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Medicine » Dentistry » "Dental Implantology and Biomaterial", book edited by Mazen Ahmad Jawad Amin Almasri, ISBN 978-953-51-2522-8, Print ISBN 978-953-51-2521-1, Published: August 17, 2016 under CC BY 3.0 license. © The Author(s).

Chapter 6

Treatments to Optimize Dental Implant Surface Topography and Enhance Cell Bioactivity

By Jaume Miranda-Rius, Eduard Lahor-Soler, Lluís Brunet-Llobet, David de Dios and Francesc Xavier Gil
DOI: 10.5772/62682

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Environmental scanning electron microscope micrograph (ESEM) of the surface of dental implants: (A) shotblasted; (B) acid etched [66].
Figure 1. Environmental scanning electron microscope micrograph (ESEM) of the surface of dental implants: (A) shotblasted; (B) acid etched [66].
ESEM micrograph of the sodium titanate surface of the implants treated by shotblasting and thermochemical treatment (two-step treatment) [66].
Figure 2. ESEM micrograph of the sodium titanate surface of the implants treated by shotblasting and thermochemical treatment (two-step treatment) [66].
ESEM images showing: (A) 2S bioactive surface; (B) in vitro nucleation of apatite on 2S bioactive surface; (C) in vitro formed apatite layer on 2S bioactive surface; (D) 2S bioactive surface at higher magnification [67].
Figure 3. ESEM images showing: (A) 2S bioactive surface; (B) in vitro nucleation of apatite on 2S bioactive surface; (C) in vitro formed apatite layer on 2S bioactive surface; (D) 2S bioactive surface at higher magnification [67].
Intraoral radiograph taken 8 years after implant placement—sandblasted, large-grit and acid etched (SLA) surface treatment type. Note the bone crater-like defect around the implant revealing a severe peri-implantitis (Clinical records, Dr. Jaume Miranda-Rius).
Figure 4. Intraoral radiograph taken 8 years after implant placement—sandblasted, large-grit and acid etched (SLA) surface treatment type. Note the bone crater-like defect around the implant revealing a severe peri-implantitis (Clinical records, Dr. Jaume Miranda-Rius).
Peri-implantitis clinical image. Surgical debridement of the granulation tissue around the implant (Clinical records, Dr. Jaume Miranda-Rius).
Figure 5. Peri-implantitis clinical image. Surgical debridement of the granulation tissue around the implant (Clinical records, Dr. Jaume Miranda-Rius).

Treatments to Optimize Dental Implant Surface Topography and Enhance Cell Bioactivity

Jaume Miranda-Rius1, Eduard Lahor-Soler1, Lluís Brunet-Llobet2, David de Dios3 and Francesc Xavier Gil4
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Osseointegration is a biological process in which histological, surgical, infectious factors, biomechanical load, and the choice of biomaterials all play important roles. In the case of dental implants, the success of this process is also influenced by the design, composition, and properties of the implant surface, which may stimulate cell bioactivity and promote osteoblast adhesion. Currently, the raw materials most frequently used in the manufacture of dental implants are titanium, its alloys, and certain ceramic materials such as zirconia. Multiple macroscopic designs incorporating various diameters, lengths, shapes, and types of screw offer different options for specific clinical situations. The characteristics of implant surfaces have aroused great interest, due to their importance in osseointegration. The different methods used to modify surface properties are classified as additive (i.e., impregnation and coating) or subtractive (i.e., physical, mechanical and chemical methods). The surface characteristics of dental implants also have a significant influence on peri-implant microbiota.

Keywords: Dental implant, Titanium, Osseointegration, Surface roughness, Coating, Peri-implantitis

1. Introduction

Over many years, dental implants have been developed and modified in order to achieve an optimal interaction between the body and the implanted material and thus to improve osseointegration and reduce the complications due to colonization of bacterial plaque [1].

Proper integration of the surface of a dental implant with the surrounding bone is essential to ensure the longevity and function of the prosthesis supported by the implant [2]. The cell adhesion between the bone interface and the implant surface is considered the most biologically important stage in the process. This structural and functional integration is influenced by the activity of adjacent cells and by the properties of the implant surface itself.

Some implant surfaces may influence the differentiation and proliferation of osteoblasts and may affect the regulation of the transcription factors responsible for the expression of the genes associated with the formation of the bone matrix. Their use may even shorten the implant integration period [3].

The treatment of a surface can be classified according to mechanical, chemical, and physical processes. In dental implants, the modifications of the outer surface are designed to modify the topography and surface energy. This improves wettability and increases cell growth and proliferation, which eventually accelerates the process of osseointegration [47].

The biocompatibility and roughness of the materials are the key features in the interaction between the tissue and osseointegration [8]. In addition, the surface of dental implants can be significantly increased using suitable modification procedures such as additive or subtractive techniques [9, 10].

2. Biomaterials for dental implants

Currently, the main materials used in the composition of dental implants are commercially pure titanium (cp Ti), Ti alloys, and ceramic compounds.

2.1. Alloys

Titanium (Ti) is a silver-gray, biologically inert transition metal with a high corrosion resistance due to the spontaneous formation of a surface oxide film (3–10 nm thick) which insulates it from the environment [11, 12]. Thanks to its composition and thickness, this oxide layer makes Ti biocompatible. Ti has four grades of purity which are related to the corrosion resistance, ductility, and strength. Grade 1 Ti is the purest and most ductile and has the highest corrosion resistance, but it is also the weakest. Grade 4 Ti is the strongest and has moderate plasticity and is therefore the grade most frequently used in dental implants [13].

Titanium alloys. Manufacturers of dental implants use a specifically designed alloy which has the following composition: 6% aluminum, 4% vanadium, up to 0.25% iron, up to 0.2% oxygen, and 90% Ti [14]. This alloy has a greater corrosion resistance, high resistance to fatigue, and low elastic modulus [11]. Due to the strict mechanical demands on dental implants during chewing, especially in the posterior areas, Ti alloys are preferred to cp Ti [2].

