Preservation of human heart valves for replacement in children with heart valve disease: past, present and future

Valvular heart disease affects 30% of the new-borns with congenital heart disease. Valve replacement of semilunar valves by mechanical, bioprosthetic or donor allograft valves is the main treatment approach. However, none of the replacements provides a viable valve that can grow and/or adapt with the growth of the child leading to re-operation throughout life. In this study, we review the impact of donor valve preservation on moving towards a more viable valve alternative for valve replacements in children or young adults.

A novel receptor-interacting protein-1 (RIP1) inhibitor (547) protects human cardiac cells from ischemia/reperfusion-triggered necroptotic cell death

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): M.M.C.P. is supported by a Netherlands Cardiovascular Research Initiative (CVON) grant (REMAIN 2014B27) and J.P.G.S is supported by Horizon2020 ERC-2016-COG-EVICARE [725229] and BRAVE (grant number 874827.

Purpose

Restoring perfusion, either by coronary angioplasty or bypass anastomosis, is performed around 2 million times per year throughout Europe to treat patients after myocardial infarction. Although this treatment is highly efficient to resolve myocardial ischemia, reperfusion is accompanied by damage through the release of reactive oxygen species (ROS). This ischemia/reperfusion (I/R) injury is manifested by cardiomyocyte death, caused to a certain extent by necroptosis. As a potential means of cardioprotection, we applied the small molecule compound 547 inhibiting RIP1-kinase, a central mediator of the necroptosis pathway, in an in vitro model of human cardiac I/R injury.

Methods

Human foetal cardiomyocyte progenitor cells (hfCPCs) were cultured and characterized for cell type defining markers before being subjected to simulated I/R damage using hydrogen peroxide (H2O2). Cardioprotective effects of 547 were assessed 24 hours after induction of damage and application of the compound. Cell viability and necroptosis pathway activation were assessed by flow cytometry, immunocytochemistry, and western blotting. Furthermore, mitochondrial damage was determined by JC-1 staining.

Results

hfCPCs expressed indicative markers SCA1, GATA4, PECAM-1, VEGF and C-KIT. Treatment with compound 547 significantly protected hfCPCs from H2O2 induced damage (viable cells: 84,3 ± 4,3% vs 1,6 ± 0,31%; P<0,0001). 547 decreased the necrotic cell population (DAPI+ AnnV-) (3,0 ± 1,1% vs 10,1 ± 1,5%, P<0,0001) and reduced phosphorylation of necrosome components RIP1 (1,3 ±  0,35 fold vs 3,7 ±  0,78 fold; P< 0,01), RIP3 (1,0 ± 0,46 fold vs 4,3 ± 1,5 fold; P< 0,05), and MLKL (1,1 ± 0,15 fold vs 5,7 ± 1,7 fold; P< 0,01) without decreasing unphosphorylated protein or mRNA levels. Interestingly, 547 treatment prevented oxidative stress induced loss of nuclear RIP1 and RIP3 as measured by immunocytochemistry and western blotting of cell fractions (nuclear/cytoplasmic ratio RIP1: 0,80 ±  0,0006 [Control] vs 1,5 ±  0,17 fold [547]; P< 0,01; nuclear/cytoplasmic ratio RIP3: 0,76 ±  0,10 [Control] vs 1,6 ± 0,18 fold [547]; P< 0,01). Remarkably, compound 547 also decreased H2O2–induced mitochondrial depolarization (JC-1 staining/membrane depolarization index: 4,5 ± 0,85% vs 1,2 ±  0,38%; P< 0,05)) and expression and activation of CAMKII (0,46 ± 0,13 fold; P<0,01), a protein mediating mitochondria-dependent cell death.

Conclusions

Administration of compound 547 led to inhibition of necroptosis, increased cell viability and reduced mitochondrial damage in an in vitro human cardiac I/R injury model, emphasizing the potential of necroptosis inhibition for cardioprotection. Assessing clinical applicability will require further studies in relevant in vivo models.

Modeling ischemic heart disease: only matured human iPS-derived cardiomyocytes are sensitive to ischemic injury

Background

Ischemic heart disease remains the leading cause of death worldwide due to irreversible loss of cardiomyocytes (CMs) during ischemic injury. To test potential factors that can stimulate cardiac repair, murine and porcine animal models or in vitro assays are often used. However, clinical translation remains ineffective as the CMs in the human heart differ signifantly from those in animal hearts1. Human induced pluripotent stem cell (hiPSC) derived CMs have been considered a very promising tool but their immature nature remains a roadblock for human cardiac disease modeling. A media to improve maturation of hiPSC-CMs has recently been developed2.

Purpose

To test whether we can model human myocardial ischemia, we assess the effect of metabolic maturation on ischemia susceptibility of hiPSC-CMs.

Methods

hiPSCs were differentiated into CMs and matured either in RPMI/B27 media or in maturation media (MM)2. Ischemia was induced by exposure to 5% or 1% oxygen for 4 to 24 hours in one of 5 types of media (DMEM/10%KOSR; RPMI/B27; RPMI pur/B27; RPMI pur/lactate; starvation MM) to assess the effect of media nutrient content on ischemia susceptibility.

Results

CMs matured in RPMI/B27 media did not show a significant increase in cell death independent of media glucose or serum content during ischemia (ratio dead/live RPMI pur/lactate: 0,02±0,004 [24 hours 21% O2]; 0,11±0,04 [24 hours 1% O2], p>0,05). CMs matured in MM did show an increase in cell death with increasing duration of ischemia for both 5% and 1% O2 (0,58±0,06 [0h]; 1,1±0,09 [24h 1%]). Furthermore, only metabolically matured CMs showed increased TUNEL+ CMs (7,5±1,3% [control]; 42,2±11,0%, p<0,001 [24 hours 1% O2]) and decreased viability measured by flow cytometry (90,8±0,71% [control]; 76,3±2,2% [24 hours 1% O2], p<0,01) compared to immature CMs (84,5±2,0% [control]; 73,7±3,4% [24 hours 1% O2], p>0,05). Although cardiomyocytes matured in MM showed stable α-actinin expression after 24 hours 1% oxygen (92,7±3,35 [24 hour 21%]; 93,8±1,7 [24 hour 1%]), both incubation in 5% and 1% oxygen led to decreased myofibrillar organization as seen by α-actinin and cardiac troponin T (cTnT) immunoreactivity. Assessment of metabolites in the media showed increased lactate production after 24 hours incubation in 1% oxygen but not in 5% oxygen (from 11,8±0,31mM [24 hour 21%], 11,7±0,3mM [24 hour 5%] to 19,9±1,4 mM [24 hour 1%], p<0,001) indicating that even though 5% oxygen levels were sufficient to induce ischemic damage, further lowering oxygen saturation does have an additional effect on the cardiomyocyte metabolic response to ischemia.

