Received: 21 November 2018 Revised: 19 February 2019 Accepted: 22 February 2019

DOI: 10.1111/cid.12755

ORIGINAL ARTICLE

Safety and efficacy of a novel anodized abutment

on soft tissue healing in Yucatan mini-pigs
Cristiano Susin DDS, MSD, PhD1 | Amanda Finger Stadler DDS, MSD, PhD1,2 |
3 4
Tiago Fiorini DDS, MSD, PhD | Mariana de Sousa Rabelo DDS, MSD, PhD |
5 6
Umberto D. Ramos DDS, MSD, PhD | Peter Schüpbach Dr sc Nat ETH

1
Department of Periodontology, Adams School
of Dentistry, University of North Carolina at Abstract
Chapel Hill, Chapel Hill, North Carolina Background: It is well established that electrochemical anodization of implant surfaces contrib-
2
Department of Oral and Craniofacial Health utes to osseointegration and long-term implant survival. Few studies have investigated its effect
Sciences, Adams School of Dentistry,
on soft tissue healing.
University of North Carolina at Chapel Hill,
Chapel Hill, North Carolina Purpose: To evaluate the safety and efficacy of a novel abutment surface prepared by electro-
3
Department of Conservative Dentistry – chemical oxidation compared to commercially available machined titanium abutments.
Periodontology, Federal University of Rio Materials and Methods: Twelve 16-19 months-old, Yucatan mini-pigs received three dental
Grande do Sul, Porto Alegre, Rio Grande do implants in each mandibular jaw quadrant. Each side was randomized to receive either an anodized
Sul, Brazil
4
or a machined titanium abutment. Titanium healing caps were placed on both abutments. Animals
Private Practice, Sao Paulo, Sao Paulo, Brazil
5
were euthanized at 6 and 13 weeks. Radiographic and histological analyses were performed.
Department of Maxillofacial Surgery and
Results: No significant differences were observed histologically between groups in regard to
Periodontics, University of Sao Paulo, Ribeirao
Preto, Sao Paulo, Brazil inflammation, epithelium length, mucosal height, bone-to-implant contact, or bone density for
6
Schupbach Ltd, Service and Research any time point. Radiographically, crestal bone level change from baseline to 6 weeks was signifi-
Laboratory for Histology, Electron Microscopy cantly lower for anodized than machined abutments (P = 0.046); no significant differences were
and Micro CT, Horgen, Switzerland
observed at 13 weeks (P = 0.12).
Correspondence
Conclusions: The novel anodized abutment showed a comparable effect on soft and hard tissue
Cristiano Susin, University of North Carolina at
Chapel Hill, Adams School of Dentistry, healing/remodeling and inflammation reaction to standard titanium abutments. Clinical studies
Department of Periodontology, Brauer Hall, should confirm these findings and explore the positive radiographic results observed at the early
111, Chapel Hill, NC.
time point.
Email: csusin@unc.edu

KEYWORDS

dental implant - abutment design, swine, miniature, osseointegration

1 | I N T RO D UC T I O N surface topography, or surface manipulation of currently available

Long-term functional and aesthetic success of dental implants depends
on the integration of the surrounding soft tissue and alveolar bone to
the prosthetic components and implant surface. The peri-implant
mucosa, which is composed of epithelium and connective tissue, pro-
vides protection to the alveolar bone-dental implant complex from func-
tional, chemical, and microbiological challenges. Different abutment
designs and materials have been proposed with mixed results in an
attempt to achieve better connective tissue attachment, reduced
inflammatory response, and stable bone levels.1–5 Recent meta-analyses
of clinical studies showed no major influence of the macroscopic design,
abutments on bone loss and soft tissue inflammation.1,2
It is well established that electrochemical anodization of the
implant surface contributes to osseointegration and long-term implant
survival.6,7 In contrast, relatively few studies have investigated the
effect of anodization on soft tissue response. Recent in vitro studies
suggested that anodized-surfaces enhance initial growth of fibroblasts
and preosteoblasts,8 and adhesion of epithelial cells and fibroblasts.9
Teng et al demonstrated a wider connective tissue attachment in
anodized compared to machined titanium surfaces in a canine
model.10 Additionally, an in vitro study showed a significantly lower
adherence of oral streptococci to anodized than commercially pure

