Bioinorganic supplementation of calcium phosphate-based bone substitutes to improve in vivo performance: a systematic review and meta-analysis of animal studies

Incorporating strontium enriched amorphous calcium phosphate granules in collagen/collagen-magnesium-hydroxyapatite osteochondral scaffolds improves subchondral bone repair

Osteochondral defect repair with a collagen/collagen-magnesium-hydroxyapatite (Col/Col-Mg-HAp) scaffold has demonstrated good clinical results. However, subchondral bone repair remained suboptimal, potentially leading to damage to the regenerated overlying neocartilage. This study aimed to improve the bone repair potential of this scaffold by incorporating newly developed strontium (Sr) ion enriched amorphous calcium phosphate (Sr-ACP) granules (100-150 μm). Sr concentration of Sr-ACP was determined with ICP-MS at 2.49 ± 0.04 wt%. Then 30 wt% ACP or Sr-ACP granules were integrated into the scaffold prototypes. The ACP or Sr-ACP granules were well embedded and distributed in the collagen matrix demonstrated by micro-CT and scanning electron microscopy/energy dispersive x-ray spectrometry. Good cytocompatibility of ACP/Sr-ACP granules and ACP/Sr-ACP enriched scaffolds was confirmed with in vitro cytotoxicity assays. An overall promising early tissue response and good biocompatibility of ACP and Sr-ACP enriched scaffolds were demonstrated in a subcutaneous mouse model. In a goat osteochondral defect model, significantly more bone was observed at 6 months with the treatment of Sr-ACP enriched scaffolds compared to scaffold-only, in particular in the weight-bearing femoral condyle subchondral bone defect. Overall, the incorporation of osteogenic Sr-ACP granules in Col/Col-Mg-HAp scaffolds showed to be a feasible and promising strategy to improve subchondral bone repair.

An increase in Wharton's jelly membrane osteocompatibility by a genipin-cross-link

Wharton's Jelly (WJ) has attracted significant interest in the field of tissue healing thanks to its biological properties, including antibacterial activity and immunomodulation. However, due to the fast degradation and poor mechanical behavior in biological environment, its application in bone regeneration is compromised. Here, we proposed to use genipin as an efficient cross-linking agent to significantly improve the elasticity and the enzymatical stability of the WJ matrix. The degree of cross-linking, linear elastic moduli, and collagenase resistance varied over a wide range depending on genipin concentration. Furthermore, our results highlighted that an increase in genipin concentration led to a decreased surface wettability, therefore impairing cell attachment and proliferation. The genipin cross-linking prevented rapid in vitro and in vivo degradation, but led to an adverse host reaction and calcification. When implanted in the parietal bone defect, a limited parietal bone regeneration to the dura was observed. We conclude that genipin-cross-linked WJ is a versatile medical device however, a careful selection is required with regards to the genipin concentration.

β-tricalcium phosphate synthesized in organic medium for controlled release drug delivery application in bio-scaffolds

β-tricalcium phosphate (β-TCP) was synthesized in an organic medium (acetone) to obtain a single-phase product while calcium carbonate (CaCO3) and ortho-phosphoric acid (H3PO4) were the sources of Ca, and P, respectively. The synthesized β-TCP was characterized by employing a number of sophisticated techniques vis. XRD, FTIR, FESEM, VSM and UV-Vis-NIR spectrometry. On the other hand, cytotoxicity, hemolysis, and antimicrobial activity for Gram-negative as well as Gram-positive (E. coli and S. aureus) bacteria were explored using this synthesized sample in powder format. However, to assess the drug loading and releasing profile, these powdered samples were first compressed into disks followed by sintering at 900 °C. Prior to loading the drug, porosity, density, and water absorbance characteristics of the scaffolds were examined in deionized water. Both loading and releasing profiles of the antibiotic (ciprofloxacin) were looked over at various selected time intervals which were continued up to 28 days. The observed results revealed that 2.87% of ciprofloxacin was loaded while 37% of this loaded drug was released within the selected time frame as set in this study. The scaffold was also immersed in SBF solution maintaining identical interim periods for the bioactivity evaluation. Furthermore, all three types of samples (e.g. drug-loaded, drug-released, and SBF-soaked) were characterized by FESEM and EDX while antimicrobial activity (against E. coli, S. typhi, and S. aureus) and efficacy to prevent hemolysis were also investigated. The drug-loaded scaffold presented a larger inhibition zone than the standard for all three types of microbes. Although powdered β-TCP was inactive in killing the Gram-negative bacteria, surprisingly the drug-released scaffold showed an inhibition zone.

