Pre-clinical models for oral and periodontal reconstructive therapies

Influence of physicochemical characteristics of calcium phosphate-based biomaterials in cranio-maxillofacial bone regeneration. A systematic literature review and meta-analysis of preclinical models

Objectives

Calcium phosphate-based biomaterials (CaP) are the most widely used biomaterials to enhance bone regeneration in the treatment of alveolar bone deficiencies, cranio-maxillofacial and periodontal infrabony defects, with positive preclinical and clinical results reported. This systematic review aimed to assess the influence of the physicochemical properties of CaP biomaterials on the performance of bone regeneration in preclinical animal models.

Methods

The PubMed, EMBASE and Web of Science databases were searched to retrieve the preclinical studies investigating physicochemical characteristics of CaP biomaterials. The studies were screened for inclusion based on intervention (physicochemical characterization and in vivo evaluation) and reported measurable outcomes.

Results

A total of 1532 articles were retrieved and 58 studies were ultimately included in the systematic review. A wide range of physicochemical characteristics of CaP biomaterials was found to be assessed in the included studies. Despite a high degree of heterogeneity, the meta-analysis was performed on 39 studies and evidenced significant effects of biomaterial characteristics on their bone regeneration outcomes. The study specifically showed that macropore size, Ca/P ratio, and compressive strength exerted significant influence on the formation of newly regenerated bone. Moreover, factors such as particle size, Ca/P ratio, and surface area were found to impact bone-to-material contact during the regeneration process. In terms of biodegradability, the amount of residual graft was determined by macropore size, particle size, and compressive strength.

Conclusion

The systematic review showed that the physicochemical characteristics of CaP biomaterials are highly determining for scaffold's performance, emphasizing its usefulness in designing the next generation of bone scaffolds to target higher rates of regeneration.

Unlocking the Future of Periodontal Regeneration: An Interdisciplinary Approach to Tissue Engineering and Advanced Therapeutics

Periodontal defects present a significant challenge in dentistry, necessitating innovative solutions for comprehensive regeneration. Traditional restoration methods have inherent limitations in achieving complete and functional periodontal tissue reconstruction. Tissue engineering, a multidisciplinary approach integrating cells, biomaterials, and bioactive factors, holds tremendous promise in addressing this challenge. Central to tissue engineering strategies are scaffolds, pivotal in supporting cell behavior and orchestrating tissue regeneration. Natural and synthetic materials have been extensively explored, each offering unique advantages in terms of biocompatibility and tunable properties. The integration of growth factors and stem cells further amplifies the regenerative potential, contributing to enhanced tissue healing and functional restoration. Despite significant progress, challenges persist. Achieving the seamless integration of regenerated tissues, establishing proper vascularization, and developing biomimetic scaffolds that faithfully replicate the natural periodontal environment are ongoing research endeavors. Collaborative efforts across diverse scientific disciplines are essential to overcoming these hurdles. This comprehensive review underscores the critical need for continued research and development in tissue engineering strategies for periodontal regeneration. By addressing current challenges and fostering interdisciplinary collaborations, we can unlock the full regenerative potential, paving the way for transformative advancements in periodontal care. This research not only enhances our understanding of periodontal tissues but also offers innovative approaches that can revolutionize dental therapies, improving patient outcomes and reshaping the future of periodontal treatments.

Regeneration of alveolar bone defects in the experimental pig model: A systematic review and meta-analysis

OBJECTIVE

Pigs are emerging as a preferred experimental in vivo model for bone regeneration. The study objective was to answer the focused PEO question: in the pig model (P), what is the capacity of experimental alveolar bone defects (E) for spontaneous regeneration in terms of new bone formation (O)?

METHODS

Following PRISMA guidelines, electronic databases were searched for studies reporting experimental bone defects or extraction socket healing in the maxillae or mandibles of pigs. The main inclusion criteria were the presence of a control group of untreated defects/sockets and the assessment of regeneration via 3D tomography [radiographic defect fill (RDF)] or 2D histomorphometry [new bone formation (NBF)]. Random effects meta-analyses were performed for the outcomes RDF and NBF.

RESULTS

Overall, 45 studies were included reporting on alveolar bone defects or extraction sockets, most frequently in the mandibles of minipigs. Based on morphology, defects were broadly classified as 'box-defects' (BD) or 'cylinder-defects' (CD) with a wide range of healing times (10 days to 52 weeks). Meta-analyses revealed pooled estimates (with 95% confidence intervals) of 50% RDF (36.87%-63.15%) and 43.74% NBF (30.47%-57%) in BD, and 44% RDF (16.48%-71.61%) and 39.67% NBF (31.53%-47.81%) in CD, which were similar to estimates of socket-healing [48.74% RDF (40.35%-57.13%) and 38.73% NBF (28.57%-48.89%)]. Heterogeneity in the meta-analysis was high (I2 > 90%).

CONCLUSION

A substantial body of literature revealed a high capacity for spontaneous regeneration in experimental alveolar bone defects of (mini)pigs, which should be considered in future studies of bone regeneration in this animal model.

Regeneration of critical-sized grade II furcation using a novel injectable melatonin-loaded scaffold

BACKGROUND

Periodontal regenerative therapy using bone-substituting materials has gained favorable clinical significance in enhancing osseous regeneration. These materials should be biocompatible, osteogenic, malleable, and biodegradable. This study assessed the periodontal regenerative capacity of a novel biodegradable bioactive hydrogel template of organic-inorganic composite loaded with melatonin.

MATERIALS AND METHODS

A melatonin-loaded alginate-chitosan/beta-tricalcium phosphate composite hydrogel was successfully prepared and characterized. Thirty-six critical-sized bilateral class II furcation defects were created in six Mongrel dogs, and were randomly divided and allocated to three cohorts; sham, unloaded composite, and melatonin-loaded. Periodontal regenerative capacity was evaluated via histologic and histomorphometric analysis.

RESULTS

Melatonin-treated group showed accelerated bone formation and advanced maturity, with a significant twofold increase in newly formed inter-radicular bone compared with the unloaded composite. The short-term regenerative efficacy was evident 4 weeks postoperatively as a significant increase in cementum length concurrent with reduction of entrapped epithelium. After 8 weeks, the scaffold produced a quality of newly synthesized bone similar to normal compact bone, with potent periodontal ligament attachment.

CONCLUSIONS

Melatonin-loaded hydrogel template accelerated formation and enhanced quality of newly formed bone, allowing complete periodontal regeneration. Furthermore, the scaffold prevented overgrowth and entrapment of epithelial cells in furcation defects.

In vivo behavior of a collagen-coated nano-hydroxyapatite enriched polycaprolactone membrane in rat mandibular defects

BACKGROUND

This research investigated the ability of fabricated collagen (COL) coated nano-hydroxyapatite (nHA) enriched polycaprolactone (PCL) membrane to facilitate new bone formation (NBF) and its biocompatibility.

METHODS

Unilateral mandibular angulus defects of 28 female 12-week-old long Evans rats were created with a trephine bur with 5 mm in diameter and divided into two groups. While the test group was treated with the membrane (M-1, M-2), the control was left as self-healing (C-1, C-2) and sacrificed at 2nd (M-1, C-1) and 8th week (M-2, C-2) postoperatively. The mandibular bone of the rats was evaluated histopathologically. Density of the regenerated bone was evaluated with PET/CT.

RESULTS

Histopathologically, NBF which started from the periphery of the defect had rich cellular character in M-1. Significantly higher NBF was found in M-2 when compared to M-1 (P=0.003). Furthermore, significantly lesser degree of inflammation was found in M-2 when compared to M-1 (P<0.05).

CONCLUSION

This study suggests that the novel COL-coated nHA-enriched PCL membrane can serve a promising design for tissue engineering as guided bone regeneration in alveolar defects.

Biomimetic Peridontium Patches for Functional Periodontal Regeneration

The unique structure of the periodontium, including the alveolar bone, cementum, and periodontal ligament (PDL), presents difficulties for the regeneration of its intricate organization. Irreversible structural breakdown of the periodontium increases the risk of tooth loosening and loss. Although the current therapies can restore the periodontal hard tissues to a certain extent, the PDL with its high directionality of multiple groups with different orientations and functions cannot be reconstructed. Here, biomimetic peridontium patches (BPPs) for functional periodontal regeneration using a microscale continuous digital light projection bioprinting method is reported. Orthotopic transplantation in the mandibles shows effective periodontal reconstruction. The resulting bioengineered tissues closely resembles natural periodontium in terms of the "sandwich structures," especially the correctly oriented fibers, showing different and specific orientation in different regions of the tooth root, which has never been found in previous studies. Furthermore, after the assessment of clinically functional properties it is found that the regenerative periodontium can achieve stable tooth movement under orthodontic migration force with no adverse consequences. Overall, the BPPs promote reconstruction of the functional periodontium and the complex microstructure of the periodontal tissue, providing a proof of principle for the clinical functional treatment of periodontal defects.

