Christoph Vasak Early bone apposition to hydrophilic

Dieter Busenlechner
Uwe Y. Schwarze
and hydrophobic titanium implant
Herbert F. Leitner surfaces: a histologic and
Fernando Munoz Guzon
Thomas Hefti
histomorphometric study in minipigs
Falko Schlottig
Reinhard Gruber

Authors’ affiliations:
Christoph Vasak, Reinhard Gruber, Department of
Oral Surgery, Medical University of Vienna,
Vienna, Austria
Christoph Vasak, Uwe Y. Schwarze, Herbert F.
Leitner, Reinhard Gruber, Department of Oral
Surgery, Austrian Cluster for Tissue Regeneration,
Vienna, Austria
Dieter Busenlechner, Academy of Oral
Implantology, Vienna, Austria
Uwe Y. Schwarze, Herbert F. Leitner, Karl Donath
Laboratory for Hard Tissue and Biomaterial
Research, Medical University of Vienna, Vienna,
Austria
Fernando Munoz Guzon, Department of Veterinary
Clinical Sciences, School of Veterinary of Lugo,
University of Santiago de Compostela, Lugo, Spain
Thomas Hefti, Falko Schlottig, Thommen Medical
AG, Waldenburg, Switzerland
Reinhard Gruber, Laboratory of Oral Cell Biology,
School of Dental Medicine, University of Bern,
Bern, Switzerland
Corresponding author:
Reinhard Gruber, PhD
Department of Oral Surgery
Medical University of Vienna, Vienna, Austria
Tel.: +43 1 40070 4101
Fax: +43 1 40070 4119
e-mails: reinhard.gruber@meduniwien.ac.at and
reinhard.gruber@zmk.unibe.ch
Key words: animal experiments, bone implant interactions, morphometric analysis
Abstract
Objective: The first objective of this pilot study was to evaluate the impact of the hydrophilicity
on the early phases of osseointegration. The second objective was to compare two hydrophilic
implant surfaces with different geometries, surface roughness, and technologies achieving
hydrophilicity.
Material and methods: Twelve weeks after extraction, all four quadrants of nine minipigs received
three dental implants, alternating between hydrophilic microrough surfaces (INICELL and SLActive)
and a conventional hydrophobic microrough surface. After 5, 10, and 15 days of submerged
healing, ground sections were prepared and subjected to histologic and histomorphometric
analysis.
Results: The histologic analysis revealed a similar healing pattern among the hydrophilic and
hydrophobic implant surfaces, with extensive bone formation occurring between day 5 and day 10.
With BIC values of greater than 50% after 10 days, all examined surfaces indicated favorable
osseointegration at this very early point in healing. At day 15, the mean new bone-to-implant
contact (newBIC) of one hydrophilic surface (INICELL; 55.8  14.4%) was slightly greater than that
of the hydrophobic microrough surface (40.6  20.2%). At day 10 and day 15, an overall of 21% of
the implants had to be excluded from analysis due to inflammations primarily caused by surgical
complications.
Conclusion: Substantial bone apposition occurs between day 5 and day 10. The data suggest that
the hydrophilic surface can provoke a slight tendency toward increased bone apposition in
minipigs after 15 days. A direct comparison of two hydrophilic surfaces with varying geometries is
of limited relevance.

