Correlation between primary stability and bone healing of surface treated titanium implants in the femoral epiphyses of rabbits

The aim of this study was to analyse the stability and osseointegration of surface treated titanium implants in rabbit femurs. The implants were either grit-blasted and acid-etched (BE Group), calcium phosphate (CaP) coated by using the electrodeposition technique, or had bioactive molecules incorporated into the CaP coatings: either cyclic adenosine monophosphate (cAMP) or dexamethasone (Dex). Twenty four cylindrical titanium implants (n = 6/group) were inserted bilaterally into the femoral epiphyses of New Zealand White, female, adult rabbits for 4 weeks. Implant stability was measured by resonance frequency analysis (RFA) the day of implantation and 4 weeks later, and correlated to histomorphometric parameters, bone implant contact (BIC) and bone growth around the implants (BS/TS 0.5 mm). The BIC values for the four groups were not significantly different. That said, histology indicated that the CaP coatings improved bone growth around the implants. The incorporation of bioactive molecules (cAMP and Dex) into the CaP coatings did not improve bone growth compared to the BE group. Implant stability quotients (ISQ) increased in each group after 4 weeks of healing but were not significantly different between the groups. A good correlation was observed between ISQ and BS/TS 0.5 mm indicating that RFA is a non-invasive method that can be used to assess the osseointegration of implants. In conclusion, the CaP coating enhanced bone formation around the implants, which was correlated to stability measured by resonance frequency analysis. Furthers studies need to be conducted in order to explore the benefits of incorporating bioactive molecules into the coatings for peri-implant bone healing.     

Bioactive TiOB‐Coating on Titanium Alloy Implants Enhances Osseointegration in a Rat Model

The surface properties of titanium alloy implants for improved osseointegration in orthopaedic and dental surgery have been modified by many technologies. Hydroxyapatite coatings with a facultative integration of growth factors deposited by plasma spraying showed improved osseointegration. Our approach in order to enhance osseointegration was carried out by a surface modification method of titanium alloy implants called plasma chemical oxidation (PCO). PCO is an electrochemical procedure that converts the nm‐thin natural occurring titanium‐oxide layer on an implant to a 5 µm thick ceramic coating (TiOB‐surface). Bioactive TiOB‐surfaces have a porous microstructure and were loaded with calcium and phosphorous, while bioinert TiOB‐surfaces with less calcium and phosphorous loadings are smooth. A rat tibial model with bilateral placement of titanium alloy implants was employed to analyze the bone response to TiOB‐surfaces in vivo. 64 rats were randomly assigned to four groups of implants: (i) pure titanium alloy (control), ii) titanium alloy, type III anodization, (iii) bioinert TiOB‐surface, and (iv) bioactive TiOB‐surface. Mechanical fixation was evaluated by pull out tests at 3 and 8 weeks. The bioactive TiOB‐surface showed significantly increased shear strength at 8 weeks compared to all other groups.     

Mechanical characterization of anti-infectious,anti-allergic,and bioactive coatings on orthopedic implant surfaces

In total joint replacement much effort has been made to reduce implant loosening. We investigated different implant coatings (copper integrated titanium dioxide (TiO₂–Cu), titanium nitride (TiN), plasma polymerized allylamine (PPAAm), and calcium phosphate (CaP)) regarding the adhesion strength and wear resistance. Standardized scratch and adhesive tests were applied. Abrasive wear was measured with artificial bone and bone cement using a special testing machine. All tested coatings have higher bonding strengths than the 22 N/mm² required for medical implant surface coatings by ASTM standard 4711-F. Using bone cement, wear testing revealed higher wear rates in most cases. Polished surfaces reduce the amount of wear, whereas rough surfaces highly increase the wear rate due to three-body wear, especially ceramic surfaces. In general, the application of bone cement in conjunction with modified implant surfaces can lead to an increase in wear rate.     

