2

d e n t a l m a t e r i a l s 3 1 ( 2 0 1 5 ) 371381

Available online at www.sciencedirect.com

ScienceDirect

jo ur nal home p ag e: www.int l .e lsev ierhea l th .com/ journa ls /dema

Review

Fiber glassbioactive glass composite for bonereplacing and bone anchoring implants

Pekka Ka DepartmenUniversity ob City of Turc DepartmenUniversity od Laboratory

a r t i c

Article histor

Received 8 S

Received in

30 Novembe

Accepted 7

Keywords:

Fiber glass

Bioglass

Bioactivce g

Fiber-reinfo

Implant

Cranial

CorresponE-mail a

http://dx.do0109-5641/. Vallittua,b,, Timo O. Nrhi c, Leena Hupad

t of Biomaterials Science and Turku Clinical Biomaterials Centre TCBC, Institute of Dentistry,f Turku, Turku, Finlandku Welfare Division, Turku, Finlandt of Prosthetic Dentistry and Turku Clinical Biomaterials Centre TCBC, Institute of Dentistry,f Turku, Turku, Finland

of Inorganic Chemistry, Process Chemistry Centre, bo Akademi University, Turku, Finland

l e i n f o

y:

eptember 2014

revised form

r 2014

January 2015

lass

rced composite

a b s t r a c t

Objective. Although metal implants have successfully been used for decades, devices made

out of metals do not meet all clinical requirements, for example, metal objects may interfere

with some new medical imaging systems, while their stiffness also differs from natural bone

and may cause stress-shielding and over-loading of bone.

Methods. Peer-review articles and other scientic literature were reviewed for providing up-

dated information how ber-reinforced composites and bioactive glass can be utilized in

implantology.

Results. There has been a lot of development in the eld of composite material research,

which has focused to a large extent on biodegradable composites. However, it has become

evident that biostable composites may also have several clinical benets. Fiber reinforced

composites containing bioactive glasses are relatively new types of biomaterials in the eld

of implantology. Biostable glass bers are responsible for the load-bearing capacity of the

implant, while the dissolution of the bioactive glass particles supports bone bonding and

provides antimicrobial properties for the implant. These kinds of combination materials

have been used clinically in cranioplasty implants and they have been investigated also as

oral and orthopedic implants.

Signicance. The present knowledge suggests that by combining glass ber-reinforced com-

posite with particles of bioactive glass can be used in cranial implants and that the

combination of materials may have potential use also as other types of bone replacing and

repairing implants.

2015 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

ding author at: Institute of Dentistry, University of Turku, Lemminkisenkatu 2, FI-20520 Turku, Finland. Tel.: +358 20 333 8332.ddress: Pekka.vallittu@utu. (P.K. Vallittu).

i.org/10.1016/j.dental.2015.01.003 2015 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

372 d e n t a l m a t e r i a l s 3 1 ( 2 0 1 5 ) 371381

Contents

1. Intro . . . . . 2. Struc . . . . . .

2.1. . . . . . 2.2. . . . . . .2.3. . . . . .

3. Bioac . . . . . 4. Impl . . . . . 5. Futu . . . . .

Ackn . . . . . Refer . . . . .

1. In

Biodegradaite materiadecades. Cin reconstrbeen used metals do nisoelasticitcient (stresimplant [1when usedmay also inof corrosioIn additiontics when allow postocontrast, dmade fromin a polymcompositesearly 1960s1990s [911in dentistryApplicationrestorativein orthodoapplicationimplant dein cranial simplants blize certainthe possibinents to thhave proverials in imimplants bing utilizata large numand implanrials like titbeam comp

