Comparative effects of platelet-derived growth factor-BB and insulin-like growth factor-I, individually and in combination, on periodontal regeneration in Macaca fascicularis

Twenty-five years of recombinant human growth factors rhPDGF-BB and rhBMP-2 in oral hard and soft tissue regeneration

Contemporary oral tissue engineering strategies involve recombinant human growth factor approaches to stimulate diverse cellular processes including cell differentiation, migration, recruitment, and proliferation at grafted areas. Recombinant human growth factor applications in oral hard and soft tissue regeneration have been progressively researched over the last 25 years. Growth factor-mediated surgical approaches aim to accelerate healing, tissue reconstruction, and patient recovery. Thus, regenerative approaches involving growth factors such as recombinant human platelet-derived growth factor-BB (rhPDGF-BB) and recombinant human bone morphogenetic proteins (rhBMPs) have shown certain advantages over invasive traditional surgical approaches in severe hard and soft tissue defects. Several clinical studies assessed the outcomes of rhBMP-2 in diverse clinical applications for implant site development and bone augmentation. Current evidence regarding the clinical benefits of rhBMP-2 compared to conventional therapies is inconclusive. Nevertheless, it seems that rhBMP-2 can promote faster wound healing processes and enhance de novo bone formation, which may be particularly favorable in patients with compromised bone healing capacity or limited donor sites. rhPDGF-BB has been extensively applied for periodontal regenerative procedures and for the treatment of gingival recessions, showing consistent and positive outcomes. Nevertheless, current evidence regarding its benefits at implant and edentulous sites is limited. The present review explores and depicts the current applications, outcomes, and evidence-based clinical recommendations of rhPDGF-BB and rhBMPs for oral tissue regeneration.

Histologic Evidence of Oral and Periodontal Regeneration Using Recombinant Human Platelet-Derived Growth Factor

Human histology provides critical information on the biological potential of various regenerative protocols and biomaterials, which is vital to advancing the field of periodontal regeneration, both in research and clinical practice. Outcomes of histologic studies are particularly valuable when interpreted considering additional evidence available from pre-clinical and clinical studies. One of the best-documented growth factors areproven to have positive effects on a myriad of oral regenerative procedures is recombinant human platelet-derived growth factor—BB (rhPDGF-BB). While a systematic review of clinical studies evaluating rhPDGF in oral regenerative procedures has been recently completed, a review article that focuses on the histologic outcomes is needed. Hence, this communication discusses the histologic effects of rhPDGF-BB on oral and periodontal regenerative procedures, including root coverage and soft tissue augmentation, intrabony defects, furcation defects, peri-implant bone augmentation, and guided bone regeneration. Studies from 1989 to 2022 have been included in this review.

Applications of Gene Therapy in Dentistry: A Review Article

Gene therapy promises to possess a good prospect in bridging the gap between dental applications and medicine. The dynamic therapeutic modalities of gene therapy have been advancing rapidly. Conventional approaches are being revamped to be more comprehensive and pre-emptive, which could do away with the need for surgery and medicine altogether. The complementary base sequences known as genes convey the instructions required to manufacture proteins. The oral cavity is one of the most accessible locations for the therapeutic intervention of gene therapy for several oral tissues. In 1990, the first significant trial of gene therapy was overseen to alleviate adenosine deaminase deficiency. The notion of genetic engineering has become increasingly appealing as a reflection of its benefits over conventional treatment modalities. An example of how this technology may alter dentistry is the implementation of gene therapy for dental and oral ailments. The objective of this article is to examine the effects of gene therapy on the field of dentistry, periodontology and implantology. Furthermore, the therapeutic factors of disease therapy, minimal invasion, and appropriate outcome have indeed been taken into consideration.

Efficacy of rh-PDGF-BB and Emdogain with or without DFDBA using M-MIST in the treatment of intrabony defects

Background

The versatile combination of emdogain or enamel matrix derivative (EMD), recombinant human platelet-derived growth factor-BB (rhPDGF-BB), and demineralized freeze-dried bone allograft (DFDBA) has not been utilized in the treatment of intrabony defects yet.

Aim

The present study attempted to investigate the efficacy of a combination of simple, uncomplicated nature of modified minimally invasive surgical technique (M-MIST) with EMD, rhPDGF-BB, and DFDBA in the surgical management of intrabony defects and to assess the possible favorable effects for a period of 6 months.

Patients and Methods

Thirty healthy subjects were included in the present double-blind, randomized controlled, two-arm parallel study. The test group was treated with M-MIST by using rhPDGF-BB, EMD, and DFDBA, and the control group was treated with M-MIST by using rhPDGF-BB and EMD.

Results

Differences between the mean values of primary clinical parameters including relative attachment level, probing depth, and gingival recession at baseline and those at 6 months after surgery were statistically significant in both groups. Inter-group comparison for clinical attachment level gain, probing depth reduction, and change in the position of gingival margin revealed no statistically significant differences. Inter-group comparison revealed significant differences in linear bone growth (LBG) and percentage bone fill (% BF) but no significant differences in the residual defect depth and change in the alveolar crest position.

Conclusion

The additional use of DFDBA provides superior benefits in terms of LBG and % BF in intrabony defects. This improvement might be attributed to the use of an osteoinductive scaffold.

