Effect of glass ceramic and titanium implants on primary calcification during rat tibial bone healing

Summary The effect of bone bonding (KG Cera, Mina 13, and titanium) and nonbone bonding (KGy-213, M 8/1) implants on primary calcification in endosteal bone was examined by comparing changes in the morphometry of matrix vesicles to those occurring during normal bone healing following ablation of rat tibial marrow. The concentration of matrix vesicles, their diameter, and their distance from the calcification front were determined using computerized cytomorphometry at the transmission electron microscopic level. The results demonstrated that bone bonding materials supported an increase in matrix vesicle concentration when compared with control bone at 6 and 14 days postimplantation. At 14 days, there were fewer matrix vesicles in the bone adjacent to the nonbonding implants. Though matrix vesicle diameter decreased in the control bone between 6 and 14 days, it increased in all of the experimental samples. Diameters were significantly greater in the bone bonding samples at 14 days and significantly lower in the nonbonding samples at 6 days. Distance from the calcification front decreased between 6 and 14 days in all groups except in bone adjacent to the KGy-213 implants. In bone adjacent to the bone bonding implants, distance from the calcification front was comparable to or further than that of control bone; in the nonbonding samples it was closer to the calcification front. These results demonstrate that production and maturation of matrix vesicles is influenced in a differential manner by the presence of implant materials.     

Modulation of matrix vesicle enzyme activity and phosphatidylserine content by ceramic implant materials during endosteal bone healing

Summary This study examined effects of bone bonding and nonbonding implants on parameters associated with matrix vesicle-mediated primary bone formation, matrix vesicle alkaline phosphatase and phospholipase A₂ specific activities, and phosphatidylserine content. Tibia marrow ablation followed by implantation of KG-Cera, Mina 13 (bonding), KGy-213, or M 8/1 (nonbonding) was used as the experimental model. Postsurgery, matrix vesicle-enriched microsomes (MVEM) were isolated from implanted and contralateral limbs. MVEM alkaline phosphatase and phospholipase A₂ were stimulated adjacent to bonding implants with similar, though reduced, effects contralaterally. Alkaline phosphatase exhibited slight stimulation in nonbonding tissue; phospholipase A₂ was inhibited or unchanged in treated and contralateral limbs. Phosphatidylserine content of MVEM was differentially affected by the implant materials. Thus, MVEM are modulated by implant materials locally and systemically. The data demonstrate that the model is a biologically relevant diagnostic for assessing the tissue/implant interface, primary calcification is affected by implant materials, and implant-specific effects are detected in the contralateral unimplanted limb.     

Osseointegration of titanium implants in the tibia: Electron microscopy of biopsies from 4 patients

We studied the ultrastructure of bone tissue around implants of pure titanium inserted into the tibia in 4 patients with arthrosis or rheumatoid arthritis. Three main appearances of the interface were noted. First, a close contact between titanium and calcified bone with living osteocytes inside the newly-formed bone was observed in all samples. Secondly, a close contact was also seen between the implant and osteoid, the newly formed collagenous matrix being either uncalcified or calcifying. Thirdly, a loose extracellular matrix with fibrillar nonfibrillar materials was sometimes obser between bone mineral and implant. There was inflammatory reaction at the interface.

We concluded that the titanium implants were osseointegrated, but the calcification of the bone tissue was not complete even after 20 months However, mineralization of osteoid and living bone cells revealed the presence of an active tissue.     

Osteointegration of hydroxyapatite-titanium implants coated with nonglycosylated recombinant human bone morphogenetic protein-2 (BMP-2) in aged sheep

