Bone morphogenetic proteins: from basic science to clinical applications

Allograft and alloplastic bone substitutes: a review of science and technology for the craniomaxillofacial surgeon

Bone healing is a complex and multifactorial process. As such, there are numerous steps in the process to which intervention can be directed. This has given rise to many bone graft technologies that have been used to regenerate bone, creating, perhaps, a bewildering array of options. The options that surgeons have the most familiarity with are the ones that have been available the longest (i.e., autograft and allograft). Although useful for the widest spectrum of clinical applications, limitations of these grafts has prompted the development of new materials. Demineralized bone matrix formulations and synthetic ceramic materials are now being used with greater frequency. These biomaterials have demonstrated their usefulness in facial plastic and reconstructive surgery with their ability to augment and replace portions of the craniofacial skeleton. The purpose of this article is to describe and discuss the allograft and alloplastic bone grafting technologies so that the reader can consider each in the context of the others and gain a better appreciation for how each fits into the universe of existing and emerging treatments for bone regeneration.

Effect of BMP-2 gene transfer on bone healing in sheep

Critical size defects of bone and delayed fracture healing due to metabolic disorders are still problems in orthopaedic surgery. Adenoviral vectors encoding bone morphogenetic protein-2 (Ad.BMP-2) have been used to stimulate bone formation in small animals. The present study evaluated the use of direct adenoviral gene transfer for inducing bone formation in a large animal. Standardized iliac crest defects were created surgically on both sides of the pelvic bone of white mountain sheep. The efficiency of gene transfer was evaluated using recombinant adenoviruses carrying the cDNA for luciferase. High levels of transgene expression, restricted to the site of injection, were found for the 1st week. Transgene expression then fell considerably, but could still be detected for up to 5 weeks. To investigate the effect on bone healing, Ad.BMP-2 (10(11) particles in 200 mul saline) was unilaterally injected into iliac crest defects and into tibial osteotomies. The contralateral defects remained untreated to evaluate possible systemic effects. The controls were treated with saline solution. Bone formation within the defect, assessed by micro-computed tomography (CT) measurement at 8 weeks, and callus formation after osteotomy were significantly reduced following direct application of Ad.BMP-2. The retardation compared to untreated control animals was additionally found at the contralateral iliac crest indicating a systemic inhibitory effect. Histological analysis confirmed the CT measurement and showed an increased number of inflammatory cells within both defects. Antibodies against the adenovirus and the transgene product were detected in all treated animals. These data show a systemic retardation of bone formation following a single local injection of Ad.BMP-2 in sheep. This finding stands in contrast to the data obtained from small animal models. Further studies are needed to determine the contribution of the immune response to these results, and whether a lower dose of Ad.BMP-2 would be advantageous.

The role of inhibitory molecules in fracture healing

The balance between all the signalling molecules involved in bone formation with their inhibitors and most importantly between BMPs and their antagonists is critical determinant of osteogenesis, and therefore of skeletal development, fracture repair, and bone remodelling. The main identified inhibitory molecules of the osteogenic lineage, either from studies during embryonic development or from in vitro and in vivo studies are presented in the herein study. Potential treatments using these molecules either alone or in combination with BMPs to control the bone growth and overgrowth are already under investigation aiming in treatments that mimic as much as possible the natural process of bone generation in various situations including fracture healing, osteoporosis, and osteoarthritis and other metabolic disorders, in order to more closely resemble the original tissue.

Gene therapeutics for periodontal regenerative medicine

There has been significant advancement in the field of periodontal tissue engineering over the past decade for the repair of tooth-supporting structures. Although encouraging results for periodontal tissue regeneration have been found in numerous clinical investigations using recombinant growth factors, limitations exist with topical protein delivery. Newer approaches seek to develop methodologies that optimize growth factor targeting to maximize the therapeutic outcome of periodontal regenerative procedures. Genetic approaches in periodontal tissue engineering show early progress in achieving delivery of growth factor genes, such as platelet-derived growth factor or bone morphogenetic protein, to periodontal lesions. Ongoing investigations in ex vivo and in vivo gene transfer to periodontia seek to examine the extent of the potential effects in stimulating periodontal tissue engineering.

Transcriptomics and proteomics: advancing the understanding of genetic basis of fracture healing

Fracture healing is a complex physiological post-natal process, which involves the coordination of several different cell types. Exploring the orchestration of events and the simultaneous activation of osteogenesis and chondrogenesis that recapitulates mammalian embryological skeletal development seems to be not only sophisticated but also challenging. A large number of genes involved in the above process are known, but many more remain to be discovered. The functional characterisation of these genes promises to elucidate the repair process as well as skeletal abnormalities and aging. We here review the current knowledge on early and late gene expression during fracture healing, the genes so far associated with osteoblast and osteoclast differentiation, the BMP antagonists, and the Wnts signalling pathway.

The Effect of Combination of Recombinant Human Bone Morphogenetic Protein-2 and Basic Fibroblast Growth Factor or Insulin-Like Growth Factor-I on Dental Implant Osseointegration by Confocal Laser Scanning Microscopy

BACKGROUND

The healing period of bone-implant osseointegration usually varies from 3 to 6 months or even longer. Failure may occur during this time. This study aimed to investigate whether osseointegration of dental implants can be enhanced by the combination of growth factors.

METHODS

Sixty-four implants were coated with polylactic acid and divided into four groups. Group I was applied with 1.0 mg recombinant human bone morphogenetic protein-2 (rhBMP-2) and 200 microg recombinant human basic fibroblast growth factor (rhbFGF), group II with 1.0 mg rhBMP-2 and 250 mug recombinant human insulin-like growth factor-I (rhIGF-I), group III with 1.0 mg rhBMP-2, and group IV without growth factors as control. In total, 16 rabbits were used, and two osteotomies were drilled on each side of the femur, in which four different groups were randomly placed. Four weeks after implanting, 20 mg calcein green/kg body weight was administered intravenously, and 8 weeks after implanting, 20 mg alizarin/kg body weight was administered intravenously. Twelve weeks after implanting, the animals were sacrificed. The block of bone with implants was embedded in methylmethacrylate and sectioned, and the percentage of new bone surrounding the implant was analyzed by confocal laser scanning microscopy.

RESULTS

There was a statistical difference in bone formation between rhBMP-2-applied groups and the non-applied group at 4 or 8 weeks, and no significant difference between groups I and II (although bone formation in group II was greater than that in group I at 4 weeks). The bone formation in group II was greater than that in group III at 4 or 8 weeks. The formed bone in group I was also greater than the one in group III at 8 weeks, but there was no difference at 4 weeks.

CONCLUSIONS

rhBMP-2 could increase new bone formation, and it acted synergistically with rhbFGF and rhIGF-I to improve bone-implant osseointegration. The combination of rhBMP-2 and rhbFGF (group 1) showed faster growth of new bone than other groups at 8 months.

A polymorphism in a conserved posttranscriptional regulatory motif alters bone morphogenetic protein 2 (BMP2) RNA:protein interactions

The bone morphogenetic protein (BMP)2 gene has been genetically linked to osteoporosis and osteoarthritis. We have shown that the 3'-untranslated regions (UTR) of BMP2 genes from mammals to fishes are extraordinarily conserved. This indicates that the BMP2 3'-UTR is under stringent selective pressure. We present evidence that the conserved region is a strong posttranscriptional regulator of BMP2 expression. Polymorphisms in cis-regulatory elements have been proven to influence susceptibility to a growing number of diseases. A common single nucleotide polymorphism (SNP) disrupts a putative posttranscriptional regulatory motif, an AU-rich element, within the BMP2 3'-UTR. The affinity of specific proteins for the rs15705 SNP sequence differs from their affinity for the normal human sequence. More importantly, the in vitro decay rate of RNAs with the SNP is higher than that of RNAs with the normal sequence. Such changes in mRNA:protein interactions may influence the posttranscriptional mechanisms that control BMP2 gene expression. The consequent alterations in BMP2 protein levels may influence the development or physiology of bone or other BMP2-influenced tissues.

Biological factors involved in the osseointegration of oral titanium implants with different surfaces: a pilot study in minipigs

BACKGROUND

The stability of titanium implants is determined by the rigid load-bearing connections that are formed by the bone, a process that involves a complex network of cells, pro- and anti-inflammatory mediators, and growth factors. The osseointegration processes at the interfaces of machined and porous implants were studied using molecular and histological techniques.

METHODS

Two machined and two porous titanium implants were inserted into the tibiae of four minipigs. The animals were sacrificed at 15, 30, 60, and 90 days post-implantation. The levels of bone morphogenetic protein (BMP)-4, transforming growth factor (TGF)-beta1, and tumor necrosis factor (TNF)-alpha were quantified in the peri-implant osseous samples. The levels of interleukin (IL)-1beta, IL-6, IL-10, and TNF-alpha in the serum were also assessed.

