Bone marrow concentrate and bovine bone mineral for sinus floor augmentation: a controlled, randomized, single-blinded clinical and histological trial--per-protocol analysis

Evolving Techniques and Trends in Maxillary Sinus Lift Procedures in Implant Dentistry: A Review of Contemporary Advances

The most challenging aspects of planning implant rehabilitation for the posterior maxillary region are the pneumatization of the maxillary sinus and the resorption of the residual alveolar ridge. To address the first aspect, there are two primary modalities for sinus augmentation: the direct or lateral window technique and the indirect or crestal technique. Clinicians must possess comprehensive knowledge of the maxillary sinus anatomy and be able to diagnose pathognomonic abnormalities through presurgical imaging and investigations. This skill is essential for performing technique-sensitive augmentation of the maxillary sinus with or without using biomaterials such as bone grafts, membranes, and platelet concentrates. These materials help create a suitable bone bed for either simultaneous or delayed implant placement through various traditional and evolving modified sinus augmentation techniques. It is also critical to effectively elevate the Schneiderian membrane during sinus floor elevation surgery, as complications in this process can adversely affect implant survival and potentially lead to implant failure. This review explores various aspects of maxillary sinus augmentation, ranging from traditional methods to evolving contemporary techniques, and draws on existing literature to examine their advantages, limitations, indications, and contraindications.

Stem cell therapies for periodontal tissue regeneration: A meta-analysis of clinical trials

Objective

Stem cell therapy in periodontal tissue regeneration has reported optimistic regenerative results; evidence supporting its superiority over conventional methods is still ambiguous. Therefore, this meta-analysis aims to evaluate the therapeutic effects of stem cells in human periodontal regeneration.

Design

A literature search was conducted to retrieve relevant articles on periodontal regeneration in stem cell therapy. A meta-analysis of the studies was conducted using the Stata software.

Results

Fifteen studies that examined the effect of stem cell therapies on periodontal tissue regeneration in 369 patients were selected from databases. Regardless of the various types of cells, both odontogenic (periodontal ligament, dental pulp, gingiva stem cell) and non-odontogenic (bone marrow, periosteum-derived, and umbilical cord stem cells), the cell therapies witnessed significant improvements in terms of clinical attachment level (SMD, -0.67; 95CI, -0.90 to -0.43), probing depth (SMD, -0.76; 95% CI, -1.21 to - 0.31), radiographic intrabony defect depth (SMD, -0.87; 95% CI, -1.52 to -0.23), and histomorphometric analysis of mineralized bone (SMD, 0.80; 95% CI, 0.42 to 1.19) when compared to traditional without-cell treatment in patients. However, evidence on gingival recession, alveolar thickness gain, bone mineral density of bone core, and bone volume fraction of bone core outcomes did not reach statistical significance.

Conclusions

Evidence suggests that the implementation of stem cell therapies in reconstructing compromised gingiva and alveolar bone tissue produces positive outcomes compared with conventional approaches. However, further well-designed investigations are needed to comprehensively identify the most effective source of cells and biomaterials for each case.

Residual Bone Height and New Bone Formation after Maxillary Sinus Augmentation Procedure Using Biomaterials: A Network Meta-Analysis of Clinical Trials

BACKGROUND

Different factors may affect new bone formation following maxillary sinus floor augmentation for the rehabilitation of posterior edentulous maxilla. The purpose of this study was to determine the influence of residual bone height (RBH) on new bone formation after lateral sinus augmentation utilizing different biomaterials, through a network meta-analysis (NMA).

METHODS

PUBMED, Scopus, and Web of Science electronic databases were searched until 31 December 2022 to obtain relevant articles. A hand search was also conducted. Randomised controlled studies on maxillary sinus augmentation comparing different grafting materials in patients with atrophic posterior maxilla, in need of prosthetic rehabilitation, were included. The risk of bias was assessed following the guidelines of the Cochrane Collaboration. The primary outcome was new bone formation (NBF), assessed histomorphometrically. The statistical analysis was performed by splitting the data according to RBH (<4 mm and ≥4 mm).

RESULTS

A total of 67 studies were eligible for conducting NMA. Overall, in the included studies, 1955 patients were treated and 2405 sinus augmentation procedures were performed. The biomaterials used were grouped into: autogenous bone (Auto), xenografts (XG), allografts (AG), alloplasts (AP), bioactive agents (Bio), hyaluronic acid (HA), and combinations of these. An inconsistency factor (IF) seen in the entire loop of the XG, AP, and Bio+AP was found to be statistically significant. The highest-ranked biomaterials for the <4 mm RBH outcome were XG+AG, XG+AP, and Auto. Similarly, the surface under the cumulative ranking curve (SUCRA) of biomaterials for ≥4 mm RBH was Auto, Bio+XG, and XG+Auto.

CONCLUSION

There is no grafting biomaterial that is consistently performing better than others. The performance of the materials in terms of NBF may depend on the RBH. While choosing a biomaterial, practitioners should consider both patient-specific aspects and sinus clinical characteristics.

Clinical and patient-reported outcomes of tissue engineering strategies for periodontal and peri-implant reconstruction

Scientific advancements in biomaterials, cellular therapies, and growth factors have brought new therapeutic options for periodontal and peri-implant reconstructive procedures. These tissue engineering strategies involve the enrichment of scaffolds with living cells or signaling molecules and aim at mimicking the cascades of wound healing events and the clinical outcomes of conventional autogenous grafts, without the need for donor tissue. Several tissue engineering strategies have been explored over the years for a variety of clinical scenarios, including periodontal regeneration, treatment of gingival recessions/mucogingival conditions, alveolar ridge preservation, bone augmentation procedures, sinus floor elevation, and peri-implant bone regeneration therapies. The goal of this article was to review the tissue engineering strategies that have been performed for periodontal and peri-implant reconstruction and implant site development, and to evaluate their safety, invasiveness, efficacy, and patient-reported outcomes. A detailed systematic search was conducted to identify eligible randomized controlled trials reporting the outcomes of tissue engineering strategies utilized for the aforementioned indications. A total of 128 trials were ultimately included in this review for a detailed qualitative analysis. Commonly performed tissue engineering strategies involved scaffolds enriched with mesenchymal or somatic cells (cell-based tissue engineering strategies), or more often scaffolds loaded with signaling molecules/growth factors (signaling molecule-based tissue engineering strategies). These approaches were found to be safe when utilized for periodontal and peri-implant reconstruction therapies and implant site development. Tissue engineering strategies demonstrated either similar or superior clinical outcomes than conventional approaches for the treatment of infrabony and furcation defects, alveolar ridge preservation, and sinus floor augmentation. Tissue engineering strategies can promote higher root coverage, keratinized tissue width, and gingival thickness gain than scaffolds alone can, and they can often obtain similar mean root coverage compared with autogenous grafts. There is some evidence suggesting that tissue engineering strategies can have a positive effect on patient morbidity, their preference, esthetics, and quality of life when utilized for the treatment of mucogingival deformities. Similarly, tissue engineering strategies can reduce the invasiveness and complications of autogenous graft-based staged bone augmentation. More studies incorporating patient-reported outcomes are needed to understand the cost-benefits of tissue engineering strategies compared with traditional treatments.

Bone Marrow Aspirate Concentrate for the Treatment of Knee Osteoarthritis: A Systematic Review

BACKGROUND

Bone marrow aspirate concentrate (BMAC) has emerged as a therapeutic option for symptomatic knee osteoarthritis (OA).

PURPOSE

To systematically review the literature to evaluate the efficacy of isolated BMAC injection in the treatment of OA of the knee joint.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review was performed by searching the PubMed, Embase, and Cochrane Library databases up to July 2020 to identify human studies that assessed the clinical outcomes of isolated BMAC injection for the treatment of knee OA. The electronic search strategy used was "bone marrow aspirate concentrate knee osteoarthritis."

RESULTS

Eight studies met the inclusion criteria, including a total of 299 knees with a mean follow-up of 12.9 months (range, 6-30 months). Of all patient-reported outcomes assessed across studies, 34 of 36 (94.4%) demonstrated significant improvement from baseline to latest follow-up (P < .05). Five studies evaluating numerical pain scores (visual analog scale and Numeric Rating Scale) reported significant improvements in pain level at final follow-up (P < .01). However, 3 comparative studies evaluating BMAC in relation to other therapeutic injections failed to demonstrate the clinical superiority of BMAC.

CONCLUSION

The BMAC injection is effective in improving pain and patient-reported outcomes in patients with knee OA at short- to midterm follow-up. Nevertheless, BMAC has not demonstrated clinical superiority in relation to other biologic therapies commonly used in the treatment of OA, including platelet-rich plasma and microfragmented adipose tissue, or in relation to placebo. The high cost of the BMAC injection in comparison with other biologic and nonoperative treatment modalities may limit its utility despite demonstrable clinical benefit.

