Engineering Human TMJ Discs with Protein-Releasing 3D-Printed Scaffolds

Specific tissue engineering for temporomandibular joint disc perforation

BACKGROUND

The temporomandibular joint (TMJ) disc is a critical fibrocartilaginous structure with limited regenerative capacity in the oral system. Perforation of the TMJ disc can lead to osteoarthritis and ankylosis of the TMJ because of the lack of disc protection. Clinical treatments for TMJ disc perforation, such as discectomy, hyaluronic acid injection, endoscopic surgery and high position arthroplasty of TMJ, are questionable with regard to long-term outcomes, and only three fourths of TMJ disc perforations are repairable by surgery, even in the short-term. Tissue engineering offers the potential for cure of repairable TMJ disc perforations and regeneration of unrepairable ones.

OBJECTIVES

This review discusses the classification of TMJ disc perforation and defines typical TMJ disc perforation. Advancements in the engineering-based repair of TMJ disc perforation by stem cell therapy, construction of a disc-like scaffold and functionalization by offering bioactive stimuli are also summarized in the review, and the barriers developing engineering technologies need to overcome to be popularized are discussed.

The 3D-McMap Guidelines: Three-Dimensional Multicomposite Microsphere Adaptive Printing

Microspheres, synthesized from diverse natural or synthetic polymers, are readily utilized in biomedical tissue engineering to improve the healing of various tissues. Their ability to encapsulate growth factors, therapeutics, and natural biomolecules, which can aid tissue regeneration, makes microspheres invaluable for future clinical therapies. While microsphere-supplemented scaffolds have been investigated, a pure microsphere scaffold with an optimized architecture has been challenging to create via 3D printing methods due to issues that prevent consistent deposition of microsphere-based materials and their ability to maintain the shape of the 3D-printed structure. Utilizing the extrusion printing process, we established a methodology that not only allows the creation of large microsphere scaffolds but also multicomposite matrices into which cells, growth factors, and therapeutics encapsulated in microspheres can be directly deposited during the printing process. Our 3D-McMap method provides some critical guidelines for issues with scaffold shape fidelity during and after printing. Carefully timed breaks, minuscule drying steps, and adjustments to extrusion parameters generated an evenly layered large microsphere scaffold that retained its internal architecture. Such scaffolds are superior to other microsphere-containing scaffolds, as they can release biomolecules in a highly controlled spatiotemporal manner. This capability permits us to study cell responses to the delivered signals to develop scaffolds that precisely modulate new tissue formation.

Bioactive Scaffold With Spatially Embedded Growth Factors Promotes Bone-to-Tendon Interface Healing of Chronic Rotator Cuff Tear in Rabbit Model

BACKGROUND

Functional restoration of the bone-to-tendon interface (BTI) after rotator cuff repair is a challenge. Therefore, numerous biocompatible biomaterials for promoting BTI healing have been investigated.

PURPOSE

To determine the efficacy of scaffolds with spatiotemporal delivery of growth factors (GFs) to accelerate BTI healing after rotator cuff repair.

STUDY DESIGN

Controlled laboratory study.

METHODS

An advanced 3-dimensional printing technique was used to fabricate bioactive scaffolds with spatiotemporal delivery of multiple GFs targeting the tendon, fibrocartilage, and bone regions. In total, 50 rabbits were used: 2 nonoperated controls and 48 rabbits with induced chronic rotator cuff tears (RCTs). The animals with RCTs were divided into 3 groups: (A) saline injection, (B) scaffold without GF, and (C) scaffold with GF. To induce chronic models, RCTs were left unrepaired for 6 weeks; then, surgical repairs with or without bioactive scaffolds were performed. For groups B and C, each scaffold was implanted between the bony footprint and the supraspinatus tendon. Four weeks after repair, quantitative real-time polymerase chain reaction and immunofluorescence analyses were performed to evaluate early signs of regenerative healing. Histological, biomechanical, and micro-computed tomography analyses were performed 12 weeks after repair.

RESULTS

Group C had the highest mRNA expression of collagen type I alpha 1, collagen type III alpha 1, and aggrecan. Immunofluorescence analysis showed the formation of an aggrecan+/collagen II+ fibrocartilaginous matrix at the BTI when repaired with scaffold with GFs. Histologic analysis revealed greater collagen fiber continuity, denser collagen fibers, and a more mature tendon-to-bone junction in GF-embedded scaffolds than those in the other groups. Group C demonstrated the highest load-to-failure ratio, and modulus mapping showed that the distribution of the micromechanical properties of the BTI repaired with GF-embedded scaffolds was comparable with that of the native BTI. Micro-computed tomography analysis identified the highest bone mineral density and bone volume/total volume ratio in group C.

CONCLUSION

Bioactive scaffolds with spatially embedded GFs have significant potential to promote the BTI healing of chronic RCTs in a rabbit model.

CLINICAL RELEVANCE

The scaffolds with spatiotemporal delivery of GF may serve as an off-the-shelf biomaterial graft to promote the healing of RCTs.

Decellularized-disc based allograft and xenograft prosthesis for the long-term precise reconstruction of temporomandibular joint disc

Currently, no effective disc reconstruction treatment strategy is clinically available for temporomandibular joint (TMJ) disc-related diseases. To address this, we developed a prosthesis construct with laser-drilled decellularized natural disc reinforced by polycaprolactone, which mimics the natural morphology, and structural, biomechanical and biological property of the TMJ disc. The construct demonstrated good biocompatibility, safety and immunological tolerance both in vitro, and in a rat subcutaneous model. During 6 months implantation in an allogeneic rabbit TMJ disc reconstruction model, the disc prosthesis maintained its integrity, collagen fiber-orientation, mechanical property, joint structural stability and prevented articular cartilage and bone from damage. Furthermore, the "upgraded" disc prosthesis obtained from decellularized porcine disc was implanted into a goat TMJ disc reconstruction model. The xenograft prosthesis, with strength and viscoelasticity similar to a natural TMJ disc, was able to restore the structure and function of TMJ up to 20 weeks. These results demonstrate the translational feasibility of an allogeneic or xenogeneic decellularized disc prosthesis for treatment of advanced TMJ disc-related diseases. STATEMENT OF SIGNIFICANCE: This study makes a significant contribution to TMJ disc disease treatment both in theory and in clinics, because: (1) it provided an innovative approach to prepare an artificial TMJ disc with decent mechanical properties and long-term condyle-protecting effect; (2) it specified an advanced decellularized method for fibrocartilage decellularization and xenograft application; (3) it developed a facile and reproducible TMJ disc reconstruction model not only for middle size animal but also for large animal study; (4) the comprehensive and unreported biomechanical tests on the natural TMJ discs would act as a valuable reference for further research in the field of artificial TMJ disc materials or TMJ disc tissue engineering; (5) it suggested a potential treatment for patients with severe TMJ diseases that were commonly met but difficult to treat in clinics.

