Significance of photobiomodulation therapy in increasing stability of orthodontic mini-implants: a systematic review and meta-analysis

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1Kotryna Jasinskaitė, Abdulla Varoneckas, Urtė Mackevičiūtė

1Lithuanian University of Health Sciences

Abstract

Background and aim. Although OMIs made a huge progress in orthodontic treatment, occasional failures such as looseness of OMIs during treatment have not been avoided. Lately studies on photobiomodulation therapy (PBMT) showed its positive impact on stability of OMIs. The aim of this systematic review and meta-analysis was to estimate the impact of PBMT on the stability of OMIs.

Materials and methods. Electronic data base search was carried out according to PRISMA principles. PubMed, Research Gate, The Cochrane Library and Wiley Online Library were used to browse the literature. Statistical analysis was conducted with the Review Manager 5.4.1. A meta-analysis was performed by using Standartized mean difference and random effect. Heterogeneity of the studies was assessed using Cochran’s Q and I2 tests.

Results. After full-text analysis, 7 articles were included. All 7 studies were pooled into meta-analysis and quantitative synthesis was performed. Meta-analysis revealed that PBMT statistically increases OMI stability 1 and 2 months after OMIs were placed. No significant heterogeneity was found between respective studies.

Conclusion. Based on present meta-analysis, LLLT irradiation on OMIs increases their secondary stability and, therefore, could be implemented clinically as adjunctive therapy to promote secondary OMI stability. However, future randomly controlled studies with larger study groups are needed to further confirm the study results.

Keywords: “Laser therapy”, “Orthodontic anchorage”, “Mini-implants”.