Diatom‐Inspired Silica Nanostructure Coatings with Controllable Microroughness Using an Engineered Mussel Protein Glue to Accelerate Bone Growth on Titanium‐Based Implants

Silica nanoparticles (SiNPs) have been utilized to construct bioactive nanostructures comprising surface topographic features and bioactivity that enhances the activity of bone cells onto titanium‐based implants. However, there have been no previous attempts to create microrough surfaces based on SiNP nanostructures even though microroughness is established as a characteristic that provides beneficial effects in improving the biomechanical interlocking of titanium implants. Herein, a protein‐based SiNP coating is proposed as an osteopromotive surface functionalization approach to create microroughness on titanium implant surfaces. A bioengineered recombinant mussel adhesive protein fused with a silica‐precipitating R5 peptide (R5‐MAP) enables direct control of the microroughness of the surface through the multilayer assembly of SiNP nanostructures under mild conditions. The assembled SiNP nanostructure significantly enhances the in vitro osteogenic cellular behaviors of preosteoblasts in a roughness‐dependent manner and promotes the in vivo bone tissue formation on a titanium implant within a calvarial defect site. Thus, the R5‐MAP‐based SiNP nanostructure assembly could be practically applied to accelerate bone‐tissue growth to improve the stability and prolong the lifetime of medical implantable devices.     

Hyrdoxyapatite Coatings on Titanium

Some ceramics, including calcium phosphates and certain glasses and glass‐ceramics, form an important class of bioactive materials that are used extensively in repair and reconstruction of diseased or damaged parts of the musculoskeletal system. The similarity between synthetic hydroxyapatite (HA) (Ca₁₀(PO₄)₆(OH)₂) and the mineral phase of bone and tooth made HA one of the earliest materials to be used to impart osteoconductive (bone‐bonding) properties to the surface of biocompatible, metallic implants. HA and other calcium phosphate surfaces are used primarily to cause early stabilization of the implant in the surrounding bone through the formation of a direct bond and enhanced bone apposition. Although bioactive ceramics are used in several compositions and forms, the focus here is on the use of HA coatings in metallic implants. The coatings made by commercially available plasma‐spray and other techniques are compared to those made recently by surface‐mediated biomimetic routes.     

Promotion of osteogenic differentiation of stem cells and increase of bone-bonding ability in vivo using urease-treated titanium coated with calcium phosphate and gelatin

Abstract

Because of its excellent biocompatibility and low allergenicity, titanium has been widely used for bone replacement and tissue engineering. To produce a desirable composite with enhanced bone response and mechanical strength, in this study bioactive calcium phosphate (CaP) and gelatin composites were coated onto titanium (Ti) via a novel urease technique. The cellular responses to the CaP/gelatin/Ti (CaP/gel/Ti) and bone bonding ability were evaluated with proliferation and osteogenic differentiation of mesenchymal stem cells (MSCs) on CaP/gel/Ti and CaP/Ti in vitro. The results showed that the optical density values, alkaline phosphatase expression and genes expression of MSCs on CaP/gel/Ti were similar to those on CaP/Ti, yet significantly higher than those on pure Ti (p < 0.05). CaP/gel/Ti and CaP/Ti rods (2 mm in diameter, 10 mm in length) were also implanted into femoral shaft of rabbits and pure Ti rods served as control (n = 10). Histological examination, scanning electron microscopy (SEM) and energy dispersive spectroscopy (EDS) measurements were performed at 4 and 8 weeks after the operation. The histological and SEM observations demonstrated clearly that more new bone formed on the surface of CaP/gel/Ti than in the other two groups at each time point. The CaP/gel/Ti bonded to the surrounding bone directly with no intervening soft tissue layer. An interfacial layer, containing Ti, Ca and P, was found to form at the interface between bone and the implant on all three groups by EDS analysis. However, the content of Ca, P in the surface of CaP/gel/Ti implants was more than in the other two groups at each time point. The CaP/gel/Ti modified by the urease method was not only beneficial for MSCs proliferation and osteogenic differentiation, but also favorable for bone bonding ability on Ti implants in vivo, suggesting that Ti functionalized with CaP and gelatin might have a great potential in clinical joint replacement or dental implants.     

NaOH treatment of vacuum-plasma-sprayed titanium on carbon fibre-reinforced poly(etheretherketone)

Carbon fibre-reinforced polyetheretherketone (CF-PEEK) substrates were coated with titanium by vacuum-plasma-spraying and chemically treated in 10 M sodium hydroxide (NaOH) solution. After NaOH treatment, the specimens were immersed in simulated body fluid (SBF) containing ions in concentrations similar to those of human blood plasma. Scanning electron microscopy, energy-dispersive X-ray analysis and diffuse reflectance Fourier transformed–infrared spectroscopy were used to analyse the NaOH-treated VPS-Ti surface and the calcium phosphate layer formed during immersion in SBF. It was observed that a carbonate-containing calcium phosphate layer was formed on the NaOH-treated VPS-Ti surface during immersion in SBF, whereas no calcium phosphate precipitation occurred on the untreated surfaces. It is therefore concluded that vacuum-plasma-spraying with titanium and subsequent chemical modification in 10 M NaOH solution at 60°C for 2 h is a suitable method for the preparation of bioactive coatings for bone ongrowth on CF-PEEK.     

