Titanium alloys identified as excellent materials in biomedical applications. The biocompatibility greatly depends on properties and morphology of biomaterial surfaces. Surface modification and texturing are effective on osseo integrations and increase biocompatibility. In biomedical engineering, sand blasting and acid etching (SLA) process on titanium alloys surface performed to increase texturing of surface. It has to be noted that surface texture and roughness characterization are important in biomedical performances. In this research, vanadium free titanium alloy (Ti13Zr13Nb) has been studied in terms of surface texturing and roughness variation. Rod shape materials were cut using diamond wheel precision cutter and were polished by automatic machine in three stages. Sandblasting process was performed with alumina particles of 150 μm mean size by a laboratory shot-blasting machine, at 2.5MPa-pressure for 30 s at10 mm nozzle distance. Kroll’s etchant (3ml HF+6ml HNO3+100 ml H2O) and Sulfuric acid (H2SO4 66%) solutions were used to etch substrates. Two etching conditions as low and high conditions were conducted for both solutions. Low condition would be defined as low time and temperature (10s, 25oC) and also high condition is defined as high time and temperature (30s, 60oC). Surface texture was evaluated by Field Emission Scanning Electron Microscope (FESEM) and the mean surface roughness Ra (nm) measured by a contact mode profilometer.Cut and polished surfaces exhibited the poor capacity to osseo integration and cell growth. The sand blasting process affected on Ti13Zr13Nb surfaces by creating peaks and valleys with sharp edges, texture form, active for corrosion and poor in biocompatibility. These surfaces significantly changed using Kroll’s etchant solution in high condition to smooth surface. After SLA, at high condition of sulfuric acid and low condition of Kroll’s etchant, observed fine textured surface including fine pits, less sharp edge and desirable morphology for cell proliferation and osseo integration. The surface roughness fluctuated significantly after cutting, polishing and sand blasting process. Both acid solutions caused a reduction in surface roughness. The Kroll’s etchant at 30s, 60oC caused Ra reduction significantly by 290 nm. This present research, demonstrates the importance of specific acid and condition selection in terms of surface texturing and roughness reduction. These reflections are important to achieve desire signal in terms of rapid osseo integration, biocompatibility and short therapeutic time.

This study reports on the development of picosecond laser system to titanium alloy surface treatment applications. In the picosecond laser-scanning system, that is based on the fiber-optics laser source and integrated with a designed optics / optical machine design and control technology of scanning system. To analyze the laser material interaction, the laser fluence, pulse repetition frequency of laser source, position of focused points, scan speed and pulse duration were adjusted. After laser surface treatment, the surface roughness and surface morphologies of treated surface were evaluated by using a field emission scanning electron microscope. Moreover, the contact angle measurement was used to analyze the hydrophilic and hydrophobic properties of the treatment surface with micro/ nanostructures.

This study investigated the effects of anodization-cyclic precalcification-heat (APH) treatment on the bonding ability of Ca-P coating to the parent metal and osseointegration of Ti-6Al-7Nb implants. Eighteen Ti-6Al-7Nb discs, 9 untreated and 9 APH-treated, were cultured with osteoblast cells in vitro, and the cellular differentiation ability was assayed at 1, 2, and 3 weeks. For in vivo testing, 28 Ti-6Al-7Nb implants (14 implants of each group) were inserted to rat tibias, and after each 4 and 6 weeks of implantation, bone bonding, and osseointegration were evaluated through removal torque and histological analysis. Osteoblast-culturing showed twice as much of the alkaline phosphatase activity on the treated surface at 3 weeks than on the untreated surface (p < 0.05). The treated implants exhibited higher removal torque values than the untreated ones (15.5 vs. 1.8 Ncm at 4 weeks and 19.7 vs. 2.6 Ncm at 6 weeks, p < 0.05). Moreover, the excellent bonding quality of coats was confirmed by the existence of cohesive fractures on the surface of removed APH implants (field emission scanning electron microscopy and histological observation). Within the limits of this study, it can be concluded that the APH treatment significantly enhanced osseointegration of the Ti-6Al-7Nb implant, with the stable bonding between the coating and the implant surface.

