Recombinant AAV-mediated VEGF gene therapy induces mandibular condylar growth

Role of gene therapy in treatment of cancer with craniofacial regeneration-current molecular strategies, future perspectives, and challenges: a narrative review

Gene therapy involves the introduction of foreign genetic material into host tissue to alter the expression of genetic products. Gene therapy represents an opportunity to alter the course of various diseases. Hence, genetic products utilizing safe and reliable vectors with improved biotechnology will play a critical role in the treatment of various diseases in the future. This review summarizes various important vectors for gene therapy along with modern techniques for potential craniofacial regeneration using gene therapy. This review also explains current molecular approaches for the management and treatment of cancer using gene therapy. The existing literature was searched to find studies related to gene therapy and its role in craniofacial regeneration and cancer treatment. Various databases such as PubMed, Science Direct, Scopus, Web of Science, and Google Scholar were searched for English language articles using the keywords "gene therapy," "gene therapy in present scenario," "gene therapy in cancer," "gene therapy and vector," "gene therapy in diseases," and "gene therapy and molecular strategies."

Early Treatment of Unilateral Condylar Hyperplasia in Adolescents: Preliminary Results

Facial asymmetry associated with unilateral condylar hyperplasia (UCH) is a rare disease. The aim of this study was to evaluate the clinical conditions of progressive facial asymmetry in young subjects treated with high condylectomy. A retrospective study was performed including nine subjects diagnosed with UCH type 1B and progressive facial asymmetry around 12 years old with an upper canine progressing towards dental occlusion. After an analysis and a decision of treatment, orthodontics began one to two weeks prior to the condylectomy (with a mean vertical reduction of 4.83 ± 0.44 mm). Facial and dental asymmetry, dental occlusion, TMJ status and an open/closing mouth were analyzed before surgery and in the final stage of treatment, almost 3 years after surgery. Statistical analyses were performed using the Shapiro-Wilk test and a Student's t-test considering a p value of <0.05. Comparing T1 (before surgery) and T2 (once orthodontic treatment was finalized), the operated condyle showed a similar height to that observed in stage 1 with a 0.12 mm difference in height (p = 0.8), whereas the non-operated condyle showed greater height increase with an average of 3.88 mm of vertical growth (p = 0.0001). This indicated that the non-operated condyle remained steady and that the operative condyle did not register significant growth. In terms of facial asymmetry in the preoperative stage, a chin deviation of 7.55 mm (±2.57 mm) was observed; in the final stage, there was a significant reduction in the chin deviation with an average of 1.55 mm (±1.26 mm) (p = 0.0001). Given the small number of patients in the sample, we can conclude that high condylectomy (approx. 5 mm), if performed early, especially in the mixed-dentition stage before full canine eruption, is beneficial for the early resolution of asymmetry and thus the avoidance of future orthognathic surgery. However, further follow-up until the end of facial growth is required.

Diagnosis and Treatment in Unilateral Condylar Hyperplasia

Unilateral condylar hyperplasia (UCH) is an uncommon disease involving progressive facial asymmetry. The aim of this research was to perform an analysis of the diagnosis and treatment of patients with UCH in a clinical series. An observational retrospective study was performed on subjects with progressive facial asymmetry in the lower third of the face; all the subjects were under treatment with condylectomy and orthodontics to improve occlusion and face balance. Variables such as age, sex, clinical type, SPECT (single photon emission computed tomography) intensity and a requirement for secondary surgery were included; the Shapiro Wilk test was performed to analyze the normality of the data and nonparametric analysis and the Kruskal-Wallis or Mann-Whitney tests were used to assess the association between the SPECT difference and the variables, where 2-tailed p values < 0.05 were considered to be statistically significant. Forty-nine patients between 10 and 45 y.o. (average age: 19.1 ± 7.4 y.o.) were included in the study. There were 41 female (83.6%) and 8 male (16.4%) subjects. The SPECT analysis comparing the right and left condyles with more than 10% in caption of the isotope was present in 46 subjects; the results obtained using SPECT were not statistically related to the age or sex of the sample (p = 0.277). The patients were classified into clinical types I, II and III, and no correlations could be confirmed between the clinical type and other variables. High condylectomy was conducted on all patients, among which 14 patients underwent a secondary surgery for orthognathic or cosmetic treatment, and was not related to the initial variables used in diagnosis (p = 0.98); interestingly, the second surgical treatment was more present in the clinical type I and in subjects under 16 years old with no statistical differences. Clinical analysis, medical records, 3D imaging and SPECT should be used as a complementary analysis in assessing the diagnosis of UCH and progressive facial asymmetry.