Date:
Accepted 28 August 2013
To cite this article:
Vasak C, Busenlechner D, Schwarze UY, Leitner HF, Munoz
Guzon F, Hefti T, Schlottig F, Gruber R. Early bone apposition
to hydrophilic and hydrophobic titanium implant surfaces: a
histologic and histomorphometric study in minipigs.
Clin. Oral Impl. Res. 25, 2014, 1378–1385
doi: 10.1111/clr.12277
The use of dental implants has become an
integral part of modern dentistry. Dental
implants that are made of titanium with
rough surfaces show predictable osseointegra-
tion with a high success rate (Junker et al.
2009). Osseointegration results in structural
and functional contact between the implant
surface and the living bone (Schenk & Buser
1998). The underlying biologic process fol-
lows a well-described sequence of events.
The initial blood clot is replaced by granula-
tion tissue, followed by immature woven
bone (Berglundh et al. 2003). Mature lamellar
bone reinforces and later replaces the woven
bone as a consequence of bone remodeling
(Schenk & Buser 1998; Berglundh et al.
2003). Short-term mechanical stability at the
time of implant placement is a prerequisite
for this long-term biologic stability. Conse-
quently, an intimate connection between
implant and bone tissue represents the main
histologic measure of osseointegration
(Albrektsson 1983).
Since the beginning of implant dentistry,
attention has been paid to the design of
implant surface topography for improved
osseointegration (Cochran et al. 2002; Wen-
nerberg & Albrektsson 2009). Microrough
surfaces support the transition from mechan-
ical to biologic stability, helping to minimize
the risk of early complications (Raghavendra
et al. 2005). Surface roughness of the

