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    Implant Surfaces - Misch

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    Manan Arora

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    reported for surfaces blasted with particles sized between 200 and 600 jm.2°2” Use of fine particle size glass particles of 150 to 230 tum results in relatively smooth sueface with an Ra value of 1.36 tum, whereas the use of coarse alumina particles of 200 co 500 jim provides @ much rougher surface with an Ra value of 5.09 jm Fig. 9.29282" Treatment with Lasers Lasers can also be used to modify implane surfaces by using an ablation technique, During laser ablation, the substrate material vaporizes and forms a crater. Depending on the material prop- cxtics, a resolidified material forms a rim along the periphery of the crater Laser ablation technofogy results in titanium surface structures with increased hardness, corrosion resistance, and purty with a standard roughness and thicker oxide ayer." Bio- logical studies evaluating the role of titanium ablation topogra phy and chemical properties showed che potential ofthe surface to orient osteoblast cell attachment and contzol the direction of ingroweh.!=? Additive Processes ‘Additive processes share the same goal, which is to roughen the implant surface to accelerate osseointegration, particularly in lower bone densities: Hydroxyapatite Coating and Titanium Plasma Spraying Plasma spraying is an industrial technique in which the desied coating, in powder form, is injected through a plasma torch 10 rele the powder and shoot it onto the substrate surface, in which iis deposited and fuses with the surface, Plasma-sprayed coatings can be deposied with thicknesses ranging from a few micrometers 10 a few millimeters. Plasma spraying has been used for applying titanium and HA coatings on the surfaces of titanium implants. This serves to toughen ice ofthe plant sly ino he rang of 7 is was considered tobe an improvement over the machined Surface because af the increased BIC. Additional sadis™ found that HA-coated implants stimulated bone growth during the heal- ing phase (Table 9.2). * Fig. 92. Resorbable blast media etrtaca ofthe Hat tapered inant, (From item Hareimpian com) CHAPTER 9 Dental implant Surfaces Em Despite the healing advantages found with HA-coated implants, in recent years hey have fallen out of favor because of inereased of complications, Implant failure can be caused by microbial infecion and occlusal trauma.” Ithas been suggested that HA- coated implants are more susceptible o bacterial colonization than ‘uncoated implants or natural teeth." Enhanced geowth of biofilm on HA-coated implant surfaces may result from the increased roughness, which chen contributes to per-implanciis °° If marginal bone loss occurs, it will lead to the HA surface implanc becoming exposed to the oral environment with resul- tant contamination. In this ease it would also be more difficult for the patient to maintain che implant, resulting i increased tsk of peri-implant disease.“ Another concer associated with HA- coated implants is dissolution of the HA layer or fracture ofthe HA coating-titanium interface, which leads to loss ofthe coating ‘with subsequent implant mobility and loss. Overall, there are major concems with the use of plasma- sprayed coatings. In the ease of both HA and titanium plasma spray (TPS)-coated implants, che surface roughness is ata higher level than the moderately rough that is currently considered opti- smal. Such rough surfaces are also thought co contribute to the spread of periimplantitis when the surface is exposed to the oral cavity and faciliaces the formation and retention of plaque. As with the HA coatings, delamination of the titanium particles in ‘TPS implants has been observed leading to mobility and eventual loss of che implancs Oxidation or Anodization Although all 10 yim ate similar to resorption activity of one or mote osteoclasts.” ** As with natural bone, ostcablasts find these surface iregularties and begin depositing matrix in and around them to form bone. ‘Surface Treatments and Various Implant ‘Systems Available Commercially Blasted and acid washed/etched Hahn Tapered Implants, Impiants undergo a blasting proces. DENTSPLY Implants F- ‘Atenas, the surface i ther ‘AIT and FRADENT pis, washed wit nonetching acid or ‘Straumann SLA Incsie etched wth song acs. RM- Tapered iplans ‘reatd implants ke te Hahn Tapered implants have the avan- ‘ag of resrbale, bocompatible last media ‘anodized Nobo! Biocare Tinto Tis eecrochemicl proves thickens and rougher the tlanum axe layer on the surface of inplans ‘cid etched ‘SIOMET i OSSEOTIE and ching with strong acids creases tbe Nanoite ‘surface roughness andthe sutace area of tanium ingles, Basted DENTSPLY implants