Lasers Med Sci (2017) 32:1197–1206

DOI 10.1007/s10103-017-2217-7

REVIEW ARTICLE

In vitro biological outcome of laser application for modification

or processing of titanium dental implants
Ahmed Hindy 1 & Farzam Farahmand 2 & Fahimeh sadat Tabatabaei 1,3

Received: 29 October 2016 / Accepted: 19 April 2017 / Published online: 27 April 2017
# Springer-Verlag London 2017

Abstract There are numerous functions for laser in modern Keywords Biocompatibility . Biological response .
implant dentistry including surface treatment, surface coating, Differentiation . Laser . Surface modification . Surface
and implant manufacturing. As laser application may poten- coating . Titanium dental implants
tially improve osseointegration of dental implants, we system-
atically reviewed the literature for in vitro biological responses
to laser-modified or processed titanium dental implants. The Introduction
literature was searched in PubMed, ISI Web, and Scopus,
using keywords Btitanium dental implants,^ Blaser,^ Developing materials that are physically and biologically
Bbiocompatibility,^ and their synonyms. After screening the compatible with alveolar bone remains a challenge in dental
136 references obtained, 28 articles met the inclusion criteria. implant design. Titanium is commonly used in dental implant
We found that Nd:YAG laser was the most commonly used manufacturing due to their proper physical properties.
lasers in the treatment or processing of titanium dental im- Titanium oxide forms a dense, protective, and strongly adher-
plants. Most of the experiments used cell attachment and cell ent layer over dental implants, which is called the passive film,
proliferation to investigate bioresponses of the implants. The and is excellent in resisting corrosion [1–4]. Under optimal
most commonly used cells in these assays were osteoblast-like conditions, bone differentiation occurs directly adjacent to
cells. Only one study was conducted in stem cells. These the implanted material. This process is called osseointegration
in vitro studies reported higher biocompatibility in laser- and is the direct structural and functional connection between
modified titanium implants. It seems that laser radiation plays living bone and load-carrying dental implant surfaces and is
a vital role in cell response to dental implants; however, it is the main requirement for long-term success of dental implants
necessary to accomplish more studies using different laser [5, 6]. Surface topography, chemistry, degree and scale of
types and parameters on various cells to offer a more conclu- roughness, and wettability can modify cellular behaviors such
sive result. as adhesion, proliferation, differentiation, and migration dur-
ing the osseous healing period and can promote
osseointegration [7, 8].
Although titanium dental implants have high clinical suc-
* Fahimeh sadat Tabatabaei cess rates [9], multiple approaches have been developed dur-
[email protected]; [email protected]
ing the last few decades to enhance physical and chemical
1
aspects of osseointegration and to reduce the duration of its
Department of Dental Biomaterials, School of Dentistry, Shahid
Beheshti University of Medical Sciences, Evin, Tehran 1983963113,
formation. Surface-roughened implants and ceramic coatings
Iran are well-established practices while three-dimensional (3D)
2
Department of Mechanical Engineering, Sharif University of
printing remains an experimental technique [6, 7, 10–15].
Technology, Tehran, Iran Several studies have suggested that the roughness of titanium
3
Department of Tissue Engineering, School of Advanced
dental implants can promote cytocompatibility, enhance sur-
Technologies in Medicine, Shahid Beheshti University of Medical face area of implants adjacent to bone cells, and increase bio-
Sciences, Tehran, Iran chemical interaction of implants with bone osteoblasts [14,
1198 Lasers Med Sci (2017) 32:1197–1206

