Tailoring the biologic responses of 3D printed PEEK medical implants by plasma functionalization

Strategies to improve the performance of polyetheretherketone (PEEK) as orthopedic implants: from surface modification to addition of bioactive materials

Polyetheretherketone (PEEK), as a high-performance polymer, is widely used for bone defect repair due to its homogeneous modulus of elasticity of human bone, good biocompatibility, excellent chemical stability and projectability. However, the highly hydrophobic surface of PEEK is biologically inert, which makes it difficult for cells and proteins to attach, and is accompanied by the development of infections that ultimately lead to failure of PEEK implants. In order to further enhance the potential of PEEK as an orthopedic implant, researchers have explored modification methods such as surface modification by physical and chemical means and the addition of bioactive substances to PEEK-based materials to enhance the mechanical properties, osteogenic activity and antimicrobial properties of PEEK. However, these current modification methods still have obvious shortcomings in terms of cost, maneuverability, stability and cytotoxicity, which still need to be explored by researchers. This paper reviews some of the modification methods that have been used to improve the performance of PEEK over the last three years in anticipation of the need for researchers to design PEEK orthopedic implants that better meet clinical needs.

Kinetics of Surface Wettability of Aromatic Polymers (PET, PS, PEEK, and PPS) upon Treatment with Neutral Oxygen Atoms from Non-Equilibrium Oxygen Plasma

The wettability of polymers is usually inadequate to ensure the appropriate spreading of polar liquids and thus enable the required adhesion of coatings. A standard ecologically benign method for increasing the polymer wettability is a brief treatment with a non-equilibrium plasma rich in reactive oxygen species and predominantly neutral oxygen atoms in the ground electronic state. The evolution of the surface wettability of selected aromatic polymers was investigated by water droplet contact angles deposited immediately after exposing polymer samples to fluxes of oxygen atoms between 3 × 1020 and 1 × 1023 m-2s-1. The treatment time varied between 0.01 and 1000 s. The wettability evolution versus the O-atom fluence for all aromatic polymers followed similar behavior regardless of the flux of O atoms or the type of polymer. In the range of fluences between approximately 5 × 1020 and 5 × 1023 m-2, the water contact angle decreased exponentially with increasing fluence and dropped to 1/e of the initial value after receiving the fluence close to 5 × 1022 m-2.

Effects of combined modification of sulfonation, oxygen plasma and silane on the bond strength of PEEK to resin

OBJECTIVE

This study aimed to evaluate the combined effects of sulfonation, non-thermal oxygen plasma and silane on the shear bond strength (SBS) of PEEK to resin materials.

MATERIALS AND METHODS

Two hundred and eighty specimens were randomly divided into four groups: (A) untreated; (B) sulfonation for 60 s; (C) oxygen plasma for 20 min; (D) sulfonation for 60 s and oxygen plasma for 20 min. According to the instructions, 120 samples (N = 30) were coated with silane, adhesive, and resin composites. Each group of bonding specimens was divided into two subgroups (n = 15) to measure immediate and post-aging SBS. The surface morphology and the interface between the samples and adhesive were analyzed through SEM. Physicochemical characteristics of the surface and mechanical properties were determined through XPS, FTIR, light interferometry, contact angle measurement, and three-point bending tests.

RESULTS

Sulfonation produced a porous layer of approximately 20 µm thickness on the surface, and the oxygen plasma increased the O/C ratio and oxygen-containing groups of the sample surface. After coating with silane, the SBS values of sulfonated PEEK and plasma-treated PEEK increased (9.96 and 10.72 MPa, respectively), and dual-modified PEEK exhibited the highest SBS value (20.99 MPa), which was significantly higher than that of blank group (p > 0.01). After 10,000 thermal cycles, the dual-modified PEEK still displayed a favorable SBS (18.68 MPa).

SIGNIFICANCE

Sulfonation strengthened the mechanical interlocking between PEEK and the resin while oxygen plasma established a chemical bonding between silane and PEEK. This dual modification of the surface microstructure and chemical state synergistically improved the bond strength of PEEK to resin and resulted in considerable long-term effects.

