Surface treatment of titanium implants

to increase osseointegration

By
Maha Hamad
Content
• Introduction
• Different Surface Treatments
- Subtractive surface treatments
- Additive surface treatments
• Future directions in implant surface modifications
• Factors affecting implant stability and osseointegration
• Evaluation of osseointegration
• Conclusion
• References
 Introduction
Definition:
• Osseointegration:
• The apparent direct attachment or connection of osseous tissue to an
inert, alloplastic material without intervening connective tissue.1

History
• The concept of osseointegration was discovered by Per-Ingvar Branemark
and his co-worker in 1965 and has had a dramatic influence on the clinical
treatment of oral implants.

• The First generation titanium implants, which were machined

with a smooth surface texture.2
• As titanium and its alloys cannot directly bond with living bone,
modification of the implant surface has been proposed as a method for
enhancing osseointegration.3

• The Second generation implants, with surface modification can

accelerate and improve implant osseointegration. Implants underwent
mechanical blasting, acid etching, bioactive coatings, and more recently,
laser modified surfaces.2
The main objective for the development of implant surface
modifications is:

1- to promote osseointegration, with a faster and stronger bone formation.

2- to accelerate the bone healing and thereby allowing immediate or early
loading.

Implant surface modifications can be classified as:

- Substractive surface modifications
- Additive surface modifications
 Different Surface Treatments

Classification
Additive treatments
Subtractive treatments • Anodization
• Machined • Fluoride surface treatment
• Sandblasted • Nanostructured surface
• Acid-etched surface • Spraying plasma
• Dual acid-etching - Ti
• Sandblasted and acid etched surface - Hydroxyapatite (HA).
(SLA) • Coating sol-gel
• Laser treatment • Sputter deposition
• Electrophoretic deposition
• Biomimetic precipitation
• Growth factor coating
• Drugs incorporated
 Subtractive surface treatments

Acid etched surface Sandblasted surface Machined surface

Laser treatment Sandblasted & acid etched Dual acid etched

1- Machined surface (turned surface)
• The first generation dental implants
• Had a relatively smooth surface after being manufactured.
• Scanning electron microscopy showed; grooves, ridges and marks derived
from tools used for their manufacturing which provides mechanical
resistance through bone interlocking.
Disadvantages:
• Macro rather than micro roughness
• Bone ingrowth from surroundings and did not start at implant surface
• Increased bone-Ti surface contact
• longer healing time required
• lower primary stability and success rates compared to modified implants.4
2- Sandblasted surface
• Roughening the Ti surface by blasting with hard ceramic particles.
• Blasting media; Alumina, silica, titanium oxide, or calcium phosphate.
• The different surface roughness produced depends on the shape and size of
particles, duration of blasting, and air pressure.
• The surface roughness usually found to be anisotropic because of craters, ridges,
and occasionally particles enclosed on the surface.
Advantages:
• Micro-retentive surface topography
• Increased surface area.
Disadvantages:
• A blasting material particles could hamper the process of osseointegration when
released into the surrounding tissues.
• May decrease the excellent corrosion resistance of Ti implant.
3- Acid-etched surface
• Immersion in strong acids (e.g., nitric acid, hydrochloric acid, hydrofluoric
acid, sulfuric acid) for a given period of time, creates a micro-roughness of
0.5–3 μm on the implant surface.
• The surface is pitted by removal of grains and grain boundaries of the
implant surface.
• It also cleans the implant surface, e.g. removes deposits.
Advantages:
• Homogeneous microporous surface with increased cell adhesion and BIC.
• Increased surface wettability which promotes fibrin adhesion and provides
contact guidance for osteoblasts migration along implant surface.
Disadvantages:
• Stochastic surface characteristics
• Not 3D4
4- Dual acid-etched surface
• The titanium implants are treated via a chemical or acid whether in
sequence or with the combination of both.
• The treatment chemical or acid may be heated prior to treatment.
• This treatment produces micro rough surface and is shown to induce rapid
osseointegration.
Advantages:
• Enhance⁄accelerate the osteoconductive process
• It produces high adhesion and enunciation of platelets and extracellular
genes, which help in immigration of osteoblasts.
Disadvantages:
• Stochastic surface characteristics
• Not 3D
5- Sandblasted and acid-etched surface (SLA)
 SLA surface refers to, those implant surfaces that have been acid etched
after sand blasting with large grit alumina particles.
• SLA has a complex microstructured surface that showed a hydrophobic
nature that host surrounding has to overcome before osteogenic cells are
laid upon to start bone synthesis.
• Advantages: Better surface microtexture and superior bone assimilation
as compared to the previous methods.
• Disadvantages: Hydrophobic surface nature

