Toward stronger robocast calcium phosphate scaffolds for bone tissue engineering: A mini-review and meta-analysis

Influence of physicochemical characteristics of calcium phosphate-based biomaterials in cranio-maxillofacial bone regeneration. A systematic literature review and meta-analysis of preclinical models

Objectives

Calcium phosphate-based biomaterials (CaP) are the most widely used biomaterials to enhance bone regeneration in the treatment of alveolar bone deficiencies, cranio-maxillofacial and periodontal infrabony defects, with positive preclinical and clinical results reported. This systematic review aimed to assess the influence of the physicochemical properties of CaP biomaterials on the performance of bone regeneration in preclinical animal models.

Methods

The PubMed, EMBASE and Web of Science databases were searched to retrieve the preclinical studies investigating physicochemical characteristics of CaP biomaterials. The studies were screened for inclusion based on intervention (physicochemical characterization and in vivo evaluation) and reported measurable outcomes.

Results

A total of 1532 articles were retrieved and 58 studies were ultimately included in the systematic review. A wide range of physicochemical characteristics of CaP biomaterials was found to be assessed in the included studies. Despite a high degree of heterogeneity, the meta-analysis was performed on 39 studies and evidenced significant effects of biomaterial characteristics on their bone regeneration outcomes. The study specifically showed that macropore size, Ca/P ratio, and compressive strength exerted significant influence on the formation of newly regenerated bone. Moreover, factors such as particle size, Ca/P ratio, and surface area were found to impact bone-to-material contact during the regeneration process. In terms of biodegradability, the amount of residual graft was determined by macropore size, particle size, and compressive strength.

Conclusion

The systematic review showed that the physicochemical characteristics of CaP biomaterials are highly determining for scaffold's performance, emphasizing its usefulness in designing the next generation of bone scaffolds to target higher rates of regeneration.

3D printable strong and tough composite organo-hydrogels inspired by natural hierarchical composite design principles

Fabrication of composite hydrogels can effectively enhance the mechanical and functional properties of conventional hydrogels. While ceramic reinforcement is common in many hard biological tissues, ceramic-reinforced hydrogels lack a similar natural prototype for bioinspiration. This raises a key question: How can we still attain bioinspired mechanical mechanisms in composite hydrogels without mimicking a specific composition and structure? Abstracting the hierarchical composite design principles of natural materials, this study proposes a hierarchical fabrication strategy for ceramic-reinforced organo-hydrogels, featuring (1) aligned ceramic platelets through direct-ink-write printing, (2) poly(vinyl alcohol) organo-hydrogel matrix reinforced by solution substitution, and (3) silane-treated platelet-matrix interfaces. Unit filaments are further printed into a selection of bioinspired macro-architectures, leading to high stiffness, strength, and toughness (fracture energy up to 31.1 kJ/m2), achieved through synergistic multi-scale energy dissipation. The materials also exhibit wide operation tolerance and electrical conductivity for flexible electronics in mechanically demanding conditions. Hence, this study demonstrates a model strategy that extends the fundamental design principles of natural materials to fabricate composite hydrogels with synergistic mechanical and functional enhancement.

Toughening 3D printed biomimetic hydroxyapatite scaffolds: Polycaprolactone-based self-hardening inks

The application of 3D printing to calcium phosphates has opened unprecedented possibilities for the fabrication of personalized bone grafts. However, their biocompatibility and bioactivity are counterbalanced by their high brittleness. In this work we aim at overcoming this problem by developing a self-hardening ink containing reactive ceramic particles in a polycaprolactone solution instead of the traditional approach that use hydrogels as binders. The presence of polycaprolactone preserved the printability of the ink and was compatible with the hydrolysis-based hardening process, despite the absence of water in the ink and its hydrophobicity. The microstructure evolved from a continuous polymeric phase with loose ceramic particles to a continuous network of hydroxyapatite nanocrystals intertwined with the polymer, in a configuration radically different from the polymer/ceramic composites obtained by fused deposition modelling. This resulted in the evolution from a ductile behavior, dominated by the polymer, to a stiffer behavior as the ceramic phase reacted. The polycaprolactone binder provides two highly relevant benefits compared to hydrogel-based inks. First, the handleability and elasticity of the as-printed scaffolds, together with the proven possibility of eliminating the solvent, opens the door to implanting the scaffolds freshly printed once lyophilized, while in a ductile state, and the hardening process to take place inside the body, as in the case of calcium phosphate cements. Second, even with a hydroxyapatite content of more than 92 wt.%, the flexural strength and toughness of the scaffolds after hardening are twice and five times those of the all-ceramic scaffolds obtained with the hydrogel-based inks, respectively. STATEMENT OF SIGNIFICANCE: Overcoming the brittleness of ceramic scaffolds would extend the applicability of synthetic bone grafts to high load-bearing situations. In this work we developed a 3D printing ink by replacing the conventional hydrogel binder with a water-free polycaprolactone solution. The presence of polycaprolactone not only enhanced significantly the strength and toughness of the scaffolds while keeping the proportion of bioactive ceramic phase larger than 90 wt.%, but it also conferred flexibility and manipulability to the as-printed scaffolds. Since they are able to harden upon contact with water under physiological conditions, this opens up the possibility of implanting them immediately after printing, while they are still in a ductile state, with clear advantages for fixation and press-fit in the bone defect.

