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1.  Biomechanical evaluation of dental implants with different surfaces: Removal torque and resonance frequency analysis in rabbits 
STATEMENT OF PROBLEM
Macroscopic and especially microscopic properties of implant surfaces play a major role in the osseous healing of dental implants. Dental implants with modified surfaces have shown stronger osseointegration than implants which are only turned (machined). Advanced surface modification techniques such as anodic oxidation and Ca-P application have been developed to achieve faster and stronger bonding between the host bone and the implant.
PURPOSE
The purpose of this study was to investigate the effect of surface treatment of titanium dental implant on implant stability after insertion using the rabbit tibia model.
MATERIAL AND METHODS
Three test groups were prepared: sandblasted, large-grit and acid-etched (SLA) implants, anodic oxidized implants, and anodized implants with Ca-P immersion. The turned implants served as control. Twenty rabbits received 80 implants in the tibia. Resonance frequencies were measured at the time of implant insertion, 2 weeks and 4 weeks of healing. Removal torque values (RTV) were measured 2 and 4 weeks after insertion.
RESULTS
The implant stability quotient (ISQ) values of implants for resonance frequency analysis (RFA) increased significantly (P < .05) during 2 weeks of healing period although there were no significant differences among the test and control groups (P > .05). The test and control implants also showed significantly higher ISQ values during 4 weeks of healing period (P < .05). No significant differences, however, were found among all the groups. All the groups showed no significant differences in ISQ values between 2 and 4 weeks after implant insertion (P > .05). The SLA, anodized and Ca-P immersed implants showed higher RTVs at 2 and 4 weeks of healing than the machined one (P < .05). However, there was no significant difference among the experimental groups.
CONCLUSION
The surface-modified implants appear to provide superior implant stability to the turned one. Under the limitation of this study, however, we suggest that neither anodic oxidation nor Ca-P immersion techniques have any advantage over the conventional SLA technique with respect to implant stability.
doi:10.4047/jap.2009.1.2.107
PMCID: PMC2994679  PMID: 21165264
surface treatment; bone to implant contact; removal torque; dental implant
2.  Osseointegration of zirconia implants compared with titanium: an in vivo study 
Head & Face Medicine  2008;4:30.
Background
Titanium and titanium alloys are widely used for fabrication of dental implants. Since the material composition and the surface topography of a biomaterial play a fundamental role in osseointegration, various chemical and physical surface modifications have been developed to improve osseous healing. Zirconia-based implants were introduced into dental implantology as an altenative to titanium implants. Zirconia seems to be a suitable implant material because of its tooth-like colour, its mechanical properties and its biocompatibility. As the osseointegration of zirconia implants has not been extensively investigated, the aim of this study was to compare the osseous healing of zirconia implants with titanium implants which have a roughened surface but otherwise similar implant geometries.
Methods
Forty-eight zirconia and titanium implants were introduced into the tibia of 12 minipigs. After 1, 4 or 12 weeks, animals were sacrificed and specimens containing the implants were examined in terms of histological and ultrastructural techniques.
Results
Histological results showed direct bone contact on the zirconia and titanium surfaces. Bone implant contact as measured by histomorphometry was slightly better on titanium than on zirconia surfaces. However, a statistically significant difference between the two groups was not observed.
Conclusion
The results demonstrated that zirconia implants with modified surfaces result in an osseointegration which is comparable with that of titanium implants.
doi:10.1186/1746-160X-4-30
PMCID: PMC2614983  PMID: 19077228
3.  Biomolecular surface coating to enhance orthopaedic tissue healing and integration 
Biomaterials  2007;28(21):3228-3235.
Implant osseointegration is a prerequisite for clinical success in orthopaedic and dental applications, many of which are restricted by loosening. Biomaterial surface modification approaches, including calcium-phosphate ceramic coatings and macro/microporosity, have had limited success in promoting integration. To improve osseointegration, titanium surfaces were coated with the GFOGER collagen-mimetic peptide, selectively promoting α2β1 integrin binding, a crucial event for osteoblastic differentiation. Titanium surfaces presenting GFOGER triggered osteoblastic differentiation and mineral deposition in bone marrow stromal cells, leading to enhanced osteoblastic function compared to unmodified titanium. Furthermore, this integrin-targeted coating significantly improved in vivo peri-implant bone regeneration and osseointegration, as characterized by bone-implant contact and mechanical fixation, compared to untreated titanium in a rat cortical bone-implant model. GFOGER-modified implants also significantly enhanced osseointegration compared to surfaces modified with full-length type I collagen, highlighting the importance of presenting specific biofunctional domains within the native ligand. In addition, this biomimetic implant coating is generated using a simple, single-step procedure that readily translates to a clinical environment with minimal processing and cytotoxicity concerns. Therefore, this study establishes a biologically active and clinically relevant implant coating strategy that enhances bone repair and orthopaedic implant integration.
doi:10.1016/j.biomaterials.2007.04.003
PMCID: PMC2034748  PMID: 17448533
biomimetic material; cell adhesion; collagen; osseointegration; integrin
4.  The effects of combined micron-/submicron-scale surface roughness and nanoscale features on cell proliferation and differentiation 
Biomaterials  2011;32(13):3395-3403.
