Leptin receptor gene deficiency minimally affects osseointegration in rats

Metabolic syndrome represents a cluster of conditions such as obesity, hyperglycaemia, dyslipidaemia, and hypertension that can lead to type 2 diabetes mellitus and/or cardiovascular disease. Here, we investigated the influence of obesity and hyperglycaemia on osseointegration using a novel, leptin receptor-deficient animal model, the Lund MetS rat. Machined titanium implants were installed in the tibias of animals with normal leptin receptor (LepR+/+) and those harbouring congenic leptin receptor deficiency (LepR-/-) and were left to heal for 28 days. Extensive evaluation of osseointegration was performed using removal torque measurements, X-ray micro-computed tomography, quantitative backscattered electron imaging, Raman spectroscopy, gene expression analysis, qualitative histology, and histomorphometry. Here, we found comparable osseointegration potential at 28 days following implant placement in LepR-/- and LepR+/+ rats. However, the low bone volume within the implant threads, higher bone-to-implant contact, and comparable biomechanical stability of the implants point towards changed bone formation and/or remodelling in LepR-/- rats. These findings are corroborated by differences in the carbonate-to-phosphate ratio of native bone measured using Raman spectroscopy. Observations of hypermineralised cartilage islands and increased mineralisation heterogeneity in native bone confirm the delayed skeletal development of LepR-/- rats. Gene expression analyses reveal comparable patterns between LepR-/- and LepR+/+ animals, suggesting that peri-implant bone has reached equilibrium in healing and/or remodelling between the animal groups.

circRNA422 enhanced osteogenic differentiation of bone marrow mesenchymal stem cells during early osseointegration through the SP7/LRP5 axis

Circular RNAs (circRNAs) play an important role in biological activities, especially in regulating osteogenic differentiation of stem cells. However, no studies have reported the role of circRNAs in early osseointegration. Here we identified a new circRNA, circRNA422, from rat bone marrow mesenchymal stem cells (BMSCs) cultured on sandblasted, large-grit, acid-etched titanium surfaces. The results showed that circRNA422 significantly enhanced osteogenic differentiation of BMSCs with increased expression levels of alkaline phosphatase, the SP7 transcription factor (SP7/osterix), and lipoprotein receptor-related protein 5 (LRP5). Silencing of circRNA422 had opposite effects. There were two SP7 binding sites on the LRP5 promoter, indicating a direct regulatory relationship between SP7 and LRP5. circRNA422 could regulate early osseointegration in in vivo experiments. These findings revealed an important function of circRNA422 during early osseointegration. Therefore, circRNA422 may be a potential therapeutic target for enhancing implant osseointegration.

A preliminary, observational study using whole-blood RNA sequencing reveals differential expression of inflammatory and bone markers post-implantation of percutaneous osseointegrated prostheses

AIMS

While the benefits of direct skeletal attachment of artificial limbs are well recognized, device failure due to infection and insufficient osseointegration remain obstacles to obtaining consistently successful outcomes. Currently, the potential for device failure is assessed by subjective pain, clinical function scores, radiographic evidence of bone atrophy, and the presence of radiolucent lines at the bone-implant interface, and subjective pain and function scores. Our hypothesis is that measurable biological indices might add another objective means to assess trends toward bone and stomal healing. This longitudinal cohort study was undertaken to identify potential serological biomarkers suggestive of bone remodeling and the presence of stomal tissue inflammation.

METHODS

Ten unilateral transfemoral amputee veterans, who were implanted with a percutaneous osseointegrated (OI) skeletal limb docking system, were recruited to participate in this IRB-approved study. Venous blood samples were obtained from before the Stage 1 Surgery up to 1 year following the Stage 2 Surgery. Whole-blood RNA was extracted, sequenced, mapped, and analyzed. Of the significant differentially expressed (DEGs) genes (p<0.05) identified, four genes of interest (IL12B, IL33, COL2A1, and SOST) were validated using qPCR. Enrichment analysis was performed to identify significant (p<0.01) Gene Ontology (GO) terms.

RESULTS

Most differentially expressed genes were only detected at PoS1 immediately after the first surgery. Of the significant genes identified, IL12B and IL33 were related to inflammation, and COL2A1 and SOST were associated with bone remodeling. These four genes were identified with greater than 20 log fold-change.

CONCLUSION

Whole-blood RNA-seq data from 10 patients who previously underwent percutaneous osseointegrated lower limb implantation revealed four genes of interest that are known to be involved in inflammation or bone remodeling. If verified in future studies, these genes may serve as markers for predicting optimal bone remodeling and stomal tissue healing following OI device implantation.

