied groups. These were in agreement with the findings of Karaca et al. who studied the impact of LLLT and Gaseous Ozone on osseointegration around immediately loaded implants, and Aimetti et al. who assess the influence of LL diode laser in the management of peri-implant mucositis.
The outcomes from this study revealed that all implants in both groups showed success and survival rate of 100%, indicating that immediate insertion of the implants in posterior mandible did not affect both implant survival and success rate in the patients in this trial. Besides, during the 1-year follow-up periods, the implant stability increased with time in all survived implants with minimal MBL. These observations are in line with other previous studies; Krafft et al. showed a high survival rate (96.8%) for implants that were placed in the posterior mandibular area; Ko et al. reported a minimal MBL and complete implants survival throughout the first year postimplantation; and Liu et al. who reported that after 1 year from the immediate implantation, the cumulative implant survival rate was 100%.
In this controlled trial, test implants showed better clinical and radiographic outcomes than those in the control group but these differences did not reach a statistically significant level. There are two explanations for no significant influence of LLLT; one reason may be the systemic effect of laser therapy because to standardize the evaluation conditions in many cases, the split-mouth technique was used. It has been reported by Rodrigo that LLLT in rats can produce systemic influences on distant areas similar to that on the treatment site; second explanation in this study, although the selected implant sites had D3 or D4 bone type quality, the placed implants had sufficient primary stability following surgery because of the advances in implant geometry and surgical techniques which is the key to successful immediate implantation. When implant primary stability is optimal, slight changes in its stability may not be easily monitored. This high stability that achieved during surgery may mask the significant positive effects of laser therapy. Thus, further studies are needed to evaluate the effect of LLLT on implants inserted in augmented sites with bone grafts and in patients with systemic disorders such as diabetes and smoking.
| Conclusion|| |
Within the limitation of this split-mouth randomized trial, the outcomes showed that LLLT that applied during the first two weeks following the implant surgery using a 660 nm wavelength aluminum gallium indium phosphide laser exhibited no statistically significant impact on the osseointegration of immediate implants inserted in the posterior mandible.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]