The feasibility of injectable PRF (I-PRF) for bone tissue engineering and its application in oral and maxillofacial reconstruction: From bench to chairside

Among all the biomaterials introduced in the field of bone tissue engineering, injectable platelet-rich fibrin (I-PRF) has recently gained considerable attention. I-PRF, as a rich source of biologically active molecules, is a potential candidate which can be easily obtained in bedside and constitutes several biological factors which can result in higher anti-bacterial, anti-inflammatory and regenerative capabilities. According to the studies evaluating the osteogenic efficacy of I-PRF, this biomaterial has exhibited favorable outcomes in terms of adhesion, differentiation, migration, proliferation and mineralization potential of stem cells. In addition, the injectability and ease-of-applicability of this biomaterial has led to its various clinical applications in the oral and maxillofacial bone regeneration such as ridge augmentation, sinus floor elevation, cleft palate reconstruction and so on. Furthermore, to enhance the clinical performance of I-PRF, albumin gel-PRF as a long-lasting material for long-term utilization has been recently introduced with a gradual increase in growth factor release pattern. This review provides a comprehensive approach to better evaluate the applicability of I-PRF by separately appraising its performance in in-vitro, in-vivo and clinical situations. The critical approach of this review toward the different production protocols and different physical and biological aspects of I-PRF can pave the way for future studies to better assess the efficacy of I-PRF in bone regeneration.

Conditioned Medium from Bone Marrow Mesenchymal Stem Cells Restored Oxidative Stress-Related Impaired Osteogenic Differentiation

Oxidative stress from high levels of intracellular reactive oxygen species (ROS) has been linked to various bone diseases. Previous studies indicate that mesenchymal stem cells (MSC) secrete bioactive factors (conditioned medium (MSC-CM)) that have antioxidant effects. However, the antioxidant role of MSC-CM on osteogenesis has not been fully studied. We aimed to identify antioxidant proteins in MSC-CM using mass spectrometry-based proteomics and to explore their effects on osteogenic differentiation of human bone marrow mesenchymal stem cells (hBMSC) exposed to oxidative stress induced by hydrogen peroxide (H₂O₂). Our analysis revealed that MSC-CM is comprised of antioxidant proteins that are involved in several biological processes, including negative regulation of apoptosis and positive regulation of cell proliferation. Then, hBMSC exposed to H₂O₂ were treated with MSC-CM, and the effects on their osteogenic differentiation were evaluated. MSC-CM restored H₂O₂-induced damage to hBMSC by increasing the antioxidant enzyme-SOD production and the mRNA expression level of the anti-apoptotic BCL-2. A decrease in ROS production and cellular apoptosis was also shown. MSC-CM also modulated mRNA expression levels of osteogenesis-related genes, runt-related transcription factor 2, collagen type I, bone morphogenic protein 2, and osteopontin. Furthermore, collagen type I protein secretion, alkaline phosphatase activity, and in vitro mineralization were increased. These results indicate that MSC-CM contains several proteins with antioxidant and anti-apoptotic properties that restored the impaired hBMSC osteogenic differentiation associated with oxidative stress.

Effects of porcine bone marrow-derived platelet-rich plasma on bone marrow-derived mesenchymal stem cells and endothelial progenitor cells

This study investigated the abundance of pro-regenerative growth factors in bone marrow-derived platelet-rich plasma (BM-PRP) and their effects on bone marrow-derived mesenchymal stem cells (BM-MSC) and bone marrow-derived endothelial progenitor cells (BM-EPC). Four 4-5 months-old domestic pigs were included, and each underwent bone marrow aspiration from its humerus bones and processed into bone marrow aspiration concentrate (BMAC) samples. The plasma and cellular portions of BMAC were subsequently separated and collected. The concentration of growth factors including BMP-2, PDGF-BB, TGF-β1 and VEGF in the plasma portion was measured and compared between BM-PRP and bone marrow-derived platelet-poor plasma (BM-PPP). It was found that platelet count was significantly higher in BM-PRP than in BM-PPP, but the concentration of above-mentioned growth factors was not significantly different between BM-PRP and BM-PPP. As most existing literature has indicated the regenerative potency of PRP, this study focused on assessing the effect of BM-PRP treatment on BM-MSC and BM-EPC proliferation, osteogenic differentiation and angiogenesis capacity by comparing samples with 2.5% BM-PRP treatment and samples without BM-PRP treatment (control). In response to BM-PRP treatment, the cellular doubling time increased with culturing time and was significantly shorter in the BM-PRP-treated samples than in control samples. For osteogenic differentiation, BM-PRP-treated BM-MSCs demonstrated a time-dependent increase in alkaline phosphatase (ALP) activity and expression levels of osteogenic differentiation markers. For the expression of angiogenic genes, none of the differences reached statistical significance despite a tendency of stronger expression at day 18 in BM-PRP-treated BM-EPCs. In conclusion, this in vitro study suggests that most BMP-2, PDGF-BB, TGF-β1 and VEGF-A contained in BM-PRP are not platelet-released and BM-PRP may have some stimulation (less than 1-fold) for MSC, EPC proliferation and MSC osteogenic differentiation.

Repair of Critical Size Bone Defects Using Synthetic Hydroxyapatite or Xenograft with or without the Bone Marrow Mononuclear Fraction: A Histomorphometric and Immunohistochemical Study in Rat Calvaria

Bone defects are a challenging clinical situation, and the development of hydroxyapatite-based biomaterials is a prolific research field that, in addition, can be joined by stem cells and growth factors in order to deal with the problem. This study compares the use of synthetic hydroxyapatite and xenograft, used pure or enriched with bone marrow mononuclear fraction for the regeneration of critical size bone defects in rat calvaria through histomorphometric (Masson's staining) and immunohistochemical (anti-VEGF, anti-osteopontin) analysis. Forty young adult male rats were divided into five groups (n = 8). Animals were submitted to critical size bone defects (Ø = 8 mm) in the temporoparietal region. In the control group, there was no biomaterial placement in the critical bone defects; in group 1, it was filled with synthetic hydroxyapatite; in group 2, it was filled with xenograft; in group 3, it was filled with synthetic hydroxyapatite, enriched with bone marrow mononuclear fraction (BMMF), and in group 4 it was filled with xenograft, enriched with BMMF. After eight weeks, all groups were euthanized, and histological section images were captured and analyzed. Data analysis showed that in groups 1, 2, 3 and 4 (received biomaterials and biomaterials plus BMMF), a significant enhancement in new bone matrix formation was observed in relation to the control group. However, BMMF-enriched groups did not differ from hydroxyapatite-based biomaterials-only groups. Therefore, in this experimental model, BMMF did not enhance hydroxyapatite-based biomaterials' potential to induce bone matrix and related mediators.

Osseointegration of different implant surfaces in areas grafted with deproteinized bovine bone associated or not with fresh bone marrow-Preclinical study in rabbits

OBJECTIVES

To assess the influence of two different implant surfaces on osseointegration in maxillary sinuses of rabbits previously grafted with deproteinized bovine bone (DBB) associated or not with fresh bone marrow (BM).

MATERIAL AND METHODS

Sixteen New Zealand albino rabbits (males, 3.5/4.5 kg and 9-12 months old) were randomly divided into two groups with 8 rabbits each, according to the type of association of biomaterials used to fill the animals' maxillary sinuses: DBB (Deproteinized Bovine Bone) and DBB/BM (Deproteinized bovine bone associated with fresh autologous bone marrow). Ninety (90) days following the grafting procedure, the animals received implants in the area with two different microstructures (SA-Sandblasting + acid attack and SA-H-Sandblasting + acid attack + immersion in 0.9% sodium chloride isotonic solution). All rabbits were euthanized 90 days after implant placement. The microtomographic analysis was performed to verify the number of mineralized tissues around the implants throughout their length (%BV/TV), while the histomorphometric analysis was performed to verify the percentage of bone-implant contact around the implants throughout their length (%BIC).

RESULTS

We observed no differences in the quantity for %BV/TV (DBB-SA:33.25 ± 19.67; DBB-SA-H:35.15 ± 22.17; DBB/BM-SA:39.71 ± 24.21; DBB/BM-SA-H:36.40 ± 23.07) and %BIC (DBB-SA:58.94 ± 24.37; DBB-SA-H:52.52 ± 24.36; DBB/BM-SA: 61.66 ± 14.60; DBB/BM-SA-H: 64.06 ± 23.30) between the groups assessed.

