Maria Bächle

Ceramic abutments and ceramic oral implants. An update

Dental implants are considered an essential treatment modality. Published data have demonstrated high success rates for implants placed in partially edentulous arches for the replacement of both single teeth (42, 66, 88) and multiple teeth (87, 117, 121, 163, 200). However, the use of implants to replace missing teeth in the aesthetic zone is challenging (64, 127, 211). The restorations are subjected, especially in patients with a gummy smile or a high lip line, to direct visual comparison with the adjacent natural teeth (81, 118). Perfect three-dimensional implant positioning and well-designed superstructures are therefore essential to mimic the appearance of a natural tooth and to achieve an optimal aesthetic outcome (118, 197, 209). Dental implants and abutments are usually fabricated out of commercially pure titanium, primarily because of its well-documented biocompatibility and mechanical properties (2). However, despite numerous modifications to the fabrication and design of metal abutments, there is still the disadvantage of metallic components showing through when such abutments are used (81, 83, 85, 126). The resultant dull grayish background may give the soft tissue an unnatural bluish appearance (64, 118, 209). The presence of a gray gingival discoloration may be attributed to a thin gingival biotype that is incapable of blocking reflective light from the metallic abutment surface (64, 209). Gingival biotype switching has been suggested when using a metal abutment to increase the thickness of the gingiva; this thicker gingiva will block the reflective light from the abutment s surface from showing through and thus improve the aesthetic outcome (91, 104, 105, 192). Biotype switching, however, requires an additional surgical procedure, which is unpleasant for most patients (105). Recent years have shown a consistent trend toward aesthetic improvements in implant restorative materials and in treatment outcome. To achieve optimal mucogingival aesthetics, ceramic abutments were developed (Figs 1 and 2).

The gene-expression and phenotypic response of hFOB 1.19 osteoblasts to surface-modified titanium and zirconia.

The osteoblastic cell-line hFOB 1.19 with the potential to proliferate and differentiate revealed that cellular differentiation is not affected by material and roughness on newly developed zirconia implant materials. Materials under investigation were surfaces machined titanium (Ti-m), modified titanium (TiUnite, machined zirconia (TZP-A-m), modified zirconia (ZiUnitemachined alumina-toughened zirconia (ATZ-m) and modified alumina-toughened zirconia (ATZ-mod). After surface description by scanning electron microscopy (SEM) and atomic force microscopy (AFM), cellular proliferation (EZ4U, Casy1) and differentiation were examined after days 1, 3, 7, 14, 21, and 28. Osteogenic differentiation was visualized by alkaline phosphatase staining, mineralization assay (alizarin red) and by expression analysis (RT-PCR) of bone- and extracellular matrix-related genes. Proliferation on rough surfaces was reduced on both titanium and zirconia. Cell-attachment and cytoskeleton organization documented by confocal laser scanning microscopy (CLSM) elucidated attenuated cell attachment within the first 4h to be the reason for impaired proliferation. A specific up-regulation of m-RNAs in an early event (RUNX2, NELL-1, RUNX3, and BMP7) and a late event (Integrin B3) could be observed on TiUnite and ZiUnite. For titanium an up-regulation of IBSP and Integrin B1 could be described at day 21. In total, differentiation was neither affected by material nor by roughness.

Biomechanical and histological behavior of zirconia implants: an experiment in the rat

OBJECTIVE This study aimed at evaluating the integration of zirconia implants in a rat femur model. MATERIAL AND METHODS Zirconia implants with two distinct surface topographies were compared with titanium implants with similar topographies. Titanium and zirconia implants were placed into the femurs of 42 male Sprague-Dawley rats. Four groups of implants were utilized: machined zirconia implants, zirconia implants with a rough surface, machined titanium implants, and titanium implants with an electrochemically roughened surface. After a healing period of 28 days, the load-bearing capacity between the bone and the implant surface was evaluated by a push-in test. Additionally, after a healing period of 14 and 28 days, respectively, bone tissue specimens containing the implants were processed and histologically analyzed. RESULTS The mean mineralized bone-to-implant contact showed the highest values after 14 and 28 days for the rough surfaces (titanium: 36%/45%; zirconia: 45%/59%). Also, the push-in test showed higher values for the textured implant surfaces, with no statistical significance between titanium (34 N) and zirconia (45.8 N). CONCLUSIONS Within the limits of the animal investigation presented, it was concluded that all tested zirconia and titanium implant surfaces were biocompatible and osseoconductive. The presented surface modification of zirconia implants showed no difference regarding the histological and biomechanical results compared with an established electrochemically modified titanium implant surface.

