Soft and hard tissue response to endosseous dental implants

The last two decades have seen a remarkable growth in the development of dental implants and their incorporation into the practice of dentistry. This turn of events was made possible by an improved understanding of the biological response of living tissues to implants as well as clinical trials that validated the long-term success of these implants. Despite major structural differences between teeth and implants, such as the absence of a periodontal ligament around implants, the latter appear to provide a reliable functional replacement for their natural counterparts. This review briefly summarizes the major structural differences of the interfacial region of teeth and dental implants and their supporting tissues. It focuses on our current understanding of the soft and hard tissue responses to submerged and nonsubmerged root-form dental implants. The influence of a number of factors that affect the tissue response is reviewed, including biomaterials, implant design, surgical technique, and the local microbiota. Our recently acquired ability to modulate wound healing with guided tissue regeneration and growth factors will undoubtedly play an important role in the future utilization and success rates of dental implants. © 1996 Wiley-Liss, Inc.     

Semi-conducting properties of titanium dioxide surfaces on titanium implants

The properties of the TiO₂ layer on titanium implant surfaces are decisive for good contact with the surrounding tissue. The oxide properties can be deliberately changed by for example chemical etching, ion incorporation or anodisation. In the present study impedance spectroscopy was used to study the semi-conducting properties of the naturally formed oxide for different pre-treatment of the surface. A turned surface was used as a reference and both physical (blasting) and chemical (hydrofluoric acid etching) treatments were investigated. Blasting of a titanium sample introduces defects in the metal surface and the study clearly shows that also the oxide layer contains defects leading to a higher number of charge carriers (increased conductivity) compared with the oxide on the turned surface. The hydrofluoric acid etching of the blasted surface results in an oxide film with even higher conductivity. Indication of the defect oxide structure for fluoride treated samples was also seen when analysing the TiO⁺/Ti⁺ ratio from ToF-SIMS data. The lowest value of this ratio was obtained for the HF etched sample, indicating a less stoichiometric oxide compared to the other surfaces. This is a result of incorporation of fluoride ions in the oxide, as proven by adsorption studies on a TiO₂ suspension. The results were treated in the context of surface complexation and two surface complexes were identified. Our results are discussed in relation to pull-out data on rabbit. The pull-out forces depend primarily on surface roughness but the contribution from the hydrofluoric acid etching might be explained by fluoride ion incorporation and the resulting increase in oxide conductivity.     

Potential of chemically modified hydrophilic surface characteristics to support tissue integration of titanium dental implants

In the past, several modifications of specific surface properties such as topography, structure, chemistry, surface charge, and wettability have been investigated to predictably improve the osseointegration of titanium implants. The aim of the present review was to evaluate, based on the currently available evidence, the impact of hydrophilic surface modifications of titanium for dental implants. A surface treatment was performed to produce hydroxylated/hydrated titanium surfaces with identical microstructure to either acid-etched, or sand-blasted, large grit and acid-etched substrates, but with hydrophilic character. Preliminary in vitro studies have indicated that the specific properties noted for hydrophilic titanium surfaces have a significant influence on cell differentiation and growth factor production. Animal experiments have pointed out that hydrophilic surfaces improve early stages of soft tissue and hard tissue integration of either nonsubmerged or submerged titanium implants. This data was also corroborated by the results from preliminary clinical studies. In conclusion, the present review has pointed to a potential of hydrophilic surface modifications to support tissue integration of titanium dental implants.     

Mesoporous titanium dioxide coating for metallic implants

A bioactive mesoporous titanium dioxide (MT) coating for surface drug delivery has been investigated to develop a multifunctional implant coating, offering quick bone bonding and biological stability. An evaporation induced self-assembly (EISA) method was used to prepare a mesoporous titanium dioxide coating of the anatase phase with BET surface area of 172 m(2)/g and average pore diameter of 4.3 nm. Adhesion tests using the scratch method and an in situ screw-in/screw-out technique confirm that the MT coating bonds tightly with the metallic substrate, even after removal from bone. Because of its high surface area, the bioactivity of the MT coating is much better than that of a dense TiO(2) coating of the same composition. Quick formation of hydroxyapatite (HA) in vitro can be related to enhance bonding with bone. The uptake of antibiotics by the MT coating reached 13.4 mg/cm(3) within a 24 h loading process. A sustained release behavior has been obtained with a weak initial burst. By using Cephalothin as a model drug, drug loaded MT coating exhibits a sufficient antibacterial effect on the material surface, and within millimeters from material surface, against E.coli. Additionally, the coated and drug loaded surfaces showed no cytotoxic effect on cell cultures of the osteoblastic cell line MG-63. In conclusion, this study describes a novel, biocompatiblemesoporous implant coating, which has the ability to induce HA formation and could be used as a surface drug-delivery system.     

