Vertical bone augmentation with granulated brushite cement set in glycolic acid

Preparation and characterizations of an injectable and biodegradable high-strength iron-bearing brushite cement for bone repair and vertebral augmentation applications

Brushite cements have good osteoconductive and resorbable properties, but the low mechanical strength and poor injectability limit their clinical applications in load-bearing conditions and minimally invasive surgery. In this study, an injectable brushite cement that contains monocalcium phosphate monohydrate (MCPM) and β-tricalcium phosphate (β-TCP) as its solid phase and ammonium ferric citrate (AFC) solution as the aqueous medium was designed to have high mechanical strength. The optimized formulation achieved a compressive strength of 62.8 ± 7.2 MPa, which is above the previously reported values of hand-mixing brushite cements. The incorporation of AFC prolonged the setting times and greatly enhanced the injectability and degradation properties of the cements. In vitro and in vivo experiments demonstrated that the brushite cements exhibited good biocompatibility and bone regeneration capacity. The novel brushite cement is promising for bone healing in load-bearing applications.

Nanostructured Zn-Substituted Monetite Based Material Induces Higher Bone Regeneration Than Anorganic Bovine Bone and β-Tricalcium Phosphate in Vertical Augmentation Model in Rabbit Calvaria

The capacity of a nanostructured multicomponent material composed of Zn-substituted monetite, amorphous calcium phosphate, hydroxyapatite and silica gel (MSi) to promote vertical bone augmentation was compared with anorganic bovine bone (ABB) and synthetic β-tricalcium phosphate (β-TCP). The relation between biological behavior and physicochemical properties of the materials was also studied. The in vivo study was conducted in a vertical bone augmentation model in rabbit calvaria for 10 weeks. Significant differences in the biological behavior of the materials were observed. MSi showed significantly higher bone regeneration (39%) than ABB and β-TCP (24%). The filled cylinder volume was similar in MSi (92%) and ABB (91%) and significantly lower in β-TCP (81%) implants. In addition, β-TCP showed the highest amount of non-osteointegrated particles (17%). MSi was superior to the control materials because it maintains the volume of the defect almost full, with the highest bone formation, the lowest number of remaining particles, which are almost fully osteointegrated and having the lowest amount of connective tissue. Besides, the bone formed was mature, with broad trabeculae, high vascularization and osteogenic activity. MSi resorbs gradually over time with an evident increment of the porosity and simultaneous colonization for vascularized new bone. In addition, the osteoinductive behavior of MSi material was evidenced.

Zoledronic Acid-Loaded β-TCP Inhibits Tumor Proliferation and Osteoclast Activation: Development of a Functional Bone Substitute for an Efficient Osteosarcoma Treatment

Osteosarcoma has a poor survival rate due to relapse and metastasis. Zoledronic acid (ZOL), an anti-resorptive and anti-tumor agent, is used for treating osteosarcoma. Delivery of ZOL to the target region is difficult due to its high binding affinity to bone minerals. This study developed a novel treatment for osteosarcoma by delivering ZOL to the target region locally and sustainably. In this study, we fabricated a novel bone substitute by loading ZOL on β-tricalcium phosphate (β-TCP). The ZOL-loaded β-TCP (ZOL/β-TCP) would be expected to express the inhibitory effects via both bound-ZOL (bound to β-TCP) and free-ZOL (release from ZOL/β-TCP). To explore the ability to release ZOL from the ZOL/β-TCP, the amount of released ZOL was measured. The released profile indicates that a small amount of ZOL was released, and most of it remained on the β-TCP. Our data showed that ZOL/β-TCP could successfully express the effects of ZOL via both bound-ZOL and free-ZOL. In addition, we examined the biological effects of bound/free-ZOL using osteosarcoma and osteoclasts (target cells). The results showed that two states of ZOL (bound/free) inhibit target cell activities. As a result, ZOL/β-TCP is a promising candidate for application as a novel bone substitute.

