Strategies for Optimizing the Soft Tissue Seal around Osseointegrated Implants

Surface modification strategies to reinforce the soft tissue seal at transmucosal region of dental implants

Soft tissue seal around the transmucosal region of dental implants is crucial for shielding oral bacterial invasion and guaranteeing the long-term functioning of implants. Compared with the robust periodontal tissue barrier around a natural tooth, the peri-implant mucosa presents a lower bonding efficiency to the transmucosal region of dental implants, due to physiological structural differences. As such, the weaker soft tissue seal around the transmucosal region can be easily broken by oral pathogens, which may stimulate serious inflammatory responses and lead to the development of peri-implant mucositis. Without timely treatment, the curable peri-implant mucositis would evolve into irreversible peri-implantitis, finally causing the failure of implantation. Herein, this review has summarized current surface modification strategies for the transmucosal region of dental implants with improved soft tissue bonding capacities (e.g., improving surface wettability, fabricating micro/nano topographies, altering the surface chemical composition and constructing bioactive coatings). Furthermore, the surfaces with advanced soft tissue bonding abilities can be incorporated with antibacterial properties to prevent infections, and/or with immunomodulatory designs to facilitate the establishment of soft tissue seal. Finally, we proposed future research orientations for developing multifunctional surfaces, thus establishing a firm soft tissue seal at the transmucosal region and achieving the long-term predictability of dental implants.

Unveiling the governing role of 'remodeling triangle area' in soft-hard tissue interface equilibrium for metal implants advancement

Metal implants holds significant promise for diverse fixed prostheses. However, their long-term reliability and broader application are hindered by challenges related to the disequilibrium at the soft-hard tissue interface. By using anti-inflammatory (PDA/IL4) and pro-inflammatory (PDA/LPS/IFNγ) coatings to modulate distinct immune characteristics, we discovered a dynamic bioactive structure at the soft-hard tissue interface around metal implant, which we have named the 'Remodeling Triangle Area' (RTA). We further demonstrate that the RTA can be influenced by the PDA/IL4 coating to favor a phenotype that enhances both innate and adaptive immunity. This leads to stronger epithelial adhesion, the formation of dense connective tissue via IGF1 secretion, and a more balanced soft-hard tissue interface through the OPG/RANKL axis. Conversely, the PDA/LPS/IFNγ coating shifts the RTA towards a phenotype that activates the innate immune response. This results in a less cohesive tissue structure and bone resorption, characterized by reduced IGF1 secretion and an imbalanced OPG/RANKL axis. Over all, our study introduces the novel concept termed the 'Remodeling Triangle Area' (RTA), an immune-rich anatomical region located at the nexus of the implant interface, epithelial, connective, and bone tissue, which becomes highly interactive post-implantation to modulate the soft-hard tissue interface equilibrium. We believe that an RTA-centric, immunomodulatory approach has the potential to revolutionize the design of next-generation metal implants, providing unparalleled soft-hard tissue interface equilibrium properties.

Interfacial delivery of carbon monoxide via smart titanium implant coating for enhanced soft tissue integration with switchable antibacterial and immunomodulatory properties

Soft tissue integration around titanium (Ti) implants is weaker than that around natural teeth, compromising long-term success of Ti implants. Carbon monoxide (CO) possesses distinctive therapeutic properties, rendering it as a highly promising candidate for enhancing STI. However, achieving controlled CO generation at the STI interface remains challenging. Herein, a controlled CO-releasing dual-function coating was constructed on Ti surfaces. Under near-infrared (NIR) irradiation, the designed surface could actively accelerate CO generation for antibiosis against both aerobic and anaerobic bacteria. More importantly, in the absence of NIR, the slow release of CO induces macrophage polarization from pro-inflammatory phenotype towards pro-regenerative phenotype. In a rat implantation model with induced infection, the designed surface effectively controlled the bacterial infection, alleviates accompanying inflammation and modulated immune microenvironment, leading to enhanced STI. Single-cell sequencing revealed that the coating alters the cytokine profile within the soft tissue, thereby influencing cellular functions. Differentially expressed genes in macrophages are highly enriched in the PIK3-Akt pathway. Furthermore, the cellular communication between fibroblasts and macrophages was significantly enhanced through the CXCL12/CXCL14/CXCR4 and CSF1-CSF1R ligand-receptor pair. These findings indicate that our coating showed an appealing prospect for enhancing STI around Ti implants, which would ultimately contribute to the improved long-term success of Ti implants.

L-arginine loading porous PEEK promotes percutaneous tissue repair through macrophage orchestration

Infection and poor tissue repair are the key causes of percutaneous implantation failure. However, there is a lack of effective strategies to cope with due to its high requirements of sterilization, soft tissue healing, and osseointegration. In this work, l-arginine (L-Arg) was loaded onto a sulfonated polyetheretherketone (PEEK) surface to solve this issue. Under the infection condition, nitric oxide (NO) and reactive oxygen species (ROS) are produced through catalyzing L-Arg by inducible nitric oxide synthase (iNOS) and thus play a role in bacteria sterilization. Under the tissue repair condition, L-Arg is catalyzed to ornithine by Arginase-1 (Arg-1), which promotes the proliferation and collagen secretion of L929 and rBMSCs. Notably, L-Arg loading samples could polarize macrophages to M1 and M2 in infection and tissue repair conditions, respectively. The results in vivo show that the L-Arg loading samples could enhance infected soft tissue sealing and bone regeneration. In summary, L-Arg loading sulfonated PEEK could polarize macrophage through metabolic reprogramming, providing multi-functions of antibacterial abilities, soft tissue repair, and bone regeneration, which gives a new idea to design percutaneous implantation materials.

A rechargeable coating with temporal-sequence antibacterial activity and soft tissue sealing

Transcutaneous implants that penetrate through skin or mucosa are susceptible to bacteria invasion and lack proper soft tissue sealing. Traditional antibacterial strategies primarily focus on bacterial eradication, but excessive exposure to bactericidal agents can induce noticeable tissue damage. Herein, a rechargeable model (HPI-Ti) was constructed using perylene polyimide, an aqueous battery material, achieving temporal-sequence regulation of bacterial killing and soft tissue sealing. Charge storage within HPI-Ti is achieved after galvanostatic charge, and chemical discharge is initiated when immersed in physiological environments. During the early discharge stage, post-charging HPI-Ti demonstrates an antibacterial rate of 99.96 ± 0.01 % for 24 h, preventing biofilm formation. Contact-dependent violent electron transfer between bacteria and the material causes bacteria death. In the later discharge stage, the attenuated discharging status creates a gentler electron-transfer micro-environment for fibroblast proliferation. After discharge, the antibacterial activity can be reinstated by recharge against potential reinfection. The antibacterial efficacy and soft tissue compatibility were verified in vivo. These results demonstrate the potential of the charge-transfer-based model in reconciling antibacterial efficacy with tissue compatibility.

A Standardized Rat Model to Study Peri-implantitis of Transmucosal Osseointegrated Implants

With the high incidence rate, distinctive implant characteristic and unique infection pattern, peri-implantitis (PI) requires a specially designed implant animal model for the researches on the pathogenesis and treatments. Previous small-animal PI models exhibit variability in implant site selection, design, and surgical procedures resulting in unnecessary tissue damage and less effectivity. Herein, a quantitative-analysis-based standardized rat model for transmucosal PI-related research was proposed. After dissecting the anatomic structures of the rat maxilla, we determined that placing the implant anterior to the molars in the rat maxilla streamlined the experimental period and enhanced animal welfare. We standardized the model by controlling the rat strain, gender, and size. The customized implant and a series of matched surgical instruments were appropriately designed. A clear, step-by-step surgical process was established. These designs ensured the success rate, stability, and replicability of the model. Each validation method confirmed the successful construction of the model. This study proposed a quantitative-analysis-based standardized transmucosal PI rat model with improved animal welfare and reliable procedures. This model could provide efficient in vivo insights to study the pathogenesis and treatments of PI and preliminary screening data for further large-animal and clinical trials.