Osteoblast response to phospholipid modified titanium surface

The objective of this study was to evaluate the effect of different phospholipid coatings on osteoblast responses in vitro. Commercially available phospholipids [phosphatidylcholine (PC), phosphatidyl-serine (PS) and phosphatidylinositol (PI)] were converted to their Ca-PL-PO(4) and were coated on commercially pure titanium (Ti) grade 2 disks. Using uncoated Ti surfaces as controls, cell responses to phospholipid-coated surfaces were evaluated using the American Type Culture Collection (Manassas, VA, USA) CRL-1486 human embryonic palatal mesenchyme cells (HEPM), an osteoblast precursor cell line, over a 14-day period. Total protein synthesis and alkaline phosphatase specific activity at 0, 7, and 14 days were measured. It was observed that Ti surfaces coated with PS exhibited enhanced protein synthesis and alkaline phosphatase specific activity compared to other phospholipids and uncoated surfaces. These results indicate the possible usefulness of PS-coated Ti surfaces for inducing enhanced bone formation and are very encouraging for bone and dental implantology.     

二氧化钛纳米管及抗菌涂层制备的进展

钛和钛合金经过表面改性处理可以获得新的优良特性,抗菌性就是其中之一。二氧化钛纳米管(titanium dioxide nanotubes, TNT),作为一种人为修饰的钛合金表面纳米结构,具有抗菌性和药物搭载能力,在制备抗菌涂层方面具有极大的应用前景。本文总结了TNT涂层常见的制备方法及其载药能力和抗菌性能的研究。     

Bone response to calcium phosphate-coated and bisphosphonate-immobilized titanium implants

Thin calcium phosphate (Ca-P) coatings have been introduced to overcome the shortcomings of plasma-sprayed Ca-P coatings. In our previous experiments, thin Ca-P coatings also enabled the immobilization of bisphosphonate, which is a drug used to treat osteoporosis. The present study was designed to evaluate the bone response to titanium implants treated with a thin Ca-P coating and bisphosphonate. Forty cylindrical commercially pure titanium implants with a length of 7 mm and a diameter of 3 mm were used as test implant fixtures. Three groups of surface-treated implants were prepared: (1) blasted with titanium powder and etched with a solution of 10% HF + 5% HNO3 (control); (2) modified with 0.5-microm thick Ca-P coatings and rapid heat-treating, and (3) immobilized with bisphosphonate by immersion in pamidronate disodium solution (10(-2) M) for 24 h at 37 degrees C. These surface-treated implants were inserted into edentulous areas in the mandibular molar region of five beagle dogs. After implantation periods of 4 and 12 weeks, the bone implant interface was evaluated histologically and histomorphometrically. All measurements were statistically evaluated using a one-way ANOVA and Fisher PLSD test for multiple comparisons among the means. Four weeks after the implantation, higher percentage of bone contact was found around the thin Ca-P-coated implants compared to that of the control group. The highest percentage of bone contact was found around the bisphosphonate-immobilized implants after 12 weeks of implantation. These data suggest that a thin coating of calcium phosphate followed by bisphosphonate-immobilization is effective in the promotion of osteogenesis on surfaces of dental implants.     

Biological response of tissues with macrophagic activity to titanium dioxide

The titanium dioxide layer is composed mainly of anatase and rutile. This layer is prone to break, releasing particles to the milieu. Therefore, corrosion may cause implant failure and body contamination. We have previously shown that commercial anatase-titanium dioxide (TiO(2)-anatase) is deposited in organs with macrophagic activity, transported in the blood by phagocytic-mononuclear cells, and induces an increase in the production of reactive oxygen species (ROS). In this study, we evaluated the effects of rutile-titanium dioxide (TiO(2)-rutile). Male Wistar rats were injected i.p. with a suspension of TiO(2)-rutile powder at a dose of 1.60 g/100 g b.w. Six months postinjection, the presence of Ti was assessed in serum, blood cells, liver, spleen, and lung. Titanium was found in phagocytic mononuclear cells, serum, and in the parenchyma of all the organs tested. TiO(2)-rutile generated a rise in the percentage of reactive cells, which was smaller than that observed when TiO(2)-anatase was employed in a previous study. Although TiO(2)-rutile provoked an augmentation of ROS, it failed to induce damage to membrane lipids, possibly due to an adaptive response. The present study reveals that TiO(2)-rutile is less bioreactive than TiO(2)-anatase.     

