Healing of experimentally created defects: a review

A clinical long-term radiographic evaluation of graft height changes after maxillary sinus floor augmentation with a 2 : 1 autogenous bone/xenograft mixture and simultaneous placement of dental implants

The aim of the present study was to assess long-term changes in sinus-graft height after maxillary sinus floor augmentation and simultaneous placement of implants. A total of 191 patients who underwent maxillary sinus floor augmentation were radiographically followed for up to about 10 years. A 2 : 1 mixture of autogenous bone and bovine xenograft (Bio-Oss) was used as the graft material. Sinus-graft height was measured using 294 panoramic images immediately after augmentation and up to 108 months subsequently. Changes in sinus-graft height were calculated with respect to implant length and original sinus height. Patients were divided into three groups based on the height of the grafted sinus floor relative to the implant apex: Group I, in which the grafted sinus floor was above the implant apex; Group II, in which the implant apex was level with the grafted sinus floor; and Group III, in which the grafted sinus floor was below the implant apex. After augmentation, the grafted sinus floor was consistently located above the implant apex. After 2-3 years, the grafted sinus floor was level with or slightly below the implant apex. This relationship was maintained over the long term. Sinus-graft height decreased significantly and approached original sinus height. The proportion of patients classified as belonging to Group III reached a maximum from year 3 onwards. The clinical survival rate of implants was 94.2%. All implant losses occurred within 3 years after augmentation. We conclude that progressive sinus pneumatization occurs after augmentation with a 2 : 1 autogenous bone/xenograft mixture, and long-term stability of sinus-graft height represents an important factor for implant success.

Radiographic and histological study of perennial bone defect repair in rat calvaria after treatment with blocks of porous bovine organic graft material

Over the last few years, various bone graft materials of bovine origin to be used in oromaxillofacial surgeries have entered the market. In the present study, we determined the capacity of a block organic bone graft material (Gen-ox, Baumer SA, Brazil) prepared from bovine cancellous bone to promote the repair of critical size bone injuries in rat calvaria. A transosseous defect measuring approximately 8mm in diameter was performed with a surgical trephine in the parietal bone of 25 rats. In 15 animals, the defects were filled with a block of graft material measuring 8mm in diameter and soaked in the animal's own blood, and in the other 10 animals the defects were only filled with blood clots. The calvariae of rats receiving the material were collected 1, 3 and 6 months after surgery, and those of animals receiving the blood clots were collected immediately and 6 months after surgery. During surgery, the graft material was found to be of easy handling and to adapt perfectly to the receptor bed after soaking in blood. The results showed that, in most animals treated, the material was slowly resorbed and served as a space filling and maintenance material, favoring angiogenesis, cell migration and adhesion, and bone neoformation from the borders of the lesion. However, a foreign body-type granulomatous reaction, with the presence of numerous giant cells preventing local bone neoformation, was observed in two animals of the 1-month subgroup and in one animal of the 3-month subgroup. These cases were interpreted as resulting from the absence of demineralization and the lack of removal of potential antigen factors during production of the biomaterial. We conclude that, with improvement in the quality control of the material production, block organic bone matrix will become a good alternative for bone defect repair in the oromaxillofacial region due to its high osteoconductive capacity.

Site-specific delivery of acidic fibroblast growth factor stimulates angiogenic and osteogenic responsesin vivo

A major clinical problem in orthopedics is the healing of nonunion fractures. Limitations of this bone repair process include insufficient angiogenesis and mineralization. Integrating appropriate biomaterials with site-specific neovascularization and osteogenesis at the wound site has been the focus of several clinically relevant therapeutic strategies. As an extracellular protein, acidic fibroblast growth factor (FGF-1) induces, coordinates, and sustains site-specific molecular responses associated with angiogenesis and osteogenesis. To establish the ability of this growth factor to coordinate bone regenerative process in vivo, site-specific delivery of FGF-1, entrapped in a fibrin/hydroxyapatite composite, was evaluated. Kinetic analysis in vivo revealed the biocomposite was capable of delivering biologically active FGF-1. Release kinetics revealed an initial delivery of 87.5 ng/h of active FGF-1 in the first 20 h, followed by a reduced delivery of 28 ng/h during the next 20 h. In situ immunohistological analyses demonstrated that FGF-1-containing implants induced increased angiogenesis and infiltration of cells expressing osteogenic related markers (i.e., osteopontin, osteocalcin). Collectively, these efforts support that site-specific delivery of active FGF-1 in a fibrin/hydroxyapatite composite is competent to induce not only angiogenesis but also osteogenic cellular responses.

