Bone formation by enamel matrix proteins and xenografts: an experimental study in the rat ramus

Healing patterns of alveolar bone following ridge preservation procedures

OBJECTIVES

Examine the histomorphometric bone composition, following alveolar ridge preservation techniques and unassisted socket healing.

MATERIALS AND METHODS

Forty-two patients (42) requiring a single rooted tooth extraction were randomly allocated into three groups (n = 14 per group): Group 1: Guided Bone Regeneration (GBR) using deproteinised bovine bone mineral (DBBM) and a porcine collagen membrane; Group 2: Socket Seal (SS) technique using DBBM and a porcine collagen matrix; Group 3: Unassisted socket healing (Control). Trephined bone biopsies were harvested following a 4-month healing period. Forty-two samples underwent Back-Scattered Electrons -Scanning Electron Microscopy (BSE-SEM) imaging, with 15 samples examined using Xray Micro-Tomography (XMT) (n = 6 for each GBR/SS and n = 3 Control). Images were analysed to determine the percentage (%) of connective tissue, new bone formation, residual DBBM particles and direct bone to DBBM particle contact (osseointegration).

RESULTS

BSE-SEM analysis demonstrated that new bone formation was higher in the Control (45.89% ± 11.48) compared to both GBR (22.12% ± 12.7/p < .004) and SS (27.62% ± 17.76/p < .005) groups. The connective tissue percentage in GBR (49.72% ± 9), SS (47.81% ± 12.57) and Control (47.81% ± 12.57) groups was similar. GBR (28.17% ± 16.64) and SS (24.37% ± 18.61) groups had similar levels of residual DBBM particles. XMT volumetric analysis indicated a lower level of bone and DBBM particles in all test groups, when matched to the BSE-SEM area measurements. Osseointegration levels (DBBM graft and bone) were recorded at 35.66% (± 9.8) for GBR and 31.18% (± 19.38) for SS.

CONCLUSION

GBR and SS ARP techniques presented with less bone formation when compared to unassisted healing. GBR had more direct contact/osseointegration between the DBBM particles and newly formed bone.

Fresh-frozen allogeneic bone blocks grafts for alveolar ridge augmentation: Biological and clinical aspects

The possibilities for oral bone regeneration procedures vary depending on the type of bone defect to be treated, which in turn dictate the type of graft to be used. Atrophic alveolar ridges are non-contained defects and pose a challenging defect morphology for bone regeneration/augmentation. Successful results are regularly obtained with the use of particulate grafts in combination with barrier membranes. In cases of very narrow ridges with need of larger amount of bone augmentation, block grafts are often used. Fresh-frozen allogeneic bone block grafts have been proposed as an alternative to autogenous (AT) bone blocks. Based on a systematic appraisal of pre-clinical in vivo studies and clinical trials including a direct comparison of fresh-frozen bone (FFB) blocks versus AT bone blocks it can be concluded that a FFB block graft: (a) cannot be considered as a reliable replacement of a AT bone block, and (b) should only be considered in cases where the amount of necessary augmentation-in a lateral direction-is relatively limited, so that the main portion of the body of the implant lies within the inner (i.e., the vital) aspect of the block.

Bone regeneration in implant dentistry: Which are the factors affecting the clinical outcome?

The key factors that are needed for bone regeneration to take place include cells (osteoprogenitor and immune-inflammatory cells), a scaffold (blood clot) that facilitates the deposition of the bone matrix, signaling molecules, blood supply, and mechanical stability. However, even when these principles are met, the overall amount of regenerated bone, its stability over time and the incidence of complications may significantly vary. This manuscript provides a critical review on the main local and systemic factors that may have an impact on bone regeneration, trying to focus, whenever possible, on bone regeneration simultaneous to implant placement to treat bone dehiscence/fenestration defects or for bone contouring. In the future, it is likely that bone tissue engineering will change our approach to bone regeneration in implant dentistry by replacing the current biomaterials with osteoinductive scaffolds combined with cells and mechanical/soluble factors and by employing immunomodulatory materials that can both modulate the immune response and control other bone regeneration processes such as osteogenesis, osteoclastogenesis, or inflammation. However, there are currently important knowledge gaps on the biology of osseous formation and on the factors that can influence it that require further investigation. It is recommended that future studies should combine traditional clinical and radiographic assessments with non-invasive imaging and with patient-reported outcome measures. We also envisage that the integration of multi-omics approaches will help uncover the mechanisms responsible for the variability in regenerative outcomes observed in clinical practice.

Amelogenin-Derived Peptides in Bone Regeneration: A Systematic Review

Amelogenins are enamel matrix proteins currently used to treat bone defects in periodontal surgery. Recent studies have highlighted the relevance of amelogenin-derived peptides, named LRAP, TRAP, SP, and C11, in bone tissue engineering. Interestingly, these peptides seem to maintain or even improve the biological activity of the full-length protein, which has received attention in the field of bone regeneration. In this article, the authors combined a systematic and a narrative review. The former is focused on the existing scientific evidence on LRAP, TRAP, SP, and C11's ability to induce the production of mineralized extracellular matrix, while the latter is concentrated on the structure and function of amelogenin and amelogenin-derived peptides. Overall, the collected data suggest that LRAP and SP are able to induce stromal stem cell differentiation towards osteoblastic phenotypes; specifically, SP seems to be more reliable in bone regenerative approaches due to its osteoinduction and the absence of immunogenicity. However, even if some evidence is convincing, the limited number of studies and the scarcity of in vivo studies force us to wait for further investigations before drawing a solid final statement on the real potential of amelogenin-derived peptides in bone tissue engineering.