16–18]. Compared to 2D surface roughness, porous implants titanium surface), AND biocompatibility (OR in vitro
decrease stress shielding and increase bone-implant bioresponse OR cell activity). Subsequently, each article’s ref-
interlocking such that a high porosity implant that mimics erences were reviewed to identify other relevant articles.
natural tissue is capable of stimulating osteoblast differentia- This systematic review assessed whether laser enhanced
tion [19, 20]. Gradient porosity is another important issue in the in vitro biological response of titanium dental implants.
producing dental implants. It confers reactive properties to the Table 1 outlines the questions that were addressed with refer-
implant surface and decreases its modulus of elasticity to ence to participants or population (P); intervention (I); com-
match that of bone [21]. Three-dimensional printing gives parison, control, or comparator (C); outcome (O); and study
the chance to directly produce dental implants with different design (S) (PICOS elements).
shapes, textures, and gradient of porosity and also minimize
post-processing requirements [22].
Nowadays, investigators use laser irradiation for sur- Inclusion criteria
face or structural modification of dental implants.
Applications of laser are versatile and laser can be used Titanium dental implants which had been treated/coated by
to heat, melt, or vaporize materials based on the type of use of laser or processed using laser were included. There
laser used [1]. Laser application for various purposes de- was no distinction made with regard to the grade of titanium,
pends on properties such as direction, divergence, wave- type of laser, or parameters of laser. In vitro studies which
length, and frequency of laser beam, which can be adjust- reported some measures of biological responses as an out-
ed by the laser components [13]. Considering the impor- come were included. Interventions based on combinations of
tance of cell-implant interaction on the success rate of laser and other modalities such as ceramic coating or growth
dental implants, the effect of laser on biological properties factors were also considered for review.
of dental implants has gained interest. The aim of this
review was to analyze the influence of laser treatments Exclusion criteria
of uncontaminated titanium implant surfaces on in vitro
behavior of cells (cellular morphology, cell adhesion, vi- Studies carried out on animal models and studies other than
ability, proliferation, and differentiation). Furthermore, the in vitro’s were excluded. Publications in languages other than
in vitro biological responses as the outcome of the laser English were excluded. In vitro studies on contaminated implants
application in surface coating were evaluated. Lastly, spe- in which disinfection of the implant surface was stimulated by
cial attention was focused onto the laser application in laser were excluded. Similarly, studies on zirconia implants, or-
additive manufacturing of titanium dental implants to de- thopedic implants, and those on abutments were excluded.
termine whether this new technology is as good as or
better than other tools for supporting cell growth.
Selection of studies and quality assessment

Two trained reviewers (A.H. and F.T.) performed independent

Materials and methods searches, assessed publication validity, and extracted the data in
duplicate. Disagreements were resolved by discussion, reread-
Search strategy ing, and consultation with the third member of the research
team (F.F.) when necessary. All citations were imported into
We searched PubMed, ISI Web, and Scopus databases to find an electronic database (EndNote). The quality rating of studies
relevant articles published between 2000 and 2016 using the was based on comprehensiveness and reproducibility of the
following keywords: laser, AND modification (OR process- methodology, the use of standard methods to appraise the bio-
ing, melting, coating), AND titanium dental implants (OR logical response, and the absence of apparent bias in results.

Table 1 PICOS format of the

question used in this systematic Component Description
review
Population Studies of titanium dental implants and the use of laser
Intervention Laser application for surface treatment, surface coating, or manufacturing of dental implants
Comparison Different types of laser that were used (pulsed vs continuous and types of laser device)
Outcome Cell behavior on the surface of dental implants
Study design In vitro studies
Lasers Med Sci (2017) 32:1197–1206 1199