A balance of biocompatibility and antibacterial capability of 3D printed PEEK implants with natural totarol coating

OBJECTIVE

Polyetheretherketone (PEEK), a biomaterial with appropriate bone-like mechanical properties and excellent biocompatibility, is widely applied in cranio-maxillofacial and dental applications. However, the lack of antibacterial effect is an essential drawback of PEEK material and might lead to infection and osseointegration issues. This study aims to apply a natural antibacterial agent, totarol coating onto the 3D printed PEEK surface and find an optimized concentration with balanced cytocompatibility, osteogenesis, and antibacterial capability.

METHODS

In this study, a natural antibacterial agent, totarol, was applied as a coating to fused filament fabrication (FFF) 3D printed PEEK surfaces at a series of increasing concentrations (1 mg/ml, 5 mg/ml, 10 mg/ml, 15 mg/ml, and 20 mg/ml). The samples were then evaluated for cytocompatibility with L929 fibroblast and SAOS-2 osteoblast using live/dead staining and CCK-8 assay. The antibacterial capability was assessed by crystal violet staining, live/dead staining, and scanning electron microscopy (SEM) utilizing the oral primary colonizer S. gordonii and isolates of mixed oral bacteria in a stirring system simulating the oral environment. The appropriate safe working concentration for totarol coating is selected based on the results of the cytocompatibility and antibacterial test. Subsequently, the influence on osteogenic differentiation was evaluated by alkaline phosphatase (ALP) and alizarin red staining (ARS) analysis of pre-osteoblasts.

RESULTS

Our results showed that the optimal concentration of totarol solution for promising antibacterial coating was approximately 10 mg/ml. Such surfaces could play an excellent antibacterial role by inducing a contact-killing effect with an inhibitory effect against biofilm development without affecting the healing of soft and hard tissues around FFF 3D printed PEEK implants or abutments.

SIGNIFICANCE

This study indicates that the totarol coated PEEK has an improved antibacterial effect with excellent biocompatibility providing great clinical potential as an orthopedic/dental implant/abutment material.

Current applications of 3D printing in dental implantology: A scoping review mapping the evidence

OBJECTIVES

This scoping review aimed to identify the available evidence in the use of 3D printing technology in dental implantology. Due to the broad scope of the subject and its application in implantology, three main areas of focus were identified: (1) customized dental implants, (2) manufacturing workflow for surgical implant guides, and (3) related implant-supported prostheses factors, which include the metallic primary frameworks, secondary ceramic or polymer superstructures, and 3D implant analog models.

MATERIALS AND METHODS

Online databases (Medline, Cochrane, Embase, and CINAHL) were used to identify the studies published up to February 2023 in English. Two experienced reviewers performed independently the screening and selection among the 1737 studies identified. The articles evaluated the additive manufacturing (AM) technology, materials, printing, and post-processing parameters regarding dental implantology.

RESULTS

The 132 full-text studies that met the inclusion criteria were examined. Thirteen studies of customized dental implants, 22 studies about the workflow for surgical implant guides, and 30 studies of related implant-supported prostheses factors were included.

CONCLUSIONS

(1) The clinical evidence about AM titanium and zirconia implants is scarce. Early data on survival rates, osseointegration, and mechanical properties are being reported. (2) 3D printing is a proven manufacturing technology to produce surgical implant guides. Adherence to the manufacturer's instructions is crucial and the best accuracy was achieved using MultiJet printer. (3) The quality of 3D printed prosthetic structures and superstructures is improving remarkably, especially on metallic alloys. However, better marginal fit and mechanical properties can be achieved with milling technology for metals and ceramics.

Optimization and manufacture of polyetheretherketone patient specific cranial implants by material extrusion - A clinical perspective

Polyetheretherketone (PEEK) is a high performing thermoplastic that has established itself as a 'gold-standard' material for cranial reconstruction. Traditionally, milled PEEK patient specific cranial implants (PSCIs) exhibit uniform levels of smoothness (excusing suture/drainage holes) to the touch (<1 μm) and homogenous coloration throughout. They also demonstrate predictable and repeatable levels of mechanical performance, as they are machined from isotropic material blocks. The combination of such factors inspires confidence from the surgeon and in turn, approval for implantation. However, manufacturing lead-times and affiliated costs to fabricate a PSCI are high. To simplify their production and reduce expenditure, hospitals are exploring the production of in-house PEEK PSCIs by material extrusion-based additive manufacturing. From a geometrical and morphological perspective, such implants have been produced with good-to-satisfactory clinical results. However, lack of clinical adoption persists. To determine the reasoning behind this, it was necessary to assess the benefits and limitations of current printed PEEK PSCIs in order to establish the status quo. Afterwards, a review on individual PEEK printing variables was performed in order to identify a combination of parameters that could enhance the aesthetics and performance of the PSCIs to that of milled implants/cranial bone. The findings from this review could be used as a baseline to help standardize the production of PEEK PSCIs by material extrusion in the hospital.

