implant s

dental mater ials 2 3 ( 2 0 0 7 ) 844854

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Review

Surfa talimpla

L. Le Guehennec, A. Soueidan, P. Layrolle , Y. AmouriqInserm U791, LIOAD, Osteoarticular and Dental Tissue Engineering, Faculty of Dental Surgery,1 Place Alexis Ricordeau, 44042 Nantes cedex 1, France

a r t i c

Article histor

Received 9 N

Received in

Accepted 20

Keywords:

Osseointegr

Dental impl

Surface rou

Nano-sized

Biomimetic

coating

Contents

1. Intro2. Chem3. Surfa

3.1.3.2.3.3.3.4.

CorresponE-mail a

0109-5641/$doi:10.1016/l e i n f o

y:

ovember 2005

revised form 9 June 2006

June 2006

ation

ants

ghness

topography

calcium phosphate

a b s t r a c t

The osseointegration rate of titanium dental implants is related to their composition and

surface roughness. Rough-surfaced implants favor both bone anchoring and biomechanical

stability. Osteoconductive calcium phosphate coatings promote bone healing and appo-

sition, leading to the rapid biological xation of implants. The different methods used

for increasing surface roughness or applying osteoconductive coatings to titanium dental

implants are reviewed. Surface treatments, such as titanium plasma-spraying, grit-blasting,

acid-etching, anodization or calcium phosphate coatings, and their corresponding sur-

face morphologies and properties are described. Most of these surfaces are commercially

available and have proven clinical efcacy (>95% over 5 years). The precise role of surface

chemistry and topography on the early events in dental implant osseointegration remain

poorly understood. In addition, comparative clinical studies with different implant surfaces

are rarely performed. The future of dental implantology should aim to develop surfaceswith

controlled and standardized topography or chemistry. This approach will be the only way to

understand the interactions between proteins, cells and tissues, and implant surfaces. The

local release of bone stimulating or resorptive drugs in the peri-implant region may also

respond to difcult clinical situations with poor bone quality and quantity. These therapeu-

tic strategies should ultimately enhance the osseointegration process of dental implants for

their immediate loading and long-term success.

2006 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

duction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 845ical composition of the surface of dental implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 845ce roughness of dental implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 845Roughening of implants by titanium plasma-spraying . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 846Roughening of implants by grit-blasting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 846Roughening of implants by acid-etching. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 847Roughening of implants by anodization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 848

ding author. Tel.: +33 2 4041 2916; fax: +33 2 40 08 37 12.ddress: [email protected] (P. Layrolle). see front matter 2006 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.j.dental.2006.06.025ce treatments of titanium dennts for rapid osseointegration

dental mater ials 2 3 ( 2 0 0 7 ) 844854 845

4. Osteoconductive calcium phosphate coatings on dental implants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8495. Future trends in dental implant surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 849

5.1.5.2.5.3.

6. ConcAcknRefer

1. Int

In the pastdures has imillion denoral implanetry and sulong-term sassociatedfor a succestitanium imDirect boneical for thestages of ostors and paof the impltation. Thetissue capsdoes not enclinical failresponse isan intervenas osseointbe a prereqlong-term stitanium imface compoeters that mosseointegr

This revthat aim toThe physicdiscussed iManufactusurfaces wness. Howefor implant

2. Chdental im

The cheminium impland surfaccritical forimplants aror titaniumious degreeSurface roughness at the nanoscale level. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 849Biomimetic calcium phosphate coatings on titanium dental implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 850Incorporation of biologically active drugs into titanium dental implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 850

lusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 851owledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 851ences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 851

roduction

20 years, the number of dental implant proce-ncreased steadily worldwide, reaching about onetal implantations per year. The clinical success ofts is related to their early osseointegration. Geom-rface topography are crucial for the short- anduccess of dental implants. These parameters arewith delicate surgical techniques, a prerequisitesful early clinical outcome [1]. After implantation,plants interact with biological uids and tissues.apposition onto the surface of the titanium is crit-rapid loading of dental implants. After the initialseointegration, both prosthetic biomechanical fac-tient hygiene are crucial for the long-term successants. There are two types of response after implan-rst type involves the formation of a brous softule around the implant. This brous tissue capsulesure proper biomechanical xation and leads to

