laser-lok clinical overview ml0606 rev f

7/28/2019 Laser-Lok Clinical Overview ML0606 REV F

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laser-lokmicrochannels

clinical overview

unique technology or unique results


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SCIENCEBioHorizons uses science and

innovation to create unique products

with proven surgical and esthetic results.

productssold

in 85markets

99.2%averageimplant

successrate1

global

leader forbiologicbased

solutions

SERVICEBioHorizons understands the

importance o providing excellent

service. Our global network o

proessional representatives and our

highly trained customer care support

team are well-equipped to meet the

needs o patients and clinicians.

INNOVATIONOur advanced implant technologies,

biologic products and computer guided

surgery sotware have made BioHorizons

a leading dental implant company.

BioHorizons is dedicated to developing evidence-based and scientically proven products. From the launch o the

External implant system (Maestro) in 1997, to the Laser-Lok 3.0 implant in 2010, dental proessionals as well as

patients have condence in our comprehensive portolio o dental implants and biologics products.

Our commitment to science, innovation and service has aided us in becoming one o the astest growing companies

in the dental industry. BioHorizons has helped restore smiles in 85 markets throughout Asia, North America, South

America, Arica, Australia and Europe.


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The following review presents some of the studies and presentations related to Laser-Lok microchannels.

Study Review

Laser-Lok abutment study (canine)

Laser-Lok ball abutment case report (human)

Laser-Lok abutment case series (human)

Laser-Lok abutment delayed restoration (human)

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Three year prospective, controlled

One year multi-unit versus NobelReplace Select

Ten year case study

Four year case study

Three year private practice study

Evidence o connective tissue attachment

Eect o crestal and subcrestal placement

Laser-Lok implants immediately loaded

Immediately loaded sinus augmentation

Immediate placement in the esthetic zone

Laser-Lok infuence on immediate placement

Predicts minimization o crestal bone stress

Comparison to other implant designs

Epithelium and connective tissue attachment

Improved stabilization and osseointegration

Laser-Lok induces contact guidance

Faster osseointegration and higher bone ingrowth

Bone cell contact guidance

Functionally stable sot tissue interace

Optimized surace dimensions

Directed tissue response

Directed tissue response

Cell orientation & organization

Inhibit cell ingrowth

Suppress brous encapsulation

Latest Research

Human Studies

Development Research


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2shop online at www.biohorizons.com

Laser-Lok Technology

Unique surace characteristicsLaser-Lok microchannels is a series o cell-sized circumerential channels that are precisely created using laser ablation technology.This technology produces extremely consistent microchannels that are optimally sized to attach and organize both osteoblasts andbroblasts.8,9 The Laser-Lok microstructure also includes a repeating nanostructure that maximizes surace area and enables cell

pseudopodia and collagen microbrils to interdigitate with the Laser-Lok surace.

Dierent than other surace treatmentsVirtually all dental implant suraces on the market are grit-blasted and/or acid-etched. These manuacturing methods create randomsuraces that vary rom point to point on the implant and alter cell reaction depending on where each cell comes in contact withthe surace.10 While random suraces have shown higher osseointegration than machined suraces,11 only the Laser-Lok surace hasbeen shown using light microscopy, polarized light microscopy and scanning electron microscopy to also be eective or sot tissueattachment.2,12

SEM image at 30X showing the Laser-Lok zone

on a BioHorizons implant.

The uniormity o the Laser-Lok microstructure

and nanostructure is evident using extrememagnication.

Laser-Lok overviewLaser-Lok microchannels is a proprietary dentalimplant surace treatment developed rom over 20

years o research initiated to create the optimal implantsurace. Through this research, the unique Laser-Loksurace has been shown to elicit a biologic responsethat includes the inhibition o epithelial downgrowthand the attachment o connective tissue (unlikeSharpey bers).2,3 This physical attachment produces

a biologic seal around the implant that protectsand maintains crestal bone health. The Laser-Lokphenomenon has been shown in post-market studiesto be more eective than other implant designs inreducing bone loss.4,5,6,7

Colorized SEM o a dental implant harvested at

6 months post-op shows the connective tissue isphysically attached and interdigitated with the

Laser-Lok surace.

Human histology shows the apical extent o the

junctional epithelium below which there is asupracrestal connective tissue attachment to the

Laser-Lok surace.2

sot tissue Laser-Lokimplant

Polarized lights show the connective tissue is

unctionally oriented.2

bone

Laser-Lokimplant


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3 shop online at www.biohorizons.com

The clinical advantageThe Laser-Lok surace has been shown in several studiesto oer a clinical advantage over other implant designs.In a prospective, controlled multi-center study, Laser-Lok implants, when placed alongside identical implantswith a traditional surace, were shown at 37 monthspost-op to reduce bone loss by 70% (or 1.35mm).4 In aretrospective, private practice study, Laser-Lok implantsplaced in a variety o site conditions and ollowed up to 3

years minimized bone loss to 0.46mm.5 In a prospective,University-based overdenture study, Laser-Lok implantsreduced bone loss by 63% versus NobelReplace Select.6

Latest discoveriesThe establishment o a physical, connective tissue

attachment (unlike Sharpey bers) to the Laser-Loksurace has generated an entirely new area o research anddevelopment: Laser-Lok applied to abutments. This couldprovide an opportunity to use Laser-Lok abutments tocreate a biologic seal and Laser-Lok implants to establishsuperior osseointegration9 a solution that oers the besto both worlds. Alternatively, Laser-Lok abutments couldsupport peri-implant health around implants withoutLaser-Lok. In a recent study, Laser-Lok abutments andstandard abutments were randomly placed on implantswith a grit-blasted surace to evaluate the dierences. Inthis proo-o-principle study, a small band o Laser-Lokmicrochannels was shown to inhibit epithelial downgrowth

and establish a connective tissue attachment (unlikeSharpey bers) similar to Laser-Lok implants.12 In thesecases, an epithelial barrier and a supracrestal connectivetissue barrier were created, even when the implants hada machined collar.12 The resulting crestal bone levels werehigher than what was seen with standard abutments andprovides some insight into the role sot tissue stability mayplay in maintaining crestal bone health.

-2.50

-2.00

-1.50

-1.00

-0.50

0.00

1 5 9 13 17 21 25 29 33 37

0.59mm

1.94mm

Laser-Lok Control

Months Post-Op

Laser-Lok advantage

ChangeinBoneL

evel(mm)

Crestal Bone Loss

In a 3-year multicenter perspective study, the Laser-Lok surace showed superior bone maintenance

over identical implants without the Laser-Lok surace.4

NobelReplace is a trademark o Nobel Biocare

Standardabutment

at 3 months

Laser-Lokabutmentat 3 months

Newbone

Boneloss

Epithelialdowngrowth

Connective

tissue

200m

Comparative histologies show the biologic dierences between standard abutments and Laser-Lokabutments including changes in epithelial downgrowth, connective tissue and crestal bone health.12

Comparative SEM images show the variation in tissue attachment strength on standard and Laser-Lokabutments when a tissue fap is incised vertically and manually lited using orceps. 12

Standard

abutmentat 3 months

Laser-Lok

abutmentat 3 months

Laser-Lokmicrochannels

Exposedimplant collar

tissuefap

Laser-Lok Technology

is available on Laser-Lok 3.0,

Tapered Internal, Single-stage,

Internal implants & abutments


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4

LA

TESTRESEARCH

Histologic Evidence o a Connective Tissue Attachment to Laser

Microgrooved Abutments: A Canine StudyM Nevins, DM Kim, SH Jun, K Guze, P Schupbach, ML Nevins.

Int J Periodontics Restorative Dent , Volume 30, 2010. p. 245-255.

ABSTRACTPrevious research has demonstrated the eectiveness o laser-ablated microgrooves placed within implant collars in supporting direct connective

tissue attachments to altered implant suraces. Such a direct connective tissue attachment serves as a physiologic barrier to the apical migrationo the junctional epithelium (JE) and prevents crestal bone resorption. The current prospective preclinical trial sought to evaluate bone and sottissue healing patterns when laser-ablated microgrooves are placed on the abutment. A canine model was selected or comparison to previousinvestigations that examined the negative bone and sot tissue sequelae o the implant-abutment microgap. The results demonstrate signicantimprovement in peri-implant hard and sot tissue healing compared to traditional machined abutment suraces.

MATERIALS AND METHODSThe current study was designed to examine the eects o two dierent implant and abutment suraces on epithelial and connective tissueattachment, as well as peri-implant bone levels. Six oxhounds were selected or this study. Each dog received 6 implants in the bilateralmandibular premolar and rst molar extraction sites, or a total o 36 implants. The sites were randomly assigned to receive tapered internalimplants (BioHorizons) with either resorbable blast texturing (RBT) or RBT with a 0.3mm machined collar. In addition, either machined-surace orLaser-Lok microchannel healing abutments were assigned randomly to each implant. The abutments were placed at the time o surgery.