34 © 2019 Wiley Periodicals, Inc. wileyonlinelibrary.com/journal/cid Clin Implant Dent Relat Res. 2019;21:34–43.
SUSIN ET AL.
titanium disks.11 Collectively, these findings appear to suggest that
anodized abutments could enhance soft tissue healing and minimize
bacterial adhesion.
Milleret et al describe the novel abutment surface prepared by elec-
12
trochemical anodization used in the present study. The novel surface
has similar roughness to machined abutments (Sa = 0.13 ± 0.02 μm),
while exhibiting regularly distributed nanostructures. Preclinical13 and
clinical studies14,15 indicate that surface treatments that modify the tita-
nium dioxide layer by creating a more nanoporous surface (pore diame-
ter ≤ 100 nm) may promote soft tissue attachment by limiting epithelial
downgrowth and providing a longer connective tissue seal compared to
machined surfaces. Moreover, in vitro experiments have indicated that
titanium oxide nanostructures, as present in the current experimental
setup, enhance cell adhesion, migration, proliferation, and collagen secre-
tion ability of human gingival fibroblasts.16–19 In a randomized clinical
trial, Hall et al observed that the novel abutment surface tested herein
yielded significantly lower bleeding after 6 weeks and higher keratinized
mucosa height after 2 years than standard machined titanium abut-
ments.20 Therefore, the objective of this preclinical study was to evaluate
the safety and efficacy of a novel abutment surface prepared by electro-
chemical anodization compared to commercially available machined tita-
nium abutments.
2 | MATERIALS AND METHODS
2.1 | Animals
Twelve, 16-19 months old, female or castrated male Mini Yucatan
swine, weight range 57-89 kg, obtained from an approved licensed
vendor (AccelLAB, Saint-Gabriel-De-Brandon, Quebec, Canada) were
used for this study. The study was conducted at a contract research
organization following Good Laboratory Practices (T3 Labs, Atlanta).
Housing, husbandry, and manipulation were performed in accordance
with the Animal Welfare Act Regulations and the Guide for the Care
and Use of Laboratory Animals and following a protocol approved by
T3 Labs Institutional Animal Care and Use Committee. The animals
were individually housed with ad libitum access to water and were fed
a soft swine-food-diet throughout the study. A soft diet was chosen
to minimize mechanical trauma to the surgical site during early heal-
ing. This manuscript was prepared following the ARRIVE guidelines
for reporting animal research.21
2.2 | Dental implants and abutments
NobelActive TiUnite ø3.5 × 10.0 mm CC NP (REF 34125, Nobel Bio-
care, Gothenburg, Sweden) dental implants were used. Two abut-
ments were tested: (a) Nobel Biocare (Gothenburg, Sweden) On1
Base CC NP 2.5 mm (REF 38690), versus (b) anodized On1 Base Xeal
CC NP 2 .5 mm. On1 Healing Caps (NP 2 .5 mm, REF 38696) were
placed on both abutments.
2.3 | Sample size and treatment distribution
Based on the literature and previous experience, we estimated that a
sample size of six animals would achieve 80% power to detect a mean
35
of paired differences of 500 ± 250 μm in epithelium length and
significance level of 5% using a two-sided paired t test. An extra ani-
mal was added to account for any loses; thus, seven animals were
used for each timepoint. Two animals were lost during the study;
one following the extractions and one immediately after implant
placement. For the present study, six NobelActive dental implants,
three in each jaw quadrant, were placed per animal (total study
n = 72). Each jaw quadrant was randomized to receive one of the
experimental abutments: three machined abutments in the control
side and three anodized abutments in the test side. Healing caps
were used on all abutments.
2.4 | Presurgery procedures
The study was conducted in two phases following similar presurgery
procedures. Food was restrained 12 hours prior to the procedure. The
animals were preanesthetized with xylazine (1 mg/kg, IM) and tiletamine
and zolazepam (5 mg/kg, IM), and buprenorphine (0.005-0.01 mg/kg,
IM). After tranquilization, propofol (2-4 mg/kg, IV) was administered for
induction when needed. Animals were maintained on gas anesthesia
(isoflurane/O2 1%-3%, inhalant) and received a slow constant rate infu-
sion of lactated Ringer's Solution (10-20 mL/kg/h, IV) to maintain hydra-
tion. Depth of anesthesia was monitored by lack of corneal reflex, jaw
tone, and swallow reflex; heart rate and depth/frequency of respiration
were also monitored. All general anesthetic procedures were performed
and monitored by the veterinary team. Routine dental infiltration anes-
thesia (lidocaine HCl 2%, epinephrine 1:50 000, 5.4 mL in each jaw
quadrant) was used at the surgical sites before incisions. A broad-
spectrum antibiotic (ceftiofur sodium, 0.1-0.3 mg/kg, IM) was adminis-
tered for infection control. Animals received analgesics for pain control
(buprenorphine 0.005-0.01 mg/kg, IM and carprofen 2-3 mg/kg, IM).
Oral prophylaxis was performed using aseptic technique prior to the sur-
gical extractions using ultrasonic instruments.
2.5 | Surgical extractions
A team of experienced surgeons conducted all surgical procedures. Ani-
mals received local anesthesia, and bilateral surgical extractions of the
mandibular 3rd, and 4th premolar as well as 1st molar teeth were per-
formed, following elevation of buccal and lingual mucoperiosteal flaps.
The mandibular 2nd premolar was reduced in height and length.
