Osteochondral tissue engineering in vivo: a comparative study using layered silk fibroin scaffolds from mulberry and nonmulberry silkworms

Enhanced effects of slowly co-released TGF-β3 and BMP-2 from biomimetic calcium phosphate-coated silk fibroin scaffolds in the repair of osteochondral defects

Bioactive agents have demonstrated regenerative potential for cell-free bone tissue engineering. Nevertheless, certain challenges persist, including ineffective delivery methods and confined therapeutic potency. Here, we demonstrated that the biomimetic calcium phosphate coating system (BioCaP) could effectively uptake and slowly release the incorporated bioactive agents compared to the surface absorption system via osteoclast-mediated degradation of BioCaP coatings. The release kinetics were determined as a function of time. The release rate was stable without remarkable burst release during the first 1 day, followed by a sustained release from day 7 to day 19. Then, we developed the bi-functional BioCaP-coated silk fibroin scaffolds enabling the effective co-delivery of TGF-β3 and BMP-2 (SFI-T/SFI-B) and the corresponding slow release of TGF-β3 and BMP-2 exhibited superior potential in promoting chondrogenesis and osteogenesis without impairing cell vitality in vitro. The SFI-T/SFI-B scaffolds could improve cartilage and bone regeneration in 5 × 4 mm rabbit osteochondral (OC) defect. These findings indicate that the biomimetic calcium-phosphate coated silk fibroin scaffolds with slowly co-released TGF-β3 and BMP-2 effectively promote the repair of OC defects, hence facilitating the future clinical translation of controlled drug delivery in tissue engineering.

Evaluation and Application of Silk Fibroin Based Biomaterials to Promote Cartilage Regeneration in Osteoarthritis Therapy

Osteoarthritis (OA) is a common joint disease characterized by cartilage damage and degeneration. Traditional treatments such as NSAIDs and joint replacement surgery only relieve pain and do not achieve complete cartilage regeneration. Silk fibroin (SF) biomaterials are novel materials that have been widely studied and applied to cartilage regeneration. By mimicking the fibrous structure and biological activity of collagen, SF biomaterials can promote the proliferation and differentiation of chondrocytes and contribute to the formation of new cartilage tissue. In addition, SF biomaterials have good biocompatibility and biodegradability and can be gradually absorbed and metabolized by the human body. Studies in recent years have shown that SF biomaterials have great potential in treating OA and show good clinical efficacy. Therefore, SF biomaterials are expected to be an effective treatment option for promoting cartilage regeneration and repair in patients with OA. This article provides an overview of the biological characteristics of SF, its role in bone and cartilage injuries, and its prospects in clinical applications to provide new perspectives and references for the field of bone and cartilage repair.

Silk fibroin-based biomaterials for cartilage/osteochondral repair

Osteoarthritis (OA) is a common joint disease with a high disability rate. In addition, OA not only causes great physiological and psychological harm to patients, but also puts great pressure on the social healthcare system. Pathologically, the disintegration of cartilage and the lesions of subchondral bone are related to OA. Currently, tissue engineering, which is expected to overcome the defects of existing treatment methods, had a lot of research in the field of cartilage/osteochondral repair. Silk fibroin (SF), as a natural macromolecular material with good biocompatibility, unique mechanical properties, excellent processability and degradability, holds great potential in the field of tissue engineering. Nowadays, SF had been prepared into various materials to adapt to the demands of cartilage/osteochondral repair. SF-based biomaterials can also be functionally modified to enhance repair performance further. In this review, the preparation methods, types, structures, mechanical properties, and functional modifications of SF-based biomaterials used for cartilage/osteochondral repair are summarized and discussed. We hope that this review will provide a reference for the design and development of SF-based biomaterials in cartilage/osteochondral repair field.

Silk Fibroin-Based Biomaterials for Tissue Engineering Applications

Tissue engineering (TE) involves the combination of cells with scaffolding materials and appropriate growth factors in order to regenerate or replace damaged and degenerated tissues and organs. The scaffold materials serve as templates for tissue formation and play a vital role in TE. Among scaffold materials, silk fibroin (SF), a naturally occurring protein, has attracted great attention in TE applications due to its excellent mechanical properties, biodegradability, biocompatibility, and bio-absorbability. SF is usually dissolved in an aqueous solution and can be easily reconstituted into different forms, including films, mats, hydrogels, and sponges, through various fabrication techniques, including spin coating, electrospinning, freeze drying, and supercritical CO₂-assisted drying. Furthermore, to facilitate the fabrication of more complex SF-based scaffolds, high-precision techniques such as micro-patterning and bio-printing have been explored in recent years. These processes contribute to the diversity of surface area, mean pore size, porosity, and mechanical properties of different silk fibroin scaffolds and can be used in various TE applications to provide appropriate morphological and mechanical properties. This review introduces the physicochemical and mechanical properties of SF and looks into a range of SF-based scaffolds that have recently been developed. The typical applications of SF-based scaffolds for TE of bone, cartilage, teeth and mandible tissue, cartilage, skeletal muscle, and vascular tissue are highlighted and discussed followed by a discussion of issues to be addressed in future studies.

Bone tissue engineering using 3D silk scaffolds and human dental pulp stromal cells epigenetic reprogrammed with the selective histone deacetylase inhibitor MI192

Epigenetics plays a critical role in regulating mesenchymal stem cells’ (MSCs) fate for tissue repair and regeneration. There is increasing evidence that the inhibition of histone deacetylase (HDAC) isoform 3 can enhance MSC osteogenesis. This study investigated the potential of using a selective HDAC2 and 3 inhibitor, MI192, to promote human dental pulp stromal cells (hDPSCs) bone-like tissue formation in vitro and in vivo within porous Bombyx Mori silk scaffolds. Both 2 and 5 wt% silk scaffolds were fabricated and characterised. The 5 wt% scaffolds possess thicker internal lamellae, reduced scaffold swelling and degradation rates, whilst increased compressive modulus in comparison to the 2 wt% silk scaffold. MI192 pre-treatment of hDPSCs on 5 wt% silk scaffold significantly enhanced hDPSCs alkaline phosphatase activity (ALP). The expression of osteoblast-related genes (RUNX2, ALP, Col1a, OCN) was significantly upregulated in the MI192 pre-treated cells. Histological analysis confirmed that the MI192 pre-treated hDPSCs-silk scaffold constructs promoted bone extracellular matrix (ALP, Col1a, OCN) deposition and mineralisation compared to the untreated group. Following 6 weeks of subcutaneous implantation in nude mice, the MI192 pre-treated hDPSCs-silk scaffold constructs enhanced the vascularisation and extracellular matrix mineralisation compared to untreated control. In conclusion, these findings demonstrate the potential of using epigenetic reprogramming and silk scaffolds to promote hDPSCs bone formation efficacy, which provides evidence for clinical translation of this technology for bone augmentation.