ASTRA Pals are projected trough amaze TECH Tidbiast, Zimmer ata fh velocity onto te implant. Denial MIX Various matarals such as ttanium Implant Direct various, Ais an estoconductne mateal tat Zimmer Donal MP-1 has the abit to form a srg bond between the bore andthe ila. Laser ablation Blooraons LaserLok Figh=ntensty pulses of laser beam strike a protective layer that coats the metalic surface Asa result, Implants demanetate «honeyeom palo wth smal pores. ‘Thanium plasma sprayed ‘Staumana tania Powdery fos of anum are injected plsma-sprayed Into a plasma torn at leated temperatures Meroe ele tt rata From Bul 6 Seo Speer rset a ation she No 27480. In summary, microroughness on implant suzfaces helps in retention of the fibrin clot. This in turn enables the migration of bone progenitor cell that deposit bone in close proximity to the implant improving the BIC, Pies on the implant surface mimic naturally occurring osteoclastic activity and lead osteoblasts to Role of Surface Roughness in Peri-implant Disease Several suds recognized safe roughness as an imporant fa tor in the formation of biofilm on implant surfaces.» By their nature, rougher surfaces encourage mote biofilm formation.*”® CHAPTER 9 Dental implant Surfaces EZ scx tect sta see — Crean soos Loe Pie ha ee ag an Sein lang Celuar odoin Cellar phencrsona a the impant-bore interface ding heal implant. from Ari, ot. Dontalimplat surface ennancomant and cssecintagraton. In Turkyraz |, ed. Implant Dentistry: A Rapidly Evolving Practice, London, UK: Infect, 2011.) Biofilm formation is direedly proportional to surface roughness: the greater che roughness, the higher the rate of biofilm formation Js around che implants. The wettability and surface free energy (SFE) of a specific surface aso influence the biofilm formation on implancs.” Future Directions Several additional surfaces are being explored as options 10 improve osseointegration and the rate of bone healing Bisphosphonate Surfaces Bisphosphates are ancresorptive agents known to inbibic osteo clase activity chat are used in the treatment of osteoporosis Bisphosphate-loaded implant surfaces have been reported to improve implant osseointegration." It has been shown that bisphosphonate incorporaced onto titanium implants increased bone density locally in the peri-implantregion®? withthe efleet of the antresorptive drug limited to the vicinity ofthe implant.'? An animal stady conducted by Peter and colleagues showed a postive effect of zoledronate-coated implants on the per-implant bone volume fraction in osteoporotic rats. Abtahi and colleagues conducted a double-blind spli-mouth seudy in which each patient reczived one bisphosphonate-coated implant and one uncoated implant. Aer 6 months of osseoin tegration, resonance frequency analysis indicated better xation of the coated implants. The implants were coated by using a nnometer-thin fibrinogen coating containing minimal amounts of bisphosphonates that improved eatly implant fixation with an effect chat was maintained at 5 yeas afer prosthetic loading Reduced marginal bone resorption was also seen. All implants funetioned well.” Ac years the bisphosphonate-coated implants showed only 2 small amoune of resorption (median 0.20 mm) “The present data suggest that bisphosphonate-coated implants cnable prolonged preservation ofthe marginal bone. Histologic analysis of test implants removed en bloc at the 6-month follow- up showed mature lamellar bone trabeculae in intimate contact withthe implanes.” Bisphosphonates inhibit che resorption and renewal of bone mediated by osteoclasts, retaining existing bone, which may increase mineralization under normal function, resulting in an increase in bone mineral density" The prevention of asteoelast mediated bone resorption and renewal influenced by bisphos- phonates results in retention of old bone, Old bone lives out its natural life span and becomes brittle.” This may create a nonideal local environment for increased BIC. Bisphosphonates can work as a bony shield co protect the early formed bone, which may explain betser fixation seen in some studies.” Statins Stasins are commonly prescribed drugs thar decrease cholesterol synthesis by the liver. This reduces serum cholesterol coneenta~ tions and lowers the risk of heart attack.” Simvastatin induces the expression of bone moxphogenetic protein 2. (BMP-2), mRNA that promotes bone formation.” Ayukawa and col- leagues” confirmed that copical application of statins to alveo lar bone increased bone formation and concurrently suppressed osteoclast actviey at the bone-healing site. In addition, clinical scudies reported that statin us is associated with increased bone mineral density." Antibiotic Coating Ansibacterial coatings on the surface of implants that provide ant- bacterial activity co the implants themselves have been studied as 4 possible way to prevent surgical sie infections associated with implants. Gentamyein, along with the layer of HA, can be coated conto the implant surface, which may act as a local prophylactic agent along with che systemic antibiotics in dental implant su zeny Tetracycline enhances blood clot attachment and retention on the implant surface during the inital phase ofthe healing pro cess, promoting osseointegration."