Behavior of CAL72 osteoblast-like cells cultured on zirconia ceramics with different surface topographies

Surface modification of dental zirconia implants with a low infiltration temperature glass

The glass infiltration technique was employed for surface modification of zirconia implants in this study. The prepared glass-infiltrated zirconia with low infiltrating temperature showed excellent mechanical properties and enough infiltrating layer. The zirconia substrate was pre-sintered at 1,200°C and the glass infiltration depth reached 400 μm after infiltrating at 1,200°C for 10 h. The infiltrating glass has good wetting ability, thermal expansion match and good chemical compatibility with the zirconia substrate. Indentation fracture toughness and flexural strength of the dense sintered glass-infiltrated zirconia composite are respectively 5.37±0.45 MPa•m1/2 and 841.03±89.31 MPa. Its elasticity modulus is 163.99±7.6 GPa and has about 500 μm infiltrating layer. The glass-infiltrated zirconia can be acid etched to a medium roughness (1.29±0.09 μm) with a flexural strength of 823.65±87.46 MPa, which promotes cell proliferation and has potential for dental implants.

Influence of clinical zirconia surface treatments on microscopic characteristics and adhesion-proliferation behavior of human gingival fibroblasts

Zirconia is favored in dental implant applications due to its biocompatibility, mechanical properties, and esthetic appeal, particularly in its interaction with soft oral tissues such as the gingiva. To optimize zirconia for clinical use, surface treatments like sanding and polishing are essential. The aim of this study was to investigate the effects of clinical surface treatments on the microscopic characteristics of zirconia and the adhesion and proliferation of human gingival fibroblasts (HGFs). Scanning electron microscopy (SEM) and fluorescence microscopy were utilized to examine the microscopic morphology and roughness resulting from various clinical surface treatment procedures on zirconia and to assess their impact on the microscopic appearance and behavior of HGFs. The results showed that the application of surface treatment procedures, particularly polishing treatments, resulted in the formation of a regular shallow groove morphology and a significant reduction in roughness in zirconia. This was accompanied by improved cell proliferation, cell adhesion, and the expression of integrin β1 in HGFs. The results suggest that smoother zirconia surfaces promote better cell-material interactions, potentially improving the clinical success of dental implants. This research contributes to our understanding of the optimal surface roughness for soft tissue adhesion and the effect of different micro-morphologies on HGF attachment.

Influence of Surface Treatment and Accelerated Ageing on Biaxial Flexural Strength and Hardness of Zirconia

The aim was to investigate how the surface treatment and the process of accelerated ageing of zirconia for dental implants affect the biaxial flexural strength and hardness. Zirconia discs with a diameter of 12.6 mm were subjected to either one of the following treatments: polishing (Zp); polishing and heat treatment at 1250 °C for 1 h (Zpt); machining (Zm); machining and heat treatment (Zmt); or sandblasting, acid-etching, and heat treatment (Z14) (n = 45 per group). Biaxial flexural strength and Martens hardness (HM) were measured without further treatment and after accelerated ageing for 5 h or 5 × 5 h according to ISO 13356 (n = 15 per group). Two-way ANOVA was applied to test the effect of surface treatment and ageing (α = 0.05). The reliability of the specimens was described with Weibull two-parameter distribution of biaxial flexural strength data. Overall, the surface treatment (p < 0.001) and ageing (p = 0.012) revealed a significant effect on biaxial flexural strength values, while HM was only affected by the surface treatment (p < 0.001) but not ageing (p = 0.160). Surface treatment significantly affected HM (p < 0.001) but not ageing (p = 0.160). The applied surface treatments affected the biaxial flexural strength and HM of zirconia. For accelerated ageing, a duration of both 5 h and 5 × 5 h is recommended to evaluate the effect of surface treatments. Zm was the most reliable surface as it was least affected by ageing and provided low standard deviations of biaxial flexural strength values.

A systematic review on neutrophils interactions with titanium and zirconia surfaces: Evidence from in vitro studies

Objectives

This systematic review aimed to assess in vitro studies that evaluated neutrophil interactions with different roughness levels in titanium and zirconia implant surfaces.

Material and Methods

An electronic search for literature was conducted on PubMed, Embase, Scopus, and Web of Science and a total of 14 studies were included. Neutrophil responses were assessed based on adhesion, cell number, surface coverage, cell structure, cytokine secretion, reactive oxygen species (ROS) production, neutrophil activation, receptor expression, and neutrophil extracellular traps (NETs) release. The method of assessing the risk of bias was done using the toxicological data reliability assessment tool (TOXRTOOL).

Results

Ten studies have identified a significant increase in neutrophil functions, such as surface coverage, cell adhesion, ROS production, and NETs released when interacting with rough titanium surfaces. Moreover, neutrophil interaction with rough–hydrophilic surfaces seems to produce less proinflammatory cytokines and ROS when compared to naive smooth and rough titanium surfaces. Regarding membrane receptor expression, two studies have reported that the FcγIII receptor (CD16) is responsible for initial neutrophil adhesion to hydrophilic titanium surfaces. Only one study compared neutrophil interaction with titanium alloy and zirconia toughened alumina surfaces and reported no significant differences in neutrophil cell count, activation, receptor expression, and death.

Conclusions

There are not enough studies to conclude neutrophil interactions with titanium and zirconia surfaces. However, different topographic modifications such as roughness and hydrophilicity might influence neutrophil interactions with titanium implant surfaces.

Clinical and radiographic success of injection-molded 2-piece zirconia implants submitted to immediate loading: A 12-month report of two cases

This case report describes the treatment of two patients who presented with single edentulous sites in the region of upper premolars and were rehabilitated through the placement of injection-molded 2-piece zirconia implants and immediate single crowns. Three months after surgery, definitive prostheses were confectioned through digital workflow. Both patients were followed for 12 months during which clinical and radiographic implant success were observed, concerning implant stability, absence of peri-implantitis signs, complete implant osseointegration, good marginal bone-level maintenance, and excellent soft tissue esthetics. No biological or mechanical complications were observed within this period.

