Fate of mineralized and demineralized osseous implants in cranial defects

Sustained local ionic homeostatic imbalance caused by calcification modulates inflammation to trigger heterotopic ossification

Heterotopic ossification (HO) is a condition triggered by an injury leading to the formation of mature lamellar bone in extraskeletal soft tissues. Despite being a frequent complication of orthopedic and trauma surgery, brain and spinal injury, the etiology of HO is poorly understood. The aim of this study is to evaluate the hypothesis that a sustained local ionic homeostatic imbalance (SLIHI) created by mineral formation during tissue calcification modulates inflammation to trigger HO. This evaluation also considers the role SLIHI could play for the design of cell-free, drug-free osteoinductive bone graft substitutes. The evaluation contains five main sections. The first section defines relevant concepts in the context of HO and provides a summary of proposed causes of HO. The second section starts with a detailed analysis of the occurrence and involvement of calcification in HO. It is followed by an explanation of the causes of calcification and its consequences. This allows to speculate on the potential chemical modulators of inflammation and triggers of HO. The end of this second section is devoted to in vitro mineralization tests used to predict the ectopic potential of materials. The third section reviews the biological cascade of events occurring during pathological and material-induced HO, and attempts to propose a quantitative timeline of HO formation. The fourth section looks at potential ways to control HO formation, either acting on SLIHI or on inflammation. Chemical, physical, and drug-based approaches are considered. Finally, the evaluation finishes with a critical assessment of the definition of osteoinduction. STATEMENT OF SIGNIFICANCE: The ability to regenerate bone in a spatially controlled and reproducible manner is an essential prerequisite for the treatment of large bone defects. As such, understanding the mechanism leading to heterotopic ossification (HO), a condition triggered by an injury leading to the formation of mature lamellar bone in extraskeletal soft tissues, would be very useful. Unfortunately, the mechanism(s) behind HO is(are) poorly understood. The present study reviews the literature on HO and based on it, proposes that HO can be caused by a combination of inflammation and calcification. This mechanism helps to better understand current strategies to prevent and treat HO. It also shows new opportunities to improve the treatment of bone defects in orthopedic and dental procedures.

Allogeneic Dentin Graft: A Review on Its Osteoinductivity and Antigenicity

Studies on allogeneic demineralized dentin matrix (Allo-DDM) implantation in the 1960s and 1970s provided the most reliable preclinical evidence of bone formation and antigenicity in an extraosseous site. Recently, applications of Allo-DDM at skeletal sites were studied, and have provided reliable evidence of bone-forming capacity and negligible antigenicity. However, the osteoinductivity and antigenicity properties of Allo-DDM in extraskeletal sites have not yet been investigated due to the lack of follow-up studies after the initial research. The clinical applications of autogenous DDM (Auto-DDM) have been standardized in some countries. Long-term clinical studies have reported the development of several shapes of Auto-DDM, such as powders, blocks, moldable forms, and composites, with recombinant human bone morphogenetic protein-2. For the development of Allo-DDM as a reliable bone graft substitute next to Auto-DDM, we reviewed preclinical studies on the bone induction capacity of allogeneic dentin at extraskeletal as well as skeletal sites. Electronic databases were screened for this review in January 2020 and searched from 1960 to 2019. This review aims to provide a foundation on the preclinical studies of Allo-DDM, which could enable future researches on its osteogenic capability and antigenicity. In conclusion, Allo-DDM showed great potential for osteoinductivity in extraskeletal sites with low antigenicity, which neither adversely affected osteogenic capability nor provoked immunologic reactions. However, the risk of viral disease transmission should be researched before the clinical application of Allo-DDM.

Citric acid, but not tetracycline, improves the microscopic pattern of healing of particulate autogenous bone grafts in critical-size defects

BACKGROUND

Bone demineralization has shown to be advantageous in autogenous onlay bone grafts and in pre-osteoblasts cultures, but such procedure has never been evaluated in particulate bone grafts. This study aimed to investigate the role of two demineralizing agents in the repair of the 8-mm critical-size defects in rats' calvaria.

METHODS

Eighty adult male Wistar rats were randomly assigned to one of eight groups as follows: particulate autogenous bone demineralized with citric acid for 15 seconds (CA15), 30 seconds (CA30), or 60 seconds (CA60); particulate autogenous bone demineralized with tetracycline hydrochloride for 15 seconds (TCN15), 30 seconds (TCN30), or 60 seconds (TCN60); blood clot (NC), and non-demineralized autogenous bone (PC). The calvariae were harvested at 30 and 60 postoperative days (n = 5) for blinded histological and histometric analysis of the percentage area of newly formed bone within the defects.

RESULTS

In the NC and TCN groups, bone formation was limited to the margins of the defects at 30 postoperative days, whereas complete closure was present in all the specimens from CA15 group. Both at 30 and 60 postoperative days, histomorphometry showed significant higher area of newly formed bone in specimens demineralized with CA than in those demineralized with TCN or non-demineralized (P < 0.05). TCN appeared to impair bone neoformation, as its use produced similar or inferior results compared to blood clot.

CONCLUSIONS

Demineralization of particulate bone grafts with CA during 15s enhanced the regeneration of critical-size defects and may be a promising adjuvant in regenerative procedures. TCN seems to be improper for this purpose.

Regenerative Materials for Surgical Reconstruction: Current Spectrum of Materials and a Proposed Method for Classification

Chronic wound management is an enormous economic strain and quality-of-life issue for patients. Current treatments are ineffective or expensive and invasive. Materials (native and artificial) can act as the basis to enhance wound repair but often fall short of complete healing. The therapeutic index of materials have often been enhanced by combining them with drug or biologic elution technologies. Combination of materials with living drugs (cells) presents a new paradigm for enhancing therapy. Cell material interaction and therapeutic output will depend on variables ascribed to the living drug as well as variables ascribed to the underlying matrix. In this article, we review medical matrices currently approved by the US Food and Drug Administration (FDA) that would likely be the first generation of materials to be used in this manner. Currently there are hundreds of different materials on the market. Identification of the right combinations would benefit from a classification scheme to group materials with similar composition or derivation. We provide a classification scheme and FDA documentation references that should provide researchers and clinicians a starting point for testing these materials in the laboratory and rapidly transitioning cell therapies to the bedside.