On-Bone Fixation of Free Gingival Graft Induces an Osteoinductive Effect in Human Alveolar Bone

We examined alveolar bone samples in the area of on-bone fixation of a free gingival graft performed during surgery in patients aged 37-55 years with a diagnosis of secondary partial adentia of the upper and lower jaws. Six months after fixation of the graft in the alveolar bone, foci of neoosteogenesis were found in the contact zone. They were characterized by the appearance of appositional lines, cords of basophilic osteoblasts, and growing osteons. An immunohistochemical study revealed an increase in the number of CD44⁺, CD29⁺, and osteocalcin+ cells in the layer of the outer circumferential lamellae, primary osteons, and the lining of the Haversian canals. TGF-β1⁺ cells were located in the intertrabecular reticular tissue and wall of microvessels. The results indicate activation of mesenchymal stem cells in the area of localization of the graft and differentiating osteoblasts. The observed osteoinductive effect of free gingival graft is associated with its participation in reorganization in MSC and induction of morphogenetic molecules.

RGD Mutation of the Heparin Binding II Fragment of Fibronectin for Guiding Mesenchymal Stem Cell Behavior on Titanium Surfaces

Installing bioactivity on metallic biomaterials by mimicking the extracellular matrix (ECM) is crucial for stimulating specific cellular responses to ultimately promote tissue regeneration. Fibronectin is an ECM protein commonly used for biomaterial functionalization. The use of fibronectin recombinant fragments is an attractive alternate to the use of full-length fibronectin because of the relatively low cost and facility of purification. However, it is necessary to combine more than one fragment, for example, the cell attachment site and the heparin binding II (HBII), either mixed or in one molecule, to obtain complete activity. In the present study, we proposed to install adhesion capacity to the HBII fragment by an RGD gain-of-function DNA mutation, retaining its cell differentiation capacity and thereby producing a small and very active protein fragment. The novel molecule, covalently immobilized onto titanium surfaces, maintained the growth factor-binding capacity and stimulated cell spreading, osteoblastic cell differentiation, and mineralization of human mesenchymal stem cells compared to the HBII native protein. These results highlight the potential capacity of gain-of-function DNA mutations in the design of novel molecules for the improvement of osseointegration properties of metallic implant surfaces.

Comparative Evaluation of Different Bone Markers in Peri-implant Crevicular Fluid of Immediate Loaded and Nonloaded Dental Implants

AIM

The present study was conducted to determine different bone markers in immediate loaded and nonloaded dental implants.

MATERIALS AND METHODS

It comprised of 60 patients (males-30, females-30) which were divided into two groups of 30 each. Group I received immediate loaded dental implants, and group II received non-loaded dental implants. Modified bleeding on probing index, peri-implant sulcus depth was assessed in both groups at 1 month, 2 months, 3 months and 4 months. The crevicular fluid was obtained to determine bone markers levels such as transforming growth factor-alpha (TGF-a), osteocalcin (OCN), osteopontin (OPN), parathyroid hormone (PTH) and osteoprotegerin (OPG).

RESULTS

Both groups revealed non-significant difference in modified bleeding on probing index and peri-implant sulcus depth (p > 0.05). Bone markers found to be elevated more in group I as compared to group II. However, the difference was non- significant (p > 0.05).

CONCLUSION

Transforming growth factor alpha (TGF-a), OCN, OPN, OPG and PTH and parathyroid hormone (PTH) levels were higher in immediate loaded dental implants as compared to nonloaded dental implants.

CLINICAL SIGNIFICANCE

Immediate loaded dental implants showed an increase in expression of bone markers such as TNF-a, OCN, OPN, PTH and OPG which may be useful in deciding future of immediate loaded dental implants.

Enhancement of Bone Marrow-Derived Mesenchymal Stem Cell Osteogenesis and New Bone Formation in Rats by Obtusilactone A

The natural pure compound obtusilactone A (OA) was identified in Cinnamomum kotoense Kanehira &amp; Sasaki, and shows effective anti-cancer activity. We studied the effect of OA on osteogenesis of bone marrow-derived mesenchymal stem cells (BMSCs). OA possesses biocompatibility, stimulates Alkaline Phosphatase (ALP) activity and facilitates mineralization of BMSCs. Expression of osteogenesis markers BMP2, Runx2, Collagen I, and Osteocalcin was enhanced in OA-treated BMSCs. An in vivo rat model with local administration of OA via needle implantation to bone marrow-residing BMSCs revealed that OA increased the new bone formation and trabecular bone volume in tibias. Micro-CT images and H&amp;E staining showed more trabecular bone at the needle-implanted site in the OA group than the normal saline group. Thus, OA confers an osteoinductive effect on BMSCs via induction of osteogenic marker gene expression, such as BMP2 and Runx2 expression and subsequently elevates ALP activity and mineralization, followed by enhanced trabecular bone formation in rat tibias. Therefore, OA is a potential osteoinductive drug to stimulate new bone formation by BMSCs.

