Jun-Beom ParkYongpyo JeonYoungkyung Ko

Effects of titanium brush on machinedand sand-blasted/acid-etched titaniumdisc using confocal microscopy andcontact profilometry

Authors’ affiliations:Jun-Beom Park, Youngkyung Ko, Department ofPeriodontics, Seoul St Mary’s Hospital, College ofMedicine, The Catholic University of Korea, Seoul,KoreaYongpyo Jeon, Dentium Co., Ltd., Suwon, Kyunggi-do, Korea

Corresponding author:Youngkyung Ko DDS, MSD, PhDDepartment of PeriodonticsSeoul St Mary’s HospitalCollege of MedicineThe Catholic University of Korea222, Banpo-daeroSeocho-gu, Seoul 137-701KoreaTel.: +82 2 2258 6295Fax: +82 2 537 2374e-mail: ko_y@catholic.ac.kr

Key words: confocal microscopy, dental implants, scanning electron microscopy, surface prop-

erties, titanium, toothbrushing

Abstract

Objective: Mechanical techniques, including scaling with metal, plastic, or ultrasonic instruments,

rubber cup polishing, air-powder abrasive system and brushing with a conventional or a rotating

brush, have been used for the debridement of dental implants. Recently, rotating brushes with

titanium bristles (titanium brush) have been introduced for the debridement of implant surface

when peri-implant osseous defects occur. The purpose of this study was to evaluate the effects of a

titanium brush on machined (MA) and sand-blasted and acid-etched (SA) titanium surfaces using

scanning electron microscopy, confocal microscopy and profilometry. Moreover, correlations

between the two quantitative evaluation methods (confocal microscopy and contact profilometry)

were assessed.

Materials and Methods: Both MA and SA discs were treated with rotating titanium brush at

300 rpm under irrigation for a total of 40 s. Roughness measurements were taken with confocal

microscopy and surface profilometry. Then, the MA and SA surfaces were evaluated using scanning

electron microscopy to determine the changes of the surface properties.

Results: Untreated MA surface demonstrated uniform roughness with circumferential machining

marks, and scratch lines over the original surfaces were observed after treatment with the titanium

brush. Similarly, the titanium brush produced noticeable changes on the SA titanium surfaces.

However, this treatment with titanium brush did not significantly change the roughness

parameters, including the arithmetic mean height of the surface (Sa) and the maximum height of

the surface (Sz), in both MA and SA surfaces. Correlations between two evaluation methods

showed a Pearson correlation coefficient of 0.98 with linear regression R2 of 0.96.

Conclusion: This study showed that the treatment with the titanium brush did not significantly

change the roughness parameters, including Sa and Sz, in both MA and SA surfaces. Correlations

between confocal microscopy and surface profilometry showed high correlation with a Pearson

correlation coefficient of 0.98.

Peri-implantitis is defined as an inflamma-

tory process affecting the tissues around an

osseointegrated implant, resulting in the loss

of the supporting bone (Amoroso et al. 2006).

Recent reports showed that the prevalence of

peri-implantitis is assumed to be between

10% and 20% (Duddeck et al. 2012). An

increasing number of dentists are including

dental implant therapy in their clinics, and

this may lead to an increasing number of

cases with peri-implantitis (Wohlfahrt &

Lyngstadaas 2012). Mechanical techniques,

including scaling with metal, plastic, or

ultrasonic instruments, rubber cup polishing,

air-powder abrasive system and brushing

with a conventional or a rotating brush, have

been used for the debridement of dental

implants (Alhag et al. 2008; Park et al.

2012a,b; Park et al. 2013). Recently, rotating

brushes with titanium bristles (titanium

brush) have been introduced for the debride-

ment of peri-implant osseous defects (Wohl-

fahrt & Lyngstadaas 2012).

