Antibacterial and pro-osteointegrative bioactive coatings on titanium implant surfaces for oromaxillofacial applications: a systematic review and bayesian network meta-analysis of preclinical studies

Numerous preclinical studies have investigated bioactive coatings on titanium implant surfaces to enhance antibacterial and osteointegrative performance in oromaxillofacial applications. However, these studies employ heterogeneous experimental methods and biological outcomes, making it difficult to identify which coating strategies hold the greatest translational potential. This systematic review and Bayesian network meta-analysis (NMA) aimed to rank titanium coating strategies published over the last five years according to their biological performance, using a quantitative statistical framework. Nine coating categories of increasing compositional complexity, ranging from single-component (inorganic, organic, peptides/growth factors) to two-component and three-component formulations combining these classes with each other or with antibiotics, were compared across six biological outcomes in preclinical models. Inclusion criteria followed the PICOS framework for studies published between 2020 and 2025. Three databases were searched according to PRISMA 2020 and its NMA extension. Mean difference (MD) was used for outcomes on a common scale; ratio of means (RoM) when measurement units were heterogeneous. Treatment ranking was estimated using the surface under the cumulative ranking curve (SUCRA). Study reporting quality and data completeness were assessed, and studies with insufficient quantitative data were excluded from the quantitative synthesis. Of 143 records identified, 59 met the inclusion criteria and 40 contributed to the quantitative synthesis. SUCRA rankings indicated that three-component hybrid coatings incorporating antibiotics achieved the highest antibacterial performance and osseointegration, while inorganic coatings functionalized with peptides or growth factors demonstrated superior osteogenic differentiation. Organic coatings combined with peptides or growth factors showed the greatest cell proliferation. These findings provide the first evidence-based ranking of bioactive coating strategies for titanium implant surfaces, suggesting a potential advantage of multi-component formulations over single-agent approaches across biological outcomes. The identified compositional complexity gradient may inform the rational design of future multifunctional coatings and help prioritize candidates for further preclinical and translational validation in oromaxillofacial applications.