A review on the wettability of dental implant surfaces I: Theoretical and experimental aspects

The surface wettability of biomaterials determines the biological cascade of events at the biomaterial/host interface. Wettability is modulated by surface characteristics, such as surface chemistry and surface topography. However, the design of current implant surfaces focuses mainly on specific micro- and nanotopographical features, and is still far from predicting the concomitant wetting behavior. There is an increasing interest in understanding the wetting mechanisms of implant surfaces and the role of wettability in the biological response at the implant/bone or implant/soft tissue interface. Fundamental knowledge related to the influence of surface roughness (i.e. a quantification of surface topography) on titanium and titanium alloy surface wettability, and the different associated wetting regimes, can improve our understanding of the role of wettability of rough implant surfaces on the biological outcome. Such an approach has been applied to biomaterial surfaces only in a limited way. Focusing on titanium dental and orthopaedic implants, the present study reviews the current knowledge on the wettability of biomaterial surfaces, encompassing basic and applied aspects that include measurement techniques, thermodynamic aspects of wetting and models predicting topographical and roughness effects on the wetting behavior.     

Bone and metal: An orthopaedic perspective on osseointegration of metals

The area of implant osseointegration is of major importance, given the predicted significant rise in the number of orthopaedic procedures and an increasingly ageing population. Osseointegration is a complex process involving a number of distinct mechanisms affected by the implant bulk properties and surface characteristics. Our understanding and ability to modify these mechanisms through alterations in implant design is continuously expanding. The following review considers the main aspects of material and surface alterations in metal implants, and the extent of their subsequent influence on osseointegration. Clinically, osseointegration results in asymptomatic stable durable fixation of orthopaedic implants. The complexity of achieving this outcome through incorporation and balance of contributory factors is highlighted through a clinical case report.     

Balancing osteoblast functions and bacterial adhesion on functionalized titanium surfaces

The demand for orthopedic and dental implants will continue to grow, and for these applications, titanium and its alloys have been used extensively. While these implants have achieved high success rates, two major complications may be encountered: the lack of bone tissue integration and implant-centered infection. The surface of the implant, through its interactions with proteins, bacteria and tissue cells, plays a determining role in the success or failure of the implant. Ideally, to enhance the success of implants, their surfaces should inhibit bacterial colonization and concomitantly promote osteoblast functions. In this article, we discuss strategies for tailoring implant surfaces by exploiting the differences in the response of bacteria and osteoblasts to proteins and surface structures. Nevertheless, limitations still exist in the quest for an ideal implant surface. Further advances in this field will require concurrent development in surface modification techniques and a better understanding of the complex and highly inter-related events occurring at the implant surface after implantation.     

Soft and hard tissue response to endosseous dental implants

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

Implant osseointegration and the role of microroughness and nanostructures: Lessons for spine implants

The use of spinal implants for spine fusion has been steadily increasing to avoid the risks of complications and donor site morbidity involved when using autologous bone. A variety of fusion cages are clinically available, with different shapes and chemical compositions. However, detailed information about their surface properties and the effects of such properties on osteogenesis is lacking in the literature. Here we evaluate the role of surface properties for spinal implant applications, covering some of the key biological processes that occur around an implant and focusing on the role of surface properties, specifically the surface structure, on osseointegration, drawing examples from other implantology fields when required. Our findings revealed that surface properties such as microroughness and nanostructures can directly affect early cell behavior and long-term osseointegration. Microroughness has been well established in the literature to have a beneficial effect on osseointegration of implants. In the case of the role of nanostructures, the number of reports is increasing and most studies reveal a positive effect from the nanostructures alone and a synergistic effect when combined with microrough surfaces. Long-term clinical results are nevertheless necessary to establish the full implications of surface nanomodifications.     