Recent Advances in Animal Models, Diagnosis, and Treatment of Temporomandibular Joint Osteoarthritis

Temporomandibular joint osteoarthritis (TMJOA) is a gradual degenerative jaw joint condition. Until recent years, TMJOA is still relatively unrecognized and ineffective to be treated. Appropriate animal models with reliable detection methods can help researchers understand the pathophysiology of TMJOA and find therapeutic options. In this study, we summarized common animal models of TMJOA created by chemical, surgical, mechanical, and genetical approaches. The relevant pathological symptoms and induction mechanisms were outlined. In addition, different pathological indicators, furthermore, emerging therapeutic regimens, such as intra-articular drug delivery and tissue engineering-based approaches to treat TMJOA based on these animal models, were summarized and updated. Understanding the physiology and pathogenesis of the TMJOA, together using various ways to diagnose the TMJOA, were elaborated, including imaging techniques, molecular techniques for detecting inflammatory cytokines, histochemical staining, and histomorphometry measures. A more reliable diagnosis will enable the development of new prevention and more effective treatment strategies and thereby improve the quality of life of TMJOA patients. Impact statement Temporomandibular joint osteoarthritis (TMJOA) affects 8 to 16 percent of the population worldwide. However, TMJOA is still relatively unrecognized and ineffective to be treated in the clinic. Appropriate animal models with reliable diagnostic methods can help researchers understand the pathophysiology of TMJOA and find therapeutic options. We herein summarized common animal models of TMJOA and various ways to diagnose the TMJOA. More importantly, emerging therapeutic regimens to treat TMJOA based on these animal models were summarized. With the aid of strategies listed, more effective treatment strategies will be developed and thereby improve the life quality of TMJOA patients.

The role of TGF-beta3 in cartilage development and osteoarthritis

Articular cartilage serves as a low-friction, load-bearing tissue without the support with blood vessels, lymphatics and nerves, making its repair a big challenge. Transforming growth factor-beta 3 (TGF-β3), a vital member of the highly conserved TGF-β superfamily, plays a versatile role in cartilage physiology and pathology. TGF-β3 influences the whole life cycle of chondrocytes and mediates a series of cellular responses, including cell survival, proliferation, migration, and differentiation. Since TGF-β3 is involved in maintaining the balance between chondrogenic differentiation and chondrocyte hypertrophy, its regulatory role is especially important to cartilage development. Increased TGF-β3 plays a dual role: in healthy tissues, it can facilitate chondrocyte viability, but in osteoarthritic chondrocytes, it can accelerate the progression of disease. Recently, TGF-β3 has been recognized as a potential therapeutic target for osteoarthritis (OA) owing to its protective effect, which it confers by enhancing the recruitment of autologous mesenchymal stem cells (MSCs) to damaged cartilage. However, the biological mechanism of TGF-β3 action in cartilage development and OA is not well understood. In this review, we systematically summarize recent progress in the research on TGF-β3 in cartilage physiology and pathology, providing up-to-date strategies for cartilage repair and preventive treatment.

Quantum dots-labeled polymeric scaffolds for in vivo tracking of degradation and tissue formation

The inevitable gap between in vitro and in vivo degradation rate of biomaterials has been a challenging factor in the optimal designing of scaffold's degradation to be balanced with new tissue formation. To enable non-/minimum-invasive tracking of in vivo scaffold degradation, chemical modifications have been applied to label polymers with fluorescent dyes. However, the previous approaches may have limited expandability due to complicated synthesis processes. Here, we introduce a simple and efficient method to fluorescence labeling of polymeric scaffolds via blending with near-infrared (NIR) quantum dots (QDs), semiconductor nanocrystals with superior optical properties. QDs-labeled, 3D-printed PCL scaffolds showed promising efficiency and reliability in quantitative measurement of degradation using a custom-built fiber-optic imaging modality. Furthermore, QDs-PCL scaffolds showed neither cytotoxicity nor secondary labeling of adjacent cells. QDs-PCL scaffolds also supported the engineering of fibrous, cartilaginous, and osteogenic tissues from mesenchymal stem/progenitor cells (MSCs). In addition, QDs-PCL enabled a distinction between newly forming tissue and the remaining mass of scaffolds through multi-channel imaging. Thus, our findings suggest a simple and efficient QDs-labeling of PCL scaffolds and minimally invasive imaging modality that shows significant potential to enable in vivo tracking of scaffold degradation as well as new tissue formation.

Three-dimensional, biomimetic electrospun scaffolds reinforced with carbon nanotubes for temporomandibular joint disc regeneration

Temporomandibular disorder (TMD) remained a huge clinical challenge, with high prevalence but limited, unstable, and only palliative therapeutic methods available. As one of the most vulnerable sites implicated in TMD, the temporomandibular joint disc (TMJD) displayed a complicated microstructure, region-specific fibrocartilaginous distribution, and poor regenerative property, which all further hindered its functional regeneration. To address the problem, with versatile and relatively simple electrospinning (ELS) technique, our study successfully fabricated a biomimetic, three-dimensional poly (ϵ-caprolactone) (PCL)/polylactide (PLA)/carbon nanotubes (CNTs) disc scaffold, whose biconcave gross anatomy and regionally anisotropic microstructure recapitulating those of the native disc. As in vitro results validated the superior mechanical, bioactive, and regenerative properties of the biomimetic scaffolds with optimal CNTs reinforcement, we further performed in vivo experiments. After verifying its biocompatibility and ectopic fibrochondrogenicity in nude mice subcutaneous implantation models, the scaffolds guided disc regeneration and subchondral bone protection were also confirmed orthotopically in rabbits TMJD defected areas, implying the pivotal role of morphological cues in contact-guided tissue regeneration. In conclusion, our work represents a significant advancement in complex, inhomogeneous tissue engineering, providing promising clinical solutions to intractable TMD ailments. STATEMENT OF SIGNIFICANCE: Complex tissue regeneration remains a huge scientific and clinical challenge. Although frequently implicated in temporomandibular joint disorder (TMD), functional regeneration of injured temporomandibular joint disc (TMJD) is extremely hard to achieve, mainly because of the complex anatomy and microstructure with regionally variant, anisotropic fiber alignments in the native disc. In this study, we developed the biomimetic electrospun scaffold with optimal CNTs reinforcement and regionally anisotropic fiber orientations. The excellent mechanical and bioactive properties were confirmed both in vitro and in vivo, effectively promoting defected discs regeneration in rabbits. Besides demonstrating the crucial role of morphological biomimicry in tissue engineering, our work also presents a feasible clinical solution for complex tissue regeneration.

Inductive Remodeling of Extracellular Matrix Scaffolds in the Temporomandibular Joint of Pigs

The temporomandibular joint (TMJ) disc is a fibrocartilaginous tissue located between the condyle of the mandible and glenoid fossa and articular eminence of the temporal bone. Damage or derangement of the TMJ disc can require surgical removal (discectomy) to restore function. Removal of the TMJ disc, however, leaves the joint space vulnerable to condylar remodeling and degradation, potentially leading to long-term complications. No consistently effective clinical option exists for repair or replacement of the disc following discectomy. This study investigates the use of an acellular scaffold composed of extracellular matrix (ECM) derived from small intestinal submucosa (SIS) as a regenerative template for the TMJ disc in a porcine model. Acellular SIS ECM scaffolds were implanted following discectomy and allowed to remodel for 2, 4, 12, and 24 weeks postimplantation. Remodeling of the implanted device was assessed by longitudinal magnetic resonance imaging (MRI) over the course of 6 months, as well as gross morphologic, histologic, biochemical, and biomechanical analysis (tension and compression) of explanted tissues (disc and condyle) at the time of sacrifice. When the scaffold remained in the joint space, longitudinal MRI demonstrated that the scaffolds promoted new tissue formation within the joint space throughout the study period. The scaffolds were rapidly populated with host-derived cells and remodeled with formation of new, dense, aligned fibrocartilage resembling native tissue as early as 1 month postimplantation. De-novo formation of peripheral muscular and tendinous attachments resembling those in native tissue was also observed. The remodeled scaffolds approached native disc biochemical composition and compressive modulus, and possessed 50% of the tensile modulus within 3 months postimplantation. No degradation of the condylar surface was observed. These results suggest that this acellular bioscaffold fills a medical need for which there is currently no effective treatment and may represent a clinically relevant "off-the-shelf" implant for reconstruction of the TMJ disc.

