Values of adhesion strength of HAp coatings deposited by electrodeposition process [33].
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\\n"}]',published:!0,mainMedia:{caption:"Highly Cited",originalUrl:"/media/original/117"}},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 191 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 261 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"621",leadTitle:null,fullTitle:"Earth Sciences",title:"Earth Sciences",subtitle:null,reviewType:"peer-reviewed",abstract:"The studies of Earth's history and of the physical and chemical properties of the substances that make up our planet, are of great significance to our understanding both of its past and its future. The geological and other environmental processes on Earth and the composition of the planet are of vital importance in locating and harnessing its resources. \nThis book is primarily written for research scholars, geologists, civil engineers, mining engineers, and environmentalists. Hopefully the text will be used by students, and it will continue to be of value to them throughout their subsequent professional and research careers. This does not mean to infer that the book was written solely or mainly with the student in mind. 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Hashim"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"57176",title:"Hydroxyapatite-Based Coating on Biomedical Implant",doi:"10.5772/intechopen.71063",slug:"hydroxyapatite-based-coating-on-biomedical-implant",body:'\nMetals or also known as metallic biomaterials that have been used for medical treatments can be traced back around 20 years. Despite a significant number of metals that are able to be produced in modern industries, there are only three commonly biocompatible metals that are used as biomedical implant materials; stainless steel (316L), cobalt-based alloys, and titanium-based alloys [1, 2, 3, 4]. These metallic biomaterials are typically used in orthopaedic practise since they have approval by the United States Food and Drug Administration (FDA) [4].
\nSince the biomaterials are employed in intimate contact with living tissues, it is important that the materials exhibited biocompatibility characteristics. The requirement of biocompatibility includes all features of bio-device functionalities during the interaction of tissues and cells with the implanted materials [5]. However, there are limitations of metallic biomaterials as an implant; weaknesses in bone-bonding ability and toxic ions released into the human body fluids after longer usage [6, 7]. Different chemical composition between the actual bone and the metal implant is one of the causes of ineffective in bone-bonding ability. Moreover, the metallic implants are also susceptible to corrosion degradation due to the surrounding aggressive body fluids [8].
\nConsequently, most of the researchers have introduced surface modification by applying bioactive ceramics such as hydroxyapatite (Ca10(PO4)6OH2) as a bioactive coating on the metallic implants to the implant to enhance bone-bonding ability [9, 10]. The hydroxyapatite (HAp) is the primary inorganic ingredient of natural bones and has been the most widely used ceramic-based biomaterial for over four decades in medicine and dentistry. It has been proven by many researchers that HAp coating allows a controlled and rapid osseointegration between living bone and the surface of an implant [11, 12].
\nThere are various commercial techniques to deposit the HAp coating on the metal-based biomaterials. In this chapter, four commercially HAp surface coating techniques including plasma spraying, sol-gel dip-coating, electrochemical deposition and high-velocity suspension plasma-spraying (HVSPS) are discussed. The discussion comprises biocompatibility, adhesion strength and corrosion behaviour studies about three aforementioned metallic biomaterials after the surface was coated by HAp.
\nThe selection of appropriate biomaterial to be classified as a metal implant material highly depends on its applications. The selected biomaterial should possess several essential characteristics such as excellent biocompatibility, osseointegration, high corrosion and wear resistance, suitable mechanical properties, ductility and high hardness.
\nThe biocompatibility properties are defined as the ability of a material to be used in intimate contact physically and chemically with living tissues of a real bone without causing any adverse effects. Intuitively, it is necessary to confirm that there are no negative issues befell to metal implanted devices and surrounding living tissues since the materials are innately compatible with living cells and tissues [13].
\nOsseointegration denotes to a direct structural and functional connection between ordered, living bone and the surface of a load-carrying implant. It involves the process of new bone production and bone healing. Therefore, it is essential for an implant to have an appropriate surface to integrate well with surrounding bone. Surface chemistry, surface roughness and surface topography are the factors that vital for good osseointegration [14, 15].
\nAmong critical issues and challenges of the medical implant are facing is the failure of an implant due to the corrosion aggressiveness. Consequently, a metal that performs well outside the human body may suffer a severe corrosivity reaction in the body as the environment is physically and chemically different from ambient. Due to that fact, all of the corrosion-resistant metallic implants reacted to an acidic environment and began to corrode when diagnosed for a long time in the human body. Most researchers have claimed that active implants corrosivity process rouse after 12–15 years of implantation period [6, 16].
\nThe surface coating application offers the possibility of modifying the surface properties of implant devices to achieve improvements in biocompatibility, reliability, and performance. Therefore, most researchers have reported excellent studies of HAp coating onto various metallic implants specifically related to their biocompatibility and corrosion behaviour. Nowadays, different HAp deposition techniques have been carried out to overcome the biocompatibility, and corrosion issues arose from the metallic biomaterials [12, 17]. These deposition techniques include plasma spraying, sol-gel technique, electrochemical deposition and High-Velocity Suspension Plasma-spraying.