Tissue Engineering for the Temporomandibular Joint

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.

The skeletal vascular system - Breathing life into bone tissue

During bone development, homeostasis and repair, a dense vascular system provides oxygen and nutrients to highly anabolic skeletal cells. Characteristic for the vascular system in bone is the serial organization of two capillary systems, each typified by specific morphological and physiological features. Especially the arterial capillaries mediate the growth of the bone vascular system, serve as a niche for skeletal and hematopoietic progenitors and couple angiogenesis to osteogenesis. Endothelial cells and osteoprogenitor cells interact not only physically, but also communicate to each other by secretion of growth factors. A vital angiogenic growth factor is vascular endothelial growth factor and its expression in skeletal cells is controlled by osteogenic transcription factors and hypoxia signaling, whereas the secretion of angiocrine factors by endothelial cells is regulated by Notch signaling, blood flow and possibly hypoxia. Bone loss and impaired fracture repair are often associated with reduced and disorganized blood vessel network and therapeutic targeting of the angiogenic response may contribute to enhanced bone regeneration.

Identification of the vascular endothelial growth factor signalling pathway by quantitative proteomic analysis of rat condylar cartilage

Angiogenesis mediated by vascular endothelial growth factor (VEGF) is known to play an important role in regulating cartilage remodelling and endochondral ossification. However, the details of how VEGF signalling mechanisms affect condyle remodelling in response to alterations in functional loading remains unclear. To explore this, eighty 16‐day‐old male SD rats were divided into two equal groups which were fed either a soft/powdery diet or a hard diet for 4 weeks; the stiffness of the diet results in alteration of mastication force and hence temporomandibular joint (TMJ) development. We performed a proteomic analysis of rat condylar cartilage using isobaric tags for relative and absolute quantification (iTRAQ) labelling, followed by 2D nano‐high performance liquid chromatography and MALDI‐TOF/time‐of‐flight technology. After protein identification, we used biological information analysis to identify the differentially expressed proteins associated with the VEGF signalling pathway. Among the identified differentially expressed proteins, we found VEGF signalling mainly via the p44/42 MAPK and p38 mitogen‐activated protein kinase (MAPK) pathways in condylar cartilage, including VEGFD, VGFR2, KPCB, KPCT, KPCZ, ARAF, RASN, PLCG2, PLCG1, JUN and M3K12. Furthermore, four representative protein candidates, VEGF, p38 MAPK and p44/42 MAPK/phospho‐p44/42 MAPK, were confirmed by immunohistochemical staining and western blot. Our data suggest that VEGF might play an important role in TMJ development and remodelling in response to alterations in functional loading through the p44/42 MAPK and p38 MAPK signalling pathway. This study provides new clues to the understanding of the signalling mechanism responsible for VEGF production in response to different masticatory functions at the protein level.

Gene Therapy for Bone Defects in Oral and Maxillofacial Surgery: A Systematic Review and Meta-Analysis of Animal Studies

Craniofacial bone defects are challenging problems for maxillofacial surgeons over the years. With the development of cell and molecular biology, gene therapy is a breaking new technology with the aim of regenerating tissues by acting as a delivery system for therapeutic genes in the craniofacial region rather than treating genetic disorders. A systematic review was conducted summarizing the articles reporting gene therapy in maxillofacial surgery to answer the question: Was gene therapy successfully applied to regenerate bone in the maxillofacial region? Electronic searching of online databases was performed in addition to hand searching of the references of included articles. No language or time restrictions were enforced. Meta-analysis was done to assess significant bone formation after delivery of gene material in the surgically induced maxillofacial defects. The search identified 2081 articles, of which 57 were included with 1726 animals. Bone morphogenetic proteins were commonly used proteins for gene therapy. Viral vectors were the universally used vectors. Sprague-Dawley rats were the frequently used animal model in experimental studies. The quality of the articles ranged from excellent to average. Meta-analysis results performed on 21 articles showed that defects favored bone formation by gene therapy. Funnel plot showed symmetry with the absence of publication bias. Gene therapy is on the top list of innovative strategies that developed in the last 10 years with the hope of developing a simple chair-side protocol in the near future, combining improvement of gene delivery as well as knowledge of the molecular basis of oral and maxillofacial structures.

