Effectiveness of a 3D simulation tool to teach the designing of metal removable partial dentures: A mixed-method study

INTRODUCTION

Acquiring insights into the framework design of metal-based removable partial dentures (mRPD) is a current challenge in dental education. The aim of the present study was to explore the effectiveness of a novel 3D simulation tool to teach designing mRPD by investigating the learning gain and the acceptance and motivation towards the tool of dental students.

MATERIALS AND METHODS

A 3D tool based on 74 clinical scenarios was developed for teaching the design of mRPD. Fifty-three third year dental students were randomly divided into two groups, with the experimental group (n = 26) having access to the tool during 1 week while the control group (n = 27) had no access. Quantitative analysis was based on a pre- and post-test in order to evaluate the learning gain, technology acceptance and motivation towards using the tool. Moreover, qualitative data was collected by means of an interview and focus group to get additional insights into the quantitative results.

RESULTS

Although the results showed a higher learning gain for students in the experimental condition, the study did not find a significant difference between both conditions based on quantitative results. However, during the focus groups, all students of the experimental group revealed that the 3D tool improved their understanding of mRPD biomechanics. Moreover, survey results revealed that students positively evaluated the perceived usefulness and ease of use of the tool and indicated to have the intention to use the tool in the future. Suggestions were made for a redesign (e.g. creating scenarios themselves) and further implementation of the tool (e.g. analysing the scenarios in pairs or small groups).

CONCLUSION

First results of the evaluation of the new 3D tool for teaching the design framework of mRPD are promising. Further research based on the design-based research methodology is needed to investigate the effects of the redesign on motivation and learning gain.

Effectiveness of implant-supported fixed partial denture in patients with history of periodontitis: A systematic review and meta-analysis

AIM

This systematic review investigates the effectiveness of implant-supported fixed partial denture (IS-FPD) in patients with history of periodontitis (HP) vs. patients with no history of periodontitis (NHP).

METHODS

A literature search was performed on different databases on May 2020. Prospective and retrospective studies assessing survival (primary outcome), success and biological/mechanical complications of IS-FPDs in HP vs. NHP patients at ≥1 year after implant loading were evaluated. Meta-analyses were conducted by estimating hazard ratio (HR), risk ratio (RR) and standardized mean differences (SMD) with 95% confidence intervals (CI) using random effect models.

RESULTS

Of the initially identified 4096 articles, 349 underwent a full-text evaluation. Finally, 17 were included. Pooled data analyses showed that overall implant survival was significantly higher in the NHP than the HP group (HR = 2.06; 95% CI = 1.37-3.09; I²  = 0%). This difference was noted when follow-up ≥5 years. The risk of peri-implantitis was higher in HP than NHP patients (RR = 3.3; 95% CI = 1.31-8.3; I²  = 0%), whereas the mean marginal bone level change over time was not different between the groups (SMD = -0.16 mm; 95% CI = -1.04-0.73; I²  = 98%).

CONCLUSIONS

In partially edentulous patients receiving IS-FPDs, a history of periodontitis is associated with poorer survival rate and higher risk of peri-implantitis during a 5-10 years period after implant loading.

Impaired soft and hard callus formation during fracture healing in diet-induced obese mice as revealed by 3D contrast-enhanced computed tomography imaging

The impact of diabetes mellitus on bone fracture healing is clinically relevant as the patients experience delayed fracture healing. Even though efforts have been made to understand the detrimental effects of type 2 diabetes mellitus (T2DM) on the fracture healing process, the exact mechanisms causing the pathophysiological outcomes remain unclear. The aim of this study was to assess alterations in bone fracture healing (tibial fracture surgery, intramedullary pinning) of diet-induced obese (DIO) mice, and to investigate the in vitro properties of osteochondroprogenitors derived from the diabetic micro-environment. High-resolution contrast-enhanced microfocus X-ray computed tomography (CE-CT) enabled a simultaneous 3D assessment of the amount and spatial distribution of the regenerated soft and hard tissues during fracture healing and revealed that osteogenesis as well as chondrogenesis are altered in DIO mice. Compared to age-matched lean controls, DIO mice presented a decreased bone volume fraction and increased callus volume and adiposity at day 14 post-fracture. Of note, bone turnover was found altered in DIO mice relative to controls, evidenced by decreased blood serum osteocalcin and increased serum CTX levels. The in vitro data revealed that not only the osteogenic and adipogenic differentiation of periosteum-derived cells (PDCs) were altered by hyperglycemic (HG) conditions, but also the chondrogenic differentiation. Elevated PPARγ expression in HG conditions confirmed the observed increase in differentiated adipocytes in vitro. Finally, chondrogenesis-related genes COL2 and COL10 were downregulated for PDCs treated with HG medium, confirming that chondrogenic differentiation is compromised in vitro and suggesting that this may affect callus formation and maturation during the fracture healing process in vivo. Altogether, these results provide novel insights into the alterations of long bone fracture repair and suggest a link between HG-induced dysfunctionality of osteochondroprogenitor differentiation and fracture healing impairment under T2DM conditions.

Regenerative Endodontic Procedure of Immature Permanent Teeth with Leukocyte and Platelet-rich Fibrin: A Multicenter Controlled Clinical Trial

INTRODUCTION

The aim of this nonrandomized, multicenter controlled clinical trial was to evaluate the impact of leukocyte-platelet-rich fibrin (LPRF) on regenerative endodontic procedures (REPs) of immature permanent teeth in terms of periapical bone healing (PBH) and further root development (RD).

METHODS

Healthy patients between 6-25 years with an inflamed or necrotic immature permanent tooth were included and divided between the test (= REP + LPRF) and control (= REP-LPRF) group depending on their compliance and the clinical setting (university hospital or private practice). After receiving REP ± LPRF, the patients were recalled after 3, 6, 12, 24, and 36 months. At each recall session, the teeth were clinically and radiographically (by means of a periapical radiograph [PR]) evaluated. A cone-beam computed tomographic (CBCT) imaging was taken preoperatively and 2 and 3 years postoperatively. PBH and RD were quantitatively and qualitatively assessed.

RESULTS

Twenty-nine teeth with a necrotic pulp were included, from which 23 (9 test and 14 control) were analyzed. Three teeth in the test group had a flare-up reaction in the first year after REP. Except for 2 no shows, all the analyzed teeth survived up to 3 years after REP, and, in case of failure, apexification preserved them. Complete PBH was obtained in 91.3% and 87% of the cases based on PR qualitative and quantitative evaluation, respectively, with no significant difference between the groups with respect to the baseline. The PR quantitative change in RD at the last recall session with respect to the baseline was not significant (all P values > .05) in both groups. The qualitative assessment of the type of REP root healing was nonuniform. In the test group, 55.6% of the teeth presented no RD and no apical closure. Only 50% of the 14 teeth assessed with CBCT imaging presented complete PBH. Regarding volumetric measurements on RD 3 years after REP for the change with respect to the baseline in root hard tissue volume, mean root hard tissue thickness, and apical area, the control group performed significantly in favor of RD than the test group (P = .03, .003, and 0.05 respectively). For the volumetric change 3 years after REP with respect to the baseline in root length and maximum root hard tissue thickness, no significant difference (P = .72 and .4, respectively) was found between the groups. The correlation between the PR and CBCT variables assessing RD was weak (root lengthening) to very weak (root thickening).

CONCLUSIONS

REP-LPRF seems to be a viable treatment option to obtain PBH and aid further RD of necrotic immature permanent teeth. Caution is needed when evaluating REP with PR.

Oral Implant Restorations By Undergraduate Students: An Up To 5-Years Clinical Outcome

PURPOSE

To clinically evaluate oral implant restorations placed by undergraduate students in the dental clinical curriculum at KU Leuven (Belgium) in terms of function and esthetics.

MATERIALS AND METHODS

A retrospective observational cohort study was designed. The esthetic and functional evaluations of implant-supported restorations placed in the framework of the undergraduate implant dentistry clinical training program using White/Pink Esthetic Score (WES/PES) and visual analog scale (VAS) scoring was performed. Furthermore, complications were registered based retrospectively on the patient's medical file. The following research questions were stipulated: (1) How well do implant-supported restorations placed by undergraduate students perform esthetically? and (2) Which complications occurred and how were these managed?

