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He L. Biomaterials for Regenerative Cranioplasty: Current State of Clinical Application and Future Challenges. J Funct Biomater 2024; 15:84. [PMID: 38667541 PMCID: PMC11050949 DOI: 10.3390/jfb15040084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 03/18/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Acquired cranial defects are a prevalent condition in neurosurgery and call for cranioplasty, where the missing or defective cranium is replaced by an implant. Nevertheless, the biomaterials in current clinical applications are hardly exempt from long-term safety and comfort concerns. An appealing solution is regenerative cranioplasty, where biomaterials with/without cells and bioactive molecules are applied to induce the regeneration of the cranium and ultimately repair the cranial defects. This review examines the current state of research, development, and translational application of regenerative cranioplasty biomaterials and discusses the efforts required in future research. The first section briefly introduced the regenerative capacity of the cranium, including the spontaneous bone regeneration bioactivities and the presence of pluripotent skeletal stem cells in the cranial suture. Then, three major types of biomaterials for regenerative cranioplasty, namely the calcium phosphate/titanium (CaP/Ti) composites, mineralised collagen, and 3D-printed polycaprolactone (PCL) composites, are reviewed for their composition, material properties, and findings from clinical trials. The third part discusses perspectives on future research and development of regenerative cranioplasty biomaterials, with a considerable portion based on issues identified in clinical trials. This review aims to facilitate the development of biomaterials that ultimately contribute to a safer and more effective healing of cranial defects.
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Affiliation(s)
- Lizhe He
- Key Laboratory of 3D Printing Process and Equipment of Zhejiang Province, School of Mechanical Engineering, Zhejiang University, Hangzhou 310028, China
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2
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Saurav S, Sharma P, Kumar A, Tabassum Z, Girdhar M, Mamidi N, Mohan A. Harnessing Natural Polymers for Nano-Scaffolds in Bone Tissue Engineering: A Comprehensive Overview of Bone Disease Treatment. Curr Issues Mol Biol 2024; 46:585-611. [PMID: 38248340 PMCID: PMC10814241 DOI: 10.3390/cimb46010038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 12/24/2023] [Accepted: 12/30/2023] [Indexed: 01/23/2024] Open
Abstract
Numerous surgeries are carried out to replace tissues that have been harmed by an illness or an accident. Due to various surgical interventions and the requirement of bone substitutes, the emerging field of bone tissue engineering attempts to repair damaged tissues with the help of scaffolds. These scaffolds act as template for bone regeneration by controlling the development of new cells. For the creation of functional tissues and organs, there are three elements of bone tissue engineering that play very crucial role: cells, signals and scaffolds. For the achievement of these aims, various types of natural polymers, like chitosan, chitin, cellulose, albumin and silk fibroin, have been used for the preparation of scaffolds. Scaffolds produced from natural polymers have many advantages: they are less immunogenic as well as being biodegradable, biocompatible, non-toxic and cost effective. The hierarchal structure of bone, from microscale to nanoscale, is mostly made up of organic and inorganic components like nanohydroxyapatite and collagen components. This review paper summarizes the knowledge and updates the information about the use of natural polymers for the preparation of scaffolds, with their application in recent research trends and development in the area of bone tissue engineering (BTE). The article extensively explores the related research to analyze the advancement of nanotechnology for the treatment of bone-related diseases and bone repair.
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Affiliation(s)
- Sushmita Saurav
- School of Bioengineering and Biosciences, Lovely Professional University, Phagwara 144401, Punjab, India; (S.S.); (P.S.); (Z.T.)
| | - Prashish Sharma
- School of Bioengineering and Biosciences, Lovely Professional University, Phagwara 144401, Punjab, India; (S.S.); (P.S.); (Z.T.)
| | - Anil Kumar
- Gene Regulation Laboratory, National Institute of Immunology, New Delhi 110067, Delhi, India;
| | - Zeba Tabassum
- School of Bioengineering and Biosciences, Lovely Professional University, Phagwara 144401, Punjab, India; (S.S.); (P.S.); (Z.T.)
| | - Madhuri Girdhar
- Division of Research and Development, Lovely Professional University, Phagwara 144401, Punjab, India;
| | - Narsimha Mamidi
- Wisconsin Centre for Nano Biosystems, School of Pharmacy, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Anand Mohan
- School of Bioengineering and Biosciences, Lovely Professional University, Phagwara 144401, Punjab, India; (S.S.); (P.S.); (Z.T.)
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Lopes VR, Birgersson U, Manivel VA, Hulsart-Billström G, Gallinetti S, Aparicio C, Hong J. Human Whole Blood Interactions with Craniomaxillofacial Reconstruction Materials: Exploring In Vitro the Role of Blood Cascades and Leukocytes in Early Healing Events. J Funct Biomater 2023; 14:361. [PMID: 37504856 PMCID: PMC10381968 DOI: 10.3390/jfb14070361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/03/2023] [Accepted: 07/05/2023] [Indexed: 07/29/2023] Open
Abstract
The present study investigated early interactions between three alloplastic materials (calcium phosphate (CaP), titanium alloy (Ti), and polyetheretherketone (PEEK) with human whole blood using an established in vitro slide chamber model. After 60 min of contact with blood, coagulation (thrombin-antithrombin complexes, TAT) was initiated on all test materials (Ti > PEEK > CaP), with a significant increase only for Ti. All materials showed increased contact activation, with the KK-AT complex significantly increasing for CaP (p < 0.001), Ti (p < 0.01), and PEEK (p < 0.01) while only CaP demonstrated a notable rise in KK-C1INH production (p < 0.01). The complement system had significant activation across all materials, with CaP (p < 0.0001, p < 0.0001) generating the most pronounced levels of C3a and sC5b-9, followed by Ti (p < 0.001, p < 0.001) and lastly, PEEK (p < 0.001, p < 0.01). This activation correlated with leukocyte stimulation, particularly myeloperoxidase release. Consequently, the complement system may assume a more significant role in the early stages post implantation in response to CaP materials than previously recognized. Activation of the complement system and the inevitable activation of leukocytes might provide a more favorable environment for tissue remodeling and repair than has been traditionally acknowledged. While these findings are limited to the early blood response, complement and leukocyte activation suggest improved healing outcomes, which may impact long-term clinical outcomes.
