Tissue-engineered oral mucosa: a review of the scientific literature

Dental implants after reconstruction with free tissue transfer

The transfer of composite tissue flaps by microvascular techniques has become the standard for reconstructing complex defects of the oral and maxillofacial regions. Despite advances in these techniques, sites reconstructed by free tissue transfer (free flaps) are often compromised by scarring, bulky tissue, and altered architecture. Dental rehabilitation is often impossible without endosseous implants to aid in stabilization and retention of prostheses. The most commonly used free flaps, however, have significant shortcomings with regard to implant placement, prosthetics, and maintenance. This article describes some site development and prosthetic techniques that can be applied to improve outcomes when dental implants are used in conjunction with free flap reconstruction.

Development of a novel model for the investigation of implant-soft tissue interface

BACKGROUND

In dental implant treatment, the long-term prognosis is dependent on the biologic seal formed by the soft tissue around the implant. The in vitro investigation of the implant-soft tissue interface is usually carried out using a monolayer cell-culture model that lacks a polarized-cell phenotype. This study developed a tissue-engineered three-dimensional oral mucosal model (3D OMM) to investigate the implant-soft tissue interface.

METHODS

A 3D OMM was constructed using primary human oral keratinocytes and fibroblasts cultured on a skin-derived scaffold at an air-liquid interface. A titanium implant was inserted into the engineered oral mucosa and further cultured to establish epithelial attachment. The 3D OMM was characterized using basic histology and immunostaining for cytokeratin (CK) 10 and CK13. Histomorphometric analyses of the implant-soft tissue interface were carried out using a light-microscopy (LM) examination of ground sections and semi-thin sections as well as scanning electron microscopy (SEM).

RESULTS

Immunohistochemistry analyses suggests that the engineered oral mucosa closely resembles the normal oral mucosa. The LM and SEM examinations reveal that the 3D OMM forms an epithelial attachment on the titanium surface.

CONCLUSION

The 3D OMM provided mimicking peri-implant features as seen in an in vivo model and has the potential to be used as a relevant alternative model to assess implant-soft tissue interactions.

Biologic interaction of three-dimensional periodontal fibroblast spheroids with collagen-based and synthetic membranes

BACKGROUND

Cell-based therapy using autologous cells has been suggested as a potential approach for periodontal tissue regeneration. Spheroid systems are a form of three-dimensional cell culture that promotes cell matrix interaction, which could recapitulate the aspect of cell homeostasis in vivo. The aim of this study is to assess the interaction of periodontal fibroblast spheroids with synthetic and collagen-based membranes that have been used in guided tissue regeneration.

METHODS

Commercially available normal human periodontal ligament fibroblasts were grown in spheroid forms using a liquid overlay technique and then transplanted onto a collagen-based and a polyglycolic acid-based membrane. The biologic interaction of the spheroids with the membranes was assessed using basic histology, Alamar blue tissue viability assay, scanning electron microscopy, and immunohistochemical analysis.

RESULTS

Periodontal fibroblast spheroids adhered to both membranes, and the cells were able to proliferate and migrate from the spheroids both horizontally and vertically into the membrane scaffolds. Immunohistochemical analysis showed expression of collagen type I, periostin, and Runx2 by the periodontal fibroblasts.

CONCLUSION

Periodontal fibroblast spheroids were able to grow three-dimensionally on the biologic membranes and may have the potential to be used together with guided tissue regeneration approaches as an adjunct for periodontal regeneration.

Novel application of artificial dermis plus autologous vital epithelial cells: improved wound epithelialization

The purpose of this study was to evaluate artificial dermis with the simultaneous addition of autologous epithelial cells for oral lesion defect reconstruction. Surgical wounds reconstructed with artificial dermis plus scraped epithelial cells were evaluated in 5 patients with oral benign lesions or squamous cell carcinoma. Clinical follow-up indices included scar formation and tissue surface texture observation. The neomucosal layers were analyzed histologically to establish the degree of epithelialization. Clinical observation showed that the oral mucosal texture was smoother in artificial dermis with added epithelial cells at 4 weeks postoperation compared with artificial dermis alone. The wound contraction and scar formation processes were slow. Viable epithelial cells with flat rete ridges remained in the artificial dermis, and a neoepithelial layer was present in the histological findings. We showed that healthy granulation tissue and neoepithelial formation in artificial dermis with epithelial cells was beneficial for the repair of oral defects. Scraping oral epithelial cells and applying them to artificial dermis assisted in the early preparation of composite grafts and minimized requirement for donor sites. This technique may improve the treatment of patients with oral benign tumors and early-stage squamous cell carcinoma.

Soft tissue augmentation using silk gels: an in vitro and in vivo study

BACKGROUND

Restoration of a three-dimensional shape with soft tissue augmentation is a challenge for surgical reconstruction and esthetic improvement of intraoral mucosa and perioral skin tissues. A connective tissue graft or free gingival graft, classically used for such indications, requires a donor site, which may lead to various clinical complications.