Combinatorial Analysis of Growth Factors Reveals the Contribution of Bone Morphogenetic Proteins to Chondrogenic Differentiation of Human Periosteal Cells

Successful application of cell-based strategies in cartilage and bone tissue engineering has been hampered by the lack of robust protocols to efficiently differentiate mesenchymal stem cells into the chondrogenic lineage. The development of chemically defined culture media supplemented with growth factors (GFs) has been proposed as a way to overcome this limitation. In this work, we applied a fractional design of experiment (DoE) strategy to screen the effect of multiple GFs (BMP2, BMP6, GDF5, TGF-β1, and FGF2) on chondrogenic differentiation of human periosteum-derived mesenchymal stem cells (hPDCs) in vitro. In a micromass culture (μMass) system, BMP2 had a positive effect on glycosaminoglycan deposition at day 7 (p < 0.001), which in combination with BMP6 synergistically enhanced cartilage-like tissue formation that displayed in vitro mineralization capacity at day 14 (p < 0.001). Gene expression of μMasses cultured for 7 days with a medium formulation supplemented with 100 ng/mL of BMP2 and BMP6 and a low concentration of GDF5, TGF-β1, and FGF2 showed increased expression of Sox9 (1.7-fold) and the matrix molecules aggrecan (7-fold increase) and COL2A1 (40-fold increase) compared to nonstimulated control μMasses. The DoE analysis indicated that in GF combinations, BMP2 was the strongest effector for chondrogenic differentiation of hPDCs. When transplanted ectopically in nude mice, the in vitro-differentiated μMasses showed maintenance of the cartilaginous phenotype after 4 weeks in vivo. This study indicates the power of using the DoE approach for the creation of new medium formulations for skeletal tissue engineering approaches.

A histologic, histomorphometric, and radiographic comparison between two complexes of CenoBoen/CenoMembrane and Bio-Oss/Bio-Gide in lateral ridge augmentation: A clinical trial

BACKGROUND

Several grafting materials have been used for alveolar ridge augmentation. The literature lacks researches to compare CenoBone to other grafting materials. The aim of this study was to compare CenoBone/CenoMembrane complex to Bio-Oss/Bio-Gide complex in lateral alveolar bone augmentation in terms of radiographic, histologic, and histomorphometric parameters.

MATERIALS AND METHODS

In this randomized controlled trial, ten patients who needed lateral ridge augmentation were selected and augmentations were done using either of CenoBone/CenoMembrane or Bio-Oss/Bio-Gide complexes. In the re-entry surgery in 6 months following augmentation, core biopsies were taken and clinical, radiographic, histologic, and histomorphometric evaluations were performed.

RESULTS

No statistically significant difference was seen between groups except for the number of blood vessels and percentage of residual graft materials.

CONCLUSION

CenoBone seems to present a comparable lateral ridge augmentation to Bio-Oss in.

Prefabricated bone flap: an experimental study comparing deep-frozen and lyophilized-demineralized allogenic bones and tissue expression of transforming growth factor β

BACKGROUND

Extensive bone defects are still a challenge for reconstructive surgery. Allogenic bones can be an alternative with no donor area morbidity and unlimited amount of tissue. Better results can be achieved after allogenic bone preparation and adding a vascular supply, which can be done along with flap prefabrication. The purpose of this study was to evaluate demineralized/lyophilized and deep-frozen allogenic bones used for flap prefabrication and the tissue expression of transforming growth factor β (TGF-β) in these bone fragments.

METHODS

Fifty-six Wistar rat bone diaphyses were prepared and distributed in 4 groups: demineralized/lyophilized (experimental group 1 and control group 2) and deep freezing (experimental group 3 and control group 4). Two bone segments (one of each group) were implanted in rats to prefabricate flaps using superficial epigastric vessels (experimental groups) or only transferred as grafts (control groups). These fragments remained in their respective inguinal regions until the death that occurred at 2, 4, and 6 weeks after the operation. Semiquantitative histologic (tetracycline marking, cortical resorption, number of giant cells, and vascularization) and histomorphometrical quantitative (osteoid thickness, cortical thickness, and fibrosis thickness) analyses were performed. Transforming growth factor β immunohistochemistry staining was also performed.

RESULTS

Group 1 fragments presented an osteoid matrix on their external surface in all periods. Cartilage formation and mineralization areas were also noticed. These findings were not observed in group 3 fragments. Group 1 had more mineralization and double tetracycline marks, which were almost not seen in group 3. Cortical resorption and the number of giant cells were greater in group 3 in all periods. Vascularization and fibrosis thickness were similar in both experimental groups. Group 1 had more intense TGF-β staining within 2 weeks of study. Nevertheless, from 4 weeks onward, group 3 presented statistically significant stronger staining.

CONCLUSIONS

Although there are some differences between the preparation methods of allogenic bone, it is possible to prefabricate flaps with demineralized/lyophilized and deep-frozen bones.

The dynamics of adult haematopoiesis in the bone and bone marrow environment

This review explores the dynamic relationship between bone and bone marrow in the genesis and regulation of adult haematopoiesis and will provide an overview of the haematopoietic hierarchical system. This will include the haematopoietic stem cell (HSC) and its niches, as well as discuss emerging evidence of the reciprocal interplay between bone and bone marrow, and support of the pleiotropic role played by bone cells in the regulation of HSC proliferation, differentiation and function. In addition, this review will present demineralized bone matrix as a unique acellular matrix platform that permits the generation of ectopic de novo bone and bone marrow and provides a means of investigating the temporal sequence of bone and bone marrow regeneration. It is anticipated that the utilization of this matrix-based approach will help researchers in gaining deeper insights into the major events leading to adult haematopoiesis in the bone marrow. Furthermore, this model may potentially offer new avenues to manipulate the HSC niche and hence influence the functional output of the haematopoietic system.

Demineralized bone matrix and platelet-rich plasma do not improve healing of osteochondral defects of the talus: an experimental goat study

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of demineralized bone matrix (DBM) with and without platelet-rich plasma (PRP) in the treatment of osteochondral defects (OCDs) of the talus. We hypothesized that treatment with DBM would result in more bone formation than no treatment in control OCDs, and that PRP would further enhance the regenerative capacity of DBM.