Approximately 5-6 mm of the alveolar bone was removed circumferen-
tially around the teeth using a high-speed contra-angle, and the teeth
were then sectioned using the high-speed contra-angle. Extractions
were accomplished by using a piezosurgery handpiece, elevators, and
forceps. The alveolar process was flattened, and any bony spicules con-
toured for enhanced flap adaptation. The periostea of the mucogingival
flaps were fenestrated at the base of the flaps to allow tension-free flap
apposition. The extraction sites were closed and sutured for primary
intention healing and allowed to heal for 15 weeks.
2.6 | Implant placement and abutment installation
Following local anesthesia, buccal and lingual mucoperiosteal flaps were
elevated. Each animal received six implants, three in each mandibular
36
jaw quadrant. Test or control abutments were installed according to the
manufacturer instructions following a randomization scheme, and heal-
ing caps were then placed. The periostea of the mucogingival flaps
were fenestrated at the base of the flaps to allow tension-free flap
apposition. The mucogingival flaps were adapted and sutured to allow
wound closure for primary intention healing. To avoid potential trauma
from the maxillary teeth to the mandibular experimental sites, the
crowns of maxillary 1st, 2nd, and 3rd premolars were reduced in height.
Radiographs were obtained using a mobile x-ray unit (Aribex Nomad,
Aribex, Charlotte, North Carolina) and Kodak RVG 6000 Digital Radiog-
raphy System (Eastman Kodak, Rochester, New York) under anesthesia
immediately following implant placement. Figure 1 depicts the surgical
sequence for implant placement and abutment installation.
2.7 | Postsurgery procedures
Once daily until suture removal and weekly thereafter, routine clinical
exam of extraction and implant sites was performed. Animals were
sedated and sutures were removed by experienced surgeons at
approximately 14 days after surgical procedures. Implant sites were
gently cleaned at suture removal for all animals, and at 6 weeks after
implant placement for animals surviving for 13 weeks. Special care
was taken to avoid any trauma to the peri-implant mucosa. Plaque
control was maintained after extractions and implant placement by
daily flushing of the oral cavity with 30 mL of chlorhexidine gluconate
0.5%-2% for 2 weeks and until the end of the study, respectively.
2.8 | Euthanasia
Six animals were euthanized at 6 and 13 weeks postimplant proce-
dure using concentrated sodium pentobarbital (100 mg/kg, IV). Block
biopsies including implants with abutments, bone, and soft tissue
were harvested, and radiographs were taken using the same mobile x-
ray unit. Samples were fixed in 10% buffered formalin (pH 7.2-7.4).
2.9 | Histotechnical processing
The tissue blocks remained in 10% buffered formalin for at least
3-5 days before they were prepared for light microscopy according
to the cutting-grinding technique22 at Schüpbach Ltd. In short, the
specimens were dehydrated in a graded series of ethanol: 60%,
FIGURE 1 Surgical sequence. A, Healed alveolar ridge before implant placement; B, osteotomies; C, implants installed; D, abutments installed; E,
healing caps installed; and F, immediate postoperatory site
SUSIN ET AL.
80%, 96% and absolute ethanol and then infiltrated with methylmetha-
crylate resin (Technovit 7200 VLC, Heraeus Kulzer, Hanau, Germany).
The infiltrated specimens were then polymerized using a light polymeri-
zation unit (Exakt Apparatebau, Norderstedt, Germany). The implants
were then cut mid-axially in a buccal-lingual plane into approximately
200 μm thick sections using a band-saw unit equipped with a diamond-
coated band (Exakt Apparatebau, Norderstedt, Germany) and were sub-
sequently ground and stepwise polished using diamond pastes (Struers,
Ballerup, Denmark) to a final thickness of 50-100 μm using a micro-
grinding unit (Exakt Apparatebau, Norderstedt, Germany), stained using
Sanderson's RBS stain and counter-stained using acid fuchsin (Dorn
and Hart Microedge, Villa Park, Illinois).
2.10 | Radiographic analysis
Experienced calibrated masked examiners (SK, AFS) evaluated the
radiographs at baseline and at weeks 6 and 13 relative to crestal bone
level change, that is, the distance between the most coronal extent of
peri-implant crestal bone and the implant platform along mesial and
distal aspects of the implant was measured.
2.11 | Histologic analysis
Two experienced masked examiners (UW, AFS) performed the histo-
pathologic evaluation using incandescent and polarized light micros-
copy (BX 43, Olympus America, Melville, New York) and a microscope
digital camera system (DP73, Olympus America, Melville, New York) to
include observations of peri-implant bone formation and remodeling
(formation/resorption), fibrovascular tissue and marrow, and inflamma-
tory response. Inflammation within the peri-implant mucosa was scored
at ×20 magnification in three regions of interest (ROI) of 300 × 500 μm
along the abutment/mucosal interface (marginal mucosa, abutment
area, and platform area). Inflammation scores were attributed to each
area of interest as follows:
• No inflammation (score 0): Inflammatory cells rarely observed in
the connective tissue or present in limited numbers mostly in
proximity to vessels. Connective tissue predominantly composed
of fibroblast-like cells and fibers. No plaque, bone fragments, or
foreign objects may be observed;
SUSIN ET AL.
