Properties of calcium phosphate ceramics in relation to their in vivo behavior

Exploring the potential of calcium-based biomaterials for bone regeneration in dentistry: a systematic review

INTRODUCTION

Regenerative medicine emerged as a promising strategy for addressing bone defects, with several bone grafts currently being used, including autografts, allografts, xenografts and alloplasts. Calcium-based biomaterials (CaXs), a well-known class of synthetic materials, have demonstrated good biological properties and are being investigated for their potential to facilitate bone regeneration. This systematic review evaluates the current clinical applications of CaXs in dentistry for bone regeneration.

EVIDENCE ACQUISITION

A comprehensive search was conducted to collect information about CaXs and their applications in the dental field over the last ten years. The search was limited to relevant articles published in peer-reviewed journals.

EVIDENCE SYNTHESIS

A total of 72 articles were included in this scoping review, with eight studies related to periodontology, 63 in implantology and three in maxillofacial surgery respectively. The findings suggest that CaXs hold promise as an alternative intervention for minor bone regeneration in dentistry.

CONCLUSIONS

Calcium-based biomaterials have shown potential as a viable option for bone regeneration in dentistry. Further research is warranted to fully understand their efficacy and safety in larger bone defects. CaXs represent an exciting avenue for researchers and clinicians to explore in their ongoing efforts to advance regenerative medicine.

Bioactive ceramic-based materials: beneficial properties and potential applications in dental repair and regeneration

Bioactive ceramics, primarily consisting of bioactive glasses, glass-ceramics, calcium orthophosphate ceramics, calcium silicate ceramics and calcium carbonate ceramics, have received great attention in the past decades given their biocompatible nature and excellent bioactivity in stimulating cell proliferation, differentiation and tissue regeneration. Recent studies have tried to combine bioactive ceramics with bioactive ions, polymers, bioactive proteins and other chemicals to improve their mechanical and biological properties, thus rendering them more valid in tissue engineering scaffolds. This review presents the beneficial properties and potential applications of bioactive ceramic-based materials in dentistry, particularly in the repair and regeneration of dental hard tissue, pulp-dentin complex, periodontal tissue and bone tissue. Moreover, greater insights into the mechanisms of bioactive ceramics and the development of ceramic-based materials are provided.

Synthetic Calcium-Phosphate Materials for Bone Grafting

Synthetic bone grafting materials play a significant role in various medical applications involving bone regeneration and repair. Their ability to mimic the properties of natural bone and promote the healing process has contributed to their growing relevance. While calcium-phosphates and their composites with various polymers and biopolymers are widely used in clinical and experimental research, the diverse range of available polymer-based materials poses challenges in selecting the most suitable grafts for successful bone repair. This review aims to address the fundamental issues of bone biology and regeneration while providing a clear perspective on the principles guiding the development of synthetic materials. In this study, we delve into the basic principles underlying the creation of synthetic bone composites and explore the mechanisms of formation for biologically important complexes and structures associated with the various constituent parts of these materials. Additionally, we offer comprehensive information on the application of biologically active substances to enhance the properties and bioactivity of synthetic bone grafting materials. By presenting these insights, our review enables a deeper understanding of the regeneration processes facilitated by the application of synthetic bone composites.

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

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

Laser Sintering Approaches for Bone Tissue Engineering

The adoption of additive manufacturing (AM) techniques into the medical space has revolutionised tissue engineering. Depending upon the tissue type, specific AM approaches are capable of closely matching the physical and biological tissue attributes, to guide tissue regeneration. For hard tissue such as bone, powder bed fusion (PBF) techniques have significant potential, as they are capable of fabricating materials that can match the mechanical requirements necessary to maintain bone functionality and support regeneration. This review focuses on the PBF techniques that utilize laser sintering for creating scaffolds for bone tissue engineering (BTE) applications. Optimal scaffold requirements are explained, ranging from material biocompatibility and bioactivity, to generating specific architectures to recapitulate the porosity, interconnectivity, and mechanical properties of native human bone. The main objective of the review is to outline the most common materials processed using PBF in the context of BTE; initially outlining the most common polymers, including polyamide, polycaprolactone, polyethylene, and polyetheretherketone. Subsequent sections investigate the use of metals and ceramics in similar systems for BTE applications. The last section explores how composite materials can be used. Within each material section, the benefits and shortcomings are outlined, including their mechanical and biological performance, as well as associated printing parameters. The framework provided can be applied to the development of new, novel materials or laser-based approaches to ultimately generate bone tissue analogues or for guiding bone regeneration.

Effects of Pore Interconnectivity on Bone Regeneration in Carbonate Apatite Blocks

Porous architecture in bone substitutes, notably the interconnectivity of pores, is a critical factor for bone ingrowth. However, controlling the pore interconnectivity while maintaining the microarchitecture has not yet been achieved using conventional methods, such as sintering. Herein, we fabricated a porous block using the crystal growth of calcium sulfate dihydrate, and controlled the pore interconnectivity by limiting the region of crystal growth. The calcium sulfate dihydrate blocks were transformed to bone apatite, carbonate apatite (CO₃Ap) through dissolution–precipitation reactions. Thus, CO₃Ap blocks with 15% and 30% interconnected pore volumes were obtained while maintaining the microarchitecture: they were designated as CO₃Ap-15 and CO₃Ap-30, respectively. At 4 weeks after implantation in a rabbit femur defect, new bone formed throughout CO₃Ap-30, whereas little bone was formed in the center region of CO₃Ap-15. At 12 weeks after implantation, a large portion of CO₃Ap-30 was replaced with new bone and the boundary with the host bone became blurred. In contrast, CO₃Ap-15 remained in the defect and the boundary with the host bone was still clear. Thus, the interconnected pores promote bone ingrowth, followed by replacement of the material with new bone. These findings provide a useful guide for designing bone substitutes for rapid bone regeneration.