Table 2 Studies on surface modification of dental implants with laser

Author Ti type Laser type Cell type Assay Result

1 Groessner-Schreiber Cp Ti grade II Nd:YAG, 50 J Mouse Cell spreading (SEM SEM showed cells cultured on laser-treated
et al. [23] fibroblasts and fluorescence titanium surfaces and on discs coated
(balb/3T3; microscopy) with TiN appeared to be stronger and
ATCC) MTT assay well spread and showed a polygonal
BCA protein assay shape, but differences in mean values
between cells cultured on polished,
oxidized, or laser-treated titanium discs
did not reach statistical significance.
2 Schwarz et al. [24] Cp Ti Er: YAG laser at an SAOS-2 cells Cell count Discs treated with laser demonstrated
energy level of nearly the same cell count as the
100 mJ/pulse and untreated surfaces
10 Hz
2 Hao et al. [25] Ti6Al4V 1.5-kW high-power diode Human Cell attachment, MTT Favorable cell response was observed on
laser osteoblastic assay the HPDL laser-treated Ti6Al4V alloy
cell line than on either un-treated samples or a
hFOB 1.19 mechanically roughened samples
3 Lawrence et al. [26] Ti6Al4V Nd:YAG, 200 W Human LDH, cell adhesion, Cell adhesion and proliferation on
osteoblastic MTT assay laser-treated samples was considerably
cell line better than those on untreated samples.
(hFOB 1.19)
4 Biswas et al. [13] Ti6Al4V 1.5-kW continuous wave L-929 (mouse MTT assay Cell counts on laser-treated surfaces
(CW) diode laser fibroblast cell exceeded those of the positive control.
line) Highest numbers were observed on
laser-nitrided surfaces, and lowest
numbers were observed on laser-melted
surfaces.
5 Ulerich et al. [12] Ti6Al4V Nd:YVO4 laser Human Cell growth Cell growth exhibited a greater density and
(355 nm), (0–300 μJ) osteosarcoma (fluorescence a greater degree of cell alignment, which
[27] cells imaging led to contact guidance, but higher
microscope) energy and greater roughness resulted in
a much larger number of cells covering
multiple grooves.
6 Heinrich et al. [28] Plasma-sprayed KrF excimer laser, Fibroblast Cell attachment Improved cell attachment to the laser hole
Ti implants (248 nm), energy ESEM boundary.
density 15–17 J/cm2
7 Erdogan et al. [29] Ti6Al4V Nd laser, 1060 and Saos-2 Cell attachment, and Cell attachment and proliferation on
1035 nm, 1 W cell count picosecond-laser-textured surfaces are as
good as commercially available surfaces
(sandblasting, acid etching, and the SLA
method)
8 Dolores Paz et al. Ti6Al4V Nd:YAG (1064 nm), Human fetal Cell proliferation, Laser macrostructuration alone did not
[30] 6.19 J/cm2 osteoblastic ALP activity promote cell response. However, UV
ArF excimer lasers cell line (Hfob laser oxidation enhanced cell
2
(193 nm) 240 mJ/cm 1.19) proliferation.
9 Ayobian-Markazi SLA titanium Er:YAG, 2940 nm, pulse Sarcoma Cell attachment, MTT Significant differences were noted in
et al. [31] energy 60–100 mJ osteogenic assay proliferation and viability between the
(SaOs-2) experimental and control groups, but the
difference in the mean MTT score did
not reach statistical significance.
10 Györgyey et al. [32] Cp Ti grade IV Doubled Q-switched Osteoblast-like Cell attachment (AB), MTT, AB, and ALP methods did not reveal
Nd:YAG 532 nm, MG-63 MTT, ALP any significant differences between
1–1.5 J/cm2, KrF laser-ablated surfaces and the controls,
excimer laser (248 nm, although cells were more homogenously
2
0.4–0.6 J/cm ) spread in laser-treated disks.
11 AyobianMarkazi SLA titanium Er:YAG, 2940 nm Sarcoma MTT assay Significantly higher cell viability was
2
et al. [27] 12.8 J/cm , pulse energy osteogenic observed in the test group.
up to 500 mJ (SaOs-2)
12 Chikarakara et al. Ti6Al4V 1.5-kW CO2 laser BALB 3T3 cells Cell viability assay, Laser-treated surfaces promoted cell
[33] (mouse MTT assay, attachment and proliferation and
embryonic Hoechst 33258 enhanced bioactivity compared to
fibroblast cell DNA assay, AB untreated samples.
line) assay
13 Vignesh et al. [34] Cp Ti grade II Nd:YAG, Q-switched L929 murine Cell attachment Laser-treated surfaces showed strong cell
laser; 1.5–4.5 J/cm2 fibroblasts adhesion and spread widely and had
denser cell growth compared to
machined or acid-etched surfaces but did
not have any particular orientation to
particular surfaces.
14 Mariscal-Muñoz Cp Ti grade IV Yb:YAG Mouse calvarial MTT assay, alizarin Laser treatment of surfaces induced
et al. [15] 1064 nm; average pulse osteoblasts red assay, ALPase calcified nodules, stimulated ALPase,
power of 10 kW (primary cell) activity, real-time decreased cell proliferation, and
PCR upregulated osteoblastic gene
expression
1200 Lasers Med Sci (2017) 32:1197–1206