Le Fort I osteotomy in atrophied maxilla and bone regeneration with pure-phase beta-tricalcium phosphate and PRP

Le Fort I osteotomy is a versatile procedure in oral and maxillofacial surgery for the correction of dysgnathias as well as for an easy approach to the surgical site in neurosurgery; however, it is rarely performed for a vertical advancement of the maxilla. This paper presents the successful use of the synthetic pure-phase beta-tricalcium phosphate (beta-TCP) Cerasorb (Curasan, Kleinostheim, Germany), together with autogenous bone at a ratio of 4:1, in combination with patients' own platelet-rich plasma for a vertical augmentation of completely atrophied maxillae, resulting in an advancement of 16 and 14 mm, respectively. After a period of 8 months the beta-TCP was completely resorbed and the x-ray control showed no residual granules in the defect sites. Pure-phase beta-TCP proved to be a bone-regeneration material, providing the patient with vital bone at the defect site in a reasonable time, making a second surgical procedure for bone harvesting (e.g., at the iliac crest) unnecessary. The relapse of approximately one third in the second case did not affect the success of treatment and was attributed to the combination of platelet-rich plasma with a resorbable polylactic membrane. Thus, in the combination of pure-phase beta-TCP and platelet-rich plasma, the use of nonresorbable membranes and suture materials is recommended. These results encourage the qualified surgeon to use the pure-phase beta-TCP for bone regeneration even when performing augmentations of this dimension.

Microradiography to evaluate bone growth into a rat mandibular defect

Microradiography has been evaluated to measure bone healing into a 5.0mm outer diameter mandibular defect in the rat. This method provides high-resolution radiographs of the defects that can be used for an accurate measurement of bone defect healing. In 12 rats, the defect widths of 42-day-old mandibular defects have been measured both using microradiographs and histological sections. The defect width+/-S.D. measured 3.42+/-0.98 mm microradiographically and 3.47+/-1.11 mm histologically. Both methods were accurate in determining defect widths but microradiography has the advantage over histology that an image is obtained from the entire defect, making it possible to measure areas of bone growth.

Carboxymethylcellulose-stabilized collagenous rhOP-1 device?a novel carrier biomaterial for the repair of mandibular continuity defects

Human recombinant osteogenic protein-1 (rhOP-1) is osteoinductive. Efforts are made to develop carrier biomaterials with improved space-keeping properties. Bovine collagen type I matrix charged with rhOP-1 was suggested to be an advantageous device of relative liquid quality. We hypothesized that the addition of carboxymethylcellulose (CMC) may stabilize the device and facilitate the regeneration of mandibular continuity defects without further addition of mineralized carrier materials. To test this hypothesis, the anatomical shape, functional remodeling, and mechanical stability of such bony regenerates were evaluated in the course of an animal experiment. Mandibular continuity defects of 5 cm in size were created in five Göttingen minipigs on one side (contralateral hemimandible: control) and bridged with titanium plates. Four animals were treated with the rhOP-1 device (3000 microg rhOP-1, 2 g collagen, 1 g CMC), and one animal was treated with a placebo device omitting rhOP-1. After 12 weeks of experimental period, bony continuity was reestablished in rhOP-1-treated hemimandibles. The bony regenerates were of good anatomical shape, volume, and functional remodeling. Placebo treatment led to insufficient bony regenerates of significant lower bone volume (volume in 3D-CT scan 29.81 cm(3) vs 8.85 cm(3)). To produce 1 mm of bending, 1972 N were needed for rhOP-1-treated hemimandibles, 2617 N for control hemimandibles, and 642 N for the placebo treated hemimandible. CMC stabilization of collagen carrier biomaterials for rhOP-1 provides good plasticity as well as excellent space-keeping properties and may not interfere with osteoinduction. The results of this preliminary study suggest that the applied rhOP-1 device offers a potential option for further studies on the reconstruction of mandibular defects.