The application of Bonelike® Poro as a synthetic bone substitute for the management of critical-sized bone defects - A comparative approach to the autograft technique - A preliminary study

The effective treatment of non-unions and critical-sized defects remains a challenge in the orthopedic field. From a tissue engineering perspective, this issue can be addressed through the application bioactive matrixes to support bone regeneration, such as Bonelike®, as opposed to the widespread autologous grafting technique. An improved formulation of Bonelike® Poro, was assessed as a synthetic bone substitute in an ovine model for critical-sized bone defects. Bone regeneration was assessed after 5 months of recovery through macro and microscopic analysis of the healing features of the defect sites. Both the application of natural bone graft or Bonelike® Poro resulted in bridging of the defects margins. Untreated defect remained as fibrous non-unions at the end of the study period. The characteristics of the newly formed bone and its integration with the host tissue were assessed through histomorphometric and histological analysis, which demonstrated Bonelike® Poro to result in improved healing of the defects. The group treated with synthetic biomaterial presented bone bridges of increased thickness and bone features that more closely resembled the native spongeous and cortical bone. The application of Bonelike® Poro enabled the regeneration of critical-sized lesions and performed comparably to the autograph technique, validating its octeoconductive and osteointegrative potential for clinical application as a therapeutic strategy in human and veterinary orthopedics.

Calcium phosphate cements: Optimization toward biodegradability

Synthetic calcium phosphate (CaP) ceramics represent the most widely used biomaterials for bone regenerative treatments due to their biological performance that is characterized by bioactivity and osteoconductive properties. From a clinical perspective, injectable CaP cements (CPCs) are highly appealing, as CPCs can be applied using minimally invasive surgery and can be molded to optimally fill irregular bone defects. Such CPCs are prepared from a powder and a liquid component, which upon mixing form a paste that can be injected into a bone defect and hardens in situ within an appropriate clinical time window. However, a major drawback of CPCs is their poor degradability. Ideally, CPCs should degrade at a suitable pace to allow for concomitant new bone to form. To overcome this shortcoming, control over CPC degradation has been explored using multiple approaches that introduce macroporosity within CPCs. This strategy enables faster degradation of CPC by increasing the surface area available to interact with the biological surroundings, leading to accelerated new bone formation. For a comprehensive overview of the path to degradable CPCs, this review presents the experimental procedures followed for their development with specific emphasis on (bio)material properties and biological performance in pre-clinical bone defect models.

In Vitro and In Vivo Biocompatibility Studies of a Cast and Coated Titanium Alloy

The biocompatibility of a cast porous and with a calcium titanate reaction layer functionalized titanium alloy (Ti-6Al-7Nb) was tested by means of cell culture, and a small (rat) and large animal (sheep) model. The uncoated titanium material served as a control. In-vitro tests included the validation of osteoblast-like cells attached to the surface of the material with scanning electron microscopy and immunofluorescence of cytoskeletal actin as well as their osteogenic development, the ability to mineralize, and their vitality. Following the in-vitro tests a small animal (rat) and big animal (sheep) model were accomplished by inserting a cylindrical titanium implant into a drill hole defect in the femoral condyle. After 7, 14, and 30 days (rat) and 6 months (sheep) the condyles were studied regarding histological and histomorphometrical characteristics. Uncoated and coated material showed a good biocompatibility both in cell culture and animal models. While the defect area in the rat is well consolidated after 30 days, the sheep show only little bone inside the implant after 6 months, possibly due to stress shielding. None of the executed methods indicated a statistically significant difference between coated and uncoated material.

Calcium phosphate cement and locked plate augmentation of distal femoral defects: A biomechanical analysis

PURPOSE

Bone tumors are common in the distal femur and often treated with intralesional curettage. The optimal method of stabilization of large distal femoral defects after curettage remains unclear. The goal of this study is to compare stabilization techniques for large distal femoral defects.

METHODS

Large defects (60 cm³) were milled in the distal lateral metaphysis of 45 adult composite sawbone femurs. The defect was either (1) left untreated or reconstructed with (2) locked plate fixation, (3) calcium phosphate cement packing, or (4) locked plate fixation with calcium phosphate cement packing, or (5) polymethylmethacrylate packing. Each specimen then underwent axial and torsional stiffness testing followed by torsional loading to failure. The data were analyzed using ANOVA with Tukey-Kramer post-hoc analysis.

RESULTS

The calcium phosphate cement filled defect with a locked plate was the stiffest construct in axial and torsional loading as well as the strongest in torque to failure. However, this difference only reached significance with respect to all other groups in torque to failure testing. The calcium phosphate cement filled defect with a locked plate was significantly stiffer than three of the four other groups in both axial and torsional stiffness testing.

CONCLUSIONS

These results indicate that calcium phosphate cement, with or without the addition of locked plate fixation, may provide improved construct stability under time zero testing conditions. This result warrants further testing under cyclic loading condition and consideration for fixation of large femoral metaphyseal defects in future clincal trails.

