| Abstract|| |
Surface plays a crucial role in biological interactions. Surface treatments have been applied to metallic biomaterials in order to improve their wear properties, corrosion resistance, and biocompatibility. A systematic review was performed on studies investigating the effects of implant surface treatments on biocompatibility. We searched the literature using PubMed, electronic databases from 1990 to 2009. Key words such as implant surface topography, surface roughness, surface treatment, surface characteristics, and surface coatings were used. The search was restricted to English language articles published from 1990 to December 2009. Additionally, a manual search in the major dental implant journals was performed. When considering studies, clinical studies were preferred followed by histological human studies, animal studies, and in vitro studies. A total of 115 articles were selected after elimination: clinical studies, 24; human histomorphometric studies, 11; animal histomorphometric studies, 46; in vitro studies, 34. The following observations were made in this review:
Limitation of this study is that we tried to give a broader overview related to implant surface treatments. It does not give any conclusion regarding the best biocompatible implant surface treatment investigated till date. Unfortunately, the eventually selected studies were too heterogeneous for inference of data.
- The focus has shifted from surface roughness to surface chemistry and a combination of chemical manipulations on the porous structure. More investigations are done regarding surface coatings.
- Bone response to almost all the surface treatments was favorable.
- Future trend is focused on the development of osteogenic implant surfaces.
Keywords: Surface roughness, surface treatment, surface coating
|How to cite this article:|
Pattanaik B, Pawar S, Pattanaik S. Biocompatible implant surface treatments. Indian J Dent Res 2012;23:398-406
Surface plays a crucial role in biological interactions. Characteristics such as surface composition, surface topography, surface roughness, and surface energy affect the mechanical stability of the implant/tissue interface. , It was found that cell attachment and proliferation were surface roughness sensitive, and increased as the roughness of Ti-6Al-4V increased.  The surface of a biomaterial is the only part in contact with the bioenvironment and is almost always different in morphology and composition from the bulk. Surface treatments have been applied to metallic biomaterials in order to improve their wear properties, corrosion resistance, and biocompatibility. A systematic review was performed on studies investigating the effects of implant surface treatments on bone response and implant fixation.
| Method|| |
Studies to be assessed were divided into four categories: clinical studies, histological human studies, animal studies, and in vitro studies. Eligibility criteria were set for each group. Clinical studies were included if (1) they reported a clear outcome of the study and (2) they included at least a 12-month follow-up analysis. Human histological studies were reviewed for the presence of the following: (1) a clear outcome, (2) examination of titanium implants and (3) minimum observation period should be 8 weeks. The following inclusion criteria were formulated for animal studies: (1) the number and type of tested animals should be clearly mentioned in the study; (2) the study should include trials with titanium or titanium alloys, (3) titanium implant should be placed in the bone and (4) minimum observation period should be 8 weeks. For in vivo studies, biological studies were included and interaction with the osteoblasts was reviewed. Investigations related to physical properties like bond strength/ corrosion/ excluded.
The objectives of this review were to find out
We searched the literature using PubMed, electronic databases from 1990 to 2009. Key words such as implant surface topography, surface roughness, surface treatment, surface characteristics, and surface coatings were used. The search was restricted to English language articles published from 1990 to December 2009. Additionally, a manual search in the major dental implant journals was performed. The issues from 2001 were searched in following journals: Clinical Oral Implant Research, International Journal of Oral and Maxillofacial Implants, Implant Dentistry, and Journal of Oral Implantology. We tried to give a broader overview related to implant surface treatments.
- the different implant surface treatments done to improve the biocompatiblity till date,
- the bone response to these treatments and
- the future trends in implant surface treatments.
A total of 115 articles were selected after elimination [Figure 1].
