Fabrication and in vitro characterization of bioactive glass composite scaffolds for bone regeneration

Clinical translation of polycaprolactone-based tissue engineering scaffolds, fabricated via additive manufacturing: A review of their craniofacial applications

The craniofacial region is characterized by its intricate bony anatomy and exposure to heightened functional forces presenting a unique challenge for reconstruction. Additive manufacturing has revolutionized the creation of customized scaffolds with interconnected pores and biomimetic microarchitecture, offering precise adaptation to various craniofacial defects. Within this domain, medical-grade poly(ε-caprolactone) (PCL) has been extensively used for the fabrication of 3D printed scaffolds, specifically tailored for bone regeneration. Its adoption for load-bearing applications was driven mainly by its mechanical properties, adjustable biodegradation rates, and high biocompatibility. The present review aims to consolidating current insights into the clinical translation of PCL-based constructs designed for bone regeneration. It encompasses recent advances in enhancing the mechanical properties and augmenting biodegradation rates of PCL and PCL-based composite scaffolds. Moreover, it delves into various strategies improving cell proliferation and the osteogenic potential of PCL-based materials. These strategies provide insight into the refinement of scaffold microarchitecture, composition, and surface treatments or coatings, that include certain bioactive molecules such as growth factors, proteins, and ceramic nanoparticles. The review critically examines published data on the clinical applications of PCL scaffolds in both extraoral and intraoral craniofacial reconstructions. These applications include cranioplasty, nasal and orbital floor reconstruction, maxillofacial reconstruction, and intraoral bone regeneration. Patient demographics, surgical procedures, follow-up periods, complications and failures are thoroughly discussed. Although results from extraoral applications in the craniofacial region are encouraging, intraoral applications present a high frequency of complications and related failures. Moving forward, future studies should prioritize refining the clinical performance, particularly in the domain of intraoral applications, and providing comprehensive data on the long-term outcomes of PCL-based scaffolds in bone regeneration. Future perspective and limitations regarding the transition of such constructs from bench to bedside are also discussed.

Fabrication and characterisation of bioglass and hydroxyapatite-filled scaffolds

Tissue engineering is a continuously evolving field. One of the main lines of research in this field focuses on the replacement of bone defects with materials designed to interact with the cells of a living organism in order to provide the body with a structure on which new tissues can easily grow. Among the most commonly used materials are bioglasses, which are frequently used due to their versatility and good properties. This article discusses the results of the production of an injectable paste of Bioglass® 45S5 and hydroxyapatite on a 3D printed porous structure by additive manufacturing, using a thermoplastic (PLA). The results were evaluated in a specific application of the paste, so the mechanical and bioactive properties were studied to show the multiple possibilities of using this combination for its application in regenerative medicine and more specifically in bone implants.

Composite Graded Melt Electrowritten Scaffolds for Regeneration of the Periodontal Ligament-to-Bone Interface

Periodontitis is a ubiquitous chronic inflammatory, bacteria-triggered oral disease affecting the adult population. If left untreated, periodontitis can lead to severe tissue destruction, eventually resulting in tooth loss. Despite previous efforts in clinically managing the disease, therapeutic strategies are still lacking. Herein, melt electrowriting (MEW) is utilized to develop a compositionally and structurally tailored graded scaffold for regeneration of the periodontal ligament-to-bone interface. The composite scaffolds, consisting of fibers of polycaprolactone (PCL) and fibers of PCL-containing magnesium phosphate (MgP) were fabricated using MEW. To maximize the bond between bone (MgP) and ligament (PCL) regions, we evaluated two different fiber architectures in the interface area. These were a crosshatch pattern at a 0/90° angle and a random pattern. MgP fibrous scaffolds were able to promote in vitro bone formation even in culture media devoid of osteogenic supplements. Mechanical properties after MgP incorporation resulted in an increase of the elastic modulus and yield stress of the scaffolds, and fiber orientation in the interfacial zone affected the interfacial toughness. Composite graded MEW scaffolds enhanced bone fill when they were implanted in an in vivo periodontal fenestration defect model in rats. The presence of an interfacial zone allows coordinated regeneration of multitissues, as indicated by higher expression of bone, ligament, and cementoblastic markers compared to empty defects. Collectively, MEW-fabricated scaffolds having compositionally and structurally tailored zones exhibit a good mimicry of the periodontal complex, with excellent regenerative capacity and great potential as a defect-specific treatment strategy.

Porous biomaterials for tissue engineering: a review

The field of biomaterials has grown rapidly over the past decades. Within this field, porous biomaterials have played a remarkable role in: (i) enabling the manufacture of complex three-dimensional structures; (ii) recreating mechanical properties close to those of the host tissues; (iii) facilitating interconnected structures for the transport of macromolecules and cells; and (iv) behaving as biocompatible inserts, tailored to either interact or not with the host body. This review outlines a brief history of the development of biomaterials, before discussing current materials proposed for use as porous biomaterials and exploring the state-of-the-art in their manufacture. The wide clinical applications of these materials are extensively discussed, drawing on specific examples of how the porous features of such biomaterials impact their behaviours, as well as the advantages and challenges faced, for each class of the materials.

Use of Polyesters in Fused Deposition Modeling for Biomedical Applications

In recent years, 3D printing techniques experienced a growing interest in several sectors, including the biomedical one. Their main advantage resides in the possibility to obtain complex and personalized structures in a cost-effective way impossible to achieve with traditional production methods. This is especially true for Fused Deposition Modeling (FDM), one of the most diffused 3D printing methods. The easy customization of the final products' geometry, composition and physico-chemical properties is particularly interesting for the increasingly personalized approach adopted in modern medicine. Thermoplastic polymers are the preferred choice for FDM applications, and a wide selection of biocompatible and biodegradable materials is available to this aim. Moreover, these polymers can also be easily modified before and after printing to better suit the body environment and the mechanical properties of biological tissues. This review focuses on the use of thermoplastic aliphatic polyesters for FDM applications in the biomedical field. In detail, the use of poly(ε-caprolactone), poly(lactic acid), poly(lactic-co-glycolic acid), poly(hydroxyalkanoate)s, thermo-plastic poly(ester urethane)s and their blends has been thoroughly surveyed, with particular attention to their main features, applicability and workability. The state-of-the-art is presented and current challenges in integrating the additive manufacturing technology in the medical practice are discussed. This article is protected by copyright. All rights reserved.