Eggshell derived brushite bone cement with minimal inflammatory response and higher osteoconductive potential

Brushite cements are known for excellent osteoconductive and degradation properties, however, its widespread use is limited due to rapid setting time and poor mechanical properties. The eggshell derived calcium phosphates exhibits improved physical and biological properties due to the presence of biologically relevant ions. In this study, eggshell derived brushite cement (EB) was fabricated using β-tricalcium phosphate synthesized from eggshells. The presence of trace elements in EB prolonged its setting time. The size of brushite crystals in EB was found to be smaller than the pure brushite cement (PB) leading to increased initial compressive strength and higher in vitro degradation rate. The L6 and MG63 cell lines exhibited good biocompatibility with the cement at the end 72 h. In vivo studies of the cements were performed in rat calvarial defect model. Micro CT analysis showed faster degradation and accelerated bone formation in EB filled defect. Histological studies revealed infiltration of inflammatory cells into the implant site for both the cements till 6th week. However, inflammation was found to be significantly reduced at the 12th week in EB compared to PB leading to complete bone bridge formation. Multi-ion substituted EB seems to be a potential bone substitute material with a reasonable setting time for ease of handling, higher mechanical strength, minimal inflammatory response and higher bone regeneration.

Treatment of Critical-Sized Calvarial Defects in Rats with Preimplanted Transplants

The local environment and the defect features have made the skull one of the most difficult regions to repair. Finding alternative strategies to repair large cranial defects, thereby avoiding the current limitations of autograft or polymeric and ceramic prostheses constitute an unmet need. In this study, the regeneration of an 8 mm critical-sized calvarial defect treated by autograft or by a monetite scaffold directly placed in the defect or preimplanted (either cranial bone transplant or subcutaneous pocket) and then transplanted within the bone defect is compared. The data reveal that transplantation of preimplanted monetite transplant scaffolds greatly improves the skull vault closure compared to subcutaneously preimplanted or directly placed materials. Autografts, while clearly filling the defect volume with bone appear effective since bone volume inside the defect volume is obviously high, but are not well fused to the skull. The preimplantation site has a large influence on the regeneration of the defect. Transplantation of induced bone inside materials has the potential to reduce the need for autograft harvest without damaging the skeleton. This first demonstration indicates that cranial repair may be possible without recourse to bioactives or cultured cell therapies.

Effect of processing conditions of dicalcium phosphate cements on graft resorption and bone formation

Dicalcium phosphate cements (brushite and monetite) are resorbable biomaterials with osteoconductive potential for bone repair and regeneration that have yet to gain widespread commercial use. Brushite can be converted to monetite by heat treatments additionally resulting in various changes in the physico-chemical properties. However, since conversion is most commonly performed using autoclave sterilisation (wet heating), it is uncertain whether the properties observed for monetite as a result of heating brushite under dry conditions affect resorption and bone formation favourably. This study was designed to produce monetite grafts of differing physical form by autoclaving and dry heating (under vacuum) to be compared with brushite biomaterials in an orthotopic pre-clinical implantation model in rabbit for 12weeks. It was observed that monetite grafts had higher porosity and specific surface area than their brushite precursors. The autoclaved monetite grafts had compressive strength reduced by 50% when compared with their brushite precursors. However, the dry heat converted monetite grafts had compressive strength comparable with brushite. Results from in vivo experiments revealed that both types of monetite graft materials resorbed faster than brushite and more bone formation was achieved. There was no significant difference in the amount of bone formed between the two types of monetite grafts. The implanted brushite grafts underwent phase transformation to form hydroxyapatite, which ultimately limited bioresorption. However, this was not observed in both types of monetite grafts. In summary, both autoclaving and dry heating the preset brushite cement grafts resulted in monetite biomaterials which were more resorbable with potential to be investigated and optimized for orthopaedic and maxillofacial bone repair and regeneration applications.

STATEMENT OF SIGNIFICANCE

We present in this original research article a comparison between dicalcium phosphate cement based grafts (brushite and 2 types of monetite grafts prepared by wet and dry thermal processing) with regards to resorption and bone formation in vivo after orthotopic implantation in rabbit condylar femural region. To the best of our knowledge this is the first in vivo study that reports a comparison resorption and bone formation using brushite and two types of monetite biomaterials. Also, we have included in the manuscript a summary of all the in vivo studies performed on brushite and monetite biomaterials to date. This includes cement composition, physical properties (porosity and surface area), implantation and histomorphometrical details such as animal species, site of implantation, observation period, percentage bone tissue formation and residual graft material. In addition, we calculated the percentage resorption of graft materials based upon various implantation sites and included that into the discussion section. The results of this original research provides greater understanding of the resorption processes of dicalcium phosphate based grafts, allowing preparation of bone substitute materials with more predictable resorption profiles in future.

