Repair of calvarial defects with flap tissue: role of bone morphogenetic proteins and competent responding tissues

Stem Cell Therapy's Efficiency in Reconstructing Alveolar Clefts: A System Review and Meta-Analysis of Randomized Controlled Trials

Objectives: The goal of this study was to examine the existing evidence from randomized controlled trials (RCTs) on the efficacy of cell treatment in alveolar cleft (AC). Design: An electronic search was done for studies published between January 2000 and May 2024 in the PubMed/MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases. Primary outcomes were the radiographic assessment of bone graft volume, and the secondary outcome of interest was the number of complications after surgery. A random-effects model and fix-effect model were employed to pool effect sizes, and heterogeneity was assessed using I 2 statistics. Results: Four RCTs, comprising 51 patients, were included in the systematic review and meta-analysis. No statistically significant difference in bone volume (MD [mean difference] -0.82; 95% CI [-3.59, 5.24]; p=0.71) when using cells therapy to repair AC compared to using autologous iliac crest bone graft repair AC. Also, there is no difference in postoperative complications (MD 0.66; 95% CI [0.13, 3.39]; p=0.62) between the two groups. In this meta-analysis, cells therapy on alveolar bone grafting produced results comparable to autologous bone grafting in new bone formation rate and complications. Conclusions: In conclusion, this systematic review and meta-analysis appear to indicate no disadvantage to utilizing cell therapy in AC reconstruction versus autologous bone grafting in terms of bone volume or complications.

Effect of Photobiomodulation Therapy Associated With Biphasic Phosphate Calcium on Bone Repair: A Histomorphometric Study in Rats

Introduction: This study aimed to investigate the effects of photobiomodulation (PBM) therapy associated with biphasic calcium phosphate on calvaria critical defects in rats. Methods: Forty-eight (90 days old) adult male rats (Rattus norvegicus, Albinus variation, Wistar) received critical defects of 5 mm in diameter, which were made on their skull, and they were randomly assigned into the following groups: C-blood clot, B-biphasic calcium phosphate, L-photobiomodulation therapy, and B + L-biphasic calcium phosphate + photobiomodulation therapy. A low-level a gallium aluminum arsenide (GaAlAs) laser was applied in a single dose during surgery, in a wavelength of 660 nm and total energy density of 45 J/cm². On 30^th and 60^th days, the animals from each group were euthanized. Histological and histomorphometric analyses were performed. Results:In 30 days, almost all specimens (C, L, B and B + L) showed bone neoformation areas in regions near the borders of the surgical defect. In 60 days, in many specimens (C, L, B, B + L), it was possible to see a narrow neoformed bone structure along almost the whole extension of the surgical defect, though it was thinner than the original calvary bone. Data were recorded as mean ± standard deviation, and after normality was tested, a suitable statistical test was applied (α = 5%). On day 60, there was a statistically significant difference when comparing the proportion of neoformation area between group L (0.52%±0.13) and group B+L (0.20%±0.08). Group L showed a difference compared with all the groups when we compared the remaining distance between the edges of neoformed bone (C×L, P=0.0431; B × L, P=0.0386; L×B+L, P=0.0352), demonstrating a great defect closure. Conclusion: Our findings suggest that although biphasic calcium phosphate exerts some osteogenic activity during bone repair, PBM therapy is not able to modulate this process.

Bone repair assessment of critical size defects in rats treated with mineralized bovine bone (Bio-Oss®) and photobiomodulation therapy: a histomorphometric and immunohistochemical study

This study aimed to investigate the effects of administering photobiomodulation therapy (PBM) with bovine bone matrix on critical size defects in rats. Seventy-two adult male rats (albinus, Wistar), 90 days old, were used. Defect of 5 mm in diameter was made in their calvaria. The animals were divided into 4 groups: C-blood clot, B-Bio-Oss®, L-PBM, B+L-Bio-Oss®+PBM. Each group has been subdivided into 07, 30, and 60 days of observation. For PBM, a low GaAlAs energy of 660 nm was irradiated, total energy density of 45 J/cm² . PBM was conducted in a trans-surgical form once only. For immunohistochemistry, a semi-quantitative analysis was made of expression of osteoprotegerin (OPG), nuclear kappa B-factor ligand receptor activator (RANKL), and tartrate-resistant acid phosphatase (TRAP). All histomorphometric data were statistically analyzed by ANOVA and Tukey test, significance level of 5%. The groups that showed the highest proportion of neoformation were L (0.39% ± 0.13) and C (0.37% ± 0.97), but groups B and B+L had larger defect size (C-1.75 mm² ± 0.40, B-3.02 mm² ± 0.63, L-2.45 mm² ± 0.53, B+L-3.23 mm² ± 1.01). In immunohistochemistry, groups B and B+L had higher immunostaining scores for OPG and RANKL at 60 days, and TRAP immunostaining increased in all groups at 30 days, but group L was the only one to present specimens with score 0. Although, at 60 days, groups L and C presented the highest proportion of bone neoformation, at 30 days group B+L had more than twice as much bone neoformation as group B, the choice of treatment application should depend on the aim of the treatment.

Free flap reconstruction of sarcoma defects in the setting of radiation: a ten-year experience

Neoadjuvant treatment and surgical resection for sarcoma patients can often leave devastating wounds necessitating soft-tissue coverage in the form of free flaps. There is still debate as to the optimal flap for reconstruction of defects in irradiated fields. We aim to describe our experiences with free fasciocutaneous and free muscle flaps for sarcoma reconstruction in the setting of radiation therapy. A retrospective chart review was conducted encompassing all patients requiring soft-tissue reconstruction secondary to sarcoma resection from January 2010 to June 2019. Patient characteristics, flap viability and post-operative healing outcomes were all recorded and examined. In total, 49 patients who underwent 51 free-flaps were identified. Of these, 30 flaps were fasciocutaneous, while 21 were muscle-based. Most patients received pre-operative radiotherapy (76.5%), although these rates were not different between groups of flap type, and had no significant association with post-operative outcomes. Complication rates (31.3%) and re-operative rates (21.6%) were also comparable between flap types. Diabetes mellitus was significantly associated with delayed wound healing (p < .016), while the presence of peripheral vascular disease had a significant association with post-operative infection (p < .006). This study shows that free fasciocutaneous and free muscle-based flaps are both viable options for soft-tissue reconstruction demanded by sarcoma resection, even in the setting of radiation. Peripheral vascular disease and diabetes mellitus may confer increased wound complications.

