JAD)A
RESEARCH R E P O R T S
Synthetic materials fo r surgical implant demces have evolved from the early metallic systems to a
variety of material combinations and composites. Current biomaterial and biomechanical proper­
ties provide relatively optimal stable bone and soft tissue interfaces and simplified restorative treat­
ments. Further improvements in existing systems require a continuation of the multidisciplinary
approach to laboratory, experimental animal, and human clinical research.
Dental implant biomaterials
Jack E. Lem ons, PhD
aturally o c c u rrin g m in erals a n d
N m e ta ls su c h as g e m s to n e s a n d
gold w ere first used fo r surgical
im p la n t a n d to o th r o o t r e p la c e m e n t
devices.1 Relative purity and strength con­
sid e ra tio n s eventually caused these sub­
stances to be rep la ce d by alloys o f iron,
cobalt, o r tita n iu m .2 In 1937, polym eric
b io m a te ria ls w ere in itia te d w ith p o ly ­
m eth y lm ethacrylate (acrylic resin ), with
m ost high m olecular w eight biopolym ers
in tro d u c ed since 1950.s T he bioceram ics
based on metallic oxides were introduced
in the 1960s, and the carbon-based dental
biom aterials were provided in the 1970s.4
D u rin g th e 1960s, th e r e la tio n s h i p
between the inertness o f surgical im plants
a n d th e associated tissue resp o n se s was
em phasized.2 H igh purity, fired ceram ics
an d carbons were investigated to provide
chem ical and biochem ical environm ental
stabilities. In th e 1970s, surgical m eth o d ­
ologies th a t p ro d u ce d m inim al m echani­
cal, chemical, and therm al traum a to the
tissue w ere in troduced to the dental pro­
fession. T he relative interactions between
th e available b io m a te ria ls an d carefully
p re p a re d tissue sites su b seq u en tly w ere
elu cid ated.5-6 C oncepts for tissue integra­
tion followed, an d m u ltice n te r investiga­
tio n s show ed th a t stag ed tre a tm e n ts to
716 ■ JADA, Vol. 121, December 1990
p ro v id e p e rio d s fo r p r o te c te d h e a lin g
co u ld be directly c o rre la te d w ith tissue
interface conditions.7
In the 1980s, new an d m odified biom a­
terials were in tro d u ced an d were specifi­
cally designed, constituted, and fabricated
for anticipated tissue interface responses,5
resulting in m echanically and chem ically
anisotropic biomaterials. Force transfer is
intended to be within the norm al limits of
the tissues, an d b iom aterial surfaces are
provided to bond chemically along the tis­
sue c o n ta c t zo n es.8 E x p erie n ce suggests
further im provem ents in both biom aterial
an d b io m e c h a n ic a l p r o p e r tie s will e n ­
hance clinical longevities a n d an ex p an ­
sion to broader patient populations in the
1990s.
Table 1 ■ Summary of synthetic biomaterials for dental implants.
Metals an d alloys Ceram ics an d carbon
Ti an d Ti-Ai-V a i 2o ,
Co-Cr-Mo C a,„(P 0 4) 6 (O H )2 HA
Fe-Cr-Ni Ca3( P 0 4)j TCP
C and C-Si
T itanium (Ti), alu m in u m (Al), vanadium (V), cobalt (Co), ch ro m iu m (C r), m olybdenum (M o), iro n (Fe), nickel (Ni),
a lu m in u m o x id e (A120 3), h y d ro x y la p a tite (H A ), tric alc iu m p h o s p h a te (T C P), c a rb o n (C ), silico n (S i), polym ethyl­
m ethacrylate (PMMA), polytetrafluoroethylene (PTFE), polyethylene (PE), polysulfone (PSF).