Proteomic and Transcriptomic Approaches for Studying Bone Regeneration in Health and Systemically Compromised Conditions

Bone regeneration is a complex biological process, where the molecular mechanisms are only partially understood. In an ageing population, where the prevalence of chronic diseases with an impact on bone metabolism is increasing, it becomes crucial to identify new strategies that would improve regenerative outcomes also in medically compromised patients. In this context, omics are demonstrating a great potential, as they offer new insights on the molecular mechanisms regulating physiologic/pathologic bone healing and, at the same time, allow the identification of new diagnostic and therapeutic targets. This review provides an overview on the current evidence on the use of transcriptomic and proteomic approaches in bone regeneration research, particularly in relation to type 1 diabetes and osteoporosis, and discusses future scenarios and potential benefits and limitations on the integration of multi-omics. It is suggested that future research will leverage the synergy of omics with statistical modeling and bioinformatics to prompt the understanding of the biology underpinning bone formation in health and medically compromised conditions. With an eye toward personalized medicine, new strategies combining the mining of large datasets and bioinformatic data with a detailed characterization of relevant phenotypes will need to be pursued to further the understanding of disease mechanisms.

Ridge Alterations following Socket Preservation Using a Collagen Membrane in Dogs

Background

The healing process following tooth extraction results in alveolar ridge resorption. The dimensional changes may complicate the subsequent implant procedure. Socket preservation using absorbable collagen membranes or a combination of membranes with calcium phosphate cement (CPC) particles might ensure that the alveolar ridge retains a suitable morphology for implant placement.

Objective

To evaluate the quality and quantity of new bone regenerated after application of either collagen membranes alone covering the sockets or a combination of membranes with CPC particles added into the sockets in dogs. Materials and Methods. Six dogs were included in this study. The mandibular premolars were extracted. For each hemimandible, three premolar extraction sites were randomly assigned to one of the following treatments: a covering collagen membrane, CPC with a covering collagen membrane, and a socket left empty. Cone-beam computed tomography (CBCT) measurements, polyfluorochrome sequential labeling, and histological assessments were performed to investigate the healing ability and repair processes within a 6-month observation period.

Results

Buccal bone height in the membrane group was significantly higher than that in the membrane+CPC and blank groups at 4 and 6 months after extraction. The mineral apposition rate over 2-4 months and the alizarin red-stained area in the membrane group were significantly higher than those in the other two groups. Histological analysis after 6 months of healing showed significantly higher amounts of newly formed bone in the membrane group than in the other groups.

Conclusion

Extraction sites treated with collagen barrier membranes showed better protection than sites not covered with membranes. And the buccal bone wall of the socket was well preserved by collagen membrane without extra CPC materials. Socket preservation using absorbable membranes alone yielded better quality and quantity of regenerated bone inside the socket site.

Ridge preservation in molar extraction sites with an open-healing approach: A randomized controlled clinical trial

AIM

To determine the effect of alveolar ridge preservation (ARP) in molar sites without primary flap closure.

MATERIALS AND METHODS

Three groups were established: extraction sockets grafted with deproteinized bovine bone mineral containing 10% collagen (DBBM-C) and covered by a native bilayer collagen membrane (NBCM) (test group 1), sockets grafted with DBBM-C only (test group 2), and sockets that healed naturally (control group). Primary flap closure was not attempted. Conebeam computed tomography scans were obtained immediately and then 4 months after ARP. A biopsy was performed. The change of the marginal bone level was measured.

RESULTS

There was significantly less horizontal resorption in test group 1 than in the control group at levels 1 mm (-1.02 ± 0.88 [mean ± SD] vs. -4.44 ± 3.71 mm) and 3 mm (-0.31 ± 1.51 vs. -2.27 ± 1.15 mm) below the crest, and significantly less vertical reduction in the midcrestal area in test group 1 than in test group 2 (-0.25 ± 0.95 vs. -1.15 ± 1.63 mm) (p < .05). There were no significant differences between test groups in clinical and histomorphometric measurements. All groups exhibited stable marginal bone levels after 1 year of loading.

CONCLUSION

Alveolar ridge preservation without primary flap closure in molar areas was effective in minimizing ridge resorption and facilitated implant treatment.

Efficacy of a mineralized collagen bone-grafting material for peri-implant bone defect reconstruction in mini pigs

The mechanism of the mineralization process induced by natural mineralized collagen (MC) has been investigated for decades. The purpose of this study was to investigate the efficacy of self-assembled MC for peri-implant bone defect reconstruction in a mini pig. A standardized peri-implant bone defect model was created using 14 mini pig mandibles. Two materials were evaluated, i.e. a mixture of hydroxyapatite and collagen (Type A, TA), and self-assembled MC (Type B, TB). Bio-Oss (BO) and untreated (blank control, BC) groups were used as controls. After 3- and 6-month healing periods, the mini pigs were sacrificed for histomorphometric and microcomputed tomography analysis. After 3 months of healing, the average alveolar ridge height was 3.27 ± 1.57 mm for group TA, 3.28 ± 2.02 mm for group TB and 3.37 ± 1.09 mm for group BO, while group BC showed the lowest height of 2.68 ± 0.47 mm. After 6 months of healing, the average alveolar ridge height was 2.64 ± 1.13 mm for group TA, 4.31 ± 1.80 mm for group TB and 3.87 ± 1.38 mm for group BO, while group BC showed the lowest height of 2.48 ± 1.80 mm. The experimental groups and control group showed similar bone volume density, bone complexity and histological reaction. The self-assembled MC (Type B) stimulated new bone formation in the reconstruction of deficient alveolar ridges around the dental implant; it also displayed excellent clinical operability compared with bone grafts without collagen.