The urge to replace missing teeth dates back to the origin of medicine. Along history, organic materials, metals, alloys, polymers, glasses, and carbon were used to substitute teeth, but only in the past thirty years was a truly scientific approach implemented introducing the concept of osseointegration. This review aims at recapitulating the materials of choice, the surface modifications, and the most updated research advancements in the field of oral osseointegrated implants. As the accepted clinical standard, commercially pure Titanium, Ti–6Al–4V and, to a lesser extent, zirconium dioxide will be described from the perspective of physical, mechanical, and biological features, together with in vitro, in vivo, and clinical assessment of biocompatibility. Outlines of the researches that are presently conducted in an endeavor to limit the drawbacks of the current technology are also provided. Novel Titanium alloys such as Ti–Zr and Ti–20Nb–10Zr–5Ta, Zr61Ti2Cu25Al12, innovative production methods for non metallic materials as well as ceramic composites will be considered as possible promising candidates for future dental implants

The surface structure, especially the roughness, has a significant influence on numerous parameters, such as friction and wear, and therefore estimates the quality of technical systems. In the last decades, a broad variety of surface roughness measurement methods were developed. A destructive measurement procedure or the lack of feasibility of online monitoring are the crucial drawbacks of most of these methods. This article proposes a new non-contact method for measuring the surface roughness that is straightforward to implement and easy to extend to online monitoring processes. The key element is a liquid-crystal-based spatial light modulator, integrated in an interferometric setup. By varying the imprinted phase of the modulator, a correlation between the imprinted phase and the fringe visibility of an interferogram is measured, and the surface roughness can be derived. This paper presents the theoretical approach of the method and first simulation and experimental results for a set of surface roughnesses. The experimental results are compared with values obtained by an atomic force microscope and a stylus profiler.

The primary stability is an important factor in achieving a predictable dental implant treatment. Therefore, in order to reach longitudinal success, it is necessary to achieve and to maintain the primary stability as basic pre-requirement [1,2]. The primary stability can be considered the first stabilization that is obtained immediately after implant insertion [3]. Thus, the insertion torque during implant installation may be an indicative of implant survival [4]. However, the initial stability may not be a factor that assures the osseiointegration, because it can be influenced by bone properties, surgical techniques and implant design [3]. Consequently, the measurement of the insertion torque could not be the only parameter to predict the osseointegration success rate. Thus, there are studies that evaluate the implants surface treatment to investigate what may influence the prognosis [5-7]. After the initial wound healing, some features determine the secondary stability as the biological response to the surgical trauma, the conditions of the wound healing and the material of the implant per se [8]. Therefore, there is an increase in the contact in the bone-implant interface [8]. At the same time, the presence of osteocytes in the bone remodeling in the bone-implant interface as well as the amount of sclerostin, osteoprotegerin and RANKL influence this remodeling [9]. Thus, when a traumatic surgery is performed or load is applied before the right time can lead to a tissue injury, resulting in bone resorption [9]. The design of the dental implant has evolved to improve its mechanical, functional and esthetic efficiency [3-8]. Nonetheless, the events that occur in the bone-implant interface are still in need of further investigation [6,7]. Having that in mind, studies involving implants with different surface treatments and the understanding the effects of different torques are important to a more comprehensive knowledge of this surfaces and the interaction with the bone tissue [1-8]. Thus, the aim of this study was to analyze the influence of the insertion torque applied to titanium dental implants with different surface treatment (acid and fluoride) on the bone adherence to the implant surface after removal from rabbit tibia by scanning electronic microscopy (SEM) after 40 days of implantation.