Standards and classifications
Standards and recom m ended practices are
available for m ost dental an d m edical bio­
m a te ria ls. T h e A m e ric a n D e n ta l A sso­
ciation originally in itiated sta n d ard s for
dental materials with am algam alloy.9 T he
A m e ric a n S o cie ty f o r T e s tin g a n d
M aterials (ASTM) co m m ittee F-4 in tro ­
duced surgical im plant standards an d rec­
o m m e n d ed p ractices.10 T h e in fo rm atio n
c o n ta in e d w ith in th e su rg ic a l im p la n t
m aterial standards norm ally includes the
chem ical analysis, m echanical properties,
and surface finish.1» Com pliance of m anu­
facturers has partly provided a controlled
an d re lia b le so u rce o f b io m a te ria ls fo r
im p la n t devices. In a d d itio n , new sub-
Polymers
PMMA, PTFE, PE, PSF
 R E S E A R C H R E P O R T S

cobalt-based alloy (Co-Cr-Mo). C urrently,

Table 2 ■ Classification of biomaterials using elastic moduli (lowest to highest
some are being m ade from cast titanium .
magnitudes). A n u m b e r o f the im p lan t designs now
in co rp o rate coatings o f calcium phosphate
M odulus o f elasticity ratio Electrical o r th erm al ceram ics, carb o n s, o r polym ers th a t are
B iom aterial (b io m ate ria l/b o n e ) * co n d u cto r C olor
p la c e d o n th e s u r fa c e s o f th e tis s u e
Polymers 0.01 -0.5x No Cream-white
im p la n t a re a s .14 T h ese co m b in atio n s o r
PE, PTFE to am ber com posites are in ten d ed to optim ize both
PTFE, PMMA, PSF b io m a te ria l a n d b io m e ch a n ic al in te ra c ­
Ceram ics 0.5 - 5.0x No W hite tions with the tissues.
C aP 04
C arbons l.Ox Yes Black
C a n d C-Si Classification by properties
M etals an d alloys
Ti an d Ti-Al-V 5 .0 - 5.7x Yes Metallic T he various biom aterials can also be classi­
Fe-Cr-Ni 8.0x
fied an d com pared using th e basic physi­
Co-Cr-Mo ll.O x
Ceram ics
cal, m echanical, chem ical, an d biological
a i 2o 3 20. Ox No Cream-white p ro p ertie s o f th e synthetic substances.510
To provide this type o f classification within
* The modulus of elasticity of compact bone was taken to be 3 x 106 psi for these ratios.
categories, th e biom aterials are from the
lowest to h ig h est m ag n itu d es o f specific
Table 3 ■ Classification of biomaterials using mechanical tensile strengths (lowest p ro p erties. For exam ple, com parisons of
to highest magnitudes). m aterial elastic m oduli or tensile strengths
w ould result in d ifferen t rankings. These
Tensile strength Ductility (% elongadon) properties are used for m aking differential
Biomaterial ratio (b io m ate ria l/b o n e )* ra d o (b io m ate ria l/b o n e ) f
d ec isio n s, o r fo r e x p la n a tio n s o f tissue
Polymers 0.1 -0.5x 1 - 300x responses. These relative classifications by
Ceram ics p roperties are provided in tabular form in
C aP 04 0.1 - 2.0x 0 Tables 2, 3, and 4.
Carbons T h e elastic m oduli, strengths, an d duc­
C a n d C-Si 1.0 - 5.0x 0
tilities are used as m aterial p roperty con­
Ceram ics
a i 2o 3 2.0 - 5.0x 0 siderations for the design, fabrication, and
Metals a n d alloys 1.5 - 7.0x 8 - 30x p r o s th o d o n tic r e s to r a tio n o f im p la n t
d evices.15 M oduli are d irectly associated
* The tensile strength of compact bone was taken as 2 x 104 psi for these ratios.