RESULTS

Histomorphological analysis showed evidence of bone ossification around the porous implant at 60 days. Surrounding the machined implants, highly sclerotic fibrous pads started the healing response at 90 days, and the levels of TGF-beta1 and BMP-4 began to increase at 60 days, at which time bone ossification around the porous implants was already evident. TNF-alpha was not present in the bone next to the implants. The serum levels of cytokines IL-1beta, IL-6, and IL-10 were not increased. The serum level of TNF-alpha increased during the healing process.

CONCLUSIONS

We observed that the levels of BMP-4 and TGF-beta1, which play essential roles in the osteogenesis process, increased earlier around the porous implants than around the machined implants. Similarly, the ossification process was initiated earlier at the surfaces of the porous implants than at the surfaces of the machined implants.

Assay of Bone Morphogenetic Protein-2, -4, and -7 in Human Demineralized Bone Matrix

Demineralized bone matrix (DBM) is a widely used bone graft material that derives its osteoinductive potential from matrix-associated bone morphogenetic proteins (BMPs). Prior investigations have shown that the osteoinductive potential can vary widely, with influence from both donor and processing sources. Although it is plausible that donor variance in the BMP profile can be an important consideration, the few published studies available have given inconsistent and incomplete information about this. The goal was to (1) characterize the variance of BMP-2, BMP-4, and BMP-7 in fully demineralized DBM derived from 20 appropriately screened (Food and Drug Administration and the American Association of Tissue Banks criteria) donors (male and female, 17-65 years) and (2) using literature review, infer the potential for this to be an important source of variability in graft function. BMPs were extracted with 4 M guanidine hydrochloride, and levels of BMP-2, BMP-4, and BMP-7 were measured using enzyme-linked immunosorbent assay. Measured levels were as follows: BMP-2 = 21.4 +/- 12.0 ng/g DBM, BMP-4 = 5.45 +/- 2.04 ng/g DBM, and BMP-7 = 84.1 +/- 34.4 ng/g DBM, which were significantly different (P < 0.05). There was a positive linear correlation between BMP-2 and BMP-7 (P = 0.0227). DBM derived from female donors had significantly greater concentrations of BMP-2 and BMP-7 than did that derived from male donors (P = 0.0257 and 0.0245, respectively). There was no significant correlation between donor age and the levels of any of the measured BMPs. The magnitude of variance of BMP profile appears to reasonably well correspond to the variance in osteoinductive potential cited by others, suggesting the possibility of using this as a method of donor screening.

Current concepts of molecular aspects of bone healing

Fracture healing is a complex physiological process. It involves the coordinated participation of haematopoietic and immune cells within the bone marrow in conjunction with vascular and skeletal cell precursors, including mesenchymal stem cells (MSCs) that are recruited from the surrounding tissues and the circulation. Multiple factors regulate this cascade of molecular events by affecting different sites in the osteoblast and chondroblast lineage through various processes such as migration, proliferation, chemotaxis, differentiation, inhibition, and extracellular protein synthesis. An understanding of the fracture healing cellular and molecular pathways is not only critical for the future advancement of fracture treatment, but it may also be informative to our further understanding of the mechanisms of skeletal growth and repair as well as the mechanisms of aging.

Osteointegration of hydroxyapatite-titanium implants coated with nonglycosylated recombinant human bone morphogenetic protein-2 (BMP-2) in aged sheep

Osteointegration of metal implants into aged organisms can be severely compromised due to reduced healing capacity of bone, lack of precursor cells for new bone formation, or osteoporosis. Here, we report on successful implant healing in a novel model of aged sheep in the presence of nonglycosylated bone morphogenetic protein 2 (BMP-2). Ewes of 8 to 12 years with significant radiologic and histologic signs of osteoporosis and adipocytic bone marrow received a cylindrical hydroxyapatite-titanium implant of 12 x 10 mm. BMP-2 has been produced as a bacterial recombinant fusion protein with maltose-binding protein and in vitro generation of mature BMP-2 by renaturation and proteolytic cleavage. A BMP-2 inhibition ELISA was developed to measure the in vitro release kinetics of bioactive human BMP-2 from immersed solid implant materials by using Escherichia coli expressed and biotinylated recombinant human BMP-2 receptor IA extracellular domain (ALK-3 ECD). The implants were placed laterally below both tibial plateaus, with the left leg implant carrying 380 microg BMP-2. Both implant types became integrated within the following 20 weeks. The control implant only integrated at the cortical bone, and little new bone formation was found within the pre-existing trabecular bone or the marrow cavity. Marrow fat tissue was partially replaced by unspecific connective tissue. In contrast, BMP-2-coated implants initiated significant new bone formation, initially in trabecular arrangements to be replaced by cortical-like bone after 20 weeks. The new bone was oriented towards the cylinder. Highly viable bone marrow appeared and filled the lacunar structures of the new bone. In mechanical tests, the BMP-2-coated implants displayed in average 50% higher stability. This animal model provided first evidence that application of nonglycosylated BMP-2 coated on solid implants may foster bone healing and regeneration even in aged-compromised individuals.

Gene therapy for spinal fusion

Spinal fusion will continue to be an important part of the surgical treatment of spinal pathology for the foreseeable future. Traditional challenges to successful spinal fusion surgery include autograft donor site morbidity and pseudoarthrosis. Recent advances in the understanding of the biology of bone formation have allowed the development of therapeutic biologics. Although recombinant bone morphogenetic proteins delivered to the arthrodesis site will stimulate fusion, these proteins have been less successful in more challenging fusion situations (posterolateral), require supraphysiologic doses to promote fusion in humans, and are quite expensive. Gene therapy may represent the easiest method for the application of bone-forming biologic agents to promote spinal fusion. Both in vivo and ex vivo techniques of delivery of therapeutic genes have been used effectively to promote fusion in lower animals. Considerable research is required to identify gene therapy techniques and vectors with acceptable safety profiles and high fusion rates.

Regenerating the periodontium: is there a magic formula?

OBJECTIVE

Left untreated, periodontal disease results in destruction of periodontal tissues including cementum, bone and the periodontal ligament, and subsequently, tooth loss. Increased research efforts focused on understanding periodontal disease at the cellular, molecular and clinical level have resulted in improved modalities for arresting disease progression; however, outcomes of existing procedures are not predictable and often disappointing. Critical to improving the predictability of regenerative therapies is targeting studies toward enhancing our understanding of the cellular and molecular events required to restore periodontal tissues.

DESIGN

Toward this goal our laboratory has focused on defining cells, mechanisms and factors regulating development of periodontal tissues, using in vitro and in vivo rodent models.

RESULTS AND CONCLUSION

Results from these studies have enabled us to identify attractive candidate factors/cells including: 1) products secreted by epithelial cells that act on mesenchymal cells (amelogenins): we observed that both follicle cells and cementoblasts are responsive to amelogenin-like molecules resulting in changes in the expression of genes associated with cell maturation; 2) morphogens (bone morphogenetic proteins, BMP): we report that follicle cells respond differently to BMPs vs. cementoblasts, depending on dose of and specific BMP used; 3) phosphates: existing data suggest that phosphates act as signaling molecules regulating the expression of genes associated with cementoblast maturation. Knowledge gained from these studies has provided insight as to the cells/factors required for designing improved regenerative therapies.

Application of recombinant BMP-7 on persistent upper and lower limb non-unions

The purpose of this study was to evaluate the efficacy and safety of recombinant bone morphogenetic protein 7 (rhBMP-7 or OP-1) as a bone-stimulating agent in the treatment of persistent fracture non-unions. Twenty-five consecutive patients [19 males, mean age 39.4 years (range: 18-79)] with 26 fracture non-unions were treated with rhBMP-7. There were 10 tibial non-unions, eight femoral, three humeral, three ulnar, one patellar, and one clavicular non-union. The mean follow-up was 15.3 months. The mean number of operations performed prior to rhBMP-7 application was 3.2, with autologous bone graft and bone marrow injection being used in 10 cases (38.5%). Both clinical and radiological union occurred in 24 (92.3%) cases, within a mean time of 4.2 months and 5.6 months, respectively. Of the remaining two cases, one patient ultimately underwent a below knee amputation, secondary to recurrence of deep sepsis. The other patient with recalcitrant ulnar non-union although the radiological union was incomplete, declined further intervention, as he was asymptomatic. No complications or adverse effects from the use of rhBMP-7 were encountered. This study supports the view that the application of rhBMP-7 as a bone-stimulating agent is safe and a power adjunct to be considered in the surgeon's armamentarium for the treatment of these challenging clinical conditions.

Clinical applications of BMP-7: the UK perspective

Treatment of fracture non-union is a challenging situation in skeletal surgery. Since the discovery of bone morphogenetic proteins (BMPs) by Urist preclinical research as well as clinical trials has shown the efficacy of these molecules in bone healing enhancement. Recombinant bone morphogenetic protein became available in UK during August 2001. We evaluated the type of indications and the efficacy of BMP-7 in a variety of clinical conditions including persistent fracture non-unions, augmentation of periprosthetic fracture treatment and osteotomies, enhancement of fracture healing following acetalular reconstruction, distraction osteogenesis, free fibular graft and arthrodesis of joints. Out of 653 cases, the overall success rate was 82% (535 cases). No local or systemic adverse effects were encountered. The role of BMP's as a bone stimulating agent is safe, well established and could be considered as a power adjunct in the surgeon's armamentarium for the treatment of these challenging clinical conditions.