2.2. Ceramic compounds

Zirconia is a highly biocompatible ceramic compound with osseointegration capacity [15, 16]. It possesses ideal physical properties as a biomaterial, with good values of resistance to flexion, hardness, and corrosion resistance. Some authors have reported that zirconia has similar biocompatibility and osseointegration values to Ti [17]. However, other comparisons of the two biomaterials have reported lower osseointegration values for zirconia implants and have attributed these differences to the treatment of the surfaces rather than to the material itself [18].

Zirconia implants, as a substitute for metals, are indicated in the restoration of anterior teeth with aesthetic aims. However, more prospective studies of their survival and long-term stability are required; indeed, some authors still recommend caution with regard to considering zirconia implants [19].

Hydroxyapatite (HA) is a bioceramic used as a surface coating on Ti implants, incorporating calcium phosphates to facilitate prompt osseointegration. HA has excellent biocompatibility, osseoconductive capacity, and satisfactory mechanical properties which make it a good surface biomaterial [20].

Implants with HA coating have demonstrated a faster reduction in early mobility and other potential advantages such as its short-term osseoconductive capacity. However, the rate of long-term survival of these implants is still controversial [2125].

3. Macro-design of dental implants

The macro-design of dental implants determines their stability and their capacity to withstand the functional loads. The length, diameter, shape, and design of the screw are influential factors in the bone–implant interface. In the long term, these features may even determine the implant’s survival.

3.1. Implant length

Implant length is the distance from the prosthetic platform to the apex of the implant. Some authors have reported a lower survival rate for short implants, especially those <7 mm long [26, 27]. Eckert et al. [28], however, noted that the relation between implant length and survival was limited and was only noticeable when implants were <13 mm in length.

The type of bone and the cortical bone anchoring are probably more important factors than the implant length. Nonetheless, the indications of implants with extra short lengths (5–6 mm) should be carefully studied and considered, especially in areas with poor bone quality. Manufacturers are making great efforts to improve these implant surfaces so as to increase the area in contact with the bone and thus improve their prognosis [29, 30].

3.2. Implant diameter

The implant diameter is the distance from the outermost point of the screw to the opposite side. It measures the external dimension of the implant screw and should not be confused with the size of the implant platform.

Implant diameters usually range from 3 to 7 mm to make them compatible with the most sizes of alveolar processes. The choice of diameter depends on both surgical and prosthetic factors. In order to achieve maximum primary stability, the implant should be lodged between the vestibular-lingual/palatal cortical bones. From a biomechanical point of view, wider implants are able to join a larger amount of bone to the implant surface and obtain a higher bicortical anchorage, thus achieving a better distribution of stress in the surrounding bone. Another advantage of large diameter implants is that they can be inserted immediately in failure sites [3133]. Some authors have found that increasing implant diameter by 1 mm increases the surface of bone–implant contact by 35% [34]. However, another parameter to consider is the crestal bone around the implant. According to Misch [35], this bone has a strong influence on the occlusal load; this author hypothesizes that it may be even more important than the length and diameter of the implant itself.

The primary stability of dental implants at the time of surgery has been considered an important factor for integration [36]. Langer et al. recommended large diameter implants to improve primary stability in low-density bones. The authors argue that increasing the diameter increases the bone–implant contact, thereby reducing initial implant mobility [37].

Small diameter implants have been introduced for narrow residual alveolar ridges and for edentulous spaces with small interdental distances. These implants do not include mini-implants, which are used to hold temporary dentures and have diameters <2.7 mm [38]. The main indications for narrow implants are the lower incisors, upper lateral incisors, and the restoration of teeth with residual spaces smaller than 5 mm without any possibility of space recovery or bone regeneration [39]. The main limitation of these implants is their reduced resistance to occlusal loads [40].

3.3. Implant shape

Shape has been one of the most thoroughly studied aspects of implant design. The most current implant systems are solid cylinders with thread; hollow implants are rare today. As for the design of the thread, attempts have been made to increase their self-threading capacity and to reduce heat generation during implantation. These design variations are most often applied in the crestal and apical areas. Some designs have attempted to imitate the natural root with a stepped cylindrical shape in the apical and crestal third of the implant. Some authors note that stepped cylindrical implants achieve better stress distribution and crestal bone load than conical and cylindrical implants [41].

Kan et al. [42] reported that threaded implants provide the best immediate retention. Other studies show that the use of a serrated thread can increase primary stability and that thread geometry plays an important role in the biomechanical properties of the implants [43, 44].

4. Dental implant surface treatments

Currently, the most manufacturers of dental implants are introducing changes in implant surfaces in order to improve the success and quality of osseointegration.

Some studies have noted that with greater surface roughness, the rate of osseointegration, and the biomechanical fixation of Ti implants both increase [45, 46]. The methods used to modify the surface properties can be divided into additive and subtractive. Before certain surface treatments, pretreatment such as grit blasting or polishing may sometimes be indicated to guarantee the absence of contaminations, scratches, and irregularities [47, 48].

4.1. Additive methods

Additive methods supply extra materials to the implant surface, either via coating or via impregnation. Coating involves the addition of a material of variable thickness to the surface of the core material. The techniques used are Ti plasma spraying (TPS), plasma-sprayed HA coating, alumina coating, and biomimetic calcium phosphate (CaP). For its part, impregnation requires the full integration of the chemical material or agent into the Ti core. This is the case of CaP crystals within the TiO2 oxide layer or the incorporation of fluoride ions to the surface [8].

Plasma Spray Coating: The coating process includes the spraying of thermally melted materials on the implant substrates [8]. This technique usually involves a fine layer of deposits such as HA and Ti. The combination of HA coating on Ti alloy substrates offers attractive mechanical properties and good biocompatibility [49]. Plasma spray significantly increases the surface area of the implant by increasing its roughness [50]. Thus, many studies have shown that plasma spray is a good additive method for improving the biomechanical behavior [47, 5155]. Some studies have even described a possible optimization of scar formation and cell proliferation thanks to HA coating [56, 57].