Preclinical evaluation of the effect of periodontal regeneration by carbonate apatite in a canine one-wall intrabony defect model

Objective

This study aimed to histologically compare periodontal regeneration of one-wall intrabony defects treated with open flap debridement, β-tricalcium phosphate (β-TCP), and carbonate apatite (CO₃Ap) in dogs.

Methods

The mandibular third premolars of four beagle dogs were extracted. Twelve weeks after the extraction, a one-wall bone defect of 4 mm × 5 mm (mesio-distal width × depth) was created on the distal side of the mandibular second premolar and mesial side of the fourth premolar. Each defect was randomly allocated to open flap debridement (control group), periodontal regeneration utilizing β-TCP, or CO₃Ap. Eight weeks after the surgery, histologic and histometric analyses were performed.

Results

No ankylosis, infection, or acute inflammation was observed at any of the experimental sites. Newly formed bone and cementum were observed in all experimental groups. The mineral apposition rate of the alveolar bone crest was higher in the CO₃Ap group than in the control and β-TCP groups. The ratio of the new bone area was significantly higher in the CO₃Ap group than in the control group (P < 0.05). The bone contact percentage of the residual granules was significantly higher in the CO₃Ap group than in the β-TCP group (P < 0.05).

Conclusion

Although this study has limitations, the findings revealed the safety and efficacy of CO₃Ap for periodontal regeneration in one-wall intrabony defects in dogs, and CO₃Ap has a better ability to integrate with bone than β-TCP.

A Biomimetic Smart Nanoplatform as “Inflammation Scavenger” for Regenerative Therapy of Periodontal Tissue

Introduction

The functional reconstruction of periodontal tissue defects remains a clinical challenge due to excessive and prolonged host response to various endogenous and exogenous pro-inflammatory stimuli. Thus, a biomimetic nanoplatform with the capability of modulating inflammatory response in a microenvironment-responsive manner is attractive for regenerative therapy of periodontal tissue.

Methods

Herein, a facile and green design of engineered bone graft materials was developed by integrating a biomimetic apatite nanocomposite with a smart-release coating, which could realize inflammatory modulation by “on-demand” delivery of the anti-inflammatory agent through a pH-sensing mechanism.

Results

In vitro and in vivo experiments demonstrated that this biocompatible nanoplatform could facilitate the clearance of reactive oxygen species in human periodontal ligament stem cells under inflammatory conditions via inhibiting the production of endogenous proinflammatory mediators, in turn contributing to the enhanced healing efficacy of periodontal tissue. Moreover, this system exhibited effective antimicrobial activity against common pathogenic bacteria in the oral cavity, which is beneficial for the elimination of exogenous pro-inflammatory factors from bacterial infection during healing of periodontal tissue.

Conclusion

The proposed strategy provides a versatile apatite nanocomposite as a promising “inflammation scavenger” and propels the development of intelligent bone graft materials for periodontal and orthopedic applications.

Decoronation-induced infected alveolar socket defect rat model for ridge preservation

Current rat alveolar ridge preservation models have not been well standardized. In this study, we proposed decoronation-induced infected alveolar socket model of rat. The bilateral maxillary first molars (M1) of twenty-four rats were decoronized or extracted. After 2, 6, 10, and 14 weeks, bone and soft tissue changes at M1 and periodontal conditions of maxillary second (M2) and third molars (M3) were evaluated by micro-computed tomography and histological analysis. Additional eighteen rats with standardized size defects were grafted with Bio-Oss Collagen to compare with unmanipulated contralateral side. Decoronation preserved greater bone and soft tissue dimensions at M1, provided larger three-dimensional (3D) bone contour volume, but also promoted periodontal breakdown of M2 Histological results showed intense inflammatory cell infiltrations and severe bone resorption within M1 socket and at mesial aspect of M2. The critical dimensions to accommodate largest standardized defect at M1 were 2.2-2.3 mm at vertical bone height and 2.8-3.2 mm at alveolar crestal width. Bio-Oss Collagen could not fully preserve buccal or palatal bone height but could be beneficial in preserving ridge width in large alveolar defects. Collectively, if periodontally-involved alveolar bone defect is preferred, we suggest extracting M1 roots 6 weeks after decoronation to allow periodontitis to occur at M2. If standardized critical dimension defect is preferred, we suggest extracting M1 roots 2 weeks after decoronation, and creating defect in the middle of M1 site with size no larger than 2.7 mm diameter to its full depth.

The optimization of ligature/bone defect-induced periodontitis model in rats

The destruction of alveolar bone is a crucial manifestation of severe chronic periodontitis, which stem cell-based bioengineered therapies are expected to cure. Therefore, a cost-effective, reproducible, quantifiability and easier to administrate animal model that mimics human periodontitis is of great importance for further endeavor. In this study, we created periodontitis rat models in silk ligation group, bone defect group and bone defect/silk ligation group, respectively. Obvious periodontal inflammation but slight alveolar bone resorption was observed in the ligation group, while surgical trauma was not robust enough to continually worsen the constructed bone defect area in the bone defect group. In the bone defect/ligature group, significant and stable periodontal inflammation was the most enduring with similar evolving pathological patterns of human periodontitis. It also exhibited enhanced clinical similarity and confirmed its superiority in quantitativeness. The present rat model is the first study to reproduce a pathological process similar to human periodontitis with reliable stability and repeatability, manifesting a priority to previous methods. Day 9-12 is the best time for reproducing severe periodontitis syndromes with vertical bone resorption in this model.

Comparison of periodontal wound healing/regeneration by recombinant human fibroblast growth factor-2 combined with β-tricalcium phosphate, carbonate apatite, or deproteinized bovine bone mineral in a canine one-wall intra-bony defect model

AIM

To evaluate periodontal wound healing/regeneration of one-wall intra-bony defects treated with recombinant human fibroblast growth factor-2 (rhFGF-2) and beta-tricalcium phosphate (β-TCP), carbonate apatite (CO₃ Ap), or deproteinized bovine bone mineral (DBBM) in dogs.

MATERIALS AND METHODS

The stability of rhFGF-2 adsorbed onto the bone substitutes was evaluated by Enzyme-Linked Immunosorbent Assay (ELISA). One-wall intra-bony defects (5 × 5 × 5 mm) created in five adult male beagle dogs were treated with rhFGF-2 alone (rhFGF-2), rhFGF-2 with β-TCP (rhFGF-2/β-TCP), rhFGF-2 with CO₃ Ap (rhFGF-2/CO₃ Ap), or rhFGF-2 with DBBM (rhFGF-2/DBBM). Histological outcomes (e.g., linear length of new cementum adjacent to the newly formed bone with inserting collagen fibres [NA] as the primary outcome) were evaluated at 10 weeks post surgery.

RESULTS

Significantly higher amount of rhFGF-2 was adsorbed onto CO₃ Ap compared with β-TCP. Among the treatment groups, the rhFGF-2/DBBM group showed the highest amount of periodontal tissue regeneration. The rhFGF-2/DBBM group showed significantly greater formation of NA (3.22 ± 0.40 mm) compared with rhFGF-2 (1.17 ± 1.00 mm, p < .01) group. Additionally, new bone area in the rhFGF-2/DBBM group (9.78 ± 2.30 mm² ) was significantly higher than that in the rhFGF-2 (5.08 ± 1.26 mm² , p < .01), rhFGF-2/β-TCP (5.91 ± 1.27 mm² , p < .05), and rhFGF-2/CO₃ Ap (6.51 ± 1.49 mm² , p < .05) groups. Slight ankylosis was found in the rhFGF-2/β-TCP (1/9 sites), rhFGF-2/CO₃ Ap (3/10 sites), and rhFGF-2/DBBM (1/9 sites) groups.

CONCLUSIONS

Within their limitations, the present data indicate that DBBM seems to be a suitable carrier for rhFGF-2 and that rhFGF-2/DBBM treatment promotes favourable periodontal regeneration compared with rhFGF-2, rhFGF-2/β-TCP, and rhFGF-2/CO₃ Ap treatments in one-wall intra-bony defects.

The Structure and Function of Next-Generation Gingival Graft Substitutes-A Perspective on Multilayer Electrospun Constructs with Consideration of Vascularization

There is a shortage of suitable tissue-engineered solutions for gingival recession, a soft tissue defect of the oral cavity. Autologous tissue grafts lead to an increase in morbidity due to complications at the donor site. Although material substitutes are available on the market, their development is early, and work to produce more functional material substitutes is underway. The latter materials along with newly conceived tissue-engineered substitutes must maintain volumetric form over time and have advantageous mechanical and biological characteristics facilitating the regeneration of functional gingival tissue. This review conveys a comprehensive and timely perspective to provide insight towards future work in the field, by linking the structure (specifically multilayered systems) and function of electrospun material-based approaches for gingival tissue engineering and regeneration. Electrospun material composites are reviewed alongside existing commercial material substitutes’, looking at current advantages and disadvantages. The importance of implementing physiologically relevant degradation profiles and mechanical properties into the design of material substitutes is presented and discussed. Further, given that the broader tissue engineering field has moved towards the use of pre-seeded scaffolds, a review of promising cell options, for generating tissue-engineered autologous gingival grafts from electrospun scaffolds is presented and their potential utility and limitations are discussed.