Improved osteogenic activity of NiTi orthopedic implant by HAp-Nb2O5 composite coatings: Materials and biological points of view

The surface properties of NiTi, as an interface between the synthetic implant and living tissue, play a vital role in guaranteeing implantation success, especially during the initial stage. This contribution endeavors to enhance the surface features of NiTi orthopedic implants through the application of HAp-based coatings, placing emphasis on assessing the influence of Nb₂O₅ particles concentration in the electrolyte on resultant properties of HAp-Nb₂O₅ composite electrodeposits. The coatings were electrodeposited via pulse current mode under galvanostatic current control from an electrolyte containing 0-1 g/L of Nb₂O₅ particles. Surface morphology, topography, and phase composition were evaluated using FESEM, AFM, and XRD, respectively. EDS was employed to study surface chemistry. In vitro biomineralization and osteogenic activity of the samples were studied by immersing the samples in SBF and incubating them with osteoblastic SAOS-2 cells, respectively. The added Nb₂O₅ particles, at the optimum concentration, stimulated biomineralization, suppressed the Ni ion leaching, and improved SAOS-2 cell adhesion and proliferation. NiTi implant coated by HAp-0.50 g/L Nb₂O₅ layer showed tremendous osteogenic properties. Overall, the HAp-Nb₂O₅ composite layers bring forth fascinating coating in vitro biological performance, reducing Ni leaching, and promoting osteogenic activity, which are fundamental for the successful use of NiTi in vivo.

Can Steam Sterilization Affect the Accuracy of Point-of-Care 3D Printed Polyetheretherketone (PEEK) Customized Cranial Implants? An Investigative Analysis

Polyetheretherketone (PEEK) has become the biomaterial of choice for repairing craniofacial defects over time. Prospects for the point-of-care (POC) fabrication of PEEK customized implants have surfaced thanks to the developments in three-dimensional (3D) printing systems. Consequently, it has become essential to investigate the characteristics of these in-house fabricated implants so that they meet the necessary standards and eventually provide the intended clinical benefits. This study aimed to investigate the effects of the steam sterilization method on the dimensional accuracy of POC 3D-printed PEEK customized cranial implants. The objective was to assess the influence of standard sterilization procedures on material extrusion-based 3D-printed PEEK customized implants with non-destructive material testing. Fifteen PEEK customized cranial implants were fabricated using an in-house material extrusion-based 3D printer. After fabrication, the cranial implants were digitalized with a professional-grade optical scanner before and after sterilization. The dimensional changes for the 3D-printed PEEK cranial implants were analyzed using medically certified 3D image-based engineering software. The material extrusion 3D-printed PEEK customized cranial implants displayed no statistically significant dimensional difference with steam sterilization (p > 0.05). Evaluation of the cranial implants’ accuracy revealed that the dimensions were within the clinically acceptable accuracy level with deviations under 1.00 mm. Steam sterilization does not significantly alter the dimensional accuracy of the in-house 3D-printed PEEK customized cranial implants.

Surface Treatments of PEEK for Osseointegration to Bone

Polymers, in general, and Poly (Ether-Ether-Ketone) (PEEK) have emerged as potential alternatives to conventional osseous implant biomaterials. Due to its distinct advantages over metallic implants, PEEK has been gaining increasing attention as a prime candidate for orthopaedic and dental implants. However, PEEK has a highly hydrophobic and bioinert surface that attenuates the differentiation and proliferation of osteoblasts and leads to implant failure. Several improvements have been made to the osseointegration potential of PEEK, which can be classified into three main categories: (1) surface functionalization with bioactive agents by physical or chemical means; (2) incorporation of bioactive materials either as surface coatings or as composites; and (3) construction of three-dimensionally porous structures on its surfaces. The physical treatments, such as plasma treatments of various elements, accelerated neutron beams, or conventional techniques like sandblasting and laser or ultraviolet radiation, change the micro-geometry of the implant surface. The chemical treatments change the surface composition of PEEK and should be titrated at the time of exposure. The implant surface can be incorporated with a bioactive material that should be selected following the desired use, loading condition, and antimicrobial load around the implant. For optimal results, a combination of the methods above is utilized to compensate for the limitations of individual methods. This review summarizes these methods and their combinations for optimizing the surface of PEEK for utilization as an implanted biomaterial.

