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Schipper JAM, Tuin AJ, van Dongen JA, van Bakelen NB, Harmsen MC, Spijkervet FKL. Intra-Articular Injection of Adipose-Derived Stromal Vascular Fraction in Osteoarthritic Temporomandibular Joints: Study Design of a Randomized Controlled Clinical Trial. Bioengineering (Basel) 2024; 11:171. [PMID: 38391657 PMCID: PMC10886020 DOI: 10.3390/bioengineering11020171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/01/2024] [Accepted: 02/07/2024] [Indexed: 02/24/2024] Open
Abstract
INTRODUCTION Temporomandibular joint (TMJ) osteoarthritis is a degenerative disease of the TMJ. It is characterized by progressive degradation of the extracellular matrix components of articular cartilage, with secondary inflammatory components leading to pain in the temporomandibular region and reduced mouth opening. Current treatments do not halt disease progression, hence the need for new therapies to reduce inflammation and, consequently, improve symptoms. The aim of our randomized controlled clinical trial protocol is to investigate the efficacy of adjuvant intra-articular injections of autologous tissue-like stromal vascular fraction (tSVF), compared to arthrocentesis alone, in reducing pain and improving mouth opening in TMJ osteoarthritis patients. MATERIALS AND METHODS The primary endpoint analysis will consist of the visual analogue scale (VAS) for pain. The secondary endpoint analyses will include maximal interincisal mouth opening measurements; assessment of oral health and mandibular function based on the oral health impact profile (OHIP) questionnaire and mandibular functional impairment questionnaire (MFIQ); complications during the follow up; synovial cytokine analysis at baseline and after 26 weeks; and nucleated cells and tSVF (immuno)histochemistry analyses of the intervention group. DISCUSSION Our randomized clinical trial protocol will be applied to evaluate the efficacy of a new promising tSVF injection therapy for TMJ osteoarthritis. The safety of intra-articular injections of tSVF has been proven for knee osteoarthritis. However, since a tSVF injection is considered a heterologous application of cell therapy, the regulatory requirements are strict, which makes medical ethical approval challenging.
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Affiliation(s)
- Jan Aart M Schipper
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, 9713 Groningen, The Netherlands
| | - Aartje Jorien Tuin
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, 9713 Groningen, The Netherlands
| | - Joris A van Dongen
- Department of Plastic Surgery, University Medical Center Utrecht, University of Utrecht, 3584 Utrecht, The Netherlands
- Department of Pathology & Medical Biology, University Medical Center Groningen, University of Groningen, 9712 Groningen, The Netherlands
| | - Nico B van Bakelen
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, 9713 Groningen, The Netherlands
| | - Martin Conrad Harmsen
- Department of Pathology & Medical Biology, University Medical Center Groningen, University of Groningen, 9712 Groningen, The Netherlands
| | - Fred K L Spijkervet
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, 9713 Groningen, The Netherlands
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Fayed HM, Khairy MA, Eldahshan D, Sabry D, Ahmed WA. Bone marrow aspirate concentrate - A novel approach to alter the course of temporomandibular joint osteoarthritis (a clinical study). JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2024; 125:101644. [PMID: 37748708 DOI: 10.1016/j.jormas.2023.101644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/17/2023] [Accepted: 09/21/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION TMJ OA is characterized by severe osteocartilaginous degradation of the joint structure resulting in severe deterioration of both joint function as well as joint structure. bone marrow aspirate concentrate (BMAC) gained wide acceptance as an auspicious addition for regenerative medicine as it is confirmed to be a rich source of pluripotent mesenchymal stem cells and growth factors that produce promising relief of clinical symptoms with significant repair of the joint structure. Thus, the study aims at assessing the efficacy of bone marrow aspirate concentrate (BMAC) as a treatment modality for TMJ osteoarthritis and compare its efficacy with that of hyaluronic acid (HA). METHODS 24 patients were included in the present study and divided into 12 patients in each group. Joint arthrocentesis was performed to all patients followed by intra-articular BMAC injection in Group I. While Group II received HA acid injection RESULTS: A trend towards long term joint repair at 12 and 18 months follow up period was observed in the bone marrow aspirate concentrate (BMAC) group as a therapeutic modality for TMJ OA by providing necessary growth factors and anti-inflammatories that impedes the progression of the osteoarthritic degeneration. On the contrary to the viscosupplementary action of hyaluronic acid (HA) that showed relapse of patients conditions. CONCLUSION Bone marrow aspirate concentrate (BMAC) is able to reverse the degenerative effects of TMJ OA however,further studies are mandatory with larger population and longer follow-up time.