Conclusion

Taken together, we have shown improvement of metabolic maturation of hiPSC-CMs increases the susceptibility to ischemia and therefore their use to mimic ischemic heart disease. It would be of interest to further investigate the underlying metabolic mechanisms of cardiac ischemia.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): MMCP is supported by a Netherlands CardioVascular ResearchInitiative (CVON) grant

Monitoring of sound and carious surfaces under sealants over 44 months

Although there is strong evidence for the effectiveness of sealants, one major barrier in sealant utilization is the concern of sealing over active caries lesions. This study evaluated detection and monitoring of caries lesions through a clear sealant over 44 mo. Sixty-four 7- to 10-year-old children with at least 2 permanent molars with International Caries Detection and Assessment System (ICDAS) scores 0-4 (and caries less than halfway through the dentin, radiographically) were examined with ICDAS, DIAGNOdent, and quantitative light-induced fluorescence (QLF) before sealant placement and 1, 12, 24, and 44 mo (except QLF) after. Bitewing radiographs were taken yearly. DIAGNOdent and QLF were able to distinguish between baseline ICDAS before and after sealant placement. There was no significant evidence of ICDAS progression at 12 mo, but there was small evidence of minor increases at 24 and 44 mo (14% and 14%, respectively) with only 2% ICDAS ≥ 5. Additionally, there was little evidence of radiographic progression (at 12 mo = 1%, 24 mo = 3%, and 44 mo = 9%). Sealant retention rates were excellent at 12 mo = 89%, 24 mo = 78%, and 44 mo = 70%. The small risk of sealant repair increased significantly as baseline ICDAS, DIAGNOdent, and QLF values increased. However, regardless of lesion severity, sealants were 100% effective at 12 mo and 98% effective over 44 mo in managing occlusal surfaces at ICDAS 0-4 (i.e., only 4 of 228 teeth progressed to ICDAS ≥ 5 associated with sealants in need of repair and none to halfway or more through the dentin, radiographically). This study suggests that occlusal surfaces without frank cavitation (ICDAS 0-4) that are sealed with a clear sealant can be monitored with ICDAS, QLF, or DIAGNOdent, which may aid in predicting the need for sealant repair.

Clinical reduction of S. mutans in pre-school children using a novel liquorice root extract lollipop: a pilot study

AIM

To determine the clinical effect of a simple herbal caries-prevention protocol aimed at reduction of Streptococcus mutans (SM) in young children in a pre-school setting.

STUDY DESIGN

Proof-of-principle pilot study.

METHODS

To prove the concept this pilot study delivered a clinical intervention using sugar-free lollipops containing liquorice root extract. Regimen: Supervised herbal lollipops, twice daily for 3 weeks. Species-specific monoclonal antibody testing of saliva provided SM counts. Children were grouped in high, medium and low caries-risk using baseline SM-levels as risk-indicator. Bacterial numbers at baseline, during intervention, and for 9 weeks post-intervention were compared.

STATISTICS

SM levels were analysed using GEE modelling.

RESULTS

High-risk children showed the steepest early decrease in mean log-SM (P<.001). At end of a follow-up period, the log-SM decrease moved the high-risk group down to moderate-risk level. High-risk children showed a decrease in fitted mean SM% not seen in other groups (P<.001). The decrease reached a nadir around 22-days post-intervention. Twice-daily use of herbal lollipop significantly reduced both number and relative percent of SM in high-risk children. SM numbers were reduced for 22 days after the last lollipop, stabilized and then began to rebound.

CONCLUSION

A potential for simple effective caries-prevention for high-risk children has been demonstrated. Encouraging results warrant randomised clinical trials (RCT) of liquorice root in herbal lollipops or alternative modes of delivery.

In vivo acid etching effect on bacteria within caries-affected dentin

Acid etching procedures may disrupt residual bacteria and contribute to the success of incomplete caries removal followed by adhesive restoration. This study evaluated the in vivo effect of acid etching on cariogenic bacterial activity within affected dentin after minimally invasive treatment of caries lesions. Twenty-eight carious permanent teeth received standardized selective caries removal and random acid etch treatment (E) or not (NE) prior to adhesive restoration. Baseline and 3-month dentin biopsies were collected. The number of bacteria and activity of total bacterial cells and Streptococcus mutans were determined by quantitative PCR and RT-PCR. No statistically significant differences were observed in total bacterial number and activity between E and NE treatments (p > 0.3008). For NE, however, the residual S. mutans bacterial cells were reduced (p = 0.0027), while the activity per cell was significantly increased (p = 0.0010) after reentry at 3 months after restoration. This effect was not observed in group E. Although no significant differences were found between groups, this study suggests that acid etching of affected dentin prior to adhesive restoration may directly or indirectly have an inhibitive effect on the activity of residual cariogenic bacteria. Further research is required to investigate this potential effect.

In vivo dentin microhardness beneath a calcium-phosphate cement

A minimally invasive caries-removal technique preserves potentially repairable, caries-affected dentin. Mineral-releasing cements may promote remineralization of soft residual dentin. This study evaluated the in vivo remineralization capacity of resin-based calcium-phosphate cement (Ca-PO(4)) used for indirect pulp-capping. Permanent carious and sound teeth indicated for extraction were excavated and restored either with or without the Ca-PO(4) base (control), followed by adhesive restoration. Study teeth were extracted after 3 months, followed by sectioning and in vitro microhardness analysis of the cavity floor to 115-microm depth. Caries-affected dentin that received acid conditioning prior to Ca-PO(4) basing showed significantly increased Knoop hardness near the cavity floor. The non-etched group presented results similar to those of the non-treated group. Acid etching prior to cement application increased microhardness of residual dentin near the interface after 3 months in situ.

