ADVANCING METALLIC BIOMATERIALS FOR BIOMEDICAL IMPLANTS: A COMPREHENSIVE INTEGRATIVE REVIEW

Objective: The aim of this study is to investigate advancements in metallic biomaterials for biomedical implants, with the goal of enhancing patient safety and reducing mortality risks associated with medical procedures. Theoretical Framework: In this study, the theoretical framework draws upon concepts such as biocompatibility, advanced manufacturing techniques, and the role of artificial intelligence in improving implant performance and patient outcomes. These theories provide a solid foundation for understanding the context and significance of the research. Method: The methodology adopted for this research comprises an integrative literature review model. Specific steps included formulating a guiding question using the PICO/PIO/PEO strategy, establishing inclusion and exclusion criteria for studies, categorizing selected research, and analyzing and interpreting the results. Data collection involved selecting articles from reputable databases such as Web of Science, Springer Nature Librarian, and Wiley Online Library, using relevant keywords related to biomedical materials and human health. Results and Discussion: The results of the integrative literature review provide a systematic synthesis of research findings on metallic biomedical materials. These findings are contextualized within the theoretical framework, emphasizing the importance of continuous research efforts in developing safer and more effective materials for medical implants. The discussion highlights the implications of these findings for enhancing healthcare technologies and patient outcomes. Research Implications: The practical implications of this research include informing the development of safer and more effective materials for biomedical implants, thereby improving patient safety and quality of life. These implications extend to various sectors involved in healthcare technology and biomedical engineering. Originality/Value: This study contributes to the literature by synthesizing existing knowledge and providing valuable insights into the field of metallic biomaterials for medical applications.


INTRODUCTION
Metallic biomedical materials play a crucial role in the development of prostheses and implants for surgical interventions, aiming to improve patient outcomes (Mamo, Adamiak, & Kunwar, 2023;Serrano-Aroca & Pous-Serrano, 2021).With ongoing advancements, the evolution of new smart biomedical materials is anticipated, promising enhanced health benefits (Mokhtari et al., 2021a(Mokhtari et al., , 2021b;;Tyagi et al., 2023).Among these materials, Nitinol stands out for its shape memory property, allowing it to deform and return to its original shape, making it suitable for applications like vascular stents and orthodontic wires (Deng, Gould, & Ali, 2022;Sharma et al., 2023;Shukla & Garg, 2022).

OBJECTIVES
This study emphasizes the critical importance of ongoing research aimed at developing safer and more effective materials for biomedical implants, with the goal of reducing patient mortality risks (Cronin & George, 2023;Yemini et al., 2023).Employing an integrative Nature Librarian, and Wiley Online Library, adhering to strict inclusion criteria regarding publication dates, blind peer review, language, and relevance to the research question (Silva et al., 2022;Bakkum et al., 2022).The study underscores the crucial need for sustained efforts in advancing healthcare technologies to enhance patient outcomes and safety, focusing on metallic biomedical materials and their potential contributions to healthcare technology and individual well-being.Additionally, adopting an integrative literature review methodology to systematically synthesize data on metallic biomedical materials, their role in medical implants, and their implications for improved quality of life and technological advancement, the study contributes to evidence-based clinical practice and scientific progress (Sarkis-Onofre et al., 2021).This holistic approach highlights the importance of continuous research efforts in developing novel materials that meet evolving healthcare needs and enhance patient care.

METHODOLOGY
This study utilizes an integrative literature review model to systematically collect data on metallic biomedical materials and their role in promoting safer and more effective medical implants, enhancing quality of life, and driving technological progress (Cronin & George, 2023;Yemini et al., 2023).Employing the PICO/PIO/PEO strategy, the research question guides an extensive exploration of esteemed databases like Web of Science, Springer Nature Librarian, and Wiley Online Library, with inclusion criteria specifying scientific articles published between 2018 and 2023 in English, blind peer-reviewed journals (Silva et al., 2022;Bakkum et al., 2022).The integrative review methodology enables the synthesis of selected studies, utilizing comparative tables to systematically organize data and facilitate the identification of patterns and critical insights (Toronto & Remington, 2020;Mendes et al., 2019).Additionally, a systematic literature review approach, guided by PRISMA and PRISMA-P, aims to offer a comprehensive overview of the research theme, identify knowledge gaps, and contribute to evidence-based clinical practice and scientific progress (Moher et al., 2010;Sarkis-Onofre et al., 2021).Moreover, this systematic approach underscores the importance of continual research efforts in advancing healthcare technologies, particularly in the domain of metallic biomedical materials, to address evolving healthcare needs and enhance patient care outcomes (Lambermon et al., 2020;Souza et al., 2010).By meticulously collating relevant evidence and critically evaluating studies, this study aims to provide valuable insights into the development of novel materials, fostering safer medical implants and contributing to scientific advancements in the field (Mantsiou et al., 2023;Livinski et al., 2015).Through a comprehensive synthesis of literature, this research endeavor seeks to bridge existing knowledge gaps, inform evidencebased clinical practice, and propel scientific innovation in the realm of biomedical materials and implantology.