METHOD

A standardized 6-mm OCD was created in each talus of 16 adult goats. According to a randomization scheme, one OCD of each goat was treated with allogeneic DBM hydrated with normal saline (n = 8) or hydrated with autologous PRP (n = 8). The contralateral OCD (n = 16) served as control. After 24 weeks, the animals were euthanized and the tali excised. Various outcome parameters were analyzed with use of macroscopic evaluation, micro-computed tomography (μCT), histology, histomorphometry, and fluorescence microscopy.

RESULTS

None of the analyses revealed statistically significant differences between the groups for any of the parameters analyzed in any volume of interest. For example, the mean bone volume fraction (BV/TV) of the defect, as measured by μCT, was 0.56 (95% confidence interval [CI], 0.44-0.68) for DBM hydrated with normal saline and 0.52 (95% CI, 0.40-0.65) for DBM hydrated with PRP, compared to 0.53 (95% CI, 0.45-0.61) and 0.54 (95% CI, 0.44-0.64) for the internal controls, respectively (P > 0.05).

CONCLUSION

In contrast to our hypotheses, no beneficial treatment effect of DBM with or without PRP was found for OCDs of the caprine talus.

Demineralized bone matrix in bone repair: history and use

Demineralized bone matrix (DBM) is an osteoconductive and osteoinductive commercial biomaterial and approved medical device used in bone defects with a long track record of clinical use in diverse forms. True to its name and as an acid-extracted organic matrix from human bone sources, DBM retains much of the proteinaceous components native to bone, with small amounts of calcium-based solids, inorganic phosphates and some trace cell debris. Many of DBM's proteinaceous components (e.g., growth factors) are known to be potent osteogenic agents. Commercially sourced as putty, paste, sheets and flexible pieces, DBM provides a degradable matrix facilitating endogenous release of these compounds to the bone wound sites where it is surgically placed to fill bone defects, inducing new bone formation and accelerating healing. Given DBM's long clinical track record and commercial accessibility in standard forms and sources, opportunities to further develop and validate DBM as a versatile bone biomaterial in orthopedic repair and regenerative medicine contexts are attractive.

Grafton and local bone have comparable outcomes to iliac crest bone in instrumented single-level lumbar fusions

STUDY DESIGN

Prospective multicenter randomized clinical trail.

OBJECTIVE

The goal of our 2-year prospective study was to perform a randomized clinical trial comparing the outcomes of Grafton demineralized bone matrix (DBM) Matrix with local bone with that of iliac crest bone graft (ICBG) in a single-level instrumented posterior lumbar fusion.

SUMMARY OF BACKGROUND DATA

There has been extensive research and development in identifying a suitable substitute to replace autologous ICBG that is associated with known morbidities. DBMs are a class of commercially available grafting agents that are prepared from allograft bone. Many such products have been commercially available for clinical use; however, their efficacy for spine fusion has been mostly based on anecdotal evidence rather than randomized controlled clinical trials.

METHODS

Forty-six patients were randomly assigned (2:1) to receive Grafton DBM Matrix with local bone (30 patients) or autologous ICBG (16 patients). The mean age was 64 (females [F] = 21, males [M] = 9) in the DBM group and 65 (F = 9, M = 5) in the ICBG group. An independent radiologist evaluated plain radiographs and computed tomographic scans at 6-month, 1-year, and 2-year time points. Clinical outcomes were measured using Oswestry Disability Index (ODI) and Medical Outcomes Study 36-Item Short Form Health Survey.

RESULTS

Forty-one patients (DBM = 28 and ICBG = 13) completed the 2-year follow-up. Final fusion rates were 86% (Grafton Matrix) versus 92% (ICBG) (P = 1.0 not significant). The Grafton group showed slightly better improvement in ODI score than the ICBG group at the final 2-year follow-up (Grafton [16.2] and ICBG [22.7]); however, the difference was not statistically significant (P = 0.2346 at 24 mo). Grafton showed consistently higher physical function scores at 24 months; however, differences were not statistically significant (P = 0.0823). Similar improvements in the physical component summary scores were seen in both the Grafton and ICBG groups. There was a statistically significant greater mean intraoperative blood loss in the ICBG group than in the Grafton group (P < 0.0031).

CONCLUSION

At 2-year follow-up, subjects who were randomized to Grafton Matrix and local bone achieved an 86% overall fusion rate and improvements in clinical outcomes that were comparable with those in the ICBG group.

Morphological Changes of Isolated Osteoclasts in Cell Culture Due to Different Biomaterials

Osteoclasts have been isolated in primary cell culture using femoral bone of laying hens being fed on an eight day calcium free diet. Placing these cells on the surface of fixed cortico-femoral chicken bone provoked the feature of resorption pits proving that they are able to resorb bone.

After placing osteoclasts on different biomaterials (Aluminumoxide ceramics, teflon, carbon fibre reinforced polysulphone, polymethylmethacrylate, polydioxanone) scanning electron microscopy was performed. Different materials provoke different morphological features of these cells, probably due to functional variations as a response to the changing surfaces. Adhesion was feasible on all the surfaces, uptake of small surface particles was possible and cell fusion took place on most materials suggesting acceptance of the tested biomaterials by the cells.

The results show that morphological changes of isolated osteoclasts in cell culture can be detected due to different functional challenges of the surfaces of different biomaterials.

Tensile resistance of mineralized and demineralized rat bones in different regions (calvarial and femur)

The aim of this study was to evaluate the tensile resistance of mineralized and demineralized bones. Twelve mice were used. Specimens were collected and divided into groups 1 and 2, mineralized and demineralized calvarial bone, and groups 3 and 4, mineralized and demineralized femoral bone. There was not a statistically significant difference (analysis of variance) between the regions; however, when comparing the demineralized and mineralized groups, a statistically significant difference (Student test) for the mineralized group was noticed.

Spontaneous healing capacity of rabbit cranial defects of various sizes

Purpose

This study evaluated the spontaneous healing capacity of surgically produced cranial defects in rabbits with different healing periods in order to determine the critical size defect (CSD) of the rabbit cranium.

Methods

Thirty-two New Zealand white rabbits were used in this study. Defects of three sizes (6, 8, and 11 mm) were created in each of 16 randomly selected rabbits, and 15-mm defects were created individually in another 16 rabbits. The defects were analyzed using radiography, histologic analysis, and histometric analysis after the animal was sacrificed at 2, 4, 8, or 12 weeks postoperatively. Four samples were analyzed for each size of defect and each healing period.