CONCLUSIONS

The addition of BM and the type of surface did not influence the osseointegration of implants installed in areas grafted with sintered deproteinized bovine bone at high temperatures in the late period assessed.

Xenograft materials in maxillary sinus floor elevation surgery: a systematic review with network meta-analyses

A systematic review and network meta-analysis was conducted to compare different commercially available xenograft materials used in maxillary sinus floor elevation surgery (MSFES). Embase, PubMed, the Cochrane Library, Web of Science, Scopus, LILACS, and grey literature were searched up to 13 July 2020. Only randomised controlled trials (RCTs) were included. A frequentist network meta-analysis using a random effects model compared different commercially available xenograft materials. The primary outcomes were the percentage of newly-formed bone and residual bone-substitute rate. Both were measured by histomorphometric analysis from bone biopsies obtained during preparation of the implant site. Of the 659 studies initially identified, 11 involving 242 MSFES were included in the quantitative analyses. A total of six bone-substitute materials were analysed (Bio-Oss® (Geistlich Pharma), InduCera® Dual Coat, Lumina-Bone Porous® (Critéria), Osseous® (SIN - Sistema de Implantes Nacional), THE Graft® (Purgo Biologics), and Osteoplant Osteoxenon® (Bioteck)). The P-score estimation showed that Osteoplant Osteoxenon® produced the most newly-formed bone and reabsorbed faster than other xenograft materials after six months. The combination of Bio-Oss® plus bone marrow aspirate concentrate (BMAC) significantly increased the percentage of newly-formed bone compared with Bio-Oss® alone. In contrast, the addition of Emdogain® (Straumann) and leucocyte and platelet-rich fibrin (L-PRF) to Bio-Oss® did not significantly improve the amount of regenerated bone. Study-level data indicated that the percentage of newly-formed bone differs among commercially available xenograft materials. Osteoplant Osteoxenon® seems to result in the highest amount of new bone in MSFES.

Enhancement of bone marrow aspirate concentrate with local self-healing corticotomies

Bone marrow aspirate concentrate (BMAC) is a potentially useful biological product for bone regeneration. This study investigated whether BMAC can be enriched by local minor corticotomies. Five 4-month-old domestic pigs were used with each pig undergoing two minor corticotomies at one randomly-selected tibia. Two weeks after the operation, bone marrow was aspirated from both tibiae and processed into BMAC samples. The amount of mesenchymal stem cells (MSCs) and the concentration of several regenerative growth factors contained in BMAC, as well as the proliferative and osteogenic differentiation capacity of MSCs, were compared between the corticotomy and the control sides. Another four weeks later, healing of the corticotomies was evaluated by radiographic and histological methods. The results demonstrated that BMAC from the corticotomy side contained significantly more MSCs than the control side. MSCs from the corticotomy side also proliferated significantly faster and tended to have stronger osteogenic differentiation than those from the control side. In contrast, the protein concentration of TGF-β, BMP-2 and PDGF contained in BMAC was only minimally changed by the corticotomies. The corticotomies in all pigs healed uneventfully, showing complete obliteration of the corticotomy gaps on CT images. Comparison between the two sides showed that the corticotomy side had thicker and denser cortical bone and more abundant osteogenic cell differentiation than the control side. These findings suggest that the quantity and proliferative/osteogenic differentiation capacity of MSCs contained in local BMAC can be enhanced by minor corticotomies, and spontaneous healing of the corticotomy can be completed within 6 weeks of the operation.

Cell-Based Therapies for Alveolar Bone and Periodontal Regeneration: Concise Review

Current regenerative strategies for alveolar bone and periodontal tissues are effective and well adopted. These are mainly based on the use of a combination of synthetic/natural scaffolds and bioactive agents, obviating the incorporation of cells. However, there are some inherent limitations associated with traditional techniques, and we hypothesized that the use of cell-based therapies as part of comprehensive regenerative protocols may help overcome these hurdles to enhance clinical outcomes. We conducted a systematic review of human controlled clinical trials investigating the clinical and/or histological effect of the use of cell-based therapies for alveolar bone and periodontal regeneration and explored the translational potential of the different cell-based strategies identified in the included trials. A total of 16 studies (11 randomized controlled trials, 5 controlled clinical trials) were included for data synthesis and qualitative analysis with meta-analyses performed when appropriate. The results suggest a clinical benefit from the use of cell therapy. Improved outcomes were shown for alveolar ridge preservation, lateral ridge augmentation, and periodontal regeneration. However, there was insufficient evidence to identify best-performing treatment modalities amongst the different cell-based techniques. In light of the clinical and histological outcomes, we identify extraction socket and challenging lateral and vertical bone defects requiring bone block grafts as strong candidates for the adjuvant application of mesenchymal stem cells. Given the complexity, invasiveness, and costs associated with techniques that include "substantial manipulation" of tissues and cells, their additional clinical benefit when compared with "minimal manipulation" must be elucidated in future trials. Stem Cells Translational Medicine 2019;8:1286&1295.

Do osteoconductive bone substitutes result in similar bone regeneration for maxillary sinus augmentation when compared to osteogenic and osteoinductive bone grafts? A systematic review and frequentist network meta-analysis

The purpose of this network meta-analysis was to identify the most effective biomaterials producing higher new bone formation (NBF) and lower residual graft (RG) and connective tissue (CT) following maxillary sinus augmentation (MSA), and to generate a ranking based on their performance. The MEDLINE, Embase, and CENTRAL databases were searched to identify randomized controlled trials (RCTs) published until March 2018, evaluating histomorphometric outcomes after MSA. Predictor variables were autogenous bone (AB), allografts (AG), xenografts (XG), alloplastic bone (AP), AB+XG, AB+AP, AG+XG, XG+AP, and grafts combined with autologous platelet concentrates/recombinant growth factors, mesenchymal stem cells (MSCs), or recombinant bone morphogenetic proteins (BMPs). Outcome variables were NBF%, RG%, and CT%. Healing time was considered. The weighted mean difference (WMD) with 95% confidence interval (CI) was calculated via frequentist network meta-analysis using Stata software. Fifty-two RCTs (1483 biopsies) were included. At a healing time <6 months, AB was superior to AP (WMD-10.66%, 95% CI-16.38% to -4.94%) and XG (WMD-7.93%, 95% CI-15.11% to -0.75%) for NBF. Regarding CT, AB was superior to XG+AP, AP, MSCs, and XG. At a healing time ≥6 months, NBF was higher for AB than AP (WMD-7.06%, 95% CI-12.59% to -1.52%). RG was lower in AB than AP (WMD 12.03%, 95% CI 3.04% to 21.03%), XG (WMD 14.62%, 95% CI 4.25% to 24.98%), and growth factors (WMD 12.32%, 95% CI 0.04% to 24.60%). The three highest ranked biomaterials for increasing NBF were AG+XG (95%, very low quality evidence), growth factors (69.9%, low quality evidence), and AB alone (69.8%, moderate quality evidence). The three highest ranked biomaterials for decreasing RG were BMPs (88.8%, very low quality evidence), AB alone (81.5%, moderate quality evidence), and AB+AP (58.9%, very low quality evidence). Finally, XG+AP (84.7%, low quality evidence), AP alone (77.7%, moderate quality evidence), and MSCs (76.1%, low quality evidence), were the three highest ranked biomaterials for decreasing the amount of CT. Network meta-analysis provided moderate quality evidence that AB alone is probably the best option to obtain greater NBF after MSA in the first 6 months after surgery. Additionally, the results of this network meta-analysis support the hypothesis that osteoconductive bone substitute materials should be combined with osteogenic or osteoinductive grafts for superior histomorphometric outcomes in MSA.

Efficacy of stem cells in maxillary sinus floor augmentation: systematic review and meta-analysis

The aim of this review was to test the hypothesis of no difference in the efficacy of bone regeneration when using stem cells in maxillary sinus floor augmentation surgery in comparison to other grafts. Nine randomized clinical trials and one follow-up study involving human subjects were identified through a search of the PubMed/MEDLINE, Scopus, Cochrane, and Web of Science databases, supplemented by a hand search. No significant difference between groups was found for the implant survival rate, increase in bone height, marginal bone loss following implant placement, or new bone formation. With regard to the residual bone graft, an effect favouring the graft group at 3-4months (P=0.001) and favouring the stem cell group at 6months (P=0.01) was found. Analyses of the subgroup in which the BMAC system extraction method was used in combination with Bio-Oss, revealed no difference in new bone formation; however, the results for residual bone graft at 3months favoured the control graft (Bio-Oss) (P=0.01), but at 6months favoured the stem cells (Bio-Oss+BMAC system) (P=0.01). Based on all findings, the use of stem cells does not contribute significantly to greater implant survival rates or the efficacy of bone regeneration following sinus lift procedures.