Promoted Osteoconduction of Polyurethane-Urea Based 3D Nanohybrid Scaffold through Nanohydroxyapatite Adorned Hierarchical Titanium Phosphate

The lack of optimal physiological properties, bacterial colonization, and auto-osteoinduction, are the foremost issues of orthopedic implantations. In terms of bone healing, many researchers have reported the release of additional growth factors of the implanted biomaterials to accelerate the bone regeneration process. However, the additional growth factor may cause side effects such as contagion, nerve pain, and the formation of ectopic bone. Thus, the design of an osteoconductive scaffold having excellent biocompatibility, appropriate physicomechanical properties, and promoted auto osteoinductivity with antibacterial activity is greatly desired. In this study, 2D rodlike nanohydroxyapatite (nHA) adorned titanium phosphate (TP) with a flowerlike morphology was synthesized by a hydrothermal precipitation reaction. The nanohybrid material (nHA-TP) was incorporated into the synthesized polycaprolactone diol and spermine based thermoplastic polyurethane-urea (PUU) via in situ technique followed by salt leaching to fabricate the macroporous 3D polymer nanohybrid scaffold (PUU/nHA-TP). Structure explication of PUU was performed by NMR spectroscopy. The synthesized nanohybrid scaffold with 1% nHA-TP showed 67% increase of tensile strength and 18% improved modulus compared to the pristine PUU via formation of H-bonding or dative bonds between the metal and the amide linkage of the polyurethane or polyurea. In vitro study showing improved cell viability and proliferation of the seeded cell revealed the superior osteoconductivity of the nanohybrid scaffold. Most importantly, the in vivo experiments revealed a significant amount of bone regeneration in the nanohybrid scaffold implanted tibial site compared to the pristine scaffold without any toxic effect. Introduction of the minute amount of titanium phosphate within the adorned nHA promotes the osteoconductivity significantly by the capability of forming coordinate bonds of the titanium ion. Depending on the mechanical, physicochemical, in vitro characteristics, and in vivo osteoconductivity, the PUU/nHA-TP nanohybrid scaffold has great potential as an alternative biomaterial in bone tissue regeneration application.

Chemical, Clinical and Histomorphometric Comparison between Equine Bone Manufactured through Enzymatic Antigen-Elimination and Bovine Bone Made Non-Antigenic Using a High-Temperature Process in Post-Extractive Socket Grafting. A Comparative Retrospective Clinical Study

Enzyme-deantigenic equine bone (EDEB) and anorganic bovine bone (ABB) are two xenografts made non-antigenic through different processing methods. This study aimed to characterize them for the presence of native bone collagen and other proteins and to compare their histomorphometric outcome when they were used to graft post-extractive sockets. The records of 46 patients treated with EDEB (n = 22) or ABB (n = 24) and followed-up for at least four months after delayed implant placement, were retrospectively collected. Samples of EDEB and ABB were analyzed using Attenuated Total Reflection Fourier Transform Infrared and Sodium Dodecyl Sulfate-Polyacrylamide Gel Electrophoresis for the presence of collagen and other proteins. For histomorphometric analysis on bone specimens, newly formed bone and residual biomaterial percentages were calculated. Results of the present study show that EDEB contains type I bone collagen in its native conformation, while no proteins were detected in ABB. Grafting EDEB resulted in a significantly greater quantity of newly formed bone and less residual biomaterial. Our findings suggest that the manufacturing process can greatly affect the graft behavior and a process preserving collagen in its native form may favor bone tissue regeneration.

Novel bioresorbable tricalcium phosphate/polyhydroxyoctanoate (TCP/PHO) composites as scaffolds for bone tissue engineering applications

Development of new composite materials for bone tissue engineering is a constantly growing field of medicine. Therefore there is a continuous need in creating novel materials that can not only regenerate the defected tissue but also nourish it while the healing process progresses. Here we present a novel type of composite material that fulfils these requirements. The study describes creation of a composite with macroporous bioceramic core that is infiltrated with a thin biopolymer layer. The ceramic component, namely tricalcium phosphate (TCP), due to its mechanistic and bioactive properties may promote new bone creation as shown through the in vitro studies. To the best of our knowledge the coating layer was created for the first time from a representative of bacterially derived medium chain length polyhydroxyalkanoate polymers (mcl-PHA), namely polyhydroxyoctanoate (PHO). This polymer layer not only profoundly changed the stress-strain characteristics of the bioceramic foam but also released (R)-3-hydroxyacids and their dimers/trimers to the investigated environment. In the manuscript we have in depth characterised these materials employing a set of basic procedures, through 3D structure reconstruction and finishing with prolonged in vitro experiments.

Functional self-assembled neocartilage as part of a biphasic osteochondral construct

Bone-to-bone integration can be obtained by osteoconductive ceramics such as hydroxyapatite (HAp) and beta-tricalcium phosphate (β-TCP), but cartilage-to-cartilage integration is notoriously difficult. Many cartilage repair therapies, including microfracture and mosaicplasty, capitalize on the reparative aspects of subchondral bone due to its resident population of stem cells and vascularity. A strategy of incorporating tissue engineered neocartilage into a ceramic to form an osteochondral construct may serve as a suitable alternative to achieve cartilage graft fixation. The use of a tissue engineered osteochondral construct to repair cartilage defects may also benefit from the ceramic’s proximity to underlying bone and abundant supply of progenitor cells and nutrients. The objective of the first study was to compare HAp and β-TCP ceramics, two widely used ceramics in bone regeneration, in terms of their ability to influence neocartilage interdigitation at an engineered osteochondral interface. Additional assays quantified ceramic pore size, porosity, and compressive strength. The compressive strength of HAp was six times higher than that of β-TCP due to differences in porosity and pore size, and HAp was thus carried forward in the second study as the composition with which to engineer an osteochondral construct. Importantly, it was shown that incorporation of the HAp ceramic in conjunction with the self-assembling process resulted in functionally viable neocartilage. For example, only collagen/dry weight and ultimate tensile strength of the chondral control constructs remained significantly greater than the neocartilage cut off the osteochondral constructs. By demonstrating that the functional properties of engineered neocartilage are not negatively affected by the inclusion of an HAp ceramic in culture, neocartilage engineering strategies may be directly applied to the formation of an osteochondral construct.