4.2. Subtractive methods

Subtractive techniques are procedures that remove a layer of core material or deform the surface in order to increase its roughness [58]. These methods can be divided into mechanical, chemical, and physical. Removal of surface material using mechanical methods includes shaping/removing, grinding, machining, or grit blasting using physical force. Chemical treatment of Ti alloys using either alkaline or acid solutions is carried out not only to increase the roughness but also to modify the composition and improve the wettability and surface energy [59]. Complementary physical treatment of the coating surface, such as thermal spray and plasma spray, improves the aesthetic appearance of the materials and their performance [8].

Grit blasting is a mechanical subtractive procedure which increases surface roughness by the pressurized projection of particles onto the surface of the implant. The main materials used are sand, HA, alumina, or TiO2 particles. After grit blasting, acid etching is applied to remove the residual particles. Grit blasting is one of the most commonly used surface treatments for increasing the surface roughness of dental implants. However, in itself, it does not accelerate the osseointegration capacity [8, 60] (Figure 1A).


Figure 1.

Environmental scanning electron microscope micrograph (ESEM) of the surface of dental implants: (A) shotblasted; (B) acid etched [66].

Aparicio et al. [61] observed that the increase in the surface roughness of the material induced by blasting in cp Ti was not the only cause of the differences in the electrochemical behavior and corrosion resistance; they also mentioned the compressive residual surface stresses induced by shotblasting.

Commercially, pure Ti is a bioinert material which lacks the ability to establish chemical bonds with surrounding bone. Kokubo et al. [62] demonstrated that the treatment of this Ti with heat and alkali procedures rendered it bioactive. Aparicio et al. [63] observed that the surface of the implant achieved by grit blasting and thermo-chemical treatment improved adhesion and differentiation of human osteoblasts. Gil et al. [64] also observed positive results for this bioactive Ti, although improvements are necessary in order to prevent bacterial colonization. It is important to bear in mind that bacteria have a greater capacity to colonize rough surfaces [8] (Figure 2).


Figure 2.

ESEM micrograph of the sodium titanate surface of the implants treated by shotblasting and thermochemical treatment (two-step treatment) [66].

Some researchers have found that the apatite layers formed on grit-blasted surfaces have a higher adhesion strength to the substrate than plasma-sprayed apatite coatings. They note the potential clinical application of this type of surface treatment in dental implants [65].

The evolution of bioactive surfaces into osseoconductive biomimetic surfaces (Contact Ti) was described by Gil et al. In this process, a CaP layer is obtained on the implant surface by thermo-chemical treatments. This achieves a structure equal to the CaP formed by the mineral content of the bone (HA). This apatite should not be confused with an additive coating; in this case, there is an extremely strong chemical bond and so it is not dislodged by mechanical action. These bioactive implant surfaces significantly reduce the time of osseointegration. The most important mechanisms involved are the protein adsorption capacity, wettability, and an optimized zeta potential which reduces the electrostatic dispersion between particles. Finally, this procedure also aims to increase the kinetics of adhesion, proliferation, and differentiation of osteoblast cells compared to other current surface treatments in order to facilitate bone formation around the implants [6668] (Figure 3).


Figure 3.

ESEM images showing: (A) 2S bioactive surface; (B) in vitro nucleation of apatite on 2S bioactive surface; (C) in vitro formed apatite layer on 2S bioactive surface; (D) 2S bioactive surface at higher magnification [67].

Anodic oxidation is an electrolytic process used to strengthen and increase the thickness of the natural oxide layer. This passivation technique manages to turn a smooth Ti surface into a tubular nanostructure with diameters below 100 nm [69]. Some authors suggest that by modifying the parameters of voltage, current density, and chemistry of electrolytes, it is possible to control the physical and chemical properties of the implant surfaces, the spacing, and the diameter of nanotubes [70]. Anodization forms pillar-like nanostructures with tunable size on the surface of Ti and deposits long nanotube arrays (10 microns), thus improving the cell bioactivity [71].

Acid treatment is a chemical subtractive method that cleans the surface of the metal and modifies its roughness. Hydrofluoric acid (HF), nitric acid (HNO3), and sulfuric acid (H2SO4) are commonly used, either alone or in combination [8]. This technique obtains a homogeneous surface roughness for different sizes and shapes. The acid-etched surfaces facilitate the process of osseointegration by increasing the capacity of cell adhesion and bone formation [7274]. Furthermore, the surface roughness of Ti also determines the stability of the bone formation and resorption at the interface with the implant [75]. The dual acid etching treats the surface by chemical means or by acids applied sequentially or in combination [76, 77]. This technique achieves a surface with micro-roughness, which some authors associate with higher values of reverse removal torque than machined surface implants [78] (Figure 1B).

Alkali treatment is a procedure in which the Ti implant is immersed in either potassium or sodium hydroxide followed by heat treatment (800°C for 20 min) and subsequent rinsing with distilled water. This technique achieves a nanostructured and bioactive sodium titanate layer on the surface of the dental implant, which provides favorable conditions for bone marrow cell differentiation [69]. The thermal oxidation works by changing the crystal structure of the nanometric oxide layer and thus increases the bioactivity of a biocompatible metal [79].

Sandblast, large grit, and acid etching (SLA) applies a strong acid on the blasted surface for the purposes of abrasion. The procedure starts with large particle blasting, which obtains a rough, irregular surface. Then, the acid etching produces surface uniformity and obtains a macro-roughness and micro-pits which are able to improve osseointegration. Kim et al. [80] observed that human osteoblasts grow well on the SLA surface which provides space for cell adhesion and proliferation.

4.3. Other techniques

Other procedures such as ion implantation, laser treatment, sputtering, and the combination of some of the techniques already mentioned have also been studied in order to improve the surface properties of dental implants [8184].