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Affiliation(s)
- Heba Mohamed Fayed
- oral and Maxillofacial surgery, Faculty of Dentistry, October 6 University, Egypt.
| | - Maggie A Khairy
- oral and Maxillofacial Surgery, Faculty of Dentistry, October 6 University, Egypt
| | - Dina Eldahshan
- Clinical & Chemical Pathology, Faculty of Medicine, Beni-Sueif University, Egypt
| | - Dina Sabry
- Medical Biochemistry and Molecular Biology, Faculty of Medicine, Cairo University, Egypt
| | - Waheed A Ahmed
- oral and Maxillofacial surgery, Faculty of Dentistry, October 6 University, Egypt
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Thalakiriyawa DS, Dissanayaka WL. Advances in Regenerative Dentistry Approaches: An Update. Int Dent J 2024; 74:25-34. [PMID: 37541918 PMCID: PMC10829373 DOI: 10.1016/j.identj.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 07/13/2023] [Accepted: 07/15/2023] [Indexed: 08/06/2023] Open
Abstract
Regenerative dentistry is a rapidly evolving field in dentistry, which has been driven by advancements in biomedical engineering research and the rising treatment expectations and demands that exceed the scope of conventional approaches. Tissue engineering, the foundation of regenerative dentistry, mainly focuses on 3 key components: stem cells, bioactive molecules, and scaffolds. Dental tissue-derived stem cells are especially significant in this regard due to their remarkable properties. Regenerative techniques have provided novel approaches to many conventional treatment strategies in various disciplines of dentistry. For instance, regenerative endodontic procedures such as pulp revascularisation have provided an alternative approach to conventional root canal treatment. In addition, conventional surgical and nonsurgical periodontal treatment is being taken over by modified approaches of guided tissue regeneration with the aid of 3-dimensional bioprinting and computer-aided design, which has revolutionised oral and maxillofacial tissue engineering. This review presents a concise overview of the latest treatment strategies that have emerged into clinical practice, potential future technologies, and the role of dental tissue-derived stem cells in regenerative dentistry.
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Affiliation(s)
| | - Waruna Lakmal Dissanayaka
- Applied Oral Sciences & Community Dental Care, Faculty of Dentistry, The University of Hong Kong, Hong Kong.
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Vaira LA, De Riu G. Temporomandibular Joint Disorders: Functional and Conservative Treatment. J Clin Med 2023; 12:4772. [PMID: 37510887 PMCID: PMC10381711 DOI: 10.3390/jcm12144772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 07/09/2023] [Indexed: 07/30/2023] Open
Abstract
Temporomandibular joint disorders (TMDs) represent a group of conditions that cause pain and dysfunction in the joints and muscles responsible for jaw movement [...].
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Affiliation(s)
- Luigi Angelo Vaira
- Maxillofacial Surgery Operative Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy
- Biomedical Science Department, PhD School of Biomedical Science, University of Sassari, 07100 Sassari, Italy
| | - Giacomo De Riu
- Maxillofacial Surgery Operative Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy
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Chęciński M, Chęcińska K, Turosz N, Brzozowska A, Chlubek D, Sikora M. Current Clinical Research Directions on Temporomandibular Joint Intra-Articular Injections: A Mapping Review. J Clin Med 2023; 12:4655. [PMID: 37510770 PMCID: PMC10380303 DOI: 10.3390/jcm12144655] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/27/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
This mapping review aims to identify and discuss current research directions on intracavitary temporomandibular joints (TMJs) injections. The inclusion criteria allowed studies published in the last full six years, based on patients diagnosed with temporomandibular joint disorders (TMDs), treated by TMJ intra-articular injections. Medical databases covered by the Association for Computing Machinery, Bielefeld Academic Search Engine, PubMed, and Elsevier Scopus engines were searched. The results were visualized with tables, charts, and diagrams. Of the 2712 records identified following the selection process, 152 reports were qualified for review. From January 2017, viscosupplementation with hyaluronic acid (HA) was the best-documented injectable administered into TMJ cavities. However, a significant growing trend was observed in the number of primary studies on centrifuged blood preparations administrations that surpassed the previously leading HA from 2021.
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Affiliation(s)
- Maciej Chęciński
- Department of Oral Surgery, Preventive Medicine Center, Komorowskiego 12, 30-106 Cracow, Poland
| | - Kamila Chęcińska
- Department of Glass Technology and Amorphous Coatings, Faculty of Materials Science and Ceramics, AGH University of Science and Technology, Mickiewicza 30, 30-059 Cracow, Poland
| | - Natalia Turosz
- Institute of Public Health, Jagiellonian University Medical College, Skawińska 8, 31-066 Cracow, Poland
| | - Anita Brzozowska
- Preventive Medicine Center, Komorowskiego 12, 30-106 Kraków, Poland
| | - Dariusz Chlubek
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland
| | - Maciej Sikora
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland
- Department of Maxillofacial Surgery, Hospital of the Ministry of Interior, Wojska Polskiego 51, 25-375 Kielce, Poland
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Vaira LA, Sergnese S, Salzano G, Maglitto F, Arena A, Carraturo E, Abbate V, Committeri U, Vellone V, Biglio A, Lechien JR, De Riu G. Are YouTube Videos a Useful and Reliable Source of Information for Patients with Temporomandibular Joint Disorders? J Clin Med 2023; 12:jcm12030817. [PMID: 36769466 PMCID: PMC9918192 DOI: 10.3390/jcm12030817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023] Open
Abstract
Counseling is considered a first-line conservative therapy with respect to temporomandibular joint disorders (TMJD). Nowadays, 50 to 80% of patients acquire health information from the internet before turning to professionals. The purpose of this study has been to investigate the quality of information about TMJD that patients can obtain from YouTube. A YouTube.com search was conducted using the terms "temporomandibular joint disorder"; "limited movement of the mandible"; and "mandibular joint pain". The videos identified were assessed independently by two panels of three professional and lay reviewers with HONcode, modified DISCERN (MD) and the global quality scale (GQS). A total of 106 videos were included. The professional reviewers reported a mean HONcode score of 4.148 ± 1.314 and a mean MD score of 2.519 ± 1.267, testifying to a modest general quality of the videos. The mean GQS score was 2.987 ± 1.012 for the professional and 3.469 ± 0.891 for the lay reviewers (p < 0.001). The correlations between the ratings were significant between the reviewers within the same group but not between the two groups. The presence of animations significantly influenced the GQS score expressed by the lay reviewers (p = 0.011) but not that of the professionals (p = 0.640). The quality of the information on TMJD on YouTube is generally of poor quality. Healthcare systems and professionals should be prepared to correct misinformation and build trusting relationships with patients which are based on quality counseling. Similarly, academic institutions should produce quality content that leads patients with TMJD toward a correct diagnostic-therapeutic process.