 SLActive surface implants, showed increased hydrophilicity compared to

that of SLA surface owing to its preparation condition.
• The modification differs from SLA in that, after acid etching, preparation is
done in protective gas condition (Nitrogen gas atmosphere), followed by
liquid instead of dry storage.
• Advantages:
- Secondary stability is far more rapid
- Early loading may be possible.
6- Laser treatment
• One of the basic criteria for osseointegration is the purity of titanium
dental implant surface i.e. no adulteration with other materials is desired.
• The surfaces obtained by classic methods show irregular non-
reproducible patterns and also contaminate surface with materials other
than titanium which may interfere with the process of osseointegration.
• Laser treatment may be used for surface alteration for osseintegration or
as treatment of periimplantitis.
• CO2 Laser and Nd:YAG laser are most commonly used.
Advantages:
• Forms complex (3D) geometry
• Allows better osteoconductive process
• Long-term bonding to the bone, and interface strength.
• Increasing the surface hardness and resistance to corrosion
• Creating a large quality of purity with a definitive surface roughness and
compact oxide layer.
• Creating a creased surface of implant that is necessary to adapt the
osteoblast cell attachment and control its direction of ingrowth.5
 Additive surface treatments

Ti plasma spraying Flouride treatment Anodized surface

Biomimetic CaPo4 coatings Sputter deposition HA coating

1- Anodized surface or oxidized surface
• Anodization, is a process by which oxide films are deposited on Ti
implant surface by means of an electrochemical reaction.
• The Ti surface to be oxidized plays as anode in an electrochemical cell with
diluted solution of acids acting as the electrolyte.
• It create a micro- or nano-porous implant surfaces.
• Depending on the electrolyte distribution, various ions could be unified in
the oxide layer, such as phosphorus, magnesium, and calcium. They are
basically amorphous with crystalline grains of anatase.
Advantages:
• 3D geometry
• Ca+2 and P− enrichment of anodized surface helps to produce a chemical
bond with the implant
• Early molecular events of healing and osseointegration
• Better interlocking through growth of bone into the surface openings
created.
Disadvantages:
• Low bond strength between the coatings and substrates
• Thick and cracked coatings6
2- Fluoride treatment
• Ti implant surface showed to be very sensible to fluoride ions.
• It forms soluble TiF4 when treated in fluoride solutions.
Advantages:
• Improved osteoblastic differentiation
• Sustained greater push-out forces and more advanced torque removal
forces.
Disadvantages:
• Decreased cell proliferation occurred after 7 days on F treated implants
3- Nanostructured surfaces for implant dentistry
• Nowadays, only a fewer nanoscale surface changes have been used to
upgrade bone responses of clinical dental implants.
• The OsseoSpeed surface contains nanostructured details produced by
TiO2 blasting followed by hydrofluoric acid treatment.
• Most of the osteoblastic gene expression was checked in cells attached to
the nanoscale HF coated surface related to the micron-scale surface.
• This nanotopography is related with the elated levels of gene enunciation
that revealed rapid osteoblastic differentiation.