f The tensile elongation to fracture for compact bone was taken as 1% for these ratios. with m icroscopic elastic strains along tis­
sue interfaces. T he m acroscopic stress and
strain relationships are influenced m ost by
the design’s size an d shape. Designs m ust
stances can b e evaluated using sta n d ard ­ Implant designs co rp o rate configurations th at are specific
ized b io m a te ria ls as a c o n tro l. D e m o n ­ n o t o nly to th e b io m a te ria l b u t also to
s tr a tio n s o f “e s s e n tia lly s im ila r ” o r V arious synthetic substances co n stitu ted an ato m ical, surgical, tech n ical, an d oral
“relativ ely im p ro v e d ” b io m a te ria l is an a n d fa b ric a te d fo r d e n ta l im p la n ts are considerations. Relative cost, sterilization
i m p o r ta n t c o n s id e r a tio n r e la te d to a sum m arized in Table 1. Biom aterials are and resterilization, and availability o f com ­
rapidly evolving discipline as im plant den­ categorized by basic m aterial type with the p le m e n ta r y su rg ic a l in s tr u m e n ts a n d
tistry.11 m o s t c o m m o n ly u s e d b io m a te r ia ls restorative intraoral m aterials are also fac­
Biomaterials are classified according to included.12 T hese biom aterials are used in tors.
th eir m aterial properties, interactions with a wide variety o f d en tal im p lan t designs.
tissues, o r prim ary area o f surgical applica­ T h e d e sig n s in c lu d e th o se p la c e d in to
tion, for exam ple, the dental, orthopedic, b o n e (e n d o s s e o u s ), ro o t fo rm s, b lad es Table 4 ■ Classification of biomateri­
o r cardiovascular fields.5 In categories, the ( p la t e s ) , tr a n s o s te a ls , s ta p le s , ra m u s als using chemical inertness (lowest to
biom aterials are listed as metals and alloys, frames, and endodontic stabilizers.13 These highest magnitudes).
ceramics an d carbons, polymers, an d com ­ have been fabricated from m ost of the bio­
B iom aterial Relative ranking*
binations an d com posites o f these m aterial m aterials listed in Table 1, although spe­
types.10 T h e biom aterials with resistance to cific lim ita tio n s exist. For ex am p le, the Ceram ics
ch em ical o r b io lo g ica l d e g ra d a tio n are ra m u s fra m e tra n s o s s e o u s , a n d sta b le TCP Biodegradable
called in e rt o r passive, w hile th o se th a t designs are m ade from metallic biom ateri­ HA Bioactive
als (Ti, Ti-6A1-4V, Co-Cr-Mo, or Fe-Cr-Ni), Polymers PMMA to PTFE
interact slightly are surface active o r bioac­
M etals and alloys Fe to Ti alloys
tive.5 Biomaterials in ten d ed to be dissolved while the endo d o n tic stabilizers are mostly In e rt
Ceram ics a n d carbons
o r to b e a b s o r b e d in vivo a r e c a lle d m anufactured from titanium (Ti) and alu­ A12O s, C, C-Si
biodegradable o r resorbable. Various bio­ m inum oxide ceram ic (A120 3). T he other
* T h ese relative rankings are d e p e n d e n t o n the specific
m aterials can be reclassified into different m ajo r im p la n t design categ o ry in clu d es b io m a te r ia l p r o d u c t a n d th e c lin ic a l a p p lic a tio n . F o r
c a te g o rie s, d e p e n d in g o n th e im p la n t th e devices placed o n to b o n e u n d e r the exam ple, PMMA is p rese n ted as th e b o n e c e m e n t p ro d u c t
application o r th e basic m aterial p ro p e r­ periosteum (the subperiosteals). Most sub- u sed in o rth o p e d ic su rg ery a n d th e biochem ical inertness
o f PTFE exceeds som e o f the m etallic m aterials.
ties. periosteals have been fabricated from cast

JADA, Vol. 121, December 1990 ■ 717

 R E S E A R C H R E P O R T S
S tre n g th s are m a x im iz e d to p ro v id e
resistance to cyclic-induced (fatigue) frac­
tures; and higher ductilities are critical to
the b en ding o f abutm ents for parallelism
o r to provide the best fit for an available
anatom ical site. Metals are strong and duc­
tile, a n d th e ceram ic s a n d c a rb o n s are
n o n d u c tile (b rittle ). T h e in e rt ceram ics
an d metals have high elastic m oduli, and
the polymers have high ductilities but low
elastic m oduli. In g en eral, th e variety of
p ro p e rtie s d ic ta te s th e a p p lic a tio n , fo r
ex a m p le , p o ly m e rs fo r so ft tissues a n d
metals o r ceramics for hard tissues.