Increased Risk of Osteoporosis in Patients With Peptic Ulcer Disease: A Nationwide Population-Based Study

To investigate osteoporosis risk in patients with peptic ulcer disease (PUD) using a nationwide population-based dataset. This Taiwan National Health Insurance Research Database (NHIRD) analysis included 27,132 patients aged 18 years and older who had been diagnosed with PUD (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 531-534) during 1996 to 2010. The control group consisted of 27,132 randomly selected (age- and gender)-matched patients without PUD. The association between PUD and the risk of developing osteoporosis was estimated using a Cox proportional hazard regression model. During the follow-up period, osteoporosis was diagnosed in 2538 (9.35 %) patients in the PUD group and in 2259 (8.33 %) participants in the non-PUD group. After adjusting for covariates, osteoporosis risk was 1.85 times greater in the PUD group compared to the non-PUD group (13.99 vs 5.80 per 1000 person-years, respectively). Osteoporosis developed 1 year after PUD diagnosis. The 1-year follow-up period exhibited the highest significance between the 2 groups (hazard ratio [HR] = 63.44, 95% confidence interval [CI] = 28.19-142.74, P < 0.001). Osteoporosis risk was significantly higher in PUD patients with proton-pump-inhibitors (PPIs) use (HR = 1.17, 95% CI = 1.03-1.34) compared to PUD patients without PPIs use. This study revealed a significant association between PUD and subsequent risk of osteoporosis. Therefore, PUD patients, especially those treated with PPIs, should be evaluated for subsequent risk of osteoporosis to minimize the occurrence of adverse events.

Adjunctive techniques for enhancing mandibular growth in Class II malocclusion

Class II malocclusions are generally characterized by mandible retrusion. For this reason, forward bite jumping appliances, also known as functional appliances were originally designed to enhance mandibular forward projection. However, there is still insufficient evidence to support the effectiveness, predictability and stability of functional appliances in modifying mandibular growth. This article was aimed at presenting evidences and hypotheses that mandibular growth may be enhanced through the use of adjunctive methods in conjunction with functional appliances. In formulating our hypothesis, we considered relevant data, mostly derived from animal studies, concerning alternative methods, such as low-intensity ultrasound and light-emitting diode, as well as their related cellular and molecular mechanisms. According to the evidences covered in this article, we suggest that both methods are potentially effective, and theoretically able to act in synergistic way to enhance functional appliances treatment on mandibular and condylar additional growth. The rationale for the use of these methods as adjunctive therapies for mandibular underdevelopment is attributed to their abilities on stimulating angiogenesis, cell differentiation, proliferation, and hypertrophy, as well as enhancing matrix production and endochondoral bone formation, especially on the condyle of growing animals. This article also proposed a study design which would be able to either prove or refute our hypothesis. If ratified, it would represent a significant scientific accomplishment which provides support for further investigations to be carried out on well-designed clinical trials.

Bringing new life to damaged bone: the importance of angiogenesis in bone repair and regeneration

Bone has the unique capacity to heal without the formation of a fibrous scar, likely because several of the cellular and molecular processes governing bone healing recapitulate the events during skeletal development. A critical component in bone healing is the timely appearance of blood vessels in the fracture callus. Angiogenesis, the formation of new blood vessels from pre-existing ones, is stimulated after fracture by the local production of numerous angiogenic growth factors. The fracture vasculature not only supplies oxygen and nutrients, but also stem cells able to differentiate into osteoblasts and in a later phase also the ions necessary for mineralization. This review provides a concise report of the regulation of angiogenesis by bone cells, its importance during bone healing and its possible therapeutic applications in bone tissue engineering. This article is part of a Special Issue entitled "Stem Cells and Bone".

Microporation is an efficient method for siRNA-induced knockdown of PEX5 in HepG2 cells: evaluation of the transfection efficiency, the PEX5 mRNA and protein levels and induction of peroxisomal deficiency