https://doi.org/10.53453/ms.2021.06.6

Journal of Medical Sciences. Jun 30, 2021 - Volume 9 | Issue 5. Electronic - ISSN: 2345-0592
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Medical Sciences 2021 Vol. 9 (5), p. 53-63, https://doi.org/10.53453/ms.2021.06.6
Significance of photobiomodulation therapy in increasing
stability of orthodontic mini-implants: a systematic review
and meta-analysis
1
Kotryna Jasinskaitė, Abdulla Varoneckas, Urtė Mackevičiūtė
1
Lithuanian University of Health Sciences
Abstract
Background and aim. Although OMIs made a huge progress in orthodontic treatment, occasional failures
such as looseness of OMIs during treatment have not been avoided. Lately studies on photobiomodulation
therapy (PBMT) showed its positive impact on stability of OMIs. The aim of this systematic review and
meta-analysis was to estimate the impact of PBMT on the stability of OMIs.
Materials and methods. Electronic data base search was carried out according to PRISMA principles.
PubMed, Research Gate, The Cochrane Library and Wiley Online Library were used to browse the
literature. Statistical analysis was conducted with the Review Manager 5.4.1. A meta-analysis was
performed by using Standartized mean difference and random effect. Heterogeneity of the studies was
assessed using Cochran’s Q and I2 tests.
Results. After full-text analysis, 7 articles were included. All 7 studies were pooled into meta-analysis and
quantitative synthesis was performed. Meta-analysis revealed that PBMT statistically increases OMI
stability 1 and 2 months after OMIs were placed. No significant heterogeneity was found between
respective studies.
Conclusion. Based on present meta-analysis, LLLT irradiation on OMIs increases their secondary stability
and, therefore, could be implemented clinically as adjunctive therapy to promote secondary OMI stability.
However, future randomly controlled studies with larger study groups are needed to further confirm the
study results.
Keywords: “Laser therapy”, “Orthodontic anchorage”, “Mini-implants”.
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INTRODUCTION
Anchorage control in modern day
orthodontics has become highly demanding as
the traditional treatment modalities were
commonly associated with anchorage loss, for
instance, mesial migration of the posterior dental
anchorage units [1]. Even though extraoral
appliances in theory are somewhat efficient in
anchorage control, this way of treatment is highly
dependent on patients’ compliance and a
desirable tooth movement is not always
accomplished [2]. Therefore, an introduction of
orthodontic mini-implants (OMIs) as temporary
orthodontic anchorage devices has become an
essential part of orthodontic treatment [3, 4]. To
this day, OMIs are considered as the most
effective way to improve anchorage control [5].
OMIs are also praised for not only being
compliance-free, but also provides the
convenience of placement and removal, are low
invasive and low cost [6].
Nevertheless, even though OMIs have
made a huge progress in orthodontic treatment,
occasional failures, such as looseness of OMIs
during orthodontic treatment have been reported
[7]. This is a result of an absence of mechanical
stability, in other words, loss of primary or
secondary stability. OMI stability depends on
numerous contributing aspects, such as bone
density and thickness, OMI type and size
parameters, surgical technique, and patient’s
medical history [8]. In the current literature, one
way of improving OMI stability is
photobiomodulation therapy (PBMT). PBMT is
the term used to describe the
mechanistic/scientific basis for this photonic
specialty and PBMT as the term for its
therapeutic application [9]. Recent studies with
animals have proven, that PBMT has a promising
impact on the stability of OMIs [10]. Therefore,
the aim of this meta-analysis was to estimate the
impact of PBMT on the stability of orthodontic
mini-implants.
METHODS
Search strategy
Electronic data base search was carried out
according to PRISMA principles [11]. PubMed,
Research Gate, The Cochrane Library and Wiley
Online Library were used to browse the literature
with the following keywords: “Laser therapy”,
“Orthodontic anchorage”, “Mini-implants”.
Inclusion and exclusion criteria
Inclusion and exclusion criteria are displayed in
Table 1.
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Table 1. Inclusion/exclusion criteria
Inclusion
Exclusion
RCT studies
Retrospective studies, case reports, literature
reviews, meta-analysis
Published less than 5 years ago
Published more than 5 years ago
Written in English
Written in other language than English
Human subject
Animal studies, in vitro studies
Patients whose treatment required as a direct
anchorage device for distalization
Patients with previous orthodontic treatment
Follow-up at least of 2 months
Follow-up less than 2 months
Quality assessment
RoB2 tool was used to assess risk of bias and
general quality of included studies [12].
Following aspects were assessed: random
sequence generation, allocation concealment,
blinding of participants and personnel, blinding
of outcome assessment, incomplete outcome
data, selective reporting, other bias.
Statistical analysis
Statistical analysis was conducted with the
Review Manager 5.4.1. A meta-analysis was
performed by using Standartized mean
difference and random effect. Heterogeneity of
the studies was assessed using Cochran’s Q and
I2 tests.
RESULTS
1. Search results
The search process was depicted in Figure 1.
After an initial search in electronic databases,
194 articles were displayed. Then, after checking
the titles and abstracts for their relevancy, 26
articles were selected for full-text analysis.
Lastly, after full-texts, 7 articles were included
into meta-analysis. [13-19] 6 of the included
studies were randomly controlled trials and 1
[16] was quasi-experimental design study.
2. Characteristics of included studies
Characteristics of all 7 included studies are
described in Table 2 and Table 3. In total, 115
patients received a total number of 230. Mean
age of the patients in the included studies ranged
from 16.77 to 31.7 years. In 3 of the studies
resonance frequency analysis was used to
determine OMI stability, while in 4 of the studies
PerioTest was used. Follow-up in the included
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studies ranged from 2 months to 3 months. In the
included studies, wavelength of the lasers ranged
from 618nm up to 940nm. Power of lasers ranged
from 100mw to 1700mw, while density ranged
from 20 to 360 mw/cm
2
. Number of sessions
ranged from 4 to 21.
3. Quality assessment
By ROBINS-I tool, all three publications had a
low risk of incomplete outcome data and
selective reporting bias. Only one study had high
risk of random sequence generation bias. Risk of
allocation concealment bias was high in four
studies. In two studies risk of blinding of
participants and personnel bias was unclear and
in one was high. Risk of blinding of outcome
assessment was not clear in three out of seven
publications. All studies had low risk of other
bias. Overall, three studies had low, two