The roles of titanium surface micro/nanotopography and wettability on the differential response of human osteoblast lineage cells

Surface micro- and nanostructural modifications of dental and orthopedic implants have shown promising in vitro, in vivo and clinical results. Surface wettability has also been suggested to play an important role in osteoblast differentiation and osseointegration. However, the available techniques to measure surface wettability are not reliable on clinically relevant, rough surfaces. Furthermore, how the differentiation state of osteoblast lineage cells impacts their response to micro/nanostructured surfaces, and the role of wettability on this response, remain unclear. In the current study, surface wettability analyses (optical sessile drop analysis, environmental scanning electron microscopic analysis and the Wilhelmy technique) indicated hydrophobic static responses for deposited water droplets on microrough and micro/nanostructured specimens, while hydrophilic responses were observed with dynamic analyses of micro/nanostructured specimens. The maturation and local factor production of human immature osteoblast-like MG63 cells was synergistically influenced by nanostructures superimposed onto microrough titanium (Ti) surfaces. In contrast, human mesenchymal stem cells cultured on micro/nanostructured surfaces in the absence of exogenous soluble factors exhibited less robust osteoblastic differentiation and local factor production compared to cultures on unmodified microroughened Ti. Our results support previous observations using Ti6Al4V surfaces showing that recognition of surface nanostructures and subsequent cell response is dependent on the differentiation state of osteoblast lineage cells. The results also indicate that this effect may be partly modulated by surface wettability. These findings support the conclusion that the successful osseointegration of an implant depends on contributions from osteoblast lineage cells at different stages of osteoblast commitment.     

Advancing dental implant surface technology--from micron- to nanotopography

Current trends in clinical dental implant therapy include use of endosseous dental implant surfaces embellished with nanoscale topographies. The goal of this review is to consider the role of nanoscale topographic modification of titanium substrates for the purpose of improving osseointegration. Nanotechnology offers engineers and biologists new ways of interacting with relevant biological processes. Moreover, nanotechnology has provided means of understanding and achieving cell specific functions. The various techniques that can impart nanoscale topographic features to titanium endosseous implants are described. Existing data supporting the role of nanotopography suggest that critical steps in osseointegration can be modulated by nanoscale modification of the implant surface. Important distinctions between nanoscale and micron-scale modification of the implant surface are presently considered. The advantages and disadvantages of nanoscale modification of the dental implant surface are discussed. Finally, available data concerning the current dental implant surfaces that utilize nanotopography in clinical dentistry are described. Nanoscale modification of titanium endosseous implant surfaces can alter cellular and tissue responses that may benefit osseointegration and dental implant therapy.     

Porous NiTi for bone implants: a review

NiTi foams are unique among biocompatible porous metals because of their high recovery strain (due to the shape-memory or superelastic effects) and their low stiffness facilitating integration with bone structures. To optimize NiTi foams for bone implant applications, two key areas are under active study: synthesis of foams with optimal architectures, microstructure and mechanical properties; and tailoring of biological interactions through modifications of pore surfaces. This article reviews recent research on NiTi foams for bone replacement, focusing on three specific topics: (i) surface modifications designed to create bio-inert porous NiTi surfaces with low Ni release and corrosion, as well as bioactive surfaces to enhance and accelerate biological activity; (ii) in vitro and in vivo biocompatibility studies to confirm the long-term safety of porous NiTi implants; and (iii) biological evaluations for specific applications, such as in intervertebral fusion devices and bone tissue scaffolds. Possible future directions for bio-performance and processing studies are discussed that could lead to optimized porous NiTi implants.     

An evaluation of ion-textured aluminum oxide dental implants

A study was undertaken to evaluate the ion-beam texturing of aluminum oxide as a means of providing a surface which will produce a biological prosthetic attachment. A wafflelike pattern of surface contours 150 x 75 x 35 microm deep was produced on cylindrical dental implants. The textured surfaces were compared to the as received surfaces in adult mongrel dogs. Implants were inserted into surgically modified healed extraction sites and were left in place for six months. Post-sacrifice mechanical testing was used to quantify the displacement response of the implants. The clinical, radiographic and mechanical testing evaluations did not reveal any statistically significant differences in the performance of the dental implants. However, it was observed that anatomical site and mandibular geometry with respect to implant size play a significant role in affecting implant retention.     