Regeneration of the Periodontal Apparatus in Aggressive Periodontitis Patients

The purpose of this study is to evaluate and compare, retrospectively, the outcome of two different periodontal regeneration procedures in patients suffering from aggressive periodontitis (AgP). Twenty-eight patients were diagnosed with AgP, suffering from several intra-bony defects (IBD); that were treated by one of two periodontal regeneration techniques randomly assigned to each patient: a. guided tissue regeneration (GTR) or b. an application of extracted enamel matrix derivatives (EMD) combined with demineralized bone xenograft particles (DBX). Probing pocket depth (PPD), clinical attachment level (CAL), and gingival recession were recorded. Pre-treatment and follow-up (up to 10 years from the surgery) recordings were analyzed statistically within and between groups. A significant reduction was shown at time on PPD and CAL values, however, not between subject groups. CAL values decreased in all sites. At the EMD group (44 sites), CAL gain was 1.92 mm (±1.68) from pre-treatment to follow-up (p < 0.001) and at the GTR group (12 sites) CAL gain of 2.27 (±1.82) mm. In conclusion, 1⁻10 years observations have shown that surgical treatment of AgP patients by either GTR or by application of EMD/DBX results in similar successful clinical results.

Degradation pattern of a porcine collagen membrane in an in vivo model of guided bone regeneration

BACKGROUND AND OBJECTIVE

Although collagen membranes have been clinically applied for guided tissue/bone regeneration for more than 30 years, their in vivo degradation pattern has never been fully clarified. A better understanding of the different stages of in vivo degradation of collagen membranes is extremely important, considering that the biology of bone regeneration requires the presence of a stable and cell/tissue-occlusive barrier during the healing stages in order to ensure a predictable result. Therefore, the aim of this study was to investigate the degradation pattern of a porcine non-cross-linked collagen membrane in an in vivo model of guided bone regeneration (GBR).

MATERIAL AND METHODS

Decalcified and paraffin-embedded specimens from calvarial defects of 18, 10-month-old Wistar rats were used. The defects were treated with a double layer of collagen membrane and a deproteinized bovine bone mineral particulate graft. At 7, 14 and 30 days of healing, qualitative evaluation with scanning electron microscopy and atomic force microscopy, and histomorphometric measurements were performed. Markers of collagenase activity and bone formation were investigated using an immunofluorescence technique.

RESULTS

A significant reduction of membrane thickness was observed from 7 to 30 days of healing, which was associated with progressive loss of collagen alignment, increased collagen remodeling and progressive invasion of woven bone inside the membranes. A limited inflammatory infiltrate was observed at all time points of healing.

CONCLUSION

The collagen membrane investigated was biocompatible and able to promote bone regeneration. However, pronounced signs of degradation were observed starting from day 30. Since successful regeneration is obtained only when cell occlusion and space maintenance exist for the healing time needed by the bone progenitor cells to repopulate the defect, the suitability of collagen membranes in cases where long-lasting barriers are needed needs to be further reviewed.

Protein expression during early stages of bone regeneration under hydrophobic and hydrophilic titanium domes. A pilot study

BACKGROUND AND OBJECTIVES

There is significant evidence that, during the early stages of osseointegration, moderately rough hydrophilic (SLActive) surfaces can accelerate osteogenesis and increase bone-to-implant contact in comparison to hydrophobic (SLA) surfaces. However, very little is known regarding the molecular mechanisms behind the influence that surface chemistry modifications to increase hydrophilicity determine on bone healing. The aim of this study was to describe for the first time the proteins and related signalling pathways expressed during early osseous healing stages under SLA and SLActive titanium domes for guided bone regeneration.

MATERIAL AND METHODS

One SLA and 1 SLActive dome with an internal diameter of 5.0 mm and a height of 3.0 mm were secured to the parietal bones of nine 6-month-old male New Zealand rabbits. Three animals were randomly euthanized at 4, 7 and 14 days and the newly formed tissues retrieved under the domes were analysed with liquid chromatography-mass spectrometry/mass spectrometry. STRING and KEGG databases were applied for Gene Ontology and pathway analyses.

RESULTS

A different modulation of several pathways was detected between the 2 groups at all healing times. The main differences in the osseous healing response associated to the 2 surfaces were related to pathways involved in regulating the inflammatory response, differentiation of osteoblast precursors and skeletogenesis. At day 7, the highest number of proteins and the highest cellular activity were observed in both groups, although a more complex and articulated proteome in terms of cellular metabolism and signal transduction was observed in SLActive samples.

CONCLUSION

This is the first study describing the proteome expressed during early healing stages of guided bone regeneration and osseointegration. A combination of enhanced early osteogenic response and reduced inflammatory response were suggested for the hydrophilic group. Future studies are needed to corroborate these findings and explore the molecular effects of different titanium surfaces on the cascade of events taking place during bone formation.

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.

The effect of experimental osteoporosis on bone regeneration: part 2, proteomics results

OBJECTIVES

To identify and describe protein expression in a Wistar rat calvarial critical size defect (CSD) model following treatment with guided bone regeneration in healthy and osteoporotic conditions.