Classification and Properties of Dental Zirconia as Implant Fixtures and Superstructures

Various types of zirconia are widely used for the fabrication of dental implant superstructures and fixtures. Zirconia-alumina composites, such as ATZ and NanoZR, are adequate for implant fixtures because they have excellent mechanical strength in spite of insufficient esthetic properties. On the other hand, yttria-stabilized zirconia has been used for implant superstructures because of sufficient esthetic properties. They are classified to 12 types with yttria content, monochromatic/polychromatic, uniform/hybrid composition, and monolayer/multilayer. Zirconia with a higher yttria content has higher translucency and lower mechanical strength. Fracture strength of superstructures strongly depends on the strength on the occlusal contact region. It suggests that adequate zirconia should be selected as the superstructure crown, depending on whether strength or esthetics is prioritized. Low temperature degradation of zirconia decreases with yttria content, but even 3Y zirconia has a sufficient durability in oral condition. Although zirconia is the hardest dental materials, zirconia restorative rarely subjects the antagonist teeth to occlusal wear when it is mirror polished. Furthermore, zirconia has less bacterial adhesion and better soft tissue adhesion when it is mirror polished. This indicates that zirconia has advantageous for implant superstructures. As implant fixtures, zirconia is required for surface modification to obtain osseointegration to bone. Various surface treatments, such as roughening, surface activation, and coating, has been developed and improved. It is concluded that an adequately selected zirconia is a suitable material as implant superstructures and fixtures because of mechanically, esthetically, and biologically excellent properties.

Using Genipin to Immobilize Bone Morphogenetic Protein-2 on Zirconia Surface for Enhancing Cell Adhesion and Mineralization in Dental Implant Applications

Our objective in this study was to promote cell responses through the immobilization of bone morphogenetic protein-2 (BMP-2) on roughened zirconia (ZrO₂) through using the natural cross-linker genipin in dental implant applications. Field emission scanning electron microscope, X-ray photoelectron spectroscopy, and attenuated total reflection-Fourier transform infrared spectroscopy were used to analyze the surface characterizations, including the topography, chemistry, and functional groups, respectively, of the test specimens. Human bone marrow mesenchymal stem cells (hMSCs) were used to detect cell responses (adhesion, proliferation, and mineralization). The surface characterizations analysis results revealed that genipin was effective in immobilizing BMP-2 on roughened zirconia surfaces. BMP-2 proved effective in promoting the adhesion and mineralization of hMSCs on roughened zirconia. The surface modification proposed has potential in zirconia dental implant applications.

Surface Characteristics and Bioactivity of Zirconia (Y-TZP) with Different Surface Treatments

Background:

Zirconia being a bio-inert material needs to be surface treated to render it more bioactive and enhance its osseointegration potential. However, bioactivity studies focusing on the ability of sandblasting and ultraviolet photofunctionalization (UVP) surface treatments in inducing apatite precipitation using simulated body fluid (SBF) are lacking.

Aim:

The aim of the study was to comparatively evaluate the effect of two different surface treatments—sandblasting with 50 µm alumina and UVP with ultraviolet C (UVC) light on the bioactivity of zirconia.

Materials and Methods:

A total of 33 discs with dimensions 10 mm × 2 mm were obtained from zirconia blanks (Amann Girrbach, Koblach, Austria) and randomly divided into three groups (n = 11), namely Group I (untreated), Group II (sandblasted), and Group III (UVP). Surface characteristics of representative test samples were analyzed using X-ray diffraction (XRD), atomic force microscopy (AFM), contact angle goniometry, scanning electron microscopy (SEM), and energy dispersive X-ray spectroscopy (EDX), to assess type of crystal phase of zirconia, surface roughness, wettability, surface topography, and elemental composition, respectively. SBF was prepared and calcium content in SBF (Ca-SBF) was determined using inductively coupled plasma mass spectrometry (ICP-MS).

Results:

Data were analyzed by one-way analysis of variance (ANOVA), post hoc Tukey honestly significant difference (HSD), and Student’s t test for statistical significance (P < 0.05, significant; P < 0.01, highly significant). Surface characteristics analyses revealed that XRD showed predominant tetragonal (t) zirconia crystal phase for all test groups. Mean surface roughness (Sa) of Group I was 41.83 nm, and it was significantly lesser than that of Group II (115.65 nm) and Group III (102.43 nm). Mean contact angles were 98.26°, 86.77°, and 68.03° for Groups I, II, and III, respectively, and these differences were highly significant. Mean pre-immersion Ca content in SBF was found to be 159 mg/L. Mean post-immersion Ca content was 70.10, 60.80, and 56.20 mg/L for Groups I, II, and III, respectively. Significant differences were found between Group I as compared to both Groups II and III. Bioactivity of Group III was marginally, but insignificantly higher with respect to Group II. Groups II and III were insignificant with respect to each other. Post-immersion XRD revealed predominant “t” phase, and SEM-EDX revealed well-formed, abundant calcium apatite layer on the treated samples as compared to that on untreated sample and an increasing Ca/P ratio from 1.15, 1.79 to 2.08, respectively from Group I to Group III.

Conclusion:

Within the limitations of this study, both sandblasting and UVP significantly and similarly improved bioactivity of zirconia as compared to the untreated samples, which was corroborated by the SEM-EDX results.

Interactions of Osteoprogenitor Cells with a Novel Zirconia Implant Surface

Background: This study compared the in vitro response of a mouse pre-osteoblast cell line on a novel sandblasted zirconia surface with that of titanium. Material and Methods: The MC3T3-E1 subclone 4 osteoblast precursor cell line was cultured on either sandblasted titanium (SBCpTi) or sandblasted zirconia (SBY-TZP). The surface topography was analysed by three-dimensional laser microscopy and scanning electron microscope. The wettability of the discs was also assessed. The cellular response was quantified by assessing the morphology (day 1), proliferation (day 1, 3, 5, 7, 9), viability (day 1, 9), and migration (0, 6, 24 h) assays. Results: The sandblasting surface treatment in both titanium and zirconia increased the surface roughness by rendering a defined surface topography with titanium showing more apparent nano-topography. The wettability of the two surfaces showed no significant difference. The zirconia surface resulted in improved cellular spreading and a significantly increased rate of migration compared to titanium. However, the cellular proliferation and viability noted in our experiments were not significantly different on the zirconia and titanium surfaces. Conclusions: The novel, roughened zirconia surface elicited cellular responses comparable to, or exceeding that, of titanium. Therefore, this novel zirconia surface may be an acceptable substitute for titanium as a dental implant material.