During the past 40 years, porous metallic orthopedic implants have been used for fixation purposes. In 1968, Hirschhorn was the first to report on the fabrication of a porous metal (a cobalt-chromium alloy) for use as an implant material in 1968.  Human osteoblasts can penetrate interconnections over 20 mm in size and colonize and proliferate inside macropores, but the most favorable size is over 40 mm. It assures cell proliferation and differentiation with blood circulation and extracellular liquid exchange.  On the basis of clinical results and histological evidence gained from retrieved implants, these porous implants revealed to be biologically fixed by the ingrowth of bony or other tissue. The ingrowth of bone into the porous structure ensures a good transfer of skeletal forces. , Reverse (or removal) torque testing showed roughened surfaces are associated with increased interfacial strength. ,, Experiments have also indicated a faster rate and higher degree of bone formation for rougher implants than for implants with smooth surfaces. ,,, Implants with the rough-surfaced microthreaded design caused minimal changes in crestal bone levels during healing (stress-free) and under functional loading.  Immediate full occlusal loading of partial prostheses supported by microtextured implants in partially edentulous patients demonstrated excellent clinical results.  One of the three-dimensional parameters for surface roughness is average surface roughness (Sa) which represents the arithmetic mean of deviations in roughness from the mean plane of analysis. Surfaces with Sa between 1 and 2 μm are included in moderately rough surfaces. Surfaces with Sa greater than 2 μm are "rough" surfaces.  Surfaces with intermediate roughness (Sa 1.5 μm) had higher bone-implant contact indices. 
Methods for fabricating porous surface can be classified as either additive or ablative.
Ablative methods remove material from the surface. Common methods for ablating dental implant surfaces include grit blasting, ,, acid etching,  grit blasting followed by acid etching, , anodizing, ,, shot peening and laser peening. ,
Ceramic particles are projected through a nozzle at high velocity by means of compressed air. Depending on the size of the ceramic particles, different surface roughnesses can be produced on titanium implants. The blasting material should be chemically stable, biocompatible and should not hamper the osseointegration of the titanium implants. Various ceramic particles have been used, such as alumina, titanium oxide and calcium phosphate particles. , Contamination could negatively influence titanium's biocompatibility. 
Alumina: Alumina (Al 2 O 3 ) is frequently used as a blasting material  and produces surface roughness varying with the size of 25, 50, and 75 mm of the blasting media. However, the blasting material is often embedded into the implant surface and the residue remains even after ultrasonic cleaning, acid passivation and sterilization. Alumina is insoluble in acid and is thus hard to remove from the titanium surface. In some cases, these particles have been released into the surrounding tissues and have interfered with the osseointegration of the implants.
Titanium oxide: Titanium oxide is also used for blasting titanium dental implants. Titanium oxide particles with an average size of 25 μm produce a moderately rough surface in the 1-2 μm range on dental implants. An experimental study using micro-implants in humans has shown a significant improvement for bone-to-implant contact (BIC) for the TiO 2 -blasted implants in comparison with machined surfaces.  Other experimental studies confirmed the increase in BIC for titanium grit-blasted surfaces. ,, Titanium dioxide-blasted implants offer predictable long-term results as supports for fixed prostheses in both the maxilla and mandible,  e.g. TiOblastTM (AstraTech Dental, Mölndal, Sweden), Neoss implant (Neoss, Harrogate, UK).
Calcium phosphates: Calcium phosphates such as hydroxyapatite (HA), beta-tricalcium phosphate and mixtures have been considered useful blasting materials.  These are biocompatible, osteoconductive and resorbable materials leading to a clean, textured, pure titanium surface. Experimental studies have demonstrated a higher BIC with these surfaces when compared to machined surfaces. , Calcium phosphates-blasted implants offer predictable long-term results as supports for fixed prostheses in both the maxilla and mandible.  Histologic analysis revealed that the mean bone-to-implant apposition was significantly greater with calcium phosphate-blasted surfaces compared to machined surfaces, regardless of bone quality,  e.g. Zimmer Dental's MTX, Nanotite (Biomet 3i, Palm Beach Gardens, FL, USA), Ospol (Malmφ, Sweden).