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Affiliation(s)
- Luigi Angelo Vaira
- Maxillofacial Surgery Operative Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy
- Biomedical Science Department, PhD School of Biomedical Science, University of Sassari, 07100 Sassari, Italy
- Correspondence: ; Tel.: +39-340-1846168
| | - Silvia Sergnese
- Maxillofacial Surgery Operative Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy
| | - Giovanni Salzano
- Maxillofacial Surgery Operative Unit, University Hospital of Naples “Federico II”, 80131 Naples, Italy
| | - Fabio Maglitto
- Maxillofacial Surgery Operative Unit, University Hospital of Naples “Federico II”, 80131 Naples, Italy
| | - Antonio Arena
- Maxillofacial Surgery Operative Unit, University Hospital of Naples “Federico II”, 80131 Naples, Italy
| | - Emanuele Carraturo
- Maxillofacial Surgery Operative Unit, University Hospital of Naples “Federico II”, 80131 Naples, Italy
| | - Vincenzo Abbate
- Maxillofacial Surgery Operative Unit, University Hospital of Naples “Federico II”, 80131 Naples, Italy
| | - Umberto Committeri
- Maxillofacial Surgery Operative Unit, University Hospital of Naples “Federico II”, 80131 Naples, Italy
| | - Valentino Vellone
- Department of Maxillofacial Surgery, Santa Maria Hospital, 05100 Terni, Italy
| | - Andrea Biglio
- Maxillofacial Surgery Operative Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy
| | - Jérome R. Lechien
- Department of Anatomy and Experimental Oncology, Mons School of Medicine, UMONS, Research Institute for Health Sciences and Technology, University of Mons (UMons), 7000 Mons, Belgium
- Department of Otolaryngology-Head Neck Surgery, Elsan Polyclinic of Poitiers, 86000 Poitiers, France
| | - Giacomo De Riu
- Maxillofacial Surgery Operative Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy
- Biomedical Science Department, PhD School of Biomedical Science, University of Sassari, 07100 Sassari, Italy
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Muacevic A, Adler JR, El Asmar EA, Abi Chahine NH. Degenerative Disorder of the Temporomandibular Joint Treated With Autologous Bone Marrow-Derived Stem Cells Using the Regentime Technique: A Case Report. Cureus 2023; 15:e34092. [PMID: 36843829 PMCID: PMC9946899 DOI: 10.7759/cureus.34092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2023] [Indexed: 01/24/2023] Open
Abstract
Temporomandibular joint (TMJ) disease is a type of degenerative musculoskeletal disorder that leads to morphological and functional abnormalities. It has a poorly understood progression with numerous independent and interrelated factors, which makes it difficult for the available treatment options to meet long-term demands. We present the case of a 37-year-old woman who suffered from excruciating pain in the right temporomandibular joint, associated with limited mandibular movement. She was found to have imaging features of TMJ disorder. She underwent the Regentime procedure which uses autologous bone marrow-derived stem cells that are partially differentiated and redirected to the targeted tissue. Clinical follow-up showed total clinical recovery.
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Temporomandibular Joint Osteoarthritis: Pathogenic Mechanisms Involving the Cartilage and Subchondral Bone, and Potential Therapeutic Strategies for Joint Regeneration. Int J Mol Sci 2022; 24:ijms24010171. [PMID: 36613615 PMCID: PMC9820477 DOI: 10.3390/ijms24010171] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/13/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022] Open
Abstract
The temporomandibular joint (TMJ) is a specialized synovial joint that is crucial for the movement and function of the jaw. TMJ osteoarthritis (TMJ OA) is the result of disc dislocation, trauma, functional overburden, and developmental anomalies. TMJ OA affects all joint structures, including the articular cartilage, synovium, subchondral bone, capsule, ligaments, periarticular muscles, and sensory nerves that innervate the tissues. The present review aimed to illustrate the main pathomechanisms involving cartilage and bone changes in TMJ OA and some therapeutic options that have shown potential restorative properties regarding these joint structures in vivo. Chondrocyte loss, extracellular matrix (ECM) degradation, and subchondral bone remodeling are important factors in TMJ OA. The subchondral bone actively participates in TMJ OA through an abnormal bone remodeling initially characterized by a loss of bone mass, followed by reparative mechanisms that lead to stiffness and thickening of the condylar osteochondral interface. In recent years, such therapies as intraarticular platelet-rich plasma (PRP), hyaluronic acid (HA), and mesenchymal stem cell-based treatment (MSCs) have shown promising results with respect to the regeneration of joint structures or the protection against further damage in TMJ OA. Nevertheless, PRP and MSCs are more frequently associated with cartilage and/or bone repair than HA. According to recent findings, the latter could enhance the restorative potential of other therapies (PRP, MSCs) when used in combination, rather than repair TMJ structures by itself. TMJ OA is a complex disease in which degenerative changes in the cartilage and bone develop through intricate mechanisms. The regenerative potential of such therapies as PRP, MSCs, and HA regarding the cartilage and subchondral bone (alone or in various combinations) in TMJ OA remains a matter of further research, with studies sometimes obtaining discrepant results.