The minipig intraoral dental implant model: A systematic review and meta-analysis

OBJECTIVES

The objective of this report was to provide a review of the minipig intraoral dental implant model including a meta-analysis to estimate osseointegration and crestal bone remodeling.

METHODS

A systematic review including PubMed and EMBASE databases through June 2021 was conducted. Two independent examiners screened titles/abstracts and selected full-text articles. Studies evaluating titanium dental implant osseointegration in native alveolar bone were included. A quality assessment of reporting was performed. Random-effects meta-analyses and meta-regressions were produced for bone-implant contact (BIC), first BIC, and crestal bone level.

RESULTS

125 out of 249 full-text articles were reviewed, 55 original studies were included. Quality of reporting was generally low, omissions included animal characteristics, examiner masking/calibration, and sample size calculation. The typical minipig model protocol included surgical extraction of the mandibular premolars and first molar, 12±4 wks post-extraction healing, placement of three narrow regular length dental implants per jaw quadrant, submerged implant healing and 8 wks of osseointegration. Approximately 90% of studies reported undecalcified incandescent light microscopy histometrics. Overall, mean BIC was 59.88% (95%CI: 57.43-62.33). BIC increased significantly over time (p<0.001): 40.93 (95%CI: 34.95-46.90) at 2 wks, 58.37% (95%CI: 54.38-62.36) at 4 wks, and 66.33% (95%CI: 63.45-69.21) beyond 4 wks. Variability among studies was mainly explained by differences in observation interval post-extraction and post-implant placement, and implant surface. Heterogeneity was high for all studies (I2 > 90%, p<0.001).

CONCLUSIONS

The minipig intraoral dental implant model appears to effectively demonstrate osseointegration and alveolar bone remodeling similar to that observed in humans and canine models.

A Highly Ordered, Nanostructured Fluorinated CaP-Coated Melt Electrowritten Scaffold for Periodontal Tissue Regeneration

Periodontitis is a chronic inflammatory, bacteria-triggered disorder affecting nearly half of American adults. Although some level of tissue regeneration is realized, its low success in complex cases demands superior strategies to amplify regenerative capacity. Herein, highly ordered scaffolds are engineered via Melt ElectroWriting (MEW), and the effects of strand spacing, as well as the presence of a nanostructured fluorinated calcium phosphate (F/CaP) coating on the adhesion/proliferation, and osteogenic differentiation of human-derived periodontal ligament stem cells, are investigated. Upon initial cell-scaffold interaction screening aimed at defining the most suitable design, MEW poly(ε-caprolactone) scaffolds with 500 µm strand spacing are chosen. Following an alkali treatment, scaffolds are immersed in a pre-established solution to allow for coating formation. The presence of a nanostructured F/CaP coating leads to a marked upregulation of osteogenic genes and attenuated bacterial growth. In vivo findings confirm that the F/CaP-coated scaffolds are biocompatible and lead to periodontal regeneration when implanted in a rat mandibular periodontal fenestration defect model. In aggregate, it is considered that this work can contribute to the development of personalized scaffolds capable of enabling tissue-specific differentiation of progenitor cells, and thus guide simultaneous and coordinated regeneration of soft and hard periodontal tissues, while providing antimicrobial protection.

Pre-Clinical Models in Implant Dentistry: Past, Present, Future

Biomedical research seeks to generate experimental results for translation to clinical settings. In order to improve the transition from bench to bedside, researchers must draw justifiable conclusions based on data from an appropriate model. Animal testing, as a prerequisite to human clinical exposure, is performed in a range of species, from laboratory mice to larger animals (such as dogs or non-human primates). Minipigs appear to be the animal of choice for studying bone surgery around intraoral dental implants. Dog models, well-known in the field of dental implant research, tend now to be used for studies conducted under compromised oral conditions (biofilm). Regarding small animal models, research studies mostly use rodents, with interest in rabbit models declining. Mouse models remain a reference for genetic studies. On the other hand, over the last decade, scientific advances and government guidelines have led to the replacement, reduction, and refinement of the use of all animal models in dental implant research. In new development strategies, some in vivo experiments are being progressively replaced by in vitro or biomaterial approaches. In this review, we summarize the key information on the animal models currently available for dental implant research and highlight (i) the pros and cons of each type, (ii) new levels of decisional procedures regarding study objectives, and (iii) the outlook for animal research, discussing possible non-animal options.

Regeneration of rat periodontium by cementum protein 1-derived peptide

BACKGROUND AND OBJECTIVE

Cementum protein 1 (CEMP1) has the capacity to promote differentiation of periodontal ligament (PDL) cells toward a cementoblastic phenotype in vitro and bone regeneration in vivo. In this study, we tested the capabilities of a synthetic cementum protein 1-derived peptide, MGTSSTDSQQAGHRRCSTSN (CEMP1-p1), to promote regeneration of periodontal structures in a periodontal fenestration defect in rats.

MATERIAL AND METHODS

Fenestration defects were created using an extra-oral approach in the buccal aspect of the mandibular first molar roots. Eighteen male Wistar rats were divided into three groups. Two controls (defects non-treated or defects treated with a gelatin matrix scaffold [GMS] only) and the experimental group treated with 5 µg/dose of CEMP1-p1 embedded in GMS. After 28 days, the animals were sacrificed, and the mandibles processed for histopathological examination. Expression of cementum proteins, cementum attachment protein (CAP), CEMP1, integrin binding sialoprotein (IBSP), and osteocalcin (OCN), was assessed using immunofluorescence. The formation of new cementum, bone, and PDL fibers were compared between control and experimental groups.

RESULTS

The histological analysis revealed that the control group without any treatment new cementum or oriented PDL fibers were not observed. However, the presence of newly bone was detected. In the control group treated with GMS, new cementum formation was not detectable, the PDL fibers were oriented parallel to the longitudinal root axis, and new bone formation was observed. The experimental group showed deposit of acellular extrinsic fiber cementum (AEFC) in a lamellae-like feature with inserted Sharpey's fibers, formation of cellular mixed stratified cementum (CMSC) with the presence of cementocytes, and newly formed bone close to the cementum-enamel junction. Cementoblast cells adjacent to new cementum expressed CAP, CEMP1, IBSP, and OCN.

CONCLUSION

These studies show that CEMP1-p1 promotes the formation of AEFC, CMSC, new PDL with Sharpey's fibers inserted in cementum and bone, thus providing strong evidence that the synthetic peptide CEMP1-p1 promotes periodontal regeneration in a rat fenestration model.

Mandible Biomechanics and Continuously Erupting Teeth: A New Defect Model for Studying Load-Bearing Biomaterials

Animals with elodont dentition and unfused mandible symphyses are hypothesized to have symmetric incisor morphology. Since these animals maintain their teeth by gnawing, they may provide physiologic feedback on mechanical function when unilateral mandible defects are created that manifest as ipsilateral changes in tooth structure. This defect model would potentially generate important information on the functional/mechanical properties of implants. Rats’ and rabbits’ mandibles and teeth are analyzed with µCT at baseline and post-intervention (n = 8 for each). Baseline incisors were compared. In a unilateral mandible pilot study, defects—ranging from critical size defect to complete ramus osteotomies—were created to assess effect on dentition (rats, n = 7; rabbits, n = 6). Within 90% confidence intervals, animals showed no baseline left/right differences in their incisors. There are apparent dental changes associated with unilateral defect type and location. Thus, at baseline, animals exhibit statistically significant incisor symmetry and there is an apparent relationship between mandible defect and incisor growth. The baseline symmetry proven here sets the stage to study the degree to which hemi-mandible destabilizing procedures result in measurable & reproducible disruption of dental asymmetry. In a validated model, an implant designed to function under load that prevents incisor asymmetry would provide supporting evidence that the implant has clinically useful load-bearing function.

Prospective cohort study to evaluate narrow diameter implants for restoration of a missing lateral incisor in patients with a cleft palate: One-year results

STATEMENT OF PROBLEM

Patients diagnosed with a cleft palate often have a congenitally missing maxillary lateral incisor. The congenital cleft presents the practitioner with challenges including the quantity and quality of bone, a surgically managed cleft correction, and limited clinical space.

PURPOSE

The purpose of the present prospective investigation was to report preliminary results at the 1-year follow-up for this planned 5-year investigation of narrow diameter implants used to restore a missing lateral incisor in patients with a cleft palate.