Hydroxyapatite calvaria graft repair in experimental diabetes mellitus in rats

Among the systemic conditions that impact negatively on the planning and execution of surgical procedures, diabetes mellitus (DM) is the primary clinical condition responsible for complications. This study investigated bone formation in critical defects surgically filled with hydroxyapatite (HA) in diabetic rats. A descriptive, randomized sample and blinded analysis were conducted to test bone regeneration in critical bone defects surgically performed in rat calvaria. Twenty adult male Wistar rats were randomly divided into two groups: control, normoglycemic animals (CG); and test, streptozotocin-induced hyperglycemic animals (TG). A circular bone defect was filled with HA and maintained subperiosteally. The clinical parameters evaluated were body weight, water and food intake, fasting blood glucose, and bone alkaline phosphatase. Bone-grafted area samples were submitted for histomorphometric and stereological analysis. The TG showed a significantly higher rate of new bone formation compared with the CG, sacrificed 15 days after surgery (p < 0.0001). However, at the end of the study, there was no significant difference in the amount of bone formed between groups (p = 0.077). In parallel, with the increase in osteoblastic activity observed in the TG by the measurement of systemic bone alkaline phosphatase (p = 0.016), the analysis of polarized microscopy and stereology demonstrated a lower level collagen maturation and mineralization in the TG. Quantitatively, the TG showed significantly better results for bone gain in the first 15 days. Qualitative assessments, however, showed fewer collagen fibers and bone maturation in the TG compared with the CG both at 15 and 45 days. Therefore, the postoperative evaluation of bone grafts with HA in hyperglycemic situations should consider the systemic and local effects of this condition on the quality of bone repair, rather than identifying the filling or stability of the grafted area after the process. We conclude that clinically detectable bone repair in diabetic animal models submitted to hydroxyapatite grafts may be satisfactory in the early stages. However, hyperglycemia compromises the quality of the newly formed bone and the collagen cross-linking involved in this process.

Outcomes of Alveolar Graft With Rhbmp-2 in CLP: Influence of Cleft Type and Width, Canine Eruption, and Surgeon

OBJECTIVE

To evaluate the influence of cleft type and width, canine eruption stage, and surgeon on the outcomes of alveolar graft with rhBMP-2.

DESIGN

Cross-sectional.

SETTING

Tertiary craniofacial center.

PARTICIPANTS

Ninety individuals submitted to alveolar graft in late mixed or early permanent dentition.

INTERVENTIONS

The 90 individuals (mean age: 16.8 years) were submitted to alveolar graft with rhBMP-2. Periapical radiographs were obtained before and 6 months after surgery. Surgeries were performed by 4 experienced maxillofacial surgeons. The alveolar grafts were assigned as success or failure by 3 blinded raters based on the modified Bergland and Chelsea scales. Permanent canines adjacent to the defect were assigned as erupted and not erupted. The greatest cleft width was measured on preoperative periapical radiographs.

MAIN OUTCOME MEASURES

The influence of 4 independent variables (cleft type, cleft width, canine eruption phase, and surgeon) on the outcome of alveolar graft was analyzed by multivariate logistic regression ( P < .05).

RESULTS

All independent variables presented significant influence on alveolar graft outcome. The subgroup of unerupted maxillary canines demonstrated better outcomes than erupted canines ( P = .001). The group with cleft lip and alveolus (CL/A) demonstrated better outcomes than complete cleft lip and palate (CLP; P < .001). The greater the alveolar cleft width, the less favorable were the graft outcomes ( P = .027). The surgeon also had a significant influence on the surgery success ( P = .003 and .001).

CONCLUSION

The type and width of CLP, the eruption of permanent canines, and the surgeon influenced the outcome of alveolar graft surgeries performed with rhBMP-2.

The Use of Sequential VEGF- and BMP2-Releasing Biodegradable Scaffolds in Rabbit Mandibular Defects

PURPOSE

Promising developments have materialized in reconstructive surgical procedures with the applications of tissue engineering. In our study, we used tissue scaffolds fabricated from polylactic acid-polyethylene glycol (PLLA-PEG) copolymers to ensure different release rates of selective growth factors recombinant human bone morphogenetic protein 2 [rhBMP-2] and vascular endothelial growth factor (rhVEGF165) in the repair of mandibular bone defects.

MATERIALS AND METHODS

In our experimental study, 54 New Zealand rabbits were used. The rabbits were separated into 4 groups: group I (control group), PLLA-PEG scaffold only; group II, PLLA-PEG scaffold plus rhBMP-2 application; group III, PLLA-PEG scaffold plus VEGF165 application; and group IV, PLLA-PEG scaffold plus rhBMP-2 and VEGF165 applications. The rabbits were killed at 4 and 8 weeks postoperatively, and histopathologic and immunohistochemical assessments were performed.

RESULTS

The greatest bone volume was observed in rhBMP-2-containing groups, the greatest vessel volume was observed in VEGF165-containing groups; however, the scaffold containing rhBMP-2 and VEGF165 provided the best outcomes in conjunction with increased remodeling of the new bone.

CONCLUSIONS

The use of polymer tissue scaffolds that release rhVEGF165 and rhBMP-2 in coordination and mimic the natural healing process in the regeneration of especially complex tissues, such as bone, is a promising treatment alternative in the field of reconstructive surgery.

Evolution of Postoperative Edema in Alveolar Graft Performed with Bone Morphogenetic Protein (rhBMP-2)

Objective

To evaluate the evolution of facial edema in the postoperative period after alveolar graft surgeries performed with collagen membrane soaked with recombinant human bone morphogenetic protein-2 (rhBMP-2) in individuals with cleft lip and palate.

Design

Longitudinal prospective.

Setting

Tertiary craniofacial center.

Participants

One hundred fifty individuals submitted to alveolar graft.

Interventions

In the preoperative consultation and 4 days after surgery, the individuals were assessed as to age, professional performing the surgery, duration of the procedure, type of cleft, measurement of facial edema, mouth opening, and global evaluation of the postoperative period.

Main Outcome Measures

Statistical analysis was performed to compare the facial edema and different variables, at a significance level of .05.

Results

The maximum facial edema occurred between 3 and 4 days postoperatively, was inversely proportional to age and mouth opening, greater for female patients compared with male patients, for incomplete unilateral cleft lip and palate compared with other types of clefts, and for surgeon 1 compared with the other surgeons at some moment postoperatively. The surgeries were longer for complete unilateral and bilateral clefts. The difference was statistically significant for these variables.

Conclusions

The facial edema was influenced by the rhBMP-2 used in alveolar graft, and trismus was proportional to the intensity of facial edema.

Multiple roles of tumor necrosis factor-alpha in fracture healing

This review presents a summary of basic science evidence examining the influence of tumor necrosis factor-alpha (TNF-α) on secondary fracture healing. Multiple studies suggest that TNF-α, in combination with the host reservoir of peri-fracture mesenchymal stem cells, is a main determinant in the success of bone healing. Disease states associated with poor bone healing commonly have inappropriate TNF-α responses, which likely contributes to the higher incidence of delayed and nonunions in these patient populations. Appreciation of TNF-α in fracture healing may lead to new therapies to augment recovery and reduce the incidence of complications.