Mechanisms of in Vivo Degradation and Resorption of Calcium Phosphate Based Biomaterials

Calcium phosphate ceramic materials are extensively used for bone replacement and regeneration in orthopedic, dental, and maxillofacial surgical applications. In order for these biomaterials to work effectively it is imperative that they undergo the process of degradation and resorption in vivo. This allows for the space to be created for the new bone tissue to form and infiltrate within the implanted graft material. Several factors affect the biodegradation and resorption of calcium phosphate materials after implantation. Various cell types are involved in the degradation process by phagocytic mechanisms (monocytes/macrophages, fibroblasts, osteoblasts) or via an acidic mechanism to reduce the micro-environmental pH which results in demineralization of the cement matrix and resorption via osteoclasts. These cells exert their degradation effects directly or indirectly through the cytokine growth factor secretion and their sensitivity and response to these biomolecules. This article discusses the mechanisms of calcium phosphate material degradation in vivo.

Biodegradable Materials for Bone Repair and Tissue Engineering Applications

This review discusses and summarizes the recent developments and advances in the use of biodegradable materials for bone repair purposes. The choice between using degradable and non-degradable devices for orthopedic and maxillofacial applications must be carefully weighed. Traditional biodegradable devices for osteosynthesis have been successful in low or mild load bearing applications. However, continuing research and recent developments in the field of material science has resulted in development of biomaterials with improved strength and mechanical properties. For this purpose, biodegradable materials, including polymers, ceramics and magnesium alloys have attracted much attention for osteologic repair and applications. The next generation of biodegradable materials would benefit from recent knowledge gained regarding cell material interactions, with better control of interfacing between the material and the surrounding bone tissue. The next generations of biodegradable materials for bone repair and regeneration applications require better control of interfacing between the material and the surrounding bone tissue. Also, the mechanical properties and degradation/resorption profiles of these materials require further improvement to broaden their use and achieve better clinical results.

Bone Replacement Materials and Techniques Used for Achieving Vertical Alveolar Bone Augmentation

Alveolar bone augmentation in vertical dimension remains the holy grail of periodontal tissue engineering. Successful dental implant placement for restoration of edentulous sites depends on the quality and quantity of alveolar bone available in all spatial dimensions. There are several surgical techniques used alone or in combination with natural or synthetic graft materials to achieve vertical alveolar bone augmentation. While continuously improving surgical techniques combined with the use of auto- or allografts provide the most predictable clinical outcomes, their success often depends on the status of recipient tissues. The morbidity associated with donor sites for auto-grafts makes these techniques less appealing to both patients and clinicians. New developments in material sciences offer a range of synthetic replacements for natural grafts to address the shortcoming of a second surgical site and relatively high resorption rates. This narrative review focuses on existing techniques, natural tissues and synthetic biomaterials commonly used to achieve vertical bone height gain in order to successfully restore edentulous ridges with implant-supported prostheses.

Control of in vivo mineral bone cement degradation

The current study aimed to prevent the formation of hydroxyapatite reprecipitates in brushite-forming biocements by minimizing the availability of free Ca(2+) ions in the cement matrix. This was achieved by both maximizing the degree of cement setting to avoid unreacted, calcium-rich cement raw materials which can deliver Ca(2+) directly to the cement matrix after dissolution, and by a reduction in porosity to reduce Ca(2+) diffusion into the set cement matrix. In addition, a biocement based on the formation of the magnesium phosphate mineral struvite (MgNH4PO4·6H2O) was tested, which should prevent the formation of low-solubility hydroxyapatite reprecipitates due to the high magnesium content. Different porosity levels were fabricated by altering the powder-to-liquid ratio at which the cements were mixed and the materials were implanted into mechanically unloaded femoral defects in sheep for up to 10 months. While the higher-porosity brushite cement quantitatively transformed into crystalline octacalcium phosphate after 10 months, slowing down cement resorption, a lower-porosity brushite cement modification was found to be chemically stable with the absence of reprecipitate formation and minor cement resorption from the implant surface. In contrast, struvite-forming cements were much more degradable due to the absence of mineral reprecipitates and a nearly quantitative cement degradation was found after 10 months of implantation.