The pathomechanism of peroxisomal biogenesis disorders (PBDs), a group of inherited autosomal recessive diseases with mutations of peroxin (PEX) genes, is not yet fully understood. Therefore, several knockout models, e.g., the PEX5 knockout mouse, have been generated exhibiting a complete loss of peroxisomal function. In this study, we wanted to knockdown PEX5 using the siRNA technology (1) to mimic milder forms of PBDs in which the mutated peroxin has some residual function and (2) to analyze the cellular consequences of a reduction of the PEX5 protein without adaption during the development as it is the case in a knockout animal. First, we tried to optimize the transfection of the hepatoma cell line HepG2 with PEX5 siRNA using different commercially available liposomal and non-liposomal transfection reagents (Lipofectamine(®) 2000, FuGENE 6, HiPerFect(®), INTERFERin™, RiboJuice™) as well as microporation using the Neon™ Transfection system. Microporation was found to be superior to the transfection reagents with respect to the transfection efficiency (100 vs. 0-70%), to the reduction of PEX5 mRNA (by 90 vs. 0-50%) and PEX5 protein levels (by 70 vs. 0-50%). Interestingly, we detected that a part of the cleaved PEX5 mRNA still existed as 3' fragment (15%) 24 h after microporation. Using microporation, we further analyzed whether the reduced PEX5 protein level impaired peroxisomal function. We indeed detected a reduced targeting of SKL-tagged proteins into peroxisomes as well as an increased oxidative stress as found in PBD patients and respective knockout mouse models. Knockdown of the PEX5 protein and functional consequences were at a maximum 48 h after microporation. Thereafter, the PEX5 protein was resynthesized, which may allow the temporal analysis of the loss as well as the reconstitution of peroxisomes in the future. In conclusion, we propose microporation as an efficient and reproducible method to transfect HepG2 cells with PEX5 siRNA. We succeeded to transiently knockdown PEX5 mRNA and its protein level leading to functional consequences similar as observed in peroxisome deficiencies.

Can we enhance fracture vascularity: What is the evidence?

Angiogenesis is a vital component of bone healing. The formation of the new blood vessels at the fracture site restores the hypoxia and nutrient deprivation found at the early stages after fracture whilst at a later stage facilitates osteogenesis by the activity of the osteoprogenitor cells. Emerging evidence suggests that there are certain molecules and gene therapies that could promote new blood vessel formation and as a consequence enhance the local bone healing response. This article summarizes the current in vivo evidence on therapeutic approaches aiming at the augmentation of the angiogenic signalling during bone repair.

Effect of nonviral plasmid delivered basic fibroblast growth factor and low intensity pulsed ultrasound on mandibular condylar growth: a preliminary study

OBJECTIVE

Basic fibroblast growth factor (bFGF) is an important regulator of tissue growth. Previous studies have shown that low intensity pulsed ultrasound (LIPUS) stimulates bone growth. The objective of this study was to evaluate the possible synergetic effect of LIPUS and local injection of nonviral bFGF plasmid DNA (pDNA) on mandibular growth in rats.

DESIGN

Groups were control, blank pDNA, bFGF pDNA, LIPUS, and bFGF pDNA + LIPUS. Treatments were performed for 28 days. Significant increase was observed in mandibular height and condylar length in LIPUS groups. MicroCT analysis showed significant increase in bone volume fraction in bFGF pDNA + LIPUS group. Histomorphometric analysis showed increased cell count and condylar proliferative and hypertrophic layers widths in bFGF pDNA group.

RESULTS

Current study showed increased mandibular condylar growth in either bFGF pDNA or LIPUS groups compared to the combined group that showed only increased bone volume fraction.

CONCLUSION

It appears that there is an additive effect of bFGF + LIPUS on the mandibular growth.

Tissue-engineered mandibular bone reconstruction for continuity defects: a systematic approach to the literature

BACKGROUND

Despite significant surgical advances over the last decades, segmental mandibular bone repair remains a challenge. In light of this, tissue engineering might offer a next step in the evolution of mandibular reconstruction.

PURPOSE

The purpose of the present report was to (1) systematically review preclinical in vivo as well as clinical literature regarding bone tissue engineering for mandibular continuity defects, and (2) to analyze their effectiveness.

MATERIALS AND METHODS

An electronic search in the databases of the National Library of Medicine and ISI Web of Knowledge was carried out. Only publications in English were considered, and the search was broadened to animals and humans. Furthermore, the reference lists of related review articles and publications selected for inclusion in this review were systematically screened. Results of histology data and amount of bone bridging were chosen as primary outcome variables. However, for human reports, clinical radiographic evidence was accepted for defined primary outcome variable. The biomechanical properties, scaffold degradation, and clinical wound healing were selected as co-outcome variables.

RESULTS

The electronic search in the databases of the National Library of Medicine and ISI Web of Knowledge resulted in the identification of 6727 and 5017 titles, respectively. Thereafter, title assessment and hand search resulted in 128 abstracts, 101 full-text articles, and 29 scientific papers reporting on animal experiments as well as 11 papers presenting human data on the subject of tissue-engineered reconstruction of mandibular continuity defects that could be included in the present review.

CONCLUSIONS

It was concluded that (1) published preclinical in vivo as well as clinical data are limited, and (2) tissue-engineered approaches demonstrate some clinical potential as an alternative to autogenous bone grafting.

