Histopathological reactions of calcium phosphate cement

Physical Properties and Antimicrobial Release Ability of Gentamicin-Loaded Apatite Cement/α-TCP Composites: An In Vitro Study

Apatite cement (AC), which has excellent osteoconductive ability, and alpha-tricalcium phosphate (α-TCP), which can be used for bone replacement, are useful bone substitute materials. The objective of this study was to clarify the physical properties and antimicrobial release ability of antibiotic-loaded AC/α-TCP composites in vitro. Gentamicin-loaded, rapid setting AC/α-TCP composites were prepared in 2 mixing ratios (10:3 and 10:6). The cement paste of AC/α-TCP composites was prepared in a plastic mold and dried in a thermostatic chamber at 37 °C and 100% relative humidity for 24 h. A diametral tensile strength test, powder X-ray diffraction analysis, and gentamicin release test were performed. The diametral tensile strengths of the AC/α-TCP composites were significantly less than that of AC alone. Powder X-ray diffraction patterns exhibited the characteristic peaks of hydroxyapatite in the AC/α-TCP composites and gentamicin-loaded AC/α-TCP composites. The concentration of the released gentamicin was maintained above the minimum inhibitory concentration of Staphylococcus aureus until Day 30 in both the gentamicin-loaded AC/α-TCP composites (10:3 and 10:6). Our results suggest that a gentamicin-loaded AC/α-TCP composite has potential as a drug delivery system. Further study is essential to investigate the antimicrobial activity and safety of the gentamicin-loaded AC/α-TCP composites in animal models.

Brushite-based calcium phosphate cement with multichannel hydroxyapatite granule loading for improved bone regeneration

In this work, we report brushite-based calcium phosphate cement (CPC) system to enhance the in vivo biodegradation and tissue in-growth by incorporation of micro-channeled hydroxyapatite (HAp) granule and silicon and sodium addition in calcium phosphate precursor powder. Sodium- and silicon-rich calcium phosphate powder with predominantly tri calcium phosphate (TCP) phase was synthesized by an inexpensive wet chemical route to react with mono calcium phosphate monohydrate (MCPM) for making the CPC. TCP nanopowder also served as a packing filler and moderator of the reaction kinetics of the setting mechanism. Strong sintered cylindrical HAp granules were prepared by fibrous monolithic (FM) process, which is 800 µm in diameter and have seven micro-channels. Acid sodium pyrophosphate and sodium citrate solution was used as the liquid component which acted as a homogenizer and setting time retarder. The granules accelerated the degradation of the brushite cement matrix as well as improved the bone tissue in-growth by permitting an easy access to the interior of the CPC through the micro-channels. The addition of micro-channeled granule in the CPC introduced porosity without sacrificing much of its compressive strength. In vivo investigation by creating a critical size defect in the femur head of a rabbit model for 1 and 2 months showed excellent bone in-growth through the micro-channels. The granules enhanced the implant degradation behavior and bone regeneration in the implanted area was significantly improved after two months of implantation.

Development of a novel fluorapatite-forming calcium phosphate cement with calcium silicate: in vitro and in vivo characteristics

Aim of this study was to develop a novel fluorapatite-forming calcium phosphate cement (FA-CPC) with tricalcium silicate (TCS) for endodontic applications and to examine its in vitro and in vivo characteristics. The FA-CPC powder consisted of 62.8% CaHPO4, 30.8% CaCO3, and 6.4% NaF. One part of TCS was combined with 9 parts of FA-CPC powder (FA-CPC with TCS). A 1.5 M phosphate solution was used as cement liquid. Setting time (ST), diametral tensile strength (DTS), phase composition by X-ray diffraction (XRD), and cement alkalinity were analyzed. Cement biocompatibility was assessed using rat subcutaneous model. Cement ST was 10.3±0.6 min and DTS was 3.89±0.76 MPa. XRD patterns showed that highly crystalline apatitic material was the only significant phase present and pH value was approximate 11.0. FA-CPC with TCS demonstrated similar biocompatibility as that of mineral trioxide aggregate control. These results suggest that FA-CPC with TCS may be useful for endodontic applications.

Case Report: retained gutta-percha as a cause for persistent maxillary sinusitis and pain

Dental sources of infection can produce acute and chronic maxillary sinusitis. In some cases, the source of the infection may be related to the presence of endodontic materials in the oral cavity. In this article, we report a case of retained gutta-percha in the maxillary sinus resulting in chronic sinusitis.

Calcium Phosphate Cements: Chemistry, Properties, and Applications

This paper reviews recent studies on self-setting calcium phosphate cements (CPC). Discussions are focused on the cement setting reactions, the products formed, those properties of the cements that contribute to their clinical efficacy, and areas of future improvements that could make CPC useful in a wider range of applications. The strengths of CPC are considerably lower than ceramic calcium phosphate biomaterials and are also lower than some of the dental cements. On the other hand, the combination of self-setting capability and high biocompatibility makes CPC a unique biomaterial. Near perfect adaptation of the cement to the tissue surfaces in a defect, and a gradual resorption followed by new bone formation are some of the distinctive advantages of CPC. In its present state CPC appears to be suitable for a number of applications. Much remains to be done to further improve its properties to meet the requirements for different applications.

Calcium phosphate-based composites as injectable bone substitute materials

A major weakness of current orthopedic implant materials, for instance sintered hydroxyapatite (HA), is that they exist as a hardened form, requiring the surgeon to fit the surgical site around an implant to the desired shape. This can cause an increase in bone loss, trauma to the surrounding tissue, and longer surgical time. A convenient alternative to harden bone filling materials are injectable bone substitutes (IBS). In this article, recent progress in the development and application of calcium phosphate (CP)-based composites use as IBS is reviewed. CP materials have been used widely for bone replacement because of their similarity to the mineral component of bone. The main limitation of bulk CP materials is their brittle nature and poor mechanical properties. There is significant effort to reinforce or improve the mechanical properties and injectability of calcium phosphate cement (CPC) and this review resumes different alternatives presented in this specialized literature.

