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Research progress of metal-based additive manufacturing in medical implants

  • Yun Zhai , Hao Zhang , Jianchuan Wang and Dewei Zhao EMAIL logo
Published/Copyright: November 29, 2023
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REVIEWS ON ADVANCED MATERIALS SCIENCE
From the journal REVIEWS ON ADVANCED MATERIALS SCIENCE Volume 62 Issue 1

Abstract

Metal-based additive manufacturing has gained significant attention in the field of medical implants over the past decade. The application of 3D-printing technology in medical implants offers several advantages over traditional manufacturing methods, including increased design flexibility for implant customization, reduced lead time for emergency cases, and the ability to create complex geometry shapes for patient-specific implants. In this review study, the working principles and conditions of metal 3D-printing technologies such as selective laser sintering, selective laser melting, and electron beam melting, as well as their applications and advantages in the medical field, are investigated in detail. The application scenarios and research status of non-degradable metals including titanium alloy, medical stainless steel, etc., and degradable metals like magnesium alloy are introduced as printing materials. We discuss the improvement of mechanical properties and biocompatibility of implants through surface modification, porous structure design, and the optimization of molding processes. Finally, the biocompatibility issues and challenges caused by the accuracy of CT imaging, fabrication, implant placement, and other aspects are summarized.

Keywords: additive manufacturing; medical implants; metal and alloys; orthopedics surface modification; biocompatibility

Abbreviations

AM

additive manufacturing

SLS

selective laser sintering

SLM

selective laser melting

EBM

electron beam melting

FEA

finite element analysis

LENS

laser-engineered net shaping

DMLS

direct laser metal sintering

CoCrMo

cobalt–chromium–molybdenum

TNTZ–5Si

Ti–Nb–5Ta–7Zr–xSi

Ta

tantalum

Ti

titanium

PT

porous tantalum

NT

nickel–titanium

BMSCs

bone marrow mesenchymal stem cells

YSZ

yttria-stabilized zirconia

bHA

biogenic hydroxyapatite

RPD

removable partial denture

GNPs

gelatin nanospheres

PSTI

patient-specific Ti implants

PDDF

pair distance distribution functions

EDD

electron density distributions

1 Introduction

There are 206 bones in the human body which can be divided into four categories: skull, trunk bone, upper-limb bone, and lower-limb bone. Every bone in the human body has irreplaceable functions, such as mechanical support, visceral protection, and mineral storage. Skeletons are composed of organic and inorganic substances. The main component of organic matter in bones is protein which renders certain toughness to the structure. The inorganic matter consists of mainly calcium and phosphorus, which renders a certain hardness to the bone [1]. The toughness and hardness of bones are affected by the ratio of organic matter and inorganic matter. In addition, different ages also lead to different toughness and hardness of bones. In the biomedical field, implants are supposed to satisfy the corresponding requirements due to the diversity of human bones: The implant materials need to be compatible with human tissues and not cause toxicity or allergic reactions in the human body. There should be no rejection or other negative reactions after implantation. It has sufficient strength and durability to exist in the human body for a long time without causing damage or rupture due to the fatigue properties of materials [2]. It needs to meet the requirements of human physiological structure and function and satisfy the treatment needs of patients. Finally, it should undergo strict safety evaluation and testing to ensure that it is safe and reliable without negatively affecting the health of patients [3,4].

As shown in Figure 1, the market size of metal implants in China, including backbone class ($0.65 billion), arthrosis class ($0.6 billion), and trauma class ($0.75 billion), amounted to a total of $2 billion in 2015. This market size has increased to $6.2 billion in 2022, with a compound annual growth rate of 16.06%. There are many reasons for the growth of the metal implant market including aging populations, sports injuries, traffic accidents, increasing quality and performance of metal implants, increased healthcare expenditures, and other factors. These factors work together to promote the rapid growth of the metal implant market. With the continuous development and application of Internet of Things technology and artificial intelligence technology, 3D-printed implant scans can be intelligently monitored and regulated. The effect and safety of the implant are enhanced accordingly. In the future medical field, the application of 3D-printed implants will be more effective and reliable.

Figure 1 Market segments of orthopedic implants in China in the past 8 years.
Figure 1

Market segments of orthopedic implants in China in the past 8 years.

3D-printing is also known as additive manufacturing (AM). It is an emerging manufacturing technology that uses computers to digitally design models and then build solid objects by stacking layers of material. With the continuous improvement of 3D-printing technology, it has become the main way to fabricate biological implants [5]. In the medical field, it has more prominent advantages than the traditional processing technology. Medical imaging technology and reverse engineering are used to obtain the original geometry of the human organ. The exact anatomical data of the bone are acquired through scanning and converted into a 3D CAD model by special software. The customized medical implant is then accurately 3D-printed with the ability to process complex structures [6]. The 3D-printing technology overcomes the problem of unsatisfactory shape and mechanical properties of traditional implants. When facing complex structures and difficult-to-machine parts, metal 3D-printing can use original materials as support to complete the processing and molding of multi-scale porous structure implants. The patient’s customized implant with surface modification can meet both the performance requirements under biomechanical conditions and the biocompatibility requirements of the physiological environment. Modified implants can effectively overcome stress-shielding effects and solve the problem of low biological activity [7]. The current 3D-printing technology is relatively suitable for bone repair and regeneration [8]. Figure 2(a) illustrates the hip cup utilized in the total hip replacement surgery, employing the cutting-edge electron beam melting (EBM) technology. Figure 2(b) shows the prototype of the lattice structure of a bone implant. According to patients’ individual needs, we can use advanced 3D-printing technology to customize the implants to improve the surgical effect and the life quality of patients.

Figure 2 Typical bone repair scenarios [8]: (a) hip cup used in the total hip replacement surgery; and (b) the lattice structure of the bone implant model.
Figure 2

Typical bone repair scenarios [8]: (a) hip cup used in the total hip replacement surgery; and (b) the lattice structure of the bone implant model.

For many years, numerous studies have explored various aspects of 3D-printing in the realm of medical implants, encompassing lattice structures, applications, molding processes, and related topics. Figure 3 shows the number of review articles and research articles published over the past 5 years using “3D-printing implants” as the search keyword. Among the 3,113 articles, 147 are review articles and the remaining 2,966 are research articles. The chronology shows an increasing trend in the research field of nanostructures and scaffold structures of 3D-printing implants. Attarilar et al. conducted a comprehensive overview of 3D-printing technologies for metallic implants, covering various techniques, parameters, historical context, medical applications, and specific materials, with a focus on meeting important requirements for biocompatibility and customized designs to emulate tissue functions [9]. Yuan et al. explored the advantages of AM technology to produce complex, bio-mimicking porous metal implants and discussed the use of triply periodic minimal surface structures for enhanced biomorphic implants [10]. In recent years, there have been diverse advancements in the processing techniques and materials of metal printing, such as the ability to achieve smaller dimensions in the final product, optimization of implant performance, and validation through biological experiments. A few studies have provided a detailed overview of the applications and performance enhancements of metal printing in medical implants over the past 2 years.

Figure 3 Data statistics of the 3D-printing implant literature in recent 5 years.
Figure 3

Data statistics of the 3D-printing implant literature in recent 5 years.

In this review, we introduce the application of metal 3D-printing in medicine in detail, including the research progress of 3D-printing technology, materials, application scenarios, and material performance improvement. We also summarize the research on some key issues, such as the development of printing technology and processing technology, implant surface modification, and gradient porous structure. In addition, we highlight the importance of CT scan accuracy, printing accuracy, and surgical operation accuracy. Finally, we discussed how to solve key scientific issues such as the stress shielding effect and biocompatibility from the perspective of a structure-processing-performance relationship.

2 3D-printing technology

AM originated in the 1980s. It is a technique for building three-dimensional parts by stacking materials layer by layer under the guidance of a digital model that can produce almost any geometry [11]. In the application of metal materials, metal AM mainly includes the following technologies: selective laser sintering (SLS), selective laser melting (SLM), EBM, direct laser metal sintering (DLMS), and laser-engineered net shaping (LENS). These techniques have many applications in manufacturing complex metal parts and implants. In addition, emerging metal printing technology is also making continuous progress, such as atom diffusion 3D-printing technology and nanoparticle ejection. These technologies provide new ideas and methods for the precision machining and manufacturing metal implants.

2.1 SLS

SLS is a powder bed melting technology. Figure 4 demonstrates the working principle of SLS molding technology. Model and slices are established by a computer-aided design and imported into a printing machine, which spreads the powder and uses a high-energy laser beam to scan according to the planned path. Utilizing layer-by-layer melting solidification accumulation, solid parts are directly obtained with arbitrary complex shapes [12]. SLS technology utilizes the laid powder as a support without additional supporting materials. The powder used in this technology is mostly a metal mixture, which means that under laser irradiation, only parts of the low melting point metal melt into adhesive to bond the unmelted metal powder [13,14]. The advantages of SLS encompass a wide range of material options, elimination of support structures, accelerated manufacturing speed, capability for high-temperature processing, and reduced geometric limitations.

Figure 4 Schematic diagram of the SLS processing forming principle [12].
Figure 4

Schematic diagram of the SLS processing forming principle [12].