1378 © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

endosseous surface provided the basis for cur-
rent treatment protocols, for example, imme-
diate and early loading of dental implants
(Weber et al. 2009). Recently, increasing
attention has been paid to the potential of
hydrophilic implant surfaces to further stim-
ulate osseointegration (Schwarz et al. 2009;
Tugulu et al. 2010). To date, two different
technologies have been used and are commer-
cially available to prepare hydrophilic dental
implants: (i) rinsing the titanium surface after
the etching process under nitrogen protection,
followed by storage in isotonic saline (Buser
et al. 2004), and (ii) chair-side treatment of
dental implants with aqueous sodium hydrox-
ide (Tugulu et al. 2010). In vitro and in vivo
studies of hydrophilic surfaces based on both
technologies are available.
In vitro, hydrophilic surfaces support the
adhesion of monocytes, platelet activation,
and blood clot formation, which are the ini-
tial events in osseointegration (Milleret et al.
2011; Hong et al. 2013). Hydrophilic surfaces
are favorable for the osteogenic differentia-
tion of mesenchymal stem cells, and they
have demonstrated anti-inflammatory proper-
ties (Wall et al. 2009; Hamlet et al. 2012).
Microarray analysis showed pro-osteogenic
and pro-angiogenic influences on gene expres-
sion for hydrophilic surfaces (Donos et al.
2011). In a minipig model, hydrophilic
implants increased bone-to-implant contacts
(BICs) after 2 and 4 weeks of healing, com-
pared with the corresponding controls (Buser
et al. 2004). In a similar animal model,
hydrophilic implants caused a tendency
toward greater BIC (Stadlinger et al. 2009).
Additional studies reported favorable out-
comes regarding osseointegration, performed
in dogs with hydrophilic implants and regard-
ing osseous healing at buccal dehiscence
defects (Schwarz et al. 2007a,b). Clinically,
hydrophilic implants showed positive
changes in histomorphometric parameters
when retrieved after 4 weeks (Bosshardt et al.
2011; Donos et al. 2011). However, the initial
steps in how hydrophilic implants affect
osseointegration are of great interest.
The primary objective of this in vivo study
was to investigate the early osseointegration
of implants with a hydrophilic surface com-
pared with a conventional hydrophobic sur-
face with the same geometry and microrough
surface roughness—allowing for the study of
the impact of only one variable: hydrophilic-
ity. The secondary objective of this study
was to evaluate early bone apposition to two
hydrophilic implant surfaces with different
implant geometries, surface roughness, and
technologies to achieve hydrophilicity. The
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Vasak et al
Early bone apposition to titanium implant surfaces
implants were placed in the mandible and
maxilla of minipigs. New BIC was chosen as
the primary endpoint. This in vivo study was
intended to gain information on the impact
of hydrophilic microrough surfaces on early
healing around implants in vivo.
Material and methods
Animals
Nine female (age 20–22 months, mean
weight 35 kg) G€ ottingen minipigs (Ellegaard
G€ottinger Minipigs A/S, Dalmose, Denmark)
were used. The Ethical Committee of the
Codina Foundation, Spain, approved the
study protocol (AE-LU-001/01/INV.MED.02/
OUTROS(04)/14-10). All of the animals were
subjected to surgery and housed in the Ani-
mal Experimentation Service Facility at the
Veterinary Teaching Hospital of Codina in
Lugo, Spain. The oral cavity was cleaned
before surgery. After the intervention, the
animals received a soft diet and had free
access to drinking water.
Implants
Three different types of titanium implants
with different surfaces were studied. Two of
the implants had a self-cutting thread and a
sandblasted and hot acid-etched microrough
surface (SPI Element, 3.5 9 8 mm, Thommen
Medical AG, Waldenburg, Switzerland); for
one group, this surface was used, as it was
(as a control); for the second group, the sur-
face (INICELL) was conditioned with a highly
diluted sodium hydroxide solution (INICELL,
Thommen Medical AG, Waldenburg, Swit-
zerland). The third group (SLActive) consisted
of implants with a non-cutting thread and a
sandblasted and acid-etched surface rinsed
under N2 protection and stored in isotonic
NaCl solution upon delivery (Straumann
bone level SLActive, 3.3 9 8 mm, Strau-
mann AG, Basel, Switzerland).
Surgical procedure
All of the surgical procedures were performed
using general anesthesia induced with
propofol (2–4 mg/kg/i.v., Propovet, Ab-
bott Laboratories, Kent, UK) and main-
tained with isofluorane 2% (Isoba-vet,
Schering-Plough, Madrid, Spain). The animals
were premedicated with ketamine (10 mg/kg/
i.m., Imalgene 1000, Merial, Toulouse,
France), midazolam (0.5 mg/kg/i.m., midazo-
lam 1 mg/ml, B. Braun Medical, Barcelona,
Spain), morphine (0.5 mg/kg/i.m., Morfina
Braun 2%, B. Braun Medical, Barcelona,
Spain), meloxicam (0.2 mg/kg/i.m., Metacam,
1379 |
Boehringer Ingelheim, Rhein, Germany), and
cefazolin (22 mg/kg/i.v., Kurgan, Normon,
Madrid, Spain) under veterinary supervision.
Post-operative pain and inflammation were
controlled with the administration of mor-
phine (0.5 mg/kg/i.m.) for 24 h and then
meloxicam (0.1 mg/kg/i.m.) over the next
5 days. During the first post-operative week,
antibiotic prophylaxis was administered
using amoxicillin (20 mg/kg/s.i.d./s.c., Amox-
oil retard, Syva, Le
on, Spain).
Surgical removal of the premolars was per-
formed in the maxilla and mandible. Special
attention was paid to the preservation of the
bony structures of the alveolar process. After
12 weeks, implants were placed into the
alveolar ridges of all four quadrants. A muco-
periosteal flap provided access to the bony
ridge of the premolar region. Sharp bone
edges were removed using a surgical drill
under water cooling. The animals received
three implants per quadrant, that is, 12
implants in total. Each quadrant received one
implant per group in quasi-randomly alternat-
ing order. All of the implants were placed
strictly following the manufacturer’s surgical
protocol. The position of the implant shoul-
der was located on bone level. The interim-
plant distance was at least 3 mm. Finally,
after application of a cover screw, the muco-
periosteal flap was repositioned and closed
