Antibacterial Titanium Implants Biofunctionalized by Plasma Electrolytic Oxidation with Silver, Zinc, and Copper: A Systematic Review

What challenges hinder the adoption of antimicrobial surface in the dental implant market?

INTRODUCTION

Implant failures resulting from peri-implant infections can have substantial consequences, underscoring the urgent need for effective strategies to prevent biofilm formation on implant surfaces. However, despite advancements in antimicrobial surface technologies, significant challenges persist in translating these innovations into clinically viable solutions.

AREAS COVERED

This article provides an overview of the limitations of current treatment protocols and explores the potential of antimicrobial surface treatments for controlling such infections. Furthermore, we highlight the importance of balancing antimicrobial efficacy with biocompatibility and mechanical stability, key factors for long-term implant performance. Finally, we address the main challenges in translating these technologies into clinical practice, including the unpredictability of long-term antimicrobial effects, regulatory compliance gaps, and methodological weaknesses in current research.

EXPERT OPINION

The development of antimicrobial surfaces holds promise for enhancing the longevity of dental implants; however, current modifications face persistent challenges, hindering their translation into the dental implant market. Future advancements should prioritize 'smart' or stimulus-responsive surfaces that can release antimicrobials on demand. This strategy aims to efficiently combat infections while minimizing the risks of cytotoxicity and antimicrobial resistance, potentially leading to more effective and clinically translatable solutions.

Various Antibacterial Strategies Utilizing Titanium Dioxide Nanotubes Prepared via Electrochemical Anodization Biofabrication Method

Currently, titanium and its alloys have emerged as the predominant metallic biomaterials for orthopedic implants. Nonetheless, the relatively high post-operative infection rate (2-5%) exacerbates patient discomfort and imposes significant economic costs on society. Hence, urgent measures are needed to enhance the antibacterial properties of titanium and titanium alloy implants. The titanium dioxide nanotube array (TNTA) is gaining increasing attention due to its topographical and photocatalytic antibacterial properties. Moreover, the pores within TNTA serve as excellent carriers for chemical ion doping and drug loading. The fabrication of TNTA on the surface of titanium and its alloys can be achieved through various methods. Studies have demonstrated that the electrochemical anodization method offers numerous significant advantages, such as simplicity, cost-effectiveness, and controllability. This review presents the development process of the electrochemical anodization method and its applications in synthesizing TNTA. Additionally, this article systematically discusses topographical, chemical, drug delivery, and combined antibacterial strategies. It is widely acknowledged that implants should possess a range of favorable biological characteristics. Clearly, addressing multiple needs with a single antibacterial strategy is challenging. Hence, this review proposes systematic research into combined antibacterial strategies to further mitigate post-operative infection risks and enhance implant success rates in the future.

Enhanced osteogenic and antibacterial properties of titanium implant surface modified with Zn-incorporated nanowires: Preclinical in vitro and in vivo investigations

OBJECTIVE

This study aimed to synthesize zinc-incorporated nanowires structure modified titanium implant surface (Zn-NW-Ti) and explore its superior osteogenic and antibacterial properties in vitro and in vivo.

MATERIALS AND METHODS

Zn-NW-Ti was synthesized via displacement reactions between zinc sulfate solutions and the titanium (Ti) surface, which was pretreated by hydrofluoric acid etching and hyperthermal alkalinization. The physicochemical properties of the Zn-NW-Ti surface were examined. Moreover, the biological effects of Zn-NW-Ti on MC3T3-E1 cells and its antibacterial property against oral pathogenic bacteria (Staphylococcus aureus, Porphyromonas gingivalis, and Actinobacillus actinomycetemcomitans) compared with sandblasted and acid-etched Ti (SLA-Ti) and nanowires modified Ti (NW-Ti) surface were assessed. Zn-NW-Ti and SLA-Ti modified implants were inserted into the anterior extraction socket of the rabbit mandible with or without exposure to the mixed bacterial solution (S. aureus, P. gingivalis, and A. actinomycetemcomitans) to investigate the osteointegration and antibacterial performance via radiographic and histomorphometric analysis.