Soft tissue reactions of different biodegradable polylactide implants

Soft tissue reactions resulting from biodegradable polylactide implants to bone have not been adequately examined during their 3-year degradation period. An osteotomy was performed on the medial femoral condyle of 36 sheep and secured by either three poly-L-DL-lactide pins (70/30) (Polypin) or three composite pins [10% beta-tricalcium phosphate (beta-TCP) (90/10)]. A histological examination was performed on the synovial membrane and lymph nodes after 3, 18 and 36 months. After 18 months two non-specific, minor reactions of the synovial membrane were observed in the composite pin group. In both groups different reactions of both inguinal lymph nodes were observed. These had no statistical relevance and could not be clearly attributed to the implants. Due to the slow degradation process of biodegradable polylactide implants, there is no clinically relevant inflammation of either joint or lymph nodes. The addition of 10% beta-TCP did not result in any significant enhancement.     

Bone response to radio frequency sputtered calcium phosphate implants and titanium implants in vivo.

The objective of this study was to evaluate the effect of radio frequency sputtered calcium phosphate (CaP) coatings of titanium (Ti) implants on the bond strength at the bone-implant interface and percent bone contact length. Cylindrical coated or noncoated implants (4.0-mm diameter by 8-mm long) were implanted for 3 and 12 weeks. At 3 weeks after implant placement, the ultimate interfacial strengths for as-deposited CaP-coated and heat-treated CaP-coated implants were 2.29 +/- 0.14 MPa and 1.28 +/- 0.04 MPa, respectively. These ultimate interfacial strength values at 3 weeks were statistically greater than the mean ultimate interfacial strength for control Ti implants (0.67 +/- 0.13 MPa). At 12 weeks after implant placement, no statistical differences in the mean ultimate interfacial strengths were observed between the as-deposited CaP-coated, heat-treated CaP-coated, and control Ti implants. Histomorphometric evaluation indicated greater percent bone contact lengths for the as-deposited CaP-coated implants compared with the heat-treated CaP-coated and control Ti implants 3 and 12 weeks after implant placement.     

Bone reaction to nano hydroxyapatite modified titanium implants placed in a gap-healing model

Nanohydroxyapatite materials show similar chemistry to the bone apatite and depending on the underlying topography and the method of preparation, the nanohydroxyapatite may simulate the specific arrangement of the crystals in bone. Hydroxyapatite (HA) and other CaP materials have been indicated in cases in which the optimal surgical fit is not achievable during surgery, and the HA surface properties may enhance bone filling of the defect area. In this study, very smooth electropolished titanium implants were used as substrata for nano-HA surface modification and as control. One of each implant (control and nano HA) was placed in the rabbit tibia in a surgical site 0.7 mm wider than the implant diameter, resulting in a gap of 0.35 mm on each implant side. Implant stability was ensured by a fixating plate fastened with two side screws. Topographical evaluation performed with an optical interferometer revealed the absence of microstructures on both implants and higher resolution evaluation with AFM showed similar nanoroughness parameters. Surface pores detected on the AFM measurements had similar diameter, depth, and surface porosity (%). Histological evaluation demonstrated similar bone formation for the nano HA and electropolished implants after 4 weeks of healing. These results do not support that nano-HA chemistry and nanotopography will enhance bone formation when placed in a gap-healing model. The very smooth surface may have prevented optimal activity of the material and future studies may evaluate the synergic effects of the surface chemistry, micro, and nanotopography, establishing the optimal parameters for each of them.     

Interface between bone tissue and implants of solid hydroxyapatite or hydroxyapatite-coated titanium implants

Loaded prestressed implants of dense hydroxyapatite and non-loaded hydroxyapatite-coated titanium implants were placed in edentulous regions of the lower jaw of dogs. After 6 month the jaw specimens were fixed and embedded in methyl-methacrylate. Thin non-decalcified ground sections were made for histology. Although the hydroxyapatite showed histological differences between the coated implants and the prestressed solid ones, both had an extensive apposition of normal lamellar bone on the whole surface of the bone-buried part of the implant. The bone contact was very intimate and without any visible intermediate tissue layer. The tissue response observed forms a good biological base for the clinical application of hydroxyapatite-coated titanium implants.     