ure of the dental implant. The second type of bonerelated to direct boneimplant contact without

ing connective tissue layer. This is what is knownegration. This biological xation is considered touisite for implant-supported prostheses and theiruccess. The rate and quality of osseointegration inplants are related to their surface properties. Sur-sition, hydrophilicity and roughness are param-ay play a role in implanttissue interaction and

ation.iew focuses on the different surfaces and methodsaccelerate the osseointegration of dental implants.al and chemical properties of implant surfaces aren relation to their biological and clinical behavior.rers of dental implants have developed a variety ofith different compositions and degrees of rough-ver, there is controversy as to the optimal featuressurfaces regarding osseointegration kinetics.

emical composition of the surface ofplants

cal composition or charges on the surface of tita-ants differ, depending on their bulk compositione treatments. The composition and charges areprotein adsorption and cell attachment. Dentale usually made from commercially pure titaniumalloys. Commercially pure titanium (cpTi) has var-s of purity (graded from 1 to 4). This purity is

characterized by oxygen, carbon and iron content. Most den-tal implants are made from grade 4 cpTi as it is stronger thanother grades. Titanium alloys aremainly composed of Ti6Al4V(grade 5 titanium alloy) with greater yield strength and fatigueproperties than pure titanium [2].

The surface chemical composition of titanium implantsalso affects the hydrophilicity of the surface. Highlyhydrophilic surfaces seem more desirable than hydropho-bic ones in view of their interactions with biological uids,cells and tissues [3,4]. Contact angle measurements give val-ues ranging from 0 (hydrophilic) to 140 (hydrophobic) fortitanium implant surfaces [3,5,6]. In a recent animal study,Buser et al. [3] found that a hydrophilic SLA surface gavehigher bone-to-implant contact than regular SLA. Neverthe-less, previous in vivo studies performed by Albrektsson andco-workers [7,8] failed to demonstrate higher osseointegrationusing hydrophilic surfaced dental implants.

3. Surface roughness of dental implants

There are numerous reports that demonstrate that the surfaceroughness of titanium implants affects the rate of osseointe-gration and biomechanical xation [9,10]. Surface roughnesscan be divided into three levels depending on the scale of thefeatures: macro-, micro- and nano-sized topologies.

The macro level is dened for topographical features asbeing in the range ofmillimetres to tens ofmicrons. This scaleis directly related to implant geometry, with threaded screwand macroporous surface treatments giving surface rough-ness of more than 10m. Numerous reports have shown thatboth the early xation and long-term mechanical stability ofthe prosthesis can be improved by a high roughness prolecompared to smooth surfaces [1113]. The high roughnessresulted in mechanical interlocking between the implant sur-face and bone ongrowth. However, a major risk with highsurface roughness may be an increase in peri-implantitis aswell as an increase in ionic leakage [14]. A moderate rough-ness of 12m may limit these two parameters [15].

The microtopographic prole of dental implants is denedfor surface roughness as being in the range of 110m. Thisrange of roughness maximizes the interlocking betweenmineralized bone and the surface of the implant [10,13]. Atheoretical approach suggested that the ideal surface shouldbe covered with hemispherical pits approximately 1.5m indepth and 4m in diameter [16].

The main clinical indication for using an implant witha rough surface is the poor quality or volume of the hostbone. In these unfavorable clinical situations, early and high

846 dental mater ials 2 3 ( 2 0 0 7 ) 844854

Table 1 Surface properties of titanium dental implants

Type of implant Surface roughness (m) Contact angle () References

cpTi Ra=0.220.01a 55.44.1 [5,107]Ti6Al4V Ra=0.230.01a 56.32.7 [5,107]TPS Ra=7.012.09 n.d. [5]SLA Sa=1.150.05 138.34.2 [3]Modied SLA Sa=1.160.04 0 [3]Plasma-sprayed HA coating Ra=1.060.21 57.43.2 [6,108]Biomimetic CaP coating Ra=1.830.64 13.40.17 This work

a Machined and polished surfaces.

bone-to-implant contact would be benecial for allowing highlevels of loading. In the cases of insufcient bone quantity oranatomical limitations, short designed implants with a roughsurface have demonstrated superior clinical outcomes thansmooth susurface rouimplant coother typesdemonstrafaces havewith smootoration hathe superio