Role of Bovine Bone Morphogenetic Proteins in Bone Matrix Protein and Osteoblast-Related Gene Expression During Rat Bone Marrow Stromal Cell Differentiation

Bone morphogenetic proteins (BMPs) are known to promote osteogenesis, and clinical trials are currently underway evaluating the ability of certain BMPs to promote bone graft and fracture healing. To observe the mechanism of osteoinductive and bone formation, 100 microg of bovine BMP was tested during osteogenic differentiation of rat bone marrow stromal cells (MSCs) and C2C12 line culture for 14 and 28 days. We examined alkaline phosphatase (ALP) by assay, immunohistochemical studies for bone matrix proteins, and mRNA expression of bone matrix proteins and osteoblast-related analysis by reverse-transcription polymerase chain reaction. ALP activity in MSC cultures was elevated by bovine BMP by two to fivefold (P < 0.05-0.001). DNA and protein content increased over 14 days. BMP significantly increased the mRNA expression of type I collagen, ALP, osterix, osteocalcin, osteopontin, vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF)-A, and parathyroid hormone receptor time dependently during the osteoblastic differentiation. There was no markedly enhanced mRNA expression of bone sialoprotein (BSP) and glyceraldehyde-3-phosphate dehydrogenase compared with that of control. Immunohistochemical results also showed BMP increased immunoreactive positivity of type I collagen, osteocalcin, osteonectin, osteopontin, and BSP during the C2C12 differentiation. These data indicated that BMP enhances our ability to stimulate the differentiation of osteoblast-like cells and increases osteoinductivity, bone matrix protein formation and mineralization, angiogenesis, and chondrogenesis during osteoblast progenitor cell differentiation in vitro and that the role of chondrogenic is weak.

The bone morphogenic protein

The molecular and cellular process to promote bone formation has been examined extensively in recent years in an attempt to minimize delayed unions and nonunions. Bone morphogenetic proteins (BMPs) have been determined to play an intricate role in the bone formation cascade. Over 14 BMPs have been isolated and more are being discovered as investigation progresses. BMP-2 and BMP-7 are being produced commercially for clinical use with specific indications. Continuing research is investigating the optimal carrier that will give the best results. This article reviews the most current information regarding BMPs.

Demineralized bone matrix graft: a scientific and clinical case study assessment

Osteoinductive demineralized bone matrix results from bone demineralization and is attributed to matrix-associated bone morphogenetic proteins. The osteoinductive potential can vary with donor. Many bioassay methods are available to screen donors, each with its own interpretation, so performance of more than one may be of value. Furthermore, little is known about the relationship between bioassay results and clinical outcomes. A study designed to meaningfully explore these issues would require assay of a large number of donors as well as clinical utilization in a large patient population. A preliminary study was undertaken to gain initial perspective. Using demineralized bone matrix derived from one 33-year-old female donor, 2 methods of bioassay and a clinical case study were performed. The levels of bone morphogenetic proteins 2, 4, and 7 in lyophilized demineralized bone matrix powder were measured (19.65 +/- 0.30 ng/g, 2.49 +/- 0.19 ng/g, and 82.03 +/- 6.89 ng/g, respectively). Also, putty (Osteostim DBM Putty), prepared from powder, was intramuscularly implanted in athymic rats and de novo bone formation quantified (6.7% +/- 3.5% new bone formation with 49% +/- 17% of the implant area associated with new bone formation). The putty, in conjunction with internal fixation, was used in the revision of a medial malleolar nonunion of an obese, 76-year-old woman. Radiographic union with excellent graft incorporation was achieved by 12 weeks postoperatively, with maintenance of an acceptable clinical result during the 14-month follow-up period. These results are interpreted in the broader context of demineralized bone grafting, in general, and an outline for further study is presented.

Enhanced osteoinduction by controlled release of bone morphogenetic protein-2 from biodegradable sponge composed of gelatin and β-tricalcium phosphate

Biodegradable gelatin sponges at different contents of beta-tricalcium phosphate (beta-TCP) were fabricated to allow bone morphogenetic protein (BMP)-2 to incorporate into them. The in vivo osteoinduction activity of the sponges incorporating BMP-2 was investigated, while their in vivo profile of BMP-2 release was evaluated. The sponges prepared had an interconnected pore structure with an average pore size of 200 microm, irrespective of the beta-TCP content. The in vivo release test revealed that BMP-2 was released in vivo at a similar time profile, irrespective of the beta-TCP content. The in vivo time period of BMP-2 retention was longer than 28 days. When the osteoinduction activity of gelatin or gelatin-beta-TCP sponges incorporating BMP-2 was studied following the implantation into the back subcutis of rats in terms of histological and biochemical examinations, homogeneous bone formation was histologically observed throughout the sponges, although the extent of bone formation was higher in the sponges with the lower contents of beta-TCP. On the other hand, the level of alkaline phosphatase activity and osteocalcin content at the implanted sites of sponges decreased with an increase in the content of beta-TCP. The gelatin sponge exhibited significantly higher osteoinduction activity than that of any gelatin-beta-TCP sponge, although every sponge with or without beta-TCP showed a similar in vivo profile of BMP-2 release. In addition, the in vitro collagenase digestion experiments revealed that the gelatin-beta-TCP sponge collapsed easier than the gelatin sponge without beta-TCP incorporation. These results suggest that the maintenance of the intrasponge space necessary for the osteoinduction is one factor contributing to the osteoinduction extent of BMP-2-incorporating sponges.

Promises and pitfalls of stem cell therapy for promotion of bone healing

There is promise in combining stem cells with allogeneic bone matrix to promote bone healing. Murine bone marrow, peripheral blood, and compact bone cells were transplanted ectopically under the kidney capsule in mice, alone or in combination with allogeneic matrix products: powder and putty to determine their bone forming potential in comparison to transplanted femoral bone fragments and long-term cultured bone marrow cells. The end point was the amount of bone formed as determined by quantitative histology. Mononuclear cells from marrow, peripheral blood, or bone alone transplanted under the kidney capsule did not form bone. Mononuclear cell populations did not combine readily with matrix products and there was in vivo migration of the transplanted combinations. Kidney subcapsular transplanted cultured bone marrow cells formed bone in proportion to the culture period, but after 9 weeks, the extent was only 20% by area of that of similarly transplanted femoral bone fragments. An inductive stimulus for bone formation seemed necessary. Osteoprogenitor cells were not detected in significant numbers in blood unless high doses of cytokines were administered. A better definition of the optimal cell populations and manipulations required for promotion of bone healing is needed along with new (transplant) models that allow for cell tracking. Much work remains to overcome current pitfalls in the use of stem cells to promote allograft integration and bone healing.

LEVEL OF EVIDENCE

Therapeutic study, Level V (expert opinion). See the Guidelines for Authors for a complete description of levels of evidence.

Multidomain synthetic peptide B2A2 synergistically enhances BMP-2 in vitro

A multidomain, synthetic peptide designated B2A2 synergizes the activity of BMP-2. B2A2 interacts with BMP receptor isoforms, potentiating the action of BMP-2 in activating alkaline phosphatase and triggering Smad and MAPK signaling. B2A2's design permits its delivery as a local surface coating as well as a soluble co-factor, thus broadening potential bioengineering applications.

INTRODUCTION

BMP-2 induces osteogenic differentiation and accelerates bone repair. Although BMP-2 inhibitors have been discovered, no BMP-2 mimetics or enhancers that function in the physiological range have yet been found. Here we report that a synthetic peptide designated B2A2, consisting of (1) a BMP receptor-targeting sequence, (2) a hydrophobic spacer, and (3) a heparin-binding sequence, is a positive modulator of recombinant BMP-2.

MATERIALS AND METHODS

Cultures of mesenchymal cell lines C2C12 and C3H10T1/2 were given B2A2, recombinant BMP-2, or both. Alkaline phosphatase (ALP) activity was assayed by conversion of paranitrophenol phosphate (PNPP). Signaling through Smad and MAP kinase pathways was monitored by Western blot. Receptor binding was assessed by incubating immobilized B2A2 with soluble recombinant receptor-Fc chimeras and detecting bound receptor by anti-Fc antibody ELISA. Surface coating of medical device materials was done by first dip-coating with silyl-heparin, followed by B2A2.

