Andreas Schedle

Potential of chemically modified hydrophilic surface characteristics to support tissue integration of titanium dental implants

In the past, several modifications of specific surface properties such as topography, structure, chemistry, surface charge, and wettability have been investigated to predictably improve the osseointegration of titanium implants. The aim of the present review was to evaluate, based on the currently available evidence, the impact of hydrophilic surface modifications of titanium for dental implants. A surface treatment was performed to produce hydroxylated/hydrated titanium surfaces with identical microstructure to either acid-etched, or sand-blasted, large grit and acid-etched substrates, but with hydrophilic character. Preliminary in vitro studies have indicated that the specific properties noted for hydrophilic titanium surfaces have a significant influence on cell differentiation and growth factor production. Animal experiments have pointed out that hydrophilic surfaces improve early stages of soft tissue and hard tissue integration of either nonsubmerged or submerged titanium implants. This data was also corroborated by the results from preliminary clinical studies. In conclusion, the present review has pointed to a potential of hydrophilic surface modifications to support tissue integration of titanium dental implants.

Polymerization shrinkage kinetics of dimethacrylate resin-cements.

OBJECTIVES To determine polymerization shrinkage-strain (S(Y)) and shrinkage-stress (S(Z)) of six resin-cements and to compare their performance with the aid of degree of conversion (DC) data. METHODS Variolink 2 (VL2), Multilink Automix (MA), Multilink Sprint (MS, all Ivoclar-Vivadent), Nexus 2 (NX2), Maxcem (MX, both Kerr) and RelyX Unicem (RX, 3M-Espe) were investigated. MS, MX and RX were self-adhesive; others require a bonding-agent. All measurements were conducted at 23 degrees C for 60min (n=5), except 80min for RX, with materials self-cured only (sc) and dual-cured (dc); NX2 and VL2 were additionally light-cured only (lc). S(Y) was measured by the bonded-disk method [Watts DC, Cash AJ. Determination of polymerization shrinkage kinetics in visible-light-cured materials: methods development. Dent Mater 1991;7(4):281-7; Watts DC, Marouf AS. Optimal specimen geometry in bonded-disk shrinkage-strain measurements on light-cured biomaterials. Dent Mater 2000;16(6):447-51]; S(Z) by the Bioman instrument [Watts DC, Satterthwaite JD. Axial shrinkage-stress depends upon both C-factor and composite mass. Dent Mater 2008;24(1):1-8 [Epub October 24, 2007]; Watts DC, Marouf AS, Al-Hindi AM. Photo-polymerization shrinkage-stress kinetics in resin-composites: methods development. Dent Mater 2003;19(1):1-11]. Light-cure was achieved by QTH at 500mW/cm(2). The respective DCs were measured under the same conditions by FTIR-ATR spectroscopy. Data were analyzed by One-Way ANOVA plus Bonferroni test, and by t-test, at p<0.05. RESULTS DC by self-curing was less than the DC by dual-curing, for all cements. Shrinkage-strain ranged from 1.77 to 5.29% and shrinkage-stress from 3.36 to 10.37MPa. NX2 and VL2 were not significantly different, when light-cured only. Except for RX, sc and dc shrinkage-strain varied maximally by 0.4%. MX showed the highest S(Y), RX the lowest. When sc, RX initially expanded by <0.5% (t approximately 5min). For most materials, S(Y) correlated with their filler loading. The highest stress with sc was exerted by MX, and when dc by MS, which was not statistically different from MX. SIGNIFICANCE Shrinkage data of resin-cements are of intrinsic clinical importance. Self-cure, despite a lower DC, did not necessarily result in a lower S(Y) compared to dual-cure. S(Y)-rate and S(Z) development depend upon cure mode and S(Y) upon filler fraction.

Initial attachment, subsequent cell proliferation/viability and gene expression of epithelial cells related to attachment and wound healing in response to different titanium surfaces

