| Abstract|| |
Purpose: Anodized implants with moderately rough surface were introduced around 2000. Whether these implants enhanced biologic effect to improve the environment for better osseointegration was unclear. The purpose of this article was to review the literature available on anodized surface in terms of their clinical success rate and bone response in patients till now. Materials and Methods: A broad electronic search of MEDLINE and PubMed databases was performed. A focus was made on peer-reviewed dental journals. Only articles related to anodized implants were included. Both animal and human studies were included. Results: The initial search of articles resulted in 581 articles on anodized implants. The initial screening of titles and abstracts resulted in 112 full-text papers; 40 animal studies, 16 studies on cell adhesion and bacterial adhesion onto anodized surfaced implants, and 47 human studies were included. Nine studies, which do not fulfill the inclusion criteria, were excluded. Conclusions: The long-term studies on anodized surface implants do favor the surface, but in most of the studies, anodized surface is compared with that of machined surface, but not with other surfaces commercially available. Anodized surface in terms of clinical success rate in cases of compromised bone and immediately extracted sockets has shown favorable success.
Keywords: Branemark rough surface implants, controlled oxide texture implant, oxidized implants
|How to cite this article:|
Mishra SK, Kumar MA, Chowdhary R. Anodized dental implant surface. Indian J Dent Res 2017;28:76-99
| Introduction|| |
Branemark implant system was introduced to clinical dentistry in 1965. Since then, these machined dental implants have shown high success rate in implant-supported oral rehabilitation., Machined surface implants were used almost till 2000. One of the key factors for the success of dental implants is the amount of primary stability they achieve immediately after their surgical placement, and to achieve the required primary stability, thread design and surface roughness are the contributing factors.,, Dental implants with moderately rough surface created by anodization were introduced in 2000 by the name TiUnite (TiU), a commercial name from Nobel Biocare, Sweden. Anodized implant surfaces were having a combination of controlled oxide texture and porosity for an enhanced biologic effect and to improve the environment for better osseointegration. It was documented that anodized implant surface increases the amount of surrounding bone formation, and the initial healing process increases the adsorption of protein and also accumulation and activation of platelets with fibrin retention., However, certain researchers documented that, when the implants are exposed in the oral cavity, the surface roughness on them will enhance plaque accumulation, which can lead to peri-implantitis.,,
With the aim to understand the influence of anodized surface in enhancing osseointegration, the present systematic review was planned through documented literature in terms of its clinical success rate and the response of the bone to its stimulation.
| Materials and Methods|| |
Source of data and search strategies
The present systematic review was designed based on the PRISMA guidelines. A broad electronic search of MEDLINE and PubMed databases was performed for articles published without any limitation of date of publication. Articles written in English only were included, with focus on peer-reviewed dental journals. The following key words were used in the search strategy: “TiUnite dental implants,” “TiUnite implants,” “oxidized TiUnite implants,” “anodized implants” and “prospective study,” “TiUnite” and “retrospective study,” and “anodized surface implants.”
The titles and abstracts were first read by all the authors for identifying studies meeting the eligibility criteria. The articles which fulfill the inclusion criteria were included for the full-text reading. Manual searches of the references of all full-text articles selected from the electronic search were also performed for additional papers that might meet the eligibility criteria for inclusion in the study. If there was any disagreement regarding the inclusion or exclusion of the selected articles, it was resolved by a discussion between reviewers.
Only articles related to anodized implant surface were included. Both abstract and full-text articles were included. The inclusive criteria of the search were limited to articles written in English only.
Inclusion criteria for each study group were included as follows:
In vivo studies (animal studies) on peri-implant soft tissue responses around anodized implants, studies investigating the tissue response around anodized implants, histomorphometric analysis of animal experiments and torque analysis, and histological analysis of peri-implant soft tissue were included.
Group 2 included in vitro studies on the surface properties of anodized implant including those on cell adhesion and bacterial adhesion onto this implant surface. Anodized as material or substrate for cell adhesion and bacterial adhesion had a description not only about the microbiologic analysis but also about the surface topography of the substrate or material.
Clinical trials with follow-up of 2 years and above were only included. The included studies reported clinical results of anodized surface and had a minimum number of 14 participants at the baseline examination. Both prospective and retrospective studies were included.