Results

The radiographic findings indicated that defect filling gradually increased over time and that smaller defects were covered with a greater amount of radiopaque substance. Bony islands were observed at 8 weeks at the center of the defect in both histologic sections and radiographs. Histometrical values show that it was impossible to determine the precise CSD of the rabbit cranium. However, the innate healing capacity that originates from the defect margin was found to be constant regardless of the defect size.

Conclusions

The results obtained for the spontaneous healing capacity of rabbit cranial defects over time and the underlying factors may provide useful guidelines for the development of a rabbit cranial model for in vivo investigations of new bone materials.

Osteoclasts can be induced in fish having an acellular bony skeleton

Kelp bass (Paralabrax clathratus) and leopard sharks (Triakis semifasciata) are characterized by an acellular (anosteocytic) bony skeleton and a focally calcified cartilaginous endoskeleton, respectively. These skeletal forms are not considered to function as mineral reservoirs. Previous studies showed that implanted bone particles are resorbed in rats by large multinucleated cells with ultrastructural features (ruffled borders) characteristic of osteoclasts. We tested the ability of fish to resorb bone matrix and to adapt to reduced salinity conditions. Bone particles were implanted in sharks and bass maintained in seawater (34 ppt, 40.5 mg of calcium per dl) or in diluted seawater (26 ppt, 28.5 mg of calcium per dl). Sera and elicited tissues were harvested 4 weeks later. In sharks, bone particles were not resorbed, and multinucleated cells were not evident under either normal or hyposalinity conditions. Shark sera were isoosmolar with the seawater or diluted seawater, with serum chemistries of the hyposalinity group reflecting the 23% reduction in environmental minerals and electrolytes, compared to sharks in normal seawater. In marked contrast, bass adapted to diluted seawater resorbed bone particles and maintained normal serum chemistries. Electron microcopy showed that the bone particles were surrounded by large, foamy multinucleated cells, many with membrane specializations typical of osteoclasts from higher vertebrates, i.e., extensive clear zones apposed to intact bone matrix and active ruffled borders overlying areas of matrix undergoing dissolution. Although osteoclasts had not been described in these fish, this study shows that bass have stem cells that can be stimulated to differentiate into bone-resorbing osteoclasts.

Effect of recombinant human bone morphogenetic protein-2 on bone regeneration in large defects of the growing canine skull after dura mater replacement with a dura mater substitute

OBJECT

This study was designed to evaluate the bone regeneration potential of the dura mater and dura mater substitute (Durepair) in the presence of recombinant human bone morphogenetic protein-2 (rhBMP-2) delivered in a collagen sponge-collagen-ceramic matrix (CCM; MasterGraft Matrix) in a large skull defect in growing canines.

METHODS

Forty immature male beagles were used to create two 2.5 x 4-cm cranial defects on each side of the sagittal suture. The dura mater on the left side was cut to make a 1 x 3-cm defect and replaced with bovine skin collagen (Durepair). The dura mater on the right side remained intact. Different doses of rhBMP-2 (none [8 animals], 0.11 mg/ml [4 animals], 0.21 mg/ml [4 animals], and 0.43 mg/ml [8 animals]) were infused on 2 Type I bovine absorbable collagen sponge (ACS) strips. The strips were layered with the CCM (15% hydroxyapatite [HA]/85% tricalcium phosphate [TCP]) to reconstruct both cranial defects. In a fifth group (8 animals), 0.43 mg/ml rhBMP-2 was directly infused into the CCM. Demineralized canine cancellous freeze-dried demineralized bone matrix (DBM; 8 animals) was used as a control in a sixth group. All materials were fixed under 2 resorbable protective sheets (MacroPore). Skulls were resected 16 weeks after operation. Histological and histomorphometric analyses on the percentage of the defect spanned by bone, and the percentage of residual HA-TCP granules and collagen were analyzed.

RESULTS

Calcified seroma was the only complication observed and only occurred in the 0.43-mg/ml rhBMP-2 groups (Groups 4 and 5). Dura mater repair appeared complete at 4 months in all animals. New bone was formed sporadically throughout the skull defect in the ACS+CCM and DBM groups without rhBMP-2. In all rhBMP-2 groups, mature new bone (compact and trabecular) was uniformly formed across the defect on both the repaired and intact dura mater sides. There was significant new compact bone formation on top of the repaired dura mater, which did not appear in the ACS+CCM and DBM groups lacking rhBMP-2. Greater HA-TCP and collagen scaffold resorption was noted in rhBMP-2 groups compared with non-rhBMP-2 groups. Statistical analysis showed there was a significantly lower percentage of bone spanning the defect in the ACS+CCM group compared with groups with rhBMP-2, with more residual HA-TCP and collagen on the repaired dura mater side than the intact dura mater side (p < 0.05). In all rhBMP-2 groups, there were no significant differences in new bone formation between the repaired and intact dura mater sides (p > 0.05).

CONCLUSIONS

The ACS+CCM combination had an effect similar to demineralized bone-on-bone regeneration in craniofacial reconstruction. The addition of rhBMP-2 to CCM directly or with ACS induces mature new bone formation in large cranial defects both in the presence of intact dura mater and repaired dura mater.

Mineralization of osteoblasts with electrospun collagen/hydroxyapatite nanofibers

Regeneration of fractured or diseased bones is the challenge faced by current technologies in tissue engineering. The major solid components of human bone consist of collagen and hydroxyapatite. Collagen (Col) and hydroxyapatite (HA) have potential in mimicking natural extracellular matrix and replacing diseased skeletal bones. More attention has been focused on HA because of its crystallographic structure similar to inorganic compound found in natural bone and extensively investigated due to its excellent biocompatibility, bioactivity and osteoconductivity properties. In the present study, electrospun nanofibrous scaffolds are fabricated with collagen (80 mg/ml) and Col/HA (1:1). The diameter of the collagen nanofibers is around 265 +/- 0.64 nm and Col/HA nanofibers are 293 +/- 1.45 nm. The crystalline HA (29 +/- 7.5 nm) loaded into the collagen nanofibers are embedded within nanofibrous matrix of the scaffolds. Osteoblasts cultured on both scaffolds and show insignificant level of proliferation but mineralization was significantly (p < 0.001) increased to 56% in Col/HA nanofibrous scaffolds compared to collagen. Energy dispersive X-ray analysis (EDX) spectroscopy results proved the presence of higher level of calcium and phosphorous in Col/HA nanocomposites than collagen nanofibrous scaffolds grown osteoblasts. The results of the present study suggested that the designed electrospun nanofibrous scaffold (Col/HA) have potential biomaterial for bone tissue engineering.