In vivo dentin remineralization by calcium-phosphate cement

Minimally invasive caries-removal procedures remove only caries-infected dentin and preserve caries-affected dentin that becomes remineralized. Dental cements containing calcium phosphate promote remineralization. This study evaluated the in vivo remineralization capacity of resin-based calcium-phosphate cement (Ca-P) used for indirect pulp-capping. Carious and sound teeth indicated for extraction were randomly restored with the Ca-P base or without base (control), followed by adhesive restoration. Study teeth were extracted after three months, followed by elemental analysis of the cavity floor. Mineral content of affected or sound dentin at the cavity floor was quantified by electron probe micro-analysis to 100-mum depth. After three months, caries-affected dentin underneath the Ca-P base showed significantly increased calcium and phosphorus content to a depth of 30 mum. Mineral content of treated caries-affected dentin was in the range of healthy dentin, revealing the capacity of Ca-P base to promote remineralization of caries-affected dentin.

Effect of bur type and conditioning on the surface and interface of dentine

The purpose of this in vitro study was to evaluate the surface and resin-dentine interface characteristics of permanent tooth dentine cut with diamond or carbide burs and treated with phosphoric acid (PA) or an acidic conditioner. Labial surfaces of permanent incisors were prepared into dentine with high-speed carbide or diamond burs and divided into two halves. Phosphoric acid 36% was applied on one half and non-rinse conditioner (NRC) was applied on the other half. Ten randomly selected scanning electron microscopy (SEM) fields from each specimen (n = 15) were evaluated. Occlusal surfaces of third molars were divided in two halves for evaluation of the resin-dentine interface. The halves were randomly assigned to one of each conditioner and restored with Prime & Bond NT/Spectrum. Ten specimens were analysed by SEM to evaluate hybrid layer formation and interfacial seal. We observed that surfaces prepared with carbide bur presented less residual smear plugs (P < 0.05) than surfaces prepared with diamond burs. Surfaces conditioned with NRC, which is a smear layer modifier, presented more residual smear plugs than surfaces conditioned with PA (P < 0.05). Treatment with PA resulted in more sealed interfaces than specimens treated with NRC. Within the limitations of this study the results showed that carbide burs leave a surface that is more conducive to bonding than diamond burs.

Decrease in inflammatory hyperalgesia by herpes vector-mediated knockdown of Nav1.7 sodium channels in primary afferents

Induction of peripheral inflammation increases the expression of the Nav1.7 sodium channel in sensory neurons, potentially increasing their excitability. Peripheral inflammation also produces hyperalgesia in humans and an increase in nociceptive responsiveness in animals. To test the relationship between these two phenomena we applied a recombinant herpes simplex-based vector to the hindpaw skin of mice, which encoded both green fluorescent protein (GFP) as well as an antisense sequence to the Nav1.7 gene. The hindpaw was subsequently injected with complete Freund's adjuvant to induce robust inflammation. Application of the vector, but not a control vector encoding only GFP, prevented an increase in Nav1.7 expression in GFP-positive neurons and prevented development of hyperalgesia in both C and Adelta thermonociceptive tests. These results provide clear evidence of the involvement of an increased expression of the Nav1.7 channel in nociceptive neurons in the development of inflammatory hyperalgesia.

Peripheral and central p38 MAPK mediates capsaicin-induced hyperalgesia

The stress-activated mitogen-activated protein kinase (MAPK) p38 is emerging as an important mediator of pain. The present study examined the possible involvement of peripheral and spinal p38 MAPK in capsaicin-induced thermal hyperalgesia. Topical capsaicin produced phosphorylation of p38 MAPK in the skin from the affected hindpaw as well as the corresponding lumbar spinal cord in a time dependent manner. Topical capsaicin produced robust C-fiber mediated thermal hyperalgesia that was inhibited by systemic, local peripheral, or central intrathecal pre-treatment with the p38 MAPK inhibitor, SD-282. Intraperitoneal SD-282 (10-60 mg/kg) significantly and dose-dependently attenuated capsaicin-induced C-fiber mediated thermal hyperalgesia. Similarly, 0.1-5mg/kg subcutaneous SD-282 in the hindpaw dose-dependently attenuated capsaicin-induced thermal hyperalgesia. Intrathecal administration of 1microg SD-282 was also anti-hyperalgesic in this model. Functionally, SD-282 decreased capsaicin-induced release of calcitonin gene related peptide in an in vitro skin release assay, consistent with a role for p38 MAPK in peripheral nerve function. These results suggest that p38 MAPK plays a role in the development of hyperalgesic states, exerting effects both centrally in the spinal cord and peripherally in sensory C fibers.

Aging affects two modes of nanoleakage expression in bonded dentin

Water sorption into resin-dentin interfaces precedes hydrolytic degradation. We hypothesized that these processes are morphologically manifested by the uptake of ammoniacal silver nitrate, which is thought to trace hydrophilic domains and water-filled channels within matrices. Water sorption is thought to be nonuniform and can be traced by the use of silver nitrate. Human teeth bonded with an experimental filled-adhesive were aged in artificial saliva (experimental) or non-aqueous mineral oil (control). Specimens retrieved for up to a 12-month period were immersed in 50 wt% ammoniacal silver nitrate and examined by transmission electron microscopy for identification of the changes in their silver uptake. Reticular silver deposits initially identified within the bulk of hybrid layers in the experimental group were gradually reduced over time, but were subsequently replaced by similar deposits that were located along the hybrid layer-adhesive interface. Silver uptake in water-binding domains of the adhesive layers increased with aging, resulting in water tree formation. These water-filled channels may act as potential sites for hydrolytic degradation of resin-dentin bonds.

Polymeric system for dual growth factor delivery

The development of tissues and organs is typically driven by the action of a number of growth factors. However, efforts to regenerate tissues (e.g., bone, blood vessels) typically rely on the delivery of single factors, and this may partially explain the limited clinical utility of many current approaches. One constraint on delivering appropriate combinations of factors is a lack of delivery vehicles that allow for a localized and controlled delivery of more than a single factor. We report a new polymeric system that allows for the tissue-specific delivery of two or more growth factors, with controlled dose and rate of delivery. The utility of this system was investigated in the context of therapeutic angiogenesis. We now demonstrate that dual delivery of vascular endothelial growth factor (VEGF)-165 and platelet-derived growth factor (PDGF)-BB, each with distinct kinetics, from a single, structural polymer scaffold results in the rapid formation of a mature vascular network. This is the first report of a vehicle capable of delivery of multiple angiogenic factors with distinct kinetics, and these results clearly indicate the importance of multiple growth factor action in tissue regeneration and engineering.