Additive manufacturing technologies in the oral implant clinic: A review of current applications and progress

Additive manufacturing (AM) technologies can enable the direct fabrication of customized physical objects with complex shapes, based on computer-aided design models. This technology is changing the digital manufacturing industry and has become a subject of considerable interest in digital implant dentistry. Personalized dentistry implant treatments for individual patients can be achieved through Additive manufacturing. Herein, we review the applications of Additive manufacturing technologies in oral implantology, including implant surgery, and implant and restoration products, such as surgical guides for implantation, custom titanium meshes for bone augmentation, personalized or non-personalized dental implants, custom trays, implant casts, and implant-support frameworks, among others. In addition, this review also focuses on Additive manufacturing technologies commonly used in oral implantology. Stereolithography, digital light processing, and fused deposition modeling are often used to construct surgical guides and implant casts, whereas direct metal laser sintering, selective laser melting, and electron beam melting can be applied to fabricate dental implants, personalized titanium meshes, and denture frameworks. Moreover, it is sometimes required to combine Additive manufacturing technology with milling and other cutting and finishing techniques to ensure that the product is suitable for its final application.

Use of Piranha Solution as An Alternative Route to Promote Bioactivation of PEEK Surface with Low Functionalization Times

This study aimed to achieve bioactivity on the PEEK surface using piranha solution through a lower functionalization time. For this purpose, the functionalization occurred with piranha solution and 98% sulfuric acid in the proportions of 1:2, 1:1, and 2:1 at periods of 30, 60, and 90 s. The samples treated for longer times at higher concentrations registered the characteristic spectroscopy band associated with sulfonation. Additionally, both chemical treatments allowed the opening of the aromatic ring, increasing the number of functional groups available and making the surface more hydrophilic. The piranha solution treatments with higher concentrations and longer times promoted greater heterogeneity in the surface pores, which affected the roughness of untreated PEEK. Furthermore, the treatments induced calcium deposition on the surface during immersion in SBF fluid. In conclusion, the proposed chemical modifications using sulfuric acid SPEEK 90 and, especially, the piranha solution PEEK-PS 2:1-90, were demonstrated to be promising in promoting the rapid bioactivation of PEEK-based implants.

Adhesive Property of 3D-Printed PEEK Abutments: Effects of Surface Treatment and Temporary Crown Material on Shear Bond Strength

Three-dimensionally printed polyetheretherketone (PEEK) materials are promising for fabricating customized dental abutments. This study aimed to investigate the adhesive property of a 3D-printed PEEK material. The effects of surface treatment and temporary crown materials on shear bond strength were evaluated. A total of 108 PEEK discs were 3D printed by fused-filament fabrication. Surface treatments, including sandblasting, abrasive paper grinding, and CO2 laser ablation, were applied to the PEEK discs, with the untreated specimens set as the control. Afterward, the surface topographies of each group were investigated by scanning electron microscopy (SEM, n = 1) and roughness measurements (n = 7). After preparing the bonding specimens with three temporary crown materials (Artificial teeth resin (ATR), 3M™ Filtek™ Supreme Flowable Restorative (FR), and Cool Temp NATURAL (CTN)), the shear bond strength was measured (n = 6), and the failure modes were analyzed by microscopy and SEM. The results showed that ATR exhibited a significantly higher shear bond strength compared to FR and CTN (p < 0.01), and the PEEK surfaces treated by sandblasting and abrasive paper grinding showed a statistically higher shear bond strength compared to the control (p < 0.05). For clinical application, the ATR material and subtractive surface treatments are recommended for 3D-printed PEEK abutments.