Customized Therapeutic Surface Coatings for Dental Implants

Dental implants are frequently used to support fixed or removable dental prostheses to replace missing teeth. The clinical success of titanium dental implants is owed to the exceptional biocompatibility and osseointegration with the bone. Therefore, the enhanced therapeutic effectiveness of dental implants had always been preferred. Several concepts for implant coating and local drug delivery had been developed during the last decades. A drug is generally released by diffusion-controlled, solvent-controlled, and chemical controlled methods. Although a range of surface modifications and coatings (antimicrobial, bioactive, therapeutic drugs) have been explored for dental implants, it is still a long way from designing sophisticated therapeutic implant surfaces to achieve the specific needs of dental patients. The present article reviews various interdisciplinary aspects of surface coatings on dental implants from the perspectives of biomaterials, coatings, drug release, and related therapeutic effects. Additionally, the various types of implant coatings, localized drug release from coatings, and how released agents influence the bone–implant surface interface characteristics are discussed. This paper also highlights several strategies for local drug delivery and their limitations in dental implant coatings as some of these concepts are yet to be applied in clinical settings due to the specific requirements of individual patients.

Surrounding Tissue Response to Surface-Treated Zirconia Implants

Yttria-stabilized tetragonal zirconia polycrystals (Y-TZP), which are partially stabilized zirconia, have been used for fabricating dental implants. This study investigated the soft tissue attachment, the collagen fiber orientation to zirconia at different surface conditions, and the bone response using implantation experiments in animals. The zirconia implant surfaces were treated with ultraviolet irradiation (UV), a combination of large-grit sandblasting and hydrofluoric acid etching (blastedHF), and a combination of blastedHF and UV (blastedHF+UV). The surface treated with blastedHF and blastedHF+UV appeared rough and hydrophilic. The surface treated with blastedHF+UV appeared to be superhydrophilic. Subsequently, tapered cylindrical zirconia implants were placed in the alveolar sockets of the maxillary molars of rats. The bone-to-implant contact ratio of blastedHF and blastedHF+UV implants was significantly higher than that of the non-treated controls and UV-treated implants. The four different surface-treated zirconia implants demonstrated tight soft tissue attachments. Perpendicularly oriented collagen fibers towards zirconia implants were more prominent in blastedHF and blastedHF+UV implants compared to the controls and UV-treated implants. The area of the soft tissue attachment was the greatest with the perpendicularly oriented collagen fibers of blastedHF+UV-treated implants. In conclusion, blastedHF+UV treatment could be beneficial for ensuring greater soft-tissue attachment for zirconia implants.

Effect of reduced airborne-particle abrasion pressure on the retention of zirconia copings resin bonded to titanium abutments

STATEMENT OF PROBLEM

The optimal conditioning of zirconia is essential for a durable bond between zirconia copings and titanium inserts in 2-piece dental implant abutments. Low-pressure activation of the zirconia surface may be adequate for retention.

PURPOSE

The purpose of this in vitro study was to evaluate the influence of airborne-particle abrasion (APA) of the zirconia surface with different pressures on the retention of zirconia copings bonded to titanium abutments. In addition, 2 luting systems were compared.

MATERIAL AND METHODS

Computer-aided design and computer-aided manufacturing (CAD-CAM) zirconia copings were divided into 3 groups (n=32): 0.1 MPa, 0.25 MPa, and not airborne-particle abraded surfaces with 50-μm alumina (Al₂O₃) particles. Compatible titanium abutments were airborne-particle abraded at a pressure of 0.25 MPa. All specimens were ultrasonically cleaned before bonding. Each group was divided into 2 subgroups (n=16) with different luting composite resins. A 10-methacryloyloxydecyl dihydrogen phosphate (10-MDP) containing self-adhesive luting composite resin (Panavia SA Cement Plus) and a conventional luting composite resin (Multilink Hybrid Abutment) in combination with a 10-MDP-containing universal primer (Monobond Plus) was compared. Two storage conditions were tested: in water (37 °C) for 3 days or 150 days with 37 500 thermocycles between 5 °C and 55 °C. After artificial aging, retention was measured in tension, and the failure modes were analyzed by using a light microscope and a scanning electron microscope. Statistical analysis was performed with 1-way ANOVA and the Games-Howell test for post hoc analysis (α=.05).

RESULTS

The mean retention of the airborne-particle abraded groups ranged from 576.0 N to 1049.3 N after 150 days of water storage and 37 500 thermocycles. No significant difference in bond strength was found between the 2 luting composite resin groups with airborne-particle abraded zirconia surfaces after 150 days (P<.05). Both bonding systems provided durable bond strength after 3 and 150 days. Failure mode was mainly cohesive at the titanium surfaces and predominantly adhesive at the zirconia surfaces. The retention was significantly higher if APA was used versus no APA (P<.05), while the APA pressure used made no significant difference.

CONCLUSIONS

The APA of zirconia copings at a pressure of 0.1 MPa in combination with 10-MDP-containing luting composite resins and primers is adequate for the durable bonding of zirconia copings to titanium inserts.

