Design of dental implants, influence on the osteogenesis and fixation

Calibration of Aseptic Loosening Simulation for Coatings Osteoinductive Effect

The risk of aseptic loosening in cementless hip stems can be reduced by improving osseointegration with osteoinductive coatings favoring long-term implant stability. Osseointegration is usually evaluated in vivo studies, which, however, do not reproduce the mechanically driven adaptation process. This study aims to develop an in silico model to predict implant osseointegration and the effect of induced micromotion on long-term stability, including a calibration of the material osteoinductivity with conventional in vivo studies. A Finite Element model of the tibia implanted with pins was generated, exploiting bone-to-implant contact measures of cylindrical titanium alloys implanted in rabbits' tibiae. The evolution of the contact status between bone and implant was modeled using a finite state machine, which updated the contact state at each iteration based on relative micromotion, shear and tensile stresses, and bone-to-implant distance. The model was calibrated with in vivo data by identifying the maximum bridgeable gap. Afterward, a push-out test was simulated to predict the axial load that caused the macroscopic mobilization of the pin. The bone-implant bridgeable gap ranged between 50 μm and 80 μm. Predicted push-out strength ranged from 19 N to 21 N (5.4 MPa-3.4 MPa) depending on final bone-to-implant contact. Push-out strength agrees with experimental measurements from a previous animal study (4 ± 1 MPa), carried out using the same implant material, coated, or uncoated. This method can partially replace in vivo studies and predict the long-term stability of cementless hip stems.

The effect of pores and connections geometries on bone ingrowth into titanium scaffolds: an assessment based on 3D microCT images

In order to support bone tissue regeneration, porous biomaterial implants (scaffolds) must offer chemical and mechanical properties, besides favorable fluid transport. Titanium implants provide these requirements, and depending on their microstructural parameters, the osteointegration process can be stimulated. The pore structure of scaffolds plays an essential role in this process, guiding fluid transport for neo-bone regeneration. The objective of this work was to analyze geometric and morphologic parameters of the porous microstructure of implants and analyze their influences in the bone regeneration process, and then discuss which parameters are the most fundamental. Bone ingrowths into two different sorts of porous titanium implants were analyzed after 7, 14, 21, 28, and 35 incubation days in experimental animal models. Measurements were accomplished with x-ray microtomography image analysis from rabbit tibiae, applying a pore-network technique. Taking into account the most favorable pore sizes for neo-bone regeneration, a novel approach was employed to assess the influence of the pore structure on this process: the analyses were carried out considering minimum pore and connection sizes. With this technique, pores and connections were analyzed separately and the influence of connectivity was deeply evaluated. This investigation showed a considerable influence of the size of connections on the permeability parameter and consequently on the neo-bone regeneration. The results indicate that the processing of porous scaffolds must be focused on deliver pore connections that stimulate the transport of fluids throughout the implant to be applied as a bone replacer.

Electrospun Poly(butylene-adipate-co-terephthalate)/Nano-hyDroxyapatite/Graphene Nanoribbon Scaffolds Improved the In Vivo Osteogenesis of the Neoformed Bone

Electrospun ultrathin fibrous scaffold filed with synthetic nanohydroxyapatite (nHAp) and graphene nanoribbons (GNR) has bioactive and osteoconductive properties and is a plausible strategy to improve bone regeneration. Poly(butylene-adipate-co-terephthalate) (PBAT) has been studied as fibrous scaffolds due to its low crystallinity, faster biodegradability, and good mechanical properties; however, its potential for in vivo applications remains underexplored. We proposed the application of electrospun PBAT with high contents of incorporated nHAp and nHAp/GNR nanoparticles as bone grafts. Ultrathin PBAT, PBAT/nHAp, and PBAT/nHAp/GNR fibers were produced using an electrospinning apparatus. The produced fibers were characterized morphologically and structurally using scanning electron (SEM) and high-resolution transmission electron (TEM) microscopies, respectively. Mechanical properties were analyzed using a texturometer. All scaffolds were implanted into critical tibia defects in rats and analyzed after two weeks using radiography, microcomputed tomography, histological, histomorphometric, and biomechanical analyses. The results showed through SEM and high-resolution TEM characterized the average diameters of the fibers (ranged from 0.208 µm ± 0.035 to 0.388 µm ± 0.087) and nHAp (crystallite around 0.28, 0.34, and 0.69 nm) and nHAp/GNR (200-300 nm) nanoparticles distribution into PBAT matrices. Ultrathin fibers were obtained, and the incorporated nHAp and nHAp/GNR nanoparticles were well distributed into PBAT matrices. The addition of nHAp and nHAp/GNR nanoparticles improved the elastic modulus of the ultrathin fibers compared to neat PBAT. High loads of nHAp/GNR (PBATnH5G group) improved the in vivo lamellar bone formation promoting greater radiographic density, trabecular number and stiffness in the defect area 2 weeks after implantation than control and PBAT groups.