Roy et al. introduced μ-SLS, an advanced methodology for efficiently fabricating high-resolution, small-scale, three-dimensional metal components. By utilizing metal nanoparticle ink, precise positional manipulation, and laser sintering, μ-SLS effectively surpasses existing constraints. It attains a sub-5 μm resolution for producing three-dimensional metal parts while achieving a forming rate surpassing 60 mm3 per hour. The prospective applications of μ-SLS in microelectronics packaging exhibit tremendous promise [15]. Mandolini et al. reconstructed the orbital cavity using SLS. It not only reduced the morbidity and operation time of patients but also reduced the related expenses [16]. Because of the high molding precision, this technology has attracted much attention in the preparation of drug materials combined with low-soluble compounds [17]. Gueche et al. [18] and Zhang et al. [19] used SLS technology to introduce carbonyl iron as a multifunctional magnetic and thermal conductivity component to prepare typical anti-tuberculosis drug isoniazid oral tablets, which have potential advantages in medicine. At present, SLS also faces some problems. For example, the low printing speed limits its large-scale industrial application. The surface roughness of the printed part is relatively high, so post-processing is needed to improve the surface quality. The density of SLS printed parts is generally low and does not meet the density requirements of many engineering applications. Therefore, optimizing the SLS printing parameters and post-processing to increase the density of printed parts is necessary. Despite some problems and challenges, SLS remains an important 3D-printing technology in the medical field that can be used to shape complex personalized structures. With the development and improvement of technology, these problems will be alleviated and solved eventually [20,21].

2.2 SLM

The Fraunhofer Institute for Laser Technology first proposed the SLM technology in the 1990s. It is a metal 3D-printing technology developed based on SLS [22]. The principle of SLS molding is very similar to SLS, as shown in Figure 5. The inert gas is introduced, and the machine body is heated to the required temperature. The metal powder is evenly spread on a workbench. The laser head scans and melts the metal powder according to the predetermined route. The solidified molding structure is then removed from the workbench and cooled. The SLM technology has a higher laser temperature, which can melt most types of metal powder. The whole process of SLM printing needs inert gas protection to avoid the oxidation of metal powder [23]. The metal parts formed by SLM have higher density, better mechanical properties, and higher-dimensional accuracy than those made by SLS. Therefore, SLM is more widely used than SLS [24].

Figure 5 Schematic diagram of the SLM processing forming principle [23].
Figure 5

Schematic diagram of the SLM processing forming principle [23].

Gao and colleagues fabricated Fe81Ga19 bulk polycrystalline alloys using SLM. The grain orientation and magnetostrictive properties were controlled by different scanning paths. Corresponding results demonstrated that the Fe81Ga19 alloy with a sawtooth scanning pattern exhibited a preferential h100i crystal orientation, achieving a magnetostrictive performance of 77.2 ppm and an increase of 23.9 and 25.1% compared to unidirectional and circular scanning, respectively. Furthermore, the alloy possessed an ultimate compressive strength of 448.6 MPa, a degradation rate of 0.09 mm per year, and excellent biocompatibility. SLM sawtooth scanning may emerge as a potential method for fabricating magnetostrictive Fe–Ga implant materials [25].

Zhang et al. used SLM to form hollow three-period minimum surface and other unit cell structures. The experimental results showed that its mechanical properties and energy absorption are the best [26]. SLM also shows increasing potential in today’s aviation industry. However, the porosity is the main reason for fatigue failure [27,28]. At present, scientists are paying great attention to the SLM printing process to improve the biocompatibility and mechanical properties of the printed implant [29,30]. Among all types of metal 3D-printing technology, SLM is the most widely used printing technology, especially in the medical field. Table 1 shows the current situation of SLM using Ti alloy, stainless steel, and other metal materials to manufacture implants such as the total hip joint and tibia for surgical operation. The application scenarios, printing materials, processing technologies, and pros and cons are summarized. During the manufacturing process of these implants, the surface roughness and porosity of the implants can be controlled by optimizing the manufacturing process parameters. The ability of bone regeneration and osseointegration could be optimized. The mechanical properties and durability of implants could also be improved.

Table 1

Application of SLM technology in the medical field

Structure Material Optimization Advantages and disadvantages Refs
Total hip joint Ti alloy (Ti6Al4V); CoCrMo Optimize SLM process parameters High corrosion resistance and excellent biocompatibility; stress shielding problem [31,32,33,34]
Shin bone CoCrMo Optimal design by the finite element method High surface finish [35]
Multiple statistical methods High adaptability and retention [36]
Dentistry Co–Cr–W Sandblasting High hardness and high viscosity [37]
Heat treatment High corrosion resistance [38]
Spongy bone Ti6Al4V Porous structure design High cell growth rate and strong carrying capacity [39]
Bone trabecula Ta Porosity size Obtain the best porosity [40]

Although SLM is a manufacturing technology with high precision, high quality, and high flexibility, there are still some limitations. The printing materials are limited and mainly concentrated in metal materials, such as Ti alloy, stainless steel, aluminum alloy, etc. The application of SLM technology is somewhat limited to non-metallic materials such as plastics and ceramics. The dimension of molding is small. SLM technology is suitable for small-batch and high-precision manufacturing. There are specific difficulties in manufacturing large-sized complex structures. The surface quality is relatively low. The surface smoothness is quiet since the SLM technology uses layer-by-layer melting. Further surface treatment is required to achieve a certain level of finishing. The manufacturing efficiency is low, and it is not suitable for large-scale and high-efficiency manufacturing tasks. Although SLM technology has some limitations, it is still the most popular technology for medical implant molding. With technology’s continuous development and innovation, these limitations will be gradually broken through and solved [41].

2.3 EBM

EBM is an advanced metal AM technique that utilizes a high-energy electron beam to melt metal powder layers sequentially, enabling precise three-dimensional printing of components. Figure 6 shows the working principle of EMB. First, the metal powder is evenly spread on the workbench, and then the high-energy electron beam is emitted by an electron gun. The metal powder melts into a liquid state and accumulates layer by layer on the workbench. After each layer, the workbench will be lowered by a height of one powder layer until the layer-by-layer stacking manufacturing is completed. EMB can control the parameters such as energy and the speed of the electron beam to manufacture high-precision and high-quality parts [42]. EMB parts mainly use Ti alloy, stainless steel, and other metal powders as raw materials. EMB technology has a significant advantage, and it creates a vacuum environment with its high-energy electron beam [43,44,45,46]. The vacuum environment can avoid the oxidation and pollution of materials. Co-axial electron beam and wire technology present a promising metal AM technique, which combines the attributes of electron beam fusion and wire-based AM, utilizing a coaxial arrangement of electron beam and wire to achieve the fabrication of metallic components, as shown in Figure 6(b). This technology enables efficient, precise, and cost-effective production of metal parts, with vast potential for applications in the aerospace, automotive, and energy sectors [47].

Figure 6 (a) Schematic diagram of the EBM processing forming principle [42]. (b) The operational principle of the co-axial electron beam and wire technology [47].
Figure 6

(a) Schematic diagram of the EBM processing forming principle [42]. (b) The operational principle of the co-axial electron beam and wire technology [47].

EBM is a promising AM technology. Goto et al. created the biomimetic bone structure using EBM to simulate bone morphology and macroporous structure, thereby promoting bone regeneration [48]. Asakura et al. used EBM to manufacture denture bases. The matching accuracy of the EBM bottom plate and casting bottom plate was compared by measuring the gap between several groups of bottom plates and the final casting. The results showed that the matching accuracy of the EBM bottom plate is higher than that of the casting bottom plate [49]. Hao et al. compared the performance of Ti–6Al–4V prints under EBM and SLM. At the respective optimum temperatures, EBM-molded structures exhibited higher ductility [50].

Although EBM is popular in the field of AM today, some aspects could be improved. The manufacturing speed of EBM is relatively slow, the vacuum environment needs to be controlled during processing. The surface quality of the EBM-formed structure is unstable, and subsequent surface treatment is necessary. EBM technology can only process specific metal materials, such as Ti and nickel-based alloys. Therefore, in practical application, it is necessary to comprehensively weigh the advantages and disadvantages and choose the appropriate materials and manufacturing technologies.

2.4 LENS

LENS is one of the most widely used and rapidly developing AM techniques. It allows the manufacturing of materials with complex geometries and compositional gradients that are not easy to achieve with conventional methods [51]. The operating principle is illustrated in Figure 7; the main difference between LENS and SLM/SLS lies in the different methods of adding metal powder, where LENS utilizes a synchronized powder feed process, where the metal powder is heated and melted by the laser beam as it is sprayed from the nozzle. The laser beam and powder feeder move synchronously under computer control until the metal powder is melted and fused with the underlying metal, and then move to the following processing point. Then, the layers are stacked on each other until the object is fully printed [52].

Figure 7 Schematic diagram of the LENS processing forming principle (1. suppliers of powder; 2. pneumatic vibrating system; 3. optical system with Imager Thermal System; 4. IPG fiber laser; 5. process control computers; 6. input data; 7. working chamber; 8. laser optical path; 9. four nozzles within the working head; 10. numerically controlled working table; 11. vacuum chamber) [52].
Figure 7

Schematic diagram of the LENS processing forming principle (1. suppliers of powder; 2. pneumatic vibrating system; 3. optical system with Imager Thermal System; 4. IPG fiber laser; 5. process control computers; 6. input data; 7. working chamber; 8. laser optical path; 9. four nozzles within the working head; 10. numerically controlled working table; 11. vacuum chamber) [52].

