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Moura D, Rohringer S, Ferreira HP, Pereira AT, Barrias CC, Magalhães FD, Bergmeister H, Gonçalves IC. Long-term in vivo degradation and biocompatibility of degradable pHEMA hydrogels containing graphene oxide. Acta Biomater 2024; 173:351-364. [PMID: 37984630 DOI: 10.1016/j.actbio.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/31/2023] [Accepted: 11/09/2023] [Indexed: 11/22/2023]
Abstract
Developing biocompatible, non-fouling and biodegradable hydrogels for blood-contacting devices remains a demanding challenge. Such materials should promote natural healing, prevent clotting, and undergo controlled degradation. This study evaluates the biocompatibility and biodegradation of degradable poly(2-hydroxyethyl methacrylate) (d-pHEMA) hydrogels with or without reinforcement with oxidized few-layer graphene (d-pHEMA/M5ox) in a long term implantation in rats, assessing non-desired side-effects (irritation, chronic toxicity, immune response). Subcutaneous implantation over 6 months revealed degradation of both hydrogels, despite slower for d-pHEMA/M5ox, with degradation products found in intracellular vesicles. No inflammation nor infection at implantation areas were observed, and no histopathological findings were detected in parenchymal organs. Immunohistochemistry confirmed d-pHEMA and d-pHEMA/M5ox highly anti-adhesiveness. Gene expression of macrophages markers revealed presence of both M1 and M2 macrophages at all timepoints. M1/M2 profile after 6 months reveals an anti-inflammatory environment, suggesting no chronic inflammation, as also demonstrated by cytokines (IL-α, TNF-α and IL-10) analysis. Overall, modification of pHEMA towards a degradable material was successfully achieved without evoking a loss of its inherent properties, specially its anti-adhesiveness and biocompatibility. Therefore, these hydrogels hold potential as blank-slate for further modifications that promote cellular adhesion/proliferation for tissue engineering applications, namely for designing blood contacting devices with different load bearing requirements. STATEMENT OF SIGNIFICANCE: Biocompatibility, tunable biodegradation kinetics, and suitable immune response with lack of chronic toxicity and irritation, are key features in degradable blood contact devices that demand long-term exposure. We herein evaluate the 6-month in vivo performance of a degradable and hemocompatible anti-adhesive hydrogel based in pHEMA, and its mechanically reinforced formulation with few-layer graphene oxide. This subcutaneous implantation in a rat model, shows gradual degradation with progressive changes in material morphology, and no evidence of local inflammation in surrounding tissue, neither signs of inflammation or adverse reactions in systemic organs, suggesting biocompatibility of degradation products. Such hydrogels exhibit great potential as a blank slate for tissue engineering applications, including for blood contact, where cues for specific cells can be incorporated.
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Affiliation(s)
- Duarte Moura
- INEB - Instituto de Engenharia Biomédica, Universidade do Porto, Rua Alfredo Allen, 208, Porto 4200-180, Portugal; i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Rua Alfredo Allen, 208, Porto 4200-180, Portugal; FEUP - Faculdade de Engenharia, Departamento de Engenharia Metalúrgica e de Materiais, Universidade do Porto, Rua Dr. Roberto Frias, Porto 4200-465, Portugal
| | - Sabrina Rohringer
- Center for Biomedical Research and Translational Surgery, Medical University of Vienna, Vienna, Austria
| | - Helena P Ferreira
- INEB - Instituto de Engenharia Biomédica, Universidade do Porto, Rua Alfredo Allen, 208, Porto 4200-180, Portugal; i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Rua Alfredo Allen, 208, Porto 4200-180, Portugal; ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto 4050-313, Portugal
| | - Andreia T Pereira
- INEB - Instituto de Engenharia Biomédica, Universidade do Porto, Rua Alfredo Allen, 208, Porto 4200-180, Portugal; i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Rua Alfredo Allen, 208, Porto 4200-180, Portugal
| | - Cristina C Barrias
- INEB - Instituto de Engenharia Biomédica, Universidade do Porto, Rua Alfredo Allen, 208, Porto 4200-180, Portugal; i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Rua Alfredo Allen, 208, Porto 4200-180, Portugal; ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto 4050-313, Portugal
| | - Fernão D Magalhães
- LEPABE - Laboratory for Process Engineering, Environment, Biotechnology and Energy, Faculty of Engineering, University of Porto, Rua Dr. Roberto Frias, Porto 4200-465, Portugal; ALiCE - Associate Laboratory in Chemical Engineering, Faculty of Engineering, University of Porto, Rua Dr. Roberto Frias, Porto 4200-465, Portugal
| | - Helga Bergmeister
- Center for Biomedical Research and Translational Surgery, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Cardiovascular Research, Austria
| | - Inês C Gonçalves
- INEB - Instituto de Engenharia Biomédica, Universidade do Porto, Rua Alfredo Allen, 208, Porto 4200-180, Portugal; i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Rua Alfredo Allen, 208, Porto 4200-180, Portugal.