3D Printing for Bone-Cartilage Interface Regeneration

Due to the vasculature defects and/or the avascular nature of cartilage, as well as the complex gradients for bone-cartilage interface regeneration and the layered zonal architecture, self-repair of cartilage and subchondral bone is challenging. Currently, the primary osteochondral defect treatment strategies, including artificial joint replacement and autologous and allogeneic bone graft, are limited by their ability to simply repair, rather than induce regeneration of tissues. Meanwhile, over the past two decades, three-dimension (3D) printing technology has achieved admirable advancements in bone and cartilage reconstruction, providing a new strategy for restoring joint function. The advantages of 3D printing hybrid materials include rapid and accurate molding, as well as personalized therapy. However, certain challenges also exist. For instance, 3D printing technology for osteochondral reconstruction must simulate the histological structure of cartilage and subchondral bone, thus, it is necessary to determine the optimal bioink concentrations to maintain mechanical strength and cell viability, while also identifying biomaterials with dual bioactivities capable of simultaneously regenerating cartilage. The study showed that the regeneration of bone-cartilage interface is crucial for the repair of osteochondral defect. In this review, we focus on the significant progress and application of 3D printing technology for bone-cartilage interface regeneration, while also expounding the potential prospects for 3D printing technology and highlighting some of the most significant challenges currently facing this field.

Nonmulberry silk proteins: multipurpose ingredient in bio-functional assembly

The emerging field of tissue engineering and regenerative medicines utilising artificial polymers is facing many problems. Despite having mechanical stability, non-toxicity and biodegradability, most of them lack cytocompatibility and biocompatibility. Natural polymers (such as collagen, hyaluronic acid, fibrin, fibroin, and others), including blends, are introduced to the field to solve some of the relevant issues. Another natural biopolymer: silkworm silk gained special attention primarily due to its specific biophysical, biochemical, and material properties, worldwide availability, and cost-effectiveness. Silk proteins, namely fibroin and sericin extracted from domesticated mulberry silkwormBombyx mori, are studied extensively in the last few decades for tissue engineering. Wild nonmulberry silkworm species, originated from India and other parts of the world, also produce silk proteins with variations in their nature and properties. Among the nonmulberry silkworm species,Antheraea mylitta(Indian Tropical Tasar),A. assamensis/A. assama(Indian Muga), andSamia ricini/Philosamia ricini(Indian Eri), along withA. pernyi(Chinese temperate Oak Tasar/Tussah) andA. yamamai(Japanese Oak Tasar) exhibit inherent tripeptide motifs of arginyl glycyl aspartic acid in their fibroin amino acid sequences, which support their candidacy as the potential biomaterials. Similarly, sericin isolated from such wild species delivers unique properties and is used as anti-apoptotic and growth-inducing factors in regenerative medicines. Other characteristics such as biodegradability, biocompatibility, and non-inflammatory nature make it suitable for tissue engineering and regenerative medicine based applications. A diverse range of matrices, including but not limited to nano-micro scale structures, nanofibres, thin films, hydrogels, and porous scaffolds, are prepared from the silk proteins (fibroins and sericins) for biomedical and tissue engineering research. This review aims to represent the progress made in medical and non-medical applications in the last couple of years and depict the present status of the investigations on Indian nonmulberry silk-based matrices as a particular reference due to its remarkable potentiality of regeneration of different types of tissues. It also discusses the future perspective in tissue engineering and regenerative medicines in the context of developing cutting-edge techniques such as 3D printing/bioprinting, microfluidics, organ-on-a-chip, and other electronics, optical and thermal property-based applications.

Electrical Stimulation and Conductive Polymers as a Powerful Toolbox for Tailoring Cell Behaviour in vitro

Electrical stimulation (ES) is a well-known method for guiding the behaviour of nerve cells in in vitro systems based on the response of these cells to an electric field. From this perspective, understanding how the electrochemical stimulus can be tuned for the design of a desired cell response is of great importance. Most biomedical studies propose the application of an electrical potential to cell culture arrays while examining the cell response regarding viability, morphology, and gene expression. Conversely, various studies failed to evaluate how the fine physicochemical properties of the materials used for cell culture influence the observed behaviours. Among the various materials used for culturing cells under ES, conductive polymers (CPs) are widely used either in pristine form or in addition to other polymers. CPs themselves do not possess the optimal surface for cell compatibility because of their hydrophobic nature, which leads to poor protein adhesion and, hence, poor bioactivity. Therefore, understanding how to tailor the chemical properties on the material surface will determine the obtention of improved ES platforms. Moreover, the structure of the material, either in a thin film or in porous electrospun scaffolds, also affects the biochemical response and needs to be considered. In this review, we examine how materials based on CPs influence cell behaviour under ES, and we compile the various ES setups and physicochemical properties that affect cell behaviour. This review concerns the culture of various cell types, such as neurons, fibroblasts, osteoblasts, and Schwann cells, and it also covers studies on stem cells prone to ES. To understand the mechanistic behaviour of these devices, we also examine studies presenting a more detailed biomolecular level of interaction. This review aims to guide the design of future ES setups regarding the influence of material properties and electrochemical conditions on the behaviour of in vitro cell studies.

Non-mulberry silk fiber-based scaffolds reinforced by PLLA porous microspheres for auricular cartilage: An in vitro study

Designing clinical applicable polymeric composite scaffolds for auricular cartilage tissue engineering requires appropriate mechanical strength and biological characteristics. In this study, silk fiber-based scaffolds co-reinforced with poly-L-lactic acid porous microspheres (PLLA PMs) combined with either Bombyx mori (Bm) or Antheraea pernyi (Ap) silk fibers were fabricated as inspired by the "steel bars reinforced concrete" structure in architecture and their chondrogenic functions were also investigated. We found that the Ap silk fiber-based scaffolds reinforced by PLLA PMs (MAF) exhibited superior physical properties (the mechanical properties in particular) as compared to the Bm silk fiber-based scaffolds reinforced by PLLA PMs (MBF). Furthermore, in vitro evaluation of chondrogenic potential showed that the MAF provided better cell adhesion, viability, proliferation and GAG secretion than the MBF. Therefore, the MAF are promising in auricular cartilage tissue engineering and relevant plastic surgery-related applications.

