The Application of Beta-Tricalcium Phosphate in Implant Dentistry: A Systematic Evaluation of Clinical Studies

A preliminary study of cell-based bone tissue engineering into 3D-printed β-tricalcium phosphate scaffolds and polydioxanone membranes

Treatment of complex craniofacial deformities is still a challenge for medicine and dentistry because few approach therapies are available on the market that allow rehabilitation using 3D-printed medical devices. Thus, this study aims to create a scaffold with a morphology that simulates bone tissue, able to create a favorable environment for the development and differentiation of osteogenic cells. Moreover, its association with Plenum Guide, through cell-based tissue engineering (ASCs) for guided bone regeneration in critical rat calvarial defects. The manufacturing and characterization of 3D-printed β-TCP scaffolds for experimental surgery was performed. Nine male rats were divided into three groups: β-TCP + PDO membrane (TCP/PG), β-TCP/ASCs + PDO membrane (TCPasc/PG), and β-TCP/ASCs + PDO membrane/ASCs (TCPasc/PGasc). A surgical defect with a 5-mm diameter was performed in the right parietal bone, and the defect was filled with the 3D-printed β-TCP scaffold and PDO membrane with or without ASCs. The animals were euthanized 7, 14, and 30 days after the surgical procedure for histomorphometric and immunolabeling analyses. 3D-printed β-TCP scaffolds were created with a 404 ± 0.0238 μm gyroid macro-pore and, the association to cell-based therapy promotes, especially in the TCPasc/PGasc group, a bone area formation at the defect border region and the center of the defect. The use of 3D-printed β-TCP scaffolds and PDO membranes associated with cell-based therapy could improve and accelerate guided bone regeneration, promoting an increase in osteogenic capacity and reducing the time involved in the bone formation process. Moreover, using ASCs optimized the bioceramics by increasing its osteoinductive and osteoprogenitor capacity and, even with the resorption of the printed scaffold, aided as a scaffold for mesenchymal cell differentiation, as well as in bone tissue formation.

Determining Hydroxyapatite Filling Volume for the Treatment of Post-Extraction Alveoli Based on Measurements of Alveolar Volume in Relation to the Body Weight of Dogs

Filling post-extraction alveoli with hydroxyapatite-based materials is becoming an increasingly common procedure in veterinary dentistry. In dogs, tooth roots vary in structure depending on the weight of the dog, but data on tooth length and volume have not yet been described. This study aimed to establish reference data on tooth root length and post-extraction alveolar volume for mature maxillary and mandibular incisors and canines in dogs. We determined the mean length and volume of these teeth in dogs in the weight ranges of 1-5 kg, 5-10 kg, 10-20 kg, and over 20 kg. The obtained values given showed a correlation between tooth length and alveolar volume in a specific weight range. A review of the commercially available hydroxyapatite-based bone substitute materials was then conducted. A table is presented which shows how to calculate the volume of bone substitute material required to fill a post-extraction alveolus with a given material. Statistics were used to assess significant differences between the mass of the bone substitute product used (μL) for specific weight ranges and to demonstrate the correlation between tooth length and alveolar volume for a specific weight range. The data obtained in this study can serve as reference values for tooth crown length and alveolar volume, allowing operators to plan a specific volume of bone substitute material for filling post-extraction alveoli. This research is interesting because it shows that the weight of an animal is an important aspect in planning the amount of bone substitute material for tooth extraction. In clinical work, it is much easier to weigh an animal than it is to make calculations based on the length of the tooth root.

Advances in Bioceramics for Bone Regeneration: A Narrative Review

Large osseous defects resulting from trauma, tumor resection, or fracture render the inherent ability of the body to repair inadequate and necessitate the use of bone grafts to facilitate the recovery of both form and function of the bony defect sites. In the United States alone, a large number of bone graft procedures are performed yearly, making it an essential area of investigation and research. Synthetic grafts represent a potential alterative to autografts due to their patient-specific customizability, but currently lack widespread acceptance in the clinical space. Early in their development, non-autologous bone grafts composed of metals such as stainless steel and titanium alloys were favorable due to their biocompatibility, resistance to corrosion, mechanical strength, and durability. However, since their inception, bioceramics have also evolved as viable alternatives. This review aims to present an overview of the fundamental prerequisites for tissue engineering devices using bioceramics as well as to provide a comprehensive account of their historical usage and significant advancements over time. This review includes a summary of commonly used manufacturing techniques and an evaluation of their use as drug carriers and bioactive coatings-for therapeutic ion/drug release, and potential avenues to further enhance hard tissue regeneration.