Ion implantation causes atomic rearrangement. It permits the injection of any element on a nearby surface with a beam of high-energy ions (10 KeV) which impacts on the surface of the metal in a vacuum chamber. On colliding with the ions of the substrate material, the incident ions lose energy and settle on the surface of the nearby metal. This technique is considered an ultra clean process because the concentration and depth of the impurities are easy to control, allowing the creation of a layer of high purity. Furthermore, the adhesion between the implanted surface and the substrate is excellent; the process does not alter the properties of the core and is highly reproducible and controllable [85]. However, some authors warn that the possible modification of the nanoscale features and the creation of stress on the Ti surface should be taken into consideration [86, 87].

Ultraviolet (UV) photo-functionalization is one of the recent advances in the chemical modification of implant surfaces which does not alter the bioactive properties.

Laser technology is an extremely clean, fast, and accurate method which allows nanostructural micromachining at the implant surface [88]. Laser peening involves striking the metal with high-intensity pulses of a laser light beam which produces a deep, regular honeycomb pattern with small pores [2].

The slow rate sputter deposition method achieves a thin layer of Ti oxide (300 pm–6.3 nm). This technique increases the oxygen components without altering the surface topography. These biological activities are correlated with the thickness of the TiO2 coating and the oxygen saturation of the surface. This means that the biological response of Ti can be improved even with picometer super thin coatings [69].

5. Peri-implantitis related to dental implant surfaces

Peri-implantitis is an infectious disease of an already integrated dental implant that causes inflammation of the surrounding hard and soft tissue, leading to the loss of supporting bone (Figure 4 and 5). The sequence of microbial colonization on dental implants and biofilm formation is similar to that of teeth. The bacteria that colonize dental implants include the same species as those present in healthy gums and in locations with gingivitis [8991]. Several in vivo studies show that streptococci and Actinomyces species predominate in the initial colonization; their presence prepares the environment for colonization by other species such as Porphyromonas, Prevotella, Capnocytophaga, and Fusobacterium which cause the peri-implantitis [91] (Table 1).


Figure 4.

Intraoral radiograph taken 8 years after implant placement—sandblasted, large-grit and acid etched (SLA) surface treatment type. Note the bone crater-like defect around the implant revealing a severe peri-implantitis (Clinical records, Dr. Jaume Miranda-Rius).


Figure 5.

Peri-implantitis clinical image. Surgical debridement of the granulation tissue around the implant (Clinical records, Dr. Jaume Miranda-Rius).

Streptococcus sanguisCapnocytophaga spp.
Streptococcus mitisCampylobacter rectus
Aggregatibacter actonimycemetcomitansSpirochetes
Porphyromonas gingivalisVeillonella parvula
Prevotella intermediaStaphylococcus aureus
Tannerella forsythiaFusobacterium spp.
Treponema denticolaPeptostreptococcus prevoti

Table 1.

List of bacterial species associated to dental implant biofilm.

The surface characteristics of dental implants—roughness, wettability, surface free energy, and composition—play a crucial role in bacterial adhesion and colonization. The highest adhesion capacity is observed on rough Ti surfaces. Some authors have observed that mean roughness values below 0.088 microns significantly inhibit plaque adhesion and maturation [92]. Furthermore, decreasing the wettability of dental implants favors bacterial colonization. Some authors suggest that autoclave-sterilized Ti presents a higher rate of bacterial colonization, given the loss of surface wettability (Figure 5).

Surface free energy is the sum of the forces of cohesion and adhesion that determine whether or not there is impregnation (the dispersion of the liquid over a surface). Decreasing surface free energy inhibits bacterial adhesion and biofilm formation on the surface of dental implants and abutments [93]. Thus, bacterial adherence is correlated with the presence of surface components with nonpolar or hydrophobic characteristics [9395]. Finally, the type of metal and its composition also has an effect on bacterial adhesion and biofilm formation on its surface. Pure metals, especially Ti, nickel, iron, and vanadium, have some bacteriostatic capacity [96].

Some authors have concluded that ZnO and TiO2 reduce the adhesion of staphylococcal bacteria and increase the adhesion of osteoblasts [97]. The addition of silver compounds to increase antimicrobial action has also been studied [98]. Other authors have analyzed the behavior of Ti surfaces modified with vancomycin attached via covalent bonds and have reported a stable surface with a greater inhibition of bacterial adhesion than with Ti alone [99].

6. Conclusion

In this chapter, we have highlighted the important role of the macro- and micro-design of implants and their composition in the process of osseointegration. We have also stressed the significant influence of the surface characteristics of implants on the peri-implant microbiota. All in all, peri-implantitis is an important area for future research. It is extremely difficult to control the progress of an infection once it is established around an implant. The rough surfaces facilitate osseointegration, but also favor the adhesion of oral biofilm. Because of the multifactorial nature of infectious peri-implant complications, studies should also take into account the influence of the permucosal seal. This biological seal aims to integration the neck of the implant or the abutment with the gingival tissue and thus prevent peri-implant infections. Currently, the challenge in the treatment of implant surfaces is to demonstrate the potential of certain coatings for releasing local antimicrobial agents. Given the clear increase in inflammatory peri-implant diseases, we believe that future research should aim to devise new strategies for obtaining antibacterial biomaterials that can help in the prevention or treatment of peri-implantitis.