Improvement of osseointegration by recruiting stem cells to titanium implants fabricated with 3D printing

Slow and incomplete osseointegration and loss of osseointegration are major problems in dental and bone implants. We designed implants with interconnected 3D-tubulous structures and hypothesized that such interconnecting 3D (I3D) structures would serve as a repository for chemoattractants to recruit stem cells to promote osseointegration. A concept Laser Mlab-cusing-R laser-powder-bed-fusion (LPBF) 3D printing system was used to produce titanium implants with designed features. The implants were loaded (coated) with stromal cell-derived factor-1 alpha (SDF-1α), and subjected to stem cell recruitment. Implants were then surgically transplanted into the rabbit skull bone. After 12 weeks, osseointegration was analyzed by reverse-torque test and the implants were examined for calcium deposition by Alizarin Red staining. The I3D implants attracted significantly more stem cells than solid implants when coated (loaded) with SDF-1α. Greater torque force was needed to extract the I3D implants with 200 and 300 µm I3D structures than to extract solid implants from the skull. Generally, more calcium deposition was observed on the I3D implants than on the solid counterparts. LPBF 3D printing can be used to fabricate implants with complex structures. I3D-tubulous structures of implants can retain chemoattractant for recruitment of stem cells to enhance osseointegration.

Hierarchical assembly in PLA-PEO-PLA hydrogels with crystalline domains and effect of block stereochemistry

Understanding the development of microstructure (e.g., structures with length scales roughly 0.5-500 μm) in hydrogels is crucial for their use in several biomedical applications. We utilize ultra-small-angle neutron scattering (USANS) and confocal microscopy to explore microstructure of poly(lactide)-poly(ethylene oxide)-poly(lactide) (PLA-PEO-PLA) triblock copolymer hydrogels with varying l/d-lactide ratio. We have previously found that these polymers self-assemble on the nanoscale into micelles. Here, we observe large-scale structures with diverse morphologies, including highly porous self-similar networks with characteristic sizes spanning approximately 120 nm-200 μm. These structural features give rise to power-law scattering indicative of fractal structures in USANS. Mass fractal and surface fractal structures are found for gels with l/d ratios of 80/20 and 50/50, respectively. Confocal microscopy shows microscale water-filled channels and pores that are more clearly evident in gels with a higher fraction of l-lactide in the PLA block as compared to the 50/50 hydrogels. Tuning block stereochemistry may provide a means of controlling the self-assembly and structural evolution at both the nanoscale and microscale, impacting application of these materials in tissue engineering and drug delivery.

Targeted Drug Delivery from Titanium Implants: A Review of Challenges and Approaches