• IBAD or ion beam assisted deposition when used creates a thin film of ions
over the implant surface by discharge of the chemical element of interest.7
 Peculiar approaches applicable to layer the Ti implants are:
• PS
• Sputter deposition
• Sol-gel coating
• Electrophoretic deposition
• Biomimetic precipitation.
4- Roughening of implant surface by plasma spraying
• Plasma spraying involves, deposition of thick layer of coating materials
such as titanium and hydroxyapatite through thermal spray mechanism.
• Plasma spray substantially increases surface area of implants by
increasing the surface roughness.
Advantages:
• Fast and strong fixation and bone growth
Disadvantages:
• 2D
• No homogeneity of crystallinity
- Ti
• Titanium plasma-spraying, is a method that injects titanium powders into
a plasma torch at high temperature that are then projected on to the
surface of the implants. Here they condense and fuse together and form a
film of about 30 μm thick.
• The thickness must reach 40-50 μm to be uniform.
Advantages:
• Chemical bond with implant surface
• Roughness of 7 μ can increase implant surface area
Disadvantages:
• Similar pullout strength to HA implants
• Lower bone contact length on TPS surface compared to HA
- HA coating
• Plasma-spraying of hydroxyapatite ceramic particles, includes injection of
hydroxyapatite ceramics into plasma torch at high temperature that is
projected on to the titanium surface where they condense and fuse
together to form a film of thickness ranging from few millimeters to few
micrometers.
• The mechanical retention of this coating is obtained mechanically after
roughening the surface with other methods like grit blasting.
Advantages:
• Bioactive
• Direct strong bone-to-implant bond
• Improved load bearing capacity and biochemical bonding
• The bone implant interface revealed to be better formed than with other
implant materials and with enhanced mineralization. 8
5- Sol-gel coated implants
• In this method, a sol-gel precursor is prepared that contains reactants which upon
heating will produce various forms of hydroxyapatite. This precursor is generally
prepared in ethanol in sol stage that will subsequently be converted to gel with
specific viscosity by thermal cycling.
• Titanium implants are then immersed in to this gel and rapidly thermo-cycled
(generally to 6000C). Thus a coated surface adhered to titanium is obtained.
• Repeat coatings and thermocycling is done to obtain desired thickness of coat.
Advantages:
• 3D
• increased toughness and mechanical strength of Ti alloys
• biological affinity of HA
6- Sputter deposition
Definition
• Sputtering is a process, in which high-energy ions are discharged in a
vacuum chamber to change the surface texture of a Ti implant surface.
Radio frequency sputtering
• This procedure involves the formation of thin films of CaP coatings on Ti
implants.
Magnetron sputtering
• It involve the formation of the TiO2 layer at the bone and implant
interface which establishes the strong bond due to the outwardly diffused
Ti into the HA layer. 9
Advantages:
• Bioactive
• Accelerate bone healing
• Maximum adhesion strength
Disadvantages:
• 2D geometry
7- Electrophoretic Deposition (EPD) of Hydroxyapatite
• EPD involve, migration of charged particles in a liquid solvent by the action
of an applied electric field (electrophoresis), and the coagulation of
particles to form an adherent layer on the electrode (deposition).

This method comprises two steps:

• (1) In EPD of Hydroxyapaptite (HA) on implant surface, colloidal solution of
HA on ethanol is generally prepared and deposited on to the implant
surface.
• (2) Coating so obtained is finally sintered at 800 ͦC.
Advantages:
• 3D geometry
• Osseoconductive
• Rapid and inexpensive way of producing a dense and uniform coating on
substrates even with complex geometries.
• Coatings produced by this method are known for controlled thickness and
morphology.
Disadvantages:
• Low bond strength between the coatings and substrates
• Thick and cracked coatings10
8- Biomimetic calcium phosphate coatings
• This technique allows for nucleation and growth of bone-like crystals on a
pretreated substrate by immersing it in a supersaturated solution of
calcium phosphate under physiological conditions (37ͦC and pH=7.4).
• In general, two subsequent steps have been used to enhance the
heterogenous nucleation of the calcium phosphate.
• First, the implants are treated with an alkaline solution in order to form
titanium hydroxyl groups on the titanium surface to serve as nucleating
points.
• In the second step, the coating develops under crystal growth conditions.
• This method can be modified for the incorporation of drugs or growth
factors onto the implant surface thereby making the implants
osteoinductive and osteoconductive.
Advantages:
• 3D
• Precipitation of a biological apatite onto implant surface
• Early biological fixation of implants
• Bone-like crystal structure
• Incorporate biomolecules and drugs
Disadvantages:
• Low bonding strength
• Did not differ in osteoporotic and non-osteoporotic healthy animal models
9- Growth factor coating
• Implant surfaces can be coated with biomolecules, such as; bioadhesive motifs or
growth factors, to promote osseointegration.
• The most commonly used growth factors are:
- The transforming growth factor (TGF-β)
- Bone morphogenetic proteins (BMPs)
- Platelet-derived growth factor (PDGF)
- Insulin-like growth factor (IGF-1 and -2)
Advantages:
• Bio-adhesive
• BMPs can induce new bone formation
Disadvantages:
• Functionalization success depends on type, delivery and concentration of coating
material10
10- Biologically active drugs incorporated dental implants
• Incorporation of some osteogenic and antiresorptive drugs, such as
bisphosphonate onto the implant surface, can be used appropriately in
clinical cases with inadequate bone support.

Bisphosphonates
• Bisphosphate-loaded implant surfaces have been reported to have
improved implant osseointegration.
• Increased density of bone around the implant.
• However, the major disadvantage will be the grafting and slow discharge
of antiresorptive drugs on the surface of Ti implant.
Simvastatin
• Improve the enunciation of bone morphogenetic protein 2 mRNA that
might promote bone formation.
• Increase the bone mineral density.