Pre-vascularized porous gelatin-coated β-tricalcium phosphate scaffolds for bone regeneration: an in vivo and in vitro investigation

Vascularization is vital in bone tissue engineering, supporting development, remodeling, and regeneration. Lack of vascularity leads to cell death, necessitating vascularization strategies. Angiogenesis, forming new blood vessels, provides crucial nutrients and oxygen. Pre-vascularized gelatin-coated β-tricalcium phosphate (G/β-TCP) scaffolds show promise in bone regeneration and vascularization. Our study evaluates G/β-TCP scaffolds' osteogenic and angiogenic potential in vitro and a canine model with vascular anastomosis. Channel-shaped G/β-TCP scaffolds were fabricated using foam casting and sintering of a calcium phosphate/silica slurry-coated polyurethane foam, then coated with cross-linked gelatin. Buccal fat pad-derived stem cells (BFPdSCs) were seeded onto scaffolds and assessed over time for adhesion, proliferation, and osteogenic capacity using scanning electron microscopy (SEM), 4,6-diamidino-2-phenylindole (DAPI) staining, Alamar blue, and alkaline phosphatase (ALP) assays. Scaffolds were implanted in a canine model to evaluate osteogenesis and angiogenesis by histology and CT scans at 12 wk. Our studies showed preliminary results for G/β-TCP scaffolds supporting angiogenesis and bone regeneration. In vitro analyses demonstrated excellent proliferation/viability, with BFPdSCs adhering and increasing on the scaffolds. ALP activity and protein levels increased, indicating osteogenic differentiation. Examination of tissue samples revealed granulation tissue with a well-developed vascular network, indicating successful angiogenesis and osteogenesis was further confirmed by a CT scan. In vivo, histology revealed scaffold resorption. However, scaffold placement beneath muscle tissue-restricted bone regeneration. Further optimization is needed for bone regeneration applications.

Radiographic Study of Transcrestal Sinus Floor Elevation Using Osseodensification Technique with Graft Material: A Pilot Study

This pilot study aimed to evaluate the level of implant success after transcrestal sinus floor elevation (tSFE) using the osseodensification technique (OD) combined with beta-tricalcium phosphate (β-TCP) by analyzing clinical and radiographic results. Moreover, the increase in bone height was analyzed immediately after surgery, 3 months after, and before loading by taking standardized radiographic measurements. Thirteen patients, four males and nine females, with a mean age of 54.69 ± 5.86 years, requiring the placement of one implant in the upper posterior maxilla, with a residual bone height of <8 mm and a minimum bone width of 5 mm, participated in the study. The bone gain data was obtained using cone-beam computed tomography (CBCT) immediately after surgery and twelve months after the placement. The correlation between initial and final bone height with implant stability was also assessed. The results were analyzed using SPSS 23 software (p < 0.05). The results of the study indicated a 100% implant success rate after a follow-up period of twelve months. Preoperative main bone height was 5.70 ± 0.95 mm. The osseodensification technique allowed a significant increase of 6.65 ± 1.06 mm immediately after surgery. After a twelve-month follow-up, a graft material contraction of 0.90 ± 0.49 mm was observed. No correlation was observed between the bone height at the different times of the study and the primary stability of the implant. Considering the limitations of the size sample of this study, the osseodensification technique used for transcrestal sinus lift with the additional bone graft material (β-TCP) may provide a predictable elevation of the maxillary sinus floor, allowing simultaneous implant insertion with adequate stability irrespective of bone height limitations.