Osteointegration of metal implants into aged organisms can be severely compromised due to reduced healing capacity of bone, lack of precursor cells for new bone formation, or osteoporosis. Here, we report on successful implant healing in a novel model of aged sheep in the presence of nonglycosylated bone morphogenetic protein 2 (BMP-2). Ewes of 8 to 12 years with significant radiologic and histologic signs of osteoporosis and adipocytic bone marrow received a cylindrical hydroxyapatite-titanium implant of 12 x 10 mm. BMP-2 has been produced as a bacterial recombinant fusion protein with maltose-binding protein and in vitro generation of mature BMP-2 by renaturation and proteolytic cleavage. A BMP-2 inhibition ELISA was developed to measure the in vitro release kinetics of bioactive human BMP-2 from immersed solid implant materials by using Escherichia coli expressed and biotinylated recombinant human BMP-2 receptor IA extracellular domain (ALK-3 ECD). The implants were placed laterally below both tibial plateaus, with the left leg implant carrying 380 microg BMP-2. Both implant types became integrated within the following 20 weeks. The control implant only integrated at the cortical bone, and little new bone formation was found within the pre-existing trabecular bone or the marrow cavity. Marrow fat tissue was partially replaced by unspecific connective tissue. In contrast, BMP-2-coated implants initiated significant new bone formation, initially in trabecular arrangements to be replaced by cortical-like bone after 20 weeks. The new bone was oriented towards the cylinder. Highly viable bone marrow appeared and filled the lacunar structures of the new bone. In mechanical tests, the BMP-2-coated implants displayed in average 50% higher stability. This animal model provided first evidence that application of nonglycosylated BMP-2 coated on solid implants may foster bone healing and regeneration even in aged-compromised individuals.     

Enhancement of healing in osteochondral defects by collagen sponge implants

Implants of porous, highly cross-linked collagen sponge (CS) were tested for their capacity to enhance the healing of osteochondral defects in rabbits. Comparison was made to the healing of similar defects with polyvinyl alcohol sponge (PVAS) implants and with no implants (CONT). Evaluation was carried out up to 44 weeks following implantation and included observation of host cellular response, biodegradability of implant, gross appearance of restored joint surface, collagenous architecture of repair tissue, and properties of the junctions of implants and host articular cartilage, subchondral bone, and medullary bone. Collagen sponge proved most effective in promoting healing of osteochondral defects with fibrous and fibrocartilaginous tissue over restored subchondral bone. Collagen sponge showed many desirable properties as a potential material for biologic resurfacing of damaged joints. These properties included porosity, biodegradability, biocompatability, ability to mechanically protect cells and matrix while directing cell ingrowth, and an available chemical technology for modifying its biomechanical and biological properties. Comparative analysis of results of healing of CS, PVAS, and CONT osteochondral defects suggest rational design criteria for implant materials to improve their effectiveness in restoration of articular surfaces.     

Impaired osteoinduction in a rat model for chronic alcohol abuse

Alcohol abuse is a risk factor for bone fractures. Following a fracture, alcoholics have a higher risk for impaired fracture healing. However, the specific alcohol-induced defect(s) in bone healing are not known. Alcohol is a potent inhibitor of bone formation during bone growth and turnover. Thus, the purpose of this study was to determine the effects of alcohol consumption on induction of new bone formation. Demineralized allogeneic bone matrix (DABM) cylinders were used to model osteoinduction in a rat model for chronic alcohol abuse. DABM cylinders, prepared from femurs and tibiae of rats fed a normal diet, were implanted into sexually mature male rats adapted to alcohol (ethanol contributed 35% of caloric intake) or control liquid diets. Food intake in the control rats was restricted to match food intake of alcohol-fed animals. The implants were recovered 6 weeks later and analyzed by histology, muCT and chemical analysis. Histological evaluation revealed a robust osteoinductive response, resulting in mature bone ossicle formation, in DABM implants in rats fed the control diet. Alcohol consumption affected bone mass and architecture of the DABM implants but not volumetric density or mineral composition. Specifically, alcohol consumption resulted in significant decreases in DABM-induced bone volume, bone volume/mg original cylinder weight, connectivity density, trabecular number and thickness, ash weight and % ash weight. There were no changes in mineral (ash) density nor in the relative amounts of calcium, magnesium, iron, selenium and zinc (microg/mg ash), indicating that alcohol consumption did not impair mineralization. Taken together, these results show that alcohol abuse resulted in decreased bone formation within the DABM implant. We conclude that reduced osteoinduction may contribute to impaired bone healing in alcoholics.     

Comparison of corticocancellous block and particulate bone grafts in maxillary sinus floor augmentation for bone healing around dental implants.