Surface Topography Steer Soft Tissue Response and Antibacterial Function at the Transmucosal Region of Titanium Implant

Metallic dental implants have been extensively used in clinical practice due to their superior mechanical properties, biocompatibility, and aesthetic outcomes. However, their integration with the surrounding soft tissue at the mucosal region remains challenging and can cause implant failure due to the peri-implant immune microenvironment. The soft tissue integration of dental implants can be ameliorated through different surface modifications. This review discussed and summarized the current knowledge of topography-mediated immune response and topography-mediated antibacterial activity in Ti dental implants which enhance soft tissue integration and their clinical performance. For example, nanopillar-like topographies such as spinules, and spikes showed effective antibacterial activity in human salivary biofilm which was due to the lethal stretching of bacterial membrane between the nanopillars. The key findings of this review were (I) cross-talk between surface nanotopography and soft tissue integration in which the surface nanotopography can guide the perpendicular orientation of collagen fibers into connective tissue which leads to the stability of soft tissue, (II) nanotubular array could shift the macrophage phenotype from pro-inflammatory (M1) to anti-inflammatory (M2) and manipulate the balance of osteogenesis/osteoclasia, and (III) surface nanotopography can provide specific sites for the loading of antibacterial agents and metallic nanoparticles of clinical interest functionalizing the implant surface. Silver-containing nanotubular topography significantly decreased the formation of fibrous encapsulation in per-implant soft tissue and showed synergistic antifungal and antibacterial properties. Although the Ti implants with surface nanotopography have shown promising in targeting soft tissue healing in vitro and in vivo through their immunomodulatory and antibacterial properties, however, long-term in vivo studies need to be conducted particularly in osteoporotic, and diabetic patients to ensure their desired performance with immunomodulatory and antibacterial properties. The optimization of product development is another challenging issue for its clinical translation, as the dental implant with surface nanotopography must endure implantation and operation inside the dental microenvironment. Finally, the sustainable release of metallic nanoparticles could be challenging to reduce cytotoxicity while augmenting the therapeutic effects.

Soft and Hard Tissue Integration around Percutaneous Bone-Anchored Titanium Prostheses: Toward Achieving Holistic Biointegration

A holistic biointegration of percutaneous bone-anchored metallic prostheses with both hard and soft tissues dictates their longevity in the human body. While titanium (Ti) has nearly solved osseointegration, soft tissue integration of percutaneous metallic prostheses is a perennial problem. Unlike the firm soft tissue sealing in biological percutaneous structures (fingernails and teeth), foreign body response of the skin to titanium (Ti) leads to inflammation, epidermal downgrowth and inferior peri-implant soft tissue sealing. This review discusses various implant surface treatments/texturing and coatings for osseointegration, soft tissue integration, and against bacterial attachment. While surface microroughness by SLA (sandblasting with large grit and acid etched) and porous calcium phosphate (CaP) coatings improve Ti osseointegration, smooth and textured titania nanopores, nanotubes, microgrooves, and biomolecular coatings encourage soft tissue attachment. However, the inferior peri-implant soft tissue sealing compared to natural teeth can lead to peri-implantitis. Toward this end, the application of smart multifunctional bioadhesives with strong adhesion to soft tissues, mechanical resilience, durability, antibacterial, and immunomodulatory properties for soft tissue attachment to metallic prostheses is proposed.

Effects of the application of low-temperature atmospheric plasma on titanium implants on wound healing in peri-implant connective tissue in rats

PURPOSE

This study aimed to clarify the effects of surface modification of titanium (Ti) implants by low-temperature atmospheric pressure plasma treatment on wound healing and cell attachment for biological sealing in peri-implant soft tissue.

METHODS

Hydrophilization to a Ti disk using a handheld low-temperature atmospheric pressure plasma device was evaluated by a contact angle test and compared with an untreated group. In in vivo experiments, plasma-treated pure Ti implants using a handheld plasma device (experimental group: PL) and untreated implants (control group: Cont) were placed into the rat upper molar socket, and samples were harvested at 3, 7 and 14 days after surgery. Histological evaluation was performed to assess biological sealing, collagen- and cell adhesion-related gene expression by reverse transcription quantitative polymerase chain reaction, collagen fiber detection by Picrosirius Red staining, and immunohistochemistry for integrins.

RESULTS

In in vivo experiments, increased width of the peri-implant connective tissue (PICT) and suppression of epithelial down growth was observed in PL compared with Cont. In addition, high gene expression of types I and XII collagen at 7 days and acceleration of collagen maturation was recognized in PL. Strong immunoreaction of integrin α2, α5, and β1 was observed at the implant contact area of PICT in PL.

CONCLUSIONS

The handheld low-temperature atmospheric pressure plasma device provided hydrophilicity on the Ti surface and maintained the width of the contact area of PICT to the implant surface as a result of accelerated collagen maturation and fibroblast adhesion, compared to no plasma application.

ε-Poly-l-lysine-hydroxyphenyl propionic acid/IL-4 composite hydrogels with inflammation regulation and antibacterial activity for improving integration stability of soft tissues and orthopedic implants

The failure of orthopedic implants is usually caused by inflammation, poor tissue integration, and infection, which can lead to pain, limited mobility, dysfunction of patients. This may require additional surgical interventions, such as removal, replacement, or repair of implants, as well as related treatment measures such as antibiotic therapy, physical therapy. Here, an injectable hydrogel carrier was developed for the steady release of inflammatory regulators to reduce the surface tissue inflammatory response of orthopedic implants and induce soft tissue regeneration, ultimately achieving the promotion of implants stability. The hydrogels carrier was prepared by hydroxyphenyl propionic acid-modified ε-Poly-l-lysine (EPA), hydrogen peroxide and horseradish peroxidase, which showed antibacterial bioactive and stable factor release ability. Due to the introduction of IL-4, EPA@IL-4 hydrogels showed good inflammatory regulation. EPA@IL-4 hydrogels regulated the differentiation of macrophages into M2 in inflammatory environment in vitro, and promoted endothelial cells to show a more obvious trend of tube formation. The composite hydrogels reduced the inflammation on the surface of the implants in vivo, induced local endothelial cell angiogenesis, and had more collagen deposition and new granulation tissue. Therefore, EPA hydrogels based on IL-4 release are promising candidates for promoting of implants surface anti-inflammatory, soft tissue regeneration, and anti-infection.

Fluoride releasing photothermal responsive TiO2 matrices for antibiosis, biosealing and bone regeneration

Peri-implantitis induced by infection leads to gingival recession, alveolar resorption and eventual dental implant failure. So, antibiosis and biosealing of abutments as well as osseointegration of roots need to be projected seriously during the whole service lifespan of dental implants. In this work, a multipurpose photothermal therapy strategy based on Si/P/F doped TiO2 matrix is proposed to address the above issues. This TiO2 matrix not only has outstanding photothermal response, but also triggers the release of F ions under near-infrared (NIR) light irradiation. Local hyperthermia assisted with the released F ions reduces adenosine triphosphate (ATP) synthesis of staphylococcus aureus (S. aureus), increases bacterial membrane permeability, and induces abundant of reactive oxygen species, resulting in the oxidation of cellular components and eventual death of bacteria. Furthermore, the synergic action of mild photothermal stimulation and Si/P/F ions of TiO2 matrix up-regulates gingival epithelial cells behavior (e.g., hemidesmosome formation) and osteoblasts response in vitro. In an infected model, this TiO2 matrix obviously eliminates bacteria, reduces inflammatory response, improves epithelial sealing and osseointegration, and reduces alveolar resorption by regulating NIR irradiation.

CREB3L2 Regulates Hemidesmosome Formation during Epithelial Sealing

The long-term success rate of dental implants can be improved by establishing a favorable biological sealing with a high-quality epithelial attachment. The application of mesenchymal stem cells (MSCs) holds promise for facilitating the soft tissue integration around implants, but the molecular mechanism is still unclear and the general application of MSC sheet for soft tissue integration is also relatively unexplored. We found that gingival tissue-derived MSC (GMSC) sheet treatment significantly promoted the expression of hemidesmosome (HD)-related genes and proteins in gingival epithelial cells (GECs). The formation of HDs played a key role in strengthening peri-implant epithelium (PIE) sealing. Further, high-throughput transcriptome sequencing showed that GMSC sheet significantly upregulated the PI3K/AKT pathway, confirming that cell adhesion and HD expression in GECs were regulated by GMSC sheet. We observed that the expression of transcription factor CREB3L2 in GECs was downregulated. After treatment with PI3K pathway inhibitor LY294002, CREB3L2 messenger RNA and protein expression levels were upregulated. Further experiments showed that overexpression or knockdown of CREB3L2 could significantly inhibit or promote HD-related genes and proteins, respectively. We confirmed that CREB3L2 was a transcription factor downstream of the PI3K/AKT pathway and participated in the formation of HDs regulated by GMSC sheet. Finally, through the establishment of early implant placement model in rats, we clarified the molecular function of CREB3L2 in PIE sealing as a mechanical transmission molecule in GECs. The application of GMSC sheet-implant complex could enhance the formation of HDs at the implant-PIE interface and decrease the penetration distance of horseradish peroxidase between the implant and PIE. Meanwhile, GMSC sheet reduced the length of CREB3L2 protein expression on PIE. These findings elucidate the potential function and molecular mechanism of MSC sheet regulating the epithelial sealing around implants, providing new insights and ideas for the application of stem cell therapy in regenerative medicine.