RESULTS

The presence o the 0.7 mm laser ablated microchanneled zone consistently enabled intense broblastic activity to occur on the abutment-grooved surace, resulting in a dense interlacing complex o connective tissue bers oriented perpendicular to the abutment surace that served asa physiologic barrier to apical JE migration. As a consequence o inhibiting JE apical migration, crestal bone resorption was prevented. Signicantly,in two cases bone regeneration coronal to the IAJ and onto the abutment surace occurred, completely eliminating the negative sequelae o theIAJ microgap.

In contrast, abutments devoid o laser-ablated microgrooved suraces, exhibited little evidence o robust broblastic activity at the abutment-tissueinterace. A long JE extended along the abutment and implant collar suraces, preventing ormation o the physiologic connective tissue barrierand causing crestal bone resorption. Parallel rather than unctionally oriented perpendicular connective tissue bers apposed the abutment-implant suraces.

A grit-blasted implant and standard

abutment demonstrated apical JE

migration, resulting in signicant crestal

bone resorption.

In a polarized light view, this specimen

clearly demonstrates parallel running

connective tissue bers against both the

abutment and implant collar suraces.

In addition, signicant crestal bone loss

is seen.

In this specimen, regenerated bone

was attached to the Laser-Lok

abutment surace and the IAJ microgap

was eliminated.

A polarized light image demonstrates

perpendicularly inserting connective

tissue bers into the microgrooved

abutment surace.

Standard Abutment Laser-Lok Abutment


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5

Histologic Evidence o Connective Tissue Integration on Laser Microgrooved

Abutments in HumansNC Geurs, PJ Vassilopoulos, MS Reddy.

Clinical Advances in Periodontics, Vol. 1, No. 1, May 2011.

INTRODUCTIONHuman histology and scanning electron microscopy (SEM) are presented, outlining the sot tissue integration to a laser microgrooved abutmentsurace.

CASE PRESENTATIONIn two patients, prosthetic abutments with a laser microgrooved surace were placed on osseointegrated implants. Ater 6 weeks o healing,the abutments and the surrounding sot tissue were removed and prepared or histology and SEM. The most apical epithelium was oundcoronal to this surace. Connective tissue demonstrated collagen bers oriented perpendicular to the microgrooved surace. There was intimatecontact between the connective tissues and the microgrooved abutment surace.

CONCLUSIONThe abutments in these patients had connective tissue integration with unctionally oriented bers to the microgrooved surace.

SUMMARYWhy is this case new inormation? To our knowledge, this is the rst human case series reported with human histology describing the connectivetissue attachment around a microgrooved abutment.

What are the keys to successul management in this case? The abutment surace characteristics can lead to connective tissue integration withthe microgrooved surace, with unctionally oriented collagen bers.

What are the primary limitations to success in this case? This is only a case series o the histology o the attachment. No clinical outcomes oradvantages are reported. Further studies will need to be conducted to demonstrate the clinical advantages.

Ground section o specimen stained

with toluidine blue/Azur ll. The oral

epithelium and junctional epithelium

are tapering o coronal to the

microgrooved surace.

Polarized light view o Figure 2

demonstrating collagen bers in a

unctional orientation toward the

abutment surace.

Higher magnication o Figure 1

showing connective tissue in close

contact with the microgrooved surace

o the abutment.

Polarized light view rom an area coronal

to Figure 3. The orientation o the

collagen bers is more parallel to the

smooth implant surace.

Figure 1 Figure 2 Figure 3 Figure 4


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6

LATESTRESEARCH

Connective Tissue Attachment to Laser Microgrooved

Abutments: A Human Histologic Case ReportM Nevins, M Camelo, ML Nevins, P Schupbach, DM Kim

Submitted or Publication, Int J Periodontics Restorative Dent

ABSTRACTPrevious preclinical and clinical studies have demonstrated the eectiveness o precisely congured laser-ablated microgrooves placed on implantcollars to allow direct connective tissue attachment to the implant surace. A recent canine study examining laser-ablated microgrooves placed ina dened healing abutment area demonstrated similar ndings. In both instances direct connective tissue attachment to the implant/abutmentsurace served as an obstacle to the apical migration o the junctional epithelium, thus preventing crestal bone resorption. The current casereport examined the eectiveness o abutment positioned laser-ablated microgrooves in human subjects. As in the preclinical trial, preciselydened laser-ablated microgrooves allowed direct connective tissue attachment to the altered abutment surace, prevented apical migration othe junctional epithelium and thus protected crestal bone rom premature resorption.

Healing abutments with Laser-Lok microchannels connect to the implant

xtures. Mucoperiosteal faps closed without tension.

At 10 weeks, healing is normal or patient #1 with no evidence o inection

or infammation.

Crestal bone is in close contact with the implant collar surace, with no

evidence o bone loss apparent, but rather new bone ormation.

At higher power, dense connective tissue is in intimate contact with the

abutments Laser-Lok micro-grooved suraces.


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8

THREEYEARPROSPECTIV

E,CONTROLLED

Clinical Evaluation o Laser Microtexturing or Sot Tissue and Bone

Attachment to Dental ImplantsGE Pecora, R Ceccarelli, M. Bonelli, H. Alexander, JL Ricci.

Best Clinical Innovations Presentation Award. Academy o Osseointegration 2004 Annual Meeting.

Implant Dentistry. Volume 18(1). February 2009. pp. 57-66.

INTRODUCTIONA tapered dental implant (Laser-Lok [LL] surace treatment) with a 2 mm wide collar, that has been laser micromachined in the lower 1.5 mmto preerentially accomplish bone and connective tissue attachment while inhibiting epithelial downgrowth, was evaluated in a prospective,controlled, multicenter clinical trial.

MATERIALSData are reported at measurement periods rom 1 to 37 months postoperative or 20 pairs o implants in 15 patients. The implants are placedadjacent to machined collar control implants o the same design. Measurement values are reported or bleeding index, plaque index, probingdepth, and crestal bone loss.

RESULTSNo statistical dierences are measured or either bleeding or plaque index. At all measurement periods there are signicant dierences in theprobing depths and the crestal bone loss dierences are signicant ater 7 months (P


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TENYEARCASESTUDY

ABSTRACTNumerous published animal and human dental implant studies report crestal bone loss rom the time o placement o the healing abutmentto various time periods ater restoration. The bone loss can result in loss o interproximal papilla and recession o crown margins. Thesetwo case reports demonstrate the long-term results that can be obtained utilizing implants with the Laser-Lok microchannel collar designto preserve crestal bone and sot tissue esthetics. Case 1 involved extraction, socket grating, 6 month delayed implant placement andnal restoration in 6 months. Case 2 involved extraction, immediate implant placement with simultaneous grating and provisional crownplacement two months later.

Bone deect immediately ollowing extraction

Tooth #9 prior to extraction

Case 1

A 34 year old emale presented with external resorption at the level o the CEJ o tooth #9. Various treatment options werepresented and the patient elected extraction and dental implant placement. Ater atraumatic extraction, the socket anatomy did not

allow or immediate placement with acceptable initial stability. The socket was grated with allograt calcied bone and allowed toheal or 6 months. At that time a dental implant with Laser-Lok microchannel collar design was placed. A subepithelial connectivetissue grat was also utilized on the adjacent tooth #10 or root coverage. Six months ater placement second stage surgery wasperormed and the tooth was restored with a customized abutment and PFM crown. Note the maintenance o excellent crestal bonelevels (within 0.5mm o the implant/abutment interace) at 10 years post-restoration. The sot tissue margins have remained stableand exhibit excellent periodontal health.

Long-term case studies using a Laser-Lok implantCourtesy o Cary Shapo, DDS (Fairfeld, CT)

Restorations by Jerey A. Babushkin, DDS (Trumbull, CT)

Laser-Lok implant at 8 years post-restoration

Bone levels maintained at10 years post-restoration

Case

Study

Laser-Lok implant at time o placement


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Tooth #9 wit h chronic inection

Case 2

This 60 year old emale presented with chronic inection evidenced by a stula at the apical extent o tooth #9. This tooth hadpreviously been treated with root canal and apical surgery. All treatment options were reviewed with the patient and dental implantreplacement was chosen. Because the patient was relocating to South America or a period o two years, immediate extraction,dental implant placement with socket grating was perormed. The dental implant was a 5 mm x 13 mm Laser-Lok microchannelcollar design. A provisional crown was placed 2 months ollowing implant placement. The patient had no other proessionaldental care or two years and upon returning home, the nal crown was placed. Note the crestal bone levels (within 0.5 mm o theabutment/implant interace) at ours years ater implant loading.

Esthetics at 4 years post-restoration

CONCLUSIONThese two cases demonstrate the ability o the Laser-Lok microchannel collar design to maintain crestal bone levels and sot tissue estheticsaround dental implants. Both cases involved implant placement in grated sites. Both cases demonstrate unequivocal clinical and radiographicevidence o crestal bone stability in close proximity to the abutment/implant interace (micro-gap). A traditional expectation o bone loss belowthe collar and to the rst thread was not noted. The ability o the Laser-Lok microchannels to maintain crestal bone and provide supracrestal

connective tissue attachment may create a new denition o normal implant biologic width.