Anodic oxidation and hydrothermal treatment of titanium results in a surface that causes increased attachment and altered cytoskeletal morphology of rat bone marrow stromal cells in vitro

Previous studies have suggested the usefulness of a new coating method-namely, the forming of a thin hydroxyapatite (HA) layer on commercially pure titanium (cpTi) by anodization and hydrothermal treatment-for use as a dental root implant material. In vivo and in vitro studies confirmed that an HA layer on cpTi (HA/cpTi) implants showed good compatibility with bone tissue, rat bone marrow stromal (RBM) cells, and immune cells. The aim of the present investigation was to further characterize the in vitro early cellular behavior of RBM cells on HA/cpTi implants. Therefore, in this study we performed surface analysis, analysis of cell initial attachment, and analysis of cell morphology and the cytoskeleton. Drops of distilled water or cell culture medium showed smaller contact angles with HA/cpTi than with cpTi. RBM cells were cultured for 30, 60, and 120 min on HA/cpTi and cpTi, and the level of cell adhesion was shown to increase with time on both substrates. However, cell adhesion on HA/cpTi was significantly higher than on cpTi at 60 and 120 min. Especially at 120 min, when compared with cpTi, the cell morphology on the surface of HA/cpTi not only adopted a flattened and spreading form, but also extended filopodium-like processes with irregular edges that were intimately adapted to the surface of the HA microcrystals. The cytoskeleton on HA/cpTi showed well-formed actin filaments that were parallel to each other and the long axis of RBM cells. The actin filaments of RBM cells on the HA/cpTi surface were localized to the periphery (corresponding to the edge of the filopodium-like processes) well after 120 min. This suggests that actin filaments of RBM cells need to be anchored at the HA/cpTi surface and the numerous HA microcrystals precipitated on the HA/cpTi surface. These findings were similar to the scanning electron microscopic morphology. The peripheral anchorage provide sufficient strength of attachment to allow recognization of actin filaments upon HA/cpTi. The surface of HA/cpTi was more hydrophilic and exhibited markedly improved wettability compared to untreated cpTi, and higher levels of early cell attachment were observed on surfaces after anodization and hydrothermal treatment than on surfaces with untreated cpTi. The results of in vitro experiments suggest that this new method for forming a thin HA layer on the surface of cpTi could be useful to ensure excellent cellular behavior on implant surfaces. The characterization of cell morphology on the thin HA layer formed by anodization and hydrothermal treatment on cpTi implant material suggests that physicochemical or biological conditioning of the implant surface involves implant surface topography.     

Topographic scale-range synergy at the functional bone/implant interface

We sought to explore the biological mechanisms by which endosseous implant surface topography contributes to bone anchorage. To address this experimentally, we implanted five groups of custom-made commercially pure titanium implants of varying surface topographical complexity in rat femora for 9 days; subjected them to mechanical testing; and then examined the interfacial bone matrix by electron microscopy. The five implant surfaces were prepared by combinations of dual acid etching and grit blasting the titanium substrates and, in some cases, modifying the created surfaces with the deposition of nanocrystals of calcium phosphate, which resulted in 10 samples per group. In parallel, we cultured rat bone marrow cells on surrogate implants constructed from polymer resin coated with the same calcium phosphate nanocrystals, and monitored the deposition of bone sialoprotein by transmission electron immunohisto-micrography. We found that implant samples modified with sub-micron scale crystals were bone-bonding, as described by the interdigitation of a mineralized cement line matrix with the underlying implant surface. The in vitro assay showed that bone sialoprotein could be deposited in the interstices between, and undercuts below, the nanocrystals. In addition, when mineralized, the cement line matrix globules occupied micron-sized pits in the implant surfaces, and in part obliterated them, creating an additional form of anchorage. Our results also showed that collagen, elaborated by the osteogenic cells, wrapped around the coarse-micron features, and became mineralized in the normal course of bone formation. This provided a mechanism by which coarse-micron implant features contributed to a functional interface, which we have previously described, that is capable of resisting the mechanical loading that increases as peri-implant bone matures. Thus, our findings provide mechanistic explanations for the biologically-relevant criteria that can be employed to assess the importance of implant surface topography at different scale-ranges.     

