Journal of Clinical and Diagnostic Research.

2014 May, Vol-8(5): ZE07-ZE10 77

DOI: 10.7860/JCDR/2014/8764.4355
Review Article

Nanosurface The Future of Implants
Keywords: Dental implants, Osteogenesis, Osseointegration, Topography, Surface treatment, Nanotechnology

GK THAKRAL
1
, RASHMI THAKRAL
2
, NEERAJ SHARMA
3
, JYOTSANA SETH
4
, PALLAVI VASHISHT
5
INTRODUCTION
Dental implant is a prosthetic device made of alloplastic material
(s) implanted into the oral tissues beneath the mucosal and/or
periosteal layer, and on/or within the bone to provide retention and
support for a xed or removable dental prosthesis. Dental implants
are poised to achieve signicant growth as increasing populations
become aware of the long term benets associated with implant
supported restorations and prostheses. Economically viable and
technologically advanced dental implants are fast shifting from an
optional surgical procedure to a more acceptable and much sought-
after treatment option for missing teeth. Majority of dental implants
today are made of commercially pure (cp) titanium (1-4 grades) or
titanium alloys like Ti-6Al-4V. Factors that contribute to the ultimate
success of an implant include the physiological conditions of the
recipient, implant placement procedure, implant material, implant
design and implant surface.
Implant surface character is one implant design factor that affects
the rate and extent of osseointegration. Precisely how much of
implant surface directly contacts bone, how rapidly this bone accrual
occurs, and the mechanical nature of the bone/implant connection is
inuenced by the nature of the implant surface itself [1,2]. There is a
range of micron level surface topography that enhances the adherent
osteoblasts differentiation and extracellular matrix formation/
mineralization. It has been shown that nano-surface topography
effectively enhances extracellular matrix synthesis of adherent cells
and provides a faster and more reliable osseointegration response
as compared to conventional implant surface [3].
The impact of nanotechnology has begun to appear on the dental
implant surface designs in a signicant manner. The technology
involves increasing the complexity of the surface topography with
the addition of nanoscale molecules [Table/Fig-1] [4]. It is now an
established fact that surface topography plays a determinant role
in the osseointegration procedure. Titanium oxide nano-tubes have
shown an increased osseointegration compared to conventional
titanium surfaces. The surface holds promise for improving the
longevity of dental implants. Since osteoblasts readily adhere to this
novel surface, dental implants coated with TiO
2
nanotubes could
signicantly improve healing following dental implant surgery [Table/
Fig-2] [4]. Nanotechnology is bound to change the prospects and
longevity of dental implants within the next decade. The article
discusses distinct advantages of nanosurface modications over
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conventional implant surface encompassing various aspects of
dental implantology.
Nano Technology
Nanotechnology can be dened as the science and engineering
involved in the design, synthesis, characterization and application
of materials and devices whose smallest functional organization, in
at least one dimension is on the nanometer scale or one billionth of
a meter [5]. Nanotechnology therefore, involves materials that have
a nano-sized topography or are composed of nano-sized materials
ranging between 1 and 100 nm (109m) [6]. An evaluation of nano-
mechanical properties of the surrounding bone by nano-indentation
revealed that while both implants exhibited similar bone-to-implant
contact, the nano-indentation demonstrated that the tissue quality
ABSTRACT
Nanotechnology is a relatively newer eld of science that is nding enormous scope in the dental & medical science. Use of endosseous
dental implant surfaces having nano-scale topography is fast becoming part of modern implantology. The purpose of this review is to discuss
and understand the role of nanoscale surface modication of titanium materials for the purpose of improving various phases of implantology
including osseointegration. Nanotechnology equips bioengineers with newer ways of interacting with relevant biological processes. On the
other hand, the eld of nanotechnology provides means of understanding and achieving cell specic functions. An understanding of the
role of nano-topography leads to the signicant osseointegration modulations by nanoscale modication of the implants surface. Use of
nanotechnology to modify the topography of titanium endosseous implant can drastically improve cellular and tissue responses that may
benet osseointegration and dental implant procedures.
[Table/Fig-1]: A cluster of titanium dioxide nanotubes
[Table/Fig-2]: Bone cell anchoring to a surface of titanium dioxide
nanotubes
GK Thakral et al., Nanosurface The Future of Implants www.jcdr.net
Journal of Clinical and Diagnostic Research. 2014 May, Vol-8(5): ZE07-ZE10 88
One of the main concerns related to coating the implant surface
is the risk of coating detachment and toxicity of related debris.
An evaluation of relationship of particle size and cell viability and
proliferation compared to micron-particles revealed that nanoparticles
of titanium and alumina had less negative impact in cell viability and