Regardleanchoring material of

emenroperole ass, ive gcrobviewe of

Str

ma. Th

at ers ir oriatrix

alsot ms, anf FRCth ausedfabrions.their

or cberhelsnd ore mduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ture and material components of FRC . . . . . . . . . . . . . . . . . . . . . . . . . Resin matrix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Reinforcing bers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Biological considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

tive glasses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ant designs preclinical studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . re direction of research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . owledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

troduction

ble and biostable medical and dental compos-ls have been developed considerably in recenturrently, they can be used in many applicationsuctive medicine. Although metal implants havesuccessfully for many years, devices made out ofot meet all biomechanical requirements, such as

y of skeleton and bone and may lead to insuf-s-shielding) or over-loading situations around the]. This problem has been recognized specically

as metal implants in long bones. Metal implantsduce cytotoxic reactions arising from the release

n products of metal ions, and nanoparticles [25]., metallic objects interfere with medical diagnos-using magnetic resonance imaging and do notperative radiation therapy to be performed [68]. Inurable and tough non-metallic composites can be

high-aspect ratio llers, namely bers embeddeder matrix. The rst studies using ber-reinforced

(FRCs) in medicine and dentistry occurred in the, but more extensive research started in the early]. Introduction of FRCs as prosthodontic material

occurred in larger scale at the end of the 1990s.s of FRCs cover several elds of dentistry from

dentistry to prosthodontics, but bers are also usedntics and periodontology [12]. Besides the dentals, FRCs have started to be used clinically as well inntistry, with the rst approved clinical applicationsurgery [13]. Research to develop oral and orthopedicased on FRC is ongoing. Implant applications uti-

biomechanical properties of FRC, and benet from

requirthe Euactive tive glBioactantimiThis reand us

2. FRC

FRC ismatrixgationthe bas bemer mmatrixCorrecprocestion ostrengbeen tional conditlimits knowntional (KrencOral ament ality of incorporating additional bioactive compo-e implant structure. Particulates of bioactive glassd its suitability in this purpose [14,15]. FRC mate-plantology have been focused initially on cranialecause nonmetallic implants enable the increas-ion of magnetic resonance imaging in identifyingber of infections related to autologous bone apsts [16,17]. In implant dentistry, radiopaque mate-anium and zirconia cause severe artifacts in coneuter tomography images [18].ss of the location of the bone replacing or boneimplant (maxillofacial, cranial or long bones), the

the implant and implant device have to fulll the

whereas coial implant

2.1. Res

ThermoplaExamples are polyethetal (PA), awhich are glycidyl-A-methacryapolyesters h. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378

ts of permanently implantable medical devices ofan Directive classes 2B or 3. If the implant has anin tissues through its components, such as bioac-the implant belongs to class 3 medical devices.lass is considered an active component because ofial nature, which is a desired property for implants.

describes the present status of the developmentnon-metallic glass FRC bioactive glass implants.

ucture and material components of

de of reinforcing bers embedded in a polymere glass ber properties tensile strength and elon-break partly control the reinforcing capacity ofn polymers. However, several other factors suchentation and length, ber adhesion to the poly-, and volume fraction of bers in the polymer

contribute to the strength of the composite [19].aterial selection, through composite fabricationd especially correct design, enables the utiliza-

in applications where high static and dynamicre required. In implant applications, bers have

as continuous unidirectional bers or bidirec-ic type arrangements according to the loading

Anisotropicity of continuous unidirectional bers use in applications where direction of load is notannot be predicted, but then continuous unidirec-s provide the highest possible reinforcing efciency

factor) against the known direction of stress [20].rthopedic implants, which are under develop-anufactured using continuous unidirectional bers

ntinuous bidirectional bers are utilized in calvar-s (Figs. 1 and 2).

in matrix

stic and thermoset resins are used in FRC implants.of thermoplastics with biomedical applicationsylene (PE), polyetheretherketone (PEEK), polyac-nd polyurethane (PU). Examples of thermosetsutilized as biomaterials are epoxy polymer, bis-dimethacylate (Bis-GMA), and triethyleneglycoldi-late (TEGDMA) copolymer. Methacrylated dendriticave been tested also as resin matrix for biomedical

d e n t a l m a t e r i a l s 3 1 ( 2 0 1 5 ) 371381 373

Fig. 1 Schber-reinfoparticles of

FRCs with glinking dencompared trials used iTable 1.

Resin mtact to the dissolved fing the hydsilane coupof thermosto bers careinforcing[23,24].