Titanium (Ti) osseointegration is critical for the success of dental and orthopaedic implants. Previous studies have shown that surface roughness at the micro- and submicro-scales promotes osseointegration by enhancing osteoblast differentiation and local factor production. Only relatively recently have the effects of nanoscale roughness on cell response been considered. The aim of the present study was to develop a simple and scalable surface modification treatment that introduces nanoscale features to the surfaces of Ti substrates without greatly affecting other surface features, and to determine the effects of such superimposed nano-features on the differentiation and local factor production of osteoblasts. A simple oxidation treatment was developed for generating controlled nanoscale topographies on Ti surfaces, while retaining the starting micro-/submicro-scale roughness. Such nano-modified surfaces also possessed similar elemental compositions, and exhibited similar contact angles, as the original surfaces, but possessed a different surface crystal structure. MG63 cells were seeded on machined (PT), nano-modified PT (NMPT), sandblasted/acid-etched (SLA), and nano-modified SLA (NMSLA) Ti disks. The results suggested that the introduction of such nanoscale structures in combination with micro-/submicro-scale roughness improves osteoblast differentiation and local factor production, which, in turn, indicates the potential for improved implant osseointegration in vivo.
doi:10.1016/j.biomaterials.2011.01.029
PMCID: PMC3350795  PMID: 21310480
(4 to 6) nanotopography; titanium oxide; surface roughness; titanium; bone; implant; osteoblasts
5.  Evaluation of Functional Dynamics during Osseointegration and Regeneration Associated with Oral Implants: A Review 
Objectives
The aim of this paper is to review current investigations on functional assessments of osseointegration and assess correlations to the peri-implant structure.
Material and methods
The literature was electronically searched for studies of promoting dental implant osseointegration, functional assessments of implant stability, and finite element (FE) analyses in the field of implant dentistry, and any references regarding biological events during osseointegration were also cited as background information.
Results
Osseointegration involves a cascade of protein and cell apposition, vascular invasion, de novo bone formation and maturation to achieve the primary and secondary dental implant stability. This process may be accelerated by alteration of the implant surface roughness, developing a biomimetric interface, or local delivery of growth-promoting factors. The current available preclinical and clinical biomechanical assessments demonstrated a variety of correlations to the peri-implant structural parameters, and functionally integrated peri-implant structure through FE optimization can offer strong correlation to the interfacial biomechanics.
Conclusions
The progression of osseointegration may be accelerated by alteration of the implant interface as well as growth factor applications, and functional integration of peri-implant structure may be feasible to predict the implant function during osseointegration. More research in this field is still needed.
doi:10.1111/j.1600-0501.2009.01826.x
PMCID: PMC2808201  PMID: 20070743
finite element analysis; growth factor; bone-implant interactions
6.  Early bone growth on the surface of titanium implants in rat femur is enhanced by an amorphous diamond coating 
Acta Orthopaedica  2011;82(4):499-503.
Background and purpose
Amorphous diamond (AD) is a durable and compatible biomaterial for joint prostheses. Knowledge regarding bone growth on AD-coated implants and their early-stage osseointegration is poor. We investigated bone growth on AD-coated cementless intramedullary implants implanted in rats. Titanium was chosen as a reference due to its well-known performance.
Materials and methods
We placed AD-coated and non-coated titanium implants (Ra ≈ 0.2 μm) into the femoral bone marrow of 25 rats. The animals were divided in 2 groups according to implant coating and they were killed after 4 or 12 weeks. The osseointegration of the implants was examined from hard tissue specimens by measuring the new bone formation on their surface.
Results
4 weeks after the operation, the thickness of new bone in the AD-coated group was greater than that in the non-coated group (15.3 (SD 7.1) μm vs. 7.6 (SD 6.0) μm). 12 weeks after the operation, the thickness of new bone was similar in the non-coated group and in the AD-coated group.
Interpretation
We conclude that AD coating of femoral implants can enhance bone ongrowth in rats in the acute, early stage after the operation and might be an improvement over earlier coatings.
