Strategies to Mitigate Variability in Engineering Human Nasal Cartilage

3D Bioprinting of Hyaline Cartilage Using Nasal Chondrocytes

Due to the limited self-repair capacity of the hyaline cartilage, the repair of cartilage remains an unsolved clinical problem. Tissue engineering strategy with 3D bioprinting technique has emerged a new insight by providing patient's personalized cartilage grafts using autologous cells for hyaline cartilage repair and regeneration. In this review, we first summarized the intrinsic property of hyaline cartilage in both maxillofacial and orthopedic regions to establish the requirement for 3D bioprinting cartilage tissue. We then reviewed the literature and provided opinion pieces on the selection of bioprinters, bioink materials, and cell sources. This review aims to identify the current challenges for hyaline cartilage bioprinting and the directions for future clinical development in bioprinted hyaline cartilage.

A multicrosslinked network composite hydrogel scaffold based on DLP photocuring printing for nasal cartilage repair

Natural hydrogels are widely employed in tissue engineering and have excellent biodegradability and biocompatibility. Unfortunately, the utilization of such hydrogels in the field of three-dimensional (3D) printing nasal cartilage is constrained by their subpar mechanical characteristics. In this study, we provide a multicrosslinked network hybrid ink made of photocurable gelatin, hyaluronic acid, and acrylamide (AM). The ink may be processed into intricate 3D hydrogel structures with good biocompatibility and high stiffness properties using 3D printing technology based on digital light processing (DLP), including intricate shapes resembling noses. By varying the AM content, the mechanical behavior and biocompatibility of the hydrogels can be adjusted. In comparison to the gelatin methacryloyl (GelMA)/hyaluronic acid methacryloyl (HAMA) hydrogel, adding AM considerably enhances the hydrogel's mechanical properties while also enhancing printing quality. Meanwhile, the biocompatibility of the multicrosslinked network hydrogels and the development of cartilage were assessed using neonatal Sprague-Dawley (SD) rat chondrocytes (CChons). Cells sown on the hydrogels considerably multiplied after 7 days of culture and kept up the expression of particular proteins. Together, our findings point to GelMA/HAMA/polyacrylamide (PAM) hydrogel as a potential material for nasal cartilage restoration. The photocuring multicrosslinked network ink composed of appropriate proportions of GelMA/HAMA/PAM is very suitable for DLP 3D printing and will play an important role in the construction of nasal cartilage, ear cartilage, articular cartilage, and other tissues and organs in the future. Notably, previous studies have not explored the application of 3D-printed GelMA/HAMA/PAM hydrogels for nasal cartilage regeneration.

Human nasal cartilage: Functional properties and structure-function relationships for the development of tissue engineering design criteria

Nose reconstruction often requires scarce cartilage grafts. Nasal cartilage properties must be determined to serve as design criteria for engineering grafts. Thus, mechanical and biochemical properties were obtained in multiple locations of human nasal septum, upper lateral cartilage (ULC), and lower lateral cartilage (LLC). Within each region, no statistical differences among locations were detected, but anisotropy at some septum locations was noted. In the LLC, the tensile modulus and ultimate tensile strength (UTS) in the inferior-superior direction were statistically greater than in the anterior-posterior direction. Cartilage from all regions exhibited hyperelasticity in tension, but regions varied in degree of hyalinicity (i.e., Col II:Col I ratio). The septum contained the most collagen II and least collagen I and III, making it more hyaline than the ULC and LLC. The septum had a greater aggregate modulus, UTS, and lower total collagen/wet weight (Col/WW) than the ULC and LLC. The ULC had greater tensile modulus, DNA/WW, and lower glycosaminoglycan/WW than the septum and LLC. The ULC had a greater pyridinoline/Col than the septum. Histological staining suggested the presence of chondrons in all regions. In the ULC and LLC, tensile modulus correlated with total collagen content, while aggregate modulus correlated with pyridinoline content and weakly with pentosidine content. However, future studies should be performed to validate these proposed structure-function relationships. This study of human nasal cartilage provides 1) crucial design criteria for nasal cartilage tissue engineering efforts, 2) quantification of major and minor collagen subtypes and crosslinks, and 3) structure-function relationships. Surprisingly, the large mechanical properties found, particularly in the septum, suggests that nasal cartilage may experience higher-than-expected mechanical loads. STATEMENT OF SIGNIFICANCE: While tissue engineering holds promise to generate much-needed cartilage grafts for nasal reconstruction, little is known about nasal cartilage from an engineering perspective. In this study, the mechanical and biochemical properties of the septum, upper lateral cartilage (ULC), and lower lateral cartilage (LLC) were evaluated using cartilage-specific methods. For the first time in this tissue, all major and minor collagens and collagen crosslinks were measured, demonstrating that the septum was more hyaline than the ULC and LLC. Additionally, new structure-function relationships in the ULC and LLC were identified. This study greatly expands upon the quantitative understanding of human nasal cartilage and provides crucial engineering design criteria for much-needed nasal cartilage tissue engineering efforts.