Surgical Management of Radicular Cyst With the Application of a Natural Platelet Concentrate: A Case Report

Traumatic dental injuries usually involve the dentoalveolar region, and they readily affect the teeth and their surrounding soft and hard tissues. The common sequelae of traumatic dental injuries lead to pulpal necrosis and apical periodontitis along with cystic changes. The current case report describes the surgical management of a radicular cyst in the periapical region of maxillary incisors and highlights the efficacy of natural platelet concentrate [platelet-rich fibrin (PRF)] used for postoperative healing. A 38-year-old male patient presented to the department with pain and mild swelling in the upper front tooth region. On radiographic examination, a radiolucent periapical lesion was evident in relation to the right maxillary central and lateral incisor. In the maxillary anterior region, root canal therapy was performed, followed by periapical surgery and retrograde filling with mineral trioxide aggregate (MTA), and PRF was placed in the surgical site to initiate the healing at a faster rate. The patient was recalled for follow-ups after 12 weeks, 24 weeks, and 36 weeks; he was found to be asymptomatic, and significant periapical healing was observed in the radiograph with almost adequate bone formation.

Challenges and tissue engineering strategies of periodontal guided tissue regeneration

Periodontitis is a chronic infectious oral disease with a high prevalence rate in the world, and is a major cause of tooth loss. Nowadays, people have realized that the local microenvironment that includes proteins, cytokines, and extracellular matrix has a key influence on the functions of host immune cells and periodontal ligament stem cells during a chronic infectious disease such as periodontitis. The above pathological process of periodontitis will lead to a defect of periodontal tissues. Through the application of biomaterials, biological agents, and stem cells therapy, guided tissue regeneration (GTR) makes it possible to reconstruct healthy periodontal ligament tissue after local inflammation control. To date, substantial advances have been made in periodontal guided tissue regeneration. However, the process of periodontal remodeling experiences complex microenvironment changes, and currently periodontium regeneration still remains to be a challenging feat. In this review, we summarized the main challenges in each stage of periodontal regeneration, and try to put forward appropriate biomaterial treatment mechanisms or potential tissue engineering strategies that provide a theoretical basis for periodontal tissue engineering regeneration research.

Periodontal Wound Healing and Regeneration: Insights for Engineering New Therapeutic Approaches

Periodontitis is a widespread inflammatory disease that leads to loss of the tooth supporting periodontal tissues. The few therapies available to regenerate periodontal tissues have high costs and inherent limitations, inspiring the development of new approaches. Studies have shown that periodontal tissues have an inherent capacity for regeneration, driven by multipotent cells residing in the periodontal ligament (PDL). The purpose of this review is to describe the current understanding of the mechanisms driving periodontal wound healing and regeneration that can inform the development of new treatment approaches. The biologic basis underlying established therapies such as guided tissue regeneration (GTR) and growth factor delivery are reviewed, along with examples of biomaterials that have been engineered to improve the effectiveness of these approaches. Emerging therapies such as those targeting Wnt signaling, periodontal cell delivery or recruitment, and tissue engineered scaffolds are described in the context of periodontal wound healing, using key in vivo studies to illustrate the impact these approaches can have on the formation of new cementum, alveolar bone, and PDL. Finally, design principles for engineering new therapies are suggested which build on current knowledge of periodontal wound healing and regeneration.

The Effect of Diabetes Mellitus on IGF Axis and Stem Cell Mediated Regeneration of the Periodontium

Periodontitis and diabetes mellitus (DM) are two of the most common and challenging health problems worldwide and they affect each other mutually and adversely. Current periodontal therapies have unpredictable outcome in diabetic patients. Periodontal tissue engineering is a challenging but promising approach that aims at restoring periodontal tissues using one or all of the following: stem cells, signalling molecules and scaffolds. Mesenchymal stem cells (MSCs) and insulin-like growth factor (IGF) represent ideal examples of stem cells and signalling molecules. This review outlines the most recent updates in characterizing MSCs isolated from diabetics to fully understand why diabetics are more prone to periodontitis that theoretically reflect the impaired regenerative capabilities of their native stem cells. This characterisation is of utmost importance to enhance autologous stem cells based tissue regeneration in diabetic patients using both MSCs and members of IGF axis.

Potential of Bone-Marrow-Derived Mesenchymal Stem Cells for Maxillofacial and Periodontal Regeneration: A Narrative Review

Bone-marrow-derived mesenchymal stem cells (BM-MSCs) are one of the most widely studied postnatal stem cell populations and are considered to utilize more frequently in cell-based therapy and cancer. These types of stem cells can undergo multilineage differentiation including blood cells, cardiac cells, and osteogenic cells differentiation, thus providing an alternative source of mesenchymal stem cells (MSCs) for tissue engineering and personalized medicine. Despite the ability to reprogram human adult somatic cells to induced pluripotent stem cells (iPSCs) in culture which provided a great opportunity and opened the new door for establishing the in vitro disease modeling and generating an unlimited source for cell base therapy, using MSCs for regeneration purposes still have a great chance to cure diseases. In this review, we discuss the important issues in MSCs biology including the origin and functions of MSCs and their application for craniofacial and periodontal tissue regeneration, discuss the potential and clinical applications of this type of stem cells in differentiation to maxillofacial bone and cartilage in vitro, and address important future hopes and challenges in this field.