OBJECTIVE: The aim of this study was to compare 2 types of bone used for maxillary sinus floor augmentation, corticocancellous block or particulate bone grafts, on bone healing around dental implants when installed simultaneously with the implant. STUDY DESIGN: The mucous membranes of 12 sinuses in 6 dogs were elevated bilaterally. On one side of the maxillary sinus, autogenous corticocancellous block bone was grafted into the space between the membrane and sinus wall. On the opposite side, autogenous corticocancellous particulate bone was grafted. Simultaneously, 2 dental implants were inserted into the grafting material through the maxillary sinus floor. The animals were killed 6 months after surgical procedure. RESULTS: The mean bone-implant contact was 56.7% on the block side and 32.1% on the particulate side (P < .05). The mean height of newly formed bone in the augmented area was 12.3 mm on the block side and 9.7 mm on the particulate side (P < .05). CONCLUSION: Our results show that maxillary sinus floor augmentation using corticocancellous block bone grafts, when installed simultaneously with the implant, is superior to corticocancellous particulate bone grafts for bone healing around dental implants.     

Influence of premature exposure of implants on early crestal bone loss: an experimental study in dogs.

OBJECTIVE: Several studies have reported on spontaneous early exposure of submerged implants, suggesting that exposed implants have greater bone loss than nonexposed implants. The purpose of this study was to compare the effects of implant-abutment connections and partial implant exposure on crestal bone loss around submerged implants. STUDY DESIGN: Bilateral, edentulated, flat alveolar ridges were created in the mandible of 6 mongrel dogs. After 3 months of healing, 2 fixtures were placed on each side of the mandible following a commonly accepted 2-stage surgical protocol. The fixtures on each side were randomly assigned to 1 of 2 procedures. In the first, a cover screw was connected to the fixture, and the incised gingiva was partially removed to expose the cover screw (partially exposed group). In the second, a healing abutment was connected to the fixture so that the coronal portion of the abutment remained exposed to the oral cavity (abutment-connected group). After 8 weeks, micro-computed tomography (micro-CT) at the implantation site was performed to measure the bone height in the peri-implant bone. Data were analyzed by Wilcoxon's signed rank test. RESULTS: The average bone height was greater for the abutment-connected fixture (9.8 +/- 0.5 mm) than for the partially exposed fixture (9.3 +/- 0.5 mm; P < .05). CONCLUSION: These results suggest that when implant exposure is detected, the placement of healing abutments may help limit bone loss around the submerged implants.     

Gap healing enhanced by hydroxyapatite coating in dogs.

During prosthetic implantation, gaps between the implant surface and the surrounding bone may occur resulting in reduced implant stability. In these instances bone-conductive materials might augment the formation of hosting bone into the pores of the implant and insure earlier implant stabilization and fixation by bony ingrowth. Titanium-alloy cylinders with a porous-titanium-alloy plasma spray coating were implanted into the medial femoral condyles in six mature dogs. In another group of six dogs, matched in age, weight, and gender, hydroxyapatite (HA) coated implants were used. All implants were surrounded by a 1-mm gap. Unilateral osteopenia of the knee, with a 20% reduction of bone density as judged by computed tomography scanning, was induced by 12 weekly intraarticular injections of carrageenin into the right knee before surgery. Four weeks after implantation, the HA-coated implants were compared to the parent porous-titanium implants by mechanical testing and histomorphometry. A marked positive influence of HA coating on bone mineralization and the strength of the interfacial bone between the bone and implant was found. The increment in interface shear strength and shear stiffness was three- to fivefold in osteopenic bone and two-fold in control bone. Coating of an unloaded porous-titanium-coated implant with HA accelerates the rate of bone ingrowth and thereby provides relatively high, early interfacial shear strengths in the presence of an initial gap between bone and implant even in the presence of osteopenic host bone.     