publications had moderate and two had high risk
of bias. Process of study quality assessment is
showed in table 3.
4. Quantitative synthesis of results
The meta-analysis indicated no significant
difference in OMI stability between PBMT and
control group at the baseline (SMD (standardized
mean difference)=0,09, 95% CI=-0,18, 0,37;
p=0,51) and after 6-7 days post-insertion
(SMD=-0,01, 95% CI=-0,32, 0,29; p=0,93). Yet,
meta-analysis revealed that PBMT statistically
increases OMI stability one month (SMD=0,63,
95% CI=0,35, 0,92; p<0,0001) and two months
(SMD=0,98, 95% CI=0,71, 1,26; p<0,00001)
after OMIs were placed. No significant
heterogeneity (I2=0%, p>0,05) was found
between respective studies. Forest plots are
depicted in figure 2.
Table 2. Characteristics of included studies
Author,
year
Study type
Sample
size
(patiens,
implants)
Age
(years)
Implantation
site
Implant
stability
evaluation
method
Follow-
up time
Abohabib,
2018
randomized
clinical trial
15,
20.9
±3.4
between the
roots of
first permanent
molar and
second premolar
resonance
frequency
analysis
10 weeks
Ekizer,
2016
randomized
clinical trial
20 (13
females, 7
males)
16.77
(±1.41)
between the
roots of
maxillary first
molars and
second
premolars
resonance
frequency
analysis
3 months
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Flieger,
2019
randomized
clinical trial
20 (13
females 7
males)
32.5
(±6.1)
gingiva between
the second
premolar and
first molar teeth
Periotest
60 days
Matys,
2020
randomized
clinical trial
22 (14
females, 8
males), 44
MIs
31.7
(±9.7)
distal region of
the maxilla
Periotest
60 days
Matys,
2020
randomized
clinical trial
15 (10
females, 5
males), 30
MIs
36.3
(±7.4)
among teeth 13
and 14, 2 mm
below the
mucogingival
junction.
Periotest
60 days
Osman,
2017
randomized
clinical trial
12 (6
females, 6
males), 24
MIs
18
between the
second premolar
and first molar
Periotest
60 days
Marañón-
Vásquez,
2019
quasi-
experimental
19 (), 35
MIS
17.3
(±7.05)
N/M
resonance
frequency
analysis
3 months
Table 3. PBMT characteristics of included studies
Author,
year
Wavelength
nm
Power
mw
Energy
density
J/cm2
Application
time per
session
Number of
sessions
Abohabib,
2018
940 nm
1.7 W
36 J/cm2
60 s
4
Ekizer,
2016
618 nm
N/M
20
mW/cm2
20 minutes
21
Flieger,
2019
635 nm
20 J
20 J/cm2
100 s
7
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Matys,
2020
808 nm
100 mW
200
mW/cm2
40 s ×2
7
Matys,
2020
635 nm
100 mW
200
mW/cm2
40 s ×2
7
Osman,
2017
910 nm
0,7 W
N/M
60 s
5
Marañón-
Vásquez,
2019
808 nm
0,1 W
4 J/cm2
(day 0),
8 J/cm2
20 s (day 0),
40s
7
Table 4. Quality assessment of included studies
Study, year
of
publication
Random
sequence
generation
Allocation
concealment
Blinding of
participants
and
personnel
Blinding of
outcome
assessment
Incomplete
outcome
data
Selective
reporting
Other
bias
Abohabib,
2018
Low
Low
Low
Low
Low
Low
Low
Ekizer,
2016
Low
Low
Low
Low
Low
Low
Low
Flieger,
2019
Low
High
Not clear
Not clear
Low
Low
Low
Matys,
2020
Low
High
Not clear
Not clear
Low
Low
Low
Matys,
2020
Low
High
High
Low
Low
Low
Low
Osman,
2017
Low
Low
Low
Not clear
Low
Low
Low
Marañón-
Vásquez,
2019
High
High
Low
Low
Low
Low
Low
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Figure 1. Detailed search process
Records identified through Pubmed
database searching
(n = 147 )
Screening
Included
Eligibility
Identification
Additional records identified
through other sources (Science
Direct, Embase, The Cochrane
Library, LILACS)
(n = 47 )
Records after duplicates removed
(n = 194 )
Records screened
(n = 194 )
Records excluded
(n = 168 )
Full-text articles
assessed for eligibility
(n = 26 )
Full-text articles
excluded, with reasons
(n = 19 )
Studies included in
qualitative synthesis
(n = 7 )
Studies included in
quantitative
synthesis (meta-
analysis)
(n = 7 )
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Figure 2. Comparison of OMI stability between PBMT and control groups, depicted using Forest plots.
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DISCUSSION
The aim of this meta-analysis was to
evaluate PBMT influence on OMI stability.
Overall, 11 micro-implants were lost in all seven
studies. According to Abohabib et al, there were
six failed mini-implants, three in each group and
their failures were mainly detected during the
first 6 weeks. [13] As for mini-implant stability,
significant difference in values was observed
from week 3 to 10. During this period the low-
intensity laser sides presented significantly
increased mean resonance frequency values
compared to control sides. Results of this study
demonstrated some minor favourable changes in
resonance frequency scores using low-intensity
laser therapy although MI stability was not
clinically affected. Ekizer et al and Osman at al
found no statistically significant differences in
MI stability between irradiated and control
groups, although according to Osman et al, the
mean mobility measures in the experimental
sides was less than the control sides both at
baseline and during the whole observation
period. [14, 19] Flieger et al reported higher
secondary stability of MI that were irradiated
with low level laser after 30 and 60 days of
follow ups and higher primary stability in test
group three days after the insertion of MI. [15]
Two different wave lengths of the same laser
diode were used in two studies carried out by
Matys et al and better stability results were
achieved while using 635 nm Red Laser Light,
although 30 days after LLLT with 808 nm
wavelength laser diode trial group has also
showed a higher rate of stability compared to
control group. [17, 18] Vasquez et al compared
not only irradiated and non-irradiated Mis but
also immediate and delayed loading protocols.
[16] After comparison of all four regimens,
authors have discovered that group where both
LLLT and delayed loading was performed
showed the lowest loss of stability, that was
statistically significantly different from non-
irradiated groups.
Regarding limitations of this meta-
analysis, there were few. Firstly, the
characteristic of PBMT modalities had a bit of
differences. Therefore, it could have influenced
the overall homogeneity of the included studies,
making some of them slightly heterogeneous.
Also, more RCT are needed to determine,
whether any particular PBMT modality
characteristics, for instance wavelength or power
output, have any influence on OMI stability.
Thus, no exact treatment protocol using PBMT
could be done up to this day. Secondly, implant
stability is greatly influenced by a patient’s oral
health [20]. Therefore, future studies should
update their methodology by considering
patient’s oral health condition. And lastly, OMI
insertion site should be a question of concern in
the included studies, since the bone type,
thickness, and density vary from site to site [21,
22].
In conclusion, based on present meta-
analysis, low-level laser therapy on orthodontic
mini-implants increase their secondary stability
and, therefore, could be implemented clinically
as adjunctive procedure. However, future
randomly controlled studies with larger samples
are needed to confirm the study results.
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