Bone, Periodontal and Dental Pulp Regeneration in Dentistry: A Systematic Scoping Review

The aim of presented systematic scoping review was to investigate the actual and future clinical possibilities of regenerative therapies and their ability to regenerate bone, periodontal and pulp with histological confirmation of the nature of formed tissue. Electronic search was conducted using a combination between Keywords and MeSH terms in PubMed, Scopus, ISI-Web of Science and Cochrane library databases up to January 2016. Two reviewers conducted independently the papers judgment. Screened studies were read following the predetermined inclusion criteria. The included studies were evaluated in accordance with Arksey and O'Malley's modified framework. From 1349 papers, 168 completed inclusion criteria. Several characterized and uncharacterized cells used in Cell Therapy have provided bone regeneration, demonstrating bone gain in quantity and quality, even as accelerators for bone and periodontal regeneration. Synthetic and natural scaffolds presented good cell maintenance, however polyglycolid-polylactid presented faster resorption and consequently poor bone gain. The Growth Factor-Mediated Therapy was able to regenerate bone and all features of a periodontal tissue in bone defects. Teeth submitted to Revascularization presented an increase of length and width of root canal. However, formed tissues not seem able to deposit dentin, characterizing a repaired tissue. Both PRP and PRF presented benefits when applied in regenerative therapies as natural scaffolds. Therefore, most studies that applied regenerative therapies have provided promising results being possible to regenerate bone and periodontal tissue with histological confirmation. However, pulp regeneration was not reported. These results should be interpreted with caution due to the short follow-up periods.

Improved guided bone regeneration by combined application of unmodified, fresh autologous adipose derived regenerative cells and plasma rich in growth factors: A first-in-human case report and literature review

BACKGROUND

Novel strategies are needed for improving guided bone regeneration (GBR) in oral surgery prior to implant placement, particularly in maxillary sinus augmentation (GBR-MSA) and in lateral alveolar ridge augmentation (LRA). This study tested the hypothesis that the combination of freshly isolated, unmodified autologous adipose-derived regenerative cells (UA-ADRCs), fraction 2 of plasma rich in growth factors (PRGF-2) and an osteoinductive scaffold (OIS) (UA-ADRC/PRGF-2/OIS) is superior to the combination of PRGF-2 and the same OIS alone (PRGF-2/OIS) in GBR-MSA/LRA.

CASE SUMMARY

A 79-year-old patient was treated with a bilateral external sinus lift procedure as well as a bilateral lateral alveolar ridge augmentation. GBR-MSA/LRA was performed with UA-ADRC/PRGF-2/OIS on the right side, and with PRGF-2/OIS on the left side. Biopsies were collected at 6 wk and 34 wk after GBR-MSA/LRA. At the latter time point implants were placed. Radiographs (32 mo follow-up time) demonstrated excellent bone healing. No radiological or histological signs of inflammation were observed. Detailed histologic, histomorphometric, and immunohistochemical analysis of the biopsies evidenced that UA-ADRC/PRGF-2/OIS resulted in better and faster bone regeneration than PRGF-2/OIS.

CONCLUSION

GBR-MSA with UA-ADRCs, PRGF-2, and an OIS shows effectiveness without adverse effects.

Effectiveness of a single intra-articular bone marrow aspirate concentrate (BMAC) injection in patients with grade 3 and 4 knee osteoarthritis

Aim

To evaluate the clinical efficacy and safety of an intra-articular injection of bone marrow aspirate concentrate (BMAC) as a treatment option for osteoarthritis (OA) of the knee.

Materials and methods

Between June 2014 and February 2017, data from 233 patients with knee osteoarthritis treated with BMAC injection at a single center, were retrospectively evaluated. Only patients with idiopathic osteoarthritis were included. Exclusion criteria were post-traumatic osteoarthritis, previous knee surgery, age less than 50 years old or more than 85 years old, active infection, uncontrolled diabetes mellitus, rheumatological or other systemic disease, malignancy, or treatment with immunosuppressive drugs. Bone marrow from the iliac crest was aspirated/concentrated with a standardized technique using a single-spin manual method. Patients were evaluated before and after the procedure, using the numeric pain scale (NPS) and Oxford knee score (OKS). Mean follow-up period was 11 months, range (6–30 months).

Results

A total of 121 of 233 patients had completed data as previously defined and were included in the statistical analysis. There were 85 females and 36 males, with mean age 70 years (range 50–85). Compared to baseline, the mean NPS decreased from 8.33 to 4.49 (p < 0.001) and the mean OKS increased from 20.20 to 32.29 (P < 0.001) at final follow-up. There were no complications.

Conclusion

A single intra-articular injection of BMAC is a safe and reliable procedure that results in clinical improvement of knee OA.

Maxillary sinus augmentation using chairside bone marrow aspirate concentrates for implant site development: a systematic review of histomorphometric studies

Maxillary sinus pneumatization following dental tooth extractions and maxillary alveolar bone resorption frequently leaves inadequate bone levels for implant placement. The objectives of this systematic review are to evaluate the effects of bone marrow aspirate concentrates (BMACs) used in maxillary sinus augmentation for implant site development.

A systematic search was conducted using PubMed, EMBASE, Web of Science, Cochrane Library, and Google Scholar for studies which histomorphometrically evaluated the efficacy of BMACs and BMAC-enriched biomaterials in sinus floor elevation. Six studies were selected, and the risk of bias was evaluated.

Reported ranges of vital mineralized tissue for the BMAC groups for the selected studies were 34.63–55.15% compared to 27.30% for control groups. For vital mineralized bone, these studies reported variable statistical significance. At 3–4 months, new bone formation for BMAC groups with controls using no BMAC was 7.4–12.6% and for the control groups was 9.45–14.3%. At 6 months, new bone formation for BMAC groups was 13.5–14.12% and for control groups was 10.41–13.9%. For new bone formation, these studies reported no significant difference between test and control and between 3 and 6 months histologic evaluation.

Within the limits of this systematic review, the chairside method to harvest BMAC produced similar implant survival and new bone formation compared to the laboratory FICOLL group, without the additional cost and time of laboratory cell isolation techniques. The iliac crest or tibia origins, single or double centrifugation, for BMAC do not appear to be a factor for implant survival or bone formation. Although some favorable outcomes were reported, the increase in new bone formation using chairside-harvested BMAC compared to control is not predictably more significant across studies.

Clinically, new bone formation in the maxillary sinus is not always contingent on the presence of BMAC. The novelty of this method requires more future studies.

Novel Biological and Technological Platforms for Dental Clinical Use

Human teeth have a limited capacity to regenerate and thus biological reconstruction of damaged or lost dental tissues remains a significant challange in modern dentistry. Recent efforts focus on alternative therapeutic approaches for partial or whole tooth regeneration that complement traditional dental treatments using sophisticated materials and dental implants. These multidisciplinary approaches are based on the combination of stem cells with advanced tissue engineer products and computing technology, and they hold great promise for future applications in dentistry. The administration to patients of dynamic biological agents composed by stem cells and scaffolds will certainly increase the regenerative capacity of dental pathological tissues. The design of innovative materials for tissue restoration, diagnostics, imaging, and targeted pharmaceutical treatment will significantly improve the quality of dental care and will have a major societal impact. This review depicts the current challenges in dentistry and describes the possibilities for novel and succesful therapeutic applications in the near future.

Intraoperative Construct Preparation: A Practical Route for Cell-Based Bone Regeneration

Stem cell-based bone tissue engineering based on the combination of a scaffold and expanded autologous mesenchymal stem cells (MSCs) represents the current state-of-the-art treatment for bone defects and fractures. However, the procedure of such construct preparation requires extensive ex vivo manipulation of patient's cells to achieve enough stem cells. Therefore, it is impractical and not cost-effective compared to other therapeutic interventions. For these reasons, a more practical strategy circumventing any ex vivo manipulation and an additional surgery for the patient would be advantageous. Intraoperative concept-based bone tissue engineering, where constructs are prepared with easily accessible autologous cells within the same surgical procedure, allows for such a simplification. In this study, we discuss the concept of intraoperative construct preparation for bone tissue engineering and summarize the available cellular options for intraoperative preparation. Furthermore, we propose methods to prepare intraoperative constructs, and review data of currently available preclinical and clinical studies using intraoperatively prepared constructs for bone regenerative applications. We identify several obstacles hampering the application of this emerging approach and highlight perspectives of technological innovations to advance the future developments of intraoperative construct preparation.