Bismuth-doped injectable calcium phosphate cement with improved radiopacity and potent antimicrobial activity for root canal filling

A bismuth-doped injectable calcium phosphate cement (BD-ICPC) with improved radiopacity, potent antimicrobial activity and sealability was developed by introducing bismuth salicylate basic (BSB) into the powder phase of the calcium phosphate cement (CPC). The results showed that the radiopacity and sealability of BD-ICPC were improved compared with pure ICPC. Although BSB had a retarding effect on the setting rate of the cement, the addition of BSB reduced the viscosity and yield stress of BD-ICPC, thus enhanced its injectability. It was noteworthy that BD-ICPC had a potent antimicrobial activity with improved sealability. In addition, BD-ICPC afforded a uniform and tight adaptation to the root canal wall. These results indicate that BD-ICPC possesses a combination of good in vitro radiopacity, high injectability, potent antimicrobial activity, improved sealability and tight adaptation to the root canal. It is expected to be used as a novel root canal filling material.

Deriving fast setting properties of tetracalcium phosphate/dicalcium phosphate anhydrous bone cement with nanocrystallites on the reactant surfaces

OBJECTIVE

This study attempts to reveal how nanocrystallites on the ceramic surfaces of non-dispersive calcium phosphate cement (nd-CPC) participate in setting processes as compared with conventional CPC (c-CPC).

METHODS

The compositions and morphologies of CPC during the early setting reactions were studied with X-ray diffraction and a scanning transmission electron microscope equipped with an energy dispersive spectroscopy system. The pH values and dispersive properties of CPC during the early setting reactions were investigated as well as the compressive strength of nd-CPC after 24h of immersion with varying liquid to powder ratios.

RESULTS

The mechanical strength of nd-CPC was approximately 60MPa after a 24h immersion in simulate body solution with a P/L ratio between 3.3 and 4.2g/mL. The nanocrystallites on the particle surfaces of nd-CPC were shown to grow rapidly and provided interlocking sites that allowed rapid development of the apatite phase in the cement, and were also shown to be non-dispersive in solution as determined by an injection test of c-CPC.

CONCLUSIONS

The interlocking particles produced by whisker growth on the ceramic particles or new crystallites formed between the ceramic particles caused the cement to be non-dispersive in solution. The particles of reactants with nanocrystallites on surfaces also gave this cement the ability to be shaped easily as a paste during an operation or to be injected into a cavity.

Fabrication of calcium phosphate-calcium sulfate injectable bone substitute using chitosan and citric acid

In this study, an injectable bone substitute (IBS) consisting of citric acid, chitosan solution as the liquid phase and tetra calcium phosphate (TTCP), dicalcium phosphate anhydrous (DCPA) and calcium sulfate hemihydrate (CSH) powders as the solid phase was prepared. Four groups containing different percentages (0-30%) of calcium sulfate hemihydrate (CSH, CaSO(4) . 0.5H(2)O) were investigated. Initial setting times for IBS with CSH were longer than those without CSH. The setting times for all compositions were in the range of 25-45 min. The injectability was improved by the addition of CSH in the present system. Scanning electron microscopy images showed that fiber-like crystallization appeared in the cements. The enhancement of crystallinity was confirmed by XRD profiles where the peak intensity of HAp increased with incubation time and the addition of CSH. Also, the compressive strength increased with the addition of CSH. The maximum compressive strength obtained for IBS was with 20% CSH after 28-day incubation in 100% humidity at 37 degrees C.

Bioactive materials in endodontics

Endodontic treatment in dentistry is a delicate procedure and many treatment attempts fail. Despite constant development of new root canal filling techniques, the clinician is confronted with both a complex root canal system and the use of filling materials that are harmful for periapical tissues. This paper evaluates reported studies on biomaterials used in endodontics, including calcium hydroxide, mineral trioxide aggregate, calcium phosphate ceramics and calcium phosphate cements. Special emphasis is made on promising new biomaterials, such as injectable bone substitute and injectable calcium phosphate cements. These materials, which combine biocompatibility, bioactivity and rheological properties, could be good alternatives in endodontics as root canal fillers. They could also be used as drug-delivery vehicles (e.g., for antibiotics and growth factors) or as scaffolds in pulp tissue engineering.

Soft tissue necrosis following using calcium phosphate cement in calcaneal bone cyst: case report

Calcium phosphate cements have received widespread attention for their possible role as bone-grafting material and bone fillers in skeletal defects. They were evaluated as a biomaterial in many aspects. No serious harmful effects such as foreign body reaction and tissue necrosis against to calcium phosphate cements have been reported yet. They were accepted as highly biocompatible materials. In this paper, we represent a patient who had soft tissue necrosis around lateral malleolar region, following using percutaneous calcium phosphate cement as a filler bone substitute in calcaneus bone cyst. The possible mechanisms were discussed.

Histological analysis of calcium phosphate bone grafts for surgically created periodontal bone defects in dogs

A calcium phosphate cement (CPC-1), prepared by mixing an equimolar mixture of tetracalcium phosphate and dicalcium phosphate anhydrous with water, has been shown to be highly biocompatible and osteoconductive. A new type of calcium phosphate cement (CPC-2), prepared by mixing a mixture of alpha-tricalcium phosphate and calcium carbonate with pH 7.4 sodium phosphate solution, was also reported to be highly biocompatible. The objective of the present study was to compare the osteoconductivities of CPC-1 and CPC-2 when implanted in surgically created defects in the jaw bones of dogs. At 1 month after surgery, implanted CPC-1 was partially replaced by new bone and converted to bone within 6 months. In comparison, at 1 month after surgery, the defect filled with CPC-2 was mostly replaced by new bone. Therefore, bone formation in CPC-2-filled pocket was more rapid than in CPC-1-filled pocket. These findings supported the hypothesis that CPC-2 converted to bone more rapidly than CPC-1.