Effects of growth hormone and ultrasound on mandibular growth in rats: MicroCT and toxicity analyses

It has been shown by previous studies that mandibular growth can be enhanced by the systemic administration of recombinant growth hormone (rGH) and/or local application of therapeutic low intensity pulsed ultrasound (LIPUS). The purpose of this study was to determine if local injection of rGH and application of LIPUS to the temporomandibular joint (TMJ) would synergistically enhance mandibular growth. In an animal study, the effect of rGH, LIPUS, and combination of rGH and LIPUS on male Sprague-Dawley rats was observed. Mandibular growth was evaluated by measuring total hemimandibular and condylar bone volume and bone surface area as well as condylar bone mineral density (BMD) after 21 days on dissected rats' mandibles using micro-computed tomography (MicroCT). The expression of c-jun mRNA extracted from the liver of each of these rats was also quantified by real-time polymerase chain reaction to evaluate possible systemic effect of local rGH administration. Significant growth stimulation was observed in the mandibular and condylar bone of the animals treated with rGH, LIPUS, and rGH/LIPUS combined when compared with the control group. Bone volume, surface area, condylar bone mineral density, and c-jun expression were also compared between the treatment groups and the control in the liver. The results suggest that mandibular growth may be enhanced by injection of rGH or LIPUS application. The current study although showed synergetic effect of rGH and LIPUS application in increasing mandibular condylar head length, there was no significant changes in mandibular bone volume using both treatments together when compared to the two individual treatments. Moreover, combined rGH and LIPUS decreased condylar bone mineral density than each treatment separately. Future research could be directed to investigate the effects of different rGH doses and/or different LIPUS exposures parameters on lower jaw growth.

Electroporation for transfection and differentiation of dental pulp stem cells

Target gene delivery is needed to induce cellular differentiation or a specific therapeutic effect. Electroporation is a relatively safe and simple technique to deliver nucleic acids to the cell that acts by rendering cells transiently permeable using short periods of high voltage. In stem cell research, human dental pulp stem cells (hDPSCS) are highly accessible, and they exhibit broad differentiation potential. Until now, no studies have attempted to optimize electroporation parameters for DPSCs with respect to transfection efficiency and viability. In this study, we aimed to optimize transfection of DPSCs through varying different electroporation parameters, including voltage, mode of pulsation, and the number of pulses. As positive control, we used commonly utilized the chemical transfection reagents Lipofectamine 2000 and FuGene 6. In addition, we used our newly optimized transfection conditions to transfect hDPSCs with a functional chondrogenic transgene. We obtained higher transfection efficiency and cell viability with these electroporation conditions compared to controls. The highest transfection efficiency (63.81±4.72%) was achieved with 100 V, 20 msec, one-pulse square-wave condition. Among chemical transfection groups, FuGene 6 showed the highest cell viability at all tested transfection ratios, while Lipofectamine 2000 showed the highest transfection efficiency (19.23±3.19%) using 1:1 DNA (μg):Lipofectamine (μL). Transfected DPSCs functionally expressed the transforming growth factor β-3 chondrogenic transgene on the mRNA level as detected by real-time polymerase chain reaction and on the protein level as detected by Western blot analysis. An increase in various chondrogenic markers was also found when studying mRNA expression in transfected cells. In conclusion, the results of our study demonstrate optimal electroporation and chemical transfection reagent conditions for hDPSCs, and, subsequently, we provide proof of concept for expression of a functional gene using those conditions. These results demonstrate a widened scope for use of DPSCs in various tissue engineering applications.

The biology of TMJ growth modification: a review

Several studies have indicated a positive response of the temporomandibular joint (TMJ) to mandibular advancement, while others have reported that TMJ adaptive responses are non-existent and negligible. Controversy continues to grow over the precise nature of skeletal changes that occur during mandibular growth modification, due to an apparent lack of tissue markers required to substantiate the precise mechanism by which this is occurring. However, evidence suggests that orthopedic forces clinically modify the growth of the mandible. To further our knowledge about the effect of orthopedic treatment on the TMJ, it is necessary that we understand the biologic basis behind the various tissues involved in the TMJ's normal growth and maturation. The importance of this knowledge is to consider the potential association between TMJ remodeling and mandibular repositioning under orthopedic loading. Considerable histologic and biochemical research has been performed to provide basic information about the nature of skeletal growth modification in response to mandibular advancement. In this review, the relevant histochemical evidence and various theories regarding TMJ growth modification are discussed. Furthermore, different regulatory growth factors and tissue markers, which are used for cellular and molecular evaluation of the TMJ during its adaptive response to biomechanical forces, are underlined.