MATERIAL AND METHODS

Thirty-six 10-month-old female Wistar rats were used. Half of them were ovariectomized (OVX) and fed with a low-calcium diet to induce an osteoporotic-like status. In each animal of both groups, two 5-mm calvarial CSDs were treated with deproteinized bovine bone mineral graft particles and a bilayer collagen membrane. Six OVX and six control rats were randomly euthanized at 7, 14, and 30 days. One defect/animal was randomly chosen for proteomic analysis. Differently expressed proteins between the two groups were identified with matrix-assisted laser desorption time-of-flight mass spectrometry and liquid chromatography-mass spectrometry/mass spectrometry.

RESULTS

At 7 days, 29 and 27 proteins were, respectively, identified in the healthy and OVX animals. At 14 days, 103 proteins were detected in the healthy controls and 20 proteins in the OVX rats, while at 30 days, 31 and 75 proteins were identified, respectively. Only limited proteins known to play a role in the later stages of bone formation and maturation were identified within the animals 'proteomes.

DISCUSSION

The osseous formation process was quite immature even at 30 days of healing. An overexpression of inflammatory and stress response pathways was detected in the OVX animals, as well as a tendency toward a delayed maturation of the osseous wound and a reduced/delayed differentiation of osteoblast cell precursors.

The effect of experimental osteoporosis on bone regeneration: Part 1, histology findings

OBJECTIVES

To histologically define the healing events occurring in calvarial critical size defects (CSDs) following treatment with a collagen barrier for guided bone regeneration (GBR) and a particulate graft in healthy and osteoporotic conditions.

MATERIAL AND METHODS

Thirty-six 10-month-old, female, Wistar rats were used in this study. Half of them were ovariectomized (OVX) and fed with a low-calcium diet to induce an osteoporotic-like status. In each animal of both groups, two 5-mm CSDs were created, one in the centre of each parietal bone, and they were treated with a deproteinized bovine bone mineral (DBBM) particulate graft and a bi-layer collagen membrane. Six OVX and six healthy control rats were randomly euthanized at 7, 14 and 30 days. One defect per animal was randomly processed for decalcified histology. Three central sections were used for qualitative histology and histomorphometric analysis.

RESULTS

No significant difference in terms of percentage of newly formed bone was detected between the two groups at the different healing periods. However, a trend towards less bone formation and of poorer quality, expressed as reduced bone maturation, was detected in the OVX animals at 30 days.

DISCUSSION

According to this study, GBR with a collagen barrier and a DBBM graft can be successfully obtained also in osteoporotic-like conditions. Future studies considering longer healing periods and controlling for the confounding factors arising from the use of a particulate graft are needed to confirm these data.

Horizontal-guided Bone Regeneration using a Titanium Mesh and an Equine Bone Graft

AIM

The present work describes a horizontal ridge augmentation in which a titanium mesh was preshaped by adapting it to a stereolithographic model of the patient's jaw that was fabricated from CT scans.

BACKGROUND

Guided bone regeneration (GBR) involves covering the augmentation site with a long-lasting barrier to protect it from the invasion of surrounding soft tissues. Among barriers, titanium meshes may provide a successful outcome, but the intraoperatory time needed to shape them is a disadvantage.

CASE DESCRIPTION

The 54-year-old patient, missing the right mandibular second bicuspid, first molar, and second molar, had her atrophic ridge augmented with a 30:70 mixture of autogenous bone and equine, enzyme-deantigenic collagen-preserved bone substitute. Two conical implants were inserted concomitantly in the second bicuspid and first molar positions, and the site was protected with the preshaped mesh. Four months later, the titanium mesh was retrieved, a bone sample was collected, and histological and histomorphometric analyses were performed. Provisional and definitive prostheses were then delivered, and follow-up controls were performed for up to 24 months.

CONCLUSION

Preshaping the mesh on a model of the patient's mandible shortened the surgical time and enabled faster mesh placement. Two years after surgery, the implants were perfectly functional, and the bone width was stable over time as shown by radiographic controls. Histological analysis of the bone sample showed the heterologous biomaterial to be biocompatible and undergoing advanced remodeling and replacement with newly formed bone.

CLINICAL SIGNIFICANCE

Preshaping a titanium mesh over a stereolithographic model of the patient's jaw allowed for a significant reduction of the intraoperative time and may be therefore, advisable in routine practice.

Vertical Guided Bone Regeneration using Titanium-reinforced d-PTFE Membrane and Prehydrated Corticocancellous Bone Graft

Guided bone regeneration (GBR) standard protocols call for filling the space underneath the membrane with autogenous bone or a mixture composed of autogenous bone particles and allogeneic bone tissue or heterologous biomaterials. This work describes the case of a GBR performed to restore a vertical bone defect with simultaneous placement of a dental implant in the posterior mandible that was carried out using a high density d-PTFE membrane and corticocancellous porcine-derived bone without the addition of any autogenous bone. Bone regeneration was assessed by histological analysis of a biopsy sample collected from the grafted site nine months after the surgery. Intraoral radiographs taken at follow-up visits showed complete maintenance of the peri-implant bone levels for up to two years after prosthesis delivery. The regenerated site successfully supported functional loading of the implant. The present case report suggests that the use of a heterologous bone substitute alone to restore a vertical defect in a GBR procedure can be as effective as the standard protocol, while avoiding the drawbacks associated with a second surgical site opening.

Surgical Approaches Based on Biological Objectives: GTR versus GBR Techniques

Guided tissue regenerative (GTR) therapies are performed to regenerate the previously lost tooth supporting structure, thus maintaining the aesthetics and masticatory function of the available dentition. Alveolar ridge augmentation procedures (GBR) intend to regain the alveolar bone lost following tooth extraction and/or periodontal disease. Several biomaterials and surgical approaches have been proposed. In this paper we report biomaterials and surgical techniques used for periodontal and bone regenerative procedures. Particular attention will be adopted to highlight the biological basis for the different therapeutic approaches.