Basic research on aw-AC/PLGA composite scaffolds for bone tissue engineering

Recently, it has become important to develop effective material to be used as scaffolds for bone tissue engineering. Therefore, we fabricated new three-dimensional (3D) scaffolds consisting of biodegradable poly(D,L-lactide-co-glycolic acid)(PLGA)(75/25) with anti-washout type AC (aw-AC) particles. The aim of this study was to evaluate this new scaffold concerning its basic properties and biocompatibility. The obtained scaffolds were observed with scanning electron microscopy (SEM), and measured for porosity, shrinkage and biaxial compressive strengths. It was shown that PLGA with aw-AC composite scaffolds (aw-AC/PL) showed a greater strength and stability than PLGA scaffolds (PL). Also, the mass reduction of aw-AC/PL during incubation decreased compared to that of PL. The number of MC3T3-E1 cell in PL and aw-AC/PL was counted at 5 h, 1 week, and 2 weeks after cell seeding. As a result, aw-AC/PL exhibited a superior performance in terms of attachment and proliferation compared to PL. Histologically, aw-AC/PL showed an excellent response toward soft tissues. Therefore, it was shown that aw-AC/PL was more biocompatible than PL. In conclusion, it was strongly suggested that aw-AC/PL was more useful for cell transplantation than PL in bone tissue engineering.

Histological Evaluation of Apatite Cement Containing Atelocollagen

Tissue response to apatite cement (AC) containing atelocollagen (AC (ate)) was evaluated using conventional AC (c-AC) as a control material. At one week, the only difference between AC (ate) and c-AC was found in the soft tissue response. With c-AC, a moderate inflammatory response was exhibited: small particles of c-AC were scattered in the cutaneous tissue and many foreign body giant cells were aggregated around the scattered c-AC, whereas AC (ate) showed only a slight inflammatory response with few foreign body giant cells. In terms of bone tissue response, difference between AC (ate) and c-AC was observed at four weeks. New bone formation was observed along the cement at the edge of the pre-existing cortical bone in both c-AC and AC (ate). However, in the case of AC (ate), more abundant and thicker new bone was formed along the cement in the bone marrow when compared with c-AC.

Novel injectable calcium phosphate/chitosan composites for bone substitute materials

In this study, a novel injectable bone substitute material was developed which consists of chitosan, citric acid and glucose solution as the liquid phase, and tricalcium phosphate powder as the solid phase. This material was moldable because of its paste consistency after mixing. We used four groups of cement to investigate the mechanical properties and biocompatibility of the new biomaterial in vitro, which were named group A (10% citric acid), B (15% citric acid), C (20% citric acid) and D (25% citric acid). The setting times of the cements were 5-30 min. X-ray diffraction analysis showed that the products were hydroxyapatite (HA) and dicalcium phosphate anhydrous. When the concentration of citric acid was increased, the compressive strength of specimen increased. Through the simulated body fluid test, we observed the material was bioactive. Group D could induce Ca and P ions to deposit the surface group D quickly. These results indicated that the concentration of citric acid in the liquid component affected the mechanical properties and bioactivity of cements. The cell cultivation test showed that the cytocompatibility of the new biomaterial was good. The method for preparing the novel bone substitute material is simple. The starting material is more readily available and cheaper than HA, poly(methyl methacrylate), and so on. The cement could have good prospects for medical application.

γ-Radiation-induced changes in structure and properties of tetracalcium phosphate and its derived calcium phosphate cement

The purpose of the present study was to investigate the gamma-radiation effect on the structure and properties of the single-phase tetracalcium phosphate (TTCP) powder and its derived calcium phosphate cement (CPC). Experimental results show that low-dosed (0-30 kGy) CPC has a setting time of 10-12 min, while high-dosed (40-120 kGy) CPC has a setting time of 8-10 min. The low dose gamma-radiation does not significantly change porosity volume fraction or compressive strength of the CPC. The pH values of all CPC samples fell in a relatively narrow band, with a band width of 8.5-9.1 (in terms of pH value). With a dose of 10 or 20 kGy gamma-radiation, the TTCP-apatite conversion ratio does not change much. With 30 kGy the conversion ratio significantly increases and reaches a maximum value. With further increases in dose, the conversion ratio quickly declines. With increasing gamma-ray dose, the CPC morphology becomes more porous/loose and apatite particles become larger in size. When exposed to a high dose (120 kGy) of gamma-radiation, TTCP structure is radiation-damaged, and gamma-ray-induced formation of apatite is confirmed by transmission electron microscopic/selected-area diffraction/lattice imaging analyses.

Physicochemical basis of the biologic properties of mineral trioxide aggregate

This study characterized the interactions of mineral trioxide aggregate with a synthetic tissue fluid composed of a neutral phosphate buffer saline solution and root canal dentin in extracted human teeth using inductively coupled plasma-atomic emission spectroscopy, scanning electron microscopy, energy dispersive X-ray analysis, and X-ray diffraction. Mineral trioxide aggregate exposed to synthetic tissue fluid at 37 degrees C released its metallic constituents and produced precipitates with a composition and structure similar to that of hydroxyapatite [Ca10(PO4)6(OH)2-HA]. Endodontically prepared teeth filled with mineral trioxide aggregate and stored in synthetic tissue fluid at 37 degrees C for 2 months produced at the dentin wall an adherent interfacial layer that resembled hydroxyapatite in composition. The authors conclude that Ca, the dominant ion released from mineral trioxide aggregate, reacts with phosphates in synthetic tissue fluid, yielding hydroxyapatite. The dentin-mineral trioxide aggregate interfacial layer results from a similar reaction. The sealing ability, biocompatibility, and dentinogenic activity of mineral trioxide aggregate is attributed to these physicochemical reactions.

In vivo study on the biocompatibility of newly developed calcium phosphate-based root canal sealers

This study compared the biocompatibility of two new calcium phosphate-based root canal sealers (CAPSEAL I, CAPSEAL II) with another type of commercially available calcium phosphate sealer (Apatite Root Sealer type I, Apatite Root Sealer type II) and a zinc oxide eugenol-based sealer (Pulp Canal Sealer EWT) after implanting them in the subcutaneous tissue of rats. After 1, 2, 4, and 12 weeks, the tubes were removed with the surrounding tissues. The tissue reactions were graded as being mild or 1, moderate or 2, and severe or 3 after a histopathological examination. The results were analyzed statistically with the Kruskal-Wallis test. The biocompatibility of the materials was interpreted according to the Federation Dentaire Internationale criteria (1980). The inflammatory reactions decreased with time. The new sealers showed a lower tissue response than any of the other sealers in all the experimental periods. All the tested sealers showed an acceptable biocompatibility.