Soft tissue response to microtextured silicone and poly-L-lactic acid implants: fibronectin pre-coating vs. radio-frequency glow discharge treatment

From in vitro studies it is known that a plasma-treatment can enhance cell spreading. Similar effects can be observed after pretreatment of the surface with a protein coating, to mediate cell adhesion. The aim of the current study was to evaluate the in vivo effects of these surface modifications, in a three-month experiment in a goat model. We made silicone and poly-L-lactic acid implants with double-sided parallel micro-grooves (depth 1.0 microm, width 10.0 microm), a random surface roughness, or a smooth surface. Implants either received a radio-frequency glow discharge (RFGD) treatment, a fibronectin (Fn) pre-coating, or no pre-treatment. Subsequently, they were inserted into subcutaneous pockets created on the flanks of goats for 1, 3 or 12 weeks. Histological analysis showed that a fibrous tissue capsule had formed around all implants. Histomorphometrical analysis was performed on capsule thickness, capsule quality and the implant-tissue interface quality. Fn-treated surfaces showed a considerable early inflammatory reaction. Besides this, RFGD treatment or Fn pre-coating did not further influence any of the measured parameters. In conclusion, pre-treatment of polymer implant surfaces with Fn or RFGD treatment did not significantly influence tissue reaction around implants with micro-grooved, roughened or smooth surfaces.     

Fluor-hydroxyapatite sol-gel coating on titanium substrate for hard tissue implants

Hydroxyapatite (HA) and fluor-hydroxyapatite (FHA) films were deposited on a titanium substrate using a sol-gel technique. Different concentrations of F- were incorporated into the apatite structure during the sol preparation. Typical apatite structures were obtained for all coatings after dipping and subsequent heat treatment at 500 degrees C. The films obtained were uniform and dense, with a thickness of approximately 5 microm. The dissolution rate of the coating layer decreased with increasing F- incorporation within the apatite structure, which demonstrates the possibility of tailoring the solubility by a functional gradient coating of HA and FHA. The cell proliferation rate on the coating layer decreased slightly with increasing F- incorporation. The alkaline phosphatase (ALP) activity of the cells on all the HA and FHA coated samples showed much higher expression levels compared to pure Ti. This confirmed the improved activity of cell functions on the substrates with the sol-gel coating treatment.     

Biocompatibility of titanium implants modified by microarc oxidation and hydroxyapatite coating

A thin hydroxyapatite (HA) layer was coated on a microarc oxidized titanium (MAO-Ti) substrate by means of the sol-gel method. The microarc oxidation (anodizing) enhanced the biocompatibility of the Ti, and the bioactivity was improved further by the sol-gel HA coating on the anodized Ti. The HA sol was aged fully to obtain a stable and phase-pure HA, and the sol concentration was varied to alter the coating thickness. Through the sol-gel HA coating, the Ca and P concentrations in the coating layer increased significantly. However, the porous morphology and roughness of the MAO-Ti was altered very little by the sol-gel treatment. The proliferation and alkaline phosphatase (ALP) activity of the osteoblast-like cells on the MAO/HA sol-gel-treated Ti were significantly higher than those on the MAO-Ti without the HA sol-gel treatment.     

In vivo histological response to anodized and anodized/hydrothermally treated titanium implants

In the study, characterization of the anodized titanium surface was performed. In addition, histological evaluation and interfacial strength at the bone-implant interface of the characterized surfaces were then evaluated with the use of a rabbit model at 6 and 12 weeks after implantation. Surface treatments consisted of either anodization or anodization followed by hydrothermal treatments. Nontreated titanium surfaces were used as controls in this study. Using scanning-electron microscopy, porous oxide layers were observed on surfaces of anodized titanium implants, whereas porous oxide layers and HA needles were observed on anodized titanium implants following hydrothermal treatments. X-ray diffraction analysis showed the oxide layers were consisted mainly of anatase and a little of rutile. By the hydrothermal treatment on the anodizing surface, HA peaks, as well as the peaks of anatase and trace amounts of rutile peaks were observed. In EPMA analysis, the Ca/P ratio for the anodic oxide was 1.54 for anodized surfaces, whereas the Ca/P ratios for HA needles and the anodic oxide were 1.64 and 0.57, respectively, for anodized surfaces following hydrothermal treatments. Although no significant difference was observed for the percent bone contact on all implants evaluated in the in vivo study, the removal torque strength was significantly higher for anodized implants (48.02+/-5.92 N/cm) than the untreated implants (controls) (27.83+/-1.78 N/cm) at 6 weeks after implantation. As such, it was concluded that the surface anodized implants resulted in a high interfacial strength at an early implantation period as compared to the nontreated titanium implants.     