Investigating the Vascularization of Tissue-Engineered Bone Constructs Using Dental Pulp Cells and 45S5 Bioglass® Scaffolds

Identification of a suitable cell source combined with an appropriate 3D scaffold is an essential prerequisite for successful engineering of skeletal tissues. Both osteogenesis and angiogenesis are key processes for bone regeneration. This study investigated the vascularization potential of a novel combination of human dental pulp stromal cells (HDPSCs) with 45S5 Bioglass^® scaffolds for tissue-engineered mineral constructs in vivo and in vitro. 45S5 Bioglass scaffolds were produced by the foam replication technique with the standard composition of 45 wt% SiO₂, 24.5 wt% Na₂O, 24.5 wt% CaO, and 6 wt% P₂O₅. HDPSCs were cultured in monolayers and on porous 45S5 Bioglass scaffolds under angiogenic and osteogenic conditions for 2–4 weeks. HDPSCs expressed endothelial gene markers (CD34, CD31/PECAM1, and VEGFR2) under both conditions in the monolayer. A combination of HDPSCs with 45S5 Bioglass enhanced the expression of these gene markers. Positive immunostaining for CD31/PECAM1 and VEGFR2 and negative staining for CD34 supported the gene expression data, while histology revealed evidence of endothelial cell-like morphology within the constructs. More organized tubular structures, resembling microvessels, were seen in the constructs after 8 weeks of implantation in vivo. In conclusion, this study suggests that the combination of HDPSCs with 45S5 Bioglass scaffolds offers a promising strategy for regenerating vascularized bone grafts.

Stereotactic radiosurgery and fracture fixation in 6 dogs with appendicular osteosarcoma

OBJECTIVE

To evaluate clinical outcome of dogs with appendicular osteosarcoma (OSA) treated with stereotactic radiosurgery (SRS) and subsequent internal fixation of a pathologic fracture.

STUDY DESIGN

Retrospective case series.

ANIMALS

Dogs with spontaneous-occurring appendicular OSA (n = 6).

METHODS

Medical records (May 2002-January 2008) of dogs that had SRS for appendicular OSA were reviewed. Dogs were included if they had a pathologic fracture either before or after SRS and were treated with internal fixation. Signalment, history, physical examination findings, clinicopathologic data, diagnostic imaging findings, biopsy results, surgical complications, number of surgeries, adjuvant therapy, development of metastatic disease and cause of death were recorded.

RESULTS

Six dogs met the inclusion criteria. Two dogs had a pathologic fracture at admission and 4 dogs developed a fracture after SRS with a mean ± SD time to fracture development of 6.25 ± 1.65 months. The first 3 fractures were repaired using an open approach and the latter three using minimally invasive percutaneous osteosynthesis (MIPO). Infection occurred in 5 dogs and implant failure in 3. Limb function was subjectively assessed as good in all dogs when the implants were stable and infections were subclinical. Survival times ranged from 364-897 days; 1 dog was lost to follow-up.

CONCLUSIONS

Fracture repair using internal fixation should be considered a viable limb-sparing alternative for pathologic fractures that have been treated with SRS.

Immunolocalization of bone morphogenetic protein 2 during the early healing events after guided bone regeneration

OBJECTIVE

The objective of this study was to evaluate the immunolocalization of bone morphogenetic protein 2 (BMP-2) after autogenous block grafting covered or not with an e-PTFE membrane.

STUDY DESIGN

Forty-eight rats were divided into 2 groups, autogenous block graft (B) and autogenous block graft + e-PTFE membrane (MB), and were evaluated by immunohistochemistry at baseline and 3, 7, 14, 21, and 45 days.

RESULTS

The largest number of positive cells in the recipient bed was observed after 3 days in both groups. At the graft border, the largest number of positive cells was seen after 7 days in group B and after 14 days in group MB. The highest proportion of staining in the graft was observed after 3 days in group B and after 21 days in group MB.

CONCLUSIONS

High proportions of stain were related to intense revascularization and osteogenesis. Except for the interface, BMP-2 staining occurred later in group MB than in group B in all structures analyzed.

Mandibular reconstruction using an axially vascularized tissue-engineered construct

Background

Current reconstructive techniques for continuity defects of the mandible include the use of free flaps, bone grafts, and alloplastic materials. New methods of regenerative medicine designed to restore tissues depend mainly on the so-called extrinsic neovascularization, where the neovascular bed originates from the periphery of the construct. This method is not applicable for large defects in irradiated fields.

Methods

We are introducing a new animal model for mandibular reconstruction using intrinsic axial vascularization by the Arterio-Venous (AV) loop. In order to test this model, we made cadaveric, mechanical loading, and surgical pilot studies on adult male goats. The cadaveric study aimed at defining the best vascular axis to be used in creating the AV loop in the mandibular region. Mechanical loading studies (3 points bending test) were done to ensure that the mechanical properties of the mandible were significantly affected by the designed defect, and to put a base line for further mechanical testing after bone regeneration. A pilot surgical study was done to ensure smooth operative and post operative procedures.

Results

The best vascular axis to reconstruct defects in the posterior half of the mandible is the facial artery (average length 32.5 ± 1.9 mm, caliber 2.5 mm), and facial vein (average length 33.3 ± 1.8 mm, caliber 2.6 mm). Defects in the anterior half require an additional venous graft. The defect was shown to be significantly affecting the mechanical properties of the mandible (P value 0.0204). The animal was able to feed on soft diet from the 3^rd postoperative day and returned to normal diet within a week. The mandible did not break during the period of follow up (2 months).

Conclusions

Our model introduces the concept of axial vascularization of mandibular constructs. This model can be used to assess bone regeneration for large bony defects in irradiated fields. This is the first study to introduce the concept of axial vascularization using the AV loop for angiogenesis in the mandibular region. Moreover, this is the first study aiming at axial vascularization of synthetic tissue engineering constructs at the site of the defect without any need for tissue transfer (in contrast to what was done previously in prefabricated flaps).

