Consensus Report

Niklaus P. Lang Sren Jepsen

Members of Working Group: Ingemar Abrahamsson Tomas Albrektsson Ju rgen Becker Tord Berglundh Daniele Botticelli Donald M. Brunette Pedro Bullon Marco Esposito Ju rgen Geis-Gerstorfer John A. Jansen Sren Jepsen Niklaus P. Lang David Nisand Stefan Renvert Sren Schou Ann Wennerberg Library assistants: Adrian Bosch Caroline Sax

Implant surfaces and design (Working Group 4)

Authors afliations: Niklaus P. Lang, Faculty of Dentistry, Comprehensive Dental Care, The University of Hong Kong, Hong Kong Sren Jepsen, Universita tsklinikum, Department of Periodontology, Rheinische-Friedrich-WilhelmUniversita Bonn, Germany t,

Key words: animal model, bone-to-implant contact, decontamination, marginal bone level, oral implants, osseointegration, peri-implantitis, re-osseointegration, surface coatings, surface composition, surface roughness, surface topography Abstract Introduction: The remit of this working group (4) was to update existing knowledge on the effects of implant surface topography, composition and design on bone integration and reosseointegration. Material and methods: Based on ve narrative reviews that were performed following a dened search strategy, clinical implications as well as suggestions for further research have been formulated. Results: The results and conclusions of the review processes in the following papers together with the group consensus, clinical implications and directions for future research are presented: 1. Effects of titanium surface topography on bone integration. 2. Effects of implant surface coatings and composition on bone integration (two reviews). 3. Effects of different implant surfaces and designs on marginal bone level alterations. 4. Re-osseointegration onto previously contaminated implant surfaces.

Conict of interest and source of funding statement: The authors declare no conicts of interest. Group 4 participants declared that they had no conict of interest. Moreover, the 2nd Consensus Conference of the European Association of Osseointegration (EAO) has been nancially supported by an unrestricted educational grant from the EAO without other resources.

To cite this article: Lang NP, Jepsen S. Implant surfaces and design (Working Group 4). Clin. Oral Impl. Res. 20 (Suppl. 4), 2009; 228231. doi: 10.1111/j.1600-0501.2009.01771.x

The literature on the inuence of surface topography and composition on osseointegration and bone levels, as well as on re-osseointegration was evaluated in ve reviews. These were:

1.

2.

Effects of titanium surface topography on bone integration Wennerberg & Albrektsson (2009a, 2009b). Effects of implant surface coatings and composition on bone integration (two
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reviews) Junker, Dimakis, Thoneck & Jansen (2009). 3. Effects of different implant surfaces and designs on marginal bone level alterations Abrahamsson & Berglundh (2009). 4. Re-osseointegration onto previously contaminated implant surfaces Renvert, Polyzois & Maguire (2009). The group discussed all submitted reviews in detail and accepted the modied and amended reports as the basis for this consensus. Even though the format of the reviews differed, it was decided to accept them as prepared by the authors rather than adapting them to a uniform style. The discussion on surfaces and implant design encompasses four reviews, and care was taken to avoid overlapping content. Nevertheless, it was realized that changes in surface congurations may affect surface composition and vice versa. Hence, the consensus will be based on Wennerberg & Albrektsson (2009b), as well as Junker et al. (2009). While their reviews predominantly dealt with data from animal research and were only sparsely supported by human clinical trial data, the review by Abrahamsson & Berglundh (2009) focused on radiographic bone levels as the only clinical outcome of implant therapy with respect to various designs. The fth review (Renvert et al. 2009) emphasized the potential for re-osseointegration onto previously contaminated implant surfaces following various treatment protocols in animal studies.

some studies indicated that surface topography on a nanometer level inuenced bone integration; and the majority of published papers presented an inadequate description of surface characteristics or did not characterize them at all. The terms rough and smooth were used in different ways among the studies. Consequently, these terms will have to be specied by this consensus conference. The measuring and evaluation techniques applied to the characterization of surfaces need standardization. When evaluating implant surface topographical characteristics, height, spatial and hybrid parameters should be included. Moreover, these parameters should be provided separately for different scale ranges.

This review has yielded the conclusion that moderately rough and rough surfaces provided enhanced bone integration compared with smooth and minimally rough surfaces. The highest level of bone-to-implant contact was associated with moderately rough surfaces.

