Lgr5-expressing secretory cells form a Wnt inhibitory niche in cartilage critical for chondrocyte identity

Osteoarthritis is a degenerative joint disease that causes pain, degradation, and dysfunction. Excessive canonical Wnt signaling in osteoarthritis contributes to chondrocyte phenotypic instability and loss of cartilage homeostasis; however, the regulatory niche is unknown. Using the temporomandibular joint as a model in multiple species, we identify Lgr5-expressing secretory cells as forming a Wnt inhibitory niche that instruct Wnt-inactive chondroprogenitors to form the nascent synovial joint and regulate chondrocyte lineage and identity. Lgr5 ablation or suppression during joint development, aging, or osteoarthritis results in depletion of Wnt-inactive chondroprogenitors and a surge of Wnt-activated, phenotypically unstable chondrocytes with osteoblast-like properties. We recapitulate the cartilage niche and create StemJEL, an injectable hydrogel therapy combining hyaluronic acid and sclerostin. Local delivery of StemJEL to post-traumatic osteoarthritic jaw and knee joints in rabbit, rat, and mini-pig models restores cartilage homeostasis, chondrocyte identity, and joint function. We provide proof of principal that StemJEL preserves the chondrocyte niche and alleviates osteoarthritis.

Sexual dimorphisms in three-dimensional masticatory muscle attachment morphometry regulates temporomandibular joint mechanics

Temporomandibular joint (TMJ) disorders disproportionally affect females, with female to male prevalence varying from 3:1 to 8:1. Sexual dimorphisms in masticatory muscle attachment morphometry and association with craniofacial size, critical for understanding sex-differences in TMJ function, have not been reported. The objective of this study was to determine sex-specific differences in three-dimensional (3D) TMJ muscle attachment morphometry and craniofacial sizes and their impact on TMJ mechanics. Human cadaveric TMJ muscle attachment morphometry and craniofacial anthropometry (10Males; 11Females) were determined by previously developed 3D digitization and imaging-based methods. Sex-differences in muscle attachment morphometry and craniofacial anthropometry, and their correlation were determined, respectively using multivariate general linear and linear regression statistical models. Subject-specific musculoskeletal models of the mandible were developed to determine effects of sexual dimorphisms in mandibular size and TMJ muscle attachment morphometry on joint loading during static biting. There were significant sex-differences in craniofacial size (p = 0.024) and TMJ muscle attachment morphometry (p < 0.001). TMJ muscle attachment morphometry was significantly correlated with craniofacial size. TMJ contact forces estimated from biomechanical models were significantly, 23% on average (p < 0.001), greater for females compared to those for males when generating the same bite forces. There were significant linear correlations between TMJ contact force and both 3D mandibular length (R² = 0.48, p < 0.001) and muscle force moment arm ratio (R² = 0.68, p < 0.001). Sexual dimorphisms in masticatory muscle morphology and craniofacial sizes play critical roles in subject-specific TMJ biomechanics. Sex-specific differences in the TMJ mechanical environment should be further investigated concerning mechanical fatigue of TMJ discs associated with TMJ disorders.

Opioid guidelines for common dental surgical procedures: a multidisciplinary panel consensus

One in 16 patients prescribed opioids after a surgical procedure will become a long-term user. The lack of procedure-specific guidelines after common dental procedures contributes to the opioid overprescribing problem. We convened a multidisciplinary panel to develop consensus recommendations for opioid prescribing after common dental procedures. We used a three-step modified Delphi method to develop a consensus recommendation for outpatient opioid prescribing for 14 common dental procedures. The multi-institution, multidisciplinary panel represented seven relevant stakeholder groups (oral surgeons, periodontists, endodontists, general dentists, general surgeons, oral surgery residents, and oral surgery patients). The panel determined the minimum and maximum number of opioid tablets a clinician should consider prescribing. For all 14 surgical procedures, ibuprofen was recommended as initial therapy. The maximum number of opioid tablets recommended varied by procedure (overall median = 5 tablets, range = 0-15 tablets). Zero opioid tablets were recommended as the maximum number for six of 14 (43%) procedures, one to 10 opioid tablets was the maximum for four of 14 (27%) procedures, and 11-15 tablets was the maximum for four of 14 (27%) procedures. Procedure-specific prescribing recommendations may help provide guidance to clinicians and help address the opioid overprescribing problem.

Evidence of vasculature and chondrocyte to osteoblast transdifferentiation in craniofacial synovial joints: Implications for osteoarthritis diagnosis and therapy

Temporomandibular joint osteoarthritis (TMJ OA) leads to permanent cartilage destruction, jaw dysfunction, and compromises the quality of life. However, the pathological mechanisms governing TMJ OA are poorly understood. Unlike appendicular articular cartilage, the TMJ has two distinct functions as the synovial joint of the craniofacial complex and also as the site for endochondral jaw bone growth. The established dogma of endochondral bone ossification is that hypertrophic chondrocytes undergo apoptosis, while invading vasculature with osteoprogenitors replace cartilage with bone. However, contemporary murine genetic studies support the direct differentiation of chondrocytes into osteoblasts and osteocytes in the TMJ. Here we sought to characterize putative vasculature and cartilage to bone transdifferentiation using healthy and diseased TMJ tissues from miniature pigs and humans. During endochondral ossification, the presence of fully formed vasculature expressing CD31⁺ endothelial cells and α-SMA⁺ vascular smooth muscle cells were detected within all cellular zones in growing miniature pigs. Arterial, endothelial, venous, angiogenic, and mural cell markers were significantly upregulated in miniature pig TMJ tissues relative to donor matched knee meniscus fibrocartilage tissue. Upon surgically creating TMJ OA in miniature pigs, we discovered increased vasculature and putative chondrocyte to osteoblast transformation dually marked by COL2 and BSP or RUNX2 within the vascular bundles. Pathological human TMJ tissues also exhibited increased vasculature, while isolated diseased human TMJ cells exhibited marked increased in vasculature markers relative to control 293T cells. Our study provides evidence to suggest that the TMJ in higher order species are in fact vascularized. There have been no reports of cartilage to bone transdifferentiation or vasculature in human-relevant TMJ OA large animal models or in human TMJ tissues and cells. Therefore, these findings may potentially alter the clinical management of TMJ OA by defining new drugs that target angiogenesis or block the cartilage to bone transformation.