doi:10.3109/17453674.2011.579522
PMCID: PMC3237044  PMID: 21504369
7.  Antimicrobial surfaces for craniofacial implants: state of the art 
In an attempt to regain function and aesthetics in the craniofacial region, different biomaterials, including titanium, hydroxyapatite, biodegradable polymers and composites, have been widely used as a result of the loss of craniofacial bone. Although these materials presented favorable success rates, osseointegration and antibacterial properties are often hard to achieve. Although bone-implant interactions are highly dependent on the implant's surface characteristics, infections following traumatic craniofacial injuries are common. As such, poor osseointegration and infections are two of the many causes of implant failure. Further, as increasingly complex dental repairs are attempted, the likelihood of infection in these implants has also been on the rise. For these reasons, the treatment of craniofacial bone defects and dental repairs for long-term success remains a challenge. Various approaches to reduce the rate of infection and improve osseointegration have been investigated. Furthermore, recent and planned tissue engineering developments are aimed at improving the implants' physical and biological properties by improving their surfaces in order to develop craniofacial bone substitutes that will restore, maintain and improve tissue function. In this review, the commonly used biomaterials for craniofacial bone restoration and dental repair, as well as surface modification techniques, antibacterial surfaces and coatings are discussed.
doi:10.5125/jkaoms.2013.39.2.43
PMCID: PMC3858148  PMID: 24471018
Dental implants; Osseointegration; Antimicrobial agents; Surface-coated materials; Bone regeneration
8.  The effect of integrin-specific bioactive coatings on tissue healing and implant osseointegration 
Biomaterials  2008;29(19):2849-2857.
Implant osseointegration, defined as bone apposition and functional fixation, is a requisite for clinical success in orthopaedic and dental applications, many of which are restricted by implant loosening. Modification of implants to present bioactive motifs such as the RGD cell-adhesive sequence from fibronectin (FN) represents a promising approach in regenerative medicine. However, these biomimetic strategies have yielded only marginal enhancements in tissue healing in vivo. In this study, clinical-grade titanium implants were grafted with a non-fouling oligo(ethylene glycol)-substituted polymer coating functionalized with controlled densities of ligands of varying specificity for target integrin receptors. Biomaterials presenting the α5β1-integrin-specific FN fragment FNIII7–10 enhanced osteoblastic differentiation in bone marrow stromal cells compared to unmodified titanium and RGD-presenting surfaces. Importantly, FNIII7–10-functionalized titanium significantly improved functional implant osseointegration compared to RGD-functionalized and unmodified titanium in vivo. This study demonstrates that bioactive coatings that promote integrin binding specificity regulate marrow-derived progenitor osteoblastic differentiation and enhance healing responses and functional integration of biomedical implants. This work identifies an innovative strategy for the rational design of biomaterials for regenerative medicine.
doi:10.1016/j.biomaterials.2008.03.036
PMCID: PMC2397448  PMID: 18406458
9.  Early loading of hydrophilic titanium implants inserted in low-mineralized (D3 and D4) bone: one year results of a prospective clinical trial 
Head & Face Medicine  2013;9:37.
Introduction
Pure titanium is the material of choice for contemporary dental implants. However, superficial reaction of the moderately rough titanium surface with atmospheric components decreases its hydrophilicity. INICELL® represents a chemical alteration and hydrophilization of a moderately rough i. e. sand-blasted and acid-etched titanium surface. The hydrophilicity leads to a more homogenous adsorption of proteins on the implant surface in-vitro, supporting the activation of a higher number of platelets and the generation of a homogenous, complete fibrin matrix in the early phases of osseointegration. This in turn helps to reduce the healing time and enhances the predictability of osseointegration in compromised bony situations.
The objective of this case series trial was therefore to investigate if early loading (after 8 weeks) of hydrophilic INICELL implants is feasible in patients with reduced bone quality.
Methods
In 10 patients, 35 hydrophilic implants were placed in sites revealing bone quality class 3 and 4, and uncovered after 4 weeks. Eight weeks later implants were released for loading if the tactile resistance was ≥35 Ncm. Lower resistances resulted in 12 weeks initial healing period. Insertion torque, ISQ, tactile resistance and vertical bone level were evaluated at implant installation, after 4 weeks (uncovering), 8 or 12 weeks (loading), and 12 weeks and one year after loading.
Results
Mean implant insertion torque was 21 Ncm. 31 (88.6%) showed a tactile resistance of >35 Ncm after eight weeks and were released for prosthetic loading. Eight weeks after insertion, one implant (2.9%) had to be removed following a soft tissue complication. One implant had to be removed after 4 weeks due to a technical complication (fractured Osstell-abutment), it was therefore excluded from the analysis.
33 of 34 implants (97%) were loaded to occlusion and were in situ/functional one year after implantation. ISQs increased from 43 at baseline to 63 at eight weeks, and 72 at three months after loading. Then, ISQ remained constant until one year after loading.
Conclusions
Within the limitations of this prospective case series, hydrophilic implants may allow for shortening of the initial healing period even in bone with compromised density.
doi:10.1186/1746-160X-9-37
PMCID: PMC3866303  PMID: 24321192
Titanium implants; Hydrophilic surface; Healing time; Bone quality; Weak bone
10.  Strain driven fast osseointegration of implants 
Background
Although the bone's capability of dental implant osseointegration has clinically been utilised as early as in the Gallo-Roman population, the specific mechanisms for the emergence and maintenance of peri-implant bone under functional load have not been identified. Here we show that under immediate loading of specially designed dental implants with masticatory loads, osseointegration is rapidly achieved.