Evaluation of an in situ setting injectable calcium phosphate as a new carrier material for gentamicin in the treatment of chronic osteomyelitis: Studies in vitro and in vivo

A study was performed to investigate the effectiveness of hydroxyapatite cement (HAC) as a new carrier system in the treatment of chronic, posttraumatic osteomyelitis. In the in vitro study, release of gentamicin from standard cylinders of HAC were measured by agar diffusion test. As a representative for mechanical properties, compression strength was measured in order to detect changes when mixing HAC with gentamicin. In the in vivo study, bone infection was induced according to the model of Norden by injection of 1 ml Na-morrhuat and 3 x 10(6)CFU Staphylococcus aureus. After 3 weeks, when chronic stage of infection was obtained, 17 animals were treated by debridement and filling the marrow either with HAC alone or HAC mixed with gentamicin (32 mg/g). Animals of the control groups were left untreated. After 6 weeks, all animals were sacrificed. Hematological, radiological, microbiological and histological examinations were carried out by covered investigation. Best evidence of the efficiency of treatment was observed in histopathological and microbiological findings. In all swabs of the control groups, taken 6 weeks following infection S. aureus were detected which were clonal to the strain used for induction of osteomyelitis. In HAC/gentamicin-treated animals, no growth was detectable after 7 days of culturing in BHI bouillon. In the HAC/gentamicin-treated group, there was no histopathological evidence of infection. In all other groups different stages of chronic osteomyelitis were found. No side effect was observed, neither locally nor systemically by HAC or gentamicin. Therefore, HAC is considered to be a very effective carrier for antibiotics in treatment of chronic, posttraumatic osteomyelitis.

Effects of various sterilization methods on the setting and mechanical properties of apatite cement

Sterilization capability is a necessary requirement for any material that is to be used in a medical application. Therefore, it is necessary for apatite cement (AC) to be sterilized. Because there is little information on the sterilization methods of AC, the aims of this investigation were to evaluate the effects of various sterilization methods, including steam, dry heat, ethylene oxide (EtO) gas, and gamma irradiation sterilizations, on the setting and mechanical properties of AC. In the case of steam sterilization, because AC powder aggregated before setting-time measurements, the setting time could not be measured. When the powder was sterilized by dry heat or EtO gas, the setting time was prolonged significantly and the wet diametral tensile strength (DTS) value decreased significantly. Therefore, sterilizations with steam, dry heat, or EtO gas were suggested to be inappropriate methods for AC. Accordingly, the following experiments focused on gamma sterilization. The setting time of AC was retarded with an increase in gamma irradiation dose. The wet DTS value decreased with the increase in gamma irradiation dose. There was no compositional change due to the gamma irradiation. The following tests were carried out in order to examine the effect of the gamma irradiation on the setting reaction of AC in detail. Tetracalcium phosphate [TTCP: Ca(4)(PO(4))(2)O] and dicalcium phosphate anhydrous (DCPA: CaHPO(4)) were separately irradiated, and the cements were produced with the use of irradiated powder and nonirradiated powder. Although the wet DTS value of AC produced from irradiated TTCP and nonirradiated DCPA decreased with increasing gamma irradiation dose, there was no significant difference. In contrast, the wet DTS value of AC produced from irradiated DCPA and nonirradiated TTCP significantly decreased with the increase in gamma irradiation dose. In conclusion, although the detailed mechanism of the delayed setting time and decreased DTS value was not clarified by the present study, it was found that gamma irradiation affected DCPA more than TTCP.

Transmission electron microscopic study on setting mechanism of tetracalcium phosphate/dicalcium phosphate anhydrous-based calcium phosphate cement

This work studied transmission electron microscopy on the setting mechanism of tetracalcium phosphate/dicalcium phosphate anhydrous (TTCP/DCPA)-based calcium phosphate cement. The results suggest the process for early-stage apatite formation as the follows: when TTCP and DCPA powders are mixed in the phosphate-containing solution, the TTCP powder is quickly dissolved because of its higher solubility in the acidic solution. The dissolved calcium and phosphate ions, along with those ions readily in the solution, are then precipitated predominantly on the surface of DCPA particles. Few apatite crystals were observed on the surface of TTCP powder. During the later stages of reaction, the extensive growth of apatite crystals/whiskers, with a calcium/phosphorous ratio very close to that of hydroxyapatite, effectively linked DCPA particles together and also bridged the larger TTCP particles. It is suggested that, when the large TTCP particles are locked in place by the bridging apatite crystals/whiskers, the CPC is set and would not dissolve when immersed in Hanks' solution after 20-40 min of reaction.

Histopathologic reaction of a calcium phosphate cement for alveolar ridge augmentation

The objective of the present study was to evaluate the feasibility of using a calcium phosphate cement (CPC) in the reconstruction of a defective alveolar ridge in conjunction with implant placement. The CPC consisted of an equimolar amount of tetracalcium phosphate and dicalcium phosphate anhydrous. At the beginning of the experiment, all mandibular premolar teeth of mature beagle dogs were extracted. After 1 month of healing, alveolar bone was reduced to make a space for a CPC block that was prefabricated from a CPC mixed with water at a powder/liquid ratio of 5 g/mL. After an additional month, 8-mm long hydroxyapatite-coated titanium implants were placed in such a way that the apical half was embedded into alveolar bone and the coronal half in the preformed CPC block. The dogs were sacrificed and biopsies were obtained at 1, 3, and 6 months after surgery. Sections that included implants were evaluated for integration of the CPC block to the alveolar bone and of the implant to the alveolar bone. Additional sections without the implants served as controls. The results obtained from this study show that the CPC ridge augmentation gradually is replaced by natural bone. Six months after surgery, histopathologic features of the augmentation area were quite similar to those of natural alveolar bone. The coronal half of the implants, previously surrounded by the CPC block, was firmly fixed by natural bone. Therefore, this method may be useful for increasing the height of the alveolar ridge.