Growth factors and craniofacial surgery

The specialty of craniofacial surgery is broad and includes trauma, aesthetics, reconstruction of congenital deformities, and regeneration of tissues. Moreover, craniofacial surgery deals with a diverse range of tissues including both "soft" and "hard" tissues. Technological advances in materials and biological sciences and improved surgical techniques have remarkably improved clinical outcomes. The quest to raise the bar for patient care continues to inspire advances for predictable biological regeneration of soft and hard tissues. As a consequence of this quest for advancement, a wide spectrum of biologicals is becoming available to surgeons. Is the use of recombinant DNA engineered biologicals daring? Sensible? Logical? Timely? Safe? It is crucial for the practicing craniofacial surgeon to take a step back periodically and carefully review the biological factors that have the potential for dramatically altering the discipline of craniofacial surgery. With this emphasis, the coauthors of this article will focus on growth factor technology underscoring bone tissue regeneration. As the 21st-century matures, recombinant human biologicals will have an overwhelming impact on the practice of craniofacial surgery.

Gene therapy: implications for craniofacial regeneration

Gene therapy in the craniofacial region provides a unique tool for delivery of DNA to coordinate protein production in both time and space. The drive to bring this technology to the clinic is derived from the fact that more than 85% of the global population may at one time require repair or replacement of a craniofacial structure. This need ranges from mild tooth decay and tooth loss to temporomandibular joint disorders and large-scale reconstructive surgery. Our ability to insert foreign DNA into a host cell has been developing since the early uses of gene therapy to alter bacterial properties for waste cleanup in the 1980s followed by successful human clinical trials in the 1990s to treat severe combined immunodeficiency. In the past 20 years, the emerging field of craniofacial tissue engineering has adopted these techniques to enhance regeneration of mineralized tissues, salivary gland, and periodontium and to reduce tumor burden of head and neck squamous cell carcinoma. Studies are currently pursuing research on both biomaterial-mediated gene delivery and more clinically efficacious, although potentially more hazardous, viral methods. Although hundreds of gene therapy clinical trials have taken place in the past 20 years, we must still work to ensure an ideal safety profile for each gene and delivery method combination. With adequate genotoxicity testing, we can expect gene therapy to augment protein delivery strategies and potentially allow for tissue-specific targeting, delivery of multiple signals, and increased spatial and temporal control with the goal of natural tissue replacement in the craniofacial complex.

The role of vascular endothelial growth factor in ossification

Osteogenesis and angiogenesis are two closely correlated processes during bone growth, development, remodelling and repair.Vascular endothelial growth factor (VEGF) is an essential mediator during the process of angiogenesis. Based on an extensive literature search, which was carried out using the PubMed database and the keywords of osteogenesis, VEGF, endochondral ossification and intramembranous ossification, this manuscript reviews the role of VEGF in ossification, with emphasis on its effect in endochondral and intramembranous ossification. Osteogenesis and angiogenesis are closely correlated processes. VEGF acts as an essential mediator during these processes. It not only functions in bone angiogenesis but also in various aspects of bone development.

Bioengineering strategies for regeneration of craniofacial bone: a review of emerging technologies

Although advances in surgical techniques and bone grafting have significantly improved the functional and cosmetic restoration of craniofacial structures lost because of trauma or disease, there are still significant limitations in our ability to regenerate these tissues. The regeneration of oral and craniofacial tissues presents a formidable challenge that requires synthesis of basic science, clinical science, and engineering technology. Tissue engineering is an interdisciplinary field of study that addresses this challenge by applying the principles of engineering to biology and medicine toward the development of biological substitutes that restore, maintain, and improve normal function. This review will explore the impact of biomaterials design, stem cell biology and gene therapy on craniofacial tissue engineering.

Engineering craniofacial structures: facing the challenge

The human innate regenerative ability is known to be limited by the intensity of the insult together with the availability of progenitor cells, which may cause certain irreparable damage. It is only recently that the paradigm of tissue engineering found its way to the treatment of irreversibly affected body structures with the challenge of reconstructing the lost part. In the current review, we underline recent trials that target engineering of human craniofacial structures, mainly bone, cartilage, and teeth. We analyze the applied engineering strategies relative to the selection of cell types to lay down a specific targeted tissue, together with their association with an escorting scaffold for a particular engineered site, and discuss their necessity to be sustained by growth factors. Challenges and expectations for facial skeletal engineering are discussed in the context of future treatment.