Recombinant factors for periodontal intrabony defects: A systematic review and network meta-analysis of preclinical studies

The use of bioactive agents combined with osteoconductive scaffolds for the regeneration of periodontal intrabony defects has been the subject of intensive research in the past 20 years. Most studies reported that such agents, used in different concentrations, doses and combined with various scaffolds, might promote periodontal tissue regeneration, but evidence for the most effective combination of such agents is lacking. The objective of this study 13 was to rank the different combinations of recombinant human-derived growth and differentiation factors with/without scaffold biomaterial in the treatment of periodontal intrabony defects, through network meta-analysis of pre-clinical studies. The systematic review and network meta-analysis protocol was registered on the PROSPERO Systematic Review database with reference number: CRD42021213673. Relevant published articles were obtained after searching five electronic databases. A specific search strategy was followed by using keywords related to intrabony defects, regenerative materials, scaffolds and recombinant factors, and animal studies. All pre-clinical studies used for periodontal regeneration were included. The primary outcomes were: regeneration of junctional epithelium (mm), new cementum, connective tissue attachment, percentage of new bone formation (%), bone area (mm² ), bone volume density (g/cm³ ) and bone height (mm) data was extracted. The analysis was carried out using network meta-analysis methods, that is illustrating network plots, contribution plots, predictive and confidence interval plot, surface under the cumulative ranking (SUCRA), multidimensional scale ranking and net funnel plots using STATA IC statistical software. An SYRCLE's tool for assessing risk of bias was used for reporting risk of bias among individual studies. A total of N = 24 for qualitative and N = 21 studies for quantitative analysis published till 2020 were included. The cumulative total number of animals included in the control and test groups were N = 162 and N = 339, respectively. The duration of the study was between 3 and 102 weeks rhBMP-2 ranked higher in SUCRA as the agent associated with the best performance for bone volume density. rhGDF-5/TCP ranked best in the bone area (mm2), rhPDGF-BB/Equine ranked best in bone height (mm), rhBMP-2 ranked best in the percentage of new bone fill, rhBMP-2/ACS ranked best in new cementum formation, and rhGDF-5/b- TCP/PLGA ranked best in connective tissue attachment and junctional epithelium. There were no adverse effects identified in the literature that could affect the different outcomes for regeneration in intrabony defects. Various recombinant factors are effective in promoting the regeneration of both soft and hard tissue supporting structures of the periodontium. However, when considering different outcomes, different agents, associated or not with biomaterials, ranked best. Keeping into account the limited transferability of results from animal studies to the clinical setting, the choice of the most appropriate formulation of bioactive agents may depend on clinical needs and purpose.

Cytokines regulate stemness of mesenchymal stem cells via miR-628-5p during periodontal regeneration

BACKGROUND

Cytokines play key roles in stimulating periodontal regeneration; however, their exact mechanisms of action remain unclear. Mesenchymal stem cells (MSCs) are multipotent cells that have self-renewal abilities and can differentiate into periodontal tissues such as bone, cementum, and periodontal ligaments following transplantation, like periodontal progenitor cells. Here, we used MSCs to identify the regulatory genes induced by periodontal regenerative cytokines.

METHODS

Human MSCs (hMSCs) were cultured under conditions of periodontal regenerative cytokine stimulation or silencing of undifferentiated hMSC transcription factors. To characterize the changes associated with periodontal regenerative cytokine-regulated microRNAs (miRNAs), miRNA, and mRNA expression was evaluated using miRNA arrays and quantitative real-time polymerase chain reaction, respectively. One of the identified miRNAs, miR-628-5p, was then overexpressed or suppressed in hMSCs during osteogenesis; the effect of these changes on osteogenesis was investigated.

RESULTS

Cytokine-stimulated MSCs showed characteristic miRNA profiles and mRNA levels of undifferentiated hMSC transcription factors ETV1, SOX11, and GATA6. Next, we silenced these transcription factors in MSCs and examined the miRNA profiles. The levels of miR-628-5p were decreased upon all cytokine treatments and were increased upon silencing of ETV1, SOX11, and GATA6. Overexpression of miR-628-5p suppressed osteogenesis; however, its inhibition enhanced OPN, ALP, OC, BMP2, and RUNX2 mRNA levels, and bone matrix mineralization, but not OSX mRNA or ALP activity.

CONCLUSIONS

miR-628-5p negatively regulates MSC stemness during periodontal regeneration. Periodontal regenerative cytokines act as miR-628-5p suppressors to support periodontal regeneration. Thus, selection of effective cytokines for different MSCs, based on miRNA profiling, is important for advancing regenerative therapies.

Biomaterials for Periodontal and Peri-Implant Regeneration

Periodontal and peri-implant regeneration is the technique that aims to restore the damaged tissue around teeth and implants. They are surrounded by a different apparatus, and according to it, the regenerative procedure can differ for both sites. During the last century, several biomaterials and biological mediators were proposed to achieve a complete restoration of the damaged tissues with less invasiveness and a tailored approach. Based on relevant systematic reviews and articles searched on PubMed, Scopus, and Cochrane databases, data regarding different biomaterials were extracted and summarized. Bone grafts of different origin, membranes for guided tissue regeneration, growth factors, and stem cells are currently the foundation of the routinary clinical practice. Moreover, a tailored approach, according to the patient and specific to the involved tooth or implant, is mandatory to achieve a better result and a reduction in patient morbidity and discomfort. The aim of this review is to summarize clinical findings and future developments regarding grafts, membranes, molecules, and emerging therapies. In conclusion, tissue engineering is constantly evolving; moreover, a tailor-made approach for each patient is essential to obtain a reliable result and the combination of several biomaterials is the elective choice in several conditions.

The Role of GH/IGF Axis in Dento-Alveolar Complex from Development to Aging and Therapeutics: A Narrative Review

The GH/IGF axis is a major regulator of bone formation and resorption and is essential to the achievement of normal skeleton growth and homeostasis. Beyond its key role in bone physiology, the GH/IGF axis has also major pleiotropic endocrine and autocrine/paracrine effects on mineralized tissues throughout life. This article aims to review the literature on GH, IGFs, IGF binding proteins, and their respective receptors in dental tissues, both epithelium (enamel) and mesenchyme (dentin, pulp, and tooth-supporting periodontium). The present review re-examines and refines the expression of the elements of the GH/IGF axis in oral tissues and their in vivo and in vitro mechanisms of action in different mineralizing cell types of the dento-alveolar complex including ameloblasts, odontoblasts, pulp cells, cementoblasts, periodontal ligament cells, and jaw osteoblasts focusing on cell-specific activities. Together, these data emphasize the determinant role of the GH/IGF axis in physiological and pathological development, morphometry, and aging of the teeth, the periodontium, and oral bones in humans, rodents, and other vertebrates. These advancements in oral biology have elicited an enormous interest among investigators to translate the fundamental discoveries on the GH/IGF axis into innovative strategies for targeted oral tissue therapies with local treatments, associated or not with materials, for orthodontics and the repair and regeneration of the dento-alveolar complex and oral bones.