Effect of surface topography on removal of cortical bone screws in a novel sheep model

Difficulty in removing implants used in trauma patients can be a complication, and increased bone–implant adhesion likely is a major contributing factor. In vitro studies have shown that surface morphology of implant materials has the ability to influence cellular responses, with polished surfaces decreasing the potential for mineralization. This study examined the effect of polishing commercially pure titanium (cpTi) and the titanium alloy TAN on the removal torque and percentage bone–implant contact in cortical and cancellous bone of sheep. Polishing had a significant effect on both removal torque and percentage bone–implant contact, with the polished implants demonstrating a lower removal torque in both cortical and cancellous bone. Polished cpTi and stainless steel were similar in terms of surface roughness and removal torque. However, polished TAN, which was not as smooth as polished cpTi, did not show the same low level for reducing removal torque. Improved polishing of TAN should reduce the removal torque further. The results of the study show that polishing is promising in improving the ease of implant removal after fracture fixation and repair. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 26:1377–1383, 2008     

Peri-implant bone reactions at delayed and immediately loaded implants: an experimental study.

OBJECTIVE: The aim of this study was to compare the peri-implant bone reactions of implants subjected to immediate loading with those subjected to delayed loading. STUDY DESIGN: In 6 mongrel dogs, bilateral edentulated flat alveolar ridges were created in the mandible. After 3 months of healing, 1 implant was placed in each side. On one side of the mandible, the implant was loaded immediately with a force of 20 N that was applied at a 120 degrees angle from the tooth's longitudinal axis at the labial surface of the crown for 1800 cycles per day for 10 weeks. On the opposite side, after a delay of 3 months to allow osseointegration to take place, the implant was loaded with the same force used for the immediately loaded implant. Ten weeks after loading, microscopic computerized tomography at the implantation site was performed. Osseointegration was calculated as the percentage of implant surface in contact with bone. Bone height was measured in the peri-implant bone. RESULTS: The mean osseointegration was greater (65.5%) for the delayed-loading implants than for the immediately loaded implants (60.9%; P < .05). The mean peri-implant bone height was greater (10.6 mm) for the delayed-loading implants than for the immediately loaded implants (9.6 mm; P < .05). CONCLUSION: The results indicate that when implants are immediately loaded, the immediate loading may decrease both osseointegration of dental implants and bone height.     

Flapless implant surgery: an experimental study.

OBJECTIVE: The purpose of this study was to examine the effect of flapless implant surgery on crestal bone loss and osseointegration in a canine mandible model. STUDY DESIGN: In 6 mongrel dogs, bilateral, edentulated, flat alveolar ridges were created in the mandible. After 3 months of healing, 2 implants in each side were placed by either flap or flapless procedures. After a healing period of 8 weeks, microcomputerized tomography at the implantation site was performed. Osseointegration was calculated as percentage of implant surface in contact with bone. Additionally, bone height was measured in the peri-implant bone. RESULTS: The mean osseointegration was greater at flapless sites (70.4%) than at sites with flaps (59.5%) (P < .05). The mean peri-implant bone height was greater at flapless sites (10.1 mm) than at sites with flaps (9.0 mm) (P < .05). CONCLUSION: Flapless surgery can achieve results superior to surgery with reflected flaps. The specific improvements of this technique include enhanced osseointegration of dental implants and increased bone height.     

Native bovine bone morphogenetic protein improves the potential of biocoral to heal segmental canine ulnar defects

We studied the effect of a composite implant consisting of coral and native bovine bone morphogenetic protein (BMP) on the healing of 2 cm segmental defects in the canine ulna. Plain coral and cortical autograft bone implants were used as controls. The fixation was temporary for 9 weeks with an intramedullary Kirschner wire (6 ulnas with a composite implant of coral and BMP, 6 with plain coral and 6 with an autograft) or a plate and screws (3 ulnas with a composite implant and 3 with plain coral). X-rays were taken at 3, 6, 9, 12, 16, 26 and 36 weeks, and mechanical torsion tests were performed at the end of the study. The score for bone formation and bone union evaluated from radiographs was significantly higher in the composite implant group than in the plain coral group at 16 weeks, but the score was even higher with autografts. BMP accelerated the resorption of the coral implant. The mechanical strength of the composite implants was higher than that of the bones with a plain coral implant (P < 0.05), while the mechanical strength of the coral implants, even with BMP, was significantly lower than the strength of autografts (P < 0.01). In conclusion, BMP enhanced the capacity of a coral implant to heal a segmental ulnar defect by increasing bone formation, but the effect of this combination was not as good as that of a cortico-cancellous autograft.     

Differences in osseointegration rate due to implant surface geometry can be explained by local tissue strains.