with absorbable sutures (Vicryl 4-0, Ethicon,
Inc., Johnson & Johnson Medical, Norder-
stedt, Germany) for submerged healing.
Three surgeons performed the operations
(B.D., T.U., and V.C.).
Necropsy and preparation of histologic
specimens
The animals were euthanized under anesthe-
sia in three groups of three animals each,
after 5, 10, and 15 days of healing, with an
overdose of pentobarbital (40–60 mg/kg,
Dolethal, Vetoquinol S.A. Lure, Cedex,
France). The tissue blocks carrying the
implants were removed and transferred into
4% neutral-buffered formalin. The tissue
blocks were further resected and reduced to
15-mm thick bone slices, with the implant
in the center. The specimens were dehy-
drated in ascending grades of alcohol. The
next step was infiltration with a light-curing
resin (Technovit 7200, Kulzer & Co., Wehr-
heim, Germany) and finally embedding in
the same resin. Using the cutting–grinding
technique of Donath & Breuner 1982; unde-
calcified, thin, ground sections approx. 30 lm
in thickness were prepared and stained with
Levai Laczko dye. Using this stain technol-
ogy, old bone, which was present before the
Clin. Oral Impl. Res. 25, 2014 / 1378–1385
Vasak et al
Early bone apposition to titanium implant surfaces
surgical intervention, exhibited a light pink
color and was readily distinguishable from
new bone (formed during tissue regeneration),
which was stained purple or exhibited darker
shades of pink (Figs 2 and 3). For each
implant, one ground section in buccolingual
direction was prepared. The slices were
scanned using the Olympus dotSlide 2.4, dig-
ital virtual microscopy system (Olympus,
Tokyo, Japan). Images with a resolution of
0.32 lm per pixel were produced.
Histomorphometric analysis
The region of interest (ROI) was defined as a
200 lm wide area parallel to the outer
implant contour, beginning 2 mm and ending
5 mm below the implant shoulder (Fig. 1), to
exclude untreated parts of the surfaces from
the analysis. Using Definiens Developer
XD2â software (Version 2.0.0; Munich,
Germany), the different tissue types were
semi-automatically classified from the com-
pressed digital images (pixel size of 1.29 lm).
First, old bone that had been present before
the second surgery, newly formed bone, and
soft tissue areas were automatically classified
(a)
(b)
Fig. 1. Definition of the region of interest (ROI) for the digital tissue differentiation procedure, beginning 2 mm and
ending 5 mm below the implant shoulder (b). Tissue in contact with the implant surface within the ROI (a) was dif-
ferentiated into new bone (red), old bone (blue), and void (yellow). Areas of new (red) and old (blue) bone were
defined within a 200 lm wide area parallel to the outer implant contour (c).
1380 | Clin. Oral Impl. Res. 25, 2014 / 1378–1385
using a Definiens rule set. Subsequently,
these automatized classifications were visu-
ally controlled and manually corrected using
Adobe Photoshopâ software (Adobe, San Jose,
CA, USA). These corrected classifications
were used to measure the areas of old bone
and of newly formed bone and the void area,
the latter consisting of soft tissue and oste-
oid. From these results, the percentage of
newly formed bone (newBV/TV), the percent-
age of old bone (oldBV/TV), and the percent-
age of old and new bone together (BV/TV)
within the region of interest were calculated.
Additionally, the contact lengths to the sur-
rounding tissue types (old bone, new bone,
soft tissue) were measured along the implant
perimeter. These values were used to deter-
mine the percentage of the implant surface
in contact with newly formed bone (new
bone-to-implant contact, newBIC), the per-
centage of the implant surface in contact
with old bone (old bone-to-implant contact,
oldBIC) and the percentage of the implant
surface in contact with old and new bone
together (BIC).
(c)
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Statistical methods
Mixed models including implant type and
date of implant placement as fixed effects
and study animal as random effect were
calculated. Visual regression diagnostics of
residuals showed that to achieve approximate
normal distribution, a transformation of all
outcome variables using the natural loga-
rithm was necessary. Regression diagnostics
confirmed the fit of the model for log-trans-
formed data. Based on this model, linear
hypotheses were evaluated using general
t-tests (Littell et al. 2006) to detect differ-
ences between hydrophobic and hydrophilic
(INICELL) implant types as well as for differ-
ences between two hydrophilic (SLActive/
INICELL) implant types at all healing peri-
ods. Further, we tested individual implants
for differences between 5 and 10 days as well
as for differences between 10 and 15 days.
Westfall’s procedure was performed to adjust
for multiplicity (Westfall 1997; Hothorn et al.
2008). The calculations and plots were imple-
mented in R statistical language (R Core
Team 2012).
Box plots were used to illustrate the data;
additionally, mean, median, SD, minimum,
and maximum values are provided in tables.
All descriptive statistics were calculated from
dependent units (implants) treated as inde-
pendent. Statistically significant differences
are indicated with an asterisk (*).
Results
Five days after implant placement, all of the
implants showed uneventful healing with no
clinical signs of inflammation. However,
after 10 days of healing, 8 implants displayed
peri-implant mucositis, of which 3 implants
exhibited mobility. On day 15 after implant
placement, 8 implants showed signs of
inflammation, among which 6 implants were
clinically mobile. The peri-implant mucositis
was related to exposed cover screws. All of
the implants were processed for histology.
The histologic examination revealed inflam-
matory tissue adjacent to 11 and 12 implants
within the region of interest on 10 and
15 days, respectively. These implants were
excluded from further analysis (Table 1).
Among the 23 excluded implants, 7 peri-
implant inflammations within the region of
interest were caused by a surgical complica-
tion as a consequence of an opened sinus.
Nevertheless, a sufficiently large number of
samples (79%) were available for histomor-
phometric analysis and for the statistical
evaluation of the results (Table 2).
 Vasak et al
Early bone apposition to titanium implant surfaces