Studies composed of languages other than English were excluded. Simple case report articles and review articles were excluded although references to potentially pertinent articles were noted for further follow-up. Articles unrelated to the topic of anodized implants were excluded. Studies not meeting any of the inclusion criteria were excluded from the review.
Outcomes and variables
For each of the selected article included in this review, the following data were obtained and presented: Year of publication, type of study, number of implants, observation period, implant type, area of implant placement, years of follow-up, number of patients, age range, type of prosthesis, number of failed implants, mean marginal bone loss, and success rate.
| Results|| |
Initial search of articles in MEDLINE and PubMed databases with the given key words resulted in 581 articles on anodized implant surface. The reviewers independently screened the abstracts for the articles related to this surface. The initial screening of titles and abstracts resulted in 112 full-text papers, out of which 40 articles were animal studies [Table 1],,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 16 studies were on cell adhesion and bacterial adhesion on to anodized implants [Table 2],,,,,,,,,,,,,,,, and 47 were related to human studies [Table 3] and [Figure 1].,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, Nine studies, which did not fulfill the inclusion criteria, were excluded.
|Table 1: Animal studies on peri-implant soft tissue responses around anodized implants|
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|Table 2: In vitro studies on the surface properties of anodized implant including those on cell adhesion and bacterial adhesion on to this implant surface|
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|Table 3: Human follow-up studies on TiUnite implant. The included studies reported results of anodized surface implants in terms of their clinical success rate and bone response in patients|
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|Figure 1: Flow chart presenting the screening of articles on anodized implant surface in MEDLINE and PubMed databases to be included in the review|
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Animal studies showed that anodized surface exhibits osteoconductive properties with benefits of rough surfaces., Results were not very clear as studies described that the bone-to-implant contact was significantly higher for the anodized implants, but other studies showed additional bone loss after treatment., In studies where implants with different surfaces were connected together, the implants placed distally with machined surface showed more bone loss.
An in vitro study showed the bone growth into the porous structure of the coating of anodized implants and also the surface that reduced the adhesion of Streptococcus mitis compared to the machined surface implants., Anodized surface has showed a potential to prevent long-term implant failure due to corrosion in a complex in vivo environment.
Human clinical trial on patients treated with immediately loaded anodized implants and restored with single crown showed 94% success rate after 3 years and 95% after 5 years., Another clinical trial on complete maxillary arch rehabilitated with anodized implant supported fixed prostheses showed a survival rate of 98.6% in comparison to machined surface implants (92.1%) after 3-year follow-up and 97.3% and 94 %, respectively, after 5 years of follow-up., A 2-year prospective study showed 100% success rate of implant-supported mandibular overdenture. Seven-to-eight years of follow-up of delayed loaded anodized implant showed no failure of implants. Immediately loaded anodized implants on patients treated in postextraction site showed a cumulative survival rate of 100% in 5-year follow-up and 96.52% at 10-year follow-up., Ten percent higher success rate was obtained in a study following immediate loading of fixed partial dentures (FPDs) in the posterior mandible supported by TiU implants. A study found that oxidized surface implants are more suitable for patients who are smokers and are susceptible to periodontitis., Another follow-up study from 1985 to 2011 found the success rate of TiU as 95.4% and machined surface as 84.9%. TiU implant has played a critical role in single-stage implant survival rate.
| Discussion|| |
The original Branemark protocol underwent many modifications to increase the success of implant treatment. One of the modifications was the introduction of anodized, porous implant surface. The questions raised during this systematic review were answered with the help of literature which included in vivo, in vitro, and clinical studies published on anodized surface implants.