Surfacerole in thecells and thducible surto producesurface nanleading toapposition

Variousa rough sunium dentaplasma-sprand anodiz

3.1. Rouplasma-spr

A titaniumproducingsists in injhigh tempe

the surface of the implants where they condense and fusetogether, forming a lm about 30m thick. The thicknessmust reach 4050m to be uniform. The resulting TPS coat-ing has an average roughness of around 7m,which increases

rfacedimeboninip

surfarageomets [2eouphagen reprodce ofic cic aen uA aned b, theinferyapasusrouthan.

Ro

er apblas

Fig. 1 SEMrfaces [17,18]. Numerous studies have shown thatghness in this range resulted in greater bone-to-ntact and higher resistance to torque removal thanof surface topography [10,13]. These reports have

ted that titanium implants with roughened sur-greater contact with bone than titanium implantsher surfaces [9,10]. However, the Cochrane collab-s not found any clinical evidence demonstratingrity of any particular implant surface [19].proles in the nanometer range play an importantadsorption of proteins, adhesion of osteoblasticus the rate of osseointegration [20]. However, repro-face roughness in the nanometer range is difcultwith chemical treatments. In addition, the optimalo topography for selective adsorption of proteins

the adhesion of osteoblastic cells and rapid boneis unknown.methods have been developed in order to createrface and improve the osseointegration of tita-l implants (Table 1). These methods use titaniumaying, blastingwith ceramic particles, acid-etchingation.

ghening of implants by titaniumaying

plasma-spraying (TPS) method has been used forrough implant surfaces (Fig. 1). This method con-ecting titanium powders into a plasma torch atrature. The titanium particles are projected on to

the suthree-at theusingma TPSan avehave simplanendossmacroalso bebe thea soursystemsystemnot being SLobservmodelto behydroxconseneratelyrather[11,26]

3.2.

Anothsists inmicrographs of a titanium plasma-sprayed (TPS) surface (Courarea of the implant. It has been shown that thisnsional topography increased the tensile strengthe/implant interface [11]. In this pre-clinical studyigs, the bone/implant interface formed faster withce than with smooth surface implants presentingroughness of 0.2m.However, particles of titaniumtimes been found in the bone adjacent to these1]. The presence of metallic wear particles froms implants in the liver, spleen, small aggregates ofes and even in the para-aortic lymph nodes haveported [21].Metal ions released from implantsmayuct of dissolution, fretting and wear, and may beconcern due to their potentially harmful local andarcinogenic effects [22,23]. However, the local anddverse effects of the release of titanium ions haveniversally recognized. In a clinical study compar-d TPS implant surfaces, no clinical difference wasetween these two surfaces [24]. In a pre-clinicalpercentage of bone/implant contact was found

ior for the TPS surface than for plasma-sprayedtite-coated implants [25]. Nowadays, there is aon the clinical advantages of implanting mod-gh surfaced implants (in the micrometric range)

using rough plasma-sprayed implant surfaces

ughening of implants by grit-blasting

proach for roughening the titanium surface con-ting the implants with hard ceramic particles. Thetesy of Cam Implants BV, The Netherlands).

dental mater ials 2 3 ( 2 0 0 7 ) 844854 847

Fig. 2 SEM micrographs of a TiO blasted surface (Courtesy of Astratech TiOblastTM, France).

ceramic particles are projected through a nozzle at high veloc-ity by means of compressed air. Depending on the size of theceramic paduced on tichemicallyosseointegrparticles hacalcium ph

Aluminaand producetry of theoften embeeven after ution. Alumifrom the titbeen releasferedwith tchemical hthe excelleical environ

Titaniumtal implantof 25m prange on dblasted surmicroimplament for bimplants inexperimenniumgrit-bhigh clinicaup to 10 yea

studies gave highermarginal bone levels and survival rates forTiO2 grit-blasted implants than formachined turned implants