RESULTS

Between August 2008 and July 2014 (6 academic terms), 251 implants (Brånemark System Mk III, Nobel Biocare) were placed in 113 patients by 155 students (> 40% of all students enrolled in the training program). Of these implants, 228 were restored in 101 patients by 118 students with varying restoration types. Esthetic scoring of the restorations in 83 of these patients revealed a satisfying mean WES of 8.14 ± 2.09 (out of 10) and PES of 9.56 ± 3.14 (out of 14). Complications were registered in 18.9% of the cases.

DISCUSSION

Clinical training in implant dentistry for undergraduates contributes to the development of advanced skills in the dental student's Master education. Overall, patients were satisfied with their implant-supported restorations. Implant and restoration success rates and complication incidence were confirmed by long-term data in the oral implant literature.

Implant functionalization with mesoporous silica: A promising antibacterial strategy, but does such an implant osseointegrate?

Objectives

New strategies for implant surface functionalization in the prevention of peri‐implantitis while not compromising osseointegration are currently explored. The aim of this in vivo study was to assess the osseointegration of a titanium‐silica composite implant, previously shown to enable controlled release of therapeutic concentrations of chlorhexidine, in the Göttingen mini‐pig oral model.

Material and Methods

Three implant groups were designed: macroporous titanium implants (Ti‐Porous); macroporous titanium implants infiltrated with mesoporous silica (Ti‐Porous + SiO₂); and conventional titanium implants (Ti‐control). Mandibular last premolar and first molar teeth were extracted bilaterally and implants were installed. After 1 month healing, the bone in contact with the implant and the bone regeneration in the peri‐implant gap was evaluated histomorphometrically.

Results

Bone‐to‐implant contact and peri‐implant bone volume for Ti‐Porous versus Ti‐Porous + SiO₂ implants did not differ significantly, but were significantly higher in the Ti‐Control group compared with Ti‐Porous + SiO₂ implants. Functionalization of titanium implants via infiltration of a SiO₂ phase into the titanium macropores does not seem to inhibit implant osseointegration. Yet, the importance of the implant macro‐design, in particular the screw thread design in a marginal gap implant surgery set‐up, was emphasized by the outstanding results of the Ti‐Control implant.

Conclusions

Next‐generation implants made of macroporous Ti infiltrated with mesoporous SiO₂ do not seem to compromise the osseointegration process. Such implant functionalization may be promising for the prevention and treatment of peri‐implantitis given the evidenced potential of mesoporous SiO₂ for controlled drug release.

Alteration of the Condylar Oral Bone in Obese and Gastric Bypass Mice

Obesity is the main cause of type 2 diabetes mellitus (T2DM). Roux-en-Y gastric bypass (RYGB) surgery is an effective treatment for this obesity-related health problem. However, the adverse effects of T2DM on bone tissue persist or even aggravate after this surgical procedure. As studies on the mandibular condyle bone are scarce, the aim of the present study was to assess its compositional characteristics in T2DM and RYGB conditions. Thirty-two male C57BL/6 mice at 8 weeks of age were randomly assigned to receive either a high-fat or low-fat diet. After 14 weeks of high-fat diet intake, seven obese mice were subjected to RYGB surgery. All animals were euthanized at the age of 30 weeks. Mandibular bones were removed and the trabecular condyle region was assessed using Raman spectroscopy. A decreased mineralization was observed for both T2DM and RYGB condyle bones when compared to controls, with elevated carbonate substitutions for the RYGB group. No compositional differences in crystallinity and presence of advanced glycation end products were found between the groups, with the exception of an increased presence of N-carboxymethyl-lysine in RYGB bone compared to their T2DM counterpart. Site-specific measurements revealed a non-uniform bone composition, with increasing mineralization and carbonate substitutions towards the centre of the mandibular condyle. T2DM and RYGB surgery affect the mandibular condyle bone quality, as investigated at compositional level. Assessment of bone structural properties and remodelling should be carried out to further explore the effects of T2DM and RYGB surgery on this skeleton area.

A core curriculum in the biological and biomedical sciences for dentistry

INTRODUCTION

The biomedical sciences (BMS) are a central part of the dental curriculum that underpins teaching and clinical practice in all areas of dentistry. Although some specialist groups have proposed curricula in their particular topic areas, there is currently no overarching view of what should be included in a BMS curriculum for undergraduate dental programmes. To address this, the Association for Dental Education in Europe (ADEE) convened a Special Interest Group (SIG) with representatives from across Europe to develop a consensus BMS curriculum for dental programmes.

CURRICULUM

This paper summarises the outcome of the deliberations of this SIG and details a consensus view from the SIG of what a BMS curriculum should include.

CONCLUSIONS

Given the broad nature of BMS applied to dentistry, this curriculum framework is advisory and seeks to provide programme planners with an indicative list of topics which can be mapped to specific learning objectives within their own curricula. As dentistry becomes increasingly specialised, these will change, or some elements of the undergraduate curriculum may move to the post-graduate setting. So, this document should be seen as a beginning and it will need regular review as BMS curricula in dentistry evolve.

Esthetic evaluation of single implant restorations, adjacent single implant restorations, and implant-supported fixed partial dentures: A 1-year prospective study

BACKGROUND

Peri-implant soft tissues esthetics varies and depends on the restoration type such as implant-supported single crowns, adjacent multiple single crowns, and fixed partial dentures (FPD).

PURPOSE

The aim of this prospective study was to assess the esthetic outcome of the peri-implant soft tissues of (NobelBiocare™) implant-supported single crowns, adjacent multiple single crowns, and FPD. A potential association between the esthetic risk profile and the esthetic outcome was assessed.

MATERIALS AND METHODS

Between 03/11 and 03/17, 300 NobelActive implants were installed in 153 partially edentulous patients. Prior to the fabrication of the final restoration, the esthetic risk profile (ERP) of the patient was determined. The pink esthetic score (PES) and white esthetic score (WES) were assessed by three investigators at 6 and 12 months post-insertion of the final restoration. Patients' appreciation was assessed on a visual analogue scale (VAS) at the 1-year follow-up.

RESULTS

The clinical acceptable limit for PES (≥6) was achieved in 56% to 68% of the single crowns at 6 and 12 months, respectively. Clinically unacceptable PES scores were recorded for 48% of the adjacent multiple single crowns and 63% of the FPDs at both time points. The association of a high ERP with WES and PESWES was noticed for single implant-supported crowns. For the latter restoration type, a ≤5 mm distance between the crestal bone level and the proximal contact positively influenced the PES and combined PESWES scores. No correlation was found between PES or WES and patient satisfaction. Mesial papilla formation was more pronounced compared to the distal one for the single implant crowns and for implant-supported FPD.

CONCLUSION

When high esthetic demands are expected, assessment of ERP prior to implant treatment is advised in order to estimate a realistic outcome.

Experimental tricalcium silicate cement induces reparative dentinogenesis

OBJECTIVES

To overcome shortcomings of hydraulic calcium-silicate cements (hCSCs), an experimental tricalcium silicate (TCS) cement, named 'TCS 50', was developed. In vitro research showed that TCS 50 played no negative effect on the viability and proliferation of human dental pulp cells, and it induced cell odontogenic differentiation. The objective was to evaluate the pulpal repair potential of TCS 50 applied onto exposed minipig pulps.

METHODS

Twenty permanent teeth from three minipigs were mechanically exposed and capped using TCS 50; half of the teeth were scheduled for 7-day and the other half for 70-day examination (n=10). Commercial hCSCs ProRoot MTA and TheraCal LC were tested as references (n=8). Tooth discoloration was examined visually. After animal sacrifice, the teeth were scanned using micro-computed tomography; inflammatory response at day 7 and day 70, mineralized tissue formation at day 70 were assessed histologically.