RESULTS AND CONCLUSIONS

Treatment of cells with B2A2 alone marginally increased ALP activity. However, B2A2 plus BMP-2 resulted in 5- to 40-fold augmentation of ALP compared with BMP-2 alone in C3H10T1/2 or C2C12 cells, respectively. This synergistic enhancement was observed over a broad concentration range (4-1000 ng/ml BMP-2). B2A2 interacted directly with BMP receptor isoforms (preferentially to BMPR-Ib and ActivinR-II). In cells, B2A2 + BMP-2 led to a repression of MAP kinase and an increase of Smad activation, consistent with known activation pathways of BMP-2. B2A2 was ineffective when paired with other cytokine/growth factors (basic fibroblast growth factor [FGF-2], TGF-beta1, vascular endothelial growth factor [VEGF]). Simultaneous co-administration was not strictly required. Pulse-chase experiments revealed that temporal separations up to 1 h were still effective. B2A2 was also effective when delivered in a polystyrene- or stainless steel-coated surface through a heparin platform (silyl-heparin) while BMP-2 was added exogenously in solution. These results suggest that B2A2 might promote aggregation of receptor subunits, enabling BMP-2 to activate signaling pathways at effectively lower concentrations. Synthetic multidomain constructs like B2A2 may be useful to accelerate bone repair/deposition through augmentation of endogenous levels of BMP-2 or through local BMP-2 contained in artificial or engineered matrices.

Mechanics and mechano-biology of fracture healing in normal and osteoporotic bone

Fracture repair, which aims at regaining the functional competence of a bone, is a complex and multifactorial process. For the success of fracture repair biology and mechanics are of immense importance. The biological and mechanical environments must be compatible with the processes of cell and tissue proliferation and differentiation. The biological environment is characterized by the vascular supply and by many biochemical components, the biochemical milieu. A good vascular supply is a prerequisite for the initiation of the fracture repair process. The biochemical milieu involves complex interactions among local and systemic regulatory factors such as growth factors or cytokines. The mechanical environment is determined by the local stress and strain within the fracture. However, the local stress and strain is not accessible, and the mechanical environment, therefore, is described by global mechanical factors, e.g., gap size or interfragmentary movement. The relationship between local stress and strain and the global mechanical factors can be obtained by numerical models (Finite Element Model). Moreover, there is considerable interaction between biological factors and mechanical factors, creating a biomechanical environment for the fracture healing process. The biomechanical environment is characterized by osteoblasts and osteocytes that sense the mechanical signal and express biological markers, which effect the repair process. This review will focus on the effects of biomechanical factors on fracture repair as well as the effects of age and osteoporosis.

The potential of gene therapy for fracture healing in osteoporosis

Osteoporosis-associated fractures impair a patient's function and quality of life and represent one of the major public health burdens. Demographic changes predict a dramatic increase in osteoporotic fractures. Experimental data have shown that osteoporosis impairs fracture healing. Clinical observations demonstrate high failure rates of implant fixation in osteoporosis. The reduced healing capacity, including impaired bone formation, in osteoporotic humans might be due to defects in mesenchymal stem cells that lead to reduced proliferation and osteoblastic differentiation. Growth factors show remarkable promise as agents that can improve the healing of bone or increase the proliferation and differentiation capacities of mesenchymal stem cells. Their clinical utility is limited by delivery problems. The attraction of gene-transfer approaches is the unique ability to deliver authentically processed gene products to precise anatomical locations at therapeutic levels for sustained periods of time. Unlike the treatment of chronic diseases, it is neither necessary nor desirable for transgene expression to persist beyond the few weeks or months needed to achieve healing. This review presents different approaches of gene therapy to enhance fracture healing and summarizes the promising results of preclinical studies. It focuses on applications of this new technique to fracture healing in osteoporosis. In our opinion, these applications represent some of the few examples in which gene therapy has a good chance of early clinical success.

Combination of porous hydroxyapatite and cationic liposomes as a vector for BMP-2 gene therapy

The clinical significance of hydroxyapatite (HAP) as a bone substitute has become apparent in recent years and bone morphogenetic protein (BMP) a substance which induces bone has attracted much attention. In this study, a 1.2 cm diameter bone defects created on rabbit cranium were treated with the BMP-2 gene (cDNA plasmid) introduced with porous HAP after completion of hemostasis and the resultant bone formation was analyzed histopathologically. The amounts of bone formation was compared BMP-2 cDNA plasmids were not combined with cationic liposomes as a vector. Four groups of rabbits were compared. In the HAP group the cranial bone defect was treated with HAP containing 40 microg of liposomes and a dummy gene (PU). The BMP gene HAP group was treated with HAP soaked in liposomes and 10 microg of the BMP-2 gene. In addition, a group was treated with the gene without implanting HAP. Bone formation on the cranial defects was evaluated 3, 6 and 9 weeks after the operation, by X-ray and histopathological examinations. Three weeks after the operation there was vigorous bone formation in the cranial defect in the group which received the BMP-2 gene without HAP, and complete ossification was observed at 9 weeks. In the group which received HAP containing the BMP-2 gene, although new bone formation was evident surrounding the scaffold 3 weeks post-operation, the induced bone tissue did not fill all the pores of the scaffold even at 9 weeks post-operation. These results confirm the clinical usefulness of gene therapy for bone formation, using the BMP-2 gene combined with cationic liposomes as a vector. It is possible that the effects of administering the BMP-2 gene will be improved by specializing the microstructure of scaffold for gene therapy.

Evolving concepts in bone tissue engineering

The field of tissue engineering integrates the latest advances in molecular biology, biochemistry, engineering, material science, and medical transplantation. Researchers in the developing field of regenerative medicine have identified bone tissue engineering as an attractive translational target. Clinical problems requiring bone regeneration are diverse, and no single regeneration approach will likely resolve all defects. Recent advances in the field of tissue engineering have included the use of sophisticated biocompatible scaffolds, new postnatal multipotent cell populations, and the appropriate cellular stimulation. In particular, synthetic polymer scaffolds allow for fast and reproducible construction, while still retaining biocompatible characteristics. These criteria relate to the immediate goal of determining the ideal implant. The search is becoming a reality with widespread availability of biocompatible scaffolds; however, the desired parameters have not been clearly defined. Currently, most research focuses on the use of bone morphogenetic proteins (BMPs), specifically BMP-2 and BMP-7. These proteins induce osteogenic differentiation in vitro, as well as bone defect healing in vivo. Protein-scaffold interactions that enhance BMP binding are of the utmost importance, since prolonged BMP release creates the most osteogenic microenvironment. Transition into clinical studies has had only mild success and relies on large doses of BMPs for bone formation. Advances within the field of bone tissue engineering will likely overcome these challenges and lead to more clinically relevant therapies.

A new approach to the treatment of osteoporosis

Osteoporosis remains a significant clinical problem despite the availability of effective therapies. The main therapy still needed is an anabolic agent for the treatment of osteoporosis. This study examined the in vivo effect of the enzyme 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor simvastatin, which controls the first step in the biosynthesis of cholesterol, on bone formation in rats. Histologic specimens were collected 7, 14, and 21 days after administration of 1 mg of simvastatin for 5 days and compared with control specimens for changes in bone tissue. The observed effects on the bone in a healthy animal model included advancement of the blood supply, acceleration of the proliferation and differentiation of osteoprogenitor cells, and formation of osteoid tissue.

Enhancement of Bone Formation by Bone Morphogenetic Protein-2 During Alveolar Distraction: An Experimental Study in Sheep

BACKGROUND

The purpose of this study was to perform alveolar ridge augmentation by distraction osteogenesis (DO) and to enhance bone regeneration through the use of recombinant human bone morphogenetic protein-2 (rhBMP-2), followed by implant placement.

METHODS

Alveolar segmental osteotomy was performed in the mandible of 10 sheep followed by placement of 1.5 mm alveolar distraction devices. The study group was injected on the fifth day of distraction with a single dose of 10 microg rhBMP-2. Only distraction was performed in the control group.

RESULTS

A mean alveolar augmentation of 12 mm was achieved. After 12 weeks of consolidation, the distraction devices were removed and biopsies were taken for histological and immunohistochemical characterization and morphometry of the newly formed bone. Titanium threaded cylindrical implants were then placed in the newly augmented bone. Radiological evaluation showed lifting of the transport segment and integration of the implants within both the transport segment and the regenerated bone. The histological study demonstrated that the association of DO and BMP resulted in increased trabecular bone size and volume (32.2%+/-0.95% versus 18.6%+/-0.71%; P <1 x 10(-17) after 24 days of lengthening and 63.8%+/-1.89% versus 42.5%+/-1.33%; P<1 x 10(-15) after 12 weeks of consolidation) and increased numbers of proliferating cell nuclear antigen stained cells (0.7+/-0.04 versus 0.47+/-0.04; P<1 x 10(-10)) compared with the DO only group.

CONCLUSIONS

Alveolar distraction augments atrophic alveolar ridge and creates new bone that permits implant placement. rhBMP-2 enhances bone quality and may shorten the consolidation period of distraction allowing for earlier implant placement.