Maharubin et al. fabricated alloys with various Ag concentrations, ranging from 0.5 to 2% by weight, were fabricated using the LENS process. Results showed that LENS-fabricated Ti–Ag alloys had a marginally higher microhardness and lower ductility compared to pure Ti [53]. Chen et al. employed LENS to prepare NiTi alloys with excellent mechanical and structural properties by controlling the equipment parameters and aging temperature [54,55]. Despite the high efficiency and density of LENS parts, the slightly lower precision of the formation process and the need for post-processing have limited its application for implants.

2.5 DMLS

DMLS employs a high-energy laser to sinter metal powder into solid parts, enabling the production of complex shapes without additional processing or cutting. It allows for the rapid formation of structures with desired shapes and sizes [56]. DMLS has a higher resolution than SLS and can process thinner layers, allowing for more intricate part shapes. It is capable of producing implants for surgical use, as well as internal fixation devices. DMLS technology is becoming increasingly popular in the manufacturing industry [57,58,59].

2.6 Other 3D-printing technologies

In addition to commonly used metal printing technologies, several less standard techniques have been widely applied in recent years, such as wire arc AM [58]. It utilizes an arc as a heat source to heat the material. It employs metal wire as a filling material to bond atoms of the same or different materials, forming the workpiece [60,61]. This technique has advantages such as high forming speed, high utilization rate, and compact structure. However, it is more suitable for the construction industry. Additionally, other techniques, such as nanoparticle jetting metal forming and ultrasonic AM, have great potential for development in the future [62].

3 Metals and their alloys as printing materials

The printing material utilized in metal printing typically exists in the form of metal powder. These powders are melted under the influence of energy sources such as lasers or electron beams and are successively layered to form metallic components ultimately. Commonly used printing materials include Ti alloys, stainless steel, CoCrMo, and magnesium alloys. Each material possesses distinct mechanical properties and is suitable for different working conditions. The selection of metallic printing materials primarily depends on the target component’s design requirements, usage, and cost. In recent years, the variety of metallic printing materials has expanded in response to the growing demand for 3D-printing. In the medical field, metallic materials are divided into two categories: non-degradable metal and degradable metal materials.

3.1 Non-degradable metal material

With the continuous advancement of AM technology, new printing materials are constantly emerging. In the medical field, non-degradable metals mainly include Ti alloys, stainless steel, and CoCrMo alloys, while other materials are generally derived from these categories.

3.1.1 Titanium and its alloys

Ti and its alloys are currently the most widely used metallic implant materials [63]. Pure Ti is an advanced biomaterial with potential applications in dentistry, bone structure replacement, and various other fields [64]. Ti alloys typically consist of binary and ternary Ti compositions [65]. Table 2 gives the derivation history of Ti and its alloys, its application in medicine, and its improvement of properties. The developmental history of Ti and its alloys can be divided into four stages: pure Ti, first-generation Ti alloys, second-generation Ti alloys, and third-generation Ti alloys. Third-generation Ti alloys offer superior strength, lower elastic modulus, exceptional formability, and enhanced corrosion resistance compared to the first and second generations. As Ti and its alloys find increasingly widespread use in medical, aerospace, and other domains, the demands on their performance continue to increase. Efforts are ongoing to improve further and research Ti alloys to enhance their performance and application range.

Table 2

Development history of Ti and its alloys

Name Date Category Application scenario Performance Refs
Pure Ti 1940s Pure Ti Dental implant Low strength and poor wear resistance [66]
First-generation Ti alloy 1960s Ti–3Al–2.5V Orthopedic implant Higher strength and better comprehensive processing performance [67]
Ti–6Al–4V
Second-generation Ti alloy 1980s Ti6–Al–7Nb Fractures, bone defects, etc. Facing the challenge of stress shielding [68]
Third-generation Ti alloy 1990s Ti–16Nb–9.5Hf Orthopedics, dentistry, joint replacement, etc. High strength, low elastic modulus, excellent formability, and corrosion resistance [69–72]
Ti–13Nb–13Zr
Ti–Nb–Zr–Si

The binary Ti–Zr alloy has been investigated as a promising substitute for Ti implants. The alloy studied by Zhao et al. shows that the mechanical, chemical, electrochemical, and biological properties of Ti–Zr alloys are related to the Ti and Zr composition ratio in the alloy, phase, manufacturing process, and surface treatment [73]. Yang et al. found that the wear rate of TNTZ–5Si alloys generated in SBF solution was only 30% of that of Ti–6Al–4V alloys, which indicates that TNTZ–5Si alloy implants exhibit superior compressive yield strength, elastic modulus, and wear resistance [74]. Bordbar-Khiabani and Gasik conducted electrochemical and biological treatment on Ti–Nb–Zr–Si alloys for orthopedic applications. Compared to Ti–6Al–4V, Ti–Nb–Zr–Si alloys demonstrated good biocompatibility in vitro [75].

Ti–6Al–4V alloy is currently the most widely used material for medical implants. Compared to materials such as CoCrMo, it possesses better mechanical properties, corrosion resistance, and biocompatibility [76]. Lee and Chen used Ti–6Al–4V to create mandibular bone frameworks. Compared with the frameworks made from polyether ether ketone and zirconia materials, patients were more satisfied with the Ti–6Al–4V mandibular bone frameworks in terms of chewing function and aesthetics [77]. The study by Vasylyev et al. analyzed microstructural characteristics and processing parameters in wire-feed 3D-printing of Ti–6Al–4V alloy, highlighting their impact on mechanical properties and the need for post-processing treatments [78].

Ti–6Al–4V orthopedic implant with an adjustable non-uniform porous structure, utilizing a heterogeneous topological microenvironment constructed with Voronoi-Thiessen biomimetic porous structures. Finite element analysis (FEA) was initially employed to pre-design and simulate mechanical and fluid dynamic properties. Their results revealed that the heterogeneous system had negligible effects on the overall strength, stiffness, and permeability but caused local fluctuations in stiffness and fluid dynamics. In vitro and in vivo experiments demonstrated that the controlled heterogeneous porous structure exhibited superior bone repair capabilities compared to entirely randomly generated systems, presenting opportunities for the development of implants with enhanced osseointegration abilities [79], as shown in Figure 8.

Figure 8 Voronoi-Thiessen biomimetic porous structures and FEA of the Ti–6Al–4V bone implant [79].
Figure 8

Voronoi-Thiessen biomimetic porous structures and FEA of the Ti–6Al–4V bone implant [79].

NT alloys exhibit extremely low cytotoxicity. As research and progress continue in surface modification techniques, a series of NT implants are expected to be introduced soon [80]. Naujokat et al. conducted biological experiments on NT shape memory alloys, implanting them into the nasal bones of pigs. The study confirmed that NT alloys exhibit sufficient biocompatibility, flexibility, and reversible deformation, making them suitable for intraosseous and subperiosteal implants [81].

3.1.2 Medical-grade stainless steel

Medical-grade stainless steel has become an indispensable material in the medical field with its exceptional properties and biocompatibility. For instance, it is employed in surgical instruments to manufacture scalpels, forceps, and scissors. In orthopedic implants, it is used to create artificial bones, bone plates, and screws. Li et al. have fabricated stents and joint implants from medical-grade stainless steel, enabling normal functioning of the heart and joints [82]. Langi et al. explored the microstructure and mechanical properties of thin-walled tubes made of 316L stainless steel by SLM technology. Comparisons with a commercial stainless-steel stent were performed regarding microstructure and surface finish variances. They investigated surface roughness, phases, microstructures, chemical composition, and the correlation between elastic modulus and crystallographic orientations. Their findings showed that the AM processes have great potential in customized stent production [83].

However, medical-grade stainless steel has some drawbacks and limitations, such as high density, high elastic modulus, elevated nickel content, and metal fatigue, all of which can affect the performance and lifespan of instruments and implants. Additionally, medical-grade stainless steel still has problems such as corrosion and tissue reactions. Long-term implantation of medical-grade stainless steel may cause adverse reactions like inflammation, allergies, and carcinogenic effects, impacting human health. Consequently, improvements and refinements are continually needed to meet the medical field’s material demands. Han et al. have enhanced the tensile performance of additive-manufactured 316L stainless steel by adding Ti [84]. Rodrigues et al. have produced stainless steel components with outstanding strength and ductility through plasma arc powder wire arc AM [85,86].