\nPlasma spray is one of the popularly used methods used to deposit biocompatible HAp coating onto metallic implants [18, 19]. In these recent years, this approach is highly utilised for dental and orthopaedic implants. The indirect method of plasma spray applies melting and spraying onto the surface by a method an electric arc. The process involves heating the dry powder feedstock by thermal plasma jet. Then, the thermal plasma jet accelerates and impacts the feedstock towards the substrate. The powder feedstock is flattened in the form of lamellae. Plasma spraying can be carried out under vacuum, controlled atmospheres, or in an ambient atmosphere. Air or vacuum spraying is one of the plasma-assisted depositions, which is very popular compared to other methods. The coatings applied by plasma spray can have relatively good mechanical properties. The relative temperatures in the jet are 10,000 K, 12,000 K or as high as 30,000 K, intensely declining with the nozzle’s distance [20]. Practically all the materials are melted and propelled towards a substrate.
\nDevelopment of the coated layer on a titanium (Ti) alloy surface with hydroxyapatite powder for 10 s shows better apatite adhesion, strong adhesion between implant and bone, and enhanced osteoconductivity [21]. The properties of HAp coating are mainly determined by the thickness of the coating layer. The thickness of HAp coating obtained on the Ti6Al4V alloy by the air plasma spray (APS) was about 150 μm thickness. This range of coating’s thickness significantly diminishes the fatigue strength while the range between 25 and 100 μm thickness does not show such effect [22]. The reasons for the reduction in fatigue strength might be due to the intrinsic stresses that happened during spraying, coating cracks, and most significantly stresses discharged during spraying. The difference in the stiffness of the metal substrate and coating is also significant.
\nThe coating deposition by a suspension plasma spray (SPS) obtained a relatively thin coating layer 5–50 μm as compared to other plasma-spray techniques and only could be achieved by dry powder processing [23]. The dry powder particles used for the SPS having diameters ranging from a few submicrometer to a few micrometres [24]. The thicknesses of APS coatings are in the range 200–300 μm and quite porous. The coating thickness depends on the composition of plasma gas used which is Ar/H2/N2/He, plasma gun input power, gas flow rate, powder feeding rate and characteristics of feed materials, and spray stand-off distance, which are frequently varied [25, 26].
\nFurthermore, the structure and bonding properties of HAp coating on metallic biomaterials can be improved by using heat treatment process. Annealing process transformed a partial amorphous coating into a crystalline layer [22]. The mostly higher crystallinity of the coating layer was supposed to have excellent adhesion characteristics. Annealing at a higher temperature such as at 700°C for 1 h could enhance the coating purity, hydroxyl group and crystallinity degree. However, the high spraying power values can cause a lowering of the adhesion strength between the coating and substrate due to the higher content of amorphous HAp [27]. Based on the observations of the annealing process of HAp coated at 1100°C under vacuum condition, the secondary β phase formed while hydroxyl groups are diminished. The higher the temperature of the annealing process, the greater the formation of the compound oxide of Ti and Ca with the characteristic metallic Ti disappeared [28].
\nAn introduction a coupling agent through chemical bonding can enhance adhesion strength between the HAp coating and metallic implants [29]. The addition of Ti to the HAp improved the bonding strength of the coating significantly [30]. The bonding strength was increased from 14.5 to 17.3 MPa as the composition of the reinforced coating was between 20 and 60 wt.% Ti. The increment in the Ti content could cause better adhesion of the coating layer to the substrate for further enhancement. According to Ref. [31] proposed HAp reinforced with 10 wt% (80Al2O3-20TiO2) on the Ti6Al4V alloy. This solution enhances the adhesion strength to above 32 MPa.
\nRecently, a combination of sol-gel preparation and dip-coating method are extensively employed for a coating on a metallic biomaterial. The method is one of the coating methods used for enhancement of adhesion strength [32, 33]. A calcium phosphate (CaP) precursors are the most important solutes for sol preparation. The CaP precursor is the combination of calcium (calcium nitrate) and phosphorus (phosphorus pentoxide or triethyl phosphate). Normally, there are two solvents will be mixed with the CaP precursors. Most often water and ethanol are used as a solvent for the sol preparation [34, 35].
\nThe dip-coating is a method which includes three steps: (i) dipping, (ii) withdrawing, and (iii) drying. This technique offers various advantages such as low-cost set-up, process simplicity, uniformity of deposition, low processing temperature, and the ability to coat irregular shapes and patterns [36, 37]. The substrate is dipped and withdrawn from the solution at a fixed speed. Therefore, the coating’s thickness is in good control without producing waste [38, 39].