Experimental evidence indicates that the surface geometry of bone-interfacing implants influences the nature and rate of tissues formed around implants. In a previously reported animal model study, we showed that non-functional, press-fitted porous-surfaced implants placed in rabbit femoral condyle sites osseointegrated more rapidly than plasma-sprayed implants. We hypothesized that the accelerated osseointegration observed with the porous-surfaced design was the result of this design providing a local mechanical environment that was more favourable for bone formation. In the present study, we tested this hypothesis using finite element analysis and homogenization methods to predict the local strains in the pre-mineralized tissues formed around porous-surfaced and plasma-sprayed implants. We found that, for loading perpendicular to the implant interface, the porous surface structure provided a large region that experienced low distortional and volumetric strains, whereas the plasma-sprayed implant provided little local strain protection to the healing tissue. The strain protected region, which was within the pores of the sintered porous surface layer. corresponded to the region where the difference in the amount of mineralization between the two implant designs was the greatest. Low distortional and volumetric strains are believed to favour osteogenesis, and therefore the model results provide initial support for the hypothesis that the porous-surfaced geometry provides a local mechanical environment that favours more rapid bone formation in certain situations.     

Osseointegration of metallic implants. I. Light microscopy in the rabbit

Thirty-eight adult albino rabbits received one implant of pure titanium and one implant of another, test, material in each tibia. The test materials were titanium-aluminum-vanadium alloy, chrome-cobalt alloy, and stainless steel. Observation times were 4 months and 11 months. Light microscopy of the interface revealed a direct contact between bone and implant surface (osseointegration) in 73 of the 76 cases. The exceptions were two implants of pure titanium and one of stainless steel. Thus, given identical healing conditions, the modern implant metals were accepted by the bone in the same way. It is suggested that osseointegration should be regarded not as an exclusive reaction to a specific implant material, but as the expression of a nonspecific and basic healing potential in bone.     

Invasion of bone into porous fiber metal implants in cats

Bone ingrowth in porous Ti-6Al-4V implants in feline femurs was assessed for the amount and composition 4, 12 and 26 weeks after implantation. During the first 12 weeks there was a rapid ingrowth that levelled out during the ensuing weeks. Bone had penetrated the implants to an average depth of 0.5 mm over their entire surface at 26 weeks. The ingrown bone was deficiently mineralized at 4 and 12 weeks, but reached full mineralization at 26 weeks. A low calcium to phosphorus ratio persisted at all observation times. The ingrown tissue was compared to bone filling drill holes that had been made in the trochanters contralaterally to the implants. By means of radioactive strontium, the mineral deposits in the holes and implants could be compared. The overall results indicate that bone ingrowth in a porous implant and bone healing are similar processes both qualitatively and quantitatively.     

Osseointegration of metallic implants: I. Light microscopy in the rabbit

Thirty-eight adult albino rabbits received one implant of pure titanium and one implant of another, test, material in each tibia. The test materials were titanium-aluminum-vanadium alloy, chrome-cobalt alloy, and stainless steel. Observation times were 4 months and 11 months.

Light microscopy of the interface revealed a direct contact between bone and implant surface (osseointegration) in 73 of the 76 cases. The exceptions were two implants of pure titanium and one of stainless steel. Thus, given identical healing conditions, the modern implant metals were accepted by the bone in the same way.

It is suggested that osseointegration should be regarded not as an exclusive reaction to a specific implant material, but as the expression of a nonspecific and basic healing potential in bone.     

Locally delivered rhBMP-2 enhances bone ingrowth and gap healing in a canine model.

The purpose of the present study was to determine if recombinant human bone morphogenetic protein-2 (rhBMP-2) enhances bone ingrowth into porous-coated implants and gap healing around the implants. In the presence of a 3-mm gap between the implant and host bone, porous-coated implants were placed bilaterally for four weeks in the proximal humeri of skeletally mature, adult male dogs. In three treatment groups, the test implant was treated with HA/TCP and rhBMP-2 in buffer at a dose of 100 microg/implant (n=5), 400 microg/implant (n=6), or 800 microg/implant (n=5) and placed in the left humerus. In these same animals, an internal control implant was treated only with HA/TCP and buffer and placed in the right humerus. These groups were compared with a previously reported external control group of seven animals in which no growth factor was delivered [J. Orthop. Res. 19 (2001) 85]. The BMP treated implants in the two lower dose groups had significantly more bone ingrowth than the external controls with the greatest effect in the 100 g/implant group (a 3.5-fold increase over the external control, p=0.008). All three dose groups had significantly more bone formation in the 3-mm gap surrounding the BMP treated implants than the external controls with the greatest effect in the 800 microg group (2.9-fold increase, p<0.001). Thus, application of rhBMP-2 to a porous-coated implant stimulated local bone ingrowth and gap healing. The enhancement of bone formation within the implant (bone ingrowth) was inversely related to dose.     