Table 1. Implant surfaces and reasons for study exclusion

Inflammations related to surgical complications caused by

Excluded from analysis exposed cover screw opened sinus

Implants 10 days 15 days Total 10 days 15 days Total 10 days 15 days Total
Control 2 3 5 2 2 4 0 1 1
INICELL 5 6 11 3 3 6 2 3 5
SLActive 4 3 7 3 3 6 1 0 1
Total 11 12 23 8 8 16 3 4 7

Table 2. Mean, median, standard deviations and minimum and maximum values of new, old and total bone-to-implant contact (newBIC; oldBIC; BIC)
as well as new, old and total bone volume per tissue volume (newBV/TV; oldBV/TV; BV/TV) for control, INICELL and SLActive at day 5, 10 and 15
post-implant placement
newBIC [%] oldBIC [%] BIC [%]

n Mean Median SD Min Max Mean Median SD Min Max Mean Median SD Min Max
5 days Control 12 0.2 0.0 0.7 0.0 2.3 9.9 9.9 5.5 0.0 18.9 10.1 9.9 5.2 2.3 18.9
INICELL 12 0.4 0.0 1.4 0.0 4.8 8.6 7.8 5.5 0.0 17.8 9.0 9.5 5.3 0.0 17.8
SLActive 12 2.2 0.0 6.4 0.0 22.2 20.4 15.6 17.6 0.0 56.0 22.6 18.6 16.2 2.4 56.0
10 days Control 10 49.4 49.3 27.9 0.0 94.3 7.4 7.6 4.6 0.3 12.1 56.8 59.3 25.7 12.1 94.6
INICELL 7 49.3 56.8 20.3 17.9 75.6 8.1 8.6 4.1 2.8 15.2 57.4 64.1 20.8 21.9 85.4
SLActive 8 50.3 58.9 27.0 0.0 82.3 18.1 9.8 22.8 0.7 67.9 68.5 66.1 10.1 55.0 83.3
15 days Control 9 40.6 50.4 20.2 9.8 61.6 11.8 12.9 7.6 0.8 23.8 52.4 51.2 16.2 23.1 74.4
INICELL 6 55.8 52.0 14.4 39.5 79.4 13.9 8.2 11.7 5.0 32.1 69.7 70.8 12.8 52.2 90.4
SLActive 9 25.5 18.9 12.2 11.7 51.1 31.9 32.2 20.6 4.2 60.2 57.4 50.8 14.4 39.7 79.0

newBV/TV [%] oldBV/TV [%] BV/TV [%]