METHODS

In this article, a new three-dimensional scaffold made of silk fibroin that could be of great interest for these indications was studied. Mechanical tests were conducted to characterize the physical properties of the materials. The biocompatibility of such scaffolds was positively assessed in vitro using a combination of immunostaining, 5-bromo-2'-deoxyuridine proliferation assays, and histologic staining. Finally, the shaped material was grafted subcutaneously in nude mice for a long-time implantation study.

RESULTS

Human fibroblasts embedded in this material had a survival rate up to 68.4% and were able to proliferate and synthesize proteins. One month after subcutaneous implantation, the three-dimensional soft tissue augmentation was stable, and histologic analysis revealed revascularization of the area through the biomaterial. A mild inflammatory reaction disappeared after 12 weeks.

CONCLUSION

The results indicate that silk-gel material was able to create a lasting three-dimensional soft tissue augmentation and is a promising biomaterial for periodontal and maxillofacial therapies, either as a scaffold for cells or alone as a biomaterial.

Biologic assessment of antiseptic mouthwashes using a three-dimensional human oral mucosal model

BACKGROUND

The biologic safety profile of oral health care products is often assumed on the basis of simplistic test models such as monolayer cell culture systems. We developed and characterized a tissue-engineered human oral mucosal model, which was proven to represent a potentially more informative and more clinically relevant alternative for the biologic assessment of mouthwashes. The aim of this study was to evaluate the biologic effects of alcohol-containing mouthwashes on an engineered human oral mucosal model.

METHODS

Three-dimensional (3D) models were engineered by the air/liquid interface culture technique using human oral fibroblasts and keratinocytes. The models were exposed to phosphate buffered saline (negative control), triethylene glycol dimethacrylate (positive control), cola, and three types of alcohol-containing mouthwashes. The biologic response was recorded using basic histology; a cell proliferation assay; 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide tissue-viability assay; transmission electron microscopy (TEM) analysis; and the measurement of release of interleukin (IL)-1beta by enzyme-linked immunosorbent assay.

RESULTS

Statistical analysis showed that there was no significant difference in tissue viability among the mouthwashes, cola, and negative control groups. However, exposure to the positive control significantly reduced the tissue viability and caused severe cytotoxic epithelial damage as confirmed by histology and TEM analysis. A significant increase of IL-1beta release was observed with the positive control and, to a lesser extent, with two of the tested mouthrinses.

CONCLUSIONS

The 3D human oral mucosal model can be a suitable model for the biologic testing of mouthwashes. The alcohol-containing mouthwashes tested in this study do not cause significant cytotoxic damage and may slightly stimulate IL-1beta release.

Odontogenic potential of post-natal oral mucosal epithelium

A bioengineered tooth would provide a powerful alternative to currently available clinical treatments. Previous experiments have succeeded in bioengineering teeth using tooth germs from animal embryos. However, the ultimate goal is to develop a technology which enables teeth to be regenerated with the use of autologous cells. To pursue this goal, we re-associated the palatal epithelium from young mice with the odontogenic dental mesenchyme and transplanted the re-associated tissues into mouse kidney capsules. Morphologically defined teeth were formed from the re-associated cultured palatal epithelial cell sheets from mice aged up to 4 wks, but no tooth was formed when the palatal epithelium from mice after 2 days of age was directly re-associated. Our results demonstrated that post-natal non-dental oral mucosal epithelium can be used as a substitute for dental epithelium, and that epithelial cell sheet improves the ability of the oral epithelium of older mice to differentiate into dental epithelium.

Biocompatibility of Resin-based Dental Materials

Oral and mucosal adverse reactions to resin-based dental materials have been reported. Numerous studies have examined the biocompatibility of restorative dental materials and their components, and a wide range of test systems for the evaluation of the biological effects of these materials have been developed. This article reviews the biological aspects of resin-based dental materials and discusses the conventional as well as the new techniques used for biocompatibility assessment of dental materials.

Diffusion studies of nanometer polymersomes across tissue engineered human oral mucosa

PURPOSE

To measure the diffusion of nanometer polymersomes through tissue engineered human oral mucosa.

METHODS

In vitro models of full thickness tissue engineered oral mucosa (TEOM) were used to assess the penetration properties of two chemically different polymersomes comprising two of block copolymers, PMPC-PDPA and PEO-PDPA. These copolymers self-assemble into membrane-enclosed vesicular structures. Polymersomes were conjugated with fluorescent rhodamine in order to track polymersome diffusion. Imaging and quantification of the diffusion properties were assessed by confocal laser scanning microscopy (CLSM).

RESULTS

TEOM is morphologically similar to natural oral mucosa. Using CLSM, both formulations were detectable in the TEOM within 6 h and after 48 h both penetrated up to 80 microm into the TEOM. Diffusion of PMPC-PDPA polymersomes was widespread across the epithelium with intra-epithelial uptake, while PEO-PDPA polymersomes also diffused into the epithelium.

CONCLUSIONS

CLSM was found to be an effective and versatile method for analysing the level of diffusion of polymersomes into TEOM. The penetration and retention of PMPC-PDPA and PEO-PDPA polymersomes means they may have potential for intra-epithelial drug delivery and/or trans-epithelial delivery of therapeutic agents.