A novel experimental model for studying transverse orthodontic tooth movement in the rat mandible

OBJECTIVES

To establish a rat model of a one-piece mandible using the principles of gingivoperiosteoplasty and guided bone regeneration to fuse the midline symphyseal area.

MATERIAL AND METHODS

Twenty-four Sprague-Dawley female rats were divided into two groups: 12 experimental and 12 control. Both groups were imaged using in vivo micro-computed tomography at baseline and at end point (5 months). The experimental group received regenerative surgery at the symphysis area; the control group received no treatment. Outcomes were evaluated by radiographic examination of gross and volumetric bony changes in the symphyseal region of interest marked between the mental foramina bilaterally and the two central incisors near the most coronal margin of the alveolar crests. These landmarks were chosen as they can be reproduced on the computed tomography images at baseline and end point. Histologic examination was performed on all samples at a level 5 mm apical to the alveolar bone crest.

RESULTS

Radiologic and histologic examinations of the experimental group revealed complete bony fusion of the symphyseal area in three subjects, partial fusion in five subjects, and thickening of the alveolar bony socket in three subjects; one rat died of anesthesia-related complications. No evidence of fusion or alveolar bone thickening was found in any of the controls.

CONCLUSIONS

This surgical animal model demonstrates that a rat mandible can be surgically manipulated to mimic the one-piece human mandible. This novel model may prove useful in studying mandibular bone remodeling and orthodontic mandibular tooth movement.

Effects of enamel matrix proteins on multi-lineage differentiation of periodontal ligament cells in vitro

The adult periodontal ligament (PDL) is considered to contain progenitor cells that are involved in the healing of periodontal wounds. Treatment with enamel matrix derivative (EMD), a heat-treated preparation derived from enamel matrix proteins (EMPs), has been shown to be of some clinical benefit in eliciting periodontal regeneration in vivo. Although there is extensive information available about the effects of EMD on periodontal regeneration, the precise influence of this material on alveolar bone and the formation of blood vessels and proprioceptive sensory nerves, prominent features of functionally active periodontal tissue, remain unclear. The aim of the present study was therefore to examine the effects of EMD on the ability of human periodontal ligament cells (HPCs) to undergo multi-lineage differentiation in vitro. Our results showed that HPCs treated with EMD under non-selective growth conditions did not show any evidence of osteogenic, adipogenic, chondrogenic, neovasculogenic, neurogenic and gliogenic "terminal" differentiation. In contrast, under selective lineage-specific culture conditions, EMD up-regulated osteogenic, chondrogenic and neovasculogenic genes and "terminal" differentiation, but suppressed adipogenesis, neurogenesis and gliogenesis. These findings thus demonstrate for the first time that EMD can differentially modulate the multi-lineage differentiation of HPCs in vitro.

Histological evaluation of bone healing using organic bovine bone in combination with platelet-rich plasma (an experimental study on rabbits)

OBJECTIVES

This study was carried out to histologically assess the effect of bone grafting materials extracted from bovine origin on the bone healing process either alone or when mixed with autologous platelet-rich plasma which could be used in many procedures of oral and maxillofacial bone and implant reconstructive surgery.

MATERIALS AND METHODS

Sixteen rabbits were used; three intrabony defects in the femur bone of each rabbit were created, one left unfilled for normal healing process and served as control, the second filled with xenogenic graft (Gen-Ox-lyophilized bovine bone organic matrix), and the third filled with (Gen-Ox-lyophilized bovine bone organic matrix) mixed with autologous platelet-rich plasma. Histological examination of the sections was performed after staining with H&E and Van Geison stains. The histomorphometric analysis including counting of bone cells (osteoblasts, osteocytes, and osteoclasts) with performance of osteon diameter and lamellar thickness at the end of the fourth week postoperatively was obtained.

RESULTS

It has been shown that with the use of autologous platelet-rich plasma in combination with the xenogenic bone graft prepared from bovine origin, new bone formation and neovascularization were enhanced significantly when compared with xenogenic graft alone.

CONCLUSION

The addition of PRP to xenogenic bone substitute in small bone defects of the rabbit femur showed a histomorphometric increase in bone formation (at the fourth week of healing).

CLINICAL RELEVANCE

Platelet concentrate might be used to accelerate the osseointegration of enosseous dental implants.

The effect of an enamel matrix derivative (Emdogain) combined with bone ceramic on bone formation in mandibular defects: a histomorphometric and immunohistochemical study in the canine

Background. The purpose of this study was to evaluate the combination of an enamel matrix derivative (EMD) and an osteoconductive bone ceramic (BC) in improving bone regeneration. Materials and Methods. Four cylindrical cavities (6 × 6 mm) were prepared bilaterally in the mandible in three dogs. The defects were randomly assigned to four different treatments—filled with EMD/BC and covered with a nonresorbable membrane, filled with EMD/BC without membrane, membrane coverage only, or control (left untreated)—and healed for 2, 4, or 6 weeks. Harvested specimens were prepared for histologic, histomorphometric, and immunohistochemical analyses. Results. Sites treated with EMD/BC with or without membrane showed more total bone formation and lamellar bone formation than membrane-only and control defects. There were no statistically significant differences in total bone formation between EMD/BC with or without membrane. Conclusion. EMD with BC might improve bone formation in osseous defects more than membrane coverage alone; the use of a membrane had no significant additive effect on total bone formation.