Osteoblast proliferation on neat and apatite-like calcium phosphate-coated titanium foam scaffolds

The biocompatibility and the load-bearing ability of lightweight titanium made it possible to be used as a biomaterial, especially in hip revision and fixation surgery. It was initially shown that sand-blasted or surface-roughened titanium implants had an improved bone-bonding ability over the bioinert metallic surfaces. Plasma-spraying of a phase mixture of loosely-attached calcium phosphates on titanium implants further improved their in vivo bone-bonding ability. However, stoichiometric calcium hydroxyapatite ceramic of high crystallinity is known to have poor in vivo resorbability, and is shy of taking part in bone remodeling and of being resorbed by the osteoclasts. Supersaturated calcium phosphate (CaP) solutions, such as synthetic body fluids (SBF), on the other hand, are able to form “carbonated, hydrophilic and apatite-like” CaP nanoaggregates on titanium surfaces. A Tris-buffered SBF solution with an HCO₃⁻ concentration of 27 mM was used in this study. Neat, NaOH-etched, and SBF-coated (biomimetic coating) titanium foams were compared with in vitro cell culture experiments by using rat osteoblasts. SBF-coated foams were found to yield the highest protein concentration at the end of the in vitro culture tests. Such biomimetic coatings were easily formed on flat strips, springs, or 3D foams of titanium, without any geometric constraints. The coated titanium springs and foams were characterized by using XRD, SEM, and FTIR.     

Assesment of the Biological Activity of Chemically Immobilized rhBMP‐2 on Titanium surfaces in vivo

Previously it has been shown that recombinant human bone morphogenetic protein (rhBMP‐2) can be chemically immobilized by “anchor molecules” on titanium surfaces for serving as a drug delivery device. This opened the question of whether the insoluble immobilized rhBMP‐2 retained its activity in comparison to the same amount of soluble rhBMP‐2 included with the implant samples. Electropolished titanium miniplates (10 × 6 × 0.8 mm) were “surface‐enhanced” by a novel treatment with chromosulfuric acid and then coated with a total amount of 150–200 ng rhBMP‐2 prepared by recombinant technology. Periosteal flaps (7 × 20 mm) were detached and isolated from the anterior surface of the tibiae of adult rabbits and wrapped around the titanium sample plates which were then implanted in the M. gastrocnemius. In the first experimental group various controls without rhBMP‐2 were combined (n = 12). In the second experimental group implants with chemically immobilized rhBMP‐2 (n = 8) were compared with implants to which non‐immobilized soluble rhBMP‐2 was added (n = 8). Animals were sacrificed after 28 days and a quantitative evaluation was carried out by means of serial sections. Untreated control plates showed bone formation in 2/12 implants, rhBMP‐2 coated implants in 6/8 and implants with free rhBMP‐2 administered subperiostally in 8/8 cases. In the case of rhBMP‐2 coated implants the induced bone had direct contact to the implant in all cases while in the group with free administered rhBMP‐2 the bone had no contact to the implant in two cases, but was separated by a fibrous capsule. Bone volume, bone surface area, and trabecular number displayed no difference between the two rhBMP‐2‐groups. However, in the biocoated group a tendency to an increase in the bone‐implant contact area was evident. No differences in osteoid area, osteoid perimeter and eroded perimeter were detected. We conclude that in the case of non‐immobilized rhBMP‐2 there is the danger for formation of fibrous tissue between the implant and the newly formed bone and in addition the generation of ectopic bone at inappropriate places. In contrast chemically immobilized rhBMP‐2 does not have these drawbacks and at the same time displays a biological activity on surfaces similar to that of soluble rhBMP‐2 demonstrating that biomaterial surfaces can be tailored for a selective and specific interaction with the target tissue.     