Platelet rich fibrin versus ozone gel for periodontal regeneration in induced rats' intrabony three-wall periodontal defects

BACKGROUND

The question of whether platelet rich fibrin and ozone can enhance regeneration of periodontal defect was addressed.

MATERIALS AND METHODS

three-wall periodontal defects were surgically created in 30 rats involving mesial aspect of right mandibular first molar. Rats were randomly assigned into three groups: 1) Group I (Positive control group). 2) Group II (Ozone treated group) and 3) Group III (PRF treated group). Two weeks after surgery, five rats from each group were euthanized and the remaining was euthanized 4 weeks post surgery. The degree of periodontal regeneration was evaluated using light microscope and scanning electron microscope. Histomorphometric measurements and anti-PCNA immunohistochemical counting were statistically analyzed.

RESULTS

group I showed intense inflammatory reaction with mild new bone formation. In group II, partial regeneration was seen with moderate new woven bone formation in 2 weeks period. After 4 weeks, almost complete restoration of periodontium was seen. In group III, after 2 weeks, moderate lamellar bone formation was observed. In 4 weeks period, the periodontal regeneration was almost completed. Histomorphometric analysis showed a significant difference between group I and group II. The difference between group I and group III was significant in 2 weeks and highly significant after 4 weeks. That between group II and group III was nonsignificant in 2 weeks and significant in 4 weeks. Anti-PCNA analysis was nonsignificant between groups.

CONCLUSIONS

both Platelet rich fibrin and ozone can improve histological parameters associated with healing of experimental intrabony periodontal defects in rats with the former being superior.

Biomaterials, Current Strategies, and Novel Nano-Technological Approaches for Periodontal Regeneration

Periodontal diseases involve injuries to the supporting structures of the tooth and, if left untreated, can lead to the loss of the tooth. Regenerative periodontal therapies aim, ideally, at healing all the damaged periodontal tissues and represent a significant clinical and societal challenge for the current ageing population. This review provides a picture of the currently-used biomaterials for periodontal regeneration, including natural and synthetic polymers, bioceramics (e.g., calcium phosphates and bioactive glasses), and composites. Bioactive materials aim at promoting the regeneration of new healthy tissue. Polymers are often used as barrier materials in guided tissue regeneration strategies and are suitable both to exclude epithelial down-growth and to allow periodontal ligament and alveolar bone cells to repopulate the defect. The problems related to the barrier postoperative collapse can be solved by using a combination of polymeric membranes and grafting materials. Advantages and drawbacks associated with the incorporation of growth factors and nanomaterials in periodontal scaffolds are also discussed, along with the development of multifunctional and multilayer implants. Tissue-engineering strategies based on functionally-graded scaffolds are expected to play an ever-increasing role in the management of periodontal defects.

The Role of Heparan Sulfate and Perlecan in Bone-regenerative Procedures

Tissue engineering, grafting procedures, regeneration, and tissue remodeling are developing therapeutic modalities with great potential medical value, but these regenerative modalities are not as effective or predictable as clinicians and patients would like. Greater understanding of growth factors, cytokines, extracellular matrix molecules, and their roles in cell-mediated healing processes have made these regenerative therapies more clinically viable and will continue advancing the fields of tissue engineering and grafting. However, millions of oral and non-oral bone-grafting procedures are performed annually, and only a small percentage yield the most desirable results. Here we review the heparan-sulfate-decorated extracellular biomolecule named perlecan and the research relating to its potential as an adjunct in bone-regenerative procedures. The review includes an overview of bone graft substitutes and biological adjuncts to bone-regenerative procedures in medicine as they apply to periodontal disease, alveolar ridge augmentation, and barrier membrane therapy. Perlecan is discussed as a potential biological adjunct in terms of growth factor sequestration and delivery, and promoting cell adhesion, proliferation, differentiation, and angiogenesis. Further, we propose delivery and application schemes for perlecan and/or its domains in bone-regenerative procedures, with particular emphasis on its heparan-sulfate-decorated domain I. The perlecan molecule, with its heparan sulfate glycosylation, may provide a multi-faceted approach for the delivery of a more comprehensive stimulus than other single potential adjuncts currently available for bone-regenerative procedures.

Platelet-Rich Fibrin and Soft Tissue Wound Healing: A Systematic Review

The growing multidisciplinary field of tissue engineering aims at predictably regenerating, enhancing, or replacing damaged or missing tissues for a variety of conditions caused by trauma, disease, and old age. One area of research that has gained tremendous awareness in recent years is that of platelet-rich fibrin (PRF), which has been utilized across a wide variety of medical fields for the regeneration of soft tissues. This systematic review gathered all the currently available in vitro, in vivo, and clinical literature utilizing PRF for soft tissue regeneration, augmentation, and/or wound healing. In total, 164 publications met the original search criteria, with a total of 48 publications meeting inclusion criteria (kappa score = 94%). These studies were divided into 7 in vitro, 11 in vivo, and 31 clinical studies. In summary, 6 out of 7 (85.7%) and 11 out of 11 (100%) of the in vitro and in vivo studies, respectively, demonstrated a statistically significant advantage for combining PRF to their regenerative therapies. Out of the remaining 31 clinical studies, a total of 8 reported the effects of PRF in a randomized clinical trial, with 5 additional studies (13 total) reporting appropriate controls. In those clinical studies, 9 out of the 13 studies (69.2%) demonstrated a statistically relevant positive outcome for the primary endpoints measured. In total, 18 studies (58% of clinical studies) reported positive wound-healing events associated with the use of PRF, despite using controls. Furthermore, 27 of the 31 clinical studies (87%) supported the use of PRF for soft tissue regeneration and wound healing for a variety of procedures in medicine and dentistry. In conclusion, the results from the present systematic review highlight the positive effects of PRF on wound healing after regenerative therapy for the management of various soft tissue defects found in medicine and dentistry.

