Relevant Aspects of Titanium and Zirconia Dental Implants for Their Fatigue and Osseointegration Behaviors

Osseointegration capacity and good mechanical behavior are key to the success of the dental implant. In many investigations, comparisons of properties are made using different dental implant designs and therefore the results can be influenced by the macrodesign of the dental implant. In this work, studies were carried out with the same dental implant model using different roughness and different materials—commercially pure titanium (grade 4) and zirconia. For this purpose, 80 smooth passivated titanium (Ti), 80 smooth zirconia (ZrO₂), and 80 rough passivated titanium (Ti-R) dental implants were used. The samples were characterized by their roughness, wettability, surface energy, residual stresses, and fatigue behavior. The implants were implanted in minipigs for 4 and 12 weeks. The animals were sacrificed, and histological studies were carried out to determine the osseointegration parameters for each of the implantation times. Ti and ZrO₂ dental implants have very similar wettability and surface energy properties. However, the roughness causes a decrease in the hydrophilic character and a decrease of the total surface energy and especially the dispersive component, while the polar component is higher. Due to the compressive residual stresses of alumina sandblasting, the rough dental implant has the best fatigue behavior, followed by Ti and due to the lack of toughness and rapid crack propagation the ZrO₂ implants have the worst fatigue behavior. The bone index contact (BIC) values for 4 weeks were around 25% for Ti, 32% for ZrO₂, and 45% for Ti-R. After 12 weeks the Ti dental implants increased to 42%, for Ti, 43% for ZrO₂, and an important increase to 76% was observed for Ti-R implants. In vivo results showed that the key factor that improves osseointegration is roughness. There was no significant difference between ZrO₂ and Ti implants without sandblasting.     

The Surface Conditions and Composition of Titanium Alloys in Implantology: A Comparative Study of Dental Implants of Different Brands

The success of titanium dental implants depends on their osseointegration into the bone, which is determined by the composition and surface properties of the implant in close contact with the bone. There is a wide variety of implants on the market. Is it possible to identify the implant with the best composition and surface topography for optimal osseointegration? To this aim, 13 brands of dental implants from nine distinct manufacturers have been selected and their composition and surface topography determined. The obtained results show differences between these implants, in this case, the Ssk averages of the three measurements performed on each implant were positive, or 0.4 (0.1–0.8), indicating that the roughness of all implants analyzed was primarily textured and not flat. Like Sa, we found the highest Sdr for implants subjected only to sandblasting. In addition, only the ALS-active^® implant had a modified microstructure on its surface. However, analysis of the NANOTITE implant surface revealed a 1.40% presence of calcium which we consider too low to have an effect on bone formation around the implant. As a result, we have also highlighted the lack of a recognized independent standard for dental implant surface conditions and the lack of independent quality control vis-à-vis manufacturers. Of all the surface types studied, none proved more satisfactory than another.     

Biomechanical Properties of Bone and Mucosa for Design and Application of Dental Implants

Dental implants’ success comprises their proper stability and adherence to different oral tissues (integration). The implant is exposed to different mechanical stresses from swallowing, mastication and parafunctions for a normal tooth, leading to the simultaneous mechanical movement and deformation of the whole structure. The knowledge of the mechanical properties of the bone and gingival tissues in normal and pathological conditions is very important for the successful conception of dental implants and for clinical practice to access and prevent potential failures and complications originating from incorrect mechanical factors’ combinations. The challenge is that many reported biomechanical properties of these tissues are substantially scattered. This study carries out a critical analysis of known data on mechanical properties of bone and oral soft tissues, suggests more convenient computation methods incorporating invariant parameters and non-linearity with tissues anisotropy, and applies a consistent use of these properties for in silico design and the application of dental implants. Results show the advantages of this approach in analysis and visualization of stress and strain components with potential translation to dental implantology.     