Magnesium matrix nanocomposites for orthopedic applications: A review from mechanical, corrosion, and biological perspectives

Magnesium (Mg) and some of its alloys have attracted extensive interests for biomedical applications as they exhibit biodegradability and low elastic modulus that is closer to natural bones than the currently used metallic implant materials such as titanium (Ti) and its alloys, stainless steels, and cobalt-chromium (Co-Cr) alloys. However, the rapid degradation of Mg alloys and loss of their mechanical integrity before sufficient bone healing impede their clinical application. Our literature review shows that magnesium matrix nanocomposites (MMNCs) reinforced with nanoparticles possess enhanced strength, high corrosion resistance, and good biocompatibility. This article provides a detailed analysis of the effects of nanoparticle reinforcements on the mechanical properties, corrosion behavior, and biocompatibility of MMNCs as promising biodegradable implant materials. The governing equations to quantitatively predict the mechanical properties and underlying synergistic strengthening mechanisms in MMNCs are elucidated. The potential, recent advances, challenges and future research directions in relation to nanoparticles reinforced MMNCs are highlighted. STATEMENT OF SIGNIFICANCE: Critically reviewing magnesium metal matrix nanocomposites (MMNCs) for the biomedical application. Clear definitions of strengthening mechanisms using reinforcement particle in the magnesium matrix, as there were controversial in governing equations of strengthening parameters. Providing better understanding of the effect of particle size, volume fraction, interfacial bonding, and uniform dispersion of reinforcement particles on MMNCs.

Modification of the Ceramic Implant Surfaces from Zirconia by the Magnetron Sputtering of Different Calcium Phosphate Targets: A Comparative Study

In this study, thin calcium phosphate (Ca-P) coatings were deposited on zirconia substrates by radiofrequency (RF) magnetron sputtering using different calcium phosphate targets (calcium phosphate tribasic (CPT), hydroxyapatite (HA), calcium phosphate monobasic, calcium phosphate dibasic dehydrate (DCPD) and calcium pyrophosphate (CPP) powders). The sputtering of calcium phosphate monobasic and DCPD powders was carried out without an inert gas in the self-sustaining plasma mode. The physico-chemical, mechanical and biological properties of the coatings were investigated. Cell adhesion on the coatings was examined using mesenchymal stem cells (MSCs). The CPT coating exhibited the best cell adherence among all the samples, including the uncoated zirconia substrate. The cells were spread uniformly over the surfaces of all samples.

Effect of Surface Modification on Viability of L929 Cells on Zirconia Nanocomposite Substrat

Introduction: Zirconia bioceramic can be considered for metallic replacement in dental implant applications. A proper method of surface modification may promote better osseointegration. Methods: In study evaluated viability of fibroblast cell following surface treatment. Therefore, viability L929 cells were characterized using MTT assay and scanning electron microscopy. Results: The viability assessment determined significant differences A-Y-TZP20 without surface treatment as compared to laser surface treatment (B), laser surface treatment + hydroxyapatiteyttrium stabilized tetragonal zirconia nanocomposite coat (C) and control. This study demonstrated that L929 cells approximately proliferated and spread on A-Y-TZP20 nanocomposite disk in laser surface treatment(B), Laser surface treatment + hydroxiapatite-yttrium stabilized tetragonal zirconia nanocomposite coat (C) groups similar to control group. Conclusion: Laser surface treatment showed positive effect on the viability of L929 cells.

In vitro surface characteristics and impurity analysis of five different commercially available dental zirconia implants

Background

The aim of this study was to assess surface characteristics, element composition, and surface roughness of five different commercially available dental zirconia implants.

Five zirconia implants (Bredent whiteSKY™ (I1), Straumann® PURE Ceramic (I2), ceramic.implant vitaclinical (I3), Zeramex® (I4), Ceralog Monobloc M10 (I5)) were evaluated.

Methods

The evaluation was performed by means of scanning electron microscopy (SEM), energy-dispersive X-ray spectroscopy (EDX), and confocal laser scanning microscopy (CLSM).

Results

The semi-quantitative element composition showed no significant impurity of any implant tested. Both the machined and the rough areas of the investigated implants were predominated by zirconium, oxygen, and carbon. Roughness values (S_a) showed highest values for I2 and I5.

Conclusions

The investigated zirconia implants showed surface characteristics and roughness values close to those of conventionally produced titanium implants, making them a promising alternative. However, zirconia implants have yet to prove themselves in clinical practice and clinical controlled trials.

Analysis of osteogenic potential on 3mol% yttria-stabilized tetragonal zirconia polycrystals and two different niobium oxide containing zirconia ceramics

PURPOSE

This study was performed to evaluate the osteogenic potential of 3mol% yttria-stabilized tetragonal zirconia polycrystals (3Y-TZP) and niobium oxide containing Y-TZPs with specific ratios, new (Y,Nb)-TZPs, namely YN4533 and YN4533/Al20 discs.

MATERIALS AND METHODS

3Y-TZP, YN4533 and YN4533/Al20 discs (15 mm diameter and 1 mm thickness) were prepared and their average surface roughness (R_a) and surface topography were analyzed using 3-D confocal laser microscope (CLSM) and scanning electron microscope (SEM). Mouse pre-osteoblast MC3T3-E1 cells were seeded onto all zirconia discs and evaluated with regard to cell attachment and morphology by (CLSM), cell proliferation by PicoGreen assay, and cell differentiation by Reverse-Transcription PCR and Quantitative Real-Time PCR, and alkaline phosphatase (Alp) staining.

RESULTS

The cellular morphology of MC3T3-E1 pre-osteoblasts was more stretched on a smooth surface than on a rough surface, regardless of the material. Cellular proliferation was higher on smooth surfaces, but there were no significant differences between 3Y-TZP, YN4533, and YN4533/Al20. Osteoblast differentiation patterns on YN4533 and YN4533/Al20 were similar to or slightly higher than seen in 3Y-TZP. Although there were no significant differences in bone marker gene expression (alkaline phosphatase and osteocalcin), Alp staining indicated better osteoblast differentiation on YN4533 and YN4533/Al20 compared to 3Y-TZP.

CONCLUSION

Based on these results, niobium oxide containing Y-TZPs have comparable osteogenic potential to 3Y-TZP and are expected to be suitable alternative ceramics dental implant materials to titanium for aesthetically important areas.