Methods
We examined the bone reaction around non- and immediately loaded dental implants inserted in the mandible of mature minipigs during the presently assumed time for osseointegration. We used threaded conical titanium implants containing a titanium2+ oxide surface, allowing direct bone contact after insertion. The external geometry was designed according to finite element analysis: the calculation showed that physiological amplitudes of strain (500–3,000 ustrain) generated through mastication were homogenously distributed in peri-implant bone. The strain-energy density (SED) rate under assessment of a 1 Hz loading cycle was 150 Jm-3 s-1, peak dislocations were lower then nm.
Results
Bone was in direct contact to the implant surface (bone/implant contact rate 90%) from day one of implant insertion, as quantified by undecalcified histological sections. This effect was substantiated by ultrastructural analysis of intimate osteoblast attachment and mature collagen mineralisation at the titanium surface. We detected no loss in the intimate bone/implant bond during the experimental period of either control or experimental animals, indicating that immediate load had no adverse effect on bone structure in peri-implant bone.
Conclusion
In terms of clinical relevance, the load related bone reaction at the implant interface may in combination with substrate effects be responsible for an immediate osseointegration state.
doi:10.1186/1746-160X-1-6
PMCID: PMC1277014  PMID: 16270927
11.  Osseointegration: An Update 
Osseointegration, defined as a direct structural and functional connection between ordered, living bone and the surface of a load-carrying implant, is critical for implant stability, and is considered a prerequisite for implant loading and long-term clinical success of end osseous dental implants. The implant–tissue interface is an extremely dynamic region of interaction. This complex interaction involves not only biomaterial and biocompatibility issues but also alteration of mechanical environment. The processes of osseointegration involve an initial interlocking between alveolar bone and the implant body, and later, biological fixation through continuous bone apposition and remodeling toward the implant. The process itself is quite complex and there are many factors that influence the formation and maintenance of bone at the implant surface. The aim of this present review is to analysis the current understanding of clinical assessments and factors that determine the success & failure of osseointegrated dental implants.
doi:10.1007/s13191-013-0252-z
PMCID: PMC3602536  PMID: 24431699
Bone–Metal interface; Endosseous implants; Mechanical interlock; Implant stability
12.  Nanostructured Surfaces of Dental Implants 
The structural and functional fusion of the surface of the dental implant with the surrounding bone (osseointegration) is crucial for the short and long term outcome of the device. In recent years, the enhancement of bone formation at the bone-implant interface has been achieved through the modulation of osteoblasts adhesion and spreading, induced by structural modifications of the implant surface, particularly at the nanoscale level. In this context, traditional chemical and physical processes find new applications to achieve the best dental implant technology. This review provides an overview of the most common manufacture techniques and the related cells-surface interactions and modulation. A Medline and a hand search were conducted to identify studies concerning nanostructuration of implant surface and their related biological interaction. In this paper, we stressed the importance of the modifications on dental implant surfaces at the nanometric level. Nowadays, there is still little evidence of the long-term benefits of nanofeatures, as the promising results achieved in vitro and in animals have still to be confirmed in humans. However, the increasing interest in nanotechnology is undoubted and more research is going to be published in the coming years.
doi:10.3390/ijms14011918
PMCID: PMC3565355  PMID: 23344062
adult stem cells; nanotechnologies; differentiation; osteogenesis; surfaces; dental implant
13.  Biofunctionalization of a titanium surface with a nano-sawtooth structure regulates the behavior of rat bone marrow mesenchymal stem cells 
Background:
The topography of an implant surface can serve as a powerful signaling cue for attached cells and can enhance the quality of osseointegration. A series of improved implant surfaces functionalized with nanoscale structures have been fabricated using various methods.
Methods:
In this study, using an H2O2 process, we fabricated two size-controllable sawtooth-like nanostructures with different dimensions on a titanium surface. The effects of the two nano-sawtooth structures on rat bone marrow mesenchymal stem cells (BMMSCs) were evaluated without the addition of osteoinductive chemical factors.
Results:
These new surface modifications did not adversely affect cell viability, and rat BMMSCs demonstrated a greater increase in proliferation ability on the surfaces of the nano-sawtooth structures than on a control plate. Furthermore, upregulated expression of osteogenic-related genes and proteins indicated that the nano-sawtooth structures promote osteoblastic differentiation of rat BMMSCs. Importantly, the large nano-sawtooth structure resulted in the greatest cell responses, including increased adhesion, proliferation, and differentiation.