Polymerresins is bation of the or by increaversion degcan be achimonomer cual monompolymer [27glass transithermal enunreacted and react w

Scht wi

ndwng boematic drawing of the structure ofrced composite oral implant, which contains

bioactive glass in the bone contacting surface.

Fig. 2 implanthe saallowiood success [21,22]. Thermosets exhibit high cross-sity, which makes them stiffer and more fragileo thermoplastics. Mechanical properties of mate-n implants and properties of bone are presented in

atrix for the reinforcing bers is cured in con-reinforcing glass bers (thermosets), or melted oror impregnation of bers (thermoplastics). By siz-roxyl group covered surface of glass bers withling agent and by using monomer resin systemet resin, the chemical adhesion of polymer matrixn be obtained. In melted thermoplastics, however,

bers are attached only physically to the surface

ization reaction of monomer systems of thermosetsed on free radical (vinyl) polymerization. Initia-polymerization is made by radiation of blue lightsing temperature, resulting to the monomer con-ree of 6065% by light activation only, while 8590%eved in post-polymerization by heat [25,26]. Higheronversion reduces the quantity of leachable resid-ers and thus improves biocompatibility of the]. Optimal post-curing temperature is close to thetion temperature of the polymer, in which enoughergy is available to create free volume, enablingcarboncarbon double bonds to form free radicalsith each other [25].

2.2. Rei

Reinforcingsorbable glglass) andborosilicatebers. E-glmatrix comronments. bioactive g(

374 d e n t a l m a t e r i a l s 3 1 ( 2 0 1 5 ) 371381

Table 1 Mechanical properties of biomaterials andrelated ha

Material

PolymersPolyethylenPolyetherePolyacetal PolyurethaPolymethyPolytetrauPolyethylenBis-GMA-TFiber-reinfoPEEK-carboGlass ber/

UnidirecBidirectio

MetalsStainless sCobalt-chrTitanium a

Hard tissuCortical boCortical boCancellousEnamel Dentin

a Polymersb Flexural m

Table 2 bers [2913-93 [79

Compone

SiO2Al2O3CaO MgO B2O3K2O Na2O Fe2O3P2O5

effects of glass corrotion, the sttype of attture and tiber may bmetal oxiddrawn frommost suitaare drawn glass formiber surfacwork and may be elim

bers. In an acidic environment, incongruent dissolution fromthe ber surface leads to differences in the surface and interior

sitio FRCNa2O

SiO. Becstems reaoduct. Thum

den strestem

record tissues [28,76,77].

Modulus(GPa)

Tensilestrength(MPa)

e (PE) 0.9 35therketone (PEEK)a 8.3 139(PA) 2.1 67ne (PU) 0.02 35lmethacarylate (PMMA)a 2.5 59oroethylene (PTFE) 0.5 28e terepthalate (PET) 2.8 61EGDMA copolymera 8.0 52rced compositesn/graphite berBis-GMA-TEGDMA

compodentalto 1% systemabilitythis syFor thiby intrcontenaluminused intensilethe syof thetional (60 vol%) 20 1200b

nal (45/45) (60 vol%) 8 400b

teel 190 586omium alloy 210 1085lloy 116 965

esne (longitudinal) 17.7 133ne (transversal) 12.8 52

bone 0.4 7.484.3 1011.0 39.3

have been used as matrix polymer for FRC implants.odulus and exural strength.

Nominal composition (wt%) of E and S glass] and bioactive glasses 45S5, S53P4 [78], and].

nt Type of glass

E S 45S5 S53P4 13-93

5355 6265 45 53 531416 2025 2024 24.5 20 202024 1015 569 01.2

d e n t a l m a t e r i a l s 3 1 ( 2 0 1 5 ) 371381 375

interfacial stresses and strains between the implant and bonemore evenly than, for example, titanium implants. Further,using FRCsof corrosionanoparticimplant anbearing arexation devrisk of debr

Thermoof dimethathe potentmonomersIn contrasmonomer good biocoperatures wrisk of residbeen demomonomersand less cy

Biologicdimethacryand animaity. E-glasswithout rein broblaanother stuwere harveand on comCell growthinvestigateactivity, osmaximal awere obsermarkers (othat the faafter sevenwas observincreased mproductionration of osto titaniumcell matura