Clinical Evaluation of Insulin like Growth Factor-I and Vascular Endothelial Growth Factor with Alloplastic Bone Graft Material in the Management of Human Two Wall Intra-Osseous Defects

INTRODUCTION

In recent years, emphasis on the use of growth factors for periodontal healing is gaining great momentum. Several growth factors showed promising results in periodontal regeneration.

AIM

This study was designed to compare the clinical outcomes of 0.8μg recombinant human Vascular Endothelial Growth Factor (rh-VEGF) and 10μg recombinant human Insulin Like Growth Factor-I (rh-IGF-I) with β-Tricalcium Phosphate (β-TCP) and Polylactide-Polyglycolide Acid (PLGA) membrane in two wall intra-osseous defects.

MATERIALS AND METHODS

A total of 29 intra-osseous defects in 27 subjects were randomly divided into 3 test and 1 control group. Test group I (n=8) received rh-VEGF+ rh-IGF-I, Test group II (n=7) rh-VEGF, Test group III (n=7) rh-IGF-I and control group (n=7) with no growth factor, β-TCP and PLGA membrane was used in all the groups. Baseline soft tissue parameters including Probing Pocket Depth (PPD), Clinical Attachment Level (CAL), and Gingival Recession (GR) at selected sites were recorded at baseline and at 6 months. Intrasurgically, intra-osseous component was calculated as a) Cemento-Enamel Junction to Bone Crest (CEJ to BC), b) Bone Crest to Base of the Defect (BC to BD) at baseline and at re-entry. The mean changes at baseline and after 6 months within each group were compared using Wilcoxon Signed Rank Test. The mean changes for each parameter between groups were compared using Mann-Whitney U test.

RESULTS

After 6 months, maximum mean PPD reduction occurred in test group I followed by test group II, III and control group. Similar trend was observed in CAL gain. Non-significant GR was present in test group I and control group whereas in test group II and III GR was absent. The use of rh-VEGF+ rhIGF-I exhibited 95.8% osseous fill as compared to 54.8% in test group II, 52.7% in test group III and 41.1 % in the control group.

CONCLUSION

Within the limitations of this study, it can be concluded that, rh-IGF-I+rh-VEGF treated sites resulted in greater improvement in PPD reduction, CAL gain as well as in osseous fill after 6 months when compared with rh-VEGF, rh-IGF-I and control sites.

Effect of PDGF-BB, IGF-I growth factors and their combination carried by liposomes in tooth socket healing

This work evaluated the bone-forming potential of the platelet-derived growth factor isoform BB (PDGF-BB), insulin-like growth factor I (IGF-I), and mixed PDGF-BB/IGF-I delivered in liposomes compared with phosphate buffered saline (PBS), in the healing process of rat tooth sockets. One hundred and twelve Wistar rats were randomized into 7 groups of 16 animals each and were evaluated at 3, 7, 14 and 21 days after extraction of the maxillary second molars. The left sockets were treated with PBS (P), empty liposome (L), IGF-I in PBS (IP), IGF-I in liposome (IL), PDGF-BB in PBS (PDP), PDGF-BB in liposome (PDL) and both growth factors (GFs) together within liposomes (PDIL). The right sockets were filled with blood clot (BC). Histological and histomorphometric analyses were used to evaluate the formation of new bone and blood vessels. Immunohistochemistry was performed to evaluate the expression of osteocalcin and vascular endothelial growth factor (VEGF) during bone repair. Data were tested statistically using a Tukey's test according to a Dunn's analysis and Mann-Whitney U test followed by Kruskal-Wallis one-way analysis. Results were considered significant when p<0.05. A significantly higher percentage of bone trabeculae and a higher number of blood vessels were observed in the IL, PDL and PDIL groups (p<0.05). However, these GF-liposome groups had statistically similar results. Immunohistochemical assays first detected osteocalcin and VEGF expression at 3 days followed by a peak at 7 days. Lower immunoreactivity levels were observed in the BC, L, P, IP and PDP groups compared with the IL, PDL and PDIL groups (p<0.05). The results suggest that GFs carried by liposomes, either in isolated or mixed forms, enhanced the healing process in rat tooth sockets. The differential expression of the osteogenic markers VEGF and osteocalcin in the early phases of bone healing support these findings.

Tissue engineering for bone regeneration and osseointegration in the oral cavity

OBJECTIVE

The focus of this review is to summarize recent advances on regenerative technologies (scaffolding matrices, cell/gene therapy and biologic drug delivery) to promote reconstruction of tooth and dental implant-associated bone defects.

METHODS

An overview of scaffolds developed for application in bone regeneration is presented with an emphasis on identifying the primary criteria required for optimized scaffold design for the purpose of regenerating physiologically functional osseous tissues. Growth factors and other biologics with clinical potential for osteogenesis are examined, with a comprehensive assessment of pre-clinical and clinical studies. Potential novel improvements to current matrix-based delivery platforms for increased control of growth factor spatiotemporal release kinetics are highlighting including recent advancements in stem cell and gene therapy.

