Tissue engineering of tooth crown, root, and periodontium

Dental stem cells for tooth regeneration and repair

Mesenchymal stem cells (MSCs) resident in bone marrow are one of the most studied and clinically important populations of adult stem cells. Cells with, similar properties to these MSCs have been described in several different tooth tissues and the potential ease with which these dental MSCs could be obtained from patients has prompted great interest in these cells as a source of MSCs for cell-based therapeutics. In this review we address the current state of knowledge regarding these cells, their properties, origins, locations, functions and potential uses in tooth tissue engineering and repair. We discuss some of the key controversies and outstanding issues, not least of which whether dental stem cells actually exist.

Amelogenin in cranio-facial development: the tooth as a model to study the role of amelogenin during embryogenesis

The amelogenins comprise 90% of the developing extracellular enamel matrix proteins and play a major role in the biomineralization and structural organization of enamel. Amelogenins were also detected, in smaller amounts, in postnatal calcifying mesenchymal tissues, and in several nonmineralizing tissues including brain. Low molecular mass amelogenin isoforms were suggested to have signaling activity; to produce ectopically chondrogenic and osteogenic-like tissue and to affect mouse tooth germ differentiation in vitro. Recently, some amelogenin isoforms were found to bind to the cell surface receptors; LAMP-1, LAMP-2 and CD63, and subsequently localize to the perinuclear region of the cell. The recombinant amelogenin protein (rHAM(+)) alone brought about regeneration of the tooth supporting tissues: cementum, periodontal ligament and alveolar bone, in the dog model, through recruitment of progenitor cells and mesenchymal stem cells. We show that amelogenin is expressed in various tissues of the developing mouse embryonic cranio-facial complex such as brain, eye, ganglia, peripheral nerve trunks, cartilage and bone, and is already expressed at E10.5 in the brain and eye, long before the initiation of tooth formation. Amelogenin protein expression was detected in the tooth germ (dental lamina) already at E13.5, much earlier than previously reported (E19). Application of amelogenin (rHAM(+)) beads together with DiI, on E13.5 and E14.5 embryonic mandibular mesenchyme and on embryonic tooth germ, revealed recruitment of mesenchymal cells. The present results indicate that amelogenin has an important role in many tissues of the cranio-facial complex during mouse embryonic development and differentiation, and might be a multifunctional protein.

Crown formation during tooth development and tissue engineering

Considering tooth crown engineering, three main parameters have to be taken into account: (1) the relationship between crown morphology and tooth functionality, (2) the growth of the organ, which is hardly compatible with the use of preformed scaffolds, and (3) the need for easily available nondental competent cell sources. In vitro reassociation experiments using either dental tissues or bone marrow-derived cells (BMDC) have been designed to get information about the mechanisms to be preserved in order to allow crown engineering. As the primary enamel knot (PEK) is involved in signaling crown morphogenesis, the formation and fate of this structure was investigated (1) in heterotopic reassociations between embryonic day 14 (ED14) incisor and molar enamel organs and mesenchymes, and (2) in reassociations between ED14 molar enamel organs and BMDC. A PEK formed in cultured heterotopic dental tissue reassociations. The mesenchyme controls the fate of the EK cells, incisor or molar-specific using apoptosis as criterion, and functionality to drive single/multiple cusps tooth development. Although previous investigations showed that they might differentiate as odontoblast- or ameloblast-like cells, BMDC reassociated to an enamel organ could not support the development of multicusp teeth. These cells apparently could neither maintain nor stimulate the formation of a PEK.