OBJECTIVES A tight seal between the epithelium and the dental implant surface is required to prevent bacterial inflammation and soft tissue recession and therefore to demonstrate a long-term success. Surface hydrophilicity was recently shown to promote osseointegration. The aim of this study was to investigate the influence of surface hydrophilicity in combination with surface topography of Ti implant surfaces on the behavior and activation/differentiation of epithelial cells using a set of in vitro experiments mimicking the implant-soft tissue contact. METHODS Hydrophobic acid-etched (A) and coarse-grit-blasted, acid-etched (SLA) surfaces and hydrophilic acid-etched (modA) and modSLA surfaces were produced. The behavior of an oral squamous cell carcinoma cell line (HSC-2) grown on all surfaces was compared through determination of cell attachment and proliferation/viability (CCK-8 and MTT assay), time-lapse microscopy of fluorescence labeled cells and determination of gene expression by real time polymerase chain reaction. RESULTS Within the surfaces with similar wettability cell spreading and cell movements observed by time-lapse microscopy after one day of incubation were most pronounced on smoother (A and modA) surfaces compared to rougher (SLA and modSLA) surfaces. Within the surfaces with similar roughness the hydrophilic surfaces (modA and modSLA) showed more cell spreading and cell activity compared to the hydrophobic surfaces (A and SLA). The relative gene expressions of cytokeratin14, integrin α6, integrin β4, vinculin, transforming growth factor (TGF)-β, TGF-β1, and TGF-β3 were decreased in HSC-2 on all four types of Ti surfaces compared to control surfaces (tissue culture polystyrene; p<0.01) and there was no significant difference of gene expression on the four different implant-surfaces. SIGNIFICANCE We have demonstrated that for proliferation and spreading of HSC-2 cells the smoother and hydrophilic surface is optimal (modA). These results suggest that surface hydrophilicity might positively influence the epithelial seal around dental implants. All tested titanium surfaces downregulate cell attachment, cell proliferation, expression of adhesion promoters, and cytokines involved in wound healing in HSC-2 cells compared to control surfaces.

Survival of direct resin restorations in posterior teeth within a 19-year period (1996–2015): A meta-analysis of prospective studies

OBJECTIVES The aim of this study is to analyze the survival of posterior composite restorations published within the last 19 years (1996-2015). METHODS In this study only prospective, clinical trials with specification of the failure rate according to Class I/II composite fillings were included. Studies were analyzed according to the observation period (all studies vs. short-term vs. long-term studies). Retrospective studies and/or open laminate studies, tunnel restorations and Class V restorations were excluded. The following variables possibly influencing the failure rate were extracted from the studies: observation period, recall rate, average age of patients, number of patients, ratio of Class I/II fillings, number of restorations, ratio of premolars/molars, operator, method of isolation, bonding generation and filler size. RESULTS A total of 88 studies were included for statistical analysis. The observation period of the studies varied between 1 and 17 years, while most of the studies did not last longer than 5 years. Fracture of the restorations, secondary caries and marginal gap are the main causes for failure in the first 5 years (in descending order), while fracture and secondary caries are similarly distributed in long-term studies. Variables of investigation differed greatly in significance according to the respective observation period. The observation period, the recall rate, the ratio of Class I/II fillings and the number of restorations and patients had a significant influence on the overall failure rate when including all studies (short- and long-term). A linear correlation between the observation period and the failure rate was observed. In long-term studies these variables were not significant any longer. No significant difference in the failure rates between the materials per study was observed. The most common commercial composites investigated were: Tetric Ceram, Surefil, Filtek Supreme (incl. XT), Filtek Z250. The mean annual failure rate was 1.46% (±1.74%) for short-term studies and 1.97% (±1.53) for long-term studies. There is still a big need for clinical studies lasting longer than 5 years, as failure rates of composite restorations in posterior teeth increases with longer observation periods. SIGNIFICANCE A decreasing failure rate with an increasing recall rate as observed in our study suggests a patient selection in regard to availability and dental awareness. Internationally standardized evaluation criteria are mandatory in order to allow comparisons of the outcomes of clinical studies.

Osteogenic properties of hydrophilic and hydrophobic titanium surfaces evaluated with osteoblast-like cells (MG63) in coculture with human umbilical vein endothelial cells (HUVEC)