Heterotopic neo-osteogenesis from vascularized periosteum and bone grafts

BACKGROUND

Periosteum is an osteogenic, flexible tissue. This study investigated the osteogenic potential of vascularized periosteal flaps in heterotopic conditions and compared it to the neo-osteogenesis from vascularized periosteal flaps combined with bone grafts with different properties (autologous and xenograft).

METHODS

Vascularized periosteal flaps from the hindlimbs of 48 rabbits formed cylindrical pouches that were buried in muscles. The pouches were filled with autologous bone grafts (P/A group, n = 16), xenograft (P/X group, n = 16), or left empty (P/E group, n = 16). Specimens were harvested between 1 and 4 months and underwent radiographic, histologic, and histomorphometric evaluation.

RESULTS

The total surface area was larger in the groups combined with bone grafts. Osseous apposition did not differ significantly in the P/A and P/X groups (p > 0.05). The central cavity contained hematopoietic cells (P/A), xenograft (P/X), or was absent (P/E).

CONCLUSION

Vascularized periosteal flaps presented strong osteogenic capacity in heterotopic conditions. Combination with bone grafts resulted in larger specimens. The quality of neo-osteogenesis was not influenced by the different properties of combined bone grafts.

Histomorphometric evaluation of the effect of doxycycline on the healing of bone defects in experimental diabetes mellitus: a pilot study

PURPOSE

Bone healing is impaired in diabetes mellitus, particularly due to increased collagen breakdown. Recently, tetracyclines have been used to treat experimental bone defects because they have anticollagenolytic properties, and positive effects on the healing process have been obtained. The objective of this study was to develop a computer-assisted histomorphometric technique to quantitatively determine the amount of regenerating bone within experimental bone defects in a diabetic rodent model.

MATERIALS AND METHODS

This study examined the effects of systemic doxycycline administration on the healing of tibial bone defects in healthy albino rats and in experimentally induced diabetic rats. Twenty-four female albino rats were assigned to 4 groups: diabetic, diabetic plus doxycycline, control, or control plus doxycycline. The standardized bone defects were histomorphometrically examined 10 and 30 days postoperatively. Histomorphometric analysis of the amount of new bone formation was performed using the Zeiss Vision image analysis program KS 400 (Kontron Elektron GmbH, Eching, Germany).

RESULTS

At 10 days of healing, the diabetic groups exhibited inferior healing compared with the control groups in terms of the amount of new bone formation within the defects. However, the effect of doxycycline administration to the diabetic and control groups was not statistically different. At 30 days of healing, there were no statistically significant differences between the amount of newly formed bone in any of the groups.

CONCLUSIONS

This study found that doxycycline administration did not significantly alter the amount of new bone formation during the healing of bone defects in control and diabetic rats.

Drug-releasing scaffolds fabricated from drug-loaded microspheres

Biodegradable scaffolds serve a central role in many strategies for engineering tissue replacements or in guiding tissue regeneration. Typically, these scaffolds function to create and maintain a space and to provide a support for cell adhesion. However, these scaffolds also can serve as vehicles for the delivery of bioactive factors (e.g., protein or DNA) in order to manipulate cellular processes within the scaffold microenvironment. This study presents a novel approach to fabricate tissue-engineering scaffolds capable of sustained drug delivery whereby drug-loaded microspheres are fabricated into structures with controlled porosity. A double-emulsion process was used to fabricate microspheres with encapsulated DNA that retained its integrity and was released from the microspheres within 24 h. These DNA-loaded microspheres subsequently were formed into a nonporous disk or an interconnected open-pore scaffold (>94% porosity) via a gas-foaming process. The disks and scaffolds exhibited sustained plasmid release for at least 21 days and had minimal burst during the initial phase of release. This approach of assembling drug-loaded microspheres into porous and nonporous structures may find great utility in the fabrication of synthetic matrices that direct tissue formation.