Gene therapy: design and prospects for craniofacial regeneration

Gene therapy is defined as the treatment of disease by transfer of genetic material into cells. This review will explore methods available for gene transfer as well as current and potential applications for craniofacial regeneration, with emphasis on future development and design. Though non-viral gene delivery methods are limited by low gene transfer efficiency, they benefit from relative safety, low immunogenicity, ease of manufacture, and lack of DNA insert size limitation. In contrast, viral vectors are nature's gene delivery machines that can be optimized to allow for tissue-specific targeting, site-specific chromosomal integration, and efficient long-term infection of dividing and non-dividing cells. In contrast to traditional replacement gene therapy, craniofacial regeneration seeks to use genetic vectors as supplemental building blocks for tissue growth and repair. Synergistic combination of viral gene therapy with craniofacial tissue engineering will significantly enhance our ability to repair and replace tissues in vivo.

Revitalization of a diastemal tooth primordium in Spry2 null mice results from increased proliferation and decreased apoptosis

An understanding of the factors that promote or inhibit tooth development is essential for designing biological tooth replacements. The embryonic mouse dentition provides an ideal system for studying such factors because it consists of two types of tooth primordia. One type of primordium will go on to form a functional tooth, whereas the other initiates development but arrests at or before the bud stage. This developmental arrest contributes to the formation of the toothless mouse diastema. It is accompanied by the apoptosis of the rudimentary diastemal buds, which presumably results from the insufficient activity of anti-apoptotic signals such as fibroblast growth factors (FGFs). We have previously shown that the arrest of a rudimentary tooth bud can be rescued by inactivating Spry2, an antagonist of FGF signaling. Here, we studied the role of the epithelial cell death and proliferation in this process by comparing the development of a rudimentary diastemal tooth bud (R(2)) and the first molar in the mandibles of Spry2(-/-) and wild-type (WT) embryos using histological sections, image analysis and 3D reconstructions. In the WT R(2) at embryonic day 13.5, significantly increased apoptosis and decreased proliferation were found compared with the first molar. In contrast, increased levels of FGF signaling in Spry2(-/-) embryos led to significantly decreased apoptosis and increased proliferation in the R(2) bud. Consequently, the R(2) was involved in the formation of a supernumerary tooth primordium. Studies of the revitalization of rudimentary tooth primordia in mutant mice can help to lay the foundation for tooth regeneration by enhancing our knowledge of mechanisms that regulate tooth formation.

Tissue engineering: state of the art in oral rehabilitation

More than 85% of the global population requires repair or replacement of a craniofacial structure. These defects range from simple tooth decay to radical oncologic craniofacial resection. Regeneration of oral and craniofacial tissues presents a formidable challenge that requires synthesis of basic science, clinical science and engineering technology. Identification of appropriate scaffolds, cell sources and spatial and temporal signals (the tissue engineering triad) is necessary to optimize development of a single tissue, hybrid organ or interface. Furthermore, combining the understanding of the interactions between molecules of the extracellular matrix and attached cells with an understanding of the gene expression needed to induce differentiation and tissue growth will provide the design basis for translating basic science into rationally developed components of this tissue engineering triad. Dental tissue engineers are interested in regeneration of teeth, oral mucosa, salivary glands, bone and periodontium. Many of these oral structures are hybrid tissues. For example, engineering the periodontium requires growth of alveolar bone, cementum and the periodontal ligament. Recapitulation of biological development of hybrid tissues and interfaces presents a challenge that exceeds that of engineering just a single tissue. Advances made in dental interface engineering will allow these tissues to serve as model systems for engineering other tissues or organs of the body. This review will begin by covering basic tissue engineering principles and strategic design of functional biomaterials. We will then explore the impact of biomaterials design on the status of craniofacial tissue engineering and current challenges and opportunities in dental tissue engineering.