In vivo studies (animals)
Many animal studies on peri-implant soft tissue responses around anodized implants were conducted and the main question raised was whether anodized implant surface promotes bone growth. A study by Xiropaidis et al. in Labrador dogs showed TiU surface exhibiting osteoconductive properties more than that of the calcium phosphate-coated implant surface. Histological studies in Beagle dogs showed benefit of rough surfaces relative to minimally rough ones. The bone growth was seen into small pores (<1 μm) of anodized implants placed in minipigs. Gedrange et al. in their study in German domestic pigs found that the immediate loading of the different implant types does not have any negative effect on the bone apposition. In a study done by Jimbo et al., the bone-to-implant contact was significantly higher for the anodized implants, whereas result of another study done by Stokholm et al. in monkeys found no statistically significant differences between anodized implants for bone reaction around immediate-loaded and delayed-loaded nonsplinted single implants. Result of a study demonstrated that the removal torque of the laser-treated titanium implant placed in rabbits was stronger than anodized implants. Albouy et al. in their study in dogs found that the amount of bone loss was significantly larger in implants with an anodized surface than in implants with a turned surface when the plaque was accumulated. The histological analysis showed that there was increase in vertical size of the lesion at anodized implants. The pocket epithelium and extension of the biofilm apically were significantly larger at anodized implants than at turned implants., When implants with different surface properties are connected, machined implants at the most distal sites might be a potential risk factor for implant–bone binding. A study showed that surface modification of titanium-zirconium by anodization is similar to anodized titanium. It enhances early osseointegration compared to machined implant surfaces. Animal studies provide mixed result on the success of anodized surface implants, so further investigation with the help of clinical trials and in vitro studies is required to comment on anodized surface implants.
In vitro studies
Surface properties and microbiologic response of anodized implants were analyzed in different in vitro studies. In a study by Giannuzzi et al., the bone growth was seen in the porous structure of the coating of anodized implants, yielding direct evidence of a mechanical locking mechanism of the bone/implant interface. The anodic-oxidized surface has inherent photocatalytic activity, which can enhance osseointegration. Under simulated conditions of inflammation, elevated dextrose concentrations, and after implantation into bone, the corrosion risk of the enhanced oxide implant is lower than machined surface titanium implant counterpart. The biological seal of the tissue-engineered oral mucosa around the four types of titanium surface (polished, machined, sandblasted, and anodized) in an in vitro study was not significantly different. Another in vitro study showed that the anodized surface reduced the adhesion of S. mitis compared to the machined surface. Proliferation, alkaline phosphatase activity, and calcium deposits were significantly higher on anodized surfaces compared to machined surfaces. Improved antibacterial properties, and at the same time, greater stem cell osteogenic capacity seen, when decorating titania nanotubes with nanosized TiO2 particles, may significantly improve implant efficacy. The results obtained in in vitro studies were quite encouraging about anodized surface implants.
Many clinical questions were raised in this review and an attempt was made to find how anodized implants perform in various clinical situations.
Success rate of anodized implants in maxillary posterior quadrant
Maxillary posterior quadrant presents many problems and limitations to implant placement such as poor bone quality and quantity, pneumatization of the maxillary sinus, and difficulty in accessibility of the area.,,, Sinus floor bone grafting may provide sufficient bone quantity and quality for implant placement; however, it is a costlier affair to the patient and there is a risk of morbidity when compared to other alternate treatment options available such as zygomatic implants. As mentioned earlier, titanium oxide-surfaced implants can be used successfully in the pterygomaxillary region for achieving successful osseointegration.,, In a study, pterygomaxillary region had shown 8% more survival rate with anodized surface implants. Glauser et al. in their prospective clinical study mentioned that immediately loaded anodized Branemark System Mk IV had a success rate of 97.1% after a 4-year follow-up even though the majority of all implants were placed in posterior regions (88%) and in soft bone conditions (76%). It was found that in regions exhibiting soft bone, modified implant surface texture had shown a successful treatment alternative. Renouard Nisand  evaluated the survival rate of short implants (6–8.5 mm) in the resorbed maxilla, four out of five lost implants had a machined surface and one had an oxidized surface, giving survival rates of 92.6% and 97.6% for the different surfaces, respectively. A 5-year cross-sectional retrospective study by Friberg and Jemt  mentioned that one turned and two anodized implants failed in the mixed group, thus indicating no significant difference of anodized surface in compromised bone. Rocci et al. found 10% higher success rate following immediate loading of FPDs in the posterior mandible supported by TiU implants. Combination of controlled oxide texture and porosity in anodized surface has made it unique for an enhanced biologic effect. There is increase in initial healing process due to textured surface of anodized implants. Increase in the bone surrounding the implant was observed due to the adsorption of protein and also there was accumulation of platelets and their activation and fibrin retention. Microtextured surface is produced by anodic oxidation of the titanium, resulting in increased thickness of the native oxide layer and provides good primary stability in areas of soft bone quality and thus leads to better secondary stability of implants.