1 - Ananth H, Kundapur V, Mohammed HS, Anand M, Amarnath GS, Mankar S. A review on biomaterials in dental implantology. Int J Biomed Sci. 2015; 11(3): 113–120.
2 - Ogle OE. Implant surface material, design, and osseointegration. Dent Clin N Am. 2015; 59(2): 505–20. doi:10.1016/j.cden.2014.12.003
3 - Cochran DL, Buser D, ten Bruggenkate CM, et al. The use of reduced healing times on ITI implants with a sandblasted and acid-etched (SLA) surface: early results from clinical trials on ITI SLA implants. Clin Oral Implants Res. 2002; 13(2): 144–153. doi:10.1034/j.1600-0501.2002.130204.x
4 - Rosales-Leal JI, Rodríguez-Valverde MA, Mazzaglia G, et al. Effect of roughness, wettability and morphology of engineered titanium surfaces on osteoblast-like cell adhesion. Colloids Surf A Physicochem Eng Asp. 2010; 365(1–3): 222–229. doi:10.1016/j.colsurfa.2009.12.017
5 - Nakae H, Yoshida M, Yokota M. Effects of roughness pitch of surfaces on their wettability. J Mater Sci. 2005; 40(9–10): 2287–2293.
6 - Ponsonnet L, Reybier K, Jaffrezic N, et al. Relationship between surface properties (roughness, wettability) of titanium and titanium alloys and cell behaviour. Mater Sci Eng C. 2003; 23(4): 551–560. doi:10.1016/S0928-4931(03)00033-X
7 - Sollazo V, Pezzetti F, Scarano A, et al. Zirconium oxide coating improves implant osseointegration in vivo. Dent Mater. 2008; 24(3): 357–361. doi:10.1016/
8 - Jemat A, Ghizali MJ, Razali M, Otsuka Y. Surface modifications and their effects on titanium dental implants. Biomed Res Int. 2015; 2015: 791725. doi:10.1155/2015/791725
9 - Lacefield WR. Materials characteristics of uncoated/ceramic coated implant materials. Adv Dent Res. 1999; 13: 21–26. doi:10.1177/08959374990130011001
10 - Ozcan M, Hammerle C. Titanium as a reconstruction and implant material in dentistry: advantages and pitfalls. Materials. 2012; 5(9): 1528–1545. doi:10.3390/ma5091528
11 - Jacobs JJ, Gilbert JL, Urban RM. Current concepts review: corrosion of metal orthopaedic implants. J Bone Jt Surg Am. 1998; 80A: 268–282.
12 - Neoh KG, Hu X, Zheng D, et al. Balancing osteoblast functions and bacterial adhesion on functionalized titanium surfaces. Biomaterials. 2012; 33: 2813–2822. doi:10.1016/j.biomaterials.2012.01.018
13 - Steinemann S. Titanium—the material of choice? Periodontology. 2000, 1998; 17(1): 7–21. doi:10.1111/j.1600-0757.1998.tb00119.x
14 - ASM Material Data Sheet. Available at: Accessed December 2015.
15 - Delgado-Ruiz RA, Calvo-Guirado JL, Abboud M, et al. Histologic and histomorphometric behavior of microgrooved zirconia dental implants with immediate loading. Clin Implant Dent Relat Res. 2013; 16(6): 856–872. doi:10.1111/cid.12069
16 - Koch FP, Weng D, Krämer S, et al. Osseointegration of one-piece zirconia implants compared with a titanium implant of identical design: a histomorphometric study in the dog. Clin Oral Implants Res. 2010; 21(3): 350–356. doi:10.1111/j.1600-0501.2009.01832.x
17 - Moller B, Terheyden H, Acil Y, et al. A comparison of biocompatibility and osseointegration of ceramic and titanium implants: an in vivo and in vitro study. Int J Oral Maxillofac Surg. 2012; 41(5): 638–645. doi:10.1016/j.ijom.2012.02.004
18 - Assal PA. The osseointegration of zirconia dental implants. Schweiz Monatsschr. Zahnmed. 2013; 123(7–8): 644–654.
19 - Wennerberg A, Albrektsson T. On implant surfaces: a review of the current knowledge and opinions. Int J Oral Maxillofac Implants. 2010; 25(1): 63–74.
20 - Strnad Z, Strnad J, Povysil C, et al. Effect of plasma-sprayed hydroxyapatite coating on the osteoconductivity of commercially pure titanium implants. Int J Oral Maxillofac Implants. 2000; 15(4): 483–490.
21 - Geurs NC, Jeffcoat RL, McGlumphy EA, Reddy MS, Jeffcoat MK. Influence of implant geometry and surface characteristics on progressive osseointegration. Int J Oral Maxillofac Implants. 2002; 17(6): 811–815.
22 - Faeda RS, Tavares HS, Sartori R, Guastaldi AC, Marcantonio EJR. Biological performance of chemical hydroxyapatite coating associated with implant surface modification by laser beam: biomechanical study in rabbit tibias. J Oral Maxillofac Surg. 2009; 67: 1706–1715. doi:10.1016/j.joms.2009.03.046
23 - Gottlander M, Johansson CB, Albrektsson T. Short and long-term animal studies with a plasma-sprayed calcium phosphate-coated implant. Clin Oral Implants Res. 1997; 8(5): 345–351.
24 - Jones JD, Saigusa M, Van Sickels JE, Tiner BD, Gardner WA. Clinical evaluation of hydroxyapatite-coated titanium plasma-sprayed and titanium plasma-sprayed cylinder dental implants: a preliminary report. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol. 1997; 84(2): 137–141. doi:10.1016/S1079-2104(97)90058-5
25 - Zhou W, Liu Z, Xu S, Hao P, Xu F, Sun A. Long-term survivability of hydroxyapatite-coated implants: a meta-analysis. Oral Surg. 2011; 4(1): 2–7. doi:10.1111/j.1752-248X.2010.01112.x
26 - Winkler S, Morris HF, Ochi S. Implant survival to 36 months as related to length and diameter. Ann Periodontol. 2000; 5(1): 22–31.