Physiologically engineered porous titanium/brushite scaffolds for critical-size bone defects: A design and manufacturing study

Repairing critical-size bone defects still represents a critical clinical challenge in the field of trauma surgery. This study focuses on a physiological design and manufacturing of porous composite scaffold (titanium Ti with 10 % mole iron doped brushite DCPD-Fe3+) which can mimic the biomechanical properties of natural cortical bone, specifically for the purpose of repairing critical-size defects. To achieve this, the principle of design of experiments (DOE) was applied for investigating the impact of sintering temperature, mineral ratio, and volume fraction of porosity on the mechanical properties of the fabricated scaffolds. The fabricated scaffolds had open porosity up to 60 %, with pore size approximately between 100 μm and 850 μm. The stiffness of the porous composite scaffolds varied between 3.30 GPa and 20.50 GPa, while the compressive strength ranged from approximately 130 MPa-165 MPa at sintering temperatures equal to or exceeding 1000 °C. Scaffolds with higher porosity and mineral content demonstrated lower stiffness values, resembling natural bone. Numerical simulation was employed by Ansys Workbench to investigate the stress and strain distribution of a critical size defect in mid-shaft femur which was designed to be replaced with the fabricated scaffold. The fabricated scaffolds showed flexible biomechanical behaviour at the bone/scaffold interface, generating lower stress levels and indicating a better match with the femoral shaft stiffness. The experimental and numerical findings demonstrated promising applications for manufacturing a patient-specific bone scaffold for critical and potentially large defects for reducing stress shielding and minimizing non-union risk.

Bio-Physical Properties of Acetylated Chitosan/Poly(ɛ-Caprolactone) Composites for Three-Dimensional Printing Material Applications

For three-dimensional (3D) printing material applications in tissue engineering, acetylated chitosan (AC)/poly(ɛ-caprolactone) (PCL) composites were prepared by the melt mixing method using the acetylation of chitosan with PCL. The physiochemical properties of the AC/PCL composites were examined by measuring the water contact angles, dispersity of AC on the cross-section using scanning electron microscopy, and temperature stability. In addition, mechanical properties such as tensile strength and bending stress recovery were measured to determine the elasticity of the composite films. The fibroblast cell line NIH-3T3 was used to test the relative cell affinities based on the AC content and cell viability on AC/PCL at various temperatures. There was no difference between the melting points and tensile strengths of the AC/PCL composites and pure PCL. Overall, the AC/PCL composites showed high initial cell adhesion after 4 h of cell culture and increased cell proliferation compared to those of PCL composites used as a control. Based on these tests, an AC of 10.7 wt% was determined to be the optimal composition for the AC/PCL composite. Thus, these composites can be used in various 3D printing material applications in tissue engineering.

Composite PLGA–Nanobioceramic Coating on Moxifloxacin-Loaded Akermanite 3D Porous Scaffolds for Bone Tissue Regeneration