Bone regeneration in defects compromised by radiotherapy

Because bone reconstruction in irradiated sites is less than ideal, we applied a regenerative gene therapy method in which a cell-signaling virus was localized to biomaterial scaffolds to regenerate wounds compromised by radiation therapy. Critical-sized defects were created in rat calvariae previously treated with radiation. Gelatin scaffolds containing lyophilized adenovirus encoding BMP-2 (AdBMP-2) or freely suspended AdBMP-2 were transplanted. Lyophilized AdBMP-2 significantly improved bone quality and quantity over free AdBMP-2. Bone mineral density was reduced after radiotherapy. Histological analyses demonstrated that radiation damage led to less bone regeneration. The woven bone and immature marrow formed in the radiated defects indicated that irradiation retarded normal bone development. Finally, we stored the scaffolds with lyophilized AdBMP-2 at -80 degrees C to determine adenovirus stability. Micro-CT quantification demonstrated no significant differences between bone regeneration treated with lyophilized AdBMP-2 before and after storage, suggesting that virus-loaded scaffolds may be convenient for application as pre-made constructs.

Validation of histologic changes induced by external irradiation in mandibular bone. An experimental animal model

The present experimental study sought to determine the effect of high-dose irradiation on the rat mandible in order to establish an experimental model of radiogenic bone damage. The left mandibles of 20 adult Wistar rats were irradiated (single fraction 1500cGy, total dose 60Gy) by means of a hypofractionated stereotactic radiotherapy (hfSRT) over a period of 6 weeks. Follow-up was 6 weeks (group 1, n=10) and 12 weeks (group 2, n=10). The contralateral mandibles as well as 5 non-irradiated animals served as controls. Primary endpoints were fibrosis, loss of cell count, decreased immunohistochemical labelling for bone morphogenetic protein-2 (BMP-2) and osteocalcin as well as increased expression of transforming growth factor (TGF-beta). Cell loss, progressive fibrosis, and focal necrosis were detected in all irradiated sites. Quantitative measurement revealed 32.0+/-8.7% and 37.3+/-9.5% empty osteocyte lacunae for groups 1 and 2 resp., compared to 16.3+/-4.7% and 18.9+/-4.9% on the contralateral side and 7.9+/-1.7% for unirradiated controls (Mann-Whitney U test; p<.01). BMP-2 and osteocalcin labelling showed a marked decrease in irradiated and contralateral sides while TGF-beta was expressed strongly in irradiated sites only (for all p<.05). External hypofractionated irradiation with a total dose of 60Gy is feasible in rats and yields all histologic changes attributed to osteoradionecrosis (ORN) after a follow-up of 6 weeks. The irradiation protocol is suitable for an assessment of regenerative options in severe radiogenic bone damage. As a split mouth design entails major inaccuracies healthy animals have to be used as controls.

Fracture healing and bone repair: an update

Bone healing represents a physiological process of repair and restoration of function. Recent advances in a variety of medical disciplines have enabled scientists and clinicians to characterise this phenomenon at the molecular level. A number of molecular mediators and cells interact utilising different pathways. Despite the involvement of many local and systemic factors failure of the naturally occurring mechanisms can occur leading to either delayed union or non-union. This review article is focused on the recent understanding of the mechanisms governing the bone repair process.

Myoblast sensitivity and fibroblast insensitivity to osteogenic conversion by BMP-2 correlates with the expression of Bmpr-1a

Background

Osteoblasts are considered to primarily arise from osseous progenitors within the periosteum or bone marrow. We have speculated that cells from local soft tissues may also take on an osteogenic phenotype. Myoblasts are known to adopt a bone gene program upon treatment with the osteogenic bone morphogenetic proteins (BMP-2,-4,-6,-7,-9), but their osteogenic capacity relative to other progenitor types is unclear. We further hypothesized that the sensitivity of cells to BMP-2 would correlate with BMP receptor expression.

Methods

We directly compared the BMP-2 sensitivity of myoblastic murine cell lines and primary cells with osteoprogenitors from osseous tissues and fibroblasts. Fibroblasts forced to undergo myogenic conversion by transduction with a MyoD-expressing lentiviral vector (LV-MyoD) were also examined. Outcome measures included alkaline phosphatase expression, matrix mineralization, and expression of osteogenic genes (alkaline phosphatase, osteocalcin and bone morphogenetic protein receptor-1A) as measured by quantitative PCR.

Results

BMP-2 induced a rapid and robust osteogenic response in myoblasts and osteoprogenitors, but not in fibroblasts. Myoblasts and osteoprogenitors grown in osteogenic media rapidly upregulated Bmpr-1a expression. Chronic BMP-2 treatment resulted in peak Bmpr-1a expression at day 6 before declining, suggestive of a negative feedback mechanism. In contrast, fibroblasts expressed low levels of Bmpr-1a that was only weakly up-regulated by BMP-2 treatment. Bioinformatics analysis confirmed the presence of myogenic responsive elements in the proximal promoter region of human and murine BMPR-1A/Bmpr-1a. Forced myogenic gene expression in fibroblasts was associated with a significant increase in Bmpr-1a expression and a synergistic increase in the osteogenic response to BMP-2.

Conclusion

These data demonstrate the osteogenic sensitivity of muscle progenitors and provide a mechanistic insight into the variable response of different cell lineages to BMP-2.

The contribution of different cell lineages to bone repair: exploring a role for muscle stem cells

An anabolic response driven by osteoblasts is critical for the process of bone healing. Current evidence suggests that these osteoblasts may arise from multiple tissue types and cell lineages. Stem cells present in the bone marrow, periosteum, local soft tissues, vasculature, and/or circulation have been shown to have osteogenic potential. Transplanted cells from these sources have also been shown to incorporate into induced ectopic bone or repaired bone. While these experiments demonstrate the latent capacity of different lineages to assume an osteoblastic phenotype under pro-osteogenic conditions, the actual contribution of the different lineages to various repair situations in vivo remains unclear. This review explores the data arising from different bone formation and repair models. We propose a model suggesting that cells arising from the local tissues, particularly muscle cells, may play an important role in fracture repair under situations where the periosteal and/or bone marrow progenitor populations are depleted.

HDR brachytherapy irradiation of the jaw - as a new experimental model of radiogenic bone damage

INTRODUCTION

Hitherto, no suitable experimental model exists to test new treatments for radiogenic bone damage, such as new step from knowledge about bone growth factors or angiogenesis factors. The goal of this investigation was to establish such a standardised experimental model.

MATERIAL AND METHODS

Twenty-four rats were used in this study. In 12 rats a plastic tube was implanted along the right half of the mandible and treated with a single dose of 20 Gy at a high-dose-rate (HDR) using an afterloading machine, the remainder served as control (n=12). One hundred days after irradiation both sides of the mandible were examined using paraffin embedding and non-decalcified histology.

RESULTS

All HDR irradiated rats developed localised alopecia within 2 weeks of radiotherapy. In the irradiated group, a clear growth reduction of the ipsilateral incisor was observed. Paraffin histology revealed minimal damage of the bone structure with slightly increased signs of regeneration. The bone apposition rate was significantly reduced on the irradiated right side, compared with the left side (p=0.028). The average diameter of the mandibular condyles on the irradiated right sides was significantly reduced when compared with the left sides (p=0.023).