• Mild inflammation (score 1): Slight inflammatory infiltrate observed
within the connective tissue;
• Moderate inflammation (score 2): Obvious inflammatory infiltrate
observed within the connective tissue, encompassing less than
half of the ROI; and
• Severe inflammation (score 3): A prominent inflammatory infil-
trate observed within the connective tissue encompassing more
than half of the ROI.
One experienced masked examiner (CS) reviewed all findings; any
differences in scores between examiners were addressed by consensus.
2.12 | Histometric analysis
Calibrated masked examiners (AFS, MLM) performed the histometric
analysis using incandescent and polarized light microscopy (BX 51,
Olympus America, Melville, New York), a microscope digital camera
system (DP73, Olympus America, Melville, New York) and a PC-based
image analysis system (cellSens Dimension 1.11 Digital Imaging Soft-
ware, Olympus America, Melville, New York). The following recordings
were performed for the buccal and lingual surfaces of the most central
sections for each implant (Figure 2):
• Mucosal height: Distance between the most coronal extent of the
mucosa along the abutment/healing cap and the most coronal
extent of the crestal bone for buccal and lingual sites;
• Epithelium length: Distance between the most coronal and apical
extents of the sulcus/pocket epithelium and junctional epithelium
along the abutment/healing cap and implant surfaces for buccal
and lingual sites;
• Epithelium to platform distance: Distance between the most api-
cal extent of the junctional epithelium and the implant platform
for buccal and lingual sites;
• Crestal bone level/loss: Distance between the most coronal
extent of crestal bone along the implant and the implant platform
for the buccal and lingual implant surfaces;
• First bone-implant contact (first BIC): Distance between the most
coronal bone-implant contact and the implant platform for the
buccal and lingual implant surfaces;
• Bone density outside the implant threads (BDOT): Ratio bone/
marrow spaces in a 500-μm wide zone immediately outside the
implant threads within the extension of the resident bone;
• Bone density within the implant threads (BDWT): Ratio bone/mar-
row spaces within implant threads along the extension of the resi-
dent bone; and
• Osseointegration: Percent bone-implant contact (BIC) measured
along the entire length of the implant within the extension of resi-
dent bone.
2.13 | Statistical analysis
Nonparametric statistics was used to describe the data and compare
the experimental groups. Site level data were averaged at the animal
level, and separate analyses were carried out for buccal and lingual
37
sites for histometric data. Descriptive analysis was done reporting the
median, 25% and 75%. Box plots were used to illustrate the distribu-
tion of the data according to experimental groups. The Wilcoxon
matched-pairs signed-ranks test was used to compare experimental
groups. Stata/MP 15.1 for Mac (College Station, Texas: StataCorp LP)
was used for the analysis.
Examiner reliability for the histometric and radiographic evalua-
tions were assessed using repeated measurements at least 1 week
apart to estimate the concordance correlation coefficient (CCC) for
continuous data and Kappa statistics for categorical data. For the his-
tometric analysis, CCC was >0.93 and Kappa was >0.85 indicating a
high degree of agreement. For the radiographic analysis CCC was
>0.95, also indicating a high degree of agreement.
3 | RE SU LT S
Altogether 72 implants were placed in 12 animals and 70 implants
were available for analysis: one implant was lost in the postsurgical
sequence and one implant was not evaluated because the histological
slide was unreadable. At 6 weeks, 18 implants for the control group
and 16 implants for the test group were available. At 13 weeks,
18 implants were available for each experimental group.
3.1 | Radiographic observations
One animal (6 weeks) exhibited pronounced bilateral crestal bone loss.
Crestal bone level change from baseline to 6 weeks was 2.1 mm
(25%-75% = 1.8-2.3) versus 0.8 mm (25%-75% = 0.7-1.4) for control
and test groups, respectively (P = 0.046). From baseline to 13 weeks,
the crestal bone level change was 1.3 mm (25%-75% = 0.9-1.6) versus
0.9 mm (25%-75% = 0.2-1.3) for control and test groups, respec-
tively (P = 0.12).
3.2 | Histologic observations
Figure 2 presents photomicrographs showing a representative speci-
men from each group at 6 (A, B) and 13 weeks (C, D). There were no
noteworthy differences for any parameter between sites receiving
implants from the control and test groups at 6 or 13 weeks.
3.2.1 | Peri-implant mucosa
Histologically, soft tissue attachment to the abutment, including
epithelium and connective tissue, was frequently observed in both
groups. At 6 weeks, the peri-implant junctional epithelium reached or
extended beyond the platform in the majority of the implants; mostly
being arrested at the level of the micro-threads. At 13 weeks, the
peri-implant junctional epithelium often extended slightly beyond the
platform at buccal sites, but it was arrested before the platform at lin-
gual sites. Most histologic specimens exhibited an inflammatory reac-
tion confined to the most marginal aspect of the alveolar mucosa; the
inflammation was more evident in the 13 weeks groups. A minimal
inflammatory infiltrate was observed at the implant platform level irre-
spective of the experimental group or observational period.
38 SUSIN ET AL.