Quasisteady aero-acoustic response of orifices

The low frequency response of orifices (slit, circular diaphragm, and perforated plate) in the presence of mean flow is well predicted by a quasisteady theory. A refinement is brought to the theory by considering a Mach number dependent vena contracta coefficient. The measurements of the vena contracta coefficient of a slit agree well with the simple analytical expression existing in the case of the Borda tube orifice. The measured scattering matrix coefficients do not depend strongly on the geometry of the element. If the frequency is increased the moduli remain relatively unaffected while the arguments exhibit a complex behavior which depends on the geometry. From these considerations an anechoic termination efficient at high mass flow is designed.

Minimally invasive operative care. I. Minimal intervention and concepts for minimally invasive cavity preparations

SUMMARY

From the mainly reparative dentistry of the 20th century, contemporary dentistry shifts towards a minimal intervention (MI) approach encompassing up-to-date caries diagnosis and risk assessment before arriving at a treatment decision. An overview is provided of incorporating MI philosophy into the field of operative dentistry. The ultimate goal of MI is to extend the lifetime of restored teeth with as little intervention as possible. When operative care is indicated, it should be aimed at "prevention of extension." Black's principles for cavity design are considered and put in the perspective of minimally invasive operative care. Guiding principles for contemporary adhesive cavities are reviewed.

CONCLUSION

Contemporary operative care should be based on a minimally invasive approach. Minimal intervention is not just a technique, it is a philosophy!

Minimally invasive operative care. II. Contemporary techniques and materials: an overview

SUMMARY

Restorative dentistry has experienced a shift from the mainly reparative dentistry of the 20th century towards a minimal intervention approach. Contemporary operative treatment incorporates the MI philosophy in cavity design. Currently available techniques to pursue minimally invasive restorative treatments are highlighted. Characteristics of adhesive materials that facilitate minimally invasive operative care are discussed.

CONCLUSION

When operative intervention is the designated treatment for initial caries, currently available operative techniques and contemporary materials warrant a minimally invasive approach. Minimal intervention applied to the operative field keeps the options open for long-term preservation of the restored tooth.

Engineering and characterization of functional human microvessels in immunodeficient mice

SUMMARY

Current model systems used to investigate angiogenesis in vivo rely on the interpretation of results obtained with nonhuman endothelial cells. Recent advances in tissue engineering and molecular biology suggest the possibility of engineering human microvessels in vivo. Here we show that human dermal microvascular endothelial cells (HDMEC) transplanted into severe combined immunodeficient (SCID) mice on biodegradable polymer matrices differentiate into functional human microvessels that anastomose with the mouse vasculature. HDMEC were stably transduced with Flag epitope or alkaline phosphatase to confirm the human origin of the microvessels. Endothelial cells appeared dispersed throughout the sponge 1 day after transplantation, became organized into empty tubular structures by Day 5, and differentiated into functional microvessels within 7 to 10 days. Human microvessels in SCID mice expressed the physiological markers of angiogenesis: CD31, CD34, vascular cellular adhesion molecule 1 (VCAM-1), and intercellular adhesion molecule 1 (ICAM-1). Human endothelial cells became invested by perivascular smooth muscle alpha-actin-expressing mouse cells 21 days after implantation. This model was used previously to demonstrate that overexpression of the antiapoptotic protein Bcl-2 in HDMEC enhances neovascularization, and that apoptotic disruption of tumor microvessels is associated with apoptosis of surrounding tumor cells. The proposed SCID mouse model of human angiogenesis is ideally suited for the study of the physiology of microvessel development, pathologic neovascular responses such as tumor angiogenesis, and for the development and investigation of strategies designed to enhance the neovascularization of engineered human tissues and organs.

Controlled growth factor release from synthetic extracellular matrices

Polymeric matrices can be used to grow new tissues and organs, and the delivery of growth factors from these matrices is one method to regenerate tissues. A problem with engineering tissues that exist in a mechanically dynamic environment, such as bone, muscle and blood vessels, is that most drug delivery systems have been designed to operate under static conditions. We thought that polymeric matrices, which release growth factors in response to mechanical signals, might provide a new approach to guide tissue formation in mechanically stressed environments. Critical design features for this type of system include the ability to undergo repeated deformation, and a reversible binding of the protein growth factors to polymeric matrices to allow for responses to repeated stimuli. Here we report a model delivery system that can respond to mechanical signalling and upregulate the release of a growth factor to promote blood vessel formation. This approach may find a number of applications, including regeneration and engineering of new tissues and more general drug-delivery applications.

Sustained release of vascular endothelial growth factor from mineralized poly(lactide-co-glycolide) scaffolds for tissue engineering

Strategies to engineer bone tissue have focused on either: (1) the use of scaffolds for osteogenic cell transplantation or as conductive substrates for guided bone regeneration; or (2) release of inductive bioactive factors from these scaffold materials. This study describes an approach to add an inductive component to an osteoconductive scaffold for bone tissue engineering. We report the release of bioactive vascular endothelial growth factor (VEGF) from a mineralized, porous, degradable polymer scaffold. Three dimensional, porous scaffolds of the copolymer 85 : 15 poly(lactide-co-glycolide) were fabricated by including the growth factor into a gas foaming/particulate leaching process. The scaffold was then mineralized via incubation in a simulated body fluid. Growth of a bone-like mineral film on the inner pore surfaces of the porous scaffold is confirmed by mass increase measurements and quantification of phosphate content within scaffolds. Release of 125I-labeled VEGF was tracked over a 15 day period to determine release kinetics from the mineralized scaffolds. Sustained release from the mineralized scaffolds was achieved, and growth of the mineral film had only a minor effect on the release kinetics from the scaffolds. The VEGF released from the mineralized and non-mineralized scaffolds was over 70% active for up to 12 days following mineralization treatment, and the growth of mineral had little effect on total scaffold porosity.