Tooth #9 extracted showing clinical deect

Laser-Lok implant at time o placement Bone levels at 4 years post-restoration


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THREEYEARPRIVATEPRACTICESTUDY

Radiographic Analysis o Crestal Bone Levels Around Laser-Lok

Collar Dental ImplantsCA Shapo, B Lahey, PA Wasserlau, DM Kim.

Int J Periodontics Restorative Dent 2010;30:129-137

Failed bridge prior to implant placement. 4-5mm ridge required

ridge splitting at implant placement.

Healing abutments placed at 3.5 months. Crestal bone adjacent

to Laser-Lok collar.

At three years, stable crestal bone adjacent to Laser-Lok

collar with no indication o bone loss to the rst thread.

This analysis o 49 implants demonstrated a mean crestal bone loss o 0.44 mm at 2 years postrestoration and 0.46 mm at 3 years.

INTRODUCTIONThis retrospective radiographic study was organized to evaluate the clinical ecacy o implants with Laser-Lok microtexturing (8- and 12-mgrooves). A physical attachment o connective tissue bers to the Laser-Lok microtexturing on the implant collar has been previously demonstratedusing human histology, polarized light microscopy, and scanning electron microscopy. This analysis o 49 implants demonstrated a mean crestalbone loss o 0.44 mm at 2 years postrestoration and 0.46 mm at 3 years. All bone loss was contained within the height o the collar, and nobone loss was evident to the level o the implant threads. The radiographic evaluation o the clinical application o this implant supports previousndings that establishing a biologic seal o connective tissue bers around a dental implant may be clinically relevant.

0.70

0.60

0.50

CrestalBoneLoss(mm)

0.40

0.30

0.20

0.10

0.00

2 yr 3 yr


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Human Histologic Evidence o a Connective Tissue Attachment to a Dental ImplantM Nevins, ML Nevins, M Camelo, JL Boyesen, DM Kim.

The International Journal o Periodontics & Restorative Dentistry. Volume 28, Number 2, 2008.

ABSTRACTThis human proo-o-principle study was designed to investigate the possibility o achieving a physical connective tissue attachment tothe Laser-Lok microchannel collar o a dental implant. Its 2-mm collar has been micromachined to encourage bone and connective tissueattachment while preventing apical migration o the epithelium. Implants were harvested with the surrounding implant sot and hard tissuesater 6 months. The histologic investigation was conducted with light microscopy, polarized light, and scanning electron microscopy.

RESULTSThe implants were osseointegrated with histologic evidence o direct bone contact. There was a connective tissue attachment to the Laser-Lok microchannels. There were no signs o infammation. The peri-implant tissues consisted o a dense, collagenous lamina propria coveredwith a stratied, squamous, keratinizing oral epithelium. The latter was continuous with the parakeratinized sulcular epithelium that lined thatlateral surace o the peri-implant sulcus. Apically, the sulcular epithelium overlapped the coronal border o the junctional epithelium. Thesulcular epithelium was continuous with the junctional epithelium, which provided epithelial union between the implant and the surroundingperi-implant mucosa. Between the apical termination o the junctional epithelium and the alveolar bone crest, connective tissue directlyapposed the implant surace.

Light microscopic evaluation o these specimens revealed intimate contact o the junctional epithelial cells with the implant surace. Themicrogrooved area o the implants was covered with connective tissue. Polarized light microscopy o this area revealed unctionally orientedcollagen bers running toward the grooves o the implant surace. SEM o a corresponding area o the specimen conrmed the presence oattached collagen bers.

All specimens demonstrated a high degree o bone-to-implant contact and intense remodeling activity. In specimens that showed collagenbers unctionally oriented toward the grooves on the implant surace, remodeling o new bone in the coronal direction was observed. SEMrevealed sulcular epithelium with the desquamating activity o the cells and the junctional epithelium. It appears that the connective tissueattachment is instrumental in preserving the alveolar bone crest and inhibiting apical migration o the epithelium.

SEM showing collagen bers attached to the rough

implant surace.High magnication identies the apical extent o the

junctional epithelium. There is then a connective tissue

attachment to the laser microchannel surace that extends

to the point o bone attachment.

Micro CT image showing an overview o osseointegration and

the bone-to-implant contact (in red). Note that the level o

bone contact extends to cover all threads o the implant and

corresponds to the histologic observations. This supports

the value o the connective tissue attachment to prevent loss

o crestal bone.


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14

CRESTALSUBCRES

TALPLACEMENT

Hard and Sot Tissue Changes Ater Crestal and Subcrestal Immediate

Implant PlacementRU Koh, TJ Oh, I Rudek, GF Neiva, CE Misch, ED Rothman, HL Wang

J Periodontol 2011;82:1112-1120.

BACKGROUNDThe purpose o this study is to assess the infuence o the placement level o implants with a laser-microtextured collar design on the outcomeso crestal bone and sot tissue levels. In addition, we assessed the vertical and horizontal deect ll and identied actors that infuenced clinicaloutcomes o immediate implant placement.

METHODSTwenty-our patients, each with a hopeless tooth (anterior or premolar region), were recruited to receive dental implants. Patients wererandomly assigned to have the implant placed at the palatal crest or 1mm subcrestally. Clinical parameters including the keratinized gingival(KG) width, KG thickness, horizontal deect depth (HDD), acial and interproximal marginal bone levels (MBLs), acial threads exposed, tissue

implant horizontal distance, gingival index (GI), and plaque index (PI) were assessed at baseline and 4 months ater surgery. In addition, sottissue prole measurements including the papilla index, papilla height (PH), and gingival level (GL) were assessed ater crown placement at 6and 12 months post-surgery.

RESULTSThe overall 4-month implant success rate was 95.8% (one implant ailed). A total o 20 o 24 patients completed the study. At baseline, therewere no signicant dierences between crestal and subcrestal groups in all clinical parameters except or the acial MBL (P = 0.035). At 4months, the subcrestal group had signicantly more tissue thickness gain (keratinized tissue) than the crestal group compared to baseline.Other clinical parameters (papilla index, PH, GL, PI, and GI) showed no signicant dierences between groups at any time. A acial platethickness =2 mm were strongly correlated with the acial marginal bone loss. A acial plate thickness =3 were strongly correlated with horizontal dimensional changes.

CONCLUSIONSThe use o immediate implants was a predictable surgical approach (96% survival rate), and the level o placement did not infuence horizontaland vertical bone and sot tissue changes. This study suggests that a thick acial plate, small gaps, and premolar sites were more avorable or

successul implant clinical outcomes in immediate implant placement.

Placement level and clinical measurements. A) Crestal placement. B) Subcrestal placement. C) Facial tissue thickness. D) Facial plate thickness. E) Palatal plate thickness. F) MBL. G) TE. H) HDD. I) T-I.

IH

CD

G

E

F

Control (crestal) Test (subcrestal)

A B


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15

Histologic Evaluation o 3 Retrieved Immediately Loaded Implants Ater a

4-Month PeriodI Giovanna, G Pecora, A Scarano, V Perrotti, A Piattelli.

Implant Dentistry. Vol 15, Number 3, 2006.

ABSTRACTObjective: To perorm a histologic and histomorphometric analysis o the peri-implant tissue reactions and bone-titanium interace in 3immediately loaded (provisional loaded) titanium implants retrieved rom a man ater a loading period o 4 months.

Materials & Methods: A 35 year-old patient with a maxillary partial edentulism did not want to wear a provisional removable prosthesisduring the healing period. It was decided to insert 3 denitive implants and use 3 provisional implants or the transitional period. Theprovisional implants were loaded the same day with a resin prosthesis in occlusal contact. During the second surgical phase, ater 4 months,the provisional prosthesis was removed, and the provisional implants were retrieved with a trephine bur. Beore retrieval, all implantsappeared to be clinically osseointegrated. The specimens were processed or observation under light microscopy.

Results: At low magnication, it was possible to observe that bone trabeculae were present around the implant. Areas o bone remodelingand haversian systems were present near the implant surace. Under polarized-light microscopy, it was possible to observe that in thecoronal aspect o the thread, the lamellar bone showed lamellae that tended to run parallel to the implant surace, while in the inerioraspect o the thread, the bone lamellae ran perpendicular to the implant surace.

Figure 3. The denitive and provisional implants have been inserted.

Figure 4. At low power magnication, it is possible to see that mainly lamellar bone is in contact with theimplant surace. Few marrow spaces are present. The rst bone to implant contact is above the level o the

rst thread. No areas o resorption are present at the tip o the threads (acid ushin and toluidine blue, original

magnication x12).


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16

IMMED

IATELYLOADEDSINUS

AUGMENTATION

Histologic evaluation o a provisional implant retrieved rom man 7 months ater

placement in a sinus augmented with calcium sulphate: a case reportG Iezzi, E Fiera, A Scarano, G Pecora, A Piattelli.