Differential effect of amelogenin peptides on osteogenic differentiation in vitro: identification of possible new drugs for bone repair and regeneration

Enamel matrix proteins (EMP) have been shown to promote regeneration of periodontal ligament and root cementum, and sometimes to enhance the differentiation of bone-forming cells in vitro and new bone growth in vivo. However, the inconsistent and unpredictable effects of EMP that have been reported for bone regeneration may be due to the highly variable composition of this heterogeneous material, which is comprised mainly of amelogenin and amelogenin-derived peptides. The present study has therefore examined the effects of naturally occurring low-molecular-weight (LMW) and high-molecular-weight (HMW) fractions of Emdogain(®) (EMD; Institut Straumann, Basel, Switzerland), a commercially available form of EMP, on osteogenic differentiation of bone precursor cells in vitro. In addition, the effects of chemically synthesized specific components of LMW and HMW-namely, the tyrosine-rich amelogenin peptide (TRAP), a specific amelogenin isoform derived by proteolytic clipping, and a leucine-rich amelogenin peptide (LRAP), an isoform derived by alternative splicing-on bone-forming cell activity were also investigated. Our findings demonstrate that while TRAP suppressed the formation of bone-like mineralized nodules, LRAP upregulated osteogenic differentiation. Furthermore, synthetically produced TRAP and its unique C-terminal 12 amino acid sequence (TCT) also suppressed bone-forming cells, whereas LRAP and its unique C-terminal 23 amino acid sequence (LCT) markedly enhanced terminal differentiation of bone-forming cells. These findings suggest that the differential effects of amelogenin-derived peptide sequences present in EMP could be of potential clinical value, with the novel bioactive TCT peptide as a useful tool for limiting pathological bone cell growth and the unique LCT sequence having therapeutic benefits in the treatment of periodontal and orthopedic diseases.

The effect of loading in regenerated bone in dehiscence defects following a combined approach of bone grafting and GBR

OBJECTIVES

To evaluate by histology the effect of loading on the regenerated bone at dehiscence type defects around implants when treated with a combined approach of bone grafting and guided bone regeneration (GBR).

MATERIALS AND METHODS

In twelve Göttingen mini-pigs, the lower premolars and first molars were extracted and the alveolar process was reduced in width. After 3 months, two Straumann SLActive (Straumann AG, Basel, Switzerland) implants were placed in each hemi-mandible. Twelve implants were placed into the reduced alveolar ridge (group P) with no further defect or treatment on the site, while on 36 implants, buccal dehiscence defects were created and treated as follows: Group T1: synthetic bone substitute (Straumann Bone Ceramic, SBC, Straumann AG). Group T2: SBC with a polyethylene glycol membrane (Straumann MembraGel, Straumann AG); Group N: the dehiscence remained untreated. Three months following implantation, long, custom-made, healing abutments were placed in one hemi-mandible only to ensure functional loading. After 2 months, histological analysis was performed.

RESULTS

A trend for lower residual defect height and higher bone-to-implant contact was observed in the loaded sites compared with non-loaded sites in groups P, T1 and N. In group T2, the opposite effect was observed. In terms of bone formation, sites treated with SBC grafting and GBR (group T2) exhibited the largest surface area of regenerated bone followed by T1 and N. Significant resorption of the graft particles was noted in group T2 and the graft surface area occupied by SBC was significantly higher in group T1 compared with group T2 (P < 0.05).

CONCLUSIONS

Loading may have a positive effect on bone-to-implant contact in implants inserted in pristine bone or inserted in dehiscence sites and treated by grafting/no grafting.

Bone regeneration using a synthetic matrix containing enamel matrix derivate

PURPOSE

The aim of the present study was to test whether the delivery of enamel matrix derivate (EMD) via synthetic polyethylene glycol (PEG)-based hydrogels with and without RGD sequences enhances bone formation in vivo.

MATERIAL AND METHODS

In each of 10 rabbits, four titanium cylinders were placed on the external cortical bones of their calvaria. The following four treatment modalities were randomly allocated: One of the four cylinders was left empty (control), the other three were filled with a combination of PEG matrix with hydroxyapatite/tricalciumphosphate (HA/TCP) granules and EMD in a concentration of 100 μg/ml (test 1) or 500 μg/ml (test 2) or 500 μg/ml and RGD peptide (test 3). After 8 weeks, the animals were sacrificed and ground sections were obtained for histological analysis. For statistical analysis, the Kruskal-Wallis test was applied (P<0.05).

RESULTS

The histomorphometric analysis revealed a statistically larger area fraction of newly formed bone in the EMD 500/RGD group (54.8±14.5%) compared with the control group (28.7±10.3%) and the EMD 500 group (31.2±14.1%) and non-significantly higher area fraction compared with the EMD 100 group (38.2±10.4%). The percentage of mineralized bone showed no statistically significant differences among the four groups. The mean percentage of mineralized bone was 13.6±3.3% in the control group, 14.2±5.8% in the EMD 100 group, 11.69±5.9% in the EMD 500 group and 15.66±5.2% in the EMD 500/RGD group. No statistically significant difference regarding the bone-to-graft contact between the EMD 100 group (23±15.7%), the EMD 500 group (22.2±14.6%) and the EMD 500/RGD group (21.6±8.8%) was observed.

CONCLUSIONS

The combination of a PEG matrix containing EMD with HA/TCP granules had no effect on the formation of mineralized bone tissue in rabbit calvaria. The addition of RGD peptide to the PEG/EMD 500 combination increased the area fraction of newly formed bone compared with the other treatment groups. Further studies are indicated to study a possible synergistic effect of EMD and RGD.