Influence of microstructure and chemical composition of sputter deposited TiO<Subscript>2</Subscript> thin films on in vitro bioactivity

Functionalisation of biomedical implants via surface modifications for tailored tissue response is a growing field of research. Crystalline TiO₂ has been proven to be a bone bioactive, non-resorbable material. In contact with body fluids a hydroxyapaptite (HA) layer forms on its surface facilitating the bone contact. Thus, the path of improving biomedical implants via deposition of crystalline TiO₂ on the surface is interesting to follow. In this study we have evaluated the influence of microstructure and chemical composition of sputter deposited titanium oxide thin films on the in vitro bioactivity. We find that both substrate bias, topography and the flow ratio of the gases used during sputtering affect the HA layer formed on the films after immersion in simulated body fluid at 37°C. A random distribution of anatase and rutile crystals, formed at negative substrate bias and low Ar to O₂ gas flow ratios, are shown to favor the growth of flat HA crystal structures whereas higher flow ratios and positive substrate bias induced growth of more spherical HA structures. These findings should provide valuable information when optimizing the bioactivity of titanium oxide coatings as well as for tailoring process parameters for sputtered-based production of bioactive titanium oxide implant surfaces.     

A histological and histomorphometrical evaluation of screw-type calciumphosphate (Ca-P) coated implants; an in vivo experiment in maxillary cancellous bone of goats

The bone response to different calcium phosphate (Ca-P) coated implants was evaluated in a goat animal model. Two types of plasma spray coatings were applied to a commercially pure titanium (cpTi) tapered, conical screw-design implant (BioComp^®); hydroxyapatite (HA-PS) and a dual coating, consisting of FA and HA (FA/HA-PS). In addition an amorphous RF magnetron sputter coating (Ca-P-a) and uncoated implants were investigated. Forty-eight implants were inserted in the maxilla of 12 adult female goats. After implantation periods of 3 and 6 months, the bone implant interface was evaluated histologically and histomorphometrically. After both implantation periods all plasma spray coated implants were maintained. On the other hand three Ca-P-a and two cpTi implants were lost. Histological examination revealed a better bone response to both plasma spray coated implants. Histomorphometrical evaluation confirmed this finding. At 3 and 6 months significantly higher percentages of bone contact (p<0.001, ANOVA) were measured for both plasma spray coated implants than for the cpTi and Ca-P-a implants, while no significant difference (p<0.05) existed between both implantation periods. Degradation of both plasma spray coatings was observed. Supported by the results, it is concluded that, although Ca-P coatings can improve the performance of dental implants, the presence of a Ca-P coating is not the only important factor for bone healing around implants placed in low density trabecular bone.     

Dextran‐based coating system for the immobilization of cell adhesion promoting molecules on titanium surfaces

Immobilization of adhesive peptides interacting with cellular integrin receptors onto metallic implant surfaces represents a promising approach to improve osseointegration of implants into the surrounding tissue. In the present study, a functional dextran‐based coating system consisting of an amino titanate adhesion promoter with dendritic structure and a carboxymethyl dextran was established to bind an RGD‐containing adhesive peptide via a selective coupling methodology onto titanium surfaces. The three‐step reaction procedure was characterized by X‐ray photoelectron spectroscopy. In cell adhesion experiments it could be demonstrated that dextran coatings containing immobilized RGD promote attachment and spreading of fibroblast and pre‐osteoblastic cells compared to native as well as CMD‐coated titanium surfaces without RGD. The direct attachment of the RGD sequence to the metal surface via the amino titanate adhesion promoter did not increase pre‐osteoblastic cell spreading, whereas coupling of RGD to the polymeric carboxy­methyl dextran layer slightly enhanced spreading of the cells.     

Electrospray deposition of nanohydroxyapatite coatings: A strategy to mimic bone apatite mineral

The biological performance of orthopaedic and oral metallic implants can be enhanced significantly by the application of bioactive coatings. In this work, a cost-efficient alternative to the traditional technique to produce a hydroxyapatite (HA) coating with a nanostructured feature onto a metallic implant surface at room temperature via electrospray deposition, is presented. To evaluate the bioactive capacity of these nanoHA (nHA) coatings in vitro, an acellular simulated body fluid soaking experiment and a human osteoblast (HOB) cell culture work were conducted. Under these physiological conditions, the accelerated apatite precipitation process occurred on the nHA-coated titanium surfaces as compared to the uncoated titanium surfaces. HOB cells developed mature cytoskeletons with distinct evidence of actin stress fibres and vinculin adhesion plaques, on these nHA coatings. Hence, this deposition technique holds great potential in producing high quality nHA coatings for biomedical applications.     