\nAdditionally, the coating amount and the layer thickness can also be controlled by altering the frequency of suspension and the number of dippings. HAp coating via sol-gel dip-coating technique can obtain homogenous coating and the coating thickness in the range 0.05–15 mm [33, 40]. The coating thickness varies according to the viscosity of the sol-gel used [12]. A lower annealing temperature used for sol-gel dip-coating process can produce adhesive thin coating layer without severe cracking. An extremely high temperature (6000–10,000°C) is applied in plasma-spray deposition can decompose the HAp properties into tricalcium phosphate, tetra-calcium phosphate, calcium oxide (CaO), and others amorphous phases [41, 42]. When increasing annealing temperature from 375 to 500°C, the adhesion strength between HAp coating and the substrate increases [43, 44].
\nLatterly, several modifications of sol-gel dip-coating method are developed to enhance the quality of coating surface. A poly ε-caprolactone (PCL) was applied to HAp to promote osseointegration by observing the pores formation on a surface level [45]. The addition of PCL on HAp onto Ti6Al4V substrate was reported as a good grouping owing to a large thickness of the coating, around 184 μm. There was no crack formation on the coating surfaces, and the most significant results revealed that the adhesion between the coating and the substrate was improved. The absence of cracks on the coating surface was reflected necessarily. This is an effective prevention of wear and corrosion for the substrate. Hence, the amount of releasing metal ions into surrounding (body fluid) can be minimised as the coated metal exhibit better corrosion resistance [46, 47, 48].
\nHeat treatment of thin and loosely packed coated substrate is often required to densify the coating layer and to increase the adhesion strength between the substrate and coating [47, 49, 50]. The high temperature is applied to cure the coated substrates to improve the adhesion strength between coating and substrate, and to achieve apatite structures inside the applied coating layers [51, 52]. However, the curing temperatures have been implemented below the melting point of the materials to prevent upsetting the surface integrity of the substrates. It has been indicating that the development of <1 μm thickness of HAp coating on 316L stainless steel was suited as the substrate also exposed to annealed temperatures of around 375–400°C [43]. The bonding strength of the as-produced coatings was about 44 MPa, which indicates good adhesion. For the presently investigated HAp/316L stainless steel system, the interlocking component of adhesion was maximised through surface roughening.
\nLately, a modification of the sol-gel dip-coating has been proposed. TiO2/HAp bi-layer coating and TiO2/HAp composite coating were introduced into 316L stainless steel (316L SS) [53]. The two types of the coating were compared, and TiO2/HAp exhibited better structural features and biocompatible properties due to the proper attachments of stem cells onto the surface, proliferated, and presented a polygonal morphology different from the fibroblastic-like morphology found on 316L SS.
\nThe combination of sol-gel and dip-coating method have been classified as uncomplicated, inexpensive, and sustainable coating technique for coating the metal-based substrate that to be used as implants. In comparison to the natural precipitation approaches, this method can coats the complex shapes or design efficiently. Also, shortened the processing times and relatively low temperatures is applied by this method to cover with the HAp layers on metallic substrates.
\nElectrochemical deposition is one of the commercial coating methods for biomedical implants [54]. Anodic or cathodic systems frequently conducted by the electrodeposition process. In this process, anodic deposition alone is inadequate to produce small feature size materials on the substrates. Regarding this, cathodic deposition has unique advantages for modern and medical applications [55, 56, 57]. Through this method, two regular procedures are applied for the coating preparation: (1) the electrophoretic process (EPD) and (2) the electrolytic procedure (ELD). EPD is the process that provides the utilisation of suspensions of ceramic particles while the ELD is the process of formation of metal salts from solutions. The electrochemical deposition is extensively employed for coating on a titanium substrate. The subsequent filtrate is used as the electrolyte once the CaP proportion dissolved in distilled water [58, 59]. The procedure is performed from watery arrangements like those appropriated as a part of the wet substance deposition. Interestingly, graphite and also platinum has been engaged as the standard reference electrode for anodic material.
\nOne of a kind favourable circumstances in HAp coating deposition process conducted through the electrochemical technique is the ability to form a uniform coating and the coating process quick [60]. The procedure can be performed at moderately low temperature [61]. Electrophoresis process can produce impregnated ceramic particle towards a porous substrate and composite consolidation. Besides, a significant aspect of sintering behaviour greatly depends on the state of agglomeration of ceramic powders. The lower the sintering temperature, the more densify the close-packed of the fine particle and further leads to the formation of agglomerate-free structures [62]. The pre-sedimentation process can separate the aggregates [63]. Besides, defect areas could drive a higher rate of deposition, bringing about the uniformity of the deposit materials and better packing assembly of materials. The higher rate and better deposition layer are due to the insulating behaviour of the deposition.