27 - Wyatt CC, Zarb GA. Treatment outcomes of patients with implant supported fixed partial prostheses. Int J Oral Maxillofac Implants. 1998; 13(2): 204–211.
28 - Eckert SE, Koka S, Wolfinger G, Choi YG. Survey of implant experience by prosthodontists in the United States. J Prosthodont. 2002; 11(3): 194–201. doi:10.1053/jopr.2002.127768
29 - Geng JP, Tan KB, Liu GR. Application of finite element analysis in implant dentistry: a review of the literature. J Prosthet Dent. 2001; 85(6): 585–598. doi:10.1067/mpr.2001.115251
30 - Nedir R, Bischof M, Briaux JM, Beyer S, Szmukler-Moncler S, Bernard JP. A 7-year life table analysis from a prospective study on ITI implants with special emphasis on the use of short implants. Results from a private practice. Clin Oral Implants Res. 2004; 15(2): 150–157. doi:10.1111/j.1600-0501.2004.00978.x
31 - Ivanoff CJ, Sennerby L, Johansson C, Rangert B, Lekholm U. Influence of implant diameters on the integration of screw implants. An experimental study in rabbits. Int J Oral Maxillofac Surg. 1997; 26(2): 141–148. doi:10.1016/S0901-5027(05)80837-9
32 - Mahon JM, Norling BK, Phoenix RD. Effect of varying fixture width on stress and strain distribution associated with an implant stack system. Implant Dent. 2000; 9(4): 310–320.
33 - Ettinger RL, Spivey JD, Han DH, Koorbusch GF. Measurement of the interface between bone and immediate endosseous implants: a pilot study in dogs. Int J Oral Maxillofac Implants. 1993; 8(4): 420–427.
34 - Misch CE. Contemporary implant dentistry. St. Louis: Elsevier. 3rd ed. 1999. ISBN:978-0-323-04373-1.
35 - Misch CE. Implant design considerations for the posterior regions of the mouth. Implant Dent. 1999; 8(4): 376–386.
36 - Kohn DH. Overview of factors important in implant design. J Oral Implantol. 1992; 18(3): 204–219.
37 - Langer B, Langer L, Herrmann I, Jorneus L. The wide fixture: a solution for special bone situations and a rescue for the compromised implant. Part 1. Int J Oral Maxillofac Implants. 1993; 8(4): 400–408.
38 - Kanie T, Nagata M, Ban S. Comparison of the mechanical properties of 2 prosthetic mini-implants. Implant Dent. 2004; 13(3): 251–256.
39 - Vigolo P, Givani A. Clinical evaluation of single-tooth mini-implant restoration: a five-year retrospective study. J Prosthet Dent. 2000; 84: 50–54. doi:10.1067/mpr.2000.107674
40 - Himmlova L, Dostalova T, Kacovsky A, Konvickova S. Influence of implant length and diameter on stress distribution: a finite element analysis. J Prosthet Dent. 2004; 91(1): 20–25. doi:10.1016/j.prosdent.2003.08.008
41 - Holmgren EP, Seckinger RJ, Kilgren LM, Mante F. Evaluating parameters of osseointegrated dental implants using finite element analysis—a two dimensional comparative study examining the effects of implant diameter, implant shape, and load direction. J Oral Implantol. 1998; 24(2): 80–88.
42 - Kan JY, Rungcharassaeng K, Kim J, Lozada JL, Goodacre CJ. Factors affecting the survival of implants placed in grafted maxillary sinuses: a clinical report. J Prosthet Dent. 2002; 87(5): 485–489. doi:10.1067/mpr.2002.124202
43 - Hansson S, Werke M. The implant thread as a retention element in cortical bone: the effect of thread size and thread profile: a finite element study. J Biomech. 2003; 36(2): 1247–1258. doi:10.1016/S0021-9290(03)00164-7
44 - Lin S, Shi S, LeGeros RZ, LeGeros JP. Three-dimensional finite element analyses of four designs of a high-strength silicon nitride implant. Implant Dent. 2000; 9(1): 53–60.
45 - Cochran DL, Schenk RK, Lussi A, Higginbottom FL, Buser D. Bone response to unloaded and loaded titanium implants with a sandblasted and acid-etched surface: a histometric study in the canine mandible. J Biomed Mater Res. 1998; 40(1): 1–11.
46 - Wennerberg A, Hallgren C, Johansson C, Danelli S. A histomorphometric evaluation of screw-shaped implants each prepared with two surface roughnesses. Clin Oral Implants Res. 1998; 9(1): 11–19. doi:10.1034/j.1600-0501.1998.090102.x
47 - Gu YW, Khor KA, Pan D, Cheang P. Activity of plasma sprayed yttria stabilized zirconia reinforced hydroxyapatite/Ti6–Al–4V composite coatings in simulated body fluid. Biomaterials. 2004; 25(16): 3177–3185. doi:10.1016/j.biomaterials.2003.09.101
48 - Ferraris S, Spriano S, Pan G, et al. Surface modification of Ti–6Al–4V alloy for biomineralization and specific biological response: part I, inorganic modification. J Mater Sci Mater Med. 2001; 22(3): 533–545. doi:10.1007/s10856-011-4246-2
49 - Simmons CA, Valiquette N, Pilliar RM. Osseointegration of sintered porous-surfaced and plasma spray-coated implants: an animalmodel study of early postimplantation healing response and mechanical stability. J Biomed Mater Res. 1999; 47(2): 127–138.
50 - Ong JL, Chan DCN. Hydroxyapatite and their use as coatings in dental implants: a review. Crit Rev Biomed Eng. 2000; 28(5–6): 667–707. doi:10.1615/CritRevBiomedEng.v28.i56.10
51 - Knabe C, Klar F, Fitzner R, Radlanski RJ, Gross U. In vitro investigation of titanium and hydroxyapatite dental implant surfaces using a rat bone marrow stromal cell culture system. Biomaterials. 2002; 23(15): 3235–3245. doi:10.1016/S0142-9612(02)00078-9