Effects of implant surface coatings and composition on bone integration

Ru diger Junker, Athanasios Dimakis, Maurice Thoneck, John Jansen A systematic search strategy for studies (with outcome variables related to bone-toimplant contact on the basis of histological analysis or mechanical stability testing) revealed 3212 publications of potential interest. Twenty-nine articles were eventually selected for inclusion in a rst narrative review, dealing with recently developed and marketed oral implants, while 32 out of 357 titles formed the basis for a second narrative review on experimental surface alterations.
Major conclusions from the paper

With respect to the confusion in terminology, the group accepted the denitions for surface roughness for oral implants specied by Albrektsson & Wennerberg (2004) and Wennerberg & Albrektsson (2009a, 2009b):    Smooth surfaces: Sa value o0.5 mm (e.g. polished abutment surface). Minimally rough surfaces: Sa value 0.5o1 mm (e.g. turned implants). Moderately rough surfaces: Sa value 1 o2 mm (e.g. most commonly used types). Rough surfaces: Sa value !2 mm (e.g. plasma-sprayed surfaces).

These reviews yielded the conclusions that:  Surface modications that alter the topography of the currently marketed implant types will inevitably also affect the surface composition. Hence, either surface characteristic may have contributed to the observed improved bone integration, and it may be difcult to attribute benecial effects to either topography or composition alone. s s For four (Osseospeed , SLActive , s s TiUnite and Nanotite ) of the ve most widely marketed implant types in Europe alterations in the surface composition improved bone integration compared with their predecessors. For s one implant type (Friadent Plus ) such s evidence is lacking. For two (TiUnite , s Nanotite ) of the ve implant types, conrmative human histological data are available. Implants with thin calcium phosphate coatings demonstrated improved bone integration compared with uncoated implants. However, conrmative human studies are lacking.

Effects of titanium surface topography on bone integration

Ann Wennerberg, Tomas Albrektsson After a systematic search strategy that revealed 1189 publications of potential interest, 100 articles were eventually selected for inclusion in a narrative review.

The absolute Sa (average height deviation) values used for the above denitions were determined by optical interferometry using Gaussian lters.
Groups consensus

Major conclusions from the paper

This review yielded that:  surface topography on a micrometer level inuenced bone integration;
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The group realized that commercial companies commonly change a number of surface parameters without adequately informing the profession. Furthermore, the measurement methods applied to the characterization of implant surfaces lack standardization and render comparison of outcomes among studies difcult. Proper characterization of implant surface topography should include height (such as Sa), spatial [such as the density of summits (Sds)] and hybrid [such as developed surface area (Sdr)] parameters.

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 Coating of implants with peptide sequences (e.g. RGD) has not consistently resulted in improved bone integration.  Coating of implants with growth factors (e.g. BMP-2) does not enhance bone integration. In fact, BMP-2 coatings may even reduce bone integration.
Groups consensus

est, 10 articles were eventually selected for inclusion in a narrative review.

Major conclusions from the paper

This review yielded the conclusions that:  Controlled prospective studies evaluating the effect of implant surface and designs on marginal bone level changes ! 3 years are few. There is no evidence that modied surfaces are superior to non-modied implant surfaces in marginal bone preservation. Comparisons between implants of different systems involve evaluations of combinations of surfaces and designs. No one implant system was found to be superior in marginal bone preservation. Implants with a conical and microthreaded marginal collar preserved marginal bone levels signicantly better than implants with a cylindrical and non-threaded marginal portion after 3 years in function (one study). The clinical relevance of this difference, however, remains unknown.

mance data from controlled studies with respect to marginal bone level preservation properly designed trials with appropriate power and duration of a minimum of 3 years are encouraged. Likewise, changes in implant surface and/or design such as the PlatformSwitching-concept must be evaluated in randomized-controlled trials.

Comparison of histological data (bone-toimplant contact ratios) between various studies is difcult due to differences in experimental protocols. Hence, only within-study comparisons are likely to yield meaningful conclusions. Recently developed implant types referred to above with alterations of surface composition and topography improved early bone integration.
Clinical implications (reviews 1, 2, 3)

Re-osseointegration onto previously contaminated implant surfaces

Stefan Renvert, Ioannis Polyzois, Rory Maguire After a systematic search strategy that revealed 381 publications of potential interest, 25 articles were eventually selected for inclusion in a narrative review.
Major conclusions from the paper

As bone integration is predominantly quantied by histological parameters, appropriate animal models are needed to test new developments in implant surface characteristics. Based on such data, some recently introduced implant surfaces have demonstrated enhanced bone integration compared with their predecessors. Hence, these modied surfaces can be recommended for testing in properly designed clinical trials. Present evidence does not indicate superiority or inferiority of any of the ve newly introduced implant surfaces mentioned above.
Suggestions for future research (reviews 1, 2, 3)

This review yielded the conclusions that, on the basis of animal studies, re-osseointegration  is possible to obtain on a previously contaminated implant surface; may occur in experimentally induced peri-implantitis defects following therapy; varied considerably within and between studies and is unpredictable; may be inuenced by implant surface characteristics; has not been achieved for the entire previously contaminated implant surface by any of the techniques tested.