Citric Acid Cross-Linked Gelatin-Based Composites with Improved Microhardness

The aim of this study is to investigate the influence of cross-linking and reinforcements in gelatin on the physico-mechanical properties of obtained composites. The gelatin-based composites cross-linked with citric acid (CA) were prepared: gelatin type B (GB) and β-tricalcium phosphate (β-TCP) and novel hybrid composite GB with β-TCP and hydroxyapatite (HAp) particles, and their structure, thermal, and mechanical properties were compared with pure gelatin B samples. FTIR analysis revealed that no chemical interaction between the reinforcements and gelatin matrix was established during the processing of hybrid composites by the solution casting method, proving the particles had no influence on GB cross-linking. The morphological investigation of hybrid composites revealed that cross-linking with CA improved the dispersion of particles, which further led to an increase in mechanical performance. The microindentation test showed that the hardness value was increased by up to 449%, which shows the high potential of β-TCP and HAp particle reinforcement combined with CA as a cross-linking agent. Furthermore, the reduced modulus of elasticity was increased by up to 288%. Results of the MTT assay on L929 cells have revealed that the hybrid composite GB-TCP-HA-CA was not cytotoxic. These results showed that GB cross-linked with CA and reinforced with different calcium phosphates presents a valuable novel material with potential applications in dentistry.

Bisphosphonates do not affect healing of a critical-size defect in estrogen-deficient mice

Bisphosphonates (BP) are anti-resorptive drugs that are widely used to prevent bone loss in osteoporosis. Since inhibition of bone resorption will cause a decrease in bone formation through a process called coupling, it is hypothesized that extended treatment protocols may impair bone healing. In this study, β-tri‑calcium-phosphate (βTCP) ceramics were inserted into critical-size long bone defects in estrogen-deficient mice under BP therapy. The study assessed the benefits of coating the ceramics with Bone Morphogenetic Protein-2 (BMP2) and an engineered BMP2 analogue (L51P) that inactivates BMP antagonists on the healing process, implant resorption, and bone formation. Female NMRI mice (11-12 weeks of age) were ovariectomized (OVX) or sham operated. Eight weeks later, after the manifestation of ovariectomy-induced osteoporotic bone changes, BP therapy with Alendronate (ALN) was commenced. After another five weeks, a femoral critical-size defect was generated, rigidly fixed, and βTCP-cylinders loaded with 0.25 μg or 2.5 μg BMP2, 2.5 μg L51P, and 0.25 μg BMP2/2.5 μg L51P, respectively, were inserted. Unloaded βTCP-cylinders were used as controls. Femora were collected six and twelve weeks post-implantation. Histological and micro-computer tomography (MicroCT) evaluation revealed that insertion of cylinders coated with 2.5 μg BMP2 accelerated fracture repair and induced significant bone formation compared to controls (unloaded cylinders or coated with 2.5 μg L51P, 0.25 μg BMP2) already six weeks post-implantation, independent of estrogen-deficiency and BP therapy. The simultaneous administration of BMP2 and L51P (0.25 μg BMP2/2.5 μg L51P) did not promote fracture healing six and twelve weeks post-implantation. Moreover, new bone formation within the critical-size defect was directly linked to the removal of the βTCP-implant in all experimental groups. No evidence was found that long-term therapy with ALN impaired the resorption of the implanted graft. However, osteoclast transcriptome signature was elevated in sham and OVX animals upon treatment with BP, with transcript levels being higher at six weeks than at twelve weeks post-surgery. Furthermore, the transcriptome profile of the developing repair tissue confirmed an accelerated repair process in animals treated with 2.5 μg BMP2 implants. L51P did not increase the bioefficacy of BMP2 in the applied defect model. The present study provides evidence that continuous administration of BP does not inhibit implant resorption and does not alter the kinetics of the healing process of critical-size long bone defects. Furthermore, the BMP2 variant L51P did not enhance the bioefficacy of BMP2 when applied simultaneously to the femoral critical-size defect in sham and OVX mice.