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Affiliation(s)
- Viviana R Lopes
- OssDsign AB, SE-754 50 Uppsala, Sweden
- Department of Medicinal Chemistry, Translational Imaging, Uppsala University, SE-751 83 Uppsala, Sweden
| | - Ulrik Birgersson
- Department of Clinical Science, Intervention and Technology, Division of Imaging and Technology, Karolinska Institute, SE-141 52 Huddinge, Sweden
- Department of Clinical Neuroscience, Neurosurgical Section, Karolinska University Hospital, SE-171 77 Stockholm, Sweden
| | - Vivek Anand Manivel
- Rudbeck Laboratory, Department of Immunology, Genetics and Pathology (IGP), Uppsala University, SE-751 85 Uppsala, Sweden
| | - Gry Hulsart-Billström
- Department of Medicinal Chemistry, Translational Imaging, Uppsala University, SE-751 83 Uppsala, Sweden
| | - Sara Gallinetti
- OssDsign AB, SE-754 50 Uppsala, Sweden
- Department of Engineering Sciences, Applied Materials Science Section, Uppsala University, SE-751 03 Uppsala, Sweden
| | - Conrado Aparicio
- Faculty of Odontology, UIC Barcelona-International University of Catalonia, 08195 Barcelona, Spain
- IBEC-Institute for Bioengineering of Catalonia, 08028 Barcelona, Spain
| | - Jaan Hong
- Rudbeck Laboratory, Department of Immunology, Genetics and Pathology (IGP), Uppsala University, SE-751 85 Uppsala, Sweden
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Kim CNT, Binh CX, Dung VT, Toan TV. Design and mechanical evaluation of a large cranial implant and fixation parts. INTERDISCIPLINARY NEUROSURGERY 2023. [DOI: 10.1016/j.inat.2022.101676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Lönnemark O, Ryttlefors M, Sundblom J. Cranioplasty in Brain Tumor Surgery: A Single-Center Retrospective Study Investigating Cranioplasty Failure and Tumor Recurrence. World Neurosurg 2023; 170:e313-e323. [PMID: 36356841 DOI: 10.1016/j.wneu.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Cranioplasty with synthetic implant can be performed to restore function and form of the skull after resection of malignancy infiltrating the bone. The aim of this study was to examine the rate of implant failure and tumor recurrence in patients undergoing nonautologous cranioplasty and tumor resection. METHODS In this retrospective single-center study, 48 patients were identified who had undergone cranioplasty with synthetic implants after tumor resection between 2010 and 2020. The medical records were analyzed to investigate patient demographics, surgery data, cranioplasty failure rates, and rate of tumor recurrence. RESULTS Cranioplasty failed in 8 patients. The median time to implant failure was 220 days with most failures occurring within 1 year (5 of 8). There was no significant difference in rate or time to failure between the different cranioplasty materials (P = 0.39). Low body mass index (P < 0.05), previous craniectomy/cranioplasty (P < 0.05), previous radiation therapy to the brain/skull (P < 0.05), and skin closure with sutures (P < 0.05) were associated with an increased risk of implant failure. Tumors recurred in 15 patients. CONCLUSIONS Cranioplasty surgery with synthetic implants carries a relatively high risk of failure, regardless of type of cranioplasty material used. Skin closure with staples may be beneficial in these patients.
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Affiliation(s)
- Olle Lönnemark
- Section of Neurosurgery, Department of Neuroscience, Uppsala University Hospital, Uppsala, Sweden.
| | - Mats Ryttlefors
- Section of Neurosurgery, Department of Neuroscience, Uppsala University Hospital, Uppsala, Sweden
| | - Jimmy Sundblom
- Section of Neurosurgery, Department of Neuroscience, Uppsala University Hospital, Uppsala, Sweden
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Analysis of PMMA versus CaP titanium-enhanced implants for cranioplasty after decompressive craniectomy: a retrospective observational cohort study. Neurosurg Rev 2022; 45:3647-3655. [PMID: 36222944 DOI: 10.1007/s10143-022-01874-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 08/24/2022] [Accepted: 09/01/2022] [Indexed: 10/17/2022]
Abstract
Numerous materials of implants used for cranioplasty after decompressive craniectomy (DC) have been investigated to meet certain demanded key features, such as stability, applicability, and biocompatibility. We aimed to evaluate the feasibility and safety of biocompatible calcium-phosphate (CaP) implants for cranioplasty compared to polymethylmethacrylate (PMMA) implants. In this retrospective observational cohort study, the medical records of all patients who underwent cranioplasty between January 1st, 2015, and January 1st, 2022, were reviewed. Demographic, clinical, and diagnostic data were collected. Eighty-two consecutive patients with a mean age of 52 years (range 22-72 years) who received either a PMMA (43/82; 52.4%) or CaP (39/82; 47.6%) cranial implant after DC were included in the study. Indications for DC were equally distributed in both groups. Time from DC to cranioplasty was 143.8 ± 17.5 days (PMMA) versus 98.5 ± 10.4 days (CaP). The mean follow-up period was 34.9 ± 27.1 months. Postoperative complications occurred in 13 patients with PMMA and 6 in those with CaP implants (13/43 [30.2%] vs. 6/39 [15.4%]; p = 0.115). Revision surgery with implant removal was necessary for 9 PMMA patients and in 1 with a CaP implant (9/43 [20.9%] vs. 1/39 [2.6%]; p = 0.0336); 6 PMMA implants were removed due to surgical site infection (SSI) (PMMA 6/43 [14%] vs. CaP 0/39 [0%]; p = 0.012). In this study, a biocompatible CaP implant seems to be superior to a PMMA implant in terms of SSI and postoperative complications. The absence of SSI supports the idea of the biocompatible implant material with its ability for osseointegration.
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Recent developments of biomaterial scaffolds and regenerative approaches for craniomaxillofacial bone tissue engineering. JOURNAL OF POLYMER RESEARCH 2022. [DOI: 10.1007/s10965-022-02928-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Svensson S, Palmer M, Svensson J, Johansson A, Engqvist H, Omar O, Thomsen P. Monocytes and pyrophosphate promote mesenchymal stem cell viability and early osteogenic differentiation. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2022; 33:11. [PMID: 35032239 PMCID: PMC8761140 DOI: 10.1007/s10856-021-06639-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 12/18/2021] [Indexed: 06/14/2023]
Abstract
Pyrophosphate-containing calcium phosphate implants promote osteoinduction and bone regeneration. The role of pyrophosphate for inflammatory cell-mesenchymal stem cell (MSC) cross-talk during osteogenesis is not known. In the present work, the effects of lipopolysaccharide (LPS) and pyrophosphate (PPi) on primary human monocytes and on osteogenic gene expression in human adipose-derived MSCs were evaluated in vitro, using conditioned media transfer as well as direct effect systems. Direct exposure to pyrophosphate increased nonadherent monocyte survival (by 120% without LPS and 235% with LPS) and MSC viability (LDH) (by 16-19% with and without LPS). Conditioned media from LPS-primed monocytes significantly upregulated osteogenic genes (ALP and RUNX2) and downregulated adipogenic (PPAR-γ) and chondrogenic (SOX9) genes in recipient MSCs. Moreover, the inclusion of PPi (250 μM) resulted in a 1.2- to 2-fold significant downregulation of SOX9 in the recipient MSCs, irrespective of LPS stimulation or culture media type. These results indicate that conditioned media from LPS-stimulated inflammatory monocytes potentiates the early MSCs commitment towards the osteogenic lineage and that direct pyrophosphate exposure to MSCs can promote their viability and reduce their chondrogenic gene expression. These results are the first to show that pyrophosphate can act as a survival factor for both human MSCs and primary monocytes and can influence the early MSC gene expression. Graphical abstract.
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Affiliation(s)
- Sara Svensson
- Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Michael Palmer
- Department of Engineering Sciences, Applied Materials Science Section, Uppsala University, Uppsala, Sweden
| | - Johan Svensson
- Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - Anna Johansson
- Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Håkan Engqvist
- Department of Engineering Sciences, Applied Materials Science Section, Uppsala University, Uppsala, Sweden
| | - Omar Omar
- Department of Biomedical Dental Sciences, College of Dentistry, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
| | - Peter Thomsen
- Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Malmberg P, Lopes VR, Billström GH, Gallinetti S, Illies C, Linder LKB, Birgersson U. Targeted ToF-SIMS Analysis of Macrophage Content from a Human Cranial Triphasic Calcium Phosphate Implant. ACS APPLIED BIO MATERIALS 2021; 4:6791-6798. [PMID: 35006979 DOI: 10.1021/acsabm.1c00513] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Macrophages play a key role in determining the fate of implanted biomaterials, especially for biomaterials such as calcium phosphates (CaPs) where these cells play a vital role in material resorption and osteogenesis, as shown in different models, including clinical samples. Although substantial consideration is given to the design and validation of different CaPs, relatively little is known about their material-cell interaction. Specifically, the intracellular content of different CaP phases remains to be assessed, even though CaP-filled macrophages have been observed in several studies. In this study, 2D/3D ToF-SIMS imaging and multivariate analysis were directly applied on the histology samples of an explant to reveal the content of macrophages. The cellular content of the macrophages was analyzed to distinguish three CaP phases, monetite, beta-tricalcium phosphate, and pyrophosphate, which are all part of the monetite-based CaP implant composition under study. ToF-SIMS combined with histology revealed that the content of the identified macrophages was most similar to that of the pyrophosphate phase. This study is the first to uncover distinct CaP phases in macrophages from a human multiphasic CaP explant by targeted direct cell content analysis. The uncovering of pyrophosphate as the main phase found inside the macrophages is of great importance to understand the impact of the selected material in the process of biomaterial-instructed osteogenesis.