3D Printing and Virtual Surgical Planning in Oral and Maxillofacial Surgery

Compared to traditional manufacturing methods, additive manufacturing and 3D printing stand out in their ability to rapidly fabricate complex structures and precise geometries. The growing need for products with different designs, purposes and materials led to the development of 3D printing, serving as a driving force for the 4th industrial revolution and digitization of manufacturing. 3D printing has had a global impact on healthcare, with patient-customized implants now replacing generic implantable medical devices. This revolution has had a particularly significant impact on oral and maxillofacial surgery, where surgeons rely on precision medicine in everyday practice. Trauma, orthognathic surgery and total joint replacement therapy represent several examples of treatments improved by 3D technologies. The widespread and rapid implementation of 3D technologies in clinical settings has led to the development of point-of-care treatment facilities with in-house infrastructure, enabling surgical teams to participate in the 3D design and manufacturing of devices. 3D technologies have had a tremendous impact on clinical outcomes and on the way clinicians approach treatment planning. The current review offers our perspective on the implementation of 3D-based technologies in the field of oral and maxillofacial surgery, while indicating major clinical applications. Moreover, the current report outlines the 3D printing point-of-care concept in the field of oral and maxillofacial surgery.

Regeneration of temporomandibular joint using in vitro human stem cells: A review

Temporomandibular joint disorders (TMDs) range from gross anatomic deformities of the disc and hard tissue to functional disturbances. Traditional treatment of TMDs includes physical therapy, use of appliances, pharmacological, surgical and psychological interventions. However, during the late stage of TMDs, conventional management often results in inadequate relief of symptoms. Stem cell‐based tissue regeneration has been studied extensively in joint regeneration, including the Temporomandibular Joint (TMJ). This study aims to review the potential of various human stem cells (HSC) for the regeneration of the TMJ. In vitro studies using human mesenchymal stem cells cultured under different conditions to evaluate regeneration of TMJ related structures were searched on PubMed, EMBASE, Cochrane, and Web of Science up to March 2020. In vitro studies utilized several different types of stem cells under varying conditions. Increased osteogenesis and/or chondrogenesis were noted with stem cell interventions compared to control groups on Alkaline Phosphatase (ALP) activity, Col‐I, Col‐II, Col‐X, RUNX2, LPL, and Aggrecan mRNA expression. This review emphasizes the potential of stem cell therapies in the regeneration of TMJ‐related structures. However, further in vivo studies are required to evaluate the efficacy and safety of these therapies in humans.

Mesenchymal Stem Cells Based Treatment in Dental Medicine: A Narrative Review

Application of mesenchymal stem cells (MSC) in regenerative therapeutic procedures is becoming an increasingly important topic in medicine. Since the first isolation of dental tissue-derived MSC, there has been an intense investigation on the characteristics and potentials of these cells in regenerative dentistry. Their multidifferentiation potential, self-renewal capacity, and easy accessibility give them a key role in stem cell-based therapy. So far, several different dental stem cell types have been discovered and their potential usage is found in most of the major dental medicine branches. These cells are also researched in multiple fields of medicine for the treatment of degenerative and inflammatory diseases. In this review, we summarized dental MSC sources and analyzed their treatment modalities with particular emphasis on temporomandibular joint osteoarthritis (TMJ OA).

Application of collagen and mesenchymal stem cells in regenerative dentistry

Collagen is an important macromolecule of extracellular matrix (ECM) in bones, teeth, and temporomandibular joints. Mesenchymal stem cells (MSCs) interact with the components of the ECM such as collagen, proteoglycans, glycosaminoglycans (GAGs), and several proteins on behalf of variable matrix elasticity and bioactive cues. Synthetic collagen-based biomaterials could be effective scaffolds for regenerative dentistry applications due to mimicking of host tissues' ECM. These biomaterials are biocompatible, biodegradable, readily available, and non-toxic to cells whose capability promotes cellular response and wound healing in the craniofacial region. Collagen could incorporate other biomolecules to induce mineralization in calcified tissues such as bone and tooth. Moreover, the addition of these molecules or other polymers to collagen-based biomaterials could enhance mechanical properties, which is important in load-bearing areas such as the mandible. A literature review was performed via reliable internet database (mainly PubMed) based on MeSH keywords. This review first describes the properties of collagen as a key protein in the structure of hard tissues. Then, it introduces different types of collagens, the correlation between collagen and MSCs, and the methods used to modify collagen in regenerative dentistry including recent progression on the regeneration of periodontium, dentin-pulp complex, and temporomandibular joint by applying collagen. Besides, the prospects and challenges of collagen-based biomaterials in the craniofacial region pointes out.

Challenge Tooth Regeneration in Adult Dogs with Dental Pulp Stem Cells on 3D-Printed Hydroxyapatite/Polylactic Acid Scaffolds

Tooth regeneration is an important issue. The purpose of this study was to explore the feasibility of using adult dental pulp stem cells on polylactic acid scaffolds for tooth regeneration. Three teeth were extracted from each side of the lower jaws of two adult dogs. In the experimental group, dental pulp stem cells were isolated and seeded in the 3D-printed hydroxyapatite/polylactic acid (HA/PLA) scaffolds for transplantation into left lower jaw of each dog. The right-side jaw of each dog was transplanted with cell-free scaffolds as the control group. Polychrome sequentially labeling was performed for observation of mineralization. Dental cone beam computed tomography (CBCT) irradiation was used for assessment. Nine months after surgery, dogs were euthanized, and the lower jaws of dogs were sectioned and fixed for histological observation with hematoxylin and eosin staining. The results showed that the degree of mineralization in the experimental group with cells seeded in the scaffolds was significantly higher than that of the control group transplanted with cell-free scaffolds. However, the HA/PLA scaffolds were not completely absorbed in both groups. It is concluded that dental pulp stem cells are important for the mineralization of tooth regeneration. A more rapid absorbable material was required for scaffold design for tooth regeneration.

The recent advances in scaffolds for integrated periodontal regeneration

The periodontium is an integrated, functional unit of multiple tissues surrounding and supporting the tooth, including but not limited to cementum (CM), periodontal ligament (PDL) and alveolar bone (AB). Periodontal tissues can be destructed by chronic periodontal disease, which can lead to tooth loss. In support of the treatment for periodontally diseased tooth, various biomaterials have been applied starting as a contact inhibition membrane in the guided tissue regeneration (GTR) that is the current gold standard in dental clinic. Recently, various biomaterials have been prepared in a form of tissue engineering scaffold to facilitate the regeneration of damaged periodontal tissues. From a physical substrate to support healing of a single type of periodontal tissue to multi-phase/bioactive scaffold system to guide an integrated regeneration of periodontium, technologies for scaffold fabrication have emerged in last years. This review covers the recent advancements in development of scaffolds designed for periodontal tissue regeneration and their efficacy tested in vitro and in vivo. Pros and Cons of different biomaterials and design parameters implemented for periodontal tissue regeneration are also discussed, including future perspectives.