Efficacy of pure beta tricalcium phosphate graft in dentoalveolar surgery: a retrospective evaluation based on serial radiographic images

BACKGROUND

The use of beta-tricalcium phosphate (beta-TCP) in dental surgery is limited owing to its rapid absorption compared to mixed formulations of hydroxyapatite. However, newly developed pure beta-TCP crystals have demonstrated slow absorption; hence, they last longer within the defect and act as a scaffold until new bone formation. The oral environment is unique and can prove unfavorable for bone grafts due to the high infection rate in the oral cavity and the fragile condition of the oral mucosa. The aim of this study was to evaluate the feasibility of using pure beta-TCP bone grafts in various dental treatments.

METHODS

Panoramic X-ray images of 25 patients who underwent bone grafting during dental surgery were analyzed. A specially treated pure beta-TCP crystal, Neo Bone® (Neo Bone®, SN Biologics Co., Ltd, Seoul, Korea), was used in this study. The bone density at the graft site was compared with that of the surrounding bone using the ImageJ software (Wayne Rasband, NIH USA).

RESULTS

Six months after surgery, the bone graft density was similar to that of the surrounding bone in 20 patients and increased in 5 patients. No adverse effects, such as infection, dehiscence, or graft failure, were observed.

CONCLUSION

The newly developed pure beta-TCP crystal was slowly absorbed and served as support until new bone formation at the defect site, thus demonstrating its potential for use in various oral conditions requiring bone grafting.

Evaluation of the osteoconductive properties of scaffold containing platete-enriched-fibrin (PRF) with three calcium phosphate (TCP) in the alveolar socket repair after tooth extraction: An animal study

Bone regeneration can be accomplished through osteogenesis, osteoinduction, and osteoconduction mechanisms. This study aimed to investigate the properties of the PRF scaffold with tricalcium phosphate nanoparticles in socket preservation in an animal model. Fabrication of PRF performed. In this experimental study, 18 rats were divided into three negative control, PRF, and PRF/TCP groups. The mechanical and chemical tests including swelling rate, degradation time, and MTT tests were applied to the scaffolds. In each animal, the first maxillary right molar was extracted, and extraction sites of test groups were filled with a resorbable biocompatible biomaterial in situ hardening bone substitute. After 2 and 4 weeks all animals were sacrificed and examined histopathologically and with qRT-PCR. Histological results showed TCP in combination with PRF accelerates bone regeneration with the highest amount of lamellar bone and collagen formation compared to the control and PRF alone. Mechanical and chemical tests on the scaffolds showed the addition of TCP to the PRF scaffold decreases the swelling rate and increases the degradation time. qRT-PCR showed expression of osteogenic genes increased significantly (p < 0.05) in PRF/TCP and PRF, respectively. In conclusion, the gelatin hydrogel containing PRF/TCP scaffold led to more bone formation after tooth extraction. Therefore, the injectable PRF\TCP hydrogel is a promising candidate for bone repair and regeneration.

Bone Formation on Murine Cranial Bone by Injectable Cross-Linked Hyaluronic Acid Containing Nano-Hydroxyapatite and Bone Morphogenetic Protein

New injection-type bone-forming materials are desired in dental implantology. In this study, we added nano-hydroxyapatite (nHAp) and bone morphogenetic protein (BMP) to cross-linkable thiol-modified hyaluronic acid (tHyA) and evaluated its usefulness as an osteoinductive injectable material using an animal model. The sol (ux-tHyA) was changed to a gel (x-tHyA) by mixing with a cross-linker. We prepared two sol−gel (SG) material series, that is, x-tHyA + BMP with and without nHAp (SG I) and x-tHyA + nHAp with and without BMP (SG II). SG I materials in the sol stage were injected into the cranial subcutaneous connective tissues of mice, followed by in vivo gelation, while SG II materials gelled in Teflon rings were surgically placed directly on the cranial bones of rats. The animals were sacrificed 8 weeks after implantation, followed by X-ray analysis and histological examination. The results revealed that bone formation occurred at a high rate (>70%), mainly as ectopic bone in the SG I tests in mouse cranial connective tissues, and largely as bone augmentation in rat cranial bones in the SG II experiments when x-tHyA contained both nHAp and BMP. The prepared x-tHyA + nHAp + BMP SG material can be used as an injection-type osteoinductive bone-forming material. Sub-periosteum injection was expected.