A curriculum vitae of teeth: evolution, generation, regeneration

The ancestor of recent vertebrate teeth was a tooth-like structure on the outer body surface of jawless fishes. Over the course of 500,000,000 years of evolution, many of those structures migrated into the mouth cavity. In addition, the total number of teeth per dentition generally decreased and teeth morphological complexity increased. Teeth form mainly on the jaws within the mouth cavity through mutual, delicate interactions between dental epithelium and oral ectomesenchyme. These interactions involve spatially restricted expression of several, teeth-related genes and the secretion of various transcription and signaling factors. Congenital disturbances in tooth formation, acquired dental diseases and odontogenic tumors affect millions of people and rank human oral pathology as the second most frequent clinical problem. On the basis of substantial experimental evidence and advances in bioengineering, many scientists strongly believe that a deep knowledge of the evolutionary relationships and the cellular and molecular mechanisms regulating the morphogenesis of a given tooth in its natural position, in vivo, will be useful in the near future to prevent and treat teeth pathologies and malformations and for in vitro and in vivo teeth tissue regeneration.

Vascularization of engineered teeth

The implantation of cultured dental cell-cell re-associations allows for the reproduction of fully formed teeth, crown morphogenesis, epithelial histogenesis, mineralized dentin and enamel deposition, and root-periodontium development. Since vascularization is critical for organogenesis and tissue engineering, this work aimed to study: (a) blood vessel formation during tooth development, (b) the fate of blood vessels in cultured teeth and re-associations, and (c) vascularization after in vivo implantation. Ex vivo, blood vessels developed in the dental mesenchyme from the cap to bell stages and in the enamel organ, shortly before ameloblast differentiation. In cultured teeth and re-associations, blood-vessel-like structures remained in the peridental mesenchyme, but never developed into dental tissues. After implantation, both teeth and re-associations became revascularized, although later in the case of the re-associations. In implanted re-associations, newly formed blood vessels originated from the host, allowing for their survival, and affording conditions organ growth, mineralization, and enamel secretion.

Phosphate: known and potential roles during development and regeneration of teeth and supporting structures

Inorganic phosphate (P(i)) is abundant in cells and tissues as an important component of nucleic acids and phospholipids, a source of high-energy bonds in nucleoside triphosphates, a substrate for kinases and phosphatases, and a regulator of intracellular signaling. The majority of the body's P(i) exists in the mineralized matrix of bones and teeth. Systemic P(i) metabolism is regulated by a cast of hormones, phosphatonins, and other factors via the bone-kidney-intestine axis. Mineralization in bones and teeth is in turn affected by homeostasis of P(i) and inorganic pyrophosphate (PPi), with further regulation of the P(i)/PP(i) ratio by cellular enzymes and transporters. Much has been learned by analyzing the molecular basis for changes in mineralized tissue development in mutant and knock-out mice with altered P(i) metabolism. This review focuses on factors regulating systemic and local P(i) homeostasis and their known and putative effects on the hard tissues of the oral cavity. By understanding the role of P(i) metabolism in the development and maintenance of the oral mineralized tissues, it will be possible to develop improved regenerative approaches.

Dental pulp tissue engineering with stem cells from exfoliated deciduous teeth

Stem cells from human exfoliated deciduous teeth (SHED) have been isolated and characterized as multipotent cells. However, it is not known whether SHED can generate a dental pulp-like tissue in vivo. The purpose of this study was to evaluate morphologic characteristics of the tissue formed when SHED seeded in biodegradable scaffolds prepared within human tooth slices are transplanted into immunodeficient mice. We observed that the resulting tissue presented architecture and cellularity that closely resemble those of a physiologic dental pulp. Ultrastructural analysis with transmission electron microscopy and immunohistochemistry for dentin sialoprotein suggested that SHED differentiated into odontoblast-like cells in vivo. Notably, SHED also differentiated into endothelial-like cells, as demonstrated by B-galactosidase staining of cells lining the walls of blood-containing vessels in tissues engineered with SHED stably transduced with LacZ. This work suggests that exfoliated deciduous teeth constitute a viable source of stem cells for dental pulp tissue engineering.

Growing bioengineered teeth from single cells: potential for dental regenerative medicine

BACKGROUND

The ultimate goal of regenerative therapy is to develop fully functioning bioengineered organs that can replace organs lost or damaged due to disease, injury or aging. Dental regenerative medicine has made the most progress and is the most useful model for the consideration of strategies in future organ replacement therapies.