Glial cell and fibroblast cytotoxicity study on plasma-deposited diamond-like carbon coatings

Diamond-like carbon films have been evaluated as coatings to improve biocompatibility of orthopedic and cardiovascular implants. This study initiates a series of investigations that will evaluate diamond-like carbon (DLC) as a coating for improved biocompatibility in chronic neuroprosthetic implants. Studies in this report assess the cytotoxicity and cell adhesion behavior of DLC coatings exposed to glial and fibroblast cell lines in vitro. It can be concluded from these studies that DLC coatings do not adversely affect 3T3 fibroblast and T98-G glial cell function in vitro. We also successfully rendered DLC coatings non-adhesive (no significant fibroblast or glial cell adhesion) with surface immobilized dextran using methods developed for other biomaterials and applications. Future work will further develop DLC coatings on prototype microelectrode devices for chronic neural implant applications.     

Orthopedic nano diamond coatings: control of surface properties and their impact on osteoblast adhesion and proliferation

The superior mechanical and tribological properties of diamond coatings suggest their promise for improving current orthopedic implants. Therefore, understanding and controlling biological responses on diamond coatings are important and necessary for their advancement in orthopedics. For this reason, the objective of the present study was to correlate surface properties of diamond coatings with osteoblast (OB) adhesion and proliferation. Diamond coatings on silicon of variable surface features (specifically, grain size, surface roughness and surface chemistry) were fabricated by microwave plasma enhanced chemical-vapor-deposition (MPCVD). Scanning electron microscopy (SEM) as well as atomic force microscopy (AFM) was applied for topographical characterization and contact angles were measured to assess surface wettability. Results revealed that the grain size, surface roughness and wettability of diamond coatings can be controlled by adjusting H(2) plasma in the MPCVD process. Further, results showed enhanced OB adhesion on nanocrystalline diamond (ND) with grain sizes less than 100 nm whereas nanostructured diamond/amorphous carbon coatings (NDp) and microcrystalline diamond (MD) inhibited OB adhesion. H(2) plasma treated ND (NDH) also promoted OB adhesion. Similarly, OB proliferated to a greater extent on ND and NDH compared with MD and uncoated silicon controls. In summary, surface properties (including topography and chemistry) of diamond coatings can be controlled to either promote or inhibit OB functions, which implies that various forms of diamond coatings can be used to either support or inhibit bone growth in different regions of an orthopedic implant.     

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

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

Percutaneous implants with porous titanium dermal barriers: an in vivo evaluation of infection risk

Osseointegrated percutaneous implants are a promising prosthetic alternative for a subset of amputees. However, as with all percutaneous implants, they have an increased risk of infection since they breach the skin barrier. Theoretically, host tissues could attach to the metal implant creating a barrier to infection. When compared with smooth surfaces, it is hypothesized that porous surfaces improve the attachment of the host tissues to the implant, and decrease the infection risk. In this study, four titanium implants, manufactured with a percutaneous post and a subcutaneous disk, were placed subcutaneously on the dorsum of eight New Zealand White rabbits. Beginning at four weeks post-op, the implants were inoculated weekly with 10(8) CFU Staphylococcus aureus until signs of clinical infection presented. While we were unable to detect a difference in the incidence of infection of the porous metal implants, smooth surface (no porous coating) percutaneous and subcutaneous components had a 7-fold increased risk of infection compared to the implants with a porous coating on one or both components. The porous coated implants displayed excellent tissue ingrowth into the porous structures; whereas, the smooth implants were surrounded with a thick, organized fibrotic capsule that was separated from the implant surface. This study suggests that porous coated metal percutaneous implants are at a significantly lower risk of infection when compared to smooth metal implants. The smooth surface percutaneous implants were inadequate in allowing a long-term seal to develop with the soft tissue, thus increasing vulnerability to the migration of infecting microorganisms.     