Regulating Macrophage Polarization in High Glucose Microenvironment Using Lithium-Modified Bioglass-Hydrogel for Diabetic Bone Regeneration

Diabetes mellitus is a chronic metabolic disease with a proinflammatory microenvironment, causing poor vascularization and bone regeneration. Due to the lack of effective therapy and one-sided focus on the direct angiogenic properties of biomaterials and osteogenesis stimulation, the treatment of diabetic bone defect remains challenging and complex. In this study, using gelatin methacryloyl (GelMA) as a template, a lithium (Li) -modified bioglass-hydrogel for diabetic bone regeneration is developed. It exhibits a sustained ion release for better bone regeneration under diabetic microenvironment. The hydrogel is shown to be mechanically adaptable to the complex shape of the defect. In vitro, Li-modified bioglass-hydrogel promoted cell proliferation, direct osteogenesis, and regulated macrophages in high glucose (HG) microenvironment, with the secretion of bone morphogenetic protein-2 and vascular endothelial growth factor to stimulate osteogenesis and neovascularization indirectly. In vivo, composite hydrogels containing GelMA and Li-MBG (GM/M-Li) release Li ions to relieve inflammation, providing an anti-inflammatory microenvironment for osteogenesis and angiogenesis. Applying Li-modified bioglass-hydrogel, significantly enhances bone regeneration in a diabetic rat bone defect. Together, both remarkable in vitro and in vivo outcomes in this study present an opportunity for diabetic bone regeneration on the basis of HG microenvironment.

Current Advances in 3D Bioprinting for Cancer Modeling and Personalized Medicine

Tumor cells evolve in a complex and heterogeneous environment composed of different cell types and an extracellular matrix. Current 2D culture methods are very limited in their ability to mimic the cancer cell environment. In recent years, various 3D models of cancer cells have been developed, notably in the form of spheroids/organoids, using scaffold or cancer-on-chip devices. However, these models have the disadvantage of not being able to precisely control the organization of multiple cell types in complex architecture and are sometimes not very reproducible in their production, and this is especially true for spheroids. Three-dimensional bioprinting can produce complex, multi-cellular, and reproducible constructs in which the matrix composition and rigidity can be adapted locally or globally to the tumor model studied. For these reasons, 3D bioprinting seems to be the technique of choice to mimic the tumor microenvironment in vivo as closely as possible. In this review, we discuss different 3D-bioprinting technologies, including bioinks and crosslinkers that can be used for in vitro cancer models and the techniques used to study cells grown in hydrogels; finally, we provide some applications of bioprinted cancer models.

Strontium Functionalization of Biomaterials for Bone Tissue Engineering Purposes: A Biological Point of View

Strontium (Sr) is a trace element taken with nutrition and found in bone in close connection to native hydroxyapatite. Sr is involved in a dual mechanism of coupling the stimulation of bone formation with the inhibition of bone resorption, as reported in the literature. Interest in studying Sr has increased in the last decades due to the development of strontium ranelate (SrRan), an orally active agent acting as an anti-osteoporosis drug. However, the use of SrRan was subjected to some limitations starting from 2014 due to its negative side effects on the cardiac safety of patients. In this scenario, an interesting perspective for the administration of Sr is the introduction of Sr ions in biomaterials for bone tissue engineering (BTE) applications. This strategy has attracted attention thanks to its positive effects on bone formation, alongside the reduction of osteoclast activity, proven by in vitro and in vivo studies. The purpose of this review is to go through the classes of biomaterials most commonly used in BTE and functionalized with Sr, i.e., calcium phosphate ceramics, bioactive glasses, metal-based materials, and polymers. The works discussed in this review were selected as representative for each type of the above-mentioned categories, and the biological evaluation in vitro and/or in vivo was the main criterion for selection. The encouraging results collected from the in vitro and in vivo biological evaluations are outlined to highlight the potential applications of materials’ functionalization with Sr as an osteopromoting dopant in BTE.

Phosphorous pentoxide-free bioactive glass exhibits dose-dependent angiogenic and osteogenic capacities which are retained in glass polymeric composite scaffolds

Bioactive glasses (BGs) are attractive materials for bone tissue engineering because of their bioactivity and osteoinductivity. In this study, we report the synthesis of a novel phosphorous pentoxide-free, silicate-based bioactive glass (52S-BG) composed of 52.1% SiO₂, 23.2% Na₂O and 22.6% CaO (wt%). The glass was thoroughly characterized. The biocompatibility and osteogenic properties of 52S-BG particles were analyzed in vitro with human adipose-derived mesenchymal stem cells (AdMSCs) and human osteoblasts. 52S-BG particles were biocompatible and induced mineralized matrix deposition and the expression of osteogenic markers (RunX2, alkaline phosphatase, osteocalcin, osteopontin, collagen I) and the angiogenic marker vascular endothelial growth factor (VEGF). Angiogenic properties were additionally confirmed in a zebrafish embryo model. 52S-BG was added to poly-ε-caprolactone (PCL) to obtain a composite with 10 wt% glass content. Composite PCL/52S-BG scaffolds were fabricated by additive manufacturing and displayed high porosity (76%) and pore interconnectivity. The incorporation of 52S-BG particles increased the Young's modulus of PCL scaffolds from 180 to 230 MPa. AdMSC seeding efficiency and proliferation were higher in PCL/52S-BG compared to PCL scaffolds, indicating improved biocompatibility. Finally, 52S-BG incorporation improved the scaffolds' osteogenic and angiogenic properties by increasing mineral deposition and inducing relevant gene expression and VEGF protein secretion. Overall, 52S-BG particles and PCL/52S-BG composites may be attractive for diverse bone engineering applications requiring concomitant angiogenic properties.

Poly-ε-Caprolactone/Fibrin-Alginate Scaffold: A New Pro-Angiogenic Composite Biomaterial for the Treatment of Bone Defects

We hypothesized that a composite of 3D porous melt-electrowritten poly-ɛ-caprolactone (PCL) coated throughout with a porous and slowly biodegradable fibrin/alginate (FA) matrix would accelerate bone repair due to its angiogenic potential. Scanning electron microscopy showed that the open pore structure of the FA matrix was maintained in the PCL/FA composites. Fourier transform infrared spectroscopy and differential scanning calorimetry showed complete coverage of the PCL fibres by FA, and the PCL/FA crystallinity was decreased compared with PCL. In vitro cell work with osteoprogenitor cells showed that they preferentially bound to the FA component and proliferated on all scaffolds over 28 days. A chorioallantoic membrane assay showed more blood vessel infiltration into FA and PCL/FA compared with PCL, and a significantly higher number of bifurcation points for PCL/FA compared with both FA and PCL. Implantation into a rat cranial defect model followed by microcomputed tomography, histology, and immunohistochemistry after 4- and 12-weeks post operation showed fast early bone formation at week 4, with significantly higher bone formation for FA and PCL/FA compared with PCL. However, this phenomenon was not extrapolated to week 12. Therefore, for long-term bone regeneration, tuning of FA degradation to ensure syncing with new bone formation is likely necessary.