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Chen R, Pye JS, Li J, Little CB, Li JJ. Multiphasic scaffolds for the repair of osteochondral defects: Outcomes of preclinical studies. Bioact Mater 2023; 27:505-545. [PMID: 37180643 PMCID: PMC10173014 DOI: 10.1016/j.bioactmat.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/18/2023] [Accepted: 04/17/2023] [Indexed: 05/16/2023] Open
Abstract
Osteochondral defects are caused by injury to both the articular cartilage and subchondral bone within skeletal joints. They can lead to irreversible joint damage and increase the risk of progression to osteoarthritis. Current treatments for osteochondral injuries are not curative and only target symptoms, highlighting the need for a tissue engineering solution. Scaffold-based approaches can be used to assist osteochondral tissue regeneration, where biomaterials tailored to the properties of cartilage and bone are used to restore the defect and minimise the risk of further joint degeneration. This review captures original research studies published since 2015, on multiphasic scaffolds used to treat osteochondral defects in animal models. These studies used an extensive range of biomaterials for scaffold fabrication, consisting mainly of natural and synthetic polymers. Different methods were used to create multiphasic scaffold designs, including by integrating or fabricating multiple layers, creating gradients, or through the addition of factors such as minerals, growth factors, and cells. The studies used a variety of animals to model osteochondral defects, where rabbits were the most commonly chosen and the vast majority of studies reported small rather than large animal models. The few available clinical studies reporting cell-free scaffolds have shown promising early-stage results in osteochondral repair, but long-term follow-up is necessary to demonstrate consistency in defect restoration. Overall, preclinical studies of multiphasic scaffolds show favourable results in simultaneously regenerating cartilage and bone in animal models of osteochondral defects, suggesting that biomaterials-based tissue engineering strategies may be a promising solution.
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Affiliation(s)
- Rouyan Chen
- Kolling Institute, Faculty of Medicine and Health, The University of Sydney, NSW, 2065, Australia
- School of Electrical and Mechanical Engineering, Faculty of Sciences, Engineering and Technology, The University of Adelaide, SA, 5005, Australia
| | - Jasmine Sarah Pye
- School of Biomedical Engineering, Faculty of Engineering and IT, University of Technology Sydney, NSW, 2007, Australia
| | - Jiarong Li
- Kolling Institute, Faculty of Medicine and Health, The University of Sydney, NSW, 2065, Australia
- School of Biomedical Engineering, Faculty of Engineering and IT, University of Technology Sydney, NSW, 2007, Australia
| | - Christopher B. Little
- Kolling Institute, Faculty of Medicine and Health, The University of Sydney, NSW, 2065, Australia
- Corresponding author. Raymond Purves Bone and Joint Research Lab, Kolling Institute, School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia.
| | - Jiao Jiao Li
- Kolling Institute, Faculty of Medicine and Health, The University of Sydney, NSW, 2065, Australia
- School of Biomedical Engineering, Faculty of Engineering and IT, University of Technology Sydney, NSW, 2007, Australia
- Corresponding author. School of Biomedical Engineering, Faculty of Engineering and IT, University of Technology Sydney, NSW, 2007, Australia.
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Hammad M, Veyssiere A, Leclercq S, Patron V, Baugé C, Boumédiene K. Hypoxia Differentially Affects Chondrogenic Differentiation of Progenitor Cells from Different Origins. Int J Stem Cells 2023; 16:304-314. [PMID: 37105555 PMCID: PMC10465331 DOI: 10.15283/ijsc21242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/16/2023] [Accepted: 02/19/2023] [Indexed: 04/29/2023] Open
Abstract
Background and Objectives Ear cartilage malformations are commonly encountered problems in reconstructive surgery, since cartilage has low self-regenerating capacity. Malformations that impose psychological and social burden on one's life are currently treated using ear prosthesis, synthetic implants or autologous flaps from rib cartilage. These approaches are challenging because not only they request high surgical expertise, but also they lack flexibility and induce severe donor-site morbidity. Through the last decade, tissue engineering gained attention where it aims at regenerating human tissues or organs in order to restore normal functions. This technique consists of three main elements, cells, growth factors, and above all, a scaffold that supports cells and guides their behavior. Several studies have investigated different scaffolds prepared from both synthetic or natural materials and their effects on cellular differentiation and behavior. Methods and Results In this study, we investigated a natural scaffold (alginate) as tridimensional hydrogel seeded with progenitors from different origins such as bone marrow, perichondrium and dental pulp. In contact with the scaffold, these cells remained viable and were able to differentiate into chondrocytes when cultured in vitro. Quantitative and qualitative results show the presence of different chondrogenic markers as well as elastic ones for the purpose of ear cartilage, upon different culture conditions. Conclusions We confirmed that auricular perichondrial cells outperform other cells to produce chondrogenic tissue in normal oxygen levels and we report for the first time the effect of hypoxia on these cells. Our results provide updates for cartilage engineering for future clinical applications.