Table 2 (continued)

Author Ti type Laser type Cell type Assay Result

15 Mukherjee et al. [35] Ti6Al4V Yb continuous wave fiber MG63 cells MTT, ALP activity, The sample with the lowest wavelength and
laser, different laser cell spreading highest duty cycle proved to be the best.
frequency, and duty
cycle
16 Hsiao et al. [36] Ti6Al4V, ArF excimer 355 nm, MC3T3 Cell growth Potential growth of both fibroblasts and
HA-coated Ti pulse energy 150 μJ osteoblast (immunofluores- bone cells
implant, precursor cence)
cells,
fibroblasts

Cp Ti commercially pure titanium, Nd:YAG neodymium-doped yttrium aluminum garnet, CO2 carbon dioxide, CW continuous-wave, Er:YAG erbium-
doped yttrium aluminum garnet, Nd:YVO4 neodymium-doped yttrium orthovanadate, ATCC American Type Culture Collection, BCA bicinchoninic
acid, TiN titanium nitride, HFOB human fetal osteoblastic cells, HPDL high-power diode laser, LDH lactate dehydrogenase, KrF krypton fluoride laser,
MG-63 osteosarcoma cell line, PCR polymerase chain reaction, Yb ytterbium-doped, HA hydroxyapatite, Saos-2 sarcoma osteogenic cell line, MTT
dimethylthiazol-diphenyl tetrazolium bromide, SEM scanning electron microscopy, ESEM environmental scanning electron microscope, FL fluores-
cence microscopy, VM video microscope, AB Alamar Blue, ALP alkaline phosphatase activity, SLA sandblasted large-grit acid etch, PCR polymerase
chain reaction

Data extraction such as surface roughness and deformation and assist coating
of biomaterial surfaces [49]. Some advantages of laser include
We extracted data from different scenarios: (1) studies generation of complex features with high resolution, high de-
reporting surface modification or treatment of dental implants gree of purity [50], suitability for selective changes in implant
with laser, (2) studies reporting laser-assisted titanium coating, surfaces, and its precision [51, 52]. Regulation agencies such
and (3) studies reporting laser-based manufacturing of titani- as the Food and Drug Administration in the USA require
um dental implants. Given the heterogeneity of the dose, type biocompatibility testing per ISO 10993 (International
of laser, and type of cells, no statistical analysis was used to Standard Organization: Standard for Biological Evaluation
synthesize the data. of Medical Devices) or ASTM F748 (American Society for
Testing of Materials: Standard Practice for Selecting Generic
Biological Test Methods for Materials and Devices) prior to
device approval. Consequently, there is a need to carry out
Results
biocompatibility testing for any new material or processing
method [53].
The initial search identified 332 articles, 136 of which were
In vitro experiments are the first step in biocompatibility
chosen after screening their titles and abstracts. After retriev-
testing of new materials by the observation of viability and
ing the articles’ full texts, 28 were included in this systematic
biofunctionality of cells on a material surface; therefore, in
review. Sixteen articles studied surface modification or treat-
this review, we focused on the in vitro biological responses
ment using laser, while six articles studied laser-assisted coat-
of dental implants processed with laser as a new processing
ing, and another six were different articles that studied using
method. Based on our review, the most common in vitro as-
laser for manufacturing titanium dental implants. All 29 arti-
says were MTT assays, cell attachment, proliferation, and cell
cles were in vitro studies published between 2000 and 2016.
counting.
Tables 2, 3, and 4 summarize the results according to the
This review was limited to the study of titanium and its
technique that was utilized.
alloys since titanium is used commonly in dental implants,
and there are many studies of the long-term outcomes of tita-
nium dental implants. Most of the studies reviewed in this
Discussion article used Ti6Al4V alloy, and only nine studies used Cp Ti.
It has been demonstrated that bone cell interactions are mainly
Today, biocompatibility is a grand area of concern in dental determined by the chemistry of the substrate, the structure of
biomaterial properties. Most dental implants support cell at- the implanted material, and the production method. However,
tachment by conferring suitable areas for cell adhesion [48]. the topography of the surface is more important in cell behav-
Laser offers a high energy that can be applied to modify sur- ior than the chemistry of implant material or the processing
faces made of different materials and to produce three- method [54], although it should be noted that these effects are
dimensional nano- and microstructures. It is used in different difficult to separate as they are interrelated [48].
surface modification techniques because of its ability to rap- Surface modification of titanium with laser can promote
idly and effectively induce physical and/or chemical changes micron-level surface texturing, increase the surface area, and
Lasers Med Sci (2017) 32:1197–1206 1201