Tissue engineered autologous cartilage-bone grafts for temporomandibular joint regeneration

Joint disorders can be detrimental to quality of life. There is an unmet need for precise functional reconstruction of native-like cartilage and bone tissues in the craniofacial space and particularly for the temporomandibular joint (TMJ). Current surgical methods suffer from lack of precision and comorbidities and frequently involve multiple operations. Studies have sought to improve craniofacial bone grafts without addressing the cartilage, which is essential to TMJ function. For the human-sized TMJ in the Yucatan minipig model, we engineered autologous, biologically, and anatomically matched cartilage-bone grafts for repairing the ramus-condyle unit (RCU), a geometrically intricate structure subjected to complex loading forces. Using image-guided micromilling, anatomically precise scaffolds were created from decellularized bone matrix and infused with autologous adipose-derived chondrogenic and osteogenic progenitor cells. The resulting constructs were cultured in a dual perfusion bioreactor for 5 weeks before implantation. Six months after implantation, the bioengineered RCUs maintained their predefined anatomical structure and regenerated full-thickness, stratified, and mechanically robust cartilage over the underlying bone, to a greater extent than either autologous bone-only engineered grafts or acellular scaffolds. Tracking of implanted cells and parallel bioreactor studies enabled additional insights into the progression of cartilage and bone regeneration. This study demonstrates the feasibility of TMJ regeneration using anatomically precise, autologous, living cartilage-bone grafts for functional, personalized total joint replacement. Inclusion of the adjacent tissues such as soft connective tissues and the TMJ disc could further extend the functional integration of engineered RCUs with the host.

Biological Treatments for Temporomandibular Joint Disc Disorders: Strategies in Tissue Engineering

The temporomandibular joint (TMJ) is an important structure for the masticatory system and the pathologies associated with it affect a large part of the population and impair people's lifestyle. It comprises an articular disc, that presents low regeneration capacities and the existing clinical options for repairing it are not effective. This way, it is imperative to achieve a permanent solution to guarantee a good quality of life for people who suffer from these pathologies. Complete knowledge of the unique characteristics of the disc will make it easier to achieve a successful tissue engineering (TE) construct. Thus, the search for an effective, safe and lasting solution has already started, including materials that replace the disc, is currently growing. The search for a solution based on TE approaches, which involve regenerating the disc. The present work revises the TMJ disc characteristics and its associated diseases. The different materials used for a total disc replacement are presented, highlighting the TE area. A special focus on future trends in the field and part of the solution for the TMJ problems described in this review will involve the development of a promising engineered disc approach through the use of decellularized extracellular matrices.

Research progress on tissue engineering in repairing tempomandibular joint

Temporomandibular joint osteoarthritis (TMJOA) is mainly manifested as perforation of temporomandibular joint disc (TMJD) and destruction of condylar osteochondral complex (COCC). In recent years, tissue engineering technology has become one of the effective strategies in repairing this damage. With the development of scaffold material technology, composite scaffolds have become an important means to optimize the performance of scaffolds with the combined advantages of natural materials and synthetic materials. The gelling method with the minimally invasive concept can greatly solve the problems of surgical trauma and material anastomosis, which is beneficial to the clinical transformation of temporomandibular joint tissue engineering. Extracellular matrix scaffolds technology can solve the problem of scaffold source and maximize the simulation of the extracellular environment, which provides an important means for the transformation of temporo joint tissue engineering to animal level. Due to the limitation of the source and amplification of costal chondrocytes, the use of mesenchymal stem cells from different sources has been widely used for temporomandibular joint tissue engineering. The fibrochondral stem cells isolated from surface layer of articular cartilage may provide one more suitable cell source. Transforming growth factor β superfamily, due to its osteochondrogenesis activity has been widely used in tissue engineering, and platelet-rich derivative as a convenient preparation of compound biological factor, gradually get used in temporomandibular joint tissue engineering. With the deepening of research on extracellular microenvironment and mechanical stimulation, mesenchymal stem cells, exosomes and stress stimulation are increasingly being used to regulate the extracellular microenvironment. In the future, the combination of complex bioactive factors and certain stress stimulation may become a trend in the temporomandibular joint tissue engineering research. In this article, the progress on tissue engineering in repairing COCC and TMJD, especially in scaffold materials, seed cells and bioactive factors, are reviewed, so as to provide information for future research design and clinical intervention.

An Update on Mesenchymal Stem Cell-Centered Therapies in Temporomandibular Joint Osteoarthritis

Temporomandibular joint osteoarthritis (TMJOA) is a degenerative disease characterized by cartilage degeneration, disrupted subchondral bone remodeling, and synovitis, seriously affecting the quality of life of patients with chronic pain and functional disabilities. Current treatments for TMJOA are mainly symptomatic therapies without reliable long-term efficacy, due to the limited self-renewal capability of the condyle and the poorly elucidated pathogenesis of TMJOA. Recently, there has been increased interest in cellular therapies for osteoarthritis and TMJ regeneration. Mesenchymal stem cells (MSCs), self-renewing and multipotent progenitor cells, play a promising role in TMJOA treatment. Derived from a variety of tissues, MSCs exert therapeutic effects through diverse mechanisms, including chondrogenic differentiation; fibrocartilage regeneration; and trophic, immunomodulatory, and anti-inflammatory effects. Here, we provide an overview of the therapeutic roles of various tissue-specific MSCs in osteoarthritic TMJ or TMJ regenerative tissue engineering, with an additional focus on joint-resident stem cells and other cellular therapies, such as exosomes and adipose-derived stromal vascular fraction (SVF). Additionally, we summarized the updated pathogenesis of TMJOA to provide a better understanding of the pathological mechanisms of cellular therapies. Although limitations exist, MSC-centered therapies still provide novel, innovative approaches for TMJOA treatment.

3D-Printed Polycaprolactone Reinforced Hydrogel as an Artificial TMJ Disc

The replacement of a damaged temporomandibular joint (TMJ) disc remains a long-standing challenge in clinical settings. No study has reported a material with comprehensively excellent properties similar to a natural TMJ disc. In this work, we designed a novel artificial TMJ disc using polyvinyl alcohol (PVA) hydrogel crosslinked by cyclic freeze-thaw and reinforced by 3D-printed polycaprolactone (PCL) implants. The mechanical properties and surface morphologies of the artificial TMJ disc and the natural goat TMJ disc were tested and compared via compression, tensile, cyclic compression/tensile, creep, friction, scanning electron microscopy, and atomic force microscopy. The fibroblasts and chondrocytes were cultured on the artificial TMJ disc for 1, 3, and 5 d for cytotoxicity testing. Importantly, the artificial discs were placed into the TMJs of goats in an innovative way to induce disc defect repair for 12 wk. The PVA + PCL artificial disc demonstrated mechanical strength similar to that of natural disc, as well as 1) better fatigue resistance, viscoelasticity, and hydrophilicity; 2) less creep; and 3) low friction, cytotoxicity, and cell adhesion. By repairing the defects of the TMJ disc in goats, the artificial disc demonstrated the ability to maintain joint stability and protect condylar cartilage and bone from damage. These promising results indicate the feasibility of using a PVA + PCL artificial TMJ disc in a clinical context.

Effect of tropical outdoor weathering on the surface roughness and mechanical properties of maxillofacial silicones

STATEMENT OF PROBLEM

The climate of tropical Southeast Asia includes high humidity and ultraviolet radiation that reduce the lifespan of silicone prostheses by inducing changes in their mechanical properties and color stability. Studies on the surface roughness (SR) and mechanical properties of different silicone elastomers (SEs) subjected to the natural tropical weather of Southeast Asia are lacking.

PURPOSE

The purpose of this in vitro study was to evaluate the SR, tensile strength (TS), and percentage elongation (% E) of different SEs subjected to outdoor weathering in the Malaysian climate.