Development of calcium phosphate cement using chitosan and citric acid for bone substitute materials

We developed a calcium phosphate cement that could be molded into any desired shape due to its chewing-gum-like consistency after mixing. The powder component of the cement consists of alpha-tricalcium phosphate and tetracalcium phosphate, which were made by decomposition of hydroxyapatite ceramic blocks. The liquid component consists of citric acid, chitosan and glucose solution. In this study, we used 20% citric acid (group 20) and 45% citric acid (group 45). The mechanical properties and biocompatibility of this new cement were investigated. The setting times of cements were 5.5 min, in group 20 and 6.4 min, in group 45. When incubated in physiological saline, the cements were transformed to hydroxyapatite at 3, and 6 weeks, the compressive strengths were 15.6 and 20.7 MPa, in group 45 and group 20, respectively. The inflammatory response around the cement implanted on the bone and in the subcutaneous tissue in rats was more prominent in group 45 than in group 20 at 1 week after surgery. After 4 weeks, the inflammation disappeared and the cement had bound to bone in both groups. These results indicate that this new calcium phosphate cement is a suitable bone substitute material and that the concentration of citric acid in the liquid component affects its mechanical properties and biocompatibility.

Calcium phosphate cement containing resorbable fibers for short-term reinforcement and macroporosity

Calcium phosphate cement (CPC) sets to form hydroxyapatite and has been used in medical and dental procedures. However, the brittleness and low strength of CPC prohibit its use in many stress-bearing locations, unsupported defects, or reconstruction of thin bones. Recent studies incorporated fibers into CPC to improve its strength. In the present study, a novel methodology was used to combine the reinforcement with macroporosity: large-diameter resorbable fibers were incorporated into CPC to provide short-term strength, then dissolved to create macropores suitable for bone ingrowth. Two types of resorbable fibers with 322 microm diameters were mixed with CPC to a fiber volume fraction of 25%. The set specimens were immersed in saline at 37 degrees C for 1, 7, 14, 28 and 56d, and were then tested in three-point flexure. SEM was used to examine crack-fiber interactions. CPC composite achieved a flexural strength 3 times, and work-of-fracture (toughness) nearly 100 times, greater than unreinforced CPC. The strength and toughness were maintained for 2-4 weeks of immersion, depending on fiber dissolution rate. Macropores or channels were observed in CPC composite after fiber dissolution. In conclusion, incorporating large-diameter resorbable fibers can achieve the needed short-term strength and fracture resistance for CPC while tissue regeneration is occurring, then create macropores suitable for vascular ingrowth when the fibers are dissolved. The reinforcement mechanisms appeared to be crack bridging and fiber pullout, the mechanical properties of the CPC matrix also affected the composite properties.

Initial tissue response to anti-washout apatite cement in the rat palatal region: comparison with conventional apatite cement

Initial tissue response to anti-washout apatite cement (aw-AC) in the palatal region was studied. Conventional apatite cement (c-AC) was employed as a control material. Bone defects generated in the rat palatal region, where complete hemostasis is difficult to effect, were filled with both cement types and examined histologically for up to 8 weeks. At 1-week postfilling, a portion of the c-AC had washed out, resulting in slight inflammation and severe foreign-body response. The degree of foreign-body response to c-AC was reduced over time; however, foreign-body response continued to be in evidence 8 weeks after surgery. As a result, poor bone formation was observed in the case of c-AC at 8 weeks post-surgery. In contrast, aw-AC set well, maintained its shape at implantation, and caused little foreign-body response. Osteoblasts were observed at 2 weeks following surgery. Moreover, the bone defect was completely covered with new bone at 8 weeks post-surgery. This observation suggests that aw-AC may be used without complication in cases where complete hemostasis is difficult to achieve, that is, where the use of c-AC is contraindicated.

Biocompatibility of root canal filling materials

Results of in vitro and in vivo studies clearly indicate that some endodontic sealers may cause local and systemic adverse effects. Though occasionally contradictory data has been reported from various authors, it may be concluded that zinc-oxide-eugenol sealers possess a marked cytotoxic and tissue-irritating potency. Most Ca(OH)2-based materials, however, were biocompatible. Genotoxic effects have been observed with sealers releasing paraformaldehyde or containing mutagenic substances, such as bisphenol-A-diglycidyl-ether or its derivatives. It cannot be excluded that these materials may pose a systemic risk because formaldehyde is rapidly distributed systemically following its application into the pulp cavity. Furthermore an increasing number of cases with an aspergillosis of the maxillary sinus have been observed which were mainly caused by zinc-releasing endodontic sealers. Overall, it is recommended that for endodontic practice, sealers that have been found to be biocompatible in a "mixed bag" of various in vitro and in vivo tests, be selected. From this point of view, ZnOE-sealers should no longer be used for root canal fillings. This recommendation applies also to sealers containing paraformaldehyde or generating this substance during their setting reaction. More experimental and clinical studies are necessary to elucidate whether new materials, such as mineral trioxide aggregate (MTA) or calcium phosphate cement, will be biocompatible alternatives in the future.

Effect of added NaHCO3 on the basic properties of apatite cement

Alternation of a composition of set apatite cement (AC) from carbonate-free apatite (CO3-free AP) to carbonate apatite (CO3-AP) may accelerate replacement of the set AC with bone because CO3-AP can be dissolved much faster than CO3-free AP in the weak acidic solution produced by osteoclasts. In this investigation, NaHCO3 was added to the AC component and the effects of added NaHCO3 on cement-setting behavior and on set mass were studied as an initial step for the fabrication of AC, which can be replaced with bone faster than current AC. When NaHCO3 was added to AC, the resultant set mass contained CO3. Although not all CO3 was incorporated in the set AC, the amount of CO3 incorporated into the set AC increased with the amount of added NaHCO3. Powder X-ray diffraction analysis and Fourier transform infrared spectrometer measurements revealed the formation of B-type CO3-AP. The setting time measured in an incubator at 37 degrees C and 100% relative humidity slowed from 30 to 45 min, indicating that NaHCO3 has an inhibitory effect on AP formation. The diametral tensile strength of the set AC decreased significantly with the addition of NaHCO3. Scanning electron microscopic observation revealed that fine crystals were formed in the set AC when NaHCO3 was added to AC. As a result, the crystallinity indices of the set AC measured using X-ray diffraction and Fourier transform infrared spectroscopy decreased with an increase in the amount of added NaHCO3. The dissolution rate of set AC in weak acid, pH 5.5, increased with the amount of added NaHCO3. We concluded that the formation of B-type CO3-AP and the resulting faster dissolution of set AC in weak acidic solution is preferable for the faster replacement of set AC with bone even though the decreased diametral tensile strength value is a shortcoming.