A Review of Titanium Zirconium (TiZr) Alloys for Use in Endosseous Dental Implants

Dental implants made from binary titanium-zirconium (TiZr) alloys have shown promise as a high strength, yet biocompatible alternative to pure titanium, particularly for applications requiring small diameter implants. The aim of this review is to summarize existing literature reporting on the use of binary TiZr alloys for endosseous dental implant applications as tested in vitro, in animals and clinically. And furthermore to show that TiZr is “at least as good as” pure titanium in terms of biocompatibility and osseointergration. From the twelve papers that met the inclusion criteria, the current literature confirms that TiZr alloys produce small diameter implants with a strength up to 40% higher than conventional, cold-worked, grade IV titanium implants, and with a corrosion resistance and biocompatibility that is at least as good as pure titanium. The surface structure of TiZr is compatible with established surface treatments proven to aid in the osseointegration of titanium implants. Furthermore, binary TiZr alloys have been shown to achieve good osseointegration and high success rates both in animal and in clinical studies.     

Customized Root-Analogue Implants: A Review on Outcomes from Clinical Trials and Case Reports

(1) It is estimated that 10% of the world’s population will need a dental implant in their lifetime. Despite all the advances in the comprehension of dental implant designs, materials and techniques, traditional implants still have many limitations. Customized root-analogue implants are, therefore, gaining increased interest in dental rehabilitation and are expected to not only preserve more hard and soft tissues but also avoid a second surgery and improve patient overall satisfaction. In this sense, the aim of this review was to collect and analyse the clinical trials and case reports on customized root-analogue implants available in the literature; (2) This review was carried out according to the PRISMA Statement. An electronic database search was performed using five databases: PubMed, Google Scholar, Medline, Science Direct, and Scopus. The following keywords were used for gathering data: custom-made, dental implants, root-analogue, anatomical, customized and tooth-like; (3) 15 articles meeting the inclusion criteria—articles reporting clinical trials, case reports or animal studies and articles with root-analogue implants and articles with totally customized implant geometries—were selected for the qualitative synthesis. The design and manufacturing techniques, implant material and surface treatments were assessed and discussed; (4) The performance of some root-analogue implants with specific features (i.e., macro-retentions) was successful, with no signs of infection, periodontitis nor bleeding during the follow-up periods.     

Electrophoretic Deposition of Biocompatible and Bioactive Hydroxyapatite-Based Coatings on Titanium

Current trends in biomaterials science address the issue of integrating artificial materials as orthopedic or dental implants with biological materials, e.g., patients’ bone tissue. Problems arise due to the simple fact that any surface that promotes biointegration and facilitates osteointegration may also provide a good platform for the rapid growth of bacterial colonies. Infected implant surfaces easily lead to biofilm formation that poses a major healthcare concern since it could have destructive effects and ultimately endanger the patients’ life. As of late, research has centered on designing coatings that would eliminate possible infection but neglected to aid bone mineralization. Other strategies yielded surfaces that could promote osseointegration but failed to prevent microbial susceptibility. Needless to say, in order to assure prolonged implant functionality, both coating functions are indispensable and should be addressed simultaneously. This review summarizes progress in designing multifunctional implant coatings that serve as carriers of antibacterial agents with the primary intention of inhibiting bacterial growth on the implant-tissue interface, while still promoting osseointegration.     

Evaluation of Implant Stability and Trephination Depth for Implant Removal—An In Vitro Study

Malpositioned and broken implants are usually fully osseointegrated; hence, their removal, especially from the lower arch, can be very challenging. Implant removal techniques include reverse torque and trephination. Trephination is an invasive technique that can jeopardize vital structures, cause mandibular fatigue fractures, or lead to osteomyelitis. In this study, we aimed to assess the relationship between trephination depth and implant stability by recording implant stability quotient (ISQ) readings at varying trephination depths in vitro. Materials and methods: Forty-eight implants were inserted into dense synthetic polyurethane foam blocks as artificial bone. Primary implant stability was measured with a Penguin resonance frequency analysis (RFA) device. Implants of two designs with a diameter of 3.75 mm and a length of 13 or 8 mm were inserted. Twenty-four internal hexagon (IH) (Seven^®) and twenty-four conical connection (CC) implants (C1^®; MIS^® Implants, Ltd., Misgav, Israel) were used. The primary implant stability was measured with the RFA device. Trephination was performed, and implant stability was recorded at depths of 0, 3, and 6 mm for the 8 mm implants and 0, 3, 6, 8, 10, and 11.5 mm for the 13 mm implants. Results: Linear regression revealed a significant relation between the trephination depth and the ISQ (F (1, 213) = 1113.192, p < 0.001, adjusted r2 = 0.839). The trephination depth significantly predicted the ISQ (β = −5.337, p < 0.001), and the ISQ decreased by −5.33 as the trephination depth increased by 1 mm. Conclusion: Implant stability reduction as measured using an RFA device during trephination may be a valuable guide to achieving safe reverse torque for implant removal. Further studies are needed to evaluate these data in clinical settings.     