\nThe electrochemical deposition process can form a homogeneous coating layer which enhances the adhesion strength between the coating layer and implant surface [64]. The HAp coating on CoCrMo metal implant with the thickness of 200 nm can hold the coating quality of around 17.5 MPa which has been considered as the base prerequisite for the minimum adhesion quality of HAp deposition on metallic biomaterials [65, 66]. However, the HAp coated substrate was deposited at 10 mA/cm2 and annealed for 1 h at 500°C showed the thickness of the coating is approximately 18.6 μm revealed stronger adhesion strength (106.3 MPa) of HAp coating [67]. The electrochemical deposition of HAp on metal substrates used common strategies to diminish their debasement; unfortunately, it contains abandon of it onto the coating surface [68]. Hydroxide (OH−) particles are created at the substrate (cathode) surface with the electric current crossed the electrodes as they immersed in an electrolyte during electrochemical deposition process [69]. The condition occurs due to the electrochemical response effect that is typically significant as the system insignificantly response towards the water, in which leads to important in the arrangement of a lot of hydrogen gas [27, 70]. Development of the hydrogen gas air pockets on the surface of the substrate may rapidly occur and thus results in the decreasing of the nucleation and presence of calcium phosphate. In this manner, it may prompt the arrangement of non-uniform coating [71, 72]. To conquer the defects, the execution of HAp coating ought to tackled and enhanced higher current thickness.
\nA few modifications are recommended to adjust the direct current electrochemical deposition technique that should be more reasonable in the accompanying approach. H2O2 was added to replace the H2O during the deposition process, thus brings down the current deposition method. Replacement of H2O2 will able to modify the entire part of the system of electrochemical response [73]. The impacts of H2 development might be evacuated due to the expansion of peroxide. Therefore, the thick and uniform coating might be shaped [61]. The increased adhesion and crystallinity of the HAp coating were achieved by pulsed current electrodeposition method at lower current density with longer pulse off time. The results of pulsed electrodeposition show that the relaxation time of the pulse is beneficial for the growth of HAP because it allows the diffusion of ions from bulk solution to the surface of the electrode and thus lowers the concentration polarisation in the next pulse on time. Besides, by applying galvanostatic pulse electrodeposition to HAp coating on metal implants showed improvement in adhesion strength of HAp coating and metal implant due to pulsed current densities [74].
\nThe previous research has confirmed that by deposition of HAp coating onto metallic biomaterial showed the improvement of corrosion performance [75]. Moreover, the coatings have significantly changed by forming new apatite crystal after 7 days immersion in SBF solution [76]. These indicate that HAp has bioactivity and biocompatibility properties which can provide improvement between tissues and metal implants.
\nAn anodization process has been introduced as pre-treatment for electrochemical deposition [77]. The purpose of anodization is to support developing mechanical interlocks flanked by the metal substrate and HAp coating [78, 79]. Without post-treatment, homogenous and pure HAp coating can be accomplished through the anodising process. It was stated by He et al. [80] that the Al coating on Ti substrate with anodization and hydrothermal treatment. The results from the holes of anodised aluminium oxide (Al2O3) within the coating deposition, there is a growth of CaP. Besides, Yang et al. [81] have conducted anodic oxidation treatment for bioactive Ti metal. Even though the electrochemical and pre-treatment process has become vital, the studies on HAp coating deposited by an electrochemical method on the porous anodised Ti substrate still in progress stage [82].
\nNowadays, a few methods have been presented to enhance mechanical properties of the implants. One of those methods is through reinforcing materials such as zirconia oxide (ZrO2), carbon nanotubes (CNTs), and titanium oxide (TiO2) [11, 83, 84, 85, 86, 87]. On the other hand, several reported regarding the HAp-based coating showed the enhancement in adhesion strength approaching 70% greater compared to pure HAp coating [88]. HAp coating with the addition of single-walled nanotubes (SWNT) managed to get homogenous, high crystallinity and crack-free coatings formation. Additionally, the adhesion strength of the coating and substrate after introducing SWNT is approaching from 15.3 to 25.7 MPa [88].
\nIn correlation to a single layer coating of HAp, the result of a double layer of HAp coating showed uniformity with good adhesion strength [89]. Furthermore, the formation of the oxide layer as an intermediate layer between the substrate and coating helps to maintain the diffusion of harmful impurities from the substrate towards the coating surface to avoid decomposition of HAp [90]. By applying high-temperature annealing or sintering in the formation of a uniform and denser CaP coating post-electrodeposition [91], a superior adhesion behaviour of coated layer can be formed. Albayrak et al. [92] have reported the same technique used by Yuan and Golden [89]. Titanium oxide (TiO2) was introduced as an oxide layer on the Ti6Al4V substrate prior HAp coating. The coated substrates with the presence of TiO2 had the thickness about 30 μm and were soaked for 1 min with different voltages as 10, 20, and 50 V. With decreasing the voltage value, the result showed an increment of adhesion strength. Comparison of the adhesion strength between electrodeposition methods was listed in \nTable 1\n.