Scanning electron microscopy, confocal

microscopy and profilometry may be used to

evaluate the characteristics of the surfaces

(Park et al. 2012a,b). Scanning electron

microscopy is one of the most widely used

methods to evaluate the surface topography,

and a magnified view may show the configu-

ration and the characteristics of the surface

(Brookshire et al. 1997; Ahn et al. 2011).

Date:Accepted 25 October 2013

To cite this article:Park J-B, Jeon Y, Ko Y. Effects of titanium brush on machinedand sand-blasted/acid-etched titanium disc using confocalmicroscopy and contact profilometry.Clin. Oral Impl. Res. 26, 2015, 130–136doi: 10.1111/clr.12302

130 © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Quantitative evaluation of the change of the

surfaces may be evaluated with confocal

microscopy and contact profilometry (Park

et al. 2012a,b). Confocal microscopy utilizes

the reconstruction of surface topography from

optical sections either by reflection or by flu-

orescence imaging (Evans et al. 2001; Howell

et al. 2002; Park et al. 2012a,b). Contact pro-

filometry utilizes a stylus, which is moved

vertically in contact with a sample and then

moved laterally across the sample (Kim et al.

2008; Zhang et al. 2010).

This study was performed to evaluate the

effects of the titanium brush on machined

(MA) and sandblasted and acid-etched (SA)

titanium surfaces using scanning electron

microscopy, confocal microscopy and profil-

ometry. Additionally, correlations between

the two quantitative evaluation methods

(confocal microscopy and contact profilome-

try) were assessed.

Material and methods

Specimen preparation for profilometry

Six MA titanium discs and six SA discs were

used in this study. The discs measured

10 mm in diameter and 2 mm in thickness.

The MA and SA titanium discs were instru-

mented with a titanium brush (Tigran Peri-

brush, Tigran Technologies AB, Malm€o,

Sweden) at 300 rpm under irrigation for 40 s

by a single operator (JP) (Fig. 1). Calibrations

were performed before the experiments, and

the average force applied in this study was

approximately 15 g.

Determination of surface properties withconfocal microscopy

Roughness parameters (arithmetic mean value

of the profile [Ra], maximum height of the pro-

file [Rz], skewness of the assessed profile

[Rsk], arithmetic mean height of the surface

[Sa], maximum height of the surface [Sz],

skewness [Ssk], developed interfacial area ratio

[Sdr], and kurtosis [Sku]) were measured before

and after instrumentation using a confocal

laser microscope (LSM5 Pascal, Zeiss, Jena,

Germany). All the values were determined at a

cutoff length of 0.04 mm in 50 sections, and

the stack size of z-sections was 0.80 lm. Each

scanning covered an area of 460.7 9 460.7 lm,

and a Gaussian filter was used to determine

the surface values. Roughness measurements

were calculated by using the proprietary soft-

ware (Topography package; Zeiss) (Stubinger

et al. 2010). Three discs were used for each

group, and measurements were taken at five

random areas from each disc.

Measurement of surface roughness withcontact profilometry

The surface roughness of MA and SA tita-

nium discs was measured using a contact

profilometer (SURFPAK-SV, Mitutoyo, Hiro-

shima, Japan). The average roughness (Ra)

was used to characterize the roughness.

Examination of the titanium discs treated withtitanium brush using scanning electronmicroscopy

Following the treating of the MA and SA tita-

nium discs with titanium brush, the surfaces

were washed twice with phosphate-buffered

saline (PBS) to remove debris. The surfaces

were evaluated using scanning electron

microscopy to determine the changes of the

surface properties after the instrumentation.

The samples were mounted on stubs. The

discs were then air-dried on a clean bench via

evaporation of hexamethyldisilazane sputter-

coated with gold palladium and observed

using a scanning electron microscope (S-4700,

Hitachi, Tokyo, Japan) at 15 kV and 20009

magnification. Images were randomly cap-

tured from each disc and were saved as TIFF.