In vitro maturation and in vivo stability of bioprinted human nasal cartilage

The removal of skin cancer lesions on the nose often results in the loss of nasal cartilage. The cartilage loss is either surgically replaced with autologous cartilage or synthetic grafts. However, these replacement options come with donor-site morbidity and resorption issues. 3-dimensional (3D) bioprinting technology offers the opportunity to engineer anatomical-shaped autologous nasal cartilage grafts. The 3D bioprinted cartilage grafts need to embody a mechanically competent extracellular matrix (ECM) to allow for surgical suturing and resistance to contraction during scar tissue formation. We investigated the effect of culture period on ECM formation and mechanical properties of 3D bioprinted constructs of human nasal chondrocytes (hNC)-laden type I collagen hydrogel in vitro and in vivo. Tissue-engineered nasal cartilage constructs developed from hNC culture in clinically approved collagen type I and type III semi-permeable membrane scaffold served as control. The resulting 3D bioprinted engineered nasal cartilage constructs were comparable or better than the controls both in vitro and in vivo. This study demonstrates that 3D bioprinted constructs of engineered nasal cartilage are feasible options in nasal cartilage reconstructive surgeries.

Characterization of Osteogenesis and Chondrogenesis of Human Decellularized Allogeneic Bone with Mesenchymal Stem Cells Derived from Bone Marrow, Adipose Tissue, and Wharton's Jelly

Allogeneic bone grafts are a promising material for bone implantation due to reduced operative trauma, reduced blood loss, and no donor-site morbidity. Although human decellularized allogeneic bone (hDCB) can be used to fill bone defects, the research of revitalizing hDCB blocks with human mesenchymal stem cells (hMSCs) for osteochondral regeneration is missing. The hMSCs derived from bone marrow, adipose tissue, and Wharton’s jelly (BMMSCs, ADMSCs, and UMSCs, respectively) are potential candidates for bone regeneration. This study characterized the potential of hDCB as a scaffold for osteogenesis and chondrogenesis of BMMSCs, ADMSCs, and UMSCs. The pore sizes and mechanical strength of hDCB were characterized. Cell survival and adhesion of hMSCs were investigated using MTT assay and F-actin staining. Alizarin Red S and Safranin O staining were conducted to demonstrate calcium deposition and proteoglycan production of hMSCs after osteogenic and chondrogenic differentiation, respectively. A RT-qPCR was performed to analyze the expression levels of osteogenic and chondrogenic markers in hMSCs. Results indicated that BMMSCs and ADMSCs exhibited higher osteogenic potential than UMSCs. Furthermore, ADMSCs and UMSCs had higher chondrogenic potential than BMMSCs. This study demonstrated that chondrogenic ADMSCs- or UMSCs-seeded hDCB might be potential osteochondral constructs for osteochondral regeneration.

Bioprinting of human nasoseptal chondrocytes-laden collagen hydrogel for cartilage tissue engineering

Skin cancer patients often have tumorigenic lesions on their noses. Surgical resection of the lesions often results in nasal cartilage removal. Cartilage grafts taken from other anatomical sites are used for the surgical reconstruction of the nasal cartilage, but donor-site morbidity is a common problem. Autologous tissue-engineered nasal cartilage grafts can mitigate the problem, but commercially available scaffolds define the shape and sizes of the engineered grafts during tissue fabrication. Moreover, the engineered grafts suffer from the inhomogeneous distribution of the functional matrix of cartilage. Advances in 3D bioprinting technology offer the opportunity to engineer cartilages with customizable dimensions and anatomically shaped configurations without the inhomogeneous distribution of cartilage matrix. Here, we report the fidelity of Freeform Reversible Embedding of Suspended Hydrogel (FRESH) bioprinting as a strategy to generate customizable and homogenously distributed functional cartilage matrix engineered nasal cartilage. Using FRESH and in vitro chondrogenesis, we have fabricated tissue-engineered nasal cartilage from combining bovine type I collagen hydrogel and human nasoseptal chondrocytes. The engineered nasal cartilage constructs displayed molecular, biochemical and histological characteristics akin to native human nasal cartilage.