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Affiliation(s)
- Per Malmberg
- Department of Chemistry and Chemical Engineering, Chalmers University of Technology, 412 96 Gothenburg, Sweden
| | - Viviana R Lopes
- Science for Life Laboratory, Department of Medicinal Chemistry, Uppsala University, 751 83 Uppsala, Sweden
| | - Gry Hulsart Billström
- Science for Life Laboratory, Department of Medicinal Chemistry, Uppsala University, 751 83 Uppsala, Sweden
| | - Sara Gallinetti
- Department of Engineering Sciences, Applied Materials Science Section, Uppsala University, 75121 Uppsala, Sweden
| | - Christopher Illies
- Department of Clinical Pathology, Karolinska University Hospital, 171 77 Stockholm, Sweden
| | - Lars Kihlström Burenstam Linder
- Department of Clinical Neuroscience, Neurosurgical Section, Karolinska University Hospital and Karolinska Institute, 171 76 Stockholm, Sweden
| | - Ulrik Birgersson
- Department of Clinical Neuroscience, Neurosurgical Section, Karolinska University Hospital and Karolinska Institute, 171 76 Stockholm, Sweden.,Division of Imaging and Technology, Department of Clinical Science, Intervention and Technology, Karolinska Institute, 14152 Huddinge, Sweden
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Lewin S, Kihlström Burenstam Linder L, Birgersson U, Gallinetti S, Åberg J, Engqvist H, Persson C, Öhman-Mägi C. Monetite-based composite cranial implants demonstrate long-term clinical volumetric balance by concomitant bone formation and degradation. Acta Biomater 2021; 128:502-513. [PMID: 33857696 DOI: 10.1016/j.actbio.2021.04.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/01/2021] [Accepted: 04/07/2021] [Indexed: 01/14/2023]
Abstract
The use of calcium phosphates (CaPs) as synthetic bone substitutes should ideally result in a volumetric balance with concomitant bone formation and degradation. Clinical data on such properties is nevertheless lacking, especially for monetite-based CaPs. However, a monetite-based composite implant has recently shown promising cranial reconstructions, with both CaP degradation and bone formation. In this study, the volumetric change at the implant site was quantified longitudinally by clinical computed tomography (CT). The retrospective CT datasets had been acquired postoperatively (n = 10), in 1-year (n = 9) and 3-year (n = 5) follow-ups. In the 1-year follow-up, the total volumetric change at the implant site was -8 ± 8%. A volumetric increase (bone formation) was found in the implant-bone interface, and a volumetric decrease was observed in the central region (CaP degradation). In the subjects with 2- or 3-year follow-ups, the rate of volumetric decrease slowed down or plateaued. The reported degradation rate is lower than previous clinical studies on monetite, likely due to the presence of pyrophosphate in the monetite-based CaP-formulation. A 31-months retrieval specimen analysis demonstrated that parts of the CaP had been remodeled into bone. The CaP phase composition remained stable, with 6% transformation into hydroxyapatite. In conclusion, this study demonstrates successful bone-bonding between the CaP-material and the recipient bone, as well as a long-term volumetric balance in cranial defects repaired with the monetite-based composite implant, which motivates further clinical use. The developed methods could be used in future studies for correlating spatiotemporal information regarding bone regeneration and CaP degradation to e.g. patient demographics. STATEMENT OF SIGNIFICANCE: In bone defect reconstructions, the use of calcium phosphate (CaP) bioceramics ideally results in a volumetric balance between bone formation and CaP degradation. Clinical data on the volumetric balance is nevertheless lacking, especially for monetite-based CaPs. Here, this concept is investigated for a composite cranial implant. The implant volumes were quantified from clinical CT-data: postoperatively, one year and three years postoperatively. In total, -8 ± 8% (n = 9) volumetric change was observed after one year. But the change plateaued, with only 2% additional decrease at the 3-year follow-up (n = 5), indicating a lower CaP degradation rate. Osseointegration was seen at the bone-implant interface, with a 9 ± 7% volumetric change after one year. This study presented the first quantitative spatiotemporal CT analysis of monetite-based CaPs.
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Affiliation(s)
- Susanne Lewin
- Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden.
| | - Lars Kihlström Burenstam Linder
- Department of Neurosurgery, Clinical Neurosciences, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Ulrik Birgersson
- Department of Neurosurgery, Clinical Neurosciences, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden; Department of Clinical Science, Intervention and Technology, Division of Imaging and Technology, Karolinska Institutet, Huddinge, Sweden; OssDsign, Uppsala, Sweden
| | - Sara Gallinetti
- Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden; OssDsign, Uppsala, Sweden
| | - Jonas Åberg
- Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden; OssDsign, Uppsala, Sweden
| | - Håkan Engqvist
- Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden
| | - Cecilia Persson
- Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden
| | - Caroline Öhman-Mägi
- Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden
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Sundblom J, Xheka F, Casar-Borota O, Ryttlefors M. Bone formation in custom-made cranioplasty: evidence of early and sustained bone development in bioceramic calcium phosphate implants. Patient series. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE20133. [PMID: 35855216 PMCID: PMC9245784 DOI: 10.3171/case20133] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 12/11/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND Implant failure (IF) rates in cranioplasty remain high despite efforts to reduce the incidence. New biomaterials may be part of the solution for this problem. Formation of autologous bone in implants may reduce rates of infection and subsequent failure. OBSERVATIONS Four patients with calcium phosphate implants supported by titanium mesh and undergoing surgery for reasons unrelated to IF were included in this series. Samples from the implants were microscopically examined. Pathological studies proved the formation of autologous bone in the calcium phosphate implants. LESSONS Bone and blood vessel formation in the implants and diminished foreign body reaction to autologous bone may reduce the rates of IF.
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Affiliation(s)
| | - Fabjola Xheka
- Clinical Pathology, Uppsala University Hospital, Uppsala, Sweden; and
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Olivera Casar-Borota
- Clinical Pathology, Uppsala University Hospital, Uppsala, Sweden; and
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
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Mellgren T, Trbakovic A, Thor A, Ekman S, Ley C, Öhman-Mägi C, Johansson PH, Jensen-Waern M, Hedenqvist P. Guided bone tissue regeneration using a hollow calcium phosphate based implant in a critical size rabbit radius defect. Biomed Mater 2021; 16. [PMID: 33477115 DOI: 10.1088/1748-605x/abde6f] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 01/21/2021] [Indexed: 11/11/2022]
Abstract
Long bone fractures are common and sometimes difficult to treat. Autologous bone (AB), bovine bone and calcium phosphates are used to stimulate bone growth with varying results. In the present study, a calcium phosphate cement (CPC) that previously showed promising grafting capabilities was evaluated for the first time in a long bone defect. A radius defect of 20 mm was created in twenty rabbits. The defect was filled by either a hollow CPC implant that had been previously manufactured as a replica of a rabbit radius through indirect 3D printing, or by particulate AB as control. Defect filling and bone formation was evaluated after 12 weeks by combining micro computed tomography (μCT) and scoring of 3D images, together with histomorphometry and histology. The μCT and histomorphometric evaluations showed a similar amount of filling of the defect (combining graft and bone) between the CPC and AB group, but the scoring of 3D images showed that the filling in the CPC group was significantly larger. Histologically the AB graft could not be distinguished from the new bone. The AB treated defects were found to be composed of more bone than the CPC group, including reorganised cancellous and cortical bone. Both the CPC and AB material was associated with new bone formation, also in the middle of the defect, which could result in closing of the otherwise critically sized gap. This study shows the potential for an indirectly 3D printed implant in guided bone regeneration in critically sized long bone defects.