Nanotextured silk fibroin/hydroxyapatite biomimetic bilayer tough structure regulated osteogenic/chondrogenic differentiation of mesenchymal stem cells for osteochondral repair

OBJECTIVES

Articular cartilage plays a vital role in bearing and buffering. Injured cartilage and subchondral bone repair is a crucial challenge in cartilage tissue engineering due to the peculiar structure of osteochondral unit and the requirement of osteogenic/chondrogenic bi-directional differentiation. Based on the bionics principle, a nanotextured silk fibroin (SF)-chondroitin sulphate (CS)/hydroxyapatite (HAp) nanowire tough bilayer structure was prepared for osteochondral repair.

METHODS

The SF-CS/HAp membrane was constructed by alcohol-induced β-sheet formation serving as the physical crosslink. Its osteochondral repairing capacity was evaluated by culturing bone marrow mesenchymal stem cells (BMSCs) in vitro and constructing a rat osteochondral defect model in vivo.

RESULTS

The bilayer SF-CS/HAp membrane with satisfactory mechanical properties similar to natural cartilage imitated the natural osteochondral unit structural layers and exerted the function of bearing and buffering timely after in vivo implantation. SF-CS layer upregulated the expression of chondrogenesis-related genes of BMSCs by surface nanotopography and sustained release CS. Meanwhile, nanotextured HAp layer assembled with nanowire endowed the membrane with an osteogenic differentiation tendency for BMSCs. In vivo results proved that the biomimetic bilayer structure dramatically promoted new cartilage formation and subchondral bone remodelling for osteochondral defect model after implantation.

CONCLUSIONS

The SF-CS/HAp biomimetic bilayer membrane provides a promising strategy for precise osteochondral repair.

Comparing bone tissue engineering efficacy of HDPSCs, HBMSCs on 3D biomimetic ABM-P-15 scaffolds in vitro and in vivo

Human bone marrow mesenchymal stem cells (HBMSCs) has been the gold standard for bone regeneration. However, the low proliferation rate and long doubling time limited its clinical applications. This study aims to compare the bone tissue engineering efficacy of human dental pulp stem cells (HDPSCs) with HBMSCs in 2D, and 3D anorganic bone mineral (ABM) coated with a biomimetic collagen peptide (ABM-P-15) for improving bone-forming speed and efficacy in vitro and in vivo. The multipotential of both HDPSCs and HBMSCs have been compared in vitro. The bone formation of HDPSCs on ABM-P-15 was tested using in vivo model. The osteogenic potential of the cells was confirmed by alkaline phosphatase (ALP) and immunohistological staining for osteogenic markers. Enhanced ALP, collagen, lipid droplet, or glycosaminoglycans production were visible in HDPSCs and HBMSCs after osteogenic, adipogenic and chondrogenic induction. HDPSC showed stronger ALP staining compared to HBMSCs. Confocal images showed more viable HDPSCs on both ABM-P-15 and ABM scaffolds compared to HBMSCs on similar scaffolds. ABM-P-15 enhanced cell attachment/spreading/bridging formation on ABM-P-15 scaffolds and significantly increased quantitative ALP specific activities of the HDPSCs and HBMSCs. After 8 weeks in vivo implantation in diffusion chamber model, the HDPSCs on ABM-P-15 scaffolds showed extensive high organised collagenous matrix formation that was positive for COL-I and OCN compared to ABM alone. In conclusion, the HDPSCs have a higher proliferation rate and better osteogenic capacity, which indicated the potential of combining HDPSCs with ABM-P-15 scaffolds for improving bone regeneration speed and efficacy.

In vitro study of cartilage tissue engineering using human adipose-derived stem cells induced by platelet-rich plasma and cultured on silk fibroin scaffold

BACKGROUND

Cartilage tissue engineering is a promising technique for repairing cartilage defect. Due to the limitation of cell number and proliferation, mesenchymal stem cells (MSCs) have been developed as a substitute to chondrocytes as a cartilage cell-source. This study aimed to develop cartilage tissue from human adipose-derived stem cells (ADSCs) cultured on a Bombyx mori silk fibroin scaffold and supplemented with 10% platelet-rich plasma (PRP).

METHODS

Human ADSCs and PRP were characterized. A silk fibroin scaffold with 500 μm pore size was fabricated through salt leaching. ADSCs were then cultured on the scaffold (ADSC-SS) and supplemented with 10% PRP for 21 days to examine cell proliferation, chondrogenesis, osteogenesis, and surface marker expression. The messenger ribonucleic acid (mRNA) expression of type 2 collagen, aggrecan, and type 1 collagen was analysed. The presence of type 2 collagen confirming chondrogenesis was validated using immunocytochemistry. The negative and positive controls were ADSC-SS supplemented with 10% foetal bovine serum (FBS) and ADSC-SS supplemented with commercial chondrogenesis medium, respectively.

RESULTS

Cells isolated from adipose tissue were characterized as ADSCs. Proliferation of the ADSC-SS PRP was significantly increased (p < 0.05) compared to that of controls. Chondrogenesis was observed in ADSC-SS PRP and was confirmed through the increase in glycosaminoglycans (GAG) and transforming growth factor-β1 (TGF-β1) secretion, the absence of mineral deposition, and increased surface marker proteins on chondrogenic progenitors. The mRNA expression of type 2 collagen in ADSC-SS PRP was significantly increased (p < 0.05) compared to that in the negative control on days 7 and 21; however, aggrecan was significantly increased on day 14 compared to the controls. ADSC-SS PRP showed stable mRNA expression of type 1 collagen up to 14 days and it was significantly decreased on day 21. Confocal analysis showed the presence of type 2 collagen in the ADSC-SS PRP and positive control groups, with high distribution outside the cells forming the extracellular matrix (ECM) on day 21.

CONCLUSION

Our study showed that ADSC-SS with supplemented 10% PRP medium can effectively support chondrogenesis of ADSCs in vitro and promising for further development as an alternative for cartilage tissue engineering in vivo.