FIGURE 2 Photomicrograph (4× magnification) showing a representative specimen from each group at 6 and 13 weeks. A, Control group,
6 weeks; B, test group, 6 weeks; C, control group, 13 weeks; D, test group, 13 weeks

3.2.2 | Peri-implant bone 3.3 | Histometric analysis

The peri-implant alveolar crest was generally characterized by crestal
resorption reaching if not encompassing the implant micro-threads at
6 weeks. Buccal crestal resorption produced dehiscence defects, whereas
lingual sites produced gap-type bone defects. Although osseointegrated,
only few implants, mostly lingual sites, maintained crestal levels parallel-
ing the implant platform. Advanced crestal resorption encompassing the
implant macro-threads if not reaching the apex of the implant were
observed evenly distributed between groups. At 13 weeks, the peri-
implant alveolar crest level was often located at the platform level with
evident new bone formation/remodeling.
3.3.1 | Peri-implant mucosa
The histometric results for the peri-implant mucosal measurements
are shown in Table 1 and Figure 3. Overall, median mucosal height
ranged between 3.0 and 3.2 mm for both experimental groups
(Figure 3); buccal sites exhibiting greater mucosal height than lingual
sites (Table 1). Epithelium length was 2.7 versus 3.2 mm and 3.5 ver-
sus 3.0 mm for control and test groups at 6 and 13 weeks, respec-
tively (Figure 3, Table 1). The epithelium extended approximately
0.1 mm below the implant platform (Figure 3). No significant differ-
ences were observed between experimental groups (Table 1).
 SUSIN ET AL.

TABLE 1 Histometric recordings of the peri-implant mucosa according to experimental group and healing interval (n = 6)

6 weeks 13 weeks
Control group Test group Control group Test group
Median 25% 75% Median 25% 75% p-value Median 25% 75% Median 25% 75% p-value
Buccal
Mucosal height (um) 3595.9 3505.0 3855.1 3861.9 3478.8 4427.9 0.25 3541.5 3422.1 3706.6 3699.1 3588.2 3803.4 0.25
Epithelium length (um) 3347.7 3016.3 3770.7 3780.2 3215.6 4219.0 0.60 4160.6 3720.1 4364.2 4222.2 3727.6 4968.0 0.92
Epithelium-platform (um)a −240.6 −338.0 −65.9 −240.8 −544.1 52.5 0.92 −136.7 −167.6 235.2 −272.8 −539.9 415.7 0.75