Roughening of implants by acid etching
Etching with strong acids such as HCl, H 2 SO 4 , HNO 3 and HF is another method for roughening titanium dental implants. ,, Acid etching produces micropits on titanium surfaces, with sizes ranging from 0.5 to 2 μm in diameter. Acid etching with 1% hydrofluoric acid/30% nitric acid after sandblasting eliminates residual alumina particles.  High temperature acid etching produces a homogeneous microporous surface. It was reported that the Ti modifications which shift very suddenly from a hydrophobic (high surface contact angle) to a hydrophilic (low surface contact angle) state adsorbed the highest amount of immunologically assayed fibronectin.  Chemical modification of the sandblasted and acid-etched (SLA) surface positively influences the osseointegration and decreases the healing time. ,,,,, Implants with the SLA surface can be restored in patients in approximately half of the time of conventional healing periods.  SLA endosseous surface can be restored after approximately 6 weeks of healing with a high predictability of success. ,, Osteotite Implant System (Implant Innovations Inc 3i, Palm Beach Gardens, FL, USA), ANKYLOS, XiVE, FRIALIT implants (DENTSPLY Friadent), and The Straumann (Basel, Switzerland) are grit-blasted and high-temperature etched surfaces. The increased roughness compared with turned implants, combined with possible microstructural changes in the oxide resulting from the acid treatment produces good cell and tissue responses, such as greater bone-implant contact.  Titanium is very reactive to fluoride ions, forming soluble TiF4 species. This chemical treatment of the titanium created both a surface roughness and fluoride incorporation favorable to the osseointegration of dental implants, e.g. Astra Osseospeed implant (AstraTech Dental, Mölndal, Sweden).
Roughening of implants by anodization
Micro or nanoporous surfaces may also be produced by potentiostatic or galvanostatic anodization of titanium in strong acids H 2 SO 4 , H 3 PO 4 , HNO 3 , HF at high current density (200 A/m 2 ) or potential (100 V). The result of the anodization is to thicken the oxide layer to more than 1000 nm on titanium. When strong acids are used in an electrolyte solution, the oxide layer will be dissolved along current convection lines and thickened in other regions. The dissolution of the oxide layer along the current convection lines creates micro or nanopores on the titanium surface. , Anodization produces modifications in the microstructure and the crystallinity of the titanium oxide layer.  The anodization process is rather complex and depends on various parameters such as current density, concentration of acids, composition and electrolyte temperature. It was found that (i) with increasing voltage, the roughness (from 0.3 to 2.5 μm) and thickness (from 1 μm to 15 μm) of the film increased and (ii) the TiO2 phase changed from anatase to rutile, a considerable improvement in their osseointegration capacity as compared to the unmodified CpTi implants.  Significantly higher bone response for anodic oxidized titanium implants was observed than for implants with a turned surface. ,
One study concluded that oxide properties of titanium implants, which include oxide thickness, micropore configurations and crystal structures, greatly influence the bone tissue response in the evaluation of removal torque values,  e.g. Nobel Biocare (TiUnite) Zurich, Switzerland.
Roughening of implants by shot peening and laser peening
Shot peening  (which is a similar technique to sandblasting, but has more controlled peening power, intensity, and direction) is a process in which the surface is bombarded with small spherical media called shot. Each piece of shot striking the material acts as a tiny hammer, imparting to the surface small indentations or dimples.  The laser peening technology is recently developed, contamination-free peening method.  Before treatment, the surface is covered with a protective layer (paint or tape). High-intensity (5-15 GW/cm 2 ) nanosecond pulses (10-30 ns) of laser light beam (3-5 mm width) strike the protective layer. Implants demonstrated a deep and regular honeycomb pattern with small pores,  e.g. laserlok Surface (Bio horizon, Birmingham, Alabama).
A number of processes have been applied to produce porous titanium and titanium alloy implants by additive method. Generally, these different methods can be divided into three categories as follows.