RESULTS

The Zn-NW-Ti surface was successfully prepared. The resultant titanium surface appeared as a nanowires structure with hydrophilicity, from which zinc ions were released in an effective concentration range. The Zn-NW-Ti surface performed better in facilitating the adhesion, proliferation, and differentiation of MC3T3-E1 cells while inhibiting the colonization of bacteria compared with SLA-Ti and NW-Ti surface. The Zn-NW-Ti implant exhibited enhanced osseointegration in vivo, which was attributed to increased osteogenic activity and reduced bacterial-induced inflammation compared with the SLA-Ti implant.

CONCLUSIONS

The Zn-incorporated nanowires structure modified titanium implant surface exhibited improvements in osteogenic and antibacterial properties, which optimized osteointegration in comparison with SLA titanium implant surface.

Orthopedic meta-implants

Meta-biomaterials, engineered materials with distinctive combinations of mechanical, physical, and biological properties stemming from their micro-architecture, have emerged as a promising domain within biomedical engineering. Correspondingly, meta-implants, which serve as the device counterparts of meta-biomaterials, offer exceptional functionalities, holding great potential for addressing complex skeletal diseases. This paper presents a comprehensive overview of the various types of meta-implants, including hybrid, shape-morphing, metallic clay, and deployable meta-implants, highlighting their unprecedented properties and recent achievement in the field. This paper also delves into the potential future developments of meta-implants, addressing the exploration of multi-functionalities in meta-biomaterials and their applications in diverse biomedical fields.

Low-Temperature Plasma Techniques in Biomedical Applications and Therapeutics: An Overview

Plasma, the fourth fundamental state of matter, comprises charged species and electrons, and it is a fascinating medium that is spread over the entire visible universe. In addition to that, plasma can be generated artificially under appropriate laboratory techniques. Artificially generated thermal or hot plasma has applications in heavy and electronic industries; however, the non-thermal (cold atmospheric or low temperature) plasma finds its applications mainly in biomedicals and therapeutics. One of the important characteristics of LTP is that the constituent particles in the plasma stream can often maintain an overall temperature of nearly room temperature, even though the thermal parameters of the free electrons go up to 1 to 10 keV. The presence of reactive chemical species at ambient temperature and atmospheric pressure makes LTP a bio-tolerant tool in biomedical applications with many advantages over conventional techniques. This review presents some of the important biomedical applications of cold-atmospheric plasma (CAP) or low-temperature plasma (LTP) in modern medicine, showcasing its effect in antimicrobial therapy, cancer treatment, drug/gene delivery, tissue engineering, implant modifications, interaction with biomolecules, etc., and overviews some present challenges in the field of plasma medicine.

In Vivo Prevention of Implant-Associated Infections Caused by Antibiotic-Resistant Bacteria through Biofunctionalization of Additively Manufactured Porous Titanium

Additively manufactured (AM) porous titanium implants may have an increased risk of implant-associated infection (IAI) due to their huge internal surfaces. However, the same surface, when biofunctionalized, can be used to prevent IAI. Here, we used a rat implant infection model to evaluate the biocompatibility and infection prevention performance of AM porous titanium against bioluminescent methicillin-resistant Staphylococcus aureus (MRSA). The specimens were biofunctionalized with Ag nanoparticles (NPs) using plasma electrolytic oxidation (PEO). Infection was initiated using either intramedullary injection in vivo or with in vitro inoculation of the implant prior to implantation. Nontreated (NT) implants were compared with PEO-treated implants with Ag NPs (PT-Ag), without Ag NPs (PT) and infection without an implant. After 7 days, the bacterial load and bone morphological changes were evaluated. When infection was initiated through in vivo injection, the presence of the implant did not enhance the infection, indicating that this technique may not assess the prevention but rather the treatment of IAIs. Following in vitro inoculation, the bacterial load on the implant and in the peri-implant bony tissue was reduced by over 90% for the PT-Ag implants compared to the PT and NT implants. All infected groups had enhanced osteomyelitis scores compared to the noninfected controls.