Application of Plasma-Sprayed Zirconia Coating in Dental Implants: Study in Implants

The aim was to investigate the osseointegration of a novel coating—plasma-sprayed nanostructured zirconia (NSZ)—for dental implants. Nanostructured zirconia coating on non-thread titanium implant was prepared by plasma spraying, and the implant surface morphology, surface roughness, and wettability were measured. In vivo, nanostructured zirconia-coated implants were inserted in rabbit tibia, and the animals were sacrificed at 2, 4, 8, and 12 weeks after implantation. The bond strength between implant and bone was measured with the removal torque (RTQ) test. Osseointegration was observed by scanning electron microscopy (SEM), microcomputerized tomography (micro CT), and histological analyses. Quantified parameters were calculated, including removal torque, bone volume to tissue volume (BV/TV), trabecular thickness (Tb.Th), trabecular number (Tb.N), trabecular separation/spacing (Tb.Sp), and bone-implant contact (BIC) percentage. The statistical differences were detected with a two-tail Mann-Whitney U test (SPSS 20.0). The surface roughness (1.58 μm) and wettability (54.61°) of a nanostructured zirconia-coated implant was more suitable than the titanium implant (0.598 μm, 74.38°) for osseointegration and hierarchical surface morphology seen on the zirconia coating. The histological analyses showed that a zirconia-coated implant induced earlier and had more condensed bone formation than did the titanium implant at 2 and 4 weeks. Quantified parameters showed the significant differences between these 2 groups at an early healing period, but the differences between the 2 groups decreased with an increased healing period. All these results demonstrated that plasma-sprayed zirconia coated implants induced better bone formation than did titanium implants at an early stage.

Is zirconia a viable alternative to titanium for oral implant? A critical review

PURPOSE

Titanium based implant systems, though considered as the gold standard for rehabilitation of edentulous spaces, have been criticized for many inherent flaws. The onset of hypersensitivity reactions, biocompatibility issues, and an unaesthetic gray hue have raised demands for more aesthetic and tissue compatible material for implant fabrication. Zirconia is emerging as a promising alternative to conventional Titanium based implant systems for oral rehabilitation with superior biological, aesthetics, mechanical and optical properties. This review aims to critically analyze and review the credibility of Zirconia implants as an alternative to Titanium for prosthetic rehabilitation.

STUDY SELECTION

The literature search for articles written in the English language in PubMed and Cochrane Library database from 1990 till December 2016. The following search terms were utilized for data search: "zirconia implants" NOT "abutment", "zirconia implants" AND "titanium implants" AND "osseointegration", "zirconia implants" AND compatibility.

RESULTS

The number of potential relevant articles selected were 47. All the human in vivo clinical, in vitro, animals' studies were included and discussed under the following subheadings: Chemical composition, structure and phases; Physical and mechanical properties; Aesthetic and optical properties; Osseointegration and biocompatibility; Surface modifications; Peri-implant tissue compatibility, inflammation and soft tissue healing, and long-term prognosis.

CONCLUSIONS

Zirconia implants are a promising alternative to titanium with a superior soft-tissue response, biocompatibility, and aesthetics with comparable osseointegration. However, further long-term longitudinal and comparative clinical trials are required to validate zirconia as a viable alternative to the titanium implant.

Thirty Years of Translational Research in Zirconia Dental Implants: A Systematic Review of the Literature

Thirty years of transitional research in zirconia (Zr) ceramics has led to significant improvements in the biomedical field, especially in dental implantology. Oral implants made of yttria-tetragonal zirconia polycrystals (Y-TZP) because of their excellent mechanical properties, good biocompatibility, and esthetically acceptable color have emerged as an attractive metal-free alternative to titanium (Ti) implants. The aim of the review was to highlight the translation research in Zr dental implants that has been conducted over the past 3 decades using preclinical animal models. A computer search of electronic databases, primarily PubMed, was performed with the following key words: "zirconia ceramics AND animal trials," "ceramic implants AND animal trials," "zirconia AND animal trials," "zirconia AND in vivo animal trials," without any language restriction. However, the search was limited to animal trials discussing percentage bone-implant contact (%BIC) around zirconia implants/discs. This search resulted in 132 articles (reviews, in vivo studies, and animal studies) of potential interest. We restricted our search terms to "zirconia/ceramic," "bone-implant-contact," and "animal trials" and found 29 relevant publications, which were then selected for full-text reading. Reasons for exclusion included the article's not being an animal study, being a review article, and not discussing %BIC around Zr implants/discs. Most of the studies investigated BIC around Zr in rabbits (30%), pigs (approximately 20%), dogs, sheep, and rats. This review of the literature shows that preclinical animal models can be successfully used to investigate osseointegration around Zr ceramics. Results of the reviewed studies demonstrated excellent %BIC around Zr implants. It should be noted that most of the studies investigated %BIC/removal torque under nonloading conditions, and results would have been somewhat different in functional loading situations because of inherent limitations of Zr ceramics. Further trials are needed to evaluate the performance of Zr ceramics in clinical conditions using implants designed and manufactured via novel techniques that enhance their biomechanical properties.

Acid etching of glass-infiltrated zirconia and its biological response

PURPOSE

The purpose of this study was to evaluate the influence of acid etching treatment on surface characteristics and biological response of glass-infiltrated zirconia.

MATERIALS AND METHODS

A hundred zirconia specimens were divided into four groups depending on surface treatments: untreated zirconia (group Z); acid-etched zirconia (group ZE); glass-infiltrated zirconia (group ZG); and glass-infiltrated and acid-etched zirconia (group ZGE). Surface roughness, surface topography, surface morphology, and Vickers hardness of specimens were evaluated. For biological response test, MC3T3-E1 cell attachment and proliferation on surface of the specimens were examined. The data were statistically analyzed using one-way ANOVA and Tukey's HSD test at a significance level of 0.05.