MATERIAL AND METHODS

Fourteen study participants with a cleft palate and a missing maxillary lateral incisor were enrolled based on established criteria. Narrow diameter implants (AstraTech OsseoSpeed TX 3.0S and 3.5 mm) were placed by using a 2-stage protocol and restored. All study participants received an Atlantis abutment and a cement-retained crown. Four probing depth measurements and bleeding on probing were measured at baseline and at 1 year. Probing depth measurements were evaluated using a 2-way repeated measures ANOVA with Tukey-Kramer multiple comparisons tests. Radiographic marginal bone loss was measured at 1-year by using a digital subtraction technique and evaluated by using a repeated measures ANOVA. Pretreatment cone beam computed tomography (CBCT) images were used to measure a mean gray level that was proportional to bone mineral density (BMD) in the implant site. One-way mixed ANOVA was used to compare the mean gray level and average implant stability quotient (ISQ) loading. A Pearson correlation was also tested between those parameters (α=.05) for each statistical analysis.

RESULTS

The mean marginal bone loss at 1 year was 0.601 ±0.48 mm. Regarding probing depth measurements, a 2-way repeated measures ANOVA found both the location (P=.012) and time (P=.009) were significant. The Tukey-Kramer multiple comparisons test showed a significant difference between the buccal and distal site (P=.006) from baseline to 1-year follow-up.

CONCLUSIONS

Narrow diameter implants are a reliable treatment for replacing a missing lateral incisor in patients with a cleft palate at 1 year, with an implant survival rate of 100% and implant success rate of 94% using the established criteria. A negative association was found between the bone mineral density and the implant stability in the alveolar cleft site of a patient with a cleft palate. The peri-implant soft tissue probe depths exhibited significant change during the first year.

Enhanced bone formation of calvarial bone defects by low-intensity pulsed ultrasound and recombinant human bone morphogenetic protein-9: a preliminary experimental study in rats

OBJECTIVES

The aim of this study was to evaluate the combined effects of recombinant human bone morphogenetic protein - 9 (rhBMP-9) loaded onto absorbable collagen sponges (ACS) and low-intensity pulsed ultrasound (LIPUS) on bone formation in rat calvarial defects.

MATERIALS AND METHODS

Circular calvarial defects were surgically created in 18 Wistar rats, which were divided into LIPUS-applied (+) and LIPUS-non-applied (-) groups. The 36 defects in each group received ACS implantation (ACS group), ACS with rhBMP-9 (rhBMP-9/ACS group), or surgical control (control group), yielding the following six groups: ACS (+/-), rhBMP-9/ACS (+/-), and control (+/-). The LIPUS-applied groups received daily LIPUS exposure starting immediately after surgery. At 4 weeks, animals were sacrificed and their defects were investigated histologically and by microcomputed tomography.

RESULTS

Postoperative clinical healing was uneventful at all sites. More new bone was observed in the LIPUS-applied groups compared with the LIPUS-non-applied groups. Newly formed bone area (NBA)/total defect area (TA) in the ACS (+) group (46.49 ± 7.56%) was significantly greater than that observed in the ACS (-) (34.31 ± 5.68%) and control (-) (31.13 ± 6.74%) groups (p < 0.05). The rhBMP-9/ACS (+) group exhibited significantly greater bone volume, NBA, and NBA/TA than the rhBMP-9/ACS (-) group (2.46 ± 0.65 mm³ vs. 1.76 ± 0.44 mm³, 1.25 ± 0.31 mm² vs. 0.88 ± 0.22 mm², and 62.80 ± 11.87% vs. 42.66 ± 7.03%, respectively) (p < 0.05). Furthermore, the rhBMP-9/ ACS (+) group showed the highest level of bone formation among all groups.

CONCLUSION

Within their limits, it can be concluded that LIPUS had osteopromotive potential and enhanced rhBMP-9-induced bone formation in calvarial defects of rats.

CLINICAL RELEVANCE

The use of rhBMP-9 with LIPUS stimulation can be a potential bone regenerative therapy for craniofacial/peri-implant bone defects.

Nanostructured Carbonated Hydroxyapatite Associated to rhBMP-2 Improves Bone Repair in Rat Calvaria

Many biomaterials are used for Bone Morphogenetic Proteins (BMPs) delivery in bone tissue engineering. The BMP carrier system's primary function is to hold these growth factors at the wound's site for a prolonged time and provide initial support for cells to attach and elaborate the extracellular matrix for bone regeneration. This study aimed to evaluate the nanostructured carbonated hydroxyapatite microspheres (nCHA) as an rhBMP-2 carrier on rats calvaria. A total of fifteen male Wistar rats were randomly divided into three groups (n = 5): clot (control group), rhBMP-2 associated with collagen membrane (COL/rhBMP-2) or associated with the microspheres (nCHA/rhBMP-2). After 45 days, the calvaria defect samples were evaluated through histological, histomorphometric, and SR-µCT analyses to investigate new-formed bone and connective tissue volume densities. The descriptive histological analysis showed that nCHA/rhBMP-2 improved bone formation compared to other groups. These results were confirmed by histomorphometric and SR-µCT analysis that showed substantially defect area filling with a higher percentage of newly formed (36.24 ± 6.68) bone than those with the COL/rhBMP-2 (0.42 ± 0.40) and Clot (3.84 ± 4.57) (p < 0.05). The results showed that nCHA is an effective carrier for rhBMP-2 encouraging bone healing and an efficient alternative to collagen membrane for rhBMP-2 delivery.

Preclinical evaluation of a 3D-printed hydroxyapatite/poly(lactic-co-glycolic acid) scaffold for ridge augmentation

BACKGROUND/PURPOSE

Supracrestal ridge augmentation (SRA) is a major challenge for clinicians. This study investigated the efficacy of a 3D-printed (3DP) hydroxyapatite/poly(lactic-co-glycolic acid) (HA/PLGA) scaffold as a potential biologic for SRA.

METHODS

Scaffolds that were 5 mm in diameter and 2.5-mm thick with a 1.2-mm diameter through-and-through central hole composed of 90% HA and 10% PLGA were printed using an extrusion-based bioprinter. The HA/PLGA scaffold was fixed with a 1.2-mm titanium mini-implant on the buccal surface of rat mandible (Ti-HPS), and the outcome of SRA were compared with sites treated with a titanium mini-implant alone (control) and a titanium mini-implant covered with deproteinized bovine bone-derived matrix (Ti-DBBM) at 4 and 8 weeks by microcomputed tomography (micro-CT), back-scattered SEM, and histology assessments.

RESULTS

The HA/PLGA scaffolds were 2.486 ± 0.082 mm thick with an outer diameter of 4.543 ± 0.057 mm and an inner diameter of 1.089 ± 0.045 mm, and the pore dimensions were 0.48-0.52 mm. There was significantly more mineralized tissue in the Ti-DBBM and Ti-HPS groups than in the control group at both time points. Newly formed bone (NB) was well-integrated with the DBBM and HA/PLGA scaffolds. The framework of the 3DP-HA/PLGA scaffold remained in place, and NB-implant contact (NBIC) was advanced to the middle level in the Ti-HPS group until 8 weeks, whereas dispersion of DBBM with a lower level NBIC was noted in the Ti-DBBM group at both time points.

CONCLUSION

The 3DP HA/PLGA scaffold maintains supracrestal space and demonstrates osteoconductivity to facilitate SRA.

Development of a multicellular 3D-bioprinted microtissue model of human periodontal ligament-alveolar bone biointerface: Towards a pre-clinical model of periodontal diseases and personalized periodontal tissue engineering

While periodontal (PD) disease is among principal causes of tooth loss worldwide, regulation of concomitant soft and mineralized PD tissues, and PD pathogenesis have not been completely clarified yet. Besides, relevant pre-clinical models and in vitro platforms have limitations in simulating human physiology. Here, we have harnessed three-dimensional bioprinting (3DBP) technology for developing a multi-cellular microtissue model resembling PD ligament-alveolar bone (PDL-AB) biointerface for the first time. 3DBP parameters were optimized; the physical, chemical, rheological, mechanical, and thermal properties of the constructs were assessed. Constructs containing gelatin methacryloyl (Gel-MA) and hydroxyapatite-magnetic iron oxide nanoparticles showed higher level of compressive strength when compared with that of Gel-MA constructs. Bioprinted self-supporting microtissue was cultured under flow in a microfluidic platform for >10 days without significant loss of shape fidelity. Confocal microscopy analysis indicated that encapsulated cells were homogenously distributed inside the matrix and preserved their viability for >7 days under microfluidic conditions. Immunofluorescence analysis showed the cohesion of stromal cell surface marker-1+ human PDL fibroblasts containing PDL layer with the osteocalcin+ human osteoblasts containing mineralized layer in time, demonstrating some permeability of the printed constructs to cell migration. Preliminary tetracycline interaction study indicated the uptake of model drug by the cells inside the 3D-microtissue. Also, the non-toxic levels of tetracycline were determined for the encapsulated cells. Thus, the effects of tetracyclines on PDL-AB have clinical significance for treating PD diseases. This 3D-bioprinted multi-cellular periodontal/osteoblastic microtissue model has potential as an in vitro platform for studying processes of the human PDL.

Platelet rich fibrin versus ozone gel for periodontal regeneration in induced rats' intrabony three-wall periodontal defects

BACKGROUND

The question of whether platelet rich fibrin and ozone can enhance regeneration of periodontal defect was addressed.