INTEGRATIVE LITERATURE REVIEW MODEL
The present work is situated within an integrative literature review framework, employing a systematic approach to gather data from a targeted search (Cronin & George, 2023;García-Peñalvo, 2022).This method forms the basis for evidence-based clinical practice, facilitating a comprehensive grasp of the research theme and pinpointing crucial areas for study and scientific progress (Yemini et al., 2023;Silva et al., 2022).Thus, the study proceeded with a systematic process guided by the literature, encompassing the formulation of the research question, establishment of inclusion and exclusion criteria for studies, categorization of selected research, analysis and interpretation of results, and presentation of the review and synthesis of knowledge.

INTEGRATIVE LITERATURE REVIEW ANALYSIS
The integrative review literature is a method aimed at systematically synthesizing research results on a specific topic or issue in a comprehensive manner, incorporating studies in an organized fashion (Toronto & Remington, 2020;Mendes et al., 2019).Additionally, a systematic literature review, a meticulously planned approach, was utilized to address specific research inquiries through systematic methodology and evaluation of selected studies (Lambermon et al., 2020;Souza et al., 2020).Systematic reviews aim to compile all relevant evidence that meets predetermined eligibility criteria to address a particular research question, utilizing frameworks like PRISMA for reporting (Flemyng et al., 2023;Mengist et al., 2020).
PRISMA-P serves to guide the development of protocols for systematic reviews and metaanalyses (Mantsiou et al., 2023).

RESULTS AND DISCUSSION
The integrative review literature explores a broad spectrum of topics concerning biomaterials for medical implants, revealing convergent themes across various studies.
Biocompatibility emerges as a central focus, crucial for the success and durability of medical implants, particularly in orthopedic and dental applications.Additive manufacturing (AM) and 3D printing, integral to Industry 4.0, offer significant benefits by enabling precise fabrication of custom biomedical parts with intricate structures and porous architectures, facilitating seamless integration with surrounding tissues and promoting superior osseointegration.
Researchers also emphasize enhancing mechanical properties and corrosion resistance in implant materials, often through the exploration of materials like titanium alloys and stainless steels.Additionally, the integration of machine learning and Artificial Intelligence (AI) shows  The analysis of literature data within the integrative review (IRL) was conducted descriptively.Table 1 was utilized to extract and synthesize data from each primary study included in the review.This table systematically presents essential information, such as the title, objectives, study design, and main findings of each study.Such an organized presentation ensures that the key details of each primary study are easily accessible, facilitating a comprehensive understanding of the reviewed literature.Focus on the applications and challenges of using 3D printed implants for the treatment of birth defects in pediatric patients.
Descriptive study -Emphasize the potential role of 3D printing in the future manufacturing of pediatric implants for the treatment of birth defects.Descriptive study -Discuss the potential of different manufacturing techniques, including traditional methods like turning, drilling, and milling, as well as non-traditional approaches such as abrasive water jet machining, laser beam machining, ultrasonic machining, and electric discharge machining, in producing patient-specific implants with precise dimensions, biocompatibility, and desired surface characteristics.Suwardi et al. (2021) Explore the application of machine learning in accelerating the development and design process of biomaterials.
Descriptive study -Discuss how machine learning has been applied in biomaterials research to optimize material properties, assist in fabrication process optimization, and study interactions with biological systems.Tabatabaeian et al. (2022) Provide a comprehensive overview of residual stress in engineering materials and its impact on material behavior, failure modes, and structural integrity.
Descriptive study -Emphasize the need for accurate determination of residual stresses to improve product performance and service life in industrial applications.-Discuss various experimental and analytical methods for determining residual stresses.
Additionally, variations exist in the application of AM processes, with some studies highlighting the potential of 3D printing and AM, while others explore traditional subtractive manufacturing methods (da Silva et al., 2021;Monfared et al., 2023;Jackson, Johnson, Williams, et al., 2022).Moreover, differences in the application of machine learning and AI, as well as in the specific medical implant applications studied, further contribute to divergent perspectives within the reviewed literature (Bowers et al., 2022;Malone et al., 2022;McElveen, Tange, & Naumann, 2022;Radice, Neto, Fischer, & Wimmer, 2022;Suwardi et al., 2021;Tabatabaeian et al., 2021).