Harnessing the HDAC-histone deacetylase enzymes, inhibitors and how these can be utilised in tissue engineering

There are large knowledge gaps regarding how to control stem cells growth and differentiation. The limitations of currently available technologies, such as growth factors and/or gene therapies has led to the search of alternatives. We explore here how a cell's epigenome influences determination of cell type, and potential applications in tissue engineering. A prevalent epigenetic modification is the acetylation of DNA core histone proteins. Acetylation levels heavily influence gene transcription. Histone deacetylase (HDAC) enzymes can remove these acetyl groups, leading to the formation of a condensed and more transcriptionally silenced chromatin. Histone deacetylase inhibitors (HDACis) can inhibit these enzymes, resulting in the increased acetylation of histones, thereby affecting gene expression. There is strong evidence to suggest that HDACis can be utilised in stem cell therapies and tissue engineering, potentially providing novel tools to control stem cell fate. This review introduces the structure/function of HDAC enzymes and their links to different tissue types (specifically bone, cardiac, neural tissues), including the history, current status and future perspectives of using HDACis for stem cell research and tissue engineering, with particular attention paid to how different HDAC isoforms may be integral to this field.

Differential chondro- and osteo-stimulation in three-dimensional porous scaffolds with different topological surfaces provides a design strategy for biphasic osteochondral engineering

Bone/cartilage interfacial tissue engineering needs to satisfy the differential properties and architectures of the osteochondral region. Therefore, biphasic or multiphasic scaffolds that aim to mimic the gradient hierarchy are widely used. Here, we find that two differently structured (topographically) three-dimensional scaffolds, namely, "dense" and "nanofibrous" surfaces, show differential stimulation in osteo- and chondro-responses of cells. While the nanofibrous scaffolds accelerate the osteogenesis of mesenchymal stem cells, the dense scaffolds are better in preserving the phenotypes of chondrocytes. Two types of porous scaffolds, generated by a salt-leaching method combined with a phase-separation process using the poly(lactic acid) composition, had a similar level of porosity (~90%) and pore size (~150 μm). The major difference in the surface nanostructure led to substantial changes in the surface area and water hydrophilicity (nanofibrous ≫ dense); as a result, the nanofibrous scaffolds increased the cell-to-matrix adhesion of mesenchymal stem cells significantly while decreasing the cell-to-cell contracts. Importantly, the chondrocytes, when cultured on nanofibrous scaffolds, were prone to lose their phenotype, including reduced chondrogenic expressions (SOX-9, collagen type II, and Aggrecan) and glycosaminoglycan content, which was ascribed to the enhanced cell-matrix adhesion with reduced cell-cell contacts. On the contrary, the osteogenesis of mesenchymal stem cells was significantly accelerated by the improved cell-to-matrix adhesion, as evidenced in the enhanced osteogenic expressions (RUNX2, bone sialoprotein, and osteopontin) and cellular mineralization. Based on these findings, we consider that the dense scaffold is preferentially used for the chondral-part, whereas the nanofibrous structure is suitable for osteo-part, to provide an optimal biphasic matrix environment for osteochondral tissue engineering.

Early angiogenesis detected by PET imaging with 64Cu-NODAGA-RGD is predictive of bone critical defect repair

Therapies using stem cells may be applicable to all fields of regenerative medicine, including craniomaxillofacial surgery. Dental pulp stem cells (DPSCs) have demonstrated in vitro and in vivo osteogenic and proangiogenic properties. The aim of the study was to evaluate whether early angiogenesis investigated by nuclear imaging can predict bone formation within a mouse critical bone defect. Two symmetrical calvarial critical-sized defects were created. Defects were left empty or filled with i) DPSC-containing dense collagen scaffold, ii) 5% hypoxia-primed DPSC-containing dense collagen scaffold, iii) acellular dense collagen scaffold, or iv) left empty. Early angiogenesis assessed by PET using ⁶⁴Cu-NODAGA-RGD as a tracer was found to be correlated with bone formation determined by micro-CT within the defects from day 30, and to be correlated to the late calcium apposition observed at day 90 using ¹⁸F-Na PET. These results suggest that nuclear imaging of angiogenesis, a technique applicable in clinical practice, is a promising approach for early prediction of bone grafting outcome, thus potentially allowing to anticipate alternative regenerative strategies. STATEMENT OF SIGNIFICANCE: Bone defects are a major concern in medicine. As life expectancy increases, the number of bone lesions grows, and occurring complications lead to a delay or even lack of consolidation. Therefore, to be able to predict healing or the absence of scarring at early times would be very interesting. This would not "waste time" for the patient. We report here that early nuclear imaging of angiogenesis, using ⁶⁴Cu-NODAGA-RGD as a tracer, associated with nuclear imaging of mineralization, using ¹⁸F-Na as a tracer, is correlated to late bone healing objectivized by classical histology and microtomography. This nuclear imaging represents a promising approach for early prediction of bone grafting outcome in clinical practice, thus potentially allowing to anticipate alternative regenerative strategies.

Fabrication and evaluation of non-mulberry silk fibroin fiber reinforced chitosan based porous composite scaffold for cartilage tissue engineering

Lack of potential regenerative medicine to reconstruct damaged cartilage tissue has accelerated investigation and development of potential biomaterial for cartilage tissue engineering. In this study, we fabricated micron-sized non-mulberry silk fibroin fiber (SFF) using N,N-Dimethylacetamide (DMA_C)/10% LiBr solution and further used to develop SFF reinforced chitosan(CH) based porous scaffold with desired pore size, porosity, swelling and structural stability. The developed scaffold was characterized for its various physico-chemical, mechanical and biological properties. The developed CH/SFF composite scaffold facilitates human mesenchymal stem cell (hMSCs) attachment, colonization and extracellular matrix deposition. Furthermore, hMSCs shows significantly higher sulfated glycosaminoglycan deposition over CH/SFF in comparison to pure chitosan scaffold (control). Immunocytochemistry studies have shown enhanced expression of collagen type II and aggrecan by hMSCs over composite scaffold than chitosan scaffold. Thus, non-mulberry silk fibroin fiber reinforced chitosan based scaffold might be suitable scaffold that can act as a potential artificial matrix for cartilage tissue engineering.

