Review
Osseointegration of metallic devices: Current trends based on implant hardware design

https://doi.org/10.1016/j.abb.2014.06.033Get rights and content

Highlights

  • Critical review of bone healing related to implant hardware.

  • Bone healing is remarkably affected by implant macrodesign and surgical drilling.

  • Multiple healing modes are described depending on hardware interplay with bone.

Abstract

Osseointegration of metallic devices has been one of the most successful treatments in rehabilitative dentistry and medicine over the past five decades. While highly successful, the quest for designing surgical instrumentation and associated implantable devices that hastens osseointegration has been perpetual and has often been approached as single variable preclinical investigations. The present manuscript presents how the interplay between surgical instrumentation and device macrogeometry not only plays a key role on both early and delayed stages of osseointegration, but may also be key in how efficient smaller length scale designing (at the micrometer and nanometer scale levels) may be in hastening early stages of osseointegration.

Introduction

From the greek osteon, bone, and the latin integrare, to make whole, osseointegration has been defined as the formation of a direct interface between an implant and bone without soft tissue interposition at the optical microscopy level [1], [2]. This phenomenon has affected the well-being of millions of patients over 50 plus years and has been the basis for multiple orthopedic and dental rehabilitation procedures. Common to modern metallic bone anchor devices utilized in orthopedics, craniomaxillofacial fixation, and in dental implants, the biomechanical competence of endosteal metallic devices is achieved through their surgical placement, appropriate bone healing, and subsequent remodeling of bone around the device [3], [4].

The healing of bone around metallic devices resulting in bone anchorage was first anecdotally described by Leventhal in 1951 [5], followed by a series of well-characterized scientific reports by the Swedish group led by Per-Ingvar Brånemark [2], [6]. At the time, prerequisites for osseointegration was considered to be both metallic device characteristics (biocompatibility, osseoconductivity, sterility, among others) and associated surgical placement technique, as well as patient related conditions (certain local and systemic) [7]. Five decades later, the constant evolution of implantable devices hardware and hardware ad-hocs (micrometer and nanometer scale design features) has allowed significant improvement in the quality and the rate of osseointegration. Such increased host-to-implant response has encouraged clinical treatment protocols that decrease or eliminate the time allowed between surgical placement and functional loading [8], [9], [10], [11].

Although osseointegration in most instances has been hastened by a multitude of individual implant design parameters, recent clinical and laboratory in vivo research suggest that we are still far from reaching implant systems (hereon defined as the implant hardware and ad-hocs altogether) that are atemporally stable [12], [13], [14], [15], [16]. An atemporally stable device is ideal since it would allow clinicians the full spectrum of treatment options while providing patients with adequate rehabilitation in the shortest treatment time [17].

The difficulty in designing atemporally stable implant systems primarily lies upon the historical lack of a hierarchical approach concerning the multivariable nature of bone healing around implants. For instance, while the key word osseointegration currently leads to over ten thousand preclinical and clinical scientific reports, its lack of sequential approach especially concerning implant system design does not allow biomedical engineers to retrospectively address the interaction of design parameters such as macrogeometry, microgeometry, nanogeometry, and surgical instrumentation in an objective fashion [3]. Thus, given the lack of baseline knowledge regarding the relative contribution of the main design variables on both early and delayed bone behavior around endosteal implants, implant design parameters have primarily been researched in a single variable fashion. Such approach, although economically viable and straightforward, may not necessarily capture the true efficiency of such variable in osseointegration since other design parameters are not evaluated in a systematic approach.

For instance, a MEDLINE literature search demonstrated that implant surface design investigations outnumbered all the other implant design parameter investigations by two orders of magnitude. While it is definitely desirable to design improved surfaces that will hasten osseointegration, its relative contribution when other parameters change (for instance, two different implant systems presenting distinct macrogeometry and surgical instrumentation and the same surface treatment) is seldom reported in the literature [18] and does not contribute in a step wise fashion to the development of an informed design platform for the improvement of implant systems.

It is unquestionable that osseointegration is determined by numerous factors such as surgical drilling protocols, drilling speed, implant macrogeometry, implant micrometer and nanometer scale engineering, and status of the host bone quality [7], [19], [20]. Discretely, some of the parameters have been investigated in numerous animal studies [21], [22], [15], [23], [24], [25] and combined effects of different design parameters intentionally considered in multifactorial study designs [18] have not been extensively investigated.

It is of great importance to assemble the available scientific evidence in an attempt to identify the role of each parameter that affects osseointegration. Thus, the objective of this manuscript was to provide in a structured manner a first step towards how implant design features potentially influence osseointegration. We have based the starting point of this critical review in how implant hardware (bulk device design and related surgical instrumentation dimensions) influences short- and long-term ossoeintegration. Then, the effect of the here defined implant hardware ad-hocs (micrometer and nanometer design alterations) is discussed in light of how these features can more efficiently be incorporated in implant systems’ design as a function of initial implant hardware design.