3.1.3 Cobalt–chromium–molybdenum alloys

The primary advantages of medical CoCrMo alloys are their excellent mechanical properties, biocompatibility, and corrosion resistance [87]. Their high hardness, strength, and wear resistance make them ideal for manufacturing artificial joints and dental restorative implants [88,89]. Furthermore, these alloys exhibit exceptional biocompatibility and bio-similarity, enabling long-term stable existence within the human body without eliciting immune or allergic reactions. Simultaneously, they possess remarkable corrosion resistance, tolerating the corrosive effects of the body’s internal environment and reducing the risk of implant corrosion and failure [90,91]. However, medical CoCrMo alloys also have some drawbacks and limitations. Long-term implantation may result in adverse reactions from cobalt, chromium, and molybdenum ions, such as allergies, toxicity, and carcinogenic effects. Additionally, their high density might cause a heavy load on patients. Metal fatigue failure is also a common problem for the CoCrMo alloys. Haftbaradaran-Esfahani et al. have reduced the release of cobalt and chromium ions and enriched Ca and P by applying a 58S Sol-Gel Bioactive Glass coating, enhancing the sample’s bioactivity [92]. Therefore, CoCrMo alloys require continuous improvement and optimization to meet the medical field’s material demands.

In summary, the properties of metal printing materials, such as strength, hardness, and flexibility, significantly impact implant biocompatibility performance. Table 3 presents the mechanical properties of commonly used metal printing materials and human bones [93]. The design of implants necessitates the selection of appropriate metallic printing materials based on distinct requirements. The quality and performance of these materials should be strictly controlled during implant manufacturing to ensure safety and efficacy.

Table 3

Physical properties of metal printing materials [93]

Property Stainless steel 316 L (Cast) F75 CoCrMo alloy (Cast) Cortical human bone Ti6Al4V alloy (Wrought) Aluminum alloy A357 (Cast)
Density (g·cm−3) 8.0 8.8 1.5–2 4.4 2.7
Yield strength (MPa) 205 500–1,500 80–220 830–1,070 265–275
Ultimate tensile strength (MPa) 515 900–1,800 130–190 920–1,140 331–351
Tensile modulus of elasticity (GPa) 195–205 200–230 10–30 100–110 70–75
Elastic elongation (%) 10–40 4–13 1–10 10–15 6

3.2 Degradable metal materials

Medical implants typically employ Ti alloys, stainless steel, and CoCrMo alloys [94]. However, in certain circumstances, conventional implant materials may produce stress-shielding effects and generate toxic metal ions after implantation, potentially necessitating secondary surgery for implant removal. In contrast, novel biodegradable alloys can naturally decompose within the human body after fulfilling their intended purpose, causing no harm [95–97]. Biodegradable metal materials primarily encompass magnesium-, zinc-, and iron-based materials. Magnesium has the fastest degradation rate, followed by zinc, while iron degrades the slowest. Figure 9 illustrates some applications of biodegradable metal materials in medicine [98]. Non-biodegradable alloys have been extensively used in clinics for applications such as knee replacement, stents, hip implants, dental implants, heart pacemakers, cranial plate implants, and valve replacement therapies. Degradable Mg-, Zn-, and Fe-based implants can also be utilized in some applications.

Figure 9 The applications of alloys in medicine [98].
Figure 9

The applications of alloys in medicine [98].

Magnesium-based materials are currently the most widely utilized in biodegradable metal materials [99]. Magnesium-based materials can be categorized into two major types: pure magnesium and magnesium alloys. However, due to pure magnesium’s excessively rapid degradation rate, it is infrequently selected as a medical material. Compared with pure magnesium, degradable magnesium alloys exhibit good biocompatibility and mechanical properties. The elastic modulus of magnesium alloys is close to that of natural bones, which offers unparalleled advantages in orthopedic implants [100,101]. For example, degradable magnesium alloys are used as materials for magnesium bone nails and vascular stents.

Liu et al. have employed various processing methods to enhance the properties of magnesium alloys, including adding strengthening elements, modifying surface treatments, and altering processing techniques [102–106]. These methods improve the mechanical properties, biocompatibility, and corrosion resistance of magnesium alloys, providing new avenues for their application in biomedical engineering. Furthermore, these methods also offer valuable reference values for studying other bioresorbable materials.

In recent years, a novel approach involves the incorporation of nanomaterials into 3D-printed polymers to produce versatile multifunctional composite materials that meet the diverse requirements of the biomedical field. The addition of nanomaterials enhances the mechanical properties of 3D-printed structures, providing new characteristics and additional functionalities to the printing materials [107].

4 The application of metal 3D-printing in bone implants

In recent years, the rapid advancement of 3D-printing technology in metal has had a profound impact on the field of orthopedics in medicine. This technology can be combined with CT scans to achieve personalized customization, opening up new surgical planning and treatment possibilities. By creating precise printing models of the human bone structure before surgery, this technique helps surgeons visualize the surgical site better and plan the procedure more accurately. This assists in subsequent bone replacement surgeries and reduces the risk of surgical complications, ultimately improving the treatment outcome for patients. Metal implants can be classified according to their location and purpose, such as orthopedic, joint, oral, and others.

4.1 Orthopedic implants

Orthopedic implants are generally used to treat diseases such as fractures and bone defects. Figure 10 shows joint orthopedic implants, such as bone screws, plates, nails, and dowels, which come in various shapes and sizes to treat different types of bone injuries or diseases. These implants can enhance bone stability, promote bone healing and recovery, and improve surgical outcomes and patients’ quality of life.

Figure 10 (a) Pedicle screw. It is a metal implant used in spinal surgery to provide support and compression force by being inserted into the pedicle, promoting vertebral healing and fusion [108]. (b) Cortical bone screw. It is a small metal implant used in shoulder surgery that is inserted into the medial cortex of the humeral head, promoting rotator cuff healing and recovery [109]. (c and d) Lumbar and cervical fusion devices. They are implants used in spinal surgery that fix adjacent vertebrae together, promoting bone healing and spinal stability [110]. (e) 3D Ti plate. It is a 3D-printed Ti alloy plate with high personalization and precision, commonly used as an orthopedic implant in surgical procedures [111].
Figure 10

(a) Pedicle screw. It is a metal implant used in spinal surgery to provide support and compression force by being inserted into the pedicle, promoting vertebral healing and fusion [108]. (b) Cortical bone screw. It is a small metal implant used in shoulder surgery that is inserted into the medial cortex of the humeral head, promoting rotator cuff healing and recovery [109]. (c and d) Lumbar and cervical fusion devices. They are implants used in spinal surgery that fix adjacent vertebrae together, promoting bone healing and spinal stability [110]. (e) 3D Ti plate. It is a 3D-printed Ti alloy plate with high personalization and precision, commonly used as an orthopedic implant in surgical procedures [111].

There is a wide variety of bone screws, including intracortical bone screws [112], hollow cancellous bone screws [113], and pedicle screws. With the increasing incidence of disc-related diseases in middle-aged and elderly individuals, the demand for implants such as pedicle screws and intervertebral fusion devices is increasing. Pedicle screw fixation is a primary method for treating osteoporotic fractures and degenerative spinal diseases. Morimoto et al. conducted a 12-year study on 104 patients, which showed that the use of cement-augmented pedicle screws during bone cement surgery could reduce the incidence of complications such as cement leakage and pulmonary embolism [114,115].

Applying bone screws and plates, independently or in combination, is a commonly employed practice in orthopedic surgery. These devices are classified into various categories based on their specific sites of implantation, such as intramedullary nails and fibular nails [116]. Through modification of their design and utilization of diverse printing materials, superior fusion outcomes can be achieved, accompanied by a reduction in complications and an enhancement of postoperative patient quality of life [117–119].

In recent years, the emergence of biodegradable bone nails has brought breakthroughs in the medical field. For example, for the first time, Kačarević et al. designed and tested a biodegradable magnesium fixation screw made of WZM211 magnesium alloy with an MgF2 coating for application in guided bone regeneration oral surgery. The fixation screw met the standards of sufficient mechanical fixation, total absorption when no longer needed, complete bone replacement, excellent biocompatibility, and clinical manageability. Researchers compared the coated magnesium alloy to other equivalent absorbable polymers. After 4 weeks of degradation, the results indicated that the mechanical properties of the magnesium alloy were slightly superior to other polymer materials. In vitro and in vivo tests examined the degradation of the magnesium screw, revealing complete, slow absorption after 52 weeks, providing ample fixation during the critical early healing phase. The magnesium fixation screw exhibited all the essential characteristics desired for GBR surgery [120].

Zhao’s team combined PT with exosomes derived from bone marrow mesenchymal stem cells (BMSCs), demonstrating that exosomes promoted BMSC proliferation and differentiation [121]. Subsequently, they constructed an integrated three-dimensional scaffold material using PT and gelatin nanosphere hydrogel, which was implanted with endothelial cells derived from BMSCs for vascular tissue engineering. Experimental outcomes revealed that PTa-GNPs exhibited excellent biocompatibility [122]. Finally, they fabricated personalized PTi bone plates using EBM and coated them with Ta metal using chemical vapor deposition technology. In vitro experiments indicated that, compared to conventional PTi containers, the Ta coating significantly enhanced cell adhesion and proliferation on the scaffold’s surface, laying the foundation for research and application of 3D-printed implants [123].

4.2 Joint implants

Joint implants are widely used for joint repair and replacement, such as the hip, shoulder, and knee joints [124]. Total hip replacement is the most common method in hip joint replacement surgery [125]. Total hip replacement involves replacing the worn cartilage and bone with four components: the femur, the stem, the acetabulum, and the femoral head [126]. However, wear on the joint surface can limit the implant’s lifespan. To address this issue, Cui et al. validated that interface lubrication is more effective in reducing wear than increasing material hardness [127]. They improved joint implants’ performance by optimizing the joint’s surface structure and performing porous treatment.