Injectable hydrogels: a new paradigm for osteochondral tissue engineering

Osteochondral tissue engineering has become a promising strategy for repairing focal chondral lesions and early osteoarthritis (OA), which account for progressive joint pain and disability in millions of people worldwide. Towards improving osteochondral tissue repair, injectable hydrogels have emerged as promising matrices due to their wider range of properties such as their high water content and porous framework, similarity to the natural extracellular matrix (ECM), ability to encapsulate cells within the matrix and ability to provide biological cues for cellular differentiation. Further, their properties such as those that facilitate minimally invasive deployment or delivery, and their ability to repair geometrically complex irregular defects have been critical for their success. In this review, we provide an overview of innovative approaches to engineer injectable hydrogels towards improved osteochondral tissue repair. Herein, we focus on understanding the biology of osteochondral tissue and osteoarthritis along with the need for injectable hydrogels in osteochondral tissue engineering. Furthermore, we discuss in detail different biomaterials (natural and synthetic) and various advanced fabrication methods being employed for the development of injectable hydrogels in osteochondral repair. In addition, in vitro and in vivo applications of developed injectable hydrogels for osteochondral tissue engineering are also reviewed. Finally, conclusions and future perspectives of using injectable hydrogels in osteochondral tissue engineering are provided.

Hierarchically structured seamless silk scaffolds for osteochondral interface tissue engineering

The osteochondral healthcare market is driven by the increasing demand for affordable and biomimetic scaffolds. To meet this demand, silk fibroin (SF) from Bombyx mori and Antheraea assamensis is used to fabricate a biphasic scaffold, with fiber-free and fiber-reinforced phases, stimulating cartilage and bone revival. The fabrication is a facile reproducible process using single polymer (SF), for both phases, designed in a continuous and integrated manner. Physicochemical and mechanical scaffold characterization, display interconnected pores with differential swelling and tunable degradation. The compressive modulus values, extend to 40 kPa and 25%, for tensile strain, at elongation. The scaffold support, for growth and proliferation of chondrocytes and osteoblasts, for respective cartilage and bone regeneration, is verified from in vitro assessment. Up-regulation of alkaline phosphatase (ALP) activity, extracellular matrix secretion and gene expression are significant; with acceptable in vitro immune response. Upon implantation in rabbit osteochondral defects for 8 weeks, the histological and micro-CT examinations show biphasic scaffolds significantly enhance regeneration of cartilage and subchondral bone tissues, as compared to monophasic scaffolds. The regenerated bone mineral density (BMD) ranges from 600-700 mg hydroxyapatite (HA) per cm³. The results, therefore, showcase the critically positive characteristics of in vitro ECM deposition, and in vivo regeneration of osteochondral tissue by this hierarchically structured biphasic scaffold.

Promising Biomolecules

The osteochondral defect (OD) comprises the articular cartilage and its subchondral bone. The treatment of these lesions remains as one of the most problematic clinical issues, since these defects include different tissues, requiring distinct healing approaches. Among the growing applications of regenerative medicine, clinical articular cartilage repair has been used for two decades, and it is an effective example of translational medicine; one of the most used cell-based repair strategies includes implantation of autologous cells in degradable scaffolds such as alginate, agarose, collagen, chitosan, chondroitin sulfate, cellulose, silk fibroin, hyaluronic acid, and gelatin, among others. Concerning the repair of osteochondral defects, tissue engineering and regenerative medicine started to design single- or bi-phased scaffold constructs, often containing hydroxyapatite-collagen composites, usually used as a bone substitute. Biomolecules such as natural and synthetic have been explored to recreate the cartilage-bone interface through multilayered biomimetic scaffolds. In this chapter, a succinct description about the most relevant natural and synthetic biomolecules used on cartilage and bone repair, describing the procedures to obtain these biomolecules, their chemical structure, common modifications to improve its characteristics, and also their application in the biomedical fields, is given.

In vitro and in vivo studies of a novel bacterial cellulose-based acellular bilayer nanocomposite scaffold for the repair of osteochondral defects

Bacterial cellulose (BC) is a naturally occurring nanofibrous biomaterial which exhibits unique physical properties and is amenable to chemical modifications. To explore whether this versatile material can be used in the treatment of osteochondral defects (OCD), we developed and characterized novel BC-based nanocomposite scaffolds, for example, BC-hydroxyapatite (BC-HA) and BC-glycosaminoglycans (BC-GAG) that mimic bone and cartilage, respectively. In vitro biocompatibility of BC-HA and BC-GAG scaffolds was established using osteosarcoma cells, human articular chondrocytes, and human adipose-derived mesenchymal stem cells. On subcutaneous implantation, the scaffolds allowed tissue ingrowth and induced no adverse immunological reactions suggesting excellent in vivo biocompatibility. Implantation of acellular bilayered scaffolds in OCD created in rat knees induced progressive regeneration of cartilage tissue, deposition of extracellular matrix, and regeneration of subchondral bone by the host cells. The results of micro-CT revealed that bone mineral density and ratio of bone volume to tissue volume were significantly higher in animals receiving bilayered scaffold as compared to the control animals. To the best of our knowledge, this study proves for the first time, the functional performance of acellular BC-based bilayered scaffolds. Thus, this strategy has great potential for clinical translation and can be used in repair of OCD.

Naturally derived proteins and glycosaminoglycan scaffolds for tissue engineering applications

Tissue engineering (TE) aims to mimic the complex environment where organogenesis takes place using advanced materials to recapitulate the tissue niche. Cells, three-dimensional scaffolds and signaling factors are the three main and essential components of TE. Over the years, materials and processes have become more and more sophisticated, allowing researchers to precisely tailor the final chemical, mechanical, structural and biological features of the designed scaffolds. In this review, we will pose the attention on two specific classes of naturally derived polymers: fibrous proteins and glycosaminoglycans (GAGs). These materials hold great promise for advances in the field of regenerative medicine as i) they generally undergo a fast remodeling in vivo favoring neovascularization and functional cells organization and ii) they elicit a negligible immune reaction preventing severe inflammatory response, both representing critical requirements for a successful integration of engineered scaffolds with the host tissue. We will discuss the recent achievements attained in the field of regenerative medicine by using proteins and GAGs, their merits and disadvantages and the ongoing challenges to move the current concepts to practical clinical application.