Biominerals Added Bioresorbable Calcium Phosphate Loaded Biopolymer Composites

Nanocrystalline calcium phosphate (CP) bioceramic coatings and their combination with biopolymers are innovative types of resorbable coatings for load-bearing implants that can promote the integration of metallic implants into human bodies. The nanocrystalline, amorphous CP particles are an advantageous form of the various calcium phosphate phases since they have a faster dissolution rate than that of crystalline hydroxyapatite. Owing to the biomineral additions (Mg, Zn, Sr) in optimized concentrations, the base CP particles became more similar to the mineral phase in human bones (dCP). The effect of biomineral addition into the CaP phases was thoroughly studied. The results showed that the shape, morphology, and amorphous characteristic slightly changed in the case of biomineral addition in low concentrations. The optimized dCP particles were then incorporated into a chosen polycaprolactone (PCL) biopolymer matrix. Very thin, non-continuous, rough layers were formed on the surface of implant substrates via the spin coating method. The SEM elemental mapping proved the perfect incorporation and distribution of dCP particles into the polymer matrix. The bioresorption rate of thin films was followed by corrosion measurements over a long period of time. The corrosion results indicated a faster dissolution rate for the dCP-PCL composite compared to the dCP and CP powder layers.

Lithium ion doped carbonated hydroxyapatite compositions: Synthesis, physicochemical characterisation and effect on osteogenic response in vitro

Hydroxyapatite is a commonly researched biomaterial for bone regeneration applications. To augment performance, hydroxyapatite can be substituted with functional ions to promote repair. Here, co-substituted lithium ion (Li⁺) and carbonate ion hydroxyapatite compositions were synthesised by an aqueous precipitation method. The co-substitution of Li⁺ and CO₃^2- is a novel approach that accounts for charge balance, which has been ignored in the synthesis of Li doped calcium phosphates to date. Three compositions were synthesised: Li⁺-free (Li 0), low Li⁺ (Li 0.25), and high Li⁺ (Li 1). Synthesised samples were sintered as microporous discs (70-75 % theoretical sintered density) prior to being ground and fractionated to produce granules and powders, which were then characterised and evaluated in vitro. Physical and chemical characterisation demonstrated that lithium incorporation in Li 0.25 and Li 1 samples approached design levels (0.25 and 1 mol%), containing 0.253 and 0.881 mol% Li⁺ ions, respectively. The maximum CO₃^2- ion content was observed in the Li 1 sample, with ~8 wt% CO₃, with the carbonate ions located on both phosphate and hydroxyl sites in the crystal structure. Measurement of dissolution products following incubation experiments indicated a Li⁺ burst release profile in DMEM, with incubation of 30 mg/ml sample resulting in a Li⁺ ion concentration of approximately 140 mM after 24 h. For all compositions evaluated, sintered discs allowed for favourable attachment and proliferation of C2C12 cells, human osteoblast (hOB) cells, and human mesenchymal stem cells (hMSCs). An increase in alkaline phosphatase (ALP) activity with Li⁺ doping was demonstrated in C2C12 cells and hMSCs seeded onto sintered discs, whilst the inverse was observed in hOB cells. Furthermore, an increase in ALP activity was observed in C2C12 cells and hMSCs in response to dissolution products from Li 1 samples which related to Li⁺ release. Complementary experiments to further investigate the findings from hOB cells confirmed an osteogenic role of the surface topography of the discs. This research has shown successful synthesis of Li⁺ doped carbonated hydroxyapatite which demonstrated cytocompatibility and enhanced osteogenesis in vitro, compared to Li⁺-free controls.