Effects of Hypochlorous Acid and Hydrogen Peroxide Treatment on Bacterial Disinfection Treatments in Implantoplasty Procedures

One of the main problems in oral implantology today is peri-implantitis, which affects almost 20% of dental implants placed in patients. One of the most commonly used techniques to eliminate bacterial biofilm is the implantoplasty, that consists of the mechanical modification of the implant surface topography followed by treatments with chemical reagents for decontamination. In this study, the main aim is to evaluate the use of two different chemical treatments based on hypochlorous acid (HClO) and hydrogen peroxide (H₂O₂). For this purpose, 75 titanium grade 3 discs were treated with implantoplasty according to established protocols. Twenty-five discs were used as controls, 25 were treated with concentrated HClO and 25 were treated with concentrated HClO followed by treatment with 6% H₂O₂. The roughness of the discs was determined using the interferometric process. Cytotoxicity with SaOs-2 osteoblastic cells was quantified at 24 and 72 h, whereas bacteria proliferation using S. gordonii and S. oralis bacteria was quantified at 5 s and 1 min of treatment. The results showed an increase in the roughness values, the control discs had an Ra of 0.33 μm and those treated with HClO and H₂O₂ reached 0.68 μm. Cytotoxicity was present at 72 h, together with a significant proliferation of bacteria. These biological and microbiological results can be attributed to the roughness produced by the chemical agents that triggered bacterial adsorption while inhibiting osteoblast adhesion. The results indicate that even if this treatment can decontaminate the titanium surface after implantation, the produced topography will generate an environment that will not favor long-term performance.

Immunomodulatory IL-23 receptor antagonist peptide nanocoatings for implant soft tissue healing

OBJECTIVE

Peri-implantitis, caused by an inflammatory response to pathogens, is the leading cause of dental implant failure. Poor soft tissue healing surrounding implants - caused by inadequate surface properties - leads to infection, inflammation, and dysregulated keratinocyte and macrophage function. One activated inflammatory response, active around peri-implantitis compared to healthy sites, is the IL-23/IL-17A cytokine axis. Implant surfaces can be synthesized with peptide nanocoatings to present immunomodulatory motifs to target peri-implant keratinocytes to control macrophage polarization and regulate inflammatory axises toward enhancing soft tissue healing.

METHODS

We synthesized an IL-23 receptor (IL-23R) noncompetitive antagonist peptide nanocoating using silanization and evaluated keratinocyte secretome changes and macrophage polarization (M1-like "pro-inflammatory" vs. M2-like "pro-regenerative").

RESULTS

IL-23R antagonist peptide nanocoatings were successfully synthesized on titanium, to model dental implant surfaces, and compared to nonfunctional nanocoatings and non-coated titanium. IL-23R antagonist nanocoatings significantly decreased keratinocyte IL-23, and downstream IL-17A, expression compared to controls. This peptide noncompetitive antagonistic function was demonstrated under lipopolysaccharide stimulation. Large scale changes in keratinocyte secretome content, toward a pro-regenerative milieu, were observed from keratinocytes cultured on the IL-23R antagonist nanocoatings compared to controls. Conditioned medium collected from keratinocytes cultured on the IL-23R antagonist nanocoatings polarized macrophages toward a M2-like phenotype, based on increased CD163 and CD206 expression and reduced iNOS expression, compared to controls.

SIGNIFICANCE

Our results support development of IL-23R noncompetitive antagonist nanocoatings to reduce the pro-inflammatory IL-23/17A pathway and augment macrophage polarization toward a pro-regenerative phenotype. Immunomodulatory implant surface engineering may promote soft tissue healing and thereby reduce rates of peri-implantitis.

On-Off Phagocytosis and Switchable Macrophage Activation Stimulated with NIR for Infected Percutaneous Tissue Repair of Polypyrrole-Coated Sulfonated PEEK

Intelligent control of the immune response is essential for obtaining percutaneous implants with good sterilization and tissue repair abilities. In this study, polypyrrole (Ppy) nanoparticles enveloping a 3D frame of sulfonated polyether ether ketone (SP) surface are constructed, which enhance the surface modulus and hardness of the sulfonated layer by forming a cooperative structure of simulated reinforced concrete and exhibit a superior photothermal effect. Ppy-coated SP could quickly accumulate heat on the surface by responding to 808 nm near-infrared (NIR) light, thereby killing bacteria, and destroying biofilms. Under NIR stimulation, the phagocytosis and M1 activation of macrophages cultured on Ppy-coated SP are enhanced by activating complement 3 and its receptor, CD11b. Phagocytosis and M1 activation are impaired along with abolishment of NIR stimulation in the Ppy-coated SP group, which is favorable for tissue repair. Ppy-coated SP promotes Collagen-I, vascular endothelial growth factor, connective tissue growth factor, and α-actin (Acta2) expression by inducing M2 polarization owing to its higher surface modulus. Overall, Ppy-coated SP with enhanced mechanical properties could be a good candidate for clinical percutaneous implants through on-off phagocytosis and switchable macrophage activation stimulated with NIR.

Generating bioactive and antiseptic interfaces with nano-silver hydroxyapatite-based coatings by pulsed electrochemical deposition for long-term efficient cervical soft tissue sealing

Infections related to osseointegrated implants have sparked the interest in studying titanium modification for long-term effective soft tissue sealing. Constructing a silver (Ag)-hydroxyapatite (HA) coating is regarded as an effective strategy for integrating antibiosis with osteanagenesis; however, the outcome for long-term cervical soft tissue sealing in vivo is compromised. It is challenging to construct an Ag-HA coating for long-term efficient soft tissue integration that instills a maximum antibacterial effect while retaining favorable bioactivity to normal gingival mesenchymal cells in vivo. In this study, we employed gradient concentrations of Ag/CaP by pulsed electrochemical deposition to fabricate optimal Ag-HA nanocoatings. By physicochemical analyses, these uniform coatings were mainly formed with spherical metallic and hydroxyapatite nanoparticles, which facilitated good hydrophilicity, moderate rough surfaces and corrosion protection. Furthermore, the nanocoating of the 1.5Ag/CaP group exhibited superior performances in dental follicle cells' proliferation, osteogenic differentiation and antibacterial properties mainly through direct contact inhibition and partially through sustained silver ion release, which resulted in functional cervical soft tissue sealing in beagles lasting for one year. Our investigations provide a feasible strategy to balance the long-term antibacterial demand and bioactive induction around osseointegrated implants for long-term efficient cervical soft tissue sealing.

Optimization of Lactoferrin-Derived Amyloid Coating for Enhancing Soft Tissue Seal and Antibacterial Activity of Titanium Implants

A poor seal of the titanium implant-soft tissue interface provokes bacterial invasion, aggravates inflammation, and ultimately results in implant failure. To ensure the long-term success of titanium implants, lactoferrin-derived amyloid is coated on the titanium surface to increase the expression of cell integrins and hemidesmosomes, with the goal of promoting soft tissue seal and imparting antibacterial activity to the implants. The lactoferrin-derived amyloid coated titanium structures contain a large number of amino and carboxyl groups on their surfaces, and promote proliferation and adhesion of epithelial cells and fibroblasts via the PI3K/AKT pathway. The amyloid coating also has a strong positive charge and possesses potent antibacterial activities against Staphylococcus aureus and Porphyromonas gingivalis. In a rat immediate implantation model, the amyloid-coated titanium implants form gingival junctional epithelium at the transmucosal region that resembles the junctional epithelium in natural teeth. This provides a strong soft tissue seal to wall off infection. Taken together, lactoferrin-derived amyloid is a dual-function transparent coating that promotes soft tissue seal and possesses antibacterial activity. These unique properties enable the synthesized amyloid to be used as potential biological implant coatings.