Table 3 Studies on laser-assisted coating of dental implants

No. Author Ti type Laser type Coat material Cell type Test Result

1 Lusquinos Ti6Al4V Nd:YAG TCP MG-63 AB Cells on TCP coat exhibited a significantly higher
et al. 1064 nm, osteoblast-like MTT assay proliferation rate, but in longer periods of time, no
[37] 2 kW/cm2 cells statistically significant differences were observed.
2 Seydlova Ti6Al4V KrF excimer ZrO2 3T3 murine line Monoclonal Laser-coated surfaces were not cytotoxic. Fibroblast
et al. 248 nm 450 mJ, interlayers, fibroblasts, antibody cell morphology did not change, and rapid cell
[38] ArF excimer HA coat human dermal (fluorescence proliferation resulted in almost confluent growth.
193 nm fibroblasts microscope)
330 mJ MTT assay
3 Teuberova Ti6Al4V KrF excimer ZrO2 buffer Human embryonal Cell count PLD zirconia/HA coating can promote the growth of
et al. laser 248 nm, layer, HA lung fibroblasts MTT assay fibroblasts as a biomimetic coating.
[39] 4 J cm−2 coat (LEP19)
4 Bose et al. Cp Nd:YAG TCP Osteoblastic Cell attachment Laser TCP coat and titania nanotube surfaces showed
[40] 99.8% 400–500 W precursor cell ALP (CSLM) good cell attachment, high cell proliferation, and
line (OPC1) MTT assay early differentiation.
5 Gao et al. Cp Ti 5 kW CW CO2 CaP Osteoblasts RT-PCR Cell growth showed significantly higher optical density
[41] laser MTT assay and TGβ1 mRNA expression, and BMP2 was
Cell morphology significantly upregulated, resulting in better surface
(SEM) cytocompatibility
6 Oyane Cp Ti Excimer CaP Chinese hamster Cell adhesion Cell adhesion assays indicated that laser Ti surface CaP
et al. 355 nm, ovary-K1 cells assay biofunctionalization enhanced cell adhesion.
[42] 4 W/cm2

CaP calcium phosphate, TGβ1 transforming growth factor β1, mRNA messenger RNA, BMP2 bone morphogenetic protein 2, TCP tricalcium phos-
phate, ZrO2/HA zircon oxide/hydroxyapatite, CaP calcium phosphate, PLD pulsed laser deposition, CSLM confocal scanning laser microscopy

significantly enhance micromechanical properties of titanium the biocompatibility of the titanium surfaces compared with a
dental implants [13, 55]. Laser can also modify the surface smooth surface [34, 55–57], depending on the type of laser
roughness as well as the physical and chemical properties and and the parameters used [58, 59], as well as the contamination

