Tailoring the biological response of zirconium implants using zirconia bioceramic coatings: A systematic review

The poor biological performance of zirconium implants in the human body resulting from their bio-inertness and vulnerability to corrosion and bacterial activity reflects the need for further studies on substitution or performing the surface modification. The suggestion of employing zirconia (ZrO₂) bioceramic coatings for surface modification seems beneficial.

This systematic review aims to identify and summarize existing documents reporting the biological responses for ZrO₂ coatings produced by the PEO process on zirconium implants.

PubMed, Scopus, and Web of Science international databases were searched for the original and English-language studies published between 2000 and 2021. All publications reported at least one study about in-vitro (cellular and immersion studies), in-vivo (animal studies), and antibacterial topics for ZrO₂-PEO coated zirconium implants.

Throughout the initial search, 496 publications were found, and 296 papers remained following the elimination of duplicates. Finally, after multiple screening and eligibility assessments, 25 publications were qualified and included in the review. Among them, 25 in-vitro (cellular and immersion in SBF and Hanks' solutions studies), one in-vivo (animal studies), and eight antibacterial studies were found.

The ZrO₂ coated samples demonstrate no cytotoxicity, high cell viability rate, and excellent biocompatibility. However, changing the solution composition and electrical parameters during the PEO procedures result in significant changes to in-vitro responses. As an instance, the ZrO₂ coating surface demonstrates greater biocompatibility after irradiated by UV, which makes the surface more suitable for cell growth. Due to weak apatite-forming ability, the zirconium sample shows low bioactivity in SBF. However, most cases (13 out of 16) show that the specific morphology and chemical composition of the ZrO₂ coating promote apatite-forming ability with good bioactivity in SBF. Nevertheless, few papers (three out of 16) showed that the ZrO₂ coatings immersed in SBF had no apatite precipitates and so no bioactivity. These cases limit the bioactivity enhancement to treatment by UV-light irradiation, hydrothermal and chemical treatment, thermal evaporation, and cathodic polarization post-treatment on ZrO₂ coatings. Both zirconium and ZrO₂ coated samples do not show apatite-forming ability in Hanks' solution. The ZrO₂ coated implant with the bone together indicates a greater shear strength and rapid new bone formation ability during 12 weeks because of containing Ca-P compounds and porous structure. The UV post-treated ZrO₂ coating induces faster new bone formation and firmer connection of bond with bone than those of untreated ZrO₂ coatings. A stronger antibacterial activity of ZrO₂ coatings is confirmed in half of the selected papers (four out of eight studies) compared to the bare zirconium samples. The antibacterial protection of ZrO₂ coatings can be influenced by the PEO procedure variables, i.e., solution composition, electrical parameters, and treatment time. In three cases, the antibacterial activity of ZrO₂ coatings is enhanced by deposition of Zn, Ag, or Cu antibacterial layers through thermal evaporation post-treatment.