?"” Functionalization with Biologically Active Substances “The purpose of Finctionalization of the implant surface with bio- logically ative substances isto diminish the initial inflammatory response after rorquing in of the implanc and encouraging rapid bone growch, Grovith factors and fragments of the organic matrix of bone and other known biologically active peptides are used to coat the surface of implants. “There are several growth factors involved in osteogenesis. Four ‘growth factors have potential use in implantology: BMP-2 and BMP-7, fibroblast growth factor (FGE-2), and platcler-derived growth factor (PDGE-B).°% PDGE-B is a potent mitogen and chemotactic agent for a variety of mesenchymal cells, including osteoblasts.” Recently, Chang and colleagues" have demonstrated that PDGF stimulates osseointegration of dental implanes in vivo, On the other hand, i has been reported that the isolated recombinant PDGF may affect. bone formation adversely." In clinics, che use of platelet-rich plasma of plaelet-brin clot i the equivalent of pure PDGF usage. This method is gaining popularity because i is safe, and it i possible to use autologous source of growth factors, The method has shown good results in a ‘number of clinical studies.9°* BMPs are a family of growth factors that are present during carly stages of bone healing and play an important role in the growth and differentiation of several cell types, including osteo: Blasts BMP-2 is often used in bone-implant interaction studies because it seems co possess the highest osteoinductive ppotencial among the BMPs.”” BMPs may be applied to bone sites through various delivery systems such a an absorbable collagen sponge used to augment the bone ridge before implant placement cor implants wich porous structures coated with rhBMP-2.”” How ever, coating an implant is an unreliable way of delivering sr Jar dosages uniformly. The thBMPs and BMPs are costly, have a high dose requirement (several micrograms up to milligrams), and have a poor distribution profle.”»°* High doses of BMP-2 have been associated with localized and temporary bone impairment” cr increased bone resorption caused by stimulation of osteoclast formation." However, once the levels drop, normal bone forma- tion i observed.”? Usage of Biologically Active Peptides Proteins of extraceliar bone matrix also have potential use as finaonal coatings. For caple fibronectin nimulated orto. to strong escintgration of implants in experimental modes bw " " ‘Common problems asocared with the ute of growth factors and biological active pepe ae increase in he cst of mplans teat with dan, complications i oe, and proctation of thebiowcive material before implantation, Tete seals concerns Sout the velease profile of thee components igo surrounding tissues (rate of rel area of release, etc.). Zirconia Implants In recent years, ytra-stabilized tetragonal zirconia polyerystal (HTZP), a high-strengeh ritconia, has become an attractive new material for dental implants. Zirconia has a woth-like color and the ability o transmit light, improving the overall esthetic ou come.” Moreover, ithas a high chemical resistance, high flexural strength (900-1200 MP), a favorable fracture toughness (KIC: 7-10 MPa/m'"), and a Youngs modulus of 210 GPa, which nakes ita strong material" Zirconia also has a low affniy for dental plaque, which reduces the risk of inflammatory changes in the peri-implanc soft tissues." Zirconia implants ate often one-piece implants, which means thar both the implane body and the permucosal portion can be dlgialy designed co fit che local anatomie conditions and indi vidually machined. One-piece implants have the advantage of zo implant-aburment movement.” Zirconia implants perform wel in areas with thin soft issue biotype and in eases in which soft cssue recession might expose some part of the implant. These advancages make Y-TZP implants a potential alternative to Gtanium implants in certain clinieal situations," aswell as ‘pening up the possibilty for computer-aided design and com- puter-aided manufacturing (CAD/CAM) of customized zirconia implans.!