Bioactive glass and glass-ceramic-coated hip endoprosthesis: experimental study in rabbit

Co–Cr–Mo endoprostheses with a dual bioactive glass (BG) coating and titanium implants coated with a bioactive glass-ceramic (BGC) were studied under lead-bearing conditions in the rabbit hip. The dual BG coating contained an inner layer of high durability and an outer bioactive layer. Each type of coating improved the stabilization of prosthesis during the experiment period of 8 weeks compared to non-coated control implants. EDXA analysis confirmed the ability of BG and BGC coatings to bond chemically to bone. The BGC coating on titanium alloy proved superior to the dual BG coating on Co–Cr–Mo prosthesis with regard to bone formation on the surface of the implant. The bioactive top layer of the dual BG coating showed resorption, especially in the areas without direct bone contact. This is explained by partial crystallization of the glass during firing. Thermal discrepancy between BGC coating and titanium core caused cracking of the coating, which remains a major obstacle to its use as a bioactive coating.     

Adjusting the chlorhexidine content of calcium phosphate coatings by electrochemically assisted co-deposition from aqueous solutions

Currently, a number of strategies to create either biologically active or antimicrobial surfaces of biomaterials are being developed and commercially applied. However, for metallic implants in contact with bone, both osteomyelitis and a fast and stable long-term fixation of implants are challenges to be overcome, especially in the case of bad bone quality. Therefore, the present work aims to develop compound coatings of calcium phosphate phases (CPP) and chlorhexidine (CHD) that combine bioactive properties with a strategy to prevent initial bacterial adhesion and thus offer a possible solution to the two major problems of implant surgery mentioned above. Using electrochemically assisted deposition of CPP on samples of Ti6Al4V together with the pH-dependent solubility of CHD, the preparation of coatings with a wide range of CHD concentrations (150 ng/cm² to 65 μ g/cm²) from electrolytes with CHD concentrations between 50 and 200 μ M was possible, thus allowing the adaptation of implant surface properties to different surgical and patient situations. Detailed SEM and FTIR analysis showed that coatings are formed by a co-deposition process of both phases and that CHD interacts with the deposition and transformation of CPP in the coating. For high CHD contents, coatings consist of CHD crystals coated by nano-crystalline hydroxyapatite.     

Production of thin calcium phosphate coatings from glass source materials

Calcium phosphate (CaP) coatings, from 40 000 to 200 000 nm thick, on titanium and titanium alloy substrates, were produced using radio frequency (RF) sputtering. Such coatings on dental implants have the potential for improving initial bone ingrowth rates. The success of these coatings may allow the movement from two stage implant systems to single stage implant systems, significantly reducing the time required for healing and fixture placement. Glass source materials were developed for the RF sputtering facility and the resultant coatings were characterized and compared to coatings sputtered from a conventional plasma sprayed hydroxyapatite (HA) source material. The coatings were characterized according to their chemistry, crystalline orientation, and residual strain.     

Modulation of human dermal microvascular endothelial cell and human gingival fibroblast behavior by micropatterned silica coating surfaces for zirconia dental implant applications

Dental ceramic implants have shown superior esthetic behavior and the absence of induced allergic disorders when compared to titanium implants. Zirconia may become a potential candidate to be used as an alternative to titanium dental implants if surface modifications are introduced. In this work, bioactive micropatterned silica coatings were produced on zirconia substrates, using a combined methodology of sol–gel processing and soft lithography. The aim of the work was to compare the in vitro behavior of human gingival fibroblasts (HGFs) and human dermal microvascular endothelial cells (HDMECs) on three types of silica-coated zirconia surfaces: flat and micropatterned (with pillars and with parallel grooves). Our results showed that cells had a higher metabolic activity (HGF, HDMEC) and increased gene expression levels of fibroblast-specific protein-1 (FSP-1) and collagen type I (COL I) on surfaces with pillars. Nevertheless, parallel grooved surfaces were able to guide cell growth. Even capillary tube-like networks of HDMEC were oriented according to the surface geometry. Zirconia and silica with different topographies have shown to be blood compatible and silica coating reduced bacteria adhesion. All together, the results indicated that microstructured bioactive coating seems to be an efficient strategy to improve soft tissue integration on zirconia implants, protecting implants from peri-implant inflammation and improving long-term implant stabilization. This new approach of micropatterned silica coating on zirconia substrates can generate promising novel dental implants, with surfaces that provide physical cues to guide cells and enhance their behavior.     