Poly(vinyl alcohol)/Gelatin Scaffolds Allow Regeneration of Nasal Tissues

Need for regeneration and repair of nasal tissues occurs as a consequence of several pathologies affecting the nose, including, but not limited to infective diseases, traumas and tumor resections. A platform for nasal tissue regeneration was set up using poly(vinyl alcohol)/gelatin sponges with 20%–30% (w/w) gelatin content to be used as scaffolds, for their intrinsic hydrophilic, cell adhesive and shape recovery properties. We propose mesodermal progenitor cells (MPCs) isolated from the bone marrow as a unique stem cell source for obtaining different connective tissues of the nose, including vascular tissue. Finally, epithelial cell immune response to these scaffolds was assessed in vitro in an environment containing inflammatory molecules. The results showed that mesenchymal stromal cells (MSCs) deriving from MPCs could be used to differentiate into cartilage and fibrous tissue; whereas, in combination with endothelial cells still deriving from MPCs, into pre-vascularized bone. Finally, the scaffold did not significantly alter the epithelial cell response to inflammatory insults derived from interaction with bacterial molecules.

A photo-crosslinkable cartilage-derived extracellular matrix bioink for auricular cartilage tissue engineering

Three-dimensional (3D) bioprinting of patient-specific auricular cartilage constructs could aid in the reconstruction process of traumatically injured or congenitally deformed ear cartilage. To achieve this, a hydrogel-based bioink is required that recapitulates the complex cartilage microenvironment. Tissue-derived decellularized extracellular matrix (dECM)-based hydrogels have been used as bioinks for cell-based 3D bioprinting because they contain tissue-specific ECM components that play a vital role in cell adhesion, growth, and differentiation. In this study, porcine auricular cartilage tissues were isolated and decellularized, and the decellularized cartilage tissues were characterized by histology, biochemical assay, and proteomics. This cartilage-derived dECM (cdECM) was subsequently processed into a photo-crosslinkable hydrogel using methacrylation (cdECMMA) and mixed with chondrocytes to create a printable bioink. The rheological properties, printability, and in vitro biological properties of the cdECMMA bioink were examined. The results showed cdECM was obtained with complete removal of cellular components while preserving major ECM proteins. After methacrylation, the cdECMMA bioinks were printed in anatomical ear shape and exhibited adequate mechanical properties and structural integrity. Specifically, auricular chondrocytes in the printed cdECMMA hydrogel constructs maintained their viability and proliferation capacity and eventually produced cartilage ECM components, including collagen and glycosaminoglycans (GAGs). The potential of cell-based bioprinting using this cartilage-specific dECMMA bioink is demonstrated as an alternative option for auricular cartilage reconstruction.

Suppression of Hypertrophy During in vitro Chondrogenesis of Cocultures of Human Mesenchymal Stem Cells and Nasal Chondrocytes Correlates With Lack of in vivo Calcification and Vascular Invasion

Objective

Human nasal septal chondrocytes (NC) are a promising minimally invasive derivable chondrogenic cell source for cartilage repair. However, the quality of NC-derived cartilage is variable between donors. Coculture of NC with mesenchymal stem cells (MSCs) mitigates the variability but with undesirable markers of chondrocyte hypertrophy, such as type X collagen, and the formation of unstable calcifying cartilage at ectopic sites. In contrast, monoculture NC forms non-calcifying stable cartilage. Formation of a stable NC-MSC coculture cartilage is crucial for clinical application. The aim of this study was to explore the utility of parathyroid hormone-related peptide (PTHrP) hormone to suppress chondrocyte hypertrophy in NC-MSC cocultures and form stable non-calcifying cartilage at ectopic sites.

Methods

Human NC and bone marrow MSCs, and cocultures of NC and MSC (1:3 ratio) were aggregated in pellet form and subjected to in vitro chondrogenesis for 3 weeks in chondrogenic medium in the presence and absence of PTHrP. Following in vitro chondrogenesis, the resulting pellets were implanted in immunodeficient athymic nude mice for 3 weeks.

Results

Coculture of NC and MSC resulted in synergistic cartilage matrix production. PTHrP suppressed the expression of hypertrophy marker, type X collagen (COL10A1), in a dose-dependent fashion without affecting the synergism in cartilage matrix synthesis, and in vivo calcification was eradicated with PTHrP. In contrast, cocultured control (CC) pellets without PTHrP treatment expressed COL10A1, calcified, and became vascularized in vivo.

Will Tissue-Engineering Strategies Bring New Hope for the Reconstruction of Nasal Septal Cartilage?