proliferation as compared to conventional particles. There may be
an advantage to nanoscale modication of surfaces using solgel
coating methods. The quantum interaction of high electron density
at the atomic level can enforce high bond strength between the
substrate and nano-scale coating [3]. Studies reveal that the
addition of a nanometer-scale calcium phosphate treatment to a
dual acid-etched implant surface appeared to increase the extent of
bone development after 4 and 8 weeks of healing. It was observed
that this rapid accrual of bone at the implant surface expedites
the implant healing period and supports early loading protocols
[10]. Some of the commercial establishment manufacturing dental
implants have already started using the technology to modify their
products. Others are on a fast track to catch-up through the process
of research and development.
Nanotechnology and Cellular activity
Studies have highlighted the signicance of micron-scale
topography that compared various surface preparations of cp
titanium to an electro-polished surface negative control-group and a
hydroxyapatite coated positive control-group [11]. Their observation
that a micron-scale rough surface prepared by grit blasting and
subsequent acid etching was capable of rapid and increased bone
accumulation further strengthened an earlier report that a TiO
2
grit
blasted surface also supported more rapid and increased bone
accrual at cp titanium implants [12]. The study also pointed to a
signicant fact that the cp titanium surface could be modied to
enhance bone accumulation and suggested that cp titanium was
not only bioinert or biocompatible, but was also capable to
inuence cellular activity or tissue responses leading to better and
greater osteogenesis and thereby promoting better osseointegration.
Nanotopography seems to inuence cell interactions at surface
of the material being used. It also leads to changed cell behavior
when compared to conventional sized topography. The cellular
protein adsorption is altered by nanoscale modication of bulk
material. Depending on the nano-architecture, cell spreading may
be increased or decreased. The present undened mechanisms
indicate that cell proliferation appears to be enhanced by nanoscale
topography. Several investigators have shown that nanoscale
topography enhances osteoblast differentiation [13-15] [Table/
Fig-4] [15].
Protein/surface interactions (surface wettability) in
Nano-surface
Alteration in initial protein surface interaction is believed to control
osteoblast adhesion, a critical aspect of the osseointegration process
was signicantly enhanced around the hydroxyapatite (HA)-coated
implants [7]. Nanotechnology may involve one-dimensional concepts
(nanodots and nanowires) or the self-assembly of more complex
structures (nanotubes). Materials are also classied according to their
form and structure as nanostructures, nanocrystals, nanocoatings,
nanoparticles, and nanobers [6]. Nano-scale modication of the
titanium endosseous implant surface may lead to alteration in the
topography as well as chemistry of the surface. Therefore, the goal
of nanoscale modication should be a specic chemical modication
of cp titanium (grade 4 and 5). A distinct implication associated
with nanoscale manipulation of any material is that it also leads to
inherent chemical changes on the material surface. Albrektsson and
Wennerberg [8] divided implant surface quality into three categories:
i) mechanical properties, ii) topographic properties, and iii) physico-
chemical properties. They pointed out that these characteristics are
inter-related and a change in any of these groups affects the others
as well. This signicant observation is quite relevant to the study of
nano-surface modications of the endosseous cp titanium implant
surface.
METHODS OF IMPARTING NANO FEATURES
There are various methods to create nanoscale features at the
implant surface. These methods include: i) Physical methods,
like self-assembly of mono-layers, compaction of nano particles
and ion beam deposition; ii) Chemical methods, like acid etching,
peroxidation, alkali treatment (NaOH) and anodization; iii) Nano
particle deposition like sol-gel (colloidal particle deposition) and
discrete crystalline deposition; and iv) Lithography and contact
printing technique [Table/Fig-3] [9].
[Table/Fig-3]: Methods for creating nano-features on cp titanium
implants
Methods Characteristics
Self-assembly of monolayers The exposed functional end group could
be a molecule with different functions
(an osteoinductive or cell adhesive
molecule).
Compaction of nanoparticles Conserves the chemistry of the surface
among different topographies. Not
readily applied over implant surfaces.
Ion beam deposition Can impart nanofeatures to the surface
based on the material used.
Acid etching Combined with other methods
(sandblasting and/or peroxidation) can
impart nanofeatures to the surface and
remove contaminants.
Peroxidation Produces a titania gel layer. Both
chemical and topography changes are
imparted.
Alkali treatment (NaOH) Produces a sodium titanate gel layer
allowing hydroxyapatite deposition. Both
chemical and topographic changes are
imparted.
Anodization Can impart nanofeatures to the surface
creating a new oxide layer (based on the
material used).
Solgel (colloidal particle
adsorption)
Creates a thin-lm of controlled
chemical characteristics. Atomic-scale