Repair of a critical size defect in the rat mandible using allogenic type I collagen

Mandibular fractures, resulting from either trauma or reconstructive surgery, can be challenging craniofacial problems. The morbidity of failed fracture healing is significant and may require bone grafting. Donor site morbidity and finite amounts of autogenous bone are major drawbacks of autogenous bone grafting. Similarly, the use of allografts and xenografts may be associated with an increased risk of rejection, infection, and nonunion. To circumvent the limitations of bone grafting, research efforts have focused on formulating a suitable bone substitute. The purpose of our study was to evaluate the efficacy of type I collagen implants in repairing critical sized mandibular defects in rats. Twelve male Sprague-Dawley rats (200-300g) were divided equally into control and experimental groups. Full thickness, round, four millimeter in diameter defects were created in the ramus of the right mandible of all rats using an electrical burr at low speed. The defects were irrigated of all bone chips, and either filled with a precisely fitted disk of allogenic collagen type I gel (experimental animals) or left empty (control animals). Animals were killed 6 weeks after surgery and healing of the bone defects was assessed in a blinded fashion using radiologic and histologic analysis. Radiologic analysis of the control group revealed a clear circular right mandibular defect in all animals, whereas the collagen disk implant group revealed an indistinct to nonexistent right mandibular defect in all animals. Densitometric analysis revealed a significant difference between these groups (* P = 0.01). Similarly, gross analysis of control mandibles revealed a 4mm round, soft-tissue filled defect, while implanted defects demonstrated gross bone spanning the defect. Finally, histologic analysis of all control mandibles revealed clearly demarcated bony edges at the defect border with connective tissue spanning the defect. In contrast, histological analysis of all implanted mandibles revealed indistinct bony edges at the defect border with a thin layer of osteoblasts and viable bone spanning the defects. We have demonstrated the ability of type I collagen to promote healing of a membranous bony defect that would not otherwise heal at 6 weeks. The suitability of type I collagen as a carrier matrix provides ample opportunity for tissue-engineered approaches to further facilitate bony defect healing. Promoting bone formation through tissue engineering matrices offers great promise for skeletal healing and reconstruction.

Poly(L-lactide)acid/alginate composite membranes for guided tissue regeneration

The barrier membranes for guided tissue regeneration (GTR) to treat bone defects have to satisfy the criteria of biocompatibility, cell-occlusiveness, space-making, tissue integration and clinical manageability. In this study a system constituted of a poly(L-lactide) acid (PLLA) asymmetric membrane combined with an alginate film was prepared. The PLLA membrane functions to both support the alginate film and separate the soft tissue; the alginate film is intended to act as potential vehicle for the growth factors to promote osteogenesis. The structural, morphological, and mechanical properties of the bilamellar membrane and its stability in culture medium were evaluated. Moreover, the feasibility of using the alginate membranes as controlled-release delivery vehicles of TGF-beta was monitored. Finally, the bacterial adhesion and permeability of Streptococcus mutans, selected for the high adhesive affinity, were monitored. The results showed that the surfaces of the alginate side, to be used in contact with the bone defect, were rougher than PLLA ones. When in contact with complete culture medium, the PLLA-alginate membrane retained its mechanical and structural properties for more than 100 days. Then, the degradation processes occurred but the membrane continued to be stable and manageable for 6 months. Growth factors such as TGF-beta can be incorporated into alginate membranes functioning as drug delivery vehicle, and retain the biological activity when tested in an in vitro model system. The obtained membrane acted as a barrier to the passage of S. mutans bacteria and showed to promote a lower bacterial adhesion with respect to commercial GTR membranes.