Brushite cement additives inhibit attachment to cell culture beads

Brushite-forming calcium phosphate cements are of great interest as bone replacement materials because they are resorbable in physiological conditions. Cell-attached culture beads formed from this material could be of great use for cell therapy. Despite a significant amount of work on optimizing the physicochemical properties of these materials, there are very few studies that have evaluated the capacity of the materials to facilitate cell adhesion. In this study, we have formed resorbable calcium phosphate (brushite) culture beads and for the first time we showed that cell attachment to the surface of the brushite cement (BC) could be inhibited by the presence of an intermediate dicalcium phosphate-citrate complex, formed in the cement as a result of using citric acid, a retardant and viscosity modifier used in many cement formulations. The BC beads formed from the mixture of β-TCP/orthophosphoric acid using citric acid did not allow cell attachment without further treatment. Ageing of BC beads in serum-free Dulbecco's Modified Eagle's Medium (DMEM) solution at 37°C for 1 week greatly enhanced the cell adhesion capacity of the material. Scanning electron microscopy, X-ray diffraction (XRD), and confocal Raman microspectrometry indicated the increased capacity for cell adhesion was due to the changes in phase composition of BC. XRD patterns collected before and after ageing in aqueous solution and a high initial mass loss, suggest the formation of a dicalcium phosphate-citrate complex within the matrix. Since compacts formed from brushite powder supported cell attachment, it was hypothesized that the dicalcium phosphate-citrate complex prevented attachment to the cement surface.

Low temperature fabrication of spherical brushite granules by cement paste emulsion

Secondary protonated calcium phosphates such as brushite (CaHPO(4)·2H(2)O) or monetite (CaHPO(4)) have a higher resorption potential in bone defects than sintered ceramics, e.g. tricalcium phosphate or hydroxyapatite. However, processing of these phosphates to monolithic blocks or granules is not possible by sintering due to thermal decomposition of protonated phosphates at higher temperatures. In this study a low temperature technique for the preparation of spherical brushite granules in a cement setting reaction is presented. These granules were synthesized by dispersing a calcium phosphate cement paste composed of β-tricalcium phosphate and monocalcium phosphate together with a surfactant to an oil/water emulsion. The reaction products were characterized regarding their size distribution, morphology, and phase composition. Clinically relevant granule sizes ranging from 200 μm to 1 mm were obtained, whereas generally smaller granules were received with higher oil viscosity, increasing temperature or higher powder to liquid ratios of the cement paste. The hardened granules were microporous with a specific surface area of 0.7 m(2)/g and consisted of plate-like brushite (>95 % according to XRD) crystals of 0.5-7 μm size. Furthermore it was shown that the granules may be also used for drug delivery applications. This was demonstrated by adsorption of vancomycin from an aqueous solution, where a load of 1.45-1.88 mg drug per g granules and an almost complete release within 2 h was obtained.

Effect of triple growth factor controlled delivery by a brushite-PLGA system on a bone defect

Bone regeneration is a complex process that involves multiple cell types, growth factors (GFs) and cytokines. A synergistic contribution of various GFs and a crosstalk between their signalling pathways was suggested as determinative for the overall osteogenic outcome. The purpose of this work was to develop a brushite-PLGA system, which controls the release rate of the integrated growth factors (GFs) to enhance bone formation. The brushite cement implants were prepared by mixing a phosphate solid phase with an acid liquid phase. PDGF (250 ng) and TGF-β1 (100 ng) were incorporated into the liquid phase. PLGA microsphere-encapsulated VEGF (350 ng) was pre-blended with the solid phase. VEGF, PDGF and TGF-β1 release kinetics and tissue distributions were determined using iodinated ((125)I) GFs. In vivo results showed that PDGF and TGF-β1 were delivered more rapidly from these systems implanted in an intramedullary defect in rabbit femurs than VEGF. The three GFs released from the brushite-PLGA system remained located around the implantation site (5 cm) with negligible systemic exposure. Bone peak concentrations of approximately 4 ng/g and 1.5 ng/g of PDGF and TGF-β1, respectively were achieved on day 3. Thereafter, PDGF and TGF-β1 concentrations stayed above 1 ng/g during the first week. The scaffolds also provided a VEGF peak concentration of nearly 6 ng/g on day 7 and a local concentration of approximately 1.5 ng/g during at least 4 weeks. Four weeks post implantation bone formation was considerably enhanced with the brushite-PLGA system loaded with each of the three GFs separately as well as with the combination of PDGF and VEGF. The addition of TGF-β1 did not further improve the outcome. In conclusion, the herein presented brushite-PLGA system effectively controlled the release kinetics and localisation of the three GFs within the defect site resulting in markedly enhanced bone regeneration.