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Affiliation(s)
- Torbjörn Mellgren
- Department of Engineering Sciences, Uppsala University, PO Box 534, Uppsala, 75121, SWEDEN
| | - Amela Trbakovic
- Surgical Sciences, Plastic & Oral Maxillofacial Surgery, Uppsala University, Käkkirurgiska kliniken, Akademiska sjukhuset ingång 79, Uppsala, 751 85, SWEDEN
| | - Andreas Thor
- Surgical Sciences, Plastic & Oral Maxillofacial Surgery, Uppsala University, Käkkirurgiska kliniken, Akademiska sjukhuset ingång 79, Uppsala, 751 85, SWEDEN
| | - Stina Ekman
- Biomedical Sciences and Veterinary Public Health, Swedish University of Agricultural Sciences, PO Box 7028, Uppsala, 750 07, SWEDEN
| | - Cecilia Ley
- Biomedical Sciences and Veterinary Public Health, Swedish University of Agricultural Sciences, PO Box 7028, Uppsala, 750 07, SWEDEN
| | | | - Petra Hammarström Johansson
- Prosthodontics, Institution for odontology, Sahlgrenska Academy at University of Gothenburg , Medicinaregaran 12, 413 90 Göteborg, Sweden, Gothenburg, 413 90, SWEDEN
| | - Marianne Jensen-Waern
- Clinical Sciences, Swedish University of Agricultural Sciences, PO Box 7054, Uppsala, 750 07, SWEDEN
| | - Patricia Hedenqvist
- Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, SWEDEN
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Gallinetti S, Burenstam Linder LK, Åberg J, Illies C, Engqvist H, Birgersson U. Titanium reinforced calcium phosphate improves bone formation and osteointegration in ovine calvaria defects: a comparative 52-weeks study. Biomed Mater 2020; 16. [PMID: 33181501 DOI: 10.1088/1748-605x/abca12] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 11/12/2020] [Indexed: 11/12/2022]
Abstract
In a 52-week ovine calvaria implantation model, the restoration of cranial defects with a bare titanium mesh (Ti-mesh) and a titanium mesh embedded in a calcium phosphate (CaP-Ti) were evaluated in seven animals. During the study, no major clinical abnormalities were observed, and all sheep presented a normal neurologic assessment. Blood and CSF analysis, made at termination, did not show any abnormalities. No indentation of the soft tissue was observed for either test article; however, the Ti-mesh burr-hole covers were associated with filling of the calvarial defect by fibrous tissue mainly. Some bone formation was observed at the bottom of the created defect, but no significant bone was formed in the proximity of the implant. The defect sites implanted with CaP-Ti were characterized by a moderate degradation of the calcium phosphate that was replaced by mature bone tissue. Calcium-phosphate-filled macrophages were observed in all animals, indicating that they might play a vital role in osteogenesis. The newly formed bone was present, especially at the bony edges of the defect and on the dura side. Integration of the titanium mesh in a calcium phosphate improved bone formation and osteointegration in comparison to a bare titanium mesh.
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Affiliation(s)
| | - Lars Kihlstrom Burenstam Linder
- Neurosurgery, Clinical Neuroscience Research Centre, Karolinska University Hospital, Eugeniav 3 Solna, Dartford, DA1 2EN, SWEDEN
| | - Jonas Åberg
- Department of Engineering Sciences, Applied Materials Science Section, Uppsala University, Uppsala, SWEDEN
| | - Christopher Illies
- Department of Clinical Pathology, Karolinska University Hospital, Stockholm, SWEDEN
| | - Håkan Engqvist
- Department of Engineering Sciences, Applied Materials Science Section, Uppsala Universitet, Uppsala, SWEDEN
| | - Ulrik Birgersson
- Clintec, Karolinska institutet Department of Clinical Sciences Intervention and Technology, Huddinge, SWEDEN
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In situ bone regeneration of large cranial defects using synthetic ceramic implants with a tailored composition and design. Proc Natl Acad Sci U S A 2020; 117:26660-26671. [PMID: 33046631 PMCID: PMC7604495 DOI: 10.1073/pnas.2007635117] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Large cranial reconstructions are increasingly performed worldwide and still represent a substantial clinical challenge. The gold standard, autologous bone, has limited availability and high donor-site morbidity. Current alloplastic materials are associated with high complication and failure rates. This study shows the capacity of a customized, purely synthetic, 3D-manufactured bioceramic implant to regenerate and restore large cranial defects with mature, well-vascularized bone, with a morphology, ultrastructure, and composition similar to those of native skull bone. This approach triggers the regenerative potential of host tissue by tailoring the implant composition and design. The regeneration of large defects using purely synthetic material without adjunct cell therapy or growth factors represents a major advancement for rehabilitating patients in need of large cranial reconstructions. The repair of large cranial defects with bone is a major clinical challenge that necessitates novel materials and engineering solutions. Three-dimensionally (3D) printed bioceramic (BioCer) implants consisting of additively manufactured titanium frames enveloped with CaP BioCer or titanium control implants with similar designs were implanted in the ovine skull and at s.c. sites and retrieved after 12 and 3 mo, respectively. Samples were collected for morphological, ultrastructural, and compositional analyses using histology, electron microscopy, and Raman spectroscopy. Here, we show that BioCer implants provide osteoinductive and microarchitectural cues that promote in situ bone regeneration at locations distant from existing host bone, whereas bone regeneration with inert titanium implants was confined to ingrowth from the defect boundaries. The BioCer implant promoted bone regeneration at nonosseous sites, and bone bonding to the implant was demonstrated at the ultrastructural level. BioCer transformed to carbonated apatite in vivo, and the regenerated bone displayed a molecular composition indistinguishable from that of native bone. Proof-of-principle that this approach may represent a shift from mere reconstruction to in situ regeneration was provided by a retrieved human specimen, showing that the BioCer was transformed into well-vascularized osteonal bone, with a morphology, ultrastructure, and composition similar to those of native human skull bone.