* "Safe modifications of tconia implant such as sandblasting and acid ecching tigger teeragonal-to-monoclinie (¢ > m)phase transformation." This uansformation is associated with 3% 0 4% phase volume expansion and induces compressive stresses chat shield the erack tip Irom the applied stress. This unique aceerisic is known as transformation toughening.!”” However, the surface flaws introduced by sandblasting and acid etching act as stress concentrators and may become potential sites for erack inition and propagation, causing suenggh degradation and the possibilty of implant fracture. Depprich and colleagues’ conducted an animal stady 10 compare the osseointegration of acid-ctched cianium and zirco- nia implants of similar macrostructure and found that the BIC during the process of osseointegration was very similar. Lang. hoff and colleagues!” conducted a study in sheep using six types of implants with identical implant geometry. All titanium and zirconia implants were sandblasted and partially etched before the surface treatments, similar to the relerence. The surfaces of the chemically modified implants were either plasma anodized cor coated with CaP. The pharmacologically modified implants were either coated with bisphosphonate or collagen type I. An acid-etched and sandblasted implant made of titanium (grade 4 SPI_1 ELEMENT, Thommen Medical AG, Waldenburg, Swiczerland) served as the reference and control for ehe surface modifications The collagen coating was based on an extracellular mattx cor taining chondroitin sullate, prepared by fibilogenesis of the cc lagen in the presence of chondroitin sulfate, and performed as dip coating in a collagen/chondroitin sulfate solution. The bisphos- phonate-coated implants were immobilized with an alendronate solution t0 a final concentration of 10 mgfem?. The zirconia implants were manufactured from yeerium partially stabilized zr conia, medical grade. The zirconia implants were sandblasted and etched in an alkaline bath. Results of the BIC measurements showed that all tanium implant types were nearly similar at 2 weeks (5996-6286 BIC) and increased with time (7896-83), except the plasma-anodized surface (58%). The two chemical surface modifications performed very differently: The CaP surface showed similar values, with the sain increase at 2 vo 4 weeks, similar to the reference, and a slight increase toward week 8. In contrast, the plasma-anodized surface Jost 2% bone contact initially and did not improve after 4 weeks. Pharmacologieally modified surfaces performed close to the czence, The collagen with chondroitin sulfate surface showed slightly higher values than the reference implant at 2 weeks and continued nearly equally, whereas the bisphosphonate-coated sur- face was higher at 2 and 4 weeks. The zitconia implant presented 20% more bone contact than the titanium implants at 2. weeks, improved toward 4 weeks, then reduced at 8 weeks to below the level of the reference surface. The overall performance of the new surface, except the plasma-anodized surface, was better than the reference. Statistically significant diferences for BIC were not found Biomimetic Formation of Hydroxyapatite on the Implant Surface “The use of coatings with similar composition of the human bone provide an accelerated osseointegration during the caliest haaling stages. In particular, CaP apatite has the same chemical composition as the mineral bone phase, which means thee is 0 inflammatory reaction.!"! Many researchers have applied coat {ngs on titanium implants by using techniques like HA plasma spraying.’ In some clinical studies," this treatment produced a quicker osseointegration a ealy stages afer implant placement, but an accelerated bone loss caused by a bacterial microleakage between the HA layer and ehe titanium has been observed in the long term." Furthermore, additive techniques such as HA plasma spraying do nor allow the formation of crystalline apatite such as in human bone, but amorphous CaP can be caused by high elaboration temperatures." The properties of chs layer are CHAPTER 9 Dental implant Surfaces not considered appropriate for dental implants because they are extremely soluble, and titanium only achieves mechanical reten~ tion and not true adhesion.""> Osseointegration of dental implancs can be improved by the application of CaP coating by plasma spraying and biomimetic and electrophoretic deposition. Although plasma-sprayed HA- coated dental implants have disadvantages related to coating delamination and hetcrogencous dissolution rate of deposited phases, an electrochemical process consisting of depositing CaP rystals from supersaturated solutions releases calcium and phos- phate fons from these coatings. This process helps inthe precpita~ tion of biologieal apatite nanocrystals with the incorporation of various proteins, which, in curn, promores cell adhesion, dfferen- tiation into osteoblast, and the synthesis of mineralized collagen (che extracellular matrix of hone tissue). "© Osteoclast calls are also able to resorb the CaP