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Affiliation(s)
- Mira Hammad
- Normandy University, UNICAEN, EA 7451 BioConnecT, Caen, France
- Fédération Hospitalo Universitaire SURFACE, Amiens, Caen, France
| | - Alexis Veyssiere
- Normandy University, UNICAEN, EA 7451 BioConnecT, Caen, France
- Fédération Hospitalo Universitaire SURFACE, Amiens, Caen, France
- Service de chirurgie Maxillo-faciale, CHU de Caen, Caen, France
| | - Sylvain Leclercq
- Normandy University, UNICAEN, EA 7451 BioConnecT, Caen, France
- Clinique Saint Martin, Service de Chirurgie Orthopédique, Caen, France
| | - Vincent Patron
- Normandy University, UNICAEN, EA 7451 BioConnecT, Caen, France
- Service ORL et chirurgie cervico-faciale, CHU de Caen, Caen, France
| | - Catherine Baugé
- Normandy University, UNICAEN, EA 7451 BioConnecT, Caen, France
- Fédération Hospitalo Universitaire SURFACE, Amiens, Caen, France
| | - Karim Boumédiene
- Normandy University, UNICAEN, EA 7451 BioConnecT, Caen, France
- Fédération Hospitalo Universitaire SURFACE, Amiens, Caen, France
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Vakil AU, Petryk NM, Du C, Howes B, Stinfort D, Serinelli S, Gitto L, Ramezani M, Beaman HT, Monroe MBB. In vitro and in vivo degradation correlations for polyurethane foams with tunable degradation rates. J Biomed Mater Res A 2023; 111:580-595. [PMID: 36752708 DOI: 10.1002/jbm.a.37504] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/19/2022] [Accepted: 01/13/2023] [Indexed: 02/09/2023]
Abstract
Polyurethane foams present a tunable biomaterial platform with potential for use in a range of regenerative medicine applications. Achieving a balance between scaffold degradation rates and tissue ingrowth is vital for successful wound healing, and significant in vivo testing is required to understand these processes. Vigorous in vitro testing can minimize the number of animals that are required to gather reliable data; however, it is difficult to accurately select in vitro degradation conditions that can effectively mimic in vivo results. To that end, we performed a comprehensive in vitro assessment of the degradation of porous shape memory polyurethane foams with tunable degradation rates using varying concentrations of hydrogen peroxide to identify the medium that closely mimics measured in vivo degradation rates. Material degradation was studied over 12 weeks in vitro in 1%, 2%, or 3% hydrogen peroxide and in vivo in subcutaneous pockets in Sprague Dawley rats. We found that the in vitro degradation conditions that best predicted in vivo degradation rates varied based on the number of mechanisms by which the polymer degraded and the polymer hydrophilicity. Namely, more hydrophilic materials that degrade by both hydrolysis and oxidation require lower concentrations of hydrogen peroxide (1%) to mimic in vivo rates, while more hydrophobic scaffolds that degrade by oxidation alone require higher concentrations of hydrogen peroxide (3%) to model in vivo degradation. This information can be used to rationally select in vitro degradation conditions that accurately identify in vivo degradation rates prior to characterization in an animal model.
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Affiliation(s)
- Anand Utpal Vakil
- Department of Biomedical and Chemical Engineering and BioInspired Syracuse, Institute for Material and Living Systems, Syracuse University, Syracuse, New York, USA
| | - Natalie Marie Petryk
- Department of Biomedical and Chemical Engineering and BioInspired Syracuse, Institute for Material and Living Systems, Syracuse University, Syracuse, New York, USA
| | - Changling Du
- Department of Biomedical and Chemical Engineering and BioInspired Syracuse, Institute for Material and Living Systems, Syracuse University, Syracuse, New York, USA
| | - Bryanna Howes
- Department of Chemistry, Le Moyne College, Syracuse, New York, USA
| | | | | | - Lorenzo Gitto
- SUNY Upstate Medical University, Syracuse, New York, USA
| | - Maryam Ramezani
- Department of Biomedical and Chemical Engineering and BioInspired Syracuse, Institute for Material and Living Systems, Syracuse University, Syracuse, New York, USA
| | - Henry T Beaman
- Department of Biomedical and Chemical Engineering and BioInspired Syracuse, Institute for Material and Living Systems, Syracuse University, Syracuse, New York, USA
| | - Mary Beth Browning Monroe
- Department of Biomedical and Chemical Engineering and BioInspired Syracuse, Institute for Material and Living Systems, Syracuse University, Syracuse, New York, USA
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Zhang J, Huang Y, Wang Y, Xu J, Huang T, Luo X. Construction of biomimetic cell-sheet-engineered periosteum with a double cell sheet to repair calvarial defects of rats. J Orthop Translat 2022; 38:1-11. [PMID: 36313975 PMCID: PMC9582589 DOI: 10.1016/j.jot.2022.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 08/31/2022] [Accepted: 09/09/2022] [Indexed: 11/06/2022] Open
Abstract
Background The periosteum plays a crucial role in the development and injury healing process of bone. The purpose of this study was to construct a biomimetic periosteum with a double cell sheet for bone tissue regeneration. Methods In vitro, the human amniotic mesenchymal stem cells (hAMSCs) sheet was first fabricated by adding 50 μg/ml ascorbic acid to the cell sheet induction medium. Characterization of the hAMSCs sheet was tested by general observation, microscopic observation, live/dead staining, scanning electron microscopy (SEM) and hematoxylin and eosin (HE) staining. Afterwards, the osteogenic cell sheet and vascular cell sheet were constructed and evaluated by general observation, alkaline phosphatase (ALP) staining, Alizarin Red S staining, SEM, live/dead staining and CD31 immunofluorescent staining for characterization. Then, we prepared the double cell sheet. In vivo, rat calvarial defect model was introduced to verify the regeneration of bone defects treated by different methods. Calvarial defects (diameter: 4 mm) were created of Sprague–Dawley rats. The rats were randomly divided into 4 groups: the control group, the osteogenic cell sheet group, the vascular cell sheet group and the double cell sheet group. Macroscopic, micro-CT and histological evaluations of the regenerated bone were performed to assess the treatment results at 8 weeks and 12 weeks after surgery. Results In vitro, hAMSCs sheet was successfully prepared. The hAMSCs sheet consisted of a large number of live hAMSCs and abundant extracellular matrix (ECM) that secreted by hAMSCs, as evidenced by macroscopic/microscopic observation, live/dead staining, SEM and HE staining. Besides, the osteogenic cell sheet and the vascular cell sheet were successfully prepared, which were verified by general observation, ALP staining, Alizarin Red S staining, SEM and CD31 immunofluorescent staining. In vivo, the macroscopic observation and micro-CT results both demonstrated that the double cell sheet group had better effect on bone regeneration than other groups. In addition, histological assessments indicated that large amounts of new bone had formed in the calvarial defects and more mature collagen in the double cell sheet group. Conclusion The double cell sheet could promote to repair calvarial defects of rats and accelerate bone regeneration. The translational potential of this article We successfully constructed a biomimetic cell-sheet-engineered periosteum with a double cell sheet by a simple, low-cost and effective method. This biomimetic periosteum may be a promising therapeutic strategy for the treatment of bone defects, which may be used in clinic in the future.