Knee osteoarthritis is a degenerative disease that affects the elderly, mainly caused by the wear and tear of joint cartilage and degenerative changes in the structures around the joint. Total knee arthroplasty is the ultimate treatment option for patients with severe knee osteoarthritis [128]. Total knee arthroplasty effectively relieves pain, restores joint function, and improves the quality of life by implanting an artificial joint [129].

Total shoulder arthroplasty replaces damaged parts of the patient’s shoulder joint with prosthetics, relieving pain and improving mobility. There are two types of total shoulder arthroplasty: reverse and anatomical [130]. Currently, the number of reverse total shoulder prostheses is significantly higher than anatomical total shoulder prostheses [131,132]. Personalized reverse shoulder prostheses with a customized design can effectively reduce the local stress of screws, ensuring the safety and effectiveness of the material during use. Therefore, personalized shoulder joint prostheses have significant application value in total shoulder arthroplasty [133].

Figure 11 shows the total hip, knee, and shoulder joint implants. Personalized joint implants can alleviate joint pain and restore joint function caused by common diseases or injuries. However, their use requires careful consideration of surgical risk, implant failure, postoperative pain, restricted activity, and high cost. Therefore, a comprehensive evaluation is needed when applying them in practice.

Figure 11 (a) Total hip prosthesis [125], (b) total knee prosthesis [128], and (c) the model of personalized reverse shoulder joint prosthesis that faces the shoulder joint [133].
Figure 11

(a) Total hip prosthesis [125], (b) total knee prosthesis [128], and (c) the model of personalized reverse shoulder joint prosthesis that faces the shoulder joint [133].

4.3 Oral implants

Oral implants are typically used to fix dentures or repair teeth to restore oral function and aesthetics, such as dental implants, maxillofacial implants, and so on [134]. The biological and mechanical properties of dental implants are influenced by various factors, including the threaded implant portion’s shape, depth, width, and rotational speed [135]. Alemayehu and Jeng conducted a design experiment on five types of thread structures [136]. The structures are shown in Figure 12(a). They found that square thread structures are the most suitable for dental implant applications, as they can reduce stress and displacement while increasing compressive stress. As shown in Figure 12(b), dental implants can be divided into single- and double-root implants [137–139]. 3D-printed double-root implants exhibit considerable stability and bone remodeling around the fixture, but bone loss in the bifurcation area remains a problem [140].

Figure 12 (a) Schematic thread diagram of the implant part of dental implant: square, buttress, reverse buttress, trapezoidal, and triangular [136]. (b) Mandible implant design (it is used to reconstruct or repair mandible) [140]. (c) 3D-printed YSZ samples [141]. (d) Schematic diagram of the square thread structure implant teeth [142].
Figure 12

(a) Schematic thread diagram of the implant part of dental implant: square, buttress, reverse buttress, trapezoidal, and triangular [136]. (b) Mandible implant design (it is used to reconstruct or repair mandible) [140]. (c) 3D-printed YSZ samples [141]. (d) Schematic diagram of the square thread structure implant teeth [142].

Vasylyev et al. investigated the influence of 3D-printing parameters on the macro- and micro-structures, mechanical properties, and thermal conditions of yttria-stabilized zirconia (YSZ) ceramics used in dental prosthetics. Their research highlighted the importance of thermal conditions during 3D-printing in shaping the solidification microstructure, including density, grain size, and crystalline phase composition. It also evaluated the actual hardness and biaxial flexural strength of 3D-printed YSZ samples and emphasized the benefits of 3D-printing ceramics in dentistry [141], as shown in Figure 12(c).

Both the maxilla and the alveolar ridge are part of the oral cavity, and due to the irregular and complex maxillofacial anatomy, implant shapes must be adapted to bone surfaces [142]. As shown in Figure 12(d), Yang et al. used patient-specific Ti implants (PSTI) to reconstruct mandibular contour defects in two patients with mandibular asymmetry (including angle reduction). The experiment showed that PSTI can be used as an additional cosmetic surgery procedure [143–145].

4.4 Other implants

In addition to common metallic implants, there are other types of implants, such as neural implants, dermal implants, ophthalmic implants, and otolaryngological implants. Different types of implants vary in shape, material, and manufacturing process, so choosing the appropriate implant according to the specific situation is necessary.

Aesthetics are critical in people’s lives, and the orbital and midfacial regions are vital areas of patients’ identity and appearance. Computer-aided 3D-printing is an indispensable means of reconstructing the orbit [146,147]. In treating comminuted fractures of the radial head, personalized radial head prosthesis implantation surgery is a convenient, short-duration, almost complete preservation, and effective treatment method [148].

In vascular implant engineering, biodegradable metal stents represent a breakthrough technology with enormous potential to revolutionize the vascular industry. However, there is currently a lack of printable materials suitable for natural degradation and clinical use inside the body. Shi et al. modified the corrosion resistance of magnesium alloy stents through surface modification and introduced the concept of a corrosion function for in vivo implants to develop a multidimensional, non-uniform corrosion model for simulating the corrosion process of in vivo implants [149–151].

5 Performance improvement of implants

With the continuous advancement of technology, the performance of implants is constantly being improved and enhanced. Techniques such as surface modification, porous structure optimization, and parameter optimization in printing have improved implants’ adaptability, accuracy, biocompatibility, and safety. As a result, the efficacy and quality of implants have been elevated, leading to a better medical experience and outcome for patients.

5.1 Surface modification

Implants undergo corrosion within the human body, leading to alterations in material structures and the release of harmful byproducts, potentially causing toxic reactions and inflammation [152]. Consequently, research on improving implants’ corrosion resistance and antimicrobial properties has emerged as a popular trend. Surface modification techniques commonly employed can be divided into three main categories: biological, chemical, and physical modifications [153,154]. The osteogenic, antibacterial, wear-resistant, and antioxidative properties of implants can be enhanced through surface modification. Scientists are actively investigating this field, continuously exploring novel methods and technologies to improve implant performance further [155].

Biological modification involves utilizing biotechnology to alter the implant surface, aiming to enhance biocompatibility, reduce injury, and augment bioactivity by improving interactions between the implant and biological entities. Common methods include biological cell and osteogenic induction, which promote bone regeneration and integration between the implant and surrounding tissues. For instance, Meesuk et al. demonstrated the proliferation and osteogenic differentiation potentials of MSCs cultured on two types of 3D-printed hydroxyapatite, including a 3D-printed HA and biomimetic calcium phosphate-coated 3D-printed HA. The experimental results revealed that the HA scaffolds could provide a suitable and favorable environment for the 3D culture of MSCs in bone tissue engineering. Additionally, biomimetic coating with octacalcium phosphate may improve the biocompatibility of the bone regeneration scaffold [156]. Zhao et al. demonstrated that Ti implants with CSMA/CaCO3 or BMSCs could promote adhesion and proliferation of BMSCs [157–160]. As illustrated in Figure 13(a), Wang et al. combined BMSC cell sheets with 3D-printed PT alloy scaffolds and cultured cells, comparing them with PT scaffolds without BMSCs. The co-cultured experimental group exhibited superior adhesion, proliferation, and osteogenic potential, making them suitable for manufacturing biomimetic-engineered bones [161].

Figure 13 (a) Schematic diagram depicting the biologically modified cell induction process [161]. (b) Schematic diagram of chemical modification/electrophoretic deposition [177]. (c) Schematic diagram of femtosecond laser processing/polydopamine bonding/bone bonding [181]. (d) Surface modification of zirconia implants. Schematic representation of various surface topographical, bioactive, and chemical modifications and the nano-engineered topographies [182].
Figure 13

(a) Schematic diagram depicting the biologically modified cell induction process [161]. (b) Schematic diagram of chemical modification/electrophoretic deposition [177]. (c) Schematic diagram of femtosecond laser processing/polydopamine bonding/bone bonding [181]. (d) Surface modification of zirconia implants. Schematic representation of various surface topographical, bioactive, and chemical modifications and the nano-engineered topographies [182].

Chemical surface modification techniques include anodic oxidation [162], chemical vapor deposition [163], micro-arc oxidation, and electrophoretic deposition [164,165], among others. These techniques can form chemical bonds, connecting new materials and strengthening their constraints. Sui et al. have improved implant osseointegration capabilities through Ta coatings [166], graphene oxide [167–171]/zinc oxide nanocomposite coatings [172], octacalcium phosphate biomimetic coatings [173], and methods combining ultrasonic etching with anodic oxidation [174]. Concurrently, Maher et al. overcame the limitations of traditional implants by utilizing chemical surface modification techniques on a nanostructured surface to achieve a highly effective antibacterial surface with dual cell compatibility [175,176]. As shown in Figure 13(b), Akshay et al. employed electrophoretic deposition to develop alginate/bioactive glass composite coatings and investigated their effects on the biodegradation, bioactivity, and biocompatibility of magnesium–calcium alloys [177]. By employing electrochemical corrosion measurements in NaCl solutions and in vitro degradation tests using simulated body fluids, it was discovered that the coated samples exhibited superior degradation resistance and bioactivity compared to bare magnesium–calcium alloys.