\nComposition | \nThickness (μm) | \nAdhesion strength (MPa) | \nReference | \n
---|---|---|---|
CoCrMo + HAp | \n0.2 | \n17.5 | \n[66] | \n
1. Ti6Al4V + HAp (flake-shaped) | \n10 | \n6.8 | \n[83] | \n
2. Ti6Al4V + HAp (spherical) | \n10 | \n10.7 | \n\n |
3. Ti6Al4V + sHAp/CNT-Ti | \n10 | \n10.6 | \n\n |
4. Ti6Al4V + HAp (needle-shaped) | \n10 | \n8.5 | \n\n |
1. Ti + HAp (without oxidation) | \n3 | \n5.0 | \n[82] | \n
2. Ti + HAp (with oxidation) | \n3 | \n7.3 | \n\n |
1. Ti + HAp | \n10 | \n15.3 | \n[88] | \n
2. Ti + SWNTs/HAp | \n10 | \n25.7 | \n\n |
1. Ti6Al4V + HAp | \n30 | \n13.8 | \n[92] | \n
2. Ti6Al4V + TiO2 (10 V)/HAp | \n30 | \n21.0 | \n\n |
3. Ti6Al4V + TiO2 (20 V)/HAp | \n30 | \n13.1 | \n\n |
4. Ti6Al4V + TiO2 (50 V)/HAp | \n30 | \n11.9 | \n\n |
Values of adhesion strength of HAp coatings deposited by electrodeposition process [33].
In conclusion, HAp coatings conducted via electrochemical deposition technique are formed progressively by nucleation and growth processes and lead to form a uniform structure. The electrochemical deposition technique can form a broad range of coating thickness. Also, the electrochemical deposition process decreases the corrosion behaviour of the substrate through the coating. Consistently, sintering procedure enhances densification, bonding and adhesion behaviours of the coating. An interlayer between the substrate and the coating has been introduced to overwhelm the issue of HAp decomposition. Therefore, the electrochemical deposition technique can be one of great guarantee of the future edition for metallic biomaterials.
\nCurrently, High-Velocity Oxygen-Fuel (HVOF) flame spraying method has been advanced. The method gives promising results regarding allowing the formation of suspension spraying layer [93, 94, 95]. By introducing the axial powder injection, the new high-velocity suspension flame spraying (HVSFS) process typically would be able to resolve the injection complications [96, 97, 98]. Regarding this, the highest velocity of the particle would be able to produce better coating protection with low porosity. This innovative suspension thermal spray technique is ideally becoming the most in-demand technique in depositing a thin layer of coating on the substrate [99, 100]. In comparison to the other method such as electrophoretic coating for pure HAp, the coating does not require any heat treatment or post-deposition for consolidation. Furthermore, the method features relatively lower processing cost with high and efficient productivity [101, 102]. As compared to conventional dry powders, the suspension based feedstock could ignite more flexibility in creating new composite materials by altering the material compositions in which controlling the primary particle morphology [103, 104]. Furthermore, a fine powder particle either in micro- or nano-sized particles could be fabricated by thermal spray community. The method enables direct delivery of the particles into the gas or plasma jet. Direct processing of fine particles dispersed in liquid solvent significantly yield smaller lamella size of the coating layer that depends on the standard parameters of spray powder processing [105].
\nHVSFS technique could produce high-quality and low-thickness coatings especially when the layer thickness is below 50 μm [96, 106]. The development of the system does indeed fill in the gap between conventional thermal spraying and thin-film technologies (PVD, CVD). The thinner coatings produced from this technique usually contain less residual stress with minimising risks of delamination [107, 108]. The coated properties especially the one involves bonding strength between the substrate and coated layer produced from HVSFS techniques tends to be affected severely due to the effect of processing parameters such as gas flow, air-fuel ratio spray distance, and electric arc current. As reported by Gadow et al., [106], bioceramic coatings could be based on dry spray HAp powder used for HVOF and APS nanoscale and HAp suspension (water-based) for HVSFS.
\nBy introducing different suspension solution medium such as diethylene glycol (DEG) as a substitute of water suspension, the result of the adhesion strength of the HAp coatings is enhanced and supposed to be superior [106]. The DEG-based solution increases the adhesion strength compared to the water-based suspension. In fact, DEG-based suspension offers many advances properties such as low interlayer porosity with denser coatings. The resulting condition is due to the higher adhesion strength. The maximum adhesion strength is around 25 N/mm2 as reported for HVSFS-HAp coating [106]. Additional of TiO2 layer acts as a thermal insulating layer onto commercially pure Ti slows down heat extraction from the deposited material to the substrate [109, 110]. The HVSFS deposited HAp coatings are typically dense with 27–37 μm in thickness and some transverse micro-cracks. Even the crystallinity characteristic is of between 10 and 70%, depending on the deposition parameters and the amount of a TiO2 concentration. The adhesion strength between the metal substrate and HAp coating enhanced due to the presence of TiO2 layer as shown in \nFigure 1\n.