Journal o Oral Implantology. Volume 33, No. 2. 2007.

ABSTRACTLittle is known about the in vivo healing processes at the interace o implants placed in dierent grating materials. For optimal sinusaugmentation, a bone grat substitute that can regenerate high-quality bone and enable the osseointegration o load-bearing titanium implantsis needed in clinical practice. Calcium sulphate (CaS) is one o the oldest biomaterials used in medicine, but ew studies have addressed its

use as a sinus augmentation material in conjunction with simultaneous implant placement. The aim o the present study was to histologicallyevaluate an immediately loaded provisional implant retrieved 7 months ater simultaneous placement in a human sinus grated with CaS.During retrieval, bone detached partially rom one o the implants which precluded its use or histologic analysis. The second implant wascompletely surrounded by native and newly ormed bone, and it underwent histologic evaluation. Lamellar bone, with small osteocyte lacunae,was present and in contact with the implant surace. No gaps, epithelial cells, or connective tissues were present at the boneimplant interace.No residual CaS was present. Boneimplant contact percentage was 55% 8%. O this percentage, 40% was represented by native bone and15% by newly ormed bone. CaS showed complete resorption and new bone ormation in the maxillary sinus; this bone was ound to be inclose contact with the implant surace ater immediate loading.

Figures 712. Figure 7. At low-power magnication, it is possible to see that bone is present around and in contact wit h the implant. The line divides native bone romnewly ormed bone (A) Native bone. (B) Newly ormed bone. (Acid uchsin and toluidine blue, magnication X12). FIGURE 8. Higher magnication o Figure 7 (area

A). Newly ormed trabecular bone with large osteocyte lacunae was present close to the implant surace. No residual calcium sulphate is present. (Acid uchsin and

toluidine blue, magnication X50). FIGURE 9. Higher magnication o Figure 7 (area A). Cortical mature bone is present near the implant surace, and bone undergoing

remodeling is in direct contact with the implant surace. (Acid uchsin and toluidine blue, magnication X100). FIGURE 10. Higher magnication o Figure 7 (area B).

High magnication o the coronal portion o the boneimplant interace. Active osteoblasts secreting osteoid matrix are present. No biomaterial is present. (Acid

uchsin and toluidine blue, magnication X100). FIGURE 11. Higher magnication o Figure 7 (area B). Newly ormed bone in close contact with the implant surace.

Wide marrow spaces are present. No calcium sulphate is present. (Acid uchsin and toluidine blue, magnication X50). FIGURE 12. Higher magnication o Figure 7

(area B). Osteoblasts (arrows) secreting osteoid matrix are observed in the apical portion o the implant. (Acid uchsin and toluidine blue, magnication X400).


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ABSTRACTEndosseous dental implants have traditionally been placed using a two-stage surgical procedure with a 6- to 12-month healing periodollowing tooth extraction. In order to decrease healing time, protocols were introduced that included immediate implant placement andprovisionalization ollowing tooth extraction. Although survival rates or this technique are high, postoperative gingival shrinkage and bone

resorption in the aesthetic zone are potential limitations. The two case reports described herein present a surgical technique or the preservationo anterior aesthetics that combines minimally invasive extraction, immediate implant placement, provisionalization, and the use o implantswith a laser micro-grooved coronal design.

DISCUSSIONThe use o implants with a laser microgrooved coronal design may have contributed to the maintenance o buccal sot tissue, providingattachment and preventing epithelial cell downgrowth, which oten occurs with machined collar implants. Maintenance o this supra crestalsot tissue oten depends on its ability to establish an attachment supercrestally to the implant surace.

Figure 1.Preoperative appearance o the FPD rom the right canine to the right centralincisor replacing the missing lateral incisor.

Figure 2A. Radiographic appearance o theimplants immediately ollowing placement.

Figure 2B.Postoperative appearance 2.5years ollowing implant loading. Note the

maintenance o the interproximal bone levels.

Figure 3. Postoperative appearance 2.5 years ollowing implant placement demonstratesaesthetic maintenance o the buccogingival marginal levels.

Immediate Implant Placement and ProvisionalizationTwo Case ReportsSJ Froum, SC Cho, H Francisco, YS Park, N Elian, D Tarnow.

Pract Proced Aesthet Dent 2007;19(10):421-428.


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Inuence o a microgrooved collar design on sot and hard tissue healing o

immediate implantation in resh extraction sites in dogsSY Shin, DH Han

Clin. Oral Impl. Res. 21, 2010; 804814.

ABSTRACTObjective: This study compared the alveolar bone reduction ater immediate implantation using microgrooved and smooth collar implants inresh extracted sockets.

Materials and Methods: Four mongrel dogs were used in this study. The ull buccal and lingual mucoperiosteal faps were elevated and

the third and ourth premolars o the mandible were removed. The implants were installed in the resh extracted sockets. The animals weresacriced ater a 3-month healing period. The mandibles were dissected and each implant site was removed and processed or a histologicalexamination.

Results: During healing, the marginal gaps in both groups, which were present between the implant and the socket walls at implantation,disappeared as a result o bone lling and resorption o the bone crest. The buccal bone crests were located apical o its lingual counterparts.

At the 12-week interval, the mean boneimplant contact in the microgrooved collar group was signicantly higher than that o the turned collargroup. From the observations in some o the microgrooved collar groups, we have ound bone attachment to the 12 mm microgrooved suraceand collagen bers perpendicular to the long axis o the implants over the 8 mm microgrooved surace.

Conclusion: Within the limitations o this study, microgrooved implants may provide more avorable conditions or the attachment o hard andsot tissues and reduce the level o marginal bone resorption and sot tissue recession.

Fig. 1. Schematic drawing describing the dierent landmarks between which histometric measurements wereperormed. (a) Microgrooved collar implant group; (b) turned collar implant group. aBE, apical termination o the

barrier epithelium; B/I, marginal level o bone-to-implant contact; C, marginal level o the bone crest; PM, margino the peri implant mucosa; M, marginal level o the microgrooved surace or machined surace o implant.

Fig. 3. Fluorescent images under polarizing microscope showing longitudinal sectiono microgrooved group (a) and turned surace group (b) ater 12 weeks o healing.The solid arrows indicate the collagen ber direction which are parallel to the implantsurace over the turned surace and the dotted arrows point the collagen bersperpendicular to the implant over the 8mm pitch microgrooved surace. CT, connectivetissue; I, implant. Original magnication x 200.

Fig. 4. Fluorescent images showing longitudinal section o microgrooved group (a) andturned surace group (b) ater 12 weeks o healing. The arrows indicate the apical level othe junctional epithelium. CT, connective tissue; I, implant. Original magnication x 50.

Fig. 2. Micrographs showing longitudinal section o microgroovedgroups (a) and turned surace groups (b) ater 12 weeks o healing. B,

buccal wall; L, lingual wall; I, implant; PM, peri-implant mucosa. H-Estaining; original magnication x 10.

IMMEDIATEPLACEMENT


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ABSTRACTThis study, analytically, through nite element analysis, predicts the minimization o crestal bone stress resulting rom implant collar suracetreatment. A tapered dental implant design with Laser-Lok (LL) and without (control, C) laser microgrooving surace treatment are evaluated.The LL implant has the same tapered body design and thread surace treatment as the C implant, but has a 2-mm wide collar that has beenlaser micromachined with 8 and 12m grooves in the lower 1.5 mm to enhance tissue attachment. In vivo animal and human studies previouslydemonstrated decreased crestal bone loss with the LL implant. Axial and side loading with two dierent collar/bone interaces (nonbonded

and bonded, to simulate the C and LL suraces, respectively) are considered. For 80 N side load, the maximum crestal bone distortional stressaround C is 91.9 MPa, while the maximum crestal bone stress around LL, 22.6 MPa, is signicantly lower. Finite element analysis suggeststhat stress overload may be responsible or the loss o crestal bone.Attaching bone to the collar with LL is predicted to diminish this eect,beneting crestal bone retention.

Mechanical basis or bone retention around dental implantsH Alexander, JL Ricci, GJ Hrico

J Biomed Mater Res B Appl Biomater. Volume 88B, Issue 2, Pages 306-311, Feb 2009.

100

90

80

70

60

50

40

30

2010

0Axial Load Side Load

Figure 2. Summary o the results o Finite Element Analysis demonstrating the stress decreaseresulting rom implant attachment.

Figure 1. Max stress o 91.9 MPa seen in Control implant (let) and 22.6 MPa seen in La ser-Lok implant (right) rom 80 Newton side load.

MPa

15.7

31.3

47.0

62.7

78.3

94.0

109.7

125.3

141.0

MPa

Laser-Lok

Control


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The Eects o Laser Microtextured Collars Upon Crestal Bone Levels o

Dental ImplantsS Weiner, J Simon, DS Ehrenberg, B Zweig, and JL Ricci.

Implant Dentistry, Volume 17, Number 2, 2008. p. 217-228.