The high success rates for the dental rehabilitation of patients with endosseous implants have resulted from many research approaches with the aim of enhancing and accelerating bone anchorage to the implant, thereby providing optimal support for the intraoral prosthetic devices. This revolutionary breakthrough has first evolved from the research efforts of the Branemark group in the late 1960s by pioneering the insertion of machined screw-type commercially pure titanium (cpTi) implants with minimum surgical trauma and a consolidation period for the healing of the bone (Albrektsson et al., 1981; Branemark et al., 1969). This first endosseous titanium implant was produced with an industrial turning process, which led to surfaces with minimally rough topographies at the micron level. The bone bonding ability, termed as “osseointegration” by Branemark et al. (1977), of this machined implant was mainly the result of the proper surgical technique providing macrostability to the implant and the biocompatible nature of the bulk titanium. In the past three decades, much has been learned about the concept of osseointegration and significant improvements on the design and surface of implants were done to eliminate the important challenges of the implant dentistry. Osseointegration was first defined as a direct contact between living bone and the surface of a load-carrying implant at the histological level (Branemark, 1983) and, in clinical terms, as a biomechanical phenomenon whereby clinically asymptomatic rigid fixation of the implant is achieved and maintained in bone during functional loading (Albrektsson & Johansson, 2001). Typically, an implant is considered to be osseointegrated when there is an absence of movement between the implant and bone under normal conditions of loading following a defined healing period. This clinical state is the result of direct bone apposition to an implant surface without formation of a poorly vascularised collagenous capsule, termed as fibrous encapsulation. Although the concept of “osseointegration” was first put forth to define the connection between bone and titanium, it has been shown that bone anchorage can also be achieved with the use of other materials without an adverse tissue reaction (Wenz et al., 2008). Thus, osseointegration is currently accepted as a general term for boneimplant surface contact. However, the quality of the host bone/foreign implant interface is

The combined requirements imposed by the enormous scale and overall complexity of designing new implants or complete organ regeneration are well beyond the reach of present technology in many dimensions, including nanoscale, as we do not yet have the basic knowledge required to achieve these goals. The need for a synthetic implant to address multiple physical and biological factors imposes tremendous constraints on the choice of suitable materials. There is a strong belief that nanoscale materials will produce a new generation of implant materials with high efficiency, low cost, and high volume. The nanoscale in materials processing is truly a new frontier. Metallic dental implants have been successfully used for decades but they have serious shortcomings related to their osseointegration and the fact that their mechanical properties do not match those of bone. This paper reviews recent advances in the fabrication of novel coatings and nanopatterning of dental implants. It also provides a general summary of the state of the art in dental implant science and describes possible advantages of nanotechnology for further improvements. The ultimate goal is to produce materials and therapies that will bring state-of-the-art technology to the bedside and improve quality of life and current standards of care.

Texturization of surfaces is usually advantageous in biomaterial engineering. However, the details of the textured surfaces can be more determining on cell adhesion and proliferation, rather than their roughness degree. Titanium is extensively used as a dental implant material in the human body. In this paper, the effect of four surface treatments on commercially pure titanium has been evaluated. These treatments were polishing (pTi); hydrofluoric acid (HF) etching (eTi); Al2O3 blasting (bTi); Al2O3 blasting + HF etching (beTi). Roughness and fractal dimensions were obtained from atomic force microscopy. Wettability was measured using water sessile drops. Morphology and surface chemical composition were analyzed with scanning electron microscopy and energy dispersive X-ray (EDX). MG-63 cell cultures were performed at different times (180 min, 24 h, 48 h, 72 h). Lowest roughness was found in pTi samples followed by eTi, bTi and beTi samples. Etching generated surfaces with the highest fractal dimension and negative skewness. Young contact angles were similar except for pTi and bTi surfaces. Silicon and aluminum traces were found in pTi and bTi samples, respectively. Cell adhesion (≤24 h) was greater on bTi and beTi surfaces. After 48 h, cell proliferation, mediated by specific morphologies, was improved in eTi samples followed by beTi surfaces. For the same surface chemistry, cell growth was driven by topography features.

Surface roughness and wettability determines the stability of bone-implant integration. Stable implants can be found in those with a rough and hydrophilic surface. Sandblasting and surface mechanical attrition treatment (SMAT) are among the current techniques to obtain surface with such typical properties. In addition, both treatments increase mechanical strength of metal through surface grains refinement. In this paper, the effect of sandblasting and SMAT on surface roughness, wettability, and microhardness distribution of AISI 316L is discussed. All treatments were conducted for 0-20 minutes. The result shows a rougher and a more hydrophilic surface on the sandblasted samples rather than on those with SMAT. A harder surface is yielded by both treatments, but the SMAT produces a thicker hardened layer.

Surface modification is an important step in production of medical implants. Surface roughening creates additional surface area to enhance the bonding between the implant and the bone. Recent research provided a means to alter the microstructure of titanium by severe plastic deformation (SPD) in order to increase its strength, and thereby reduce the size of the implants (specifically, their diameter). The purpose of the present study was to examine the effect of bulk microstructure of commercially pure titanium with coarse-grained (CG) and ultrafine-grained (UFG) bulk structure on the surface state of these materials after surface modification by sand blasting and acid etching (SLA). It was shown that SLA-modified surface characteristics, in particular, roughness, chemistry, and wettability, were affected by prior SPD processing. Additionally, biocompatibility of UFG titanium was examined using osteosarcoma cell line SaOS-2 and primary human adipose-derived mesenchymal stem cell (adMSC) cultures. Enhanced cell viability as well as increased matrix mineralization during osteogenic differentiation of MSCs on the surface of ultrafine-grained titanium was shown.