\nAdhesion strength of the HVSFS-deposited HAp coatings [
The APS, HVOF and HVSFS methods are extensively practised for HAp coating processes especially the one involves Ti metal as substrates [111, 112]. The processing parameters such as gas flow, air-fuel ratio, electric arc current and spray distance are the primary factor in determining the coating properties performance concerning the adhesion strength between substrate and coating of these thermal spraying techniques [113, 114]. The increment of the flow rate of oxygen enhances the behaviour of the coating composite. Besides that, fuel flow rate also plays a significant role in influencing the coating performance. Increasing oxygen flow rate along with fuel flow rate leads to higher adhesion strength. Other than that, reducing the spray distance also brings to stronger adhesion strength [98, 104, 115].
\nThe choice of metallic biomaterials such as 316L stainless steel, cobalt-based alloy, titanium and its alloys will continue to be used extensively in the medical field as medical implants due to their excellent mechanical properties and adaptability within the physiological environment. Currently, a major issue of metallic implants is the failure to perfect pair to the local tissue environment in the human body. This inharmonious is due to the different chemical compositions between metallic implants and human bone. The surface modification of the metal-based materials via four common coating techniques namely plasma-spray, sol-gel, dip-coating, electrochemical deposition and high-velocity suspension plasma-spraying (HVSPS) was introduced to enhance bioactivity, to prevent wear and corrosion and to control harmful metal ions released into the body. It is proven that the surface modification via coating can succeed the limitation of the metallic biomaterials.
\nAuthors would like to acknowledge the kind assistantship from the Green Research for Advanced Materials Laboratory (GRAMsLab) and Human Engineering Group (HEG), Universiti Malaysia Pahang (UMP). This work was supported by the Qatar National Research Fund NPRP88762375 (UIC161504), internal grant of Universiti Malaysia Pahang RDU140354, RDU160337, and the support of Research Acculturation Grant Scheme provided by the Ministry of Higher Education, Malaysia RDU151404.
\nAtrial fibrillation is the most frequent sustained cardiac arrhythmia in adults.
It has two differential characteristics, one electrocardiographic and another clinical.
Clinically it is characterized by an irregularly irregular pulse, due to a supraventricular tachycardia producing a chaotic atrial activity. In addition, the electrocardiogram (ECG) shows the following defining characteristics [1]:
Irregular R-R interval
Absence of P waves
Irregular atrial activation (f waves)
Nowadays, the prevalence of this arrhythmia is rising due to, among to other causes, the increase in life expectancy and the effort to diagnose it. [2] In addition to the importance of this fact, AF has a special relevance resulting from its treatments and its complications, existing multiple pharmacologic treatments to control the harmful effects of this arrhythmia on patients. However, there are alternatives to pharmacological treatments that we would like to summarize in this chapter.
To be considered as AF, the arrhythmia must be documented by ECG and lasts >30 seconds [3]. If these two features are met, the arrhythmia is called clinical AF, and if not, the arrhythmia is considered as an rapid atrial rate episode or subclinical AF.
Based on the time of evolution, the AF is classified as [4]:
First diagnosed AF: AF has not been diagnosed before.
Paroxysmal AF: self-terminated or cardioverted within 7 days.
Persistent AF: AF that lasts longer than 7 days, but it is still considered rhythm control strategy.
Permanent AF: Rate control but not rhythm control is pursued.
There are a number of factors that predispose to AF, including [5, 6, 7]:
Older age
High blood pressure
Type 2 diabetes mellitus
Heart failure
Coronary disease
Chronic kidney disease
Obesity
Obstructive sleep apnea
These risk factors contribute to the damage in the atrial as changes in the structure, architecture, contractility, and electrophysiology that may lead to the dilatation, fibrosis, dysfunction, and distortion conduction in the left atrial. This cumulative damage is the substrate on which atrial fibrillation develops [8].
Diagnosis of AF requires rhythm documentation on an ECG showing this arrhythmia lasting at least 30 seconds. There are other ways to detect AF that will require further diagnostic confirmation by performing a 12-lead ECG and interpretation by an experienced physician.
There are multiple tools that can be used to screen for atrial fibrillation:
Blood pressure monitor
Pulse palpation
ECG Holter monitor
Single-lead ECG
Implanted cardiac devices
Hospital telemetry/noninvasive long-term ECG monitoring
Smartwatches
Mobile devices
Most recently, mobile devices are increasingly being used as screening tools as they are becoming easy to use and are widely distributed among the population.