Human fetal bone cells associated with ceramic reinforced PLA scaffolds for tissue engineering

Fetal bone cells were shown to have an interesting potential for therapeutic use in bone tissue engineering due to their rapid growth rate and their ability to differentiate into mature osteoblasts in vitro. We describe hereafter their capability to promote bone repair in vivo when combined with porous scaffolds based on poly(l-lactic acid) (PLA) obtained by supercritical gas foaming and reinforced with 5 wt.% beta-tricalcium phosphate (TCP). Bone regeneration was assessed by radiography and histology after implantation of PLA/TCP scaffolds alone, seeded with primary fetal bone cells, or coated with demineralized bone matrix. Craniotomy critical size defects and drill defects in the femoral condyle in rats were employed. In the cranial defects, polymer degradation and cortical bone regeneration were studied up to 12 months postoperatively. Complete bone ingrowth was observed after implantation of PLA/TCP constructs seeded with human fetal bone cells. Further tests were conducted in the trabecular neighborhood of femoral condyles, where scaffolds seeded with fetal bone cells also promoted bone repair. We present here a promising approach for bone tissue engineering using human primary fetal bone cells in combination with porous PLA/TCP structures. Fetal bone cells could be selected regarding osteogenic and immune-related properties, along with their rapid growth, ease of cell banking and associated safety.

A review of bone substitutes

The use of bone grafts in the repair of defects has a long history of success, primarily with the use of autologous bone. With increasing technologic advances, researchers have been able to broaden the spectrum of grafting materials to allografts, xenografts, and synthetic materials, which provide the surgeon and patient with options, each with unique advantages. It is with the knowledge of each material that the clinician can present and suggest the best material and tailor treatment plans to fit each individual. In this article, we present an overview of the principles of bone grafting, the types of graft materials available, and an outlook to what the future holds in this area of medicine and dentistry.

Particulate bone allograft incorporation in regeneration of osseous defects; importance of particle sizes

Packing of bone defect with particulate allografts is a commonly performed clinical procedure. However, the ideal size of bone particles used to fill bone defects is ill-defined. For this reason the study of biology of bone allografts with different particle sizes has been performed. Standard size bone defects in the femur and the tibia of experimental animals were filled with freeze-dried cortical bone allografts with particle sizes of 1-2mm, 800-500μm, 500-300μm, 300-90μm, 250-125μm, 125-106μm, 106 to 75μm and 75-25μm. Unfilled defects and those filled with autologous bone served as controls. Cortical bone was chosen because it produced better clinical results than did cancellous bone. Likewise freeze-dried particulate bone effected more rapid healing than did frozen bone. Numerical scores were assigned to each defect based on the gross, radiographic and histomorphometric studies. Particles in the range of 300 to 90 microns produced rapid healing by direct ossification. Particles below 100µm had a significantly reduced osteogenic potential. Particles in the range of 75-25μm failed to heal the defects all together. Healing of defects packed with particles larger than 300μm was slower than with 300 – 90 μm grafts. Rapid healing of bone defects packed with particulate bone allografts in the range of 300 to 90μm indicates such allografts can be used effectively in the filling of bone defects. This is of clinical relevance.

Repair of critical size defects in the rat cranium using ceramic-reinforced PLA scaffolds obtained by supercritical gas foaming

Bioresorbable scaffolds made of poly(L-lactic acid) (PLA) obtained by supercritical gas foaming were recently described as suitable for tissue engineering, portraying biocompatibility with primary osteoblasts in vitro and interesting mechanical properties when reinforced with ceramics. The behavior of such constructs remained to be evaluated in vivo and therefore the present study was undertaken to compare different PLA/ceramic composite scaffolds obtained by supercritical gas foaming in a critical size defect craniotomy model in Sprague-Dawley rats. The host-tissue reaction to the implants was evaluated semiquantitatively and similar tendencies were noted for all graft substitutes: initially highly reactive but decreasing with time implanted. Complete bone-bridging was observed 18 weeks after implantation with PLA/ 5 wt % beta-TCP (PLA/TCP) and PLA/5 wt % HA (PLA/HA) scaffolds as assessed by histology and radiography. We show here for the first time that this solvent-free technique provides a promising approach in tissue engineering demonstrating both the biocompatibility and osteoconductivity of the processed structures in vivo.

Review: Mineralization of Synthetic Polymer Scaffolds for Bone Tissue Engineering

It has repeatedly been shown that demineralization improves the ability of bone auto- and allografts to regenerate natural bone tissue. Conversely, much work in the field of bone tissue engineering has used composite materials consisting of a mineralized phase or materials designed to mineralize rapidly in situ. In this review, we seek to examine these disparate roles of mineralization and the underlying factors that cause this discordance and to examine methods and principles of the mineralization of synthetic polymer scaffolds. Biomimetic approaches to mineralization and phosphorus-containing materials are highlighted, and a brief section focusing on drug-delivery strategies using mineralized scaffolds is included.

Safety and efficacy of use of demineralised bone matrix in orthopaedic and trauma surgery

Demineralised bone matrix (DBM) acts as an osteoconductive, and possibly as an osteoinductive, material. It is widely used in orthopaedic, neurosurgical, plastic and dental areas. More than 500,000 bone grafting procedures with DBM are performed annually in the US. It does not offer structural support, but it is well suited for filling bone defects and cavities. The osteoinductive nature of DBM is presumably attributed to the presence of matrix-associated bone morphogenetic proteins (BMPs) and growth factors, which are made available to the host environment by the demineralisation process. Clinical results have not been uniformly favourable; however, a variable clinical response is attributed partly to nonuniform processing methods found among numerous bone banks and commercial suppliers. DBMs remain reasonably safe and effective products. The ultimate safe bone-graft substitute, one that is osteoconductive, osteoinductive, osteogenic and mechanically strong, remains elusive.