RESULTS

Up to 70 days, TCS 50 induced no discoloration, ProRoot MTA generated gray/black discoloration in all teeth. For TCS 50, 40.0% pulps exhibited a mild/moderate inflammation at day 7. No inflammation was detected and complete reparative dentin with tubular structures was formed in all pulps after 70 days. ProRoot MTA induced a similar response, TheraCal LC generated a less favorable response in terms of initial inflammation and reparative dentin formation; however, these differences were not significant (Chi-square test of independence: p>0.05).

SIGNIFICANCE

TCS 50 induced reparative dentinogenesis in minipig pulps. It can be considered as a promising pulp-capping agent, also for aesthetic areas.

Effect of high-frequency loading and parathyroid hormone administration on peri-implant bone healing and osseointegration

The objective of this study is to examine the effect of low-magnitude, high-frequency (LMHF) loading, and anti-osteoporosis medications such as parathyroid hormone (PTH) and bisphosphonates on peri-implant bone healing in an osteoporosis model, and to assess their combined effects on these processes. Thirteen-week-old ovariectomized rats (n = 44) were divided into three groups: PTH, alendronate, and saline. After 3 weeks of drug administration, titanium implants were inserted into the tibiae. Each group was subdivided into two groups: with or without LMHF loading via whole-body vibration (50 Hz at 0.5 g, 15 min per day, 5 days per week). Rats were killed 4 weeks following implantation. Removal torque test, micro-CT analyses (relative gray (RG) value, water = 0, and implant = 100), and histomorphometric analyses (bone-to-implant contact (BIC) and peri-implant bone formation (bone volume/tissue volume (BV/TV))) were performed. Removal torque values and BIC were significantly differed by loading and drug administration (ANOVA). Post hoc analysis showed that PTH-treated groups were significantly higher than the other drug-treated groups. BV/TV was significantly enhanced by PTH administration. In cortical bone, RG values were significantly increased by loading. In trabecular bone, however, RG values were significantly increased by PTH administration. These findings suggest that LMHF loading and PTH can act locally and additively on the bone healing process, improving the condition of implant osseointegration.

Whole-body vibration and administration of a hormone used to treat osteoporosis can enhance bone healing at the site of a titanium implant. Toru Ogawa of Tohoku University Graduate School of Dentistry in Sendai, Japan, and colleagues gave anti-osteoporosis medications, either parathyroid hormone or the bisphosphonate drug alendronate, to female rat models of osteoporosis. After three weeks of drug administration or a saline control, the researchers inserted titanium implants into the rats’ leg bones. Half the rats were then exposed to whole-body vibration, which applies low-magnitude, high-frequency mechanical forces. A multitude of tests showed that parathyroid hormone improved bone healing at the implant more than alendronate or saline did. The vibrational stimulus further increased the healing. The findings suggest that these treatments could aid in oral bone healing for patients receiving dental implants.

The Impact of Type 2 Diabetes on Bone Fracture Healing

Type 2 diabetes mellitus (T2DM) is a chronic metabolic disease known by the presence of elevated blood glucose levels. Nowadays, it is perceived as a worldwide epidemic, with a very high socioeconomic impact on public health. Many are the complications caused by this chronic disorder, including a negative impact on the cardiovascular system, kidneys, eyes, muscle, blood vessels, and nervous system. Recently, there has been increasing evidence suggesting that T2DM also adversely affects the skeletal system, causing detrimental bone effects such as bone quality deterioration, loss of bone strength, increased fracture risk, and impaired bone healing. Nevertheless, the precise mechanisms by which T2DM causes detrimental effects on bone tissue are still elusive and remain poorly studied. The aim of this review was to synthesize current knowledge on the different factors influencing the impairment of bone fracture healing under T2DM conditions. Here, we discuss new approaches used in recent studies to unveil the mechanisms and fill the existing gaps in the scientific understanding of the relationship between T2DM, bone tissue, and bone fracture healing.

In vitro activity of the antiasthmatic drug zafirlukast against the oral pathogens Porphyromonas gingivalis and Streptococcus mutans

Oral infections are among the most common diseases worldwide. Many protocols for the prevention and treatment of oral infections have been described, yet no golden standard has been developed so far. The antiseptic chlorhexidine and antibiotics are often used in these treatment procedures. However, long-term use of chlorhexidine can lead to side effects and extensive use of antibiotics can promote the development of antibiotic-resistant bacteria, which in turn can compromise the effectiveness of the treatment. Consequently, it remains important to search for new antibacterial agents for the treatment of oral infections. In this study, we report on the antibacterial activity of the antiasthma drug zafirlukast against oral pathogens Porphyromonas gingivalis and Streptococcus mutans. Furthermore, its activity against oral biofilms grown on titanium surfaces was confirmed. In addition, we demonstrated that zafirlukast displays no cytotoxicity against human osteoblasts. Combined, this study paves the way for further research to determine the potential of zafirlukast to be used as a new antibiotic against oral pathogens.

Repurposing AM404 for the treatment of oral infections by Porphyromonas gingivalis

Porphyromonas gingivalis is a major pathogen involved in oral diseases such as periodontitis and peri‐implantitis. Management of these diseases typically includes mechanical debridement of the colonized surfaces followed by application of antiseptics or antibiotics. Disadvantages associated with the use of antiseptics and the growing worldwide problem of antibiotic resistance have necessitated the search for alternative agents. In this study, the antibacterial and antibiofilm properties of AM404, an active metabolite of paracetamol, were tested against P. gingivalis and other bacterial pathogens. The activity of AM404 was tested against 10 bacteria, including both oral and nonoral human pathogens. The minimal inhibitory concentration (MIC) of AM404 was determined by measuring optical density (OD) values. The minimum biofilm inhibitory concentration (MBIC) was detected by crystal violet staining. The activity of structural analogs of AM404 was tested by MIC determinations. The effect of AM404 on P. gingivalis biofilms formed on titanium disks as a model for dental implants was evaluated by colony forming unit counting. Potential cytotoxicity of AM404 towards HEK‐293 (human embryonic kidney cells), HepG2 (human hepatoma cells), IEC‐6 (rat intestinal cells), and Panc‐1 cells (pancreatic cancer cells) was assessed by 3‐(4,5‐dimethylthiazol‐2‐yl)‐2,5‐diphenyltetrazolium bromide assays. To get more insight in the mode of action of AM404, we used the fluorescent dyes N‐phenyl‐1‐napthylamine and SYTOX green to investigate outer and inner membrane damage of P. gingivalis induced by AM404, respectively. Of all tested pathogens, AM404 only inhibited growth and biofilm formation of P. gingivalis. Moreover, it showed potent activity against P. gingivalis biofilms formed on titanium surfaces. A structure–activity analysis demonstrated that the unsaturated carbon chain is essential for its antibacterial activity. Importantly, AM404 was not toxic towards the tested mammalian cells up to concentrations approaching 4× the MIC. Membrane damage assays using fluorescent probes N‐phenyl‐1‐napthylamine and SYTOX green revealed that membrane permeabilization presumably is the primary antibacterial mode of action of AM404. Collectively, our results suggest that AM404 has the potential to be used for the development of new drugs specifically targeting P. gingivalis‐related infections.

Can the alendronate dosage be altered when combined with high-frequency loading in osteoporosis treatment?

Alendronate therapy has been associated with serious side effects. Altering the alendronate concentration and combining with high-frequency loading as mechanical intervention was explored in this animal study as a treatment for osteoporosis. The bone anabolic potency of high-frequency loading was overruled by the different alendronate dosages applied in the present study. Further exploration of reduced hormonal therapy associated with mechanical interventions in osteoporosis treatment should be sought.

INTRODUCTION

The aim of the present study was to investigate the effect of alendronate (ALN) administration at two different dosages, associated or not with high-frequency (HF) loading, on the bone microstructural response.

METHODS

Sixty-four female Wistar rats were used, of which 48 were ovariectomized (OVX) and 16 were sham-operated (shOVX). The OVX animals were divided into three groups: two groups were treated with alendronate, at a dosage of 2 mg/kg (ALN(₂)) or at a reduced dosage of 1 mg/kg (ALN(₁)) three times per week. A third OVX group did not receive pharmaceutical treatment. All four groups were mechanically stimulated via whole body vibration (WBV) at HF (up to 150 Hz) or left untreated (shWBV). ALN and HF were administered for 6 weeks, starting at 10-week post-(sh)OVX. Tibia bone structural parameters were analyzed using ex vivo microcomputed tomography.