Statistical methods

Data are represented as mean � standard

deviation. Non-parametric Mann–Whitney

U-test was used to test for statistical differ-

ences between the test and the control

groups with commercially available statisti-

cal software (SPSS 12 for Windowsl SPSS

Inc., Chicago, IL, USA). Statistical signifi-

cance was set at P < 0.05. Correlations

between the two evaluation methods were

assessed with Pearson’s correlation analysis.

Fig. 1. Titanium brush used in this study.

(a) (b)

(c) (d)

Fig. 2. The morphology of the surface of the titanium discs after treatment. (a) Untreated MA surface; (b) MA tita-

nium brush; (c) SA control (no treatment); (d) SA titanium brush. MA, Machined; SA, sand-blasted and acid-etched.

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 131 | Clin. Oral Impl. Res. 26, 2015 / 130–136

Park et al �Titanium brush and titanium disc

Results

The gross morphology of the surface of the

MA and SA titanium discs after treatment

with titanium is shown in Fig. 2. Differences

in colour and surface texture between MA

and SA and changes after the instrumenta-

tion with titanium brush could be discrimi-

nated by visual inspection alone. The change

in the surface morphology after treatment

was obvious when compared with the

untreated MA and SA surfaces.

The surface properties measured with the

confocal microscope are shown in Fig. 3. The

untreated MA surface demonstrated uniform

roughness with circumferential machining

marks (Fig. 3a). The untreated MA surface

showed a relatively flat topographic configu-

ration with isotropic grooves. Scratch lines

over the original surfaces were observed after

treatment with titanium brush (Fig. 3b). The

untreated SA surface demonstrated uniform

roughness (Fig. 3c), and the titanium brush

produced noticeable changes on the SA tita-

nium surfaces (Fig. 3d). The surface charac-

teristics of examined areas are listed in

Fig. 4, and the profiles of each group are

listed in Fig. 5. Fig. 6 shows the images

obtained with contact profilometry.

The qualitative analyses of roughness

parameters using two different methods are

seen in Tables 1 and 2. There were no signifi-

cant changes of Ra value after treatment in

MA and SA discs when evaluations were per-

formed with confocal microscopy and contact

profilometry (P > 0.05). Similarly, no signifi-

cant changes of Sa and Sz values were

noticed in MA and SA surfaces after treat-

ment (P > 0.05). The changes of Ssk, Sdr and

Sku after treatments are shown in Table 1.

Ssk values were increased after the treat-

ment, and Sdr and Sku values were decreased

after the treatment. Correlations in Ra mea-

surements between two evaluation methods

showed a Pearson correlation coefficient of

0.98 with linear regression R2 of 0.96.

Fig. 7 shows the images obtained with

scanning electron microscopy from untreated

MA, treated MA, untreated SA and treated

SA implant discs. SEM images of untreated

MA showed smooth configuration with

machining marks (Fig. 7a). Scratch lines over

the original surfaces were observed after

treatment with titanium brush (Fig. 7b).

Untreated SA surface demonstrated rough

surface with sharp spikes and deep pits

(Fig. 7c). The titanium brush produced

noticeable changes on the SA titanium

surfaces (Fig. 7d).

Discussion

This study showed that treatment with tita-

nium brush did not produce significant changes

on the roughness parameters, including Sa and

Sz, in both MA and SA surfaces. Secondly,

high correlations between two evaluation

methods using Spearman’s correlation analy-

sis with coefficient of 0.98 suggested that

both methods (confocal microscopy and

(a) (b)

(c) (d)

Fig. 3. The results of the surfaces using confocal microscopy (Intensity projection with extended depth of focus). (a)

MA control (no treatment); (b) MA titanium brush; (c) SA control (no treatment); (d) SA titanium brush. MA,

Machined; SA, sand-blasted and acid-etched.

