Effects of immediately static loading on osteointegration and osteogenesis around 3D-printed porous implant: A histological and biomechanical study

Effects of immediate loading directionality on the mechanical sensing protein PIEZO1 expression and early-stage healing process of peri-implant bone

BACKGROUND

The reduced treatment time of dental implants with immediate loading protocol is an appealing solution for dentists and patients. However, there remains a significant risk of early peri-implant bone response following the placement of immediately loaded implants, and limited information is available regarding loading directions and the associated in vivo characteristics of peri-implant bone during the early stages. This study aimed to investigate the effects of immediate loading directionality on the expression of mechanical sensing protein PIEZO1 and the healing process of peri-implant bone in the early stage.

METHODS

Thirty-two implants were inserted into the goat iliac crest models with 10 N static lateral immediate loading applied, followed by histological, histomorphological, immunohistochemical, X-ray microscopy and energy dispersive X-ray spectroscopy evaluations conducted after 10 days.

RESULTS

From evaluations at the cellular, tissue, and organ levels, it was observed that the expression of mechanical sensing protein PIEZO1 in peri-implant bone was significantly higher in the compressive side compared to the tensile side. This finding coincided with trends observed in interfacial bone extracellular matrix (ECM) contact percentage, bone mass, and new bone formation.

CONCLUSIONS

This study provides a novel insight into the immediate loading directionality as a potential influence factor for dental implant treatments by demonstrating differential effects on the mechanical sensing protein PIEZO1 expression and related early-stage healing processes of peri-implant bone. Immediate loading directions serve as potential therapeutic influence factors for peri-implant bone during its early healing stage.

Synergistic Amelioration of Osseointegration and Osteoimmunomodulation with a Microarc Oxidation-Treated Three-Dimensionally Printed Ti-24Nb-4Zr-8Sn Scaffold via Surface Activity and Low Elastic Modulus

Biomaterial scaffolds, including bone substitutes, have evolved from being primarily a biologically passive structural element to one in which material properties such as surface topography and chemistry actively direct bone regeneration by influencing stem cells and the immune microenvironment. Ti-6Al-4V(Ti6Al4V) implants, with a significantly higher elastic modulus than human bone, may lead to stress shielding, necessitating improved stability at the bone-titanium alloy implant interface. Ti-24Nb-4Zr-8Sn (Ti2448), a low elastic modulus β-type titanium alloy devoid of potentially toxic elements, was utilized in this study. We employed 3D printing technology to fabricate a porous scaffold structure to further decrease the structural stiffness of the implant to approximate that of cancellous bone. Microarc oxidation (MAO) surface modification technology is then employed to create a microporous structure and a hydrophilic oxide ceramic layer on the surface and interior of the scaffold. In vitro studies demonstrated that MAO treatment enhances the proliferation, adhesion, and osteogenesis capabilities on the scaffold surface. The chemical composition of the MAO-Ti2448 oxide layer is found to enhance the transcription and expression of osteogenic genes in bone mesenchymal stem cells (BMSCs), potentially related to the enrichment of Nb2O5 and SnO2 in the oxide layer. The MAO-Ti2448 scaffold, with its synergistic surface activity and low stiffness, significantly activates the anti-inflammatory macrophage phenotype, creating an immune microenvironment that promotes the osteogenic differentiation of BMSCs. In vivo experiments in a rabbit model demonstrated a significant improvement in the quantity and quality of the newly formed bone trabeculae within the scaffold under the contact osteogenesis pattern with a matched elastic modulus. These trabeculae exhibit robust connections to the external structure of the scaffold, accelerating the formation of an interlocking structure between the bone and implant and providing higher implantation stability. These findings suggest that the MAO-Ti2448 scaffold has significant potential as a bone defect repair material by regulating osteoimmunomodulation and osteogenesis to enhance osseointegration. This study demonstrates an optional strategy that combines the mechanism of reducing the elastic modulus with surface modification treatment, thereby extending the application scope of β-type titanium alloy.