Silver-Containing Biomaterials for Biomedical Hard Tissue Implants

Bacterial infection caused by biomaterials is a very serious problem in the clinical treatment of implants. The emergence of antibiotic resistance has prompted other antibacterial agents to replace traditional antibiotics. Silver is rapidly developing as an antibacterial candidate material to inhibit bone infections due to its significant advantages such as high antibacterial timeliness, high antibacterial efficiency, and less susceptibility to bacterial resistance. However, silver has strong cytotoxicity, which can cause inflammatory reactions and oxidative stress, thereby destroying tissue regeneration, making the application of silver-containing biomaterials extremely challenging. In this paper, the application of silver in biomaterials is reviewed, focusing on the following three issues: 1) how to ensure the excellent antibacterial properties of silver, and not easy to cause bacterial resistance; 2) how to choose the appropriate method to combine silver with biomaterials; 3) how to make silver-containing biomaterials in hard tissue implants have further research. Following a brief introduction, the discussion focuses on the application of silver-containing biomaterials, with an emphasis on the effects of silver on the physicochemical properties, structural properties, and biological properties of biomaterials. Finally, the review concludes with the authors' perspectives on the challenges and future directions of silver in commercialization and in-depth research.

Biomaterial engineering surface to control polymicrobial dental implant-related infections: focusing on disease modulating factors and coatings development

INTRODUCTION

Peri-implantitis is the leading cause of dental implant loss and is initiated by a polymicrobial dysbiotic biofilm formation on the implant surface. The destruction of peri-implant tissue by the host immune response and the low effectiveness of surgical or non-surgical treatments highlight the need for new strategies to prevent, modulate and/or eliminate biofilm formation on the implant surface. Currently, several surface modifications have been proposed using biomolecules, ions, antimicrobial agents, and topography alterations.

AREAS COVERED

Initially, this review provides an overview of the etiopathogenesis and host- and material-dependent modulating factors of peri-implant disease. In addition, a critical discussion about the antimicrobial surface modification mechanisms and techniques employed to modify the titanium implant material is provided. Finally, we also considered the future perspectives on the development of antimicrobial surfaces to narrow the bridge between idea and product and favor the clinical application possibility.

EXPERT OPINION

Antimicrobial surface modifications have demonstrated effective results; however, there is no consensus about the best modification strategy and in-depth information on the safety and longevity of the antimicrobial effect. Modified surfaces display recurring challenges such as short-term effectiveness, the burst release of drugs, cytotoxicity, and lack of reusability. Stimulus-responsive surfaces seem to be a promising strategy for a controlled and precise antimicrobial effect, and future research should focus on this technology and study it from models that better mimic clinical conditions.

DMP1 and IFITM5 Regulate Osteogenic Differentiation of MC3T3-E1 on PEO-Treated Ti-6Al-4V-Ca2+/Pi surface

Despite numerous studies on various surface modifications on titanium and its alloys, it remains unclear what kind of titanium-based surface modifications are capable of controlling cell activity. This study aimed to understand the mechanism at the cellular and molecular levels and investigate the in vitro response of osteoblastic MC3T3-E1 cultured on the Ti-6Al-4V surface modified by plasma electrolytic oxidation (PEO) treatment. A Ti-6Al-4V surface was prepared by PEO at 180, 280, and 380 V for 3 or 10 min in an electrolyte containing Ca²⁺/P_i ions. Our results showed that PEO-treated Ti-6Al-4V-Ca²⁺/P_i surfaces enhanced the cell attachment and differentiation of MC3T3-E1 compared to the untreated Ti-6Al-4V control but did not affect cytotoxicity as shown by cell proliferation and cell death. Interestingly, on the Ti-6Al-4V-Ca²⁺/P_i surface treated by PEO at 280 V for 3 or 10 min, MC3T3-E1 showed a higher initial adhesion and mineralization. In addition, the alkaline phosphatase (ALP) activity significantly increased in MC3T3-E1 on the PEO-treated Ti-6Al-4V-Ca²⁺/P_i (280 V for 3 or 10 min). In RNA-seq analysis, the expression of dentin matrix protein 1 (DMP1), sortilin 1 (Sort1), signal-induced proliferation-associated 1 like 2 (SIPA1L2), and interferon-induced transmembrane protein 5 (IFITM5) was induced during the osteogenic differentiation of MC3T3-E1 on the PEO-treated Ti-6Al-4V-Ca²⁺/P_i. DMP1 and IFITM5 silencing decreased the expression of bone differentiation-related mRNAs and proteins and ALP activity in MC3T3-E1. These results suggest that the PEO-treated Ti-6Al-4V-Ca²⁺/P_i surface induces osteoblast differentiation by regulating the expression of DMP1 and IFITM5. Therefore, surface microstructure modification through PEO coatings with Ca²⁺/P_i ions could be used as a valuable method to improve biocompatibility properties of titanium alloys.