Conclusion:
The enhanced adhesion, proliferation, and osteogenic differentiation abilities of rat BMMSCs on the nano-sawtooth structures suggest the potential to induce improvements in bone-titanium integration in vivo. Our study reveals the key role played by the nano-sawtooth structures on a titanium surface for the fate of rat BMMSCs and provides insights into the study of stem cell-nanostructure relationships and the related design of improved biomedical implant surfaces.
doi:10.2147/IJN.S33575
PMCID: PMC3422101  PMID: 22927760
nanotechnology; surface modification; osteogenic differentiation; BMMSCs; implants; osseointegration
14.  Osseointegration of zirconia implants: an SEM observation of the bone-implant interface 
Head & Face Medicine  2008;4:25.
Background
The successful use of zirconia ceramics in orthopedic surgery led to a demand for dental zirconium-based implant systems. Because of its excellent biomechanical characteristics, biocompatibility, and bright tooth-like color, zirconia (zirconium dioxide, ZrO2) has the potential to become a substitute for titanium as dental implant material. The present study aimed at investigating the osseointegration of zirconia implants with modified ablative surface at an ultrastructural level.
Methods
A total of 24 zirconia implants with modified ablative surfaces and 24 titanium implants all of similar shape and surface structure were inserted into the tibia of 12 Göttinger minipigs. Block biopsies were harvested 1 week, 4 weeks or 12 weeks (four animals each) after surgery. Scanning electron microscopy (SEM) analysis was performed at the bone implant interface.
Results
Remarkable bone attachment was already seen after 1 week which increased further to intimate bone contact after 4 weeks, observed on both zirconia and titanium implant surfaces. After 12 weeks, osseointegration without interposition of an interfacial layer was detected. At the ultrastructural level, there was no obvious difference between the osseointegration of zirconia implants with modified ablative surfaces and titanium implants with a similar surface topography.
Conclusion
The results of this study indicate similar osseointegration of zirconia and titanium implants at the ultrastructural level.
doi:10.1186/1746-160X-4-25
PMCID: PMC2583968  PMID: 18990214
15.  Electrical Implications of Corrosion for Osseointegration of Titanium Implants 
Journal of Dental Research  2011;90(12):1389-1397.
The success rate of titanium implants for dental and orthopedic applications depends on the ability of surrounding bone tissue to integrate with the surface of the device, and it remains far from ideal in patients with bone compromised by physiological factors. The electrical properties and electrical stimulation of bone have been shown to control its growth and healing and can enhance osseointegration. Bone cells are also sensitive to the chemical products generated during corrosion events, but less is known about how the electrical signals associated with corrosion might affect osseointegration. The metallic nature of the materials used for implant applications and the corrosive environments found in the human body, in combination with the continuous and cyclic loads to which these implants are exposed, may lead to corrosion and its corresponding electrochemical products. The abnormal electrical currents produced during corrosion can convert any metallic implant into an electrode, and the negative impact on the surrounding tissue due to these extreme signals could be an additional cause of poor performance and rejection of implants. Here, we review basic aspects of the electrical properties and electrical stimulation of bone, as well as fundamental concepts of aqueous corrosion and its electrical and clinical implications.
doi:10.1177/0022034511408428
PMCID: PMC3215755  PMID: 21555775
biopotentials; electrical stimulation; corrosion; titanium; bone; osseointegration of dental and orthopedic implants
16.  Biomechanics of the press-fit phenomenon in dental implantology: an image-based finite element analysis 
Head & Face Medicine  2012;8:18.
Background
A fundamental pre-requisite for the clinical success in dental implant surgery is the fast and stable implant osseointegration. The press-fit phenomenon occurring at implant insertion induces biomechanical effects in the bone tissues, which ensure implant primary stability. In the field of dental surgery, the understanding of the key factors governing the osseointegration process still remains of utmost importance. A thorough analysis of the biomechanics of dental implantology requires a detailed knowledge of bone mechanical properties as well as an accurate definition of the jaw bone geometry.
Methods
In this work, a CT image-based approach, combined with the Finite Element Method (FEM), has been used to investigate the effect of the drill size on the biomechanics of the dental implant technique. A very accurate model of the human mandible bone segment has been created by processing high resolution micro-CT image data. The press-fit phenomenon has been simulated by FE analyses for different common drill diameters (DA = 2.8 mm, DB = 3.3 mm, and DC = 3.8 mm) with depth L = 12 mm. A virtual implant model has been assumed with a cylindrical geometry having height L = 11 mm and diameter D = 4 mm.
Results
The maximum stresses calculated for drill diameters DA, DB and DC have been 12.31 GPa, 7.74 GPa and 4.52 GPa, respectively. High strain values have been measured in the cortical area for the models of diameters DA and DB, while a uniform distribution has been observed for the model of diameter DC . The maximum logarithmic strains, calculated in nonlinear analyses, have been ϵ = 2.46, 0.51 and 0.49 for the three models, respectively.
Conclusions
This study introduces a very powerful, accurate and non-destructive methodology for investigating the effect of the drill size on the biomechanics of the dental implant technique.
