Bone Response to Conventional Titanium Implants and New Zirconia Implants Produced by Additive Manufacturing

The aim of the present study was to evaluate the in vivo bone response to an additively manufactured zirconia surface compared to osseointegration into titanium (Ti) surfaces. Scanning electron microscopy, confocal laser scanning microscopy, and electron spectroscopy for chemical analysis were performed to assess the surface characteristics of implant specimens. For the in vivo evaluation, eight Ti implants and eight 3D-printed zirconia implants were used. The surface of four Ti implants was sandblasted, large-grit, and acid-etched (Ti-SLA group), while those of the other four Ti implants were left untreated (Ti-turned group). The zirconia implants had no further surface modification. Implants were placed into the tibiae of four rabbits; two received the Ti-SLA and zirconia implants and the other two received Ti-turned and zirconia implants. The experimental animals were sacrificed after four weeks of surgery, and the undecalcified microscopic slides were prepared. The bone–implant interface was analyzed by histomorphometry to evaluate the bone response. The degree of surface roughness showed that Ti-SLA was the highest, followed by zirconia and Ti-turned surfaces. The 3D-printed zirconia surface showed similar bone-to-implant contact to the Ti-turned surface, and Ti-SLA had the most bone-to-implant contact. The additively manufactured zirconia implant surface is biocompatible with respect to osseointegration compared to the commercially pure Ti surface.     

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.     

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.     

Electrical Impedance of Surface Modified Porous Titanium Implants with Femtosecond Laser

The chemical composition and surface topography of titanium implants are essential to improve implant osseointegration. The present work studies a non-invasive alternative of electrical impedance spectroscopy for the characterization of the macroporosity inherent to the manufacturing process and the effect of the surface treatment with femtosecond laser of titanium discs. Osteoblasts cell culture growths on the titanium surfaces of the laser-treated discs were also studied with this method. The measurements obtained showed that the femtosecond laser treatment of the samples and cell culture produced a significant increase (around 50%) in the absolute value of the electrical impedance module, which could be characterized in a wide range of frequencies (being more relevant at 500 MHz). Results have revealed the potential of this measurement technique, in terms of advantages, in comparison to tiresome and expensive techniques, allowing semi-quantitatively relating impedance measurements to porosity content, as well as detecting the effect of surface modification, generated by laser treatment and cell culture.     

Titanium and Protein Adsorption: An Overview of Mechanisms and Effects of Surface Features

Titanium and its alloys, specially Ti6Al4V, are among the most employed materials in orthopedic and dental implants. Cells response and osseointegration of implant devices are strongly dependent on the body–biomaterial interface zone. This interface is mainly defined by proteins: They adsorb immediately after implantation from blood and biological fluids, forming a layer on implant surfaces. Therefore, it is of utmost importance to understand which features of biomaterials surfaces influence formation of the protein layer and how to guide it. In this paper, relevant literature of the last 15 years about protein adsorption on titanium-based materials is reviewed. How the surface characteristics affect protein adsorption is investigated, aiming to provide an as comprehensive a picture as possible of adsorption mechanisms and type of chemical bonding with the surface, as well as of the characterization techniques effectively applied to model and real implant surfaces. Surface free energy, charge, microroughness, and hydroxylation degree have been found to be the main surface parameters to affect the amount of adsorbed proteins. On the other hand, the conformation of adsorbed proteins is mainly dictated by the protein structure, surface topography at the nano-scale, and exposed functional groups. Protein adsorption on titanium surfaces still needs further clarification, in particular concerning adsorption from complex protein solutions. In addition, characterization techniques to investigate and compare the different aspects of protein adsorption on different surfaces (in terms of roughness and chemistry) shall be developed.     

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.     