RESULTS

Group ZGE showed the highest surface roughness (Ra = 1.54 µm) compared with other groups (P < .05). Meanwhile, the hardness of group Z was significantly higher than those of other groups (P < .05). Cell attachment and cell proliferation were significantly higher in group ZGE (P < .05).

CONCLUSION

We concluded that effective surface roughness on zirconia could be made by acid etching treatment after glass infiltration. This surface showed significantly enhanced osteoblast cell response.

Bioactivity of NANOZR Induced by Alkali Treatment

In recent years, zirconia has been a recognized implant material in clinical dentistry. In the present study, we investigated the performance of an alkali-modified ceria-stabilized tetragonal ZrO₂ polycrystalline ceramic-based nanostructured zirconia/alumina composite (NANOZR) implant by assessing surface morphology and composition, wettability, bovine serum albumin adsorption rate, rat bone marrow (RBM) cell attachment, and capacity for inducing bone differentiation. NANOZR surfaces without and with alkali treatment served as the control and test groups, respectively. RBM cells were seeded in a microplate with the implant and cultured in osteogenic differentiation medium, and their differentiation was evaluated by measuring alkaline phosphatase (ALP) activity, osteocalcin (OCN) production, calcium deposition, and osteogenic gene expression. The alkali-treated NANOZR surface increased ALP activity, OCN production, calcium deposition, and osteogenesis-related gene expression in attached RBM cells. These data suggest that alkali treatment enhances the osteogenesis-inducing capacity of NANOZR implants and may therefore improve their biointegration into alveolar bone.

Impact of Physical Chemical Characteristics of Abutment Implant Surfaces on Bacteria Adhesion

Surface attachment is the first step in biofilm formation, and the ability of bacteria to adhere to surfaces and develop a biofilm is directly influenced by electrostatic interactions between the bacteria and the chemical composition of material surfaces. Here, we investigated the influence of physical and chemical characteristics of titanium (Ti) and zirconia (ZrO2) as implant abutment surfaces on the bacterial adhesion phase and compared the results to bovine enamel (BE) simulating a human tooth. To achieve this goal, we used 2 common pathogens of the oral cavity, Streptococcus mutans UA140 and Porphyromonas gingivalis 33277. To investigate the influence of material surfaces on bacterial adhesion, we studied the surface free energy as well as the topography by atomic force microscopy, and the chemical elements composition by scanning electron microscopy equipped with an energy dispersive X-ray spectroscope. Our results indicated a hydrophobic characteristic for all of the materials; however, the presence of polar and nonpolar components could aid in understanding why greater numbers of bacteria had adhered to BE compared to the other surfaces. Our confocal microscopy data support the proposition that electrostatic interactions, indeed, affected the initial adhesion phase. Within the limitations of a laboratory study, the results revealed bacterial adhered on BE and no bacteria could be observed by confocal images on Ti and ZrO2 implant abutment surfaces.

In Vitro Cell Proliferation and Mechanical Behaviors Observed in Porous Zirconia Ceramics

Zirconia ceramics with porous structure have been prepared by solid-state reaction using yttria-stabilized zirconia and stearic acid powders. Analysis of its microstructure and phase composition revealed that a pure zirconia phase can be obtained. Our results indicated that its porosity and pore size as well as the mechanical characteristics can be tuned by changing the content of stearic acid powder. The optimal porosity and pore size of zirconia ceramic samples can be effective for the increase of surface roughness, which results in higher cell proliferation values without destroying the mechanical properties.

Zirconia in dental implantology: A review

Background:

Titanium has been the most popular material of choice for dental implantology over the past few decades. Its properties have been found to be most suitable for the success of implant treatment. But recently, zirconia is slowly emerging as one of the materials which might replace the gold standard of dental implant, i.e., titanium.

Materials and Methods:

Literature was searched to retrieve information about zirconia dental implant and studies were critically analyzed. PubMed database was searched for information about zirconia dental implant regarding mechanical properties, osseointegration, surface roughness, biocompatibility, and soft tissue health around it. The literature search was limited to English language articles published from 1975 to 2015.

Results:

A total of 45 papers met the inclusion criteria for this review, among the relevant search in the database.

Conclusion:

Literature search showed that some of the properties of zirconia seem to be suitable for making it an ideal dental implant, such as biocompatibility, osseointegration, favourable soft tissue response and aesthetics due to light transmission and its color. At the same time, some studies also point out its drawbacks. It was also found that most of the studies on zirconia dental implants are short-term studies and there is a need for more long-term clinical trials to prove that zirconia is worth enough to replace titanium as a biomaterial in dental implantology.

A Critical Review of Dental Implant Materials with an Emphasis on Titanium versus Zirconia

The goal of the current publication is to provide a comprehensive literature review on the topic of dental implant materials. The following paper focuses on conventional titanium implants and more recently introduced and increasingly popular zirconia implants. Major subtopics include the material science and the clinical considerations involving both implant materials and the influence of their physical properties on the treatment outcome. Titanium remains the gold standard for the fabrication of oral implants, even though sensitivity does occur, though its clinical relevance is not yet clear. Zirconia implants may prove to be promising in the future; however, further in vitro and well-designed in vivo clinical studies are needed before such a recommendation can be made. Special considerations and technical experience are needed when dealing with zirconia implants to minimize the incidence of mechanical failure.

Microstructured zirconia surfaces modulate osteogenic marker genes in human primary osteoblasts

In dentistry, zirconia has been used since the early 1990s for endodontic posts, more recently for implant abutments and frameworks for fixed dental prostheses. Zirconia is biocompatible and mechanically strong enough to serve as implant material for oral implants. Although several zirconia implant systems are available, currently the scientific and clinical data for zirconia implants are not sufficient to recommend them for routine clinical use. Here the influence of microstructured yttria-stabilized zirconia (YZ) on human primary osteoblast (HOB) behavior was determined. YZ surfaces were treated by sandblasting (YZ-S), acid etching (YZ-SE) and additionally heat treatment (YZ-SEH). Morphological changes of HOB were determined by scanning electron microscopy. Actin cytoskeleton was investigated by laser scanning microscopy and analyzed by novel actin quantification software. Differentiation of HOB was determined by real time RT-PCR. Improved mechanical interlocking of primary HOB into the porous microstructure of the acid etched and additionally heat treated YZ-surfaces correlates with drastically increased osteocalcin (OCN) gene expression. In particular, OCN was considerably elevated in primary HOB after 3 days on YZ-SE (13-fold) as well as YZ-SEH (12-fold) surfaces. Shorter actin filaments without any favored orientation on YZ-SE and YZ-SEH surfaces are associated with higher roughness (Ra) values. Topographically modified yttria-stabilized zirconia is a likely material for dental implants with cell stimulating properties achieving or actually exceeding those of titanium.