Dissolution of Amorphous S53P4 Glass Scaffolds in Dynamic In Vitro Conditions

The silicate-based bioactive glass S53P4 is clinically used in bone regenerative applications in granule form. However, utilization of the glass in scaffold form has been limited by the high tendency of the glass to crystallize during sintering. Here, careful optimization of sintering parameters enabled the manufacture of porous amorphous S53P4 scaffolds with a strength high enough for surgical procedures in bone applications (5 MPa). Sintering was conducted in a laboratory furnace for times ranging from 25 to 300 min at 630 °C, i.e., narrowly below the commencement of the crystallization. The phase composition of the scaffolds was verified with XRD, and the ion release was tested in vitro and compared with granules in continuous flow of Tris buffer and simulated body fluid (SBF). The amorphous, porous S53P4 scaffolds present the possibility of using the glass composition in a wider range of applications.

3D Printed Composite Scaffolds in Bone Tissue Engineering: A systematic review

OBJECTIVE

This study aimed to analyze the effect of fabrication factors on both biological and physico-chemical features of 3-dimensional (3D) printed composite scaffolds.

METHOD

Electronic search was done according to the PRISMA guideline in PubMed and Scopus databases limited to English articles published until May 2021.Studies in which composite scaffolds were fabricated through computer-aided design and computer-aided manufacturing (CAD-CAM)-based methods were included.Articles regarding the features of the scaffolds fabricated through indirect techniques were excluded.

RESULTS

Full text of 121 studies were reviewed, and 69 met the inclusion criteria. According to analyzed studies, PCL and HA were the most commonly used polymer and ceramic,respectively. Besides,the Solvent-based technique was the most commonly used composition technique, which enabled preparing blends with high concentrations of ceramic materials. The most common fabrication method used in the included studies was Fused deposition modeling (FDM).The addition of bio-ceramics enhanced the mechanical features and the biological behaviors of the printed scaffolds in a ratio-dependent manner. However,studies that analyzed the effect of ceramic weight ratio showed that scaffolds with the highest ceramic content did not necessarily possess the optimal biological and non-biological features.

CONCLUSION

The biological and physico-chemical behaviors of the scaffold can be affected by pre-printing factors, including utilized materials, composition techniques, and fabrication methods. Fabricating scaffolds with high mineral content as of the natural bone may not provide the optimal condition for bone formation. Therefore, it is recommended that future studies compare the efficiency of different kinds of biomaterials rather than different weight ratios of one type.

Composite Scaffolds for Bone Tissue Regeneration Based on PCL and Mg-Containing Bioactive Glasses

Simple Summary

Polycaprolactone (PCL) is a bioresorbable and biocompatible polymer that has been widely used in long-term implants. However, when it comes to regenerative medicine, PCL suffers from some shortcomings such as a slow degradation rate, poor mechanical properties, and low cell adhesion. The incorporation of ceramics such as bioactive glasses into the PCL matrix has yielded a class of hybrid biomaterials with remarkably improved mechanical properties, controllable degradation rates, and enhanced bioactivity, which are suitable for bone tissue engineering. The use of conventional approaches (such as solvent casting and particulate leaching, phase separation, electrospinning, freeze drying, etc.) in realizing these composite scaffolds strongly affects the control of both the internal and the external architecture of scaffolds, including pore size, pore morphology, and overall structure porosity. Accordingly, 3D printing was used in this study because of the benefits offered over conventional methods, such as high flexibility in shape and size, high reproducibility, capabilities of precise control over internal architecture down to the microscale level, and a customized design that can be tailored to specific patient needs. The optimization of the scaffold structure was previously investigated in terms of architecture through the combination of the Taguchi method and CAD drawing, and, in this study, it was investigated by varying the composition of the composite material.

Abstract

Polycaprolactone (PCL) is widely used in additive manufacturing for the construction of scaffolds for tissue engineering because of its good bioresorbability, biocompatibility, and processability. Nevertheless, its use is limited by its inadequate mechanical support, slow degradation rate and the lack of bioactivity and ability to induce cell adhesion and, thus, bone tissue regeneration. In this study, we fabricated 3D PCL scaffolds reinforced with a novel Mg-doped bioactive glass (Mg-BG) characterized by good mechanical properties and biological reactivity. An optimization of the printing parameters and scaffold fabrication was performed; furthermore, an extensive microtopography characterization by scanning electron microscopy and atomic force microscopy was carried out. Nano-indentation tests accounted for the mechanical properties of the scaffolds, whereas SBF tests and cytotoxicity tests using human bone-marrow-derived mesenchymal stem cells (BM-MSCs) were performed to evaluate the bioactivity and in vitro viability. Our results showed that a 50/50 wt% of the polymer-to-glass ratio provides scaffolds with a dense and homogeneous distribution of Mg-BG particles at the surface and roughness twice that of pure PCL scaffolds. Compared to pure PCL (hardness H = 35 ± 2 MPa and Young’s elastic modulus E = 0.80 ± 0.05 GPa), the 50/50 wt% formulation showed H = 52 ± 11 MPa and E = 2.0 ± 0.2 GPa, hence, it was close to those of trabecular bone. The high level of biocompatibility, bioactivity, and cell adhesion encourages the use of the composite PCL/Mg-BG scaffolds in promoting cell viability and supporting mechanical loading in the host trabecular bone.