RESULTS

Trabecular bone loss and structural deterioration resulting from ovariectomy were partially restored by ALN administration, demonstrated by the improvement of trabecular patter factor (Tb.Pf), trabecular separation (Tb.Sp), and structure model index (SMI) of the ALN groups compared to that of the OVX group, regardless of the applied dosage [ALN(₂) or ALN(₁)] or mechanical loading regime (shWBV or WBV). However, a significant positive effect of the ALN(₁) administration on trabecular (decrease of Tb.Sp and SMI) and cortical bone (increase of cortical thickness) microarchitecture compared to that of the OVX status group was observed for both loading regimes was not seen for ALN(₂). Furthermore, HF loading resulted in cortical bone changes, with an increased trabeculary area and endocortical perimeter. Finally, the benefits of a combined therapy of ALN with HF loading could not be discerned in the present experimental conditions.

CONCLUSIONS

The bone anabolic potency of HF loading was overruled by the ALN dosages applied in the present study. Further altering the ALN dosage combined with robust mechanical stimuli needs to be considered in osteoporosis research and eventually therapy.

Controlled release of chlorhexidine from a mesoporous silica-containing macroporous titanium dental implant prevents microbial biofilm formation

Roughened surfaces are increasingly being used for dental implant applications as the enlarged contact area improves bone cell anchorage, thereby facilitating osseointegration. However, the additional surface area also entails a higher risk for the development of biofilm associated infections, an etiologic factor for many dental ailments, including peri-implantitis. To overcome this problem, we designed a dental implant composed of a porous titanium-silica (Ti/SiO2) composite material and containing an internal reservoir that can be loaded with antimicrobial compounds. The composite material consists of a sol-gel derived mesoporous SiO2 diffusion barrier integrated in a macroporous Ti load-bearing structure obtained by powder metallurgical processing. The antimicrobial compounds can diffuse through the porous implant walls, thereby reducing microbial biofilm formation on the implant surface. A continuous release of µM concentrations of chlorhexidine through the Ti/SiO2 composite material was measured, without initial burst effect, over at least 10 days and using a 5 mM chlorhexidine solution in the implant reservoir. Metabolic staining, CFU counting and visualisation by scanning electron microscopy confirmed that Streptococcus mutans biofilm formation on the implant surface was almost completely prevented due to chlorhexidine release (preventive setup). Moreover, we demonstrated efficacy of released chlorhexidine against mature Streptococcus mutans biofilms (curative setup). In conclusion, we provide a proof of concept of the sustained release of chlorhexidine, one of the most widely used oral antiseptics, through the Ti/SiO2 material thereby preventing and eradicating biofilm formation on the surface of the dental implant. In principle, our flexible design allows for the use of any bioactive compound, as discussed.

Changes in bone macro- and microstructure in diabetic obese mice revealed by high resolution microfocus X-ray computed tomography

High resolution microfocus X-ray computed tomography (HR-microCT) was employed to characterize the structural alterations of the cortical and trabecular bone in a mouse model of obesity-driven type 2 diabetes (T2DM). C57Bl/6J mice were randomly assigned for 14 weeks to either a control diet-fed (CTRL) or a high fat diet (HFD)-fed group developing obesity, hyperglycaemia and insulin resistance. The HFD group showed an increased trabecular thickness and a decreased trabecular number compared to CTRL animals. Midshaft tibia intracortical porosity was assessed at two spatial image resolutions. At 2 μm scale, no change was observed in the intracortical structure. At 1 μm scale, a decrease in the cortical vascular porosity of the HFD bone was evidenced. The study of a group of 8 week old animals corresponding to animals at the start of the diet challenge revealed that the decreased vascular porosity was T2DM-dependant and not related to the ageing process. Our results offer an unprecedented ultra-characterization of the T2DM compromised skeletal micro-architecture and highlight an unrevealed T2DM-related decrease in the cortical vascular porosity, potentially affecting the bone health and fragility. Additionally, it provides some insights into the technical challenge facing the assessment of the rodent bone structure using HR-microCT imaging.

The impact of autologous platelet concentrates on endodontic healing: a systematic review

The current literature was reviewed to determine the impact of autologous platelet concentrates (APCs) on endodontic healing. All types of clinical study designs concerning any kind of endodontic treatment involving the application of APCs were included. Two independent reviewers searched three databases (PubMed, Embase, and Cochrane Library) for studies, complemented by hand search, until 16/1/2016. From the 423 identified records, 48 articles met the inclusion criteria. Selected randomized controlled clinical trials (RCTs) underwent Cochrane Collaboration's risk-of-bias assessment and data extraction. Only two RCTs showed low risk of bias. There was considerable heterogeneity between the RCTs with regard to the type of therapy, type of APCs, assessment method, and study quality, and therefore the data could not be analyzed quantitatively. The included case reports/series and non-randomized comparative studies underwent qualitative analysis with the revised Methodological Index for Non-Randomized Studies (MINORS) and data extraction. The two comparative non-randomized studies scored qualitatively high, though the MINORS-scores of the case series and reports were dispersed. APCs were involved in five endodontic treatment modalities, namely apexification, regenerative endodontic procedures, pulpotomy, apical surgery, and treatment of endo-perio/perio-endo lesions. APCs seem to accelerate postoperative bone healing, augment the patients' postoperative quality of life, aid further root development, and support maintenance/regaining of pulp vitality. No adverse events were reported. APCs in endodontic treatments seem to contribute to the healing of soft and hard tissues, though there is a lack of long-term high quality clinical trials and standardized treatment protocols.

Impact of Denture Cleaning Method and Overnight Storage Condition on Denture Biofilm Mass and Composition: A Cross-Over Randomized Clinical Trial

Background

Appropriate oral hygiene is required to maintain oral health in denture wearers. This study aims to compare the role of denture cleaning methods in combination with overnight storage conditions on biofilm mass and composition on acrylic removable dentures.

Methods

In a cross-over randomized controlled trial in 13 older people, 4 conditions with 2 different mechanical cleaning methods and 2 overnight storage conditions were considered: (i) brushing and immersion in water without a cleansing tablet, (ii) brushing and immersion in water with a cleansing tablet, (iii) ultrasonic cleaning and immersion in water without a cleansing tablet, and (iv) ultrasonic cleaning and immersion in water with a cleansing tablet. Each test condition was performed for 5 consecutive days, preceded by a 2-days wash-out period. Biofilm samples were taken at baseline (control) and at the end of each test period from a standardized region. Total and individual levels of selected oral bacteria (n = 20), and of Candida albicans were identified using the Polymerase Chain Reaction (PCR) technique. Denture biofilm coverage was scored using an analogue denture plaque score. Paired t-tests and Wilcoxon-signed rank tests were used to compare the test conditions. The level of significance was set at α< 5%.

Results

Overnight denture storage in water with a cleansing tablet significantly reduced the total bacterial count (p<0.01). The difference in total bacterial level between the two mechanical cleaning methods was not statistically significant. No significant effect was observed on the amount of Candida albicans nor on the analogue plaque scores.

Conclusions

The use of cleansing tablets during overnight denture storage in addition to mechanical denture cleaning did not affect Candida albicans count, but reduced the total bacterial count on acrylic removable dentures compared to overnight storage in water. This effect was more pronounced when combined with ultrasonic cleaning compared to brushing.

Trial Registration

ClinicalTrials.gov NCT02454413

Covalent immobilization of antimicrobial agents on titanium prevents Staphylococcus aureus and Candida albicans colonization and biofilm formation

OBJECTIVES

Biofilm-associated implant infections represent a serious public health problem. Covalent immobilization of antimicrobial agents on titanium (Ti), thereby inhibiting biofilm formation of microbial pathogens, is a solution to this problem.