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Kuliński W. Physical Procedure in Temporomandibular Joint Dysfunctions. Clinical Study. ACTA BALNEOLOGICA 2022. [DOI: 10.36740/abal202206101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Aim: Temporomandibular joint dysfunction is a common and difficult clinical problem. To present the use of physical therapy in patients with temporomandibular joint dysfunctions.
Materials and Methods: The paper presents the etiopathogenesis and clinical presentation of temporomandibular joint dysfunctions as well as patient cases and describes physical therapy in joint dysfunction, including the methods and equipment used to perform the procedures.
Conclusion: The paper stresses the importance of physical therapy in the treatment of temporomandibular joint dysfunctions. Physical therapy is a crucial part of treatment in patients with temporomandibular joint dysfunctions.
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Affiliation(s)
- Włodzisław Kuliński
- Department of Rehabilitation, Military Institute of Medicine, Warsaw, Poland
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10
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Tsui HC, Lam CM, Leung YY, Li KY, Wong NSM, Li DTS. Lavage Volume of Arthrocentesis in the Management of Temporomandibular Disorders: A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2022; 12:diagnostics12112622. [PMID: 36359466 PMCID: PMC9689331 DOI: 10.3390/diagnostics12112622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/14/2022] [Accepted: 10/19/2022] [Indexed: 11/16/2022] Open
Abstract
The aim of this study was to investigate the most effective lavage volume of arthrocentesis in the management of temporomandibular disorders. A comprehensive electronic search, based on the PRISMA guidelines, was performed, which included a computer search with specific keywords, a reference list search and a manual search. The inclusion criteria were the following: a randomized controlled trial, at least 20 subjects who underwent arthrocentesis, mention of the irrigation materials used for the arthrocentesis, mention of the irrigation volumes used for the arthrocentesis, MMO and pain measured as VAS or NRS, were reported as outcome figures, mention of a specific diagnosis or signs and symptoms, and inclusion of the data on the MMO or VAS/NRS at 6-month follow-up. Sixteen publications were enrolled in the meta-analysis, comparing arthrocentesis with a lavage volume <150 mL and arthrocentesis with a lavage volume ≥150 mL, in the efficacy of the improvement in the mouth opening and pain reduction. The results revealed the group with a lavage volume <150 mL had a greater improvement in the mouth opening and pain reduction. However, results are to be interpreted with caution, due to the paucity of the randomized controlled literature and other confounding factors. Further high-quality studies are required to provide a better conclusion to the treatment outcomes of the different lavage volumes.
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Affiliation(s)
| | - Chun Mo Lam
- Faculty of Dentistry, The University of Hong Kong, Hong Kong, China
| | - Yiu Yan Leung
- Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong, China
| | - Kar Yan Li
- Clinical Research Centre, Faculty of Dentistry, The University of Hong Kong, Hong Kong, China
| | - Natalie Sui Miu Wong
- Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong, China
| | - Dion Tik Shun Li
- Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong, China
- Correspondence:
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Matheus HR, Özdemir ŞD, Guastaldi FPS. Stem cell-based therapies for temporomandibular joint osteoarthritis and regeneration of cartilage/osteochondral defects: a systematic review of preclinical experiments. Osteoarthritis Cartilage 2022; 30:1174-1185. [PMID: 35597373 DOI: 10.1016/j.joca.2022.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 05/04/2022] [Accepted: 05/10/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The aim of this systematic review was to assess the effects of stem cell-based therapies on the treatment of Temporomandibular Joint Osteoarthritis (TMJ-OA) and the regeneration of cartilage/osteochondral defects. METHODS Data on preclinical studies evaluating the effectiveness of stem cell-based therapies for treating Temporomandibular Disorders (TMDs) were extracted from PubMed, Web of Science, and Cochrane Library and the grey literature by three independent reviewers. A manual search was performed in the databases, the reference list of review studies, and relevant journals in the field. Compliance with the ARRIVE guidelines was evaluated for quality assessment. SYRCLE's risk of bias tool for animal experimental studies was assessed to define internal validity. RESULTS After applying the inclusion and exclusion criteria, 10 studies were included in the qualitative synthesis. Regardless of cell origin, stem cell-based therapeutic approaches induced protective, anti-inflammatory, and chondroregenerative potential in the treatment of TMJ-OA. Regeneration of the cartilage layer on the surface of the condyle was achieved when stem cells were directly flushed into the defect or when delivered within a carrier. CONCLUSION Stem cell-based therapies may be considered a promising approach for the treatment of TMJ-OA and for the regeneration of full-thickness cartilage and osteochondral defects in the TMJ. Human studies shall be performed to validate these results found in animals.