3. Bio

Bioactive sgrafting mformation, of the inteexplained cglass surfaThe biologiattachmenitor cells. Tsurface depthe surfacesolution ra

Schematic drawing of the dissolution of bioactiven bone.

d knowledge of these reactions is a key to selectingve glasses as components in FRC.

rst bioactive glasses consist of four oxides only: SiO2main component (around 4550 weight%), around 20%

and Na2O, and a few percent of P2O5. The choice ofmpositions was ingenious in several aspects. Firstly,active glasses consist of elements that are present ately high concentrations in the body, thus minimizingk of rejection by the tissue. Secondly, low silica glassess the bioactive glasses have poor chemical durabilitytral to slightly alkaline solutions (pH of blood plasma45). The reactions at the bioactive glass surface startiately after implantation in the tissue. When immersed

od plasma at 37 C, the glass primarily releases the bonded glass network, modifying alkalis and alkaline

via rapid ion exchange with the H+ from the uid. Thehange leads also to an increase in the pH of the interfa-lution. The higher pH again leads to attack of the silicark leading to release of silica as Si(OH)4 into the solutionrmation of silanols, SiOH at the glass surface. In thetep, silanols condensate and repolymerize at the glasse. All these steps lead to formation of a silica-rich layerglass surface (Fig. 3). In the subsequent steps, calciumosphate from the solution, and migrating from the bulkform rst amorphous hydroxyapatite, Ca10 (PO4)6(OH)2en crystallize at carbonate substituted hydroxyapatite(HA) at the glass surface (Fig. 3). This HA layer is instead of metal implants eliminates formationn products and release of metal ions and metalles, which may predispose aseptic loosening of thed unwanted tissue reactions. When used in loadas, tribological properties of the composites andices must be optimized to eliminate any potentialis formation from the implant.set polymer FRC, made of epoxy polymers andcrylate polymers, has been criticized regardingial toxic and sensitizing (allergic) effects of its, which are present as residuals in the FRC [34,35].t, thermoset polymers made of dimethacrylatesystems of Bis-GMA and TEGDMA have shownmpatibility after polymerization at elevated tem-ithout presence of oxygen, although potentialual monomer effects have been discussed. It has

nstrated that hydroxylated metabolites of residual of Bis-GMA were non-mutagenic, non-estrogenictotoxic than their parent monomers [36].al testing of E-glass containing FRC withlate thermoset polymer matric by cell culturesl testing have shown acceptable biocompatibil-

bers having silane containing surface sizingsin matrix have shown no signs of cytotoxityst or osteoblast cell culture studies [3739]. Indy, rat bone-marrow derived osteoblast-like cellssted and cultured on experimental FRC platesmercially pure titanium plates as control [40].

and differentiation kinetics were subsequentlyd by evaluating proliferation, alkaline phosphataseteocalcin, and bone sialoprotein production. Thelkaline phospatase activities on FRC and titaniumved after three weeks. Expression of osteoblasticsteocalsin and sialoprotein production) indicatedstest osteogenic differentiation took place on FRC

days. In contrast, a slower differentiation processed on titanium than on FRC, as was conrmed byRNA expression of ostecalsin and sialoprotein

. It was concluded that the proliferation and matu-teoblast-like cells on FRC appear to be comparable. In addition, presence of bioactive glass enhancedtion.

active glasses

ilicate glasses were originally designed as boneaterials, which do not induce brous capsulebut bond directly to the living tissues. Formationrfacial bonding between the glass and tissue isommonly as a series of reactions starting at the

ce followed by a series of biological reactions [41].cal reactions include adsorption of growth factors,t, proliferation, and differentiation of osteoprogen-he different reaction steps taking place at the glassend mainly on the glass composition but also on

topography, surface area of glass to volume oftio, and ow of the uid along the glass surfaces.