Three-dimensional temporomandibular joint muscle attachment morphometry and its impacts on musculoskeletal modeling

In musculoskeletal models of the human temporomandibular joint (TMJ), muscles are typically represented by force vectors that connect approximate muscle origin and insertion centroids (centroid-to-centroid force vectors). This simplification assumes equivalent moment arms and muscle lengths for all fibers within a muscle even with complex geometry and may result in inaccurate estimations of muscle force and joint loading. The objectives of this study were to quantify the three-dimensional (3D) human TMJ muscle attachment morphometry and examine its impact on TMJ mechanics. 3D muscle attachment surfaces of temporalis, masseter, lateral pterygoid, and medial pterygoid muscles of human cadaveric heads were generated by co-registering measured attachment boundaries with underlying skull models created from cone-beam computerized tomography (CBCT) images. A bounding box technique was used to quantify 3D muscle attachment size, shape, location, and orientation. Musculoskeletal models of the mandible were then developed and validated to assess the impact of 3D muscle attachment morphometry on joint loading during jaw maximal open-close. The 3D morphometry revealed that muscle lengths and moment arms of temporalis and masseter muscles varied substantially among muscle fibers. The values calculated from the centroid-to-centroid model were significantly different from those calculated using the 'Distributed model', which considered crucial 3D muscle attachment morphometry. Consequently, joint loading was underestimated by more than 50% in the centroid-to-centroid model. Therefore, it is necessary to consider 3D muscle attachment morphometry, especially for muscles with broad attachments, in TMJ musculoskeletal models to precisely quantify the joint mechanical environment critical for understanding TMJ function and mechanobiology.

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.

Anatomic Customization of Root-Analog Dental Implants With Cone-Beam CT and CAD/CAM Fabrication: A Cadaver-Based Pilot Evaluation

Existing root-analog dental implant systems have no standardized protocols regarding retentive design, surface manipulation, or prosthetic attachment design relative to the site's unique anatomy. Historically, existing systems made those design choices arbitrarily. For this report, strategies were developed that deliberately reference the adjacent anatomy, implant and restorable path of draw, and bone density for implant and retentive design. For proof of concept, dentate arches from human cadavers were scanned using cone-beam computed tomography and then digitally modeled. Teeth of interest were virtually extracted and manipulated via computer-aided design to generate root-analog implants from zirconium. We created a stepwise protocol for analyzing and developing the implant sites, implant design and retention, and prosthetic emergence and connection all from the pre-op cone-beam data. Root-analog implants were placed at the time of extraction and examined radiographically and mechanically concerning ideal fit and stability. This study provides proof of concept that retentive root-analog implants can be produced from cone-beam data while improving fit, retention, safety, esthetics, and restorability when compared to the existing protocols. These advancements may provide the critical steps necessary for clinical relevance and success of immediately placed root-analog implants. Additional studies are necessary to validate the model prior to clinical trial.

Tensile biomechanical properties of human temporomandibular joint disc: Effects of direction, region and sex

Approximately 30% of temporomandibular joint (TMJ) disorders include degenerative changes to the articular disc, with sex-specific differences in prevalence and severity. Limited tensile biomechanical properties of human TMJ discs have been reported. Stress relaxation tests were conducted on TMJ disc specimens harvested bilaterally from six males and six females (68.9±7.9 years), with step-strain increments of 5%, 10%, 15%, 20% and 30%, at 1% strain-per-second. Stress versus strain plots were constructed, and Young׳s Modulus, Instantaneous Modulus and Relaxed Modulus were determined. The effects of direction, region, and sex were examined. Regional effects were significant (p<0.01) for Young׳s Modulus and Instantaneous Modulus. Anteroposteriorly, the central region was significantly stiffer than medial and lateral regions. Mediolaterally, the posterior region was significantly stiffer than central and anterior regions. In the central region, anteroposteriorly directed specimens were significantly stiffer compared to mediolateral specimens (p<0.04). TMJ disc stiffness, indicated by Young׳s Modulus and Instantaneous Modulus, was higher in directions corresponding to high fiber alignment. Additionally, human TMJ discs were stiffer for females compared to males, with higher Young׳s Modulus and Instantaneous Modulus, and female TMJ discs relaxed less. However, sex effects were not statistically significant. Using second-harmonic generation microscopy, regional collagen fiber organization was identified as a potentially significant factor in determining the biomechanical properties for any combination of direction and region. These findings establish structure-function relationships between collagen fiber direction and organization with biomechanical response to tensile loading, and may provide insights into the prevalence of TMJ disorders among women.