Silane-Coating Strategy for Titanium Functionalization Does Not Impair Osteogenesis In Vivo

Silane-coating strategy has been used to bind biological compounds to the titanium surface, thereby making implant devices biologically active. However, it has not been determined if the presence of the silane coating itself is biocompatible to osseointegration. The aim of the present study was to evaluate if silane-coating affects bone formation on titanium using a rabbit model. For this, titanium screw implants (3.75 by 6 mm) were hydroxylated in a solution of H₂SO₄/30% H₂O₂ for 4 h before silane-coating with 3-aminopropyltriethoxysilane (APTES). A parallel set of titanium screws underwent only the hydroxylation process to present similar acid-etched topography as a control. The presence of the silane on the surface was checked by x-ray photoelectron spectroscopy (XPS), with scanning electron microscopy (SEM) and atomic force microscopy (AFM). A total of 40 titanium screws were implanted in the tibia of ten New Zealand rabbits in order to evaluate bone-to-implant contact (BIC) after 3 weeks and 6 weeks of healing. Silane-coated surface presented higher nitrogen content in the XPS analysis, while micro- and nano-topography of the surface remained unaffected. No difference between the groups was observed after 3 and 6 weeks of healing (p > 0.05, independent t-test), although an increase in BIC occurred over time. These results indicate that silanization of a titanium surface with APTES did not impair the bone formation, indicating that this can be a reliable tool to anchor osteogenic molecules on the surface of implant devices.     

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.     

Anatase Forming Treatment without Surface Morphological Alteration of Dental Implant

The osseointegration of titanium implants is allowed by the TiO₂ layer that covers the implants. Titania can exist in amorphous form or in three different crystalline conformations: anatase, rutile and brookite. Few studies have characterized TiO₂ covering the surface of dental implants from the crystalline point of view. The aim of the present study was to characterize the evolution of the TiO₂ layer following different surface treatments from a crystallographic point of view. Commercially pure titanium and Ti-6Al-4V implants subjected to different surface treatments were analyzed by Raman spectroscopy to evaluate the crystalline conformation of titania. The surface treatments evaluated were: machining, sandblasting, sandblasting and etching and sandblasting, etching and anodization. The anodizing treatment evaluated in this study allowed to obtain anatase on commercially pure titanium implants without altering the morphological characteristics of the surface.     

Effects of Surface Modification on Adsorption Behavior of Cell and Protein on Titanium Surface by Using Quartz Crystal Microbalance System

Primary stability and osseointegration are major challenges in dental implant treatments, where the material surface properties and wettability are critical in the early formation of hard tissue around the implant. In this study, a quartz crystal microbalance (QCM) was used to measure the nanogram level amount of protein and bone marrow cells adhered to the surfaces of titanium (Ti) surface in real time. The effects of ultraviolet (UV) and atmospheric-pressure plasma treatment to impart surface hydrophilicity to the implant surface were evaluated. The surface treatment methods resulted in a marked decrease in the surface carbon (C) content and increase in the oxygen (O) content, along with super hydrophilicity. The results of QCM measurements showed that adhesion of both adhesive proteins and bone marrow cells was enhanced after surface treatment. Although both methods produced implants with good osseointegration behavior and less reactive oxidative species, the samples treated with atmospheric pressure plasma showed the best overall performance and are recommended for clinical use. It was verified that QCM is an effective method for analyzing the initial adhesion process on dental implants.     

Surface Functionalisation of Dental Implants with a Composite Coating of Alendronate and Hydrolysed Collagen: DFT and EIS Studies

The success of the osseointegration process depends on the surface characteristics and chemical composition of dental implants. Therefore, the titanium dental implant was functionalised with a composite coating of alendronate and hydrolysed collagen, which are molecules with a positive influence on the bone formation. The results of the quantum chemical calculations at the density functional theory level confirm a spontaneous formation of the composite coating on the titanium implant, ∆G*_INT = −8.25 kcal mol⁻¹. The combination of the results of X-ray photoelectron spectroscopy and quantum chemical calculations reveals the structure of the coating. The alendronate molecules dominate in the outer part, while collagen tripeptides prevail in the inner part of the coating. The electrochemical stability and resistivity of the implant modified with the composite coating in a contact with the saliva depend on the chemical nature of alendronate and collagen molecules, as well as their inter- and intramolecular interactions. The formed composite coating provides a 98% protection to the implant after the 7-day immersion in the artificial saliva. From an application point of view, the composite coating could effectively promote osseointegration and improve the implant’s resistivity in contact with an aggressive environment such as saliva.     