CONCLUSIONS

It is possible to induce radiogenic damage of the mandible by using HDR brachytherapy with a single dose of 20 Gy comparable to 45 x 2 Gy of conventional irradiation. This new model is easy and predictable and appears to be suitable for the testing of new treatment modalities. It is advantageous for the testing of bone growth and angiogenesis factors that the contralateral side exhibits completely normal bone apposition characteristics enabling a split-mouth design for future experiments.

BMP-2 and bFGF in an irradiated bone model

INTRODUCTION

Basic fibroblast growth factor (bFGF) is considered to enhance angiogenesis and to support bone formation in the presence of vital bone cells. Bone morphogenetic protein-2 (rhBMP-2) is known to induce bone formation. The aim of this study was to analyze the effect of bFGF and rhBMP-2 in the irradiated mandible.

MATERIAL AND METHODS

The right mandibles of 24 rats were irradiated with a single dose of 20 Gy at a high-dose-rate (HDR) after loading machine (bio effective equivalent dose to ca. 45 x 2 Gy). After 12 weeks 100 microg rhBMP-2 (n=6 animals, group 1), 100 microg bFGF (n=6 animals, group 2) and 100 microg rhBMP-2 plus 100 microg bFGF (n=6 animals, group 3) were injected along the right mandible (left mandible: no irradiation, no growth factor). Another 6 animals (group 4) remained untreated after the irradiation. After another 7 weeks the specimens were examined by non-decalcified histology.

RESULTS

Bone apposition of the experimental versus control sides was not statistically significantly different when one of the growth factors was applied alone (rhBMP-2: p=0.917; bFGF: p=0.345). Average bone apposition was significantly decreased on the experimental sides of group 3 (rhBMP-2+bFGF: p=0.046) and group 4 (p=0.008). Average bone densities were unaffected in all settings (for all p>0.1).

CONCLUSIONS

The application of bFGF and the application of rhBMP-2 alone did result in predictable bone generation in the irradiated mandible with the bone apposition being equal to that of the non-irradiated side. The application of both growth factors together or none at all after irradiation results in significantly reduced bone apposition.

Primary Stability of Simultaneously Placed Dental Implants in Extraoral Donor Graft Sites: A Human Cadaver Study

PURPOSE

To compare the primary stability of dental implants placed in fibula, iliac crest, and scapula of human cadavers.

MATERIALS AND METHODS

Straumann Dental Implants (Institut Straumann, Basel, Switzerland) 4.1 mmx10 mm in diameter were placed into bilateral fibula, iliac crest, and scapula of 4 fresh human cadavers. For the assessment of primary stability of implants, installation torque values (ITV) and removal torque values (RTV) were measured using a custom-made strain-gauged torque wrench, and resonance frequency analysis was carried out to quantify the implant stability quotients (ISQ). Bone specimens from each donor site were harvested to perform radiographic and histomorphometric analyses. Linear distance and optical density (OD) measurements were made on digitized parallel periapical radiographs and bone area fraction (BAF) was calculated on digitized images of decalcified histologic sections.

RESULTS

Fibula donor site presented higher ITVs and RTVs and cortical bone height for implants than other sites (P<.05). BAF measurements for iliac crest were higher than fibula and scapula bone donor sites. OD was higher in the iliac crest followed by scapula and fibula.

CONCLUSION

The primary mechanical stability of implants placed in the fibula is higher than those placed in the iliac crest and the scapula, although the bone mass and density around implants in latter sites are higher.

Craniofacial tissue engineering by stem cells

Craniofacial tissue engineering promises the regeneration or de novo formation of dental, oral, and craniofacial structures lost to congenital anomalies, trauma, and diseases. Virtually all craniofacial structures are derivatives of mesenchymal cells. Mesenchymal stem cells are the offspring of mesenchymal cells following asymmetrical division, and reside in various craniofacial structures in the adult. Cells with characteristics of adult stem cells have been isolated from the dental pulp, the deciduous tooth, and the periodontium. Several craniofacial structures--such as the mandibular condyle, calvarial bone, cranial suture, and subcutaneous adipose tissue--have been engineered from mesenchymal stem cells, growth factor, and/or gene therapy approaches. As a departure from the reliance of current clinical practice on durable materials such as amalgam, composites, and metallic alloys, biological therapies utilize mesenchymal stem cells, delivered or internally recruited, to generate craniofacial structures in temporary scaffolding biomaterials. Craniofacial tissue engineering is likely to be realized in the foreseeable future, and represents an opportunity that dentistry cannot afford to miss.

Augmentation of demineralized bone matrix (DBM) mineralization by a synthetic growth factor mimetic

These studies evaluated whether F2A4-K-NS, a peptide mimetic of FGF-2, could augment ectopic bone production following the subcutaneous implant of human demineralized bone matrix (DBM). DBM was formulated into a gel with and without F2A4-K-NS, and injected subcutaneously into athymic rats. After 28 days the resultant tissue was excised and fixed. The tissue was examined with soft X-rays and microcomputerized tomography (micro-CT), and by histological methods. Inclusion of F2A4-K-NS with DBM resulted in an increased mineral deposition as determined by soft X-ray and micro-CT analysis and von Kossa staining. DBM-containing tissues showed extensive mineralization compared to the carrier alone, which was poorly mineralized. The mineralization was qualitatively and quantitatively the most extensive in the samples containing F2A4-K-NS plus DBM. Additionally, the highest amount of von Kossa staining for calcium was observed in tissues from animals that had received DBM plus F2A4-K-NS. In these studies, 100 ng of peptide per 0.2 mL of injectable DBM gel generated the most optimal results. The synthetic peptide F2A4-K-NS augmented DBM-induced ectopic mineralization in athymic animals.

Clinical Applications of Bioactive Factors in Sports Medicine

The ability to biologically manipulate musculoskeletal healing and augment bone and soft tissue repair and regeneration holds great promise. Advances in the basic science study and clinical application of bioactive proteins and growth factors continues to evolve. Improvement in the surgical resurfacing of articular cartilage defects and tendon and ligament repair through the addition of bioactive polypeptides is currently underway. The purpose of this article is to review the present array of biologically active materials that may be clinically applicable in sports medicine and arthroscopy. Mechanisms for biologic augmentation of tissue repair and regeneration will be discussed. Current limitations and future considerations will be reviewed particularly as they relate to practical clinical approaches.