Different effects of BMP-2 on marrow stromal cells from human and rat bone

Bone morphogenetic proteins (BMPs) promote the differentiation of osteoprogenitor cells, and also induce osteogenesis in bone marrow stromal cells (MSC) from rats and mice. However, compared to results with animal models, BMPs are relatively inefficient in inducing human MSC to undergo osteogenesis, and are much less effective in promoting bone formation in human clinical trials. Previous studies indicated that, while human MSC respond to dexamethasone with elevated levels of the osteoblast marker alkaline phosphatase, most isolates of human MSC fail to show alkaline phosphatase induction in response to BMP-2, BMP-4, or BMP-7. Several other genes known to be induced by BMPs are appropriately regulated; thus, human MSC are capable of some BMP-activated signaling. Analysis of the BMP receptors ALK-3 and ALK-6 indicated that, although ALK-6 mRNA was not expressed in human MSC, overexpressing a constitutively active ALK-6 receptor did not induce elevated alkaline phosphatase. Real-time RT-PCR was used to investigate expression of several osteoblast-related transcription factors in MSC after 6 days' exposure to BMP2 or dexamethasone. Msx-2, a transcription factor that has been reported to inhibit differentiation of osteoprogenitor cells, showed 10-fold elevation in BMP-2-treated human MSC, but not in BMP-2-treated rat MSC. Overexpression of Msx-2 in human and rat MSC, however, did not alter alkaline phosphatase levels, which suggests that absence of BMP-stimulated alkaline phosphatase was not caused by the BMP-2-induced increase in Msx-2. Although Runx2 isoforms have been implicated in control of osteoblast differentiation, levels of this transcription factor were unaffected by BMP treatment. Expression of the FKHR transcription factor, which has been reported to regulate alkaline phosphatase transcription in mouse cells, showed a modest increase in response to BMP-2, but a much greater increase in dexamethasone-treated cells. We propose that BMP regulation of the bone/liver/kidney alkaline phosphatase gene is indirect, requiring expression of new transcription factor(s) that behave differently in rodent and human MSC.

Conservation of Bmp2 post-transcriptional regulatory mechanisms

Bone morphogenetic protein (BMP) orthologs from diverse species like flies and humans are functionally interchangeable and play key roles in fundamental processes such as dorso-ventral axis formation in metazoans. Because both transcriptional and post-transcriptional mechanisms play central roles in modulating developmental protein levels, we have analyzed the 3'-untranslated region (3'UTR) of the Bmp 2 gene. This 3'UTR is unusually long and is alternatively polyadenylated. Mouse, human, and dog mRNAs are 83-87% identical within this region. A 265-nucleotide sequence, conserved between mammals, birds, frogs, and fish, is present in Bmp2 but not Bmp4. The ability of AmphiBMP2/4, a chordate ortholog to Bmp2 and Bmp4, to align with this sequence suggests that its function may have been lost in Bmp4. Activation of reporter genes by the conserved region acts by a post-transcriptional mechanism. Mouse, human, chick, and zebrafish Bmp2 synthetic RNAs decay rapidly in extracts from cells not expressing Bmp2. In contrast, these RNAs are relatively stable in extracts from Bmp2-expressing cells. Thus, Bmp2 RNA half-lives in vitro correlate with natural Bmp2 mRNA levels. The fact that non-murine RNAs interact appropriately with the mouse decay machinery suggests that the function of these cis-regulatory regions has been conserved for 450 million years since the fish and tetrapod lineages diverged. Overall, our results suggest that the Bmp2 3'UTR contains essential regulatory elements that act post-transcriptionally.

Repair of articular cartilage defects in rabbits using CDMP1 gene-transfected autologous mesenchymal cells derived from bone marrow

OBJECTIVE

Cartilage-derived morphogenetic protein 1 (CDMP1), which is a member of the transforming growth factor-beta superfamily, is an essential molecule for the aggregation of mesenchymal cells and acceleration of chondrocyte differentiation. In this study, we investigated whether CDMP1-transfected autologous bone marrow-derived mesenchymal cells (BMMCs) enhance in vivo cartilage repair in a rabbit model.

METHODS

BMMCs, which had a fibroblastic morphology and pluripotency for differentiation, were isolated from bone marrow of the tibia of rabbits, grown in monolayer culture, and transfected with the CDMP1 gene or a control gene (GFP) by the lipofection method. The autologous cells were then implanted into full-thickness articular cartilage defects in the knee joints of each rabbit.

RESULTS

During in vivo repair of full-thickness articular cartilage defects, cartilage regeneration was enhanced by the implantation of CDMP1-transfected autologous BMMCs. The defects were filled by hyaline cartilage and the deeper zone showed remodelling to subchondral bone over time. The repair and reconstitution of zones of hyaline articular cartilage was superior to simple BMMC implantation. The histological score of the CDMP1-transfected BMMC group was significantly better than those of the control BMMC group and the empty control group.

CONCLUSION

Modulation of BMMCs by factors such as CDMP1 allows enhanced repair and remodelling compatible with hyaline articular cartilage.

Bone inductive properties of rhBMP-2 loaded porous calcium phosphate cement implants in cranial defects in rabbits

In this study, the osteoinductive properties of porous calcium phosphate (Ca-P) cement loaded with bone morphogenetic protein 2 (rhBMP-2) were evaluated and compared with rhBMP-2 loaded absorbable collagen sponge (ACS). Discs with a diameter of 8mm were loaded with a buffer solution with or without 10 microg rhBMP-2 and inserted in 8mm full thickness cranial defects in rabbits for 2 and 10 weeks of implantation. Histological analysis revealed excellent osteoconductive properties of the Ca-P material. It maintained its shape and stability during the implantation time better than the ACS but showed no degradation like the ACS. Quantification of the Ca-P cement implants showed that bone formation was increased significantly by administration of rhBMP-2 (10 weeks pore fill: 53.0+/-5.4%), and also reached a reasonable amount without rhBMP-2 (43.1+/-10.4%). Remarkably, callus-like bone formation outside the implant was observed frequently in the 2 weeks rhBMP-2 loaded Ca-P cement implants, suggesting a correlation with the presence of growth factor in the surrounding tissue. However, an additional in vitro assay revealed an accumulative release of no more than 9.7+/-0.9% after 4 weeks. We conclude that: (1). Porous Ca-P cement is an appropriate candidate scaffold material for bone engineering. (2). Bone formation can be enhanced by lyophilization of rhBMP-2 on the cement. (3). Degradation of porous Ca-P cement is species-, implantation site- and implant dimension-specific.

Converse relationship between in vitro osteogenic differentiation and in vivo bone healing elicited by different populations of muscle-derived cells genetically engineered to express BMP4

In this study, we compared the use of primary muscle-derived osteoprogenitor cells (PP6 cells) for the delivery of BMP4 to improve bone healing to that of muscle-derived non-osteoprogenitor cells (PP1 cells). Surprisingly, the use of PP1 cells resulted in an improved outcome because of the lack of adverse responses to BMP4 involving cell differentiation, proliferation, and apoptosis.

INTRODUCTION

Although researchers frequently opt to use osteogenic cells for osteogenic bone morphogenetic protein (BMP)-based ex vivo gene therapy to improve bone healing, it remains unclear whether the osteogenic potential of a cellular vehicle affects the outcome of bone healing applications. Here we compared the use of muscle-derived non-osteoprogenitor cells (PP1 cells) to that of primary muscle-derived osteoprogenitor cells (PP6 cells) for the delivery of BMP4 to improve the healing of bone defects.

MATERIALS AND METHODS

Two distinct populations of primary rat muscle-derived cells--PP1 and PP6--were selected, transduced with retroviral vectors to express BMP4 or a marker gene (LacZ), and implanted into critical-sized calvarial defects created in syngeneic rats. The bone healing was monitored radiographically and histologically at 7 and 14 weeks after implantation. Cellular responses to BMP4 were evaluated by alkaline phosphatase histochemical staining and RT-PCR of another osteogenic marker to indicate osteogenic differentiation, a cell proliferation assay and BrdU (bromodeoxyuridine) labeling to assess cell proliferation, and the TUNEL assay to determine apoptosis.

RESULTS AND CONCLUSIONS

In all animals (nine rats per group), transduced PP1 cells expressing BMP4 demonstrated significantly advanced healing compared with PP6 cells expressing BMP4 and control cells expressing LacZ. We found that constitutive BMP4 expression negatively impacted the in vitro proliferation and in vivo survival rates of PP6 cells, but not PP1 cells. BMP4 exposure also directly inhibited the proliferation and induced the apoptosis of PP6 cells, but not PP1 cells. The impairment in PP6 cell proliferation was directly associated with the osteogenic differentiation of these cells. These results indicate that PP1 cells are better suited than osteoprogenitor cells for use as cellular vehicles to deliver osteogenic BMP4 to improve bone healing and that cellular behavior in response to a particular gene can be used to predict the cells' performance as delivery vehicles in ex vivo gene therapy.

[Experimental pilot study on surface activation of implants with liposomal vectors]

BACKGROUND

Surface coating with mitogenic or morphogenic proteins can improve the healing of bone adjacent to implants and increase the bone-implant interface. Clinical surveys have shown liposome-mediated gene transfer to be a promising and safe new therapeutic method. The aim of our study was to evaluate an experimental model of new approaches for topical treatment of the implant surface and of periimplant defects by using DNA liposomes encoding for BMP-2 (bone morphogenetic protein).