Reconstruction of alveolar bone defect by calcium phosphate compounds

Osteoconductivity of newly developed calcium phosphate cements (CP-1, CP-2) was estimated in mandibular periapical alveolar bone of rats. The powder phase of CP-1 was an equimolar mixture of tetracalcium phosphate and dicalcium phosphate dihydrate, and that of CP-2 was alpha-tricalcium phosphate. The liquid phase of CP-1 and CP-2 was a solution containing tannic acid and citric acid. CP-1, CP-2, an apatitic sealer (ARS), or a zinc oxide eugenol sealer (ZOE) was respectively applied in the mechanically injured periapical regions through the root canals of both mandibular first molars of 15 rats. A further 15 rats were used as controls with no material in the region. The results of histopathological examination at 1, 3, and 5 weeks after operation were analyzed by the chi(2) test (95% confidence level). At 1 week, foreign-body giant cells were observed around CP-1 and CP-2, but not around ARS or ZOE. Congestion of small blood vessels was seen in bone defect areas of the controls. After 5 weeks, statistically significant bone reconstruction was induced by application of CP-1 (80.0%), CP-2 (90.0%) compared with ARS (33.3%). Fibrous scaring was seen in the controls. It is concluded that resolvability of CP-1 and CP-2 should contribute to osseous healing.

Reinforcement of a self-setting calcium phosphate cement with different fibers

A water-based calcium phosphate cement (CPC) has been used in a number of medical and dental procedures due to its excellent osteoconductivity and bone replacement capability. However, the low tensile strength of CPC prohibits its use in many unsupported defects and stress-bearing locations. Little investigation has been carried out on the fiber reinforcement of CPC. The aims of the present study, therefore, were to examine whether fibers would strengthen CPC, and to investigate the effects of fiber type, fiber length, and volume fraction. Four different fibers were used: aramid, carbon, E-glass, and polyglactin. Fiber length ranged from 3-200 mm, and fiber volume fraction ranged from 1.9-9.5%. The fibers were mixed with CPC paste and placed into molds of 3 x 4 x 25 mm. A flexural test was used to fracture the set specimens and to measure the ultimate strength, work-of-fracture, and elastic modulus. Scanning electron microscopy was used to examine specimen fracture surfaces. Fiber type had significant effects on composite properties. The composite ultimate strength in MPa (mean +/- SD; n = 6) was (62+/-16) for aramid, (59+/-11) for carbon, (29+/-8) for E-glass, and (24+/-4) for polyglactin, with 5.7% volume fraction and 75 mm fiber length. In comparison, the strength of unreinforced CPC was (13+/-3). Fiber length also played an important role. For composites containing 5.7% aramid fibers, the ultimate strength was (24+/-3) for 3 mm fibers, (36+/-13) for 8 mm fibers, (48 +/-14) for 25 mm fibers, and (62+/-16) for 75 mm fibers. At 25 mm fiber length, the ultimate strength of CPC composite was found to be linearly proportional to fiber strength. In conclusion, a self-setting calcium phosphate cement was substantially strengthened via fiber reinforcement. Fiber length, fiber volume fraction, and fiber strength were found to be key microstructural parameters that controlled the mechanical properties of CPC composites.

Histological and compositional evaluations of three types of calcium phosphate cements when implanted in subcutaneous tissue immediately after mixing

To evaluate the soft tissue response of calcium phosphate cement (CPC), consisting of an equimolar mixture of tetracalcium phosphate (TTCP) and dicalcium phosphate anhydrous (DCPA) under conditions close to those encountered in actual surgical procedures, we implanted three types of CPC [conventional CPC (c-CPC), fast-setting CPC (FSCPC), and antiwashout type FSCPC (aw-FSCPC; formerly called nondecay type FSCPC or nd-FSCPC)] subcutaneously in the abdomens of rats immediately (1 min) after mixing. At 1 week after surgery, histological examination and compositional analysis were performed using light microscopy and powder X-ray diffraction (XRD), respectively. The implanted c-CPC was crumbled completely, whereas FSCPC and aw-FSCPC retained their shape. Large vesicles containing copious inflammatory effusion were subcutaneously formed around the c-CPC. Histologically, many foreign-body giant cells were collected around the c-CPC, and moderate inflammatory cell infiltration was observed at 1 week after surgery. In contrast, the FSCPC and aw-FSCPC were covered with a thin layer of granulation tissue that included few giant cells and presented slight inflammatory cell infiltration, and no effusion was observed. The XRD analysis of the c-CPC revealed the presence of some unreacted DCPA even 1 week after implantation, whereas almost no DCPA was found in the FSCPC or aw-FSCPC. In conclusion, it was found that CPC does not always show excellent tissue response. When c-CPC is implanted subcutaneously in rats immediately after mixing, it fails to set and causes a severe inflammatory response. Therefore, the type of CPC should be chosen according to the clinical particulars. CPC should be used in a manner that assures its setting reaction. We recommend the use of FSCPC and aw-FSCPC for surgical applications, such as orthopedics, plastic and reconstructive surgery, and oral and maxillofacial surgery, where the cement might otherwise crumble due to the pressure before setting.