Recombinant adeno-associated virus serotype 2 (rAAV2)-An efficient vector for gene delivery in condylar cartilage, glenoid fossa and TMJ disc in an experimental study in vivo

OBJECTIVE

To elaborate whether rAAV2 can be used for future TMJ gene therapy, we examined the infection efficiencies of rAAV2 in vitro, and the transgene expression pattern mediated by rAAV2 in glenoid fossa, TMJ disc and condylar cartilage in vivo.

MATERIALS AND METHODS

Different dosages of rAAV2-eGFP (MOI: 5 x 10(4), 1 x 10(4), 5 x 10(3)) were applied to primary cultured condylar chondrocytes of rats. Infection efficiencies were analysed by FACSCalitur at different time points. Vastatin, a molecule not naturally expressed in TMJ, was used as a reporter for detection of rAAV2 mediated transgene expression in vivo. Thirty SD rats were injected with either rAAV2-sec-Vastatin (experimental group) or rAAV2-eGFP (control group) into both sides of TMJ. They were sacrificed at the indicated time (7, 14, 21, 30 and 60 days of injection) and the TMJ samples were collected for RT-PCR and immunostaining analysis.

RESULTS

High dosage (MOI 5 x 10(4)) of rAAV2-eGFP can achieve desirable transduction efficiencies in vitro after 5 days. Transgene expression of rAAV-sec-Vastatin persisted for about 21 days in glenoid fossa, around 7 days in TMJ disc and at least 60 days in condylar cartilage in vivo. In condylar cartilage, transgene expression was found in the proliferative layer and chondroblast layer (day 7), chondrocyte layer (day 14), pre-hypertrophic and hypertrophic layer (day 21), hypertrophic layer and deep hypertrophic layer (day 30 and 60).

CONCLUSION

Recombinant AAV2 could be considered as a promising vector for gene therapy in TMJ which can mediate therapeutic gene expression in glenoid fossa, articular disc and condylar cartilage in vivo.

Effects of bisphosphonate on the endochondral bone formation of the mandibular condyle

The development of the mandibular condylar cartilage is important for the overall growth of the mandible. However, there have been a few researches into medical approaches aimed at controlling condylar growth. This study examined the effects of bisphosphonate on the growth of the condylar cartilage. Alendronate (3.5 mg/kg/week) was administered to postnatal day 1 SD rats for 7 and 10 days. The thickness of each chondrocyte layer and the level of MMP-9 expression were measured. The anteroposterior diameter of the developing condyle was unaffected by the alendronate treatment for 7 days (P > 0.05). The total thickness of the cartilage layers was also unaffected by the treatment for 7 days (P > 0.05). In particular, there was no change in the thickness of the perichondrium and reserve cell layer at the measured condylar regions (P > 0.05). However, the thickness of the proliferating cell layer was reduced significantly, whereas the thickness of hypertrophied cartilage layer was increased (P < 0.05). The number of chondroclasts engaged in hypertrophied cartilage resorption was reduced significantly by the alendronate treatment (P < 0.05). The level of MMP-9 expression was reduced at both the transcription and translation levels by the alendronate treatment for 7 and 10 days. These results indicate that alendronate (>3.5 mg/kg/week) inhibits the longitudinal growth of the mandibular condyle by inhibiting chondrocyte proliferation and the resorption of hypertrophied cartilage for ossification.

Gene therapy: design and prospects for craniofacial regeneration

Gene therapy is defined as the treatment of disease by transfer of genetic material into cells. This review will explore methods available for gene transfer as well as current and potential applications for craniofacial regeneration, with emphasis on future development and design. Though non-viral gene delivery methods are limited by low gene transfer efficiency, they benefit from relative safety, low immunogenicity, ease of manufacture, and lack of DNA insert size limitation. In contrast, viral vectors are nature's gene delivery machines that can be optimized to allow for tissue-specific targeting, site-specific chromosomal integration, and efficient long-term infection of dividing and non-dividing cells. In contrast to traditional replacement gene therapy, craniofacial regeneration seeks to use genetic vectors as supplemental building blocks for tissue growth and repair. Synergistic combination of viral gene therapy with craniofacial tissue engineering will significantly enhance our ability to repair and replace tissues in vivo.

Interplay of mechanical loading and growth factors in the mandibular condyle

The mandibular condyle is an important growth site in the developing mandible. The growth of the condyle is known to be highly adaptable to functional factors. This property is exploited in orthodontics for the treatment of class II malocclusions and mandibular asymmetries. However, there is an ongoing debate on the efficacy of functional appliances. The comparison of experimental studies is complicated by the lack of detailed analyses of the load distribution within the condyle. In spite of this, there is a large body of evidence showing that mechanical manipulation of the condyle induces metabolic changes, and changes in the expression of growth factors and other signalling molecules. This review aims to give an overview of the role of growth factors in the condyle with special emphasis on their responsiveness to mechanical perturbation.