5 days Control 12 0.1 0.0 0.3 0.0 1.1 33.8 35.6 10.6 9.4 45.9 33.9 35.8 10.4 10.5 45.9
INICELL 12 0.3 0.0 0.8 0.0 2.7 31.1 31.9 8.4 16.2 43.8 31.4 31.9 8.0 18.9 43.8
SLActive 12 0.4 0.0 1.1 0.0 3.8 47.0 40.6 17.7 24.8 77.2 47.4 41.0 17.4 25.0 77.2
10 days Control 10 15.4 13.4 11.2 0.4 36.2 22.6 22.0 11.1 5.5 40.8 38.0 40.7 10.1 17.9 50.2
INICELL 7 14.8 13.4 9.1 3.1 27.5 22.7 19.0 7.8 15.6 33.4 37.4 36.4 6.4 29.3 47.4
SLActive 8 15.2 17.5 9.0 0.0 27.7 27.3 18.3 19.6 6.2 62.4 42.5 39.3 12.4 28.1 62.4
15 days Control 9 14.3 12.6 8.0 4.3 25.3 24.1 23.3 9.0 12.6 42.6 38.4 35.9 7.5 27.3 49.9
INICELL 6 16.0 13.7 6.2 10.9 26.9 32.9 31.1 8.4 22.9 47.4 48.9 46.8 8.4 39.4 59.6
SLActive 9 11.2 11.1 5.4 5.2 23.4 36.2 34.1 17.4 16.6 57.0 47.3 42.3 14.5 27.8 62.7

Histologic analysis
Overall, a descriptive, qualitative histologic
analysis revealed no differences in bone
formation, bone resorption, mode, and loca-
tion of bone regeneration, contact and dis-
tance osteogenesis or tissue maturation
between the three groups. Bone formation
was initiated between day 5 and day 10,
when a sharp increase in bone volume was
present for either the hydrophobic or the two
hydrophilic surfaces (Figs 2 and 3).
In particular, 5 days after implant place-
ment, almost no new bone tissue was visible,
but severe osteoclastic resorption with How-
ship’s lacunae was found at the implant-facing
side of the host bone. Commonly, the gap
between the host bone and the implant sur-
face was partly filled with drilling debris,
with large particles also showing osteoclastic
resorption. In only a few areas of the implant
surface, initial stages of woven bone forma-
tion were detectable. This especially occurred
at sites in a close proximity to the host bone
(i.e., there was a small “jumping distance”).
At day 10, the predominant features
observed were wallpaper-like layers of woven
bone covering the implant surfaces. Woven
bone apposition was also present at the
implant-facing side of the parent bone
structures. Most of the drilling debris was
resorbed, and a decrease in osteoclastic resorp-
tion was detectable. In proximity to the woven
bone structures, an initial lining of osteoblasts
became visible. Within the network of newly
built bone and the peri-implant space, vascular
structures formed.
Histologic sections at day 15 of healing
showed continued bone formation; however,
the characteristics changed from woven to
lamellar bone. Almost all of the surfaces of
woven bone were covered with a layer of
osteoblasts forming parallel-fibered bone,
whereby the trabeculae increased in size and
dimension. Furthermore, no peri-implant osteo-
clastic resorption or drilling debris was visible.
Histomorphometric analysis
Hydrophilic vs. hydrophobic surface with same
geometry and surface roughness
At day 5, newly formed bone in contact with
the implant (newBIC) was almost undetect-
able in both the hydrophobic and hydrophilic
groups (control 0.25  0.7%, INICELL 0.4 
1.4%). The same finding was true for newly
formed bone volume (newBV/TV; control
0.1  0.3%; INICELL 0.3  0.8%). No statis-
tically significant differences were observed
among the two groups (Fig. 4; Table 2).
Comparing the changes in newBIC from day
5 to day 10, statistically significant changes
occurred in the hydrophilic as well as in the
hydrophobic group, with almost half of the
implant surfaces covered with newly formed
bone (newBIC; control 49.4  27.9%,
P < 0.001; INICELL 49.3  20.4%, P < 0.001).
NewBV/TV also increased; however, the
changes were not as pronounced compared
with newBIC (newBV/TV; control of 15.4
 11.2%, P = 0.01; INICELL 14.8  9.1%,
P = 0.01). No differences were observed among
the two groups (Fig. 4; Table 2).
At day 15, the mean new bone-to-implant
contact (newBIC) of the hydrophilic surface
(INICELL: 55.8  14.4%) was slightly greater
compared with that of the conventional
hydrophobic surface (40.6  20.2%). New
BV/TV was similar for the control implants