Analysis of performance of root-form endosseous implants placed in the maxillary sinus

To evaluate the long-term effect on metal-bone interface of the perforation of the maxillary antral floor by root-form titanium implants, a study was undertaken in five mature Macaca fascicularis monkeys. One root-form titanium implant was placed bilaterally in the maxillary sinus perforating the sinus 5 mm and a second implant was placed completely in bone tissue. The protruding implant in the right antrum was grafted with autogenous cancellous bone and porous bone mineral (Bio-Oss) and the contralateral antral implant protruding in the antrum was left without grafting. The bilateral implants were used to support "free-standing" fixed prostheses, which were in full function for 14 months, during which time there was excellent clinical function and no mobility of the implants. Histomorphometric analysis of specimens revealed that there was no difference in the trabecular pattern or the amount of calcified matrix vs. marrow vascular spaces along the titanium implant interface. New reparative bone partially restored the osseous surface along the implant on the ungrafted side. Implants in the grafted antrum demonstrated bone regeneration over the implant surface ranging from 2 cm to complete regeneration. Histomorphometric analysis revealed the peri-implant bone to contain some particles of the Bio-Oss, although most of the implant bone interface exhibited only vital bone and marrow vascular spaces. The study indicates that the protrusion of implants maximally into the sinus floor does not necessarily require a bone graft to produce functional abutments for fixed prostheses and that implants can function well with 5 mm of protrusion into the antrum with excellent bone-metal interface.     

Locally delivered rhTGF-beta2 enhances bone ingrowth and bone regeneration at local and remote sites of skeletal injury.

The purposes of the present study were to determine if recombinant human transforming growth factor-beta-2 (rhTGF-beta2) enhances bone ingrowth into porous-coated implants and bone regeneration in gaps between the implant and surrounding host bone. The implants were placed bilaterally for four weeks in the proximal humeri of skeletally mature, adult male dogs in the presence of a 3-mm gap. In three treatment groups of animals, the test implant was treated with hydroxyapatite/tricalcium phosphate (HA/TCP) and rhTGF-beta2 in buffer at a dose per implant of 1.2 microg (n = 6), 12 microg (n = 7), or 120 microg (n = 7) and placed in the left humerus. In these same animals, an internal control implant treated only with HA/TCP and buffer was placed in the right humerus. In a non-TGF-beta treated external control group of animals (n = 7), one implant was treated with HA/TCP while the contralateral implant was not treated with the ceramic. In vitro analyses showed that approximately 15%, of the applied dose was released within 120 h with most of the release occurring in the first 24 h. The TGF-beta treated implants had significantly more bone ingrowth than the controls with the greatest effect in the 12 microg/implant group (a 2.2-fold increase over the paired internal control (P = 0.004) and a 4-fold increase over the external control (P < 0.001)). The TGF-beta treated implants had significantly more bone formation in the gap than the controls with the greatest effect in the 12 and 120 microg groups (1.8-fold increases over the paired internal controls (P = 0.003 and P = 0.012, respectively) and 2.8-fold increases over the external controls (P < 0.001 and P = 0.001, respectively)). Compared to the external controls, the internal control implants tended to have more bone ingrowth (1.9-fold increase, P = 0.066) and had significantly more bone formation in the gap (1.7-fold increase. P = 0.008). Thus, application of rhTGF-beta2 to a porous-coated implant-stimulated local bone ingrowth and gap healing in a weakly dose-dependent manner and stimulated bone regeneration in the 3-mm gap surrounding the contralateral control implant, a site remote from the local treatment with the growth factor.