Cellular investigations on electrochemically deposited calcium phosphate composites

Electrochemically deposited calcium phosphate (CaP) coatings are fast resorbable and existent only during the first period of osseointegration. In the present study, composite coatings with varying solubility (hydroxyapatite (HA), brushite with less HA and monetite (M) with less HA) were prepared and the influence of the degradation and the reprecipitation of CaP on osteoblastic cells were investigated. On the brushite composite coating a new precipitated, finely structured CaP phase was observed during immersion in cell culture medium with or without osteoblastic cells. The surface morphology of monetite and HA coatings were entirely unmodified under the same conditions. So it could be assumed that electrochemically deposited brushite with less HA acts as a precursor for new precipitated CaP. On this surface osteoblastic cells revealed a well-spread morphology with pronounced actin cytoskeleton and demonstrated good proliferation behaviour. Thus we suggest that brushite seems to be especially suitable for coating of implants as a matrix for nucleation and growth of new bone.     

How Degradation of Calcium Phosphate Bone Substitute Materials is influenced by Phase Composition and Porosity

The chemical composition of calcium phosphate (CaP) materials for the regenerative therapy of large bone defects is similar to that of bone. Additionally, calcium phosphates show an excellent biocompatibility. Besides the support of defect healing calcium phosphate implants should be completely degraded within an adequate time period to be replaced by newly formed bone. Although degradation of CaP‐implants occurs mainly by dissolution of the material, it is important to characterize the osteoclastic resorption as well, which is involved in native bone remodeling. The degradation of bone substitutes made of calcium phosphate ceramics is influenced by various parameters, such as defect size and localization, the general health situation, and age of the patient, but also material properties are important. Especially, the calcium phosphate composition is crucial for the degradation behavior of a calcium phosphate material. Additionally, at the cellular level the micro‐ and macroporosity, including interconnecting pores, influences both, the dissolution and the osteoclastic resorption. In our study, three different calcium phosphate materials (hydroxyapatite, tricalcium phosphate, and a biphasic calcium phosphate) and two different geometries (dense 2D samples and porous 3D scaffolds) are compared regarding their dissolution and resorption behavior. The results show, that the dissolution of CaP‐ceramics, as examined by the incubation in a degradation solution, depends mainly on the calcium phosphate phase but also on the porosity of the implant. Regarding the resorption, cell proliferation and differentiation of a monocytic cell line as well as the formation of resorption lacunas are analyzed. Cell proliferation is comparable on all phase compositions. Cell differentiation and resorption, however, are influenced by the calcium phosphate phase composition and by the implant porosity as well. By understanding these two mechanisms of degradation, bone substitute materials and, as a result, the bone regeneration of large bone defects using CaP‐ceramics can be improved.     

Biological behavior of sol-gel coated dental implants

The biocompatibility of dental implants coated with titania/hydroxyapatite (HA) and titania/bioactive glass (BG) composites obtained via sol-gel process was investigated using an in vitro and in vivo model. A device for the in vitro testing of screw-shaped dental implants was developed, in order to well compare the two experimental models studying the behavior of human MG63 osteoblast-like cells seeded onto a particular geometry. The expression of some biochemical parameters of osteoblastic phenotype (alkaline phosphatase specific activity, collagen and osteocalcin production) and some indications on cells morphology obtained by scanning electron microscopy were evaluated. The in vitro and in vivo models were compared after implants insertion in rabbit tibia and femur. The removal torque and histomorphometric parameters (percentage of bone in contact with implant surface and the amount of bone inside the threaded area) were examined. A good agreement was found between the in vitro and in vivo models. These experiments showed better performances of HA and BG sol-gel coated dental implants with respect to uncoated titanium; in particular, it was found that in vitro the HA coating stimulates osteoblastic cells in producing higher level of ALP and collagen, whereas in vivo this surface modification resulted in a higher removal torque and a larger bone-implant contact area. This behavior could be ascribed to the morphology and the chemical composition of the implants with rough and bioactive surfaces.