Titanium implants are considered the gold standard of treatment for dental and orthopedic applications. Biocompatibility, low elasticity, and corrosion resistance are some of the key properties of these metallic implants. Nonetheless, a long-term clinical failure of implants may occur due to inadequate osseointegration. Poor osseointegration induces mobility, inflammation, increased bone resorption, and osteolysis; hence, it may result in painful revision surgeries. Topographical modifications, improvement in hydrophilicity, and the development of controlled-release drug-loading systems have shown to improve cellular adhesion, proliferation, and differentiation. Surface modifications, along with drug coating, undoubtedly demonstrate better osseointegration, especially in challenged degenerative conditions, such as osteoporosis, osteoarthritis, and osteogenesis imperfecta. Anabolic bone-acting drugs, such as parathyroid hormone peptides, simvastatin, prostaglandin-EP4-receptor antagonist, vitamin D, strontium ranelate, and anti-catabolic bone-acting drugs, such as calcitonin, bisphosphonates, and selective estrogen receptor modulators, expedite the process of osseointegration. In addition, various proteins, peptides, and growth factors may accessorize the idea of localized therapy. Loading these substances on modified titanium surfaces is achieved commonly by mechanisms such as direct coating, adsorption, and incorporating in biodegradable polymers. The primary approach toward the optimum drug loading is a critical trade-off between factors preventing release of a drug immediately and those allowing slow and sustained release. Recent advances broaden the understanding of the efficacy of adsorption, hydrogel coating, and electrospinning layer-by-layer coating facilitated by differential charge on metallic surface. This review discusses the existing approaches and challenges for the development of stable and sustained drug delivery systems on titanium implants, which would promote faster and superior osseointegration.

Direct Contact Test for Evaluating Bacterial Growth on Machined and Rough Surface Implants: An In Vitro Study

OBJECTIVE

To use a modified direct contact test (DCT) to evaluate the bacterial growth on 3 commercially available implants.

MATERIALS AND METHODS

Streptococcus salivarius growth was tested on 1 machined surface and 2 commercial rough surface implants. Seven implants from each group were fixed to the cover of a 96-well microtiter plate. Bacterial suspension was placed on each implant, and the plate was incubated at 37°C for 1 hour to allow the suspension fluid to evaporate. Fresh medium was added to 7 corresponding wells in the microtiter plate, and the cover holding the implants was placed on the plate to enable immersion of the implant. Noncontaminated implant samples served as control. Bacterial growth was monitored spectrophotometrically at 650 nm for 24 hours.

RESULTS

There was a significant S. salivarius growth in all groups of test implants compared with the control. There was no significant difference between bacterial growth kinetics on treated and nontreated implant surfaces (P = 0.241).

CONCLUSION

Using the DCT, we found no difference in bacterial growth between machined and rough surface implants.

Influence of macroporosity on NIH/3T3 adhesion, proliferation, and osteogenic differentiation of MC3T3-E1 over bio-functionalized highly porous titanium implant material

Highly porous Ti implant materials are being used in order to overcome the stress shielding effect on orthopedic implants. However, the lack of bioactivity on Ti surfaces is still a major concern regarding the osseointegration process. It is known that the rapid recruitment of osteoblasts in bone defects is an essential prerequisite for efficient bone repair. Conventionally, osteoblast recruitment to bone defects and subsequent bone repair has been achieved using growth factors. Thus, in this study highly porous Ti samples were processed by powder metallurgy using space holder technique followed by the bio-functionalization through microarc oxidation using a Ca- and P-rich electrolyte. The biological response in terms of early cell response, namely, adhesion, spreading, viability, and proliferation of the novel biofunctionalized highly porous Ti was carried out with NIH/3T3 fibroblasts and MC3T3-E1 preosteoblasts in terms of viability, adhesion, proliferation, and alkaline phosphatase activity. Results showed that bio-functionalization did not affect the cell viability. However, bio-functionalized highly porous Ti (22% porosity) enhanced the cell proliferation and activity. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 107B: 73-85, 2019.

Titanium scaffold osteogenesis in healthy and osteoporotic rats is improved by the use of low-level laser therapy (GaAlAs)