RESULTS

An analysis of existing scaffold materials, their strategic design for tissue regeneration, and use of growth factors for improved bone formation in oral regenerative therapies results in the identification of current limitations and required improvements to continue moving the field of bone tissue engineering forward into the clinical arena.

SIGNIFICANCE

Development of optimized scaffolding matrices for the predictable regeneration of structurally and physiologically functional osseous tissues is still an elusive goal. The introduction of growth factor biologics and cells has the potential to improve the biomimetic properties and regenerative potential of scaffold-based delivery platforms for next-generation patient-specific treatments with greater clinical outcome predictability.

Management of large preiapical lesion with the combination of second generation platelet extract and hydroxyapatite bone graft: a report of three cases

The pulp tissue necrosis and extensive periodontal diseases leads to the development of the inflammatory periapical lesion which causes a local response of bone around the apex of the tooth. Depends upon the nature of wound and available biological growth factors the outcome will be either regeneration or repair. Being a rich source of growth factors, platelet rich fibrin (PRF) posses many advantages in bone regeneration. The purpose of this case report is to present an attempt to evaluate the healing potential of the combination of PRF and Hydroxyapatite bone graft as opposed to using these materials alone. A periapical endodontic surgery was performed on three patients with a large periapical inflammatory lesion and a large bony defect. The defect was then filled with a combination of PRF and Hydroxyapatite bone graft crystals. Clinical examination exhibited uneventful wound healing. The HA crystals have been replaced by new bone radiographically at the end of two years in Case 1 and Case 2, Case 3 were followed upto one year. On the basis of our cases outcome, we conclude the use of PRF in combination with HA crystals might have accelerate the bone regeneration.

Tissue engineering in periodontal tissue

Periodontitis, a recognized disease worldwide, is bacterial infection-induced inflammation of the periodontal tissues that results in loss of alveolar bone. Once it occurs, damaged tissue cannot be restored to its original form, even if decontaminating treatments are performed. For more than half a century, studies have been conducted to investigate true periodontal regeneration. Periodontal regeneration is the complete reconstruction of the damaged attachment apparatus, which contains both hard tissue (alveolar bone and cementum) and soft tissue (periodontal ligament). Several treatments, including bone grafts, guided tissue regeneration with physical barriers for epithelial cells, and growth factors have been approved for clinical use; however, their indications and outcomes are limited. To overcome these limitations, the concept of "tissue engineering" was introduced. Combination treatment using cells, growth factors, and scaffolds, has been studied in experimental animal models, and some studies have been translated into clinical trials. In this review, we focus on recent progressive tissue engineering studies and discuss future perspectives on periodontal regeneration.

Platelet-Rich Fibrin as a Biofuel for Tissue Regeneration

Wound healing is a staged process which involves the activity of leukocytes and platelets. For this process to work efficiently, the platelets play a vital role. The growth factors present in platelets are important to guide the regenerating cells to the area of healing. Platelet-rich-fibrin (PRF) is one such material that holds on to these growth factors enmeshed in the fibrin network resulting in their sustained release over a period of time that can accelerate the wound healing process. With this knowledge, research has been carried out for a past few years for the clinical application of PRF. Various platelet concentrates have been studied including the platelet-rich-plasma (PRP). However, the short duration of cytokine release and its poor mechanical properties have resulted in the search of a new material with adequate properties for clinical application and ease of preparation. PRF has found a place in the regenerative field owing to its advantages over PRP. This review focuses on the properties and various applications of PRF in the clinical practice.

Effects of enamel matrix proteins on multi-lineage differentiation of periodontal ligament cells in vitro

The adult periodontal ligament (PDL) is considered to contain progenitor cells that are involved in the healing of periodontal wounds. Treatment with enamel matrix derivative (EMD), a heat-treated preparation derived from enamel matrix proteins (EMPs), has been shown to be of some clinical benefit in eliciting periodontal regeneration in vivo. Although there is extensive information available about the effects of EMD on periodontal regeneration, the precise influence of this material on alveolar bone and the formation of blood vessels and proprioceptive sensory nerves, prominent features of functionally active periodontal tissue, remain unclear. The aim of the present study was therefore to examine the effects of EMD on the ability of human periodontal ligament cells (HPCs) to undergo multi-lineage differentiation in vitro. Our results showed that HPCs treated with EMD under non-selective growth conditions did not show any evidence of osteogenic, adipogenic, chondrogenic, neovasculogenic, neurogenic and gliogenic "terminal" differentiation. In contrast, under selective lineage-specific culture conditions, EMD up-regulated osteogenic, chondrogenic and neovasculogenic genes and "terminal" differentiation, but suppressed adipogenesis, neurogenesis and gliogenesis. These findings thus demonstrate for the first time that EMD can differentially modulate the multi-lineage differentiation of HPCs in vitro.

Platelet-Rich Fibrin with β-Tricalcium Phosphate-A Noval Approach for Bone Augmentation in Chronic Periapical Lesion: A Case Report

Introduction. This paper describes a case of bone augmentation with combination of Platelet-Rich Fibrin (PRF) and β-TCP for treatment of chronic periapical cyst. The case was followed for 12 months. Methods. Patient presented with chronic periapical lesion in maxillary anterior teeth with history of trauma 8 years back. Radiographically, a periapical cyst was seen in relation to maxillary left central and lateral incisors. Conventional endodontic treatment was started. Since it was not successful, apical surgery was performed. Bone augmentation was done using PRF in combination with β-TCP bone graft to achieve faster healing of the periapical region. Regular followups at 3, 6, 9, and 12 months were done. Results. Healing was uneventful. Follow-up examinations revealed progressive, significant, and predictable clinical and radiographic bone regeneration/healing without any clinical symptoms. Conclusions. Combined use of PRF and β-TCP for bone augmentation in treatment of periapical defects is a potential treatment alternative for faster healing than using these biomaterials alone.