Recent Developments of Biomaterials for Additive Manufacturing of Bone Scaffolds

Recent years have witnessed surging demand for bone repair/regeneration implants due to the increasing number of bone defects caused by trauma, cancer, infection, and arthritis worldwide. In addition to bone autografts and allografts, biomaterial substitutes have been widely used in clinical practice. Personalized implants with precise and personalized control of shape, porosity, composition, surface chemistry, and mechanical properties will greatly facilitate the regeneration of bone tissue and satiate the clinical needs. Additive manufacturing (AM) techniques, also known as 3D printing, are drawing fast growing attention in the fabrication of implants or scaffolding materials due to their capability of manufacturing complex and irregularly shaped scaffolds in repairing bone defects in clinical practice. This review aims to provide a comprehensive overview of recent progress in the development of materials and techniques used in the additive manufacturing of bone scaffolds. In addition, clinical application, pre-clinical trials and future prospects of AM based bone implants are also summarized and discussed.

A comprehensive comparison of cell seeding methods using highly porous melt electrowriting scaffolds

Cell seeding is challenging in the case of additively manufactured 3-dimensional scaffolds, as the open macroscopic pore network impedes the retention of the seeding solution. The present study aimed at comparing several seeding conditions (no fetal bovine serum, 10% or 100% serum) and methods (Static seeding in Tissue Culture Treated plate (CT), Static seeding of the MES in non-Culture Treated plate (nCT), Seeding in nCT plate placed on an orbital shaker at 20 rpm (nCTR), Static seeding of the MES previously incubated with 100% FBS for 1 h to allow for protein adsorption (FBS)) commonly utilised in tissue engineering using highly porous melt electrowritten scaffolds, assessing their seeding efficacy, cell distribution homogeneity and reproducibility. Firstly, we demonstrated that the incubation in 100% serum was superior to the 10% serum pre-incubation and that 1 h only was sufficient to obtain enhanced cell attachment. We further compared this technique to the other methods and demonstrated significant and beneficial impact of the 100% serum pre-incubation, which resulted in enhanced efficacy, homogeneous cell distribution and high reproducibility, leading to accelerated colonisation/maturation of the tissue engineered constructs. We further showed the superior performance of this method using 3D-printed scaffolds also made of different polymers, demonstrating its capacity for up-scaling. Therefore, the pre-incubation of the scaffold in 100% serum is a simple yet highly effective method for enhancing cell adhesion and ensuring seeding reproducibility. This is crucial for tissue engineering applications, especially when cell availability is scarce, and for product standardisation from a translational perspective.

Fabrication and Application of a 3D-Printed Poly-ε-Caprolactone Cage Scaffold for Bone Tissue Engineering

Poly-ε-caprolactone (PCL) is a promising synthetic material in bone tissue engineering (BTE). Particularly, the introduction of rapid prototyping (RP) represents the possibility of manufacturing PCL scaffolds with customized appearances and structures. Bio-Oss is a natural bone mineral matrix with significant osteogenic effects; however, it has limitations in being constructed and maintained into specific shapes and sites. In this study, we used RP and fabricated a hollow-structured cage-shaped PCL scaffold loaded with Bio-Oss to form a hybrid scaffold for BTE. Moreover, we adopted NaOH surface treatment to improve PCL hydrophilicity and enhance cell adhesion. The results showed that the NaOH-treated hybrid scaffold could enhance the osteogenesis of human bone marrow-derived mesenchymal stem cells (hBMMSCs) both in vitro and in vivo. Altogether, we reveal a novel hybrid scaffold that not only possesses osteoinductive function to promote bone formation but can also be fabricated into specific forms. This scaffold design may have great application potential in bone tissue engineering.

Composite Membranes of Poly(ε-caprolactone) with Bisphosphonate-Loaded Bioactive Glasses for Potential Bone Tissue Engineering Applications

Poly(ε-caprolactone) (PCL) is a bioresorbable synthetic polyester with numerous biomedical applications. PCL membranes show great potential in guided tissue regeneration because they are biocompatible, occlusive and space maintaining, but lack osteoconductivity. Therefore, two different types of mesoporous bioactive glasses (SiO2-CaO-P2O5 and SiO2-SrO-P2O5) were synthesized and incorporated in PCL thin membranes by spin coating. To enhance the osteogenic effect of resulting membranes, the bioglasses were loaded with the bisphosphonate drug ibandronate prior to their incorporation in the polymeric matrix. The effect of the composition of the bioglasses as well as the presence of absorbed ibandronate on the physicochemical, cell attachment and differentiation properties of the PCL membranes was evaluated. Both fillers led to a decrease of the crystallinity of PCL, along with an increase in its hydrophilicity and a noticeable increase in its bioactivity. Bioactivity was further increased in the presence of a Sr substituted bioglass loaded with ibandronate. The membranes exhibited excellent biocompatibility upon estimation of their cytotoxicity on Wharton's Jelly Mesenchymal Stromal Cells (WJ-SCs), while they presented higher osteogenic potential in comparison with neat PCL after WJ-SCs induced differentiation towards bone cells, which was enhanced by a possible synergistic effect of Sr and ibandronate.

Strontium‑containing α‑calcium sulfate hemihydrate promotes bone repair via the TGF‑β/Smad signaling pathway

Calcium phosphate-based bone substitutes have been widely used for bone repair, augmentation and reconstruction in bone implant surgery. While some of these substitutes have shown excellent biological efficacy, there remains a need to improve the performance of the current calcium phosphate-based bone substitutes. Strontium ions (Sr) can promote new osteogenesis, inhibit osteoclast formation and increase osteoconductivity. However, the therapeutic effect and mechanism of strontium-containing α-calcium sulfate hemihydrate (Sr-CaS) remains unclear. The present study created bone injuries in rats and treated the injuries with Sr-CaS. Then Cell Counting Kit-8, soft agar colony formation, flow cytometry, Transwell and Alizarin Red staining assays were performed to assess the bone cells for their proliferation, growth, apoptosis, invasion, and osteogenic differentiation abilities. The bone reconstructive states were measured by the microCT method, hematoxylin and eosin staining and Masson staining. Bone-related factors were analyzed by the reverse transcription-quantitative PCR assay; transforming growth factor (TGF)-β, mothers against decapentaplegic homolog (Smad)2/3 and β-catenin expression was measured by western blot analysis and osteocalcin (OCN) expression was assessed by immunohistochemistry. Sr-CaS did not significantly affect the proliferation and apoptosis of bone marrow stem cells (BMSCs), but did accelerate the migration and osteogenic differentiation of BMSCs in vitro. Sr-CaS promoted bone repair and significantly increased the values for bone mineral density, bone volume fraction, and trabecular thickness, but decreased trabecular spacing in vivo in a concentration-dependent manner. In addition, Sr-CaS dramatically upregulated the expression levels of genes associated with osteogenic differentiation (Runt-related transcription factor 2, Osterix, ALP, OCN and bone sialoprotein) both in vitro and in vivo. Sr-CaS also increased Smad2/3, TGF-β and phosphorylated-β-catenin protein expression in vitro and in vivo. These results indicated that materials that contain 5 or 10% Sr can improve bone defects by regulating the TGF-β/Smad signaling pathway.