Inflammation score
Marginal 2.2 2.0 2.3 1.8 1.7 2.0 0.40 2.8 2.3 3.0 2.5 2.0 2.7 0.46
Abutment 0.7 0.3 1.0 0.9 0.3 1.5 0.53 0.7 0.7 1.7 1.0 0.7 1.3 0.40
Platform 0.5 0.3 0.7 0.5 0.3 0.7 0.75 0.7 0.3 0.7 0.5 0.3 0.7 0.43
Lingual
Mucosal height (um) 2411.9 2341.2 2658.0 2438.5 2326.5 2696.8 0.35 2349.2 2218.0 2429.2 2295.2 1741.7 2485.6 0.17
Epithelium length (um) 2306.3 2122.7 2404.2 2637.7 2374.6 2819.1 0.60 2931.0 1674.5 3189.8 2019.5 1547.6 2969.3 0.60
Epithelium-platform (um)a −109.7 −424.8 561.2 −197.0 −450.8 270.3 0.60 268.0 −139.0 763.4 304.4 −494.4 1018.8 0.25

Inflammation score
Marginal 1.2 0.7 2.0 0.8 0.3 2.3 0.83 1.3 1.0 1.7 2.0 1.7 2.7 0.13
Abutment 0.3 0.0 1.0 0.0 0.0 1.0 0.57 0.3 0.3 0.7 0.7 0.3 1.3 0.28
Platform 0.3 0.3 0.3 0.3 0.0 0.5 0.99 0.3 0.0 0.3 0.3 0.0 1.0 0.83
a
Negative values indicate epithelium extension below the implant platform.
39
40
No significant differences with regards to inflammation scores
were observed between experimental groups irrespective of area of
interest (Figure 3, Table 1). Increased inflammation scores were
observed at the marginal level compared with abutment and platform
levels, which showed limited inflammatory infiltrates (Figure 3).
3.3.2 | Peri-implant bone
The histometric results for the peri-implant bone measurements are
presented in Table 2 and Figure 4. Overall, crestal bone levels were
approximately 0.8 and 0.6 mm below the platform for group control
and test at 6 weeks, respectively (Figure 4). At 13 weeks, crestal bone
was at the platform level for both groups. Buccal sites showing greater
bone loss than lingual sites at 6 but not at 13 weeks (Table 2). The
implant platform to first BIC distance was approximately 1.5 mm
below the implant platform for both groups at 6 weeks, to approxi-
mate 1.0 mm at 13 weeks; buccal sites generally exhibited greater dis-
tances than lingual sites. No significant differences were observed
between experimental groups for any of the parameters analyzed.
Osseointegration was comparable between groups and observa-
tion interval, median BIC approximating 60%-65% (Figure 4). Bone
density within (BDWT) and outside (BDOT) the implant threads was
also comparable. No major differences were observed between buccal
and lingual sites (Table 2). No significant differences were observed.
4 | DISCUSSION
The aim of this study was to evaluate the safety and efficacy of a
novel abutment surface prepared by electrochemical anodization
compared to a commercially available machined titanium abutment.
No significant differences were observed between the test and con-
trol abutments for the histological parameters, including inflammation.
Radiographically, the anodized abutment showed significantly less
crestal bone loss than the machined abutment at 6 weeks, but not at
13 weeks.
Anodic oxidation is a controlled electrochemical process that can
be used to manipulate the oxide layer structure and topography in tita-
nium implant components. In general, in vitro studies have consistently
FIGURE 3 Box plot depicting peri-implant mucosal parameters according to experimental group and healing interval: (A) inflammation scores;
(B) mucosal height, epithelium length, epithelium to implant platform distance
SUSIN ET AL.
shown higher cell proliferation and adhesion on anodized than in
machined titanium surfaces.3 Giannasi et al showed that human gingival
keratinocytes and oral mucosa progenitor cells presented a significant
higher adhesion to anodized surfaces as compared to machined and
sandblasted-acid etched surfaces.23 Mussano et al compared anodized
versus machined surfaces and demonstrated higher viability and adhe-
sion of epithelial and fibroblastic cells lines in anodized surfaces.9
Wheelis et al demonstrated higher cell growth of human fibroblasts at
24 hours in anodized than nonanodized titanium surfaces, and this
effect was irrespective of the oxide thickness.8 Histological analysis of
preclinical studies suggested a more coronal location of the junctional
epithelium and crestal bone in treated than nontreated abutments.3
Using a canine model, Teng et al showed greater connective tissue
length and peri-implant mucosa height in anodized surfaces when
compared to controls.10 The positive effect of anodic oxidation on
bone healing is well established in the literature. Recent preclinical
studies have shown increased osseointegration24 and bone matura-
tion25 around implants with anodized than machined surfaces. In
humans, two recent systematic reviews of clinical studies showed
that implants with anodized surface have the lowest probability of
failure after 10 years.6,26
Long-term functional and aesthetic success of dental implants
depends on the integration of the surrounding soft tissue and alveolar
bone to the prosthetic components and implant surface. In this
intraoral minipig study, no statistically significant differences were
observed histologically between groups regarding inflammation, epi-
thelium length, mucosal height, bone-to-implant contact, or bone den-
sity in both tested timepoints. In a randomized clinical trial, Hall et al
observed a significantly higher keratinized mucosa height in anodized
than machined titanium abutments. Herein, the mucoperiosteal flaps
were coronally advanced to achieve primary closure, which may have
influenced the amount of keratinized mucosa in direct contact with
the alveolar bone.20 Radiographically, crestal bone level change from
baseline to 6 weeks was significantly lower for anodized than
machined abutments (p = 0.046); no significant differences were
observed at 13 weeks (p = 0.12). BIC in the present study ranged
within values for early osseointegration previous intraoral minipig
studies. Although a positive effect of the anodized surface was
SUSIN ET AL. 41