Silica-based ceramics doped with calcium and magnesium have been proposed as suitable materials for scaffold fabrication. Akermanite (Ca2MgSi2O7) has attracted interest for bone regeneration due to its controllable biodegradation rate, improved mechanical properties, and high apatite-forming ability. Despite the profound advantages, ceramic scaffolds provide weak fracture resistance. The use of synthetic biopolymers such as poly(lactic-co-glycolic acid) (PLGA) as coating materials improves the mechanical performance of ceramic scaffolds and tailors their degradation rate. Moxifloxacin (MOX) is an antibiotic with antimicrobial activity against numerous aerobic and anaerobic bacteria. In this study, silica-based nanoparticles (NPs) enriched with calcium and magnesium, as well as copper and strontium ions that induce angiogenesis and osteogenesis, respectively, were incorporated into the PLGA coating. The aim was to produce composite akermanite/PLGA/NPs/MOX-loaded scaffolds through the foam replica technique combined with the sol–gel method to improve the overall effectiveness towards bone regeneration. The structural and physicochemical characterizations were evaluated. Their mechanical properties, apatite forming ability, degradation, pharmacokinetics, and hemocompatibility were also investigated. The addition of NPs improved the compressive strength, hemocompatibility, and in vitro degradation of the composite scaffolds, resulting in them keeping a 3D porous structure and a more prolonged release profile of MOX that makes them promising for bone regeneration applications.

Review of Physical, Mechanical, and Biological Characteristics of 3D-Printed Bioceramic Scaffolds for Bone Tissue Engineering Applications

This review focuses on the advancements in additive manufacturing techniques that are utilized for fabricating bioceramic scaffolds and their characterizations leading to bone tissue regeneration. Bioscaffolds are made by mimicking the human bone structure, material composition, and properties. Calcium phosphate apatite materials are the most commonly used scaffold materials as they closely resemble live bone in their inorganic composition. The functionally graded scaffolds are fabricated by utilizing the right choice of the 3D printing method and material combinations to achieve the requirement of the bioscaffold. To tailor the physical, mechanical, and biological properties of the scaffold, certain materials are reinforced, doped, or coated to incorporate the functionality. The biomechanical loading conditions that involve flexion, torsion, and tension exerted on the implanted scaffold are discussed. The finite element analysis (FEA) technique is used to investigate the mechanical property of the scaffold before fabrication. This helps in reducing the actual number of samples used for testing. The FEA simulated results and the experimental result are compared. This review also highlights some of the challenges associated while processing the scaffold such as shrinkage, mechanical instability, cytotoxicity, and printability. In the end, the new materials that are evolved for tissue engineering applications are compiled and discussed.

Prestrain Programmable 4D Printing of Nanoceramic Composites with Bioinspired Microstructure

Four-dimensional (4D) printing enables programmable, predictable, and precise shape change of responsive materials to achieve desirable behaviors beyond conventional three-dimensional (3D) printing. However, applying 4D printing to ceramics remains challenging due to their intrinsic brittleness and inadequate stimuli-responsive ability. Here, this work proposes a conceptional combination of bioinspired microstructure design and a programmable prestrain approach for 4D printing of nanoceramics. To overcome the flexibility limitation, the bioinspired concentric cylinder structure in the struts of 3D printed lattices are replicated to develop origami nanoceramic composites with high inorganic content (95 wt%). Furthermore, 4D printing is achieved by applying a programmed prestrain to the printed lattices, enabling the desired deformation when the prestrain is released. Due to the bioinspired concentric cylinder microstructures, the printed flexible nanoceramic composites exhibit superior mechanical performance and anisotropic thermal management capability. Further, by introducing oxygen vacancies to the ceramic nanosheets, conductive nanoceramic composites are prepared with a unique sensing capability for various sensing applications. Hence, this research breaks through the limitation of ceramics in 4D printing and achieves high-performance shape morphing materials for applications under extreme conditions, such as space exploration and high-temperature systems.

Calcium Orthophosphate (CaPO4)-Based Bioceramics: Preparation, Properties, and Applications

Various types of materials have been traditionally used to restore damaged bones. In the late 1960s, a strong interest was raised in studying ceramics as potential bone grafts due to their biomechanical properties. A short time later, such synthetic biomaterials were called bioceramics. Bioceramics can be prepared from diverse inorganic substances, but this review is limited to calcium orthophosphate (CaPO4)-based formulations only, due to its chemical similarity to mammalian bones and teeth. During the past 50 years, there have been a number of important achievements in this field. Namely, after the initial development of bioceramics that was just tolerated in the physiological environment, an emphasis was shifted towards the formulations able to form direct chemical bonds with the adjacent bones. Afterwards, by the structural and compositional controls, it became possible to choose whether the CaPO4-based implants would remain biologically stable once incorporated into the skeletal structure or whether they would be resorbed over time. At the turn of the millennium, a new concept of regenerative bioceramics was developed, and such formulations became an integrated part of the tissue engineering approach. Now, CaPO4-based scaffolds are designed to induce bone formation and vascularization. These scaffolds are usually porous and harbor various biomolecules and/or cells. Therefore, current biomedical applications of CaPO4-based bioceramics include artificial bone grafts, bone augmentations, maxillofacial reconstruction, spinal fusion, and periodontal disease repairs, as well as bone fillers after tumor surgery. Prospective future applications comprise drug delivery and tissue engineering purposes because CaPO4 appear to be promising carriers of growth factors, bioactive peptides, and various types of cells.