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Affiliation(s)
- H R Matheus
- Skeletal Biology Research Center, Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Harvard School of Dental Medicine, Boston, MA, USA; Department of Diagnosis and Surgery - Periodontics Division, São Paulo State University (UNESP), School of Dentistry, Araçatuba, SP, Brazil.
| | - Ş D Özdemir
- Skeletal Biology Research Center, Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Harvard School of Dental Medicine, Boston, MA, USA; Istanbul Medipol University, School of Dentistry, İstanbul, Turkey.
| | - F P S Guastaldi
- Skeletal Biology Research Center, Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Harvard School of Dental Medicine, Boston, MA, USA.
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Autologous Stem Cells Transplants in the Treatment of Temporomandibular Joints Disorders: A Systematic Review and Meta-Analysis of Clinical Trials. Cells 2022; 11:cells11172709. [PMID: 36078117 PMCID: PMC9454527 DOI: 10.3390/cells11172709] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/24/2022] [Accepted: 08/26/2022] [Indexed: 11/17/2022] Open
Abstract
This systematic review aims to analyze the outcomes of the treatment of temporomandibular joint (TMJ) articular pain (AP) and restricted maximum mouth opening (MMO) with intra-articular administration of mesenchymal stem cells (MSCs). The inclusion criteria allowed primary studies involving AP and/or MMO pre-treatment and post-intervention values. Medical databases that were covered by ACM Digital, BASE, EBSCOhost, Google Scholar, PubMed, Scopus, and Web of Science engines were searched. The risk of bias was assessed with RoB 2 and ROBINS-I tools. The results were tabulated, plotted, and analyzed for regression. A total of 5 studies involving 51 patients/69 TMJs were identified, and 4 studies on 50 patients/67 TMJs were synthesized. Interventions were each time effective in decreasing AP and increasing MMO in a 6-month follow-up period by an average of about 85% and over 40%, respectively. Regression analysis showed a good fit of the logarithmic model for AP relief (5.8 − 0.8 ln x; R2 = 0.90) and MMO increase (33.5 + 2.4 ln x; R2 = 0.89). The results for AP and MMO were based on 3 studies in 39 patients and 4 studies in 50 patients, respectively, all at high risk of bias. The intra-articular administration of MSCs to TMJs, based on weak evidence, may be highly effective in reducing AP and improving MMO. This study received no funding.
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Memiş S. Evaluation of the effects of temporomandibular joint arthrocentesis with hyaluronic acid injection on mandibular condyles using fractal dimension analysis: A retrospective study. J Craniomaxillofac Surg 2022; 50:643-650. [DOI: 10.1016/j.jcms.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/15/2022] [Accepted: 07/02/2022] [Indexed: 12/01/2022] Open
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Chęciński M, Chęcińska K, Nowak Z, Sikora M, Chlubek D. Treatment of Mandibular Hypomobility by Injections into the Temporomandibular Joints: A Systematic Review of the Substances Used. J Clin Med 2022; 11:2305. [PMID: 35566431 PMCID: PMC9102811 DOI: 10.3390/jcm11092305] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/13/2022] [Accepted: 04/19/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Hyaluronic acid, steroids and blood products are popularly injected into the temporomandibular joint (TMJs) to relieve pain and increase the extent of mandibular abduction. The purpose of this review is to identify other injectable substances and to evaluate them in the above-mentioned domains. MATERIAL AND METHODS The review included articles describing clinical trials of patients treated with intra-articular injections with or without arthrocentesis. RESULTS The following emerging substances were initially evaluated to be effective in treating TMJ pain and increasing the amplitude of mandibular abduction: analgesics, dextrose with lidocaine, adipose tissue, nucleated bone marrow cells and ozone gas. DISCUSSION Better effects of intra-articular administration are achieved by preceding the injection with arthrocentesis. CONCLUSIONS The most promising substances appear to be bone marrow and adipose tissue.
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Affiliation(s)
- Maciej Chęciński
- Department of Oral Surgery, Preventive Medicine Center, Komorowskiego 12, 30-106 Cracow, Poland;
| | - Kamila Chęcińska
- Department of Glass Technology and Amorphous Coatings, Faculty of Materials Science and Ceramics, AGH University of Science and Technology, Mickiewicza 30, 30-059 Cracow, Poland;
| | - Zuzanna Nowak
- Department of Temporomandibular Disorders, Medical University of Silesia in Katowice, Traugutta 2, 41-800 Zabrze, Poland;
| | - Maciej Sikora
- Department of Maxillofacial Surgery, Hospital of the Ministry of Interior, Wojska Polskiego 51, 25-375 Kielce, Poland;
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland
| | - Dariusz Chlubek
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland
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15
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Gong S, Emperumal CP, Al-Eryani K, Enciso R. Regeneration of temporomandibular joint using in vitro human stem cells: A review. J Tissue Eng Regen Med 2022; 16:591-604. [PMID: 35357772 PMCID: PMC9310826 DOI: 10.1002/term.3302] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 02/21/2022] [Accepted: 03/16/2022] [Indexed: 11/25/2022]
Abstract
Temporomandibular joint disorders (TMDs) range from gross anatomic deformities of the disc and hard tissue to functional disturbances. Traditional treatment of TMDs includes physical therapy, use of appliances, pharmacological, surgical and psychological interventions. However, during the late stage of TMDs, conventional management often results in inadequate relief of symptoms. Stem cell‐based tissue regeneration has been studied extensively in joint regeneration, including the Temporomandibular Joint (TMJ). This study aims to review the potential of various human stem cells (HSC) for the regeneration of the TMJ. In vitro studies using human mesenchymal stem cells cultured under different conditions to evaluate regeneration of TMJ related structures were searched on PubMed, EMBASE, Cochrane, and Web of Science up to March 2020. In vitro studies utilized several different types of stem cells under varying conditions. Increased osteogenesis and/or chondrogenesis were noted with stem cell interventions compared to control groups on Alkaline Phosphatase (ALP) activity, Col‐I, Col‐II, Col‐X, RUNX2, LPL, and Aggrecan mRNA expression. This review emphasizes the potential of stem cell therapies in the regeneration of TMJ‐related structures. However, further in vivo studies are required to evaluate the efficacy and safety of these therapies in humans.