Bioabsorbable polymer scaffolds for tissue engineering capable of sustained growth factor delivery

Engineering new tissues utilizing cell transplantation on biodegradable polymer matrices is an attractive approach to treat patients suffering from the loss or dysfunction of a number of tissues and organs. The matrices must maintain structural integrity during the process of tissue formation, and promote the vascularization of the developing tissue. A number of molecules (angiogenic factors) have been identified that promote the formation of new vascular beds from endothelial cells present within tissues, and the localized, controlled delivery of these factors from a matrix may allow an enhanced vascularization of engineered tissues. We have developed a gas foaming polymer processing approach that allows the fabrication of three-dimensional porous matrices from bioabsorbable materials (e.g., copolymers of lactide and glycolide [PLG]) without the use of organic solvents or high temperatures. The effects of several processing parameters (e.g., gas type, polymer composition and molecular weight) on the process were studied. Several gases (CO(2), N(2), He) were utilized in the fabrication process, but only CO(2) resulted in the formation of highly porous, structurally intact matrices. Crystalline polymers (polylactide and polyglycolide) did not form porous matrices, while amorphous copolymers (50:50, 75:25, and 85:15 ratio of lactide:glycolide) foamed to yield matrices with porosity up to 95%. The mechanical properties of matrices were also regulated by the choice of PLG composition and molecular weight. Angiogenic factors (e.g., vascular endothelial growth factor) were subsequently incorporated into matrices during the fabrication process, and released in a controlled manner. Importantly, the released growth factor retains over 90% of its bioactivity. In summary, a promising system for the incorporation and delivery of angiogenic factors from three-dimensional, biodegradable polymer matrices has been developed, and the fabrication process allows incorporation under mild conditions.

Comparison of two measurement techniques for clinical wear

OBJECTIVES

Clinical wear of restorations is generally evaluated by marginal integrity over time. In this study, both a subjective and an objective method for wear assessment are compared, and the relative advantages and disadvantages of each are considered.

METHODS

A surface evaluation technique for quantitative measurement of wear, as developed at the University of Minnesota (UMN) has been compared to the commonly employed method of wear assessment used by Leinfelder (LF). Measurements were made by comparing suitable casts of restored teeth before and after clinical function. Semi-quantitative wear assessment was studied in comparison with detailed quantitative information about the topology of the pre- and post-wear occlusal surfaces obtained from stylus profilometry and processed by imaging techniques. Fourteen model sets of baseline, 2, 3 and 5 year old Class II composite restorations from a Danish clinical trial were evaluated using both techniques.

RESULTS

In general, after 5 years of function, the digitizing method (UMN) generated wear values that were twice as high, indicating that general wear of restorative materials is underestimated by the LF-method.

CONCLUSIONS

The comparison clearly revealed the advantages and limitations of each technique. Evaluation of wear by means of the LF technique provides global semi-quantitative data on restoration margins relative to enamel, underestimating general wear of the restorative material. Advanced 3-D measuring techniques such as the UMN method provide extensive quantitative data regarding wear patterns of the entire occlusal surface, i.e. restoration and enamel. Such a highly accurate technique is capable of differentiation between wear behavior of restorative materials early on in clinical studies. In addition, through its digital alignment procedure, the UMN method provides data on accuracy of the replication process used in clinical studies.

Dimensional changes during veneering procedures on discoloured teeth

OBJECTIVES

The aim of the study was to determine the dimensional changes of teeth when veneering procedures are involved.

METHODS

Fifteen discoloured central incisors were selected from a group of 180 veneer restorations (VRs) composed of three different types of materials (direct resin composite, indirect resin composite and porcelain). Impressions and dies were made before treatment, after preparation and after placement and finishing the restoration. Contact stylus profilometry and subsequent analysis of the 3-D surface images provided quantitative data of the differences between the various treatment phases.

RESULTS

The preparation reduction was the most for indirect resin composite VRs and the least for direct resin composite VRs. All veneer restorations showed nearly the same thickness and dimensional change after treatment, except one, which resulted in an additional increase of volume of the tooth.

CONCLUSION

From the results of this study it is concluded that the dimensions of a discoloured tooth treated with a veneer restoration unintentionally increased, resulting in overcontour.

Enamel cracks. The role of enamel lamellae in caries initiation

Lamellae or cracks are distributed throughout tooth enamel in both deciduous and permanent dentitions. While earlier authors postulated that lamellae may be pathways of entry for caries, no evidence was adduced and the theory appears to have been discounted. The present study seeks to show that, at least in some cases, lamellae are permeable to dyes, may be associated with caries initiated in the dentine, supporting the hypothesis of Hardwick and Manly of lamellae penetration by Streptococcus mutans and lactobacilli. The enamel lamellae are shown to be a permeable pathway allowing caries-producing bacteria access to the dentine-enamel junction. Caries can thus be established within the tooth without visible evidence at the surface.

Release from alginate enhances the biological activity of vascular endothelial growth factor

A primary factor which limits engineering tissues of substantial size is the lack of nutrients readily available to transplanted cells. One potential solution to this nutrient limitation is to encourage the rapid development of a vascular network within three-dimensional tissue engineering matrices. Vascular endothelial growth factor (VEGF) has been identified as a potent stimulator of angiogenesis in vivo. Though effective at stimulating endothelial cells to form blood vessels VEGF degrades rapidly. Spherical alginate beads (3.3+/-0.1 mm diameter) were examined as a means of delivering biologically functional VEGF at a controlled rate over extended times. The alginate beads demonstrated the ability to incorporate VEGF with an efficiency between 30 and 67%, depending on the processing conditions, and release it at a constant rate (5%/day) for up to 14 days in vitro. The released VEGF, when assayed for its ability to stimulate endothelial cells in culture, was found not only to be functional but more potent (three to five times) than the same mass of VEGF added directly to the culture medium. The release kinetics of freeze dried VEGF containing alginate beads were also examined and found to be comparable to non-freeze dried samples.