ABSTRACTPurpose: The purpose o this study was to examine the crestal bone, connective tissue, and epithelial cell response to a laser microtexturedcollar compared with a machined collar, in the dog model.

Materials: Six mongrel dogs had mandibular premolars and rst molars extracted and ater healing replaced with BioLok implants 4x8 mm.Each dog had 3 control implants placed on one side o the mandible and 3 experimental, laser microtextured, implants placed contralaterally.

Ater 3 months, 1 dog was killed. Bridges were placed on the implants o 4 o the dogs. The sixth dog served as a negative control or theduration o the experiment. Two o the dogs were killed 3 months ater loading, two o the dogs were killed 6 months ater loading as was the

negative (unloaded) control. Histology, electron microscopy, and histomorphometric analysis was done on histologic sections obtained romblock sections o the mandible containing the implants.

Results: Initially the experimental implants showed greater bone attachment along the collar. With time the bone heights along the controland experimental collars were equivalent. However, the controls had more sot tissue downgrowth, greater osteoclastic activity, and increasedsaucerization compared with sites adjacent to experimental implants. There was closer adaptation o the bone to the laser microtexturedcollars.

Conclusion: Use o tissue engineered collars with microgrooving seems to promote bone and sot tissue attachment along the collar andacilitate development o a biological width.

Figures 1A (let), 1B (middle), 1C (right). Light photomicrographs o epithelial andsot connective tissue interaction with experimental (1A and 1B) and control (1C)

suraces at 6 months (3 months ater loading). An epithelial layer is seen in the upperportion o Fig.1A which ends in a burst o epithelial cells that are attached at the

edge o the laser-micromachined region (center o photo). The lower part o Fig. 1A

and all o Fig. 1B show connective at tachment to the laser-micromachined suraces.

Fig. 1C shows sot tissue downgrowth between the bone and implant interace in a

control implant.

Figure 3 Scanning electron photomicrograph (backscatteredelectron imaging model) o bone integration o an experimental

implant at 3 months (uncovering). Let: Overview (collage)o several images showing bone integration o the body o

the implant as well as direct bone integration o the laser-

micromachined collar. Right: Higher magnication o bone

integration o the implant body. Thread pitch = 1 mm.

Fig. 1A Fig. 1B Fig. 1C

Table 1. Nonparametric Histomorphometric Analysis Data (Standard Error)

OsteoclasticActivity Saucerization

BoneUpgrowth

Sot TissueDowngrowth

3-mo loaded specimensControl/smooth(8 sections rom 3implants)

Laser micromachined(6 sections rom 4implants)

6-mo loaded specimensControl/smooth (12interaces)

Laser micromachined(14 interaces)

1.500.29

0.880.16

1.750.22

1.300.17

0.920.05

0.500.10

0.550.07

0.220.04

00

00

0.150.04

0.900.04

0.830.10

0.250.13

0.550.07

00


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ABSTRACTSurace microgeometry plays a role in tissue implant surace interactions, but our understanding o its eects is incomplete. Substratemicrogrooves strongly infuence cells in vitro, as evidenced by contact guidance and cell alignment. We studied dot colonies o primary

broblasts and bone marrow cells that were grown on titanium-coated, microgrooved polystyrene suraces that we designed and produced.Rat tendon broblast and rat bone marrow colony growth and migration varied (p < 0.01) by microgroove dimension and slightly by cell type.We observed prooundly altered morphologies, reduced growth rates, and directional growth in colonies grown on microgrooved substrates,when compared with colonies grown on fat, control suraces (p < 0.01). The cells in our colonies grown on microgrooved suraces werewell aligned and elongated in the direction parallel to the grooves and colonies. Our dot colony is an easily reproduced, easily measuredand articial explant model o tissue-implant interactions that better approximates in vivo implant responses than culturing isolated cells onbiomaterials. Our results correlate well with in vivo studies o titanium dioxide-coated polystyrene, titanium, and titanium alloy implants withcontrolled microgeometries. Microgrooves and other surace eatures appear to directionally or spatially organize cells and matrix molecules inways that contribute to improved stabilization and osseointegration o implants.

Connective-tissue responses to defned biomaterial suraces. I. Growth o rat

fbroblast and bone marrow cell colonies on microgrooved substratesJL Ricci, JC Grew, H Alexander

Journal o Biomedical Materials Research Part A. 85A: 313325, 2008.

Light micrograph o RTF colonies grown or 4 days on control and 6-m

microgrooved substrates. The colony grown on the control substrate

(a) displays radial outgrowth rom the initial collagen gel dot seen as

the dark area in t he center o the colony. The colony grown on the 6-m

microgrooved substrate (b) displays extensive outgrowth rom the initial gel

dot in the direction parallel with the direction o the microgrooves. Bar =

100 m (a and b).

IMPROVEDSTA

BILIZATIONANDOSSE

OINTEGRATION

Light micrograph o RTF colonies grown or 4 days on control and 6-m

microgrooved substrates. The colony grown on the control substrate (a)

displays radial outgrowth rom the initial collagen gel dot seen as the

dark area in the center o the colony. The extent o colony outgrowth can

also be seen. The original gel dot is ~2 mm in diameter. The colony grown

on the 6 -m microgrooved substrate (b) displays extensive outgrowth

rom the initial gel dot in the direction parallel with the direction o the

microgrooves. Less extensive outgrowth is observed in the direction

perpendicular to the direction o the microgrooves. This microgroove

dimension is below the resolution limit o the microscope at this

magnication. Bar = 1 mm (a and b).


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ABSTRACTSurace microgeometry strongly infuences the shapes, orientations, and growth characteristics o cultured cells, but in-depth, quantitativestudies o these eects are lacking. We investigated several contact guidance eects in cells within dot colonies o primary broblastsand in cultures o a transormed broblast cell line, employing titanium-coated, microgrooved polystyrene suraces that we designed andproduced. The aspect ratios, orientations, densities, and attachment areas o rat tendon broblasts (RTF) colony cells, in most cases, varied (p< 0.01) by microgroove dimension. We observed prooundly altered cell morphologies, reduced attachment areas, and reduced cell densitieswithin colonies grown on microgrooved substrates, compared with cells o colonies grown on fat, control suraces. 3T3 broblasts culturedon microgrooved suraces demonstrated similarly altered morphologies. Fluorescence microscopy revealed that microgrooves alter thedistribution and assembly o cytoskeletal and attachment proteins within these cells. These ndings are consistent with previous results, andtaken together with the results o our in vivo and cell colony growth studies, enable us to propose a unied hypothesis o how microgroovesinduce contact guidance.

Connective-tissue responses to defned biomaterial suraces. II. Behavior o rat

and mouse fbroblasts cultured on microgrooved substratesJC Grew, JL Ricci, H Alexander

Journal o Biomedical Materials Research Part A. 85A: 326-335, 2008.

Scanning electron micrograph o a portion o a silicon-waer mold bearing 12-m

microgrooves. Bar = 100 m.

Scanning-electron micrographs o NIH-3T3 broblasts grown on 8- (a)

and 12-m (b) microgrooved substrates or 8 days. The individual cell

grown on 8-m grooves is attached to several adjacent ridges, bridging the

intervening grooves. The cells grown on 12-m grooves most requently

lie atop the ridges or within the grooves. Both microgroove dimensions

impose a strong orientation eect upon the cells. Bar = 10 m.


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Osseointegration on metallic implant suraces: eects o microgeometry and

growth actor treatmentSR Frenkel, J Simon, H Alexander, M Dennis, JL Ricci.

J Biomed Mater Res. 2002;63(6):706-13.

ABSTRACTOrthopedic implants oten loosen due to the invasion o brous tissue. The aim o this study was to devise a novel implant surace that wouldspeed healing adjacent to the surace, and create a stable interace or bone integration, by using a chemoattractant or bone precursorcells, and by controlling tissue migration at implant suraces via specic surace microgeometry design. Experimental suraces were testedin a canine implantable chamber that simulates the intramedullary bone response around total joint implants. Titanium and alloy suraceswere prepared with specic microgeometries, designed to optimize tissue attachment and control brous encapsulation. TGF, a mitogenand chemoattractant (Hunziker EB, Rosenberg LC. J Bone Joint Surg Am 1996;78:721-733) or osteoprogenitor cells, was used to recruitprogenitor cells to the implant surace and to enhance their prolieration. Calcium sulate hemihydrate (CS) was the delivery vehicle or TGF;CS resorbs rapidly and appears to be osteoconductive. Animals were sacriced at 6 and 12 weeks postoperatively. Results indicated that TGFcan be reliably released in an active orm rom a calcium sulate carrier in vivo. The growth actor had a signicant eect on bone ingrowth intoimplant channels at an early time period, although this eect was not seen with higher doses at later periods. Adjustment o dosage shouldrender TGF more potent at later time periods. Calcium sulate treatment without TGF resulted in a signicant increase in bone ingrowththroughout the 12-week time period studied. Bone response to the microgrooved suraces was dramatic, causing greater ingrowth in 9 o the12 experimental conditions. Microgrooves also enhanced the mechanical strength o CS-coated specimens. The grooved surace was able tocontrol the direction o ingrowth. This surace treatment may result in a clinically valuable implant design to induce rapid ingrowth and a strongbone-implant interace, contributing to implant longevity.