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Affiliation(s)
- Shan Gong
- Master of Science Program in Orofacial Pain and Oral Medicine, Herman Ostrow School of Dentistry of University of Southern California, Los Angeles, California, USA
| | - Chitra Priya Emperumal
- Master of Science Program in Orofacial Pain and Oral Medicine, Herman Ostrow School of Dentistry of University of Southern California, Los Angeles, California, USA
| | - Kamal Al-Eryani
- Division of Periodontology, Diagnostic Sciences & Dental Hygiene, Herman Ostrow School of Dentistry of University of Southern California, Los Angeles, California, USA
| | - Reyes Enciso
- Department of Geriatrics, Special Needs and Behavioral Sciences, Herman Ostrow School of Dentistry of University of Southern California, Los Angeles, California, USA
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16
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Gomez M, Wittig O, Diaz-Solano D, Cardier JE. Mesenchymal Stromal Cell Transplantation Induces Regeneration of Large and Full-Thickness Cartilage Defect of the Temporomandibular Joint. Cartilage 2021; 13:1814S-1821S. [PMID: 32493042 PMCID: PMC8808815 DOI: 10.1177/1947603520926711] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Cartilage damage (CD) in the temporomandibular joint (TMJ) continues being a major problem in maxillofacial field. Evidence suggests that cellular therapy may be used for repairing CD in the TMJ. DESIGN A murine model of condyle CD (CCD) was generated in the TMJ to evaluate the capacity of mesenchymal stromal cells (MSCs) to induce cartilage regeneration in CCD. A large CCD was surgically created in a condyle head of the TMJ of C57BL/6 mice. Human MSC embedded into preclotted platelet-rich plasma (PRP) were placed on the surface of CCD. As controls, untreated CCD and exposed TMJ condyle (sham) were used. After 6 weeks, animals were sacrificed, and each mandibular condyle was removed and CCD healing was assessed macroscopically and histologically. RESULTS Macroscopic observation of CCD treated with MSC showed the presence of cartilage-like tissue in the CCD site. Histological analysis showed a complete repair of the articular surface with the presence of cartilage-like tissue and subchondral bone filling the CCD area. Chondrocytes were observed into collagen and glycosaminoglycans extracellular matrix filling the repaired tissue. There was no evidence of subchondral bone sclerosis. Untreated CCD showed denudated osteochondral lesions without signs of cartilage repair. Histological analysis showed the absence of tissue formation over the CCD. CONCLUSIONS Transplantation of MSC induces regeneration of TMJ-CCD. These results provide strong evidence to use MSC as potential treatment in patients with cartilage lesions in the TMJ.
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Affiliation(s)
- Marcos Gomez
- Unidad de Terapia Celular,
Laboratorio de Patología Celular y Molecular, Instituto Venezolano de
Investigaciones Científicas (IVIC), Caracas, Miranda, Venezuela
| | - Olga Wittig
- Unidad de Terapia Celular,
Laboratorio de Patología Celular y Molecular, Instituto Venezolano de
Investigaciones Científicas (IVIC), Caracas, Miranda, Venezuela
| | - Dylana Diaz-Solano
- Unidad de Terapia Celular,
Laboratorio de Patología Celular y Molecular, Instituto Venezolano de
Investigaciones Científicas (IVIC), Caracas, Miranda, Venezuela
| | - José E. Cardier
- Unidad de Terapia Celular,
Laboratorio de Patología Celular y Molecular, Instituto Venezolano de
Investigaciones Científicas (IVIC), Caracas, Miranda, Venezuela,José E. Cardier, Unidad de Terapia
Celular, Laboratorio de Patología Celular y Molecular, Centro de
Medicina Experimental, Instituto Venezolano de Investigaciones
Científicas (IVIC). Apartado Postal: 20632. Caracas, Miranda, 1020A,
Venezuela.