A Review on Nano Ti-Based Oxides for Dark and Photocatalysis: From Photoinduced Processes to Bioimplant Applications

Catalysis on TiO₂ nanomaterials in the presence of H₂O and oxygen plays a crucial role in the advancement of many different fields, such as clean energy technologies, catalysis, disinfection, and bioimplants. Photocatalysis on TiO₂ nanomaterials is well-established and has advanced in the last decades in terms of the understanding of its underlying principles and improvement of its efficiency. Meanwhile, the increasing complexity of modern scientific challenges in disinfection and bioimplants requires a profound mechanistic understanding of both residual and dark catalysis. Here, an overview of the progress made in TiO₂ catalysis is given both in the presence and absence of light. It begins with the mechanisms involving reactive oxygen species (ROS) in TiO₂ photocatalysis. This is followed by improvements in their photocatalytic efficiency due to their nanomorphology and states by enhancing charge separation and increasing light harvesting. A subsection on black TiO₂ nanomaterials and their interesting properties and physics is also included. Progress in residual catalysis and dark catalysis on TiO₂ are then presented. Safety, microbicidal effect, and studies on Ti-oxides for bioimplants are also presented. Finally, conclusions and future perspectives in light of disinfection and bioimplant application are given.

Conferring Antioxidant Activity to an Antibacterial and Bioactive Titanium Surface through the Grafting of a Natural Extract

The main unmet medical need of bone implants is multifunctional activity, including their ability to induce rapid and physiological osseointegration, counteract bacterial biofilm formation, and prevent in situ chronic inflammation at the same time. This research starts from an already developed c.p. titanium surface with proven bioactive (in vitro hydroxyl apatite precipitation) and antibacterial activities, due to a calcium titanate layer with nano- and micro-scale roughness and loaded with iodine ions. Here, antioxidant ability was added to prevent chronic inflammation by grafting polyphenols of a green tea extract onto the surface, without compromising the other functionalities of the surface. The surface was characterized before and after functionalization through XPS analysis, zeta potential titrations, ion release measurements, in vitro bioactivity tests, SEM and fluorescence microscopy, and Folin-Ciocalteu and biological tests. The presence of grafted polyphenols as a homogeneous layer was proven. The grafted polyphenols maintained their antioxidant ability and were anchored to the surface through the linking action of Ca²⁺ ions added to the functionalizing solution. Iodine ion release, cytocompatibility towards human mesenchymal stem cells (hMSC), and antibacterial activity were maintained even after functionalization. The antioxidant ability of the functionalized surface was effective in preserving hMSC viability in a chemically induced pro-inflammatory environment, thus showing a scavenger activity towards toxic active species responsible for inflammation.