MATERIAL AND METHODS

A total of 27 implants (3.5 x 14 mm) were placed in critically sized defects of the frontal skull bone of adult pigs (n=3). The bottom of the implant was placed in the base of the defect which guaranteed primary stability, whereas the superior part of the implant (10 mm) represented an implant in a defect area. Liposomes containing DNA encoding for BMP-2 and GFP (green fluorescence protein) were used. In a first trial GFP-DNA liposomes on a collagen matrix were directly applied to the periimplant defect. In a second stage, the surface of the implants was encoded with BMP-2 DNA liposomes. Subsequently, these implants were inserted in the manner described. The resulting bone samples were prepared for immunohistochemical staining. Staining for GFP was performed in the area of the defect and for BMP-2 on the bone-implant interface.

RESULTS

Immunohistochemical staining on day 3 postoperatively revealed an increased GFP expression in the periimplant defect. Therefore, the effectiveness of the liposomal vector was verified for the chosen animal model. On the surface of the implants encoded with BMP-2 DNA liposomes an increased BMP-2 expression was found. Thus, the liposomal vector system was validated also for BMP-2 DNA transfer in the chosen animal model. Further, the established system allows a sustainable and delayed release of BMP-2 in the area of the bone-implant interface.

CONCLUSIONS

As a result of the study we were able to collect data concerning the influence of implant surface conditioning on the bone-implant interface and on therapeutically relevant options for the treatment of periimplant defects. These approaches are currently being evaluated in a long-term study.

An evolutionary and molecular analysis of Bmp2 expression

The coding regions of many metazoan genes are highly similar. For example, homologs to the key developmental factor bone morphogenetic protein (BMP) 2 have been cloned by sequence identity from arthropods, mollusks, cnidarians, and nematodes. Wide conservation of protein sequences suggests that differential gene expression explains many of the vast morphological differences between species. To test the hypothesis that the regulatory mechanisms controlling this evolutionarily ancient and critical gene are conserved, we compared sequences flanking Bmp2 genes of several species. We identified numerous conserved noncoding sequences including some retained because the fish lineage separated 450 million years ago. We tested the function of some of these sequences in the F9 cell model system of Bmp2 expression. We demonstrated that both mouse and primate Bmp2 promoters drive a reporter gene in an expression pattern resembling that of the endogenous transcript in F9 cells. A conserved Sp1 site contributes to the retinoic acid responsiveness of the Bmp2 promoter, which lacks a classical retinoic acid response element. We have also discovered a sequence downstream of the stop codon whose conservation between humans, rodents, deer, chickens, frogs, and fish is striking. A fragment containing this region influences reporter gene expression in F9 cells. The conserved region contains elements that may mediate the half-life of the Bmp2 transcript. Together, our molecular and evolutionary analysis has identified new regulatory elements controlling Bmp2 expression.

Distinct functions of BMP4 and GDF5 in the regulation of chondrogenesis

Bone morphogenetic protein 4 (BMP4) and growth/differentiation factor 5 (GDF5) are closely related protein family members and regulate early cartilage patterning and differentiation. In this study, we compared the functional outcome of their actions systematically at various stages of chondrogenesis in mouse embryonic limb bud mesenchyme grown in micromass cultures. Overall, both growth factors enhanced cartilage growth and differentiation in these cultures. Uniquely, BMP4 not only accelerated the formation and maturation of cartilaginous nodules, but also induced internodular mesenchymal cells to express cartilage differentiation markers. On the other hand, GDF5 increased the number of prechondrogenic mesenchymal cell condensation and cartilaginous nodules, without altering the overall pattern of differentiation. In addition, GDF5 caused a more sustained elevated expression level of Sox9 relative to that associated with BMP4. BMP4 accelerated chondrocyte maturation throughout the cultures and sustained an elevated level of Col10 expression, whereas GDF5 caused a transient increase in Col10 expression. Taken together, we conclude that BMP4 is instructive to chondrogenesis and induces mesenchymal cells toward the chondrogenic lineage. Furthermore, BMP4 accelerates the progression of cartilage differentiation to maturation. GDF5 enhances cartilage formation by promoting chondroprogenitor cell aggregation, and amplifying the responses of cartilage differentiation markers. These differences may serve to fine-tune the normal cartilage differentiation program, and can be exploited for the molecular manipulation in biomimetics.

Differential expression of osteogenic factors associated with osteoinductivity of human osteosarcoma cell lines

Differential expression of multiple osteogenic factors may be responsible for the different osteoinductivity of osteosarcoma cell lines. We compared in vivo osteoinductivity of human osteosarcoma cell lines (Saos-2 vs. U-2 OS) in nude mice, and their in vitro expression of various osteogenic factors of protein level by quantitative immunocytochemistry and mRNA level by RT-PCR and/or in situ hybridization. Saos-2 cells, but not U-2 OS, were osteoinductive in vivo. Significantly higher expression (independent t-test, all p < 0.005) of osteogenic factors were observed in Saos-2 cells compared with U-2 OS, which included bone morphogenetic proteins (particularly BMPs-2, 3, 4, and 7), transforming growth factor-beta (TGF-beta), BMP receptor (BMPR)-1A, receptor-regulated Smads (R-Smads), Smads 1, 2, and 5, and common-mediator Smad (Co-Smad), Smad 4. In contrast, U-2 OS cells expressed higher levels of inhibitory Smad 6 (I-Smad) protein than Saos-2 cells (p < 0.001). These results suggest that a combination of osteogenic factors (BMPs, TGF-beta, BMPRs, and R/Co-Smads) against I-Smad may play important roles in the Saos-2 cell osteoinductivity. This may have a clinical implication in selecting key osteogenic factors for combined therapy for bone defect diseases. The characterized cell lines can be used as positive and negative controls for the assessments of both in vitro and in vivo bone formation capabilities of designed tissues or biomaterials.

Noggin gene delivery inhibits cementoblast-induced mineralization

Bone morphogenetic proteins (BMPs) are known to promote periodontal tissue regeneration, while noggin inhibits the biological activities of BMP-2, -4, and -7. To investigate the effect of BMPs and noggin gene transfer on cementogenesis, we used cloned murine cementoblasts (OCCM). Cells were transduced using adenoviruses encoding BMP-7 (Ad-BMP-7), noggin devoid of the heparin binding site (Ad-NOGDeltaB2), or a control adenovirus encoding green fluorescent protein (Ad-GFP). Cells were seeded into 3D polymer scaffolds and implanted into SCID mice to determine the in vivo mineral-inducing ability of the cells. Cells transduced with Ad-NOGDeltaB2 at 3 and 6 weeks postimplantation exhibited reduced mineral formation compared with all other groups. Although gene expression of osteocalcin and bone sialoprotein increased after Ad-BMP-7 transduction in vitro, following BMP-7 gene transfer in vivo, transcripts for OCN and BSP were not significantly different from controls, and mineral density was not significantly increased compared with Ad-GFP and NT groups. These results indicate that in mature cementoblast populations, gene transfer of noggin inhibits biomineralization induced by cementoblasts, whereas exogenous BMP has minimal effects on mineralization.

Bone morphogenetic protein-2 facilitates expression of chondrogenic, not osteogenic, phenotype of human intervertebral disc cells

STUDY DESIGN

In vitro experiment using bone morphogenetic protein-2 (BMP-2) and human intervertebral disc (IVD) cells.

OBJECTIVES

To demonstrate the effect of BMP-2 on mRNAs expression (collagen type I, collagen type II, aggrecan, and osteocalcin), proteoglycan synthesis, expression of alkaline phosphatase, bone nodule formation in human IVD cells.

SUMMARY OF BACKGROUND DATA

BMP-2 was widely known as a powerful agent for osteoinduction and a crucial growth factor for early chondrogenesis and maintenance of cartilaginous phenotype. BMP-2 proved to be effective in stimulating proteoglycan synthesis in articular chondrocytes and IVD cells. Nevertheless, the effect of BMP-2 on IVD cells, whether chondrogenic or osteogenic, was not thoroughly elucidated in transcriptional level and histochemical stains.

MATERIALS AND METHODS

Human IVDs were harvested and enzymatically digested. Then IVD cells were cultured three-dimensionally in alginate beads. Osteoblasts were cultured from cancellous bone of ilium for histochemical stains. Recombinant human BMP-2 (rhBMP-2) was produced by Chinese hamster ovary cells after transduction of BMP-2 cDNA, then concentrated and purified. Then IVD cell cultures were exposed to various concentrations of rhBMP-2. Reverse transcription-polymerase chain reaction for mRNA expression of aggrecan, collagen type I, collagen type II, and osteocalcin was performed. Newly synthesized proteoglycan was measured by 35S-sulfate incorporation on Sephadex G-25 M in PD 10 columns. As a histochemical examination, alkaline phosphatase and Alizarin red-S stains were used to detect osteogenic marker and bone nodule formation, respectively.