METHODS

Vancomycin (VAN) and caspofungin (CAS) were covalently bound on Ti substrates using an improved processing technique adapted to large-scale coating of implants. Resistance of the VAN-coated Ti (VAN-Ti) and CAS-coated Ti (CAS-Ti) substrates against in vitro biofilm formation of the bacterium Staphylococcus aureus and the fungal pathogen Candida albicans was determined by plate counting and visualized by confocal laser scanning microscopy. The efficacy of the coated Ti substrates was also tested in vivo using an adapted biomaterial-associated murine infection model in which control-Ti, VAN-Ti or CAS-Ti substrates were implanted subcutaneously and subsequently challenged with the respective pathogens. The osseointegration potential of VAN-Ti and CAS-Ti was examined in vitro using human bone marrow-derived stromal cells, and for VAN-Ti also in a rat osseointegration model.

RESULTS

In vitro biofilm formation of S. aureus and C. albicans on VAN-Ti and CAS-Ti substrates, respectively, was significantly reduced compared with biofilm formation on control-Ti. In vivo, we observed over 99.9% reduction in biofilm formation of S. aureus on VAN-Ti substrates and 89% reduction in biofilm formation of C. albicans on CAS-Ti substrates, compared with control-Ti substrates. The coated substrates supported osseointegration in vitro and in vivo.

CONCLUSIONS

These data demonstrate the clinical potential of covalently bound VAN and CAS on Ti to reduce microbial biofilm formation without jeopardizing osseointegration.

Micro-CT analysis of the rodent jaw bone micro-architecture: A systematic review

Introduction

Knowledge about macro- and micro-structural characteristics may improve in vivo estimation of the quality and quantity of regenerated bone tissue. For this reason, micro-CT imaging has been applied to evaluate alveolar bone remodelling, alterations of periodontal ligament thickness and cortical and trabecular bone changes in rodent jaw bones. In this paper, we provide a systematic review on the available micro-CT literature on jaw bone micro-architecture.

Methodology

A detailed search through the PubMed database was performed. Articles published up to December 2013 and related to maxilla, mandible and condyle with quantitatively analysed bone micro-architectural parameters were considered eligible for inclusion. Two reviewers assessed the search results according to inclusion criteria designed to identify animal studies quantifying the bone micro-architecture of the jaw rodent bones in physiological or drug-induced disease status, or in response to interventions such as mechanical loading, hormonal treatment and other metabolic alterations. Finally, the reporting quality of the included publications was evaluated using the tailored ARRIVE guidelines outlined by Vignoletti and Abrahamsson (2012).

Results

Database search, additional manual searching and assessment of the inclusion and exclusion criteria retrieved 127 potentially relevant articles. Eventually, 14 maxilla, 20 mandible and 12 condyle articles with focus on bone healing were retained, and were analysed together with 3 methodological papers. Each study was described systematically in terms of subject, experimental intervention, follow-up period, selected region of interest used in the micro-CT analysis, parameters quantified, micro-CT scanner device and software. The evidence level evaluated by the ARRIVE guidelines showed high mean scores (between 18 and 25; range: 0–25), indicating that most of the selected studies are well-reported. The major obstacles identified were related to sample size calculation, absence of adverse event descriptions, randomization or blinding procedures.

Conclusions

The evaluated studies are highly heterogeneous in terms of research topic and the different regions of interest. These results illustrate the need for a standardized methodology in micro-CT analysis. While the analysed studies do well according to the ARRIVE guidelines, the micro-CT procedure is often insufficiently described. Therefore we recommend to extend the ARRIVE guidelines for micro-CT studies.

•

This review investigates discrepancies between reports using micro-CT imaging of rodent jaw bone, the applied methodology and reported results.

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Knowledge about the bone micro-architecture of the rodent jaw is scarce.

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Jaw bone micro-architecture varies according to ROI selections and the methodology applied to define a specific region are insufficient.

Novel anti-infective implant substrates: controlled release of antibiofilm compounds from mesoporous silica-containing macroporous titanium

Bone implants with open porosity enable fast osseointegration, but also present an increased risk of biofilm-associated infections. We design a novel implant material consisting of a mesoporous SiO2 diffusion barrier (pore diameter: 6.4 nm) with controlled drug release functionality integrated in a macroporous Ti load-bearing structure (fully interconnected open porosity: 30%; pore window size: 0.5-2.0 μm). Using an in vitro tool consisting of Ti/SiO2 disks in an insert set-up, through which molecules can diffuse from feed side to release side, a continuous release without initial burst effect of the antibiofilm compound toremifene is sustained for at least 9 days, while release concentrations (up to 17 μM daily) increase with feed concentrations (up to 4mM). Toremifene diffusivity through the SiO2 phase into H2O is estimated around 10(-13)m(2)/s, suggesting configurational diffusion through mesopores. Candida albicans biofilm growth on the toremifene-release side is significantly inhibited, establishing a proof-of-concept for the drug delivery functionality of mesoporous SiO2 incorporated into a high-strength macroporous Ti carrier. Next-generation implants made of this composite material and equipped with an internal reservoir (feed side) can yield long-term controlled release of antibiofilm compounds, effectively treating infections on the implant surface (release side) over a prolonged time.

Single and combined effect of high-frequency loading and bisphosphonate treatment on the bone micro-architecture of ovariectomized rats

Mechanical loading at high frequency affects bone. Whether this also applies to osteoporotic bone, combined or not with bisphosphonate therapy, was investigated in this animal study through imaging. An anabolic effect of high-frequency loading on osteoporotic bone, however non-synergistic with bisphosphonates, was found, thereby revealing its potential for treatment of osteoporosis.

INTRODUCTION

In an effort to elucidate the effect of high-frequency (HF) loading on bone and to optimize its potential for treatment osteoporosis, this study aimed to investigate the effect of HF loading via whole body vibration (WBV), alone or in association with bisphosphonate treatment (alendronate--ALN), on the micro-architecture of ovariectomy (OVX)-induced compromised bone.

METHODS

Eighty-four female Wistar rats were ovariectomized (OVX) or sham-operated (shOVX). OVX animals were treated either with ALN (3 days/week at a dose of 2 mg/kg) or with saline solution. Each group (shOVX, OVX, ALN) was further divided into subgroups relative to the loading status (sham-WBV versus WBV) and the duration of experimental period (4 days versus 14 days). (Sham)WBV loading was applied for 10 min/day using 10 consecutive steps of HF loading (130, 135, 140, 145, 150, 130, 135, 140, 145, 150 Hz). Tibial bone structural responses to WBV and/or ALN treatment were analyzed using ex vivo micro-computed tomography.

RESULTS

The animal's hormonal status displayed a major impact on the trabecular and cortical bone structural parameters. Furthermore, mechanical treatment with HF WBV increased the cortical thickness and reduced the medullar area in OVX rats. However, OVX trabecular bone was not affected by HF stimuli. Finally, ALN prevented OVX-associated bone loss, but the association of ALN with WBV did not lead to a synergistic bone response in OVX bone.

CONCLUSIONS

HF WBV mechanical stimulation displayed an anabolic effect on osteoporotic cortical bone, confirming its therapeutic properties for enhancing compromised bone. Additionally, its association with bisphosphonates' administration did not produce any additive effect on the bone micro-architecture in the present study.

High-frequency loading positively impacts titanium implant osseointegration in impaired bone

High-frequency loading via whole body vibration promotes bone formation and increases bone strength. Whether this translates to positive titanium implant osseointegration in osteoporotic bone was explored in this animal study. An anabolic effect of not only bisphosphonate treatment but also high-frequency loading on implant osseointegration in osteoporotic bone was observed.

INTRODUCTION

The present study investigated the impact of high-frequency (HF) loading, applied via whole body vibration (WBV), on titanium implant osseointegration in healthy versus ovariectomy-induced compromised versus pharmacologically treated compromised bone.

METHODS

A custom-made Ti implant was inserted into the metaphyseal tibia of 59 rats and left to heal for either 4 or 14 days. Rats were divided into six groups according to their hormonal and mechanical status. WBV, consisting of 10 consecutive frequency steps at an acceleration of 0.3 g, was applied daily for either 4 or 14 days. Tissue samples were processed for quantitative histology at the tibial cortical and medullar level. Data were analyzed by three-way ANOVA and by post hoc pairwise comparisons.