observed radiographically after 6 weeks of healing, the underlying

p-value
mechanisms that explain these results need further investigation.

0.60
0.46
0.75
0.17
0.17

0.60
0.12
0.35
0.60
0.92
Moreover, no significant differences were observed between groups
for the histological analysis of crestal bone level. It is important to

73.0
62.1
77.7

69.2
62.4
60.9
452.5

313.1
1813.2

1592.8
acknowledge that whereas the buccal and lingual sites were evaluated
75%

histologically, mesial and distal sites were evaluated radiographically,

which may explain differences in the results.
Test group

Other surface modifications of the abutment or transmucosal

−88.7

53.6
53.7
66.4

62.6
41.7
55.6
808.9

−163.5
603.9
25%

implant surface have also been evaluated previously in vivo, with similar
outcomes. Linares et al compared different transmucosal implant sur-
faces and found no significant differences among acid-etched titanium,
13 weeks

Median

147.0

190.3
1233.7

1261.5
68.8
57.8
74.4

64.8
47.7
59.5
acid-etched titanium-zirconium alloy, and titanium machined sur-
faces.27,28 Neiva et al showed that the junctional epithelium was fre-
quently positioned more coronal in laser etched abutments than
titanium machined abutments.29 Zhao et al compared implants with dif-
74.2
61.1
74.4

72.5
60.2
60.6
218.2

379.9
1500.0

1140.3
75%

ferent porosity at the transmucosal surface and found no difference in

connective tissue attachment length and number of inflammatory cells
Control group

in the soft tissues.30 Recently, Garcia et al evaluated a modification of

−83.6

55.8
42.6
59.2

67.0
47.1
55.8
618.9

−270.6
550.4
25%

the abutment surface by plasma of argon in humans. Compared to con-

trols, a significant increase in the collagen fiber density was observed in
Abbreviations: BDOT, bone density outside the implant threads; BDWT, bone density within the implant thread; BIC, bone to implant contact.

the area in close contact with the surface of abutments modified by the
Median

58.9

64.9
49.6
61.7

−24.9

68.3
51.0
57.4
661.2
1052.5

plasma of argon.31
The roughness of the test abutments was 0.13 μm12 which was
lower than the acid-etched surfaces evaluated by Linares et al (0.26 μm
Histometric recordings of the peri-implant bone according to experimental group and healing interval (n = 6)

and 0.47 μm)27 and Zhao et al (3.75 μm).30 Increased surface roughness
p-value

0.75
0.35
0.25
0.60
0.25

0.17
0.92
0.17
0.35
0.60

has been associated with biofilm accumulation32 and peri-implant

mucosal inflammation.33 The anodization process used to modify the
test abutment did not increase surface roughness,12 and was reflected
65.0
49.9
60.4

67.2
54.8
61.2
825.0
1219.2
2219.1

1648.2

in the lack of statistically significant differences in peri-implant mucosa

75%

inflammation scores between groups. Importantly, only minimal inflam-

mation was observed at the platform level, which would have had an
Test group

46.9
34.5
45.9

62.0

39.4
39.2
49.7
856.2
1245.9

1091.6

impact on marginal bone stability. While microbial plaque and marginal

25%

inflammation were found, these are expected findings since plaque con-
trol is challenging in large animal models. Plaque control was maintained
by daily flushing of the oral cavity with chlorhexidine. According to Hall
6 weeks

Median

53.4
44.2
58.1

54.5
47.0
57.3
988.4

321.7
1649.2

1397.6

et al, no significant differences in biofilm formation after 6 weeks and

bleeding index over a 2-year period were observed between anodized
and machined titanium abutments.20
1288.7
2537.3