The burden of diabetes on the soft tissue seal surrounding the dental implants

Soft tissue seal around implant prostheses is considered the primary barrier against adverse external stimuli and is a critical factor in maintaining dental implants' stability. Soft tissue seal is formed mainly by the adhesion of epithelial tissue and fibrous connective tissue to the transmembrane portion of the implant. Type 2 diabetes mellitus (T2DM) is one of the risk factors for peri-implant inflammation, and peri-implant disease may be triggered by dysfunction of the soft tissue barrier around dental implants. This is increasingly considered a promising target for disease treatment and management. However, many studies have demonstrated that pathogenic bacterial infestation, gingival immune inflammation, overactive matrix metalloproteinases (MMPs), impaired wound healing processes and excessive oxidative stress may trigger poor peri-implant soft tissue sealing, which may be more severe in the T2DM state. This article reviews the structure of peri-implant soft tissue seal, peri-implant disease and treatment, and moderating mechanisms of impaired soft tissue seal around implants due to T2DM to inform the development of treatment strategies for dental implants in patients with dental defects.

Plasma polymerized bio-interface directs fibronectin adsorption and functionalization to enhance "epithelial barrier structure" formation via FN-ITG β1-FAK-mTOR signaling cascade

BACKGROUND

Transepithelial medical devices are increasing utilized in clinical practices. However, the damage of continuous natural epithelial barrier has become a major risk factor for the failure of epithelium-penetrating implants. How to increase the "epithelial barrier structures" (focal adhesions, hemidesmosomes, etc.) becomes one key research aim in overcoming this difficulty. Directly targeting the in situ "epithelial barrier structures" related proteins (such as fibronectin) absorption and functionalization can be a promising way to enhance interface-epithelial integration.

METHODS

Herein, we fabricated three plasma polymerized bio-interfaces possessing controllable surface chemistry. Their capacity to adsorb and functionalize fibronectin (FN) from serum protein was compared by Liquid Chromatography-Tandem Mass Spectrometry. The underlying mechanisms were revealed by molecular dynamics simulation. The response of gingival epithelial cells regarding the formation of epithelial barrier structures was tested.

RESULTS

Plasma polymerized surfaces successfully directed distinguished protein adsorption profiles from serum protein pool, in which plasma polymerized allylamine (ppAA) surface favored adsorbing adhesion related proteins and could promote FN absorption and functionalization via electrostatic interactions and hydrogen bonds, thus subsequently activating the ITG β1-FAK-mTOR signaling and promoting gingival epithelial cells adhesion.

CONCLUSION

This study offers an effective perspective to overcome the current dilemma of the inferior interface-epithelial integration by in situ protein absorption and functionalization, which may advance the development of functional transepithelial biointerfaces. Tuning the surface chemistry by plasma polymerization can control the adsorption of fibronectin and functionalize it by exposing functional protein domains. The functionalized fibronectin can bind to human gingival epithelial cell membrane integrins to activate epithelial barrier structure related signaling pathway, which eventually enhances the formation of epithelial barrier structure.

Junctional epithelium and hemidesmosomes: Tape and rivets for solving the "percutaneous device dilemma" in dental and other permanent implants

The percutaneous device dilemma describes etiological factors, centered around the disrupted epithelial tissue surrounding non-remodelable devices, that contribute to rampant percutaneous device infection. Natural percutaneous organs, in particular their extracellular matrix mediating the "device"/epithelium interface, serve as exquisite examples to inspire longer lasting long-term percutaneous device design. For example, the tooth's imperviousness to infection is mediated by the epithelium directly surrounding it, the junctional epithelium (JE). The hallmark feature of JE is formation of hemidesmosomes, cell/matrix adhesive structures that attach surrounding oral gingiva to the tooth's enamel through a basement membrane. Here, the authors survey the multifaceted functions of the JE, emphasizing the role of the matrix, with a particular focus on hemidesmosomes and their five main components. The authors highlight the known (and unknown) effects dental implant - as a model percutaneous device - placement has on JE regeneration and synthesize this information for application to other percutaneous devices. The authors conclude with a summary of bioengineering strategies aimed at solving the percutaneous device dilemma and invigorating greater collaboration between clinicians, bioengineers, and matrix biologists.

Antibacterial Properties of Gold Nanoparticles in the Modification of Medical Implants: A Systematic Review

The widespread occurrence of bacterial infections and their increased resistance to antibiotics has led to the development of antimicrobial coatings for multiple medical implants. Owing to their desirable properties, gold nanoparticles (AuNPs) have been developed as antibacterial agents. This systematic investigation sought to analyze the antibacterial effects of implant material surfaces modified with AuNPs. The data from 27 relevant studies were summed up. The included articles were collected from September 2011 to September 2021. According to the retrieved literature, we found that medical implants modified by AuNPs have good antibacterial effects against gram-positive and gram-negative bacteria, and the antibacterial effects would be improved by near-infrared (NIR) radiation.

Immunohistochemical analysis of soft tissue response to polyetheretherketone (PEEK) and titanium healing abutments on dental implants: a randomized pilot clinical study

Background

The data on polyetheretherketone (PEEK) influence on the peri-implant soft tissues in clinical settings are deficient. The aims of this pilot study were to analyze and compare soft tissues’ response to PEEK and titanium (Ti) healing abutments (HA) by means of histological and immunohistochemical analyses.

Methods

A total of 22 implants with PEEK or Ti HA were placed in 11 patients, applying the “split-mouth” study design. Three months later, soft tissue specimens were harvested from 20 implants for histology in order to qualitatively detect the inflammatory cells’ presence, to semi-qualitatively analyze the inflammation intensity and to assess the inflammatory responses type by immunohistochemical analysis using LCA, CD3, CD20 and CD68 antibodies.

Results

Epithelial infiltrate followed by an intensive inflammation in sub-epithelium was observed in 100% around PEEK HA. A number of LCA+ and CD 68+ cells was significantly higher in PEEK comparing to Ti group (p = 0.001 and p = 0.020, respectively), while CD 20+ and CD3+ counted cells were found in a significantly higher amount in Ti than in PEEK group (p = 0.006 and p = 0.010, respectively).

Conclusion

PEEK HA seems to evoke the more intense tissue inflammatory response demonstrated predominantly by histocytes’ and plasmacytes’ activation, while Ti HA triggers the inflammatory reaction of lower intensity, dominantly mediated by B-cells.

Trial registration

The study registered at ClinicalTrials.gov (NCT04436939).

Inspired by the Periodontium: A Universal Bacteria-Defensive Hydrogel for Preventing Percutaneous Device-Related Infection

Percutaneous device-related infection has greatly shortened the service period of devices and seriously reduced the quality of life of patients. Bacteria are one of the main pathogenic factors and cannot be effectively and conveniently eradicated by traditional strategies (e.g., construct coatings and introduce antibiotics), due to the complex interface among medical devices, surrounding tissue, and colonizing bacteria. Inspired by the periodontium, a universal bacteria-defensive hydrogel adapting to the complicated interface is fabricated by introducing phenol-amine chemistry to a polymeric matrix of N-hydroxyethyl acrylamide (HPC hydrogels). The HPC hydrogels with excellent toughness (2.1 MJ/m3), adhesion (10.2 and 13.2 kPa for pigskin and Ti-6Al-4V alloy, respectively), and antibacterial property (up to 99.9% for both Escherichia coli and Staphylococcus aureus) contributed to the innate microbe barrier via sealing the tissue-device interface and adaptive defense to eradicate bacteria. Meanwhile, bacterial invasion experiments demonstrate HPC hydrogels possess both a bacteria-defensive property (up to 24 h) and cell-protecting function at the same time. Furthermore, the biocompatibility of HPC hydrogels is verified in tests for in vitro cytotoxicity and in vivo irritation. Hence, the designed HPC hydrogels are considered as an emerging and universal candidate for preventing bacterial infection and can protect the deep tissue around a percutaneous device.