RESULTS

The bone healing response at the interface and surrounding titanium implants was negatively influenced by osteoporotic bone conditions, mainly at the trabecular bone level. Furthermore, the administration of bisphosphonates for preventing the ovariectomy-induced impaired peri-implant response was successful. Finally, the effect of HF WBV loading on the peri-implant bone healing was dependent on the bone condition and was anabolic solely in untreated osteoporotic trabecular bone when applied for an extended period of time.

CONCLUSIONS

The bone healing response to implant installation is compromised in osteoporotic bone conditions, in particular at the trabecular bone compartment. Meanwhile, not only pharmacological treatment but also mechanical loading via HF WBV can exert a positive effect on implant osseointegration in this specific bone micro-environment. The peri-implant cortical bone, however, seems to be less sensitive to HF WBV loading influences.

Hind limb unloading, a model of spaceflight conditions, leads to decreased B lymphopoiesis similar to aging

Within the bone marrow, the endosteal niche plays a crucial role in B-cell differentiation. Because spaceflight is associated with osteoporosis, we investigated whether changes in bone microstructure induced by a ground-based model of spaceflight, hind limb unloading (HU), could affect B lymphopoiesis. To this end, we analyzed both bone parameters and the frequency of early hematopoietic precursors and cells of the B lineage after 3, 6, 13, and 21 d of HU. We found that limb disuse leads to a decrease in both bone microstructure and the frequency of B-cell progenitors in the bone marrow. Although multipotent hematopoietic progenitors were not affected by HU, a decrease in B lymphopoiesis was observed as of the common lymphoid progenitor (CLP) stage with a major block at the progenitor B (pro-B) to precursor B (pre-B) cell transition (5- to 10-fold decrease). The modifications in B lymphopoiesis were similar to those observed in aged mice and, as with aging, decreased B-cell generation in HU mice was associated with reduced expression of B-cell transcription factors, early B-cell factor (EBF) and Pax5, and an alteration in STAT5-mediated IL-7 signaling. These findings demonstrate that mechanical unloading of hind limbs results in a decrease in early B-cell differentiation resembling age-related modifications in B lymphopoiesis.

Stimulation of titanium implant osseointegration through high-frequency vibration loading is enhanced when applied at high acceleration

Low-magnitude high-frequency loading, applied by means of whole body vibration (WBV), affects the bone. Deconstructing a WBV loading stimulus into its constituent elements and investigating the effects of frequency and acceleration individually on bone tissue kinetics around titanium implants were aimed for in this study. A titanium implant was inserted in the tibia of 120 rats. The rats were divided into 1 control group (no loading) and 5 test groups with low (L), medium (M) or high (H) frequency ranges and accelerations [12-30 Hz at 0.3×g (F(L)A(H)); 70-90 Hz at 0.075×g (F(M)A(M)); 70-90 Hz at 0.3×g (F(M)A(H)); 130-150 Hz at 0.043×g (F(H)A(L)); 130-150 Hz at 0.3×g (F H A H)]. WBV was applied for 1 or 4 weeks. Implant osseointegration was evaluated by quantitative histology (bone-to-implant contact (BIC) and peri-implant bone formation (BV/TV)). A 2-way ANOVA (duration of experimental period; loading mode) with α = 0.05 was performed. BIC significantly increased over time and under load (p < 0.0001). The highest BICs were found for loading regimes at high acceleration with medium or high frequency (F(M)A(H) and F(H)A(H)), and significantly differing from F(L)A(H) and F(M)A(M) (p < 0.02 and p < 0.005 respectively). BV/TV significantly decreased over time (p < 0.0001). Loading led to a site-specific BV/TV increase (p < 0.001). The highest BV/TV responses were found for F(M)A(H) and F(H)A(H), significantly differing from F(M)A(M) (p < 0.005). The findings reveal the potential of high-frequency vibration loading to accelerate and enhance implant osseointegration, in particular when applied at high acceleration. Such mechanical signals hold great, though untapped, potential to be used as non-pharmacologic treatment for improving implant osseointegration in compromised bone.

The pH in the microenvironment of human mesenchymal stem cells is a critical factor for optimal osteogenesis in tissue-engineered constructs

The present study aimed at elucidating the effect of local pH in the extracellular microenvironment of tissue-engineered (TE) constructs on bone cell functions pertinent to new tissue formation. To this aim, we evaluated the osteogenicity process associated with bone constructs prepared from human Bone marrow-derived mesenchymal stem cells (hBMSC) combined with 45S5 bioactive glass (BG), a material that induces alkalinization of the external medium. The pH measured in cell-containing BG constructs was around 8.0, that is, 0.5 U more alkaline than that in two other cell-containing materials (hydroxyapatite/tricalcium phosphate [HA/TCP] and coral) constructs tested. When implanted ectopically in mice, there was no de novo bone tissue in the BG cell-containing constructs, in contrast to results obtained with either HA/TCP or coral ceramics, which consistently promoted the formation of ectopic bone. In addition, the implanted 50:50 composites of both HA/TCP:BG and coral:BG constructs, which displayed a pH of around 7.8, promoted 20-30-fold less amount of bone tissue. Interestingly, hBMSC viability in BG constructs was not affected compared with the other two types of material constructs tested both in vitro and in vivo. Osteogenic differentiation (specifically, the alkaline phosphatase [ALP] activity and gene expression of RUNX2, ALP, and BSP) was not affected when hBMSC were maintained in moderate alkaline pH (≤7.90) external milieu in vitro, but was dramatically inhibited at higher pH values. The formation of mineralized nodules in the extracellular matrix of hBMSC was fully inhibited at alkaline (>7.54) pH values. Most importantly, there is a pH range (specifically, 7.9-8.27) at which hBMSC proliferation was not affected, but the osteogenic differentiation of these cells was inhibited. Altogether, these findings provided evidence that excessive alkalinization in the microenvironment of TE constructs (resulting, for example, from material degradation) affects adversely the osteogenic differentiation of osteoprogenitor cells.

Cephalometric assessment of craniofacial dysmorphologies in relation with Msx2 mutations in mouse

OBJECTIVES

To determine the role of Msx2 in craniofacial morphology and growth, we used a mouse model and performed a quantitative morphological characterization of the Msx2 (-/-) and the Msx2 (+/-) phenotype using a 2D cephalometric analysis applied on micrographs.

MATERIALS AND METHODS

Forty-four three-and-a-half-month-old female CD1 mice were divided into the following three groups: Msx2 (+/+) (n = 16), Msx2 (+/-) (n = 16), and Msx2 (-/-) (n = 12). Profile radiographs were scanned. Modified cephalometric analysis was performed to compare the three groups.

RESULTS

Compared with the wild-type mice, the Msx2 (-/-) mutant mice presented an overall craniofacial size decrease and modifications of the shape of the different parts of the craniofacial skeleton, namely the neurocranium, the viscerocranium, the mandible, and the teeth. In particular, dysmorphologies were seen in the cochlear apparatus and the teeth (taurodontism, reduced incisor curvature). Finally contrary to previous published results, we were able to record a specific phenotype of the Msx2 (+/-) mice with this methodology. This Msx2 (+/-) mouse phenotype was not intermediate between the Msx2 (-/-) and the wild-type animals.

CONCLUSION

Msx2 plays an important role in craniofacial morphogenesis and growth because almost all craniofacial structures were affected in the Msx2(-/-) mice including both intramembranous and endochondral bones, the cochlear apparatus, and the teeth. In addition, Msx2 haploinsufficiency involves a specific phenotype with subtle craniofacial structures modifications compared with human mutations.