The nasal septal cartilage plays an important role in the growth of midface and as a vertical strut preventing the collapse of the nasal bones. The repair of nasal cartilage defects remains a major challenge in reconstructive surgery. The tissue engineering strategy in the development of tissue has opened a new perspective to generate functional tissue for transplantation. Given the poor regenerative properties of cartilage and a limited amount of autologous cartilage availability, intense interest has evoked for tissue engineering approaches for cartilage development to provide better outcomes for patients who require nasal septal reconstruction. Despite numerous attempts to substitute the shapely hyaline cartilage in the nasal cartilages, many significant challenges remained unanswered. The aim of this research was to carry out a critical review of the literature on research work carried out on the development of septal cartilage using a tissue engineering approach, concerning different cell sources, scaffolds and growth factors, as well as its clinical pathway and trials have already been carried out.

Tissue engineering applications in otolaryngology-The state of translation

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.

Nasal Chondrocyte-Derived Soluble Factors Affect Chondrogenesis of Cocultured Mesenchymal Stem Cells

To investigate the effect of soluble factors released from human nasal chondrocytes (NCs) on cocultured human bone marrow mesenchymal stem cells (MSCs) and NC tissue-engineered constructs. Cartilage engineered from pure NCs on a three-dimensional (3D) porous collagen scaffold was cultured indirectly in a Transwell system with cartilage engineered from a direct coculture of human bone marrow-derived MSCs and NCs on a 3D porous collagen scaffold. The soluble factors were measured in the conditioned media from the different chambers of the Transwell system. Engineered cartilage from cocultures exposed to the pure NC construct exhibited reduced chondrogenic potential relative to control constructs, shown by reduced extracellular matrix deposition and increased expression of hypertrophic markers. Analysis of the soluble factors within the conditioned media showed an increase in inflammatory cytokines in the coculture chamber exposed to the pure NC construct. Principal component analysis revealed that the majority of the data variance could be explained by proinflammatory factors and hypertrophic chondrogenesis. In conclusion, our data suggest that inflammatory cytokines derived from NCs reduce the chondrogenic potential of coculture engineered cartilage through the induction of hypertrophic chondrogenesis. Impact statement The use of engineered cartilage from cocultured nasal chondrocytes (NCs) and mesenchymal stem cells for nasal cartilage reconstruction may be problematic. Our data suggest that the soluble factors from surrounding native NCs in the cartilage to be fixed can compromise the quality of the engineered cartilage if used in reconstructive surgery.

3D printing for tissue engineering in otolaryngology

Airway and other head and neck disorders affect hundreds of thousands of patients each year and most require surgical intervention. Among these, congenital deformity that affects newborns is particularly serious and can be life-threatening. In these cases, reconstructive surgery is resolutive but bears significant limitations, including the donor site morbidity and limited available tissue. In this context, tissue engineering represents a promising alternative approach for the surgical treatment of otolaryngologic disorders. In particular, 3D printing coupled with advanced imaging technologies offers the unique opportunity to reproduce the complex anatomy of native ear, nose, and throat, with its import in terms of functionality as well as aesthetics and the associated patient well-being. In this review, we provide a general overview of the main ear, nose and throat disorders and focus on the most recent scientific literature on 3D printing and bioprinting for their treatment.

Effect of cell seeding density on matrix-forming capacity of meniscus fibrochondrocytes and nasal chondrocytes in meniscus tissue engineering

The presence of intact menisci is imperative for the proper function of the knee joint. Meniscus injuries are often treated by the surgical removal of the damaged tissue, which increases the likelihood of post-traumatic osteoarthritis. Tissue engineering holds great promise in producing viable engineered meniscal tissue for implantation using the patient's own cells; however, the cell source for producing the engineered tissue is unclear. Nasal chondrocytes (NC) possess many attractive features for engineering meniscus. However, in order to validate the use of NC for engineering meniscus fibrocartilage, a thorough comparison of NC and meniscus fibrochondrocytes (MFC) must be considered. Our study presents an analysis of the relative features of NC and MFC and their respective chondrogenic potential in a pellet culture model. We showed considerable differences in the cartilage tissue formed by the two different cell types. Our data showed that NC were more proliferative in culture, deposited more extracellular matrix, and showed higher expression of chondrogenic genes than MFC. Overall, our data suggest that NC produce superior cartilage tissue to MFC in a pellet culture model. In addition, NCs produce higher quality cartilage tissue at higher cell seeding densities during cell expansion.