Fig. 3 glass i

Detailebioacti

Theas the of CaOthe cothe biorelativthe rissuch ain neu7.357.immedin blolooselyearthsion exccial sonetwoand fonext ssurfacat the and phglass, and thlayer

376 d e n t a l m a t e r i a l s 3 1 ( 2 0 1 5 ) 371381

compatible with the biological apatite and provides an inter-facial bonding between the material and tissue [41]. Today,materials, are commo

Formatiregarded asgel like stration sitescompatiblehydroxyapalayer formaa biocompaHydroxyapof bioactiveHydroxyapas well as oregions surers containdissolving ftion on biocreported atpolymers a

Today, inknown to senhancing ion dissoluconcentrataffects the [5054].

Several bioactive glpolymers. Msurroundinconductivedeal with dscaffolds inscaffold thultimately solve and boral, and opolymers aglass is thotion [56]. Defrom the gl

When utration of tgive the deentrapped extracellularapidly enoions, whichfunctions tof bone. Abe varied wbe tailoredglasses 45Sin biopolymS53P4 are received thmedical de

Ins one-1,

/min

nd Sainl

to alsed bsitios haver coand a optof 45f freuffersamphss for

phitioneasesS53P

the to 45S5 suggests that the calcium concentration has notd values needed for precipitation yet. Clearly lower val-r all ions are shown for glass 13-93, while the E-glasssition is practically inert by showing only some verynitial dissolution. Finally, the pH values of the solutions

the dissolution trends; the highest initial dissolu-r 45S5 and clearly lower values for S53P4 and 13-93.ssolution proles in Fig. 4 clearly show that the glassomposition controls the initial and the overall dissolu-tes. Although glass 45S5 gives rapid initial dissolution,ormation of hydroxyapatite at the particle surfaces maythe ion release rate at longer times. Thus, S53P4 maynterest to satisfy a critical concentration of a speciceasing from the glass. The particle size of the glasses

the dissolution; the smaller the particles, the highercentration. For example, using bioactive glasses as thin

uous bers in a polylactide composite gave rapid dis-n due to the high surface area and modied surfacesition as compared to the bulk glass [59].which are able to form HA layer at their surfacenly termed as bioactive.on of the silica gel and the HA layer are generally

essential characteristics of bioactive glasses. Theucture of the silica layer provides exible nucle-

for apatite, with a size in the nanometre scale with the biological apatite crystals [42]. However,tite precipitation without extensive silica-richtion in vitro has been reported also at the surface oftible glass in close vicinity to bioactive glass [43].atite is known to also form in vitro on a composite

glass bers and a non-degradable polymer [44].atite formed on the bers within the composite,n the surface of the polymer of the composite inrounding the bers. Interestingly, these halo lay-ed silicon, calcium, and phosphorus. Thus, the ionsrom the bioactive glasses may induce layer forma-ompatible surfaces. Similar halo effect in vitro was

surfaces of composites consisting of biodegradablend bioactive glass spheres or particles [4547].organic ions dissolving from bioactive glasses aretimulate the osteogenesis and angiogenesis, thusregeneration of bone tissue [48,49]. In addition, thetion from the bioactive glasses changing the ionion and increasing the pH of the interfacial solutionviability of several anaerobic and aerobic bacteria

studies report developing composites in whichass particles or bers are used to reinforce organicoreover, the bioactive glass, when exposed to the

g extracellular uids, gives the composite osteo- and osteoinductive properties [55]. Most studiesevelopment of highly porous temporary templates,

which the organic polymer is bioresorbable. Theus allows three-dimensional growth of bone, andboth the bioactive glass and the polymer will dis-e replaced by new tissue. In contrast, the cranial,rthopedic FRC implants contain biostable organicnd glass bers. In such structures, the bioactiveught to provide osteoinduction and osteoconduc-pending on the implants design, the ions releasedass may give antimicrobial effects.sed in the FRC implants, composition and concen-he bioactive glass should be optimized carefully tosired bioactivity. If used as particles, they must bewithin the FRC layers while being exposed to ther uids. Optimally, the bioactive glass dissolvesugh to release critical concentrations of inorganic

activate and stimulate the bodys own cellularo anchor the implant via ingrowth and ongrowths the oxide composition of bioactive glasses canithin wide ranges, their ion dissolution rate can

for controlled ion release. Melt-derived bioactive5, S53P4, and 13-93 have been studied frequentlyer composites. At present, these glasses 45S5 and

the only melt-quenched compositions that havee US Food and Drug Administration acceptance forvices to be used inside the human body. Because