These devices perform the interpretation of the electrical tracing through applications. Currently there are studies carried out by the different companies that manufacture mobile devices. (e.g., Estudio Apple Heart) [9, 10].
The opportunistic AF screening with these devices is cost-effective, but the diagnostic efforts must be done in those high-risk patients, who are those older than 65 years and at risk of stroke [9, 11].
AF treatment is fundamentally based on rhythm and heart rate control and its thrombotic complications. Lately, multiple drugs and therapeutic attitudes have been developed for this purpose. In this section, we will show a few hints about nonpharmacological treatments for atrial fibrillation, often less known and used than conventional treatments, which are much more widespread.
AF increases the risk of cardioembolic events. There are several scales to quantify this risk, and the most widely used is the CHA2DS2-VASC scale. Only the patients with low risk would not need to take preventive treatment [12].
Anticoagulant treatments are the most known choice to prevent cardioembolic events secondary to AF. These include vitamin-K-dependent (AVK) and nondependent (NAVK) anticoagulants. However, there is a nonpharmacological alternative for stroke prevention, the surgical left atrial appendage occlusion (LAAO) or exclusion. This technique has shown to be noninferior to VKA anticoagulation for stroke prevention in patients with AF and moderate risk of stroke [13].
This technique is reserved for patients with absolute contraindications to pharmacological anticoagulation. The contraindications are as follows [14]:
Severe active bleeding
Severe thrombocytopenia
Severe anemia
Very high risk of bleeding risk
There are two main techniques to LAA occlusion/exclusion, either by devices or by cardiac surgery. The last one is left as an alternative when invasive treatment is to be performed, such as cardiac surgery for another cause or when surgical ablation of AF is performed [15].
These techniques has the advantage that they will not require subsequent anticoagulation, so they are exempt from the hemorrhagic complications derived from anticoagulant treatment maintained over time. On the other hand, these patients will need antiplatelet treatment for life [16].
This is one of the mainstay established in the AF control. As the name suggests, this measure aims to control the patient’s heart rate without attempting to restore sinus rhythm, allowing AF to remain.
However, there is a serious controversy among the targets set out because to date it has not been established which attitude is more favorable for the patient, strict heart rate (HR) control <80 bpm, or a more permissive one <110 bpm [17]. Nevertheless, there is certainty that the heart rate should be controlled at the acute moment when it produces hemodynamic instability as quickly as possible and with fewer side effects for the patient.
Pharmacological treatments are the first-line treatments, and there is a wide range of therapeutic families from which to choose the best alternative. When pharmacological treatment fails, there is another alternative, such as atrioventricular node ablation and subsequent implantation of a pacemaker [18]. The efficacy of the procedure improves when the pacemaker is implanted a few weeks before the AV nodal ablation, and the initial pacing rate after ablation is set at 70–90 bpm [19].
Within this technique there are variants because in patients with permanent AF hospitalized due to heart failure, it can be considered the implantation of resynchronization devices or even the His bundle pacing [19, 20].
This is the last mainstay we will deal with in this review. As in the previous section, there are several pharmacological treatments approved for this purpose, but we also have available nonpharmacological treatments with proved efficacy.
The fundamental purpose to rhythm control is to reduce symptoms related to AF and improve patients’ quality of life. In addition, it reduces the AF progression rate and the deleterious anatomopathological changes caused by AF on the myocardium [21, 22].
Among the nonpharmacological options to try to keep patients in sinus rhythm, we would like to outline the electrical cardioversion, AF ablation, and AF surgery.
This technique has the advantage of allowing immediate cardioversion, which makes it the technique of choice in patients with hemodynamically unstable AF, although it is also used for elective cardioversion. It is faster and more effective than pharmacological cardioversion [23, 24].
Electrical cardioversion is performed with directly and synchronous biphasic defibrillators with maximum power and placing the electrodes in an anteroposterior position [23, 25].
This is a painful procedure, and it is not exempt from complications. For this reason, the patient must be properly sedated and monitored in order to be able to handle any incidents that may arise [26].
This is a very effective technique, but there are factors that increase the risk of recurrence after cardioversion [27]:
Older age
Female sex
Previous failed cardioversion
Chronic obstructive pulmonary disease
Renal failure
Structural cardiopathy
Heart failure
Dilated left atria
Catheter ablation is a recognized technique for preventing AF recurrence, but there are several factors that increase the risk of failure [28, 29]:
Older age
Renal disease
Left atrial size
AF duration
AF substrate in an MRI study
Intensive control of AF risk factors could decrease the AF recurrence rate after ablation [30].
The aim of ablation is to improve patients’ symptoms and quality of life, as it has not demonstrated in general population to reduce neither patients’ mortality nor preventing cardioembolic events or bleedings related to pharmacologic treatment [31]. However, it has shown benefits in selected population as they are patients with heart failure and depressed ventricular ejection fraction and also when AF-mediated tachycardia induced cardiomyopathy is suspected, because in these cases can improve the left ventricular function [31, 32].