Section snippets

The effect of implant hardware in bone healing pathway and long-term osseointegration

It is a general consensus that properly cleaned and sterilized biocompatible titanium-based alloys (primarily comprised by commercially pure Ti and Ti-6Al-4V) devices will be incorporated within the bone tissue after installation [3]. The scientific literature has extensively described that after some time following implantation, an intimate contact between bone and endosteal device will biomechanically stabilize these bone anchors that are utilized for multiple purposes [26], [27], [28], [29].

Acknowledgments

Both authors (PC and RJ) equally contributed to the content of this manuscript. Both authors would like to express their immense gratitude to all collaborators and students involved in all research projects leading to this compilation.

References (101)

  • R. Adell et al.

    Int. J. Oral Surg.

    (1981)
  • S. Yeniyol et al.

    Oral Surg. Oral Med. Oral Pathol. Oral Radiol.

    (2013)
  • P.G. Coelho et al.

    J. Mech. Behav. Biomed. Mater.

    (2011)
  • A. Halldin et al.

    Bone

    (2011)
  • F. Javed et al.

    J. Dent.

    (2010)
  • A. Chamay et al.

    J. Biomech.

    (1972)
  • V. Bentolila et al.

    Bone

    (1998)
  • D.B. Burr et al.

    J. Biomech.

    (1998)
  • T.M. Zizic et al.

    Am. J. Med.

    (1985)
  • R. Jimbo et al.

    Biomaterials

    (2007)
  • P.G. Coelho et al.

    Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod.

    (2010)
  • M. Suzuki et al.

    J. Oral Maxillofac. Surg.

    (2010)
  • F.E. Campos et al.

    J. Oral Maxillofac. Surg.

    (2012)
  • P.G. Coelho et al.

    J. Oral Maxillofac. Surg.

    (2013)
  • G. Giro et al.

    J. Oral Maxillofac. Surg.

    (2011)
  • M. Sharawy et al.

    J. Oral Maxillofac. Surg.

    (2002)
  • M.B. Abouzgia et al.

    Int. J. Oral. Maxillofac. Surg.

    (1996)
  • A. Eriksson et al.

    Int. J. Oral Surg.

    (1982)
  • D.B. Burr et al.

    Bone

    (1996)
  • J. Klein-Nulend et al.

    Pathol. Biol.

    (2005)
  • C.N. Elias et al.

    J. Mech. Behav. Biomed. Mater.

    (2012)
  • V. Bucci-Sabattini et al.

    Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod.

    (2010)
  • P.G. Coelho et al.

    Bone

    (2014)
  • D.W. Hamilton et al.

    Biomaterials

    (2007)
  • D. Yang et al.

    Biomaterials

    (2013)
  • T. Albrektsson et al.

    Eur. Spine J.

    (2001)
  • P.I. Branemark et al.

    Supplementum

    (1977)
  • P.G. Coelho et al.

    Appl. Biomater.

    (2009)
  • P.G. Coelho et al.

    Clin. Implant Dent. Relat. Res.

    (2010)
  • G.S. Leventhal

    J. Bone Joint Surg. Am.

    (1951)
  • T. Albrektsson et al.

    Acta Orthop. Scand.

    (1981)
  • H. De Bruyn et al.

    Clin. Oral Implants Res.

    (2008)
  • S. Shigehara et al.

    J. Oral Implantol.

    (2014)
  • S. Vervaeke et al.

    Int. J. Oral Maxillofac. Implants

    (2013)
  • S. Vandeweghe et al.

    Int. J. Prosthod.

    (2013)
  • H. Browaeys et al.

    Clin. Implant Dent. Relat. Res.

    (2014)
  • D.A. Deporter et al.

    Int. J. Period. Restor. Dent.

    (2012)
  • R. Jimbo et al.

    Implant Dent.

    (2013)
  • R. Jimbo et al.

    Clin. Oral Implants Res.

    (2013)
  • R. Jimbo et al.

    Int. J. Oral Maxillofac. Surg.

    (2014)
  • T.J. Oh et al.

    J. Periodontol.

    (2002)
  • R. Jimbo et al.

    J. Dent. Res.

    (2012)
  • R. Chowdhary et al.

    Implant Dent.

    (2013)
  • G. Giro et al.

    Int. J. Biomater.

    (2013)
  • R. Jimbo et al.

    J. Periodontol.

    (2013)
  • C.M. Aegerter et al.

    PLoS ONE

    (2013)
  • J.E. Ellingsen et al.

    Int. J. Oral Maxillofac. Implants

    (2004)
  • P.G. Coelho et al.

    Appl. Biomater.

    (2014)
  • R. Chowdhary et al.

    Clin. Implant Dent. Relat. Res.

    (2013)
  • J. Gottlow et al.

    Clin. Implant Dent. Relat. Res.

    (2012)
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