.nnerrit-blof bchanh titancrecompeselantir biird pts inableyapaonsres

surfabonred temoed weved

Rou

g withertchinangi

Fig. 3 rticles, different surface roughnesses can be pro-tanium implants. The blasting material should bestable, biocompatible and should not hamper theation of the titanium implants. Various ceramicve been used, such as alumina, titanium oxide andosphate particles.(Al2O3) is frequently used as a blasting material

es surface roughness varying with the granulom-blasting media. However, the blasting material isdded into the implant surface and residue remainsltrasonic cleaning, acid passivation and steriliza-na is insoluble in acid and is thus hard to removeanium surface. In some cases, these particles haveed into the surrounding tissues and have inter-he osseointegration of the implants.Moreover, thiseterogeneity of the implant surface may decreasent corrosion resistance of titanium in a physiolog-ment [27].oxide is also used for blasting titanium den-

s. Titanium oxide particles with an average sizeroduce a moderately rough surface in the 12mental implants. An example of a titanium oxide-face is shown in Fig. 2. An experimental study usingnts in humans has shown a signicant improve-one-to-implant contact (BIC) for the TiO2 blastedcomparison with machined surfaces [28]. Other

tal studies conrmed the increase in BIC for tita-lasted surfaces [12,29]. Other studies have reportedl success rates for titanium grit-blasted implants,rs after implantation [30,31]. Comparative clinical

[32,33]We

that gvaluesbiomesmootforce iwhile[34]. Thtal impnot the

A thconsisresorbhydroxbeen cals areniumhighercompahave dobservis achi

3.3.

Etchinis anotAcid-esizes rSEM micrographs of an SLA surface on a titanium dental implaberg et al. [13] demonstrated with a rabbit modelasting with TiO2 or Al2O3 particles gave similaroneimplant contact, but drastically increased theical xation of the implants when compared tonium. These studies have shown that the torqueased with the surface roughness of the implantsarable values in bone apposition were observedstudies corroborate that roughening titanium den-s increases their mechanical xation to bone butological xation.ossibility for roughening titanium dental implantsusing a biocompatible, osteoconductive and

blasting material. Calcium phosphates such astite, beta-tricalciumphosphate andmixtures have

idered useful blasting materials. These materi-orbable, leading to a clean, textured, pure tita-ce. Experimental studies have demonstrated ae-to-implant contact with these surfaces wheno machined surfaces [35,36]. Experimental studiesnstrated a bone-to-implant contact similar to thatith other blasting surfaces when osseointegration[37].

ghening of implants by acid-etching

h strong acids such as HCl, H2SO4, HNO3 and HFmethod for roughening titanium dental implants.g produces micro pits on titanium surfaces withng from 0.5 to 2m in diameter [38,39]. Acid-nt (Courtesy of Straumann AG, Switzerland).

848 dental mater ials 2 3 ( 2 0 0 7 ) 844854

etching has been shown to greatly enhance osseointegra-tion [40]. Immersion of titanium implants for several min-utes in a mixture of concentrated HCl and H2SO4 heatedabove 100 C (dual acid-etching) is employed to produce amicrorough surface (Fig. 3). This type of surface promotesrapid osseointegration while maintaining long-term suc-cess over 3 years [41]. It has been found that dual acid-etched surfaces enhance the osteoconductive process throughthe attachment of brin and osteogenic cells, resulting inbone formation directly on the surface of the implant [42].In the peri-implant area, woven bone with thin trabecu-lae projecting into the implants, has been described [43].These studies hypothesized that implants treated by dualacid-etching have a specic topography able to attach tothe brin scaffold, to promote the adhesion of osteogeniccells, and thus to promote bone apposition [44,45]. Severalexperimental studies have reported higher bone-to-implantcontact ansurfaces coRecently, ato increastemperaturporous surTPS surfacity of therin adhesiance for texperimenface greatlystandard sa[3].

Anotherimplants inoride ions,has amicrotreatmentand uoridof dental imical surfacein compariimplants alsignicantl[50,51]. Thifurther impimplant su

Nevertheless, chemical treatments might reduce themechanical properties of titanium. For instance, acid-etchingcan lead to hydrogen embrittlement of the titanium, creatingmicro cracks on its surface that could reduce the fatigue resis-tance of the implants [53]. Indeed, experimental studies havereported the absorption of hydrogen by titanium in a biologi-cal environment. This hydrogen embrittlement of titanium isalso associated with the formation of a brittle hybrid phase,leading to a reduction in the ductility of the titanium. Thisphenomenon is related to the occurrence of fracture mecha-nisms in dental implants [53].