Table 4 Studies on manufacturing dental implants using laser

Author/year Ti type Laser Cell type Test Result

1 Hollander Ti6Al4V Nd: YAG laser Human XTT assay, enzymatic High growth of human osteoblasts on laser prepared
et al./2006 primary photo-metric construct. DLF Ti6Al4V guides osteoblast-specific
[43] osteoblasts assay(alkaline differentiation.
(HOB) phosphatase)
2 Xue Cp Ti Nd:YAG Osteoblast MTT assay, cell Evidence of cell proliferation, adhesion, and
et al./2007 1064 nm, precursor morphology (SEM) differentiation. Proliferation was improved, with
[44] 250–300 W cell line 1 obvious ALP production
(OPC1)
3 Mangano Ti6Al4V Ytterbium fiber Primary Cell culture Conducive to cell attachment and proliferation
et al./2009 laser osteoblasts SEM
[45] 1054 nm, 200 W
4 Mangano Ti6Al4V Ytterbium fiber DPSCs Adhesion assays, PCR Better and quicker osteoblast differentiation of DPSCs,
et al./2010 laser system analysis and bone morphogenetic protein production was
[22] 1054 nm, ELISA obtained in laser-sintered titanium.
200 W PCR
5 Shishkovskii Cp Ti/HA Nd:YAG Human dermal Cell adhesion assay; cell Not cytotoxic, pronounced cell adhesion with a high
et al./2012 GA- 1064-nm laser fibroblasts count density of cells. The cells retained their structural and
[46] P85d, proliferative activity. HAP did not significantly affect
nitinol the behavior of fibroblasts.
6 Cheng Ti6Al4V Ytterbium fiber MG63 human DNA content and total 3D constructs with the highest porosity and surface
et al./2014 laser osteoblast-- protein content, ALP, modification supported the greatest osteoblast
[47] 1054 nm, 200 W like cell cell adhesion differentiation

DLF direct laser forming, DPSCs dental pulp stem cells, GAP85d a grade of hydroxyapatite, HAP hydroxyapatite, DNA deoxyribonucleic acid, SEM
scanning electron microscopy, XTT assays (colorimetric assay based on the oxidation of the tetrazolium derivate XTT by vital cells), SBF simulated body
fluid, OM optical microscopy, ELISA enzyme-linked immunosorbent assay, MMSC multipotent mesenchymal stromal cells, OPC1 osteoblast precursor
cell line 1
1202 Lasers Med Sci (2017) 32:1197–1206