Reaction of calcium phosphate cements with different amounts of tetracalcium phosphate and dicalcium phosphate anhydrous

Calcium phosphate cements (CPCs) with different amounts of tetracalcium phosphate (TTCP) and dicalcium phosphate anhydrous (DCPA) (TTCP/DCPA molar ratio from 0.25 to 2.00) were prepared to further understand the setting reaction and the factors that could influence the properties of CPCs. Quantitative X-ray diffraction patterns, Fourier transform IR spectra, and diametral tensile strength of the set mass were measured along with pH measurements of the CPC suspension. Calcium-deficient hydroxyapatite (d-HAP) with a calcium to phosphate molar ratio of approximately 1.5 was formed initially in the CPC setting consisting of an equimolar mixture of TTCP and DCPA. This gradually transformed into stoichiometric HA (s-HA) with increasing incubation time. The s-HA was formed in the initial stage when the CPC contained an excess amount of TTCP. In contrast, maturation to s-HAP was slow when the CPC contained excess amounts of DCPA. The highest mechanical strength of set CPC was associated with an equimolar mixture of TTCP and DCPA, and the mechanical strength decreased as the TTCP/DCPA molar ratio deviated from 1.00. We concluded, therefore, that the setting reaction and the nature of the resulting set mass are dependent on the molar ratios of TTCP and DCPA.

Osteotransductive bone cements

Calcium phosphate bone cements (CPBCs) are osteotransductive, i.e. after implantation in bone they are transformed into new bone tissue. Furthermore, due to the fact that they are mouldable, their osteointegration is immediate. Their chemistry has been established previously. Some CPBCs contain amorphous calcium phosphate (ACP) and set by a sol-gel transition. The others are crystalline and can give as the reaction product dicalcium phosphate dihydrate (DCPD), calcium-deficient hydroxyapatite (CDHA), carbonated apatite (CA) or hydroxyapatite (HA). Mixed-type gypsum-DCPD cements are also described. In vivo rates of osteotransduction vary as follows: gypsum-DCPD > DCPD > CDHA approximately CA > HA. The osteotransduction of CDHA-type cements may be increased by adding dicalcium phosphate anhydrous (DCP) and/or CaCO3 to the cement powder. CPBCs can be used for healing of bone defects, bone augmentation and bone reconstruction. Incorporation of drugs like antibiotics and bone morphogenetic protein is envisaged. Load-bearing applications are allowed for CHDA-type, CA-type and HA-type CPBCs as they have a higher compressive strength than human trabecular bone (10 MPa).

Effects of added antibiotics on the basic properties of anti-washout-type fast-setting calcium phosphate cement

The effect of added antibiotics on the basic properties of anti-washout-type fast-setting calcium phosphate cement (aw-FSCPC) was investigated in a preliminary evaluation of aw-FSCPC containing drugs. Flomoxef sodium was employed as the antibiotic and was incorporated into the powder-phase aw-FSCPC at up to 10%. The setting time, consistency, wet diametral tensile strength (DTS) value, and porosity were measured for aw-FSCPC containing various amounts of flomoxef sodium. X-ray diffraction (XRD) analysis was also conducted for the identification of products. To evaluate the drug-release profile, set aw-FSCPC was immersed in saline and the released flomoxef sodium was determined at regular intervals. The spread area of the cement paste as an index of consistency of the cement increased progressively with the addition of flomoxef sodium, and it doubled when the aw-FSCPC contained 8% flomoxef sodium. In contrast, the wet DTS value decreased with increase in flomoxef sodium content. Bulk density measurement and scanning electron microscopic observation revealed that the set mass was more porous with the amount of flomoxef sodium contained in the aw-FSCPC. The XRD analysis revealed that formation of hydroxyapatite (HAP) from aw-FSCPC was reduced even after 24 h, when the aw-FSCPC contained flomoxef sodium at > or = 6%. Therefore, the decrease of wet DTS value was thought to be partly the result of the increased porosity and inhibition of HAP formation in aw-FSCPC containing large amounts of flomoxef sodium. The flomoxef sodium release from aw-FSCPC showed the typical profile observed in a skeleton-type drug delivery system (DDS). The rate of drug release from aw-FSCPC can be controlled by changing the concentration of sodium alginate. Although flomoxef sodium addition has certain disadvantageous effects on the basic properties of aw-FSCPC, we conclude that aw-FSCPC is a good candidate for potential use as a DDS carrier that may be useful in surgical operations.

Tissue response to fast-setting calcium phosphate cement in bone

Fast-setting calcium phosphate cement (FSCPC) is a promising new bioactive cement with a significantly short setting time (approximately 5-6 min) compared to conventional calcium phosphate cement (c-CPC) (30-60 min) at physiologic temperatures. As a result of its ability to set quickly, it is applicable in surgical procedures where fast setting is required. In this study, FSCPC was implanted in rat tibiae to evaluate tissue response and biocompatibility. FSCPC was converted to hydroxyapatite (HAP) in bone faster than c-CPC in the first 6 h. By 24 h, significant amounts of both FSCPC and c-CPC had been converted to HAP. The conversion of FSCPC into HAP further proceeded gradually, reaching 100% within 8 weeks. Infrared spectroscopic analysis disclosed the deposition of B-type carbonate apatite, which is a biological apatite contained in human dentin or bone, on the surface of the FSCPC. Histologically, FSCPC showed a tissue response similar to that of c-CPC. A slight inflammatory reaction was observed in the soft tissue apposed to both cements in the early period, and new bone was formed along the surface of the FSCPC at the adjacent bone. However, no resorption of either cement by osteoclasts or macrophages was observed within 8 weeks. We conclude that FSCPC is superior to c-CPC in clinical applications in oral and maxillofacial, orthopedic, plastic, and reconstructive surgery, since it shows a faster setting time and higher mechanical strength in the early period that are required in these surgical procedures, as well as osteoconductivity and excellent biocompatibility similar to that of c-CPC.

Repair of craniofacial defects with hydroxyapatite cement

PURPOSE

The objective of this study was to evaluate the course of healing of craniofacial bone defects when filled with hydroxyapatite cement and to determine whether adding various percentages by weight of demineralized bone powder to the cement will result in enhanced bone formation.

MATERIALS AND METHODS

The model for the study was the canine calvarium. The implants were placed into cranial defects and harvested at 3 or 6 months for qualitative evaluation by light microscopy, microradiography, and quantitative histomorphometry.