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Emshoff R, Bertram A, Hupp L, Rudisch A. A logistic analysis prediction model of TMJ condylar erosion in patients with TMJ arthralgia. BMC Oral Health 2021; 21:374. [PMID: 34303363 PMCID: PMC8305951 DOI: 10.1186/s12903-021-01687-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 06/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In terms of diagnostic and therapeutic management, clinicians should adequately address the frequent aspects of temporomandibular joint (TMJ) osteoarthritis (OA) associated with disk displacement. Condylar erosion (CE) is considered an inflammatory subset of OA and is regarded as a sign of progressive OA changes potentially contributing to changes in dentofacial morphology or limited mandibular growth. The purpose of this study was to establish a risk prediction model of CE by a multivariate logistic regression analysis to predict the individual risk of CE in TMJ arthralgia. It was hypothesized that there was a closer association between CE and magnetic resonance imaging (MRI) indicators. METHODS This retrospective paired-design study enrolled 124 consecutive TMJ pain patients and analyzed the clinical and TMJ-related MRI data in predicting CE. TMJ pain patients were categorized according to the research diagnostic criteria for temporomandibular disorders (RDC/TMD) Axis I protocol. Each patient underwent MRI examination of both TMJs, 1-7 days following clinical examination. RESULTS In the univariate analysis analyses, 9 influencing factors were related to CE, of which the following 4 as predictors determined the binary multivariate logistic regression model: missing posterior teeth (odds ratio [OR] = 1.42; P = 0.018), RDC/TMD of arthralgia coexistant with disk displacement without reduction with limited opening (DDwoR/wLO) (OR = 3.30, P = 0.007), MRI finding of disk displacement without reduction (OR = 10.96, P < 0.001), and MRI finding of bone marrow edema (OR = 11.97, P < 0.001). The model had statistical significance (chi-square = 148.239, Nagelkerke R square = 0.612, P < 0.001). Out of the TMJs, 83.9% were correctly predicted to be CE cases or Non-CE cases with a sensitivity of 81.4% and a specificity of 85.2%. The area under the receiver operating characteristic curve was 0.916. CONCLUSION The established prediction model using the risk factors of TMJ arthralgia may be useful for predicting the risk of CE. The data suggest MRI indicators as dominant factors in the definition of CE. Further research is needed to improve the model, and confirm the validity and reliability of the model.
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Affiliation(s)
- Rüdiger Emshoff
- Orofacial Pain and TMD Unit, University Clinic of Oral and Maxillofacial Surgery, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
| | - Annika Bertram
- Otto Von Guericke University of Magdeburg, Magdeburg, Germany
| | - Linus Hupp
- University Clinic of Oral and Maxillofacial Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Ansgar Rudisch
- University Clinic of Radiology, Medical University of Innsbruck, Innsbruck, Austria
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18
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Pagotto LEC, de Santana Santos T, Pastore GP. The efficacy of mesenchymal stem cells in regenerating structures associated with the temporomandibular joint: A systematic review. Arch Oral Biol 2021; 125:105104. [PMID: 33706151 DOI: 10.1016/j.archoralbio.2021.105104] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/13/2021] [Accepted: 03/02/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVES The objective of this systematic review is to evaluate the role of mesenchymal stem cells in the regenerative treatment of temporomandibular joint resorption. DESIGN Search strategies were performed in the following databases: PubMed/MEDLINE, EMBASE, Cochrane Collaboration Library, and Web of Science. Two independent reviewers selected the included articles using a two-phase process based on the eligibility criteria. The reviewers independently collected the required information from the included articles. The methodological quality of the selected studies was assessed individually. RESULT In accordance with the inclusion and exclusion criteria, 703 studies were found and 8 articles were included. Thus, six studies using animal models and two human studies were included in this systematic review. CONCLUSION Based on the data of our systematic review, the use of mesenchymal stem cells is a promising method for the repair and regeneration of temporomandibular joint components.
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Affiliation(s)
| | | | - Gabriel Pires Pastore
- Institute of Education and Research - IEP, Sírio Libanês Hospital, São Paulo, Brazil
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Sembronio S, Tel A, Tremolada C, Lazzarotto A, Isola M, Robiony M. Temporomandibular Joint Arthrocentesis and Microfragmented Adipose Tissue Injection for the Treatment of Internal Derangement and Osteoarthritis: A Randomized Clinical Trial. J Oral Maxillofac Surg 2021; 79:1447-1456. [PMID: 33675704 DOI: 10.1016/j.joms.2021.01.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 01/07/2021] [Accepted: 01/29/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Internal derangement and osteoarthritis are the most common degenerative temporomandibular joint diseases and initial treatment for such conditions relies on arthrocentesis. Microfragmentation of adipose tissue has been proven in orthopedic literature to represent a more effective method to preserve stem cells, but no application has ever been reported in the temporomandibular joint. The purpose of this randomized clinical trial is to compare standard treatment conducted by injecting hyaluronic acid after the procedure to the new treatment relying upon microfragmented adipose tissue injection using the Lipogems technology. MATERIALS AND METHODS A randomized clinical trial was designed enrolling 20 patients in the control group receiving the standard treatment and 20 patients in the experimental group receiving microfragmented adipose tissue obtained through the Lipogems technology after arthrocentesis. Two main outcomes were defined, pain (visual analogic scale) and function (maximum interincisal opening). Both were measured in the immediate preoperative time, and 10 days, 1 month, and 6 months after the procedure. RESULTS In both groups, pain reduction and mouth opening significantly improved compared with the preoperative situation (P = .001). At 6-month follow-up, there was an almost statistically significant reduction of pain compared with preoperative visual analogic scale (P = .0546) and a statistically significant improvement of mouth opening (P = .0327). Overall, statistical analyses showed that the experimental group had a statistically significant superiority in the success rate of the procedure compared with the control group (P = .018). CONCLUSIONS Preliminary results of this clinical trial show that the injection of microfragmented adipose tissue can significantly improve outcomes of pain and function compared with the standard treatment and encourage to pursue research on this topic. Further studies with a longer follow-up time are needed to evaluate the clinical stability of the achieved improvement in pain and function.