Ultrastructural characterization of the implant interface response to loading

Dynamic loading can affect the bone surrounding implants. For ultrastructural exploration of the peri-implant tissue response to dynamic loading, titanium implants were installed in rat tibiae, in which one implant was loaded while the contralateral served as the unloaded control. The loaded implants received stimulation either within 24 hrs after implantation (immediate loading) or after a 28-day healing period (delayed loading) for 4, 7, 14, 21, or 28 days. The samples were processed for histology and gene expression quantification. Compared with the unloaded control, bone-to-implant contact increased significantly by immediate loading for 28 days (p < .05), but not in case of delayed loading. No effect of loading was observed on the bone formation in the implant thread areas, on the blood vessel area, and on endosteal callus formation. Loading during healing (immediate) for 7 days induced, relative to the unloaded control, a 2.3-fold increase of Runx2 in peri-implant cortical bone (p < .01) without a change in the RANKL/Opg ratio. Loading after healing (delayed) for 7 days up-regulated Runx2 (4.3-fold, p < .01) as well as Opg (22.3-fold, p < .05) compared with the unloaded control, resulting in a significantly decreased RANKL/Opg ratio. These results indicate a stimulating effect of dynamic loading on implant osseointegration when applied during the healing phase. In addition, gene expression analyses revealed molecular adaptations favoring bone formation and, at the same time, affecting bone remodeling.

Occlusal overload and bone/implant loss

AIM

The aim of this search was to assess the biological consequences that overload might have on already osseointegrated oral implants through a systematic screening of the scientific literature.

METHOD

Detailed searches through PUBMED, OVID, EMBASE and LILACS databases were made. Articles published up to December 2011 and those reported on the clinical, radiographic and/or histological outcome of oral implants subjected to so-called overload were considered eligible for inclusion. Identified studies were assessed by one non-blinded reviewer according to well-defined inclusion and exclusion criteria. When doubt arose, the co-authors were counselled until final agreement was obtained. The PICO questions formulated was:"what is the effect of overload vs. no overload on bone/implant loss in clinically stable implants?"

RESULTS

The database searches as well as additional hand searching, resulted in 726 potentially relevant titles. Eventually, 16 clinical and 25 animal studies were considered relevant to the topic. After inclusion/exclusion criteria assessment, all clinical studies and all but three animal studies and one systematic review were considered at high risk of bias and excluded. The included animal studies did not reveal an association between overload and peri-implant bone loss in the absence of peri-implant inflammation, whereas in its presence, overload seemed to aggravate the peri-implant tissue breakdown.

CONCLUSIONS

The effect of implant overload on bone/implant loss in clinically well-integrated implants is poorly reported and provides little unbiased evidence to support a cause-and-effect relationship. The PICO question remained unanswered. At the animal level, "overload", mimicked by supra-occlusal contacts acting in an uninflamed peri-implant environment, did not negatively affect osseointegration and even was anabolic. In contrast, supra-occlusal contacts in the presence of inflammation significantly increased the plaque-induced bone resorption.

Effect of insertion torque on titanium implant osseointegration: an animal experimental study

OBJECTIVE

To evaluate the effect of implant insertion torque on the peri-implant bone healing and implant osseointegration.

MATERIAL AND METHODS

Bilaterally in the tibia of five adult New Zealand white rabbits, 20 implants were installed, subdivided into four groups, corresponding to two insertion torque conditions (low, < 10 Ncm vs. high > 50 Ncm) and 2 experimental periods (2 weeks vs. 4 weeks of healing). The implant insertion torque was determined by the surgical drill diameter relative to the implant diameter. Implant osseointegration was evaluated by quantitative histology (bone-to-implant contact with host bone [BIC-host], with neoformed bone [BIC-de novo], with both bone types [BIC-total], and peri-implant bone [BA/TA]). Every response was modelled over time using GEE (general estimation equation) with an unstructured variance-covariance matrix to correct for dependency between the measurements from one animal. The statistical significance level of α = 0.05 was applied.

RESULTS

Significantly, more BIC-host and BIC-total were recorded for H implants compared with L implants after 2 week of healing (P = 0.010 and P = 0.0001, respectively). However, this result was no longer found for the extended healing period. Furthermore, BIC-total significantly increased over time for L implants (P < 0.00001). In contrast, the significant increase in BA/TA over time was found for H implants (P < 0.01). Finally, H insertion torque led to an increased BA/TA after 4 week of healing (P < 0.02) compared with the L insertion protocol.

CONCLUSION

L insertion torque implants installed in the rabbit tibial bone osseointegrate with considerable de novo bone formation. This bone neoformation enables L implants to catch up, already during the early osseointegration stage, the initial inferior amount BIC contact compared with that of H implants. A negative impact of the created strain environment accompanying H insertion torque implant installation on the biological process of osseointegration could not be observed, at least not at tissue level.

Impaired osteoblastogenesis potential of progenitor cells in skeletal unloading is associated with alterations in angiogenic and energy metabolism profile

Skeletal unloading provokes bone loss. These bone alterations have been shown to be associated with impairment of osteoblastic activity. In the present study, we evaluated the effect of skeletal unloading on bone marrow progenitor cells, for exploration of the underlying mechanism. Wistar rats were randomized to be either hindlimb unloaded for 9 days or to act as controls. Micro-CT was used to detect tibial trabecular architecture changes in response to skeletal unloading. Microgravity conditions for 9 days resulted in a decreased number and an increased spacing of the bone trabeculae in the proximal tibia. The proliferative capacity of the femoral bone marrow samples was assessed (fibroblast-colony-forming assay). By using qPCR, the expression of selected markers of vascularization (Vegfa; Hif1a; Angpt1), energy metabolism (Prkaa2; Mtor), bone formation (Runx2; Alp; Bglap; Bmp2; Bmp4; Bmp7) and bone resorption (Acp5; Tnfsf11; Tnfrsf11b) in these bone marrow suspensions was measured. We demonstrated a striking decrease in the number of fibroblastic progenitors in response to hindlimb unloading. This deficit in proliferation was shown to be accompanied by altered hindlimb perfusion and cellular energy homeostasis. Ex vivo culture assays of the bone marrow-derived progenitor cells screened for osteogenic (Runx2; Alp; Bglap) and adipogenic (Pparg; Fabp4) differentiation alterations in response to microgravity. Induced progenitor cells from unloaded rats showed a delay in osteogenic differentiation and impaired adipogenic differentiation compared to control. The data of this multi-level approach demonstrate that skeletal unloading significantly affects the bone tissue and its metabolism at the progenitor stage. The molecular expressions of the bone marrow population support a role of cellular metabolic stresses in skeletal alterations induced by inactivity.

Bone tissue response to BMP-2 adsorbed on amorphous microporous silica implants

AIM

To evaluate bone regeneration potential of bone morphogenetic protein-2 (BMP-2) adsorbed on amorphous microporous silica (AMS).

MATERIALS & METHODS

Four implants [titanium as control (CTR); AMS-coated titanium (AMS), BMP-2 adsorbed on titanium (CTR+BMP) and AMS (AMS+BMP)] were implanted randomly in the tibiae of 20 New Zealand white rabbits. Bone specimens with implants were retrieved 2/4 weeks post implantation and analysed histologically and histomorphometrically. Bone fraction was measured in initial bone-free area (bone regeneration area, BRA) and in the area with initial bone-implant contact [bone adaptation area (BAA)] (BF(BRA) & BF(BAA) ). Bone-implant contact was measured in BRA (BIC(BRA) ). In vitro BMP-2 release profiles were determined to evaluate the impact of the carrier surface. Mixed models were used for statistical analysis.

RESULTS

BMP-2 release profiles were different for CTR+BMP and AMS+BMP. BIC(BRA) and BF(BRA) were significantly increased after 4 weeks compared to 2 weeks for AMS, CTR+BMP and AMS+BMP. However, no differences between the implant types were observed within both healing periods. BF(BAA) for CTR+BMP was smaller than that for CTR and AMS+BMP after 4 weeks. Despite slower BMP-2 release, AMS+BMP did not stimulate bone regeneration. CTR+BMP caused bone resorption at the bone-implant interface.

CONCLUSIONS

BMP-2 functionalized implant surfaces failed to stimulate bone regeneration and osseointegration.

Enhancement of implant osseointegration by high-frequency low-magnitude loading

Background

Mechanical loading is known to play an important role in bone remodelling. This study aimed to evaluate the effect of high- and low-frequency axial loading, applied directly to the implant, on peri-implant bone healing and implant osseointegration.