Optimized Bone Regeneration in Calvarial Bone Defect Based on Biodegradation-Tailoring Dual-shell Biphasic Bioactive Ceramic Microspheres

Bioceramic particulates capable of filling bone defects have gained considerable interest over the last decade. Herein, dual-shell bioceramic microspheres (CaP@CaSi@CaP, CaSi@CaP@CaSi) with adjustable beta-tricalcium phosphate (CaP) and beta-calcium silicate (CaSi) distribution were fabricated using a co-concentric capillary system enabling bone repair via a tailorable biodegradation process. The in vitro results showed the optimal concentration (1/16 of 200 mg/ml) of extracts of dual-shell microspheres could promote bone marrow mesenchymal cell (BMSC) proliferation and enhance the level of ALP activity and Alizarin Red staining. The in vivo bone repair and microsphere biodegradation in calvarial bone defects were compared using micro-computed tomography and histological evaluations. The results indicated the pure CaP microspheres were minimally resorbed at 18 weeks post-operatively and new bone tissue was limited; however, the dual-shell microspheres were appreciably biodegraded with time in accordance with the priority from CaSi to CaP in specific layers. The CaSi@CaP@CaSi group showed a significantly higher ability to promote bone regeneration than the CaP@CaSi@CaP group. This study indicates that the biphasic microspheres with adjustable composition distribution are promising for tailoring material degradation and bone regeneration rate, and such versatile design strategy is thought to fabricate various advanced biomaterials with tailorable biological performances for bone reconstruction.

Involvement of FAK-mediated BMP-2/Smad pathway in mediating osteoblast adhesion and differentiation on nano-HA/chitosan composite coated titanium implant under diabetic conditions

Nanophase HA/CS composite coated porous titanium implant exhibited superior biological performance under diabetic conditions compared to pure Ti.

Engineering Concepts in Stem Cell Research

The field of regenerative medicine integrates advancements made in stem cells, molecular biology, engineering, and clinical methodologies. Stem cells serve as a fundamental ingredient for therapeutic application in regenerative medicine. Apart from stem cells, engineering concepts have equally contributed to the success of stem cell based applications in improving human health. The purpose of various engineering methodologies is to develop regenerative and preventive medicine to combat various diseases and deformities. Explosion of stem cell discoveries and their implementation in clinical setting warrants new engineering concepts and new biomaterials. Biomaterials, microfluidics, and nanotechnology are the major engineering concepts used for the implementation of stem cells in regenerative medicine. Many of these engineering technologies target the specific niche of the cell for better functional capability. Controlling the niche is the key for various developmental activities leading to organogenesis and tissue homeostasis. Biomimetic understanding not only helped to improve the design of the matrices or scaffolds by incorporating suitable biological and physical components, but also ultimately aided adoption of designs that helped these materials/devices have better function. Adoption of engineering concepts in stem cell research improved overall achievement, however, several important issues such as long-term effects with respect to systems biology needs to be addressed. Here, in this review the authors will highlight some interesting breakthroughs in stem cell biology that use engineering methodologies.

Enhancement of Osteoblastic-Like Cell Activity by Glow Discharge Plasma Surface Modified Hydroxyapatite/β-Tricalcium Phosphate Bone Substitute

Glow discharge plasma (GDP) treatments of biomaterials, such as hydroxyapatite/β-tricalcium phosphate (HA/β-TCP) composites, produce surfaces with fewer contaminants and may facilitate cell attachment and enhance bone regeneration. Thus, in this study we used argon glow discharge plasma (Ar-GDP) treatments to modify HA/β-TCP particle surfaces and investigated the physical and chemical properties of the resulting particles (HA/β-TCP + Ar-GDP). The HA/β-TCP particles were treated with GDP for 15 min in argon gas at room temperature under the following conditions: power: 80 W; frequency: 13.56 MHz; pressure: 100 mTorr. Scanning electron microscope (SEM) observations showed similar rough surfaces of HA/β-TCP + Ar-GDP HA/β-TCP particles, and energy dispersive spectrometry analyses showed that HA/β-TCP surfaces had more contaminants than HA/β-TCP + Ar-GDP surfaces. Ca/P mole ratios in HA/β-TCP and HA/β-TCP + Ar-GDP were 1.34 and 1.58, respectively. Both biomaterials presented maximal intensities of X-ray diffraction patterns at 27° with 600 a.u. At 25° and 40°, HA/β-TCP + Ar-GDP and HA/β-TCP particles had peaks of 200 a.u., which are similar to XRD intensities of human bone. In subsequent comparisons, MG-63 cell viability and differentiation into osteoblast-like cells were assessed on HA/β-TCP and HA/β-TCP + Ar-GDP surfaces, and Ar-GDP treatments led to improved cell growth and alkaline phosphatase activities. The present data indicate that GDP surface treatment modified HA/β-TCP surfaces by eliminating contaminants, and the resulting graft material enhanced bone regeneration.