Injectable and 3D Bioprinted Polysaccharide Hydrogels: From Cartilage to Osteochondral Tissue Engineering

Biomechanical performance of functional cartilage is executed by the exclusive anisotropic composition and spatially varying intricate architecture in articulating ends of diarthrodial joint. Osteochondral tissue constituting the articulating ends comprise superfical soft cartilage over hard subchondral bone sandwiching interfacial soft-hard tissue. The shock-absorbent, lubricating property of cartilage and mechanical stability of subchondral bone regions are rendered by extended chemical structure of glycosaminoglycans and mineral deposition, respectively. Extracellular matrix glycosaminoglycans analogous polysaccharides are major class of hydrogels investigated for restoration of functional cartilage. Recently, injectable hydrogels have gained momentum as it offers patient compliance, tunable mechanical properties, cell deliverability, and facile administration at physiological condition with long-term functionality and hyaline cartilage construction. Interestingly, facile modifiable functional groups in carbohydrate polymers impart tailorability of desired physicochemical properties and versatile injectable chemistry for the development of highly potent biomimetic in situ forming scaffold. The scaffold design strategies have also evolved from single component to bi- or multilayered and graded constructs with osteogenic properties for deep subchondral regeneration. This review highlights the significance of polysaccharide structure-based functions in engineering cartilage tissue, injectable chemistries, strategies for combining analogous matrices with cells/stem cells and biomolecules and multicomponent approaches for osteochondral mimetic constructs. Further, the rheology and precise spatiotemporal positioning of cells in hydrogel bioink for rapid prototyping of complex three-dimensional anisotropic cartilage have also been discussed.

Accelerated craniofacial bone regeneration through dense collagen gel scaffolds seeded with dental pulp stem cells

Therapies using mesenchymal stem cell (MSC) seeded scaffolds may be applicable to various fields of regenerative medicine, including craniomaxillofacial surgery. Plastic compression of collagen scaffolds seeded with MSC has been shown to enhance the osteogenic differentiation of MSC as it increases the collagen fibrillary density. The aim of the present study was to evaluate the osteogenic effects of dense collagen gel scaffolds seeded with mesenchymal dental pulp stem cells (DPSC) on bone regeneration in a rat critical-size calvarial defect model. Two symmetrical full-thickness defects were created (5 mm diameter) and filled with either a rat DPSC-containing dense collagen gel scaffold (n = 15), or an acellular scaffold (n = 15). Animals were imaged in vivo by microcomputer tomography (Micro-CT) once a week during 5 weeks, whereas some animals were sacrificed each week for histology and histomorphometry analysis. Bone mineral density and bone micro-architectural parameters were significantly increased when DPSC-seeded scaffolds were used. Histological and histomorphometrical data also revealed significant increases in fibrous connective and mineralized tissue volume when DPSC-seeded scaffolds were used, associated with expression of type I collagen, osteoblast-associated alkaline phosphatase and osteoclastic-related tartrate-resistant acid phosphatase. Results demonstrate the potential of DPSC-loaded-dense collagen gel scaffolds to benefit of bone healing process.

Effect of the surface morphology of silk fibroin scaffolds for bone regeneration

Existing scaffolds cannot adequately satisfy the simultaneous requirements for the regeneration of bone. The challenge remains of how to improve the integration of newly formed bone with the surrounding tissues. The purpose of this study was to investigate the effects of two silk fibroin scaffolds, a hexafluoro isopropanol-based silk fibroin (HFIP-F) and an aqueous-based silk fibroin (A-F), for their osteoinductive potentials in large critical size bone defects in vivo. β-tricalcium phosphate (β-TCP) was used as a positive control. After implantation into defects created in the knee joints of rabbits for 1 and 2 weeks, hematoxylin and eosin (H-E) and Azan staining revealed that the A-F scaffold as well as β-TCP had stronger osteoinductive ability than the HFIP-F scaffold. The A-F scaffold exhibited prominent areas of neo-tissue containing bone-like nodules. Furthermore, induced osteointegration was observed between native and neo-tissue within the osteo defects in the knee joints of rabbits. Immunohistochemical staining showed the highest expression of Runx2, BMP-2, BMP-7, Smad1/5/9 and Phospho-Smad in the A-F scaffold implants. Osteoinduction of the porous A-F scaffold might be influenced by the amount of BMP signaling present in the local microenvironment in the implants. This study opens a new avenue to use A-F silk fibroin scaffolds for the regeneration of bone defects.

Potential of Agarose/Silk Fibroin Blended Hydrogel for in Vitro Cartilage Tissue Engineering

An osteoarthritis pandemic has accelerated exploration of various biomaterials for cartilage reconstruction with a special emphasis on silk fibroin from mulberry (Bombyx mori) and non-mulberry (Antheraea assamensis) silk worms. Retention of positive attributes of the agarose standard and nullification of its negatives are central to the current agarose/silk fibroin hydrogel design. In this study, hydrogels of mulberry and non-mulberry silk fibroin blended with agarose were fabricated and evaluated in vitro for two weeks for cartilaginous tissue formation. The fabricated hydrogels were physicochemically characterized and analyzed for cell viability, proliferation, and extra cellular matrix deposition. The amalgamation of silk fibroin with agarose impacted the pore size, as illustrated by field emission scanning electron microscopy studies, swelling behavior, and in vitro degradation of the hydrogels. Fourier transform infrared spectroscopy results indicated the blend formation and confirmed the presence of both components in the fabricated hydrogels. Rheological studies demonstrated enhanced elasticity of blended hydrogels with G' > G″. Biochemical analysis revealed significantly higher levels of sulfated glycosaminoglycans (sGAGs) and collagen (p ≤ 0.01) in blended hydrogels. More specifically, the non-mulberry silk fibroin blend showed sGAG and collagen content (∼1.5-fold) higher than that of the mulberry blend (p ≤ 0.05). Histological and immunohistochemical analyses further validated the enhanced deposition of sGAG and collagen, indicating maintenance of chondrogenic phenotype within constructs after two weeks of culture. Real-time PCR analysis further confirmed up-regulation of cartilage-specific aggrecan, sox-9 (∼1.5-fold) and collagen type II (∼2-fold) marker genes (p ≤ 0.01) in blended hydrogels. The hydrogels demonstrated immunocompatibility, which was evidenced by minimal in vitro secretion of tumor necrosis factor-α (TNF-α) by murine macrophages. Taken together, the results suggest promising attributes of blended hydrogels and particularly the non-mulberry silk fibroin/agarose blends as alternative biomaterial for cartilage tissue engineering.