RESULTS

In the rhBMP-2 treated cultures, there was increased newly synthesized proteoglycan (67% in 300 ng/mL and 200% in 1,500 ng/mL of rhBMP-2) and up-regulated expression of aggrecan, collagen type I, and collagen type II mRNA over untreated control. However, rhBMP-2 did not up-regulate expression of osteocalcin mRNA in the given dose and culture period. IVD cell cultures with rhBMP-2 showed no evidence of bone formation in histochemical stains, i.e., alkaline phosphatase and Alizarin red-S, while osteoblast culture exhibited strong positive stains.

CONCLUSIONS

The rhBMP-2 clearly up-regulated mRNA expression of chondrogenic components and also stimulated proteoglycan synthesis without expression of osteogenic phenotype. Taken together, this study raise the possibility of rhBMP-2 can be anabolic agent for regenerating matrix of intervertebral disc.

Controlling cell fate by bone morphogenetic protein receptors

Bone morphogenetic proteins (BMPs) are multifunctional proteins that regulate the fate of different cell types, including mesenchymal and endothelial cells. BMPs inhibit myogenic differentiation, but promote the differentiation of mesenchymal cells into osteoblasts. Furthermore, endothelial migration and tube formation are stimulated by BMPs. Like other members of the transforming growth factor-beta (TGF-beta) superfamily, BMPs elicit their cellular effects via specific types I and II serine/threonine receptors. The activated BMP type I receptor phosphorylates specific receptor-regulated (R)-Smad proteins, which assemble into heteromeric complexes with common partner (Co)-Smad4. Heteromeric Smad complexes efficiently translocate into the nucleus, where they regulate the transcription of target genes. Inhibitors of differentiation (Id) are genes that are specifically induced by BMPs in tissues of different origin. Promoter analysis of Id1 indicates three distinct sequence elements that are sufficient and essential for efficient BMP-induced activation. Furthermore, recent studies reveal an important effector function for Id1 in various BMP-induced biological responses.

Growth and Amelogenin-Like Factors in Periodontal Wound Healing. A Systematic Review

BACKGROUND

Regeneration of tooth-supporting structures destroyed by periodontitis is a major goal of periodontal therapy. Periodontal tissue engineering utilizing growth and amelogenin-like factors (GAFs) applies advances in materials science and biology to regenerate alveolar bone, periodontal ligament, and cementum. Amelogenin-like factors (e.g., enamel matrix derivative [EMD]) and growth factors (e.g., platelet-derived growth factor [PDGF] and bone morphogenetic proteins [BMPs, also considered morphogens]) have demonstrated pleotrophic effects on the stimulation of several key events required for tissue regeneration including DNA synthesis, chemotaxis, differentiation, and matrix synthesis.

RATIONALE

GAFs have been used for the treatment of periodontal disease as shown in preclinical and clinical studies. This systematic review evaluates the evidence to support the utilization of EMD and growth factors (GFs) for periodontal repair and regeneration associated with natural teeth.

FOCUSED QUESTION

In patients with periodontal osseous defects, what is the effect of GAFs compared with controls on clinical, radiographic, histologic, adverse, and patient-centered outcomes?

SEARCH PROTOCOL

Two investigators searched MEDLINE, pre-MEDLINE, and the Cochrane Oral Health Group trials register for clinical and preclinical studies published in English. Hand searches were performed on the International Journal of Periodontics and Restorative Dentistry, Journal of Clinical Periodontology, Journal of Dental Research, Journal of Periodontology, and Journal of Periodontal Research. Searches were performed for articles published through April 2002. In addition, investigators contacted manufacturers of GAF products for related unpublished data and studies in progress.

SELECTION CRITERIA

INCLUSION CRITERIA

Randomized controlled clinical trials (RCTs), cohort studies, case-control studies, case reports, and preclinical (animal) randomized controlled investigations that included a cohort population diagnosed with periodontal disease and presenting data on intrabony/interproximal defects and/or furcation defects were screened.

EXCLUSION CRITERIA

In vitro studies or those that did not include quantifiable data with respect to clinical or bone measures were not included.

DATA COLLECTION AND ANALYSIS

Meta-analyses were performed for studies that fulfilled the eligibility criteria for the following continuous variables: clinical attachment level (CAL), probing depth (PD), or bone level (radiographic, re-entry, or histologic). Heterogeneity was assessed to determine whether the differences among therapies were due to systematic confounding factors (as noted in study quality assessments).

MAIN RESULTS

1. Eight studies, representing 7 RCTs and 1 quasi-experimental study, representing a total population of 511 subjects were analyzed with respect to EMD. 2. The majority of the remaining papers had a low evidence rating. 3. Most reports were case studies or case series without controls. 4. There were insufficient data to conduct a meta-analysis on the effect of growth factors used in periodontal repair around teeth.

REVIEWERS' CONCLUSIONS

1. There is evidence supporting the use of EMD for periodontal osseous defects to improve CAL and reduce PD, although long-term benefits have not been established. 2. EMD has demonstrated notable consistency among the studies investigated in terms of superiority to controls (in general compared to open flap debridement [OFD]). 3. EMD appears to be safe for single and multiple administrations in terms of lack of elicitation of antibody responses or other local/systemic inflammatory events. 4. Preclinical and initial clinical data for growth factors appear promising but are insufficient to draw definitive conclusions at this time.

Angiogenesis and bone repair

The intimate connection, both physical and biochemical, between blood vessels and bone cells has long been recognized. Genetic, biochemical, and pharmacological studies have identified and characterized factors involved in the conversation between endothelial cells (EC) and osteoblasts (OB) during both bone formation and repair. The long-awaited FDA approval of two growth factors, BMP-2 and OP-1, with angiogenic and osteogenic activity confirms the importance of these two processes in human skeletal healing. In this review, the role of osteogenic factors in the adaptive response and interactive function of OB and EC during the multi-step process of bone repair will be discussed.

Inhibition of proteoglycan and type II collagen synthesis of disc nucleus cells by nicotine

OBJECT

Systemic nicotine has been hypothesized to cause degeneration of the intervertebral disc which in turn decreases vascular supply to the disc through a cholinergic receptor-mediated process. Another possible mechanism may be through direct regulatory effects on disc cells. In this study, the authors tested the hypothesis that nicotine adversely affects nucleus pulposus cells by directly inhibiting proteoglycan synthesis and gene expression of type II collagen (Phase I study). They also assessed the hypothesis that nicotine inhibits the bone morphogenetic protein (BMP)-2-induced upregulation of extracellular matrix (Phase II study).

METHODS

Cells were isolated from nucleus pulposus obtained in rat lumbar discs and cultured on a monolayer. Media were treated with nicotine and/or recombinant human (rh)BMP-2 for 7 days. Sulfated glycosaminoglycan (SO4-GAG) in media was quantified using 1,9-dimethylmethylene blue (DMMB) assay. Gene assay of types I and II collagen, Sox9, and glyceraldehyde-3-phosphate dehydrogenase were quantified using reverse transcriptase-polymerase chain reaction (RT-PCR) and real time PCR. In the Phase I study, nicotine-treated (100 microg/ml) and non-treated cells were compared. The s-GAG production and messenger RNA (mRNA) of type II collagen and Sox9 decreased significantly in the nicotine-treated group. In the Phase II study, five groups were compared: 1) non-treatment; 2) rhBMP-2 only (100 ng/ml); and 3-5) with rhBMP-2 (100 ng/ml) and increasing doses of nicotine (1 [third group], 10, [fourth group], 100 [fifth group] microg/ml). The SO4-GAG production and mRNA of type II collagen and Sox9 decreased significantly in the groups treated with rhBMP-2 combined with 10 and 100 microg/ml of nicotine compared with the group treated with rhBMP-2.

CONCLUSIONS

The results of this study raise the possibility that nicotine may contribute to the process of disc degeneration by a direct effect on the nucleus pulposus cells, possibly by antagonizing the effect of BMP-2.

Mutations in bone morphogenetic protein receptor 1B cause brachydactyly type A2

Brachydactyly (BD) type A2 is an autosomal dominant hand malformation characterized by shortening and lateral deviation of the index fingers and, to a variable degree, shortening and deviation of the first and second toes. We performed linkage analysis in two unrelated German families and mapped a locus for BD type A2 to 4q21-q25. This interval includes the gene bone morphogenetic protein receptor 1B (BMPR1B), a type I transmembrane serinethreonine kinase. In one family, we identified a T599 --> A mutation changing an isoleucine into a lysine residue (I200K) within the glycine/serine (GS) domain of BMPR1B, a region involved in phosphorylation of the receptor. In the other family we identified a C1456 --> T mutation leading to an arginine-to-tryptophan amino acid change (R486W) in a highly conserved region C-terminal of the BMPR1B kinase domain. An in vitro kinase assay showed that the I200K mutation is kinase-deficient, whereas the R486W mutation has normal kinase activity, indicating a different pathogenic mechanism. Functional analyses with a micromass culture system revealed a strong inhibition of chondrogenesis by both mutant receptors. Overexpression of mutant chBmpR1b in vivo in chick embryos by using a retroviral system resulted either in a BD phenotype with shortening and/or missing phalanges similar to the human phenotype or in severe hypoplasia of the entire limb. These findings imply that both mutations identified in human BMPR1B affect cartilage formation in a dominant-negative manner.