Biomimetic surface functionalization of clinically relevant metals used as orthopaedic and dental implants

Titanium and its alloys or tantalum (Ta) are materials used in orthopaedic and dental implants due to their excellent mechanical properties and biocompatibility. However, their bioactivity and osteoconductivity is low. With a view to improving the bioactivity of these materials we hypothesised that the surface of Ta and TiAl6V4 can be functionalised with biomimetic, amorphous nano-sized calcium phosphate (CaP) apatite-like deposits, instead of creating uniform coatings, which can lead to flaking, delamination and poor adherence. We used Ta and TiAl6V4 metal discs with smooth and rough surfaces. Amorphous CaP apatite-like particles were deposited on the different surfaces by a biomimetic rapid two-step soaking method using concentrated simulated body fluid (SBF) solutions without a pre-treatment of the metal surfaces to induce CaP deposition. Immersion times in the second SBF solution of 48 and 18 h for Ta and TiAl6V4 respectively produced CaP deposits composed of amorphous globular nano-sized particles that also contained Mg, C and O. Longer immersion times produced more uniform coatings as well as an undesired calcite mineral phase. Prediction of in vivo behaviour by immersion in regular SBF showed that the obtained CaP deposits would act as a catalyst to rapidly form a Ca deficient CaP layer that also incorporates Mg. The amorphous CaP apatite-like deposits promoted initial attachment, proliferation and osteogenic differentiation of bone marrow derived mesenchymal stem cells. Finally, we used our method to functionalise 3D porous structures of titanium alloy made by selective laser sintering. Our study uses a novel and cost-effective approach to functionalise clinically relevant metal surfaces in order to increase the bioactivity of these materials, which could improve their clinical performance.

Maxillary sinus augmentation with leukocyte and platelet-rich fibrin and deproteinized bovine bone mineral: A split-mouth histological and histomorphometric study

OBJECTIVES

To evaluate the effect of leukocyte and platelet-rich fibrin (L-PRF) in combination with deproteinized bovine bone mineral (DBBM) on bone regeneration in maxillary sinus augmentation.

MATERIAL AND METHODS

Thirteen patients (nine males and four females, mean age ± SD; 49.92 ± 10.37) were enrolled to the study. 26 maxillary sinus augmentation procedures were randomly performed using DBBM and L-PRF mixture (test) or DBBM alone (control) in a split-mouth design. The same surgical procedures were performed in both groups, and bone biopsies were harvested from the implant sites 6 months postoperatively for histological and histomorphometric evaluations as the primary outcome of the study. Implants were placed and then loaded in the augmented sites after 6 months. The secondary outcomes included clinical and radiographic data and were obtained pre- and postoperatively.

RESULTS

There was no qualitative difference in histological analyses among the groups. In all samples, a newly formed bone was in direct contact with the residual material. The percentages of newly formed bone (test; 21.38 ± 8.78% and control; 21.25 ± 5.59%), residual bone graft (test; 25.95 ± 9.54% and control; 32.79 ± 5.89%), bone graft in contact with the newly formed bone (test; 47.33 ± 12.33% and control; 54.04 ± 8.36%), and soft tissue (test; 52.67 ± 12.53% and control; 45.96 ± 8.36%) were similar among the groups (p < .05). Similar radiographic bone height in the augmented area was observed, and implant survival rate was 100% for both groups.

CONCLUSIONS

Both techniques were effective for maxillary sinus augmentation, and after 6 months of healing, the addition of L-PRF in DBBM did not improve the amount of regenerated bone or the amount of the graft integrated into the newly formed bone under histological and histomorphometric evaluation.

Comparison of Two Xenograft Materials Used in Sinus Lift Procedures: Material Characterization and In Vivo Behavior

Detailed information about graft material characteristic is crucial to evaluate their clinical outcomes. The present study evaluates the physico-chemical characteristics of two xenografts manufactured on an industrial scale deproteinized at different temperatures (non-sintered and sintered) in accordance with a protocol previously used in sinus lift procedures. It compares how the physico-chemical properties influence the material’s performance in vivo by a histomorphometric study in retrieved bone biopsies following maxillary sinus augmentation in 10 clinical cases. An X-ray diffraction analysis revealed the typical structure of hydroxyapatite (HA) for both materials. Both xenografts were porous and exhibited intraparticle pores. Strong differences were observed in terms of porosity, crystallinity, and calcium/phosphate. Histomorphometric measurements on the bone biopsies showed statistically significant differences. The physic-chemical assessment of both xenografts, made in accordance with the protocol developed on an industrial scale, confirmed that these products present excellent biocompatibilitity, with similar characteristics to natural bone. The sintered HA xenografts exhibited greater osteoconductivity, but were not completely resorbable (30.80 ± 0.88% residual material). The non-sintered HA xenografts induced about 25.92 ± 1.61% of new bone and a high level of degradation after six months of implantation. Differences in the physico-chemical characteristics found between the two HA xenografts determined a different behavior for this material.

Management of traumatic bone defects: Metaphyseal versus diaphyseal defects

Although bone defects after trauma appear in different locations and forms, many clinicians have adopted a single strategy to deal with any defect. In this overview, a distinction is made between metaphyseal, or cancellous defects, and diaphyseal, or cortical defects. The treatment goals and background of these two types of defects are discussed in order to describe the difference in strategy and hence the difference in treatment method.