3.4. Roughening of implants by anodization

Micro- or nano-porous surfaces may also be produced bypotentiostatic or galvanostatic anodization of titanium instrong acids (H2SO4, H3PO4, HNO3, HF) at high current density

m2)hickeWheidend tlayero-poes my ofrath

s cuectrodizeespophom. A hed tsurfaropocking [55

aniummagen foxideto otummality

Fig. 4 SEM uoOsseoSpeed less bone resorption with dual acid-etchedmpared to machined or TPS surfaces [9,46,47].

cid-etching methods have been improved in ordere cell adhesion and bone neoformation. Highe acid-etching produces a homogeneous micro-face with higher bone-to-implant contact thanes in experimental studies [48,49]. The wettabil-surface has also been proposed to promote b-on. This brin adhesion provides contact guid-he osteoblasts migrating along the surface. Antal study has demonstrated that a hydrophilic sur-improved the bone/implant contact compared tond-blasted and acid-etched implants in minipigs

approach involves treating titanium dentaluoride solutions. Titanium is very reactive to u-

forming soluble TiF4 species. The surface producedrough topography as shown in Fig. 4. This chemicalof the titanium created both a surface roughnesse incorporation favorable to the osseointegrationplants [50,51]. It has been shown that this chem-treatment enhanced osteoblastic differentiation

son with control samples [52]. Fluoridated roughsowithstood greater push-out forces and showed ay higher torque removal than the control implantss chemical treatment may have the potential torove implant anchorage in bone by rendering therface bioactive.

(200A/is to tnium.the oxlines aoxideor nanproductallinitcess issuch aand el

Anobone rtomor[59,60]anodizniumbeen pinterlobondinthe tittion ofhas benium opared

In sthe qu

micrographs of treatment of titanium dental implants in adTM, France).or potential (100V). The result of the anodizationn the oxide layer to more than 1000nm on tita-n strong acids are used in an electrolyte solution,layer will be dissolved along current convectionhickened in other regions. The dissolution of thealong the current convection lines creates micro-res on the titanium surface [5457]. Anodizationodications in the microstructure and the crys-

the titanium oxide layer [58]. The anodization pro-er complex and depends on various parameters

rrent density, concentration of acids, compositionlyte temperature.d surfaces result in a strong reinforcement of thense with higher values for biomechanical and his-etric tests in comparison to machined surfacesigher clinical success rate was observed for the

itanium implants in comparison with turned tita-ces of similar shapes [61]. Two mechanisms havesed to explain this osseointegration: mechanicalg through bone growth in pores, and biochemical,62]. Modications to the chemical composition ofoxide layer have been tested with the incorpora-

nesium, calcium, sulfur or phosphorus [63,64]. Itund that incorporating magnesium into the tita-layer leads to a higher removal torque value com-

her ions [55].ary, surface roughness plays a major role in bothand rate of osseointegration of titanium dental

ride solution surface (Courtesy of Astratech

dental mater ials 2 3 ( 2 0 0 7 ) 844854 849

implants. Highly roughened implants such as TPS or grit-blasted have been shown to favor mechanical anchorageand primary xation to bone. Topographies in the nanome-ter range have been used to promote protein adsorption,osteoblastic cell adhesion and the rate of bone tissue healingin the peri-implant region.

4. Osteoconductive calcium phosphatecoatings on dental implants

Metal implants have been coated with layers of calciumphosphates mainly composed of hydroxyapatite. Followingimplantation, the release of calcium phosphate into the peri-implant region increases the saturation of body uids andprecipitates a biological apatite onto the surface of the implant[65,66]. Thinous proteiment and gimplant is tThe biologifaster withIt is well-reto better clititanium imdue to a supmethodshaspraying, sdepositionplasma-sprdental imp

Plasma-(HA) ceramtemperaturwhere theyPlasma-sprranging froto obtain mthemetalliblasting, w

The plassuch as ththe substrain the comphosphatehave been

tricalcium phosphates (- and -TCP), tetracalcium phos-phate, calcium oxide and amorphous calcium phosphate(ACP) [7375]. Plasma-sprayed HA coatings are usually com-posed of large crystalline HA particles embedded into a highlysoluble amorphous calcium phosphate phase. Moreover, theplasma-spraying technique is not very effective for coatingtiny dental implants with a complex shape.