Channel Aperture Characteristics of Carbonate Apatite Honeycomb Scaffolds Affect Ingrowths of Bone and Fibrous Tissues in Vertical Bone Augmentation

Synthetic scaffolds with the ability to prevent fibrous tissue penetration and promote bone augmentation may realize guided bone regeneration without the use of a barrier membrane for dental implantation. Here, we fabricated two types of honeycomb scaffolds of carbonate apatite, a bone mineral analog, whose channel apertures were square (HC-S) and rectangular (HC-R). The side lengths of the HC-Ss and HC-Rs were 265.8 ± 8.9; 817.7 ± 2.4 and 267.1 ± 5.2 μm, respectively. We placed cylindrical HC-Ss and HC-Rs on the rabbit calvaria. At 4 weeks post-implantation, the HC-Ss prevented fibrous tissue penetration from the top face via the channels, which allowed the new bone to reach the top of the scaffold from the bottom face or the calvarium. In contrast, in the HC-Rs, fibrous tissues filled the channels in the top region. At 12 weeks post-implantation, the HC-Ss were partially replaced with new bone. In the top region of the HC-Rs, although new bone had formed, fibrous tissue remained. According to the findings here and in our previous study, the longer side length rather than the shorter side length of a rectangular scaffold channel aperture is the dominant factor that affects fibrous tissue penetration and new bone augmentation. Furthermore, even though channel aperture areas are similar, bone and fibrous tissue ingrowths are different when the aperture shapes are different.

Bioactive Inorganic Materials for Dental Applications: A Narrative Review

Over time, much attention has been given to the use of bioceramics for biomedical applications; however, the recent trend has been gaining traction to apply these materials for dental restorations. The bioceramics (mainly bioactive) are exceptionally biocompatible and possess excellent bioactive and biological properties due to their similar chemical composition to human hard tissues. However, concern has been noticed related to their mechanical properties. All dental materials based on bioactive materials must be biocompatible, long-lasting, mechanically strong enough to bear the masticatory and functional load, wear-resistant, easily manipulated, and implanted. This review article presents the basic structure, properties, and dental applications of different bioactive materials i.e., amorphous calcium phosphate, hydroxyapatite, tri-calcium phosphate, mono-calcium phosphate, calcium silicate, and bioactive glass. The advantageous properties and limitations of these materials are also discussed. In the end, future directions and proposals are given to improve the physical and mechanical properties of bioactive materials-based dental materials.

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

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

Combination of Carbonate Hydroxyapatite and Stem Cells from Human Deciduous Teeth Promotes Bone Regeneration by Enhancing BMP-2, VEGF and CD31 Expression in Immunodeficient Mice

The objective of this study was to clarify the efficiency of a combination of stem cells from human deciduous teeth and carbonate apatite in bone regeneration of calvarial defects. Immunodeficient mice (n = 5 for each group/4 groups) with artificial calvarial bone defects (5 mm in diameter) were developed, and stem cells from human deciduous teeth (SHEDs) and carbonate hydroxyapatite (CAP) granules were transplanted with an atelocollagen sponge as a scaffold. A 3D analysis using microcomputed tomography, and 12 weeks after transplantation, histological and immunohistochemical evaluations of markers of bone morphogenetic protein-2 (BMP-2), vascular endothelial growth factor (VEGF), and cluster of differentiation (CD) 31 were performed. In the 3D analysis, regenerated bone formation was observed in SHEDs and CAP, with the combination of SHEDs and CAP showing significantly greater bone regeneration than that in the other groups. Histological and immunohistochemical evaluations showed that combining SHEDs and CAP enhanced the expression of BMP-2, VEGF, and CD31, and promoted bone regeneration. This study demonstrates that the combination of SHEDs and CAP transplantation may be a promising tool for bone regeneration in alveolar defects.