Figure 1. Percentage o bone ingrowth into channels at 6 and 12 weeks.

6 Time (weeks) 12

%B

oneingrowth

0

20

40

60

80

100 gAgCPMGgA/CSHgCP/CSHMG/CSH

FASTEROSSEOINTEGRATIONANDHIGHERB

ONEINGROWTH


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Interactions between MC3T3-E1 cells and textured Ti6Al4V suracesSoboyejo WO, Nemetski B, Allameh S, Marcantonio N, Mercer C, Ricci J.

J Biomed Mater Res. 2002 Oct; 62(1):56-72.

ABSTRACTThis paper presents the results o an experimental study o the interactions between MC3T3-E1 (mouse calvarian) cells and textured Ti6Al4Vsuraces, including suraces produced by laser microgrooving; blasting with alumina particles; and polishing. The multiscale interactionsbetween MC3T3-E1 cells and these textured suraces are studied using a combination o optical scanning transmission electron microscopyand atomic orce microscopy. The potential cytotoxic eects o microchemistry on cell-surace interactions also are considered in studies ocell spreading and orientation over 9-day periods. These studies show that cells on microgrooved Ti6Al4V geometries that are 8 or 12 microndeep undergo contact guidance and limited cell spreading. Similar contact guidance is observed on the suraces o diamond-polished suraces

on which nanoscale grooves are ormed due to the scratching that occurs during polishing. In contrast, random cell orientations are observedon alumina-blasted Ti6Al4V suraces. The possible eects o surace topography are discussed or scar-tissue ormation and improved cell-surace integration.

A B

C D

Figure 1. Extracellular matrix ormation ater 9 days o cell culture on (a) 12-m microgrooved substrate; (b) 8-m microgrooved substrate; (c) Al2O

3-blasted suraces;

and (d) smooth suraces.


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Tissue Response to Transcutaneous Laser Microtextured ImplantsCL Ware, JL Simon, JL Ricci.

Presented at the 28th Annual Meeting o the Society or Biomaterials.

April 24-27, 2002. Tampa, FL.

ABSTRACTIntroduction: This report describes the use o laser-microtextured transcutaneous implants in a rabbit calvarial model to enhance sottissue integration. Dental and orthopaedic implants are routinely microtextured to enhance tissue integration. Computer-controlled lasermicrotexturing techniques that produce microgrooved suraces with dened 8-12m eatures on controlled regions o implant suraces havebeen developed based on results rom cell culture experiments and in vivo models. These textures have been replicated onto the collars odental implants to provide specic areas or both osteointegration and the ormation o a stable sot tissue-implant interace. The objective othis study is to evaluate these implants in a transcutaneous rabbit calvarial model to determine whether controlled laser microtexturing can be

used to create a stable interace with connective tissue and epithelium.

Methods: Laser microtextures were produced on the 4mm diameter collars o modied dental implants designed or rabbit studies (Figure 1).The implants were 4.5mm in length and the threaded portion was 3.75mm in diameter. Implants were produced and supplied by OrthogenCorporation (Springeld, NJ) and BioLok International (Deereld Beach, FL). The implant suraces were modied by ablation o denedareas, using an Excimer laser and large-area masking techniques. Controlled laser ablation allows accurate abrication o dened suracemicrostructure with resolution in the micron scale range. Laser machined suraces contained 8m and 12m microgrooved systems orientedcircumerentially on the collars. The collars o the control implants were as machined, and were characterized by small machining marks ontheir suraces. All implants were cleaned and passivated in nitric acid prior to sterilization.

Four transcutaneous implants were surgically implanted bilaterally in the parietal bones in each rabbit using single-stage procedures. Thesurgical protocol was similar to dental implant placement. An incision was made over the sagittal suture, and the skin and sot tissues wererefected laterally. Implants were placed using pilot drills and futed spade drills to produce 3.4mm sites or the 3.75mm diameter implants.The implants were placed with the threaded portion in bone, and the laser-microtextured collar penetrating the subcutaneous sot tissue andepithelium. Each rabbit received two implants on either side o the midline (1 control and 3 experimental implants per subject). The skin wasthen sutured over the implants. Punch openings were made to expose the tops o the platorms o the implants, and the cover screws were

used to asten down small plastic washers coated with triple antibiotic ointment. The plastic washers were used to prevent the skin romclosing over the implant during the swelling that occurred during early healing. They were removed ater two weeks. Twelve rabbits were usedin the study. Rabbits were sacriced at 2, 4 and 8 weeks, and the implants and surrounding tissues were processed or histology. Hard andsot tissue response to the implants was examined histologically.Results and Discussion: No complications or inections were encountered during the course o the experiment. The 2 and 4 week histologydisplayed immature sot tissue ormations around all implants, and little epithelial interaction with the implant suraces was noted as theepithelium had not regenerated at the implant surace by 2 weeks, and no clear relationship between epithelium and implant was seen at 4weeks. 8-week samples showed more mature sot tissue and epithelial tissue. In these samples, the epithelium had ully regenerated and thesot tissue showed more mature and organized collagen. In the control samples, the epithelium consistently grew down the interace betweenimplant and sot tissue and ormed a deep sulcus along the implant collar. This sulcus extended to the bone surace and there was little orno direct sot tissue interaction or integration with the control suraces. The 8-week laser machined implants produced a dierent pattern otissue interaction. The epithelium also produced a sulcus at the upper collars o these implants. However, in most cases the sulcus did notextend down as ar as the bone surace, but ended at a 300-700m wide band o tissue, which was attached to the base o the microtexturedcollar. Even though the laser-microtexturing extended to the top o the collar, this sot tissue attachment ormed only at the lower portion othe implant collar, where a stable corner o sot tissue attached to both the implant collar and the bone surace. This arrangement o sulcus,epithelial attachment, and sot tissue attachment was similar to the biologic width structural arrangement that has been described aroundteeth and in some cases around implants.

Conclusions: This preliminary study suggests that laser microtextured suraces can be applied to transcutaneous implants and used to improvesot tissue integration. Results suggested that the sot tissues at the skin interace are capable o producing an arrangement similar to thebiologic width arrangement seen around teeth. These laser-machined microtextures are hypothesized to work by increasing surace andorganization o attached cells and tissues. They can be used to orm a unctionally stable interace with sot tissues, establishing an eectivetranscutaneous barrier. While longer-term studies are needed, the results suggest that perormance o transcutaneous prosthetic xation maybe enhanced through the use o regional organized microtexturing.

Figure 1. (A) Scanning electron micrograph(SEM) o the surace o a laser microtextured

implant. The microtexturing is in two bandson the two millimeter-wide collar. (B) Higher

magnication SEM o the laser microtextured

surace showing 12m grooves and ridges

(bar = 40m).

FUNCTIONALLYSTABLESOFTTISSUEINTERFACE


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Bone Response to Laser Microtextured SuracesJL Ricci, J Charvet, SR Frenkel, R Change, P Nadkarni, J Turner and H Alexander.

Bone Engineering (editor: JE Davies). Chapter 25.

Published by Em2 Inc., Toronto, Canada. 2000.

INTRODUCTIONTissue response to any implantable device has been ound to correlate with a complex combination o material interace parameters based oncomposition, surace chemistry, and surace microgeometry. The relative contributions o these actors are dicult to assess.

In vitro and in vivo experiments have demonstrated the role o surace microgeometry in tissue-implant surace interaction although no well-denedrelationship has been established. The general relationship, as demonstrated by in vivo experiments on metallic and ceramic implants indicates

that smooth suraces promote ormation o thick brous tissue encapsulation and rough suraces promote thinner sot tissue encapsulation andmore intimate bone integration. Smooth and porous titanium suraces have also been shown to have dierent eects on the orientation o broustissue cells in vitro. Surace roughness has been shown to be a actor in tissue integration o implants with hydroxyapatite suraces, and to altercell attachment and growth on polymer suraces roughened by hydrolytic etching. Roughened suraces have also shown pronounced eects ondierentiation and regulatory actor production o bone cells in vitro. Dened surace microgeometries, such as grooved and machined metalsand polymer suraces have been shown to cause cell and ECM orientation in vivo and can be used to encourage or impede epithelial downgrowthin experimental dental implants. Surace texturing has also been shown to adhere brin clot matrix more eectively than smooth suraces,orming a more stable interace during the collagenous matrix contracture that occurs during healing. This is an eect which may be important indetermining early events in tissue integration.