The bone response of oxidized bioactive and non-bioactive titanium implants

A number of experimental and clinical data on so-called oxidized implants have reported promising outcomes. However, little is investigated on the role of the surface oxide properties and osseointegration mechanism of the oxidized implant. Sul [On the Bone Response to Oxidized Titanium Implants: The role of microporous structure and chemical composition of the surface oxide in enhanced osseointegration (thesis). G?teborg: Department of Biomaterials/Handicap Research, University of G?teborg, Sweden; 2002; Biomaterials 2003; 24: 3893-3907] recently proposed two action mechanisms of osseointegration of oxidized implants, i.e. mechanical interlocking through bone growth in pores/other surface irregularities (1) and biochemical bonding (2). The aim of the present study is two-fold: (i) investigating the role of the implant surface chemistry on bone responses; (ii) investigating the validity of the biochemical bonding theory of the oxidized, bioactive bone implants with specific implant surface chemistry. Two groups of oxidized implants were prepared using micro arc oxidation process and were then inserted in rabbit bone. One group consisted of magnesium ion incorporated implants (MgTiO implant), the other consisted of TiO2 stoichiometry implants (TiO implant). Surface oxide properties of the implants were characterized with various surface analytic techniques. After 6 weeks of follow up, the mean peak values of removal torque of Mg implants dominated significantly over TiO implants (p < or = 0.0001). Bonding failure generally occurred in the bone away from the bone to implant interface for the MgTiO implant and mainly occurred at the bone to implant interface for the TiO implant that consisted mainly of TiO2 chemistry and significantly rougher surface as compared to the MgTiO implant. Between bone and the Mg- incorporated implant surface, ionic movements and ion concentrations gradient were detected. The current in vivo experimental data may provide positive evidence for the surface chemistry-mediated biochemical bonding theory of oxidized bioactive implants. However, the present study does not rule out potential synergy effects of the oxide thickness, micro-porous structure, crystal structure and surface roughness on improvements of bone responses to oxidized bioactive implants.     

Surface spectroscopic characterization of titanium implants after separation from plastic-embedded tissue

The method of plastic embedding of tissue and implant and subsequent separation of plastic and implant for preparing sections of tissue adjacent to solid metallic implants relies on a successful separation of the embedment and the implant. In this work, the surface of machined Ti implants has been analysed in order to investigate to what extent plastic remnants exist on the implant after separation. SEM and AES analyses show that at least 70% of the implant surface is free of plastic remnants to a proximity of 10 nm or less from the implant surface. The method is simple and suitable for both light and transmission electron microscopy of the interface tissue.     

Efficacy of titanium dioxide photocatalyst for inhibition of bacterial colonization on percutaneous implants

The purpose of this study was to evaluate the efficacy of titanium dioxide photocatalyst in inhibition of bacterial colonization on percutaneous implants. Titanium dioxide photocatalyst was prepared by direct oxidization of pure titanium substrate, and a comparative study with pure titanium was performed. The bactericidal ability of the photocatalyst was examined using methicillin-resistant Staphylococcus aureus (MRSA) suspensions in a colony-forming assay according to the Japanese Industrial Standards committee standard. After exposing the MRSA suspension on sample plates to ultraviolet A (UVA) light, the number of surviving bacteria was estimated. Next, an animal model for inhibition of colonization was examined in vivo. Pins were inserted into the femurs of rabbits, were infected with 10(8) colony-forming units of MRSA suspension, and were illuminated with UVA light for 60 min daily; the number of colonizing bacteria was estimated after 7 days. The bactericidal ability of the photocatalyst was apparent after 60 min, when the bacteria had almost disappeared. The number of colonizing bacteria on photocatalytic pins was decreased significantly in vivo. The photocatalyst was effective even against resistant bacterial colonization. Clinically, the incidence of percutaneous implant infection such as pin tract infection in external fixation could be reduced using the titanium photocatalyst.