OBJECTIVE

This review describes strategies that have been pursued to date and experiments currently being conducted to bioengineer teeth in anticipation of the production of fully functional organs.

METHODS

To realize the practical application of 'bioengineered tooth' transplantation therapy, four major hurdles must be overcome. The present status of the hurdles to this therapy are described and discussed in this review.

RESULTS/CONCLUSION

The bioengineering techniques developed for tooth regeneration will in the future make substantial contributions to the ability to grow primordial organs in vitro and also to grow fully functioning organs, such as the liver, kidney and heart.

Tooth agenesis: from molecular genetics to molecular dentistry

Tooth agenesis may originate from either genetic or environmental factors. Genetically determined hypodontic disorders appear as isolated features or as part of a syndrome. Msx1, Pax9, and Axin2 are involved in non-syndromic hypodontia, while genes such as Shh, Pitx2, Irf6, and p63 are considered to participate in syndromic genetic disorders, which include tooth agenesis. In dentistry, artificial tooth implants represent a common solution to tooth loss problems; however, molecular dentistry offers promising solutions for the future. In this paper, the genetic and molecular bases of non-syndromic and syndromic hypodontia are reviewed, and the advantages and disadvantages of tissue engineering in the clinical treatment of tooth agenesis are discussed.

Bioengineered dental tissues grown in the rat jaw

Our long-term objective is to develop methods to form, in the jaw, bioengineered replacement teeth that exhibit physical properties and functions similar to those of natural teeth. Our results show that cultured rat tooth bud cells, seeded onto biodegradable scaffolds, implanted into the jaws of adult rat hosts and grown for 12 weeks, formed small, organized, bioengineered tooth crowns, containing dentin, enamel, pulp, and periodontal ligament tissues, similar to identical cell-seeded scaffolds implanted and grown in the omentum. Radiographic, histological, and immunohistochemical analyses showed that bioengineered teeth consisted of organized dentin, enamel, and pulp tissues. This study advances practical applications for dental tissue engineering by demonstrating that bioengineered tooth tissues can be regenerated at the site of previously lost teeth, and supports the use of tissue engineering strategies in humans, to regenerate previously lost and/or missing teeth. The results presented in this report support the feasibility of bioengineered replacement tooth formation in the jaw.

Tooth Regenerative Therapy, Approached from Organogenesis

Regenerative medicine is expected to be a novel therapeutic system in this century [1-3]. The human body consists of 200 cell species generated from immature stem cells. In the 1990s, a treatment transplanting hematopoietic stem cells to replace all blood cells was established and successfully cured leukemia [4]. With this as a model, stem cell transplantation therapy is being developed to restore the partial loss of organ function [5, 6]. The ultimate goal of regenerative medicine is to replace loss or damaged organs with artificial organs, so-called organ replacement therapy. Technical development to produce “tissues” made of a single cell species modeled on skin, bone, heart muscle, and cornea is advancing, but little development of organs per se has been attempted. In the sections that follow, we discuss why and explain how we are trying with the problems of “tooth regeneration.”

Stem cells and tooth tissue engineering

The notion that teeth contain stem cells is based on the well-known repairing ability of dentin after injury. Dental stem cells have been isolated according to their anatomical locations, colony-forming ability, expression of stem cell markers, and regeneration of pulp/dentin structures in vivo. These dental-derived stem cells are currently under increasing investigation as sources for tooth regeneration and repair. Further attempts with bone marrow mesenchymal stem cells and embryonic stem cells have demonstrated the possibility of creating teeth from non-dental stem cells by imitating embryonic development mechanisms. Although, as in tissue engineering of other organs, many challenges remain, stem-cell-based tissue engineering of teeth could be a choice for the replacement of missing teeth in the future.