The effect of platelet derived growth factor-AB on periodontal ligament fibroblasts: An in vitro study

Background and Objectives:

Traditional methods of periodontal therapy produce results in healing of tissues by repair; however, what we require is regeneration of the lost tissues. The periodontal ligament (PDL) cells appear to be important in periodontal wound healing. Platelet derived growth factor (PDGF), a potent mitogen and useful mediator for wound healing, has been extensively studied in periodontal regeneration. This in vitro study was designed to evaluate the effect of PDGF-AB on human PDL fibroblasts (hPDLF) at 50, 100 and 150 ng/ml dosages at 24, 48 and 72 hours time duration.

Materials and Methods:

Tissue explants from three different patients were harvested from the roots of freshly extracted, uninfected and impacted third molars. The cells cultured from all samples were divided into 4 groups: Group-1 was the control group, and the experimental groups were designated as Group-2, Group-3 and Group-4, to test the effect of PDGF-AB at 50, 100 and 150 ng/ml by proliferation assay carried out at 24, 48 and 72 hours.

Results:

The results revealed maximum mitogenic response of PDL cells at 100 ng/ml and at 48 hours, suggesting that the mitogenic response of PDGF-AB is both, time and dose dependent.

Conclusions:

The results of this in vitro study suggest that PDGF has maximum mitogenic response on hPDLF at 48 hours and for 100 ng dose. However for clinical application, randomized controlled clinical trials are required to substantiate the results of this in vitro study.

Translational research and therapeutic applications of stem cell transplantation in periodontal regenerative medicine

Stem cells have received a great deal of interest from the research community as potential therapeutic "tools" for a variety of chronic debilitating diseases that lack clinically effective therapies. Stem cells are also of interest for the regeneration of tooth-supporting tissues that have been lost to periodontal disease. Indeed, substantial data have demonstrated that the exogenous administration of stem cells or their derivatives in preclinical animal models of periodontal defects can restore damaged tissues to their original form and function. As we discuss here, however, considerable hurdles must be overcome before these findings can be responsibly translated to novel clinical therapies. Generally, the application of stem cells for periodontal therapy in clinics will not be realized until the best cell(s) to use, the optimal dose, and an effective mode of administration are identified. In particular, we need to better understand the mechanisms of action of stem cells after transplantation in the periodontium and to learn how to preciously control stem cell fates in the pathological environment around a tooth. From a translational perspective, we outline the challenges that may vary across preclinical models for the evaluation of stem cell therapy in situations that require periodontal reconstruction and the safety issues that are related to clinical applications of human stem cells. Although clinical trials that use autologous periodontal ligament stem cells have been approved and have already been initiated, proper consideration of the technical, safety, and regulatory concerns may facilitate, rather than inhibit, the clinical translation of new therapies.

Platelet-rich plasma in the treatment of Class II furcation defects: a histometrical study in dogs

Objective

This study was designed to evaluate the potential adjunctive benefits of platelet-rich plasma (PRP) when used with guided-tissue regeneration (GTR) and bioactive glass (BG) in the treatment of Class II furcation lesions.

Material and Methods

Bilateral Class II furcation lesions were surgically created and allowed to become chronic in the mandibular third premolars of 9 dogs. The defects were randomly assigned to: A) GTR+BG and B) GTR+BG+PRP. Similar defects were created in the maxillary third premolars and received the same treatments after 45 days. Dogs were sacrificed 90 days after the first treatment. The histometric parameters evaluated were: connective tissue adaptation, new cementum, new bone, mineralized bone area, non-mineralized bone area, and residual BG particle area.

Results

Data analysis showed a superior length of new cementum and a greater mineralized bone area for group B in both periods (p<0.05). The non-mineralized bone area was greater in the control group (p<0.05) in both periods.

Conclusion

Within the limits of this study, it can be concluded that the use of PRP in the treatment of Class II furcation defects may enhance the amount of new cementum and provide a more mineralized bone in a shorter period of time.

Bone repair cells for craniofacial regeneration

Reconstruction of complex craniofacial deformities is a clinical challenge in situations of injury, congenital defects or disease. The use of cell-based therapies represents one of the most advanced methods for enhancing the regenerative response for craniofacial wound healing. Both somatic and stem cells have been adopted in the treatment of complex osseous defects and advances have been made in finding the most adequate scaffold for the delivery of cell therapies in human regenerative medicine. As an example of such approaches for clinical application for craniofacial regeneration, Ixmyelocel-T or bone repair cells are a source of bone marrow derived stem and progenitor cells. They are produced through the use of single pass perfusion bioreactors for CD90+ mesenchymal stem cells and CD14+ monocyte/macrophage progenitor cells. The application of ixmyelocel-T has shown potential in the regeneration of muscular, vascular, nervous and osseous tissue. The purpose of this manuscript is to highlight cell therapies used to repair bony and soft tissue defects in the oral and craniofacial complex. The field at this point remains at an early stage, however this review will provide insights into the progress being made using cell therapies for eventual development into clinical practice.

Advanced reconstructive technologies for periodontal tissue repair

Reconstructive therapies to promote the regeneration of lost periodontal support have been investigated through both preclinical and clinical studies. Advanced regenerative technologies using new barrier-membrane techniques, cell-growth-stimulating proteins or gene-delivery applications have entered the clinical arena. Wound-healing approaches using growth factors to target the restoration of tooth-supporting bone, periodontal ligament and cementum are shown to significantly advance the field of periodontal-regenerative medicine. Topical delivery of growth factors, such as platelet-derived growth factor, fibroblast growth factor or bone morphogenetic proteins, to periodontal wounds has demonstrated promising results. Future directions in the delivery of growth factors or other signaling models involve the development of innovative scaffolding matrices, cell therapy and gene transfer, and these issues are discussed in this paper.