Potential of silk fibroin/chondrocyte constructs of muga silkworm Antheraea assamensis for cartilage tissue engineering

Articular cartilage damage represents one of the most perplexing clinical problems of musculoskeletal therapeutics due to its limited self-repair and regenerative capabilities. In this study, 3D porous silk fibroin scaffolds derived from non-mulberry muga silkworm Antheraea assamensis were fabricated and examined for their ability to support cartilage tissue engineering. Additionally, Bombyx mori and Philosamia ricini silk fibroin scaffolds were utilized for comparative studies. Herein, the fabricated scaffolds were thoroughly characterized and compared for cartilaginous tissue formation within the silk fibroin scaffolds seeded with primary porcine chondrocytes and cultured in vitro for 2 weeks. Surface morphology and structural conformation studies revealed the highly interconnected porous structure (pore size 80-150 μm) with enhanced stability within their structure. The fabricated scaffolds demonstrated improved mechanical properties and were followed-up with sequential experiments to reveal improved thermal and degradation properties. Silk fibroin scaffolds of A. assamensis and P. ricini supported better chondrocyte attachment and proliferation as indicated by metabolic activities and fluorescence microscopic studies. Biochemical analysis demonstrated significantly higher production of sulphated glycosaminoglycans (sGAGs) and type II collagen in A. assamensis silk fibroin scaffolds followed by P. ricini and B. mori scaffolds (p < 0.001). Furthermore, histochemistry and immunohistochemical studies indicated enhanced accumulation of sGAGs and expression of collagen II. Moreover, the scaffolds in a subcutaneous model of rat demonstrated in vivo biocompatibility after 8 weeks of implantation. Taken together, these results demonstrate the positive attributes from the non-mulberry silk fibroin scaffold of A. assamensis and suggest its suitability as a promising scaffold for chondrocyte based cartilage repair.

Potential of non-mulberry silk protein fibroin blended and grafted poly(Є-caprolactone) nanofibrous matrices for in vivo bone regeneration

An in vivo investigation is conducted to evaluate effectiveness of poly(Є-caprolactone) (PCL) nanofibrous matrices, with non-mulberry silk fibroin (NSF) (from Antheraea mylitta) inclusion, for bone tissue engineering. Inclusion is achieved by either blending NSF with PCL prior to electrospinning substrates or by grafting NSF onto electrospun PCL substrates. Proceeding from our previous in vitro results, showing that NSF grafted matrices have an edge when it comes to aiding cellular adhesion and proliferation, animal trials using rabbits are planned. As this is first in vivo trial of nanofibrous scaffolds with silk fibroin from A. mylitta, aim is to both evaluate the grafted and blended scaffolds independently and compare the method of silk fibroin introduction into the nanofibrous structures. The scaffolds are implanted at bone defect site in distal metaphysis region of the rabbits' femur. Host tissue immuno-compatibility of implants is assessed from measurements of IL-2, IL-6 and TNF-α level through 4 weeks after implantation. Barring an initial inflammatory response, IL-2, IL-6 and TNF-α levels fall back at baseline values in 2 or 4 weeks, thus confirming long term compatibility. Substantial interfacial bonding strength between grafts and host bone is evidenced from mechanical push-out test. Formation of bone tissue for both implant varieties is confirmed using histological and radiological examinations along with fluorochrome labelling and scanning electron microscopy. Significantly better bone formation is observed for NSF grafted matrices. The cumulative results from in vivo tests indicate suitability of NSF grafted PCL nanofibrous matrix as an ECM for bone repair and regrowth.

Fabrication and characterization of Eri silk fibers-based sponges for biomedical application

Cocoon-derived semi-domesticated Eri silk fibers still lack exploitation for tissue engineering applications due to their poor solubility using conventional methods. The present work explores the ability to process cocoon fibers of non-mulberry Eri silk (Samia/Philosamia ricini) into sponges through a green approach using ionic liquid (IL)--1-buthyl-imidazolium acetate as a solvent. The formation of β-sheet structures during Eri silk/IL gelation was acquired by exposing the Eri silk/IL gels to a saturated atmosphere composed of two different solvents: (i) isopropanol/ethanol (physical stabilization) and (ii) genipin, a natural crosslinker, dissolved in ethanol (chemical crosslinking). The sponges were then obtained by freeze-drying. This approach promotes the formation of both stable and ordered non-crosslinked Eri silk fibroin matrices. Moreover, genipin-crosslinked silk fibroin sponges presenting high height recovery capacity after compression, high swelling degree and suitable mechanical properties for tissue engineering applications were produced. The incorporation of a model drug--ibuprofen--and the corresponding release study from the loaded sponges demonstrated the potential of using these matrices as effective drug delivery systems. The assessment of the biological performance of ATDC5 chondrocyte-like cells in contact with the developed sponges showed the promotion of cell adhesion and proliferation, as well as extracellular matrix production within 2 weeks of culture. Sponges' intrinsic properties and biological findings open up their potential use for biomedical applications.

STATEMENT OF SIGNIFICANCE

This work addresses the preparation and characterization of non-mulberry cocoon-derived Eri silk sponges. The insolubility of cocoons-derived non-mulberry silkworms impairs their processability and applications in the healthcare field. We used a green approach with ionic liquids to overcome the lack solubility of such silk fibers. The formation of beta-sheet structures into Eri-based sponges was physically and chemically induced. The sponges were obtained by freeze-drying. The developed structures exhibited flexibility to adapt and recover their shapes upon application and subsequent removal of load, high swelling degree, ability to load an anti-inflammatory drug and to promote its sustained release. They promoted in vitro cellular adhesion, proliferation and extracellular matrix production of a chondrocyte-like cell line, opening up their potential application for biomedical applications.

Articular cartilage: from formation to tissue engineering

Hyaline cartilage is the nonlinear, inhomogeneous, anisotropic, poro-viscoelastic connective tissue that serves as friction-reducing and load-bearing cushion in synovial joints and is vital for mammalian skeletal movements. Due to its avascular nature, low cell density, low proliferative activity and the tendency of chondrocytes to de-differentiate, cartilage cannot regenerate after injury, wear and tear, or degeneration through common diseases such as osteoarthritis. Therefore severe damage usually requires surgical intervention. Current clinical strategies to generate new tissue include debridement, microfracture, autologous chondrocyte transplantation, and mosaicplasty. While articular cartilage was predicted to be one of the first tissues to be successfully engineered, it proved to be challenging to reproduce the complex architecture and biomechanical properties of the native tissue. Despite significant research efforts, only a limited number of studies have evolved up to the clinical trial stage. This review article summarizes the current state of cartilage tissue engineering in the context of relevant biological aspects, such as the formation and growth of hyaline cartilage, its composition, structure and biomechanical properties. Special attention is given to materials development, scaffold designs, fabrication methods, and template-cell interactions, which are of great importance to the structure and functionality of the engineered tissue.