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Affiliation(s)
- Salvatore Sembronio
- Consultant, Maxillofacial Surgery Department, Academic Hospital of Udine, Department of Medicine, University of Udine, Udine, Italy
| | - Alessandro Tel
- Resident, Maxillofacial Surgery Department, Academic Hospital of Udine, Department of Medicine, University of Udine, Udine, Italy
| | - Carlo Tremolada
- Professor, Manchester Metropolitan University (UK), Founder of Lipogems, Scientific Director of Image Regenerative Clinic, Udine, Italy
| | - Andrea Lazzarotto
- Resident, Maxillofacial Surgery Department, Academic Hospital of Udine, Department of Medicine, University of Udine, Udine, Italy
| | - Miriam Isola
- Assistant Professor, Statistics Institute, University of Udine, Udine, Italy
| | - Massimo Robiony
- Department Head and Full Professor, Maxillofacial Surgery Department, Academic Hospital of Udine, Department of Medicine, University of Udine, Udine, Italy.
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Martínez-Gimeno C, García-Hernández A, Martínez-Martínez R. Single portal arthroscopic temporomandibular joint discopexy: Technique and results. J Craniomaxillofac Surg 2021; 49:171-176. [PMID: 33546966 DOI: 10.1016/j.jcms.2021.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 12/22/2020] [Accepted: 01/12/2021] [Indexed: 10/22/2022] Open
Abstract
The aim of the present study is to assess the outcomes of monoportal arthroscopic disc repositioning (discopexy) for disc displacement of the temporomandibular joint. A retrospective, single-institutional clinical study included patients with temporomandibular joint internal derangements diagnosed and treated by monoportal discopexy. Each patient was diagnosed as having anterior disk displacement with or without reduction. The arthroscopy treatment consists of one portal approach fixing the disc with a 3/0 nylon to the tragus cartilage without anterior liberation. Arthroscopy surgery was carried out with a 1.9-mm 0° arthroscope and only one simple cannula. We use a needle to pierce of the disc through the skin and retrieve the suture inside the joint using a blind method through the arthroscopic cannula. The evaluated variables included the maximum interincisal opening, the presence of clicking and pain score. A total of 19 patients, 21 joints, were included in the present study. Of the 21 joints, 16 were classified as disc displacement with reduction and 5 without. Visual analogue scale (VAS) values (0-10) decreased from 5.5 to 1.26 (p < 0.0001) 1 year after surgery. At the first review, all patients had a VAS of at least 4 points less than before the surgery, four patients showed a VAS of 0, and nine patients near to 1. Mouth opening increased from 36.6 (±8.09) mm to 39.37 (±4.35) mm, and no significant limitations in the mouth opening range were seen (p < 0.12) 1 year after surgery. Clicking disappeared in all patients and remained stable after 12 months of follow-up. Postoperative magnetic resonance imaging demonstrated a correct or improved position of the disc in all but one patient. A minimally invasive single portal arthroscopic discopexy is an effective technique to improve function and pain reduction in patients with anterior disk displacement with or without reduction.
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Affiliation(s)
- Carlos Martínez-Gimeno
- Department of Oral and Maxillofacial Surgery, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain; Head of Department of Oral and Maxillofacial Surgery, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain.
| | - Alberto García-Hernández
- Department of Oral and Maxillofacial Surgery, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain.
| | - Ricardo Martínez-Martínez
- Department of Oral and Maxillofacial Surgery, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain.
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21
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Comparison of Different Intraarticular Injection Substances Followed by Temporomandibular Joint Arthroscopy. J Craniofac Surg 2020; 31:637-641. [DOI: 10.1097/scs.0000000000006098] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Bone Regeneration, Reconstruction and Use of Osteogenic Cells; from Basic Knowledge, Animal Models to Clinical Trials. J Clin Med 2020; 9:jcm9010139. [PMID: 31947922 PMCID: PMC7019836 DOI: 10.3390/jcm9010139] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 12/21/2019] [Accepted: 01/02/2020] [Indexed: 01/01/2023] Open
Abstract
The deterioration of the human skeleton's capacity for self-renewal occurs naturally with age. Osteoporosis affects millions worldwide, with current treatments including pharmaceutical agents that target bone formation and/or resorption. Nevertheless, these clinical approaches often result in long-term side effects, with better alternatives being constantly researched. Mesenchymal stem cells (MSCs) derived from bone marrow and adipose tissue are known to hold therapeutic value for the treatment of a variety of bone diseases. The following review summarizes the latest studies and clinical trials related to the use of MSCs, both individually and combined with other methods, in the treatment of a variety of conditions related to skeletal health. For example, some of the most recent works noted the advantage of bone grafts based on biomimetic scaffolds combined with MSC and growth factor delivery, with a greatly increased regeneration rate and minimized side effects for patients. This review also highlights the continuing research into the mechanisms underlying bone homeostasis, including the key transcription factors and signalling pathways responsible for regulating the differentiation of osteoblast lineage. Paracrine factors and specific miRNAs are also believed to play a part in MSC differentiation. Furthering the understanding of the specific mechanisms of cellular signalling in skeletal remodelling is key to incorporating new and effective treatment methods for bone disease.
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