52 - Hung KY, Lo SC, Shih CS, Yang YC, Feng HP, Lin YC. Titanium surface modified by hydroxyapatite coating for dental implants. Surf Coat Technol. 2013; 231: 337–345. doi:10.1016/j.surfcoat.2012.03.037
53 - Eom TG, Jeon GR, Jeongetal CM. Experimental study of bone response to hydroxyapatite coating implants: bone implant contact and removal torque test. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012; 114(4): 411–418. doi:10.1016/j.oooo.2011.10.036
54 - Ochsenbein A, Chai F, Winter S, Traisnel M, Breme M, Hildebrand HF. Osteoblast responses to different oxide coatings produced by the sol–gel process on titanium substrates. Acta Biomater. 2008; 4(5): 1506–1517. doi:10.1016/j.actbio.2008.03.012
55 - Braceras I, Alava JI, Oñate JI, et al. Improved osseointegration in ion implantation-treated dental implants. Surf Coat Technol. 2002; 158–159: 28–32. doi:10.1016/S0257-8972(02)00203-7
56 - Fouda MFA, Nemat A, Gawish A, Baiuomy AR. Does the coating of titanium implants by hydroxyapatite affect the elaboration of free radicals. An experimental study. Aust J Basic Appl Sci. 2009; 3: 1122–1129.
57 - Xie Y, Liu X, Zheng X, Ding C, Chu PK. Improved stability of plasma-sprayed dicalcium silicate/zirconia composite coating. Thin Solid Films. 2006; 515(3): 1214–1218. doi:10.1016/j.tsf.2006.07.124
58 - Le Guéhennec L, Soueidan A, Layrolle P, Amouriq Y. Surface treatments of titanium dental implants for rapid osseointegration. Dent Mater. 2007; 23(7): 844–854. doi:10.1016/
59 - Liu X, Chu PK, Ding C. Surface modification of titanium, titanium alloys, and related materials for biomedical applications. Mater Sci Eng R Rep. 2004; 47(3–4): 49–121. doi:10.1016/j.mser.2004.11.001
60 - Jones FH. Teeth and bones: applications of surface science to dental materials and related biomaterials. Surf Sci Rep. 2001; 42(3–5): 75–205. doi:10.1016/S0167-5729(00)00011-X
61 - Aparicio C, Gil FJ, Fonseca C, Barbosa M, Planell JA. Corrosion behaviour of commercially pure titanium shot blasted with different materials and sizes of shot particles for dental implant applications. Biomaterials. 2003; 24(2): 263–273. doi:10.1016/S0142-9612(02)00314-9
62 - Kokubo T, Miyaji F, Kim HM, Nakamura T. Spontaneous formation of bonelike apatite layer on chemically treated titanium metals. J Am Ceram Soc. 1996; 79(4): 1127–1129. doi:10.1111/j.1151-2916.1996.tb08561.x
63 - Aparicio C, Gil FJ, Planell JA. Human-osteoblast proliferation and differentiation on grit-blasted and bioactive titanium for dental applications. J Mater Sci Mater Med. 2002; 13(12): 1105–1111.
64 - Gil FJ, Padrós A, Manero JM, Aparicio C, Nilsson M, Planell JA. Growth of bioactive surfaces on titanium and its alloys for orthopaedic and dental implants. Mater Sci Eng C. 2002; 22(1): 53–60. doi:10.1016/S0928-4931(01)00389-7
65 - Aparicio C, Rodriguez D, Gil FJ. Variation of roughness and adhesion strength of deposited apatite layers on titanium dental implants. Mater Sci Eng C. 2011; 31(2): 320–324. doi:10.1016/j.msec.2010.09.018
66 - Gil FJ, Manzanares N, Badet A, Aparicio C. Biomimetic treatment on dental implants for short-term bone regeneration. Clin Oral Investig. 2014; 18(1): 59–66. doi:10.1007/s00784-013-0953-z
67 - Gil FJ, Espinar E, Llamas JM, Sevilla P. Fatigue live of bioactive titanium dental implants treated by means of grit-blasting and thermo-chemical treatment. Clin Implant Dent Res. 2014; 16(2): 273–281. doi:10.1111/j.1708-8208.2012.00468.x
68 - Albertini M, Fernández-Yague M, Lázaro P, Herrero-Climent, et al. Advances in surfaces and osseointegration in implantology. Biomimetic surfaces. Med Oral Patol Oral Cir Bucal. 2015; 20(3): 316–325.
69 - Pachauri P, Bathala LR, Sangur R. Techniques for dental implant nanosurface modifications. J Adv Prosthodont. 2014; 6(6): 498–504. doi:10.4317/medoral.20353
70 - Park J, Bauer S, Schlegel KA, Neukam FW, von der Mark K, Schmuki P. TiO2 nanotube surfaces: 15 nm-an optimal length scale of surface topography for cell adhesion and differentiation. Small. 2009; 5: 666–671. doi:10.1002/smll.200801476
71 - Sjöström T, Dalby MJ, Hart A, Tare R, Oreffo RO, Su B. Fabrication of pillar-like titania nanostructures on titanium and their interactions with human skeletal stem cells. Acta Biomater. 2009; 5(5): 1433–1441. doi:10.1016/j.actbio.2009.01.007
72 - Cho SA, Park KT. The removal torque of titanium screw inserted in rabbit tibia treated by dual acid etching. Biomaterials. 2003; 24(20): 3611–3617. doi:10.1016/S0142-9612(03)00218-7
73 - Al-Radha ASD, Dymock D, Younes C, O’Sullivan D. Surface properties of titanium and zirconia dental implant materials and their effect on bacterial adhesion. J Dent. 2012; 40(2): 146–153. doi:10.1016/j.jdent.2011.12.006
74 - Novaes ABJr, Papalexiou V, Grisi MFM, Souza SSLS, Taba MJr, Kajiwara JK. Influence of implant microstructure on the osseointegration of immediate implants placed in periodontally infected sites. Clin Oral Implants Res. 2004; 15(1): 34–43. doi:10.1046/j.1600-0501.2003.00968.x