Gene Therapy to Enhance Condylar Growth Using rAAV-VEGF

Objective: To test the hypothesis that the introduction of specific vascular growth inducting genes would favorably affect mandibular condylar growth in Sprague-Dawley (SD) rats over a limited experimental period. Therefore, the aim of this study is to examine the effect of gene therapy on condylar growth by means of a morphological assessment.

Materials and Methods: Ninety 35-day-old female SD rats were randomly divided into three groups, which received any of the injections of recombinant adeno-associated virus mediated vascular endothelial growth factor (rAAV-VEGF), rAAV mediated enhanced green fluorescence protein (rAAV-eGFP), or phosphate-buffered saline (PBS) into both mandibular condyles. Each group of rats was sacrificed on the following experimental days: 7, 14, 21, 30, and 60. Left halves of the mandibles were isolated and digital pictures were obtained in a standardized manner.

Results: The length of condylar process (B-F) as well as mandibular length (A-F) significantly increased on day 30 and continued to increase until the end of the experiment. Moreover, the width of condyle (Q-R) had increased significantly from day 30 and lasted to day 60. Condylar length (C-D) was found to be significantly longer on day 60.

Conclusions: Gene therapy with VEGF stimulates condylar growth at will. The rAAV-VEGF is an excellent candidate for future gene therapy to induce mandibular growth.

A new approach to control condylar growth by regulating angiogenesis

OBJECTIVE

To provide a comprehensive review of the mechanisms of growth of mandibular condyle, the roles of angiogenesis enhancers and inhibitors during endochondral ossification in mandibular condyle and newly developed delivery methods for local gene delivery that may represent strategies to regulate condylar growth.

DESIGN

Narrative review.

RESULTS

Angiogenesis is the crucial step in mandibular condylar growth for it regulates the transformation from cartilage to bone. Angiognesis enhancers, especially VEGF and FGF, play important roles in the process of new blood lumen formation and invasion. On the other hand, angiostatin and endostatin inhibit angiogenesis by targeting endothelial cells and several signal cascades. Delivery methods such as liposomes, stem cells and virus vectors have been studied. Recombinant AAV-mediated gene therapy is considered as one of the most promising strategies of condylar growth management.

CONCLUSION

AAV-mediated gene therapy using VEGF or angiogenesis inhibitor will be a promising way to regulate condylar growth at an early stage.

VEGF: an essential mediator of both angiogenesis and endochondral ossification

During bone growth, development, and remodeling, angiogenesis as well as osteogenesis are closely associated processes, sharing some essential mediators. Vascular endothelial growth factor (VEGF) was initially recognized as the best-characterized endothelial-specific growth factor, which increased vascular permeability and angiogenesis, and it is now apparent that this cytokine regulates multiple biological functions in the endochondral ossification of mandibular condylar growth, as well as long bone formation. The complexity of VEGF biology is paralleled by the emerging complexity of interactions between VEGF ligands and their receptors. This narrative review summarizes the family of VEGF-related molecules, including 7 mammalian members, namely, VEGF, placenta growth factor (PLGF), and VEGF-B, -C, -D, -E, and -F. The biological functions of VEGF are mediated by at least 3 corresponding receptors: VEGFR-1/Flt-1, VEGFR-2/Flk-1, VEGFR-3/Flt-4 and 2 co-receptors of neuropilin (NRP) and heparan sulfate proteoglycans (HSPGs). Current findings on endochondral ossification are also discussed, with emphasis on VEGF-A action in osteoblasts, chondroblasts, and chondroclasts/osteoclasts and regulatory mechanisms involving oxygen tension, and some growth factors and hormones. Furthermore, the therapeutic implications of recombinant VEGF-A protein therapy and VEGF-A gene therapy are evaluated. Abbreviations used: VEGF, Vascular endothelial growth factor; PLGF, placenta growth factor; NRP, neuropilin; HSPGs, heparan sulfate proteoglycans; FGF, fibroblast growth factor; TGF, transforming growth factor; HGF, hepatocyte growth factor; TNF, tumor necrosis factor; ECM, extracellular matrix; RTKs, receptor tyrosine kinases; ERK, extracellular signal kinases; HIF, hypoxia-inducible factor.