control [60]. Laser adjusts the titanium oxide layer and im- of such discrepancies. It seems that surface features di-
proves biocompatibility [12, 13, 33, 36, 61]. Assessment of mensionally closer to the cell dimensions are able to pos-
surfaces for roughness, microhardness, and phase develop- itively affect the viability and spreading of cells [35].
ment after melting with laser showed titanium oxide forma- Alkaline phosphatase activity and gene expression were
tion, which has a sterilizing effect and provides a contaminant- assays used in six studies to investigate osteogenic differ-
free surface that can effectively enhance biocompatibility [33, entiation of cells.
56]. In order to enhance the integration of titanium into living
The laser parameters play an important role in determining tissues, researchers have used laser to coat implant with ma-
bioresponses [62]. The main parameters related to processing terials such as bioactive ceramics that imitate bone [41, 42,
include laser power and peak power for continuous wave 68]. Surface modification with laser, in association with bio-
(CW) and pulsed lasers, respectively, as well as laser spot mimetic coating, shortens implant healing period by increas-
diameter [63]. The main advantage of pulsed lasers compared ing bone implant interaction [39]. Cell adhesion assays indi-
with CW lasers is the ability to deliver high peak power in a cate that laser Ti surface CaP biofunctionalization enhances
short pulse length, resulting in effective melting with a small cell adhesion to the surface and provides osteoconductivity
heat-affected zone [64]. In contrast, evaluation of the process- [42]. Also, Nd:YAG laser-assisted nitride titanium surface
ing window for pulsed lasers is more troublesome because (TiN) treatment appears to support tissue growth on the sur-
peak power, pulse width, and frequency need to be optimized. face of dental implants [23]. The Q-switched Nd:YAG laser
One study showed that the best parameters for using selective titanium surface microscale patterning plays a significant role
laser melting with pulsed laser were a scan speed of 6 mm/s, in enhancing metal-ceramic bond strength and is a promising
laser peak power of 1 kW, and hatching pitch of 0.4 mm, method for manufacturing dental implant biomaterial with
yielding a tensile strength of 300 MPa and torsional fatigue high osteoconductivity, cell growth, and differentiation and
strength of 100 MPa [63]. As we summarized in tables, dif- better adherence to bone surfaces compared to oxidized tita-
ferent laser devices were used in different studies. It seems that nium surfaces [69]. Commercially available dental implants
the power or energy used depends on the desired effect (melt- coated by pulsed laser deposition demonstrate uniform coat-
ing vs surface texturing or coating). ing thickness around the corners and sidewalls of implants
The growth and differentiation of osteoblasts are essen- [42, 70, 71].
tial for the regeneration of bone around dental implants. Surface treatment and coating of dental implants could
This may explain the greater use of osteoblast-like cells in be further customized with additive manufacturing. Some
biocompatibility investigation. However, it appears that additive manufacturing techniques use laser as energy
cell type does not play a great role in determining the source for printing with high accuracy and maneuverabil-
biological response of laser-processed dental implants as ity [21, 43, 72–74]. Laser additive manufacturing is a
most of the articles showed that biofunctionalization with scalable manufacturing method that can create complex
laser led to higher levels of cell bioactivity, proliferation, structures with high dimensional accuracy and controlla-
and attachment to titanium surfaces [33, 65]. Observation ble density and reduce material waste. It also provides the
of Alamar Blue proliferation assay measurements showed ability to produce costume made dental implants with en-
positive cellular metabolic activity [37] while MTT assays hanced osseointegration [73]. Titanium dental implants
showed an increase in the number and viability of cells are made by laser-forming techniques such as laser
[27, 31–33]. Also, creation of hybrid nano- and micro- sintering and laser melting. Laser sintering is an efficient
scale titanium surface roughness by laser treatment allows method, which meets the required micromechanical and
stimulation of osteoblast differentiation and bioactivity to surface criteria for dental implant biomaterials. It is better
form mineralized zones [15] and improves the bone re- adapted to the elastic properties of bone and minimizes
sponse to the laser-modified titanium surfaces [66, 67]. stress-shielding effects while improving long-term perfor-
The main mechanism governing the cell adhesion on the mance [21, 43, 75]. One advantage of laser melting is the
laser-treated groups could be change of the wettability ability to fabricate parts with controlled porosity. Implants
characteristics [25]. However, Györgyey et al. did not find manufactured by this technique have a porous surface
any significant differences in cell bioactivity or attach- structure that increases bone osseointegration and a com-
ment between laser-treated and controlled groups. In their pact core that enhances mechanical strength [76]. Three-
study, they used osteogenic sarcoma cells (SaOs-2) treated dimensional laser synthesized porous titanium constructs
with Er:YAG laser (60–100-mJ pulse energy) [32]. have improved cell bioactivity and stimulate osteoblast
Ayobian-Markazi et al., also found that the difference be- differentiation and maturation. Osteoblasts retain their
tween laser-treated and controlled groups in the mean structural proliferative activity activated by high-porosity
MTT score did not reach statistical significance [31]. laser additive manufacturing [22, 46, 77]. Bone shows
Variations in the irradiation protocols could be the cause active growth into the intricate porous structure of
Lasers Med Sci (2017) 32:1197–1206 1203