An ionic silver coating prevents implant-associated infection by anaerobic bacteria in vitro and in vivo in mice

Currently, implants are utilized clinically for bone transplant procedures. However, if infectious osteomyelitis occurs at implant sites, removal of bacteria can be challenging. Moreover, altered blood flow at peri-implant infectious sites can create an anaerobic environment, making it more difficult to treat infection with antibiotics. Thus, it would be beneficial if implants could be modified to exhibit antibacterial activity, even in anaerobic conditions. Here, we show antibacterial activity of silver ions coated on titanium rods, even against the anaerobic bacteria Porphyromonas gingivalis (P. gingivalis), both in vitro and in vivo. Specifically, we implanted silver-coated or control uncoated titanium rods along with P. gingivalis in mouse femoral bone BM cavities and observed significantly inhibited P. gingivalis infection with silver-coated compared with non-coated rods, based on in vivo bio-imaging. Osteonecrosis by infectious osteomyelitis and elevation of the inflammatory factors C-reactive protein and IL-6 promoted by P. gingivalis s were also significantly reduced in the presence of silver-coated rods. Overall, our study indicates that silver ion coating of an implant represents a therapeutic option to prevent associated infection, even in anaerobic conditions or against anaerobic bacteria.

Trabecular Titanium for Orthopedic Applications: Balancing Antimicrobial with Osteoconductive Properties by Varying Silver Contents

Periprosthetic joint infection (PJI) and implant loosening are the most common complications after joint replacement surgery. Due to their increased surface area, additively manufactured porous metallic implants provide optimal osseointegration but they are also highly susceptible to bacterial colonization. Antibacterial surface coatings of porous metals that do not inhibit osseointegration are therefore highly desirable. The potential of silver coatings on arthroplasty implants to inhibit PJI has been demonstrated, but the optimal silver content and release kinetics have not yet been defined. A tight control over the silver deposition coatings can help overcome bacterial infections while reducing cytotoxicity to human cells. In this regard, porous titanium sputtered with silver and titanium nitride with increasing silver contents enabled controlling the antibacterial effect against common PJI pathogens while maintaining the metabolic activity of human primary cells. Electron beam melting additively manufactured titanium alloys, coated with increasing silver contents, were physico-chemically characterized and investigated for effects against common PJI pathogens. Silver contents from 7 at % to 18 at % of silver were effective in reducing bacterial growth and biofilm formation. Staphylococcus epidermidis was more susceptible to silver ions than Staphylococcus aureus. Importantly, all silver-coated titanium scaffolds supported primary human osteoblasts proliferation, differentiation, and mineralization up to 28 days. A slight reduction of cell metabolic activity was observed at earlier time points, but no detrimental effects were found at the end of the culture period. Silver release from the silver-coated scaffolds also had no measurable effects on primary osteoblast gene expression since similar expression of genes related to osteogenesis was observed regardless the presence of silver. The investigated silver-coated porous titanium scaffolds may thus enhance osseointegration while reducing the risk of biofilm formation by the most common clinically encountered pathogens.

Biodegradable Bone Implants as a New Hope to Reduce Device-Associated Infections-A Systematic Review

Bone fractures often require fixation devices that frequently need to be surgically removed. These temporary implants and procedures leave the patient more prone to developing medical device-associated infections, and osteomyelitis associated with trauma is a challenging complication for orthopedists. In recent years, biodegradable materials have gained great importance as temporary medical implant devices, avoiding removal surgery. The purpose of this systematic review was to revise the literature regarding the use of biodegradable bone implants in fracture healing and its impact on the reduction of implant-associated infections. The systematic review followed the PRISMA guidelines and was conducted by searching published studies regarding the in vivo use of biodegradable bone fixation implants and its antibacterial activity. From a total of 667 references, 23 studies were included based on inclusion and exclusion criteria. Biodegradable orthopedic implants of Mg-Cu, Mg-Zn, and Zn-Ag have shown antibacterial activity, especially in reducing infection burden by MRSA strains in vivo osteomyelitis models. Their ability to prevent and tackle implant-associated infections and to gradually degrade inside the body reduces the need for a second surgery for implant removal, with expectable gains regarding patients' comfort. Further in vivo studies are mandatory to evaluate the efficiency of these antibacterial biodegradable materials.