Histologic Evaluation of Soft Tissues around Dental Implant Abutments: A Narrative Review

The basis for dental implant success comes not only with the titanium implant osseointegration but also depends on other factors such as the development of a soft tissue barrier, which protects the peri-implant bone from the oral environment. The characteristics of surfaces in contact with peri-implant soft tissues may affect the capacity of peri-implant mucosal cells to create a tight seal around the implant, thus influencing long-term implant success. Many histological studies on animals have been conducted on different materials to better understand their influence on peri-implant soft tissues, with the limitation that results from animal studies cannot be fully translated in humans. The aim of this review paper was to analyze the literature focusing on histological clinical studies in humans which have examined different materials or different surface treatments and their effects on peri-implant soft tissues. The research was conducted according to the following PICO question: “Do different implant/abutment materials affect peri-implant soft tissues adhesion and health?”. Nine articles were analyzed in this review. The results of this review show the influence of different abutment materials on the peri-implant soft tissues, and the need of further research regarding the effect that abutment materials, surface treatments, and surface properties have on soft tissues.     

Implants Survival Rate in Regenerated Sites with Innovative Graft Biomaterials: 1 Year Follow-Up

In thirteen different dental clinics in Singapore, Spain, Czech Republic and Italy, 504 patients were selected, and 483 dental implants were placed in maxillary sites after alveolar socket preservation (ASP) procedures with an autologous demineralized tooth extracted as graft material from an innovative Tooth Transformer device was obtained. All procedures used were reported in n°638 Ethical Committee surgical protocol of University of Chieti and approved. After 4 months, at dental implant placing, bone biopsies were performed to evaluate the histologic outcomes, and 12 months after implant loading, global implant survival rate, failure percentage and peri-implant bone loss were detected. After ASP, only 27 post-operative complications were observed and after 4 months, bone biopsy histomorphometric analysis showed a high percentage of bone volume (BV) 43.58 (±12.09), and vital new bone (NB) 32.38 (±17.15) with an absence of inflammation or necrosis areas. Twelve months after loading, only 10 dental implants failed (2.3%), with a 98.2% overall implant survival rate, nine cases showed mucositis (1.8%) and eight showed peri-implantitis (1.6%). At mesial sites, 0.43 mm (±0.83) of bone loss around the implants was detected and 0.23 mm (±0.38) at the distal sites with an average value of 0.37 mm (±0.68) (p > 0.568). Several studies with a longer follow-up will be necessary to confirm the preliminary data observed. However, clinical results seem to suggest that the post-extraction socket preservation procedure using innovative demineralized autologous tooth-derived biomaterial may be a predictable procedure to produce new vital bone able to support dental implant rehabilitation of maxilla edentulous sites.     

Biochemical Modification of Titanium Oral Implants: Evidence from In Vivo Studies

The discovery of osseointegration of titanium implants revolutionized the dental prosthesis field. Traditionally, implants have a surface that is processed by additive or subtractive techniques, which have positive effects on the osseointegration process by altering the topography. In the last decade, innovative implant surfaces have been developed, on which biologically active molecules have been immobilized with the aim of increasing stimulation at the implant–biological tissue interface, thus favoring the quality of osseointegration. Among these molecules, some are normally present in the human body, and the techniques for the immobilization of these molecules on the implant surface have been called Biochemical Modification of Titanium Surfaces (BMTiS). Different techniques have been described in order to immobilize those biomolecules on titanium implant surfaces. The aim of the present paper is to present evidence, available from in vivo studies, about the effects of biochemical modification of titanium oral implants on osseointegration.     