Prefabrication of Vascularized Bone Flap by Demineralized Bone Matrix

Demineralized bone matrix (DBM) has been reported to have osteoconductive and osteoinductive properties and has been clinically used as a bone graft alternative. In the present study we attempted to generate a vascularized bone flap by subcutaneous implantation of DBM with a vascular loop to provide blood supply in a rat model. Thirty male Sprague-Dawley rats were divided into two groups according to the presence or absence of blood supply. In the experimental group, the bone flap was created by application of 0.4 mL of DBM onto two pieces of gelatin sponge sheets between which a vascular loop was sandwiched. A prefabricated flap without a vascular loop served as the control. The flaps were biopsied at three different time intervals postoperatively (2, 4, and 6 weeks). The results showed that DBM induced subcutaneous bone formation in both of the groups. However, in the nonvascularized group, the amount of bony tissue had decreased at four postoperative weeks and continued to do so afterwards. In contrast, bone formation was active at four weeks in the vascularized group. Our study indicated that implantation of DBM can prefabricate a bone flap. Blood supply to the flap is considered a key factor of the success of this prefabrication.

Histomorphometric evaluation of six dental implant surfaces after early loading in augmented human sinuses

This study investigated the bone-to-implant contact (BIC) and osteoconductive capacity (OC) of 6 different implant surfaces after early loading in humans. Two implants with different surfaces were placed side-by-side in the grafted (n= 5) and nongrafted (n = 1) sinuses of 3 volunteers. Single-tooth restorations were delivered 60 days later. After 6 months of full occlusal loading, implants were retrieved in block sections for histomorphometric analysis. One implant (acid etched) placed in grafted bone failed when loaded. There were no other complications. In grafted bone, the microtextured surface achieved the highest BIC value (94.08%), followed by the oxidized (77.32%), hydroxyapatite (HA) (74.51%), sandblasted and acid-etched (51.85%), and titanium plasma-sprayed (TPS) (41.48%) surfaces. In native bone, the acid-etched surface achieved a higher BIC value (69.03%) than the HA surface (59.03%). The highest OC value in grafted bone was exhibited by the microtextured surface (34.31%), followed by the HA (28.62%), sandblasted and acid-etched (25.08%), oxidized (17.55%), and TPS (-20.47%) surfaces. The HA surface exhibited a higher OC value (30.39%) in native bone compared with the acid-etched surface (24.0%). As a whole, highest BIC and OC values were exhibited by the microtextured surface, and lowest values were exhibited by the TPS surface. All other surfaces demonstrated excellent BIC (>50%) but varied in OC (range = 17.55%-28.62%). These findings are tempered by the limited scope and sample size of the study and should be considered preliminary. More research is needed to determine the impact of implant surface texture on BIC and OC.

Prevention of Temporal Depression That Follows Fronto-orbital Advancement for Craniosynostosis

Contour abnormalities presenting after fronto-orbital advancement for craniosynostosis are common. Often there is bilateral temporal depression, the result of leaving a coronal bony gap posterior to the advanced segments. The authors present techniques to prevent this temporal depression by utilizing full-thickness bone grafts for structural support in the inferior coronal defects, and cortico-cancellous graft in the remaining superior coronal and parietal donor defects. Prior to contouring and repositioning the frontal elements, a hand-driven Hudson brace and D'Ericco bit is used to harvest cortico-cancellous bone "mush" from the endo- and ectocortical surfaces. The bandeau and frontal elements are advanced and secured, and the resultant coronal gap is measured. Full-thickness cranial bone grafts are harvested from the parietal regions (near the vertex) and secured in the coronal defect behind the frontal elements. The temporalis muscle is rotated, advanced, and secured to the bandeau. Bone mush is used to fill the remaining superior coronal and donor site defects. Representative case examples are presented.

Accelerated repair of cortical bone defects using a synthetic extracellular matrix to deliver human demineralized bone matrix

Injectable hydrogel and porous sponge formulations of Carbylan-GSX, a crosslinked synthetic extracellular matrix (ECM), were used to deliver human demineralized bone matrix (DBM) in a rat femoral defect model. A cortical, full-thickness 5-mm defect was created in two femurs of each rat. Six rats were assigned to each of five experimental groups (thus, 12 defects per group). The defects were either untreated or filled with Carbylan-GSX hydrogel or sponges with or without 20% (w/v) DBM. Radiographs were obtained on day 1 and at weeks 2, 4, 6, and 8 postsurgery of each femur. Animals were sacrificed at week 8 postsurgery and each femur was fixed, embedded, sectioned, and processed for Masson's Trichrome staining. The bone defects were measured from radiographs and the fraction of bone healing was calculated. The average fractions of bone healing for each group were statistically different among all groups, and all treatment groups were significantly better than the control group. The Carbylan-GSX sponge with DBM was superior to the sponge without DBM and to the hydrogel with DBM. Histology showed that defects treated with the Carbylan-GSX sponge plus DBM were completely filled with newly generated bone tissue with a thickness comparable to native bone. Carbylan-GSX sponge was an optimal delivery vehicle for human DBM to accelerate bone healing.

Validity of radiographic evaluations of bone formation in a rat calvaria osteotomy defect model

OBJECTIVE

The objective of this study was to evaluate the validity of radiographic evaluations of bone formation in a critical-size rat calvaria osteotomy defect model.

METHODS

Bilateral, critical-size ( [symbol in text] 6 mm) calvaria osteotomy defects in 30 adult Sprague-Dawley rats treated with a rat platelet-rich plasma preparation or control treatments were evaluated by radiographic and histometric measures following a 4- or 8-week healing interval. Standardized radiographic images of the rat calvaria gross specimens were used to assess bone formation within the defect sites by visual evaluation of the grey scale by three masked examiners. The most central portion of each defect site was subject to histometric analysis using a PC-based image analysis system. Kappa statistics and percentage agreement between the radiographic and histometric analysis were estimated.

RESULTS

Radiographic evaluations of bone formation are associated with significant weaknesses poorly representing actual healing events; kappa statistics (0.17) denoting slight agreement beyond chance. Perfect agreement between the histologic and radiographic analysis for defect sites showing complete and partial histologic bone fill was achieved 63% and 50% of the time, respectively. Agreement reached only 20% for sites with no/limited bone fill. When no/limited and partial bone fill occurred, the radiographic analysis tended to overestimate bone fill and underestimate bone fill when complete closure of the defect sites was observed in the histologic analysis.