Development of technologies aiding large-tissue engineering

There are many clinical situations in which a large tissue mass is required to replace tissue lost to surgical resection (e.g., mastectomy). It is possible that autologous cell transplantation on biodegradable polymer matrices may provide a new therapy to engineer large tissue which can be used to treat these patients. A number of challenges must be met to engineer a large soft tissue mass. These include the design of (1) a structural framework to maintain a space for tissue development, (2) a space-filling matrix which provides for localization of transplanted cells, and (3) a strategy to enhance vascularization of the forming tissue. In this paper we provide an overview of several technologies which are under development to address these issues. Specifically, support matrices to maintain a space for tissue development have been fabricated from polymers of lactide and glycolide. The ability of these structures to resist compressive forces was regulated by the ratio of lactide to glycolide in the polymer. Smooth muscle cell seeding onto polyglycolide fiber-based matrices has been optimized to allow formation of new tissues in vitro and in vivo. Finally, polymer microsphere drug delivery technology is being developed to release vascular endothelial growth factor (VEGF), a potent angiogenic molecule, at the site of tissue formation. This strategy, which combines several different technologies, may ultimately allow for the engineering of large soft tissues.

Electron probe microanalysis and transverse microradiography studies of artificial lesions in enamel and dentin: a comparative study

In cardiology and research involving the interactions between restorative materials and dental hard tissues, it is important for small changes in tooth mineral content to be measurable. Currently, transverse microradiography (TMR) is the most accepted tool for the above purpose. Electron Probe Microanalysis (EPMA) can yield both qualitative identification of elements and quantitative compositional information. The purpose of this study was to compare the mineral distribution in well-defined artificial lesions, in dentin and enamel, by the use of both TMR and EPMA on the same sample. The good correlation between the two sets of data validates EPMA as a technique and helps in the interpretation of its results. The data from TMR analysis are expressed as vol% of mineral, while EPMA gives the levels of Ca and phosphate in wt%. The conversion between the two sets of data is complicated by the fact that local density is, as yet, unknown.

A study of glass-ionomer cement and its interface with enamel and dentin using a low-temperature, high-resolution scanning electron microscopic technique

This report describes a method of immobilizing the water contained in glass-ionomer cement and dental hard tissues and stabilizing the delicate organic component of dentin. With this method, the intact interface between glass-ionomer and dental hard tissues can be observed under scanning electron microscope with few of the artifacts that are caused by the desiccation associated with conventional scanning electron microscopic studies. There was a distinct zone of interaction between the glass-ionomer cement and enamel and dentin. Under severe thermal stress, glass-ionomer cement failed cohesively, leaving an intact interface with enamel and dentin. Machine-mixed glass-ionomer cements displayed a high level of porosity. Some glass particles were separated from the matrix, and there was evidence that some are dislodged from the matrix during specimen preparation.

The strength of auto-cured and light-cured materials. The shear punch test

This paper examines the versatility of the shear punch test as described by Roydhouse and suggests that it should be considered as an alternative to the present standard compressive strength test for glass ionomer cements and flexural strength for composite resins. The shear punch test can be used for examining small thin specimens, about 1.0 mm thick and 8.0 mm in diameter, of both auto-cured and light-cured restorative materials such as composite resins and glass ionomer cements. The preparation of the specimen is simple and does not require a precision mould or subsequent machining to size except that, after curing, it may need to be abraded gently to obtain flat parallel test surfaces. The test apparatus consists of a punch approximately 3.0 mm in diameter opposing a true fitting matching die. The specimen is supported over the die section and the punch is advanced through it in a compression cage. The formula used to calculate the shear strength allows for variation in specimen thickness and thus provides comparative data between materials. It also allows examination of the effects of variations in manipulation, maturation and storage of each material. It is suggested this test should be considered as an alternative to the present compression and flexural strength tests because it would provide a single strength test for a range of restorative materials being manipulated under a variety of circumstances. It is of particular significance for testing the light-cured materials because it examines a specimen size below that of the diameter of the exit window of a normal clinical light curing unit and also at a thickness where depth of cure of the material is not a problem.

Distributed crack analysis of ceramic inlays

In all-ceramic restorations, crack formation and propagation phenomena are of major concern, since they may result in intra-oral fracture. The objective of this study was calculation of damage in porcelain MOD inlays by utilization of a finite-element (FE) implementation of the distributed crack theory. "Damage" is defined as the parameter that describes the local decrease of stiffness caused by microdefects. In the simulated MOD ceramic inlay, the crack initiation starts at the internal occlusal surface near the pulpo-axial line angle. This initiation is invisible from the external surface and cannot be detected by the clinician. The crack initiation at the internal surface started as soon as 55-60% of the loading needed for complete fracture was reached. The use of FE techniques for calculation of the fracture in loaded ceramic inlays offers prospects for further detailed study of the crack behavior, including three-dimensional modeling and cyclic loading situations.

Failure behaviour of fatigue-tested post and cores

Evaluation of the long-term behaviour of restorations in clinical trials can be time-consuming. A partial alternative to the clinical trial can be found in mechanical fatigue testing. The aim of this study was to evaluate the failure behaviour of post and core restored teeth when subjected to cyclic mechanical loading and to compare it with quasistatic failure. Eighty seven premolar teeth were restored with a titanium alloy post and an amalgam or composite core. Five to 21 days after restoration, the specimens were subjected to cyclic loading (frequency 5 Hz), at an angle of 45 degrees to the long axis of the tooth. The load levels were 50, 60, 65 and 70% of mean quasistatic failure loads. The specimens were divided into three groups according to their survival time: short (S) (< 10(4) cycles), intermediate (I) (10(4) < or = life < 10(5) cycles) and long (L) (> or = 10(5) cycles). For both core materials failure behaviour changed after approximately 10(5) cycles, and the change was most marked for the composite group. Catastrophic fatigue failure consisted of core fracture in the amalgam group (three times) and of post fracture in the composite L group (four times). Three post fractures occurred at a site theoretically predisposed to fatigue failure. It was concluded that fatigue failure characteristics of post and core restorations may be very different from those of quasistatic failure. Therefore, in addition to quasistatic tests, fatigue tests are necessary, covering at least 10(5) load cycles.

The Weibull distribution applied to post and core failure

In this study, data on initial failure loads of direct post and core-restored premolar teeth were analyzed using the Weibull distribution. Restorations consisted of a prefabricated titanium alloy post, and an amalgam, composite or glass cermet core buildup in human upper premolar teeth. The specimens were subjected to compressive forces until failure at angles of 10, 45 and 90 degrees to their long axis. The two- and three-parameter Weibull distributions were compared for applicability to the failure load data. For estimation of the parameters of the two-parameter distribution: sigma 0 (reference stress) and m (Weibull modulus), linear regression was used. In this distribution, it is assumed that the third parameter, sigma u (cut-off stress), equals 0. The Maximum Likelihood (MLH) method was used to estimate all three parameters. It was found that the choice of distribution has a strong influence on the estimated values and that the three-parameter distribution is best fitted for the failure loads in this study. Comparisons were made between the failure probability curves as found by MLH estimation for the different core materials and loading angles. The results indicated that the influence of loading angle on the failure mechanism was stronger than that of core material.

