Bioactive implantology: what clinical feedback for calcium-nanostructured surfaces?

While implant survival rates now exceed 90%, biological and mechanical failures persist, often linked to imperfect tissue integration. New-generation surfaces, incorporating bioactive ions, aim to reach a new milestone. Among them, the nanostructured calcium titanate (CaTiO3) surface promises superior biocompatibility compared to conventional SLA or RBM surfaces by stimulating early osteoblastic activity. However, despite encouraging preclinical results, long-term clinical evidence in daily practice has until now remained limited to small cohorts or specific protocols.

This cross-sectional retrospective study, conducted over a follow-up period of 24 to 124 months, therefore aims to evaluate the cumulative survival rate (CSR) and the evolution of marginal bone loss (MBL) of 753 implants featuring this technology (AnyOne® and Mini® systems). By analyzing data from real-world clinical conditions — including guided bone regeneration and sinus lift procedures — the authors seek to verify the stability of the bone-implant interface over a decade. The central hypothesis rests on the ability of this surface modification to maintain stable and non-accelerated bone remodeling beyond the initial prosthetic restoration phase.

Study design and protocol

This retrospective cross-sectional study was conducted within a university periodontology department to evaluate the clinical performance of internal connection implants featuring a nanostructured surface incorporating calcium. The analysis covers an observation period ranging from August 2015 to December 2023.

The experimental protocol and sampling are based on the following criteria:

• Population: 753 implants placed in adult patients (≥ 18 years).
• Follow-up: A follow-up period ranging from 24 to 124 months after the placement of the final prosthesis.
• Inclusion criteria: Availability of radiographic data and a minimum of 12 months post-prosthetic follow-up (except in cases of failure before this period).
• Surgical procedures: Implant placement with, depending on clinical indications, guided bone regeneration (GBR) or sinus lift procedures (crestal or lateral approach).

Analyses and measurements

All surgeries were performed by a certified periodontologist, followed by a healing phase of 3 to 6 months before prosthetic restoration. For the practitioner, the assessment of tissue stability was based on two major indicators:

• Cumulative survival rate: Estimated via Kaplan-Meier analysis.
• Marginal Bone Loss (MBL): Measured radiographically between a fixed reference point and the most coronal bone-to-implant contact.

La progression de la MBL a été modélisée statistiquement par régression linéaire et par l'utilisation de splines cubiques naturelles pour identifier d'éventuelles accélérations du remodelage osseux au fil du temps.

Analysis of implant survival and bone stability

The study involved a total of 753 implants followed over a period ranging from 24 to 124 months. The results highlight an exceptional cumulative survival rate of 99.6%. Across the entire cohort, only three failures were documented, resulting from the following causes: a lack of osseointegration, an implant fracture, and advanced peri-implantitis.

Kinetics of marginal bone loss (MBL)

The evaluation of marginal bone loss (MBL) shows extremely limited progression over time. Linear regression analysis identified a slope of 0.016 mm per year. Furthermore, the use of natural cubic spline models confirmed a stable bone remodeling profile, with no signs of long-term accelerated resorption. This radiographic stability suggests effective maintenance of the bone-implant interface under conventional or early loading protocols.

Qualitative observations and biological characteristics

The evaluated surface technology is based on the formation of a nanostructured calcium titanate layer. According to the authors, this surface modification offers biological advantages compared to conventional SLA (sandblasted large-grit acid-etched) or RBM (resorbable blast media) surfaces:

• Enhanced biocompatibility: The calcium titanate layer prevents the retention of acid residues on the titanium.
• Osteoblastic activity: The release of calcium ions into the surrounding tissues promotes protein interactions and stimulates bone regeneration.
• Hierarchical topography: The surface features a micro-roughness on which nanometric-scale crystalline structures are superimposed, optimizing the bone-to-implant contact (BIC).

Analysis of results and clinical impact

The cumulative survival rate of 99.6% over a period of up to 124 months confirms the reliability of this technology in real-world conditions. What can be learned from the only three recorded failures? They illustrate the multifactorial nature of classic complications (fracture, loss of osseointegration, peri-implantitis), without calling into question the biocompatibility of the nanostructured surface incorporating calcium.

Marginal bone stability is the salient point here. Natural cubic spline analysis reveals stable bone remodeling, without any late acceleration. This inertia of bone loss, coupled with stable calcium incorporation (approximately 2 atomic %), suggests a bone-implant interface that is particularly resilient to functional stress.

Compared to literature data where survival rates generally exceed 90%, this study ranks at the high end of the predictability spectrum. It validates the use of these implants even during guided bone regeneration or sinus lift procedures. The limitations lie primarily in the retrospective design of the study, although the sample size (753 implants) and the 10-year follow-up provide a solid perspective for daily practice.

Summary of results

Sur 753 implants followed for up to 124 months, this retrospective study demonstrates a cumulative survival rate of 99.6%, with only three reported failures. Bone stability is remarkable: marginal bone loss (MBL) is limited to 0.016 mm/year, confirming stable and non-accelerated physiological remodeling over the long term.

In concrete terms, for the practitioner:

• Long-term predictability: The calcium-enriched nanostructured surface (XPEED) ensures exceptional clinical durability, even in heterogeneous daily practice conditions.
• Bone capital management: With almost zero bone loss after the initial phase (less than 0.2 mm over 10 years), this system secures your aesthetic and functional results over time.
• Reliability in complex sites: These data validate the system's efficacy even during concomitant GBR procedures or sinus lifts, without compromising the survival rate.

Technical lexicon of the study

Marginal Bone Loss (MBL): Quantification of the change in distance between a fixed reference point on the implant and the most coronal bone-to-implant contact between baseline and follow-up radiographs.

Osseointegration: Biological process consisting of the establishment of primary mechanical stability, followed by bone formation and remodeling at the implant interface.

Cumulative Survival Rate (CSR): Statistical estimation, calculated here using the Kaplan-Meier method, representing the probability that an implant remains in place over a given follow-up period.

Calcium-incorporated nanostructured surface: Surface modification creating a calcium titanate (CaTiO3) layer aimed at improving biocompatibility and promoting early osteoblastic activity.

Natural cubic spline modeling: Statistical approach used in this study to analyze bone loss progression patterns and confirm the stability of long-term remodeling.

Internal connection: Prosthetic interface characterized by a morse taper (11°) and an internal hexagon, designed to optimize the stability of the implant-abutment assembly.

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