Tooth regeneration: implications for the use of bioengineered organs in first-wave organ replacement

Experiments with animal models have shown that the tooth crown structure can be regenerated using tissue engineering techniques that combine tooth bud cells and biodegradable materials, or by using embryonic tissue and adult stem cells. Moreover, tooth roots and periodontal tissues have been reconstructed by grafting dental stem cells, which leads to the recovery of tooth function, suggesting that tooth regeneration will become possible in humans in the near future. The present article reviews current research on tooth regeneration, discusses a model of tooth replacement that could be used clinically, and proposes a new tooth regeneration approach that overcomes the difficulties associated with the tooth replacement model. Tooth regeneration is an important stepping stone in the establishment of engineered organ transplantation, which is one of the ultimate goals of regenerative therapies.

Cell apoptosis control using BMP4 and noggin embedded in a polyelectrolyte multilayer film

Programmed cell death (apoptosis) is a genetically regulated process of cell elimination essential during development. During development, programmed cell death is involved in the specific shaping of organs, in the elimination of cells having achieved their program, and in regulating the number of cells to differentiate. Tooth development includes these three aspects and was used here as a model to study the control of apoptosis. Bone morphogenetic proteins (BMPs) are currently considered as playing a major role in signaling apoptosis. This apoptosis could be stopped by treatments with a BMP antagonist ("Noggin"). We selected a model system made by a layer-by-layer approach using poly-L-glutamic acid (PlGA) and poly-L-lysine (PlL) films into which BMP4 and/or Noggin have been embedded. Our results indicate that in situ control of apoptosis during tooth differentiation mediated by both BMP4 and Noggin embedded in a polyelectrolyte multilayer film is possible. We show here for the first time that in the presence of BMP4 and Noggin embedded in a multilayered film, we can induce or inhibit cell death in tooth differentiation, and conserve their biological effects.

The development of a bioengineered organ germ method

To bioengineer ectodermal organs such as teeth and whisker follicles, we developed a three-dimensional organ-germ culture method. The bioengineered tooth germ generated a structurally correct tooth, after both in vitro organ culture as well as transplantation under a tooth cavity in vivo, showing penetration of blood vessels and nerve fibers. Our method provides a substantial advance in the development of bioengineered organ replacement strategies and regenerative therapies.

New era in health care: tissue engineering

Tissue engineering is a rapidly expanding field, which applies the principles and methods of physical sciences, life sciences and engineering to understand physiological and pathological systems and to modify and create cells and tissues for therapeutic applications. It has emerged as a rapidly expanding ‘interdisciplinary field’ that is a significant potential alternative wherein tissue and organ failure is addressed by implanting natural, synthetic, or semi synthetic tissue or organ mimics that grow into the required functionality or that are fully functional from the start. This review presents in a comprehensive manner the various considerations for the reconstruction of various tissues and organs as well as the various applications of this young emerging field in different disciplines.

Buonocore Memorial Lecture

For many years, operative dentistry has been using regenerative approaches to treat dental disease. The use of calcium hydroxide to stimulate reparative or reactionary dentin is clearly an example of such a therapeutic strategy. The advent of tissue engineering is allowing dentistry to move forward in the use of regeneration as an underlying principle for the treatment of dental disease. Tissue engineering is a multi-disciplinary science that brings together biology, engineering and clinical sciences with developing new tissues and organs. It is based on fundamental principles that involve the identification of appropriate cells, the development of conducive scaffolds and an understanding of the morphogenic signals required to induce cells to regenerate the tissues that were lost. This review is focused on the presentation and discussion of existing literature that covers the engineering of enamel, dentin and pulp, as well on the engineering of entire teeth. There are clearly major roadblocks to overcome before such strategies move to the clinic and are used regularly to treat patients. However, existing evidence strongly suggests that the engineering of new dental structures to replace tissues lost during the process of caries or trauma will have a place in the future of operative dentistry.