Allogeneic bone block for challenging augmentation-a clinical, histological, and histomorphometrical investigation of tissue reaction and new bone formation

OBJECTIVES

The aim of the present study was the histological investigation of an allogeneic spongious bone block for horizontal and vertical ridge augmentation in humans. The amount of new bone, soft tissue, and residual bone substitute were histomorphometrically assessed after a mean healing period of 6 months.

MATERIALS AND METHODS

Fourteen patients received augmentation with an allogeneic spongious bone block (Tutobone^®, Tutogen Medical, Neunkirchen, Germany). After 6 months of healing, 28 implants were placed with simultaneous harvesting of bone biopsies for histological and histomorphometrical analysis. Moreover, samples from the bone blocks were collected as blanks and analyzed histologically. The formation of new bone, connective tissue, and remaining bone substitute material as well as vascularization and formation of multinucleated giant cells (MNCGs) within the augmentation bed were analyzed.

RESULTS

New bone formation could be observed primarily in close proximity to the bone block. Histomorphometrical analyses showed 18.65 ± 12.20% newly formed bone, 25.93 ± 12.36% allogeneic spongious bone block, and 53.45 ± 10.34% connective tissue. MNCGs were observed on the biomaterial surface. Furthermore, organic residues were evident, as donor-related cellular remnants within the osteocyte lacunae were found in the blank bone blocks and in the analyzed biopsies.

CONCLUSION

Despite the presence of donor-related organic remnants, the bone block shows the ability to serve as a scaffold for new bone formation. Within the limits of the present study, the detect organic remnants seemed not to affect the bone formation or influence the host in the long term.

CLINICAL RELEVANCE

Clinicians have to make a conscious choice of the applied biomaterials with regard to their components and structure to support tissue regeneration and maintain patient safety.

Bone marrow concentrate promotes bone regeneration with a suboptimal-dose of rhBMP-2

Bone marrow concentrate (BMC), which is enriched in mononuclear cells (MNCs) and platelets, has recently attracted the attention of clinicians as a new optional means for bone engineering. We previously reported that the osteoinductive effect of bone morphogenetic protein-2 (BMP-2) could be enhanced synergistically by co-transplantation of peripheral blood (PB)-derived platelet-rich plasma (PRP). This study aims to investigate whether BMC can effectively promote bone formation induced by low-dose BMP-2, thereby reducing the undesirable side-effects of BMP-2, compared to PRP. Human BMC was obtained from bone marrow aspirates using an automated blood separator. The BMC was then seeded onto β-TCP granules pre-adsorbed with a suboptimal-dose (minimum concentration to induce bone formation at 2 weeks in mice) of recombinant human (rh) BMP-2. These specimens were transplanted subcutaneously to the dorsal skin of immunodeficient-mice and the induction of ectopic bone formation was assessed 2 and 4 weeks post-transplantation. Transplantations of five other groups [PB, PRP, platelet-poor plasma (PPP), bone marrow aspirate (BM), and BM-PPP] were employed as experimental controls. Then, to clarify the effects on vertical bone augmentation, specimens from the six groups were transplanted for on-lay placement on the craniums of mice. The results indicated that BMC, which contained an approximately 2.5-fold increase in the number of MNCs compared to PRP, could accelerate ectopic bone formation until 2 weeks post-transplantation. On the cranium, the BMC group promoted bone augmentation with a suboptimal-dose of rhBMP-2 compared to other groups. Particularly in the BMC specimens harvested at 4 weeks, we observed newly formed bone surrounding the TCP granules at sites far from the calvarial bone. In conclusion, the addition of BMC could reduce the amount of rhBMP-2 by one-half via its synergistic effect on early-phase osteoinduction. We propose here that BMC transplantation facilitates the clinical use of rhBMP-2 as an alternative strategy for bone engineering.

Concentrated Bone Marrow Aspirate-Coated Hydroxyapatite for Reconstruction of Small-to-Moderate-Sized Mandibular Defects Caused by the Removal of Benign Pathologies

Purpose:

The aim of this study was to evaluate the bone regeneration potential of concentrated bone marrow aspirate (BMA)-coated hydroxyapatite (HA) for reconstruction of mandibular defects caused by the removal of benign pathologies.

Patients and Methods:

This prospective clinical study included ten patients with histopathologically proven benign pathologies of the mandible measuring <5 cm anteroposteriorly, who were treated with enucleation or marginal resection, followed by autologous concentrated BMA-coated synthetic biphasic HA (HA and beta-tricalcium phosphate) graft placement. Clinical and radiological evaluations of grafted sites of the mandible were done at 1 week, 1, 3, and 6 months postoperatively using Irwin's radiologic staging and grayscale histogram.

Results:

All patients (10/10, 100%) had proper incorporation of the graft with the normal adjacent bone. Grayscale histogram revealed the initial stages of graft resorption, followed by formation of new bone-grafted sites. No complications such as infection and total graft loss were encountered except for one patient who had partial wound dehiscence that responded well to local wound care and resuturing.

Conclusion:

Concentrated BMA-coated synthetic HA effectively promotes bone regeneration in small-to-moderate-sized defects of the mandible.

Advanced Therapy Medicinal Products: A Guide for Bone Marrow-derived MSC Application in Bone and Cartilage Tissue Engineering

Millions of people worldwide suffer from trauma- or age-related orthopedic diseases such as osteoarthritis, osteoporosis, or cancer. Tissue Engineering (TE) and Regenerative Medicine are multidisciplinary fields focusing on the development of artificial organs, biomimetic engineered tissues, and cells to restore or maintain tissue and organ function. While allogenic and future autologous transplantations are nowadays the gold standards for both cartilage and bone defect repair, they are both subject to important limitations such as availability of healthy tissue, donor site morbidity, and graft rejection. Tissue engineered bone and cartilage products represent a promising and alternative approach with the potential to overcome these limitations. Since the development of Advanced Therapy Medicinal Products (ATMPs) such as TE products requires the knowledge of diverse regulation and an extensive communication with the national/international authorities, the aim of this review is therefore to summarize the state of the art on the clinical applications of human bone marrow-derived stromal cells for cartilage and bone TE. In addition, this review provides an overview of the European legislation to facilitate the development and commercialization of new ATMPs.

Long-term Radiological and Clinical Outcomes After Using Bone Marrow Mesenchymal Stem Cells Concentrate Obtained With Selective Retention Cell Technology in Posterolateral Spinal Fusion

STUDY DESIGN

Retrospective study.

OBJECTIVE

The aim of this study was to evaluate the long-term clinical and radiological outcomes of the use of bone marrow mesenchymal stem cell concentrate obtained with selective cell retention technology using Cellect with a particular collagen scaffold, Healos for posterolateral spinal fusion.

SUMMARY OF BACKGROUND DATA

With the increasing rate of spinal fusion, the problem of pseudarthrosis, which contributes to recurrent pain with patient disability, is considered to be the most common cause of revision lumbar spine surgery. Intensive research is being carried out to develop an alternative source of bone grafting and improve the spinal fusion rate.

METHODS

A retrospective review of hospital records was performed. Identified patients were contacted to have a clinical and radiological evaluation follow-up. Clinical outcome was evaluated using visual analog scales for the back pain (VAS), Oswestry Disability Index (ODI) scores, and quality of life (EQ-5D) questionnaire. Radiological outcome was evaluated by performing dynamic flexion/extension lateral views and calculation of segmental Cobb angle. Any implant-associated complication was reported. Computed tomography (CT) scans were also performed.

RESULTS

Twenty-one patients were included and all patients achieved successful fusion. The mean difference of the segmental Cobb angle was 0.48° (range 0.3°-0.7°). Computed tomography scans showed solid bilateral fusion with bridging bone (Grade I) in all patients, but solid unilateral fusion with bridging bone (Grade II) was detected for one patient at one level. Patients started to resume working activities within a mean period of 3.5 months. The VAS score for the residual back pain was 4.1 ± 2.1, whereas the ODI was 10.5 ± 5.6 points, and the mean disability index was 21.1%.

CONCLUSION

The use of bone marrow mesenchymal stem cell concentrate obtained with selective cell retention technology could be considered as an effective means for augmenting spinal fusion.

LEVEL OF EVIDENCE

3.

A systematic review of the clinical applications and complications of bone marrow aspirate concentrate in management of bone defects and nonunions

PURPOSE

Fracture healing encompasses a succession of dynamic multifactorial metabolic events, which ultimately re-establishes the integrity of the biomechanical properties of the bone. Up to 10% of the fractures occurring annually will need additional surgical procedures because of impaired healing. The aim of this article is to review the current literature regarding the use of bone marrow aspirate concentrate (BMAC) and its effectiveness in the management of bone defects.