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Key Words
- Biomimetic periosteum
- Bone regeneration
- Double cell sheet
- Osteogenic cell sheet
- Trabecular number, Tb.N
- Trabecular thickness, Tb.Th
- Vascular cell sheet
- adiposetissue derivedstromalcells, ADSCs
- alkaline phosphatase, ALP
- bone mineral density, BMD
- bonemarrowmesenchymlstemcells, BMSCs
- bonevolume fraction, BV/TV
- cell sheet technology, CST
- cytokeratin 19, CK-19
- extracellular matrix, ECM
- hAMSCs sheet
- hematoxylin and eosin, HE
- human amniotic mesenchymal stem cells, hAMSCs
- human ethmoid sinus mucosa derived mesenchymal stem cells, hESMSCs
- periodontal ligament-derived cells, PDLCs
- polylactic-co-glycolic acid, PLGA
- scanning electron microscopy, SEM
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A review of composition‐structure‐function properties and tissue engineering strategies of articular cartilage: compare condyle process and knee‐joint. ADVANCED ENGINEERING MATERIALS 2022. [DOI: 10.1002/adem.202200304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Seon GM, Lee MH, Koo MA, Hong SH, Park YJ, Jeong HK, Park JC. A collagen-AS/εPLL bilayered artificial substitute regulates anti-inflammation and infection for initial inflamed wound healing. Biomater Sci 2021; 9:6865-6878. [PMID: 34494620 DOI: 10.1039/d1bm01071a] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Despite the development of advanced tissue engineering substitutes, inflammation is still a significant problem that can arise from inflamed burn injuries, chronic wounds, or microbial diseases. Although topical wound dressing accelerates healing by minimizing or preventing the consequences of skin inflammation, there remains a need for the development of a novel substitute scaffold that can effectively eliminate immoderate inflammation and infection in the initial phase of the healing meachanism. In this study, an artificial skin substitute scaffold fabricated with asiaticoside (AS) and epsilon-poly-L-lysine (εPLL) was prepared. Upon the release of these bioactive compounds, they accelerate wound healing and inhibit any bacterial infection at the wound site. We determined whether AS and εPLL exhibit anti-inflammatory and bactericidal effects through different mechanisms. Collectively, the collagen-AS/εPLL artificial skin substitute could be a significant therapeutic agent for scar-less rapid wound healing (without infection and inflammation) of initially-inflamed full-thickness wounds.
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Affiliation(s)
- Gyeung Mi Seon
- Cellbiocontrol Laboratory, Department of Medical Engineering, Yonsei University College of Medicine, Seoul 03722, Republic of Korea.
| | - Mi Hee Lee
- Cellbiocontrol Laboratory, Department of Medical Engineering, Yonsei University College of Medicine, Seoul 03722, Republic of Korea.
| | - Min-Ah Koo
- Cellbiocontrol Laboratory, Department of Medical Engineering, Yonsei University College of Medicine, Seoul 03722, Republic of Korea. .,Department of Medical Engineering, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Seung Hee Hong
- Cellbiocontrol Laboratory, Department of Medical Engineering, Yonsei University College of Medicine, Seoul 03722, Republic of Korea. .,Department of Medical Engineering, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Ye Jin Park
- Cellbiocontrol Laboratory, Department of Medical Engineering, Yonsei University College of Medicine, Seoul 03722, Republic of Korea.
| | - Ha Kyeong Jeong
- Cellbiocontrol Laboratory, Department of Medical Engineering, Yonsei University College of Medicine, Seoul 03722, Republic of Korea.