Plasma-sprayed HA-coated dental implants have also beenassociated with clinical problems [6,7679]. One of the majorconcernswith plasma-sprayed coatings is the possible delam-ination of the coating from the surface of the titanium implantand failure at the implant-coating interface despite the factthat the coating is well-attached to the bone tissue. The dis-crepancy in dissolution between the various phases thatmakeup the coating has led to delamination, particle release andthus the clinical failure of implants [7679]. Coating delamina-

s bema-sts [6ally w

all odHAatededicmetates wts co

Fu

trateort ats. Te routiongs fobiolthe

Sur

emisthess, s

Fig. 5 SEM tingNetherlands layer of biological apatite might contain endoge-ns and serve as amatrix for osteogenic cell attach-rowth [67]. The bone healing process around theherefore enhanced by this biological apatite layer.cal xation of titanium implants to bone tissue isa calcium phosphate coating than without [68,69].cognized that calciumphosphate coatings have lednical success rates in the long-term than uncoatedplants [68,70]. These long-term success rates areerior initial rate of osseointegration [70]. Differentve beendeveloped to coatmetal implants: plasma-putter-deposition, solgel coating, electrophoreticor biomimetic precipitation. However, only theaying coating method has been used for titaniumlants in clinical practice.spraying is a technique in which hydroxyapatiteic particles are injected into a plasma torch at highe and projected on to the surface of the titaniumcondense and fuse together, forming a lm (Fig. 5).ayed coatings can be deposited with a thicknessm a few micrometers to a few millimeters. In orderechanical retention of the coating, the surface of

c implantmust be roughened, e.g. bymeans of grit-hen using this method.ma-spraying method has disadvantages, however,e porosity of the coating and residual stress atte/coating interface, as well as drastic changesposition and crystallinity of the initial calciumpowder [71,72]. Several calcium phosphate phasesobserved in plasma-sprayed HA coatings such as

tion haof plasimplanespecibone.

ForsprayeHA-coorthoptice, avival raimplan

5.

A few sthe shimplansurfacadsorpcoatintion ofcess in

5.1.

The chrole inerthele

micrographs of a plasma-sprayed hydroxyapatite (HA) coas).en reported in dental situations where the efcacypraying is not optimal due to the size of the dental]. Loosening of the coating has also been reported,hen the implants have been inserted into dense

f the above reasons, the clinical use of plasma--coated dental implants is limited. Plasma-sprayedprostheses are nevertheless highly successful ins. Despite their negative reputation in dental prac--analytic review did not show that long-term sur-ere inferior for plasma-sprayed HA-coated dentalmpared to other types of dental implant [78].

ture trends in dental implant surfaces

gies should be considered in order to improve bothnd long-term osseointegration of titanium dentalhese future trends concern the modications ofghness at thenanoscale level for promotingproteinand cell adhesion, biomimetic calcium phosphater enhancing osteoconduction and the incorpora-ogical drugs for accelerating the bone healing pro-peri-implant area.

face roughness at the nanoscale level

try and roughness of implant surfaces play amajorbiological events that follow implantation. Nev-urfaces are often developed using an empirical

surface (Courtesy of Cam Implants BV, The

850 dental mater ials 2 3 ( 2 0 0 7 ) 844854

alciu

approach wfaces currerange of thexact biolothe absencraphy at thand depth,standardizetions betwesurfaces mimplants.