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.

Carbamazepine Transbuccal Delivery: The Histo-Morphological Features of Reconstituted Human Oral Epithelium and Buccal Porcine Mucosae in the Transmucosal Permeation

Transbuccal drug delivery is an attractive way of administration since several well-known advantages are provided, especially with respect to peroral management. Carbamazepine (CBZ) is an anticonvulsant which is useful in controlling neuropathic pain, and it is currently administered by peroral route, although its absorption and bioavailability is limited due to various factors. The oral cavity could be an interesting site for transbuccal CBZ delivery due to two properties: slow administration of constant low drug doses and less dose-related side effects. However, in transbuccal absorption a major limitation could be the low permeability of the mucosa which results in low drug bioavailability; thus the aptitude of the drug to penetrate the buccal mucosa has to be assessed by using tissue models resembling human normal mucosa. In our experience, CBZ well permeates mucosal membranes. In order to assess the efficacy of CBZ transbuccal delivery and to verify the reliability of these tissues in permeability testing before and after the passage of CBZ, the histo-morphological features of reconstituted human oral (RHO) epithelium (E) and buccal porcine mucosae were investigated. Significant histological changes due to CBZ passage were observed both in RHO-E and porcine mucosa. The main findings detected in RHO samples were cellular swellings with a signet ring-like appearance, nuclear swelling, prominent nucleoli lined against the nuclear membrane and the presence of keratohyalin granules. The most striking finding regarding porcine buccal mucosa was a cytoplasmic vacuolization, mainly involving the basal layer.

Development, optimization and characterization of a full-thickness tissue engineered human oral mucosal model for biological assessment of dental biomaterials

Restorative dental materials and oral health care products come into direct contact with oral mucosa and can cause adverse reactions. In order to obtain an accurate risk assessment, the in vitro test model must reflect the clinical situation as closely as possible. The aim of this study was to develop and optimize a three-dimensional full-thickness engineered human oral mucosal model, which can be used for biological assessment of dental materials. In this study human oral fibroblasts and keratinocytes were isolated from patients and seeded onto a number of collagen-based and synthetic scaffolds using a variety of cell seeding techniques and grown at the air/liquid interface to construct human oral mucosa equivalents. Suitability of 10 different scaffolds for engineering human oral mucosa was evaluated in terms of biocompatibility, biostability, porosity, and the ability to mimic normal human oral mucosa morphology. Finally an optimized full-thickness engineered human oral mucosa was developed and characterized using transmission electron microscopy and immunostaining. The oral mucosa reconstruct resembled native human oral mucosa and it has the potential to be used as an accurate and reproducible test model in mucotoxicity and biocompatibility evaluation of dental materials.

Khat (Catha edulis) induces reactive oxygen species and apoptosis in normal human oral keratinocytes and fibroblasts

Khat chewing is widely practiced in Eastern Africa and the Middle East. Khat is genotoxic to cells within the oral mucosa, and several studies have suggested an association between khat use and oral lesions like hyperkeratosis and oral cancer. This study investigated the mechanism of khat-induced cytotoxicity using primary normal human oral keratinocytes (NOK) and fibroblasts (NOF). Khat induced rounding up of cells, plasma membrane blebbing, and condensation of nuclear chromatin within 3-6 h of exposure. The cells also showed externalization of phosphatidylserine and fragmentation of DNA. Morphological and biochemical features were compatible with cell death by apoptosis. Khat also induced an increase in cytosolic reactive oxygen species (ROS) and a depletion of intracellular glutathione (GSH) within 1 h of exposure. Antioxidants reduced ROS generation, GSH depletion and delayed the onset of cytotoxicity in both cell types. Generally, NOF cells were more sensitive to khat-induced cytotoxicity than NOK cells. These effects were elicited at concentrations of khat expected to occur in the oral cavity during khat chewing. In summary, khat induced apoptotic cell death in primary normal oral keratinocytes and fibroblasts by an early effect on mechanisms that regulate oxidative stress.

Characterisation of human dental stem cells and buccal mucosa fibroblasts

Human craniofacial stem cells are recently discovered sources of putative mesenchymal stem cells that hold great promise for autogenic or allogenic cell therapy and tissue engineering. Prior to employing these cells in clinical applications, they must be thoroughly investigated and characterized. In this study, the surface marker expression was investigated on dental pulp stem cells (DPSCs), dental follicle cells (DFCs), periodontal ligament stem cells (PDLSCs), and buccal mucosa fibroblasts (BMFs) utilising surface markers for flow cytometry. The osteogenic potential was also examined by bone-associated markers alkaline phosphatase, Runx2, collagen type I, osteocalcin, and osteopontin. The results from our study demonstrate that the dental cell sources exhibit comparable surface marker and bone-associated marker profiles parallel to those of other mesenchymal stem cell sources, yet distinct from the buccal mucosa fibroblasts. Our data support evidence towards clinical applicability of dental stem cells in hard tissue regeneration.