coatings and activate osteoblast eels to produce bone tissue. Thus these CaP coatings promote a direct bone-implant contact without an incervening connective tissue layer leading to a proper biome- chanical fixation of dental implants.” Osteoclast cells are also able co resorb the CaP coatings and activate osteoblast cells to produce bone tissue. Thus these CaP coatings promote a dizect bone-implant contact without an intervening connective tis- sue laye, leading to a proper biomechanieal fixation of dental implants.!? ‘Implants coated with CaP have a berter BIC compared with currently availabe titanium implants. Implants coated with CaP claim wo offer a physicochemical matex for che deposition of new bone by osteoclasts, which could explain the increased BIC. Ie also leads to an increased attachment of osteogenic cells." Tons released from CaP coating have been reported to control the cellular signals that improve osteoblast differentiation!" “These ions have a potential to stimulate numerous intraellu- lar signaling pathways in osteoblasts and support the bone for- ‘mation process.”'"” Even though it has been suggested that CaP coatings can enhance adhesion/activation of bone cells on the surface of implants,'*" possible delamination of the coat- ing from the surface of the titanium implant and failure at the implantlcoating interface may happen when the coating is rather thick. 2 ‘The hope of developing bioactive implane surfaces is co sig- nificantly reduce the time required for osseointegration. The most important mechanisms involved ae the protein adsoxption eapac- iy, wettability, and an optimized zeta potential, which reduces the clectroxatie dispersion between particles. These procedures also aim to increase adhesion, proliferation, and differentiation of osteoblast cells compared with other currene surface treatments (0 faciliate bone formation around the implants.” ‘Alenezi and colleagues investigated the effects of the use of local drug and chemical compound delivery systems on. the osseointegration of endosscous implants in animal models. They looked at chemical agents incorporated, coated, o: immobilized con implant surfaces and also at chemical agents that were locally delivered atthe implant site using carrier materials such as inject- able gels, microsphere hydrogel, or collagen sponges. BIC was evaluated for CaP. bisphosphonates, and BMPs. They found that implants coated with CaP and BMPs showed statistically significant bone growth compared with uncoated implants.” ‘Well-designed clinical ils will help us better understand the effect of chese coatings of implant surfaces and their interaction with bone, as well asthe long-term suceess of these biochemical modifications ‘Biomechanical Properties of Dental Implants Summary Our understanding of the role played by dental implant surfaces inthe process of osseointegration continues to evolve as research provides additional insights. Research continues in the areas of Suice teatments, chemical modiiations, and how they both influence the ccllular and biological proceses. With current reported success rates well above 90%, tis unlikely that new sur- faces will provide incremental improvement of these overall rac, However improvements in outcomes in poor bone quality and in medically compromised patients may well be enhanced by future developments References 1, Albrektson‘T, Zarb G, Worthington, Eriksson AR. ‘The long-term efficacy of curently wed dental implant a review and proposed criteria of success. int. J Ona! Maxillofac Implants, 1986;1:11-25, 2, Smeets R, Stadlinger , Schware F, et al. Impact of dental implan surface modiestions on osseointegration. Biomed Res It 2016 2-1 3. Boyan B, Dean D, Lohmann C. The ttanium-bone eel face in vito: the role of the surface in promoting ostcointegrs- tion. Ln: Brunette D, etal. ed. Titantum in Medicine. Springet: 2001. 4, Weanerberg A, Albrekuson T. Suggested guidelines for the top- graphic evaluation of implant surfaces. Int J Oral Maxilfc JImplans 2000;15:331-344. 5. Burger EH, Klein/Nulend J. 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Physiol. 2005:98:1922-1929. bps) dol.or/10.1152/japplpiysiol.01080.2004. Titanium, ‘MoheeniE, Zalneehad E, Bushroa AR. Comparative investigation ‘on the adhesion of hydroxyapatite coating on T-GAL-V implanc 8 review paper. Jt J Adher Adher, 2014348:238-257, hsp ‘1g/10.1016) jadhadh-2013.09.030 Rosenberg ES, Toroian JP, Sots. Micrabial differences in 2 lin cally distinceypes of ilusesofesscointegrated implants. Clin Oral Implants Res. 1991:23):135-144. ‘Verheyen CCPM, Dhere WIA, Petic PLC, etal. In vitro snady on the inegrity of « hydroxylapatite coating when challenged with staphylococci. J Biomed Mater Res, 1993:27(6}:775-781. bps!

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