(a) (b)

(c) (d)

Fig. 4. The surface characteristics of examined area. (a) MA control (no treatment); (b) MA titanium brush; (c) SA

control (no treatment); (d) SA_titanium brush. MA, Machined; SA, sand-blasted and acid-etched.

132 | Clin. Oral Impl. Res. 26, 2015 / 130–136 © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Park et al �Titanium brush and titanium disc

contact profilometry) might be useful for the

evaluation of the surface characteristics.

In this study, different methods were used

to evaluate the changes of the surface proper-

ties. Scanning electron microscopy showed

the change of the surface in MA and SA sur-

faces very clearly. This method is very use-

ful, but additional sample preparation is

needed, and quantitative analysis is difficult

(Brookshire et al. 1997; Lu et al. 2012). Con-

focal microscopy can measure various rough-

ness parameters and has been applied in

various applications in dentistry, including

teeth and titanium (Howell et al. 2002; Park

et al. 2012a,b). Contact profilometry, which

utilizes stylus, has several advantages

because most of the surface finish standards

in the world are written for this profilometry,

which is less influenced by a dirty environ-

ment with contaminants (Durakbasa et al.

2011). It should be kept in mind that the sty-

lus readings are influenced by the radius of

the stylus tip, the pressure of the stylus tip

on the surface and the hardness of material

(Wen et al. 1996; Durakbasa et al. 2011).

In this study, surface topography was quan-

titatively evaluated by confocal microscopy

to measure roughness parameters Ra, Rz,

Rsk, Sa, Sz, Ssk, Sdr and Sku, and by contact

profilometry to evaluate Ra. Ra is one of the

most widely used parameters of roughness,

and it remains useful as a general guideline

on the surface texture (Park et al. 2012a,b).

However, it has been shown to be too general

to describe the surface’s functional nature in

today’s ever-increasing complexity of applica-

tions because Ra averages all peaks and val-

leys of the roughness profile (Taylor et al.

2006). Rz reflects outlying points better

because it averages only the five highest

peaks and the five deepest valleys (Demircio-

glu & Durakbasa 2011). Moreover, Ra and Rz

give information only from a profile, but Sa

and Sz provide information about a surface

area, resulting in three-dimensional parame-

ters with higher reliability (Wennerberg &

Albrektsson 2010). Ssk shows the skewness

of surface height distribution and represents

the degree of symmetry of the surface heights

about the mean plane (Gruhn et al. 2012),

and it is useful in monitoring for different

types of wear conditions (Whitehouse 2000).

If Ssk is greater than zero, it indicates the

predominance of peaks; if Ssk is less than

zero, it means that valley structures have

more quantity (Tudose et al. 2007). Sdr pre-

sents information about the number and the

height of peaks of a given surface, and it is

defined as the developed interfacial area ratio

and expresses the increment of the interfacial

(a) (b)

(c) (d)

00 50 100 150 200

Distance [µm]250 300 350 400 450 0 50 100 150 200

Distance [µm]250 300 350 400 450

0 50 100 150 200Distance [µm]

250 300 350 400 4500 50 100 150 200Distance [µm]

250 300 350 400 450

5

10

15

z [µ

m] 20

25

30

0

5

10

15

z [µ

m] 20

25

30

05

1015z

[µm

]

2025303540

0

5

10

15

z [µ

m] 20

25

30

Fig. 5. Profile of each group with confocal microcopy. (a) MA control (no treatment); (b) MA_titanium brush; (c) SA

control (no treatment); (d) SA_titanium brush. MA, Machined; SA, sand-blasted and acid-etched.

(a)

(b)

(c)

(d)

Fig. 6. Profile of each group using surface profilometry. (a) MA control (no treatment); (b) MA_titanium brush; (c)

SA control (no treatment); (d) SA_titanium brush. MA, Machined; SA, sand-blasted and acid-etched.