Surface modifications of dental ceramic implants with different glass solder matrices: in vitro analyses with human primary osteoblasts and epithelial cells

Ceramic materials show excellent esthetic behavior, along with an absence of hypersensitivity, making them a possible alternative implant material in dental surgery. However, their surface properties enable only limited osseointegration compared to titanium implants. Within this study, a novel surface coating technique for enhanced osseointegration was investigated biologically and mechanically. Specimens of tetragonal zirconia polycrystal (TZP) and aluminum toughened zirconia (ATZ) were modified with glass solder matrices in two configurations which mainly consisted of SiO2, Al2O3, K2O, and Na2O. The influence on human osteoblastic and epithelial cell viability was examined by means of a WST-1 assay as well as live/dead staining. A C1CP-ELISA was carried out to verify procollagen type I production. Uncoated/sandblasted ceramic specimens and sandblasted titanium surfaces were investigated as a reference. Furthermore, mechanical investigations of bilaterally coated pellets were conducted with respect to surface roughness and adhesive strength of the different coatings. These tests could demonstrate a mechanically stable implant coating with glass solder matrices. The coated ceramic specimens show enhanced osteoblastic and partly epithelial viability and matrix production compared to the titanium control. Hence, the new glass solder matrix coating could improve bone cell growth as a prerequisite for enhanced osseointegration of ceramic implants.

Cell attachment and proliferation of bone marrow-derived osteoblast on zirconia of various surface treatment

PURPOSE

This study was performed to characterize the effects of zirconia coated with calcium phosphate and hydroxyapatite compared to smooth zirconia after bone marrow-derived osteoblast culture.

MATERIALS AND METHODS

Bone marrow-derived osteoblasts were cultured on (1) smooth zirconia, (2) zirconia coated with calcium phosphate (CaP), and (3) zirconia coated with hydroxyapatite (HA). The tetrazolium-based colorimetric assay (MTT test) was used for cell proliferation evaluation. Scanning electron microscopy (SEM) and alkaline phosphatase (ALP) activity was measured to evaluate the cellular morphology and differentiation rate. X-ray photoelectron spectroscopy (XPS) was employed for the analysis of surface chemistry. The genetic expression of the osteoblasts and dissolution behavior of the coatings were observed. Assessment of the significance level of the differences between the groups was done with analysis of variance (ANOVA).

RESULTS

From the MTT assay, no significant difference between smooth and surface coated zirconia was found (P>.05). From the SEM image, cells on all three groups of discs were sporadically triangular or spread out in shape with formation of filopodia. From the ALP activity assay, the optical density of osteoblasts on smooth zirconia discs was higher than that on surface treated zirconia discs (P>.05). Most of the genes related to cell adhesion showed similar expression level between smooth and surface treated zirconia. The dissolution rate was higher with CaP than HA coating.

CONCLUSION

The attachment and growth behavior of bone-marrow-derived osteoblasts cultured on smooth surface coated zirconia showed comparable results. However, the HA coating showed more time-dependent stability compared to the CaP coating.

Response of osteoblast-like cells to zirconia with different surface topography

The objective of this study was to clarify the effect of surface topography on osteoblast-like cell behavior on yttria stabilized tetragonal zirconia polycrystals (TZP). Mirror-polished; blasted with 50- or 150-µm alumina (SB50 and SB150); and SB150 acid-etched with hydrofluoric acid (SB150E) were prepared on TZP. Initial attachment, proliferation and differentiation of MC3T3-E1 were evaluated. The scanning electron microscopy and Sdr (developed interfacial area ratio) values indicated that both micro- and nano-topographies produced on the SB150E surfaces. Although no clear differences were observed in initial cell attachment among specimens, the proliferation rate and expression of ALP activity on the SB150E specimens was significantly higher than that on the other specimens. These results indicate that the creation of micro- and nano-topographies on TZP by surface treatment offers a promising method of enhancing the proliferation and differentiation of MC3T3-E1 cells.

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.

Investigation of biomaterials by human epithelial gingiva cells: an in vitro study

Introduction

In modern medicine and dentistry the use of biomaterials is a fast developing field of increasing interest. Especially in dentistry the interaction between biomaterials like implant materials and the soft tissue in the oral cavity is in the focus of daily research. In this context the high importance of testing materials and their surfaces concerning their biocompatibility towards corresponding cells is very likely. For this purpose this study investigates cells derived from human gingival biopsies on different materials and surfaces.

Methods

Cells in this study were cultivated out of human biopsies by a grow out explant technique and were sub cultivated on titanium, zirconium dioxide and collagen membrane specimens. To characterise the cells on the material surfaces used in this study immunohistochemical and histological staining techniques as well as different methods of microscopy (light microscopy and SEM) were applied.

Results

With the aid of the explant technique and the chosen cell cultivation method it was possible to investigate the human gingiva derived cells on different materials. The data of the present study show that the human gingival cells attach and proliferate on all three tested materials by exhibiting characteristic gingival keratinocyte protein expression even after long periods of culture e.g. up to 70 days.

Conclusions

It could be shown that the three tested materials titanium, zirconium dioxide and collagen membrane (and their special surfaces) are good candidates for the application as materials in the dental gingival environment or, in the case of the collagen membrane as scaffold/cell-carrier for human gingival cells in tissue engineering.