OBJECTIVES Osteogenesis on titanium (Ti) surfaces is a complex process involving cell-substrate and cell-cell interaction of osteoblasts and endothelial cells. The aim of this study was to investigate the osteogenic properties of Ti surfaces on osteoblasts in the presence of endothelial cells (ECs). METHODS Osteoblast-like cells (MG63 cells) and human umbilical vein endothelial cells (HUVECs) were grown in cocultures on four kinds of Ti surfaces: acid-etched (A), coarse-grit-blasted and acid-etched (SLA), hydrophilic A (modA) and hydrophilic SLA (modSLA) surfaces. MG63 cells in single cultures served as controls. Cell ratios and cell types in cocultures were determined and isolated using flow cytometry. Cell numbers were obtained by direct cell counting. In MG63 cells, alkaline phosphatase (ALP) activity was determined and protein levels of osteocalcin (OC) and osteoprotegerin (OPG) were detected with enzyme-linked immunosorbant assay (ELISA). The mRNA levels of ALP, OC and OPG of sorted MG63 cells were determined with real time polymerase chain reaction (PCR). RESULTS MG63 cells proliferated in the presence of HUVECs, which showed higher cell numbers on Ti surfaces (A, SLA, modSLA) after 72h, and lower cell numbers on Ti surfaces (modA, SLA, modSLA) after 120h in comparison to single cultures. Protein and mRNA levels of ALP and OPG were higher in cocultures than in single cultures, while OC exhibited a lower expression. These three parameters were higher expressed on modA, SLA and modSLA surfaces compared to A surfaces. SIGNIFICANCE Cocultures of osteoblasts and endothelial cells represent the most recently developed research model for investigating osteogenesis and angiogenesis which play both a major role in bone healing. This paper investigates for the first time the osteogenic properties of titanium surfaces used for dental implants with a coculture system with osteoblast-like cells and endothelial cells: (1) In cocultures with ECs (HUVECs) osteoblast-like cells (MG63 cells) show enhanced expression of early differentiation markers and osteogenic factors on Ti surfaces compared to single cultures of MG63 cells. (2) The differentiation and the expression of an osteogenic phenotype of osteoblast-like cells (MG63 cells) in coculture with ECs (HUVECs) is enhanced by both hydrophilicity and roughness of Ti surfaces.

Proliferation, behavior, and cytokine gene expression of human umbilical vascular endothelial cells in response to different titanium surfaces

Success of dental implantation is initially affected by wound healing of both, hard and soft tissues. Endothelial cells (ECs) are involved as crucial cells in the angiogenesis and inflammation process of wound healing. In the present study, proliferation, mobility, cluster formation, and gene expression of angiogenesis-related molecules of human umbilical vascular endothelial cells (HUVECs) were investigated on titanium surfaces with different roughnesses: acid-etched (A), coarse-grit-blasted and acid-etched (SLA) surfaces, as well as on hydrophilic modified modA and modSLA surfaces. Cell behaviors were analyzed by proliferation assay and time-lapse microscopy, gene expression was analyzed by real time PCR. Results showed that cell proliferation, mobility, and cluster formation were highest on modA surfaces compared with all other surfaces. HUVECs moved slowly and exhibited seldom cell aggregation on SLA and modSLA surfaces during the whole observing period of 120 h. The gene expressions of the angiogenesis-related factors von Willebrand factor, thrombomodulin, endothelial cell protein C receptor, and adhesion molecules intercellular adhesion molecule-1 and E-selectin were most enhanced on modSLA surfaces. These results suggest that modA surface is optimal for proliferation and angiogenic behavior of ECs. However, modSLA surface seems to promote ECs to express angiogenesis-related factor genes, which play essential roles in controlling inflammation and revascularization of wound healing.

Cytotoxicity of a calcium aluminate cement in comparison with other dental cements and resin-based materials

The objective of this study was to compare the cytotoxic effects of a calcium aluminate cement with several currently used direct restorative materials. Specimens of three composites (QuiXfil, Tetric Ceram, Filtek Supreme), one zinc phosphate cement (Harvard Cement), one glass ionomer cement (Ketac Molar), and one calcium aluminate cement (DoxaDent), were used fresh or after 7-days’ preincubation in cell culture medium at 37°C, pH 7.2. PVC strips for ISO 10993-5 cytotoxicity test were used as positive control and glass specimens as negative control. L-929 fibroblasts (5-ml aliquots, containing 3×104 cells/ml), cultivated in DMEM with 10% FCS, 1% glutamine, and 1% penicillin/streptomycin at 37°C/5% CO2 and trypsinized, were exposed to the specimens for 72 h. The cells were harvested, centrifuged, and resuspended in 500 µl DMEM and then counted in 500 µl DMEM for 30 s with a flow cytometer at 488 nm. The analysis of variance comparing the six materials showed different influences on L-929 fibroblast cytotoxicity (p<0.0001). The cytotoxicity of all specimens diminished with increasing preincubation time (p<0.0001). Fresh DoxaDent exhibited the lowest cytotoxicity, followed by QuiXfil. Ketac Molar showed the highest cytotoxicity. After 7 days of preincubation, Harvard Cement and Filtek Supreme demonstrated more cytotoxicity than the other materials (p<0.005).

Cytotoxicity and shear bond strength of four orthodontic adhesive systems.