Accuracy and dimensional stability of a combined hydrocolloid impression system

The accuracy of a combined hydrocolloid impression system was studied as a function of time of pour. There was little change in dimension between posts for all time intervals studied. No statistically significant differences were noted among the observation periods until 3 hours. The results indicate that for the impression system studied, a 3-hour pouring time can be used for transport to a commercial dental laboratory, provided the impressions are stored in 100% relative humidity. The hydrocolloid impression system tested resulted in a stone cast of slightly deviating dimensions compared with the master model. Therefore laboratory procedures should compensate for cement thickness, taking into account the minimal changes in dimensions of the die.

Curing light performance and polymerization of composite restorative materials

The majority of modern composite restorative materials require light activation for polymerization. Variables affecting light energy absorption by the composite have been examined for their effect on the polymerization contraction. Since the polymerization contraction is closely associated in a complex way to the degree of cure of the restoration, this parameter served as an empirical indicator for the extent of polymerization. Variables included the composite shade, distance between the light source and composite sample, and light intensity. Three resin composites are evaluated. Post-gel polymerization contraction was evaluated using a strain gauge method. Curing light intensity diminished rapidly for distances greater than 2 mm between the tip of the light guide and material surface. A linear relationship was demonstrated between polymerization contraction and light intensity. The polymerization contraction of a microfilled composite and posterior composite, using a constant curing time and light intensity, decreased linearly with increasing sample thickness. Less than optimal light output of the curing light source can be compensated by increasing application time within reasonable limits.

Effects of polymerization contraction in composite restorations

Post-gel polymerization contraction of resin composite induces contraction stresses at the composite-tooth bond and in surrounding tooth structure. Strain gauges have been shown to be an effective method for measuring linear post-gel polymerization contraction of composites. A new model was developed in which the composite sample was bonded to and circumscribed by an acrylic ring. The model simulates a composite restoration surrounded by dentine. A strain gauge measured the deformation of the ring while a second strain gauge simultaneously recorded the dimensional change of the sample. Stresses placed on the acrylic ring as a result of polymerization contraction of the composite were calculated, based on the strains on the ring and the ring's material properties. Four composites (Heliomolar, Vivadent, Tonawanda, NY, USA; Herculite XR, Kerr Manufacturing Co., Romulus, MI, USA; P-50, 3M Co., St Paul, MN, USA; Silux Plus 3M Co.) were evaluated for polymerization contraction strain and stress on the surrounding acrylic ring during polymerization. At the end of the 60 s light application, Heliomolar demonstrated significantly lower post-gel contraction (0.12 per cent, P less than 0.05) when compared to the other materials. When the strain reached an equilibrium at the end of 14 min Heliomolar continued to demonstrate lower post-gel contraction, however this was not statistically significant at P less than 0.05. When the contraction stress on the surrounding acrylic ring was considered, P-50 rapidly developed and produced the largest stress values (1.7 MPa) at the end of the light application while Heliomolar produced the lowest stress values (0.3 MPa). These values, however, were not significantly different when evaluated statistically.(ABSTRACT TRUNCATED AT 250 WORDS)

Failure characteristics of endodontically treated premolars restored with a post and direct restorative material

Ninety-one extracted maxillary premolar teeth were restored with a prefabricated post and amalgam, composite resin or glass-cermet core. Each group was again divided into three groups of 9-13 teeth to be subjected to an increasing load in one of three standardized directions (10, 45 and 90 degrees to the long axis of the tooth). Failure load and characteristics of failure were recorded. The glass-cermet-restored teeth had a lower strength than the other groups for every load direction (Student's t-test: P less than 0.01). Amalgam and composite resin groups showed a significant difference only for the 10 degrees loading condition (Student's t-test: P less than 0.02). Teeth restored with amalgam cores displayed a higher mean failure load, in combination with a 46% occurrence of root fracture.

Fatigue behavior of direct post-and-core-restored premolars

Evaluation of long-term mechanical behavior of new types of restorations in clinical trials is time-consuming. A partial alternative can be found in experimental fatigue-testing, which simulates accelerated mechanical deterioration. The aim of this study was to determine the feasibility of using fatigue-testing of a complex dental restoration and to evaluate the mechanical fatigue behavior of premolar teeth restored with a titanium alloy post and an amalgam or composite core. Eighty-seven human upper premolar teeth were decoronated, embedded, and restored with a prefabricated post of 1 mm diameter. The teeth were randomly assigned to one of two groups corresponding with a core build-up of amalgam or chemically-cured core composite, respectively. Five to 21 days after restoration, the specimens were subjected to cyclic loading (frequency, 5 Hz), at an angle of 45 degrees to the long axis of the tooth. The boundary technique was used for determination of the mean fatigue strengths of the restorations at 10(4), 10(5), and 10(6) cycles, simulating up to 1-3 years of clinical functioning. Mean fatigue strength was expressed in percentage of initial strength: For 10(4), 10(5), and 10(6) cycles, the results were 66%, 58%, and 52%, respectively, for the amalgam and 62%, 62%, and 53% for the composite group. It is concluded that fatigue-testing of more complex systems is possible, if a suitable testing method is selected. The restorations showed a comparable strength reduction after 10(6) cycles of about 50% of their initial strength. The composite core build-up showed a behavior less predictable than that of the amalgam, which might be attributed to handling parameters.

Estimation of the mechanical lifetime of dental restorations: method and preliminary results

To assess the clinical performance of restorative materials with respect to mechanical failure, the shape of the restoration, the strength and fatigue properties and the loading history are important. This study deals with the feasibility of a method to estimate the mechanical lifetime of dental restorations. The method takes into account that the mechanical lifetime is a stochastic quantity determined by shape, strength and fatigue properties and by the cyclic nature of the mastication forces. The general outline of the method is described and the necessary experimental data are discussed. Preliminary estimates of the lifetime of a composite and an amalgam restoration are made. The method is found to be feasible and the estimated lifetimes of the restoration are of the same order of magnitude as found clinically.