Shot-peening is one of the surface modification methods to increase material hardness and smoothen its surface at the same time. SS-316L, one type of biocompatible material, is commonly used in medical field particularly for joining fractured bones. However, the surface-crack-prone characteristic of SS-316L has limited its application to be used for such application. In this research, steel balls with diameter 0.4 mm is subjected to the surface of SS-316L Osteosynthesis Plate with variation of time; 9, 10, 11 and 12 minutes holding at constant pressure of 6 bar. The nozzle-to-plate distance is fixed at 100 mm. The impact of the shot balls is a deformed surface and produces a flat-like structure on osteosynthesis plate shot in 12 minutes time. The result shows that shot peening of SS 316L gives its best microstructure after 12 minutes of treatment.

Osseointegration has been defined as “a direct structural and functional connection between ordered, living bone and the surface of a load-carrying implant”. However, titanium and its alloys cannot directly bond to living bone after being implanted into the body. The osseointegration of titanium dental implants is critically dependent on the implant surface properties. Various surface modifications have been proposed in order to provide commercially pure titanium with bioactive bone bonding ability. In the present work, the titanium dental implant surface morphology was modified by acid etching and electrochemical treatments with the purpose of enhancing tissue response, and decreasing the waiting time for implant loading. The results show that surface morphology, topography, roughness and chemical composition were changed by the treatments and these changes has a significant influence on osseointegration. The best results were observed in the samples submitted to the electrochemical treatment.

Micrometer- and submicrometer-scale surface roughness enhances osteoblast differentiation on titanium (Ti) substrates and increases bone-to-implant contact in vivo. However, the low surface wettability induced by surface roughness can retard initial interactions with the physiological environment. We examined chemical modifications of Ti surfaces [pretreated (PT), R(a) ≤ 0.3 μm; sand blasted/acid etched (SLA), R(a) ≥ 3.0 μm] in order to modify surface hydrophilicity. We designed coating layers of polyelectrolytes that did not alter the surface microstructure but increased surface ionic character, including chitosan (CHI), poly(L-glutamic acid) (PGA), and poly(L-lysine) (PLL). Ti disks were cleaned and sterilized. Surface chemical composition, roughness, wettability, and morphology of surfaces before and after polyelectrolyte coating were examined by X-ray photoelectron spectroscopy (XPS), contact mode profilometry, contact angle measurement, and scanning electron microscopy (SEM). High-resolution XPS spectra data validated the formation of polyelectrolyte layers on top of the Ti surface. The surface coverage of the polyelectrolyte adsorbed on Ti surfaces was evaluated with the pertinent SEM images and XPS peak intensity as a function of polyelectrolyte adsorption time on the Ti surface. PLL was coated in a uniform thin layer on the PT surface. CHI and PGA were coated evenly on PT, albeit in an incomplete monolayer. CHI, PGA, and PLL were coated on the SLA surface with complete coverage. The selected polyelectrolytes enhanced surface wettability without modifying surface roughness. These chemically modified surfaces on implant devices can contribute to the enhancement of osteoblast differentiation.

Like most bone deficits, mandibular segmental defects may result from surgical reconstruction due to congenital deformity, tumor resection, other pathologies, senescence, trauma, or infection. The goals of mandibular reconstruction are to restore the mandible’s function and normal appearance. Clinical methods to restore the mandible typically rely on bone replacement using some combination of bone tissue transfer and metal implants. This paper reviews the safety, design, and efficacy of metal implants in general and specifically for the repair of mandibular segmental defects. These problems include implant incorporation, implant failure mechanisms (e.g., stress concentration, stress shielding), corrosion and toxicity, infection, and muscle re-attachment. Finally, this paper presents the use of porous nickel-titanium (NiTi) implants for the repair of skeletal defects through the example of mandibular segmental defects. Resorbable magnesium, and porous and non-porous NiTi, immobilization hardware are also discussed. These materials provide new options which may better match the material properties, and if they can be 3D printed, better match the shape of surrounding host tissue. These advances might reduce engrafted bone and metal implant failure and restore musculoskeletal function for the long term. Patient-specific hardware and grafting strategies might prove to be useful tools in determining both the patient’s appearance and functional outcome following reconstructive musculoskeletal surgery.