Clinical Evaluation of Dental Implants with a Double Acid-Etched Surface Treatment: A Cohort Observational Study with Up to 10-Year Follow-Up

Background and objectives: The main purpose of this study was to evaluate the survival and success rates of dental implants with a double acid-etched surface treatment with evaluation times up to 10 years post-loading. Materials and Methods: This study was conducted at a hospital oral surgery and implantology unit. It included 111 dental implants with a double acid-etched surface. Three groups were created: Group 1 (1–3 years loading), Group 2 (3–5 years loading), and Group 3 (over 5 years loading). Probing depth, resonance frequency analysis (ISQ value), and marginal bone loss were evaluated. Results: The data obtained underwent statistical analysis. Overall, 78 patients were included in the study, who received, in total, 111 dental implants, all replacing single teeth. Mean probing depth was 3.03 mm and mean ISQ was 65.54. Regarding marginal bone loss, in Group 1, 67.6% of implants did not undergo any thread loss, in Group 2, 48.3%, and in Group 3, 59.6%; 59.10% of all implants did not present thread loss with a mean bone loss of 0.552 mm. The implant survival rate was 99.1%, and the success rate was 96.37%. Conclusions: Implants with a double acid-etched surface showed excellent success rates in terms of marginal bone loss, ISQ, and probing depth after up to 10 years of loading, making them a clinically predictable treatment option. Future studies are needed to compare this implant surface with other types in different restorative situations.     

Histological and Histomorphometric Comparison of Innovative Dental Implants Laser Obtained: Animal Pilot Study

Objective: Evaluation of the in vivo bone response of two innovative titanium surfaces ytterbium laser active fiber obtained (L1-L2) compared to a sandblasted and acid etched (SBAE) during early phase of osseointegration. Material and Methods: Three implant groups with the same macroscopic features were obtained (L1-L2-SBAE) to promote specific surface characteristics. Scanning electron microscopy, profilometric evaluation, X-ray spectrometry, and diffraction analysis were performed. For each group, six implants were placed in the tibiae of three Peli Buey sheep, and histologic, histomorphometric analysis, bone to implant contact (BIC), and the Dynamic Osseointegration index (DOI) were performed. Results: During the early phases of osseointegration, the histological and histomorphometric results showed significant differences between L1-L2-SBAE implants. At 15 and 30 days, histological analysis detected a newly bone formation around all specimens with an higher vital bone in L2 compared to L1 and SBAE both in cortical and in poor-quality marrow bone. At same time, histomorphometric analysis showed significantly higher BIC values in L2 (42.1 ± 2.6 and 82.4 ± 2.2) compared to L1 (5.2 ± 3.1 and 56.2 ± 1.3) and SBAE (23.3 ± 3.9 and 77.3 ± 0.4). DOI medium value showed a higher rate in L2 (2.83) compared to SBAE (2.60) and L1 (1.91). Conclusions: With the limitations of this pilot study, it is possible to assess that the titanium surface characteristics, and not the technologies used to obtain the modification, played a crucial role during the osseointegration process. Histological, histomorphometric, BIC, and DOI evaluation showed a significantly higher rate in L2 specimens compared to others, confirming that the implant surface could increase the bone response in cortical or marrow poor quality bone during the initial phases of osseointegration.     

Improved Osseointegration of Selective Laser Melting Titanium Implants with Unique Dual Micro/Nano-Scale Surface Topography

Selective laser melting manufacture of patient specific Ti implants is serving as a promising approach for bone tissue engineering. The success of implantation is governed by effective osseointegration, which depends on the surface properties of implants. To improve the bioactivity and osteogenesis, the universal surface treatment for SLM-Ti implants is to remove the primitive roughness and then reengineer new roughness by various methods. In this study, the micro-sized partially melted Ti particles on the SLM-Ti surface were preserved for assembling mesoporous bioactive glass nanospheres to obtain a unique micro/nano- topography through combination of SLM manufacture and sol–gel processes. The results of simulated body fluid immersion test showed that bioactive ions (Ca, Si) can be continuously and stably released from the MBG nanospheres. The osseointegration properties of SLM-Ti samples, examined using pre-osteoblast cells, showed enhanced adhesion and osteogenic differentiation compared with commercial pure titanium commonly used as orthopedic implants. Overall, the developed approach of construction of the dual micro/nano topography generated on the SLM-Ti native surface could be critical to enhance musculoskeletal implant performance.     