It is likely that textured suraces work on several levels. These suraces have higher surace areas than smooth suraces and interdigitate withtissue in such a way as to create a more stable mechanical interace. They may also have signicant eects on adhesion o brin clot, adhesiono more permanent extracellular matrix components, and long-term interaction o cells at stable interaces. We have observed that, in the shortterm, brous tissue cells orm an earlier and more organized collagenous capsule at smooth interaces than at textured interaces. We suggest

that textured suraces have an additional advantage over smooth suraces. They inhibit colonization by broblastic cell types that arrive early inwound healing and encapsulate smooth substrates.

We have investigated (1) the eects o textured suraces on colony ormation by broblasts, and (2) the eects o controlled surace microgeometrieson broblast colonization. Based on these results, we have designed, abricated, and tested titanium alloy and commercially-pure titaniumimplants with controlled microgeometries in in vivo models. These experimental suraces have highly-oriented, consistent microstructures whichare applied using computer-controlled laser ablation techniques. The results suggest that controlled surace microgeometry, in specic sizeranges, can enhance bone integration and control the local microstructural geometry o attached bone.

Figure 1. Graphs oX-axis growth by RTF

cells on microgrooved

suraces ater 8 days

compared to control

colonies (diameter

increase).

Figure 3. Lightphotomicrograph

o RTF cells

growing on a 12

m microgrooved

culture surace.

Cells are attached

to tops, bottoms

and sides o

grooves. Cells are

aligned along the

long axis o the

substrate.

Figure 4. Scanningelectron micrograph

o RTF cells

growing on a 2

m microgrooved

culture surace. Cellsare attached to tops

o grooves and span

several grooves.

Cells are aligned

along the long axis

o the substrate.

Bar=100 m.

RTF Cell X-Axis Growth

2

4

6

8

10

12

14

0

2-X

C-D

4-X

6-X

8-X

12-X

X-AxisGrowthbetween4and8

days(mm)

Figure 2. Graphs oY-axis growth by RTF

cells on microgrooved

suraces ater 8 dayscompared to control

colonies (diameter

increase).

RTF Cell Y-Axis Growth

1

2

3

4

5

6

7

0

2-Y

C-D

4-Y

6-Y

8-Y

12-Y

Y-AxisGrowthbetween

4and8

days(mm)

8


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Cytoskeletal Organization in Three Fibroblast Variants Cultured on

Micropatterned SuracesJC Grew, JL Ricci.

Presented at the Sixth World Biomaterials Congress. Kamuela, HI.

May 15-20, 2000.

ABSTRACTIntroduction: Implant surace geometry and microgeometry infuence tissue responses to implants. The physical and chemical propertieso synthetic substrates aect the morphology, physiology and behavior o cultured cells o various types. To date, studies o tissue-implantinteraction have emphasized cell attachment, signaling and other cellular response mechanisms. Cellular attributes infuenced by micrometricsubstrate eatures include cell shape, attachment, migration, orientation, and cytoskeletal organization. We studied three phenotypic variantso a murine broblast cell line to explore the infuence o substrate microgeometry on cell shape, orientation, and microlament distribution.Microlament organization refects cell shape and orientation, attendant to cell signaling events that also regulate cell attachment, mitosis,migration and apoptosis. Microlament bundles (stress bers) terminate at clusters o actin-associated proteins, adhesion molecules, andprotein kinases which contribute to in vitro cell responses to culture substrates.

Methodology: NIH-3T3 broblasts, 3T3-Li broblasts (ATCC, Manassas, VA) and MC-3T3 broblasts (git o JP OConnor) were grown inDMEM with 10% NCS and 1% antibiotics in 24-well plates containing TiO2-coated, microtextured polystyrene inserts. Culture substrates hadeither 8m parallel grooves, 12m parallel grooves, 3x3m square posts separated by 3m perpendicular grooves, or no eatures (controls).Ten thousand cells were seeded into wells containing the inserts and ater 1 day, were prepared or scanning electron microscopy (SEM) orstained with rhodamine-phalloidin.

Results: All three variants o 3T3 broblasts adhered to all substrates within 1 day. There was no predominant orientation or shape incells grown on control suraces. The cytoplasms o some cells grown on control suraces showed random arrays o stress ber, apparentlyterminating at ocal adhesions. Nearly all cells o all types grown on 8 or 12m grooved substrates were elongated and oriented parallel tothe grooves, growing atop the ridges or within the troughs (Figure 1). Cells cultured on 8m grooves bridged grooves more requently thancells cultured on 12m grooves. Few cells o any type demonstrated evidence o stress bers ormation ater 1 day in culture on groovedsuraces. Many cells grown on posted substrates displayed stress bers terminating on posts. These assumed a stellate conormation, withprocess extending orthogonally rom a central cytoplasmic mass and terminating atop the elevated posts (Figure 1). This nding is similar toour previous observations o NIH-3T3 cells grown on posted substrates. SEM observations conrmed the shape and orientation eects o thesubstrates on the 3T3 variants.

Discussion:This experiment demonstrated that parallel and intersecting grooves dictate the cell shape, orientation and cytoskeletal organizationo three phenotypic variants o 3T3 broblasts. The NIH-3T3 variant is a brogenic line, while the 3T3-L1 variant is lipogenic and the MC-3T3

variant is osteogenic. The phenotypes o these cells were assessed by alkaline phosphatase assay (MC-3T3 cells are alkaline phosphatasepositive) and by Sudan Black B staining (or lipid inclusions in 3T3-Li cells). The roles o extracellular matrix and cell adhesion molecules inthe contact guidance events described above were not characterized, but are not discounted. We have previously demonstrated that integrindistribution and tyrosine kinase activity is physically constrained by micrometric substrate eatures. We hypothesize that the same constrainthas occurred in the cells described herein. Elucidation o phenotypic dierences between cell types that direct the tissue response to implantsmay yield inormation leading to improved implant integration and extended implant liespan.

Acknowledgements: This work was aided by NSF grants SBIR-9160684 and DUE-9750533, and by NJCU SBR grant 220253. Microgeometry

molds were prepared by the Cornell Nanoabrication Facility.

Figure 2. MC-3T3 broblasts cultured on a smooth surace.Figure 1. 3T3-L1 broblasts cultured on 12 m grooves. Note theuniorm orientation o the elongated cells.

DIRECTEDTISSUERESPONSE


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ABSTRACTIntroduction: Implant surace geometry and microgeometry aect tissue responses, although the tissue-implant interaction is incompletelycharacterized. Physical and chemical properties o synthetic substrates aect the morphology, physiology and behavior o cultured cells ovarious types. Investigators are just now beginning to describe these in vitro eects in detail. Shape, attachment, migration, orientation,and cytoskeletal organization dier between cells cultured on fat substrates and substrates having regular surace eatures o micrometricdimensions. We studied murine broblast shape, orientation, and microlament and ocal adhesion distribution parameters relevant tocontact guidance and to other actors infuenced by substrate microgeometry. Microlament organization refects cell shape and orientation,but is also important in signal transduction schemes governing cell attachment, mitosis, migration and apoptosis. Microlament bundlesterminate in clusters o actin-associated proteins, adhesion proteins, and protein kinases having signal transduction unctions. We employedassays that revealed the distribution o (1) microlaments/stress bers; (2) ocal adhesion molecules; and (3) phosphotyrosine, the product othe major class o kinases associated with cell attachments.

Methodology: 3T3 broblasts (ATCC, Rockville, MD) rom rozen stocks were grown in DMEM with 10% FBS in multiwell plates containing1cm square microtextured inserts. The inserts consisted o polystyrene solvent cast on silicon molds and titanium-oxide coated. The resultantsuraces had either 8m parallel grooves, 12m parallel grooves, 3m square posts (created by perpendicular 3m grooves), or no eatures(controls). Four thousand cells were seeded into wells containing the inserts and ater 4 or 8 days were prepared or scanning electronmicroscopy (SEM) or stained with (1) rhodamine-phalloidin; (2) either mouse antitalin or mouse antivinculin ollowed by rhodamine-antimouseantibodies; or (3) fuorescein-antiphosphotyrosine antibody.

Results: By day 4, the 3T3 cells had adhered to all substrates, and by day 8 they showed considerable growth in places approachingconfuences. There was no predominant orientation or shape in cells grown on control suraces. Their cytoplasms showed diuse rhodaminestaining; demonstrable stress bers were absent. Focal adhesions and phosphotyrosine were diusely distributed. Cells grown on 8 or 12mgrooved substrates were nearly uniormly oriented in the direction o the grooves. Cells cultured on 8m grooves mostly grew atop the ridges,oten bridging the troughs between ridges. Cells cultured on 12m grooves mostly grew either atop the ridges or within the troughs, onlyinrequently bridging the troughs between ridges. Some cells demonstrated limited evidence o stress bers ater 8 days in culture on thegrooved suraces. Focal adhesions and phosphotyrosine were limited to areas o cell-substrate contact; portions o cells spanning troughslacked ocal adhesions and phosphotyrosine. Cells grown on the posted suraces showed orthogonal arrays o microlaments that conormedto the intersecting troughs between posts; stress bers, however, were not observed. These cells either rested atop the posts or settled down

onto the posts, with the posts apparently displacing cytoplasm and limiting the distribution o microlament bundles to areas o basal contact.SEM observations conrmed that the posts penetrated the basal cell membrane surace, with the cell contents settling around the posts. Focalattachments and phosphotyrosine were similarly distributed in these cultures.