Platelet-derived growth factor promotes periodontal regeneration in localized osseous defects: 36-month extension results from a randomized, controlled, double-masked clinical trial

BACKGROUND

Recombinant human platelet-derived growth factor (rhPDGF) is safe and effective for the treatment of periodontal defects in short-term studies up to 6 months in duration. We now provide results from a 36-month extension study of a multicenter, randomized, controlled clinical trial evaluating the effect and long-term stability of PDGF-BB treatment in patients with localized severe periodontal osseous defects.

METHODS

A total of 135 participants were enrolled from six clinical centers for an extension trial. Eighty-three individuals completed the study at 36 months and were included in the analysis. The study investigated the local application of β-tricalcium phosphate scaffold matrix with or without two different dose levels of PDGF (0.3 or 1.0 mg/mL PDGF-BB) in patients possessing one localized periodontal osseous defect. Composite analysis for clinical and radiographic evidence of treatment success was defined as percentage of cases with clinical attachment level (CAL) ≥2.7 mm and linear bone growth (LBG) ≥1.1 mm.

RESULTS

The participants exceeding this composite outcome benchmark in the 0.3 mg/mL rhPDGF-BB group went from 62.2% at 12 months, 75.9% at 24 months, to 87.0% at 36 months compared with 39.5%, 48.3%, and 53.8%, respectively, in the scaffold control group at these same time points (P <0.05). Although there were no significant increases in CAL and LBG at 36 months among all groups, there were continued increases in CAL gain, LBG, and percentage bone fill over time, suggesting overall stability of the regenerative response.

CONCLUSION

PDGF-BB in a synthetic scaffold matrix promotes long-term stable clinical and radiographic improvements as measured by composite outcomes for CAL gain and LBG for patients possessing localized periodontal defects ( ClinicalTrials.gov no. CT01530126).

Future dentistry: cell therapy meets tooth and periodontal repair and regeneration

Cell-based tissue repair of the tooth and – tooth-supporting – periodontal ligament (PDL) is a new attractive approach that complements traditional restorative or surgical techniques for replacement of injured or pathologically damaged tissues. In such therapeutic approaches, stem cells and/or progenitor cells are manipulated in vitro and administered to patients as living and dynamic biological agents. In this review, we discuss the clonogenic potential of human dental and periodontal tissues such as the dental pulp and the PDL and their potential for tooth and periodontal repair and/or regeneration. We propose novel therapeutic approaches using stem cells or progenitor cells, which are targeted to regenerate the lost dental or periodontal tissue.

Fibrin glue mixed with platelet-rich fibrin as a scaffold seeded with dental bud cells for tooth regeneration

Odontogenesis is a complex process with a series of epithelial-mesenchymal interactions and odontogenic molecular cascades. In tissue engineering of teeth from stem cells, platelet-rich fibrin (PRF), which is rich in growth factors and cytokines, may improve regeneration. Accordingly, PRF was added into fibrin glue to enrich the microenvironment with growth factors. Unerupted second molar tooth buds were harvested from miniature swine and cultured in vitro for 3 weeks to obtain dental bud cells (DBCs). Whole blood was collected for the preparation of PRF and fibrin glue before surgery. DBCs were suspended in fibrin glue and then enclosed with PRF, and the DBC-fibrin glue-PRF composite was autografted back into the original alveolar sockets. Radiographic and histological examinations were used to identify the regenerated tooth structure 36 weeks after implantation. Immunohistochemical staining was used to detect proteins specific to tooth regeneration. One pig developed a complete tooth with crown, root, pulp, enamel, dentin, odontoblast, cementum, blood vessels, and periodontal ligaments in indiscriminate shape. Another animal had an unerupted tooth that expressed cytokeratin 14, dentin matrix protein-1, vascular endothelial growth factor, and osteopontin. This study demonstrated, using autogenic cell transplantation in a porcine model, that DBCs seeded into fibrin glue-PRF could regenerate a complete tooth.

The combination of purified recombinant human platelet-derived growth factor-BB and equine particulate bone graft for periodontal regeneration

BACKGROUND

The objective of this study is to evaluate the potential for periodontal regeneration of a critical-sized defect with the application of recombinant human platelet-derived growth factor (rhPDGF-BB) combined with either a particulate equine or a β-tricalcium phosphate (β-TCP) matrix.

METHODS

Critical-sized intrabony 2-wall defects were created bilaterally on the distal surface of the second premolar and the mesial surface of the first molar in nine hounds. Twelve defects received rhPDGF-BB/equine treatment, 12 defects received rhPDGF-BB/β-TCP treatment, and the remaining 12 sites served as sham-surgery controls. The animals were sacrificed after a 10-week healing period.

RESULTS

Clinical healing was uneventful without obvious signs of overt gingival inflammation. Histologic and histomorphometric analyses revealed statistically that there were differences among the three groups in terms of new bone formation (P <0.001). The amount of test material for both rhPDGF-BB/equine and rhPDGF-BB/β-TCP groups was comparable, but the amount of newly formed bone was significantly higher (P <0.01) in favor of the rhPDGF-BB/equine group. The amount of new cementum formed for the rhPDGF-BB/equine group (4.8 ± 1.3 mm) was significantly higher (P =0.001) than the sham-surgery control group (1.7 ± 1.9 mm).

CONCLUSION

Both rhPDGF-BB/equine and rhPDGF-BB/β-TCP have the potential to support the regeneration of the periodontal attachment apparatus.