Fig. 4 glassepropan0.2 ml

45S5 aused minally been ucompoglassepolymP, Ca, plasmticles ow odiol)-bof the the gratrationcalciumIn addSi incrGlass for allpared reacheues focompoearly iconrmtion foThe dioxide ction raearly faffect be of iion relaffectsthe concontinsolutiocompouence of initial ion dissolution from bioactive the pH of TRIS (2-amino-2-hydroxymethyl-3-diol)-buffered solution at 40 C. Fluid ow rate, particle size 300500 m.

53P4 easily crystallize in glass fabrication, they arey as particles. However, 13-93 was developed orig-low drawing of continuous bers, and thus it hasoth as bers and particles in composites. The oxidens of the glasses are given in Table 2. All thesee been reported to induce bioactivity to organicmposites. Fig. 4 shows the initial dissolution of Si,Na, measured with ICP-OES (inductively coupledical emission spectrometry) from 300500 m par-S5, S53P4, and 13-93 in a continuous 0.2 ml/minsh TRIS (2-amino-2-hydroxymethyl-propane-1,3-ed solution at 40 C [57,58]. The initial dissolutione ions from particles also of E-glass is indicated in

(Fig. 5ad). Glass 45S5 shows the highest concen- all but phosphate, suggesting that formation ofosphates starts rapidly at the particles surfaces., the concentration of Na is very high, while that of

rapidly to values that indicate a level of saturation.4 also shows relatively high initial concentrationsions. The higher phosphate concentration com-

d e n t a l m a t e r i a l s 3 1 ( 2 0 1 5 ) 371381 377

a b

c

Fig. 5 Dis3-diol)-buff

When uof the partdense commay lead ting bioactilayer retardthe polymethe additiorelease ratethe implanglass compthe access oglass to ind

4. Im

Numerous explore bioof those excles have bor incorporstructural dtive glass those madeimplants hdsolution of (a) Na, (b) Ca, (c) Si and (d) P from bioactive glasses inered solution at 40 C. Fluid ow rate 0.2 ml/min, particle size 30

sing bioactive glasses in composites, the adhesionicles or bers also affects the dissolution rate. Inposites, formation of capillaries at the interfaceso enhanced dissolution of the glass [47]. Coat-ve glass particles or ber with a suitable sizings the dissolution and increases the adhesion tor [60,61]. Thus, depending on the FRC structure,nal coating may help in controlling the initial ion

from the glasses and thus aid osseointegration oft. FRC implant porosity, uid ow rate, bioactiveosition, concentration, and particle size, as well asf the particles to uid, control the capability of theuce osteoinduction and osteoconduction.

plant designs preclinical studies

animal experiments have been carried out tological responses to E-glass FRC implants. In manyperimental FRC materials, bioactive glass parti-een embedded in the surface of the FRC implant,ated inside the implant construction. There areifferences in the implants made of FRC and bioac-for the lamellar cranial bone applications, and

for oral and orthopedic applications in which theave to withstand higher mechanical loads. Cranial

implants hfor free painner laminof implantother autolfactors, intinteract wiin the applto withstanof continuoglass are in(Fig. 2). Exptive isles onosteogenestion proces

FRC biical animafor orthopeneck applicial defect mfor use as lstrength anwith local to test the made of unface was c TRIS (2-amino-2-hydroxymethyl-propane-1,0500 m.

ave sandwich structure, where there is a spacerticles of bioactive glass between the outer andates (Fig. 1). Mechanism of function of this kind

is based on absorption of blood and cells withogous bone forming components, such as growtho the interlaminate space where they are able toth particles of bioactive glass. On the other hand,ications where the implant is designed primarilyd a higher load, i.e. they are made predominantlyus unidirectional bers, the particles of bioactivecorporated in the surface of the FRC implant onlyosed particles of bioactive glass form osteoconduc-

the implant surface, which are actively promotingis and guiding new bone formation by surface reac-ses of BG particles.oactive glass implants have been tested in preclin-l tests for head and neck applications as well asdics and oral implantology applications. Head andations have been tested with critical size calvar-odel with rabbits [27,62]. FRC have the potential

oad-bearing dental and orthopedic implants if thed elastic modulus of FRC implant can be matchedrequirements. An animal study was carried outin vivo performance of novel orthopedic implantsidirectional glass FRC bers [14]. The implant sur-overed with particles of bioactive glass. Control