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 133 | Clin. Oral Impl. Res. 26, 2015 / 130–136

Park et al �Titanium brush and titanium disc

surface area relative to a flat plane baseline

(Dohan Ehrenfest et al. 2010). For a totally

flat surface, Sdr is 0%, and when Sdr is

100%, it means that the roughness of a sur-

face doubled its developed area (Dohan

Ehrenfest et al. 2010). Sdr may further differ-

entiate surfaces of similar amplitudes and

average roughness (Ejaz et al. 2006). Greater

surface area increases the area available for

bacterial adhesion (Teughels et al. 2006) and

research on biofilm formation on implant

surfaces need to consider differences in Sdr

as well. Sku characterizes the spread of the

height distribution (Ejaz et al. 2004), and Sku

is 3.00 if the surface heights are normally dis-

tributed (i.e., bell curve). If there are extreme

high peaks or deep valley features, Sku is

>3.00, and Sku is <3.00 in the absence of

extreme peaks or valleys (Qi et al. 2008).

One weakness of this study would be that

the effects of the titanium brush were tested on

titanium discs instead of using titanium

implant fixtures. Implant surface structures

vary in millimeter by design of the implant, in

micrometer and in nanometer level by surface

roughness (Svanborg et al. 2010) and the thread

of the implant demonstrate form, waviness and

roughness (Wennerberg & Albrektsson 2000).

Implant fixtures may have different thread

pitches (from narrow-pitch to wide pitch), and

thread pitch be from 0.5 mm or less to 1.6 mm

or greater (Orsini et al. 2012). The units of

roughness parameters are in micrometer ranges

(0.5–15). Thus, the thread pitch may not have

much influence on the roughness parameters

(Wennerberg et al. 1993). However, the accessi-

bility of instruments may differ with fixtures

with different pitches (Svanborg et al. 2010).

Clinically, it may be more difficult to manoeu-

vre the titanium brush in infrabony areas and

more than optimal lateral force may be applied

to the implant.

In MA surfaces, scanning electron micros-

copy showed scratch lines over the untreated

Table 1. Surface topographic properties of the MA and SA discs (mean � standard deviation, median) after titanium brush (Tigran PeriBrush, TigranTechnologies AB, Malm€o, Sweden) for 40 s at 300 rpm under saline irrigation using confocal microscopy. Three discs were used for each group, andmeasurements were taken at five random areas from each disc. A total of 15 measurements were taken for each group

Group Ra (lm) Rz (lm) Rsk Sa (lm) Sz (lm) Ssk Sdr (%) Sku

MA untreated 0.72 � 0.500.50

2.59 � 1.483.20

0.71 � 0.740.86

0.82 � 0.540.74

4.33 � 1.775.08

0.66 � 0.680.80

62.77 � 67.4026.84

4.54 � 2.765.05

MA titanium brush 0.39 � 0.150.32

1.52 � 0.561.34

0.78 � 0.720.66

0.41 � 0.140.33

3.57 � 1.022.98

0.94 � 0.310.87

8.28 � 4.985.80

5.66 � 1.285.59

P-value 0.345 0.233 0.935 0.161 0.233 0.486 0.116 0.106SA untreated 1.87 � 0.21

1.927.25 � 0.637.21

�0.21 � 0.57�0.21

1.94 � 0.091.92

13.52 � 0.7613.54

0.10 � 0.130.10

111.35 � 7.68110.74

3.18 � 0.223.15

SA titanium brush 1.73 � 0.201.71

6.35 � 0.66*

6.130.33 � 0.39*

0.391.89 � 0.101.88

13.26 � 0.6613.06

0.43 � 0.41*

0.3889.13 � 12.35*

87.314.28 � 1.50*

3.64P-value 0.074 0.001 0.002 0.116 0.233 0.002 0.000 0.000

MA, Machined; SA, sand-blasted and acid-etched.*Statistically significant differences were noted between untreated and treated groups.