Dicalcium phosphate cements: brushite and monetite

Dicalcium phosphate cements were developed two decades ago and ever since there has been a substantial growth in research into improving their properties in order to satisfy the requirements needed for several clinical applications. The present paper presents an overview of the rapidly expanding research field of the two main dicalcium phosphate bioceramics: brushite and monetite. This review begins with a summary of all the different formulae developed to prepare dicalcium phosphate cements, and their setting reaction, in order to set the scene for the key cement physical and chemical properties, such as compressive and tensile strength, cohesion, injectability and shelf-life. We address the issue of brushite conversion into either monetite or apatite. Moreover, we discuss the in vivo behavior of the cements, including their ability to promote bone formation, biodegradation and potential clinical applications in drug delivery, orthopedics, craniofacial surgery, cancer therapy and biosensors.

Material-related effects of BMP-2 delivery systems on bone regeneration

Material-related effects of a brushite and a PLGA controlled release system loaded with two distinct doses of bone morphogenetic protein-2 (BMP-2) (3.5 and 17.5 μg), pre-encapsulated in poly(lactic-co-glycolic acid) (PLGA), were investigated in an intramedullary femur defect model in rabbits. The systems were characterized in vitro and in vivo over 12 weeks in terms of morphology, release kinetics, porosity, molecular weight, and composition using scanning electron microscopy, mercury porosimetry, radioactivity counting, X-ray diffractometry, differential scanning calorimetry, and gel permeation chromatography. During the experimental period the investigated systems underwent significant changes in vitro as well as in vivo. It should be stressed that the two in vitro release patterns were similar, however in vivo parallel profiles were observed with a higher burst effect for BMP-2 in the PLGA system. The PLGA system degraded and disintegrated significantly faster than the brushite system, which suffered slowly progressing external erosion and, additionally, material resorption by osteoclasts in vivo. The consequences of this were reflected in the degree of bone regeneration. Although a sustained delivery of BMP-2 was achieved with both systems, the brushite construct, independent of the loaded growth factor dose, failed to consistently induce defect repair, a result attributed to its slow resorption rate. In contrast, the PLGA system resulted in complete regeneration with mature trabecular bone formation 8 weeks after implantation.

In vivo degradation of low temperature calcium and magnesium phosphate ceramics in a heterotopic model

Bone replacement using synthetic and degradable materials is desirable in various clinical conditions. Most applied commercial materials are based on hydroxyapatite, which is not chemically degradable under physiological conditions. Here we report the effect of a long-term intramuscular implantation regime on the dissolution of various low temperature calcium and magnesium phosphate ceramics in vivo. The specimens were analysed by consecutive radiographs, micro-computed tomography scans, compressive strength testing, scanning electron microscopy and X-ray diffractometry. After 15months in vivo, the investigated materials brushite (CaHPO(4)·2H(2)O), newberyite (MgHPO(4)·3H(2)O), struvite (MgNH(4)PO(4)·6H(2)O) and hydroxyapatite (Ca(9)(PO(4))(5)HPO(4)OH) showed significant differences regarding changes of their characteristics. Struvite presented the highest loss of mechanical performance (95%), followed by newberyite (67%) and brushite (41%). This was accompanied by both a distinct extent of cement dissolution as well as changes of the phase composition of the retrieved cement implants. While the secondary phosphate phases (brushite, newberyite, struvite) completely dissolved, re-precipitates of whitlockite and octacalcium phosphate were formed in either particulate or whisker-like morphology. Furthermore, for the first time the possibility of a macropore-free volume degradation mechanism of bioceramics was demonstrated.