SEM-EDX Study of the Degradation Process of Two Xenograft Materials Used in Sinus Lift Procedures

Some studies have demonstrated that in vivo degradation processes are influenced by the material’s physico-chemical properties. The present study compares two hydroxyapatites manufactured on an industrial scale, deproteinized at low and high temperatures, and how physico-chemical properties can influence the mineral degradation process of material performance in bone biopsies retrieved six months after maxillary sinus augmentation. Residual biomaterial particles were examined by field scanning electron microscopy (SEM) and energy dispersive X-ray spectroscopy (EDX) to determine the composition and degree of degradation of the bone graft substitute material. According to the EDX analysis, the Ca/P ratio significantly lowered in the residual biomaterial (1.08 ± 0.32) compared to the initial composition (2.22 ± 0.08) for the low-temperature sintered group, which also presented high porosity, low crystallinity, low density, a large surface area, poor stability, and a high resorption rate compared to the high-temperature sintered material. This demonstrates that variations in the physico-chemical properties of bone substitute material clearly influence the degradation process. Further studies are needed to determine whether the resorption of deproteinized bone particles proceeds slowly enough to allow sufficient time for bone maturation to occur.

Ceramic Biocomposites as Biodegradable Antibiotic Carriers in the Treatment of Bone Infections

Local release of antibiotic has advantages in the treatment of chronic osteomyelitis and infected fractures. The adequacy of surgical debridement is still key to successful clearance of infection but local antibiotic carriers seem to afford greater success rates by targeting the residual organisms present after debridement and delivering much higher local antibiotic concentrations compared with systemic antibiotics alone. Biodegradable ceramic carriers can be used to fill osseous defects, which reduces the dead space and provides the potential for subsequent repair of the osseous defect as they dissolve away. A dissolving ceramic antibiotic carrier also raises the possibility of single stage surgery with definitive closure and avoids the need for subsequent surgery for spacer removal.

In this article we provide an overview of the properties of various biodegradable ceramics, including calcium sulphate, the calcium orthophosphate ceramics, calcium phosphate cement and polyphasic carriers. We summarise the antibiotic elution properties as investigated in previous animal studies as well as the clinical outcomes from clinical research investigating their use in the surgical management of chronic osteomyelitis.

Calcium sulphate pellets have been shown to be effective in treating local infection, although newer polyphasic carriers may support greater osseous repair and reduce the risk of further fracture or the need for secondary reconstructive surgery. The use of ceramic biocomposites to deliver antibiotics together with BMPs, bisphosphonates, growth factors or living cells is under investigation and merits further study.

We propose a treatment protocol, based on the Cierny-Mader classification, to help guide the appropriate selection of a suitable ceramic antibiotic carrier in the surgical treatment of chronic osteomyelitis.

Hydroxyapatite synthesis from a starfish and β-tricalcium phosphate using a hydrothermal method

Hydroxyapatite HAp, Ca₁₀(PO₄)₆(OH)₂, was successfully synthesized using a hydrothermal method using β-tricalcium phosphate (β-TCP) and CaO from the starfish Mellita eduardobarrosoi sp. nov.

Influence of Post-deposition Heating Time and the Presence of Water Vapor on Sputter-coated Calcium Phosphate Crystallinity

Extensive research suggested that calcium phosphate (CaP) coatings on titanium implants are essential for early bone response. However, the characterization of CaP crystallinity and the means to control coating crystallinity are not well-established. In this study, the effect of a 400°C heat treatment for 1, 2, or 4 hours, and in the presence or absence of water vapor, on CaP crystallinity was investigated. Scanning electron microscopy indicated dense as-sputtered coatings. Increase in coating crystallinity was observed to be consistent with the increasing number of PO4 peaks observed as a result of different heat treatments. In addition, x-ray diffraction analyses indicated amorphous as-sputtered coatings, whereas crystalline CaP coatings in the range of 0-85% were observed after different post-deposition heat treatments. It was concluded that the presence of water vapor and post-deposition heat treatment time significantly affect the crystallinity of CaP coatings, which may ultimately affect bone healing.

Gelatin-Modified Bone Substitute with Bioactive Molecules Enhance Cellular Interactions and Bone Regeneration

In this work, we have synthesized injectable bone cement incorporated with gelatin to enhance cellular interaction. Human osteosarcoma Saos-2 cells derived bone morphogenetic proteins (BMP's) and a bisphosphonate (zoledronic acid (0.2 mM)) were also incorporated to cement. In vitro studies conducted using Saos-2 demonstrated enhanced cell proliferation on gelatin (0.2%w/v) cement. The differentiation of C2C12 mouse myoblast cells into bone forming cells showed 6-fold increase in ALP levels on gelatin cement. Polymerase chain reaction (PCR) for bone biomarkers showed osteoinductive potential of gelatin cement. We investigated efficacy for local delivery of these bioactive molecules in enhancing bone substitution qualities of bone cements by implanting in 3.5 mm critical size defect in tibial metaphysis of wistar rats. The rats were sacrificed after 12 weeks and 16 weeks post implantation. X-ray, micro-CT, histology, and histomorphometry analysis were performed to check bone healing. The cement materials slowly resorbed from the defect site leaving HAP creating porous matrix providing surface for bone formation. The materials showed high biocompatibility and initial bridging was observed in all the animals but maximum bone formation was observed in animals implanted with cement incorporated with zoledronic acid followed by cement with BMP's compared to other groups.