Osteoconductive calcium phosphate coatings on dental implants
- Porous coatings can be produced by sintering uniformly sized beads or fibers onto the substrate by isostatic pressing or loose packing.  These methods are associated with numerous drawbacks. These include: a low porosity (generally less than 50%), uncontrollable pore size (which is determined by the size of the particles) and incomplete interconnections between the pores.
- Porous coatings can also be fabricated by mixing titanium powder with an organic spacer holder. This mixture is applied to the surface of the implant and becomes permanently affixed under controlled conditions of temperature and pressure. The organic material is subsequently removed, leaving a porous, metallic coating on the implant surface. The problem with this method is that it is difficult to control the interconnectivity of the pores, some of which remain closed.
- The third methodological category includes titanium plasma sprayed (TPS) surfaces. To prepare these surfaces, titanium particles are heated to a nearly molten state and sprayed at the substrate via inert gas plasmas. The softened particles "splat" on the surface and rapidly solidify. The resultant surface is quite irregular and rough. This increased surface texture, with relatively greater void volume into which bone can grow, results in higher removal torque value. The Sa depends on the manufacturer but can be up to 6 μm.  The drawbacks of this method are the poor interconnectivity of the pores and a small pore size. Several studies, however, have shown cause for concern with TPS implants. For example, titanium particles have been detected in peri-implant tissues.  TPS surfaces have also been associated with increased mobility and higher incidence of peri-implant inflammation and recession,  e.g. PITT-EASY (Sybron Implant Solutions GmbH, Germany).
Metal implants have been coated with layers of calcium phosphates mainly composed of HA. Following implantation, the release of calcium phosphate into the peri-implant region increases the saturation of body fluids and precipitates a biological apatite onto the surface of the implant.  This layer of biological apatite might contain endogenous proteins and serve as a matrix for osteogenic cell attachment and growth.  Calcium phosphate coated surfaces adsorb twice as much albumin as the titanium surfaces.  HA coating is an effective method for improving bone formation and ingrowth in the porous implants. ,, One study found that the osteoblast amount and activity on the surfaces containing Ca are higher than those on the surface containing sole P ions. 
Different methods have been developed to coat metal implants: plasma spraying, , sputter deposition, ,, radiofrequent (RF) magnetron sputtering technique, ,,,, sol-gel coating, ,,, pulsed laser deposition (PLD), ,, electrophoretic deposition, , or biomimetic precipitation, ,, and dipping method. 
Metal implants have been coated (by plasma spraying or other methodologies) with layers of HA,  calcium phosphate  or mixtures of the two.  These coated implants are, moreover, characterized by a rough surface profile, which further improves osseoconduction and osseointegration. By coating implants with HA such as by plasma spraying, both the roughness and surface chemistry are altered. The roughness increases to Sa 5.8 μm  and the surface chemistry is dramatically changed from TIO 2 to a bone-like ceramic with the potential for chemically bonding to bone. Unfortunately, the properties of commercial coatings can be quite variable. During plasma splaying, HA can be transformed to other foams of calcium phosphate, with different crystalline structures, such as β-tricalcium phosphate. There are reports ,,,, documenting the clinical success of dental implants coated with calcium phosphate. In Bicon Implant System (Boston, USA), Star lock implants (Park Dental Research Corp, USA), Osstem (South Korea) surfaces are HA coated. There is a report on fluoridated HA coating where fluoride was incorporated. 