Low-Temperature Printed Hierarchically Porous Induced-Biomineralization Polyaryletherketone Scaffold for Bone Tissue Engineering

Polyetheretherketone (PEEK) as a popular orthopaedic implant is usually fabricated into a hierarchically porous structure for improving osteogenic activity. However, the applications are limited due to the excessively high processing temperature and uncontrollably tedious modification routes. Here, an amorphous polyaryletherketone with carboxyl groups (PAEK-COOH) is synthesized and fabricated to the hierarchically controllable porous scaffolds via a low-temperature 3D-printing process. The prepared PAEK-COOH scaffolds present controllable porous structures ranging from nano- to micro-scale, and their mechanical strengths are comparable to that of trabecular bone. More importantly, the in vitro experiments show that the nanoporous surface is conducive to promoting cellular adhesion, and carboxyl groups can induce hydroxyapatite mineralization via electrostatic interaction. The in vivo experiments demonstrate that the PAEK-COOH scaffolds offer much better osseointegration without additional active ingredients, compared to that of PEEK. Therefore, this work will not only develop a promising candidate for bone tissue engineering, but provide a viable method to design PAEK biomaterials.

Recent advances in 3D-printed polylactide and polycaprolactone-based biomaterials for tissue engineering applications

The three-dimensional printing (3DP) also known as the additive manufacturing (AM), a novel and futuristic technology that facilitates the printing of multiscale, biomimetic, intricate cytoarchitecture, function-structure hierarchy, multi-cellular tissues in the complicated micro-environment, patient-specific scaffolds, and medical devices. There is an increasing demand for developing 3D-printed products that can be utilized for organ transplantations due to the organ shortage. Nowadays, the 3DP has gained considerable interest in the tissue engineering (TE) field. Polylactide (PLA) and polycaprolactone (PCL) are exemplary biomaterials with excellent physicochemical properties and biocompatibility, which have drawn notable attraction in tissue regeneration. Herein, the recent advancements in the PLA and PCL biodegradable polymer-based composites as well as their reinforcement with hydrogels and bio-ceramics scaffolds manufactured through 3DP are systematically summarized and the applications of bone, cardiac, neural, vascularized and skin tissue regeneration are thoroughly elucidated. The interaction between implanted biodegradable polymers, in-vivo and in-vitro testing models for possible evaluation of degradation and biological properties are also illustrated. The final section of this review incorporates the current challenges and future opportunities in the 3DP of PCL- and PLA-based composites that will prove helpful for biomedical engineers to fulfill the demands of the clinical field.

Hierarchical Porous Ceramics with Distinctive Microstructures by Emulsion-Based Direct Ink Writing

Hierarchical porous materials are ubiquitous in nature and have inspired the fabrication of cellular structures for a multitude of applications. As an extrusion-based 3D printing technique, direct ink writing (DIW) allows for customizable design and accurate control of printed structures. Recently, its combination with colloidal processing methods used for bulk porous ceramics, such as emulsion templating, has further extended its capability of fabricating porous ceramics across multiple length scales. In light of the recent development, the ink formulation for emulsion-based DIW can be further explored, and there is still a need for a better understanding of the structure-property relationship. Herein, we introduce two types of gelling additives, i.e., poly(ethylenimine) (PEI) and Pluronic F-127, respectively, into particle-stabilized emulsions and fabricate hierarchical porous alumina lattices by DIW. We discover that the two gelling additives can lead to distinctive microstructures due to their different gelling mechanisms. Moreover, the 3D printed hierarchical porous ceramic lattices are found to exhibit a potential energy absorption property. The effects of ink formulations, including gelling additives and solid loading, on ink rheology, microstructure, and mechanical properties are investigated. The 3D printed hierarchical porous ceramic lattices exhibit a high average porosity of 73.7%-79.3% with an average compressive strength of 1.53-9.61 MPa and a specific energy absorption of 0.33-2.67 J/g. Featuring two distinctive microstructures with tunable structural features and mechanical properties, the 3D printed hierarchical porous ceramics in this study have potential in many applications, including lightweight structures, tissue engineering scaffolds, filtration, etc.