Small-sized granules of biphasic bone substitutes support fast implant bed vascularization

The present study investigated the influence of granule size of 2 biphasic bone substitutes (BoneCeramic® 400–700 μm and 500–1000 μm) on the induction of multinucleated giant cells (MNGCs) and implant bed vascularization in a subcutaneous implantation model in rats. Furthermore, degradation mechanisms and particle phagocytosis of both materials were examined by transmission electron microscopy (TEM). Both granule types induced tissue reactions involving primarily mononuclear cells and only small numbers of MNGCs. Higher numbers of MNGCs were detected in the group with small granules starting on day 30, while higher vascularization was observed only at day 10 in this group. TEM analysis revealed that both mono- and multinucleated cells were involved in the phagocytosis of the materials. Additionally, the results allowed recognition of the MNGCs as the foreign body giant cell phenotype. Histomorphometrical analysis of the size of phagocytosed particles showed no differences between the 2 granule types. The results indicate that granule size seems to have impact on early implant bed vascularization and also on the induction of MNGCs in the late phase of the tissue reaction. Furthermore, the results revealed that a synthetic bone substitute material can induce tissue reactions similar to those of some xenogeneic materials, thus pointing to a need to elucidate their “ideal” physical characteristics. The results also show that granule size in the range studied did not alter phagocytosis by mononuclear cells. Finally, the investigation substantiates the differentiation of material-induced MNGCs, which are of the foreign body giant cell type.

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.

Effects of P-15 Peptide Coated Hydroxyapatite on Tibial Defect Repair In Vivo in Normal and Osteoporotic Rats

This study assessed the efficacy of anorganic bone mineral coated with P-15 peptide (ABM/P-15) on tibia defect repair longitudinally in both normal and osteoporotic rats in vivo. A paired design was used. 24 Norwegian brown rats were divided into normal and osteoporotic groups. 48 cylindrical defects were created in proximal tibias bilaterally. Defects were filled with ABM/P-15 or left empty. Osteoporotic status was assessed by microarchitectural analysis. Microarchitectural properties of proximal tibial defects were evaluated at 4 time points. 21 days after surgery, tibias were harvested for histology and histomorphometry. Significantly increased bone volume fraction, surface density, and connectivity were seen in all groups at days 14 and 21 compared with day 0. Moreover, the structure type of ABM/P-15 group was changed toward typical plate-like structure. Microarchitectural properties of ABM/P-15 treated newly formed bones at 21 days were similar in normal and osteoporotic rats. Histologically, significant bone formation was seen in all groups. Interestingly, significantly increased bone formation was seen in osteoporotic rats treated with ABM/P-15 indicating optimized healing potential. Empty defects showed lower healing potential in osteoporotic bone. In conclusion, ABM/P-15 accelerated bone regeneration in osteoporotic rats but did not enhance bone regeneration in normal rats.

A Novel Porcine Graft for Regeneration of Bone Defects

Bone regeneration procedures require alternative graft biomaterials to those for autogenous bone. Therefore, we developed a novel porcine graft using particle sizes of 250–500 μm and 500–1000 μm in rabbit calvarial bone defects and compared the graft properties with those of commercial hydroxyapatite (HA)/beta-tricalcium phosphate (β-TCP) over eight weeks. Surgery was performed in 20 adult male New Zealand white rabbits. During a standardized surgical procedure, four calvarial critical-size defects of 5 mm diameter and 3 mm depth were prepared. The defects were filled with HA/β-TCP, 250–500 μm or 500–1000 μm porcine graft, and control defects were not filled. The animals were grouped for sacrifice at 1, 2, 4, and 8 weeks post-surgery. Subsequently, sample blocks were prepared for micro-computed tomography (micro-CT) scanning and histological sectioning. Similar bone formations were observed in all three treatment groups, although the 250–500 μm porcine graft performed slightly better. Rabbit calvarial bone tissue positively responded to porcine grafts and commercial HA/β-TCP, structural analyses showed similar crystallinity and porosity of the porcine and HA/β-TCP grafts, which facilitated bone formation through osteoconduction. These porcine grafts can be considered as graft substitutes, although further development is required for clinical applications.

Investigation of structural resorption behavior of biphasic bioceramics with help of gravimetry, μCT, SEM, and XRD

Resorbable bone substitute materials are widely used for bone augmentation after tumor resection, parallel to implant placement, or in critical size bone defects. In this study, the structural dissolution of a biphasic calcium phosphate bone substitute material with a hydroxyapatite (HA)/tricalcium phosphate (β-TCP) ratio of 60/40 was investigated by repeatedly placing porous blocks in EDTA solution at 37 °C. At several time points, the blocks were investigated by SEM, µCT, and gravimetry. It was found that always complete 2-3 µm sized grains were removed from the structure and that the β-TCP is dissolved more rapidly. This selective dissolution of the β-TCP grains was confirmed by XRD measurements. The blocks were eroded from the outside toward the center. The structure remained mechanically stable because the central part showed a delayed degradation and because the slower dissolving HA grains preserved the integrity of the structure.

Cranioplasty of Hemispherical Defects Using Calcium Phosphate Cements Along with Titanium Mesh: Our Experience

INTRODUCTION

Cranial defects may arise due to trauma, infection, surgical ablation or errors in development. Restoration of such defects is important for esthetics, function and morale of the patient. Several materials are available. Each has its advantages and disadvantages. Search is on for an ideal material. Autogenous grafts remain the gold standard in reconstruction of such defects. However, the morbidity associated with their harvest, additional time required, the need for a second surgical site and the limited supply has led to the search for newer substitutes. Although many materials are available today including biologic and non biologic substitutes, there is still no consensus about the best material. In this article we describe our use of calcium phosphate cements for reconstruction of hemispherical cranial defects.