Instructive Conductive 3D Silk Foam-Based Bone Tissue Scaffolds Enable Electrical Stimulation of Stem Cells for Enhanced Osteogenic Differentiation

Stimuli-responsive materials enabling the behavior of the cells that reside within them to be controlled are vital for the development of instructive tissue scaffolds for tissue engineering. Herein, we describe the preparation of conductive silk foam-based bone tissue scaffolds that enable the electrical stimulation of human mesenchymal stem cells (HMSCs) to enhance their differentiation toward osteogenic outcomes.

Current strategies in multiphasic scaffold design for osteochondral tissue engineering: A review

The repair of osteochondral defects requires a tissue engineering approach that aims at mimicking the physiological properties and structure of two different tissues (cartilage and bone) using specifically designed scaffold-cell constructs. Biphasic and triphasic approaches utilize two or three different architectures, materials, or composites to produce a multilayered construct. This article gives an overview of some of the current strategies in multiphasic/gradient-based scaffold architectures and compositions for tissue engineering of osteochondral defects. In addition, the application of finite element analysis (FEA) in scaffold design and simulation of in vitro and in vivo cell growth outcomes has been briefly covered. FEA-based approaches can potentially be coupled with computer-assisted fabrication systems for controlled deposition and additive manufacturing of the simulated patterns. Finally, a summary of the existing challenges associated with the repair of osteochondral defects as well as some recommendations for future directions have been brought up in the concluding section of this article.

Integrated trilayered silk fibroin scaffold for osteochondral differentiation of adipose-derived stem cells

Repairing osteochondral defects (OCD) remains a formidable challenge due to the high complexity of native osteochondral tissue and the limited self-repair capability of cartilage. Osteochondral tissue engineering is a promising strategy for the treatment of OCD. In this study, we fabricated a novel integrated trilayered scaffold using silk fibroin and hydroxyapatite by combining paraffin-sphere leaching with a modified temperature gradient-guided thermal-induced phase separation (TIPS) technique. This biomimetic scaffold is characterized by three layers: a chondral layer with a longitudinally oriented microtubular structure, a bony layer with a 3D porous structure and an intermediate layer with a dense structure. Live/dead and CCK-8 tests indicated that this scaffold possesses good biocompatibility for supporting the growth, proliferation, and infiltration of adipose-derived stem cells (ADSCs). Histological and immunohistochemical stainings and real-time polymerase chain reaction (RT-PCR) confirmed that the ADSCs could be induced to differentiate toward chondrocytes or osteoblasts in vitro at chondral and bony layers in the presence of chondrogenic- or osteogenic-induced culture medium, respectively. Moreover, the intermediate layer could play an isolating role for preventing the cells within the chondral and bony layers from mixing with each other. In conclusion, the trilayered and integrated osteochondral scaffolds can effectively support cartilage and bone tissue generation in vitro and are potentially applicable for OC tissue engineering in vivo.

Scaffold-based regeneration of skeletal tissues to meet clinical challenges

The management and reconstruction of damaged or diseased skeletal tissues have remained a significant global healthcare challenge. The limited efficacy of conventional treatment strategies for large bone, cartilage and osteochondral defects has inspired the development of scaffold-based tissue engineering solutions, with the aim of achieving complete biological and functional restoration of the affected tissue in the presence of a supporting matrix. Nevertheless, significant regulatory hurdles have rendered the clinical translation of novel scaffold designs to be an inefficient process, mainly due to the difficulties of arriving at a simple, reproducible and effective solution that does not rely on the incorporation of cells and/or bioactive molecules. In the context of the current clinical situation and recent research advances, this review will discuss scaffold-based strategies for the regeneration of skeletal tissues, with focus on the contribution of bioactive ceramic scaffolds and silk fibroin, and combinations thereof, towards the development of clinically viable solutions.

Protein-based materials in load-bearing tissue-engineering applications

Proteins such as collagen and elastin are robust molecules that constitute nanocomponents in the hierarchically organized ultrastructures of bone and tendon as well as in some of the soft tissues that have load-bearing functions. In the present paper, the macromolecular structure and function of the proteins are reviewed and the potential of mammalian and non-mammalian proteins in the engineering of load-bearing tissue substitutes are discussed. Chimeric proteins have become an important structural biomaterial source and their potential in tissue engineering is highlighted. Processing of proteins challenge investigators and in this review rapid prototyping and microfabrication are proposed as methods for obtaining precisely defined custom-built tissue engineered structures with intrinsic microarchitecture.

Stem cell-based microphysiological osteochondral system to model tissue response to interleukin-1β

Osteoarthritis (OA) is a chronic degenerative disease of the articular joint that involves both bone and cartilage degenerative changes. An engineered osteochondral tissue within physiological conditions will be of significant utility in understanding the pathogenesis of OA and testing the efficacy of potential disease-modifying OA drugs (DMOADs). In this study, a multichamber bioreactor was fabricated and fitted into a microfluidic base. When the osteochondral construct is inserted, two chambers are formed on either side of the construct (top, chondral; bottom, osseous) that is supplied by different medium streams. These medium conduits are critical to create tissue-specific microenvironments in which chondral and osseous tissues will develop and mature. Human bone marrow stem cell (hBMSCs)-derived constructs were fabricated in situ and cultured within the bioreactor and induced to undergo spatially defined chondrogenic and osteogenic differentiation for 4 weeks in tissue-specific media. We observed tissue specific gene expression and matrix production as well as a basophilic interface suggesting a developing tidemark. Introduction of interleukin-1β (IL-1β) to either the chondral or osseous medium stream induced stronger degradative responses locally as well as in the opposing tissue type. For example, IL-1β treatment of the osseous compartment resulted in a strong catabolic response in the chondral layer as indicated by increased matrix metalloproteinase (MMP) expression and activity, and tissue-specific gene expression. This induction was greater than that seen with IL-1β application to the chondral component directly, indicative of active biochemical communication between the two tissue layers and supporting the osteochondral nature of OA. The microtissue culture system developed here offers novel capabilities for investigating the physiology of osteochondral tissue and pathogenic mechanisms of OA and serving as a high-throughput platform to test potential DMOADS.