METHODS

We have included all published clinical literature investigating the development, techniques and applications of BMAC. Language, design and risk of bias did not deter the initial inclusion of any study. Our search was exclusively limited to studies involving human subjects. A PRISMA compliant search was carried out as published in 2009. This included the online databases: PubMed, EMBASE, clinical trial.gov and the Cochrane library from 1960 to the end of May 2015. MeSH terms used included: "Bone" AND "Marrow" AND "Aspirate" AND "Concentrate" AND "Bone Defects" AND "NONUNION". Eligible studies were independently appraised by two authors using the Critical Appraisal Skills Program checklist. For the purpose of narrative review, relevant studies were included irrespective of methodology or level of evidence.

RESULTS

Thirty-four of the 103 (48 PubMed and 55 EMBASE) results yielded by the preliminary search were included. Exclusions included three duplicate records, six letters, 17 non-orthopaedics related studies and four records irrelevant to our search topic. The CASP appraisal confirmed a satisfactory standard of 31 studies. They all had clearly defined objectives, were well designed and conducted appropriately to meet them. The published studies reported the use of BMAC in non-union and fracture healing (15 studies), bone defects (nine studies), spine fusion (two studies), distraction osteogensis (two studies) and complications related to the use of BMAC (seven studies).

CONCLUSIONS

Stem cells found in BMAC have the potential to self-renew, undertake clonal expansion and differentiate into different musculoskeletal tissues. The commercial processing of BMAC needs to be optimized in order to achieve a consistent end product, which will provide predicable and translatable results. The future potential of cell characterization in order to determine the optimum cell for repair/regeneration of bone also needs to be explored.

LEVEL OF EVIDENCE

Systematic Review of minimum level IV studies.

Quantitative Assessment of Optimal Bone Marrow Site for the Isolation of Porcine Mesenchymal Stem Cells

Background. One of the most plentiful sources for MSCs is the bone marrow; however, it is unknown whether MSC yield differs among different bone marrow sites. In this study, we quantified cellular yield and evaluated resident MSC population from five bone marrow sites in the porcine model. In addition, we assessed the feasibility of a commercially available platelet concentrator (Magellan® MAR01™ Arteriocyte Medical Systems, Hopkinton, MA) as a bedside stem cell concentration device. Methods. Analyses of bone marrow aspirate (BMA) and concentrated bone marrow aspirate (cBMA) included bone marrow volume, platelet and nucleated cell yield, colony-forming unit fibroblast (CFU-F) number, flow cytometry, and assessment of differentiation potential. Results. Following processing, the concentration of platelets and nucleated cells significantly increased but was not significantly different between sites. The iliac crest had significantly less bone marrow volume; however, it yielded significantly more CFUs compared to the other bone marrow sites. Culture-expanded cells from all tested sites expressed high levels of MSC surface markers and demonstrated adipogenic and osteogenic differentiation potential. Conclusions. All anatomical bone marrow sites contained MSCs, but the iliac crest was the most abundant source of MSCs. Additionally, the Magellan can function effectively as a bedside stem cell concentrator.

Reduction of relative centrifugation force within injectable platelet-rich-fibrin (PRF) concentrates advances patients' own inflammatory cells, platelets and growth factors: the first introduction to the low speed centrifugation concept

Purpose

The aim of this study was to analyze systematically the influence of the relative centrifugation force (RCF) on leukocytes, platelets and growth factor release within fluid platelet-rich fibrin matrices (PRF).

Materials and methods

Systematically using peripheral blood from six healthy volunteers, the RCF was reduced four times for each of the three experimental protocols (I–III) within the spectrum (710–44 g), while maintaining a constant centrifugation time. Flow cytometry was applied to determine the platelets and leukocyte number. The growth factor concentration was quantified 1 and 24 h after clotting using ELISA.

Results

Reducing RCF in accordance with protocol-II (177 g) led to a significantly higher platelets and leukocytes numbers compared to protocol-I (710 g). Protocol-III (44 g) showed a highly significant increase of leukocytes and platelets number in comparison to -I and -II. The growth factors’ concentration of VEGF and TGF-β1 was significantly higher in protocol-II compared to -I, whereas protocol-III exhibited significantly higher growth factor concentration compared to protocols-I and -II. These findings were observed among 1 and 24 h after clotting, as well as the accumulated growth factor concentration over 24 h.

Discussion

Based on the results, it has been demonstrated that it is possible to enrich PRF-based fluid matrices with leukocytes, platelets and growth factors by means of a single alteration of the centrifugation settings within the clinical routine.

Conclusions

We postulate that the so-called low speed centrifugation concept (LSCC) selectively enriches leukocytes, platelets and growth factors within fluid PRF-based matrices. Further studies are needed to evaluate the effect of cell and growth factor enrichment on wound healing and tissue regeneration while comparing blood concentrates gained by high and low RCF.

Can stem cells enhance bone formation in the human edentulous alveolar ridge? A systematic review and meta-analysis

Several non-biological materials are currently being used to increase the alveolar bone volume to support dental implants. Recently, stem cell therapy has emerged as a promising biological substitute or adjuvant to enhance bone healing. In order to determine if stem cell therapy has enough clinical evidence to bone ridge augmentation in humans, a systematic review and meta-analysis were conducted. Two independent investigators searched the Entrez PubMed, SCOPUS and Web of Science databases for eligible randomized clinical trials that describe stem cell therapies for alveolar bone formation. The included studies were evaluated for risk of bias. A random-effects meta-analysis model was used to evaluate the percentage of bone formation in the selected studies. Heterogeneity was evaluated using the Cochrane Chi ² and I ². Nine eligible trials were included. These studies presented an overall unclear risk of bias. A comparison between the lower heterogeneity studies and the long term observational outcomes showed a slight tendency to enhance bone formation. High heterogeneity between the included studies was observed. The lack of outcome standardization made a wide-ranging comparison difficult. The application of stem cells in oral surgery and implantology appears to be promising although more standardized study designs, increased samples and long-term observations are needed to strength the clinical evidence that stem cell therapy is effective for alveolar bone formation.

Can bone marrow aspirate concentrate change the mineralization pattern of the anterior maxilla treated with xenografts? A preliminary study

Objective:

To evaluate bony reconstruction of the atrophic anterior maxilla using particulate grafts with or without autologous bone marrow aspirate concentrate (BMAC).

Materials and Methods:

Eight patients with atrophy of the anterior maxilla due to teeth loss were selected and split into groups according to the type of material used: Control Group (CG) (n = 4) - particulate xenograft only and Test Group (TG) (n = 4) - a combination of particulate xenograft and BMAC. Both groups received a collagen membrane to cover the xenograft. After 4 months, during implant placement, a sample of bone was removed from the graft area using a 2 mm diameter trephine bur. The specimens were fixed and preserved for histomorphometric evaluation, which included the following parameters: Mineralized tissue (MT) and non-MT (NMT). Cone beam computed tomography was performed at 3 time intervals to measure bone thickness: (1) Before grafting, (2) 4 months and (3) 8 months postgrafting, using localized bone gain (mm) as the outcome variable.

Results:

Tomographic analysis revealed bone gain in CG of 3.78 ± 1.35 mm and 4.34 ± 1.58 mm at 4 and 8 months, respectively. TG showed an increase of 3.79 ± 0.52 mm and 4.09 ± 1.33 mm after 4 and 8 months, respectively. Histomorphometric analysis revealed that, for CG, MT- and NMT-related values were 52.3% ± 16.78% and 47.70% ± 5.55%, respectively, whereas for TG, they were 65.04% ± 20.98% and 34.96 ± 10.38, respectively.

Conclusion:

Although radiographic bone gain appeared similar between the groups, the use of BMAC obtained via the BMAC^® method revealed an increased mineralization trend in the anterior maxilla. It must be highlighted, however, that this is a preliminary study with a relatively small sample population and further studies with larger sample sizes are needed to verify these results.

Treatment of Peri-Implant Defects in the Rabbit's Tibia with Adipose or Bone Marrow-Derived Mesenchymal Stems Cells

BACKGROUND

Mesenchymal stem cell (MSC) treatment in conjunction with bone graft materials or space filler can be an alternative to autogenous bone grafts in the treatment of peri-implant bone defects.

PURPOSE

To evaluate the success of bone regeneration capacity of adipose-derived and bone marrow-derived MSCs for the treatment of peri-implant bone defects when applied with a beta-tricalcium phosphate/collagen-based scaffold.

MATERIAL AND METHODS

Forty implants were placed into the tibiae of 10 rabbits bilaterally. Surgical defects created around the implants were treated with one the following treatment modalities: 1) adipose-derived MSC transplanted scaffold + collagen membrane; 2) bone marrow-derived MSC transplanted scaffold + collagen membrane; 3) autogenous bone + collagen membrane; and 4) collagen membrane only. The bone regeneration capacity of each technique was determined by histomorphometry, micro-CT, and measuring the implant stability by resonance frequency analysis.