MATERIAL AND METHODS

Type-II dumbbell-shaped specimens (N-120) (nonweathered=15, weathered=15) were made from 3 room-temperature vulcanized (A-2000, A-2006, and A-103) and 1 heat-temperature vulcanized (M-511) silicone (Factor II). For 6 months, weathered specimens were subjected to outdoor weathering inside a custom exposure rack. Simultaneously, the nonweathered specimens were kept in a dehumidifier. Subsequently, the SR was measured with a profilometer; TS and % E were measured by using a universal testing machine. Two-way ANOVA was used to compare the means of the tested properties of the nonweathered and weathered specimens, and pairwise comparison was carried out between the silicones (α=.05).

RESULTS

After outdoor weathering, the SR, TS, and % E were adversely affected by weathering in the Malaysian environment. Among the silicone materials, A-2000 showed the least TS changes (2.51 MPa), while A-2006 demonstrated significant changes in percentage elongation after outdoor weathering (266.5%). M-511 exhibited the highest mean value (2.50 μm) for SR changes. In addition, A-103 SE showed statistically significant differences in most pairwise comparisons for all 3 dependent variables.

CONCLUSIONS

Based on the evaluation of mechanical properties, A-103 can be suggested as a suitable silicone for maxillofacial prostheses fabricated for tropical climates. However, A-2000 can be a suitable alternative, although significant changes to surface roughness were detected after outdoor weathering.

3D bioprinting and craniofacial regeneration

BACKGROUND

Considering the structural and functional complexity of the craniofacial tissues, 3D bioprinting can be a valuable tool to design and create functional 3D tissues or organs in situ for in vivo applications. This review aims to explore the various aspects of this emerging 3D bioprinting technology and its application in the craniofacial bone or cartilage regeneration.

METHOD

Electronic database searches were undertaken on pubmed, google scholar, medline, embase, and science direct for english language literature, published for 3D bioprinting in craniofacial regeneration. The search items used were 'craniofacial regeneration' OR 'jaw regeneration' OR 'maxillofacial regeneration' AND '3D bioprinting' OR 'three dimensional bioprinting' OR 'Additive manufacturing' OR 'rapid prototyping' OR 'patient specific bioprinting'. Reviews and duplicates were excluded.

RESULTS

Search with above described criteria yielded 476 articles, which reduced to 108 after excluding reviews. Further screening of individual articles led to 77 articles to which 9 additional articles were included from references, and 18 duplicate articles were excluded. Finally we were left with 68 articles to be included in the review.

CONCLUSION

Craniofacial tissue and organ regeneration has been reported a success using bioink with different biomaterial and incorporated stem cells in 3D bioprinters. Though several attempts have been made to fabricate craniofacial bone and cartilage, the strive to achieve desired outcome still continues.

Engineering Anisotropic Meniscus: Zonal Functionality and Spatiotemporal Drug Delivery

Human meniscus is a fibrocartilaginous structure that is crucial for an adequate performance of the human knee joint. Degeneration of the meniscus is often followed by partial or total meniscectomy, which enhances the risk of developing knee osteoarthritis. The lack of a satisfactory treatment for this condition has triggered a major interest in drug delivery (DD) and tissue engineering (TE) strategies intended to restore a bioactive and fully functional meniscal tissue. The aim of this review is to critically discuss the most relevant studies on spatiotemporal DD and TE, aiming for a multizonal meniscal reconstruction. Indeed, the development of meniscal tissue implants should involve a provision for adequate active molecules and scaffold features that take into account the anisotropic ultrastructure of human meniscus. This zonal differentiation is reflected in the meniscus biochemical composition, collagen fiber arrangement, and cell distribution. In this sense, it is expected that a proper combination of advanced DD and zonal TE strategies will play a key role in the future trends in meniscus regeneration. Impact statement Meniscus degeneration is one of the main causes of knee pain, inflammation, and reduced mobility. Currently used suturing procedures and meniscectomy are far from being ideal solutions to the loss of meniscal function. Therefore, drug delivery (DD) and tissue engineering (TE) strategies are currently under investigation. DD systems aim at an in situ controlled release of growth factors, whereas TE strategies aim at mimicking the anisotropy of native meniscus. The goal of this review is to discuss these two main approaches, as well as synergies between them that are expected to lead to a real breakthrough in the field.

Engineering self-assembled neomenisci through combination of matrix augmentation and directional remodeling

Knee meniscus injury is frequent, resulting in over 1 million surgeries annually in the United States and Europe. Because of the near-avascularity of this fibrocartilaginous tissue and its intrinsic lack of healing, tissue engineering has been proposed as a solution for meniscus repair and replacement. This study describes an approach employing bioactive stimuli to enhance both extracellular matrix content and organization of neomenisci toward augmenting their mechanical properties. Self-assembled fibrocartilages were treated with TGF-β1, chondroitinase ABC, and lysyl oxidase-like 2 (collectively termed TCL) in addition to lysophosphatidic acid (LPA). TCL + LPA treatment synergistically improved circumferential tensile stiffness and strength, significantly enhanced collagen and pyridinoline crosslink content per dry weight, and achieved tensile anisotropy (circumferential/radial) values of neomenisci close to 4. This study utilizes a combination of bioactive stimuli for use in tissue engineering studies, providing a promising path toward deploying these neomenisci as functional repair and replacement tissues. STATEMENT OF SIGNIFICANCE: This study utilizes a scaffold-free approach, which strays from the tissue engineering paradigm of using scaffolds with cells and bioactive factors to engineer neotissue. While self-assembled neomenisci have attained compressive properties akin to native tissue, tensile properties still require improvement before being able to deploy engineered neomenisci as functional tissue repair or replacement options. In order to augment tensile properties, this study utilized bioactive factors known to augment matrix content in combination with a soluble factor that enhances matrix organization and anisotropy via cell traction forces. Using a bioactive factor to enhance matrix organization mitigates the need for bioreactors used to apply mechanical stimuli or scaffolds to induce proper fiber alignment.

Multi-Material Implants for Temporomandibular Joint Disc Repair: Tailored Additive Manufacturing Production

Temporomandibular disorders (TMD) affect a substantial percentage of the population, and the resources spent on their treatment are considerable. Despite the worldwide efforts around Tissue Engineering of the temporomandibular joint (TMJ) disc, a proper implant offering a long-term solution for TMD was not yet developed. To contribute to these efforts, this work is focused on the research and development of implants for TMJ disc regeneration. Scaffolds and hydrogels mimicking the TMJ disc of black Merino sheep were produced using different materials, poly(ε-caprolactone) (PCL) and poly(ethylene glycol) diacrylate (PEGDA), and as a multi-material structure. Different parameters of the scaffold manufacturing were assessed: the influence of processing temperatures, filament diameter, and biological environment. Moreover, two multi-material approaches were also assessed, scaffold with a hydrogel shell and scaffold with a hydrogel core. It was found that increasing temperature, the scaffolds' porosity decreases, increasing their compressive modulus. Decreasing the filament size (300 to 200 μm) decreases the compressive modulus to almost half of the initial value. Scaffolds with 200 μm filaments are the ones with a closer modulus to the native disc and their properties are maintained under hydrated conditions. The introduction of a hydrogel core in these scaffolds presented better mechanical properties to TMJ disc substitution.

Effects of dynamic radial tensile stress on fibrocartilage differentiation of bone marrow mesenchymal stem cells

BACKGROUND

Uniaxial/biaxial tensile stress has been employed to induce chondrocyte differentiation of mesenchymal stem cells. However, the effects of radial tensile stimuli on differentiation of MSCs into fibrocartilage remain unclear.