Biomechanical and histomorphometric evaluation of skin integration on titanium and PEEK implants with different surface treatments

Percutaneous implants are frequently affected by bacterial growth at the skin-implant interface. Integration between implant and surrounding skin is important to prevent bacteria from spreading to the underlying tissue. The standard method to evaluate skin-implant integration is by histomorphometry on samples which have been placed in tissue grown in vivo or ex vivo. In this study, a biomechanical method was developed and evaluated. The integration of implants into porcine skin was studied in an ex vivo model, where pig skin samples were cultivated in a nutrient solution. Cylindrical shaped implants, consisting of polyether ether ketone (PEEK) and titanium (Ti) with different surface treatments, were implanted in the skin tissue and the skin was grown in nutrient solution for 2 weeks. The implants were then extracted from the implantation site and the mechanical force during extraction was measured as a quantitative assessment of skin-implant integration. Implants from each group were also processed for histomorphometry and the degree of epidermal downgrowth (ED) and tissue to implant contact (TIC) was measured. A higher mean pullout force was observed for the PEEK implants compared to the Ti implants. Applying nanosized hydroxyapatite (HA) on Ti and PEEK increased the pullout force compared to uncoated controls, 24% for machined and 70% for blasted Ti, and 51% for machined PEEK. Treatment of Ti and PEEK with nanosized zirconium phosphate (ZrP) did not increase the pullout force. The histomorphometry analysis showed correlation between ED and pullout force, where the pullout force was inversely proportional to ED. For TIC, no significant differences were observed between the groups of same material (i.e. Ti, Ti+HA, Ti+ZrP, and PEEK, PEEK + HA, PEEK + ZrP), but it was significantly higher for PEEK compared to Ti. Scanning electron microscopy analysis was done on samples before and after the pullout tests, showing that the ZrP coating was unaffected by the 2 week ex vivo implantation and pullout procedure, no dissolution or detachment of the coating was observed. For the HA coating, a loss of coating was seen on approximately 5% of the total surface area of the implant. Graphical abstract.

Titanium Surfaces Modified with Graphene Oxide/Gelatin Composite Coatings for Enhanced Antibacterial Properties and Biological Activities

Titanium alloys have been widely used in orthopedic implants due to their excellent physicochemical properties and good biocompatibility. However, in practice, titanium implants may fail to integrate or develop an implant-centered infection. Because of its excellent mechanical properties, bone integrability, biocompatibility, antibacterial properties, and so on, graphene oxide is increasingly being used in the preparation of composite biomaterials. The percutaneous titanium implants are used as the research object in this project. To solve the integration of implant and tissue, a graphene oxide/gelatin (GO/gel) composite coating was used to optimize the implant surface. Bacterial and cell experiments were used to investigate the antimicrobial activity, biocompatibility, and regulation of macrophage polarization of GO/gel-modified titanium. According to our findings, GO/gel-modified titanium has a good bacteriostatic effect against Staphylococcus aureus. On the modified surface, L929 cells proliferated well and showed no cytotoxicity. Simultaneously, the GO/gel-modified titanium surface could inhibit macrophage adhesion and spread in the early stage of culture and showed a more obvious inflammatory decline in the late stage of culture. These findings implied that GO/gel-modified titanium is advantageous for resistant bacteria and tissue remolding.

Graphene Oxide Loaded on TiO2-Nanotube-Modified Ti Regulates the Behavior of Human Gingival Fibroblasts

Surface topography, protein adsorption, and the loading of coating materials can affect soft tissue sealing. Graphene oxide (GO) is a promising candidate for improving material surface functionalization to facilitate soft tissue integration between cells and biomaterials. In this study, TiO₂ nanotubes (TNTs) were prepared by the anodization of Ti, and TNT-graphene oxide composites (TNT-GO) were prepared by subsequent electroplating. The aim of this study was to investigate the effect of TNTs and TNT-GO surface modifications on the behavior of human gingival fibroblasts (HGFs). Commercially pure Ti and TNTs were used as the control group, and the TNT-GO surface was used as the experimental group. Scanning electron microscopy, X-ray photoelectron spectroscopy, and X-ray diffraction were used to perform sample characterization. Cell adhesion, cell proliferation, cell immunofluorescence staining, a wound-healing assay, real-time reverse-transcriptase polymerase chain reaction (RT-PCR), and Western blotting showed that the proliferation, adhesion, migration, and adhesion-related relative gene expression of HGFs on TNT-GO were significantly enhanced compared to the control groups, which may be mediated by the activation of integrin β1 and the MAPK-Erk1/2 pathway. Our findings suggest that the biological reactivity of HGFs can be enhanced by the TNT-GO surface, thereby improving the soft tissue sealing ability.

Tailoring Copper-Doped Bioactive Glass/Chitosan Coatings with Angiogenic and Antibacterial Properties

Implant coatings are frequently applied to modulate tissue response and delivery of drugs. Copper (Cu)-containing coatings on dental implant abutments have been proposed to improve soft tissue integration and reduce the risk for peri-implant infections. However, precise control over Cu loading and release kinetics remains a major challenge. In this study, we introduced a bottom-up coating deposition method based on nanoparticle assembly to allow for local release of Cu ions from implant surfaces. We first doped mesoporous bioactive glass (MBG) nanoparticles with various amounts of Cu. Subsequently, we suspended these Cu-doped MBG (Cu-MBG), Cu-free MBG nanoparticles, or mixtures thereof in chitosan solution and prepared a series of composite coatings on commercially pure titanium disks as model surfaces for transmucosal components of bone implants through electrophoretic deposition (EPD). By changing the Cu-MBG:MBG ratio of the composite coatings, we controlled the Cu release kinetics without changing other coating properties. Human gingival fibroblasts proliferated on the composite coatings except for coatings with the highest amount of Cu, which inhibited their proliferation. The migration rate of human umbilical vein endothelial cells cultured on the composite coatings was highest on coatings containing equal amounts of Cu-MBG and Cu-free MBG. Antibacterial tests confirmed that Cu-containing coatings reduced the growth of Porphyromonas gingivalis up to fivefold compared with uncoated implants. In conclusion, our data indicate that the EPD method is suitable to deposit nanoparticle-based coatings onto dental implants, which enhance endothelial cell migration and reduce bacterial growth.

Three interfaces of the dental implant system and their clinical effects on hard and soft tissues

Anatomically, the human tooth has structures both embedded within and forming part of the exterior surface of the human body. When a tooth is lost, it is often replaced by a dental implant, to facilitate the chewing of food and for esthetic purposes. For successful substitution of the lost tooth, hard tissue should be integrated into the implant surface. The microtopography and chemistry of the implant surface have been explored with the aim of enhancing osseointegration. Additionally, clinical implant success is dependent on ensuring that a barrier, comprising strong gingival attachment to an abutment, does not allow the infiltration of oral bacteria into the bone-integrated surface. Epithelial and connective tissue cells respond to the abutment surface, depending on its surface characteristics and the materials from which it is made. In particular, the biomechanics of the implant-abutment connection structure (i.e., the biomechanics of the interface between implant and abutment surfaces, and the screw mechanics of the implant-abutment assembly) are critical for both the soft tissue seal and hard tissue integration. Herein, we discuss the clinical importance of these three interfaces: bone-implant, gingiva-abutment, and implant-abutment.

In vitro behaviour of human gingival fibroblasts cultured on 3D-printed titanium alloy with hydrogenated TiO2 nanotubes

Selective laser melting (SLM), as one of the most common 3D-printed technologies, can form personalized implants, which after further surface modification can obtain excellent osseointegration. To study the surface properties of SLM titanium alloy (Ti6Al4V) with hydrogenated titanium dioxide (TiO₂)nanotubes (TNTs) and its influence on the biological behaviour of human gingival fibroblasts (HGFs), we used SLM to prepare 3D-printed titanium alloy samples (3D-Ti), which were electrochemically anodizing to fabricate 3D-TNTs and then further hydrogenated at high temperature to obtain 3D-H₂-TNTs. Polished cast titanium alloy (MP-Ti) was used as the control group. The surface morphology, hydrophilicity and roughness of MP-Ti, 3D-Ti, 3D-TNTs and 3D-H₂-TNTs were measured and analysed by scanning electron microscopy (SEM), contact angle metre, surface roughness measuring instrument and atomic force microscope, respectively. HGFs were cultured on the four groups of samples, and the cell morphology was observed by SEM. Fluorescence staining (DAPI) was used to observe the number of adhered cell nuclei, while a cell counting kit (CCK-8) was used to detect the early adhesion and proliferation of HGFs. Fluorescence quantitative real time polymerase chain reaction (RT-qPCR) and enzyme-linked immunosorbent assay (ELISA) were used to detect the expression of adhesion-related genes and fibronectin (FN), respectively. The results of this in vitro comparison study indicated that electrochemical anodic oxidation and high-temperature hydrogenation can form a superhydrophilic micro-nano composite morphology on the surface of SLM titanium alloy, which can promote both the early adhesion and proliferation of human gingival fibroblasts and improve the expression of cell adhesion-related genes and fibronectin. Graphical abstract.