It is generally recognised that mesenchymal stem cells (MSCs) can differentiate into multiple lineages through guidance from the biophysical properties of the substrates. However, the precise biophysical mechanism that enables MSCs to respond to substrate properties remains unclear. In the current study, polydimethylsiloxane (PDMS) substrates with different stiffnesses were fabricated and the way in which the elastic modulus of the substrate regulated differentiation towards osteogenesis and adipogenesis in adipose-derived stromal cells (ASCs) was explored. Initially, a cell morphology change by SEM was observed between the stiff and soft substrates. The cytoskeleton stains including microfilament by F-actin and microtubule by α- and β-tubulin further showed a larger cell spreading area on the stiff substrate. Then the expression of vinculin, in charge for the linkage of adhesion molecules to the actin cytoskeleton, was enhanced on the stiff substrate. This change in focal adhesion plaque further triggered intracellular β-catenin signaling and promoted its nuclear translocation especially on the stiff substrate. The influence of β-catenin signaling on direct differentiation to osteogenic lineages was through direct binding between its downstream protein, Lef-1, and the osteogenic transcriptional factors, Runx2 and Osx, while on differentiation to adipogenic lineages was through modulating the expression of PPARγ. The imbalance of stiffness-induced β-catenin signaling finally induced a stronger osteogenesis and a weaker adipogenesis on the stiff substrate relative to those on the soft substrate. This study indicates the importance of stiffness on ASC differentiation and could help to increase understanding of the mechanism underlying molecular signal transduction from mechanosensing, mechanotransducing to stem cell differentiation. STATEMENT OF SIGNIFICANCE Mesenchymal stem cells can differentiate into multiple lineages, such as adipogenesis, myogenesis, neurogenesis, angiogenesis and osteogenesis, through influence of biophysical properties of the extracellular matrix. However, the precise bio-mechanism that triggers stem cell differentiation in response to matrix biophysical properties remains unclear. In the current study, we provide a series of experiments involving the characterization of cell morphology, microfilament, microtubule and adhesion capacity of adipose-derived stromal cells (ASCs) in response to substrate stiffness, and further elucidation of cytoplasmic β-catenin-dependent signal transduction, nuclear translocation and resultant promoter activation of transcriptional factors for osteogenesis and adipogenesis. This study provides an explanation on deeper understanding of bio-mechanism underlying substrate stiffness-triggered β-catenin signal transduction from active mechanosensing, mechanotransducing to stem cell differentiation.

Herein we present an innovative method of coating the surface of Titanium-Aluminium-Niobium bone scaffold implants with bacterial cellulose (BC) polymer saturated with antibiotic. Customized Ti6Al7Nb scaffolds manufactured using Selective Laser Melting were immersed in a suspension of Komagataeibacter xylinus bacteria which displays an ability to produce a 3-dimensional structure of bio-cellulose polymer. The process of complete implant coating with BC took on average 7 days. Subsequently, the BC matrix was cleansed by means of alkaline lysis and saturated with gentamycin. Scanning electron microscopy revealed that BC adheres and penetrates into the implant scaffold structure. The viability and development of the cellular layer on BC micro-structure were visualized by means of confocal microscopy. The BC-coated implants displayed a significantly lower cytotoxicity against osteoblast and fibroblast cell cultures in vitro in comparison to non-coated implants. It was also noted that gentamycin released from BC-coated implants inhibited the growth of Staphylococcus aureus cultures in vitro, confirming the suitability of such implant modification for preventing hostile microbial colonization. As demonstrated using digital microscopy, the procedure used for implant coating and BC chemical cleansing did not flaw the biomaterial structure. The results presented herein are of high translational value with regard to future use of customized, BC-coated and antibiotic-saturated implants designed for use in orthopedic applications to speed up recovery and to reduce the risk of musculoskeletal infections.