CONCLUSION

Low accuracy was observed when radiographic evaluations were employed in identifying and characterizing bone fill in the rat calvaria osteotomy defects. Assessment of bone healing in animal models aiming at treatment recommendations for clinical application must not solely be based on radiographic analysis, but should be confirmed using histologic observations.

The Effect of Residual Calcium in Decalcified Freeze-dried Bone Allograft in a Critical-sized Defect in the Rattus norvegicus Calvarium

Demineralized freeze-dried bone allograft (DFDBA), a widely used graft material in periodontal regenerative procedures, is processed with hydrochloric acid in the attempt to expose proteins located within the bone matrixes that are capable of inducing new bone formation. However, the degree of DFDBA demineralization varies between tissue banks, which may have an effect on clinical regeneration. This study uses the critical-sized defect (CSD) model to evaluate the wound-healing response to the residual calcium of donor bone. If the percentage of residual calcium in a graft were demonstrated to significantly enhance wound healing, then periodontal patients may benefit from further standardization of human-allograft processing. Sixty adult, male, Harlan Sprague-Dawley rats (Rattus norvegicus) were randomly and equally divided into 4 test groups (ie, DFDBA at 1%, 2%, and 3% to 6% residual calcium levels and FDBA at 23% residual calcium) and a control group (no allograft). An 8-mm-diameter craniotomy was made in the rat calvarium, and polytetrafluoroethylene membranes with pore sizes of 0.50 μm were placed intracranially and ectocranially. Treatment materials were carefully placed into the CSD with a new sterilized dental amalgam carrier. Tetracycline hydrochloride was injected intraperitoneally for labeling new bone growth, and animals were euthanized 12 weeks postsurgery. As a result, histomorphometric bone fill at 12 weeks showed a statistically significant increase in the 2% DFDBA group as compared to all other groups. The authors conclude that a 2% residual calcium level in human DFDBA appears to significantly (P ≤ .05) enhance osseous wound healing in the rat calvarium.

Effect of carbonate substitution on the ultrastructural characteristics of hydroxyapatite implants

Carbonate ion substitution has been shown to be beneficial for increasing the amount of in vivo osseointegration to hydroxyapatite (HA). Nevertheless, mechanisms by which carbonate ions increase in vivo bioactivity are not fully understood. Sintered granules of HA and carbonate-substituted hydroxyapatite (CHA) were implanted for 6 and 12 weeks in an ovine model. Samples containing the bone-implant interface were prepared for transmission electron microscopy (TEM) and TEM was used to compare the in vivo reactivity of sintered granules of HA and CHA. The current findings demonstrated that CHA (1.2 and 2.05 wt.%) is more soluble than pure HA in vivo. More dissolution was observed from the CHA, at the bone-implant interface and within the implant, when compared to pure HA. A less crystalline phase was formed between the 2.05 wt.% CHA and bone at 12 weeks in vivo. Bone surrounding both the pure HA and 1.2 wt.% CHA was relatively disorganised at 12 weeks. In comparison, bone surrounding the 2.05 wt.% CHA was considerably more organised and in many regions collagen fibrils were present. Despite increased quality of bone surrounding 2.05 wt.% CHA, compared to 1.2 wt.% CHA, the amount of dissolution from both materials was similar.

Clinical, Histologic, and Histomorphometric Evaluation of Mineralized Solvent-dehydrated Bone Allograft (Puros) in Human Maxillary Sinus Grafts

Demineralized freeze-dried bone allografts (DFDBA) have been successfully used alone or in composite grafts for many decades. Little research has been done on the effect of retaining the mineral content of bone allografts. This study histologically and histomorphometrically evaluated a new mineralized bone allograft material placed in human atrophic maxillary sinuses. Seven partially edentulous patients requiring sinus grafts before implant placement were selected for this study Their age range was 56 to 81 years (mean 67.7 years). Test grafts consisted of a mineralized solvent-dehydrated cancellous bone allograft, and control grafts were a composite of DFDBA and deproteinized bovine bone xenograft (1:1). Bilateral cases (n = 3) received both test and control grafts on opposite sides, and unilateral cases received either a test (n = 3) or control (n = 1) graft only. At 10 months, core biopsies were taken from each graft site, and dental implants were placed into the augmented bone. All bone grafts resulted in new bone formation and all implants osseointegrated. Test grafts resorbed and were replaced by newly formed bone significantly faster and in greater quantities than were control grafts. No complications with grafts or implants were noted. Both test and control grafts achieved excellent results. The faster bone formation observed with the test graft may be due, in part, to its smaller particle size compared with the bovine portion of the control graft. Test grafts were either replaced by new bone or displayed new bone-to-particle surface contact in higher percentages than did control grafts. No differences in osseointegration or graft stability were noted 2 years after the study.

Mechanisms of action of demineralized bone matrix in the repair of cortical bone defects

Demineralized bone matrix commonly is used to enhance and to facilitate bone grafting after skeletal injury or disease; however, the biologic bases for its bone-inducing abilities remain obscure. We have taken advantage of a mouse model of cortical bone defect healing to elucidate its mechanisms of action in vivo. Demineralized bone matrix combined with hyaluronan improved skeletal healing by inducing early deposition of an osteoid matrix. Demineralized bone matrix combined with hyaluronan might accelerate bone formation because it serves as a scaffold on which osteoprogenitor cells attach. We tested this possibility by comparing demineralized bone matrix combined with hyaluronan with heat-inactivated demineralized bone matrix combined with hyaluronan and found that the intact material was superior in terms of its ability to stimulate new bone formation. We also compared the bone inducing capacity of demineralized bone matrix combined with hyaluronan with a synthetic collagen sponge and found that not only the synthetic collagen scaffold delayed bone healing but also impaired bony bridging at later stages of repair. Another important property of demineralized bone matrix combined with hyaluronan was its ability to become actively degraded by osteoclasts during healing. Therefore, demineralized bone matrix combined with hyaluronan may not only attract osteoblasts and stimulate their differentiation, but also induce bone matrix resorption, which is a critically important regulator of bone formation and mineralization.