Stress-based performance comparison of dental implants by finite element analysis

The geometric shape of a dental implant plays an important role on the osteo-integration process. The purpose of this paper is to study the biomechanical behavior of different commercial dental implants and to analyse how thread profile may affect the stress concentration and distribution. Three different commercially-available dental implants were considered and acquired by means of a no-contact reverse engineering system. Stresses at bone–implant interface, in presence of perfect and not-perfect osteo-integration, were numerically evaluated by means of finite element (FEM) analyses applying occlusal and lateral loads. The results show more dangerous stresses at implant–bone interface in the case of not-perfect osteo-integration and stresses gradient enough uniform around the threads in the case of osteo-integration. In particular, the implant with the lowest thread-pitch exhibits the lowest bone damage. This confirms the crucial role of the geometric shape of the implant to reduce bone induced stresses and bone damage. The structural and functional connection between living bone and implant is a key issue in implantology field. When a guest device is installed in the living bone, many clinical responses may arise, such as inflammatory processes or osteo-integration failure. The results of this study can give useful information to understand the influence of the implant features and to appropriately apply it in the science of dental implants with the aim to reduce the potential implant failure.     

Titanium Corrosion Mechanisms in the Oral Environment: A Retrieval Study

Corrosion of titanium dental implants has been associated with implant failure and is considered one of the triggering factors for peri-implantitis. This corrosion is concerning, because a large amount of metal ions and debris are generated in this process, the accumulation of which may lead to adverse tissue reactions in vivo. The goal of this study is to investigate the mechanisms for implant degradation by evaluating the surface of five titanium dental implants retrieved due to peri-implantitis. The results demonstrated that all the implants were subjected to very acidic environments, which, in combination with normal implant loading, led to cases of severe implant discoloration, pitting attack, cracking and fretting-crevice corrosion. The results suggest that acidic environments induced by bacterial biofilms and/or inflammatory processes may trigger oxidation of the surface of titanium dental implants. The corrosive process can lead to permanent breakdown of the oxide film, which, besides releasing metal ions and debris in vivo, may also hinder re-integration of the implant surface with surrounding bone.     

Microscopic Characterization of Bioactivate Implant Surfaces: Increasing Wettability Using Salts and Dry Technology

The surface topography of dental implants plays an important role in cell-surface interaction promoting cell adhesion, proliferation and differentiation influencing osseointegration. A hydrophilic implant leads to the absorption of water molecules and subsequently promotes the adhesion of cells to the implant binding protein. Dried salts on the implant surfaces allow one to store the implant surfaces in a dry environment while preserving their hydrophilic characteristics. This process has been identified as “dry technology”. The aim of the present study is to describe from a micrometric and nanometric point of view the characteristics of this new bioactivated surface obtained using salts dried on the surface. Topographic analysis, energy-dispersive X-ray spectroscopy, and contact angle characterization were performed on the samples of a sandblasted and dual acid-etched surface (ABT), a nanosurface (Nano) deriving from the former but with the adding of salts air dried and a nanosurface with salts dissolved with distilled water (Nano H₂O). The analysis revealed promising results for nanostructured surfaces with increased wettability and a more articulated surface nanotopography than the traditional ABT surface. In conclusion, this study validates a new promising ultra-hydrophilic nano surface obtained by sandblasting, double acid etching and surface salt deposition using dry technology.     