Table 2. Surface topographic properties of the MA and SA discs (mean � standard deviation, med-ian) after titanium brush (Tigran PeriBrush) using surface profilometry

Group Ra (lm)

MA untreated 0.37 � 0.080.42

95% confidence of interval (0.17, 0.58)MA titanium brush 0.37 � 0.08

0.4295% confidence of interval (0.30, 0.43)P-value 0.436SA untreated 1.36 � 0.11

1.4095% confidence of interval (1.27, 1.44)SA titanium brush 1.40 � 0.07

1.4295% confidence of interval (1.34, 1.45)P-value 1.000

MA, Machined; SA, sand-blasted and acid-etched.

(a) (b)

(c) (d)

Fig. 7. SEM images of each group. (a) MA control (no treatment); (b) MA_titanium brush; (c) SA control (no treat-

ment); (d) SA_titanium brush. MA, Machined; SA, sand-blasted and acid-etched.

134 | Clin. Oral Impl. Res. 26, 2015 / 130–136 © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Park et al �Titanium brush and titanium disc

surface. However, there were no significant

changes of Sa and Sz after treatment. A sta-

tistically significant decrease in Sdr value

suggests that spatial intricacy was decreased

after treatment. In SA surfaces, significant

changes were noted in Ssk, Sdr and Sku. A

decrease in Sdr value suggests that spatial

intricacy was reduced, and an increase in Ssk

and Sku suggests that there was a higher ten-

dency for the predominance of peaks.

Titanium brush was suggested to offer easier

access to narrow spaces and implant threads

(Tigran Technologies AB 2011). Compared with

other mechanical instrumentation, including

ultrasonic scaling, titanium brush may be con-

sidered gentler to the implant surface because

less force is applied on the titanium surface

than in previous studies (40–300 g) (Sato et al.

2004; Ramaglia et al. 2006; Duddeck et al.

2012). Titanium brushes may adapt closely to

the architecture of the implant, and rotating

titanium brush at 300–600 rpm under continu-

ous irrigation may shorten treatment time

(Duddeck et al. 2012).

It is reported that material that is less

hard than titanium may leave remnants on

the surface after treatment (Unursaikhan

et al. 2012; Ruhling et al. 1994; Schwarz

et al. 2003). Plastic- and teflon-coated

instruments may leave plastic contamina-

tions that are macroscopically visible

(Gosau et al. 2010), and the biocompatibil-

ity of the titanium surfaces may be

impaired by the contaminants (Schwarz

et al. 2006). Stainless steel particles abraded

from the metal brush may become embed-

ded in the titanium surface, and this may

initiate galvanic corrosion (Tigran Technolo-

gies AB 2009). A significant decrease in the

number of osteoblast-like cells was seen in

the presence of debris of the carbon fibres

(Schwarz et al. 2003). Similarly, fibroblasts

grown on stainless steel instrumented sur-

faces showed a somewhat rounded morphol-

ogy and a relatively reduced degree of

spreading (Dmytryk et al. 1990). Negative

impact coming from plastic or stainless

steel tools may be avoided by using tita-

nium brush (Tigran Technologies AB 2009).

Further research is needed to evaluate the

efficiency of titanium brush on removing

the contaminants and adhering bacteria and

effects of treatment on the cellular attach-

ment, proliferation and differentiation.

Conclusions

This study evaluated the effects of titanium

brush on MA and SA titanium discs using

confocal microscopy, contact profilometry

and scanning electron microscopy. Treat-

ment with titanium brush did not signifi-

cantly change the roughness parameters,

including Sa and Sz, in both MA and SA sur-

faces. Correlations between confocal micros-

copy and surface profilometry showed high

correlation with a Pearson correlation coeffi-

cient of 0.98.

Acknowledgements: This research

was supported by Seoul St. Mary’s Hospital

Clinical Medicine Research Program year of

2013 through the Catholic University of

Korea. The authors acknowledge Dentium

(Seoul, Korea) for donating the titanium discs

for this study.

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