75 - Suzuki K, Aoki K, Ohya K. Effects of surface roughness of titanium implants on bone remodeling activity of femur in rabbits. Bone. 1997; 21(6): 507–514. doi:10.1016/S8756-3282(97)00204-4
76 - Vanzillotta P, Soares GA, Bastos IN, Simao RA, Kuromoto NK. Potentialities of some surface characterization techniques for the development of titanium biomedical alloys. Mater Res. 2004; 7(3): 437–444. doi:10.1590/S1516-14392004000300011
77 - Takeuchi M, Abe Y, Yoshida Y, Nakayama Y, Okazaki M, Akagawa Y. Acid pretreatment of titanium implants. Biomaterials. 2003; 24(10): 1821–1827. doi:10.1016/S0142-9612(02)00576-8
78 - Ban S, Iwaya Y, Kono H, Sato H. Surface modification of titanium by etching in concentrated sulfuric acid. Dent Mater. 2006; 22(12): 1115–1120. doi:10.1016/
79 - Vandrovcova M, Jirka I, Novotna K, Lisa V, Frank O, Kolska Z, Stary V, Bacakova L. Interaction of human osteoblast-like Saos-2 and MG-63 cells with thermally oxidized surfaces of a titanium-niobium alloy. Plos One 2014; 9: e100475. doi:10.1371/journal.pone.0100475
80 - Kim H, Choi SH, Ryu JJ, Koh SY, Park JH, Lee IS. The biocompatibility of SLA-treated titanium implants. Biomed Mater. 2008; 3(2): 025011. doi:10.1088/1748-6041/3/2/025011
81 - Aparicio C, Padrós A, Gil FJ. In vivo evaluation of micro-rough and bioactive titanium dental implants using histometry and pull-out tests. J Mech Behav Biomed Mater. 2011; 4(8): 1672–1682. doi:10.1016/j.jmbbm.2011.05.005
82 - Ban S, Iwaya Y, Kono H, Sato H. Surface modification of titanium by etching in concentrated sulfuric acid. Dent Mater. 2006; 22(12): 1115–1120. doi:10.1016/
83 - Velasco-Ortega E, Jos A, Cameán AM, Pato-Mourelo J, Segura-Egea JJ. In vitro evaluation of cytotoxicity and genotoxicity of a commercial titanium alloy for dental implantology. Mutat Res Genet Toxicol Environ Mutagen. 2010; 702(1): 17–23. doi:10.1016/j.mrgentox.2010.06.013
84 - Braceras I, Alava JI, Oñateetal JI. Improved osseointegration in ion implantation-treated dental implants. Surf Coat Technol. 2002; 158–159: 28–32. doi:10.1016/S0257-8972(02)00203-7
85 - Rautray TR, Narayanan R, Kim KH. Ion implantation of titanium based biomaterials. Prog Mater Sci. 2011; 56(8): 1137–77. doi:10.1016/j.pmatsci.2011.03.002
86 - Hanawa T, Kamiura Y, Yamamoto S, Kohgo T, Amemiya A, Ukai H, Murakami K, Asaoka K. Early bone formation around calcium-ion-implanted titanium inserted into rat tibia. J Biomed Mater Res. 1997; 36(1): 131–136. doi:10.1002/(SICI)1097-4636(199707)36:1<131::AID-JBM16>3.0.CO;2-L
87 - Rautray TR, Narayanan R, Kwon TY, Kim KH. Surface modification of titanium and titanium alloys by ion implantation. J Biomed Mater Res B Appl Biomater. 2010; 93B(2): 581–591. doi:10.1002/jbm.b.31596
88 - Fasasia AY, Mwenifumbob S, Rahbarb N, Chenb J, Lid M, Beyeb AC, Arnoldb CB, Soboyejob WO. Nano-second UV laser processed micro-grooves on Ti6Al4V for biomedical applications. Mater Sci Eng C. 2009; 29(1): 5–13. doi:10.1016/j.msec.2008.05.002
89 - Tanner A, Maiden MF, Lee K, Shulman LB, Weber HB. Dental implant infections. Clin Infect Dis. 1997; 25(Suppl. 2): S213–S217.
90 - Mombelli A, Van Oosten MA, Schurch EJr, Lang NP. The microbiota associated with successful or failing osseointegrated titanium implants. Oral Microbiol Immunol. 1987; 2(4): 145–151. doi:10.1111/j.1399-302X.1987.tb00298.x
91 - Rams TE, Roberts TW, Feik D, Molzan AK, Slots J. Clinical and microbiological findings on newly inserted hydroxyapatite-coated and pure titanium human dental implants. Clin Oral Implant Res. 1991; 2: 121–127. doi:10.1034/j.1600-0501.1991.020304.x
92 - Wu-Yuan CD, Eganhouse KJ, Keller JC, Walters KS. Oral bacterial attachment to titanium surfaces: a scanning electron microscopy study. J Oral Implantol. 1995; 21(3): 207–213.
93 - Subramani K, Jung RE, Molenberg A. Hammerle CHF. Int J Oral Maxillofac Implants. 2009; 24: 616.
94 - Mabboux F, Ponsonnet L, Morrier JJ, Jaffrezic N, Barsotti O. Surface free energy and bacterial retention to saliva-coated dental implant materials—an in vitro study. Colloid Surf B Biointerfaces. 2004; 39(4): 199–205. doi:10.1016/j.colsurfb.2004.08.002
95 - Sardin S, Morrier JJ, Benay G, Barsotti O. In vitro streptococcal adherence a prosthetic and implant materials. Interactions with physicochemical surface properties. J Oral Rehabil. 2004; 31(2): 140–148. doi:10.1046/j.0305-182X.2003.01136.x
96 - Bundy KJ, Butler MF, Hochman RF. An investigation of the bacteriostatic properties of pure metals. J Biomed Mater Res. 1980; 14(5): 653–663. doi:10.1002/jbm.820140511
97 - Colon G, Ward BC, Webster TJ. Increased osteoblast and decreased Staphylococcus epidermidis functions on nanophase ZnO and TiO2. J Biomed Mater Res A. 2006; 78A(3): 595–604. doi:10.1002/jbm.a.30789
98 - Ewald A, Glückermann SK, Thull R, Gbureck U. Antimicrobial titanium/silver PVD coatings on titanium. Biomed Eng Online. 2006; 5: 22. doi:10.1186/1475-925X-5-22
99 - Lauson MC, Bowman CN, Anseth KS. Vancomycin derivative photopolymerized to titanium kills S. epidermidis. Clin Orthop Relat Res. 2007; 461: 96–105. doi:10.1097/BLO.0b013e3180986706