Characterization of the foreign body response of titanium implants modified with polyphenolic coatings

The foreign body response is dictating the outcome of wound healing around any implanted materials. Patients who suffer from chronic inflammatory diseases and impaired wound healing often face a higher risk for implant failure. Therefore, functional surfaces need to be developed to improve tissue integration. For this purpose, we evaluated the impact of surface coatings made of antioxidant polyphenolic molecules tannic acid (TA) and pyrogallol (PG) on the host response in human blood. Our results showed that although the polyphenolic surface modifications impact the initial blood protein adsorption compared to Ti, the complement and coagulation systems are triggered. Despite complement activation, monocytes and granulocytes remained inactivated, which was manifested in a low pro-inflammatory cytokine expression. Under oxidative stress, both coatings were able to reduce intracellular reactive oxygen species in human gingival fibroblasts (hGFs). However, no anti-inflammatory effects of polyphenolic coatings could be verified in hGFs stimulated with lipopolysaccharide and IL-1β. Although polyphenols reportedly inhibit the NF-κB signaling pathway, phosphorylation of NF-κB p65 was observed. In conclusion, our results indicated that TA and PG coatings improved the hemocompatibility of titanium surfaces and have the potential to reduce oxidative stress during wound healing.

Poly-L-Lysine and Human Plasmatic Fibronectin Films as Proactive Coatings to Improve Implant Biointegration

The success of stable and long-term implant integration implies the promotion, control, and respect of the cell microenvironment at the site of implantation. The key is to enhance the implant–host tissue cross talk by developing interfacial strategies that guarantee an optimal and stable seal of soft tissue onto the implant, while preventing potential early and late infection. Indeed, implant rejection is often jeopardized by lack of stable tissue surrounding the biomaterial combined with infections which reduce the lifespan and increase the failure rate of implants and morbidity and account for high medical costs. Thin films formed by the layer-by-layer (LbL) assembly of oppositely charged polyelectrolytes are particularly versatile and attractive for applications involving cell–material contact. With the combination of the extracellular matrix protein fibronectin (Fn, purified from human plasma) and poly-L-lysine (PLL, exhibiting specific chain lengths), we proposed proactive and biomimetic coatings able to guarantee enhanced cell attachment and exhibiting antimicrobial properties. Fn, able to create a biomimetic interface that could enhance cell attachment and promote extracellular cell matrix remodeling, is incorporated as the anionic polymer during film construction by the LbL technic whereas PLL is used as the cationic polymer for its capacity to confer remarkable antibacterial properties.

Dual keratinocyte-attachment and anti-inflammatory coatings for soft tissue sealing around transmucosal oral implants

Unlike the attachment of soft epithelial skin tissue to penetrating solid natural structures like fingernails and teeth, sealing around percutaneous/permucosal devices such as dental implants is hindered by inflammation and epidermal down growth. Here, we employed a dual keratinocyte-adhesive peptide and anti-inflammatory biomolecule coating on titanium to promote oral epithelial tissue attachment. For minimizing inflammation-triggered epidermal down growth, we coated pristine and oxygen plasma pre-treated polished titanium (pTi) with conjugated linoleic acid (CLA). Further, in order to aid in soft tissue attachment via the formation of hemidesmosomes, adhesive structures by oral keratinocytes, we coated the anionic linoleic acid (LA) adsorbed titanium with cationic cell adhesive peptides (CAP), LamLG3, a peptide derived from Laminin 332, the major extracellular matrix component of the basement membrane in skin tissue and Net1, derived from Netrin-1, a neural chemoattractant capable of epithelial cell attachment via α6β4 integrins. The dual CLA-CAP coatings on pTi were characterized by X-ray photoelectron spectroscopy and dynamic water contact angle measurements. The proliferation of human oral keratinocytes (TERT-2/OKF6) was accelerated on the peptide coated titanium while also promoting the expression of Col XVII and β-4 integrin, two markers for hemidesmosomes. Simultaneously, CLA coating suppressed the production of inducible nitric oxide synthase (anti-iNOS); a pro-inflammatory M1 marker expressed in lipopolysaccharide (LPS) stimulated murine macrophages (RAW 264.7) and elevated expression of anti-CD206, associated to an anti-inflammatory M2 macrophage phenotype. Taken together, the dual keratinocyte-adhesive peptide and anti-inflammatory biomolecule coating on titanium can help reduce inflammation and promote permucosal/peri-implant soft tissue sealing.

Silk Fibroin/Collagen Blended Membrane Fabricated via a Green Papermaking Method for Potential Guided Bone Regeneration Application: In Vitro and In Vivo Evaluation

Guided bone regeneration (GBR) technology is a commonly used surgical procedure for the repair of damaged periodontal tissues. Poor mechanical property and rapid degradation rate are the major reasons for GBR membrane failure in clinical applications. Herein, we applied a green papermaking method to fabricate silk fibroin (SF) membranes blended with collagen and tested their performance. The results showed that the blended SF75 (SF and collagen in a weight ratio of 75:25) membranes are biocompatible with good mechanical properties in the wet condition and appropriate biodegradation rate. MC3T3-E1 osteoblast cell adhesion and proliferation on the membranes were improved by the hybrid biological functions of SF and collagen. Subcutaneous implantation in rats for 9 weeks demonstrated that the membranes induced a less severe inflammatory response. The biodegradation time of the SF75 membranes was appropriate for tissue regeneration. This research, for the first time, reports a blended membrane prepared from silk fibroin and collagen with an ecofriendly method, which shows promise for application in guided bone regeneration.

In Vitro Assessment of the Cell Metabolic Activity, Cytotoxicity, Cell Attachment, and Inflammatory Reaction of Human Oral Fibroblasts on Polyetheretherketone (PEEK) Implant-Abutment

The purpose of this research is to compare the cytotoxicity of polyetheretherketone (PEEK) and polyetherketoneketone (PEKK) with conventional dental implant–abutment materials, namely titanium alloy (Ti-6Al-4V) and yttria-stabilized tetragonal zirconia polycrystal (Y-TZP), to evaluate the cell metabolic activity, cytotoxicity, and inflammation potential of human oral fibroblasts (HOF) on these materials. Disk-shaped specimens were designed and prepared via a dental computer-aided manufacturing technology system. Surface topography, roughness, and free energy were investigated by atomic force microscope and contact angle analyzer; cell metabolic activity and cytotoxicity by MTT assay; and morphological changes by scanning electron microscopy (SEM). The effect of pro-inflammatory gene expression was evaluated by RT-qPCR. The obtained data were analyzed with one-way analysis of variance and post-hoc Tukey’s honest significant difference tests. PEEK and PEKK exhibited higher submicron surface roughness (0.04 μm) and hydrophobicity (>80°) than the control. Although the cell activity of PEEK was lower than that of Ti-6Al-4V and Y-TZP for the first 24 h (p < 0.05), after 48 h there was no difference (p > 0.05). According to the cell cytotoxicity and the pro-inflammatory cytokine gene expression assays, there was no difference between the materials (p > 0.05). SEM observations indicated that HOF adhered poorly to PEKK but properly to Ti-6Al-4V, Y-TZP, and PEEK. PEEK and PEKK show comparable epithelial biological responses to Ti-6Al-4V and Y-TZP as implant–abutment materials. Between the two polymeric materials, the PEEK surface, where the HOF showed better cell metabolic activity and cytotoxicity, was a more promising implant–abutment material.