C lassification by chem ical in e rtn ess is
com plicated because the relative listings
Implant restorative treatments in dentistry provide a signifi­
cant opportunity to better understand the roles of biomaterial
and biomechanical properties and their relationship to bio-
compatibility criteria for all types of surgical implants.
change d e p e n d in g on in te rfa ce bonding
c o n d itio n (b o n e o r fib ro u s tissu e), th e
specific tim e o f ev alu atio n , o r th e local
en v iro n m ental co n d itio n s (fluid, soft tis­
sue, o r b o n e ). C o n d itio n s o f in terfacial
m o tio n (slip) o r local in fectio n (altered
pH ) would change the category. Generally,
th e high ceram ics an d carb o n s are m ost
inert, the metals are interm ediate, and the
polym ers a re m o st subject to interfacial
w ear o r the leach in g o f low er m olecular
w eight o r plasticizer constituents.2-5
These various properties have been cor­
re la te d w ith b o th b io m a te ria l- an d b io ­
m ech an ical-based co m p atib ility criteria.
E la s tic m o d u li s im ila r to th e tis su e
replaced, high strength and ductility, and
chem ical inertn ess have b ee n co rrelated
with biocom patibility profiles. T h ere are
ex cep tio n s to th e se g en eralizatio n s, b u t
these criteria have been broadly applied to
m aterial and design selections for im plant
devices.
Tissue interfaces
Biocom patibility profiles have been con­
sidered in term s o f the elem ents and the
forces transferred across biomaterial-to-tis-
su e i n t e r f a c e s . 13-15 T h e p h y sic a l a n d
m echanical properties o f biom aterials are
directly c o m p a re d w ith biophysical and
biom echanical requirem ents fo r function.
S eparately, th e c h e m ic al a n d electrical
p r o p e r tie s a re c o m p a r e d w ith th e b i­
chemical interaction along the tissue inter­
718 ■ JADA, Vol. 121, D ecember 1990
faces. Elem ents and electrochem ical fields
are known to directly influence tissue reac­
tio n pathw ay s.14 T h u s, b io c o m p atib ility
profiles provide o p p o rtu n itie s to investi­
gate and com pare the phenom enological
d a ta g e n e ra te d from lab o rato ry , la b o ra­
tory animal, an d h um an clinical investiga­
tions.
Surface and bulk properties
S y n th etic c o m p o u n d s su c h as m e tallic
o x id e s , c a lc iu m p h o s p h a te c e ra m ic s,
glasses, an d glass ceram ics have d em o n ­
stra te d d ire c t b o n d in g to b o n e .414 T his
b o n d in g , w h ich h a s te n s ile a n d sh e a r
strength m agnitudes w ithin th e range o f
chem ical bo n d in g , su p p o rts an interface
c o n d itio n th a t co u ld strongly in flu e n ce
fu n ctio n al fo rce tran sfe r co n d itio n s.16 If
these b io m a te ria l su rfaces are c o n tam i­
n a t e d w ith d ilu te im p u r itie s , th e n
b io d ég rad atio n p ro d u cts could adversely
influ en ce th e local tissue responses an d
in terfacial b o n d in g . Also, w hen th e sub­
strate biodegrades, th e reaction products
could result in adverse tissue responses.17
Design and force transfer
E n h a n c e m e n t o f b io m a te ria l-to -tis s u e
interfaces, through com puter-based finite
elem ent m odeling an d analysis, and com­
p u te r-a s s is te d d e s ig n (FEM , FEA, a n d
CAD) should provide significant improve­
m en ts.18 However, basic selection criteria
can be applied to any new design concept.