Further studies could aim at understanding how different drill shapes can determine the optimal press-fit condition with an equally distributed preload on both the cortical and trabecular structure around the implant.
doi:10.1186/1746-160X-8-18
PMCID: PMC3464165  PMID: 22642768
17.  Adhesion of Streptococcus mitis and Actinomyces oris in co-culture to machined and anodized titanium surfaces as affected by atmosphere and pH 
BMC Oral Health  2013;13:4.
Background
With the rising demand for osseointegrated titanium implants for replacing missing teeth, often in patients with a history of periodontitis, implant-related infections have become an issue of growing concern. Novel methods for treating and preventing implant-associated infections are urgently needed. The aim of this study was to investigate if different pH, atmosphere and surface properties could restrict bacterial adhesion to titanium surfaces used in dental implants.
Methods
Titanium discs with machined or anodized (TiUnite™) surface were incubated with a co-culture of Streptococcus mitis and Actinomyces oris (early colonizers of oral surfaces) at pH 5.0, 7.0 and 9.0 at aerobic or anaerobic atmosphere. The adhesion was analysed by counting colony forming (CFU) units on agar and by confocal laser scanning microscopy (CLSM).
Results
The CFU analysis showed that a pH of 5.0 was found to significantly decrease the adhesion of S. mitis, and an aerobic atmosphere, the adhesion of A. oris. S. mitis was found in significantly less amounts on the anodized surface than the machined surface, while A. oris was found in equal amounts on both surfaces. The CLSM analysis confirmed the results from the CFU count and provided additional information on how the two oral commensal species adhered to the surfaces: mainly in dispersed clusters oriented with the groves of the machined surface and the pores of the anodized surface.
Conclusions
Bacterial adhesion by S. mitis and A. oris can be restricted by acidic pH and aerobic atmosphere. The anodized surface reduced the adhesion of S. mitis compared to the machined surface; while A. oris adhered equally well to the pores of the anodized surface and to the grooves of the machined surface. It is difficult to transfer these results directly into a clinical situation. However, it is worth further investigating these findings from an in vitro perspective, as well as clinically, to gain more knowledge of the effects acid pH and aerobic atmosphere have on initial bacterial adhesion.
doi:10.1186/1472-6831-13-4
PMCID: PMC3556164  PMID: 23298213
Bacterial adhesion; Dental implants; Peri-implant disease; Confocal laser scanning microscopy
18.  The Effectiveness of Poly-(4-vinyl-N-hexylpyridiniumbromide) as an Antibacterial Implant Coating: An In Vitro Study 
The clinical success of osseointegrated dental implants depends on the strong attachment of the surrounding hard and soft tissues. Bacterial adhesion on implant surfaces can cause inflammatory reactions and may influence healing and long-term success of dental implants. Promising implant coatings should minimize bacterial adhesion, but allow epithelial and connective tissue attachment. Therefore, the present study has examined the bioactive effect of poly-(4-vinyl-N-hexylpyridiniumbromide) regarding typical oral bacteria as well as cytotoxicitiy to human cells considering different methods of connecting polymers to silicate-containing surfaces. The results revealed that the application of putative antibacterial and biocompatible polymer in coating strategies is affected by a variety of parameters. Published findings regarding reduced bacterial adhesion could not be verified using oral pathogens whereas hexylated polymers seem problematic for strong adhesion of soft tissue. Concerning innovative coatings for dental implants basic aspects (surface roughness, thickness, alkylation, combination with other polymers) have to be considered in further investigations.
doi:10.1155/2011/859140
PMCID: PMC3249688  PMID: 22229031
19.  No Positive Effect of Acid Etching or Plasma Cleaning on Osseointegration of Titanium Implants in a Canine Femoral Condyle Press-Fit Model 
Purpose:
Implant surface treatments that improve early osseointegration may prove useful in long-term survival of uncemented implants. We investigated Acid Etching and Plasma Cleaning on titanium implants.
Methods:
In a randomized, paired animal study, four porous coated Ti implants were inserted into the femurs of each of ten dogs.
PC (Porous Coating; control)PC+PSHA (Plasma Sprayed Hydroxyapatite; positive control)PC+ET (Acid Etch)PC+ET+PLCN (Plasma Cleaning)
After four weeks mechanical fixation was evaluated by push-out test and osseointegration by histomorphometry.
Results:
The PSHA-coated implants were better osseointegrated than the three other groups on outer surface implant porosity (p<0.05) while there was no statistical difference in deep surface implant porosity when compared with nontreated implant. Within the deep surface implant porosity, there was more newly formed bone in the control group compared to the ET and ET+PCLN groups (p<0.05). In all compared groups, there was no statistical difference in any biomechanical parameter.
Conclusions:
In terms of osseointegration on outer surface implant porosity PC+PSHA was superior to the other three groups. Neither the acid etching nor the plasma cleaning offered any advantage in terms of implant osseointegration. There was no statistical difference in any of the biomechanical parameters among all groups in the press-fit model at 4 weeks of evaluation time.
doi:10.2174/1874325001307010001
PMCID: PMC3547294  PMID: 23341850
Acid etching; canine; osseointegration; plasma cleaning; press-fit; titanium implants.