The present study aimed to assess the effects of low-level laser therapy (GaAlAs) on the bone repair process within titanium scaffolds in the femurs of healthy and osteoporotic rats. Fifty-six rats were divided into four groups: group Sh: SHAM animals that received scaffolds; group LSh: SHAM animals that received scaffolds and were subjected to laser therapy; group OV: ovarietomized (OVX) animals that received scaffolds; and group LOV: OVX animals that received scaffolds and were subjected to laser therapy. Thirty days following ovariectomy or sham surgery, scaffolds were implanted in the left femurs of all animals in the study. Immediately after opening the surgical site, the inner part of the surgical cavity was stimulated with low-level laser (GaAlAs). In addition to this procedure, the laser group was also subjected to sessions of low-level laser therapy (LLLT) at 48-h intervals, with the first session performed immediately after surgery. The rats were sacrificed at 2 and 6 weeks, time in which femur fragments were submitted for histological and histomorphometric examination, and skin tissue above the scaffold was submitted to histological analysis. At the end of the study, greater bone formation was observed in the animals submitted to LLLT. At 2 and 6 weeks, statistically significant differences were observed between LSh and Sh groups (p = 0.009 and 0.0001) and LOV and OV (p = 0.0001 and 0.0001), respectively. No statistical difference was observed when assessing the estrogen variable. On the basis of our methodology and results, we conclude that LLLT improves and accelerates bone repair within titanium scaffolds in both ovariectomized and healthy rats, when compared to animals not subjected to radiation.

Effect of low-level mechanical vibration on osteogenesis and osseointegration of porous titanium implants in the repair of long bone defects

Emerging evidence substantiates the potential of porous titanium alloy (pTi) as an ideal bone-graft substitute because of its excellent biocompatibility and structural properties. However, it remains a major clinical concern for promoting high-efficiency and high-quality osseointegration of pTi, which is beneficial for securing long-term implant stability. Accumulating evidence demonstrates the capacity of low-amplitude whole-body vibration (WBV) in preventing osteopenia, whereas the effects and mechanisms of WBV on osteogenesis and osseointegration of pTi remain unclear. Our present study shows that WBV enhanced cellular attachment and proliferation, and induced well-organized cytoskeleton of primary osteoblasts in pTi. WBV upregulated osteogenesis-associated gene and protein expression in primary osteoblasts, including OCN, Runx2, Wnt3a, Lrp6 and β-catenin. In vivo findings demonstrate that 6-week and 12-week WBV stimulated osseointegration, bone ingrowth and bone formation rate of pTi in rabbit femoral bone defects via μCT, histological and histomorphometric analyses. WBV induced higher ALP, OCN, Runx2, BMP2, Wnt3a, Lrp6 and β-catenin, and lower Sost and RANKL/OPG gene expression in rabbit femora. Our findings demonstrate that WBV promotes osteogenesis and osseointegration of pTi via its anabolic effect and potential anti-catabolic activity, and imply the promising potential of WBV for enhancing the repair efficiency and quality of pTi in osseous defects.

Titanium-35niobium alloy as a potential material for biomedical implants: In vitro study

Research on new titanium alloys and different surface topographies aims to improve osseointegration. The objective of this study is to analyze the behavior of osteogenic cells cultivated on porous and dense samples of titanium-niobium alloys, and to compare them with the behavior of such type of cells on commercial pure titanium. Samples prepared using powder metallurgy were characterized using scanning electron microscopy (SEM), energy dispersive spectroscopy (EDS), X-ray diffraction (XRD), and metallographic and profilometer analyses. Osteogenic cells from newborn rat calvaria were plated over different groups: dense or porous samples composed of Ti or Ti-35niobium (Nb). Cell adhesion, cell proliferation, MTT assay, cell morphology, protein total content, alkaline phosphatase activity, and mineralization nodules were assessed. Results from XRD and EDS analysis confirmed the presence of Ti and Nb in the test alloy. Metallographic analysis revealed interconnected pores, with pore size ranging from 138 to 150μm. The profilometer analysis detected the greatest rugosity within the dense alloy samples. In vitro tests revealed similar biocompatibility between Ti-35Nb and Ti; furthermore, it was possible to verify that the association of porous surface topography and the Ti-35Nb alloy positively influenced mineralized matrix formation. We propose that the Ti-35Nb alloy with porous topography constitutes a biocompatible material with great potential for use in biomedical implants.