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Lewin S, Fleps I, Neuhaus D, Öhman-Mägi C, Ferguson SJ, Persson C, Helgason B. Implicit and explicit finite element models predict the mechanical response of calcium phosphate-titanium cranial implants. J Mech Behav Biomed Mater 2020; 112:104085. [PMID: 33080431 DOI: 10.1016/j.jmbbm.2020.104085] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 08/14/2020] [Accepted: 09/08/2020] [Indexed: 11/29/2022]
Abstract
The structural integrity of cranial implants is of great clinical importance, as they aim to provide cerebral protection after neurosurgery or trauma. With the increased use of patient-specific implants, the mechanical response of each implant cannot be characterized experimentally in a practical way. However, computational models provide an excellent possibility for efficiently predicting the mechanical response of patient-specific implants. This study developed finite element models (FEMs) of titanium-reinforced calcium phosphate (CaP-Ti) implants. The models were validated with previously obtained experimental data for two different CaP-Ti implant designs (D1 and D2), in which generically shaped implant specimens were loaded in compression at either quasi-static (1 mm/min) or impact (5 kg, 1.52 m/s) loading rates. The FEMs showed agreement with experimental data in the force-displacement response for both implant designs. The implicit FEMs predicted the peak load with an underestimation for D1 (9%) and an overestimation for D2 (11%). Furthermore, the shape of the force-displacement curves were well predicted. In the explicit FEMs, the first part of the force-displacement response showed 5% difference for D1 and 2% difference for D2, with respect to the experimentally derived peak loads. The explicit FEMs efficiently predicted the maximum displacements with 1% and 4% difference for D1 and D2, respectively. Compared to the CaP-Ti implant, an average parietal cranial bone FEM showed a stiffer response, greater energy absorption and less deformation under the same impact conditions. The framework developed for modelling the CaP-Ti implants has a potential for modelling CaP materials in other composite implants in future studies since it only used literature based input and matched boundary conditions. Furthermore, the developed FEMs make an important contribution to future evaluations of patient-specific CaP-Ti cranial implant designs in various loading scenarios.
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Affiliation(s)
- Susanne Lewin
- Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden.
| | - Ingmar Fleps
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | | | - Caroline Öhman-Mägi
- Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden
| | | | - Cecilia Persson
- Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden
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Bloom O, Goddard N, Yannoulias B, Eccles S. The successful use of a bespoke OssDsign cranial plate to reconstruct an occipital defect following excision of a recurrent epithelioid sarcoma. JPRAS Open 2020; 24:71-76. [PMID: 32426442 PMCID: PMC7225370 DOI: 10.1016/j.jpra.2020.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/07/2020] [Indexed: 11/23/2022] Open
Abstract
A cranioplasty has a number of known associated complications including infection for non-biological implants and bone flap resorption where autologous grafts are used. In recent years, bioactive ceramic cranial implants have been developed as a new reconstructive option. The OssDsign cranial plate (OssDsign AB, Uppsala, Sweden) was first introduced in 2010 and consists of an interconnected mosaic of hydroxyapatite tiles mounted onto a 3D-printed titanium mesh. Each tile is composed of a monetite, beta-calcium pyrophosphate, beta-tricalcium phosphate and brushite compound designed to mimic the process of coupled bone formation once implanted. This case presents a patient's journey from diagnosis of an epithelioid sarcoma over the posterior scalp and its management in the following 7 years. Initial excision of the lesion was reconstructed with a tissue expander and local rotational flap. Recurrence of the disease 3 years later was treated with a course of radical radiotherapy. Persistent osteomyelitis over the next 3 years resulted in chronic ulceration and exposed bone in the treated area. As the first part of a 3-stage treatment plan, two separate tissue expanders became infected. The multidisciplinary team therefore chose to use a bespoke OssDsign cranial plate combined with a deep inferior epigastric perforator (DIEP) free flap to provide a definitive single operative solution. The advantages over other reconstruction options include that the plate can be removed should further excision be required, greater potential for long-term integration with surrounding tissues and the ability to be soaked in antibiotic to reduce the risk of infection.
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Affiliation(s)
- Oliver Bloom
- Correspondence to: 34 Lilac Court, Cambridge, CB1 7AY, United Kingdom.
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Lewin S, Åberg J, Neuhaus D, Engqvist H, Ferguson SJ, Öhman-Mägi C, Helgason B, Persson C. Mechanical behaviour of composite calcium phosphate-titanium cranial implants: Effects of loading rate and design. J Mech Behav Biomed Mater 2020; 104:103701. [PMID: 32174441 DOI: 10.1016/j.jmbbm.2020.103701] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/04/2020] [Accepted: 02/13/2020] [Indexed: 11/28/2022]
Abstract
Cranial implants are used to repair bone defects following neurosurgery or trauma. At present, there is a lack of data on their mechanical response, particularly in impact loading. The aim of the present study was to assess the mechanical response of a recently developed composite calcium phosphate-titanium (CaP-Ti) implant at quasi-static and impact loading rates. Two different designs were tested, referred to as Design 1 (D1) and Design 2 (D2). The titanium structures in the implant specimens were additively manufactured by a powder-bed fusion process and subsequently embedded in a self-setting CaP material. D1 was conceptually representative of the clinically used implants. In D2, the titanium structure was simplified in terms of geometry in order to facilitate the manufacturing. The mechanical response of the implants was evaluated in quasi-static compression, and in impact using a drop-tower. Similar peak loads were obtained for the two designs, at the two loading rates: 808 ± 29 N and 852 ± 34 for D1, and 840 ± 40 N and 814 ± 13 for D2. A strain rate dependency was demonstrated for both designs, with a higher stiffness in the impact test. Furthermore, the titanium in the implant fractured in the quasi-static test (to failure) but not in the impact test (to 5.75 J) for D1. For D2, the displacement at peak load was significantly lower in the impact test than in the quasi-static test. The main difference between the designs was seen in the quasi-static test results where the deformation zones, i.e. notches in the titanium structure between the CaP tiles, in D1 likely resulted in a localization of the deformation, compared to in D2 (which did not have deformation zones). In the impact test, the only significant difference between the designs was a higher maximum displacement of D2 than of D1. In comparison with other reported mechanical tests on osteoconductive ceramic-based cranial implants, the CaP-Ti implant demonstrates the highest reported strength in quasi-static compression. In conclusion, the titanium structure seems to make the CaP-Ti implant capable of cerebral protection in impact situations like the one tested in this study.
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Affiliation(s)
- Susanne Lewin
- Div. of Applied Materials Science, Dept. of Engineering Sciences, Uppsala University, Uppsala, Sweden.
| | - Jonas Åberg
- Div. of Applied Materials Science, Dept. of Engineering Sciences, Uppsala University, Uppsala, Sweden
| | | | - Håkan Engqvist
- Div. of Applied Materials Science, Dept. of Engineering Sciences, Uppsala University, Uppsala, Sweden
| | | | - Caroline Öhman-Mägi
- Div. of Applied Materials Science, Dept. of Engineering Sciences, Uppsala University, Uppsala, Sweden
| | | | - Cecilia Persson
- Div. of Applied Materials Science, Dept. of Engineering Sciences, Uppsala University, Uppsala, Sweden
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Sundblom J, Nowinski D, Casar-Borota O, Ryttlefors M. Removal of giant intraosseous meningioma followed by cranioplasty using a custom-made bioceramic implant: case report. J Neurosurg 2019; 131:735-739. [DOI: 10.3171/2018.4.jns1850] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 04/23/2018] [Indexed: 11/06/2022]
Abstract
Intraosseous meningioma of the chordoid type is a rare clinical entity. Radical surgical removal and subsequent cranioplasty is the treatment of choice. Here, the authors report a severe case involving more than 70% of the calvarial surface area, which was removed and repaired using a prefabricated custom-made, titanium-reinforced, bioceramic implant and bone-cutting guides. Tumor removal and good esthetic outcome were achieved, along with a 17.1% increase of intracranial volume. Bioceramic implants have shown promising initial results and may represent an important new tool in the surgeon’s armamentarium.