A review of osteoinductive testing methods and sterilization processes for demineralized bone

Allogeneic demineralized bone has been used extensively as a clinical graft material because it has osteoinductive and osteoconductive properties. Concerns over processing and terminal sterilization procedures that may reduce performance have led clinicians to call for assurances of product potency. There is extensive experience on effects of demineralized bone in animal and cell culture models with the possibility for future evidence-based standards for release of products. Evaluation of the current state of knowledge leads to the fact that we cannot conclude that performance of different lots of demineralized bone allografts in in vivo or in vitro test systems can be used as a measure of clinical performance. It may be possible to adopt an osteoinductivity standard for release-to-market, but it should be followed by clinical monitoring and further research.

Demineralized bone alters expression of Wnt network components during chondroinduction of post-natal fibroblasts

OBJECTIVE

The Wnt family of secreted proteins, their receptors (Fzd proteins) and antagonists (secreted Fzd-related proteins, or Sfrp) regulate chondrocyte differentiation and chrondrogenesis during embryonic development. Here, the hypothesis that the Wnt regulatory network contributes to chondrocyte differentiation of post-natal cells was tested in an in vitro model of chondroinduction by demineralized bone powder (DBP).

DESIGN

Human dermal fibroblasts (hDFs) were cultured in porous, three-dimensional (3D) collagen sponges with or without chondroinductive DBP. In some experiments, lithium chloride (LiCl), an agonist of the Wnt/beta-catenin signaling pathway, was added to the culture media. Sponges were cultured for intervals (0.5-21 days) before processing for molecular, histologic, and biochemical analyses. Expression of wnt, fzd, and sfrp genes was characterized by semi-quantitative RT-PCR. Fibroblasts' contacts with DBP were documented by histology. Accumulation of proteoglycan in extracellular matrix was evaluated by histology (metachromasia in toluidine blue-stained sections) and quantitative immunoassay (chondroitin 4-sulfate ELISA).

RESULTS

Expression of 15 wnt, fzd, and sfrp family members was detected in hDFs by RT-PCR. A subset of those genes (wnt2b, wnt5b, wnt10b, fzd6, fzd7) showed altered expression in hDFs exposed to DBP for 3 days. wnt and fzd gene expression was not altered before hDFs contacted the DBP within the collagen sponge. Human DFs cultured in plain collagen sponges and treated with LiCl accumulated significantly more metachromatic matrix than NaCl-treated controls on day 10, and showed a trend towards increased matrix chondroitin-4 sulfate content.

CONCLUSIONS

These data suggest that changes in Wnt signaling contribute to chondroinduction of post-natal fibroblasts by DBP. This is the first evidence that Wnt components, which are essential regulators of pre-natal chondrocyte differentiation, may also influence post-natal chondrocyte differentiation induced by DBP.

Radiographic and histological study of perennial bone defect repair in rat calvaria after treatment with blocks of porous bovine organic graft material

Over the last few years, various bone graft materials of bovine origin to be used in oromaxillofacial surgeries have entered the market. In the present study, we determined the capacity of a block organic bone graft material (Gen-ox, Baumer SA, Brazil) prepared from bovine cancellous bone to promote the repair of critical size bone injuries in rat calvaria. A transosseous defect measuring approximately 8mm in diameter was performed with a surgical trephine in the parietal bone of 25 rats. In 15 animals, the defects were filled with a block of graft material measuring 8mm in diameter and soaked in the animal's own blood, and in the other 10 animals the defects were only filled with blood clots. The calvariae of rats receiving the material were collected 1, 3 and 6 months after surgery, and those of animals receiving the blood clots were collected immediately and 6 months after surgery. During surgery, the graft material was found to be of easy handling and to adapt perfectly to the receptor bed after soaking in blood. The results showed that, in most animals treated, the material was slowly resorbed and served as a space filling and maintenance material, favoring angiogenesis, cell migration and adhesion, and bone neoformation from the borders of the lesion. However, a foreign body-type granulomatous reaction, with the presence of numerous giant cells preventing local bone neoformation, was observed in two animals of the 1-month subgroup and in one animal of the 3-month subgroup. These cases were interpreted as resulting from the absence of demineralization and the lack of removal of potential antigen factors during production of the biomaterial. We conclude that, with improvement in the quality control of the material production, block organic bone matrix will become a good alternative for bone defect repair in the oromaxillofacial region due to its high osteoconductive capacity.

Lumbar Intervertebral Body Fusion Cages: Histological Evaluation of Clinically Failed Cages Retrieved from Humans

The purpose of this study is to investigate the diagnostic value of evoked spinal cord potentials (ESCPs) and choline acetyltransferase (CAT) activity during exploration of injuries to the brachial plexus. We assessed 25 spinal roots in 19 patients. The results of the two investigations were consistent in all except two roots. Although assessment of ESCPs is easy and quick, it mainly records the nerve potentials along the sensory pathway. Although measurement of CAT activity needs a specimen of the nerve and the availability of a radioisotope laboratory, it gives direct information regarding the motor function of ventral spinal roots. These two techniques should be complementary to each other in order to achieve a more accurate diagnosis.

Comparative evaluation of the osteoinductivity of two formulations of human demineralized bone matrix

In the United States, demineralized bone matrix (DBM) is considered a transplantable tissue and therefore is regulated primarily by the American Association of Tissue Banks. Even though DBM is not subjected to the same regulations relative to performance claims as medical devices are, one would expect different processing methods might yield DBM preparations of different osteoinductive potential. The purpose of this study was to use an established athymic rat model to compare the osteoinductive properties of two commercially available human DBMs prepared using different methods but having essentially identical product claims. Sixteen female athymic rats were used to test equivalent volumes of two lots each of Grafton Putty (Osteotech, Inc., Eatontown, NJ), Osteofil (Regeneration Technologies, Inc., Alachua, FL), and rat DBM. At 28 days after implantation, qualitative and semiquantitative microscopy showed no significant differences in bone formation between the two lots from each source, but rat DBM produced significantly more bone than Grafton, which produced significantly more bone than Osteofil. Our results suggest that methods of graft processing may represent a greater source of variability than do differences among individual donors. Whether these differences relate to methods of demineralization, carrier, dose of DBM per volume, or to some other factor remains to be determined.