| | - Jong-Chul Park
- Cellbiocontrol Laboratory, Department of Medical Engineering, Yonsei University College of Medicine, Seoul 03722, Republic of Korea. .,Department of Medical Engineering, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
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Ângelo DF, Wang Y, Morouço P, Monje F, Mónico L, González-Garcia R, Moura C, Alves N, Sanz D, Gao J, Sousa R, Neto L, Faísca P, Salvado F, López Peña M, Permuy M, Munñoz F. A randomized controlled preclinical trial on 3 interposal temporomandibular joint disc implants: TEMPOJIMS-Phase 2. J Tissue Eng Regen Med 2021; 15:852-868. [PMID: 34323386 DOI: 10.1002/term.3230] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 05/31/2021] [Accepted: 07/22/2021] [Indexed: 01/03/2023]
Abstract
The effort to develop an effective and safe temporomandibular joint (TMJ) disc substitute has been one of the mainstreams of tissue engineering. Biodegradable customized scaffolds could approach safety and effectiveness to regenerate a new autologous disc, rather than using non-biodegradable materials. However, it is still technically challenging to mimic the biomechanical properties of the native disc with biodegradable polymers. In this study, new 3D tailored TMJ disc implants were developed: (1) Poly(glycerol sebacate) (PGS) scaffold reinforced with electrospun Poly(εcaprolactone) (PCL) fibers on the outer surface (PGS+PCL); (2) PCL and polyethylene glycol diacrylate (PEGDA) (PCL+PEGDA); and (3) PCL. The TMJ implants were tested in a randomized preclinical trial, conducted in 24 black Merino sheep TMJ, perfoming bilateral interventions. Histologic, imaging, and kinematics analysis was performed. No statistical changes were observed between the PGS+PCL disc and the control group. The PCL+PEGDA and PCL groups were associated with statistical changes in histology (p = 0.004 for articular cartilage mid-layer; p = 0.019 for structure changes and p = 0.017 for cell shape changes), imaging (p = 0.027 for global appreciation) and dangerous material fragmentation was observed. No biomaterial particles were observed in the multi-organ analysis in the different groups. The sheep confirmed to be a relevant animal model for TMJ disc surgery and regenerative approaches. The PCL and PCL+PEGDA discs presented a higher risk to increase degenerative changes, due to material fragmentation. None of the tested discs regenerate a new autologous disc, however, PGS+PCL was safe, demonstrated rapid resorption, and was capable to prevent condyle degenerative changes.
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Affiliation(s)
- David Faustino Ângelo
- Instituto Português da Face, Lisboa, Portugal.,Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal.,Centre for Rapid and Sustainable Product Development, Polytechnic Institute of Leiria, Leiria, Portugal
| | | | | | - Florencio Monje
- Complejo Hospitalario Universitario de Badajoz, Badajoz, Spain
| | | | | | - Carla Moura
- Centre for Rapid and Sustainable Product Development, Polytechnic Institute of Leiria, Leiria, Portugal
| | - Nuno Alves
- Centre for Rapid and Sustainable Product Development, Polytechnic Institute of Leiria, Leiria, Portugal
| | - David Sanz
- Instituto Português da Face, Lisboa, Portugal
| | - Jin Gao
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rita Sousa
- Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Lia Neto
- Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Pedro Faísca
- Gulbenkian Institute of Science, Oeiras, Portugal
| | | | | | - Maria Permuy
- University of Santiago de Compostela-Lugo Campus, Lugo, Spain
| | - Fernando Munñoz
- University of Santiago de Compostela-Lugo Campus, Lugo, Spain
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Zurina IM, Presniakova VS, Butnaru DV, Svistunov AA, Timashev PS, Rochev YA. Tissue engineering using a combined cell sheet technology and scaffolding approach. Acta Biomater 2020; 113:63-83. [PMID: 32561471 DOI: 10.1016/j.actbio.2020.06.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 06/08/2020] [Accepted: 06/10/2020] [Indexed: 12/13/2022]
Abstract
Cell sheet technology has remained quite popular among tissue engineering techniques over the last several years. Meanwhile, there is an apparent trend in modern scientific research towards combining different approaches and strategies. Accordingly, a large body of work has arisen where cell sheets are used not as separate structures, but in combination with scaffolds as supporting constructions. The aim of this review is to analyze the intersection of these two vast areas of tissue engineering described in the literature mainly within the last five years. Some practical and technical details are emphasized to provide information that can be useful in research design and planning. The first part of the paper describes the general issues concerning the use of combined technology, its advantages and limitations in comparison with those of other tissue engineering approaches. Next, the detailed literature analysis of in vivo studies aimed at the regeneration of different tissues is performed. A significant part of this section concerns bone regeneration. In addition to that, other connective tissue structures, including articular cartilage and fibrocartilage, ligaments and tendons, and some soft tissues are discussed. STATEMENT OF SIGNIFICANCE: This paper describes the intersection of two technologies used in designing of tissue-engineered constructions for regenerative medicine: cell sheets as extracellular matrix-rich structures and supporting scaffolds as essentials in tissue engineering. A large number of reviews are devoted to each of these scientific problems. However, the solution of complex problems of tissue engineering requires an integrated approach that includes both three-dimensional scaffolds and cell sheets. This manuscript serves as a description of advantages and limitations of this method, its use in regeneration of bones, connective tissues and soft tissues and some other details.
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Affiliation(s)
- Irina M Zurina
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), 119991 8-2 Trubetskaya St., Moscow, Russia; FSBSI Institute of General Pathology and Pathophysiology, 125315, 8 Baltiyskaya St., Moscow, Russia; FSBEI FPE "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of Russia, 125993, 2/1-1 Barrikadnaya St., Moscow, Russia
| | - Viktoria S Presniakova
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), 119991 8-2 Trubetskaya St., Moscow, Russia
| | - Denis V Butnaru
- Sechenov First Moscow State Medical University (Sechenov University), 119991, 8-2 Trubetskaya St., Moscow, Russia
| | - Andrey A Svistunov
- Sechenov First Moscow State Medical University (Sechenov University), 119991, 8-2 Trubetskaya St., Moscow, Russia
| | - Peter S Timashev
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), 119991 8-2 Trubetskaya St., Moscow, Russia; Institute of Photonic Technologies, Research Center "Crystallography and Photonics", Russian Academy of Sciences, 108840, 2 Pionerskaya st., Troitsk, Moscow, Russia; Department of Polymers and Composites, N.N. Semenov Institute of Chemical Physics, 119991 4 Kosygin st., Moscow, Russia; Chemistry Department, Lomonosov Moscow State University, Leninskiye Gory 1‑3, Moscow 119991, Russia.