Antibacterial and Cytocompatible: Combining Silver Nitrate with Strontium Acetate Increases the Therapeutic Window

Microbial infection and insufficient tissue formation are considered to be the two main causes of dental implant failure. Novel studies have focused on designing dual-functional strategies to promote antibacterial properties and improve tissue cell response simultaneously. In this study, we investigated the antibacterial properties and cytocompatibility of silver nitrate (AgNO₃) and strontium acetate (SrAc) in a mono-culture setup for dental application. Additionally, we defined the therapeutic window between the minimum inhibitory concentration against pathogenic bacteria and maximum cytocompatible dose in the case of combined applications in a co-culture setup. Antibacterial properties were screened using Aggregatibacter actinomycetemcomitans and cell response experiments were performed with osteoblastic cells (MC3T3) and fibroblastic cells (NIH3T3). The osteoinductive behavior was investigated separately on MC3T3 cells using alizarin red staining. A therapeutic window for AgNO₃ as well as SrAc applications could be defined in the case of MC3T3 cells while the cytocompatibility of NIH3T3 cells was compromised for all concentrations with an antibacterial effect. However, the combined application of AgNO₃/SrAc caused an enhanced antibacterial effect and opened a therapeutic window for both cell lines. Enhanced mineralization rates could be observed in cultures containing SrAc. In conclusion, we were able to demonstrate that adding SrAc to AgNO₃ not only intensifies antibacterial properties but also exhibits bone inductive characteristics, thereby offering a promising strategy to combat peri-implantitis and at the same time improve osseointegration in implant therapy.

Smart Hydrogels for Advanced Drug Delivery Systems

Since the last few decades, the development of smart hydrogels, which can respond to stimuli and adapt their responses based on external cues from their environments, has become a thriving research frontier in the biomedical engineering field. Nowadays, drug delivery systems have received great attention and smart hydrogels can be potentially used in these systems due to their high stability, physicochemical properties, and biocompatibility. Smart hydrogels can change their hydrophilicity, swelling ability, physical properties, and molecules permeability, influenced by external stimuli such as pH, temperature, electrical and magnetic fields, light, and the biomolecules' concentration, thus resulting in the controlled release of the loaded drugs. Herein, this review encompasses the latest investigations in the field of stimuli-responsive drug-loaded hydrogels and our contribution to this matter.

Decontamination-Induced Modification of Bioactivity in Essential Oil-Based Plasma Polymer Coatings

Plasma polymer coatings fabricated from Melaleuca alternifolia essential oil and its derivatives have been previously shown to reduce the extent of microbial adhesion on titanium, polymers, and other implantable materials used in dentistry. Previous studies have shown these coatings to maintain their performance under standard operating conditions; however, when used in e.g., a dental implant, these coatings may inadvertently become subject to in situ cleaning treatments, such as those using an atmospheric pressure plasma jet, a promising tool for the effective in situ removal of biofilms from tissues and implant surfaces. Here, we investigated the effect of such an exposure on the antimicrobial performance of the Melaleuca alternifolia polymer coating. It was found that direct exposure of the polymer coating surface to the jet for periods less than 60 s was sufficient to induce changes in its surface chemistry and topography, affecting its ability to retard subsequent microbial attachment. The exact effect of the jet exposure depended on the chemistry of the polymer coating, the length of plasma treatment, cell type, and incubation conditions. The change in the antimicrobial activity for polymer coatings fabricated at powers of 20–30 W was not statistically significant due to their limited baseline bioactivity. Interestingly, the bioactivity of polymer coatings fabricated at 10 and 15 W against Staphylococcus aureus cells was temporarily improved after the treatment, which could be attributed to the generation of loosely attached bioactive fragments on the treated surface, resulting in an increase in the dose of the bioactive agents being eluted by the surface. Attachment and proliferation of Pseudomonas aeruginosa cells and mixed cultures were less affected by changes in the bioactivity profile of the surface. The sensitivity of the cells to the change imparted by the jet treatment was also found to be dependent on their origin culture, with mature biofilm-derived P. aeruginosa bacterial cells showing a greater ability to colonize the surface when compared to its planktonic broth-grown counterpart. The presence of plasma-generated reactive oxygen and nitrogen species in the culture media was also found to enhance the bioactivity of polymer coatings fabricated at power levels of 10 and 15 W, due to a synergistic effect arising from simultaneous exposure of cells to reactive oxygen and nitrogen species (RONS) and eluted bioactive fragments. These results suggest that it is important to consider the possible implications of inadvertent changes in the properties and performance of plasma polymer coatings as a result of exposure to in situ decontamination, to both prevent suboptimal performance and to exploit possible synergies that may arise for some polymer coating-surface treatment combinations.