Physical modifications primarily alter the ultrafine structure (micro/nanostructure) of the implant surface and include techniques such as laser surface engineering, arc ion plating, shot peening, and ultrasonic nanotechnology. Physical modifications are typically employed to enhance wear resistance, corrosion resistance, and antioxidative properties of implants. For example, Wang et al. achieved an optimal micro-groove width of 45 μm on the surface of Ti alloy implants, enhancing the biocompatibility of the implant [178]. Sun et al. improved the musculoskeletal performance of orthopedic implants by generating a dual micro/nano-morphology on the natural surface of SLM Ti [179]. As shown in Figure 13(c), Jiao et al. utilized a femtosecond laser to create micro-groove structures on the surface of Ti6Al4V scaffolds, which were combined with polydopamine to optimize the material–bone interface. The modified surface exhibited enhanced antibacterial properties, providing a superior advantage over the original surface [180]. The comparative study by Chenakin et al. explored the ramifications of ultrasonic impact treatment on the Zr31Ti18Nb alloy. It comprehensively analyzed the s microstructure, surface composition, roughness, hardness, and corrosion properties of the alloy. Their findings revealed that the single-pin impacting mode exhibited the most substantial surface modifications attributed to the heightened energy and power densities involved [181].

Chopra and associates applied physical, chemical, and biological modifications concurrently to dental implants, as illustrated in Figure 13(d). Physical modification optimized the implant surface roughness. Chemical modification enhanced the implant’s bioactivity, and biological modification augmented osteoblast function, induced hydroxyapatite formation, promoted osteogenesis, and achieved antimicrobial capabilities. Surface modification increased the bioactivity of zirconia implants, accelerating their osseointegration capacity [182].

5.2 Porous structure

Addressing infectious bone defects has long posed a challenge in orthopedics. Traditional metallic implants exhibit considerable elastic modulus discrepancies with host bones, potentially leading to complications such as aseptic loosening with prolonged use. Porous structures, on the other hand, allow for tailored implant elastic modulus and feature interconnected pore architectures, fostering suitable biomimetic microenvironments for cell proliferation and nutrient transport [183,184]. Gradient porous designs, closely resembling natural bone structures, hold immense potential. Consequently, it is imperative to investigate these gradient designs further to enhance implant biocompatibility and osteogenic performance, providing more effective solutions for treating infectious bone defects and other orthopedic ailments [185].

If porous bone implants possess an elastic modulus akin to natural bone, they will exhibit exceptional compressive strength and energy absorption capabilities, effectively circumventing subsidence and achieving superior osseointegration [186,187]. Zhai et al. conducted comparative experiments on octahedral structures, concluding that a unit cell length of 1.5 mm and a diameter of 0.4 mm yielded optimal mechanical properties closely resembling human bone [188]. Furthermore, in vitro studies by Torres-Sanchez et al. comparing triply periodic minimal surfaces and pillar-based trabecular scaffolds revealed accelerated cell proliferation rates in the latter [189]. Izri et al. proposed various unit-cell structures in total hip arthroplasty, as illustrated in Figure 14. Through simulation and experimentation, they determined the optimal parameters for Ti alloys to be 3.5 mm unit cell size and 0.6 mm strut thickness. In contrast, CoCrMo alloys necessitated thicker strut dimensions (approximately 0.8 mm). These parameters can yield better porous implant designs to enhance biocompatibility and osteogenic properties for improved application in orthopedics [190].

Figure 14 The design of a porous crystal lattice structure [190].
Figure 14

The design of a porous crystal lattice structure [190].

In recent years, research on porous structures has primarily focused on designing homogeneous porous configurations [191,192]. For instance, Przekora et al. have developed a homogeneous porous interbody fusion cage made from the Ti6Al4V material that exhibits outstanding bioactivity, osteoconductivity, and surface adhesion [193]. The Ti6Al4V interbody fusion cage outperforms common orthopedic implant materials like PEEK in osteoconductivity [194]. Researchers have proposed gradient porous structure designs to accommodate complex stress–strain scenarios encountered in practical applications [195,196]. These designs emulate nature’s gradient structural distributions to augment implant biocompatibility and osteogenic performance while adapting to varying physiological and mechanical environments at different sites [197,198]. Therefore, studying gradient porous structures bears significant theoretical and practical implications for devising superior porous implant design strategies.

Beyond mechanical properties, porous designs must also address porosity concerns. Yu et al. devised morphological gradient scaffolds with 50, 60, and 70% porosities. Among these, the 50% porosity scaffold exhibited exceptional mechanical properties and favorable cell compatibility, suitable for bone defect repair [199]. Mondal et al. modeled various homogeneous porous structures with different morphologies, including rhombic, grid, cross, and vines. Research findings indicated that maintaining a theoretical porosity of 65% for scaffolds produced a more compatible elastic modulus with human bone, which helps to reduce stress shielding effects and extend implant longevity [200]. These studies underscore the importance of porosity as a critical factor to consider when designing porous implant devices.

5.3 Optimization of processing

During the 3D-printing process, different processing methods impact implants’ mechanical properties and biocompatibility. These influencing factors include deposition angle, printing temperature, heat treatment, and slicing-related parameters. Therefore, to obtain implants with excellent mechanical performance and biocompatibility, it is necessary to consider these factors when 3D-printing the implants comprehensively.

5.3.1 Deposition angle

SLM is a powerful technology that enables the production of implants with complex geometries to meet the personalized needs of patients. However, research indicates that different deposition angles can impact the physical properties and printing accuracy of implants, thereby affecting their mechanical performance [201–203].

Kobayashi et al. investigated the effects of deposition angle on the accuracy and defects of removable partial denture (RPD) frameworks fabricated using SLM, as shown in Figure 15(a). Three different deposition angle conditions were tested (0°, 45°, and −45°). The results showed that at a deposition angle of 0°, the overall shape error of the RPD framework was small, and the number of supporting structures was the highest. However, many internal defects were observed in the RPD framework at deposition angles of 45° and −45°. Additionally, the surface roughness was the smallest under the −45° condition [204].

Figure 15 (a) Schematic diagram of three different deposition angles of the RPD framework [204]. (b) Illustration of the production angles and the sample codes. (c) The calculated pair distance distribution functions (PDDFs) (p(r)) as a function of the radial distance of r: an ideal monodispersed nanostructured sample shows a smooth hump. (d) Electron density distributions (EDDs) calculated from PDDFs of samples and a view of the ideal case: the fluctuations are not required for uniform implants [205].
Figure 15

(a) Schematic diagram of three different deposition angles of the RPD framework [204]. (b) Illustration of the production angles and the sample codes. (c) The calculated pair distance distribution functions (PDDFs) (p(r)) as a function of the radial distance of r: an ideal monodispersed nanostructured sample shows a smooth hump. (d) Electron density distributions (EDDs) calculated from PDDFs of samples and a view of the ideal case: the fluctuations are not required for uniform implants [205].

As shown in Figure 15(b), Bayirli et al. calculated the PDDF and EDD of samples with different deposition angles using small-angle X-ray scattering data. From Figure 15(c) and (d), it can be observed that the peak shape of the PDDF for samples 4–50 is smoother than that of the PDDFs for other angles, indicating that the nanospheres in this sample have a smaller radius and higher precision. Therefore, it can be concluded that a production angle of 50° yields the best sample. Additionally, the EDD shows that samples 4–50 have a more compact structure, uniform EDD, and more stable nano- and micro-scale structures. According to all the study results, uniformity increases with an increase in the production angle, up until 50°, and then gradually decreases [205].

The research findings indicate that the deposition angle significantly impacts the mechanical performance and surface quality of implants. Therefore, careful consideration of the impact of the deposition angle is necessary during 3D-printing to obtain implants with excellent mechanical performance and surface quality [206].

5.3.2 Heat treatment and printing temperature

In 3D-printed implants, the mechanical properties and biocompatibility of the materials can be significantly improved by controlling the printing temperature and conducting heat treatment [207]. Heat treatment involves two processes, heating and cooling, and can handle the material’s properties by changing the rates and temperatures of heating and cooling [208].

Zang et al. investigated the effects of EBM ultra-low temperature processing on the properties of Ti alloy components. They found that at a temperature of 20 K, the fracture elongation reached 20.0%, resulting in a high ultimate tensile strength of 1,500 MPa [209]. Jichang et al. utilized SLM technology to manufacture Co–Cr alloy implants for dental applications and examined the effects of heat treatment on their mechanical properties. The research findings indicated that the wear resistance of Co–Cr alloy implants increased first and then decreased with the increase of the heat treatment temperature. At 950℃, the critical load, nano hardness, and H 3/E 2 value reached their maximum values, while the scratch resistance was also the highest [210]. Srinivasan et al. conducted heat treatment on printed parts at 800 and 1,100°C in vacuum and air. The results indicated little difference in microstructure and mechanical properties when heat treatment was conducted in air or vacuum at 800℃. However, at 1,100℃, heat treatment in a vacuum had a beneficial effect on the printed parts, whereas it was not feasible in air [211].