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 1381 | Clin. Oral Impl. Res. 25, 2014 / 1378–1385
Vasak et al
Early bone apposition to titanium implant surfaces

Hydrophilic surfaces (INICELL, SLActive) with

different geometries, surface roughness, and
(a) (b) (c) technologies
At day 5, SLActive showed more oldBIC
(20.4  17.6%) and oldBV/TV (47  17.7%)
compared with the other hydrophilic surface
(oldBIC; INICELL 8.6  5.5%; oldBV/TV; INI-
CELL 31.1  8.4%). The total BIC and BV/TV
values for SLActive were significantly greater
compared with those of INICELL (BIC,
P = 0.002; BV/TV, P = 0.02) (Fig. 4; Table 2)
Hence, the total BIC and total BV/TV were
primarily the results of preexisting old bone.
From day 5 to day 10, statistically significant
changes in newBIC and newBV/TV occurred
in both hydrophilic surfaces (NewBIC; INI-
CELL 49.3  20.4%, P < 0.001; SLActive
50.4  27%, P < 0.001; newBV/TV; INICELL
14.8  9.1%, P = 0.01; SLActive 15.3  9%,
P = 0.03). No differences were observed among
(d) (e) (f)
the two groups (Fig. 4; Table 2).
At day 15, the mean newBIC of the SLAc-
tive surface (25.5  12.2%) was significantly
lower compared with that of the INICELL
surface (55.8  14.4%; P = 0.02), that was,
however, compensated for by the greater old-
BIC values (SLActive; 31.9  20.6%; INI-
CELL; 13.0  11.7%). Therefore, total BIC
for both hydrophilic surfaces reached similar
values (INICELL; 69.7  12.8%; SLActive;
57.4  14.5%) without statistical signifi-
cance. (Fig. 4; Table 2).

Discussion

The primary objective of the present study

(g) (h)
Fig. 2. Photomicrographs of dental implants with control, INICELL, and SLActive surfaces after 5, 10, and 15 days
of healing.
(14.3  8%) and for the hydrophilic surface
(INICELL: 16.0  6.2%). Additionally, total
BIC and total BV/TV for the hydrophilic sur-
face reached slightly greater values (INICELL;
(i)
69.7  12.8% and 48.9  8.4%) compared
with the control surface (52.4  16.2% and
38.4  7.5%), but without statistical signifi-
cance. (Fig. 4; Table 2).
was to analyze the impact of hydrophilicity
on initial peri-implant bone formation. Sec-
ondly, the early bone apposition to two
hydrophilic implant surfaces with different
geometries, roughness, and technologies
achieving hydrophilicity was evaluated. Four
main findings arise from the above-presented
results. First, an initial increase in bone for-
mation occurred between day 5 and day 10.
The significant increase in newBIC was pres-
ent for hydrophilic and hydrophobic surfaces.
Second, with BIC values of greater than 50%
after 10 days, both hydrophilic and hydropho-
bic surfaces indicated favorable osseointegra-
tion at this very early point in healing (Lang
et al. 2011). Third, there was a slight ten-
dency toward greater newBIC values for the
hydrophilic implant surface (INICELL) after
15 days compared with the hydrophobic con-
trol surface. Finally, a direct comparison of
two hydrophilic implant surfaces with differ-
ent geometries is of limited relevance espe-
cially for this short observation period of the
initial 15 days of osseointegration.