| | - Yury A Rochev
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), 119991 8-2 Trubetskaya St., Moscow, Russia; Centre for Research in Medical Devices (CÚRAM), National University of Ireland Galway, Galway H91 W2TY, Ireland
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Niermeyer WL, Rodman C, Li MM, Chiang T. Tissue engineering applications in otolaryngology-The state of translation. Laryngoscope Investig Otolaryngol 2020; 5:630-648. [PMID: 32864434 PMCID: PMC7444782 DOI: 10.1002/lio2.416] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/06/2020] [Accepted: 05/11/2020] [Indexed: 12/14/2022] Open
Abstract
While tissue engineering holds significant potential to address current limitations in reconstructive surgery of the head and neck, few constructs have made their way into routine clinical use. In this review, we aim to appraise the state of head and neck tissue engineering over the past five years, with a specific focus on otologic, nasal, craniofacial bone, and laryngotracheal applications. A comprehensive scoping search of the PubMed database was performed and over 2000 article hits were returned with 290 articles included in the final review. These publications have addressed the hallmark characteristics of tissue engineering (cellular source, scaffold, and growth signaling) for head and neck anatomical sites. While there have been promising reports of effective tissue engineered interventions in small groups of human patients, the majority of research remains constrained to in vitro and in vivo studies aimed at furthering the understanding of the biological processes involved in tissue engineering. Further, differences in functional and cosmetic properties of the ear, nose, airway, and craniofacial bone affect the emphasis of investigation at each site. While otolaryngologists currently play a role in tissue engineering translational research, continued multidisciplinary efforts will likely be required to push the state of translation towards tissue-engineered constructs available for routine clinical use. LEVEL OF EVIDENCE NA.
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Affiliation(s)
| | - Cole Rodman
- The Ohio State University College of MedicineColumbusOhioUSA
| | - Michael M. Li
- Department of Otolaryngology—Head and Neck SurgeryThe Ohio State University Wexner Medical CenterColumbusOhioUSA
| | - Tendy Chiang
- Department of OtolaryngologyNationwide Children's HospitalColumbusOhioUSA
- Department of Otolaryngology—Head and Neck SurgeryThe Ohio State University Wexner Medical CenterColumbusOhioUSA
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11
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Helgeland E, Pedersen TO, Rashad A, Johannessen AC, Mustafa K, Rosén A. Angiostatin-functionalized collagen scaffolds suppress angiogenesis but do not induce chondrogenesis by mesenchymal stromal cells in vivo. J Oral Sci 2020; 62:371-376. [PMID: 32684573 DOI: 10.2334/josnusd.19-0327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Tissue engineering for fibrocartilage regeneration using mesenchymal stromal cells (MSC) and biomaterial scaffolds is emerging as a promising strategy, but inhibiting vascularization to prevent endochondral ossification is important to develop stable implants. The objective of this study was to investigate the effect of angiostatin on inhibition of angiogenesis and promotion of chondrogenesis by collagen scaffolds with or without MSC implanted subcutaneously in rats. One scaffold from the following groups was implanted in each animal: Collagen scaffolds only, scaffolds functionalized with angiostatin, scaffolds loaded with MSC and scaffolds functionalized with angiostatin and loaded with MSC. The various scaffolds were harvested after 2 and 8 weeks for histological analysis, Real-time quantitative polymerase chain reaction (RT-qPCR) and immunofluorescence quantification. Results demonstrated significantly decreased expression of inflammatory (interleukin 1 alpha and beta) and angiogenic genes (platelet and endothelial cell adhesion molecule 1) in scaffolds functionalized with angiostatin after 2 weeks in vivo. Histologically, after 8 weeks, the scaffolds with angiostatin had less inflammatory cells and more collagen matrix formation, but no fibrocartilage formation was detected. Thus, although angiostatin suppressed angiogenesis, it did not stimulate ectopic chondrogenesis in tissue engineered constructs in vivo.
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Affiliation(s)
| | - Torbjørn O Pedersen
- Department of Clinical Dentistry, University of Bergen.,Department of Oral and Maxillofacial Surgery, University of Bergen and Haukeland University Hospital
| | - Ahmad Rashad
- Department of Clinical Dentistry, University of Bergen
| | - Anne C Johannessen
- Gade Laboratory for Pathology, Department of Clinical Medicine, University of Bergen.,Department of Pathology, Haukeland University Hospital
| | - Kamal Mustafa
- Department of Clinical Dentistry, University of Bergen
| | - Annika Rosén
- Department of Clinical Dentistry, University of Bergen.,Department of Oral and Maxillofacial Surgery, University of Bergen and Haukeland University Hospital
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12
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Glycosaminoglycan-based hydrogels with programmable host reactions. Biomaterials 2020; 228:119557. [DOI: 10.1016/j.biomaterials.2019.119557] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/06/2019] [Accepted: 10/15/2019] [Indexed: 12/16/2022]
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13
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Lu Y, Zhang W, Wang J, Yang G, Yin S, Tang T, Yu C, Jiang X. Recent advances in cell sheet technology for bone and cartilage regeneration: from preparation to application. Int J Oral Sci 2019; 11:17. [PMID: 31110170 PMCID: PMC6527566 DOI: 10.1038/s41368-019-0050-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/08/2019] [Accepted: 04/10/2019] [Indexed: 12/19/2022] Open
Abstract
Bone defects caused by trauma, tumour resection, infection and congenital deformities, together with articular cartilage defects and cartilage-subchondral bone complex defects caused by trauma and degenerative diseases, remain great challenges for clinicians. Novel strategies utilising cell sheet technology to enhance bone and cartilage regeneration are being developed. The cell sheet technology has shown great clinical potential in regenerative medicine due to its effective preservation of cell-cell connections and extracellular matrix and its scaffold-free nature. This review will first introduce several widely used cell sheet preparation systems, including traditional approaches and recent improvements, as well as their advantages and shortcomings. Recent advances in utilising cell sheet technology to regenerate bone or cartilage defects and bone-cartilage complex defects will be reviewed. The key challenges and future research directions for the application of cell sheet technology in bone and cartilage regeneration will also be discussed.