The effect of magnesium on early osseointegration in osteoporotic bone: a histological and gene expression investigation

Magnesium has a key role in osteoporosis and could enhance implant osseointegration in osteoporotic patients. Titanium implants impregnated with Mg ions were installed in the tibia of ovariectomized rats. The release of Mg induced a significant increase of bone formation and the expression of anabolic markers in the peri-implant bone.

INTRODUCTION

The success of endosseous implants is highly predictable in patients possessing normal bone status, but it may be impaired in patients with osteoporosis. Thus, the application of strategies that adjuvate implant healing in compromized sites is of great interest. Magnesium has a key role in osteoporosis prevention and it is an interesting candidate for this purpose. In this study, the cellular and molecular effects of magnesium release from implants were investigated at the early healing stages of implant integration.

METHODS

Osteoporosis was induced in 24 female rats by means of ovariectomy and low-calcium diet. Titanium mini-screws were coated with mesoporous titania films and were loaded with magnesium (test group) or left as native (control group). The implants were inserted in the tibia and femur of the rats. One, 2 and 7 days after implantation, the implants were retrieved and histologically examined. In addition, expression of genes was evaluated in the peri-implant bone tissue at day 7 by means of quantitative polymerase chain reactions with pathway-oriented arrays.

RESULTS

The histological evaluation revealed that new bone formation started already during the first week of healing for both groups. However, around the test implants, new bone was significantly more abundant and spread along a larger surface of the implants. In addition, the release of magnesium induced a significantly higher expression of BMP6.

CONCLUSIONS

These results provide evidence that the release of magnesium promoted rapid bone formation and the activation of osteogenic signals in the vicinity of implants placed in osteoporotic bone.

Use of supercharged cover screw as static magnetic field generator for bone healing, 1st part: in vitro enhancement of osteoblast-like cell differentiation

Since 1979, Pulsed electromagnetic fields (PEMFs) have been approved by the Food and Drug Administration as an effective method in the treatment of non-unions. As well as PEMFs, also static magnetic fields (SMFs) have been widely investigated in orthopaedic studies. Even if the exact mechanism of action is not well understood, a large number of studies showed specific effects both at cellular and tissue levels. As bone fracture healing and osseointegration share the same biological events, the application of magnetic field stimulation in order to facilitate the osseointegration process has been suggested. In this study we investigated the proliferation rate and gene expression profile of MG63 osteoblastic-like cells after a 24, 48 and 72-hour SMF stimulation, generated by a small, customized cover screw-shaped neodymium-iron-bore magnet placed in the inner cavity of a dental implant. As a result, we found that the application of a SMF to osteoblastic-like cells does slightly decrease cell proliferation rate while enhancing the expression of those genes correlated to differentiation and mineralization. Our findings represent, to our knowledge, the first clinical ready technique for dental implants showing the ability of SMF to promote the osteogenesis process in vitro.

Genes Differentially Expressed in Titanium Implant Healing

Bone generation occurs around titanium implants; however, its underlying mechanisms are unknown. We hypothesized that molecular determinants distinct from those undertaking normal bone healing regulate osseointegration. Using differential display-polymerase chain-reaction in the male rat model, we isolated 3 genes that are differentially expressed in bone healing with implants, but not in osteotomy healing. A homology search indicated that these 3 genes are apolipoprotein E, prolyl 4-hydroxylase α-subunit, and an unknown transcript. Differential expression of these genes was remarkable during early healing stages up to week 2, and accelerated with rough acid-etched surfaces compared with machined surfaces. The differential expression was confirmed in the female rats, with enhanced expression for the acid-etched surfaces. The osseointegration-unfavorable condition created by gonadal estrogen deficiency reduced the level of differential expression. This study provides evidence that selected gene transcripts are induced by titanium implants under regulatory control strongly associated with the nature of osseointegration.

Molecular assessment of osseointegration in vivo: a review of the current literature

This paper reports on the results of a structured review of the literature concerning in vivo molecular assessment of osseointegrated endosseous dental implants. A search of electronic databases was performed up to and including August 2011. Thirty articles met the inclusion criteria. A descriptive evaluation and analysis of the gene expression data concerning the process of osseointegration were performed. Broad consensus was observed among the study results, perhaps as a result of the similar targeted gene expression events. More recent investigations using gene arrays or gene profiling techniques offer new insights into the fundamental molecular events that support the osseointegration process. Evidence for the influence of surface topography on osteogenesis and osteoinduction has been reported. Additional investigations are required to further solidify the functional associations between individual or orchestrated gene expression events and the clinical result of osseointegration.