As shown in Figure 16, Mao et al. investigated the effects of vacuum heat treatment (temperature range of 1,300–1,400°C) on the density, porosity, linear shrinkage, microstructure evolution, and tensile properties of 316L stainless steel. The research findings indicated that after heat treatment at 1,380℃, the relative density of the sintered 316L reached 92.0% and exhibited good mechanical properties (ultimate tensile strength of up to 473.7 MPa and elongation of up to 40.22%) [212].

Figure 16 Schematic illustration of the 316L process including 316L powder and binder preparation, BJ printing process, low-temperature curing, de-powdering, high-temperature debinding and sintering, and post-processing [212].
Figure 16

Schematic illustration of the 316L process including 316L powder and binder preparation, BJ printing process, low-temperature curing, de-powdering, high-temperature debinding and sintering, and post-processing [212].

Zhou et al. utilized SLM technology to fabricate Co–Cr samples and investigated the effect of different annealing temperatures (850, 950, 1,050, and 1150°C) on their properties. The study demonstrated that Co–Cr samples fabricated by SLM exhibited higher bonding strength and better fracture interface characteristics under the annealing condition of 1,150°C [213].

Rajendran and Pattanayak enhanced the biocompatibility of porous scaffolds through heat treatment and surface modification, including coverage with Ag nanoparticles, Ca2+ ions, and TiO2 layers. The study found that the combination of SLM technology, heat treatment, and surface modification can effectively prepare implants with biologically active, antibacterial, and osteocompatible properties [214].

However, heat treatment may also have a negative impact on the performance of implants. For instance, excessively high temperatures or prolonged treatment times may cause the material’s grains to grow, reducing the strength and toughness. Heat treatment may also result in material deformation or cracking, reducing its availability and reliability. Therefore, when performing heat treatment for 3D-printed implants, choosing and controlling the processing parameters reasonably is necessary based on the material’s characteristics and application requirements. Moreover, thorough experimentation and testing are required to ensure that heat treatment positively impacts the performance of implants, thereby enhancing their clinical application value [215].

6 Biological implantation experiments

The requirements for a metal material to be allowed for implantation in the human body involve a rigorous process to ensure the safety and effectiveness of the device. The procedures typically involve regulatory approval, quality control, and clinical testing. Preclinical testing involves laboratory and animal studies to assess the implant’s safety and performance. Factors such as biocompatibility, toxicity, mechanical stability, and material properties should be evaluated. It is common practice to conduct in vivo experiments by placing the metal additive manufactured implant into animals to observe its compatibility with surrounding tissues and inflammatory response.

As shown in Figure 17(a), Yan et al. used a degradable Mg alloy in guided bone regeneration for treating bone defects after tooth extraction. Mg exhibited higher trabecular volume/total volume, indicating improved osteogenesis. The Mg alloy completely degraded within 3 months, forming new bone near the degradation products. Although the concentration of rare-earth elements in mandibular lymph nodes was higher in the Mg, no histopathological changes were observed. Overall, the Mg alloy displayed promising potential for guided bone regeneration, and further optimization of the degradation rate can enhance its osteogenic effect [216]. Mahmoud et al. found that the implantation of a Ti/Al-alloy device coated with bHA in dogs’ femur bones was safe and biocompatible. The bHA-coated alloy exhibited high osteoconductivity, promoting new bone formation and seamless integration with the original bone, as shown in Figure 17(b). After 90 days, the coated alloy assimilated within the bone without appearing as a foreign body. Scanning electron microscopy, energy-dispersive X-ray, histology analyses, and blood tests confirmed the safety and effectiveness of the coated device [217]. Seong et al. conducted a biological experiment in the oral cavity of hunting dogs to observe potential causes of treatment failure for inflammation around dental implants [218]. Zhou et al. experimented with mice to observe the causes of hip position performance and hip joint capsule laxity [219]. Sun et al. validated a rat femoral fracture model. They conducted a multimodal long-term in vivo monitoring study of the dynamic bone healing process using external fixation and intramedullary magnesium implants. The results demonstrated that the fracture healing process could be observed through in vivo imaging techniques such as X-ray, micro-CT, and ultrasound. The combined application of external fixation and intramedullary magnesium implants showed excellent efficacy in the dynamic in vivo monitoring of the bone healing process [220].

Figure 17 (a) Guided bone regeneration surgical procedure [216]. (b) In vivo evaluation of the biogenic hydroxyapatite (bHA) coating on titanium–aluminum alloy implants in canine femur [217].
Figure 17

(a) Guided bone regeneration surgical procedure [216]. (b) In vivo evaluation of the biogenic hydroxyapatite (bHA) coating on titanium–aluminum alloy implants in canine femur [217].

7 Issues and challenges in the current field

Metal 3D-printing faces multiple challenges and issues in the field of implants, including biocompatibility, material selection, precision and surface quality, printing speed and efficiency, material cost, and sustainability. Through continuous research and technological innovation, these challenges will gradually be addressed, thereby driving the development and application of metal 3D-printed implants.

The main challenge currently faced by metallic implants is biocompatibility, which refers to a material’s ability to interact with living organisms without adversely affecting physiological functions such as inflammation, carcinogenesis, and immune rejection. Depending on the specific application, differing degrees of biocompatibility are required for materials. Improper use of implants may result in bone infections, a notoriously difficult issue to address. Furthermore, implants may provoke hypersensitivity reactions within the human body, and the incidence of aseptic loosening leading to revision surgery remains high. To tackle these problems, further optimization of the metal implants through surface modification and porous structure design is recommended.

Material selection is also a crucial aspect. Implants necessitate materials with excellent biocompatibility, enabling compatibility with human tissues and promoting bone growth and regeneration. In addition, the materials should possess adequate strength and durability to ensure the long-term stability of the implants within the body. The precision and surface quality of metal 3D-printing technology are also critical factors. The shape and dimensions of the implants are crucial for the effectiveness of the treatment for patients, thus requiring high precision in the printing process. Furthermore, the surface quality of the implants plays a vital role in their integration with surrounding tissues and biocompatibility. Another challenge is the improvement of printing speed and efficiency. Metal 3D-printing is typically a relatively slow process. The prolonged printing cycles can cause delays in patient treatment and recovery. Therefore, it is necessary to research and optimize printing parameters to enhance printing speed and efficiency while ensuring printing quality and stability. Moreover, there is a need to address the issues of material cost and sustainability. Metal printing materials are typically expensive, which may limit the widespread application of implants. The search for more cost-effective material choices and sustainable metal 3D-printing process development are valuable topics worth investigating.

In conclusion, metal 3D-printing for implants is a promising but challenging field. Biocompatibility remains a primary concern, with a need for ongoing research into surface modification and porous structure design to minimize adverse effects on the human body. Material selection, mechanical properties modification, and surface quality are vital for effective treatment. Manufacture efficiency is essential to reduce patient waiting times, and addressing material cost and sustainability issues is crucial for wider adoption. Through continuous research and technological advancements, the field of metal 3D-printed implants is expected to overcome these challenges, driving innovation, and enhancing the availability of effective and affordable implant solutions for patients in need.

Acknowledgments

The authors thank their research classmates for their valuable work and for providing experimental data, and the anonymous reviewers for their critiques and comments.

  1. Funding information: This research is financially funded by the General Program from the Educational Commission of Liaoning Province of China (Grant No. LJKZ0500).

  2. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Conflict of interest: The authors state no conflict of interest.

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Received: 2023-07-11
Revised: 2023-10-08
Accepted: 2023-11-02
Published Online: 2023-11-29

© 2023 the author(s), published by De Gruyter

This work is licensed under the Creative Commons Attribution 4.0 International License.