Osteogenesis in rats induced by a novel recombinant helper-dependent bone morphogenetic protein-9 (BMP-9) adenovirus

BACKGROUND

Although recombinant first-generation BMP adenoviruses can induce ectopic bone formation in immune deficient animals, the osteoinductive activity of these BMP vectors is reduced in immune competent animals. Helper-dependent adenoviral vectors have been developed to decrease the immune response and, therefore, increase gene expression in immune competent animals compared with first-generation vectors. In the present study, the osteoinductive activity of a helper-dependent GFP and BMP-9 adenoviral vector (ADGBMP9) was evaluated in vitro and in vivo.

METHODS

Initially, purified ADGBMP9 was used to transduce human mesenchymal stem cells (hMSCs) and the alkaline phosphatase activity was determined as a measure of osteogenic activity. The vector was then injected into the thigh muscle of athymic nude and Sprague-Dawley rats, and CT scans and histology were subsequently used to assess bone formation.

RESULTS

In vitro, ADGBMP9 was capable of inducing alkaline phosphatase expression in hMSCs. In vivo in athymic nude and Sprague Dawley rats, ADGBMP9 initiated the process of bone formation 3 days after percutaneous injection into the thigh musculature. The rats demonstrated intramuscular ectopic ossification in CT scans as early as day 9 post viral injection and ultimately formed significant amounts of ectopic bone. Histologically, the induced bone was formed via normal endochondral mechanisms.

CONCLUSIONS

A helper-dependent adenoviral vector containing the BMP-9 and GFP genes has significant osteoinductive activity in both athymic nude and immune competent rats. Additional direct and ex vivo BMP gene therapy studies are required to assess the vector's activity in more animal models.

Osteogenic potential of five different recombinant human bone morphogenetic protein adenoviral vectors in the rat

Bone morphogenetic protein (BMP) adenoviral vectors for the induction of osteogenesis are being developed for the treatment of bone pathology. However, it is still unknown which BMP adenoviral vector has the highest potential to stimulate bone formation in vivo. In this study, the osteogenic activities of recombinant human BMP-2, BMP-4, BMP-6, BMP-7, and BMP-9 adenoviruses were compared in vitro, in athymic nude rats, and in Sprague-Dawley rats. In vitro osteogenic activity was assessed by measuring the alkaline phosphatase activity in C2C12 cells transduced by the various BMP vectors. The alkaline phosphatase activity induced by 2 x 10(5) PFU/well of BMP viral vector was 4890 x 10(-12) U/well for ADCMVBMP-9, 302 x 10(-12) U/well for ADCMVBMP-4, 220 x 10(-12) U/well for ADCMVBMP-6, 45 x 10(-12) U/well for ADCMVBMP-2, and 0.43 x 10(-12) U/well for ADCMVBMP-7. The average volume of new bone induced by 10(7) PFU of BMP vector in athymic nude rats was 0.37+/-0.03 cm(3) for ADCMVBMP-2, 0.89+/-0.07 cm(3) for ADCMVBMP-4, 1.02+/-0.07 cm(3) for ADCMVBMP-6, 0.24+/-0.05 cm(3) for ADCMVBMP-7, and 0.63+/-0.07 cm(3) for ADCMVBMP-9. In immunocompetent Sprague-Dawley rats, no bone formation was demonstrated in the ADCMVBMP-2, ADCMVBMP-4, and ADCMVBMP-7 groups. ADCMVBMP-6 at a viral dose of 10(8) PFU induced 0.10+/-0.03 cm(3) of new bone, whereas ADCMVBMP-9 at a lower viral dose of 10(7) PFU induced more bone, with an average volume of 0.29+/-0.01 cm(3).

BMP signaling components are expressed in human fracture callus

Of the various growth factors involved in the healing response after a fracture, bone morphogenetic proteins (BMPs) are emerging as key modulators. BMPs exert their effects by binding to a complex of type I and type II receptors leading to the phosphorylation of specific downstream effector proteins called Smads. The current study examined the presence of BMP signaling components in human callus obtained from five nascent malunions undergoing fracture fixation. These callus samples represented various stages of bone healing and a mixture of endochondral and intramembraneous bone healing. We performed immunohistochemistry on the callus, using antibodies for BMP (BMP-2,-3,-4,-7), their receptors (BMPR-IA, -IB, -II), and phosphorylated BMP receptor-regulated Smads (pBMP-R-Smads). Active osteoblasts showed fairly consistent positive staining for all BMPs that were examined, with the immunoreactivity most intense for BMP-7 and BMP-3. Immunostaining for BMPs in osteoblasts appeared to colocalize with the expression of BMPR-IA, -IB, and -II. Positive immunostaining for pBMP-R-Smads suggests that the BMP receptors expressed in these cells are activated. Staining for BMPs in cartilage cells was variable. The immunostaining appeared stronger in more mature cells, whereas staining for BMP receptors in cartilage cells was less ubiquitous. However, the expression of pBMP-R-Smads in cartilage cells suggests active signal transduction. Fibroblast-like cells also had a variable staining pattern. Overall, our findings indicate the presence of BMPs, their various receptors, and activated forms of receptor-regulated Smads in human fracture callus. To the best of our knowledge, this is the first study that documents the expression of these proteins in human fracture tissue. Complete elucidation of the roles of BMP in bone formation will hopefully lead to improved fracture healing care.

The effect of bone morphogenetic protein-2 on rat intervertebral disc cells in vitro

STUDY DESIGN

An in vitro experiment to determine the molecular and cellular effect of recombinant human bone morphogenetic protein-2 on cultured rat intervertebral disc cells was performed.

OBJECTIVES

To determine the effect of recombinant human bone morphogenetic protein-2 on cell proliferation, production of sulfated-glycosaminoglycan, and the expression of genes specific for chondrocytes (Type II collagen, aggrecan, and Sox9) in cultured rat intervertebral disc cells.

SUMMARY OF BACKGROUND DATA

Intervertebral disc degeneration is associated with cellular and biochemical changes, which include decreased synthesis of cartilage specific gene products such as Type II collagen and aggrecan. Although bone morphogenetic protein-2 is known to induce chondrogenesis during new bone formation, the effects on intervertebral disc cells have not been characterized.

METHOD

Cells were isolated from the anulus fibrosus and transition zones of lumbar discs from Sprague-Dawley rats. The cells were grown in monolayer and treated with recombinant human bone morphogenetic protein-2 (0, 10, 100, 1000 ng/mL) in Dulbecco's Modified Eagle Medium/F-12 with 1% fetal bovine serum (day 0). On days 2, 4, and 7 after recombinant human bone morphogenetic protein-2 treatment, sulfated-glycosaminoglycan content in the media was quantified using 1,9-dimethylmethylene blue staining. The results were normalized according to culture duration and cell number. On day 7, mRNA was extracted for reverse transcriptase-polymerase chain reaction and real-time polymerase chain reaction to quantitate mRNAs of Type I collagen, Type II collagen, aggrecan, Sox9, osteocalcin, and glyceraldehyde phosphate dehydrogenase. Cell number was determined with a hemocytometer.

RESULTS

Recombinant human bone morphogenetic protein-2 at 100 and 1000 ng/mL yielded a 17% and 42% increase in cell number on day 4, and a 59% and 79% on day 7, respectively. Recombinant human bone morphogenetic protein-2 at 10 ng/mL had no effect on cell number. Sulfated-glycosaminoglycan increase was greatest at day 7, increasing by 1.3-, 2.1-, and 3.6-fold with recombinant human bone morphogenetic protein-2 treatments of 10, 100, and 1000 ng/mL, respectively. Increases in mRNA levels of Type II collagen, aggrecan, Sox9, and osteocalcin were observed with recombinant human bone morphogenetic protein-2 concentrations of 100 and 1000 ng/mL on day 7 as determined by reverse transcriptase-polymerase chain reaction. No detectable increase in mRNA level of Type I collagen was observed with any levels of recombinant human bone morphogenetic protein-2. Real-time polymerase chain reaction showed the greatest effect at 1000 ng/mL recombinant human bone morphogenetic protein-2, leading to an 11.5-fold increase in aggrecan, a 4.6-fold increase in Type II collagen, a 5.3-fold increase in Sox9, and a 1.9-fold increase in osteocalcin mRNA above untreated controls at day 7.

CONCLUSION

The results of this study show that recombinant human bone morphogenetic protein-2 enhances disc matrix production and chondrocytic phenotype of intervertebral disc cells. Recombinant human bone morphogenetic protein-2 increases cell proliferation and sulfated-glycosaminoglycan (proteoglycan) synthesis. It increases mRNA of Type II collagen, aggrecan, and Sox9 genes (chondrocyte specific genes), and osteocalcin, but not Type I collagen or glyceraldehyde phosphate dehydrogenase.