Biological sealing and integration of a fibrinogen-modified titanium alloy with soft and hard tissues in a rat model

Percutaneous or transcutaneous devices are important and unique, and the corresponding biological sealing at the skin-implant interface is the key to their long-term success. Herein, we investigated the surface modification to enhance biological sealing, using a metal sheet and screw bonded by biomacromolecule fibrinogen mediated via pre-deposited synthetic macromolecule polydopamine (PDA) as a demonstration. We examined the effects of a Ti-6Al-4V titanium alloy modified with fibrinogen (Ti-Fg), PDA (Ti-PDA) or their combination (Ti-PDA-Fg) on the biological sealing and integration with skin and bone tissues. Human epidermal keratinocytes (HaCaT), human foreskin fibroblasts (HFF) and preosteoblasts (MC3T3-E1), which are closely related to percutaneous implants, exhibited better adhesion and spreading on all the three modified sheets compared with the unmodified alloy. After three-week subcutaneous implantation in Sprague-Dawley (SD) rats, the Ti-PDA-Fg sheets could significantly attenuate the soft tissue response and promote angiogenesis compared with other groups. Furthermore, in the model of percutaneous tibial implantation in SD rats, the Ti-PDA-Fg screws dramatically inhibited epithelial downgrowth and promoted new bone formation. Hence, the covalent immobilization of fibrinogen through the precoating of PDA is promising for enhanced biological sealing and osseointegration of metal implants with soft and hard tissues, which is critical for an orthopedic percutaneous medical device.

The effect of fluid shear stress on fibroblasts and stem cells on plane and groove topographies

In this study, we aimed to study the effect of fluid shear stress on fibroblasts and BMSCs on plane and groove topographies. The results showed that 0.6-Hz stress had the greatest influence on the alignment, polarity, migration and adhesion of fibroblasts on plane by increasing the expression of reoriented actin and vinculin; whereas 1.0-Hz stress promoted differentiation of fibroblasts into myofibroblasts by increasing Col-I and α-SMA expression. Interestingly, under the given frequency stress, the groove structure strengthened the above characteristics of fibroblasts beyond adhesion, and promoted differentiation of BMSCs into myofibroblasts. The above results indicate that 0.6 Hz may improve the implant-tissue sealing, while 1.0-Hz stress probably causes the disordered fiber deposition around implants.

Clinical Performance of a Novel Two-Piece Abutment Concept: Results from a Prospective Study with a 1-Year Follow-Up

Development of a stable and healthy soft-tissue barrier around dental implants is key to long-term success of implant-supported prostheses. The novel two-piece abutment concept shifts the prosthetic interface to the soft-tissue level to protect bone interface/connective tissue during the healing phase and restorative procedures. This prospective study included 72 patients treated with 106 implants to support a single-tooth or a three-unit bridge restored with two-piece abutments. The evaluation included marginal bone level change (MBLC), implant and prosthetic survival, soft-tissue health including keratinized mucosa height and mucosal margin position, patient quality of life (QoL) and satisfaction, and clinician satisfaction and ease-of-use rating of the concept. Mean MBLC from implant placement to 1 year was -0.36 ± 1.26 mm (n = 89), the 1-year implant and prosthetic survival rates were 97.1 and 96.7%, respectively, while keratinized mucosa height increased from 2.9 ± 1.2 mm at prosthetic delivery to 3.2 ± 1.3 mm, and mucosal margin migrated coronally by 0.49 ± 0.61 mm by 1 year. Patient satisfaction and QoL were high. Clinicians were satisfied with the esthetic and functional results and rated the concept as easy to use. In conclusion, the novel two-piece abutment concept promotes good peri-implant tissue health, while providing an easy-to-use workflow and high treatment satisfaction to both patients and clinicians.

Multifunctional Surfaces for Improving Soft Tissue Integration

Metallic implants are widely used in diverse clinical applications to aid in recovery from lesions or to replace native hard tissues. However, the lack of integration of metallic surfaces with soft tissue interfaces causes the occurrence of biomaterial-associated infections, which can trigger a complicated inflammatory response and, ultimately, implant failure. Here, a multifunctional implant surface showing nanoscale anisotropy, based on the controlled deposition of cellulose nanocrystals (CNC), and biological activity derived from platelet lysate (PL) biomolecules sequestered and presented on CNC surface, is proposed. The anisotropic radial nanopatterns are produced on polished titanium surfaces by spin-coating CNC at high speed. Furthermore, CNC surface chemistry allows to further sequester and form a coating of bioactive molecules derived from PL. The surface anisotropy provided by CNC guides fibroblasts growth and alignment up to 14 days of culture. Moreover, PL-derived biomolecules polarize macrophages toward the M2-like anti-inflammatory phenotype. These results suggest that the developed multifunctional surfaces can promote soft tissue integration to metallic implants and, at the same time, prevent bacterial invasion, tissue inflammation, and failure of biomedical metallic implants.

Time-dependent reactive oxygen species inhibit Streptococcus mutans growth on zirconia after a helium cold atmospheric plasma treatment

As an efficient strategy for the modification of material surfaces, cold atmospheric plasma (CAP) has been used in dentistry to improve hard and soft tissue integration of dental implant materials. We previously found the Streptococcus mutans growth was inhibited on the surface of zirconia implant abutment after a 60-second helium cold atmospheric plasma treatment. However, the mechanism of bacterial growth inhibition on CAP-treated zirconia has not been fully understood. The duration of bacterial inhibition effectiveness on CAP-treated zirconia has also been insufficiently examined. In this work, we assume that reactive oxygen species (ROS) are the primary cause of bacterial inhibition on CAP-treated zirconia. The ROS staining and an ROS scavenger were utilized to evaluate the bacterial intracellular ROS level, and to determine the role of ROS in bacterial growth inhibition when seeded on CAP-treated zirconia. The time-dependent effectiveness of CAP treatment was determined by changes in surface characteristics and antibacterial efficacy of zirconia with different storage times after CAP treatment. This study confirmed that the presence of reactive oxygen species on the zirconia surface after CAP treatment inhibits the growth of Streptococcus mutans on the material surface. Although the antibacterial efficacy of the 60-second CAP-treated zirconia decreased over time, there were fewer bacteria on the treated surface than those on the untreated surface after 14 days.

Systematic Review of Effectiveness of Chitosan as a Biofunctionalizer of Titanium Implants

Simple Summary

The low bioactivity of titanium limits its applications. The biofunctionalization of its surfaces with certain polymers could improve and accelerate the osseointegration process. Chitosan is a natural polysaccharide derived from chitin, which has been proposed in biomedical engineering. This systematic review evaluated in vivo studies with chitosan-coated titanium implants compared with non-functionalized implants.

Abstract

Chitosan is a natural polysaccharide extracted from the shells of crustaceans that has been proposed as a scaffold in tissue engineering. Certain studies have proven a greater osseointegration of titanium surfaces that are functionalized with chitosan. The MEDLINE, CENTRAL, PubMed, and Web of Science databases were electronically searched for in vivo studies. Seven studies met the inclusion criteria. Animal models, implant site, chitosan incorporation methods, and methods of analysis were emphasized. The selected studies were individually discussed regarding the coatings, osseointegration potential, and suitability of the experimental models used, analyzing their limitations. We concluded that chitosan-biofunctionalized titanium surfaces have greater osseointegration capacity that uncoated control titanium alloys.

Nanostructured Coating of Non-Crystalline Tantalum Pentoxide on Polyetheretherketone Enhances RBMS Cells/HGE Cells Adhesion

PURPOSE

As a dental material, polyetheretherketone (PEEK) is bioinert that does not induce cellular response and bone/gingival tissues regeneration. This study was to develop bioactive coating on PEEK and investigate the effects of coating on cellular response.

MATERIALS AND METHODS

Tantalum pentoxide (TP) coating was fabricated on PEEK surface by vacuum evaporation and responses of rat bone marrow mesenchymal stem (RBMS) cells/human gingival epithelial (HGE) were studied.