Direct role of interrod spacing in mediating cell adhesion on Sr-HA nanorod-patterned coatings

The process in which nanostructured surfaces mediate cell adhesion is not well understood, and may be indirect (via protein adsorption) or direct. We prepared Sr-doped hydroxyapatite (Sr1-HA) 3D nanorods (with interrod spacing of 67.3 ± 3.8, 95.7 ± 4.2, and 136.8 ± 8.7 nm) and 2D nanogranulate patterned coatings on titanium. Employing the coatings under the same surface chemistry and roughness, we investigated the indirect/direct role of Sr1-HA nanotopographies in the regulation of osteoblast adhesion in both serum-free and serum-containing Dulbecco's Modified Eagle/Ham's Medium. The results reveal that the number of adherent cells, cell-secreted anchoring proteins (fibronectin, vitronectin, and collagen), vinculin and focal adhesion kinase (FAK) denoted focal adhesion (FA) contact, and gene expression of vinculin, FAK, and integrin subunits (α2, α5, αv, β1, and β3), undergo significant changes in the inter-nanorod spacing and dimensionality of Sr1-HA nanotopographies in the absence of serum; they are significantly enhanced on the <96 nm spaced nanorods and more pronounced with decreasing interrod spacing. However, they are inhibited on the >96 nm spaced nanorods compared to nanogranulated 2D topography. Although the adsorption of fibronectin and vitronectin from serum are higher on 136.8 ± 8.7 nm spaced nanorod patterned topography than nanogranulated topography, cell adhesion is inhibited on the former compared to the latter in the presence of serum, further suggesting that reduced cell adhesion is independent of protein adsorption. It is clearly indicated that 3D nanotopography can directly modulate cell adhesion by regulating integrins, which subsequently mediate anchoring proteins' secretion and FA formation rather than via protein adsorption.

Smoking and diabetes. Epigenetics involvement in osseointegration

Bone quality is a poorly defined parameter for successful implant placement, which largely depends upon many environmental and genetic factors unique to every individual. Smoking and diabetes are among the environmental factors that most impact osseointegration. However, there is an inter-individual variability of bone response in smokers and diabetic patients. Recent data on gene-environment interactions highlight the major role of epigenetic changes to induce a specific phenotype. Histone acetylation and DNA methylation are the main events that occur and modulate the gene expression. In this paper, we emphasize the impact of epigenetics on diabetes and smoking and describe their significance in bone healing. Also, we underscore the importance of adopting a new approach in clinical management for implant placement by customizing the treatment according to the patient's specific characteristics.

The bone-forming effects of HIF-1α-transduced BMSCs promote osseointegration with dental implant in canine mandible

The presence of insufficient bone volume remains a major clinical problem for dental implant placement to restore the oral function. Gene-transduced stem cells provide a promising approach for inducing bone regeneration and enhancing osseointegration in dental implants with tissue engineering technology. Our previous studies have demonstrated that the hypoxia-inducible factor-1α (HIF-1α) promotes osteogenesis in rat bone mesenchymal stem cells (BMSCs). In this study, the function of HIF-1α was validated for the first time in a preclinical large animal canine model in term of its ability to promote new bone formation in defects around implants as well as the osseointegration between tissue-engineered bone and dental implants. A lentiviral vector was constructed with the constitutively active form of HIF-1α (cHIF). The ectopic bone formation was evaluated in nude mice. The therapeutic potential of HIF-1α-overexpressing canine BMSCs in bone repair was evaluated in mesi-implant defects of immediate post-extraction implants in the canine mandible. HIF-1α mediated canine BMSCs significantly promoted new bone formation both subcutaneously and in mesi-implant defects, including increased bone volume, bone mineral density, trabecular thickness, and trabecular bone volume fraction. Furthermore, osseointegration was significantly enhanced by HIF-1α-overexpressing canine BMSCs. This study provides an important experimental evidence in a preclinical large animal model concerning to the potential applications of HIF-1α in promoting new bone formation as well as the osseointegration of immediate implantation for oral function restoration.