Force transfer along interfaces loaded in
m echanical shear strain could be signifi­
cantly influenced by biomaterial-to-tissue
bonding. The p roduction o f localized n o n ­
slip o r b o n d e d in terfaces th a t w ould be
s ta b le in vivo c o u ld r e s u lt in a lte r e d
im plant design concepts. This type of sta­
ble bonding may be possible with biom ate­
rials that are currently within clinical trials.
T he tissue interface provides a healing
stage u n d e r p ro te c te d (iso lated ) co n d i­
tio n s .7 T h e p r o c e d u re o f n o t ap p ly in g
fu n ctio n al lo ad in g fo r e x ten d e d periods
after surgical p lacem en t affords tim e for
establishing biom aterial-to-tissue in te rfa­
cial relationships w ithout im posed force or
m o tio n . T h e sta g in g o f tre a tm e n ts an d
protected healing provide an optim al situ­
ation for b o n e an d soft tissue bonding to
synthetic biom aterial surfaces. In contrast,
if a stable soft tissue (p seu d o lig am e n t)
were m ost functional over the long-term ,
early m echanical loading (one-stage) treat­
m ent is probably indicated.
Device retrieval analyses
Analyses of devices eventually retrieved for
p sy ch o lo g ical, p ro s th e tic , o r tra u m a tic
conditions provided clinical histories from
which com parisons o f biomaterial-to-tissue
interfaces an d the actual devices could be
m ade.13-19 T itanium oxide (Tix Oy) surfaces
f o r o n e -sta g e e n d o s s e o u s b la d e s have
d e m o n s tra te d fib ro u s tissue in te rfa ce s.
T his sam e su rface o x id e fo r ro o t form s
and blades, restored after two-stage or pro­
tected healing restorative treatm ents, have
d em o n strate d ad jac en t b o n e (osteointe-
g ra tio n ). T h e c h ro m iu m oxide surfaces
(cobalt- o r iron-based alloys) for one-stage
subperiosteals, blades, an d ram us fram es
have shown fibrous tissue interfacial con­
ditions. In contrast, th e calcium phosphate
and alum inum oxide ceram ic surfaces of
ro o t form s an d the coated subperiosteals
and blades have shown direct bone inter­
faces fo r two-stage o r p ro te c te d h ealing
restorative treatm ents.
C o m p a riso n s o f sim ila r d e sig n s a n d
m aterials with an d w ith o u t surface coat­
ings may c o n trib u te significant in fo rm a­
tio n from fu tu re retrie v al analyses. For
ex am p le, m any o f th e available designs
with metallic oxide surfaces are now being
coated with calcium p hosphate ceramics.
T he constancy o f design and variability of
surface chem istry could provide answers
to questions ab o u t interfacial bo n d in g to
bone, electrical conductivity, elasticity, and
elem ental com positions.
Summary
Im plant restorative treatm ents in dentistry
provide a significant opportunity to b etter
u n d e rsta n d th e ro les o f biom aterial an d
biom echanical p ro p ertie s an d th eir rela­
tionship to biocom patibility criteria for all
types o f surgical im plants. Various biom a­
terials and designs are being used for long­
te rm tr e a t m e n t m o d a litie s . E x istin g
science an d technology support the need
f o r m e c h a n ic a lly a n d c h e m ic a lly
a n iso tro p ic su b stan ce s to re p la c e fu n c ­
tional, lo ad -b earin g tissues an d afford a
m ost prom ising fu tu re for dental im plant
r e s e a r c h a n d d e v e lo p m e n t. M u ltid is-

ciplinary analyses should provide the basis
for quantitative classifications of interfacial
phenom ena, and, thereby, the directly
associated clinical longevities.
---------------------- J!* O A -----------------------
Dr. Lemons is professor and chairman, department
o f b iom ateria ls, U niversity o f A labam a S c h o o l o f
Dentistry, Birmingham 35294.
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JADA,VoL 121, December 1990 ■ 719