Critical Role of Etching Parameters in the Evolution of Nano Micro SLA Surface on the Ti6Al4V Alloy Dental Implants

The surface of dental implants plays a vital role in early and more predictable osseointegration. SLA (sandblasted large grit and acid-etched) represents the most widely accepted, long-term clinically proven surface. Primarily, dental implants are manufactured by either commercially pure titanium (CP-Ti) or Ti6Al4V ELI alloy. The acid etch behavior of CP-Ti is well known and its effects on the surface microstructure and physicochemical properties have been studied by various researchers in the past. However, there is a lack of studies showing the effect of acid etching parameters on the Ti6Al4V alloy surface. The requirement of the narrow diameter implants necessitates implant manufacturing from alloys due to their high mechanical properties. Hence, it is necessary to have an insight on the behavior of acid etching of the alloy surface as it might be different due to changed compositions and microstructure, which can further influence the osseointegration process. The present research was carried out to study the effect of acid etching parameters on Ti6Al4V ELI alloy surface properties and the optimization of process parameters to produce micro- and nanotopography on the dental implant surface. This study shows that the Ti6Al4V ELI alloy depicts an entirely different surface topography compared to CP-Ti. Moreover, the surface topography of the Ti6Al4V ELI alloy was also different when etching was done at room temperature compared to high temperature, which in turn affected the behavior of the cell on these surfaces. Both microns and nano-level topography were achieved through the optimized parameters of acid etching on Ti6Al4V ELI alloy dental implant surface along with improved roughness, hydrophilicity, and enhanced cytocompatibility.     

Titanium Functionalized with Polylysine Homopolymers: In Vitro Enhancement of Cells Growth

In oral implantology, the success and persistence of dental implants over time are guaranteed by the bone formation around the implant fixture and by the integrity of the peri-implant mucosa seal, which adheres to the abutment and becomes a barrier that hinders bacterial penetration and colonization close to the outer parts of the implant. Research is constantly engaged in looking for substances to coat the titanium surface that guarantees the formation and persistence of the peri-implant bone, as well as the integrity of the mucous perimeter surrounding the implant crown. The present study aimed to evaluate in vitro the effects of a titanium surface coated with polylysine homopolymers on the cell growth of dental pulp stem cells and keratinocytes to establish the potential clinical application. The results reported an increase in cell growth for both cellular types cultured with polylysine-coated titanium compared to cultures without titanium and those without coating. These preliminary data suggest the usefulness of polylysine coating not only for enhancing osteoinduction but also to speed the post-surgery mucosal healings, guarantee appropriate peri-implant epithelial seals, and protect the fixture against bacterial penetration, which is responsible for compromising the implant survival.     

Benefits of Residual Aluminum Oxide for Sand Blasting Titanium Dental Implants: Osseointegration and Bactericidal Effects

Objectives. The purpose of this work was to determine the influence of residual alumina after sand blasting treatment in titanium dental implants. This paper studied the effect of alumina on physico-chemical surface properties, such as: surface wettability, surface energy. Osseointegration and bacteria adhesion were determined in order to determine the effect of the abrasive particles. Materials and Methods. Three surfaces were studied: (1) as-received, (2) rough surface with residual alumina from sand blasting on the surface and (3) with the same roughness but without residual alumina. Roughness was determined by white light interferometer microscopy. Surface wettability was evaluated with a contact angle video-based system and the surface free energy by means of Owens and Wendt equation. Scanning electron microscopy equipped with microanalysis was used to study the morphology and determine the chemical composition of the surfaces. Bacteria (Lactobacillus salivarius and Streptococcus sanguinis) were cultured in each surface. In total, 110 dental implants were placed into the bone of eight minipigs in order to compare the osseointegration. The percentage of bone-to-implant contact was determined after 4 and 6 weeks of implantation with histometric analysis. Results. The surfaces with residual alumina presented a lower surface free energy than clean surfaces. The in vivo studies demonstrated that the residual alumina accelerated bone tissue growth at different implantation times, in relation to clean dental implants. In addition, residual alumina showed a bactericidal effect by decreasing the quantity of bacteria adhering to the titanium. Conclusions. It is possible to verify the benefits that the alumina (percentages around 8% in weight) produces on the surface of titanium dental implants. Clinical relevance. Clinicians should be aware of the benefits of sand-blasted alumina due to the physico-chemical surface changes demonstrated in in vivo tests.