A comprehensive review of biodegradable synthetic polymer-ceramic composites and their manufacture for biomedical applications

The application of various materials in biomedical procedures has recently experienced rapid growth. One area that is currently receiving significant attention from the scientific community is the treatment of a number of different types of bone-related diseases and disorders by using biodegradable polymer-ceramic composites. Biomaterials, the most common materials used to repair or replace damaged parts of the human body, can be categorized into three major groups: metals, ceramics, and polymers. Composites can be manufactured by combining two or more materials to achieve enhanced biocompatibility and biomechanical properties for specific applications. Biomaterials must display suitable properties for their applications, about strength, durability, and biological influence. Metals and their alloys such as titanium, stainless steel, and cobalt-based alloys have been widely investigated for implant-device applications because of their excellent mechanical properties. However, these materials may also manifest biological issues such as toxicity, poor tissue adhesion and stress shielding effect due to their high elastic modulus. To mitigate these issues, hydroxyapatite (HA) coatings have been used on metals because their chemical composition is similar to that of bone and teeth. Recently, a wide range of synthetic polymers such as poly (l-lactic acid) and poly (l-lactide-co-glycolide) have been studied for different biomedical applications, owing to their promising biocompatibility and biodegradability. This article gives an overview of synthetic polymer-ceramic composites with a particular emphasis on calcium phosphate group and their potential applications in tissue engineering. It is hoped that synthetic polymer-ceramic composites such as PLLA/HA and PCL/HA will provide advantages such as eliminating the stress shielding effect and the consequent need for revision surgery.

Osteoconductive 3D porous composite scaffold from regenerated cellulose and cuttlebone-derived hydroxyapatite

Recently, usage of marine-derived materials in biomedical field has come into prominence due to their promising characteristics such as biocompatibility, low immunogenicity and wide accessibility. Among these marine sources, cuttlebone has been used as a valuable component with its trace elemental composition in traditional medicine. Recent studies have focused on the use of cuttlebone as a bioactive agent for tissue engineering applications. In this study, hydroxyapatite particles were obtained by hydrothermal synthesis of cuttlebone and incorporated to cellulose scaffolds to fabricate an osteoconductive composite scaffold for bone regeneration. Elemental analysis of raw cuttlebone material from different coastal zones and cuttlebone-derived HAp showed that various macro-, micro- and trace elements - Ca, P, Na, Mg, Cu, Sr, Cl, K, S, Br, Fe and Zn were found in a very similar amount. Moreover, biologically unfavorable heavy metals, such as Ag, Cd, Pb or V, were not detected in any cuttlebone specimen. Carbonated hydroxyapatite particle was further synthesized from cuttlebone microparticles via hydrothermal treatment and used as a mineral filler for the preparation of cellulose-based composite scaffolds. Interconnected highly porous structure of the scaffolds was confirmed by micro-computed tomography. The mean pore size of the scaffolds was 510 µm with a porosity of 85%. The scaffolds were mechanically characterized with a compression test and cuttlebone-derived HAp incorporation enhanced the mechanical properties of cellulose scaffolds. In vitro cell culture studies indicated that MG-63 cells proliferated well on scaffolds. In addition, cuttlebone-derived hydroxyapatite significantly induced the ALP activity and osteocalcin secretion. Besides, HAp incorporation increased the surface mineralization which is the major step for bone tissue regeneration.

Biocompatible Nanobioglass Reinforced Poly(ε-Caprolactone) Composites Synthesized via In Situ Ring Opening Polymerization

Poly(ε-caprolactone) (PCL) is a bioresorbable synthetic polyester widely studied as a biomaterial for tissue engineering and controlled release applications, but its low bioactivity and weak mechanical performance limits its applications. In this work, nanosized bioglasses with two different compositions (SiO₂–CaO and SiO₂–CaO–P₂O₅) were synthesized with a hydrothermal method, and each one was used as filler in the preparation of PCL nanocomposites via the in situ ring opening polymerization of ε-caprolactone. The effect of the addition of 0.5, 1 and 2.5 wt % of the nanofillers on the molecular weight, structural, mechanical and thermal properties of the polymer nanocomposites, as well as on their enzymatic hydrolysis rate, bioactivity and biocompatibility was systematically investigated. All nanocomposites exhibited higher molecular weight values in comparison with neat PCL, and mechanical properties were enhanced for the 0.5 and 1 wt % filler content, which was attributed to extensive interactions between the filler and the matrix, proving the superiority of in situ polymerization over solution mixing and melt compounding. Both bioglasses accelerated the enzymatic degradation of PCL and induced bioactivity, since apatite was formed on the surface of the nanocomposites after soaking in simulated body fluid. Finally, all samples were biocompatible as Wharton jelly-derived mesenchymal stem cells (WJ-MSCs) attached and proliferated on their surfaces.

Strength, toughness, and reliability of a porous glass/biopolymer composite scaffold

Development of bioactive glass and ceramic scaffolds intended for the reconstruction of large segmental bone defects remains a challenge for materials science due to the complexities involved in clinical implantation, bone-implant reaction, implant degradation and the multiple loading modes the implants subjected to. A comprehensive evaluation of the mechanical properties of inorganic scaffolds and exploration of new ways to toughen brittle constructs are critical prior to their successful application in loaded sites. A simple and widely adopted approach involves the coating of an inorganic scaffold with a polymeric material. In this work, a systematic evaluation of the influence of a biopolymer, polycaprolactone (PCL), coating on the mechanical performance of bioactive glass scaffolds was carried out. Results from this work indicate that a biopolymer PCL coating was more effective in increasing the compressive strength and reliability of the glass scaffold under compression, but less effective in improving its flexural strength or fracture toughness. This is the first report that reveals the limited successfulness of a polymer coating in improving the toughness of strong scaffolds, suggesting that new and novel ways of toughening inorganic scaffolds should be future research directions for scaffolds applied in loaded sites. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 1209-1217, 2018.