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Affiliation(s)
- Yuezhi Lu
- Department of Prosthodontics, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine; National Clinical Research Center for Oral Diseases; Shanghai Engineering Research Center of Advanced Dental Technology and Materials; Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, Shanghai, China
| | - Wenjie Zhang
- Department of Prosthodontics, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine; National Clinical Research Center for Oral Diseases; Shanghai Engineering Research Center of Advanced Dental Technology and Materials; Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, Shanghai, China
| | - Jie Wang
- Department of Prosthodontics, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine; National Clinical Research Center for Oral Diseases; Shanghai Engineering Research Center of Advanced Dental Technology and Materials; Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, Shanghai, China
| | - Guangzheng Yang
- Department of Prosthodontics, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine; National Clinical Research Center for Oral Diseases; Shanghai Engineering Research Center of Advanced Dental Technology and Materials; Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, Shanghai, China
| | - Shi Yin
- Department of Prosthodontics, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine; National Clinical Research Center for Oral Diseases; Shanghai Engineering Research Center of Advanced Dental Technology and Materials; Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, Shanghai, China
| | - Tingting Tang
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chunhua Yu
- Department of Prosthodontics, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine; National Clinical Research Center for Oral Diseases; Shanghai Engineering Research Center of Advanced Dental Technology and Materials; Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, Shanghai, China.
| | - Xinquan Jiang
- Department of Prosthodontics, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine; National Clinical Research Center for Oral Diseases; Shanghai Engineering Research Center of Advanced Dental Technology and Materials; Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, Shanghai, China.
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14
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Acri TM, Shin K, Seol D, Laird NZ, Song I, Geary SM, Chakka JL, Martin JA, Salem AK. Tissue Engineering for the Temporomandibular Joint. Adv Healthc Mater 2019; 8:e1801236. [PMID: 30556348 DOI: 10.1002/adhm.201801236] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/17/2018] [Indexed: 12/24/2022]
Abstract
Tissue engineering potentially offers new treatments for disorders of the temporomandibular joint which frequently afflict patients. Damage or disease in this area adversely affects masticatory function and speaking, reducing patients' quality of life. Effective treatment options for patients suffering from severe temporomandibular joint disorders are in high demand because surgical options are restricted to removal of damaged tissue or complete replacement of the joint with prosthetics. Tissue engineering approaches for the temporomandibular joint are a promising alternative to the limited clinical treatment options. However, tissue engineering is still a developing field and only in its formative years for the temporomandibular joint. This review outlines the anatomical and physiological characteristics of the temporomandibular joint, clinical management of temporomandibular joint disorder, and current perspectives in the tissue engineering approach for the temporomandibular joint disorder. The tissue engineering perspectives have been categorized according to the primary structures of the temporomandibular joint: the disc, the mandibular condyle, and the glenoid fossa. In each section, contemporary approaches in cellularization, growth factor selection, and scaffold fabrication strategies are reviewed in detail along with their achievements and challenges.