RESULTS

It was found that induced bone marrow mesenchymal stem cells (BMSCs) were not only similar to TMJ disc cells in morphology, but also could synthesize type I collagen (Col I), a small amount of type II collagen (Col II) and glycosaminoglycans (GAGs). The synthesis of Col I significantly increased while that of Col II gradually decreased with increasing tensile strength. The ratio of Col I to Col II was 1.8 to 1 and 2 to 1 in the 10% and 15% stretching groups, respectively. The gene expression of Col I and GAGs was significantly upregulated, whereas that of Col II was downregulated. However, the higher tensile stimulation (15%) promoted the synthesis of α-smooth muscle actin (α-SMA). Too much α-SMA is not conducive to constructing engineered tissue.

CONCLUSION

Therefore, the 10% radial tensile stimulus was the optimal strength for inducing the BMSCs to differentiate into fibrochondrocytes of the temporomandibular joint (TMJ) disc. This work provided a novel approach for inducing BMSCs to differentiate into fibrochondrocytes.

Tooth Regeneration: Insights from Tooth Development and Spatial-Temporal Control of Bioactive Drug Release

Tooth defect and tooth loss are common clinical diseases in stomatology. Compared with the traditional oral restoration treatment, tooth regeneration has unique advantages and is currently the focus of oral biomedical research. It is known that dozens of cytokines/growth factors and other bioactive factors are expressed in a spatial-temporal pattern during tooth development. On the other hand, the technology for spatial-temporal control of drug release has been intensively studied and well developed recently, making control release of these bioactive factors mimicking spatial-temporal pattern more feasible than ever for the purpose of tooth regeneration. This article reviews the research progress on the tooth development and discusses the future of tooth regeneration in the context of spatial-temporal release of developmental factors.

Clinical assessment of acellular dermal matrix (AlloDerm©) as an option in the replacement of the temporomandibular joint disc: A pilot study

BACKGROUND

There is limited data available in the literature describing the utility of acellular dermal matrix (AlloDerm©) in the replacement of the temporomandibular joint disc. Few reports of clinicians using implantable AlloDerm to replace the disc do exist, however, this has been described for reconstruction after surgical resection of the entire temporomandibular joint complex to treat pathology, as opposed to isolated articular disc disorders. Moreover, there is a lack of description in the literature regarding associated perioperative outcomes after such a procedure. We sought to assess the immediate perioperative outcomes in the form of a pilot study, to determine whether this technique warrants further investigation in the form of prospective clinical studies.

METHODS

The study team conducted a retrospective review of medical records for patients who underwent temporomandibular joint discectomy and replacement with AlloDerm© at a single tertiary care center, from 2011 to 2016. Perioperative outcomes of interest including pain levels and range of motion were recorded and descriptive statistics were utilized for statistical analysis.

RESULTS

15 patients met the inclusion criteria, of which 87% were females and 13% males. The mean age was 47.27±15.93 years. Preoperatively, 74% of the patients reported severe pain (VAS scores of 7-10); in contrast, 73% of the patients reported only mild pain (VAS scores of 1-3) during the postoperative visits, suggesting an overall reduction in pain intensity. Range of motion also improved from an average of 27.73±13.04mm, to an average of 38.60±6.08mm (P<0.01).

CONCLUSIONS

Based on our preliminary data, patients with advanced TMJ articular disc disorders showed clinical improvement from discectomy and replacement with acellular dermal matrix (AlloDerm©). Further longitudinal studies evaluating long-term outcomes need to be conducted to validate this technique, in the form of larger sample sizes with a control group, as well as radiographic assessment of long-term clinical outcomes.

In situ tissue engineering of the tendon-to-bone interface by endogenous stem/progenitor cells

The long-term success of surgical repair of rotator cuff tears is largely dependent on restoration of a functional tendon-to-bone interface. We implemented micro-precise spatiotemporal delivery of growth factors in three-dimensional printed scaffolds for integrative regeneration of a fibrocartilaginous tendon-to-bone interface. Sustained and spatially controlled release of tenogenic, chondrogenic and osteogenic growth factors was achieved using microsphere-based delivery carriers embedded in thin membrane-like scaffolds. In vitro, the scaffolds embedded with spatiotemporal delivery of growth factors successfully guided regional differentiation of mesenchymal progenitor cells, forming multiphase tissues with tendon-like, cartilage-like and bone-like regions. In vivo, when implanted at the interface between the supraspinatus tendon and the humeral head in a rat rotator cuff repair model, these scaffolds promoted recruitment of endogenous tendon progenitor cells followed by integrative healing of tendon and bone via re-formation of strong fibrocartilaginous interfaces. Our findings demonstrate the potential of in situ tissue engineering of tendon-to-bone interfaces by endogenous progenitor cells. The in situ tissue engineering approach shows translational potential for improving outcomes after rotator cuff repair.

Tissue engineering toward temporomandibular joint disc regeneration

Treatments for temporomandibular joint (TMJ) disc thinning and perforation, conditions prevalent in TMJ pathologies, are palliative but not reparative. To address this, scaffold-free tissue-engineered implants were created using allogeneic, passaged costal chondrocytes. A combination of compressive and bioactive stimulation regimens produced implants with mechanical properties akin to those of the native disc. Efficacy in repairing disc thinning was examined in minipigs. Compared to empty controls, treatment with tissue-engineered implants restored disc integrity by inducing 4.4 times more complete defect closure, formed 3.4-fold stiffer repair tissue, and promoted 3.2-fold stiffer intralaminar fusion. The osteoarthritis score (indicative of degenerative changes) of the untreated group was 3.0-fold of the implant-treated group. This tissue engineering strategy paves the way for developing tissue-engineered implants as clinical treatments for TMJ disc thinning.

Allogenic tooth transplantation using 3D printing: A case report and review of the literature

BACKGROUND

The history of allogenic tooth transplantation can be traced back to the 16^th century. Although there have been many successful cases, much needs to be better understood and researched prior to the technique being translated to everyday clinical practice.

CASE SUMMARY

In the present report, we describe a case of allogenic tooth transplantation between a mother and her daughter. The first left maxillary molar of the mother was diagnosed with residual root resorption and needed to be extracted. The 3^rd molar of the daughter was used as a donor tooth. Prior to transplantation, a 3D printing system was introduced to fabricate an individualized reamer drill specifically designed utilizing the donor’s tooth as a template. The specific design of our 3D printed bur allowed for the recipient site to better match the donor tooth. With the ability to 3D print in layers, even the protuberance of the root can be matched and 3D printed, thereby minimizing unnecessary bone loss.

CONCLUSION

Our study is a pioneering case combining 3D printing with allogenic tooth transplantation, which could be able to minimize unnecessary bone loss and improve the implant stability. This article aims to enhance our understanding of allogenic tooth transplantation and 3D printing, and may potentially lead to tooth transplantation being utilized more frequently - especially since transplantations are so commonly utilized in many other fields of medicine with high success rates.

The Applications of 3D Printing for Craniofacial Tissue Engineering

Three-dimensional (3D) printing is an emerging technology in the field of dentistry. It uses a layer-by-layer manufacturing technique to create scaffolds that can be used for dental tissue engineering applications. While several 3D printing methodologies exist, such as selective laser sintering or fused deposition modeling, this paper will review the applications of 3D printing for craniofacial tissue engineering; in particular for the periodontal complex, dental pulp, alveolar bone, and cartilage. For the periodontal complex, a 3D printed scaffold was attempted to treat a periodontal defect; for dental pulp, hydrogels were created that can support an odontoblastic cell line; for bone and cartilage, a polycaprolactone scaffold with microspheres induced the formation of multiphase fibrocartilaginous tissues. While the current research highlights the development and potential of 3D printing, more research is required to fully understand this technology and for its incorporation into the dental field.