MATERIALS AND METHODS

three-wall periodontal defects were surgically created in 30 rats involving mesial aspect of right mandibular first molar. Rats were randomly assigned into three groups: 1) Group I (Positive control group). 2) Group II (Ozone treated group) and 3) Group III (PRF treated group). Two weeks after surgery, five rats from each group were euthanized and the remaining was euthanized 4 weeks post surgery. The degree of periodontal regeneration was evaluated using light microscope and scanning electron microscope. Histomorphometric measurements and anti-PCNA immunohistochemical counting were statistically analyzed.

RESULTS

group I showed intense inflammatory reaction with mild new bone formation. In group II, partial regeneration was seen with moderate new woven bone formation in 2 weeks period. After 4 weeks, almost complete restoration of periodontium was seen. In group III, after 2 weeks, moderate lamellar bone formation was observed. In 4 weeks period, the periodontal regeneration was almost completed. Histomorphometric analysis showed a significant difference between group I and group II. The difference between group I and group III was significant in 2 weeks and highly significant after 4 weeks. That between group II and group III was nonsignificant in 2 weeks and significant in 4 weeks. Anti-PCNA analysis was nonsignificant between groups.

CONCLUSIONS

both Platelet rich fibrin and ozone can improve histological parameters associated with healing of experimental intrabony periodontal defects in rats with the former being superior.

Regeneration of critical-sized mandibular defect using a 3D-printed hydroxyapatite-based scaffold: An exploratory study

BACKGROUND

Three-dimensional (3D) printing has become an available technology to fabricate customized tissue engineering scaffolds with delicate architecture. This exploratory study aimed to evaluate the potential of a 3D-printed hydroxyapatite-based scaffold as a biomaterial for obtaining guided bone regeneration (GBR) in vivo.

METHODS

Scaffolds composed of 90% hydroxyapatite and 10% poly(lactic-co-glycolic acid) were printed using a microextrusion process to fit 4 mm diameter and 0.5 mm thick through-and-through osseous defects on the mandibular ramus of rats, with unfilled defects serving as controls. Specimens were analyzed for regeneration-associated gene expression on day 7, and micro-computed tomography (micro-CT) and histology assessments were carried out on day 28.

RESULTS

The scaffolds were 3.56 ± 0.43 mm (x-axis) and 4.02 ± 0.44 mm (y-axis) in diameter and 0.542 ± 0.035 mm thick (z-axis), with a mean pore size of 0.420 ± 0.028 × 0.328 ± 0.005 mm² . Most scaffolds fit the defects well. Type I collagen, VEGF, and Cbfa1 were upregulated in the scaffold-treated defects by day 7. By day 28, de novo osteogenesis and scaffold-tissue integration were evident in the scaffold-treated defects, and entire mineralized tissue, as well as newly formed bone, was significantly promoted, as seen in the micro-CT and histologic analyses.

CONCLUSION

The 3D-printed hydroxyapatite-based scaffold showed acceptable dimensional stability and demonstrated favorable osteoregenerative capability that fulfilled the need for GBR.

Application of BMP-Bone Cement and FGF-Gel on Periodontal Tissue Regeneration in Nonhuman Primates

The ultimate challenge of tissue engineering research is the translation of experimental knowledge into clinical application. In the preclinical testing phase of any new therapy, animal models remain the gold standard. Therefore, the methodological choice of a suitable model is critical to meet the requirements for a safe clinical application of the developed treatment. For instance, we have shown in rats that the application of calcium phosphate cement (CPC)/propylene glycol alginate (PGA) with bone morphogenetic protein (BMP)-2 or fibroblast growth factor (FGF)-2 resulted in the regeneration of periodontal defects. However, it is debated whether using small models form a predictive method for translation to larger species. At the same time, the 3R framework is encouraged as guiding principles of the ethical use of animal testing. Therefore, based on the successful rat study, the objective of this study was to further investigate the periodontal regenerative efficacy of the CPC/BMP and PGA/FGF system in a periodontal defect model with a low number of nonhuman primates (NHPs). Three Macaca fascicularis-overstocked from breeding for other purposes-were used (reuse of animals and appropriateness of the experimental animal species according to 3R framework). Three-wall periodontal defects were surgically created in the mandible. In total, 10 defects were created and distributed over two groups: (1) control group: PGA+CPC (n = 5) and (2) experimental group: PGA/FGF+CPC/BMP (n = 5). After 3 months, tissue regeneration was evaluated by histomorphometry and radiographic measurements. Data showed that epithelial downgrowth, cementum, and ligament regeneration were significantly enhanced in the experimental group compared with the control group (n = 5; p = 0.013, p = 0.028, and p = 0.018, respectively). However, the amount of newly formed bone did not differ (p = 0.146). Overall, as a translational proof-of-principle study, the hybrid periodontal regenerative method of CPC/BMP+PGA/FGF promoted periodontal regeneration in NHPs. This study warrants the application of CPC/BMP/PGA/FGF in clinical trials. Impact Statement This study validated an earlier successful periodontal regeneration strategy from a rat model into a few spare nonhuman primates (NHPs). The hybrid periodontal regenerative method of calcium phosphate cement (CPC)/bone morphogenetic protein (BMP)-2/propylene glycol alginate (PGA)/fibroblast growth factor (FGF)-2 promoted periodontal regeneration in NHPs, which corroborated the previous rat results. This translational approach was a very practical option and thus reduced the number and species of experimental animals in translational research. These results found in NHPs indicate a consistent conclusion with the earlier findings in the rat model. It further warrants the application of CPC/BMP-2+PGA/FGF-2 in human clinical trials.

The Impact of Bioceramic Scaffolds on Bone Regeneration in Preclinical In Vivo Studies: A Systematic Review

Bioceramic scaffolds are appealing for alveolar bone regeneration, because they are emerging as promising alternatives to autogenous and heterogenous bone grafts. The aim of this systematic review is to answer to the focal question: in critical-sized bone defects in experimental animal models, does the use of a bioceramic scaffolds improve new bone formation, compared with leaving the empty defect without grafting materials or using autogenous bone or deproteinized bovine-derived bone substitutes? Electronic databases were searched using specific search terms. A hand search was also undertaken. Only randomized and controlled studies in the English language, published in peer-reviewed journals between 2013 and 2018, using critical-sized bone defect models in non-medically compromised animals, were considered. Risk of bias assessment was performed using the SYRCLE tool. A meta-analysis was planned to synthesize the evidence, if possible. Thirteen studies reporting on small animal models (six studies on rats and seven on rabbits) were included. The calvarial bone defect was the most common experimental site. The empty defect was used as the only control in all studies except one. In all studies the bioceramic materials demonstrated a trend for better outcomes compared to an empty control. Due to heterogeneity in protocols and outcomes among the included studies, no meta-analysis could be performed. Bioceramics can be considered promising grafting materials, though further evidence is needed.

Alveolar bone repair of rhesus monkeys by using BMP-2 gene and mesenchymal stem cells loaded three-dimensional printed bioglass scaffold

Over the past years, the study about bone tissue engineering in the field of regenerative medicine has been a main research topic. Using three-dimensional (3D) porous degradable scaffold complexed with mesenchymal stem cells (MSCs) and growth factor gene to improve bone tissue repair and regeneration has raised much interest. This study mainly evaluated the osteogenesis of alveolar bone defects of animal in the following experimental groups: sham-operated (SO), 3D printed bioglass (3D-BG), 3D-BG with BMP-2 gene loaded CS (3D-BG + BMP/CS) and 3D-BG with rhesus marrow bone MSCs and BMP/CS (3D-BG + BMP/CS + rBMSCs). Simulated human bone defect with critical size of 10 × 10 × 5 mm were established in quadrumana - rhesus monkeys, and in vivo osteogenesis was characterized by X-ray, micro-Computed Tomography (mCT) and history. Our results revealed that 3D-BG + rBMSCs + BMP/CS scaffold could improve bone healing best by showing its promote osteogenic properties in vivo. Considering the great bone repair capacity of 3D-BG + BMP/CS + rBMSCs in humanoid primate rhesus monkeys, it could be a promising therapeutic strategy for surgery trauma or accidents, especially for alveolar bones defects.

Cellular therapy in periodontal regeneration

Periodontitis is a chronic inflammatory condition leading to destruction of the tooth supporting tissues, which if left untreated may cause tooth loss. The treatment of periodontitis mainly aims to arrest the inflammatory process by infection control measures, although in some specific lesions a limited periodontal regeneration can also be attained. Current regenerative approaches are aimed to guide the cells with regenerative capacity to repopulate the lesion and promote new cementum and new connective tissue attachment. The first phase in periodontal tissue regeneration involves the differentiation of mesenchymal cells into cementoblasts to promote new cementum, thus facilitating the attachment of new periodontal ligament fibers to the root and the alveolar bone. Current regenerative approaches limit themselves to the confines of the lesion by promoting the self-regenerative potential of periodontal tissues. With the advent of bioengineered therapies, several studies have investigated the potential use of cell therapies, mainly the use of undifferentiated mesenchymal cells combined with different scaffolds. The understanding of the origin and differentiation patterns of these cells is, therefore, important to elucidate their potential therapeutic use and their comparative efficacy with current technologies. This paper aims to review the in vitro and experimental studies using cell therapies based on application of cementoblasts and mesenchymal stem cells isolated from oral tissues when combined with different scaffolds.