1032.9
1660.6
64.0
50.2
57.5

68.5
51.5
61.0

Historically, dental implants have been mostly tested using canine

75%

Positive values indicate bone levels below the implant platform.

models.34 Recently, intraoral swine models have been used to study peri-
implant soft and hard tissues wound healing.34 Minipigs are considered
Control group

54.7
40.5
50.5

55.7

54.8
34.1
52.4
671.0
1744.2

1189.8

to be anatomically and physiologically similar to humans. From a bone

25%

biology standpoint, these animals have comparable lamellar structure and

remodeling rate to humans.35,36 Minipigs usually achieve skeletal matu-
rity around 16-1837,38 months of age, which coincides with the eruption
Median

63.4
43.7
50.9

62.8
41.2
57.6
822.4

823.2
1880.5

1325.7

of the permanent lower premolars.39 Compared to other studies,27,40–42

skeletal mature animals were selected for this study (16-19 months-old)
and premolars were fully erupted at time of extraction. Older minipigs
Crestal bone level (um)a

Crestal bone level (um)a

have a high prevalence of periodontal inflammation, which may affect

soft tissue healing.34 Hence, oral prophylaxis and adequate chemical pla-
First BIC (um)a

First BIC (um)a

que control are essential for the success of the minipig intraoral model.
Most studies using the minipig intraoral model have placed implants
BDWT (%)

BDWT (%)
BDOT (%)

BDOT (%)
BIC (%)

BIC (%)

4-12 weeks following mandibular teeth extractions, and the healing time
TABLE 2

Lingual
Buccal

after implant placement ranged from 1 to 12 weeks.25,27,40–45 In this

study, implants were placed 15 weeks post-extractions in completely
a
42
FIGURE 4 Box plot depicting peri-implant bone parameters according to experimental group and healing interval: (A) crestal bone levels and first
bone-implant contact (BIC) distance, and (B) bone-implant contact (BIC), bone density within the implant threads (BDWT), and bone density
outside the implant threads (BDOT)
healed alveolar ridges, and the tissues were allowed to heal for 6 and
13 weeks. Therefore, no direct comparison with other intraoral minipig
studies can be made, yet some preclinical studies have shown compara-
ble peri-implant mucosa parameters and findings around machined
abutments.27,45
The present study was conducted by experienced surgeons fol-
lowing Good Laboratory Practices, including measures to assure the
quality and integrity of the data. Limitations include the limited sample
size, lack of a shorter healing interval, and the use of conventional
radiography instead of microtomography.
5 | CO NC LUSIO N
The novel anodized abutment showed a comparable effect on soft
and hard tissue healing/remodeling and inflammation reaction to stan-
dard machined titanium abutments, confirming its safety and efficacy.
Clinical studies should confirm these findings and explore the positive
radiographic results observed at the early time point.
ACKNOWLEDGMENTS
The authors would like to thank Dr Marta Liliana Musskopf (MLM) for
her support in the surgical procedures, histological analysis, and draft-
ing the manuscript; Dr Rodrigo Carlos Nahas de Castro Pinto for the
support in the surgical procedures; Dr Sajitha Kalatingal (SK) for the
support in the radiographic analysis, and Dr Ulf ME Wikesjo (UW) for
the support in the histological analysis and interpretation of the data.
Authors would also like to thank Michael Sandholzer (Nobel Biocare
AG) for his support during the study execution.
CONF LICT OF IN TE RE ST
This study was supported by a research grant from Nobel Biocare AG,
Kloten, Switzerland. CS and PS serve as scientific advisors and lec-
turers for Nobel Biocare. MSR, TF, and UDR serve as consultants for
Nobel Biocare.
SUSIN ET AL.
ORCID
Cristiano Susin https://orcid.org/0000-0002-4092-908X
Amanda Finger Stadler https://orcid.org/0000-0001-5846-7496
Tiago Fiorini https://orcid.org/0000-0002-5452-3822
Mariana de Sousa Rabelo https://orcid.org/0000-0003-1385-8471
Umberto D. Ramos https://orcid.org/0000-0002-3759-1364
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How to cite this article: Susin C, Finger Stadler A, Fiorini T,
de Sousa Rabelo M, Ramos UD, Schüpbach P. Safety and effi-
cacy of a novel anodized abutment on soft tissue healing in
Yucatan mini-pigs. Clin Implant Dent Relat Res. 2019;21:34–43.
https://doi.org/10.1111/cid.12755