Trends in computer-aided manufacturing in prosthodontics: a review of the available streams

In prosthodontics, conventional methods of fabrication of oral and facial prostheses have been considered the gold standard for many years. The development of computer-aided manufacturing and the medical application of this industrial technology have provided an alternative way of fabricating oral and facial prostheses. This narrative review aims to evaluate the different streams of computer-aided manufacturing in prosthodontics. To date, there are two streams: the subtractive and the additive approaches. The differences reside in the processing protocols, materials used, and their respective accuracy. In general, there is a tendency for the subtractive method to provide more homogeneous objects with acceptable accuracy that may be more suitable for the production of intraoral prostheses where high occlusal forces are anticipated. Additive manufacturing methods have the ability to produce large workpieces with significant surface variation and competitive accuracy. Such advantages make them ideal for the fabrication of facial prostheses.

Repair of segmental long bone defect in a rabbit radius nonunion model: comparison of cylindrical porous titanium and hydroxyapatite scaffolds

A segmental long bone defect in a rabbit radius nonunion model was repaired using cylindrical porous titanium (Ti) and hydroxyapatite (HA) scaffolds. Each scaffold was produced using the same method, namely, a slurry foaming method. Repairing ability was characterized using x-radiographic score 12 and 24 weeks postprocedure; failure load of the radius-ulna construct, under three-point bending, 12 weeks postprocedure; and the percentage of newly formed bone within the implant, 12 and 24 weeks after postprocedure. For each of these parameters, the difference in the results when porous Ti scaffold was used compared with when HA scaffolds were used was not significant; both porous scaffolds showed excellent repairing ability. Because the trabecular bone is a porous tissue, the interconnected porous scaffolds have the advantages of natural bone, and vasculature can grow into the porous structure to accelerate the osteoconduction and osteointegration between the implant and bone. The porous Ti scaffold not only enhanced the bone repair process, similar to porous HA scaffolds, but also has superior biomechanical properties. The present results suggest that porous Ti scaffolds may have promise for use in the clinical setting.

Trabecular titanium can induce in vitro osteogenic differentiation of human adipose derived stem cells without osteogenic factors

Trabecular Titanium (TT) is an innovative highly porous structure that imitates the morphology of trabecular bone with good mechanical properties. Adipose-derived stem cells are a multipotent cell population that can be used in regenerative medicine, in particular, for bone therapeutic applications. The ability of TT to induce the osteogenic differentiation of human adipose derived stem cells (hASCs) in the absence of osteogenic factors was evaluated using molecular biological, biochemical, and immunohistochemical methods. At 7 and 21 days from differentiation, the hASCs grown on TT scaffolds showed similar expressions of alkaline phosphatase (ALP) and Runx-2 both in the presence and in the absence of osteogenic factors, as well as at transcript and protein levels. hASCs cultured on monolayer in the presence of the medium obtained from the wells where hASCs/scaffold constructs were cultured in the absence of osteogenic factors differentiated towards the osteogenic phenotype: their gene and protein expression of ALP and Runx-2 was similar to that of the same cells cultured in the presence of osteogenic factors, and significantly higher than that of the ones cultured in growth medium.

Effects of sintering temperature on morphology and mechanical characteristics of 3D printed porous titanium used as dental implant

Porous titanium samples were manufactured using the 3D printing and sintering method in order to determine the effects of final sintering temperature on morphology and mechanical properties. Cylindrical samples were printed and split into groups according to a final sintering temperature (FST). Irregular geometry samples were also printed and split into groups according to their FST. The cylindrical samples were used to determine part shrinkage, in compressive tests to provide stress-strain data, in microCT scans to provide internal morphology data and for optical microscopy to determine surface morphology. All of the samples were used in microhardness testing to establish the hardness. Below 1100 °C FST, shrinkage was in the region of 20% but increased to approximately 30% by a FST of 1300 °C. Porosity varied from a maximum of approximately 65% at the surface to the region of 30% internally. Between 97 and 99% of the internal porosity is interconnected. Average pore size varied between 24 μm at the surface and 19 μm internally. Sample hardness increased to in excess of 300 HV0.05 with increasing FST while samples with an FST of below 1250 °C produced an elastic-brittle stress/strain curve and samples above this displayed elastic-plastic behaviour. Yield strength increased significantly through the range of sintering temperatures while the Young's modulus remained fairly consistent.