Biofilm formation and composition on different implant materials in vivo

Biofilm formation was evaluated on the following titanium and zirconia implants in vivo: machined titanium (Ti-m), modified titanium (TiUnite), modified zirconia (ZiUnite), machined alumina-toughened zirconia (ATZ-m), sandblasted alumina-toughened zirconia (ATZ-s), and machined zirconia (TZP-A-m). Bovine enamel slabs were used as controls. Surface morphologies were examined by atomic force (AFM) and scanning electron microscopy (SEM). The surface wettability was also determined. Twelve healthy volunteers wore a splint system with the tested materials. After 3 and 5 days the materials were examined by fluorescence in situ hybridization (FISH) and confocal laser scanning microscopy (CLSM). The levels of Streptococcus spp., Veillonella spp., Fusobacteriaum nucleatum, and Actinomyces naeslundii were quantitatively determined. The biofilm thickness was found to be between 19.78 and 36.73 μm after 3 days and between 26.11 and 32.43 μm after 5 days. With the exception of Ti-m the biofilm thickness after 3 days was correlated with surface roughness. In addition to Streptococcus spp. as the main component of the biofilm (11.23-25.30%), F. nucleatum, A. naeslundii, and Veillonella spp. were also detected. No significant differences in biofilm composition on the implant surfaces could be observed. In total, the influence of roughness and material on biofilm formation was compensated by biofilm maturation.

Osteoblast and bone tissue response to surface modified zirconia and titanium implant materials

OBJECTIVE This study examined the in vitro and in vivo response of osteoblasts to a novel, acid-etched and sandblasted zirconia surface. METHODS Osteoblastic hFOB 1.19 cells were cultured either on electrochemically anodized titanium (TiUnite(®)), machined titanium (Ti-m), sandblasted and acid-etched zirconia (TZP-proc), and machined zirconia (TZP-A-m). The surface topography of the various substrates was analyzed by 3D laserscan measurements and scanning electron microscopy. At culture days 1, 3, 7, 14, 21, and 28, cell proliferation was determined. Gene expression was analyzed using RT-PCR. Histologic analysis and biomechanical testing was performed on miniature implants placed in the rat femur. RESULTS During the first 7 days, a retarded cell proliferation was observed on the TiUnite(®) surface. After 28 days of cultivation, cell proliferation reached similar levels on all surfaces. An up-regulation of bone and extracellular matrix specific genes could be seen for TZP-proc at day 21. The mean bone-implant contact rate after a healing period of 14 and 28 days, respectively, was higher for TiUnite(®) than for TZP-proc. At 28 day, the biomechanical test showed significantly higher values for TiUnite(®) than for all other surfaces. SIGNIFICANCE The novel, rough zirconia surface was accepted by hFOB 1.19 cells and integrates into rat bone tissue. However, osseointegration seemed to proceed more slowly and to a lesser extent compared to a moderately roughened titanium surface.

Evaluation of alumina toughened zirconia implants with a sintered, moderately rough surface: An experiment in the rat

OBJECTIVE Alumina toughened zirconia (ATZ) is more fracture resistant than unmodified zirconia and has been shown to be a viable substrate for the growth of osteoblasts. In this study, we examined the histological and biomechanical behavior of moderately roughened ATZ implants in rat femoral bone. METHODS Miniature implants made of ATZ with pore-building polymers sintered onto the surface and electrochemically anodized titanium (TiUnite®) were placed into the femurs of Sprague-Dawley rats. Implant surface topography was analyzed by 3D laserscan measurements and scanning electron microscopy (SEM). After a healing period of 14 and 28 days, respectively, histologic and biomechanical testing was performed. RESULTS Under the SEM, the TiUnite® surface could be clearly distinguished from the ATZ surface, but 3D laserscan measurements indicated a moderately rough surface topography for both, TiUnite® (Sa=1.31μm) and ATZ (Sa=1.51μm). The mean mineralized bone-to-implant contact showed the highest values after 14 and 28 days for TiUnite® (58%/75%) as compared to ATZ (24%/41%). The push-in values after a healing period of 14 and 28 days, respectively, increased from 20N to 39N for TiUnite® and from 10N to 25N for ATZ. SIGNIFICANCE Our findings suggest that the moderately roughened ATZ implant surface is well accepted by rat bone tissue. However, compared to titanium, the osseointegration-process of ATZ seems to proceed more slowly in that early phase of implant integration.

Peri-implant bone response to retrieved human zirconia oral implants after a 4-year loading period: A histologic and histomorphometric evaluation of 22 cases.