Chondroinductive Alginate-Based Hydrogels Having Graphene Oxide for 3D Printed Scaffold Fabrication

Scaffolds based on bioconjugated hydrogels are attractive for tissue engineering because they can partly mimic human tissue characteristics. For example, they can further increase their bioactivity with cells. However, most of the hydrogels present problems related to their processability, consequently limiting their use in 3D printing to produce tailor-made scaffolds. The goal of this work is to develop bioconjugated hydrogel nanocomposite inks for 3D printed scaffold fabrication through a micro-extrusion process having improved both biocompatibility and processability. The hydrogel is based on a photocrosslinkable alginate bioconjugated with both gelatin and chondroitin sulfate in order to mimic the cartilage extracellular matrix, while the nanofiller is based on graphene oxide to enhance the printability and cell proliferation. Our results show that the incorporation of graphene oxide into the hydrogel inks considerably improved the shape fidelity and resolution of 3D printed scaffolds because of a faster viscosity recovery post extrusion of the ink. Moreover, the nanocomposite inks produce anisotropic threads after the 3D printing process because of the templating of the graphene oxide liquid crystal. The in vitro proliferation assay of human adipose tissue-derived mesenchymal stem cells (hADMSCs) shows that bioconjugated scaffolds present higher cell proliferation than pure alginate, with the nanocomposites presenting the highest values at long times. Live/Dead assay otherwise displays full viability of hADMSCs adhered on the different scaffolds at day 7. Notably, the scaffolds produced with nanocomposite hydrogel inks were able to guide the cell proliferation following the direction of the 3D printed threads. In addition, the bioconjugated alginate hydrogel matrix induced chondrogenic differentiation without exogenous pro-chondrogenesis factors as concluded from immunostaining after 28 days of culture. This high cytocompatibility and chondroinductive effect toward hADMSCs, together with the improved printability and anisotropic structures, makes these nanocomposite hydrogel inks a promising candidate for cartilage tissue engineering based on 3D printing.

Current concepts and novel techniques in the prosthodontic management of head and neck cancer patients

'The face is the mirror of the mind', so said St Jerome. Patients affected by head and neck cancer have to deal not only with the effects of the disease but also with the effects of the treatment for the disease. This is one cancer which is literally and figuratively 'in your face'! And it is a disease which is difficult to hide. This article attempts to summarise head and neck cancer and its treatment modalities as well as the effects of treatment and the defects it creates. It will also attempt to explore and elaborate on the novel prosthodontic management techniques in advanced jaw reconstruction and extraoral anatomical defects. The concept of functional assessment and rehabilitation in head and neck cancer patient management will also be briefly explained.

Toward tissue-engineering of nasal cartilages

Nasal cartilage pathologies are common; for example, up to 80% of people are afflicted by deviated nasal septum conditions. Because cartilage provides the supportive framework of the nose, afflicted patients suffer low quality of life. To correct pathologies, graft cartilage is often required. Grafts are currently sourced from the patient's septum, ear, or rib. However, their use yields donor site morbidity and is limited by tissue quantity and quality. Additionally, rhinoplasty revision rates exceed 15%, exacerbating the shortage of graft cartilage. Alternative grafts, such as irradiated allogeneic rib cartilage, are associated with complications. Tissue-engineered neocartilage holds promise to address the limitations of current grafts. The engineering design process may be used to create suitable graft tissues. This process begins by identifying the surgeon's needs. Second, nasal cartilages' properties must be understood to define engineering design criteria. Limited investigations have examined nasal cartilage properties; numerous additional studies need to be performed to examine topographical variations, for example. Third, tissue-engineering processes must be applied to achieve the engineering design criteria. Within the recent past, strategies have frequently utilized human septal chondrocytes. As autologous and allogeneic rib graft cartilage is used, its suitability as a cell source should also be examined. Fourth, quantitative verification of engineered neocartilage is critical to check for successful achievement of the engineering design criteria. Finally, following the FDA paradigm, engineered neocartilage must be orthotopically validated in animals. Together, these steps delineate a path to engineer functional nasal neocartilages that may, ultimately, be used to treat human patients. STATEMENT OF SIGNIFICANCE: Nasal cartilage pathologies are common and lead to greatly diminished quality of life. The ability to correct pathologies is limited by cartilage graft quality and quantity, as well as donor site morbidity and surgical complications, such as infection and resorption. Despite the significance of nasal cartilage pathologies and high rhinoplasty revision rates (15%), little characterization and tissue-engineering work has been performed compared to other cartilages, such as articular cartilage. Furthermore, most work is published in clinical journals, with little in biomedical engineering. Therefore, this review discusses what nasal cartilage properties are known, summarizes the current state of nasal cartilage tissue-engineering, and makes recommendations via the engineering design process toward engineering functional nasal neocartilage to address current limitations.