378 d e n t a l m a t e r i a l s 3 1 ( 2 0 1 5 ) 371381

implants were made of surface-roughened titanium. After ahealing period, the femurs were harvested and analyzed byradiographraphy) imarecovery wnal analyfractures inanalysis deof the titanconsequentime of theretrieved fethe groupsreturned timplants sadverse tis

Most coof specic sosseointegrical modior acid etcincrease imlogically acbeen showhave been results sugare adequatant role inare known response. Hremain actand fabricathe outer ican be embufacturing used in pabone bondbers, whetial to chancoagulation

Osseoinconstant bobution of loby the prothe implanthe highestimplant anmanufactuto distributcortical bonloads [67]. Itributed evhas good padvantage tive for tradresist mechimplant alsThreads oftionally orisufcient s

conditions [6]. In clinical environments, particles of bioac-tive glass on FRC implants conduct bone formation along the

implce. I

bos [69ive mempt

prepl toointraetallhe hh meC, o

nsidet dagivaltatio

sing of frents

leve thaed suival

ic pro imperal,ed by

Fu

teriaradaue enl exper co

can bediciber t kna thn altg auts [aps tly uonta

bioay, exand liniccicate bmec

in lxten. Alsy, torsional testing, micro-CT (computer tomog-ging, and hard tissue histology. The functionalas unremarkable in both groups, although thesis revealed two healed undisplaced peri-implant

the femurs with FRC implants. Finite elementmonstrated differences in stress-shielding effectsium and FRC implants, but the expected biologicalces did not become evident during the follow-up

animal study [14,68]. Biomechanical testing of themurs showed no signicant differences between. The torsional strength of the xed bones hado the level of contralateral intact femurs. Bothhowed ongrowth of intramedullary new bone. Nosue reactions were observed.mmercially available oral implants have some kindurface treatment, which enables better and fasteration. Surface treatments involve only topograph-cations with the means of air-particle abrasionhing or combination thereof. These treatmentsplant surface area, but as such they are not bio-tive. In many studies, calcium phosphates haven to improve osseointegration. Various methodsdeveloped for implant coatings and currently thegest that the quality and thickness of such coatingste. It is clear that surface chemistry plays an impor-

the osseointegration process. Ions such as uorideto improve bone formation and enhance osteoblastowever, it is not known how long implant surfacesive after initial healing process [63]. FRC structuretion process offer unique possibilities for tailoringmplant surface zone. Biologically active materialsedded in the composite structure during the man-process. Bioactive glasses, for example, have beenrticulate form on the implant surface to enhanceing. Interestingly it has been shown that E glassn exposed on the implant surface, have the poten-ge surface charge and enhance, for example, blood

process [64,65].tegration is a dynamic process, which includesne remodeling toward mechanical loading. Distri-ading forces into bone tissue is dictated primarilyperties of an implant material and the design oft as such. In the case of titanium oral implants,

mechanical stress concentrates on the neck of thed on the top of screw threads [66]. Many implantrers have introduced implant designs which aime the load on the marginal bone in a manner thate can be maintained even under extensive occlusaln the case of FRC implants, mechanical load is dis-enly to the surrounding bone structure [68], whichotential for maintaining bone. This is an obviousexplaining why FRC offers an interesting alterna-itional titanium implants. Unidirectional bers cananical loading, but the strength of screw type oralo depends also on the strength of implant threads.

FRC implants have been reinforced with bidirec-ented ber fabrics, which have proven to providetrength against mechanical loading in laboratory

entire interfaformedthreadexcess

Attcan benaturanium, and mover, tthroug[72]. FRout cowithou

Ginimplanincreain caseabutmTissuelogicalnot neof gingesthetof FRCin genadjust

5.