Therefore, the indications for catheter ablation of AF are as follows:
Second-line treatment after anti-arrhythmic medications
Paroxysmal or recurrent AF in patients without recurrence risk factors
Ablation versus pharmacological treatment as first-line treatment of paroxysmal AF has shown to have a lower recurrent atrial arrhythmias rate, similar risk of serious adverse events, and lower consumption of healthcare resources [33].
The technique consists of the complete electrical pulmonary veins isolation by sequential ablation with radiofrequency or cryoablation around the atrioventricular junction or with single-discharge devices, although electrical isolation is very difficult, so if the point of origin of the arrhythmia is not detected, more extensive ablations tend to be performed [34, 35]. The procedure is not exempted of complications, even though they are unfrequent: periprocedure death, esophageal perforation, thromboembolism, cardiac tamponade, pulmonary veins stenosis, phrenic nerve permanent paralysis… [36].
The technique of choice is the COX procedure, which, like ablation, has an impact on patients’ quality of life, but not on the other indicators [37]. Recurrence risk factors are also overlappable to those of AF catheter ablation.
AF surgery is usually performed in the context of other cardiac surgery, such as mitral valve repair, but can also be performed in isolation demonstrating less need for repeat procedure than in cases where ablation was performed, but with longer hospital stays and more frequent complications [38, 39].
Surgery can also be concomitantly performed with ablation, improving the results respect to both techniques separately, but having more complications than when ablation is done alone [24].
Thrombotic events prevention:
Left atrial appendage occlusion or exclusion: recommended in patients with contraindications to anticoagulation therapies.
Rate control:
Atrioventricular node ablation and subsequent implantation of a pacemaker: recommended in selected patients when pharmacologic treatment is ineffective or contraindicated.
Rhythm control:
Electric cardioversion:
Urgent: performed in patients with hemodynamic instability
Elective: performed in patients in whom pharmacological treatment has failed
Catheter ablation:
Second-line therapy after pharmacologic treatment
First-line treatment in selected patients
AF surgery: recommended in patients who are already undergoing cardiac surgery for another reason. For example, mitral valve prosthetic replacement.
Hybrid technique of AF surgery and ablation: recommended for refractory cases.
After this review, we can conclude that the procedures of choice for the treatment of atrial fibrillation are the less invasive, so the fundamental pillar remains pharmacological treatments. However, there are a number of alternatives that can be used when pharmacological treatments fail, when they are contraindicated or in electively, so we have to keep them in mind to enrich our therapeutic arsenal. Moreover, these techniques are a safe and effective solution and are widely supported by the literature.
The authors declare no conflict of interest.
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She graduated from Gazi University Faculty of Dentistry, Ankara, Turkey in 2000. \r\nLater she received her Ph.D. degree from the Oral Diagnosis and Radiology Department; which was recently renamed as Oral and Dentomaxillofacial Radiology, from the same university. \r\nShe is working as a full-time Associate Professor and is a lecturer and an academic researcher. \r\nHer expertise areas are dental caries, cancer, dental fear and anxiety, gag reflex in dentistry, oral medicine, and dentomaxillofacial radiology.",institutionString:"Gazi University",institution:{name:"Gazi University",institutionURL:null,country:{name:"Turkey"}}}]},{type:"book",id:"7139",title:"Current Approaches in Orthodontics",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/7139.jpg",slug:"current-approaches-in-orthodontics",publishedDate:"April 10th 2019",editedByType:"Edited by",bookSignature:"Belma Işık Aslan and Fatma Deniz Uzuner",hash:"2c77384eeb748cf05a898d65b9dcb48a",volumeInSeries:2,fullTitle:"Current Approaches in Orthodontics",editors:[{id:"42847",title:"Dr.",name:"Belma",middleName:null,surname:"Işik Aslan",slug:"belma-isik-aslan",fullName:"Belma Işik Aslan",profilePictureURL:"https://mts.intechopen.com/storage/users/42847/images/system/42847.jpg",biography:"Dr. Belma IşIk Aslan was born in 1976 in Ankara-TURKEY. 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Having been personally trained by Dr. Robert Kerstein on this method, Dr. Gözler has been lecturing on the T-Scan Occlusion Analysis Method in conferences both in Turkey and abroad. Dr. Gözler has various articles and presentations on Digital Occlusion Analysis methods. 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Dr. Al Ostwani is an assistant professor and faculty member at IUST University since 2014. \nDuring his academic experience, he has received several awards including the scientific research award from the Union of Arab Universities, the Syrian gold medal and the international gold medal for invention and creativity. Dr. Al Ostwani is a Member of the International Association of Dental Traumatology and the Syrian Society for Research and Preventive Dentistry since 2017. 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