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https://doi.org/10.1515/rams-2023-0148
Keywords for this article
additive manufacturing; medical implants; metal and alloys; orthopedics surface modification; biocompatibility
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  19. Research evolution on self-healing asphalt: A scientometric review for knowledge mapping
  20. Recent developments in the mechanical properties of hybrid fiber metal laminates in the automotive industry: A review
  21. A review of microscopic characterization and related properties of fiber-incorporated cement-based materials
  22. Comparison and review of classical and machine learning-based constitutive models for polymers used in aeronautical thermoplastic composites
  23. Gold nanoparticle-based strategies against SARS-CoV-2: A review
  24. Poly-ferric sulphate as superior coagulant: A review on preparation methods and properties
  25. A review on ceramic waste-based concrete: A step toward sustainable concrete
  26. Modification of the structure and properties of oxide layers on aluminium alloys: A review
  27. A review of magnetically driven swimming microrobots: Material selection, structure design, control method, and applications
  28. Polyimide–nickel nanocomposites fabrication, properties, and applications: A review
  29. Design and analysis of timber-concrete-based civil structures and its applications: A brief review
  30. Effect of fiber treatment on physical and mechanical properties of natural fiber-reinforced composites: A review
  31. Blending and functionalisation modification of 3D printed polylactic acid for fused deposition modeling
  32. A critical review on functionally graded ceramic materials for cutting tools: Current trends and future prospects
  33. Heme iron as potential iron fortifier for food application – characterization by material techniques
  34. An overview of the research trends on fiber-reinforced shotcrete for construction applications
  35. High-entropy alloys: A review of their performance as promising materials for hydrogen and molten salt storage
  36. Effect of the axial compression ratio on the seismic behavior of resilient concrete walls with concealed column stirrups
  37. Research Articles
  38. Effect of fiber orientation and elevated temperature on the mechanical properties of unidirectional continuous kenaf reinforced PLA composites
  39. Optimizing the ECAP processing parameters of pure Cu through experimental, finite element, and response surface approaches
  40. Study on the solidification property and mechanism of soft soil based on the industrial waste residue
  41. Preparation and photocatalytic degradation of Sulfamethoxazole by g-C3N4 nano composite samples
  42. Impact of thermal modification on color and chemical changes of African padauk, merbau, mahogany, and iroko wood species
  43. The evaluation of the mechanical properties of glass, kenaf, and honeycomb fiber-reinforced composite
  44. Evaluation of a novel steel box-soft body combination for bridge protection against ship collision
  45. Study on the uniaxial compression constitutive relationship of modified yellow mud from minority dwelling in western Sichuan, China
  46. Ultrasonic longitudinal torsion-assisted biotic bone drilling: An experimental study
  47. Green synthesis, characterizations, and antibacterial activity of silver nanoparticles from Themeda quadrivalvis, in conjugation with macrolide antibiotics against respiratory pathogens
  48. Performance analysis of WEDM during the machining of Inconel 690 miniature gear using RSM and ANN modeling approaches
  49. Biosynthesis of Ag/bentonite, ZnO/bentonite, and Ag/ZnO/bentonite nanocomposites by aqueous leaf extract of Hagenia abyssinica for antibacterial activities
  50. Eco-friendly MoS2/waste coconut oil nanofluid for machining of magnesium implants
  51. Silica and kaolin reinforced aluminum matrix composite for heat storage
  52. Optimal design of glazed hollow bead thermal insulation mortar containing fly ash and slag based on response surface methodology
  53. Hemp seed oil nanoemulsion with Sapindus saponins as a potential carrier for iron supplement and vitamin D
  54. A numerical study on thin film flow and heat transfer enhancement for copper nanoparticles dispersed in ethylene glycol
  55. Research on complex multimodal vibration characteristics of offshore platform
  56. Applicability of fractal models for characterising pore structure of hybrid basalt–polypropylene fibre-reinforced concrete
  57. Influence of sodium silicate to precursor ratio on mechanical properties and durability of the metakaolin/fly ash alkali-activated sustainable mortar using manufactured sand
  58. An experimental study of bending resistance of multi-size PFRC beams
  59. Characterization, biocompatibility, and optimization of electrospun SF/PCL composite nanofiber films
  60. Morphological classification method and data-driven estimation of the joint roughness coefficient by consideration of two-order asperity
  61. Prediction and simulation of mechanical properties of borophene-reinforced epoxy nanocomposites using molecular dynamics and FEA
  62. Nanoemulsions of essential oils stabilized with saponins exhibiting antibacterial and antioxidative properties
  63. Fabrication and performance analysis of sustainable municipal solid waste incineration fly ash alkali-activated acoustic barriers
  64. Electrostatic-spinning construction of HCNTs@Ti3C2T x MXenes hybrid aerogel microspheres for tunable microwave absorption
  65. Investigation of the mechanical properties, surface quality, and energy efficiency of a fused filament fabrication for PA6
  66. Experimental study on mechanical properties of coal gangue base geopolymer recycled aggregate concrete reinforced by steel fiber and nano-Al2O3
  67. Hybrid bio-fiber/bio-ceramic composite materials: Mechanical performance, thermal stability, and morphological analysis
  68. Experimental study on recycled steel fiber-reinforced concrete under repeated impact
  69. Effect of rare earth Nd on the microstructural transformation and mechanical properties of 7xxx series aluminum alloys
  70. Color match evaluation using instrumental method for three single-shade resin composites before and after in-office bleaching
  71. Exploring temperature-resilient recycled aggregate concrete with waste rubber: An experimental and multi-objective optimization analysis
  72. Study on aging mechanism of SBS/SBR compound-modified asphalt based on molecular dynamics
  73. Evolution of the pore structure of pumice aggregate concrete and the effect on compressive strength
  74. Effect of alkaline treatment time of fibers and microcrystalline cellulose addition on mechanical properties of unsaturated polyester composites reinforced by cantala fibers
  75. Optimization of eggshell particles to produce eco-friendly green fillers with bamboo reinforcement in organic friction materials
  76. An effective approach to improve microstructure and tribological properties of cold sprayed Al alloys
  77. Luminescence and temperature-sensing properties of Li+, Na+, or K+, Tm3+, and Yb3+ co-doped Bi2WO6 phosphors
  78. Effect of molybdenum tailings aggregate on mechanical properties of engineered cementitious composites and stirrup-confined ECC stub columns
  79. Experimental study on the seismic performance of short shear walls comprising cold-formed steel and high-strength reinforced concrete with concealed bracing
  80. Failure criteria and microstructure evolution mechanism of the alkali–silica reaction of concrete
  81. Mechanical, fracture-deformation, and tribology behavior of fillers-reinforced sisal fiber composites for lightweight automotive applications
  82. UV aging behavior evolution characterization of HALS-modified asphalt based on micro-morphological features
  83. Preparation of VO2/graphene/SiC film by water vapor oxidation
  84. A semi-empirical model for predicting carbonation depth of RAC under two-dimensional conditions
  85. Comparison of the physical properties of different polyimide nanocomposite films containing organoclays varying in alkyl chain lengths
  86. Effects of freeze–thaw cycles on micro and meso-structural characteristics and mechanical properties of porous asphalt mixtures
  87. Flexural performance of a new type of slightly curved arc HRB400 steel bars reinforced one-way concrete slabs
  88. Alkali-activated binder based on red mud with class F fly ash and ground granulated blast-furnace slag under ambient temperature
  89. Facile synthesis of g-C3N4 nanosheets for effective degradation of organic pollutants via ball milling
  90. DEM study on the loading rate effect of marble under different confining pressures
  91. Conductive and self-cleaning composite membranes from corn husk nanofiber embedded with inorganic fillers (TiO2, CaO, and eggshell) by sol–gel and casting processes for smart membrane applications
  92. Laser re-melting of modified multimodal Cr3C2–NiCr coatings by HVOF: Effect on the microstructure and anticorrosion properties
  93. Damage constitutive model of jointed rock mass considering structural features and load effect
  94. Thermosetting polymer composites: Manufacturing and properties study
  95. CSG compressive strength prediction based on LSTM and interpretable machine learning
  96. Axial compression behavior and stress–strain relationship of slurry-wrapping treatment recycled aggregate concrete-filled steel tube short columns
  97. Space-time evolution characteristics of loaded gas-bearing coal fractures based on industrial μCT
  98. Dual-biprism-based single-camera high-speed 3D-digital image correlation for deformation measurement on sandwich structures under low velocity impact
  99. Effects of cold deformation modes on microstructure uniformity and mechanical properties of large 2219 Al–Cu alloy rings
  100. Basalt fiber as natural reinforcement to improve the performance of ecological grouting slurry for the conservation of earthen sites
  101. Interaction of micro-fluid structure in a pressure-driven duct flow with a nearby placed current-carrying wire: A numerical investigation
  102. A simulation modeling methodology considering random multiple shots for shot peening process
  103. Optimization and characterization of composite modified asphalt with pyrolytic carbon black and chicken feather fiber
  104. Synthesis, characterization, and application of the novel nanomagnet adsorbent for the removal of Cr(vi) ions
  105. Multi-perspective structural integrity-based computational investigations on airframe of Gyrodyne-configured multi-rotor UAV through coupled CFD and FEA approaches for various lightweight sandwich composites and alloys
  106. Influence of PVA fibers on the durability of cementitious composites under the wet–heat–salt coupling environment
  107. Compressive behavior of BFRP-confined ceramsite concrete: An experimental study and stress–strain model
  108. Interval models for uncertainty analysis and degradation prediction of the mechanical properties of rubber
  109. Preparation of PVDF-HFP/CB/Ni nanocomposite films for piezoelectric energy harvesting
  110. Frost resistance and life prediction of recycled brick aggregate concrete with waste polypropylene fiber
  111. Synthetic leathers as a possible source of chemicals and odorous substances in indoor environment
  112. Mechanical properties of seawater volcanic scoria aggregate concrete-filled circular GFRP and stainless steel tubes under axial compression
  113. Effect of curved anchor impellers on power consumption and hydrodynamic parameters of yield stress fluids (Bingham–Papanastasiou model) in stirred tanks
  114. All-dielectric tunable zero-refractive index metamaterials based on phase change materials
  115. Influence of ultrasonication time on the various properties of alkaline-treated mango seed waste filler reinforced PVA biocomposite
  116. Research on key casting process of high-grade CNC machine tool bed nodular cast iron
  117. Latest research progress of SiCp/Al composite for electronic packaging
  118. Special Issue on 3D and 4D Printing of Advanced Functional Materials - Part I
  119. Molecular dynamics simulation on electrohydrodynamic atomization: Stable dripping mode by pre-load voltage
  120. Research progress of metal-based additive manufacturing in medical implants
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