Biomechanical Analysis of Axial Gradient Porous Dental Implants: A Finite Element Analysis

The porous structure can reduce the elastic modulus of a dental implant and better approximate the elastic characteristics of the material to the alveolar bone. Therefore, it has the potential to alleviate bone stress shielding around the implant. However, natural bone is heterogeneous, and, thus, introducing a porous structure may produce pathological bone stress. Herein, we designed a porous implant with axial gradient variation in porosity to alleviate stress shielding in the cancellous bone while controlling the peak stress value in the cortical bone margin region. The biomechanical distribution characteristics of axial gradient porous implants were studied using a finite element method. The analysis showed that a porous implant with an axial gradient variation in porosity ranging from 55% to 75% was the best structure. Under vertical and oblique loads, the proportion of the area with a stress value within the optimal stress interval at the bone-implant interface (BII) was 40.34% and 34.57%, respectively, which was 99% and 65% higher compared with that of the non-porous implant in the control group. Moreover, the maximum equivalent stress value in the implant with this pore parameter was 64.4 MPa, which was less than 1/7 of its theoretical yield strength. Axial gradient porous implants meet the strength requirements for bone implant applications. They can alleviate stress shielding in cancellous bone without increasing the stress concentration in the cortical bone margin, thereby optimizing the stress distribution pattern at the BII.

In vitro fatigue behavior and in vivo osseointegration of the auxetic porous bone screw

The incidence of screw loosening, migration, and pullout caused by the insufficient screw-bone fixation stability is relatively high in clinical practice. To solve this issue, the auxetic unit-based porous bone screw (AS) has been put forward in our previous work. Its favorable auxetic effect can improve the primary screw-bone fixation stability after implantation. However, porous structure affected the fatigue behavior and in vivo longevity of bone screw. In this study, in vitro fatigue behaviors and in vivo osseointegration performance of the re-entrant unit-based titanium auxetic bone screw were studied. The tensile-tensile fatigue behaviors of AS and nonauxetic bone screw (NS) with the same porosity (51%) were compared via fatigue experiments, fracture analysis, and numerical simulation. The in vivo osseointegration of AS and NS were compared via animal experiment and biomechanical analysis. Additionally, the effects of in vivo dynamic tensile loading on the osseointegration of AS and NS were investigated and analyzed. The fatigue strength of AS was approximately 43% lower while its osseointegration performance was better than NS. Under in vivo dynamic tensile loading, the osseointegration of AS and NS both improved significantly, with the maximum increase of approximately 15%. Preferrable osseointegration of AS might compensate for the shortage of fatigue resistance, ensuring its long-term stability in vivo. Adequate auxetic effect and long-term stability of the AS was supposed to provide enough screw-bone fixation stability to overcome the shortages of the solid bone screw, developing the success of surgery and showing significant clinical application prospects in orthopedic surgery. STATEMENT OF SIGNIFICANCE: This research investigated the high-cycle fatigue behavior of re-entrant unit-based auxetic bone screw under tensile-tensile cyclic loading and its osseointegration performance, which has not been focused on in existing studies. The fatigue strength of auxetic bone screw was lower while the osseointegration was better than non-auxetic bone screw, especially under in vivo tensile loading. Favorable osseointegration of auxetic bone screw might compensate for the shortage of fatigue resistance, ensuring its long-term stability and longevity in vivo. This suggested that with adequate auxetic effect and long-term stability, the auxetic bone screw had significant application prospects in orthopedic surgery. Findings of this study will provide a theoretical guidance for design optimization and clinical application of the auxetic bone screw.

Nanoscale Morphologies on the Surface of 3D-Printed Titanium Implants for Improved Osseointegration: A Systematic Review of the Literature