Novel production method of porous surface Ti samples for biomedical application

A porous implant material with adequate pore structure and the appropriate mechanical properties for bone ingrowth has long been sought. This article presents details of the development, characterization and in vivo evaluations of powder metallurgy-processed titanium samples exhibiting a dense core with an integrated porous surface for biomedical applications. A space-holder method was applied to investigate the effects of different percentages and particle sizes of the urea on bone neoformation in 30 rabbits. The samples were previously characterized using scanning electron microscopy and mechanical testing. After 8 and 12 weeks of implantation, bone ingrowth was histologically and histometrically analyzed and push-out testing was performed. This study demonstrated that the association of a dense core integrated with the greatest number of interconnected pores of the smallest size is a promising biomaterial for bone tissue engineering. This sample exhibits appropriate mechanical properties combined with increased bone ingrowth, providing enhanced resistance to displacement.

The effect of bone ingrowth depth on the tensile and shear strength of the implant-bone e-beam produced interface

New technologies, such as selective electron beam melting, allow to create complex interface structures to enhance bone ingrowth in cementless implants. The efficacy of such structures can be tested in animal experiments. Although animal studies provide insight into the biological response of new structures, it remains unclear how ingrowth depth is related to interface strength. Theoretically, there could be a threshold of ingrowth, above which the interface strength does not further increase. To test the relationship between depth and strength we performed a finite element study on micro models with simulated uncoated and hydroxyapatite (HA) coated surfaces. We examined whether complete ingrowth is necessary to obtain a maximal interface strength. An increase in bone ingrowth depth did not always enhance the bone-implant interface strength. For the uncoated specimens a plateau was reached at 1,500 μm of ingrowth depth. For the specimens with a simulated HA coating, a bone ingrowth depth of 500 μm already yielded a substantial interface strength, and deeper ingrowth did not enhance the interface strength considerably. These findings may assist in optimizing interface morphology (its depth) and in judging the effect of bone ingrowth depth on interface strength.

Evaluation of bone ingrowth into porous titanium implant: histomorphometric analysis in rabbits

A porous material for bone ingrowth with adequate pore structure and appropriate mechanical properties has long been sought as the ideal bone-implant interface. This study aimed to assess in vivo the influence of three types of porous titanium implant on the new bone ingrowth. The implants were produced by means of a powder metallurgy technique with different porosities and pore sizes: Group 1 = 30 % and 180 µm; Group 2 = 30% and 300 µm; and Group 3 = 40% and 180 µm;. Six rabbits received one implant of each type in the right and left tibiae and were sacrificed 8 weeks after surgery for histological and histomorphometric analyses. Histological analysis confirmed new bone in contact with the implant, formed in direction of pores. Histomorphometric evaluation demonstrated that the new bone formation was statistically significantly lower in the group G1 than in group G3, (P = 0.023). Based on these results, increased porosity and pore size were concluded to have a positive effect on the amount of bone ingrowth.

Initial evaluation of bone ingrowth into a novel porous titanium coating

Porous metals (sintered beads and meshes) have been used for many years for different orthopedic applications. Metal foams have been recently developed. These foams have the advantage of being more porous than the traditional coatings. Their high porosity provides more space for bone ingrowth and mechanical interlocking and presents more surface for implant-bone contact. The objective of this study was to evaluate in vivo bone ingrowth into Ti implants covered with a novel Ti foam coating. This foam contains 50% in volume of interconnected pores and a higher surface area compared to dense Ti. Both coated implants and dense Ti controls were placed transcortically in the rat tibia. The animals were sacrificed at 2 weeks after implantation, and the amount of bone in the implants was determined using backscattered electron imaging and X-ray microtomography. Already at this time interval, the pores within the Ti foam showed 97.7% bone filling, and the bone-implant contact area was significantly increased compared to dense Ti controls. These initial results indicate that this novel Ti foam is biocompatible, has the capacity to sustain bone formation, and can potentially improve osseointegration.