Three-dimensional printing with biomaterials in craniofacial and dental tissue engineering

With the development of technology, tissue engineering (TE) has been widely applied in the medical field. In recent years, due to its accuracy and the demands of solid freeform fabrication in TE, three-dimensional printing, also known as additive manufacturing (AM), has been applied for biological scaffold fabrication in craniofacial and dental regeneration. In this review, we have compared several types of AM techniques and summarized their advantages and limitations. The range of printable materials used in craniofacial and dental tissue includes all the biomaterials. Thus, basic and clinical studies were discussed in this review to present the application of AM techniques in craniofacial and dental tissue and their advances during these years, which might provide information for further AM studies in craniofacial and dental TE.

Remaining Hurdles for Tissue-Engineering the Temporomandibular Joint Disc

The temporomandibular joint (TMJ) disc, a fibrocartilaginous structure between the mandible and temporal bone, is implicated in temporomandibular disorders (TMDs). TMDs symptomatically affect approximately 25% of the population, of which 70% have internal derangement of the disc. Treatments lack efficiency, motivating novel therapies, including tissue-engineering toward TMJ disc regeneration. Recent developments in scaffold-based or scaffold-free approaches, cell sources, and biochemical and mechanical stimulation have resulted in constructs exhibiting native tissue mechanics. Safety and efficacy of tissue-engineered implants have shown promising results in orthotopic animal studies. However, many hurdles need to be overcome in tissue-engineering approaches, and clinical and regulatory pathways. Future studies present an opportunity for clinicians and researchers to work together toward safe and effective clinical trials.

Progress in three-dimensional printing with growth factors

Incorporation of growth factors in biomedical constructs can encourage cellular activities necessary for tissue regeneration within an implant system. Three-dimensional printing offers a capacity for spatial dictation and dosage control of incorporated growth factors which promises to minimize complications from the supraphysiologic doses and burst release involved in current growth factor delivery systems. Successful implementation of three-dimensional printing with growth factors requires preservation of the bioactivity of printed growth factors, spatial localization of growth factors within the construct architecture during printing, and controlled release of growth factors after printing. This review describes demonstrated approaches for addressing each of these goals, including direct inclusion of growth factors with the biomaterial during printing, or intermediary encapsulation of growth factors in delivery vehicles such as microparticles or nanoparticles.

Tissue Engineering for the Temporomandibular Joint

Tissue engineering potentially offers new treatments for disorders of the temporomandibular joint which frequently afflict patients. Damage or disease in this area adversely affects masticatory function and speaking, reducing patients' quality of life. Effective treatment options for patients suffering from severe temporomandibular joint disorders are in high demand because surgical options are restricted to removal of damaged tissue or complete replacement of the joint with prosthetics. Tissue engineering approaches for the temporomandibular joint are a promising alternative to the limited clinical treatment options. However, tissue engineering is still a developing field and only in its formative years for the temporomandibular joint. This review outlines the anatomical and physiological characteristics of the temporomandibular joint, clinical management of temporomandibular joint disorder, and current perspectives in the tissue engineering approach for the temporomandibular joint disorder. The tissue engineering perspectives have been categorized according to the primary structures of the temporomandibular joint: the disc, the mandibular condyle, and the glenoid fossa. In each section, contemporary approaches in cellularization, growth factor selection, and scaffold fabrication strategies are reviewed in detail along with their achievements and challenges.

Considerations for translation of tissue engineered fibrocartilage from bench to bedside

Fibrocartilage is found in the knee meniscus, the temporomandibular joint (TMJ) disc, the pubic symphysis, the annulus fibrosus of intervertebral disc, tendons, and ligaments. These tissues are notoriously difficult to repair due to their avascularity, and limited clinical repair and replacement options exist. Tissue engineering has been proposed as a route to repair and replace fibrocartilages. Using the knee meniscus and TMJ disc as examples, this review describes how fibrocartilages can be engineered toward translation to clinical use. Presented are fibrocartilage anatomy, function, epidemiology, pathology, and current clinical treatments because they inform design criteria for tissue engineered fibrocartilages. Methods for how native tissues are characterized histomorphologically, biochemically, and mechanically to set gold standards are described. Then, provided is a review of fibrocartilage-specific tissue engineering strategies, including the selection of cell sources, scaffold or scaffold-free methods, and biochemical and mechanical stimuli. In closing, the Food and Drug Administration paradigm is discussed to inform researchers of both the guidance that exists and the questions that remain to be answered with regard to bringing a tissue engineered fibrocartilage product to the clinic.

Spatiotemporal Control of Growth Factors in Three-Dimensional Printed Scaffolds

Three-dimensional printing (3DP) has enabled the fabrication of tissue engineering scaffolds that recapitulate the physical, architectural, and biochemical cues of native tissue matrix more effectively than ever before. One key component of biomimetic scaffold fabrication is the patterning of growth factors, whose spatial distribution and temporal release profile should ideally match that seen in native tissue development. Tissue engineers have made significant progress in improving the degree of spatiotemporal control over which growth factors are presented within 3DP scaffolds. However, significant limitations remain in terms in pattern resolution, the fabrication of true gradients, temporal control of growth factor release, the maintenance of growth factor distributions against diffusion, and more. This review summarizes several key areas for advancement of the field in terms of improving spatiotemporal control over growth factor presentation, and additionally highlights several major tissues of interest that have been targeted by 3DP growth factor patterning strategies.

Tissue Engineered Constructs for Periodontal Regeneration: Current Status and Future Perspectives

The periodontium, consisting of gingiva, periodontal ligament, cementum, and alveolar bone, is a hierarchically organized tissue whose primary role is to provide physical and mechanical support to the teeth. Severe cases of periodontitis, an inflammatory condition initiated by an oral bacterial biofilm, can lead to significant destruction of soft and hard tissues of the periodontium and result in compromised dental function and aesthetics. Although current treatment approaches can limit the progression of the disease by controlling the inflammatory aspect, complete periodontal regeneration cannot be predictably achieved. Various tissue engineering approaches are investigated for their ability to control the critical temporo-spatial wound healing events that are essential for achieving periodontal regeneration. This paper reviews recent progress in the field of periodontal tissue engineering with an emphasis on advanced 3D multiphasic tissue engineering constructs (TECs) and provides a critical analysis of their regenerative potential and limitations. The review also elaborates on the future of periodontal tissue engineering, including scaffold customization for individual periodontal defects, TEC's functionalization strategies for imparting enhanced bioactivity, periodontal ligament fiber guidance, and the utilization of chair-side regenerative solutions that can facilitate clinical translation.