20.  Preparation of Bioactive Titanium Surfaces via Fluoride and Fibronectin Retention 
Statement of Problem. The chemical or topographic modification of the dental implant surface can affect bone healing, promote accelerated osteogenesis, and increase bone-implant contact and bonding strength. Objective. In this work, the effects of dental implant surface treatment and fibronectin adsorption on the adhesion of osteoblasts were analyzed. Materials and Methods. Two titanium dental implants (Porous-acid etching and PorousNano-acid etching followed by fluoride ion modification) were characterized by high-resolution scanning electron microscopy, atomic force microscopy, and X-ray diffraction before and after the incorporation of human plasma fibronectin (FN). The objective was to investigate the biofunctionalization of these surfaces and examine their effects on the interaction with osteoblastic cells. Results. The evaluation techniques used showed that the Porous and PorousNano implants have similar microstructural characteristics. Spectrophotometry demonstrated similar levels of fibronectin adsorption on both surfaces (80%). The association indexes of osteoblastic cells in FN-treated samples were significantly higher than those in samples without FN. The radioactivity values associated with the same samples, expressed as counts per minute (cpm), suggested that FN incorporation is an important determinant of the in vitro cytocompatibility of the surfaces. Conclusion. The preparation of bioactive titanium surfaces via fluoride and FN retention proved to be a useful treatment to optimize and to accelerate the osseointegration process for dental implants.
doi:10.1155/2012/290179
PMCID: PMC3503304  PMID: 23197981
21.  Surface Contaminants Inhibit Osseointegration in a Novel Murine Model 
Bone  2011;49(5):923-930.
Surface contaminants, such as bacterial debris and manufacturing residues, may remain on orthopaedic implants after sterilization procedures and affect osseointegration. The goals of this study were to develop a murine model of osseointegration in order to determine whether removing surface contaminants enhances osseointegration. To develop the murine model, titanium alloy implants were implanted into a unicortical pilot hole in the mid-diaphysis of the femur and osseointegration was measured over a five week time course. Histology, backscatter scanning electron microscopy and x-ray energy dispersive spectroscopy showed areas of bone in intimate physical contact with the implant, confirming osseointegration. Histomorphometric quantification of bone-to-implant contact and peri-implant bone and biomechanical pullout quantification of ultimate force, stiffness and work to failure increased significantly over time, also demonstrating successful osseointegration. We also found that a rigorous cleaning procedure significantly enhances bone-to-implant contact and biomechanical pullout measures by two-fold compared with implants that were autoclaved, as recommended by the manufacturer. The most likely interpretation of these results is that surface contaminants inhibit osseointegration. The results of this study justify the need for the development of better detection and removal techniques for contaminants on orthopaedic implants and other medical devices.
doi:10.1016/j.bone.2011.07.013
PMCID: PMC3200470  PMID: 21801863
contaminants; osseointegration; murine; histomorphometry; biomechanical testing
22.  Investigation of Peri-Implant Bone Healing Using Autologous Plasma Rich in Growth Factors in the Canine Mandible After 12 Weeks: A Pilot Study 
The Open Dentistry Journal  2011;5:168-173.
Introduction:
Faster reconstruction of patients’ masticatory systems is the aim of modern dentistry. A number of studies have indicated that application of growth factors to the surface of a dental implant leads to accelerated and enhanced osseointegration. The objective of the present study was to investigate the effect of plasma rich in growth factors on peri-implant bone healing.
Materials and Methods:
For the purpose of this study, two healthy, mixed-breed canines were selected, and the premolars were extracted from both sides of the mandible. Three months after premolar removal, 12 implants, each 5 mm in diameter and 10 mm in length, were placed in osteotomy sites on both sides of the mandible. Prior to placement, plasma rich in growth factors was applied to the surfaces of six implants, while the other six were used without plasma rich in growth factors. The implants were removed after 12 weeks along with the bone surrounding the sites using a trephine bur. One mesiodistal section containing the surrounding bone from each implant block, 50 µm in diameter, was prepared for histologic and histomorphometric investigation with an optical microscope.
Results:
The sites with implants treated with plasma rich in growth factors showed more bone-to-implant contact compared to control sites. Also, higher values for bone trabecular thickness and bone maturity were recorded for the PRGF-treated sites than for the control sites.
Conclusion:
Application of plasma rich in growth factors to the surface of an implant may enhance the bone healing process as well as bone-to-implant contact, thereby helping to achieve faster osseointegration.
doi:10.2174/1874210601105010168
PMCID: PMC3227874  PMID: 22145011
Plasma Rich in Growth Factors (PRGF); Bone-to-Implant Contact (BIC); Histomorphometric Analysis; Histologic Examination; Osteo Implant Corporation.