interactions display strong physical
interactions
Discrete crystalline deposition Superimposes a nanoscale surface
topographical complexity on the surface
Lithography and contact
printing technique
Many different shapes and materials
can be applied over the surface.
Approaches are labor intensive and
require considerable development prior
to clinical translation and application on
implant surface. [Table/Fig-4]: Depiction of broad range of nano-scale topography
effects observed in cellular protein adsorption in bulk materials. Both
cell specicity and extent of cell adhesion are altered. Depending on the
nano-architecture cell spreading may be increased or decreased
www.jcdr.net GK Thakral et al., Nanosurface The Future of Implants
Journal of Clinical and Diagnostic Research. 2014 May, Vol-8(5): ZE07-ZE10 99
such as smooth muscle cells and chondrocytes have also reported
similar results [25]. All these observations may lead to some major
implications in specication of tissue response at bone and mucosal
surface of the dental implant/abutment assembly.
Differentiation
A rapid differentiation of adherent mesenchymal cells along the
osteoblast lineage is as signicant for the process of osseointegration
as supporting osteoblast-specic adhesion and adherent cellular
proliferation. Studies have revealed that alkaline phosphatase
synthesis and calcium mineral content increased in cell layers
formed on nanosized materials after 21 and 28 days [26, 27].
Nanosurface and bacterial proliferation
Another signicant nding with nanosurfaces has been found to be
a diminished bacterial adhesion and proliferation [28]. There was
a marked decrease in bacterial colonization on nanostructured
TiO
2
and ZnO irrespective of the fact that these surfaces promote
osteoblast adhesion and differentiation. These initial observations
may suggest the need for further exploration of the implant abutment
surface with focus on biolm accumulation and peri-implantitis.
Nanosurface and surface-reactivity
Endosseous implant surface reactivity may get inuenced by
nanosurface modications. Insignicant bone bonding occurs at
endosseous titanium implants, especially during the initial phases
of bone formation [29]. Nano-scale topographic modications tend
to change the chemical reactivity of materials and presence of bone
on implant surface during early stages [30]. Bone bonding seems to
be an advantage associated with titanium implants with nano-scale
surface modications.
Nano-surface implants in dentistry
Advantages of nanotopography on biomaterials have been
demonstrated as early as 1999 by Webster et al., [25]. The
nanotopography is linked to increased gene expression and is
indicative of faster osteoblastic differentiation. Various options are
available to impart nanoscale surface modications on implants
[Table/Fig-3]. Some of these have already been commercially
deployed and clinically used to enhance bone response. A positive
bone response on nanosurface biomaterials is already an established
fact. Up to what extent the nanotechnology and nanotopography
can be used to improve tissue and abutment interface bonding
remain to be seen. Commercially available current implants using
nanotopography may not have acquired the level of microstructure
desired for the ultimate goal of perfection in the area. Further
research and study in the eld may open up new horizons of a more
favorable use of titanium with nanosurface in implant dentistry. The
development may well make dental implants last for life in the mouth
with practically no failures.
CONCLUSION
Available research data may just be the tip of an iceberg on a
very complex issue of nano-surface modications in implants
and an improved bone response associated with it. Nanosurface
modication changes the chemical / biological reaction of the
implant in the mouth. This altered behavioral pattern has been linked
to a changed implant surface interaction with ions, biomolecules
and cells. This change in interactions, in turn favorably inuences
molecular and cellular activities leading to altered osseointegration.
It still needs to be explored whether this changed behavior can be
attributed to the nanosurface modications alone. The inherent
benets and limitations of nanostructure modications on implant
surface will become evident on further evaluation and clinical trials
after their long term use in human mouth.
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GK Thakral et al., Nanosurface The Future of Implants www.jcdr.net
Journal of Clinical and Diagnostic Research. 2014 May, Vol-8(5): ZE07-ZE10 10 10

PARTICULARS OF CONTRIBUTORS:
1. Professor, Department of Prosthodontics, SDCH, Rishikesh, India.
2. Professor, Department of Periodontology, SDCH, Rishikesh, India.
3. Senior Lecturer, Department of Prosthodontics, SDCH, Rishikesh, India.
4. Senior Lecturer, Department of Prosthodontics, SDCH, Rishikesh, India.
5. Senior Lecturer, Department of Prosthodontics, SDCH, Rishikesh, India.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:
Dr. GK Thakral,
Saket, Kinkraig Bridle Path, Kulri, Mussoorie-248179, India.
Phone: +91-98-972-60666, E-mail: [email protected]
FINANCIAL OR OTHER COMPETING INTERESTS: None.
Date of Submission: Feb 03, 2014
Date of Peer Review: Apr 05, 2014
Date of Acceptance: Apr 07, 2014
Date of Publishing: May 15, 2014
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