Influence of surface topography and surface physicochemistry on wettability of zirconia (tetragonal zirconia polycrystal)

Surface modification technologies are available for tetragonal zirconia polycrystal (TZP) to enhance its bioactivity and osseointegration capability. The surface wettability of an implant material is one of the important factors in the process of osseointegration, possibly regulating protein adsorption, and subsequent cell behavior. The aim of this study was to clarify the effect of topographical or physicochemical modification of TZP ceramics on wettability to determine the potential of such treatment in application to implants. Several types of surface topography were produced by alumina blasting and acid etching with hydrofluoric acid; surface physicochemistry was modified with oxygen (O(2)) plasma, ultraviolet (UV) light, or hydrogen peroxide treatment. The obtained specimens were also subjected to storage under various conditions to evaluate their potential to maintain superhydrophilicity. The results showed that surface modification of surface topography or physicochemistry, especially of blast/acid etching as well as O(2) plasma and UV treatment, greatly increased the surface wettability, resulting in superhydrophilicity. X-ray photoelectron spectroscopy revealed that a remarkable decrease in carbon content and the introduction of hydroxyl groups were responsible for the observed superhydrophilicity. Furthermore, superhydrophilicity was maintained, even after immersion in an aqueous solution, an important consideration in the clinical application of this technology.

Biocompatibility and bone tissue compatibility of alumina ceramics reinforced with carbon nanotubes

Aims: The addition of carbon nanotubes (CNTs) remarkably improves the mechanical characteristics of base materials. CNT/alumina ceramic composites are expected to be highly functional biomaterials useful in a variety of medical fields. Biocompatibility and bone tissue compatibility were studied for the application of CNT/alumina composites as biomaterials. Methods & results: Inflammation reactions in response to the composite were as mild as those of alumina ceramic alone in a subcutaneous implantation study. In bone implantation testing, the composite showed good bone tissue compatibility and connected directly to new bone. An in vitro cell attachment test was performed for osteoblasts, chondrocytes, fibroblasts and smooth muscle cells, and CNT/alumina composite showed cell attachment similar to that of alumina ceramic. Discussion & conclusion: Owing to proven good biocompatibility and bone tissue compatibility, the application of CNT/alumina composites as biomaterials that contact bone, such as prostheses in arthroplasty and devices for bone repair, are expected.

Original submitted 23 March 2011; Revised submitted 16 November 2011; Published online 8 March 2012

Immediate provisional restoration of single-piece zirconia implants: a prospective case series - results after 24 months of clinical function

OBJECTIVE

Aim of this prospective case series was to evaluate the outcome of immediately provisionalized single-piece zirconia implants.

MATERIAL AND METHODS

A total of 20 zirconia implants were inserted in single-tooth gaps in the maxilla (11) and mandible (9) of 20 patients. Implants were restored with all-ceramic CAD/CAM provisionals without occlusal contacts immediately after placement. Permanent all-ceramic restoration was performed 4 months after surgery. Plaque index (PI), bleeding on probing (BOP), Periotest(®) (PV), pink aesthetic score (PES), mean radiographic marginal bone levels (MBL), implant survival and success were evaluated up to 24 months.

RESULTS

Assessment of PI at baseline and follow-ups after 6, 12, 18 and 24 months revealed 27% (±5.3), 24% (±6), 23% (±6.1), 23% (±5.3) and 22% (±6.4), respectively. Evaluation of BOP revealed 25% (±5.6), 21% (±6), 21% (±7.2), 18% (±5.9) and 15% (±5.5), respectively. Implants presented stable at follow-ups (PV). PES improved, but not statistically significant from 8.13 (±1.5) at baseline to 10 (±2) 24 months after implantation. Measurements of MBL showed a significant bone loss of 1.01 mm within the first year after placement (P < 0.001) and 1.29 mm 24 months post-implant insertion, not reaching further statistically significant levels (P > 0.05). One implant was lost 4 months after placement, resulting in a survival and success rate of 95%.

CONCLUSION

Clinical and radiographic parameters demonstrated a 95% integration of immediately loaded zirconia single-piece implants. A long-term randomized-controlled clinical trial was initiated to confirm evidence of this protocol.

Response of osteoblast-like cells cultured on zirconia to bone morphogenetic protein-2

Purpose

The aim of this study was to compare osteoblast behavior on zirconia and titanium under conditions cultured with bone morphogenetic protein-2.

Methods

MC3T3-E1 cells were cultured on sandblasted zirconia and sandblasted/etched titanium discs. At 24 hours after seeding MC3T3-E1, the demineralized bone matrix (DBM) gel alone and the DBM gel with bone morphogenetic protein-2 (BMP-2) were added to the culture medium. The surface topography was examined by confocal laser scanning microscopy. Cellular proliferation was measured at 1, 4, and 7 days after gel loading. Alkaline phosphatase activity was measured at 7 days after gel loading. The mRNA expression of ALPase, bone sialoprotein, type I collagen, runt-related transcription factor 2 (Runx-2), osteocalcin, and osterix were evaluated by real-time polymerase chain reaction at 4 days and 7 days.

Results

At 1, 4, and 7 days after loading the DBM gel alone and the DBM gel with BMP-2, cellular proliferation on the zirconia and titanium discs was similar and that of the groups cultured with the DBM gel alone and the DBM gel with BMP-2 was not significantly different, except for titanium with BMP-2 gel. ALPase activity was higher in the cells cultured with BMP-2 than in the other groups, but there was no difference between the zirconia and titanium. In ALPase, bone sialoprotein, osteocalcin, Runx-2 and osterix gene expression, that of cells on zirconia or titanium with BMP-2 gel was much more highly increased than titanium without gel at day 7. The gene expression level of cells cultured on zirconia with BMP-2 was higher than that on titanium with BMP-2 at day 7.

Conclusions

The data in this study demonstrate that the osteoblastic cell attachment and proliferation of zirconia were comparable to those of titanium. With the stimulation of BMP-2, zirconia has a more pronounced effect on the proliferation and differentiation of the osteoblastic cells compared with titanium.