Biomabiodegin tissclinicapolymwhichtive mglass Currenthe ideoffer aof usinimplanbone presenglass ctainingsurgerto expterm cfor speadequthe biormedused ementsant surface, which strengthens the implant-bonen the case of fully osseointegrated implants, newlyne structure lls the space between the implant71] and protects the FRC implant threads fromechanical loads.s to make oral implants or implant abutments thatared in the oral cavity on a similar manner with

th have not been very successful. In the case of tita-oral preparation of implant abutments is difcultic debris is released into surrounding tissues. More-eat generated into the surrounding bone structuretal can lead to bone necrosis and loss of an implant

n the other hand, is relatively easy to prepare with-rable heat generation to use for crown abutmentsmaging the surrounding bone or gingival tissues.

attachment starts to form immediately uponn on oral implant surface [73]. There has been anconcern about the stability of gingival attachmentequent disconnection and reconnection of implant

during the restoration phase of treatment [74,75].l implants are, in this consideration, far more bio-n bone level implants. Tissue level implants dobgingival implant manipulation. However, in case

retraction or too big misalignment of will causeblems as implant neck becomes visible. One piece

lant has the same benets as tissue level implants but in case of visible implant margin, FRC can be

normal tooth preparation process.

ture direction of research

l researchers have put a lot of effort into developingble polymer based materials, which could be usedgineering scaffolds and implants. However, theirloitation is still very limited. Biostable, bioactivemposites offer an interesting group of materials,e used in a wide range of treatments in reconstruc-ne and dentistry. One example of such materials isreinforced composites containing bioactive glass.owledge obtained from clinical studies supportsat bioactive ber reinforced cranial implants canernative route for cranial reconstructions insteadtologous bone aps or bulk polymer and metal

13,16]. Surgical site infections and resorption ofare causing the most frequent complications in thesed cranioplasties. Although glass FRC, bioactiveining implants (glass ber reinforced implants con-ctive glass particles), have good potential in cranialtensive in vitro and in vivo research is still neededthe areas of indications. Evaluation of their long-al outcomes and tailoring of the implant designs

applications is needed urgently. Besides the knowniocompatibility and bone bonding properties withhanical properties, all requirements have to be con-ong term clinical trials before glass FRC can besively in oral implant and orthopedic implant treat-o, question of potential estrogenic effect of certain

d e n t a l m a t e r i a l s 3 1 ( 2 0 1 5 ) 371381 379

resin systems deriving from bis-phenol A/bis-GMA needs to beanswered [8mize implatraumatologlasses is wabout the aon a molecrial interaccomposite

Acknowle

Authors exthe BioCitybiomateriaimplant restion (TEKES(Grant: NEWsity Hospita

r e f e r e n

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Novecons38.neybumamplijury artinhackllowimplitientusis

intenmpoplanead llittuatinlingapenchchniljaneethacd de05;16usa Sne dmpoater Rsen yondchnoatinlie effoperher Cutzfeantitd in 00;28in SHodulurinkaring usa Sonomotopi Matssilaexuraater 2erem: Ehreitorsasskkerrstr

E-glaysico0,81]. Therefore, more research is required to opti-nt geometries for oral implantology as well as forgy and orothopaedics. Surface kinetics of bioactiveell documented, but there is still very limited datactual biological mechanisms of tissue integrationular level. Deep understanding of tissue biomate-tions would aid in developing strong and effectivematerials for reconstructive medicine at large.

dgements

press their gratitude to the researcher team of Turku Biomaterials Research Program (www.

ls.utu.) and principal nancing partners of the FRCearch: Finnish Agency for Technology and Innova-), Academy of Finland and European CommissionBONE NMP3-CT-006-026279-2) and Turku Univer-l.

c e s

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Fiber glassbioactive glass composite for bone replacing and bone anchoring implants1 Introduction2 Structure and material components of FRC2.1 Resin matrix2.2 Reinforcing fibers2.3 Biological considerations

3 Bioactive glasses4 Implant designs preclinical studies5 Future direction of researchAcknowledgementsReferences