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Affiliation(s)
- Jimmy Sundblom
- 1Department of Neuroscience, Neurosurgery, Uppsala University Hospital
| | - Daniel Nowinski
- 2Department of Surgical Sciences, Plastic Surgery, Uppsala University Hospital
| | - Olivera Casar-Borota
- 3Department of Immunology, Genetics and Pathology, Uppsala University; and
- 4Department of Clinical Pathology, Uppsala University Hospital, Uppsala, Sweden
| | - Mats Ryttlefors
- 1Department of Neuroscience, Neurosurgery, Uppsala University Hospital
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Siegmund BJ, Rustemeyer J. Case report: chronic inflammatory ulcer and osteoradionecrosis of the skull following radiotherapy in early childhood. Oral Maxillofac Surg 2019; 23:239-246. [PMID: 31011848 DOI: 10.1007/s10006-019-00752-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 02/15/2019] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Chronic inflammatory diseases of the skin are the most common differential diagnosis of tumorous lesions of the craniofacial region. Detailed information about a patient's medical history is important for the clinical diagnosis of such cases. Previous radiotherapy should be taken into account, especially in cases of chronic dermatitis, since complications include osteoradionecrois of the adjacent bone strucutres with surrounding inflammation. CASE REPORT We present the case of a 77-year-old femal patient who was admitted to our department with a slightly progressive ulcerating lesion of the frontotemporal skull. The patient had received radiotherapy in early childhood as primary therapy for hemangioma. Diagnostic imaging and biopsies revealed a diagnosis of chronic ulceration with underlying osteonecrosis and fibrotic osteomyelitis of the skull. A complex reconstruction of osseous structures and soft tissue was necessary to resolve her complaints. CONCLUSION Chronic radiodermatitis and osteoradionecrosis in adults, occurring as late complications, are uncommon, but can be observed even nearly 80 years after radiation. Large defects of the skull require a complete reconstruction to avoid several complications.
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Affiliation(s)
- Birte Julia Siegmund
- Department of Oral and Maxillofacial Surgery and Plastic Operations, Central Medical Centre Bremen, Bremen, Germany.
| | - Jan Rustemeyer
- Department of Oral and Maxillofacial Surgery and Plastic Operations, Central Medical Centre Bremen, Bremen, Germany
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Reconstruction of Acquired Frontal Bone Defects Using Titanium Mesh Implants: A Retrospective Study. J Maxillofac Oral Surg 2019; 18:34-39. [PMID: 30728689 DOI: 10.1007/s12663-018-1083-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 01/12/2018] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Frontal bone deformities can be acquired due to trauma or ablative tumor resection surgeries and osteomyelitis. It may also occur due to congenital malformations. Repair of these defects have long been a challenge to oral and maxillofacial surgeons. We report our experience in the reconstruction of acquired frontal bone defects by titanium mesh implant. PATIENTS AND METHODS Titanium mesh was used for reconstruction in 35 patients (18-55 years age-group) (34 males and 01 females) of acquired frontal bone defects secondary to trauma (RTA). All these patients have been referred to author by Department of Neurosurgery of the institute of Affiliation. RESULTS All these cases acquired defects as a result of trauma. Follow-up ranged from 12 to 18 months after the reconstruction. Patients were followed up for the progress of healing, stability of implants, infection, wound dehiscence, discharging sinus, exposure of implants, collections, patient satisfaction regarding esthetics and reaction to thermal changes. No postoperative complications were found. CONCLUSION In reconstruction of frontal bone defects, titanium mesh gives satisfactory results.
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Pujari-Palmer M, Guo H, Wenner D, Autefage H, Spicer CD, Stevens MM, Omar O, Thomsen P, Edén M, Insley G, Procter P, Engqvist H. A Novel Class of Injectable Bioceramics that Glue Tissues and Biomaterials. MATERIALS 2018; 11:ma11122492. [PMID: 30544596 PMCID: PMC6316977 DOI: 10.3390/ma11122492] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 11/30/2018] [Accepted: 12/03/2018] [Indexed: 01/21/2023]
Abstract
Calcium phosphate cements (CPCs) are clinically effective void fillers that are capable of bridging calcified tissue defects and facilitating regeneration. However, CPCs are completely synthetic/inorganic, unlike the calcium phosphate that is found in calcified tissues, and they lack an architectural organization, controlled assembly mechanisms, and have moderate biomechanical strength, which limits their clinical effectiveness. Herein, we describe a new class of bioinspired CPCs that can glue tissues together and bond tissues to metallic and polymeric biomaterials. Surprisingly, alpha tricalcium phosphate cements that are modified with simple phosphorylated amino acid monomers of phosphoserine (PM-CPCs) bond tissues up to 40-fold stronger (2.5–4 MPa) than commercial cyanoacrylates (0.1 MPa), and 100-fold stronger than surgical fibrin glue (0.04 MPa), when cured in wet-field conditions. In addition to adhesion, phosphoserine creates other novel properties in bioceramics, including a nanoscale organic/inorganic composite microstructure, and templating of nanoscale amorphous calcium phosphate nucleation. PM-CPCs are made of the biocompatible precursors calcium, phosphate, and amino acid, and these represent the first amorphous nano-ceramic composites that are stable in liquids.
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Affiliation(s)
- Michael Pujari-Palmer
- Applied material science, Department of Engineering, Uppsala University, Uppsala 75121, Sweden.
| | - Hua Guo
- Department of Materials and Environmental Chemistry, Stockholm University, Stockholm 106 91, Sweden.
| | - David Wenner
- Applied material science, Department of Engineering, Uppsala University, Uppsala 75121, Sweden.
| | - Hélène Autefage
- Department of Medical Biochemistry and Biophysics, Karolinska Institute, Stockholm 17177, Sweden.
| | - Christopher D Spicer
- Department of Medical Biochemistry and Biophysics, Karolinska Institute, Stockholm 17177, Sweden.
| | - Molly M Stevens
- Department of Medical Biochemistry and Biophysics, Karolinska Institute, Stockholm 17177, Sweden.
- Department of Materials, Department of Bioengineering and Institute of Biomedical Engineering, Imperial College London, London SW7 2AZ, UK.
| | - Omar Omar
- Department of Biomaterials, Institute of Clinical Sciences, University of Gothenburg, Gothenburg 40530, Sweden.
| | - Peter Thomsen
- Department of Biomaterials, Institute of Clinical Sciences, University of Gothenburg, Gothenburg 40530, Sweden.
| | - Mattias Edén
- Department of Materials and Environmental Chemistry, Stockholm University, Stockholm 106 91, Sweden.
| | - Gerard Insley
- Applied material science, Department of Engineering, Uppsala University, Uppsala 75121, Sweden.
| | - Philip Procter
- Applied material science, Department of Engineering, Uppsala University, Uppsala 75121, Sweden.
| | - Hakan Engqvist
- Applied material science, Department of Engineering, Uppsala University, Uppsala 75121, Sweden.
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Kihlström Burenstam Linder L, Birgersson U, Lundgren K, Illies C, Engstrand T. Patient-Specific Titanium-Reinforced Calcium Phosphate Implant for the Repair and Healing of Complex Cranial Defects. World Neurosurg 2018; 122:e399-e407. [PMID: 30342265 DOI: 10.1016/j.wneu.2018.10.061] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 10/08/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The reconstruction of complex cranial defects is challenging and is associated with a high complication rate. The development of a patient-specific, titanium-reinforced, calcium phosphate-based (CaP-Ti) implant with bone regenerative properties has previously been described in 2 case studies with the hypothesis that the implant may improve clinical outcome. OBJECTIVE To identify whether the introduction of CaP-Ti implant has the potential to improve clinical outcome. METHODS A retrospective review of all patients having undergone CaP-Ti cranioplasty was conducted. Comprehensive clinical data were collected from the hospital computer database and patient records. Bone formation and osseointegration were analyzed in a single retrieval specimen. RESULTS Fifty patients, with 52 cranial defects, met the inclusion criteria. The patient cohort displayed a previous failure rate of 64% (32/50) with autologous bone, alloplastic materials, or both. At a median follow-up time of 25 months, the explantation rate due to either early postoperative infection or persistent wound dehiscence was 1.9% (1/53) or 3.8% (2/53), respectively. Surgical intervention with local wound revision was required in 2 patients without the need of implant removal. One patient had a brain tumor recurrence, and the implant was explanted 31 months after implantation. Histologic examination showed that the entire implant was partly yet evenly transformed into vascularized compact bone. CONCLUSION In the present study the CaP-Ti implant appears to have improved the clinical outcomes in a cohort of patients with a high rate of previous cranioplasty failures. The bone regenerative effect may in particular have an impact on the long-term success rate of the implant.