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Affiliation(s)
- Timothy M. Acri
- Department of Pharmaceutical Sciences and Experimental Therapeutics; College of Pharmacy; University of Iowa; Iowa City, Iowa 52242 USA
| | - Kyungsup Shin
- Department of Orthodontics; College of Dentistry and Dental Clinics; University of Iowa; Iowa City, Iowa 52242 USA
| | - Dongrim Seol
- Department of Orthopedics and Rehabilitation; Carver College of Medicine; University of Iowa; Iowa City, Iowa 52242 USA
| | - Noah Z. Laird
- Department of Pharmaceutical Sciences and Experimental Therapeutics; College of Pharmacy; University of Iowa; Iowa City, Iowa 52242 USA
| | - Ino Song
- Department of Orthopedics and Rehabilitation; Carver College of Medicine; University of Iowa; Iowa City, Iowa 52242 USA
| | - Sean M. Geary
- Department of Pharmaceutical Sciences and Experimental Therapeutics; College of Pharmacy; University of Iowa; Iowa City, Iowa 52242 USA
| | - Jaidev L. Chakka
- Department of Pharmaceutical Sciences and Experimental Therapeutics; College of Pharmacy; University of Iowa; Iowa City, Iowa 52242 USA
| | - James A. Martin
- Department of Orthopedics and Rehabilitation; Carver College of Medicine; University of Iowa; Iowa City, Iowa 52242 USA
| | - Aliasger K. Salem
- Department of Pharmaceutical Sciences and Experimental Therapeutics; College of Pharmacy; University of Iowa; Iowa City, Iowa 52242 USA
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15
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Khorramirouz R, Go JL, Noble C, Jana S, Maxson E, Lerman A, Young MD. A novel surgical technique for a rat subcutaneous implantation of a tissue engineered scaffold. Acta Histochem 2018. [PMID: 29519681 PMCID: PMC5914524 DOI: 10.1016/j.acthis.2018.02.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objectives Subcutaneous implantations in small animal models are currently required for preclinical studies of acellular tissue to evaluate biocompatibility, including host recellularization and immunogenic reactivity. Methods Three rat subcutaneous implantation methods were evaluated in six Sprague Dawley rats. An acellular xenograft made from porcine pericardium was used as the tissue-scaffold. Three implantation methods were performed; 1) Suture method is where a tissue-scaffold was implanted by suturing its border to the external oblique muscle, 2) Control method is where a tissue-scaffold was implanted without any suturing or support, 3) Frame method is where a tissue-scaffold was attached to a circular frame composed of polycaprolactone (PCL) biomaterial and placed subcutaneously. After 1 and 4 weeks, tissue-scaffolds were explanted and evaluated by hematoxylin and eosin (H&E), Masson’s trichrome, Picrosirius Red, transmission electron microscopy (TEM), immunohistochemistry, and mechanical testing. Results Macroscopically, tissue-scaffold degradation with the suture method and tissue-scaffold folding with the control method were observed after 4 weeks. In comparison, the frame method demonstrated intact tissue scaffolds after 4 weeks. H&E staining showed progressive cell repopulation over the course of the experiment in all groups with acute and chronic inflammation observed in suture and control methods throughout the duration of the study. Immunohistochemistry quantification of CD3, CD 31, CD 34, CD 163, and αSMA showed a statistically significant differences between the suture, control and frame methods (P < 0.05) at both time points. The average tensile strength was 4.03 ± 0.49, 7.45 ± 0.49 and 5.72 ± 1.34 (MPa) after 1 week and 0.55 ± 0.26, 0.12 ± 0.03 and 0.41 ± 0.32 (MPa) after 4 weeks in the suture, control, and frame methods; respectively. TEM analysis showed an increase in inflammatory cells in both suture and control methods following implantation. Conclusion Rat subcutaneous implantation with the frame method was performed with success and ease. The surgical approach used for the frame technique was found to be the best methodology for in vivo evaluation of tissue engineered acellular scaffolds, where the frame method did not compromise mechanical strength, but it reduced inflammation significantly.
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16
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Helgeland E, Shanbhag S, Pedersen TO, Mustafa K, Rosén A. Scaffold-Based Temporomandibular Joint Tissue Regeneration in Experimental Animal Models: A Systematic Review. TISSUE ENGINEERING PART B-REVIEWS 2018; 24:300-316. [PMID: 29400140 DOI: 10.1089/ten.teb.2017.0429] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Reconstruction of degenerated temporomandibular joint (TMJ) structures remains a clinical challenge. Tissue engineering (TE) is a promising alternative to current treatment options, where the TMJ is either left without functional components, or replaced with autogenous, allogeneic, or synthetic grafts. The objective of this systematic review was to answer the focused question: in experimental animal models, does the implantation of biomaterial scaffolds loaded with cells and/or growth factors (GFs) enhance regeneration of the discal or osteochondral TMJ tissues, compared with scaffolds alone, without cells, or GFs? Following PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) guidelines, electronic databases were searched for relevant controlled preclinical in vivo studies. Thirty studies reporting TMJ TE strategies in both small (rodents, rabbits; n = 25) and large animals (dogs, sheep, goats; n = 5) reporting histological and/or radiographic outcomes were included. Twelve studies reported ectopic (subcutaneous) implantation models in rodents, whereas 18 studies reported orthotopic, surgically induced defect models in large animals. On average, studies presented with an unclear-to-high risk of bias. In most studies, mesenchymal stem cells or chondrocytes were used in combination with either natural or synthetic polymer scaffolds, aiming for either TMJ disc or condyle regeneration. In summary, the overall preclinical evidence (ectopic [n = 6] and orthotopic TMJ models [n = 6]) indicate that addition of chondrogenic and/or osteogenic cells to biomaterial scaffolds enhances the potential for TMJ tissue regeneration. Standardization of animal models and quantitative outcome evaluations (biomechanical, biochemical, histomorphometric, and radiographic) in future studies, would allow more reliable comparisons and increase the validity of the results.
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Affiliation(s)
- Espen Helgeland
- 1 Department of Clinical Dentistry, Center for Clinical Dental Research, University of Bergen , Bergen, Norway
| | - Siddharth Shanbhag
- 1 Department of Clinical Dentistry, Center for Clinical Dental Research, University of Bergen , Bergen, Norway
| | - Torbjørn Ostvik Pedersen
- 1 Department of Clinical Dentistry, Center for Clinical Dental Research, University of Bergen , Bergen, Norway .,2 Department of Oral and Maxillofacial Surgery, University of Bergen and Haukeland University Hospital , Bergen, Norway
| | - Kamal Mustafa
- 1 Department of Clinical Dentistry, Center for Clinical Dental Research, University of Bergen , Bergen, Norway
| | - Annika Rosén
- 1 Department of Clinical Dentistry, Center for Clinical Dental Research, University of Bergen , Bergen, Norway .,2 Department of Oral and Maxillofacial Surgery, University of Bergen and Haukeland University Hospital , Bergen, Norway
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