Periodontal regeneration using bone morphogenetic protein 2 incorporated biomimetic calcium phosphate in conjunction with barrier membrane: A pre-clinical study in dogs

Aim

To evaluate the effect of bone morphogenetic protein 2 (BMP‐2) incorporated biomimetic calcium phosphate (BMP‐2/BioCaP) in conjunction with barrier membrane on periodontal regeneration in chronic periodontitis experimental model.

Material and Methods

Chronic periodontitis experimental model with critical‐sized supra‐alveolar defects was created in 15 dogs’ mandibles. After the initial periodontal therapy, the defects were randomly assigned to the following groups: (a) control; (b) barrier membrane; (c) deproteinized bovine bone mineral + barrier membrane; (d) BioCaP + barrier membrane and (e) BMP‐2/BioCaP + barrier membrane (6 quadrants with 18 teeth per group). Eight weeks later, clinical examinations, micro‐CT, and histomorphometric analyses were performed.

Results

Clinical examinations, including plaque index, bleeding index, and probing depth, were similar for all groups. In contrast, the clinical attachment loss was significantly lower in defects grafted with BMP‐2/BioCaP and barrier membrane. The micro‐CT results showed that the height of mineralized tissue in defects grafted with BMP‐2/BioCaP and barrier membrane was significantly higher. For histometric analysis, the defects grafted with BMP‐2/BioCaP and barrier membrane exhibited significantly more connective tissue height, new cementum height, new bone height and area, as well as less down‐growth of junctional epithelium.

Conclusion

BMP‐2/BioCaP could be a promising bone substitute for periodontal regeneration.

Prx1 Expressing Cells Are Required for Periodontal Regeneration of the Mouse Incisor

Previous studies have shown that post-natal skeletal stem cells expressing Paired-related homeobox 1 (PRX1 or PRRX1) are present in the periosteum of long bones where they contribute to post-natal bone development and regeneration. Our group also identified post-natal PRX1 expressing cells (pnPRX1+ cells) in mouse calvarial synarthroses (sutures) and showed that these cells are required for calvarial bone regeneration. Since calvarial synarthroses are similar to dentoalveolar gomphosis (periodontium) and since there is no information available on the presence or function of pnPRX1+ cells in the periodontium, the present study aimed at identifying and characterizing pnPRX1+ cells within the mouse periodontium and assess their contribution to periodontal development and regeneration. Here we demonstrated that pnPRX1+ cells are present within the periodontal ligament (PDL) of the mouse molars and of the continuously regenerating mouse incisor. By means of diphtheria toxin (DTA)-mediated conditional ablation of pnPRX1+ cells, we show that pnPRX1+ cells contribute to post-natal periodontal development of the molars and the incisor, as ablation of pnPRX1+ cells in 3-days old mice resulted in a significant enlargement of the PDL space after 18 days. The contribution of pnPRX1+ cells to periodontal regeneration was assessed by developing a novel non-critical size periodontal defect model. Outcomes showed that DTA-mediated post-natal ablation of pnPRX1+ cells results in lack of regeneration in periodontal non-critical size defects in the regeneration competent mouse incisors. Importantly, gene expression analysis of these cells shows a profile typical of quiescent cells, while gene expression analysis of human samples of periodontal stem cells (PDLSC) confirmed that Prx1 is highly expressed in human periodontium. In conclusion, pnPRX1+ cells are present within the continuously regenerating PDL of the mouse incisor, and at such location they contribute to post-natal periodontal development and regeneration. Since this study further reports the presence of PRX1 expressing cells within human periodontal ligament, we suggest that studying the mouse periodontal pnPRX1+ cells may provide significant information for the development of novel and more effective periodontal regenerative therapies in humans.

Transplantation of Adipose-derived Cells for Periodontal Regeneration: A Systematic Review

This systematic review evaluated the transplantation of cells derived from adipose tissue for applications in dentistry. SCOPUS, PUBMED and LILACS databases were searched for in vitro studies and pre-clinical animal model studies using the keywords "ADIPOSE", "CELLS", and "PERIODONTAL", with the Boolean operator "AND". A total of 160 titles and abstracts were identified, and 29 publications met the inclusion criteria, 14 in vitro and 15 in vivo studies. In vitro studies demonstrated that adipose- derived cells stimulate neovascularization, have osteogenic and odontogenic potential; besides adhesion, proliferation and differentiation on probable cell carriers. Preclinical studies described improvement of bone and periodontal healing with the association of adipose-derived cells and the carrier materials tested: Platelet Rich Plasma, Fibrin, Collagen and Synthetic polymer. There is evidence from the current in vitro and in vivo data indicating that adipose-derived cells may contribute to bone and periodontal regeneration. The small quantity of studies and the large variation on study designs, from animal models, cell sources and defect morphology, did not favor a meta-analysis. Additional studies need to be conducted to investigate the regeneration variability and the mechanisms of cell participation in the processes. An overview of animal models, cell sources, and scaffolds, as well as new perspectives are provided for future bone and periodontal regeneration study designs.

Topical application of phenytoin or nifedipine-loaded PLGA microspheres promotes periodontal regeneration in vivo

OBJECTIVES

Gingival recession and alveolar bone loss are common manifestations of periodontitis. Periodontal regeneration is the ideal strategy for rehabilitating periodontal tissue defects and preventing tooth loss. The present study examined whether localized, topical application of gingival overgrowth-inducing drugs, phenytoin, nifedipine or cyclosporine, induces periodontal regeneration.

METHODS

Polylactic-co-glycolic acid (PLGA) was used as the carrier for preparation of phenytoin, nifedipine or cyclosporine-loaded PLGA microspheres, using an oil-in-water emulsification technique. The drug-loaded microspheres were delivered to periodontal defects created on alveolar ridges mesial to the first maxillary molars of Sprague-Dawley rats. After eight weeks, the operation area in each rat, including the maxillary molars and periodontal tissues, was harvested and evaluated by micro-computed tomography, histochemical and immunohistochemical analyses.

RESULTS

Physical parameters representative of periodontal regeneration, including the length of new alveolar bone (p < 0.01) and the area of new alveolar bone (p < 0.01) were significantly improved in the phenytoin group. Compared to other groups, the phenytoin group demonstrated increased expression of COL-1, VEGF-A, osteoblast and osteoclast markers (BMP-2, TGF-β1, OCN and TRAP staining), as well as decreased expression of MMP-8.

CONCLUSIONS

Results of the present study provided new evidence that localized, controlled release of phenytoin confers therapeutic benefits toward gingival recession and alveolar bone loss. Phenytoin appears to be a promising drug that promotes periodontal regeneration.

Healing of two-wall intra-bony defects treated with a novel EMD-liquid-A pre-clinical study in monkeys

AIM

To investigate the effect of a novel enamel matrix derivative formulation (EMD-liquid or Osteogain) combined with an absorbable collagen sponge (ACS) on periodontal wound healing in intra-bony defects in monkeys.

MATERIALS AND METHODS

Chronic two-wall intra-bony defects were created at the distal aspect of eight teeth in three monkeys (Macaca fascicularis). The 24 defects were randomly assigned to one of the following treatments: (i) open flap debridement (OFD) + ACS alone, (ii) OFD + Emdogain + ACS (Emdogain/ACS), (iii) OFD + Osteogain + ACS (Osteogain/ACS) or (iv) OFD alone. At 4 months, the animals were euthanized for histologic evaluation.

RESULTS

Osteogain/ACS resulted in more consistent formation of cementum, periodontal ligament and bone with limited epithelial proliferation compared to OFD alone, Emdogain/ACS and OFD + ACS. Among the four treatment groups, the Osteogain/ACS group demonstrated the highest amount of regenerated tissues. However, complete periodontal regeneration was not observed in any of the defects in the four groups.

CONCLUSIONS

The present findings indicate that in two-wall intra-bony defects, reconstructive surgery with Osteogain/ACS appears to be a promising novel approach for facilitating periodontal wound healing/regeneration, thus warranting further clinical testing.