Success rate of anodized implants in grafted sites
Patients with insufficient bone volume may require bone reconstructive procedures before implant placement. Sinus floor augmentation and onlay bone grafting are commonly used in cases of severely resorbed maxilla.,,,,, To achieve and maintain primary stability in such cases is a very difficult challenge. Brechter et al. studied the survival and stability of anodized implants placed in patients with reconstructive jaw surgery. In a mean follow-up period of 30 months, there was successful outcome of 200 consecutive oxidized implants in various reconstruction situations, with only three failures. Grafting of the maxillary sinus floor with intraorally harvested bone and delayed placement of either turned or oxidized implants result in equally high long-term survival rates (95.7% for turned implants and 97.7% for oxidized implants). Bahat et al. studied the radiographic outcome of Branemark Mk IV implants in compromised and grafted bone after 3–7-year follow-ups. Long-term clinical outcome of oxidized titanium oxide surface implants were very predictable and successful. They observed that in case of poor bone quality and grafted sites, anodized Branemark MK IV implants inserted with a modified surgical protocol were successful. MK IV implants are fully body-tapered implants and they distribute progressive forces more uniformly into the bone then the parallel-walled self-tapping implants.
Immediate loading of anodized implants
The standard protocols in implant dentistry recommend a healing period of 6 months for the maxilla. However, sometimes, patients did not opt for implant treatment due to more time required for treatment and additional surgical procedures required in case of two-stage implant surgery. An immediate or early loading protocol of dental implants has overcome these patients' problems and has given a good treatment option to them. Some reports indicate that immediate loading in soft bone was very discouraging,, but many recent studies have demonstrated encouraging results for immediately loaded anodized implants, where bone quantity and quality were not sufficient for implant placement.,,,, Degidi et al. did a 36-month follow-up study of immediately loaded implants with a porous anodized surface. All implants appeared to be osseointegrated. Immediate-loaded implants with a porous anodized surface in the long-term were found to work well with a success rate of 100%. In a prospective study by Turkyilmaz, Branemark System MK III TiU implants were placed in the maxilla. The success rates for both implant and prosthesis were 94% after 3 years. Results showed that early loading of anodized surface implants in the maxilla may offer an alternative treatment option to the standard loading protocol. Turkyilmaz and Tumer  carried out another prospective study of 2 years on early versus late loading of unsplinted TiU surface implants supporting mandibular overdentures. The results of the study showed that 1-week early loading approach for implants supporting mandibular overdentures does not adversely influence their clinical performance. No implant was lost, and 100% implant success with both early and delayed loading protocols was obtained. Calandriello andTomatis  did a follow-up study for 5 years, for the clinical and radiological performance of anodized Branemark System wide platform implant-loaded immediately supporting single molars in the lower jaw. The cumulative success rate at 5 years was 95.0%. The results of this study encourage the use of immediately loaded anodized implants. Anodized implants with pore diameter of ≤8 mm facilitate the growth of bone into the pores and thus show better osseointegration and can be successfully used for immediate loading of implants. Maló et al. in their long-term study (1–13.5 years) found that anodized implants inserted using an immediate function protocol to support fixed partial rehabilitations (FPR) in both jaws is a viable and safe concept. The cumulative survival rate of anodized implants for ten years in their study was 99.1%. Liddelow and Henry  found that immediately loaded overdenture with oxidized implants provides beneficial treatment outcome with 100% success rate of oxidized implants and 57.1% that of machined surface implants.