3D printing of bone and cartilage with polymer materials

Damage and degeneration to bone and articular cartilage are the leading causes of musculoskeletal disability. Commonly used clinical and surgical methods include autologous/allogeneic bone and cartilage transplantation, vascularized bone transplantation, autologous chondrocyte implantation, mosaicplasty, and joint replacement. 3D bio printing technology to construct implants by layer-by-layer printing of biological materials, living cells, and other biologically active substances in vitro, which is expected to replace the repair mentioned above methods. Researchers use cells and biomedical materials as discrete materials. 3D bio printing has largely solved the problem of insufficient organ donors with the ability to prepare different organs and tissue structures. This paper mainly discusses the application of polymer materials, bio printing cell selection, and its application in bone and cartilage repair.

Strategies for Improved Wettability of Polyetheretherketone (PEEK) Polymers by Non-Equilibrium Plasma Treatment

Polyetheretherketone (PEEK) is the material of choice in several applications ranging from the automotive industry to medicine, but the surface properties are usually not adequate. A standard method for tailoring surface properties is the application of gaseous plasma. The surface finish depends enormously on the processing parameters. This article presents a review of strategies adapted for improved wettability and adhesion of PEEK. The kinetics of positively charged ions, neutral reactive plasma species, and vacuum ultraviolet radiation on the surface finish are analyzed, and synergies are stressed where appropriate. The reviewed articles are critically assessed regarding the plasma and surface kinetics, and the surface mechanisms are illustrated. The directions for obtaining optimal surface finish are provided together with the scientific explanation of the limitations of various approaches. Super-hydrophilic surface finish is achievable by treatment with a large dose of vacuum ultraviolet radiation in the presence of oxidizing gas. Bombardment with positively charged ions of kinetic energy between about 100 and 1000 eV also enable high wettability, but one should be aware of excessive heating when using the ions.

Polyether Ether Ketone Coated with Ultra-Thin Films of Titanium Oxide and Zirconium Oxide Fabricated by DC Magnetron Sputtering for Biomedical Application

Recently, polyether ether ketone has raised increasing interest in research and industry as an alternative material for bone implants. This polymer also has some shortcomings, as it is bioinert and its surface is relatively hydrophobic, causing poor cell adhesion and therefore slow integration with bone tissue. In order to improve biocompatibility, the surface of polyether ether ketone-based implants should be modified. Therefore, polished disc-shaped polyether ether ketone samples were surface-modified by direct current magnetron sputtering with ultrathin titanium and zirconium coatings (thickness < 100 nm). The investigation results show a uniform distribution of both types of coatings on the sample surfaces, where the coatings mostly consist of titanium dioxide and zirconium dioxide. Differential scanning calorimetry revealed that the crystalline structure of the polyether ether ketone substrates was not changed by the coating deposition. Both coatings are amorphous, as shown by X-ray diffraction investigations. The roughness of both coating types increases with increasing coating thickness, which is beneficial for cell colonization. The coatings presented and investigated in this study improve wettability, increasing surface energies, in particular the polar component of the surface energies, which, in turn, are important for cell adhesion.

Biomechanical performance of Ti-PEEK dental implants in bone: An in-silico analysis

Stress-shielding is caused by a significant mismatch in stiffness between bone tissue and Ti alloy dental implants. Therefore, in this study, a Ti-PEEK composite implant was examined and compared with conventional titanium, to determine the behavior of the host bone. Twelve 3D finite element models were modeled with two conditions of marginal cortical bone (with and without marginal bone loss). Six implant designs were constructed. Implant (A) was made with a conventional design (dense titanium), implants (B), (C) and (D) are designed with Ti-PEEK composite (outer layer made of PEEK and inner structures made of Ti with hexagonal, cylindrical, and cross shapes for implants (B), (C) and (D), respectively), the implant (E) is designed with Ti at the upper half section and PEEK at the bottom half section, and the implant (F) is designed with PEEK at the upper half section and Ti at the bottom half section. An axial load of 200 N was applied to the buccal cusp and central fossa of the occlusal surface. The displacements, stress, and equivalent strain were analyzed at the level of bone tissue. The mechanostat of Frost was used to determine the behavior of the cancellous bone under these biomechanical conditions. Results showed that strains were greater in cancellous bone with marginal bone loss than in healthy bone (w/o MBL). When compared to implants (B)-(F), conventional implant (A) did not produce as much strain. Thus, results and analyses suggest that the Ti-PEEK implants outperform compared with the implant (A) in the case of no marginal bone loss. However, the implants (A) and (E) perform equally in terms of bone loss.