Methodology

Titanium implants were bilaterally installed in rat tibiae. For every animal, one implant was loaded (test) while the other one was not (control). The test implants were randomly divided into 8 groups according to 4 loading regimes and 2 experimental periods (1 and 4 weeks). The loaded implants were subject to an axial displacement. Within the high- (HF, 40 Hz) or low-frequency (LF, 8 Hz) loading category, the displacements varied 2-fold and were ranked as low- or high-magnitude (LM, HM), respectively. The strain rate amplitudes were kept constant between the two frequency groups. This resulted in the following 4 loading regimes: 1) HF-LM, 40 Hz-8 µm; 2) HF-HM, 40 Hz-16 µm; 3) LF-LM, 8 Hz-41 µm; 4) LF-HM, 8 Hz-82 µm. The tissue samples were processed for resin embedding and subjected to histological and histomorphometrical analyses. Data were analyzed statistically with the significance set at p<0.05.

Principal Findings

After loading for 4 weeks, HF-LM loading (40 Hz-8 µm) induced more bone-to-implant contact (BIC) at the level of the cortex compared to its unloaded control. No significant effect of the four loading regimes on the peri-implant bone fraction (BF) was found in the 2 experimental periods.

Conclusions

The stimulatory effect of immediate implant loading on bone-to-implant contact was only observed in case of high-frequency (40 Hz) low-magnitude (8 µm) loading. The applied load regimes failed to influence the peri-implant bone mass.

Ischemia is the prime but not the only cause of human multipotent stromal cell death in tissue-engineered constructs in vivo

Local tissue ischemia is a prime cause responsible for the massive cell death in tissue-engineered (TE) constructs observed postimplantation. To assess the impact of ischemia on the death of implanted human multipotent stromal cells (hMSCs), which have great potential for repairing damaged tissues, we hereby investigated the in vivo temporal and spatial fate of human Luc-GFP-labeled MSCs within fibrin gel/coral scaffolds subcutaneously implanted in nude mice. In vivo bioluminescence imaging monitoring and histological analyses of the constructs tested confirmed the irremediable death of hMSCs over 30 days postimplantation. The kinetics of expression of three hypoxic/ischemic markers (HIF-1α, LDH-A, and BNIP3) was also monitored. Our results provided evidence that hMSCs located within the core of implanted constructs died faster and predominantly and strongly expressed the aforementioned ischemic markers. In contrast, cells located in the outer regions of TE constructs were reperfused by neovascularization and were still viable (as evidenced by their ex-vivo proliferative potential) at day 15 postimplantation. These results support the explanation that in the central part of the constructs tested, death of hMSCs was due to ischemia, whereas in the periphery of these constructs, cell death was due to another mechanism that needs to be elucidated.

In vivo assessment of the effect of controlled high- and low-frequency mechanical loading on peri-implant bone healing

The aim of this study was to investigate the effect of controlled high- (HF) and low-frequency (LF) mechanical loading on peri-implant bone healing. Custom-made titanium implants were inserted in both tibiae of 69 adult Wistar rats. For every animal, one implant was loaded by compression through the axis of tibia (test), whereas the other one was unloaded (control). The test implants were randomly distributed among four groups receiving different loading regimes, which were determined by ex vivo calibration. Within the HF (40 Hz) or LF (2 Hz) loading category, the magnitudes were chosen as low- (LM) and high-magnitude (HM), respectively, leading to constant strain rate amplitudes for the two frequency groups. This resulted in the four loading regimes: (i) HF-LM (40 Hz-0.5 N); (ii) HF-HM (40 Hz-1 N); (iii) LF-LM (2 Hz-10 N); and (iv) LF-HM (2 Hz-20 N) loading. Loading was performed five times per week and lasted for one or four weeks. Tissue samples were processed for histology and histomorphometry (bone-to-implant contact, BIC; and peri-implant bone fraction, BF) at the cortical and medullar level. Data were analysed statistically with ANOVA and paired t-tests with the significance level set at 0.05. For the one-week experiments, an increased BF adjacent to the implant surface at the cortical level was exclusively induced by the LF-HM loading regime (2 Hz-20 N). Four weeks of loading resulted in a significant effect on BIC (and not on BF) in case of HF-LM loading (40 Hz-0.5 N) and LF-HM loading (2 Hz-20 N): BIC at the cortical level significantly increased under both loading regimes, whereas BIC at the medullar level was positively influenced only in case of HF-LM loading. Mechanical loading at both HF and LF affects osseointegration and peri-implant BF. Higher loading magnitudes (and accompanying elevated tissue strains) are required under LF loading to provoke a positive peri-implant bone response, compared with HF loading. A sustained period of loading at HF is needed to result in an overall enhanced osseointegration.

Strategies for improving the efficacy of bioengineered bone constructs: a perspective

Bioengineered bone scaffolds are intended for use in large bone defects. Successful bone constructs should stimulate and support both the onset and the continuance of bone ingrowth. In an attempt to improve their performance and to compete with the one of autologous bone grafts, a growing symbiosis at the biological and material level is required. Recent advances have been made to further exploit the osteogenic potential of MSCs in scaffold development. Current research encompasses new strategies for reducing cell death after implantation and the manufacturing of tailored, instructive scaffolds.

In vivo molecular evidence of delayed titanium implant osseointegration in compromised bone

Optimization of implant osseointegration in patients with reduced bone healing potential is a challenge remaining in implant dentistry. Identification of the genes that are modulated during implant osseointegration in normal versus osteopenic bone is needed to successfully address these pertinent clinical needs. The present study aimed to assess the initial and early molecular events following titanium implant installation in normal and compromised bone in a rat tibia model. Peri-implant tissue from a well-defined tissue regeneration compartment was analyzed at 2 and 7 days post-surgery for the expression of select markers of inflammation, angiogenesis, bone resorption and bone formation. Impaired bone was induced by hindlimb unloading and validated using μCT. The essential step of angiogenesis preceding bone regeneration was evidenced for the peri-implant setting in healthy bone. Compromised bone significantly affected the angiogenesis-osteogenesis coupling in the initial phase (2 days post-surgery), with altered expressions of Vegfa and Epas1 coinciding with downregulated expressions of Col1a1, Bmp2, Bmp4, Alpl and Bglap. At 7 days post-implantation, differences between normal and compromised peri-implant bone were no longer observed. This in vivo molecular evidence of delayed implant osseointegration in compromised bone reassert modern strategies in implant development, such as surface modifications and bioengineered approaches, to improve implant osseointegration in compromised conditions.

Computer-aided designed/computer-assisted manufactured composite resin versus ceramic single-tooth restorations: a 3-year clinical study

PURPOSE

No clinical evidence has been provided to suggest that metal-free all-composite resin indirect restorations are a functional and esthetic alternative to all-ceramic restorations. The aim of this study was to evaluate the clinical performance of single-tooth computer-aided design/computer-assisted manufacturing (CAD/CAM)-generated all-composite resin and all-ceramic crowns after 3 years of function.

MATERIALS AND METHODS

In a prospective trial, 200 all-composite resin and all-ceramic crowns were rated over a 3-year period. Restorations were evaluated at 3 weeks and 1 and 3 years after insertion by the California Dental Association quality evaluation index, the patient's self-assessment, marginal fit, periodontal parameters, volume loss, and wear patterns of the veneering material. Statistical analysis was performed using t tests (a = .05).

RESULTS

Cumulative survival and success rates after 3 years were 87.9% and 55.6% for all-composite resin and 97.2% and 81.2% for all-ceramic crowns, respectively (P < .05 for success rates). Restoration loosening occurred exclusively for all-composite resin crowns cemented on a cast post. All-ceramic restorations demonstrated satisfactory esthetic results. All-composite resin crowns resulted in significantly more mean total volume loss and mean vertical wear at occlusal contact areas after 6 months and 3 years of function. The clinical performance of the CAD/CAM-generated all-ceramic crowns used in this study was similar to that of other all-ceramic CAD/CAM systems.

CONCLUSION

For up to 3 years of function, all-composite resin single-tooth restorations have inferior success rates compared to all-ceramic restorations. Due to the inferior esthetics and wear resistance of all-composite resin crowns, all-ceramic crowns remain the preferred treatment for CAD/CAM-generated metal-free single-tooth restorations.