Modified Titanium Surface-Mediated Effects on Human Bone Marrow Stromal Cell Response

Surface modification of titanium implants is used to enhance osseointegration. The study objective was to evaluate five modified titanium surfaces in terms of cytocompatibility and pro-osteogenic/pro-angiogenic properties for human mesenchymal stromal cells: amorphous microporous silica (AMS), bone morphogenetic protein-2 immobilized on AMS (AMS + BMP), bio-active glass (BAG) and two titanium coatings with different porosity (T1; T2). Four surfaces served as controls: uncoated Ti (Ti), Ti functionalized with BMP-2 (Ti + BMP), Ti surface with a thickened titanium oxide layer (TiO₂) and a tissue culture polystyrene surface (TCPS). The proliferation of eGFP-fLuc (enhanced green fluorescence protein-firefly luciferase) transfected cells was tracked non-invasively by fluorescence microscopy and bio-luminescence imaging. The implant surface-mediated effects on cell differentiation potential was tracked by determination of osteogenic and angiogenic parameters [alkaline phosphatase (ALP); osteocalcin (OC); osteoprotegerin (OPG); vascular endothelial growth factor-A (VEGF-A)]. Unrestrained cell proliferation was observed on (un)functionalized Ti and AMS surfaces, whereas BAG and porous titanium coatings T1 and T2 did not support cell proliferation. An important pro-osteogenic and pro-angiogenic potential of the AMS + BMP surface was observed. In contrast, coating the Ti surface with BMP did not affect the osteogenic differentiation of the progenitor cells. A significantly slower BMP-2 release from AMS compared to Ti supports these findings. In the unfunctionalized state, Ti was found to be superior to AMS in terms of OPG and VEGF-A production. AMS is suggested to be a promising implant coating material for bioactive agents delivery.     

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.     

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.     

Introducing a Novel Experimental Model for Osseo-Disintegration of Titanium Dental Implants Induced by Monobacterial Contamination: An In-Vivo Feasibility Study

Background and Objectives: The aim of the current study was to establish an osseo-disintegration model initiated with a single microorganism in mini-pigs. Materials and Methods: A total of 36 titanium dental implants (3.5 mm in diameter, 9.5 mm in length) was inserted into frontal bone (n: 12) and the basis of the corpus mandible (n: 24). Eighteen implants were contaminated via inoculation of Enterococcus faecalis. Six weeks after implant insertion, bone-to-implant contact (BIC) ratio, interthread bone density (ITBD), and peri-implant bone density (PIBD) were examined. In addition to that, new bone formation was assessed via fluorescence microscopy, histomorphometry, and light microscopical examinations. Results: Compared to the sterile implants, the contaminated implants showed significantly reduced BIC (p < 0.001), ITBD (p < 0.001), and PBD (p < 0.001) values. Around the sterile implants, the green and red fluorophores were overlapping and surrounding the implant without gaps, indicating healthy bone growth on the implant surface, whereas contaminated implants were surrounded by connective tissue. Conclusions: The current experimental model could be a feasible option to realize a significant alteration of dental-implant osseointegration and examine novel surface decontamination techniques without impairing local and systemic inflammatory complications.     

Hydroxyapatite Formation on Coated Titanium Implants Submerged in Simulated Body Fluid

Titanium implants are commonly used in the field of dentistry for prosthetics such as crowns, bridges, and dentures. For successful therapy, an implant must bind to the surrounding bone in a process known as osseointegration. The objective for this ongoing study is to determine the potential of different implant surface coatings in providing the formation of hydroxyapatite (HA). The coatings include titanium nitride (TiN), silicon dioxide (SiO₂), and quaternized titanium nitride (QTiN). The controls were a sodium hydroxide treated group, which functioned as a positive control, and an uncoated titanium group. Each coated disc was submerged in simulated body fluid (SBF), replenished every 48 h, over a period of 28 days. Each coating successfully developed a layer of HA, which was calculated through mass comparisons and observed using scanning electron microscopy (SEM) and energy dispersive analysis x-rays (EDX). Among these coatings, the quaternized titanium nitride coating seemed to have a better yield of HA. Further studies to expand the data concerning this experiment are underway.     