Nanoscale and Macroscale Scaffolds with Controlled-Release Polymeric Systems for Dental Craniomaxillofacial Tissue Engineering

Tremendous progress in stem cell biology has resulted in a major current focus on effective modalities to promote directed cellular behavior for clinical therapy. The fundamental principles of tissue engineering are aimed at providing soluble and insoluble biological cues to promote these directed biological responses. Better understanding of extracellular matrix functions is ensuring optimal adhesive substrates to promote cell mobility and a suitable physical niche to direct stem cell responses. Further, appreciation of the roles of matrix constituents as morphogen cues, termed matrikines or matricryptins, are also now being directly exploited in biomaterial design. These insoluble topological cues can be presented at both micro- and nanoscales with specific fabrication techniques. Progress in development and molecular biology has described key roles for a range of biological molecules, such as proteins, lipids, and nucleic acids, to serve as morphogens promoting directed behavior in stem cells. Controlled-release systems involving encapsulation of bioactive agents within polymeric carriers are enabling utilization of soluble cues. Using our efforts at dental craniofacial tissue engineering, this narrative review focuses on outlining specific biomaterial fabrication techniques, such as electrospinning, gas foaming, and 3D printing used in combination with polymeric nano- or microspheres. These avenues are providing unprecedented therapeutic opportunities for precision bioengineering for regenerative applications.

Effect of Measurement Technique on TMJ Mandibular Condyle and Articular Disc Morphometry: CBCT, MRI, and Physical Measurements

PURPOSE

Accurate description of the temporomandibular size and shape (morphometry) is critical for clinical diagnosis and surgical planning and the design and development of regenerative scaffolds and prosthetic devices and to model the temporomandibular loading environment. The study objective was to determine the 3-dimensional morphometry of the temporomandibular joint (TMJ) condyle and articular disc using cone-beam computed tomography (CBCT), magnetic resonance imaging (MRI), and physical measurements of the same joints using a repeated measures design and to determine the effect of the measurement technique on temporomandibular size and shape.

MATERIALS AND METHODS

Human cadaveric heads underwent a multistep protocol to acquire physiologically meaningful measurements of the condyle and disc. The heads first underwent CBCT scanning, and solid models were automatically generated. The superficial soft tissues were dissected, and intact TMJs were excised and underwent MRI scanning, with solid models generated after manual segmentation. After MRI, the intact joints were dissected, and physical measurements of the condyle and articular disc were performed. The CBCT-based model measurements, MRI-based model measurements, and physical measurements were standardized, and a repeated measures study design was used to determine the effect of the measurement technique on the morphometric parameters.

RESULTS

Multivariate general linear mixed effects models showed significant effects for measurement technique for condylar morphometric outcomes (P < .001) and articular disc morphometric outcomes (P < .001). The physical measurements after dissection were larger than either the CBCT-based or MRI-based measurements. Differences in imaging-based morphometric parameters followed a complex relationship between imaging modality resolution and contrast between tissue types.

CONCLUSIONS

Physical measurements after dissection are still considered the reference standard. However, owing to their inaccessibility in vivo, understanding how the imaging technique affects the temporomandibular size and shape is critical toward the development of high-fidelity solid models to be used in the design and development of regenerative scaffolds, surgical planning, prosthetic devices, and anatomic investigations.

Fibro/chondrogenic differentiation of dental stem cells into chitosan/alginate scaffolds towards temporomandibular joint disc regeneration

Tissue engineering (TE) may provide effective alternative treatment for challenging temporomandibular joint (TMJ) pathologies associated with disc malpositioning or degeneration and leading to severe masticatory dysfunction. Aim of this study was to evaluate the potential of chitosan/alginate (Ch/Alg) scaffolds to promote fibro/chondrogenic differentiation of dental pulp stem cells (DPSCs) and production of fibrocartilage tissue, serving as a replacement of the natural TMJ disc. Ch/Alg scaffolds were fabricated by crosslinking with CaCl2 combined or not with glutaraldehyde, resulting in two scaffold types that were physicochemically characterized, seeded with DPSCs or human nucleus pulposus cells (hNPCs) used as control and evaluated for cell attachment, viability, and proliferation. The DPSCs/scaffold constructs were incubated for up to 8 weeks and assessed for extracellular matrix production by means of histology, immunofluorescence, and thermomechanical analysis. Both Ch/Alg scaffold types with a mass ratio of 1:1 presented a gel-like structure with interconnected pores. Scaffolds supported cell adhesion and long-term viability/proliferation of DPSCs and hNPCs. DPSCs cultured into Ch/Alg scaffolds demonstrated a significant increase of gene expression of fibrocartilaginous markers (COLI, COL X, SOX9, COM, ACAN) after up to 3 weeks in culture. Dynamic thermomechanical analysis revealed that scaffolds loaded with DPSCs significantly increased storage modulus and elastic response compared to cell-free scaffolds, obtaining values similar to those of native TMJ disc. Histological data and immunochemical staining for aggrecan after 4 to 8 weeks indicated that the scaffolds support abundant fibrocartilaginous tissue formation, thus providing a promising strategy for TMJ disc TE-based replacement.

Three-dimensional Printing in Maxillofacial Surgery: Hype versus Reality

Three-dimensional printing technology is getting more attention recently, especially in the craniofacial region. This is a review of literature enlightening the materials that have been used to date and the application of such technology within the scope of maxillofacial surgery.

Temporomandibular Joint Regenerative Medicine

The temporomandibular joint (TMJ) is an articulation formed between the temporal bone and the mandibular condyle which is commonly affected. These affections are often so painful during fundamental oral activities that patients have lower quality of life. Limitations of therapeutics for severe TMJ diseases have led to increased interest in regenerative strategies combining stem cells, implantable scaffolds and well-targeting bioactive molecules. To succeed in functional and structural regeneration of TMJ is very challenging. Innovative strategies and biomaterials are absolutely crucial because TMJ can be considered as one of the most difficult tissues to regenerate due to its limited healing capacity, its unique histological and structural properties and the necessity for long-term prevention of its ossified or fibrous adhesions. The ideal approach for TMJ regeneration is a unique scaffold functionalized with an osteochondral molecular gradient containing a single stem cell population able to undergo osteogenic and chondrogenic differentiation such as BMSCs, ADSCs or DPSCs. The key for this complex regeneration is the functionalization with active molecules such as IGF-1, TGF-β1 or bFGF. This regeneration can be optimized by nano/micro-assisted functionalization and by spatiotemporal drug delivery systems orchestrating the 3D formation of TMJ tissues.

Regionally variant collagen alignment correlates with viscoelastic properties of the disc of the human temporomandibular joint

OBJECTIVE

To determine the regionally variant quality of collagen alignment in human TMJ discs and its statistical correlation with viscoelastic properties.

DESIGN

For quantitative analysis of the quality of collagen alignment, horizontal sections of human TMJ discs with Pricrosirius Red staining were imaged under circularly polarized microscopy. Mean angle and angular deviation of collagen fibers in each region were analyzed using a well-established automated image-processing for angular gradient. Instantaneous and relaxation moduli of each disc region were measured under stress-relaxation test both in tensile and compression. Then Spearman correlation analysis was performed between the angular deviation and the moduli. To understand the effect of glycosaminoglycans on the correlation, TMJ disc samples were treated by chondroitinase ABC (C-ABC).

RESULTS

Our imaging processing analysis showed the region-variant direction of collagen alignment, consistently with previous findings. Interestingly, the quality of collagen alignment, not only the directions, was significantly different in between the regions. The angular deviation of fiber alignment in the anterior and intermediate regions were significantly smaller than the posterior region. Medial and lateral regions showed significantly bigger angular deviation than all the other regions. The regionally variant angular deviation values showed statistically significant correlation with the tensile instantaneous modulus and the relaxation modulus, partially dependent on C-ABC treatment.

CONCLUSION

Our findings suggest the region-variant degree of collagen fiber alignment is likely attributed to the heterogeneous viscoelastic properties of TMJ disc that may have significant implications in development of regenerative therapy for TMJ disc.