titanium implant surface with no signs of inflammation, but not porous, surface) and concluded that porous dental
indicating high compatibility of the titanium implants [63, implants produced by laser sintering showed better biocom-
77]. Enhanced bone growth and osseointegration into the patibility [80]. It seems that laser engineered net shaping to
surface with adequate micro- to nanoroughness support construct porous structures from Ti6Al4V alloy across the
osteoblastic differentiation and increase the production range of 23–32% porosity with low modulus (7–60 GPa),
of local factors important for creating an osteogenic envi- which can be tailored to match human cortical bone [81].
ronment [78]. The studies reviewed in this article may have been incon-
The main lasers used in metal forming or manufactur- sistent with regard to laser parameters disclosed. This can
ing of titanium dental implants include 1054 nm Yb- make the studies heterogeneous and difficult to compare, even
doped fiber laser system and 1064 nm Nd:YAG, with an if lasers with the same wavelength were used.
average power of 200–300 W [44, 45]. Nd:YAG laser In addition, studies of in vitro biocompatibility of laser-
creates efficient constructs with functionally graded com- processed dental implants are limited in number. More re-
plex structures and costume-made dental implants with search is needed to investigate the effect of cell type, laser
high chemotaxis for cells that stimulate osteoblast differ- type, and laser power on biocompatibility and functionality
entiation and maturation and are activated by high poros- of titanium dental implants that are manufactured by a range
ity laser additive manufacturing [21, 22, 43, 44, 46, 63, of additive and advanced manufacturing technologies that are
73, 74, 78]. Hollander and colleagues in their study on available.
porous blasted direct metal laser-sintered (DMLS) speci-
mens demonstrated that DMLS-fabricated Ti6Al4V
allowed structure-oriented growth of human osteoblasts Conclusions
on its surface. In their study, the biocompatibility of se-
lective laser melting (SLM) Ti-64 material was also stud- In the present review, an attempt was made to summarize
ied. Comparisons were made between SLM surfaces and in vitro biological outcome of different applications of laser
commercially available Thermanox® (Nalge Nunc Int., technology in titanium dental implants (surface treatment,
New York, NY, USA) control and conventional bulk tita- assisted coating, and 3D construction). Based on the obtained
nium. The authors concluded that the increased metabolic results, the following conclusions can be drawn:
activity of osteoblasts on SLM discs compared to the con-
trols may have been due to the greater surface area of the – Almost, all examined surface modifications by laser
SLM material, which took longer to be covered by the were as good as or better than other treatments for
cells [43]. supporting cell attachment and growth. However, the
Mangano et al. seeded human dental pulp stem cells property of laser (type, wavelength, and time of radi-
(DPSCs) on direct laser-sintered titanium scaffolds and acid- ation) might affect the cell proliferation or at least the
etched surfaces. They observed that gene expression and pro- cell spreading.
tein secretion were faster on laser-sintered scaffolds [79]. – Laser-assisted coating of Ti dental implants might
These results were confirmed by another study on cell cul- produce uniform coating thickness around the corners
tures, where rat calvarial osteoblasts were seeded and cultured and sidewalls of implants and shorten the healing
on disc specimens produced by DMLS. Cell density was sim- period.
ilar to that of commercially available rough microtextured – Three-dimensional laser forming of titanium implants is a
surfaces but lower than that of machined and smooth- reasonable and effective technology to produce titanium
textured grit-blasted, acid-etched surfaces [45]. Finally, in an- constructs with controlled porosity, which can be further
other in vitro study, human osteoblasts and human DPSCs modified to enhance their biocompatibility.
were cultured either on acid-etched or DMLS titanium sur- – The environment or atmosphere that the titanium surface
faces, in order to investigate their osseointegration and clinical is modified in or coated in can affect the surface
applicability of the derived implants. When stem cells were characteristics.
exposed to DMLS titanium surface, osteoblastic differentia- – Laser type and parameters used in all three applications
tion of DPSCs and bone morphogenetic protein production examined may affect the dental implant’s biocompatibil-
occurred more quickly. These successful results suggest that ity outcome.
DMLS titanium surfaces may represent a promising alterna- – Diverse assays and cells have been used by various re-
tive for clinical use in implants [22]. searchers as biological assessment of laser application in
Witek et al. measured bone implant contact and removal implantology.
torque of dental implants that had a porous layer, which were
produced by laser sintering and compared them with Acknowledgments This study was supported by a grant from Iran
sandblasted acid-etched implants (i.e., those with a rough, National Science Foundation (Project no. 95819948).
1204 Lasers Med Sci (2017) 32:1197–1206

Compliance with ethical standards 19. Parthasarathy J, Starly B, Raman S, Christensen A (2010)
Mechanical evaluation of porous titanium (Ti6Al4V) structures
with electron beam melting (EBM). J Mech Behav Biomed Mater
Conflict of interest The authors declare that there is no conflict of
3(3):249–259
interest.
20. Sumner DR, Galante JO (1992) Determinants of stress shielding: design
versus materials versus interface. Clin Orthop Relat Res 274:202–212
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