A Novel Surface Modification Strategy via Photopolymerized Poly-Sulfobetaine Methacrylate Coating to Prevent Bacterial Adhesion on Titanium Surfaces

Recent investigations on the anti-adhesive properties of polysulfobetaine methacrylate (pSBMA) coatings had shown promising potential as antifouling surfaces and have given the impetus for the present paper, where a pSBMA coating is applied via photopolymerization on a macro-roughened, sandblasted, and acid-etched titanium implant surface in order to assess its antifouling properties. Current emphasis is placed on how the coating is efficient against the adhesion of Enterococcus faecalis by quantitative assessment of colony forming units and qualitative investigation of fluorescence imaging and scanning electron microscopy. pSBMA coatings via photopolymerization of titanium surfaces seems to be a promising antiadhesion strategy, which should bring substantial benefits once certain aspects such as biodegradation and osseointegration were addressed. Additionally, commercial SAL-titanium substrates may be coated with the super-hydrophilic coating, appearing resistant to physiological salt concentrations and most importantly lowering E. faecalis colonization significantly, compared to titanium substrates in the as-received state. It is very likely that pSBMA coatings may also prevent the adhesion of other germs.     

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.     

Nanoparticles and Nanostructured Surface Fabrication for Innovative Cranial and Maxillofacial Surgery

A novel strategy to improve the success of soft and hard tissue integration of titanium implants is the use of nanoparticles coatings made from basically any type of biocompatible substance, which can advantageously enhance the properties of the material, as compared to its similar bulk material. So, most of the physical methods approaches involve the compaction of nanoparticles versus micron-level particles to yield surfaces with nanoscale grain boundaries, simultaneously preserving the chemistry of the surface among different topographies. At the same time, nanoparticles have been known as one of the most effective antibacterial agents and can be used as effective growth inhibitors of various microorganisms as an alternative to antibiotics. In this paper, based on literature research, we present a comprehensive review of the mechanical, physical, and chemical methods for creating nano-structured titanium surfaces along with the main nanoparticles used for the surface modification of titanium implants, the fabrication methods, their main features, and the purpose of use. We also present two patented solutions which involve nanoparticles to be used in cranioplasty, i.e., a cranial endoprosthesis with a sliding system to repair the traumatic defects of the skull, and a cranial implant based on titanium mesh with osteointegrating structures and functional nanoparticles. The main outcomes of the patented solutions are: (a) a novel geometry of the implant that allow both flexible adaptation of the implant to the specific anatomy of the patient and the promotion of regeneration of the bone tissue; (b) porous structure and favorable geometry for the absorption of impregnated active substances and cells proliferation; (c) the new implant model fit 100% on the structure of the cranial defect without inducing mechanical stress; (d) allows all kinds of radiological examinations and rapid osteointegration, along with the patient recover in a shorter time.     

Approach to the Fatigue and Cellular Behavior of Superficially Modified Porous Titanium Dental Implants

In this work, the fatigue and cellular performance of novel superficially treated porous titanium dental implants made up using conventional powder metallurgy and space-holder techniques (30 vol.% and 50 vol.%, both with a spacer size range of 100–200 µm) are evaluated. Before the sintering stage, a specific stage of CNC milling of the screw thread of the implant is used. After the consolidation processing, different surface modifications are performed: chemical etching and bioactive coatings (BG 45S5 and BG 1393). The results are discussed in terms of the effect of the porosity, as well as the surface roughness, chemical composition, and adherence of the coatings on the fatigue resistance and the osteoblast cells’ behavior for the proposed implants. Macro-pores are preferential sites of the nucleation of cracks and bone cell adhesion, and they increase the cellular activity of the implants, but decrease the fatigue life. In conclusion, SH 30 vol.% dental implant chemical etching presents the best bio-functional (in vitro osseointegration) and bio-mechanical (stiffness, yield strength and fatigue life) balance, which could ensure the required characteristics of cortical bone tissue.