23.  Effect of heat treatment on H2O2/HCl etched pure titanium dental implant: An in vitro study 
Summary
Background
Surface chemistry of dental implant plays an important role in osseointegration. Heat treatment might alter surface chemistry and result in different biological response. The aim of this study was to investigate the roles of heat treatment of H2O2/HCl-treated Ti implants in cell attachment, proliferation and osteoblastic differentiation.
Material/Methods
Sandblasted, dual acid-etched and H2O2/HCl heat-treated discs were set as the control group and sandblasted, dual acid-etched H2O2/HCl-treated discs were the test group. Both groups’ discs were sent for surface characterization. MC3T3-E1 cells were seeded on these 2 groups’ discs for 3 hours to 14 days, and then cell attachment, cell proliferation and cell differentiation were evaluated.
Results
Scanning electron microscope analysis revealed that the titanium discs in the 2 groups shared the same surface topography, while x-ray diffraction examination showed an anatase layer in the control group and titanium hydride diffractions in the test group. The cell attachment of the test group was equivalent to that of the control group. Cell proliferation was slightly stimulated at all time points in the control group, but the alkaline phosphatase (ALP) activity and osteocalcin (OC) production increased significantly in the test group compared with those in the control group at every time point investigated (p<0.05 or p<0.01). Moreover, the osteoblastic differentiation-related genes AKP-2, osteopontin (OPN) and OC were greatly up-regulated in the test group (p<0.05 or p<0.01).
Conclusions
The results implied that surface chemistry played an important role in cell response, and H2O2/HCl etched titanium surface without subsequent heat treatment might improve osseointegration response.
doi:10.12659/MSM.883204
PMCID: PMC3560775  PMID: 22739726
titanium implant; heat treatment; anatase; titanium hydride
24.  The Otto Aufranc Award: Enhanced Biocompatibility of Stainless Steel Implants by Titanium Coating and Microarc Oxidation 
Background
Stainless steel is one of the most widely used biomaterials for internal fixation devices, but is not used in cementless arthroplasty implants because a stable oxide layer essential for biocompatibility cannot be formed on the surface. We applied a Ti electron beam coating, to form oxide layer on the stainless steel surface. To form a thicker oxide layer, we used a microarc oxidation process on the surface of Ti coated stainless steel. Modification of the surface using Ti electron beam coating and microarc oxidation could improve the ability of stainless steel implants to osseointegrate.
Questions/purposes
The ability of cells to adhere to grit-blasted, titanium-coated, microarc-oxidated stainless steel in vitro was compared with that of two different types of surface modifications, machined and titanium-coated, and microarc-oxidated.
Methods
We performed energy-dispersive x-ray spectroscopy and scanning electron microscopy investigations to assess the chemical composition and structure of the stainless steel surfaces and cell morphology. The biologic responses of an osteoblastlike cell line (SaOS-2) were examined by measuring proliferation (cell proliferation assay), differentiation (alkaline phosphatase activity), and attraction ability (cell migration assay).
Results
Cell proliferation, alkaline phosphatase activity, migration, and adhesion were increased in the grit-blasted, titanium-coated, microarc-oxidated group compared to the two other groups. Osteoblastlike cells on the grit-blasted, titanium-coated, microarc-oxidated surface were strongly adhered, and proliferated well compared to those on the other surfaces.
Conclusions
The surface modifications we used (grit blasting, titanium coating, microarc oxidation) enhanced the biocompatibility (proliferation and migration of osteoblastlike cells) of stainless steel.
Clinical Relevance
This process is not unique to stainless steel; it can be applied to many metals to improve their biocompatibility, thus allowing a broad range of materials to be used for cementless implants.
doi:10.1007/s11999-010-1613-0
PMCID: PMC3018231  PMID: 20936386
25.  Bioengineered Periodontal Tissue Formed on Titanium Dental Implants 
Journal of Dental Research  2011;90(2):251-256.
The ability to use autologous dental progenitor cells (DPCs) to form organized periodontal tissues on titanium implants would be a significant improvement over current implant therapies. Based on prior experimental results, we hypothesized that rat periodontal ligament (PDL)-derived DPCs can be used to bioengineer PDL tissues on titanium implants in a novel, in vivo rat maxillary molar implant model. Analyses of recovered implants revealed organized PDL tissues surrounding titanium implant surfaces in PDL-cell-seeded, and not in unseeded control, implants. Rat PDL DPCs also exhibited differentiative potential characteristic of stem cells. These proof-of-principle findings suggest that PDL DPCs can organize periodontal tissues in the jaw, at the site of previously lost teeth, indicating that this method holds potential as an alternative approach to osseointegrated dental implants. Further refinement of this approach will facilitate the development of clinically relevant methods for autologous PDL regeneration on titanium implants in humans.
doi:10.1177/0022034510384872
PMCID: PMC3144101  PMID: 21149858
periodontal ligament; bioengineered tissues; titanium; dental implants

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