Dental implants are fully placed in the bone in order to replace the natural root of the tooth and allow the installation of a dental prosthesis. The implant has gained importance with the work of Professor Per Ingvar Branemark, who studied the microcirculation in bone tissue. Branemark used stainless steel optical chambers to investigate the anatomy and physiology of tissue injury. The chamber was inserted in rabbit and dog legs. In some experiments the chamber structure of stainless steel was replaced by titanium. At the end of the experiments, Prof Branemark observed that the titanium chamber was firmly attached to the bone (Branemark et al., 1964). In fact, the titanium chamber could not remove from the surrounding bone once it had healed. Histological studies showed complete integration of titanium with the bone. After this chance observation, Branemark developed a new concept of osseointegration which led to dental implants. The use of titanium-based dental implants in humans begun in 1965. Dental implant technology was improved in recent years, providing patients with unparalleled levels of effectiveness, convenience, and affordability. This is one of the main reasons why so many dentists recommend dental implants as their preferred method to replace missing teeth. Titanium dental implants can offer many benefits. Because they present osseointegration with the jawbone, they are more stable than dentures. Patients with dental implants may be able to talk and eat more easily because they do not face the risk of their dentures dislodging. Dentures require replacement when the gum tissue shrinks and changes the fit; implants are not affected by this problem. The maintenance and hygiene of dental implants are easier than with dentures. Another reason for continued growth of the global market for dental implants is that dental implants offer an effective treatment for edentulism and because of the rising demand for cosmetic dentistry worldwide across all age groups. The conventional clinical protocol proposed by Branemark (Branemark, 1990) for placement of dental implants involves two phases. The first is the placement of the implant in a surgical cavity prepared in the bone. The protocol recommends a healing period for tissue reorganization. The waiting time for healing to occur depends on bone quality and the region in which the implant was performed and was estimated by Branemark as between 3 months to 6 months. The second phase of treatment is the prosthesis placement. With this technique, all natural teeth can be replaced, restoring function and aesthetics to the patient.

Dental implant systems are composed of an implant, prosthetic components, and a crown. Since the implants are made of commercially pure Ti (cp Ti) and prosthetic components are often made of Ti and CoCrMo alloys, a galvanic couple between these two devices may lead to galvanic corrosion, ions release, and even loss of the implant. This study aimed to investigate the corrosion resistance and measure the galvanic potential between cp Ti alloys (annealed microstructured cp Ti G4 and cold-worked nanostructured cp Ti G4) and a CoCrMo alloy. The corrosion resistance has been characterized by measuring the open circuit potential, the potentiodynamic polarization, the potentiostatic polarization, and the zero-resistance current. The cp Ti has been tested before and after a surface acid treatment. The samples' surfaces have been examined by scanning electron microscopy, and their surface roughness has been measured by a 3D optical profilometer. The polarization results showed that the CoCrMo alloy showed lower corrosion resistance than cp Ti. The surface acid treatment improves dental implant corrosion resistance. The galvanic analysis showed that the cp Ti without surface treatment behaved as an anode and after the acid treatment has a cathodic behavior in relation to the CrCoMo alloy. The highest value of galvanic current was cp TiG4 acid etched in contact with CoCrMo, in pH 2 solution. The galvanic couple with the lowest current has been the nanostructured cp Ti in contact with CoCrMo alloy.

Bacterial infection of in-dwelling medical devices is a growing problem that cannot be treated by traditional antibiotics due to the increasing prevalence of antimicrobial resistance and biofilm formation. Here, due to changes in surface parameters, it is proposed that bacterial adhesion can be prevented through nanosurface modifications of the medical device alone. Toward this goal, titanium was created to possess nanotubular surface topographies of highly controlled diameters of 20, 40, 60, or 80 nm, sometimes followed by heat treatment to control chemistry and crystallinity, through a novel anodization process. For the first time it was found that through the control of Ti surface parameters including chemistry, crystallinity, nanotube size, and hydrophilicity, significantly changed responses of both Staphylococcus epidermidis and Staphylococcus aureus (pathogens relevant for orthopaedic and other medical device related infections) were measured. Specifically, heat treatment of 80 nm diameter titanium tubes produced the most robust antimicrobial effect of all surface treatment parameters tested. This study provides the first step toward understanding the surface properties of nano-structured titanium that improve tissue growth (as has been previously observed with nanotubular titanium), while simultaneously reducing infection without the use of pharmaceutical drugs.