Three-dimensional (3D) printing is serving as the most promising approach to fabricate personalized titanium (Ti) implants for the precise treatment of complex bone defects. However, the bio-inert nature of Ti material limits its capability for rapid osseointegration and thus influences the implant lifetime in vivo. Despite the macroscale porosity for promoting osseointegration, 3D-printed Ti implant surface morphologies at the nanoscale have gained considerable attention for their potential to improve specific outcomes. To evaluate the influence of nanoscale surface morphologies on osseointegration outcomes of 3D-printed Ti implants and discuss the available strategies, we systematically searched evidence according to the PRISMA on PubMed, Embase, Web of Science, and Cochrane (until June 2022). The inclusion criteria were in vivo (animal) studies reporting the osseointegration outcomes of nanoscale morphologies on the surface of 3D-printed Ti implants. The risk of bias (RoB) was assessed using the Systematic Review Centre for Laboratory Animal Experimentation (SYRCLE's) tool. The quality of the studies was evaluated using the Animal Research: Reporting of In Vivo Experiments (ARRIVE) guidelines. (PROSPERO: CRD42022334222). Out of 119 retrieved articles, 9 studies met the inclusion criteria. The evidence suggests that irregular nano-texture, nanodots and nanotubes with a diameter of 40-105nm on the surface of porous/solid 3D-printed Ti implants result in better osseointegration and vertical bone ingrowth compared to the untreated/polished ones by significantly promoting cell adhesion, matrix mineralization, and osteogenic differentiation through increasing integrin expression. The RoB was low in 41.1% of items, unclear in 53.3%, and high in 5.6%. The quality of the studies achieved a mean score of 17.67. Our study demonstrates that nanostructures with specific controlled properties on the surface of 3D-printed Ti implants improve their osseointegration. However, given the small number of studies, the variability in experimental designs, and lack of reporting across studies, the results should be interpreted with caution.

An Optimized Method for Microcomputed Tomography Analysis of Trabecular Parameters of Metal Scaffolds for Bone Ingrowth

Owing to its superior mechanical and biological properties, titanium metal is widely used in dental implants, orthopedic devices, and bone regenerative materials. Advances in 3D printing technology have led to more and more metal-based scaffolds being used in orthopedic applications. Microcomputed tomography (μCT) is commonly applied to evaluate the newly formed bone tissues and scaffold integration in animal studies. However, the presence of metal artifacts dramatically hinders the accuracy of μCT analysis of new bone formation. To acquire reliable and accurate μCT results that reflect new bone formation in vivo, it is crucial to lessen the impact of metal artifacts. Herein, an optimized procedure for calibrating μCT parameters using histological data was developed. In this study, the porous titanium scaffolds were fabricated by powder bed fusion based on computer-aided design. These scaffolds were implanted in femur defects created in New Zealand rabbits. After 8 weeks, tissue samples were collected to assess new bone formation using μCT analysis. Resin-embedded tissue sections were then used for further histological analysis. A series of deartifact two-dimensional (2D) μCT images were obtained by setting the erosion radius and the dilation radius in the μCT analysis software (CTan) separately. To get the μCT results closer to the real value, the 2D μCT images and corresponding parameters were subsequently selected by matching the histological images in the particular region. After applying the optimized parameters, more accurate 3D images and more realistic statistical data were obtained. The results demonstrate that the newly established method of adjusting μCT parameters can effectively reduce the influence of metal artifacts on data analysis to some extent. For further validation, other metal materials should be analyzed using the process established in this study.

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.

Efficient bone regeneration of BMP9-stimulated human periodontal ligament stem cells (hPDLSCs) in decellularized bone matrix (DBM) constructs to model maxillofacial intrabony defect repair

BACKGROUND

BMP9-stimulated DPSCs, SCAPs and PDLSCs are effective candidates for repairing maxillofacial bone defects in tissue engineering, while the most suitable seed cell source among these three hDMSCs and the optimal combination of most suitable type of hDMSCs and BMP9 have rarely been explored. Moreover, the orthotopic maxillofacial bone defect model should be valuable but laborious and time-consuming to evaluate various candidates for bone regeneration. Thus, inspired from the maxillofacial bone defects and the traditional in vivo ectopic systems, we developed an intrabony defect repair model to recapitulate the healing events of orthotopic maxillofacial bone defect repair and further explore the optimized combinations of most suitable hDMSCs and BMP9 for bone defect repair based on this modified ectopic system.

METHODS

Intrabony defect repair model was developed by using decellularized bone matrix (DBM) constructs prepared from the cancellous part of porcine lumbar vertebral body. We implanted DBM constructs subcutaneously on the flank of each male NU/NU athymic nude mouse, followed by directly injecting the cell suspension of different combinations of hDMSCs and BMP9 into the central hollow area of the constructs 7 days later. Then, the quality of the bony mass, including bone volume fraction (BV/TV), radiographic density (in Hounsfield units (HU)) and the height of newly formed bone, was measured by micro-CT. Furthermore, the H&E staining and immunohistochemical staining were performed to exam new bone and new blood vessel formation in DBM constructs.