VEGF scaffolds enhance angiogenesis and bone regeneration in irradiated osseous defects

Bone regeneration is challenging in sites where the blood supply has been compromised by radiation. We examined the potential of a growth factor (VEGF) delivery system to enhance angiogenesis and bone formation in irradiated calvarial defects. VEGF-releasing polymers significantly increased blood vessel density and vascular perfusion in irradiated defects and increased bone formation relative to control conditions.

INTRODUCTION

Radiation therapy causes damage to tissues and inhibits its regenerative capacity. Tissue injury from radiation is in large part caused by a compromised vascular supply and reduced perfusion of tissues. The aim of this study was to determine if delivery of vascular endothelial growth factor (VEGF) from a biodegradable PLGA (copolymer of D,L-lactide and glycolide) scaffold could enhance neovascularization and bone regeneration in irradiated osseous defects.

MATERIALS AND METHODS

An isolated area of the calvarium of Fisher rats was irradiated (12 Gy) 2 weeks preoperatively, and two 3.5-mm osseous defects were created in this area, followed by the placement of PLGA scaffolds or VEGF scaffolds (PLGA scaffolds with incorporated VEGF) into the defects. Laser Doppler perfusion imaging was performed to measure perfusion of these areas at 1, 2, and 6 weeks. Implants were retrieved at 2, 6, and 12 weeks, and histologic and muCT analyses were performed to determine neovascularization and bone regeneration.

RESULTS

Histological analyses revealed statistically significant increases in blood vessel formation (>2-fold) and function (30%) within the VEGF scaffolds compared with PLGA scaffolds. Additionally, evaluation of bone regeneration through bone histomorphometric and muCT analyses revealed significantly greater bone coverage (26.36 +/- 6.91% versus 7.05 +/- 2.09% [SD]) and increased BMD (130.80 +/- 58.05 versus 71.28 +/- 42.94 mg/cm(3)) in VEGF scaffolds compared with PLGA scaffolds.

CONCLUSIONS

Our findings show that VEGF scaffolds have the ability to enhance neovascularization and bone regeneration in irradiated osseous defects, outlining a novel approach for engineering tissues in hypovascular environments.

Current concepts of molecular aspects of bone healing

Fracture healing is a complex physiological process. It involves the coordinated participation of haematopoietic and immune cells within the bone marrow in conjunction with vascular and skeletal cell precursors, including mesenchymal stem cells (MSCs) that are recruited from the surrounding tissues and the circulation. Multiple factors regulate this cascade of molecular events by affecting different sites in the osteoblast and chondroblast lineage through various processes such as migration, proliferation, chemotaxis, differentiation, inhibition, and extracellular protein synthesis. An understanding of the fracture healing cellular and molecular pathways is not only critical for the future advancement of fracture treatment, but it may also be informative to our further understanding of the mechanisms of skeletal growth and repair as well as the mechanisms of aging.

Bone Regeneration in Cranial Defects Previously Treated with Radiation

OBJECTIVES/HYPOTHESIS

Bone reconstruction in the head and neck region is frequently performed in the context of previous radiation treatment. Thus, the effectiveness of tissue engineering approaches for regenerating bone in radiated defects needs to be determined before considering application to patients. Incomplete healing is described when using osteoinductive protein therapy alone for bone defects previously treated with radiation. We hypothesized that a different approach using ex vivo gene therapy can heal these severely compromised defects.

STUDY DESIGN

Animal study using Fisher rats.

METHODS

Two weeks before surgery, rats received either no radiation or a 12 Gray radiation dose to the calvarium. Syngeneic dermal fibroblasts were transduced ex vivo using an adenoviral vector containing the cDNA for bone morphogenetic protein (BMP)-7. Critical-sized calvarial defects were created, and either a transduced cell-seeded scaffold or an autologous bone graft was placed into the defect. Nonradiated defects were harvested 4 weeks later for both groups. Radiated defects treated with bone grafts were harvested at 4 weeks, and those treated with gene therapy were harvested either at 4 or 8 weeks. Gross inspection and histology were used to evaluate wound healing.

RESULTS

None of the bone grafts had gross or histologic evidence of healing at the wound margins. The nonradiated gene therapy treated defects revealed gross and histologic near-100% bone regeneration by 4 weeks after surgery. By gross inspection, the radiated defects had soft tissue admixed with islands of bone at both 4 and 8 weeks. The histologic appearance revealed areas of dense bone in a nonconfluent pattern admixed with adjacent cells having the morphologic appearance of hypertrophic chondrocytes, suggesting continued endochondral ossification.

CONCLUSIONS

Preoperative radiation significantly impairs the ability of BMP-7 ex vivo gene therapy to heal rat critical-sized cranial defects. This finding has significant implications for translating this tissue engineering approach to patients with cancer-related segmental bone defects.

DBM induced ectopic bone formation in the rat: the importance of surface area

Demineralized bone matrix (DBM) has been shown to induce ectopic endochondral bone formation, when intramuscularly implanted in rats. In earlier studies we have found a variation in bone formation capacity of this DBM. This might be due to the properties of the DBM itself, but the use of DBM blocks could be of influence as well. Therefore, this study was designed to investigate whether increasing the surface area of the DBM by morsellizing, influences the bone formation capacity. In view of this, DBM implants and morsellized DBM (MDBM) implants were placed intramuscularly in a rat model. At six weeks the implants were retrieved and evaluated by histology and histomorphometry. The results demonstrated that significant amounts of newly formed bone were present in some DBM as well as some MDBM implants while in others no, or very little new bone was found. Histomorphometric analysis showed an average bone formation of 2.6% in DBM implants and an average of 1.9% in MDBM implants. Still, the amount of bone formation was limited compared with previous studies. It is concluded that enlargement of the surface area by morsellizing DBM implants is not an important factor in bone forming capacity.

BMP-9-transduced prefabricated muscular flaps for the treatment of bony defects

Autologous bone grafting techniques involve the use of tissues that need to be extracted from healthy sites. This can lead to significant donor site morbidity that causes a one-site defect to become a two-site defect. Bone grafts can be especially difficult to manipulate, because bone is a relatively nonmoldable tissue. Furthermore, the inability of a bone graft to contain a transplantable vascular supply also limits the possible size that such a bone graft can be. Because of these limitations, a graft that was moldable with a vascular supply would possess significant advantages in reconstructive applications. In this research, gene therapy techniques were used to create such a graft. An adenovirus expressing BMP-9 was injected into the latissimus dorsi of a nude animal to cause bony differentiation of that muscle. Differentiation of the muscle to cartilage in bone was measured by reverse transcription polymerase chain reaction and immunohistochemistry to determine the optimal time of flap elevation. After injection of the BMP-9 virus, the animals were biopsied weekly over a 3-week period. Both bone and cartilage markers were discovered in these tissues over the study period. Optimal flap elevation time was established to be 2 weeks after injection of the virus.