Engineered bone development from a pre-osteoblast cell line on three-dimensional scaffolds

Bone regeneration is based on the hypothesis that healthy progenitor cells, either recruited or delivered to an injured site, can ultimately regenerate lost or damaged tissue. Three-dimensional porous polymer scaffolds may enhance bone regeneration by creating and maintaining a space that facilitates progenitor cell migration, proliferation, and differentiation. As an initial step to test this possibility, osteogenic cells were cultured on scaffolds fabricated from biodegradable polymers, and bone development on these scaffolds was evaluated. Porous polymer scaffolds were fabricated from biodegradable polymers of lactide and glycolide. MC3T3-E1 cells were statically seeded onto the polymer scaffolds and cultured in vitro in the presence of ascorbic acid and beta-glycerol phosphate. The cells proliferated during the first 4 weeks in culture and formed a space-filling tissue. Collagen messenger RNA levels remained high in these cells throughout the time in culture, which is consistent with an observed increase in collagen deposition on the polymer scaffold. Mineralization of the deposited collagen was initially observed at 4 weeks and subsequently increased. The onset of mineralization corresponded to increased mRNA levels for two osteoblast-specific genes: osteocalcin and bone sialoprotein. Culture of cell/polymer constructs for 12 weeks led to formation of a three-dimensional tissue with architecture similar to that of native bone. These studies demonstrate that osteoblasts within a three-dimensional engineered tissue follow the classic differentiation pathway described for two-dimensional culture. Polymer scaffolds such as these may ultimately be used clinically to enhance bone regeneration by delivering or recruiting progenitor cells to the wound site.

Histological evaluation of different biodegradable and non-biodegradable membranes implanted subcutaneously in rats

Different types of biodegradable membranes have become available for guided tissue regeneration. The purpose of this study was to evaluate histologically three different biodegradable membranes (Bio-Gide, Resolut and Vicryl) and one non-biodegradable membrane (expanded polytetrafluoroethylene/e-PTFE) implanted subcutaneously in rats. Five subcutaneous pouches were created in each of 24 rats. One of the four test membranes was randomly placed in each of the four pouches and one pouch was left empty to serve as a control. Histological evaluation was performed after 4, 10 and 21 days which demonstrated that e-PTFE was well tolerated and encapsulated by a fibrous connective tissue capsule. There was capsule formation around Resolut and Vicryl and around Bio-Gide in the early phase there was a wide inflammatory zone already. e-PTFE and Vicryl were stable materials while Resolut and Bio-Gide fragmented in the early phase. In the late phase Vicryl was surrounded by an increasing amount of multinucleated macrophages and a thin capsule, whilst around Resolut and Bio-Gide a strong foreign body reaction was observed. Also granuloma formation was noted around the fragmented Resolut material in its capsule and a mild inflammatory reaction surrounding Bio-Gide within its thin capsule.

Mineralization processes in demineralized bone matrix grafts in human maxillary sinus floor elevations

For reconstruction of the severely resorbed lateral maxilla for dental implant placement, one of the successful procedures is to elevate the maxillary sinus floor by implanting demineralized bone matrix (DBM). We studied bone formation in DBM grafts in the lateral maxilla in humans by means of histology and histomorphometry. Six months after grafting, at the time of dental implantation biopsies were taken from the grafted areas of seven patients. All biopsies contained mineralized matrix (MM) in the grafted area. At close inspection, three types of mineralization were found. First, lamellar biomineralization was seen in and near the maxillary host bone. Second, remineralization was observed in some particles that probably had not been completely demineralized. In the area connecting the graft and host bone, where woven bone was formed against DBM particles, a third mechanism was detected. In this case many dotlike foci of remineralization appeared close to the bone-DBM interface. The remineralized DBM and woven bone were both subsequently remodeled. Bone formation was most active in the area adjoining the maxillary host bone. We conclude that in human sinus floor elevation, allogenic DBM increases mineralized tissue volume by osteoconduction that is supported by the remineralization processes. Osteoinduction by this material seems questionable.