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Affiliation(s)
- Lars Kihlström Burenstam Linder
- Department of Neurosurgery, Clinical Neurosciences, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden.
| | - Ulrik Birgersson
- Department of Clinical Science, Intervention and Technology, Division of Imaging and Technology, Karolinska Institutet, Huddinge, Sweden
| | - Kalle Lundgren
- Department of Molecular Medicine and Surgery, Unit for Craniofacial diseases, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Christopher Illies
- Department of Clinical Pathology, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Engstrand
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Autologous Bone Is Inferior to Alloplastic Cranioplasties: Safety of Autograft and Allograft Materials for Cranioplasties, a Systematic Review. World Neurosurg 2018; 117:443-452.e8. [DOI: 10.1016/j.wneu.2018.05.193] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/25/2018] [Accepted: 05/26/2018] [Indexed: 11/19/2022]
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Persson J, Helgason B, Engqvist H, Ferguson SJ, Persson C. Stiffness and strength of cranioplastic implant systems in comparison to cranial bone. J Craniomaxillofac Surg 2018; 46:418-423. [DOI: 10.1016/j.jcms.2017.11.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 11/17/2017] [Accepted: 11/28/2017] [Indexed: 11/17/2022] Open
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Trbakovic A, Hedenqvist P, Mellgren T, Ley C, Hilborn J, Ossipov D, Ekman S, Johansson CB, Jensen-Waern M, Thor A. A new synthetic granular calcium phosphate compound induces new bone in a sinus lift rabbit model. J Dent 2018; 70:31-39. [PMID: 29258851 DOI: 10.1016/j.jdent.2017.12.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 11/29/2017] [Accepted: 12/15/2017] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES The aim of this study was to investigate if a synthetic granular calcium phosphate compound (CPC) and a composite bisphosphonate-linked hyaluronic acid-calcium phosphate hydrogel (HABP·CaP) induced similar or more amount of bone as bovine mineral in a modified sinus lift rabbit model. MATERIAL AND METHODS Eighteen adult male New Zeeland White rabbits, received randomly one of the two test materials on a random side of the face, and bovine mineral as control on the contralateral side. In a sinus lift, the sinus mucosa was elevated and a titanium mini-implant was placed in the alveolar bone. Augmentation material (CPC, HABP·CaP or bovine bone) was applied in the space around the implant. The rabbits were euthanized three months after surgery and qualitative and histomorphometric evaluation were conducted. Histomorphometric evaluation included three different regions of interest (ROIs) and the bone to implant contact on each installed implant. RESULTS Qualitative assessment (p = <.05), histomorphometric evaluations (p = < .01), and implant incorporation (p = <.05) showed that CPC and bovine mineral induced similar amount of bone and more than the HABP·CaP hydrogel. CONCLUSION CPC induced similar amount of bone as bovine mineral and both materials induced more bone than HABP·CaP hydrogel. CLINICAL SIGNIFICANCE The CPC is suggested as a synthetic alternative for augmentations in the maxillofacial area.
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Affiliation(s)
- Amela Trbakovic
- Department of Surgical Sciences, Plastic & Oral and Maxillofacial Surgery, Uppsala University, 751 85 Uppsala, Sweden.
| | - Patricia Hedenqvist
- Swedish University of Agricultural Sciences, Department of Clinical Sciences, PO Box 7054, 750 07 Uppsala, Sweden.
| | - Torbjörn Mellgren
- Polymer Chemistry, Department of Chemistry, Ångströms Laboratory, Uppsala University, Box 538, 75121 Uppsala, Sweden.
| | - Cecilia Ley
- Swedish University of Agricultural Sciences, Department of Biomedical Sciences and Veterinary Public Health, Division of Pathology, PO Box 7028, 750 07 Uppsala, Sweden.
| | - Jöns Hilborn
- Polymer Chemistry, Department of Chemistry, Ångströms Laboratory, Uppsala University, Box 538, 75121 Uppsala, Sweden.
| | - Dmitri Ossipov
- Polymer Chemistry, Department of Chemistry, Ångströms Laboratory, Uppsala University, Box 538, 75121 Uppsala, Sweden
| | - Stina Ekman
- Swedish University of Agricultural Sciences, Department of Biomedical Sciences and Veterinary Public Health, Division of Pathology, PO Box 7028, 750 07 Uppsala, Sweden.
| | - Carina B Johansson
- University of Gothenburg, The Sahlgrenska Academy, Institute of Odontology, Department of Prosthodontics, Dental Materials Science, P.O. Box 450, 405 30 Gothenburg, Sweden.
| | - Marianne Jensen-Waern
- Swedish University of Agricultural Sciences, Department of Clinical Sciences, PO Box 7054, 750 07 Uppsala, Sweden.
| | - Andreas Thor
- Department of Surgical Sciences, Plastic & Oral and Maxillofacial Surgery, Uppsala University, 751 85 Uppsala, Sweden.
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Ajaxon I, Holmberg A, Öhman-Mägi C, Persson C. Fatigue performance of a high-strength, degradable calcium phosphate bone cement. J Mech Behav Biomed Mater 2018; 79:46-52. [DOI: 10.1016/j.jmbbm.2017.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/30/2017] [Accepted: 12/04/2017] [Indexed: 01/18/2023]
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27
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Elastic properties and strain-to-crack-initiation of calcium phosphate bone cements: Revelations of a high-resolution measurement technique. J Mech Behav Biomed Mater 2017; 74:428-437. [DOI: 10.1016/j.jmbbm.2017.06.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/16/2017] [Accepted: 06/20/2017] [Indexed: 11/18/2022]
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Moiduddin K, Darwish S, Al-Ahmari A, ElWatidy S, Mohammad A, Ameen W. Structural and mechanical characterization of custom design cranial implant created using additive manufacturing. ELECTRON J BIOTECHN 2017. [DOI: 10.1016/j.ejbt.2017.06.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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Bone Morphogenetic Protein-7 Enhances Degradation of Osteoinductive Bioceramic Implants in an Ectopic Model. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1375. [PMID: 28740783 PMCID: PMC5505844 DOI: 10.1097/gox.0000000000001375] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 04/21/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of the present study was to evaluate the degradation pattern of highly porous bioceramics as well as the bone formation in presence of bone morphogenetic protein 7 (BMP-7) in an ectopic site. METHODS Novel calcium phosphate ceramic cylinders sintered at 1,300°C with a total porosity of 92-94 vol%, 45 pores per inch, and sized 15 mm (Ø) × 5 mm were grafted on the musculus latissimus dorsi bilaterally in 10 Göttingen minipigs: group I (n = 5): hydroxyapatite (HA) versus biphasic calcium phosphate (BCP), a mixture of HA and tricalcium phosphate (TCP) in a ratio of 60/40 wt%; group II (n = 5): TCP versus BCP. A test side was supplied in situ with 250 μg BMP-7. Fluorochrome bone labeling and computed tomography were performed in vivo. Specimens were evaluated 14 weeks after surgery by environmental scanning electron microscopy, fluorescence microscopy, tartrate-resistant acid phosphatase, and pentachrome staining. RESULTS Bone formation was enhanced in the presence of BMP-7 in all ceramics (P = 0.001). Small spots of newly formed bone were observed in all implants in the absence of BMP-7. Degradation of HA and BCP was enhanced in the presence of BMP-7 (P = 0.001). In those ceramics, osteoclasts were observed. TCP ceramics were almost completely degraded independently of the effect of BMP-7 after 14 weeks (P = 0.76), osteoclasts were not observed. CONCLUSIONS BMP-7 enhanced bone formation and degradation of HA and BCP ceramics via osteoclast resorption. TCP degraded via dissolution. All ceramics were osteoinductive. Novel degradable HA and BCP ceramics in the presence of BMP-7 are promising bone substitutes in the growing individual.