Enhanced ectopic bone formation by strontium-substituted calcium phosphate ceramics through regulation of osteoclastogenesis and osteoblastogenesis

To explore how strontium influences osteoclastogenesis and osteoblastogenesis during material-induced ectopic bone formation, porous strontium-substituted biphasic calcium phosphate (Sr-BCP) and BCP ceramics with equivalent pore structures and comparable grain size and porosity were prepared. In vitro results showed that compared with BCP, Sr-BCP inhibited the osteoclastic differentiation of osteoclast precursors by delaying cell fusion, down-regulating the expression of osteoclast marker genes, and reducing the activity of osteoclast specific proteins, possibly due to the activated ERK signaling pathway but the suppressed p38, JNK and AKT signaling pathways. Meanwhile, Sr-BCP promoted the osteogenic differentiation of mesenchymal stem cells (MSCs) by up-regulating the osteogenic gene expression. Sr-BCP also mediated the expression of important osteoblast-osteoclast coupling factors, as evidenced by the increased Opg/Rankl ratio in mMSCs, and the reduced Rank expression and enhanced EphrinB2 expression in osteoclast precursors. Similar results were observed in an in vivo study based on a murine intramuscular implantation model. The sign of ectopic bone formation was only seen in Sr-BCP at 8 weeks. Compared to BCP, Sr-BCP obviously hindered the formation of TRAP- and CTSK-positive multinucleated osteoclast-like cells during the early implantation time up to 6 weeks, which is consistent with the in vivo PCR results. This suggested that Sr-BCP could clearly accelerate the ectopic bone formation by promoting osteogenesis but suppressing osteoclastogenesis, which might be closely related to the expression of osteoblast-osteoclast coupling factors regulated by Sr²⁺. These findings may help in the design and fabrication of smart bone substitutes with the desired potential for bone regeneration through modulating both osteoclastic resorption and osteoblastic synthesis.

Does the incorporation of strontium into calcium phosphate improve bone repair? A meta-analysis

Background

The application of calcium phosphate (CaP)-based bone substitutes plays an important role in periodontal regeneration, implant dentistry and alveolar bone reconstruction. The incorporation of strontium (Sr) into CaP-based bone substitutes appears to improve their biological properties, but the reported in vivo bone repair performance is inconsistent among studies. Herein, we conducted a systematic review and meta-analysis to investigate the in vivo performance of Sr-doped materials.

Methods

We searched PubMed, EMBASE (via OVIDSP), and reference lists to identify relevant animal studies. The search, study selection, and data extraction were performed independently by two investigators. Meta-analyses and sub-group analyses were conducted using Revman version 5.4.1. The heterogeneity between studies were assessed by I². Publication bias was investigated through a funnel plot.

Results

Thirty-five studies were finally enrolled, of which 16 articles that reported on new bone formation (NBF) were included in the meta-analysis, covering 31 comparisons and 445 defects. The overall effect for NBF was 2.25 (95% CI 1.61–2.90, p < 0.00001, I² = 80%). Eight comparisons from 6 studies reported the outcomes of bone volume/tissue volume (BV/TV), with an overall effect of 1.42 (95% CI 0.65–2.18, p = 0.0003, I² = 75%). Fourteen comparisons reported on the material remaining (RM), with the overall effect being -2.26 (95% CI − 4.02 to − 0.50, p = 0.0009, I² = 86%).

Conclusions

Our study revealed that Sr-doped calcium phosphate bone substitutes improved in vivo performance of bone repair. However, more studies are also recommended to further verify this conclusion.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02092-7.

Synthetic Material for Bone, Periodontal, and Dental Tissue Regeneration: Where Are We Now, and Where Are We Heading Next?

Alloplasts are synthetic, inorganic, biocompatible bone substitutes that function as defect fillers to repair skeletal defects. The acceptance of these substitutes by host tissues is determined by the pore diameter and the porosity and inter-connectivity. This narrative review appraises recent developments, characterization, and biological performance of different synthetic materials for bone, periodontal, and dental tissue regeneration. They include calcium phosphate cements and their variants β-tricalcium phosphate (β-TCP) ceramics and biphasic calcium phosphates (hydroxyapatite (HA) and β-TCP ceramics), calcium sulfate, bioactive glasses and polymer-based bone substitutes which include variants of polycaprolactone. In summary, the search for synthetic bone substitutes remains elusive with calcium compounds providing the best synthetic substitute. The combination of calcium sulphate and β-TCP provides improved handling of the materials, dispensing with the need for a traditional membrane in guided bone regeneration. Evidence is supportive of improved angiogenesis at the recipient sites. One such product, (EthOss^® Regeneration, Silesden, UK) has won numerous awards internationally as a commercial success. Bioglasses and polymers, which have been used as medical devices, are still in the experimental stage for dental application. Polycaprolactone-TCP, one of the products in this category is currently undergoing further randomized clinical trials as a 3D socket preservation filler. These aforementioned products may have vast potential for substituting human/animal-based bone grafts.