Electrospun F18 Bioactive Glass/PCL-Poly (ε-caprolactone)-Membrane for Guided Tissue Regeneration

Barrier membranes that are used for guided tissue regeneration (GTR) therapy usually lack bioactivity and the capability to promote new bone tissue formation. However, the incorporation of an osteogenic agent into polymeric membranes seems to be the most assertive strategy to enhance their regenerative potential. Here, the manufacturing of composite electrospun membranes made of poly (ε-caprolactone) (PCL) and particles of a novel bioactive glass composition (F18) is described. The membranes were mechanically and biologically tested with tensile strength tests and tissue culture with MG-63 osteoblast-like cell line, respectively. The PCL-F18 composite membranes demonstrated no increased cytotoxicity and an enhanced osteogenic potential when compared to pure PCL membranes. Moreover, the addition of the bioactive phase increased the membrane tensile strength. These preliminary results suggested that these new membranes can be a strong candidate for small bone injuries treatment by GTR technique.

Bone biomaterials and interactions with stem cells

Bone biomaterials play a vital role in bone repair by providing the necessary substrate for cell adhesion, proliferation, and differentiation and by modulating cell activity and function. In past decades, extensive efforts have been devoted to developing bone biomaterials with a focus on the following issues: (1) developing ideal biomaterials with a combination of suitable biological and mechanical properties; (2) constructing a cell microenvironment with pores ranging in size from nanoscale to submicro- and microscale; and (3) inducing the oriented differentiation of stem cells for artificial-to-biological transformation. Here we present a comprehensive review of the state of the art of bone biomaterials and their interactions with stem cells. Typical bone biomaterials that have been developed, including bioactive ceramics, biodegradable polymers, and biodegradable metals, are reviewed, with an emphasis on their characteristics and applications. The necessary porous structure of bone biomaterials for the cell microenvironment is discussed, along with the corresponding fabrication methods. Additionally, the promising seed stem cells for bone repair are summarized, and their interaction mechanisms with bone biomaterials are discussed in detail. Special attention has been paid to the signaling pathways involved in the focal adhesion and osteogenic differentiation of stem cells on bone biomaterials. Finally, achievements regarding bone biomaterials are summarized, and future research directions are proposed.

Fast-degrading PLA/ORMOGLASS fibrous composite scaffold leads to a calcium-rich angiogenic environment

The success of scaffold implantation in acellular tissue engineering approaches relies on the ability of the material to interact properly with the biological environment. This behavior mainly depends on the design of the graft surface and, more precisely, on its capacity to biodegrade in a well-defined manner (nature of ions released, surface-to-volume ratio, dissolution profile of this release, rate of material resorption, and preservation of mechanical properties). The assessment of the biological behavior of temporary templates is therefore very important in tissue engineering, especially for composites, which usually exhibit complicated degradation behavior. Here, blended polylactic acid (PLA) calcium phosphate ORMOGLASS (organically modified glass) nanofibrous mats have been incubated up to 4 weeks in physiological simulated conditions, and their morphological, topographical, and chemical changes have been investigated. The results showed that a significant loss of inorganic phase occurred at the beginning of the immersion and the ORMOGLASS maintained a stable composition afterward throughout the degradation period. As a whole, the nanostructured scaffolds underwent fast and heterogeneous degradation. This study reveals that an angiogenic calcium-rich environment can be achieved through fast-degrading ORMOGLASS/PLA blended fibers, which seems to be an excellent alternative for guided bone regeneration.

Via precise interface engineering towards bioinspired composites with improved 3D printing processability and mechanical properties

Precise interface engineering in inorganic–organic hybrid materials enhances both the elastic moduli and toughness of a biodegradable composite, which is of relevance for load-bearing applications in bone tissue engineering.

Polylactides in additive biomanufacturing

New advanced manufacturing technologies under the alias of additive biomanufacturing allow the design and fabrication of a range of products from pre-operative models, cutting guides and medical devices to scaffolds. The process of printing in 3 dimensions of cells, extracellular matrix (ECM) and biomaterials (bioinks, powders, etc.) to generate in vitro and/or in vivo tissue analogue structures has been termed bioprinting. To further advance in additive biomanufacturing, there are many aspects that we can learn from the wider additive manufacturing (AM) industry, which have progressed tremendously since its introduction into the manufacturing sector. First, this review gives an overview of additive manufacturing and both industry and academia efforts in addressing specific challenges in the AM technologies to drive toward AM-enabled industrial revolution. After which, considerations of poly(lactides) as a biomaterial in additive biomanufacturing are discussed. Challenges in wider additive biomanufacturing field are discussed in terms of (a) biomaterials; (b) computer-aided design, engineering and manufacturing; (c) AM and additive biomanufacturing printers hardware; and (d) system integration. Finally, the outlook for additive biomanufacturing was discussed.

In vitro colonization of stratified bioactive scaffolds by pre-osteoblast cells

Mesoporous bioactive glass-polycaprolactone (MBG-PCL) scaffolds have been prepared by robocasting, a layer by layer rapid prototyping method, by stacking of individual strati. Each stratus was independently analyzed during the cell culture tests with MC3T3-E1 preosteblast-like cells. The presence of MBG stimulates the colonization of the scaffolds by increasing the cell proliferation and differentiation. MBG-PCL composites not only enhanced pre-osteoblast functions but also allowed cell movement along its surface, reaching the upper stratus faster than in pure PCL scaffolds. The cells behavior on each individual stratus revealed that the scaffolds colonization depends on the chemical stimuli supplied by the MBG dissolution and surface changes associated to the apatite-like formation during the bioactive process. Finally, scanning electron and fluorescence microscopy revealed that the kinetic of cell migration strongly depends on the architectural features of the scaffolds, in such a way that layers interconnections are used as migration routes to reach the farther scaffolds locations from the initial cells source.

STATEMENT OF SIGNIFICANCE

This manuscript provides new insights on cell behavior in bioceramic/polymer macroporous scaffolds prepared by rapid prototyping methods. The experiments proposed in this work have allowed the evaluation of cell behavior within the different levels of the scaffolds, i.e. from the initials source of cells towards the farther scaffold locations. We could demonstrate that the in vitro cell colonization is encouraged by the presence of a highly bioactive mesoporous glass (MBG). This bioceramic enhances the cell migration towards upper strati through the dissolution of chemical signals and the changes occurred on the scaffolds surface during the bioactive process. In addition the MBG promotes preosteblastic proliferation and differentiation respect to scaffolds made of pure polycaprolactone. Finally, this study reveals the significance of the architectural design to accelerate the cell colonization. These experiments put light on the factors that should be taken into account to accelerate the regeneration processes under in vivo conditions.