The use of human hypertrophic chondrocytes-derived extracellular matrix for the treatment of critical-size calvarial defects

OBJECTIVES

To evaluate the effect of immortalized hypertrophic chondrocytes extracellular matrix (HCM) with or without the use of guided bone regeneration (GBR) on the healing of critical-size calvarial defects.

MATERIAL AND METHODS

In 42 rats, 5 mm critical-size calvarial defects were surgically created. The animals were randomly allocated to six groups of seven rats each: Group A1: one defect was left untreated (control), while the contralateral defect was covered by a double non-resorbable membrane (GBR). Group B1: one defect was filled with calcium phosphate cement (CP), while the contralateral defect was treated with GBR and CP. Group C1: one defect was filled with a mixture of CP and HCM, while the contralateral defect was treated with GBR and CP+HCM. The healing period for all three groups was 30 days. The remaining three groups were treated in a similar manner but the healing period was 60 days. Five animals from each group were evaluated by maceration and two animals were analysed histologically.

RESULTS

At 30 days, all the control-treated defects did not present complete closure. When GBR was applied alone or combined with CP, 3/5 and 5/5 defects, respectively, presented complete closure. At 60 days, one defect from the control group presented complete closure. All the defects treated with GBR alone presented complete closure, whereas the combined use of GBR with CP or CP+HCM resulted in 4/5 and 3/5 defects with complete closure, respectively. The only treatment modality that did not present any specimen with defect closure at both 30 and 60 days was the combination of CP+HCM. The histological analysis indicated that when GBR was not used alone, the healing consisted of an amorphous acellular structure and loose granulation tissue, which, even though clinically resembled hard tissue, did not demonstrate the histological characteristics of bone.

CONCLUSION

The predictability of bone formation in critical-size defects depends mainly on the presence or absence of barrier membranes. The combined use of GBR with calcium phosphate alone or in combination with immortalized human HCM did not enhance the potential for osseous healing provided by the GBR procedure.

The effect of SLActive surface in guided bone formation in osteoporotic-like conditions

OBJECTIVES

The aim of the study was to evaluate new bone formation under etched titanium (SLA) and modified-etched hydrophilic titanium (modSLA) domes placed on the calvarium of healthy, osteoporotic and osteoporotic treated with bisphosphonates rabbits.

METHODS

Experimental osteoporosis was induced by ovariectomy (OV) and calcium-deficient diet in 24 New Zealand female rabbits. Twelve OV rabbits were treated with weekly dozes of alendronate (Fosamax(®)) (B) while 12 OV rabbits received no treatment (O). Another 12 rabbits were sham operated and used as healthy controls (C). At 6 weeks following OV, one modSLA and one SLA titanium dome were placed in the parietal bones of each rabbit. The animals were sacrificed at 30 and 120 days following the dome placement. Various histomorphometric measurements were performed in the most central of the undecalcified sections produced.

RESULTS

After 30 days of healing, in the C group, the total bone (TB) area was 37.6% and 37.0% under the modSLA and SLA domes, respectively. In the O group, the TB was 35.7% and 24.8%. In the B group, TB was 37.0% and 32.1%, respectively. After 120 days of healing, in the C group TB was 40.1% and 36.4%, respectively. In the O group, TB was 29.6% and 27.9%, respectively. In the B group, TB was 49.7% and 42.5%, respectively. Hierarchical analysis of variance showed that the type of titanium dome significantly influenced new bone and the amount of new bone being in contact with inner surface of the dome (BIC) independently of the observation period and group (P<0.05). The administration of bisphosphonates influenced the BIC (P<0.05).

CONCLUSION

The use of modSLA surface may promote bone healing and osseointegration in osteoporotic rabbits, whereas administration of bisphosphonates may compromise the osseointegration of the newly formed bone at the early healing period.

Alveolar ridge preservation with guided bone regeneration and a synthetic bone substitute or a bovine-derived xenograft: a randomized, controlled clinical trial

OBJECTIVES

The aim of this randomized, controlled clinical trial was to compare the potential of a synthetic bone substitute or a bovine-derived xenograft combined with a collagen membrane to preserve the alveolar ridge dimensions following tooth extraction.

METHODS

Twenty-seven patients were randomized into two treatment groups following single tooth extraction in the incisor, canine and premolar area. In the test group, the alveolar socket was grafted with Straumann Bone Ceramic (SBC), while in the control group, Bio-Oss deproteinized bovine bone mineral (DBBM) was applied. In both groups, a collagen barrier was used to cover the grafting material. Complete soft tissue coverage of the barriers was not achieved. After 8 months, during re-entry procedures and before implant placement, the horizontal and vertical dimensions of the residual ridge were re-evaluated and trephine biopsies were performed for histological analysis in all patients.

RESULTS

Twenty-six patients completed the study. The bucco-lingual dimension of the alveolar ridge decreased by 1.1+/-1 mm in the SBC group and by 2.1+/-1 in the DBBM group (P<0.05). Both materials preserved the mesio-distal bone height of the ridge. No differences in the width of buccal and palatal bone plate were observed between the two groups. The histological analysis showed new bone formation in the apical part of the biopsies, which, in some instances, was in direct contact with both SBC and DBBM particles. The coronal part of the biopsies was occupied by a dense fibrous connective tissue surrounding the SBC and DBBM particles.

CONCLUSION

Both biomaterials partially preserved the width and the interproximal bone height of the alveolar ridge.