Groups consensus

Experimental studies on new implant surfaces should include proper characterization of implant surfaces. Publication of detailed surface characteristics is pertinent for proper data interpretation. The clinical relevance of differences in bone integration demonstrated in experimental models remains to be determined in clinical trials.

Prospective controlled studies on the effects of different implant designs and surfaces demonstrate that marginal bone levels are generally well preserved following installation of the dental prosthesis (at least for xed restorations) on a variety of implant types (cumulative bone loss o0.5 mm after 3 years). The duration of these studies, however, does not in general exceed 3 years. Studies applying the Platform-Switching-concept to maintain marginal bone levels did not meet the inclusion criteria of this review mainly due to short follow-up. Present data do not reveal any clinically signicant superiority for any particular implant surface or design in maintaining marginal bone levels.
Clinical implications

  

Groups consensus

Effects of different implant surfaces and designs on marginal bone level alterations
Ingemar Abrahamsson, Tord Berglundh After a systematic search strategy that revealed 69 publications of potential inter-

Based on the types of implants evaluated in the present review, the preservation of marginal bone levels points to improvement compared with previously published criteria for success.
Implications for research

Because a great majority of the currently used implant types do not disclose perfor-

In the context of this review, re-osseointegration was analyzed as the formation of new bone onto a previously biolm-contaminated implant surface. The extent of re-osseointegration achieved in the various studies is difcult to assess, owing to the difculty to identify the extent of the contaminated surface. Different techniques have been used for decontamination of implant surfaces and may result in different efcacy of decontamination. Re-osseointegration may occur on implant surfaces following such procedures. While the studies reviewed indicate the necessity for open ap debridement of contaminated surfaces, other factors inuencing
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optimal outcomes are not known as yet. The group realized that the studies of reosseointegration in the present review were limited to the use of the experimental ligature-induced peri-implantitis model. The group also noted the difculty of performing clinical trials on this topic, because of the ethical problems posed in and collecting histological specimens in humans.
Clinical implications

commonly used clinical (probing, bone sounding and re-entry) and radiographical methods can only reveal bone ll, but not re-osseointegration.
Implications for research

Because detection of re-osseointegration requires histological assessment, other

Efforts should be made to accurately identify the extent of the contaminated implant surface before decontamination in future studies. The use of sequential uorochromic labelling of newly formed bone or the placement of reference markings on the implants as well as standardized reproducible radiographic documentation may be useful approaches in that respect.

Besides the importance of decontamination other factors relevant to re-osseointegration (e.g. surface structure, clot stability, adhesion, reconstructive procedures and pharmaceuticals) should be explored. Future studies should also be directed toward the identication of the role of bacterial contaminants in the process of re-osseointegration. Moreover, long-term clinical studies using surrogate variables are needed to demonstrate the effectiveness of procedures aiming to achieve re-osseointegration for the longevity of oral implants.

References
Abrahamsson, I. & Berglundh, T. (2009) Effects of different implant surfaces and designs on marginal bone level alterations. Clinical Oral Implants Research 20 (Suppl. 4): 207215. Albrektsson, T. & Wennerberg, A. (2004) Oral implant surfaces: part 1 review focusing on topographic and chemical properties of different surfaces and in vivo responses to them. International Journal of Prosthodontics 17: 536543. Junker, R., Dimakis, A., Thoneck, M. & Jansen, J. (2009) Effects of implant surface coatings and composition on bone integration. Clinical Oral Implants Research 20 (Suppl. 4): 185206. Renvert, S., Polyzois, J. & Maguire, R. (2009) Reosseointegration onto previously contaminated surfaces. Clinical Oral Implants Research 20 (Suppl. 4): 216227. Wennerberg, A. & Albrektsson, T. (2009a) On implant surfaces. Review. The International Journal of Oral & Maxillofacial Implants, in press. Wennerberg, A. & Albrektsson, T. (2009b) Effects of titanium surface topography on bone integration. Clinical Oral Implants Research 20 (Suppl. 4): 172184.

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