RESULTS

The implantation of hydroxyapatite cement resulted in characteristic replacement of the material with new bone ingrowth. The addition of demineralized bone powder to the hydroxyapatite cement appeared to improve the handling characteristics of the cement; however, improvement in the replacement of the material by bone was not observed. The implantation of only allogeneic demineralized bone showed limited new bone formation within the defect site.

CONCLUSIONS

Hydroxyapatite cement formed an effective osseoconductive scaffold for bone replacement. The addition of demineralized bone powder to the cement to serve as a carrier of osseoinductive factors did not result in additional bone being formed.

Evaluation of the biocompatibility of a nonceramic hydroxyapatite

In this study, the biocompatibility of calcium phosphate cement (CPC) was systematically investigated, which included systemic injection acute toxicity assay, cell culture cytotoxicity assay, gene mutation assay (Ames test), chromosome aberration assay (micronucleus test), DNA damage assay (unscheduled DNA synthesis test) and implant histological evaluation. The results showed that the CPC had no toxicity and all tests for mutagenicity and potential carcinogenicity of CPC extracts are negative. CPC was implanted into the femurs of rabbits under no-load condition and the histology of specimens revealed that the implant tightly joined with the surrounding bone, only a very slight histological inflammatory reaction occurred. Thus, CPC is a highly biocompatible material and seems to be safe for application in humans.

Effects of hydroxypropyl methylcellulose and other gelling agents on the handling properties of calcium phosphate cement

The calcium phosphate cement (CPC) used in this study was formed by combining equimolar amounts of tetracalcium phosphate (TTCP) and dicalcium phosphate anhydrous (DCPA). This powder, when mixed with water, sets to a hard cement in about 30 min. However, the water-based CPC paste is not highly cohesive and is vulnerable to washout until hardening occurs. The objectives of this study were to investigate the effects on handling properties, washout resistance, cement hardening behavior, and mechanical properties of adding several gelling agents to CPC paste. Aqueous solutions that contained a mass fraction of 2-4% of hydroxypropyl methylcellulose (HPMC), carboxyl methylcellulose (CMC), chitosan acetate, and chitosan lactate were used as cement liquids. Hardening time was measured by the Gilmore needle test; resistance to washout was evaluated by the disintegration of the cement specimen in water with agitation; and mechanical strength was evaluated by the measurement of diametral tensile strength and compressive strength. Handling properties were greatly improved by the addition of HPMC, CMC, chitosan acetate, and chitosan lactate. Hardening time was retarded by the additions of HPMC and CMC, and mechanical strength was weakened by the addition of either the chitosan lactate or the chitosan acetate.

Histopathological study of a newly developed root canal sealer containing tetracalcium-dicalcium phosphates and 1.0% chondroitin sulfate

We studied the possibility of the clinical use of a calcium phosphate-type newly developed sealer composed of tetracalcium phosphate, dicalcium phosphate dihydrate, and a modified McIlvain's buffer solution (TDM). Another sealer using the buffer solution, to which 2.5% chondroitin sulfate was added to promote wound healing (TDM-S), was also studied. TDM and TDM-S were histopathologically compared with another type of calcium phosphate sealer (ARS), which is commercially available in Japan, in the dorsal subcutaneous tissue and in the periapical tissue of rats. TDM and TDM-S caused no inflammatory reactions in the subcutaneous tissue. The periapical tissue reacted mildly to them. ARS caused severe inflammatory reactions in both the subcutaneous and the periapical tissue. These results indicate that TDM-S has excellent histocompatibility and potential as a root canal sealer.

Non-decay type fast-setting calcium phosphate cement: setting behaviour in calf serum and its tissue response

Non-decay type fast-setting calcium phosphate cement (nd-FSCPC) was evaluated in terms of its setting behaviour in calf serum and its tissue response to investigate the feasibility of its clinical use in surgical applications. Non-decay type cements were prepared by adding various amounts of sodium alginate to the liquid phase of base cements, fast-setting calcium phosphate cement (FSCPC) and conventional calcium phosphate cement (c-CPC). Cement pastes were immersed in serum at 37 degrees C immediately after mixing, and decay behaviour, setting time and mechanical strength were measured to evaluate the possibility of their use in surgical applications. Also, nd-FSCPC was implanted into rat subcutaneous tissue for the initial evaluation of biocompatibility of this potential bioactive cement. nd-FSCPC set in approximately 6-7 min in serum, even when the cement paste was immersed in the serum immediately after mixing, whereas c-CPC and FSCPC decayed completely upon immersion. nd-FSCPC transforms to hydroxyapatite (HA) within 24 h and shows a diametral tensile strength of approximately 4-5 MPa. As a result of transformation to HA, nd-FSCPC showed excellent tissue response when implanted subcutaneously in rats. We conclude that nd-FSCPC has good potential value for use in orthopaedics, plastic and reconstructive surgery, and oral and maxillofacial surgery, where the cement is exposed to blood.

Estimation of ideal mechanical strength and critical porosity of calcium phosphate cement

The ideal mechanical strength and critical porosity of calcium phosphate cement (CPC) were estimated to help determine ways to improve its properties. CPC at various porosities was made by packing CPC paste, at various powder-to-liquid (P/L) ratios (2.0-6.0), into a mold under various pressures (0-173 MPa). The mechanical strength of CPC, in terms of diametral tensile strength (DTS), increased with decreases in porosity. Intercrystalline fracture was observed in specimens made without the application of pressure, while fracture within the crystals increased with the packing pressure. These observations support the application of the relationship between DTS and porosity in fractographic equations. The ideal wet DTS and critical porosity of CPC were estimated to be 102 MPa and 63%, respectively. The minimum porosity of the currently used CPC was approximately 26-28%, even when it was packed under 173 MPa, and the maximum DTS value was thus approximately 13-14 MPa. Because reducing the porosity of currently used CPC would be difficult, we conclude that in CPC-related research, we should focus on ways in which to accelerate bone-replacing behavior, in addition to improving the mechanical strength of CPC.