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BMP-7 Preserves Surface Integrity of Degradable-ceramic Cranioplasty in a Göttingen Minipig Model. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1255. [PMID: 28458969 PMCID: PMC5404440 DOI: 10.1097/gox.0000000000001255] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 01/11/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND The aim of the study was to evaluate the integrity of a craniotomy grafted site in a minipig model using different highly porous calcium phosphate ceramic scaffolds either loaded or nonloaded with bone morphogenetic protein-7 (BMP-7). METHODS Four craniotomies with a diameter of 15 mm (critical-size defect) were grafted with different highly porous (92-94 vol%) calcium phosphate ceramics [hydroxyapatite (HA), tricalcium phosphate (TCP), and biphasic calcium phosphate (BCP; a mixture of HA and TCP)] in 10 Göttingen minipigs: (a) group I (n = 5): HA versus BCP; (b) group II (n = 5): TCP versus BCP. One scaffold of each composition was supplied with 250 μg of BMP-7. In vivo computed tomography scan and fluorochrome bone labeling were performed. Specimens were evaluated 14 weeks after surgery by environmental scanning electron microscopy, fluorescence microscopy, and Giemsa staining histology. RESULTS BMP-7 significantly enhanced bone formation in TCP (P = 0.047). Slightly enhanced bone formation was observed in BCP (P = 0.059) but not in HA implants. BMP-7 enhanced ceramic degradation in TCP (P = 0.05) and BCP (P = 0.05) implants but not in HA implants. Surface integrity of grafted site was observed in all BMP-7-loaded implants after successful creeping substitution by the newly formed bone. In 9 of 10 HA implants without BMP-7, partial collapse of the implant site was observed. All TCP implants without BMP-7 collapsed. Fluorescent labeling showed bone formation at week 1 in BMP-7-stimulated implants. CONCLUSIONS BMP-7 supports bone formation, ceramic degradation, implant integration, and surface integrity of the grafted site.
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Ajaxon I, Öhman Mägi C, Persson C. Compressive fatigue properties of an acidic calcium phosphate cement-effect of phase composition. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2017; 28:41. [PMID: 28144853 PMCID: PMC5285421 DOI: 10.1007/s10856-017-5851-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 01/10/2017] [Indexed: 06/06/2023]
Abstract
Calcium phosphate cements (CPCs) are synthetic bone grafting materials that can be used in fracture stabilization and to fill bone voids after, e.g., bone tumour excision. Currently there are several calcium phosphate-based formulations available, but their use is partly limited by a lack of knowledge of their mechanical properties, in particular their resistance to mechanical loading over longer periods of time. Furthermore, depending on, e.g., setting conditions, the end product of acidic CPCs may be mainly brushite or monetite, which have been found to behave differently under quasi-static loading. The objectives of this study were to evaluate the compressive fatigue properties of acidic CPCs, as well as the effect of phase composition on these properties. Hence, brushite cements stored for different lengths of time and with different amounts of monetite were investigated under quasi-static and dynamic compression. Both storage and brushite-to-monetite phase transformation was found to have a pronounced effect both on quasi-static compressive strength and fatigue performance of the cements, whereby a substantial phase transformation gave rise to a lower mechanical resistance. The brushite cements investigated in this study had the potential to survive 5 million cycles at a maximum compressive stress of 13 MPa. Given the limited amount of published data on fatigue properties of CPCs, this study provides an important insight into the compressive fatigue behaviour of such materials.
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Affiliation(s)
- Ingrid Ajaxon
- Materials in Medicine, Division of Applied Materials Science, Department of Engineering Sciences, Uppsala University, The Ångström Laboratory, Box 534, SE-751 21, Uppsala, Sweden
| | - Caroline Öhman Mägi
- Materials in Medicine, Division of Applied Materials Science, Department of Engineering Sciences, Uppsala University, The Ångström Laboratory, Box 534, SE-751 21, Uppsala, Sweden
| | - Cecilia Persson
- Materials in Medicine, Division of Applied Materials Science, Department of Engineering Sciences, Uppsala University, The Ångström Laboratory, Box 534, SE-751 21, Uppsala, Sweden.
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Pujari-Palmer M, Pujari-Palmer S, Lu X, Lind T, Melhus H, Engstrand T, Karlsson-Ott M, Engqvist H. Pyrophosphate Stimulates Differentiation, Matrix Gene Expression and Alkaline Phosphatase Activity in Osteoblasts. PLoS One 2016; 11:e0163530. [PMID: 27701417 PMCID: PMC5049792 DOI: 10.1371/journal.pone.0163530] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 09/09/2016] [Indexed: 12/29/2022] Open
Abstract
Pyrophosphate is a potent mitogen, capable of stimulating proliferation in multiple cell types, and a critical participant in bone mineralization. Pyrophosphate can also affect the resorption rate and bioactivity of orthopedic ceramics. The present study investigated whether calcium pyrophosphate affected proliferation, differentiation and gene expression in early (MC3T3 pre-osteoblast) and late stage (SAOS-2 osteosarcoma) osteoblasts. Pyrophosphate stimulated peak alkaline phosphatase activity by 50% and 150% at 100μM and 0.1μM in MC3T3, and by 40% in SAOS-2. The expression of differentiation markers collagen 1 (COL1), alkaline phosphatase (ALP), osteopontin (OPN), and osteocalcin (OCN) were increased by an average of 1.5, 2, 2 and 3 fold, by high concentrations of sodium pyrophosphate (100μM) after 7 days of exposure in MC3T3. COX-2 and ANK expression did not differ significantly from controls in either treatment group. Though both high and low concentrations of pyrophosphate stimulate ALP activity, only high concentrations (100μM) stimulated osteogenic gene expression. Pyrophosphate did not affect proliferation in either cell type. The results of this study confirm that chronic exposure to pyrophosphate exerts a physiological effect upon osteoblast differentiation and ALP activity, specifically by stimulating osteoblast differentiation markers and extracellular matrix gene expression.
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Affiliation(s)
- Michael Pujari-Palmer
- Division of Applied Material Science, Department of Engineering Sciences, Uppsala University, Uppsala, Sweden
| | - Shiuli Pujari-Palmer
- Division of Applied Material Science, Department of Engineering Sciences, Uppsala University, Uppsala, Sweden
| | - Xi Lu
- Division of Applied Material Science, Department of Engineering Sciences, Uppsala University, Uppsala, Sweden
| | - Thomas Lind
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Håkan Melhus
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Thomas Engstrand
- Stockholm Craniofacial Centre, Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Materials Chemistry, Polymer section, Uppsala University, Uppsala, Sweden
| | - Marjam Karlsson-Ott
- Division of Applied Material Science, Department of Engineering Sciences, Uppsala University, Uppsala, Sweden
- * E-mail:
| | - Hakan Engqvist
- Division of Applied Material Science, Department of Engineering Sciences, Uppsala University, Uppsala, Sweden
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