Surface Design for Antibacterial Materials: From Fundamentals to Advanced Strategies

Healthcare-acquired infections as well as increasing antimicrobial resistance have become an urgent global challenge, thus smart alternative solutions are needed to tackle bacterial infections. Antibacterial materials in biomedical applications and hospital hygiene have attracted great interest, in particular, the emergence of surface design strategies offer an effective alternative to antibiotics, thereby preventing the possible development of bacterial resistance. In this review, recent progress on advanced surface modifications to prevent bacterial infections are addressed comprehensively, starting with the key factors against bacterial adhesion, followed by varying strategies that can inhibit biofilm formation effectively. Furthermore, "super antibacterial systems" through pre-treatment defense and targeted bactericidal system, are proposed with increasing evidence of clinical potential. Finally, the advantages and future challenges of surface strategies to resist healthcare-associated infections are discussed, with promising prospects of developing novel antimicrobial materials.

Toward Bactericidal Enhancement of Additively Manufactured Titanium Implants

Implant-associated infections (IAIs) are among the most intractable and costly complications in implant surgery. They can lead to surgery failure, a high economic burden, and a decrease in patient quality of life. This manuscript is devoted to introducing current antimicrobial strategies for additively manufactured (AM) titanium (Ti) implants and fostering a better understanding in order to pave the way for potential modern high-throughput technologies. Most bactericidal strategies rely on implant structure design and surface modification. By means of rational structural design, the performance of AM Ti implants can be improved by maintaining a favorable balance between the mechanical, osteogenic, and antibacterial properties. This subject becomes even more important when working with complex geometries; therefore, it is necessary to select appropriate surface modification techniques, including both topological and chemical modification. Antibacterial active metal and antibiotic coatings are among the most commonly used chemical modifications in AM Ti implants. These surface modifications can successfully inhibit bacterial adhesion and biofilm formation, and bacterial apoptosis, leading to improved antibacterial properties. As a result of certain issues such as drug resistance and cytotoxicity, the development of novel and alternative antimicrobial strategies is urgently required. In this regard, the present review paper provides insights into the enhancement of bactericidal properties in AM Ti implants.

TiAl6V4 Alloy Surface Modifications and Their Impact on Biofilm Development of S. aureus and S. epidermidis

One of the most serious complications following joint replacement surgeries are periprosthetic infections (PIs) arising from the adhesion of bacteria to the artificial joint. Various types of titanium-aluminum-vanadium (TiAl6V4) alloy surface modifications (coatings with silver (Ag), titanium nitride (TiN), pure titanium (cpTi), combinations of cpTi and hydroxyapatite (HA), combinations of cpTi and tricalcium phosphate (TCP), and a rough-blasted surface of TiAl6V4) have been investigated to assess their effects on biofilm development. Biofilms were grown, collected, and analyzed after 48 h to measure their protein and glucose content and the cell viability. Biofilm-associated genes were also monitored after 48 h of development. There was a distinct difference in the development of staphylococcal biofilms on the surfaces of the different types of alloy. According to the findings of this study, the base alloy TiAl6V4 and the TiN-coated surface are the most promising materials for biofilm reduction. Rough surfaces are most favorable when it comes to bacterial infections because they allow an easy attachment of pathogenic organisms. Of all rough surfaces tested, rough-blasted TiAl6V4 was the most favorable as an implantation material; all the other rough surfaces showed more distinct signs of inducing the development of biofilms which displayed higher protein and polysaccharide contents. These results are supported by RT-qPCR measurements of biofilm associated genes for Staphylococcus aureus (icaA, icaC, fnbA, fnbB, clfB, atl) and Staphylococcus epidermidis (atle, aap).