RESULTS

A dense coating (around 400 nm in thickness) of TP was closely combined with PEEK (PKTP). Moreover, the coating was non-crystalline TP, which contained many small humps (around 10 nm in size), exhibiting a nanostructured surface. In addition, the roughness, hydrophilicity, surface energy, and protein adsorption of PKTP were remarkably higher than that of PEEK. Furthermore, the responses (adhesion, proliferation, and osteogenic gene expression) of RBMS cells, and responses (adhesion and proliferation) of HGE cells to PKTP were remarkably improved in comparison with PEEK. It could be suggested that the nanostructured coating of TP on PEEK played crucial roles in inducing the responses of RBMS/HGE cells.

CONCLUSION

PKTP with elevated surface performances and outstanding cytocompatibility might have enormous potential for dental implant application.

Harnessing biomolecules for bioinspired dental biomaterials

Dental clinicians have relied for centuries on traditional dental materials (polymers, ceramics, metals, and composites) to restore oral health and function to patients. Clinical outcomes for many crucial dental therapies remain poor despite many decades of intense research on these materials. Recent attention has been paid to biomolecules as a chassis for engineered preventive, restorative, and regenerative approaches in dentistry. Indeed, biomolecules represent a uniquely versatile and precise tool to enable the design and development of bioinspired multifunctional dental materials to spur advancements in dentistry. In this review, we survey the range of biomolecules that have been used across dental biomaterials. Our particular focus is on the key biological activity imparted by each biomolecule toward prevention of dental and oral diseases as well as restoration of oral health. Additional emphasis is placed on the structure-function relationships between biomolecules and their biological activity, the unique challenges of each clinical condition, limitations of conventional therapies, and the advantages of each class of biomolecule for said challenge. Biomaterials for bone regeneration are not reviewed as numerous existing reviews on the topic have been recently published. We conclude our narrative review with an outlook on the future of biomolecules in dental biomaterials and potential avenues of innovation for biomaterial-based patient oral care.

The biological width around implant

PURPOSE

The concept of biological width has been proposed and widely used in oral implantation. This review aimed to summarize the biological width around implant in detail.

STUDY SELECTION

An electronic search of the literature prior to March 2019 was performed to identify all articles related to biological width in periimplant soft tissue. The search was conducted in the MEDLINE (National Library of Medicine) database accessed through PubMed with no date restriction. The following main keywords were used: "implant", "biological width", "soft tissue", "junctional epithelium", "peri-implant epithelium", "connective tissue", "gingiva", "mucosa" (connecting multiple keywords with AND, OR).

RESULTS

The identified researches focused on several aspects related to biological width in oral implantation, namely the concept, formation, remodeling, dimension, structure and function.

CONCLUSIONS

Based on of the reviewed literature, the concept, formation, remodeling, structure, dimension, and functional significances of periimplant biological width are explored in this narrative review. The formation of biological width around implant is a complex process after several weeks of healing. The biological width around implant is a 3-4mm distance from the top of the peri-implant mucosa to the first bone-to-implant contact or the stabilized top of the adjacent bone, consisting of sulcular epithelium, junctional epithelium and fibrous connective tissue between the epithelium and the first bone-to-implant contact or the stabilized top of the adjacent bone. The biological width forms a biological barrier against the bacteria, influences the remodeling of soft and hard tissue around implant and has implications for clinical aspects of dental implantation.

Adenovirus-Mediated LAMA3 Transduction Enhances Hemidesmosome Formation and Periodontal Reattachment during Wound Healing

A robust dento-epithelial junction prevents external pathogenic factors from entering connective tissue and could be crucial for periodontal reattachment after periodontal surgery. The junctional epithelium (JE) is attached to the tooth surface through the hemidesmosome (HD) and internal basal lamina, where the primary component is laminin-332. Destruction of the JE leads to the loss of periodontal attachment. Traditional treatments are effective in eliminating local inflammation of the gingiva; however, few directly promote periodontal reattachment and HD formation. Here, we designed a gene-therapy strategy using the adenovirus-mediated human laminin-332 α3 chain (LAMA3) gene (Ad-LAMA3) transduced into a human-immortalized epidermal cell line (HaCaT) to study the formation of HD in vitro. Ad-LAMA3 promoted early adhesion and fast migration of HaCaT cells and increased expression of LAMA3 and type XVII collagen (BP180) significantly. Furthermore, HaCaT cells could facilitate formation of mature HDs after LAMA3 overexpression. In vivo experiments demonstrated that the JE transduced with Ad-LAMA3 could increase expression of LAMA3 and BP180 and “biological sealing” between the tooth and gingival epithelium. These results suggested that adenovirus-mediated LAMA3 transduction is a novel therapeutic strategy that promotes the stability and integration of the JE around the tooth during wound healing.

Biological Responses to the Transitional Area of Dental Implants: Material- and Structure-Dependent Responses of Peri-Implant Tissue to Abutments

The stability of peri-implant tissue is essential for the long-term success of dental implants. Although various types of implant connections are used, little is known about the effects of the physical mechanisms of dental implants on the stability of peri-implant tissue. This review summarizes the relevant literature to establish guidelines regarding the effects of connection type between abutments and implants in soft and hard tissues. Soft tissue seals can affect soft tissue around implants. In external connections, micromobility between the abutment and the hex component of the implant, resulting from machining tolerance, can destroy the soft tissue seal, potentially leading to microbial invasion. Internal friction connection implants induce strain on the surrounding bone via implant wall expansion that translates into masticatory force. This strain is advantageous because it increases the amount and quality of peri-implant bone. The comparison of internal and external connections, the two most commonly used connection types, reveals that internal friction has a positive influence on both soft and hard tissues.

Regulating the Behavior of Human Gingival Fibroblasts by sp2 Domains in Reduced Graphene Oxide

Long-term function of dental implants relies on not only stable osseointegration but also strong soft tissue-sealing ability. Ideal soft tissue sealing around implants is an effective protective barrier between the external environment and alveolar bone, preventing the invasion of bacteria that is considered as a vital trigger of irreversible marginal bone loss. Carbon-based materials have been reported to be beneficial to soft tissue sealing, which can be regulated through the hybridization type of carbon atoms (sp² or sp³), but its internal mechanism is still not clear. In this work, graphene oxide with both sp²- and sp³-hybridized carbons was electrophoretic deposited on titanium and reduced to regulate the hybridization type of carbon atoms to investigate its effect and possible mechanism on human gingival fibroblasts (HGFs). X-ray photoelectron spectroscopy and Raman mapping test show the increase of sp² domain content and the decrease of their size after reduction. Through computer simulation, the possible mechanism of the decrease of sp² domain size was proposed. In vitro studies disclose that the HGFs exhibit higher proliferation rate, better adhesion, and migration ability with the increase of sp² domains and the decrease of their sizes. It may be due to the amount and size of sp² domains that synergistically regulate the amount and properties of adsorbed proteins, thereby influencing the cellular behaviors of HGFs. Our results may offer a different perspective on material designing and academic research to enhance the soft tissue integration of implants.

Surface modification via plasmid-mediated pLAMA3-CM gene transfection promotes the attachment of gingival epithelial cells to titanium sheets in vitro and improves biological sealing at the transmucosal sites of titanium implants in vivo

Although titanium implants have been applied in dental clinics to replace lost teeth and to restore masticatory function for decades, strategies to design the surface of the transmucosal sites of implants to achieve ideal and predictable biological sealing following implantation remain to be optimized. In this study, we hypothesized that gingival epithelial cell (GEC) adhesion and new tissue attachment to titanium sheets/implants could be promoted by the release of plasmid pLAMA3-CM (encoding a motif of the C-terminal globular domain of LAMA3) from a titanium surface. To test this hypothesis, a chitosan/collagen (Chi/Col) coating was immobilized on the surfaces of titanium substrates with nanotube topography (NT-Ti) through cathodic electrophoretic deposition; it was found that pLAMA3-CM could be released from the coating in a highly sustained manner. After culturing on titanium with nanotube topography coated by Chi/Col with the plasmid pLAMA3-CM (Chi/Col/pLAMA3-CM-Ti), human GECs (hGECs) were found to effectively uptake the incorporated plasmids, which resulted in improved attachment, as evidenced by morphological and immunofluorescence analyses. In addition, Chi/Col/pLAMA3-CM-Ti induced better biological sealing at transmucosal sites following immediate implantation into Sprague-Dawley rats. Our findings indicate that the modification of titanium implants by plasmid-mediated pLAMA3-CM gene transfection points to a practical strategy for optimizing biological sealing around the transmucosal sites of implants.