AIM To evaluate the bone tissue response to surface modified zirconia oral implants retrieved from humans. MATERIALS AND METHODS Twenty-nine one-piece zirconia implants showed increased marginal bone loss and did not response to the applied peri-implantitis therapy. After their removal using a trephine bur, 22 of the implant-bone biopsies were suitable for an evaluation and immediately immersed in formalin for two weeks. Subsequent, the retrieved specimens were histologically prepared and the regions still showing osseointegration computer-assisted analyzed regarding the bone-to-implant contact (BIC) and bone density using a transmitted-light microscope. RESULTS The removed implants were in situ for a mean time period of 47.7 months. After their removal, compact bone could be depicted at the apical regions. The remaining bone that was attached to the implants contained a regular lamellar structure with osteons and osteocytes. The BIC ranged from 58.1% to 93.7% (mean: 76.5%) and the bone area/density within the implant threads ranged from 57% to 97.2% (mean: 84.8%). CONCLUSIONS The porous zirconia implants showed a sufficient BIC in the areas where bone still was attached. Although the implants had to be removed due to increased bone loss, it seems that the presented zirconia implant surface per se elicited appropriate osseointegration.

Effect of two different healing times on the mineralization of newly formed bone using a bovine bone substitute in sinus floor augmentation: a randomized, controlled, clinical and histological investigation

PURPOSE To investigate the amount of the mineralization of a bovine bone substitute material in sinus floor augmentation after healing times of 3 and 6 months. MATERIALS AND METHODS Fifty-one patients were randomized into two healing time groups and received sinus floor augmentations with a bovine bone material. After 3 or 6 months of healing, trephine bone biopsies were retrieved. The biopsies were processed for histological and histomorphometric evaluations to primarily investigate the amount of mineralized bone in the augmented area and secondarily compare the amount of mineralized bone in the augmented area and in the pristine bone. Statistical tests were performed to analyse the fraction of the mineralized bone (p < 0.05). RESULTS The biopsies of both groups showed remnants of the well-integrated bone substitute material. The histology revealed osteoblasts, osteocytes with osteoid, and osteoclasts. The mean percentage of mineralized bone in the augmented area was 23.8% (3 months group) and 23.6% (6 months group; p = 0.9246); the amount of remaining bone substitute material was 35% (3 months group) and 33.9% (6 months group; p = 0.6325). CONCLUSION It can be concluded that the bone maturation in the augmented sinus using the bovine bone material is similar after 3 and 6 months. Thus, implant installation after 3 months following a lateral window sinus floor augmentation approach using a bovine bone material seems to be clinically acceptable.

Evaluation of Guided Bone Regeneration around Oral Implants over Different Healing Times Using Two Different Bovine Bone Materials: A Randomized, Controlled Clinical and Histological Investigation

PURPOSE To evaluate the potential of two bone substitute materials and the influence of different healing periods in guided bone regeneration therapy of osseous defects around implants. MATERIALS AND METHODS Twenty-four edentulous patients received implants in the region of the lost lower incisors. Around two standardized osseous defects were created, treated either with a 50:50 mixture of PepGen P-15® and OsteoGraf®/N-700 (test group) or with BioOss® (control group), and covered with titanium membranes. After healing periods of 2, 4, 6, or 9 months, the implants were removed together with the surrounding bone and subsequently prepared for histological evaluations. RESULTS Defect depths in both groups showed a clinical reduction after intervention. The histologically measured distance from the implant shoulder to the first point of bone-implant contact (BIC) after treatment did not differ between the two groups. The healing time influenced the level of the first point of BIC, with a longer healing period producing a more coronal first point of BIC. A greater percentage BIC and a higher fraction of mineralized bone were found in the pristine bone area compared with the augmented defect area. CONCLUSION It can be concluded that in the treatment of osseous defects around oral implants, both materials were equally effective bone substitute materials when used in combination with guided bone regeneration.

The Effect of UV Treatment on the Osteoconductive Capacity of Zirconia-Based Materials

Objective: Improvements in the bioactivity of zirconia implants for accelerated healing and reduced morbidity have been of continuing interest in the fields of dentistry and orthopedic surgery. The aim of the present study was to examine whether UV treatment increases the osteoconductivity of zirconia-based materials. Materials and Methods: Smooth and rough zirconia-based disks and cylindrical implants were treated with UV light for 15 min and subsequently placed in rat femurs. Surface characterization was performed using scanning electron microscopy (SEM), atomic force microscopy (AFM), X-ray photoelectron spectroscopy (XPS) and contact angle measurements. Results: In vivo histomorphometry revealed that the percentage of bone-implant contact and the amount of bone volume, formed around UV-treated implants, increased by 3–7-fold for smooth surfaces and by 1.4–1.7-fold for rough surfaces compared to non-treated specimens at Weeks 2 and 4 of healing, respectively. A biomechanical test showed that UV treatment accelerated the establishment of bone-zirconia integration and enhanced the strength of the bone-implant interface by two-fold. Additionally, surface characterization of the zirconia disks revealed that UV treatment decreased the amount of surface carbon and converted the hydrophilic status from hydrophobic to superhydrophilic. Conclusions: This study indicates that UV light pretreatment enhances the osteoconductive capacity of zirconia-based materials.