Ectopic bone formation in rats: the importance of vascularity of the acceptor site

Bone graft substitutes (BGS) can be fabricated by the combination of three key ingredients: (1) competent bone-forming cells, (2) a suitable framework or scaffold, and (3) the presence of biological stimulants. Although much research has been done to develop the ideal BGS, still the results are not very consistent. In view of this, the cellularity and vascularity of the recipient site are supposed to be important for the osteoinductive capacity of BGS. Therefore, we hypothesized that a muscle recipient site could favor bone formation in a cell-based BGS compared to a subcutaneous recipient site due to the higher vascularity of muscle tissue. To prove this hypothesis, 48 titanium fiber mesh implants were seeded with rat bone marrow stromal cells (RBM) and implanted subcutaneously and intramuscularly in the adductor thigh muscle of rats. The amount of bone formation after 1, 3 and 6 weeks was evaluated by histology and histomorphometry as well as by calcium content. Analysis revealed that the bone formation increased during implantation. However, bone formation did not exceed 12% of the implant surface, both for the intramuscular and subcutaneous recipient site. Also, no significant differences in bone amount between these two sites existed. Consequently, our hypothesis could not be confirmed.

Prefabrication of vascularized bone grafts using recombinant human osteogenic protein-1—part 3: dosage of rhOP-1, the use of external and internal scaffolds

In a previous study vascularized bone grafts were prefabricated with recombinant human osteogenic protein-1 (rhOP-1) using blocks of xenogenic bone mineral (BioOss) as scaffolds. The present study addressed the dosage of rhOP-1 and the combination of an external (mould) and internal scaffold (granular BioOss). In five Göttingen minipigs six prefabrication sites in the latissimus dorsi muscles were randomly assigned to groups a-f. Moulds were prepared by shaping collagen/polylactide membranes in a cylindrical form which was filled with 1g BioOss granules and rhOP-1 (a: 0; b: 50; c, f, e: 250; d: 1000 microg of rhOP-1, a-e: cylinder open to muscle, e cylinder perforated, f: cylinder open to subcutaneous fat). After 6 weeks a dose dependency of bone density (a-d: 0%; 9.4%; 15.8%; 31.1%) and vessel density (a-d: 0.3; 2.4; 7.9; 25.4 counts/view) was observed histomorphometrically. Muscular surrounding was advantageous to subcutaneous tissue. Perforations of the membranes increased vessel density and did not impair bone formation. Bone density decreased in the proximity of the polylactide membranes. The membrane material was too soft and partly collapsed and therefore needs not to be reconsidered. The use of BioOss granules with 1000 microg rhOP-1 per gram proved to be a suitable concept for prefabrication of bone transplants.

Comparison of Membranous Bone Healing Characteristics in Fetal and Postnatal Periods: An Experimental Study

In this experimental study, the postnatal and fetal membranous bone healing were investigated radiologically, histologically and levels of growth factors. Sixteen sheep fetuses and 16 sheep were included in this study. In the fetal group, 5 mm diameter ostectomy, and a 10 mm osteotomy were created in 90th gestational day. In the postnatal group, similar ostectomy and osteotomies were created. In the early period, radiologically similar radiolucencies in the ostectomy areas were seen in both groups. Histologically, fetal bone healing was decreased in the early postoperative period. However, it was accelerated in further time points. Histomorphometric analyses revealed accelerated fetal bone healing. TGF-beta1 levels were higher and then lower in early and late postoperative periods respectively in the fetal group. In the postnatal group, the levels of TGF-beta1 were lower and the differences between two groups were statistically significant in all time points (p < 0.05). The FGF and PDGF levels in both areas were higher in early postoperative period whereas lower in the late period in both groups. However, the fetal FGF levels were higher compared to the postnatal group (p < 0.05). The fetal PDGF levels were lower compared to the postnatal ones (p < 0.05). In conclusion, the calvarial bone gap model at the end of the second trimester of gestation in the fetal sheep model proved useful in examining the membranous bone healing. Histologically, the process of fetal bone healing seems similar to that of postnatal healing, albeit at an accelerated rate. Histomorphometric evaluation is a valuable tool in the evaluation of bone formation and gives more objective information about the ratio of bone formation.

Ex vivo gene therapy for skeletal regeneration in cranial defects compromised by postoperative radiotherapy

Because radiation remains a common postoperative treatment for head and neck cancers, it is critical to determine whether new bone-regenerative approaches are effective for healing craniofacial defects challenged by therapeutic doses of radiation. The objective of this study was to determine whether the deleterious effects of radiotherapy could be overcome by ex vivo gene therapy to heal craniofacial defects. Rat calvarial critical-sized defects were treated with either an inlay calvarial bone graft or syngeneic dermal fibroblasts transduced ex vivo with an adenovirus engineered to express bone morphogenetic protein 7 (BMP-7), a morphogen known to stimulate bone formation. Two weeks postoperatively, either no radiation or a single 12-Gy radiation dose was delivered to the operated area and the tissue was harvested 4 weeks later. None of the inlay bone grafts healed at the wound margins of either the radiated or nonradiated sites. In contrast, bone was successfully regenerated when using an ex vivo gene therapy approach. More bone formed in the nonradiated group as determined by the percentage of defect surface covered (87 +/- 4.1 versus 65 +/- 4.7%; p = 0.003) and percentage of defect area filled by new bone (60 +/- 5.9 versus 32 +/- 2.7%; p = 0.002). Although the effects of radiation on the wound were not completely overcome by the gene therapy approach, bone regeneration was still successful despite the radiation sensitivity of the fibroblasts. These results indicate that BMP-7 ex vivo gene therapy is capable of successfully regenerating bone in rat calvarial defects even after a therapeutic dose of radiation. This approach may represent a new strategy for regenerating skeletal elements lost due to head and neck cancer.

In vivo magnetic resonance imaging explorative study of ectopic bone formation in the rat

In animal studies of tissue engineering of bone, histology remains the standard for assessing bone formation. As longitudinal studies with this method are feasible only at the cost of large numbers of animals, we looked for an alternative. Therefore, demineralized bone matrix (DBM) and inactivated demineralized bone matrix (iDBM) implants were subcutaneously implanted in a rat. At 1, 3, 5, and 7 weeks postimplantation soft X-ray and magnetic resonance imaging (MRI) were done to monitor bone formation in the implants. At 7 weeks, the animal was killed and the implants were retrieved for histology. Our results showed that in vivo MRI is well suited to assess bone formation larger than 0.5 mm in diameter and to monitor the complete three-dimensional shape of the newly formed bone noninvasively and longitudinally. The MRI results matched well with the histology results obtained at 7 weeks. In contrast, X-ray imaging appeared inappropriate to monitor the bone formation process in DBM.