RESULTS

One limb of one rabbit was excluded because of fracture, and another limb was excluded because of infection. All parameters on 36 implants revealed that both sources of MSC can form equivalently new bone that is comparable with autogenous bone. The defects treated with membrane only had significantly less bone formation compared with other groups.

CONCLUSION

Both adipose-derived and bone marrow-derived MSC treatments are feasible alternatives to autogenous bone grafts in the treatment of peri-implant osseos defects.

Mesenchymal stem cells in maxillary sinus augmentation: A systematic review with meta-analysis

AIM: To investigate the effectiveness of mesenchymal stem cells (MSCs) in maxillary sinus augmentation (MSA), with various scaffold materials.

METHODS: MEDLINE, EMBASE and SCOPUS were searched using keywords such as sinus graft, MSA, maxillary sinus lift, sinus floor elevation, MSC and cell-based, in different combinations. The searches included full text articles written in English, published over a 10-year period (2004-2014). Inclusion criteria were clinical/radiographic and histologic/ histomorphometric studies in humans and animals, on the use of MSCs in MSA. Meta-analysis was performed only for experimental studies (randomized controlled trials and controlled trials) involving MSA, with an outcome measurement of histologic evaluation with histomorphometric analysis reported. Mean and standard deviation values of newly formed bone from each study were used, and weighted mean values were assessed to account for the difference in the number of subjects among the different studies. To compare the results between the test and the control groups, the differences of regenerated bone in mean and 95% confidence intervals were calculated.

RESULTS: Thirty-nine studies (18 animal studies and 21 human studies) published over a 10-year period (between 2004 and 2014) were considered to be eligible for inclusion in the present literature review. These studies demonstrated considerable variation with respect to study type, study design, follow-up, and results. Meta-analysis was performed on 9 studies (7 animal studies and 2 human studies). The weighted mean difference estimate from a random-effect model was 9.5% (95%CI: 3.6%-15.4%), suggesting a positive effect of stem cells on bone regeneration. Heterogeneity was measured by the I² index. The formal test confirmed the presence of substantial heterogeneity (I² = 83%, P < 0.0001). In attempt to explain the substantial heterogeneity observed, we considered a meta-regression model with publication year, support type (animal vs humans) and follow-up length (8 or 12 wk) as covariates. After adding publication year, support type and follow-up length to the meta-regression model, heterogeneity was no longer significant (I² = 33%, P = 0.25).

CONCLUSION: Several studies have demonstrated the potential for cell-based approaches in MSA; further clinical trials are needed to confirm these results.

In vivo comparison of hard tissue regeneration with ovine mesenchymal stem cells processed with either the FICOLL method or the BMAC method

INTRODUCTION

The aim of this work was to analyse the suitability of mesenchymal stem cell isolation by FICOLL density centrifugation and the closed bone marrow aspirate concentrate (BMAC) system for sinus augmentation with bovine bone mineral (BBM) in the sheep model.

METHODS

16 sheep underwent sinus augmentation with BBM and MSCs; they were divided between two groups with survival points of 8 and 16 weeks. For the FICOLL control arm three, and for the BMAC test arm, five augmentations were performed for each time point. The derived cell numbers were counted; a colony forming unit (CFU) assay was performed; the pluripotency of the MSCs was proved; histological and histomorphometrical analysis were performed.

RESULTS

The approach of using BBM and MSCs in combination with fibrin adhesive was sufficient for new bone formation as the FICOLL experiment indicated. However, due to significantly lower cell numbers isolated using the BMAC in sheep, less new bone was formed in the test arm.

CONCLUSIONS

The BMAC system is well suited for human MSC isolation but it needs to be optimized to fit sheep cell characteristics if it is to be used in this animal model.

Versatility of Pleuripotent Undifferentiated Stem Cells Aspirated from Bone Marrow and its Applications in Oral and Maxillofacial Surgery

INTRODUCTION

Bone marrow (BM) derived pleuripotent undifferentiated stem cells represent a promising population for supporting new concepts in cellular therapy.

AIM

The aim of this study is to evaluate the versatility of pleuripotent undifferentiated stem cells derived from BM aspiration and its applications in oral and maxillofacial surgical procedures.

MATERIALS AND METHODS

A total of 30 patients out of which 15 were with hard tissue defects (cystic lesions n = 6, post surgical alveolar defects n = 4, peri implant defects n = 3, alveolar clefts n = 2) and 15 soft tissue lesions (leukoplakia and lichen planus n = 6, oral submucous fibrosis n = 7, post traumatic soft tissue loss n = 2) were included in the study on randomized clinical basis. The patients received autologous BM derived mononuclear cells which were being locally delivered into the lesion and followed up. The parameters used were (1) To compare and evaluate the bone regeneration by radiographic assessment at the end of 3rd and 6th month postoperatively. (2) Duration of the procedure. (3) Clinical improvement in the management of soft tissue lesions. (4) Assessment of wound healing by Vancouver burn scar assessment of wound. (5) Safety, postoperative infections and complications.

RESULTS

For hard tissue lesions CT scans and OPG revealed adequate regenerated bone, bridging the defect after 3 months. Hounsfield units of regenerated bone after 6 months were more or less similar to native bone which was statistically significant (unpaired t test = p < 0.05). For soft tissue lesions (1) 7 cases of OSMF showed adequate clinical mouth opening (one way anova test = p < 0.05), reduction in burning sensation and blanching of mucosa, (2) 6 cases of leukoplakia and lichen planus and 2 cases of post traumatic soft tissue defects showed good clinical improvement by Vancouver burn scar assessment of wound index.

CONCLUSION

The study shows that there is a definite beneficial effect in bone regeneration and soft tissue wound healing with the use of BM-derived mononuclear cells.

Clinical Application of Mesenchymal Stem Cells and Novel Supportive Therapies for Oral Bone Regeneration

Bone regeneration is often needed prior to dental implant treatment due to the lack of adequate quantity and quality of the bone after infectious diseases, trauma, tumor, or congenital conditions. In these situations, cell transplantation technologies may help to overcome the limitations of autografts, xenografts, allografts, and alloplastic materials. A database search was conducted to include human clinical trials (randomized or controlled) and case reports/series describing the clinical use of mesenchymal stem cells (MSCs) in the oral cavity for bone regeneration only specifically excluding periodontal regeneration. Additionally, novel advances in related technologies are also described. 190 records were identified. 51 articles were selected for full-text assessment, and only 28 met the inclusion criteria: 9 case series, 10 case reports, and 9 randomized controlled clinical trials. Collectively, they evaluate the use of MSCs in a total of 290 patients in 342 interventions. The current published literature is very diverse in methodology and measurement of outcomes. Moreover, the clinical significance is limited. Therefore, the use of these techniques should be further studied in more challenging clinical scenarios with well-designed and standardized RCTs, potentially in combination with new scaffolding techniques and bioactive molecules to improve the final outcomes.

Characterization and cytocompatibility of a new injectable multiphasic bone substitute based on a combination of polysaccharide gel-coated OSPROLIFE(®) HA/TTCP granules and bone marrow concentrate

The purpose of this study was to examine the in vitro cytocompatibility of a novel injectable multiphasic bone substitute (MBS) based on polysaccharide gel-coated OSPROLIFE(®) hydroxyapatite (HA)/tetracalcium phosphate (TTCP) granules combined with bone marrow concentrate (BMC). Polysaccharide gel-coated granules loaded in syringe were combined with BMC diluted in ionic crosslinking solution. The product was then maintained in culture to investigate the cytocompatibility, distribution, and osteogenic differentiation function of cells contained in the BMC. The in vitro cytocompatibility was assessed after 0, 24, and 96 h from the injectable MBS preparation using the LIVE/DEAD(®) staining kit. The results highlighted that cells remained viable after combination with the polysaccharide gel-coated granules; also, viability was maintained over time. The distribution of the cells in the product, observed using confocal microscopy, showed viable cells immersed in the polysaccharide gel formed between the granules after ionic crosslinking. The mesenchymal stromal cells (MSC) contained in the injectable MBS, the basic elements for bone tissue regeneration, were able to differentiate toward osteoblasts, producing an osteogenic matrix as evidenced by alizarin red-s (AR-S) staining. In conclusion, we found that the injectable MBS may have the potential to be used as a bone substitute by applying a "one-step" procedure in bone tissue engineering applications. © 2015 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 104B: 894-902, 2016.