Alveolar bone tissue engineering in critical-size defects of experimental animal models: a systematic review and meta-analysis

Regeneration of large, 'critical-size' bone defects remains a clinical challenge. Bone tissue engineering (BTE) is emerging as a promising alternative to autogenous, allogeneic and biomaterial-based bone grafting. The objective of this systematic review was to answer the focused question: in animal models, do cell-based BTE strategies enhance regeneration in alveolar bone critical-size defects (CSDs), compared with grafting with only biomaterial scaffolds or autogenous bone? Following PRISMA guidelines, electronic databases were searched for controlled animal studies reporting maxillary or mandibular CSD and implantation of mesenchymal stem cells (MSCs) or osteoblasts (OBs) seeded on biomaterial scaffolds. A random effects meta-analysis was performed for the outcome histomorphometric new bone formation (%NBF). Thirty-six studies were included that reported on large- (monkeys, dogs, sheep, minipigs) and small-animal (rabbits, rats) models. On average, studies presented with an unclear-to-high risk of bias and short observation times. In most studies, MSCs or OBs were used in combination with alloplastic mineral-phase scaffolds. In five studies, cells were modified by ex vivo gene transfer of bone morphogenetic proteins (BMPs). The meta-analysis indicated statistically significant benefits in favour of: (1) cell-loaded vs. cell-free scaffolds [weighted mean difference (WMD) 15.59-49.15% and 8.60-13.85% NBF in large- and small-animal models, respectively]; and (2) BMP-gene-modified vs. unmodified cells (WMD 10.06-20.83% NBF in small-animal models). Results of cell-loaded scaffolds vs. autogenous bone were inconclusive. Overall, heterogeneity in the meta-analysis was high (I2  > 90%). In summary, alveolar bone regeneration is enhanced by addition of osteogenic cells to biomaterial scaffolds. The direction and estimates of treatment effect are useful to predict therapeutic efficacy and guide future clinical trials of BTE. Copyright © 2016 John Wiley & Sons, Ltd.

Efficacy of Humanized Mesenchymal Stem Cell Cultures for Bone Tissue Engineering: A Systematic Review with a Focus on Platelet Derivatives

Fetal bovine serum (FBS) is the most commonly used supplement for ex vivo expansion of human mesenchymal stem cells (hMSCs) for bone tissue engineering applications. However, from a clinical standpoint, it is important to substitute animal-derived products according to current good manufacturing practice (cGMP) guidelines. Humanized alternatives to FBS include three categories of products: human serum (HS), human platelet derivatives (HPDs)-including platelet lysate (PL) or platelet releasate (PR), produced by freeze/thawing or chemical activation of platelet concentrates, respectively, and chemically defined media (serum-free) (CDM). In this systematic literature review, the in vitro and in vivo osteogenic potential of hMSCs expanded in humanized (HS-, HPD-, or CDM-supplemented) media versus hMSCs expanded in FBS-supplemented media, was compared. In addition, PL and PR were compared in terms of their growth factor (GF)/cytokine-content and cell-culture efficacy. When using either 10-20% autologous or pooled HS, 3-10% pooled HPDs or CDM supplemented with GFs, in comparison with 10-20% FBS, a majority of studies reported similar or superior in vitro proliferation and osteogenic differentiation, and in vivo bone formation in ectopic or orthotopic rodent models. Moreover, a trend for higher GF content was observed in PL versus PR, although evidence for cell culture efficacy is limited. In summary, humanized supplements seem at least equally effective as FBS for hMSC expansion and osteogenic differentiation. Although pooled HPDs appear to be the most favorable supplement for large-scale hMSC expansion, further efforts are needed to standardize the preparation and composition of these products in compliance with cGMP standards.

Bone tissue engineering in oral peri-implant defects in preclinical in vivo research: A systematic review and meta-analysis

The regeneration and establishment of osseointegration within oral peri-implant bone defects remains a clinical challenge. Bone tissue engineering (BTE) is emerging as a promising alternative to autogenous and/or biomaterial-based bone grafting. The objective of this systematic review was to answer the focused question: in animal models, do cell-based BTE strategies enhance bone regeneration and/or implant osseointegration in experimental peri-implant defects, compared with grafting with autogenous bone or only biomaterial scaffolds? Electronic databases were searched for controlled animal studies reporting on peri-implant defects and implantation of mesenchymal stem cells (MSC) or other cells seeded on biomaterial scaffolds, following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Random effects meta-analyses were performed for the outcomes histomorphometric bone area fraction (BA) and bone-to-implant contact (BIC). Nineteen studies reporting on large animal models (dogs and sheep) were included. Experimental defects were created surgically (16 studies) or via ligature-induced peri-implantitis (LIPI, three studies). In general, studies presented with an unclear to high risk of bias. In most studies, MSC were used in combination with alloplastic mineral phase or polymer scaffolds; no study directly compared cell-loaded scaffolds vs. autogenous bone. In three studies, cells were also modified by ex vivo gene transfer of osteoinductive factors. The meta-analyses indicated statistically significant benefits in favour of: (a) cell-loaded vs. cell-free scaffolds [weighted mean differences (WMD) of 10.73-12.30% BA and 11.77-15.15% BIC] in canine surgical defect and LIPI models; and (b) gene-modified vs. unmodified cells (WMD of 29.44% BA and 16.50% BIC) in canine LIPI models. Overall, heterogeneity in the meta-analyses was high (I² 70-88%); considerable variation was observed among studies regarding the nature of cells and scaffolds used. In summary, bone regeneration and osseointegration in peri-implant defects are enhanced by the addition of osteogenic cells to biomaterial scaffolds. Although the direction of treatment outcome is clearly in favour of BTE strategies, due to the limited magnitude of treatment effect observed, no conclusive statements regarding the clinical benefit of such procedures for oral indications can yet be made. Copyright © 2017 John Wiley & Sons, Ltd.

Histologic and Histomorphometric Comparison of Bone Regeneration Between Bone Morphogenetic Protein-2 and Platelet-Derived Growth Factor-BB in Experimental Groups

Efficacy of recombinant human bone morphogenetic protein-2 (rhBMP-2) and recombinant human platelet-derived growth factor-BB (rhPDGF-BB) delivered via absorbable collagen sponge (ACS) on bone formation was evaluated in guinea pig tibias. Three-millimeter-circular bone tibia defects were created in 24 guinea pigs assigned randomly to 4 groups according to the following defect filling materials: ACS only, rhBMP-2+ACS, rhPDGF-BB+ACS, or empty. New bone formation was evaluated histologically and histomorphometrically at 15 (early healing) and 45 days (late healing). Mean new bone per total defect area ratio was 0.73, 0.57, 0.43, and 0.42 in rhBMP-2+ACS, rhPDGF-BB+ACS, ACS only, and empty groups at early healing, respectively. During early healing, significantly more new bone formation was observed in rhBMP-2+ACS and rhPDGF-BB+ACS groups than in the control groups. New bone formation was significantly higher with rhBMP-2+ACS than with rhPDGF-BB+ACS. Mean new bone per total defect area ratio was 0.81, 0.86, 0.74, and 0.75 in the rhBMP-2+ACS, rhPDGF-BB+ACS, ACS only, and empty groups at late healing, respectively. During late healing, new bone formation was significantly higher in the rhPDGF-BB+ACS group relative to both control groups, but the results did not differ significantly from those in the rhBMP-2+ACS group. New bone formation in the rhBMP-2+ACS group did not change significantly between the healing periods. In the rhPDGF-BB+ACS group, however, new bone formation was significantly higher in the late healing period. Both growth factors accelerated new bone formation in the early healing period. Although rhBMP-2 was more effective in the early healing period, the effects of rhPDGF-BB were longer lasting.

Incorporation of Human-Platelet-Derived Growth Factor-BB Encapsulated Poly(lactic-co-glycolic acid) Microspheres into 3D CORAGRAF Enhances Osteogenic Differentiation of Mesenchymal Stromal Cells

Tissue engineering aims to generate or facilitate regrowth or healing of damaged tissues by applying a combination of biomaterials, cells, and bioactive signaling molecules. In this regard, growth factors clearly play important roles in regulating cellular fate. However, uncontrolled release of growth factors has been demonstrated to produce severe side effects on the surrounding tissues. In this study, poly(lactic-co-glycolic acid) (PLGA) microspheres (MS) incorporated three-dimensional (3D) CORAGRAF scaffolds were engineered to achieve controlled release of platelet-derived growth factor-BB (PDGF-BB) for the differentiation of stem cells within the 3D polymer network. Fourier transform infrared spectroscopy, energy-dispersive X-ray spectroscopy, scanning electron microscopy, and microtomography were applied to characterize the fabricated scaffolds. In vitro study revealed that the CORAGRAF-PLGA-PDGF-BB scaffold system enhanced the release of PDGF-BB for the regulation of cell behavior. Stromal cell attachment, viability, release of osteogenic differentiation markers such as osteocalcin, and upregulation of osteogenic gene expression exhibited positive response. Overall, the developed scaffold system was noted to support rapid cell expansion and differentiation of stromal cells into osteogenic cells in vitro for bone tissue engineering applications.

Comparison of the effects of recombinant human bone morphogenetic protein-2 and -9 on bone formation in rat calvarial critical-size defects

OBJECTIVES

Among bone morphogenetic protein (BMP) family members, BMP-2 and BMP-9 have demonstrated potent osteoinductive potential. However, in vivo differences in their potential for bone regeneration remain unclear. The present study aimed to compare the effects of recombinant human (rh) BMP-2 and rhBMP-9 on bone formation in rat calvarial critical-size defects (CSD).