Threaded versus porous-surfaced designs for implant stabilization in bone-endodontic implant model

An endodontic implant model system was used to compare the effect of implant design on stabilization in bone. Specifically a porous-surfaced design was compared to conventional threaded and smooth-tapered endodontic implant designs. All implants were placed in immediate function thereby assessing the effect of early limited movement on the fixation achieved. A total of eighty-three endodontic implants were inserted in the mandibles of six adult mongrel dogs. Animals were sacrificed immediately after implantation and after 3, 6, and 12 months. Implants were evaluated by clinical and radiographic examination and after animal sacrifice by pull-out tests of the implant from the tissues, SEM examination of the pulled-out implants and, finally, histology. The pull-out test results indicated increasing shear strength with implantation time for the porous-surfaced implants in contrast to the gradual loss of fixation for the threaded implants and the continuous low shear strength for the smooth implants. Histological studies and SEM examination indicated the reason for these changes. Smooth implants became encapsulated by fibrous connective tissue from early post-implantation time periods. Threaded implants, although initially mechanically interlocked with bone, developed a fibrous connective tissue capsule that gradually thickened with time until, by 6 months, little mechanical interlock of bone and implant was present. It was assumed that this fibrous capsule thickening was caused by implant movement. The porous-surfaced implants, however, became stabilized by bone ingrowth and showed more extensive bone formation within the surface pores with time. It is concluded that for implants that are made functional immediately after implantation, as in this study, porous-surfaced implants can become strongly fixed by bone ingrowth, in contrast to conventional threaded or smooth-surfaced designs, thus presenting a more favourable long term prognosis.     

Biological responses to multilayered DNA-coatings

This study was performed to evaluate the basic biological response to deoxyribonucleic acid (DNA)-based coatings for soft tissue implants. To that end, in vitro experiments were used to study their cytocompatibility, and in vivo subcutaneous implantation studies with transponders in a rat model were performed to evaluate their histocompatibility. The DNA-based coatings were fabricated using the electrostatic self-assembly technique using cationic poly-D-lysine or poly-allylamine hydrochloride and anionic DNA. Noncoated substrates served as controls. In vitro, the behavior of primary rat dermal fibroblasts was assessed in terms of cell proliferation and morphology. Both types of multilayered DNA-coatings significantly increased rat dermal fibroblast proliferation without altering the morphological appearance of the cells. The tissue response to multilayered DNA-coatings was assessed using an in vivo rat model, in which transponders were inserted subcutaneously for 4 and 12 weeks. No macroscopic signs of inflammation or adverse tissue reactions were observed at implant retrieval. Histological analyses demonstrated a uniform tissue response to all types of implants. All implants were encapsulated in a fibrous tissue capsule without intervening inflammatory cells at the implant surface. Histomorphometrically, multilayered DNA-coatings induced fibrous tissue capsules with similar quality and thickness compared to noncoated controls. In addition, all fibrous tissue capsules showed similar expression of alpha-smooth muscle actin. This study demonstrates that multilayered DNA-coatings are cytocompatible and histocompatible, and justifies further research on their functionalization with biologically active compounds to modulate tissue responses.     

Critical overview of Nitinol surfaces and their modifications for medical applications

Nitinol, a group of nearly equiatomic shape memory and superelastic NiTi alloys, is being extensively explored for medical applications. Release of Ni in the human body, a potential problem with Nitinol implant devices, has stimulated a great deal of research on its surface modifications and coatings. In order to use any of the developed surfaces in implant designs, it is important to understand whether they really have advantages over bare Nitinol. This paper overviews the current situation, discusses the advantages and disadvantages of new surfaces as well as the limitations of the studies performed. It presents a comprehensive analysis of surface topography, chemistry, corrosion behavior, nickel release and biological responses to Nitinol surfaces modified mechanically or using such methods as etching in acids and alkaline solutions, electropolishing, heat and ion beam treatments, boiling in water and autoclaving, conventional and ion plasma implantations, laser melting and bioactive coating deposition. The analysis demonstrates that the presently developed surfaces vary in thickness from a few nanometers to micrometers, and that they can effectively prevent Ni release if the surface integrity is maintained under strain and if no Ni-enriched sub-layers are present. Whether it is appropriate to use various low temperature pre-treatment protocols (160 °C) developed originally for pure titanium for Nitinol surface modifications and coatings is also discussed. The importance of selection of original Nitinol surfaces with regard to the performance of coatings and comparative performance of controls in the studies is emphasized. Considering the obvious advantages of bare Nitinol surfaces for superelastic implants, details of their preparation are also outlined.     

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

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