Only aroughnessin a reprodprocessinglithographystudies [80osteoblastitures but ndirectly enment of thmayalso gitive attachselective atof initial he

5.2. Biotitanium de

In order toings (see Smethod insIn this biomphate apatlated body(Fig. 6). In oaqueous so

The rstphosphateinum anodconductedto the formconverted itrochemicabuffered ating directly

le peof coshory [86sec

of caSBFnd gt at. Inanceplanm hleatif cala t

he che htitaano, stanicaurfaitioniumlciumeenphyntina-sprts cogatee deeticFig. 6 SEM micrographs of a biomimetic c

ith in vitro and in vivo tests. Most of the sur-ntly available have random topographywith awideicknesses, from nanometers to millimeters. Thegical role of these features is unknown because ofe of standardized surfaces with repetitive topog-e nano-sized level (e.g. pits with xed diameterslanes with controlled proles). Such controlled ord surfaces might help to understand the interac-en specic proteins and cells. These standardizedight also promote early bone apposition on the

few studies have reported modications to theas well as the chemistry at the nanometer scaleucible manner. Most of these attempts have usedmethods from the electronic industry such asand surface laser-pitting. In vitro experimental

82] have demonstrated that the attachment ofc cells was enhanced on submicron scale struc-ot on smooth surfaces. Well-developed lopodiatered nanometer-sized pores for the initial attach-e osteoblastic cells. These nanometer structuresve the cells positive guidance bymeansof the selec-ment of osteoblasts to the implant surface. Thistachment processmight result in the improvementaling around dental implants.

mimetic calcium phosphate coatings onntal implants

avoid the drawbacks of plasma-sprayed HA coat-ection 4), scientists have developed a new coatingpired by the natural process of biomineralization.imetic method, the precipitation of calcium phos-

ite crystals onto the titanium surface from simu-

possibkindsis veryefcac

Thetationsion ination aimplanditionsto enhthe imtitaniuas nuctions oto formstep, t[89]. Ton theing of nmatrixmechanium sIn addof calcoctacaIt has buble inlike deplasmimplaninvestiies havbiomimuids (SBF) formed a coating at room temperaturerder to accelerate the deposition of coatings fromlutions, several methods have been developed.method involves the electrodeposition of calciumby using a current, a titanium cathode and a plat-e [83,84]. This electrochemical method is usuallyin acidic calcium phosphate solutions and leadsation of brushite coatings which are subsequentlynto apatite by hydrothermal processing. The elec-l deposition performed in simulated body uidneutral pH can produce a carbonated apatite coat-on the titanium surfaces [85]. This method makes

titanium imtitanium dbeen compmodels.

5.3. Inctitanium de

The surfacbone-stimuto enhancethe transfom phosphate coating.

rfect control of the thickness of the deposit on allmplicated surfaces. The time required for coatingt and the process presents high reproducibility and,87].ond method is based on the biomimetic precipi-lcium phosphate on titanium surfaces by immer-. This method involves the heterogeneous nucle-rowth of bone-like crystals on the surface of thephysiological temperatures and under pH con-general, two subsequent steps have been usedthe heterogeneous nucleation of the CaP. First,ts are treated with an alkaline in order to formydroxyl groups on the titanium surface, to serveng points [88]. Others have used high concentra-cium and phosphate in an increasing pH solutionhin layer on the titanium surface. In the secondoating develops under crystal growth conditionseterogeneous nucleation and growth of the CaPnium surface is initiated by the chemical bond--sized clusters, forming an interfacial unstructuredbilized by the presence ofmagnesium ions [90]. Thel stability of the CaP coating requires a rough tita-ce to ensure themechanical stability of the coating., this physiological method broadens the varietyphosphate phases that can be deposited, such asphosphate or bone-like carbonate apatite [88,91].

shown that such biomimetic coatings aremore sol-siological uids and resorbable by osteoclastic cellsmaterials than high temperature coatings such asayed HA [91,92]. The osseointegration of titaniumatedwith biomimetic calciumphosphate has beend in pre-clinical comparative models. These stud-monstrated a higher bone-to-implant contact forcalcium phosphate coatings than for uncoated

plants [69,93]. However, the osseointegration of

ental implants coated biomimetically has not yetared with other surface treatments in pre-clinical

orporation of biologically active drugs intontal implants

e of titanium dental implants may be coated withlating agents such as growth factors in orderthe bone healing process locally. Members of

rming growth factor (TGF-) superfamily, and

dental mater ials 2 3 ( 2 0 0 7 ) 844854 851

in particular bone morphogenetic proteins (BMPs), TGF-1,platelet-derived growth factor (PDGF) and insulin-like growthfactors (IGFdates for thbeen incorpfrom a varis that theand not inadjunction[100]. Thisinserting pprotein. Innot be desi

The sumoleculesporation onates, mighsupport, e.recently thimplants inregion [101limited tostudies havbut only a[102,103]. OHA-coateddronate dearea [1041tained releasurface. Dufor calciumsorptive druthe biomimever, the iddeterminedsity is biph

6. Co

There aredental impcal efcacythese surfaand in vivousing diffeThe exactearly eventpoorly undies with diffuture of dfaces withistry. Thiscell and tisrelease ofimplant regwith poor bgies shouldof dental imsuccess.