MATERIALS AND METHODS

Twenty-eight Wistar rats surgically received two calvarial defects bilaterally in each parietal bone. Defects (n = 56) were allocated into four groups: absorbable collagen sponge (ACS) alone, rhBMP-2 with ACS (rhBMP-2/ACS), rhBMP-9/ACS, or sham surgery (control), on the condition that the treatments of rhBMP-2/ACS and rhBMP-9/ACS, or the same treatments were not included in the same animal. Animals were sacrificed at 2 and 8 weeks post-surgery. The calvarial defects were analyzed for bone volume (BV) by micro-computed tomography and for percentages of defect closure (DC/DL), newly formed bone area (NBA/TA), bone marrow area (BMA/NBA), adipose tissue area (ATA/NBA), central bone height (CBH), and marginal bone height (MBH) by histomorphometric analysis.

RESULTS

The BV in the rhBMP-2/ACS group (5.44 ± 3.65 mm³, n = 7) was greater than the other groups at 2 weeks post-surgery, and the rhBMP-2/ACS and rhBMP-9/ACS groups (18.17 ± 2.51 and 16.30 ± 2.46 mm³, n = 7, respectively) demonstrated significantly greater amounts of BV compared with the control and ACS groups (6.02 ± 2.90 and 9.30 ± 2.75 mm³, n = 7, respectively) at 8 weeks post-surgery. The rhBMP-2/ACS and rhBMP-9/ACS groups significantly induced new bone formation compared to the control and ACS groups at 8 weeks post-surgery. However, there were no statistically significant differences found between the rhBMP-2/ACS and rhBMP-9/ACS groups in any of the histomorphometric parameters. The ATA/NBA in the rhBMP-2/ACS group (9.24 ± 3.72%, n = 7) was the highest among the treatment groups at 8 weeks post-surgery.

CONCLUSIONS

Within the limits of this study, it can be concluded that rhBMP-2/ACS induced a slight early increase in new bone formation at 2 weeks and that rhBMP-9/ACS provided comparable new bone formation to rhBMP-2/ACS with less adipose tissues after a healing period of 8 weeks in rat CSD.

CLINICAL RELEVANCE

RhBMP-9/ACS treatment provided new bone formation with less adipose tissues compared with rhBMP-2/ACS.

Pre-clinical in vivo models for the screening of bone biomaterials for oral/craniofacial indications: focus on small-animal models

Preclinical in vivo experimental studies are performed for evaluating proof-of-principle concepts, safety and possible unwanted reactions of candidate bone biomaterials before proceeding to clinical testing. Specifically, models involving small animals have been developed for screening bone biomaterials for their potential to enhance bone formation. No single model can completely recreate the anatomic, physiologic, biomechanic and functional environment of the human mouth and jaws. Relevant aspects regarding physiology, anatomy, dimensions and handling are discussed in this paper to elucidate the advantages and disadvantages of small-animal models. Model selection should be based not on the 'expertise' or capacities of the team, but rather on a scientifically solid rationale, and the animal model selected should reflect the question for which an answer is sought. The rationale for using heterotopic or orthotopic testing sites, and intraosseous, periosseous or extraskeletal defect models, is discussed. The paper also discusses the relevance of critical size defect modeling, with focus on calvarial defects in rodents. In addition, the rabbit sinus model and the capsule model in the rat mandible are presented and discussed in detail. All animal experiments should be designed with care and include sample-size and study-power calculations, thus allowing generation of meaningful data. Moreover, animal experiments are subject to ethical approval by the relevant authority. All procedures and the postoperative handling and care, including postoperative analgesics, should follow best practice.

Cell Cotransplantation Strategies for Vascularized Craniofacial Bone Tissue Engineering: A Systematic Review and Meta-Analysis of Preclinical In Vivo Studies

The regenerative potential of tissue-engineered bone constructs may be enhanced by in vitro coculture and in vivo cotransplantation of vasculogenic and osteogenic (progenitor) cells. The objective of this study was to systematically review the literature to answer the focused question: In animal models, does cotransplantation of osteogenic and vasculogenic cells enhance bone regeneration in craniofacial defects, compared with solely osteogenic cell-seeded constructs? Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, electronic databases were searched for controlled animal studies reporting cotransplantation of endothelial cells (ECs) with mesenchymal stem cells (MSCs) or osteoblasts in craniofacial critical size defect (CSD) models. Twenty-two studies were included comparing outcomes of MSC/scaffold versus MSC+EC/scaffold (co)transplantation in calvarial (n = 15) or alveolar (n = 7) CSDs of small (rodents, rabbits) and large animal (minipigs, dogs) models. On average, studies presented with an unclear to high risk of bias. MSCs were derived from autologous, allogeneic, xenogeneic, or human (bone marrow, adipose tissue, periosteum) sources; in six studies, ECs were derived from MSCs by endothelial differentiation. In most studies, MSCs and ECs were cocultured in vitro (2-17 days) before implantation. Coculture enhanced MSC osteogenic differentiation and an optimal MSC:EC seeding ratio of 1:1 was identified. Alloplastic copolymer or composite scaffolds were most often used for in vivo implantation. Random effects meta-analyses were performed for histomorphometric and radiographic new bone formation (%NBF) and vessel formation in rodents' calvarial CSDs. A statistically significant benefit in favor of cotransplantation versus MSC-only transplantation for radiographic %NBF was observed in rat calvarial CSDs (weighted mean difference 7.80% [95% confidence interval: 1.39-14.21]); results for histomorphometric %NBF and vessel formation were inconclusive. Overall, heterogeneity in the meta-analyses was high (I² > 80%). In summary, craniofacial bone regeneration is enhanced by cotransplantation of vasculogenic and osteogenic cells. Although the direction of treatment outcome is in favor of cotransplantation strategies, the magnitude of treatment effect does not seem to be of relevance, unless proven otherwise in clinical studies.

Periodontal ligament stem/progenitor cells with protein-releasing scaffolds for cementum formation and integration on dentin surface

Purpose/Aim: Cementogenesis is a critical step in periodontal tissue regeneration given the essential role of cementum in anchoring teeth to the alveolar bone. This study is designed to achieve integrated cementum formation on the root surfaces of human teeth using growth factor-releasing scaffolds with periodontal ligament stem/progenitor cells (PDLSCs).

MATERIALS AND METHODS

Human PDLSCs were sorted by CD146 expression, and characterized using CFU-F assay and induced multi-lineage differentiation. Polycaprolactone scaffolds were fabricated using 3D printing, embedded with poly(lactic-co-glycolic acids) (PLGA) microspheres encapsulating connective tissue growth factor (CTGF), bone morphogenetic protein-2 (BMP-2), or bone morphogenetic protein-7 (BMP-7). After removing cementum on human tooth roots, PDLSC-seeded scaffolds were placed on the exposed dentin surface. After 6-week culture with cementogenic/osteogenic medium, cementum formation and integration were evaluated by histomorphometric analysis, immunofluorescence, and qRT-PCR.

RESULTS

Periodontal ligament (PDL) cells sorted by CD146 and single-cell clones show a superior clonogenecity and multipotency as compared with heterogeneous populations. After 6 weeks, all the growth factor-delivered groups showed resurfacing of dentin with a newly formed cementum-like layer as compared with control. BMP-2 and BMP-7 showed de novo formation of tissue layers significantly thicker than all the other groups, whereas CTGF and BMP-7 resulted in significantly improved integration on the dentin surface. The de novo mineralized tissue layer seen in BMP-7-treated samples expressed cementum matrix protein 1 (CEMP1). Consistently, BMP-7 showed a significant increase in CEMP1 mRNA expression.

CONCLUSION

Our findings represent important progress in stem cell-based cementum regeneration as an essential part of periodontium regeneration.

Changing Paradigms in Cranio-Facial Regeneration: Current and New Strategies for the Activation of Endogenous Stem Cells

Craniofacial area represent a unique district of human body characterized by a very high complexity of tissues, innervation and vascularization, and being deputed to many fundamental function such as eating, speech, expression of emotions, delivery of sensations such as taste, sight, and earing. For this reasons, tissue loss in this area following trauma or for example oncologic resection, have a tremendous impact on patients' quality of life. In the last 20 years regenerative medicine has emerged as one of the most promising approach to solve problem related to trauma, tissue loss, organ failure etc. One of the most powerful tools to be used for tissue regeneration is represented by stem cells, which have been successfully implanted in different tissue/organs with exciting results. Nevertheless, both autologous and allogeneic stem cell transplantation raise many practical and ethical concerns that make this approach very difficult to apply in clinical practice. For this reason different cell free approaches have been developed aiming to the mobilization, recruitment, and activation of endogenous stem cells into the injury site avoiding exogenous cells implant but instead stimulating patients' own stem cells to repair the lesion. To this aim many strategies have been used including functionalized bioscaffold, controlled release of stem cell chemoattractants, growth factors, BMPs, Platelet-Rich-Plasma, and other new strategies such as ultrasound wave and laser are just being proposed. Here we review all the current and new strategies used for activation and mobilization of endogenous stem cells in the regeneration of craniofacial tissue.