1382 | Clin. Oral Impl. Res. 25, 2014 / 1378–1385 © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Vasak et al
Early bone apposition to titanium implant surfaces

Our data showing a weak tendency toward

greater newBIC after 15 days for the hydro-
(a) (b) (c)
philic implant surface INICELL, compared
with the hydrophobic surface, confirmed ear-
lier findings. At the initial phase of osseoin-
tegration (day 5 and day 10), the hydrophilic
and hydrophobic surfaces revealed no differ-
(d) (e) (f) ences among the evaluated histomorphomet-
ric values. In a similar animal model, a slight
advantage of the INICELL implant surface,
compared with the matching control
implants, was observed on day 14 (Stadlinger
(g) (h) (i) et al. 2009). In the maxilla of minipigs,
hydrophilic bone chamber implants showed
significantly greater BIC compared with the
respective control implants after 14 days
(Buser et al. 2004). Additionally, dog studies
Fig. 3. Photomicrographs of dental implants with control, INICELL, and SLActive surfaces after 5, 10, and 15 days have been reported with advantageous results
of healing. Day 5 showed severe resorption indicated by Howship’s lacunae at the implant-facing side of the parent for hydrophilic surfaces (Schwarz et al.
bone (a, b). Bone debris was present in the peri-implant region (c). At day 10, woven bone formations were visible at
2007a,b). However, due to the differing
the implant surface, the peri-implant space, and the bone (d, e, f). Day 15 was characterized by osteoblasts lining
layers of osteoid onto the woven bone (g, h, i). No remains of bone debris were visible.
regions of interest and implant geometry, a

Fig. 4. New, old, and total bone-to-implant contact (newBIC; oldBIC; BIC) as well as new, old and total bone volume per tissue volume (newBV/TV; oldBV/TV; BV/TV) for con-
trol, INICELL, and SLActive at day 5, 10, and 15 post-implant placement. The results are shown as medians and quartile values. Statistically significant differences (P < 0.05)
are indicated by an asterisk (*).

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 1383 | Clin. Oral Impl. Res. 25, 2014 / 1378–1385
Vasak et al
Early bone apposition to titanium implant surfaces
direct comparison of those data with this
study is not possible. Together, all of the
studies, including ours, point toward a bene-
fit of hydrophilicity for early osseointegration
with dental implants. The present study
focused on the early phase of osseointegra-
tion in a relevant animal model.
The lower newBIC for SLActive on day 15,
compared with day 10, was unexpected,
although similar newBIC (28%) was reported
for SLActive after 2 weeks of healing (Born-
stein et al. 2005). The significantly lower
newBIC for SLActive compared with INI-
CELL at day 15 was thoroughly paralleled by
greater oldBIC. Old bone in close contact
with the implant surface must be resorbed
before new bone apposition can occur (Lang
et al. 2011). Therefore, the greater oldBIC
was most likely the result of the implant
geometry. Compared with the other hydro-
philic implant geometry (INICELL), the
reduced thread pitch and thread depth have
resulted in greater oldBIC values, thus reduc-
ing the peri-implant gap area for new bone
formation (Orsini et al. 2009, 2012; Abuhus-
sein et al. 2010). The decrease in newBIC for
the SLActive between day 10 and the day 15
is likely a random phenomenon. Thus, our
study data demonstrate, that the direct com-
parison of two hydrophilic implant surfaces
with varying implant geometries is of lim-
ited significance. For a sufficient evaluation
of two hydrophilic surfaces with different
surface roughness and technologies achieving
hydrophilicity, the implants should be pro-
vided with the same geometry as the macro-
design of an implant has been shown to
affect implant osseointegration (Abuhussein
et al. 2010; Gottlow et al. 2012). Therefore,
the effect of one factor only, such as hydro-
philicity could not be isolated and compared
when using the present experimental design,
but the intention of the present study was
instead to compare these two hydrophilic
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