Maxillary Sinus Augmentation Combining Bio-Oss with the Bone Marrow Aspirate Concentrate: A Histomorphometric Study in Humans

Purpose. To investigate the regenerative results obtained with the association of bone marrow aspirate concentrate using the Bone Marrow Aspirate Concentrate (BMAC) method to a xenogeneic bone graft (Bio-Oss) in sinus floor elevation. Materials and Methods. Using a randomized controlled study design in eight consecutive patients (age of 55.4 ± 9.2 years), 16 sinus floor lift procedures were performed with Bio-Oss alone (control group, CG, n = 8) or combined with bone marrow aspirate concentrate obtained via the BMAC method (test group, TG, n = 8). Six months after the grafting procedures, bone biopsies were harvested during implant placement and were analyzed by histomorphometry. Results. Histomorphometric analysis revealed a significantly higher amount (p < 0.05) of vital mineralized tissue in TG when compared to the CG (55.15 ± 20.91% and 27.30 ± 5.55%, resp.). For nonvital mineralized tissue, TG presented a statistically higher level of Bio-Oss resorption (p < 0.05) when compared with the CG (6.32 ± 12.03% and 22.79 ± 9.60%, resp.). Both groups (TG and CG) showed no significantly different levels (p > 0.05) of nonmineralized tissue (38.53 ± 13.08% and 49.90 ± 7.64%, resp.). Conclusion. The use of bone marrow concentrate obtained by BMAC method increased bone formation in sinus lift procedures.

Bone marrow aspirate concentrate and platelet-rich plasma enhanced bone healing in distraction osteogenesis of the tibia

BACKGROUND

During lower limb lengthening, poor bone regeneration is a devastating complication. Several local or systemic applications have been used to promote osteogenesis, and biologic stimulations are gaining attention, but their utility has not been proven in this setting.

QUESTIONS/PURPOSES

In patients undergoing bilateral tibial lengthening, we compared those receiving an osteotomy site injection of autologous bone marrow aspirate concentrate (BMAC) plus platelet-rich plasma (PRP) with those not receiving such an injection in terms of external fixator index (time in external fixation divided by amount of lengthening), full weightbearing index (time until a patient was permitted to do full weightbearing divided by amount of lengthening), four cortical healing indexes (time until each cortical union divided by amount of lengthening), and callus shape and type.

METHODS

Twenty-two patients (44 tibias) undergoing bilateral tibial lengthening enrolled in this randomized trial. Two patients were excluded, one due to insufficient radiographic evaluation and one who was lost to followup, leaving 20 patients (40 segments) for inclusion. Ten patients (20 segments) received BMAC combined with PRP injection (treatment group) and 10 patients (20 segments) received no injection (control group). All patients underwent stature lengthening for familial short stature with the lengthening over nail technique. Autologous BMAC combined with PRP was injected at the tibial osteotomy site at the end of the index surgery. Mean distraction rates were similar between groups (0.75 mm/day in the treatment group versus 0.72 mm/day in the control group; p = 0.24). Full weightbearing was permitted when we observed radiographic evidence of healing at two cortices; this assessment was made by the surgeon who was blinded to the treatment each patient received. Minimum followup was 24 months (mean, 28 months; range, 24-34 months).

RESULTS

There was no difference in mean external fixator index between groups. However, mean cortical healing indexes (anterior/posterior/medial/lateral) were 1.14/0.81/0.96/0.88 months/cm in the treatment group and 1.47/1.26/1.42/1.22 months/cm in the control group (all p < 0.001), showing faster healing in the treatment group at each cortex. Full weightbearing was permitted earlier in the treatment group than in the control group (index: 0.99 months/cm and 1.38 months/cm, respectively, p < 0.001). Callus shape and type were not different between groups.

CONCLUSIONS

Autologous BMAC combined with PRP injection at the osteotomy site helped improve bone healing in distraction osteogenesis of the tibia, although the effect size was small.

LEVEL OF EVIDENCE

Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Recent Trends in Sinus Lift Surgery and Their Clinical Implications

BACKGROUND

Sinus lift procedures are used to allow residual bone to accommodate functional implants in atrophic posterior maxilla. Numerous anatomical and surgical advancements in sinus lift surgery are still inspiring clinicians.

PURPOSE

The purpose of this study was to describe the recent trends in sinus lift surgery focusing on implant survival, bone grafting, anatomical and surgical considerations, and their clinical implications on the practice of implant dentistry in atrophic posterior maxilla.

MATERIALS AND METHODS

We performed an extensive search in MEDLINE, Embase, Scopus, Web of Science, Trip, Cochrane Oral Health Group's Trials Register, Cochrane Central Register of Controlled Trials, and ProQuest Dissertations & Theses. Articles were critically reviewed to determine the level of evidence as per the Canadian Task Force on Preventive Health Care.

RESULTS

Comprehensive assessment of sinus septa, sinus pathology, and bone quality and quantity using three-dimensional cone beam computed tomography radiographs is important before placing implants in posterior maxilla. With a residual bone height of less than 5 mm, the survival rate of implant decreases substantially. Lateral window approach can increase the vertical bone height to greater than 9 mm, while osteotome approach can increase this height from 3 to 9 mm. The perforation of Schneiderian membrane doubles the risk for the incidence of sinusitis or infection. The use of piezoelectric surgery allows adequate sinus lift while protecting soft tissues and minimizing patient discomfort.

CONCLUSIONS

Although both osteotome and lateral window procedures can help clinicians in overcoming the challenges of placing implants in atrophic posterior maxilla, pre-implant residual bone height is crucial in determining the survival of these implants. Future research directions should consider study designs grounded on longitudinal randomized controlled trials of large sample size.

Repair of orbital bone defects in canines using grafts of enriched autologous bone marrow stromal cells

Backgroud

Bone tissue engineering is a new approach for the repair of orbital defects. The aim of the present study was to explore the feasibility of tissue-engineered bone constructed using bone marrow stromal cells (BMSCs) that were rapidly isolated and concentrated from bone marrow (BM) by the red cell lysis method, then combined with β-tricalcium phosphate (β-TCP) to create grafts used to restore orbital bone defects in canines.

Methods

In the experimental group, grafts were constructed using BMSCs obtained by red cell lysis from 20 ml bone marrow, combined with β-TCP and BM via the custom-made stem cell-scaffold device, then used to repair 10 mm diameter medial orbital wall bony defects in canines. Results were compared with those in groups grafted with BM/β-TCP or β-TCP alone, or with defects left untreated as controls. The enrichment of BMSCs and nucleated cells (NCs) in the graft was calculated from the number in untreated bone marrow and in suspensions after red cell lysis. Spiral computed tomography (CT) scans were performed 1, 4, 12 and 24 weeks after implantation in all groups. Gross examination, micro-CT and histological measurements were performed 24 weeks after surgery. The results were analyzed to evaluate the efficacy of bone repair.

Results

The number of NCs and of colony-forming units within the scaffolds were increased 54.8 times and 53.4 times, respectively, compared with untreated bone marrow. In the BMSC-BM/β-TCP group, CT examination revealed that the scaffolds were gradually absorbed and the bony defects were restored. Micro-CT and histological examination confirmed that the implantations led to good repair of the defects, with 6 out 8 orbital defects completely restored in the experimental group, while by contrast, the grafts in the control groups did not fully repair the bony defects, a difference which was statistically significant (p < 0.05).

Conclusions

Tissue-engineered bone, constructed using BMSCs isolated by red cell lysis of BM, can restore critical-sized orbital wall defects in canines.

Maxillary sinus floor elevation surgery with BioOss® mixed with a bone marrow concentrate or autogenous bone: test of principle on implant survival and clinical performance

The purpose of this study was to assess implant survival and 1-year clinical performance of implants placed in the posterior maxilla that had been subjected to maxillary sinus floor elevation surgery with bovine bone mineral (BioOss®) mixed with autogenous bone marrow concentrate or autogenous bone. In a randomized, controlled, split-mouth design study, a bilateral sinus floor augmentation procedure was performed in 12 edentulous patients. At random, one side was treated with BioOss® seeded with an iliac crest bone marrow concentrate enriched in mesenchymal stem cells (test side) and the other with BioOss® mixed with autogenous bone (control side). Three to four months after augmentation, 66 implants were placed. Implant survival, plaque, gingival, and bleeding indices, probing depth, and peri-implant radiographic bone levels were assessed at baseline and 12 months after functional loading. During osseointegration, three implants failed on the test side (two patients) and no implants failed on the control side, resulting in 3-month survival rates of 91% and 100%, respectively. No implants were lost after functional loading and no differences in soft tissue parameters or peri-implant bone loss were observed between the control and test sides. After 1 year in function, no clinically relevant differences were observed regarding soft tissue parameters or peri-implant bone loss.