MATERIALS AND METHODS

Cases requiring reconstruction of hemispherical cranial defects (more than 15 cm in any dimension) were selected for study. After exposing the defect under GA, titanium mesh was adapted to the defect for support. Then the calcium phosphate cement was prepared and injected on the mesh to establish good contour. The alloplastic insert in each patient was evaluated for: (a) Immediate post-operative complications (b) Restoration of contour and soft tissue support (c) New bone formation ascertained on HRCT at the end of 2 years. Patients were examined on postoperative first week, at 3 and at 6 months. High resolution computed tomography scans were taken at 2 years postop. There were two female and three male patients.

RESULTS

There were no complications in the post operative period. The general condition of the patients improved post operatively. Even though the cements maintained their contour at 2 years, there were no signs of bone formation within the cement.

CONCLUSION

Calcium phosphate cement is a good bone substitute for use in cranioplasty. In defects requiring mechanical strength, it should be supported by a titanium mesh. It retains the contour but is not replaced by bone even after 2 years.

The role of Carboxydothermus hydrogenoformans in the conversion of calcium phosphate from amorphous to crystalline state

Two previously unknown modes of biomineralization observed in the presence of Carboxydothermus hydrogenoformans are presented. Following the addition of NaHCO₃ and the formation of an amorphous calcium phosphate precipitate in a DSMZ medium inoculated with C. hydrogenoformans, two distinct crystalline solids were recovered after 15 and 30 days of incubation. The first of these solids occurred as micrometric clusters of blocky, angular crystals, which were associated with bacterial biofilm. The second solid occurred as 30–50 nm nanorods that were found scattered among the organic products of bacterial lysis. The biphasic mixture of solids was clearly dominated by the first phase. The X-ray diffractometry (XRD) peaks and Fourier transform infrared spectroscopy (FTIR) spectrum of this biphasic material consistently showed features characteristic of Mg-whitlockite. No organic content or protein could be identified by dissolving the solids. In both cases, the mode of biomineralization appears to be biologically induced rather than biologically controlled. Since Mg is known to be a strong inhibitor of the nucleation and growth of CaP, C. hydrogenoformans may act by providing sites that chelate Mg or form complexes with it, thus decreasing its activity as nucleation and crystal growth inhibitor. The synthesis of whitlockite and nano-HAP-like material by C. hydrogenoformans demonstrates the versatility of this organism also known for its ability to perform the water-gas shift reaction, and may have applications in bacterially mediated synthesis of CaP materials, as an environmentally friendly alternative process.

Calcium Orthophosphate-Based Bioceramics

Various types of grafts have been traditionally used to restore damaged bones. In the late 1960s, a strong interest was raised in studying ceramics as potential bone grafts due to their biomechanical properties. A bit later, such synthetic biomaterials were called bioceramics. In principle, bioceramics can be prepared from diverse materials but this review is limited to calcium orthophosphate-based formulations only, which possess the specific advantages due to the chemical similarity to mammalian bones and teeth. During the past 40 years, there have been a number of important achievements in this field. Namely, after the initial development of bioceramics that was just tolerated in the physiological environment, an emphasis was shifted towards the formulations able to form direct chemical bonds with the adjacent bones. Afterwards, by the structural and compositional controls, it became possible to choose whether the calcium orthophosphate-based implants remain biologically stable once incorporated into the skeletal structure or whether they were resorbed over time. At the turn of the millennium, a new concept of regenerative bioceramics was developed and such formulations became an integrated part of the tissue engineering approach. Now calcium orthophosphate scaffolds are designed to induce bone formation and vascularization. These scaffolds are often porous and harbor different biomolecules and/or cells. Therefore, current biomedical applications of calcium orthophosphate bioceramics include bone augmentations, artificial bone grafts, maxillofacial reconstruction, spinal fusion, periodontal disease repairs and bone fillers after tumor surgery. Perspective future applications comprise drug delivery and tissue engineering purposes because calcium orthophosphates appear to be promising carriers of growth factors, bioactive peptides and various types of cells.

Bone graft substitutes currently available in orthopaedic practice: the evidence for their use

We reviewed 59 bone graft substitutes marketed by 17 companies currently available for implantation in the United Kingdom, with the aim of assessing the peer-reviewed literature to facilitate informed decision-making regarding their use in clinical practice. After critical analysis of the literature, only 22 products (37%) had any clinical data. Norian SRS (Synthes), Vitoss (Orthovita), Cortoss (Orthovita) and Alpha-BSM (Etex) had Level I evidence. We question the need for so many different products, especially with limited published clinical evidence for their efficacy, and conclude that there is a considerable need for further prospective randomised trials to facilitate informed decision-making with regard to the use of current and future bone graft substitutes in clinical practice.

Current status of bone graft options for anterior interbody fusion of the cervical and lumbar spine

Anterior cervical discectomy and fusion (ACDF) and anterior lumbar interbody fusion (ALIF) are common surgical procedures for degenerative disc disease of the cervical and lumbar spine. Over the years, many bone graft options have been developed and investigated aimed at complimenting or substituting autograft bone, the traditional fusion substrate. Here, we summarise the historical context, biological basis and current best evidence for these bone graft options in ACDF and ALIF.