Biodegradable ceramic-polymer composites for biomedical applications: A review

The present work focuses on the state-of-the-art of biodegradable ceramic-polymer composites with particular emphasis on influence of various types of ceramic fillers on properties of the composites. First, the general needs to create composite materials for medical applications are briefly introduced. Second, various types of polymeric materials used as matrices of ceramic-containing composites and their properties are reviewed. Third, silica nanocomposites and their material as well as biological characteristics are presented. Fourth, different types of glass fillers including silicate, borate and phosphate glasses and their effect on a number of properties of the composites are described. Fifth, wollastonite as a composite modifier and its effect on composite characteristics are discussed. Sixth, composites containing calcium phosphate ceramics, namely hydroxyapatite, tricalcium phosphate and biphasic calcium phosphate are presented. Finally, general possibilities for control of properties of composite materials are highlighted.

Ultrafast laser processing of materials: from science to industry

Processing of materials by ultrashort laser pulses has evolved significantly over the last decade and is starting to reveal its scientific, technological and industrial potential. In ultrafast laser manufacturing, optical energy of tightly focused femtosecond or picosecond laser pulses can be delivered to precisely defined positions in the bulk of materials via two-/multi-photon excitation on a timescale much faster than thermal energy exchange between photoexcited electrons and lattice ions. Control of photo-ionization and thermal processes with the highest precision, inducing local photomodification in sub-100-nm-sized regions has been achieved. State-of-the-art ultrashort laser processing techniques exploit high 0.1-1 μm spatial resolution and almost unrestricted three-dimensional structuring capability. Adjustable pulse duration, spatiotemporal chirp, phase front tilt and polarization allow control of photomodification via uniquely wide parameter space. Mature opto-electrical/mechanical technologies have enabled laser processing speeds approaching meters-per-second, leading to a fast lab-to-fab transfer. The key aspects and latest achievements are reviewed with an emphasis on the fundamental relation between spatial resolution and total fabrication throughput. Emerging biomedical applications implementing micrometer feature precision over centimeter-scale scaffolds and photonic wire bonding in telecommunications are highlighted.

Micro-CT Analysis of Bone Healing in Rabbit Calvarial Critical-Sized Defects with Solid Bioactive Glass, Tricalcium Phosphate Granules or Autogenous Bone

Objectives

The purpose of the present study was to evaluate bone healing in rabbit critical-sized calvarial defects using two different synthetic scaffold materials, solid biodegradable bioactive glass and tricalcium phosphate granules alongside solid and particulated autogenous bone grafts.

Material and Methods

Bilateral full thickness critical-sized calvarial defects were created in 15 New Zealand white adult male rabbits. Ten defects were filled with solid scaffolds made of bioactive glass or with porous tricalcium phosphate granules. The healing of the biomaterial-filled defects was compared at the 6 week time point to the healing of autologous bone grafted defects filled with a solid cranial bone block in 5 defects and with particulated bone combined with fibrin glue in 10 defects. In 5 animals one defect was left unfilled as a negative control. Micro-computed tomography (micro-CT) was used to analyze healing of the defects.

Results

Micro-CT analysis revealed that defects filled with tricalcium phosphate granules showed new bone formation in the order of 3.89 (SD 1.17)% whereas defects treated with solid bioactive glass scaffolds showed 0.21 (SD 0.16)%, new bone formation. In the empty negative control defects there was an average new bone formation of 21.8 (SD 23.7)%.

Conclusions

According to findings in this study, tricalcium phosphate granules have osteogenic potential superior to bioactive glass, though both particulated bone with fibrin glue and solid bone block were superior defect filling materials.

Data for accelerated degradation of calcium phosphate surface-coated polycaprolactone and polycaprolactone/bioactive glass composite scaffolds

Polycaprolactone (PCL)-based composite scaffolds containing 50 wt% of 45S5 bioactive glass (45S5) or strontium-substituted bioactive glass (SrBG) particles were fabricated into scaffolds using melt-extrusion based additive manufacturing technique. Additionally, the PCL scaffolds were surface coated with a layer of calcium phosphate (CaP). For a comparison of the scaffold degradation, the scaffolds were then subjected to in vitro accelerated degradation by immersion in 5 M sodium hydroxide (NaOH) solution for up to 7 days. The scaffold׳s morphology was observed by means of SEM imaging and scaffold mass loss was recorded over the experimental period.

Indirect rapid prototyping of sol-gel hybrid glass scaffolds for bone regeneration - Effects of organic crosslinker valence, content and molecular weight on mechanical properties

We present a series of organic/inorganic hybrid sol-gel derived glasses, made from a tetraethoxysilane-derived silica sol (100% SiO2) and oligovalent organic crosslinkers functionalized with 3-isocyanatopropyltriethoxysilane. The material was susceptible to heat sterilization. The hybrids were processed into pore-interconnected scaffolds by an indirect rapid prototyping method, described here for the first time for sol-gel glass materials. A large panel of polyethylene oxide-derived 2- to 4-armed crosslinkers of molecular weights ranging between 170 and 8000Da were incorporated and their effect on scaffold mechanical properties was investigated. By multiple linear regression, 'organic content' and the 'content of ethylene oxide units in the hybrid' were identified as the main factors that determined compressive strength and modulus, respectively. In general, 3- and 4-armed crosslinkers performed better than linear molecules. Compression tests and cell culture experiments with osteoblast-like SaOS-2 cells showed that macroporous scaffolds can be produced with compressive strengths of up to 33±2MPa and with a pore structure that allows cells to grow deep into the scaffolds and form mineral deposits. Compressive moduli between 27±7MPa and 568±98MPa were obtained depending on the hybrid composition and problems associated with the inherent brittleness of sol-gel glass materials could be overcome. SaOS-2 cells showed cytocompatibility on hybrid glass scaffolds and mineral accumulation started as early as day 7. On day 14, we also found mineral accumulation on control hybrid glass scaffolds without cells, indicating a positive effect of the hybrid glass on mineral accumulation.