Anodized implants, marginal bone loss, and peri-implantitis
Many longitudinal studies have shown the marginal bone level to resorb to the first thread after functional loading. This phenomenon could be explained as biomechanical adaptation of bone to the occlusal loading. The problem with rough-surfaced implants was that they accumulate more plaque than smooth-surfaced implants.,,,, Many studies showed low levels of plaque and marginal bone loss around anodized implants in spite of early concerns of increased plaque accumulation on rough-surfaced implants when compared to machined implants.,,,,,,,, Lee et al. in their 3-year prospective radiographic study evaluated the level of marginal bone around different implant systems. They found that functionally loaded rough surface implants with microthread might maintain marginal bone level more positively than anodized implants and hybrid of smooth and rough surface implants. Gelb et al. studied 7–8 year functional loading performance of anodized surface Branemark implants by clinical and radiographic analyses. No implant failure was found. It was found that around 95% of implants in the peri-implant mucosa was healthy. Caous et al. concluded in an in vitro study that the anodized surface reduced the adhesion of S. mitis compared to the machined surface. Mozzati et al. studied the long-term clinical and radiological results in a group of patients having single-tooth and partial restorations supported by Branemark TiU implants, they showed an excellent survival rate of anodized implants; the marginal bone response and soft tissue conditions to anodized implants were favorable. Jungner et al. compared the clinical performance of turned and oxidized implants after more than 5 years of loading. Seven turned implants and one oxidized implant failed, with an overall cumulative survival rate of 94.7 and 99.4%, respectively. After 5 years of function, there was no difference in the rate of implant failure and marginal bone loss around oxidized implants when compared to turned titanium implants. Polizzi et al. in their study found a small but significant difference in bone level in favor of the TiU implants. Thus, the current data are in contrast with other studies reporting similar bone remodeling values for turned and moderately rough surface implants or, most frequently, showing better outcomes for turned implants., Wagenberg and Froum  retrospectively evaluated bone stability around implants with anodic oxidized surfaces and compared this with variables which were compared in a previous study. They found that the mesiodistal bone loss of anodic oxidized surface (TiU) implants over a period of 2–12 years was significantly less when compared with machined implants placed with the same immediate implant placement protocol. Watzak et al. in their study found less peri-implant bone loss around rough implant surfaces, which had beneficial effects at distal implants and in smokers. Nicu et al. did a 3-year prospective randomized controlled trial. They compared the clinical, microbiological, and biochemical results of minimally turned (machined) and moderately rough (anodized) implant surfaces in a split-mouth design. In patients more prone to periodontitis, the moderately rough, TiU implants placed in both postextractive and healed areas demonstrated similar clinical results when compared with the smoother, turned implants in 10 years of clinical performance. Five of over 210 implants included in this study (2.38%) were treated for recurrent peri-implantitis, but were lost because treatment failed to completely eradicate the infection. Good treatment outcome with regard to implant survival, condition of the soft tissue, and response of marginal bone was obtained when implants were immediately loaded in postextraction sockets.
Success rate of anodized implants in postextraction sites
Balshi et al. in their complete arch maxillary prospective study evaluated the survival rates of anodized Branemark implants and also compared them with similar study on machined surface implants. Implants were placed in immediate extraction or healed sites. TiU implants had a significantly higher survival rate of 98.6% in comparison to 92.1% for machined surface implants. Degidi et al. in their prospective study evaluated 10-year performance of TiU implant-supported fixed prostheses with an immediate loading protocol in both postextracted and healed regions. The implants placed in healed sites obtained a cumulative survival rate of 98.05%, and in postextractive sites, it was 96.52%. In a 5-year retrospective study by Mura, it was found that there was no implant failure when immediately loaded in postextracted sites, which could be because of anodized surface favoring faster bone healing without either soft or hard tissue problems.
| Conclusion|| |
The findings of the systematic review on anodized surface can be concluded as follows:
- Animal studies showed mixed result. There was increase in bone loss after treatment with anodized surface implants. However, when implants with different surfaces were connected in such cases, distal implant with machined surface showed more bone loss
- Favorable results were obtained in in vitro studies with bone growth into the porous structure of the coating of anodized implants. Proliferation, alkaline phosphatase activity, and calcium deposits were significantly higher on anodized surfaces compared to machined surfaces
- Long-term clinical studies on anodized surfaced implants do favor the surface, but in most of the studies, anodized surface is compared with that of machined surface, but not with other surface commercially available. Anodized surface in terms of clinical success rate in cases of compromised bone and immediately extracted sockets has shown favorable success with more than 95% of clinical success. Anodized surface did show plaque accumulation in marginal bone losses when compared to machine surfaces in one study, but several other studies showed decreased levels of plaque and reduced marginal bone loss around anodized implants. Many recent studies have demonstrated encouraging results for immediately loaded anodized implants where bone quantity and quality were not sufficient for implant placement with success rate of more than 94%.
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Conflicts of interest
There are no conflicts of interest.
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Dr. Ramesh Chowdhary
Department of Maxillofacial Prosthodontics and Implantology, Rajarajeswari Dental College and Hospital, Bengaluru - 560 074, Karnataka
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]