Discussion: This experiment demonstrated that parallel and intersecting grooves are capable o aecting the shape, orientation, cytoskeletalorganization, and distribution o ocal adhesions in 3T3 broblasts, extending our previous ndings o these eects in rat tendon broblasts.The role o extracellular matrix in guiding this process, while not characterized, is not discounted. The limitation o kinase activity by physicalsubstrate eatures is a novel nding and could shed light on mechanisms by which cell types respond dierentially to substrates. Ultimately,we hope to uncover phenotypic dierences in these properties between cell types that will direct the tissue response to implants in ways thatimprove the incorporation o and extend the unctional lie spans o the implants.

Acknowledgements: This work was aided by National Science Foundation SBIR phase I grant #9160684 and by Jersey City State College SBR

grant #220251. Microgeometry molds were prepared by the Cornell Nanoabrication Facility.

Cytological Characteristics o 3T3 Fibroblasts Cultured on

Micropatterned SubstratesJC Grew, SR Frenkel, E Goldwyn, T Herman, and JL Ricci.

Presented at the 24th Annual Meeting o the Society or Biomaterials.

April 22-26, 1998. San Diego, CA.


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CELLORIENTATION&

ORGANIZATION

Eects o Surace Microgeometry on Fibroblast Shape and CytoskeletonJC Grew, JL Ricci, AH Teitelbaum, JL Charvet.

Presented at the 23rdAnnual Meeting o the Society or Biomaterials.

April 30-May 4, 1997. New Orleans, LA.

ABSTRACTIntroduction: Surace microgeometry infuences tissue-implant interaction, although the interaction is poorly understood. Cellular contactguidance, a tissue response to surace microgeometry, prooundly infuences cell growth and other behaviors. For example, on groovedsuraces, groove depth and width minima are required to aect cell shape and orientation and the direction o growth. Cytoskeletal organizationrefects cell attachment, shape and orientation and likely contributes to these microgeometry-directed phenomena. We examined someproperties o broblasts cultured on simulated biomaterials with various surace microgeometries. We studied rat tendon broblast (RTF)cells, because human brous tissue cells are among the rst cells to contact implants. Fibrous implant encapsulation is infuenced by suraceroughness and microgeometry: roughening promotes thinner capsule development and, thereore, more intimate contact o bone cells andtissue with the implant and improved implant integration.

Methodology: RTFs rom stock cultures derived rom hind oot extensor tendons were grown on smooth (control) and patterned polystyrenesubstrates having parallel 2 or 12m linear grooves or 8x50 or 80x50m diamond-shaped islands separated by 3x3m grooves. Substrateswere solvent-cast on silicon molds and titanium oxide coated. Fiteen millimeter circular cutouts were tted into 24-well plates, and wellscontaining inserts were seeded with 20,000 RTFs and xed ater 4 and 8 days in culture. Cell morphology was studied and recorded byscanning electron microscopy and by fuorescence microscopy o cultures stained with rhodamine phalloidin and anti-vinculin ollowed by afuorescein-conjugated secondary antibody.

Results: The orientations and shapes o RTFs grown on control and patterned suraces were consistently dierent. Cell orientation tendedto be random in control cultures, but generally coincided with the directions o the linear grooves and the longer dimensions o the diamonds.RTFs grown on 2m grooved and diamond-patterned substrates oten bridged the grooves, attaching to elevated substrates. RTFs grownon 12m grooves grew both within the grooves and on elevated suraces, but rarely bridged grooves. RTFs grown on the larger diamond-patterned substrate oten grew in clusters on elevated areas. RTFs grown on control suraces were approximately round and symmetrical,extending short processes omnidirectionally rom a central cell mass. RTFs grown on linear substrates more typically assumed a spindle shape,and extend processes perpendicular to the grooves only when spanning a narrow (2 or 3m) groove or to establish lateral contact with groovewalls (12m grooves). Substrate microgeometry also aected the organization o microlament bundles (stress bers), which were alignedwith the predominant direction o cellular orientation in cells grown on the patterned substrates. RTFs rom control cultures typically showed

microlament bundles extending at miscellaneous angles throughout the cell cytoplasm. In all cells, vinculin was localized at microlamentbundle termini, as revealed by imunofuorescence microscopy, indicating points o cell-substrate attachment consistent with the presence oocal attachments.

Conclusions: This study showed that both the linear and diamond patterns are capable o infuencing the orientation and cytoskeletalorganization o broblast cells, extending previous observations o contact guidance eects based on substrate microgeometry on cell shapealteration and directional growth. RTFs, which vary rom 3 to 10m in width, requently bridged 2 and 3m grooves, suggesting that morepronounced surace eatures may be required to optimally control the growth o these cells. The results o this experiment dier romearlier reports o the growth o dot cultures prepared with cells suspended in a collagen gel. Seeded cultures appear to be less sensitiveto microgeometry eects than dot cultures. Outgrowing dot culture cells probably migrate considerable distances across substrate suraces.Grooves may thus serve as more substantial guides to migrating dot culture cells than to cells in seeded cultures, which settle and thereaterremain stationary. Continued experimentation and comparison o these models, particularly in cellular attachment to substrates, will yieldadditional insight into the behaviors o these cells on patterned substrates. For instance, it may prove possible to control the rate and directiono brous tissue growth at the tissue-implant interace, thereby optimizing the stability o these implants.

Acknowledgements: This work was aided by NSF SBIR phase I grant# 9160684. Microgeometry molds were prepared by the Cornell

Nanoabrication Facility.


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1. Implant success rate is the weighted average o all published human studies on BioHorizons implants.

These studies are available or review in this document and BioHorizons document number ML0130.

2. Human Histologic Evidence o a Connective Tissue Attachment to a Dental Implant. M Nevins, ML Nevins,

M Camelo, JL Boyesen, DM Kim. International Journal o Periodontics & Restorative Dentistry. Vol. 28, No. 2, 2008.

3. The Eects o Laser Microtextured Collars Upon Crestal Bone Levels o Dental Implants. S Weiner, J Simon,

DS Ehrenberg, B Zweig, JL Ricci. Implant Dentistry, Volume 17, Number 2, 2008. p. 217-228.

4. Clinical Evaluation o Laser Microtexturing or Sot Tissue and Bone Attachment to Dental Implants. GE Pecora,

R Ceccarelli, M Bonelli, H Alexander, JL Ricci. Implant Dent. 2009 Feb;18(1):57-66.

5. Radiographic Analysis o Crestal Bone Levels on Laser-Lok Collar Dental Implants. C Shapo, B Lahey,

P Wasserlau, D Kim. Int J Periodontics Restorative Dent 2010;30:129-137.

6. The eects o laser microtexturing o the dental implant collar on crestal bone levels and peri-implant health.

S Botos, H Youse, B Zweig, R Flinton and S Weiner. Int J Oral Maxilloac Implants 2011;26:492-498.

7. Marginal Tissue Response to Dierent Implant Neck Design. HEK Bae, MK Chung, IH Cha, DH Han.

J Korean Acad Prosthodont. 2008, Vol. 46, No. 6.

8. Bone Response to Laser Microtextured Suraces. JL Ricci, J Charvet, SR Frenkel, R Change, P Nadkarni,

J Turner and H Alexander. Bone Engineering (editor: JE Davies). Chapter 25. Published by Em2 Inc.,

Toronto,Canada. 2000.

9. Osseointegration on metallic implant suraces: eects o microgeometry and growth actor treatment.

SR Frankel, J Simon, H Alexander, M Dennis, JL Ricci. J Biomed Mater Res. 2002;63(6): 706-13.

10. Surace Topography Modulates Osteoblast Morphology. BD Boyan, Z Schwartz .

Bone Engineering (editor: JE Davies). Chapter 21. Published by Em2 Inc., Toronto, Canada. 2000.

11. Eects o titanium surace topography on bone integration: a systematic review. A Wennerberg,

T Albrektsson. Clin Oral Implants Res. 2009 Sep;20 Suppl 4:172-84.

12. Histologic Evidence o a Connective Tissue Attachment to Laser Microgrooved Abutments: A Canine Study.

M Nevins, DM Kim, SH Jun, K Guze, P Schupbach, ML Nevins.

International Journal o Periodontics & Restorative Dentistry. Vol. 30, No. 3, 2010.


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BioHorizons, Laser-Lok, MinerOss, Autotac and Mem-Lok are registered trademarks o BioHorizons IPH, Inc. Zimmer and Screw-Ventare registered trademarks oZimmer, Inc. Graton DBM and LADDEC are registered trademarks o Osteotech, Inc.AlloDerm and AlloDerm GBR are registered trademarks o LieCell Corporation.

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