STATEMENT OF SIGNIFICANCE

We produced a hybrid sol-gel glass material with significantly improved mechanical properties towards an application in bone regeneration and processed the material into macroporous scaffolds of controlled architecture by indirect rapid prototyping. We were able to produce macroporous materials of relevant porosity and pore size with compressive moduli, covering the range reported for cancellous bone while an even higher compressive strength was maintained. By multiple linear regression, we identified crosslinker parameters, namely organic content and the content of ethylene oxide units in the hybrids that predominantly determined the mechanics of the hybrid materials. The scaffolds proved to be cytocompatible and induced mineralization in SaOS-2 cells. This provides new insight on the critical parameters for the design of the organic components of covalent hybrid sol-gel glasses.

In vitro and in vivo bone formation potential of surface calcium phosphate-coated polycaprolactone and polycaprolactone/bioactive glass composite scaffolds

In this study, polycaprolactone (PCL)-based composite scaffolds containing 50wt% of 45S5 Bioglass(®) (45S5) or strontium-substituted bioactive glass (SrBG) particles were fabricated into scaffolds using an additive manufacturing technique for bone tissue engineering purposes. The PCL scaffolds were surface coated with calcium phosphate (CaP) to enable further comparison of the osteoinductive potential of different scaffolds: PCL (control), PCL/CaP-coated, PCL/50-45S5 and PCL/50-SrBG scaffolds. The PCL/50-45S5 and PCL/50-SrBG composite scaffolds were reproducibly manufactured with a morphology highly resembling that of PCL only scaffolds. However, 50wt% loading of the bioactive glass (BG) particles into the PCL bulk decreased the scaffold's compressive Young's modulus. Coating of PCL scaffolds with CaP had a negligible effect on the scaffold's porosity and compressive Young's modulus. When immersed in culture media, BG dissolution ions (Si and Sr) were detected for up to 10weeks in the immersion media and surface precipitates were formed on both PCL/50-45S5 and PCL/50-SrBG scaffolds' surfaces, indicating good in vitro bioactivity. In vitro cell studies were conducted using sheep bone marrow stromal cells (BMSCs) under non-osteogenic or osteogenic conditioned media, and under static or dynamic culture environments. All scaffolds were able to support cell adhesion, growth and proliferation. However, when cultured in non-osteogenic media, only PCL/CaP, PCL/50-45S5 and PCL/50-SrBG scaffolds showed an up-regulation of osteogenic gene expression. Additionally, under a dynamic culture environment, the rate of cell growth, proliferation and osteoblast-related gene expression was enhanced across all scaffold groups. Subsequently, PCL/CaP, PCL/50-45S5 and PCL/50-SrBG scaffolds, with or without seeded cells, were implanted subcutaneously into nude rats for the evaluation of osteoinductivity potential. After 8 and 16weeks, host tissue infiltrated well into the scaffolds, but no mature bone formation was observed in any scaffolds groups.

STATEMENT OF SIGNIFICANCE

This novelty of this research work is that it provide a comprehensive comparison, both in vitro and in vivo, between 3 different composite materials widely used in the field of bone tissue engineering for their bone regeneration capabilities. The materials used in this study include polycaprolactone, 45S5 Bioglass, strontium-substituted bioactive glass and calcium phosphate. Additionally, the composite materials were fabricated into the form of 3D scaffolds using additive manufacturing technique, a widely used technique in tissue engineering.

Osteoinduction of bone grafting materials for bone repair and regeneration

Regeneration of bone defects caused by trauma, infection, tumours or inherent genetic disorders is a clinical challenge that usually necessitates bone grafting materials. Autologous bone or autograft is still considered the clinical "gold standard" and the most effective method for bone regeneration. However, limited bone supply and donor site morbidity are the most important disadvantages of autografting. Improved biomaterials are needed to match the performance of autograft as this is still superior to that of synthetic bone grafts. Osteoinductive materials would be the perfect candidates for achieving this task. The aim of this article is to review the different groups of bone substitutes in terms of their most recently reported osteoinductive properties. The different factors influencing osteoinductivity by biomaterials as well as the mechanisms behind this phenomenon are also presented, showing that it is very limited compared to osteoinductivity shown by bone morphogenetic proteins (BMPs). Therefore, a new term to describe osteoinductivity by biomaterials is proposed. Different strategies for adding osteoinductivity (BMPs, stem cells) to bone substitutes are also discussed. The overall objective of this paper is to gather the current knowledge on osteoinductivity of bone grafting materials for the effective development of new graft substitutes that enhance bone regeneration.

Cytotoxicity of resin composites containing bioactive glass fillers

OBJECTIVE

To determine the in vitro cytotoxicity of dental composites containing bioactive glass fillers.

METHODS

Dental composites (50:50 Bis-GMA/TEGDMA resin: 72.5wt% filler, 67.5%Sr-glass and 5% OX50) containing different concentrations (0, 5, 10 and 15wt%) of two sol-gel bioactive glasses, BAG65 (65mole% SiO2, 31mole% CaO, 4mole% P2O5) and BAG61 (3mole% F added) were evaluated for cytotoxicity using Alamar Blue assay. First, composite extracts were obtained from 7 day incubations of composites in cell culture medium at 37°C. Undifferentiated pulp cells (OD-21) were exposed to dilutions of the original extracts for 3, 5, and 7 days. Then freshly cured composite disks were incubated with OD-21 cells (n=5) for 2 days. Subsequently, fresh composite disks were incubated in culture medium at 37°C for 7 days, and then the extracted disks were incubated with OD-21 cells for 2 days. Finally, fresh composites disks were light cured for 3, 5, and 20s and incubated with OD-21 cells (n=5) for 1, 3, 5, and 7 days. To verify that the three different curing modes produced different levels of degree of conversion (DC), the DC of each composite was determined by FTIR. Groups (n=5) were compared with ANOVA/Tukey's (α≤0.05).

RESULTS

Extracts from all composites significantly reduced cell viability until a dilution of 1:8 or lower, where the extract became equal to the control. All freshly-cured composites showed significantly reduced cell viability at two days. However, no reduction in cell viability was observed for any composite that had been previously soaked in media before exposure to the cells. Composites with reduced DC (3s vs. 20s cure), as verified by FTIR, showed significantly reduced cell viability.

SIGNIFICANCE

The results show that the composites, independent of composition, had equivalent potency in terms of reducing the viability of the cells in culture. Soaking the composites for 7 days before exposing them to the cells suggested that the "toxic" components had been extracted and the materials were no longer cytotoxic. The results demonstrate that the cytotoxicity of composites with and without BAG must predominantly be attributed to the release of residual monomers, and not to the presence of the BAG.