The objective of this study was to compare the cytotoxicity of four orthodontic bonding systems, Light Bond, Enlight, Concise, and Transbond, and to evaluate their shear bond strength (SBS). These orthodontic bonding materials were applied to metal brackets (Mini Diamond). Glass specimens were used as controls in all experiments. Only Concise was a chemically cured system, the other systems were light cured. The specimens were added to L-929 fibroblast cultures immediately after fabrication or after pre-incubation for 7 days. The incubation time was 72 hours and the cells were counted by flow cytometry. One hundred and fifty-seven freshly extracted human third molars were used for testing the SBS in a universal testing machine. Statistical significance was determined using analysis of variance followed by post hoc comparisons for multiple-level alpha control. Pairwise comparisons showed a significant difference only between Light Bond and Concise (P = 0.0126). The highest SBS was obtained with Light Bond (23.23 +/- 1.53 MPa) followed by Transbond (20.39 +/- 1.18 MPa) and Enlight, (20.32 +/- 1.06 MPa). Concise (17.87 +/- 1.04 MPa) showed the lowest SBS. The cytotoxicity of all light-cured systems for fresh specimens was comparable, whereas the chemically cured system, Concise, was significantly more cytotoxic. After 7 days of pre-incubation, all systems were significantly less cyotoxic than fresh specimens (P < 0.001). Brackets alone were not cytotoxic. All bonding systems showed a clinically satisfactory bond strength higher than 10 MPa, with the chemically cured system showing the lowest SBS.

The proliferation and differentiation of osteoblasts in co-culture with human umbilical vein endothelial cells: An improved analysis using fluorescence-activated cell sorting

The interaction of osteoblasts and endothelial cells plays a pivotal role in osteogenesis. This interaction has been extensively studied using their direct co-culture in vitro. However, co-culture experiments require clear discrimination between the two different cell types in the mixture, but this was rarely achieved. This study is the first to use fluorescence-activated cell sorting (FACS) for the separation and quantitative analysis of the proliferation and differentiation of MG-63 cells grown in direct co-culture with human umbilical vein endothelial cells (HUVECs). The cells of the MG-63 cell line have properties consistent with the characteristics of normal osteoblasts. We labeled HUVECs with fluorescent antibody against CD31 and used FACS to measure the proportions of each cell type and to separate them based on their different fluorescence intensities. The rate of proliferation of the MG-63 cells was estimated based on a count of the total viable cells and the proportion of MG-63 cells in the mixture. The mRNA expression levels of the osteoblast differentiation markers alkaline phosphatase (ALP), collagen type 1 (Coll-1) and osteocalcin (OC) in the MG-63 cells were measured via real-time PCR after the separation via FACS. We found that HUVECs stimulated the proliferation of the MG-63 cells after 72 h of co-culture, and inhibited it after 120 h of co-culture. The mRNA expression levels of ALP and Coll-1 significantly increased, whereas that of OC significantly decreased in MG-63 after co-culture with HUVECs. Using FACS for the quantitative analysis of the proliferation and differentiation of osteoblasts directly interacting with endothelial cells could have merit for further co-culture research.

Microleakage after thermocycling of cemented crowns - A meta-analysis.

OBJECTIVES Microleakage testing of dental materials is a commonly accepted evaluation technique of margin integrity. Thermocycling has been utilized by many researchers to study the influence of temperature extremes on the marginal gap of cemented restorations. The aim of this investigation was to analyze microleakage data on cemented crowns, published in the dental literature until Dec 2009, to identify methodological factors that might potentially affect the results of in vitro microleakage tests and to compare the results. METHODS The following databases were included: Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) 1950 to Present, Ovid-MEDLINE(R) 1950 to Present with Daily Update, EMBASE, EBM Reviews - Cochrane Database of Systematic Reviews and Pub Med. The search was limited to articles in English, French, Italian and German published until the end of 2009. Classical reviews, comments, animal studies, in vivo articles and studies investigating restorative materials or milk teeth were excluded. 33 different studies were finally selected. The studies were entered in a database and compared using selected literature criteria: sample, restoration procedures, thermocycling and mechanical cycling, evaluation method. For statistical analysis only 16 studies could be applied. RESULTS It was not possible to make a quantitative synthesis of most of the data, due to the heterogeneity of the studies concerning methods, treatment and outcome variables. Comparing the main groups of materials (ceramics, gold alloys and base metal alloys), no significant difference in the proportion of teeth without microleakage was found. Furthermore no significant difference in the proportion of teeth showing microleakage less than two third of the wall or teeth showing microleakage including the entire wall was found. Using the mean values in the meta-analysis instead of the proportions does not change the results. Confidence intervals could only be calculated for two materials (gold alloy, metal alloy). No difference between materials was found. SIGNIFICANCE Comparison of the results from different studies is critical, since there are no generally accepted standards for experimental parameters, such as type and concentration of the storage solution, time of storage, temperature during storage, type and duration of thermal cycling and/or mechanical cycling, and the scoring criteria. There is lack of standardization of experimental conditions, which would ensure confidence in the studies and would further allow better comparability of various results.