RESULTS

BMP9-stimulated periodontal ligament stem cells (PDLSCs) exhibited the most effective bone regeneration among the three types of hDMSCs in DBM constructs. Furthermore, an optimal dose of PDLSCs with a specific extent of BMP9 stimulation was confirmed for efficacious new bone and new blood vessel formation in DBM constructs.

CONCLUSIONS

The reported intrabony defect repair model can be used to identify optimized combinations of suitable seed cells and biological factors for bone defect repair and subsequent development of efficacious bone tissue engineering therapies.

Dental Reimplantation Treatment and Clinical Care for Patients with Previous Implant Failure-A Retrospective Study

(1) Objectives: This study evaluated the clinical outcomes of dental implants placed in previously failed sites and discussed the risk factors that mattered in reimplantation. (2) Methods: All the cases by one specific implantologist during his first five years of clinical practice were screened, with a focus on those who received reimplantation. The clinical outcomes were assessed, including the implant survival, peri-implant health, and patients' satisfaction. (3) Results: 28 patients (31 implants) were recorded as failures from 847 patients (1269 implants), with a 2.4% overall failure rate at the implant level, of whom 19 patients (21 implants) received reimplantation treatment. After a mean follow-up of 33.7 ± 10.1 months (95% CI 29.1-38.3 months), 20 implants remained functional, but 1 implant revealed a secondary early failure, indicating a 95.2% overall survival rate. The mean probing depth (PD), modified sulcus bleeding index (mSBI), and marginal bone loss (MBL) of the surviving reinserted implants were 2.7 ± 0.6 mm (95% CI 2.5-3.0 mm), 0.7 ± 0.5 (95% CI 0.5-1.0), and 0.5 ± 0.6 mm (95% CI 0.3-0.8 mm), respectively. Embedded healing occurred more frequently in the reinserted implants than in the primary implants (p = 0.052). The patients' satisfaction suffered from implant failure, but a successful reimplantation could reverse it with close doctor-patient communication. (4) Conclusions: Reimplantation treatment was recommended, based on a thorough evaluation and consideration of the risk factors combined with effective communication with the patients.

3D-Printed Porous Titanium Root-Analogue Implant for the Treatment of Longitudinal Fracture of Mandibular Molars with Periapical Periodontitis: A Case Report

Customized porous titanium root-analogue implant (RAI) can be produced using CBCT data acquisition and three-dimensional image processing, combined with selective laser melting (SLM) technology. However, there is no report on the treatment of chronic periapical periodontitis with RAI. We report a case of longitudinal fissure of mandibular molars with periapical periodontitis and immediately implanted RAI after extraction. After a continuous observation for one year, it was found that the bone around the root grew into RAI and achieved a good effect of osseointegration. This report describes a situation in which traditional immediate implantation is untreatable, and the use of customized porous titanium RAI may open up new indications for immediate implantation.

In vivo study of dual functionalized mussel-derived bioactive peptides promoting 3D-printed porous Ti6Al4V scaffolds for repair of rabbit femoral defects

The 3D printed porous titanium alloy scaffolds are beneficial to enhance angiogenesis, osteoblast adhesion, and promote osseointegration. However, titanium alloys are biologically inert, which makes the bond between the implant and bone tissue weak and prone to loosening. Inspired by the natural biological marine mussels, we designed four-claw-shaped mussel-derived bioactive peptides for the decoration of porous titanium alloy scaffolds: adhesion peptide-DOPA, anchoring peptide-RGD and osteogenic-inducing peptide-BMP-2. And the bifunctionalization of 3D-printed porous titanium alloy scaffolds was evaluated in vivo in a rabbit model of bone defect with excellent promotion of osseointegration and mechanical stability. Our results show that the in vivo osseointegration ability of the modified 3D printed porous titanium alloy test piece is significantly improved, and the bifunctional polypeptide coating group E has the strongest osseointegration ability. In conclusion, our experimental design partially solves the problems of stress shielding effect and biological inertness, and provides a convenient and feasible method for the clinical application of titanium alloy implants in biomedical implant materials.