CONCLUSIONS
The integrative review literature offers a thorough and all-encompassing exploration of the development and application of biomaterials for medical implants.Despite the diversity in the objectives and types of studies included in the review, a set of crucial themes consistently emerge, shaping the trajectory of research in this essential field.Biocompatibility is emphasized across multiple studies as critical for medical implants, especially in orthopedic and dental applications (Saptaji, Gebremariam, & Azhari, 2018;Wickramasinghe, Navarreto-Lugo, Ju, & Samia, 2018;Mehjabeen, Song, Xu, Tang, & Qian, 2018;Şensoy et al., 2019;Radice, Neto, Fischer, & Wimmer, 2022).
Additive Manufacturing and 3D Printing have emerged as promising methods for producing custom biomedical parts and implants (da Silva et al., 2021;Monfared et al., 2023).Mechanical Properties and Corrosion Resistance are areas of focus for researchers, with studies exploring various materials to improve implant strength, fatigue properties, and wear resistance (Şensoy et al., 2019;Radice et al., 2022;Jackson, Johnson, Williams, et al., 2022).
Machine Learning and AI show potential in accelerating biomaterials development and predicting material behavior (Suwardi et al., 2021).Despite these convergent points, the reviewed literature also reveals divergent aspects: • Focus on Different Biomaterials: Studies concentrate on different biomaterials, such as Zirconium alloys, stainless steels, and high-nitrogen steels, each with unique properties for specific implant applications.
• Manufacturing Techniques: Some studies explore the potential of additive manufacturing and 3D printing, while others investigate traditional subtractive methods for creating patient-specific implants.
• Specific Medical Implant Applications: Different studies examine various medical devices, such as orthopedic joint replacements, stapes surgery prostheses, and LVADs, addressing their failure modes and materials engineering aspects.
In conclusion, the integrative review literature in Table 1 highlights the interdisciplinary nature of biomaterials research and showcases innovative technologies in implant development.
The convergent points underscore the significance of biocompatibility, advanced manufacturing techniques, improved mechanical properties, and the potential of AI in the field.
However, the divergent points reflect the diverse array of materials, manufacturing methods, and medical implant applications studied by various authors.These insights can guide researchers in designing advanced biomaterials that enhance implant performance and improve patient outcomes.
___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.5 | p.1-15 | e05255 | 2024.4 literature review model, the methodology involves formulating a guiding question, establishing inclusion and exclusion criteria, categorizing selected research, and critically analyzing and interpreting outcomes.The guiding question, developed using the PICO/PIO/PEO strategy, facilitated a comprehensive search across esteemed databases such as Web of Science, Springer , encompassed Patient/Problem, Intervention, Comparison, and Outcome for PICO; Population/Problem/Patient, Outcome for PIO; and Population/Problem/Patient, Exposure, Outcome for PEO.This strategy facilitated a comprehensive search on research platforms, providing relevant keywords to address the research question.As such, the guiding question for this study is as follows: How can research in metallic biomedical materials contribute to the development of safer and more effective materials, improve the quality of life of individuals, and advance technological development in the country?.
promise in accelerating biomaterials development and predicting material behavior.The literature underscores the importance of interdisciplinary collaboration and innovative technologies to advance biomaterials, aiming to improve biocompatibility, mechanical properties, and long-term performance for better patient outcomes.Despite commonalities, divergence exists in biomaterial types, manufacturing techniques, machine learning applications, and specific medical implant studies, offering valuable insights for designing advanced biomaterials and revolutionizing medical implant applications to advance healthcare technology.4.1 LITERATURE DATA ANALYSIS Bibliometric research was conducted to analyze scientific literature on the topic, utilizing specific search terms in databases.The search yielded articles from Web of Science, Springer Nature, and Wiley Online Library.After applying exclusion and inclusion criteria, 17 papers were selected from the initial 21 articles, and a descriptive analysis of these papers was conducted in the Integrative Review (IRL).The variation in the number of articles among databases reflects their different focuses and coverage areas.While Springer Nature and Wiley Online Library contributed more relevant articles due to their comprehensive content, the selected articles from the keyword-based search demonstrated significance and applicability to the research theme.Visual representation of the selection process and criteria was provided using the PRISMA protocol.The bibliometric analysis offers insights into literature distribution across databases, emphasizing the importance of utilizing multiple sources for a comprehensive literature review.
computer-aided material selection strategy for hip prosthesis, considering essential design parameters such as strength, malleability, corrosion resistance, and biocompatibilityinfluence of ECAP on austenitic 316L and Cr-Ni-Ti stainless steels, leading to the formation of an ultrafine-grained structure with an average size of about 200 nm and fine deformation twins.advantages of titanium and its alloys over other materials for use as biomedical implants, emphasizing their superior mechanical properties, high specific strength, excellent corrosion resistance, inertness to the body environment, and superior biocompatibility.Bolzoni et al. (2020) Design and manufacture beta eutectoid bearing Experimental study -Analyze a series of ternary Ti-xCu-yMn alloys with varying ratios of copper and functionalized Ti alloys with antibacterial activity.manganese, using a cost-effective press and sinter powder metallurgy route.-Ternary Ti-xCu-yMn alloys exhibited promising mechanical ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.5 | p.1-15 | e05255 | 2024.

Table 1
Integrative Review Literature in Chronological Order