The effect of enamel matrix derivative (Emdogain) on bone formation: a systematic review

This systematic review focused on the question, if and to what extent enamel matrix derivative (Emdogain) [EMD]) promotes the regeneration of bone. The influence of combinations with other biomaterials was additionally evaluated. Twenty histomorphometric studies were included in this systematic review. Main results of the reviewed articles were (i) guide tissue regeneration (GTR) of infrabony defects seems to result in a higher degree of bone regeneration compared to treatment with EMD; (ii) combined therapy (GTR + EMD) of infrabony defects might not lead to better results than GTR therapy alone; (iii) there seems to be no additional benefit of combined therapy (GTR + EMD) in furcation defects over GTR therapy alone; (iv) EMD seems to lead to more bone regeneration of infrabony defects compared to open flap debridement; (v) however, EMD application might result in more bone formation when applied in supporting defects compared to nonsupporting defects; and (vi) EMD does not seem to promote external jaw/parietal bone formation in the titanium capsule model. The results of one study that suggest that EMD increases the initial growth of trabecular bone around endosseous implants by new bone induction need to be confirmed by additional research.

Ridge augmentation and maxillary sinus grafting with a biphasic calcium phosphate: histologic and histomorphometric observations

OBJECTIVES

This retrospective study reports on histologic and histomorphometric observations performed on human biopsies harvested from sites augmented exclusively by biphasic calcium phosphate [BCP: hydroxyapatite (HA)/ tricalcium phosphate (TCP) 60/40] and healed for a minimum of 6 months.

MATERIALS AND METHODS

Five patients benefited from three augmentation regimens (i.e.: one-stage lateral augmentation; two-stage lateral augmentation; and two-stage sinus grafting). In all patients, a degradable collagen membrane served as a cell-occlusive barrier. Core biopsies were obtained from lateral as from crestal aspects 6-10 months after augmentation surgeries. For histologic and histomorphometric evaluations, the non-decalcified tissue processing was performed.

RESULTS

The histological examination of 11 biopsies showed graft particles frequently being bridged by the new bone, and a close contact between the graft particles and newly formed bone was seen in all samples. The mean percentages of newly formed bone, soft tissue compartment, and graft material were 38.8% (+/-5.89%), 41.75% (+/-6.08%), and 19.63% (+/-4.85%), respectively. Regarding bone-to-graft contact values, the percentage of bone coverage of graft particles for all biopsies ranged from 27.83% to 80.17%. The mean percentage of bone coverage was 55.39% (+/-13.03%).

CONCLUSIONS

Data from the present study demonstrated osteoconductivity scores for the BCP material (HA/TCP 60/40) in patients resembling those previously shown for grafting materials of xenogenic and alloplastic origin.

Histologic and histomorphometric evaluation of two bone substitute materials for bone regeneration: an experimental study in sheep

INTRODUCTION

In the past decade, there has been an increase focus on regeneration approaches as related to periodontics and implant therapies. The main objective of the present study is the evaluation of quality, density, and thickness of the newly formed bone in experimental defects treated with deproteinized bovine bone mineral (DBBM) and bioapatite-collagen.

MATERIALS

Fifteen identical cuboidal defects were prepared in the alveolar edentulous mandibular ridges in 10 male sheep. Defects were randomly assigned to be treated either with DBBM, Bioapatite-collagen or remained unfilled as the control group. Defects of these 3 groups were histologically examined after 6 months.

RESULTS

The mean percentages of bone regeneration with DBBM, Bioapatite-collagen, and control group were 51.40% +/- 3.57%, 27.66% +/- 4.18%, and 19% +/- 1%, respectively (P < 0.05). Defects filled with Bio-Oss and control defects did not show foreign body reaction, whereas Biostite particles had a reaction in 40% of the specimens. Trabecular thickness and type of new regenerated bone were also significantly different between Bio-Oss and Biostite (P < 0.05) and control group (P < 0.05).

CONCLUSION

The results of the present study suggest that using of DBBM particles can promote bone regeneration more effectively than Bioapatite-collagen, and both materials were more promising than the control group.

The bone-regenerative properties of Emdogain adsorbed onto poly(D,L-lactic-coglycolic acid)/calcium phosphate composites in an ectopic and an orthotopic rat model

BACKGROUND AND OBJECTIVE

The aim of this study was to evaluate the bone-regenerative properties of Emdogain in osseous and nonosseous sites.

MATERIAL AND METHODS

For the orthotopic study, unloaded poly(D,L-lactic-coglycolic acid)/calcium phosphate implants, and poly(D,L-lactic-coglycolic acid)/calcium phosphate implants loaded with different concentrations (0.25, 0.50 or 0.80 mg per implant) of enamel matrix derivative (EMD), were inserted into cranial defects of 24 rats. The implantation time was 4 wk. For the ectopic study, 32 implants were placed subcutaneously. The same study period and groups as in the orthotopic study were used. Methods of evaluation consisted of descriptive histology, histomorphometry and an in vitro EMD-release study.

RESULTS

In the orthotopic study, new bone formation was most abundant in unloaded implants followed by 0.50-mg EMD composites. Histomorphometric measurements showed 54 +/- 15.0% bone ingrowth for unloaded implants, 19 +/- 22.5% bone ingrowth for 0.25-mg EMD composites, 40 +/- 23.6% bone ingrowth for 0.50-mg EMD composites and 26 +/- 17.6% bone ingrowth for 0.80-mg EMD composites. Light microscopic analysis of the subcutaneous sections from the ectopic study revealed no bone formation in any group after 4 wk. The in vitro release study showed 60% cumulative EMD release after 4 wk.

CONCLUSION

Emdogain is not osteoinductive and is not able to enhance bone healing in combination with an osteoconductive material, such as poly(D,L-lactic-coglycolic acid)/calcium phosphate cement.