Muscle-based gene therapy and tissue engineering to improve bone healing

Failed fracture healing is a significant problem in orthopaedics, often seen in patients with scaphoid fractures, high-energy injuries, and osteoporosis. Current treatments often result in poor outcomes and donor site morbidity. Gene therapy has been the focus of much recent research to improve bone healing. In the current review, the authors specifically evaluate the use of muscle-derived cells as a gene delivery vehicle and inducible osteoprogenitor cell that can enhance bone regeneration. Muscle-derived cells have been used to deliver bone morphogenetic protein-2 and produce ectopic bone. These cells express osteocalcin and have been found within newly generated bone in locations normally occupied by osteoblasts and osteocytes. Finally, it is shown that muscle-derived cells coupled with ex vivo gene therapy can heal critical-sized calvarial defects.

Allogeneic bone grafting of calvarial defects: an experimental study in the rabbit

The purpose of this study was to investigate the incorporation of fresh frozen irradiated membranous allogeneic bone grafts into critical size calvarial defects in the rabbit. Fifteen rabbits had calvarial defects prepared. Twelve rabbits received allogeneic grafts and three received autogenous bone grafts. The rabbits were sacrificed at 9 and 12 months postoperatively, and the specimens were examined radiologically, histopathologically and with fluorescence microscopy. Neovascularization, bone marrow regeneration and new bone formation was evident throughout the grafts however revitalization of the entire graft was incomplete at 12 months. This study revealed that the FFI membranous grafts were well incorporated into rabbit calvarial defects.

Collagen-targeted BMP3 fusion proteins arrayed on collagen matrices or porous ceramics impregnated with Type I collagen enhance osteogenesis in a rat cranial defect model

Bone morphogenetic protein 3 (BMP3) is a potent osteoinductive growth factor belonging to the TGF-beta superfamily. In this study, we engineered a recombinant BMP3 protein to include an auxiliary collagen-targeting domain derived from von Willebrand coagulation factor (vWF). The collagen-targeted BMP3 fusion protein (rhBMP3-C) was expressed in E. coli, purified from bacterial inclusion bodies, renatured under controlled redox conditions, and assayed for biological activity in vitro and in vivo. The renatured rhBMP3-C fusion protein bound tightly to collagen matrices and inhibited DNA synthesis in normal rat calvaria cells and in two out of three human osteosarcoma cell lines tested. Alkaline phosphatase activity was increased in rat calvarial cells and was decreased in osteosarcoma cells in vitro in a dose-dependent manner. Collagen sponges impregnated with rhBMP3-C and implanted subcutaneously in Fischer-344 rats induced dose-dependent dystrophic calcification of the collagen matrix, with no evidence of ectopic bone formation. However, local injection of rhBMP3-C infused in a collagen suspension induced new bone formation on the periosteal surface of rat calvaria. Finally, in a rat cranial defect model, surgical implantation of rhBMP3-C arrayed on either collagen sponges or on porous ceramics coated with Type I collagen exhibited marked osteoinductive properties. Taken together, these results demonstrate the feasibility of engineering and manufacturing targeted-BMPs which exhibit an integral gain-of-function that may be exploited to therapeutic advantage in (i) the enhancement of effective local concentrations, (ii) the prevention of systemic biodistribution and side effects, and (iii) the design of improved osteoinductive matrices.

Gene therapy and tissue engineering in orthopaedic surgery

A new biologic era of orthopaedic surgery has been initiated by basic scientific advances that have resulted in the development of gene therapy and tissue engineering approaches for treating musculoskeletal disorders. The terminology, fundamental concepts, and current research in this burgeoning field must be understood by practicing orthopaedic surgeons. Different gene therapy approaches, multiple gene vectors, a multitude of cytokines, a growing list of potential scaffolds, and putative stem cells are being studied. Gene therapy and tissue engineering applications for bone healing, articular disorders, intervertebral disk pathology, and skeletal muscle injuries are being explored. Innovative methodologies that ensure patient safety can potentially lead to many new treatment strategies for musculoskeletal conditions.

Mandibular reconstruction with prefabricated vascularized bone grafts using recombinant human osteogenic protein-1: an experimental study in miniature pigs. Part II: transplantation

Osteogenic Protein-1 (rhOP-1), also called bone morphogenetic protein-7 (BMP-7), is osteoinductive. The aim of this study was to present a new surgical technique: the prefabrication of a vascularized bone graft using rhOP-1 and its microsurgical transplantation. During 6 weeks, osteomuscular grafts were prefabricated in the latissimus dorsi muscle of five adult minipigs. Six hundred micrograms rhOP-1 on a carrier of xenogenic bone mineral in block form were used. The grafts were transplanted into defects of the mandibular angles performing a microsurgical anastomosis and using miniplates for fixation. Identical defects of the contralateral side were treated by direct application of 600 microg rhOP-1 and xenogenic bone mineral. A polychrome sequential labelling was applied. After transplantation the bone stayed viable, demonstrated by continuous apposition of fluorochromes (non-decalcified histologic sections) and bone scintigraphy. The reconstructive result was significantly superior in the prefabrication technique, assessed by histology and computerized tomography (CT). In conclusion, the method has a potential to become a clinical alternative for conventional vascularized bone grafts.

Mandibular reconstruction with a prefabricated vascularized bone graft using recombinant human osteogenic protein-1: an experimental study in miniature pigs. Part I: Prefabrication

Osteogenic protein-1 (rhOP-1), also called bone morphogenetic protein-7 (BMP-7), is osteoinductive. It may be possible to reconstruct a mandible by local application of rhOP-1. However, in tumour patients this can be impossible due to scars or preceding radiotherapy. Usually vascularized bone grafts are indicated. The aim of this study was to prefabricate a vascularized bone graft in the latissimus dorsi muscle for microsurgical transplantation. In nine minipigs 600 microgram rhOP-1 were used with 8 ml xenogenic bone mineral (BioOss, Geistlich, Waldenburg, Germany) as a carrier and inserted into a pouch prepared in the M. latissimus dorsi. After 6, 12, and 24 weeks the grafts were harvested. The results were evaluated using computed tomography, histology, macro- and microangiography. A high yield of newly formed bone was obtained on the osteoconductive scaffold of the xenogenic bone. It was possible to create a vascularized osseous graft in the given shape of the BioOss blocks. In cross-sections, 68% of the scaffold was coated with new bone. The amount of new bone did not differ between the prefabrication times. Bone overgrowth was 2.1% of the graft volume. In conclusion, this study has shown that it can be possible to prefabricate a neomandible within a muscle graft, which then could be transferred for microvascular reconstruction of the mandible. Further research is required before this technique can be refined for clinical use.