Fracture-mechanics parameters of the composite-enamel bond

In a previous study, the critical values of the opening mode stress intensity factor (K1), its equivalent, the strain energy-release rate (G1), and the J integral (J1) (in the elastic case being equal to that of G1) were determined for resin composite. In this study, the strength of the composite-tooth interface was investigated. The critical values of K1 and J1 were measured with single-edge notched-bend (SENB) specimens of resin composite bonded to enamel, with the notch at midspan at the bonded interface. Due to enamel's anisotropy, the values of Klc and Jlc to be used in a fracture-mechanics application for failure prediction of a structure depend on the enamel prism orientation relative to the adhesive interface. Where interfacial failure is to be expected, the following values for Jlc and Klc can be used: Silux, Jlc = 145 +/- 35 Jm-2 and Klc = 0.84 +/- 0.16 MNm-3/2; P-30, Jlc = 163 +/- 13 Jm-2 and Klc = 1.02 +/- 0.07 MNm-3/2. Where enamel failure is expected or where the failure mode cannot be predicted, the following values can be applied: Silux, Jlc = 89 +/- 15 Jm-2 and Klc = 0.84 +/- 0.16 MNm-3/2; P-30, Jlc = 89 +/- 15 Jm-2 and Klc = 0.75 +/- 0.10 MNm-3/2.

Bulk fracture of amalgam restorations--a 5-year controlled clinical trial

A controlled clinical study, containing 720 posterior amalgam restorations placed in a group of 103 adult patients by three dentists, was used for examination of the influences on the incidence of occlusal and approximal bulk fractures. These fractures were evaluated from black and white photographs, taken annually, of the occlusal surface of the restorations over a 5-year period, using a three point photo-rating scale for both fracture sites. The influence of the dentist as well as the influence of the alloy and tooth type were statistically analysed. The results of these analyses demonstrated that the dentist, as well as the alloy and tooth type, have a statistically significant influence on the incidence of bulk fracture of amalgam restorations.

Fracture mechanics parameters for failure prediction of composite resins

This study contains the first part of a research project in which the applicability of fracture mechanics parameters to predict failure of a restored tooth was investigated. Fracture mechanics parameters have been used in dental research before, but were restricted to comparative studies between various brands of composites. The critical values of the opening mode stress intensity factor (KI), its equivalents, the strain energy release rate (GI), and the J integral (JI), were measured with single-edge notched-bend (SENB) specimens of dental composite in a three-point bend test. The measured values of KIc for Silux (KIc = 0.99 +/- 0.03 MNm-3/2) and P-30 (KIc = 1.88 +/- 0.12 MNm-3/2), compared with values from the literature, show quantitative agreement. The J integral was computed by means of finite element analysis (FEA) on a two-dimensional model of the SENB specimens. The critical value of the J integral (measured with SENB specimens, notch depth-to-width ratio (a/W) = 1/2) was used to predict failure of specimens having an arbitrary geometry. In this study, failure was predicted for SENB specimens with notch depth-to-width ratio (a/W) = 1/4 and 3/4. The predicted deflection and load at failure correspond well with the measured deflection and load.

Failure stress criteria for composite resin

In previous work (Peters and Poort, 1983), the stress distribution in axisymmetric models of restored teeth was analyzed by finite element analysis (FEA). To compare the tri-axial stress state at different sites, they calculated the Von Mises equivalent stress and used it as an indication for weak sites. However, the use of Von Mises' theory for material failure requires that the compressive and tensile strengths be equal, whereas for composite resin the compressive strength values are, on the average, eight times larger than the tensile strength values. The objective of this study was to investigate the applicability of a modified Von Mises and the Drücker-Prager criterion to describe mechanical failure of composite resin. In these criteria, the difference between compressive and tensile strength is accounted for. The stress criteria applied to an uni-axial tensile stress state are compared with those applied to a tri-axial tensile stress state. The uni-axial state is obtained in a Rectangular Bar (RB) specimen and the tri-axial state in a Single-edge Notched Bend (SENB) specimen with a chevron notch at midspan. Both types of specimens, made of light-cured composite, were fractured in a three-point bend test. The size of the specimens was limited to 16 mm x 2 mm x 2 mm (span, 12 mm). Load-deflection curves were recorded and used for linear elastic FEA. The results showed that the Drücker-Prager criterion is a more suitable criterion for describing failure of composite resins due to multi-axial stress states than are the Von Mises criterion and the modified Von Mises criterion.

Verification of theoretical modeling of heat transmission in teeth by in vivo experiments

A theoretical axisymmetric tooth model, simulating the conditions involved in the drinking of a liquid of a certain temperature, was compared with results of a similar in vivo experiment. The temperature changes as a result of one draught of a hot/cold liquid were recorded within the model as well as in the surrounding environment. The experimental data obtained were compared with the calculated results for the theoretical model as determined by the Finite Element Analysis. The temperatures recorded experimentally agreed reasonably with the calculated results. It can be concluded that the assumptions which have been made concerning the described thermal loading conditions lead to a good approximation of the physical reality.

Cohesive and adhesive fracture patterns of the composite-enamel bond

A method was developed to adhere composite to a small (1 mm2) surface of human enamel. The geometrical configuration resulted in a complex stress distribution in the vicinity of the composite-enamel bond during fracture in a tension test. The fracture surfaces were examined by scanning electron microscopy. The observed fracture areas at the enamel showed cohesive (composite-composite) as well as adhesive (composite-enamel) parts. The adhesive part of the fracture surface was surrounded by a composite wall. The typical fracture pattern can be explained by the complex stress situation and the deviant structure of the composite near the edge.

The influence of modification of cavity design on distribution of stresses in a restored molar

In this study, two different cavity designs were compared from a mechanical point of view: (a) an axisymmetric model of a conventional class 1 cavity preparation and restoration; and (b) an axisymmetric model of a modified cavity design. The modified design was characterized by a cavo-surface angle (c.s.a.) of approximately 90 degrees and a stepped cavity wall. Using a mathematical model, stresses were calculated by finite element analysis to compare the force distribution. It is concluded that the clinical superiority of the modified cavity design, with respect to the marginal breakdown of the amalgam restoration, can be supported by stress calculations.