Antibiotic coating
• Antibacterial coatings on the surface of implants provide antibacterial
activity to the implants themselves.
• Help to prevent surgical site infections associated with implants.
• Examples of antibiotics used:
- Gentamicin and
- Tetracycline
• Tetracycline, could also hinder the collagenase activity, accentuates the
proliferation and attachment of cells and bone healing. It could enhance
blood clot formation, attachment and retention on the implant surface
during the early healing phase and thus it accentuates osseointegration.
Advantages:
• Bioactive
• Antibacterial effect
• Antiresorptive
Disadvantages:
• Not commercially available
 Future directions in implant surface
modifications
• Future development of the next, third generation of dental implants
should be based on increased knowledge about the interface biology on
cellular and molecular levels. The development of future generations of
oral implants for compromised tissue conditions will, most probably, entail
tailored modifications of material surfaces. Implant surfaces, selectively,
designed for drug and/or cell releases represent promising candidate
strategy.
• Other surface modifications, such as selective ion substitutions of
biomimetic surfaces may further improve the biological response to those
surfaces.
• Further, future trends concern the modifications of surface roughness at
the nano-scale level for promoting protein adsorption and cell adhesion.
Factors affecting implant stability and
osseointegration
 Surgical factors
Factors affecting osseointegration
Controlled surgical -1
technique is important
-Tissue handling -2
,minimum tissue trauma
improves results
Profuse irrigation to -3
prevent bone heating and
necrosis
Use of sharp drills with -4
suitable speed
Use of torque wrench -5
with moderate torque of
45 N⁄cm is ideal
Implant related factors Patient related factors
1- Implant Biomaterial Age -1
(Biocompatibility) Compromised oral -2
2- Implant Biomechanics hygiene
3- Implant Design Heavy smoking -3
4- Implant Width &Taper Uncontrolled -4
6-Crest module design periodontal disease
7- Implant Surface Uncontrolled Diabetes -5
Topography (Surface Anemia -6
roughness) Vitamin c deficiency -7
8- Implant Surface Psychological problems -8
Modifications Radiation treatment -9
9- Contamination Chemotherapy -10
10- Heat Production Bone density -11
11- Implant Loading Available bone -12
Methods of evaluation of osseointegration

1- Invasive methods
• Histological sections (10 microns sections)

• Histomorphometric to know the percentage of bone contact

• Transmission electron microscopy

• By using torque guages

2- Non-invasive methods
Clinical perception
• Is frequently based on the mobility detected by blunt ended instruments.
It's a very unreliable and nonobjective method.

Percussion test
• May involve tapping with metallic instruments
- Ringing sound is an indication of good stability or osseointegration.
- Dull sound is an indication of fibrous integration

Radiographs
• Can detect radiolucent areas around implant fixture.
Reverse torque test
• Using a reverse or unscrewing torque for assessment
of implant stability at the time of abutment
connection. Implants that rotate under the
applied torque are considered failures and
are then removed.

Cutting torque resistance analysis

• The energy required for a current-fed electric motor in cutting off a unit
volume of bone during implant surgery is measured. The energy correlates
to bone density, which is one of the factors determining implant stability.
• However, It can only be used during the surgery and not as a diagnostic aid.
Periotest
• using a device that is an electrically driven and electronically monitored
(fig,9). The instrument includes a tapping rod that impacts the
abutment/implant assembly.
• The end of the rod inside the hand piece is rigidly connected to an
accelerometer, which produces an output proportional to its acceleration.
The readings are from −8 to +50 and are interpreted as in [Table 1].
Resonance frequency analysis
• It is a noninvasive diagnostic method that measures implant stability and
bone density at various time points using vibration and structural principle
analysis.

• Two commercially devices have been developed to assess implant

stability.
- The original (electrical) method uses a direct connection (wire) between
the transducer and the resonance frequency analyzer (eletrical resonance
frequency).
- The second method uses (magnetic) frequencies between transducer and
resonance frequency analyzer (magnetic resonance frequency).
 Conclusion
• There are number of surfaces commercially available for dental implants.

• Various methods modifying the implant surface have greatly influenced

the quality of clinical service in implant prosthodontics.

• Implant surface characterization and working knowledge about how

surface and bulk biomaterial properties could inter relate to implant osseo
integration represent an important area in implant based reconstructive
surgery.
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