3D-printed porous Ti6Al4V scaffolds for long bone repair in animal models: a systematic review

BACKGROUND

Titanium and its alloys have been widely employed for bone tissue repair and implant manufacturing. The rapid development of three-dimensional (3D) printing technology has allowed fabrication of porous titanium scaffolds with controllable microstructures, which is considered to be an effective method for promoting rapid bone formation and decreasing bone absorption. The purpose of this systematic review was to evaluate the osteogenic potential of 3D-printed porous Ti6Al4V (Ti64) scaffold for repairing long bone defects in animal models and to investigate the influential factors that might affect its osteogenic capacity.

METHODS

Electronic literature search was conducted in the following databases: PubMed, Web of Science, and Embase up to September 2021. The SYRCLE's tool and the modified CAMARADES list were used to assess the risk of bias and methodological quality, respectively. Due to heterogeneity of the selected studies in relation to protocol and outcomes evaluated, a meta-analysis could not be performed.

RESULTS

The initial search revealed 5858 studies. Only 46 animal studies were found to be eligible based on the inclusion criteria. Rabbit was the most commonly utilized animal model. A pore size of around 500-600 µm and porosity of 60-70% were found to be the most ideal parameters for designing the Ti64 scaffold, where both dodecahedron and diamond pores optimally promoted osteogenesis. Histological analysis of the scaffold in a rabbit model revealed that the maximum bone area fraction reached 59.3 ± 8.1% at weeks 8-10. Based on micro-CT assessment, the maximum bone volume fraction was found to be 34.0 ± 6.0% at weeks 12.

CONCLUSIONS

Ti64 scaffold might act as a promising medium for providing sufficient mechanical support and a stable environment for new bone formation in long bone defects. Trail registration The study protocol was registered in the PROSPERO database under the number CRD42020194100.

Additively-manufactured PEEK/HA porous scaffolds with highly-controllable mechanical properties and excellent biocompatibility

Polyetheretherketone (PEEK) was widely applied into fabricating of orthopaedic implants, benefitting its excellent biocompatibility and similar mechanical properties to native bones. However, the inertness of PEEK hinders its integration with the surrounding bone tissue. Here PEEK scaffolds with a series of hydroxyapatite (HA) contents in gradient were manufactured via fused filament fabrication (FFF) 3D printing techniques. The influence of the pore size, HA content and printing direction on the mechanical properties of the PEEK/HA scaffolds was systematically evaluated. By adjusting the pore size and HA contents, the elastic modulus of the PEEK/HA scaffolds can be widely tuned in the range of 624.7-50.6 MPa, similar to the variation range of natural cancellous bone. Meanwhile, the scaffolds exhibited higher Young's modulus and lower compressive strength along Z printing direction. The mapping relationship among geometric parameters, HA content, printing direction and mechanical properties was established, which gave more accurate predictions and controllability of the modulus and strength of scaffolds. The PEEK/HA scaffolds with the micro-structured surface could promote cell attachment and mineralization in vitro. Therefore, the FFF-printed PEEK/HA composites scaffolds can be a good candidate for bone grafting and tissue engineering.

Integrating Finite Element Death Technique and Bone Remodeling Theory to Predict Screw Loosening Affected by Radiation Treatment after Mandibular Reconstruction Surgery

This study developed a numerical simulation to understand bone mechanical behavior and micro-crack propagation around a fixation screw with severe mandibular defects. A mandible finite element (FE) model was constructed in a rabbit with a right unilateral body defect. The reconstruction implant was designed to be fixed using six screws distributed on the distal and mesial sides. The element death technique provided in FE analysis was combined with bone remodeling theory to simulate bone necrosis around the fixation screw in which the strain value reached the overload threshold. A total of 20 iterations were performed to observe the micro-crack propagation pattern for each screw according to the high strain locations occurring in each result from consecutive iterations. A parallel in vivo animal study was performed to validate the FE simulation by placing specific metal 3D printing reconstruction implants in rabbits to compare the differences in bone remodeling caused by radiation treatment after surgery. The results showed that strain values of the surrounding distal bone fixation screws were much larger than those at the mesial side. With the increase in the number of iteration analyses, the micro-crack prorogation trend for the distal fixation screws can be represented by the number and element death locations during the iteration analysis process. The corresponding micro-movement began to increase gradually and induced screw loosening after iteration calculation. The strained bone results showed that relatively high bone loss (damage) existed around the distal fixation screws under radiation treatment. This study concluded that the FE simulation developed in this study can provide a better predictive diagnosis method for understanding fixation screw loosening and advanced implant development before surgery.