Acknowledgements

uthofor, Rue

sseoSlandsmascoscar c

en

lbreksseonsurn mateineerioduserochrhem004;8haoochrespoateragnorope004;1iavaimonvaluareatm003;2arlsslasmmplaennre-trschaeochroneith atudy998;4ennistomach pmplausernueitaniuiniaotfrejortind mabbitennistomcrewurfacecket al. A-1 and 2) are some of the most promising candi-is purpose. Experimental data, inwhich BMPs haveorated into dental implants, have been obtained

iety of methodologies [9499]. The limiting factoractive product has to be released progressivelya single burst. Another possibility may be the

of a plasmid containing the gene coding for a BMPpossibility is limited due to the poor efcacy oflasmids into the cells and the expression of theaddition, overproduction of BMPs by cells mightrable after the bone healing process.rface of implants could also be loaded withcontrolling the bone remodeling process. Incor-f bone antiresorptive drugs, such as biphospho-t be very relevant in clinical cases lacking boneg. resorbed alveolar ridges. It has been shownat a biphosphonate incorporated on to titaniumcreased bone density locally in the peri-implant]. The effect of the antiresorptive drug seems to bethe vicinity of the implant. Experimental in vivoe demonstrated the absence of negative effectsslight increase in dental implant osseointegrationther experimental studies using plasma-sprayeddental implants immersed in pamidronate or zole-monstrated a signicant increase in bone contact06]. The main problem lies in the grafting and sus-se of antiresorptive drugs on the titanium implante to the high chemical afnity of biphosphonatesphosphate surfaces, incorporation of the antire-g on to dental implants could be achieved by usingetic coating method at room temperatures. How-eal dose of antiresorptive drug will have to bebecause the increase in peri-implant bone den-

osphonate concentration-dependent [106].

nclusion

a number of surfaces commercially available forlants. Most of these surfaces have proven clini-(>95% over 5 years). However, the development ofceshas beenempirical, requiringnumerous in vitrotests. Most of these tests were not standardized,

rent surfaces, cell populations or animal models.role of surface chemistry and topography on thes of the osseointegration of dental implants remainerstood. Furthermore, comparative clinical stud-ferent implant surfaces are rarely performed. Theental implantology should aim at developing sur-controlled and standardized topography or chem-approach is the only way to understand protein,sue interactions with implant surfaces. The localbone-stimulating or resorptive drugs in the peri-ionmay also respond to difcult clinical situationsone quality and quantity. These therapeutic strate-ultimately enhance the osseointegration processplants for their immediate loading and long-term

The aland)Zenecaand ONetherHA plathe Migramm

r e f e r

[1] AOei

[2] SP

[3] BCc2

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[13] WHss

[14] Bers acknowledge Straumann AG (Bern, Switzer-providing the SLA samples, Astra Tech (Astrail-Malmaison, France) for providing theTiOblastTM

peedTM samples. Cam Implants BV (Leiden, Thes) is also acknowledged for providing the TPS and-sprayed samples. We also thank Paul Pilet fromopy Centre for SEM pictures and Kirsty Snaith fororrections of the manuscript.

c e s

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Surface treatments of titanium dental implants for rapid osseointegrationIntroductionChemical composition of the surface of dental implantsSurface roughness of dental implantsRoughening of implants by titanium plasma-sprayingRoughening of implants by grit-blastingRoughening of implants by acid-etchingRoughening of implants by anodization

Osteoconductive calcium phosphate coatings on dental implantsFuture trends in dental implant surfacesSurface roughness at the nanoscale levelBiomimetic calcium phosphate coatings on titanium dental implantsIncorporation of biologically active drugs into titanium dental implants

ConclusionAcknowledgementsReferences