The plasma spray method employs extremely high temperatures (10,000-12,000°C) during the coating process. Unfortunately, it results in potentially serious problems including (i) an alteration of structure, (ii) formation of apatite with extremely high crystallinity, and (iii) long-term dissolution and the accompanying debonding of the coating layer. Studies ,, have observed failures with HA-coated implants. Therefore, in recent coating techniques like RF sputtering technique, ,, electrophoretic deposition, , sol-gel coating ,,, and biomimetic precipitation, ,, the calcium phosphate coatings are thin and there is increase in bond strength between calcium phosphate and the implant surfaces. The surface treatment method affects the type of TiO2 layer formed (anatase or rutile) and affects apatite deposition and adhesion on the Ti surface.  Electrochemical deposition is more efficient and less sensitive to the conditions of the Ti surfaces compared to the biomimetic depositions; however, the electrochemical deposition produces less uniform and thinner coating layers on the inner pore surfaces compared with the biomimetic deposition.  The biomimetic coating technique involves the nucleation and growth of bone-like crystals upon a pretreated substrate by immersing this in a supersaturated solution of calcium phosphate under physiological conditions of temperature (37°C) and pH (7.4). The method, originally developed by Kokubo,  has since undergone improvement and refinement by several groups of investigators. , The same principle would also apply to the incorporation of other drugs into such implants. By this means, implants can be osteoinductive (growth factors) as well as osteoconductive (calcium phosphate layer). Some recent coating techniques investigated are listed in [Table 1].
| Future Trends in Dental Implant Surfaces|| |
The surface of titanium dental implants may be coated with bone-stimulating agents such as growth factors in order to enhance the bone healing process locally. Some of the most promising candidates for this purpose are bone morphogenetic proteins (BMPs), transforming growth factor (TGF)-1, platelet-derived growth factor (PDGF) and insulin-like growth factor (IGF)-1 and -2, fibroblast growth factor-fibronectin (FGF-FN) fusion protein.  BMPs incorporated into dental implants have been obtained from by various methods. ,,, Titanium alloy implants bearing a fine, dense, amorphous layer of calcium phosphate were immersed in a supersaturated solution of calcium phosphate containing growth factors such as BMP-2 for 48 h under physiological conditions of temperature (37°C) and pH (7.4). The implants became coated with a crystalline latticework of the inorganic components into which BMP-2 was incorporated. Although BMP-2 is itself osteoinductive, its osteogenic potency was markedly enhanced after incorporation into biomimetic calcium phosphate coatings.
The surface of implants could also be loaded with molecules controlling the bone remodeling process. Incorporation of bone antiresorptive drugs, such as biphosphonates, might be very relevant in compromised clinical cases, e.g. resorbed alveolar ridges. Other experimental studies using plasma-sprayed HA-coated dental implants immersed in pamidronate or zoledronate demonstrated a significant increase in bone contact area. ,, The main problem lies in the grafting and sustained release of antiresorptive drugs on the titanium implant surface. Mixing antibiotics with polymethylmetaacrylate (PMMA) bone cements has been shown to provide adequate local antibiotic concentrations for extended periods of time. ,
| Summary|| |
Quest for excellence has led to innovative materials and techniques. Concepts are gradually changing based on evidence. In early days of implant dentistry, smooth surface titanium implants were used. Porous surface implants were developed by additive and ablative methods. The continuing search for "osseogenic" implants is leading to surface modifications involving biological molecules. Powerful cytokines and growth factors are incorporated to obtain the desired cell and tissue responses. Limitation of this study is that we have tried to give a broader overview related to implant surface treatments. It does not give any conclusion regarding the best biocompatible implant surface treatment investigated till date. Unfortunately, the eventually selected studies were too heterogeneous for inference of data.
The following observations were made from this review:
It can be said that the key message in this study is that in compromised conditions like in poor bone quality, calcium phosphate coated implants can be useful. Rough surface implants are more osteoconductive than smooth surface implants.
- The focus has shifted from surface roughness to surface chemistry and a combination of chemical manipulations on the porous structure. More investigations are done regarding surface coatings.
- Almost all the study comparisons were done with machined smooth implants and there were a few studies comparing different new methods of surface modifications.
- In animal study models, maximum studies investigated only, the bone response and very few studies were investigated with loaded implants.
- Careful controlled clinical trials comparing different recent surface modifications are needed to evaluate clinical efficacy.
- Bone response to almost all the surface treatments was favorable.
- Future trend is focused on the development of osteogenic implant surfaces.
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Department of Prosthodontics, Rungta College of Dental Sciences and Research Centre, Bhilai, Chattisgarh
Source of Support: None, Conflict of Interest: None