Implantomania: prosthodontics at a crossroads

Throughout the 1980s and '90s, a small core group of clinical scholars played a major and pivotal role in the combined surgical and prosthodontic dissemination of osseointegration scholarship. As professor of oromaxillofacial surgery at the University of Washington, Dr Philip Worthington was one such pioneering educator. His academic leadership was acknowledged via numerous academic honors and tributes, including his recent postretirement recognition as distinguished professor at his university. This invited paper is a personal assessment of the impact of clinical changes ushered in by the osseointegration technique and was recently presented at the University of Washington's unique celebratory tribute to Professor Worthington.

Genetic susceptibility to dental implant failure: a critical review

The observation that clinical factors alone do not explain why some patients develop implant loss; the understanding of the osseointegrated implant failure as a complex, multifactorial process; and the observed aggregation of repetitive failure in certain individuals raise interesting questions related to host susceptibility to dental implant failure. Genetic analysis applied to dental implants began in the late 1990s, and since then, increased interest in genetic susceptibility to the phenotype has been demonstrated by several studies. These studies, however, have been based on and limited to candidate gene association analysis and were intended to find associations between specific alleles and/or genotypes of genetic markers and susceptibility to implant failure. The aim of this review is to provide a brief description of the current methodology for genetic analysis of complex traits, followed by a comprehensive review of the literature related to genetic susceptibility to dental implant failure and a discussion of different aspects of the applied methodology. Moreover, a novel approach of genome wide, case-control analysis is discussed as an alternative method to access genetic influence to dental implant failure mechanisms. Advances toward the elucidation of the genetic basis of dental implant loss may contribute to the understanding of why some patients do not respond to currently available treatments while others do and provide potential targets for effective screening, prevention, and treatment. For example, clinicians might be able to estimate, before the elective surgical procedure, the risk of a given patient to develop a negative individual host response.

Biological responses in osteoblast-like cell line according to thin layer hydroxyapatite coatings on anodized titanium

Several features of the implant surface, such as roughness, topography and composition play a relevant role in implant integration with bone. This study was conducted in order to determine the effects of various thin layer hydroxyapatite (HA) coatings on anodized Ti surfaces on the biological responses of a human osteoblast-like cell line (MG63). MG63 cells were cultured on 100 nm HA (100 nm HA coating on anodized surface), 500-700 nm HA (500-700 nm HA coating on anodized surface), 1 mum HA (1 mum HA coating on anodized surface) and anodize (non-HA coating on anodized surface) Ti. The morphology of these cells was assessed by scanning electron microscopy (SEM). The cDNAs prepared from the total RNAs of the MG63 were hybridized into a human cDNA microarray (1152 elements). The appearances of the surfaces observed by SEM were different on each of the four dental substrate types. MG63 cells cultured on 100 nm HA, 1 mum HA and anodize exhibited cell-matrix interactions. It was 500-700 nm HA surface showing cell-cell interaction. In the expression of genes involved in osseointegration, several genes, including bone morphogenetic protein 2, latent transforming growth factor beta binding protein 1, catenin (cadherin-associated protein), integrin, PDGFRB and GDF-1 growth differentiation factor 1 were up-regulated on the different surfaces. Several genes, including fibroblast growth factor receptor 3, fibroblast growth factor 12 and CD4 were down-regulated on the different surfaces. The attachment and expression of key osteogenic regulatory genes were enhanced by the surface morphology of the dental materials used.

The osteoinductive properties of Nell-1 in a rat spinal fusion model

BACKGROUND CONTEXT

Recombinant growth factors bone morphogenetic protein-2 (BMP-2) and BMP-7 are currently approved for human use but are associated with various adverse effects including ectopic bone formation and local inflammatory reaction. The development of alternative growth factors may help minimize the adverse effects of current osteoinductive therapeutics. Nell-1 (Nel-like molecule-1; Nel [a protein strongly expressed in neural tissue encoding epidermal growth factor like domain]) is a novel secretory molecule that appears to act more specifically on osteoblasts than the BMPs, which can act on multiple cell types. From a molecular point of view, Nell-1 is directly regulated by runt-related transcription factor 2 (Runx2/Cbfa1), a master regulatory gene controlling bone formation. Previous studies showed that Nell-1 accelerates osteogenic differentiation in vitro and calvarial bone formation in vivo. We hypothesize that Nell-1 may also effectively form bone in spinal fusion.

PURPOSE

Our primary aim was to assess if direct adenoviral gene delivery with Nell-1 in a demineralized bone matrix (DBM) carrier can improve spinal fusion in a rat model. Because adenoviral vectors allow for sustained growth factor delivery, they were used for initial feasibility testing before protein studies.

STUDY DESIGN/SETTING

Two groups of 20 athymic rats underwent posterolateral intertransverse process spinal fusion at L4-L5 with implanted DBM carrier containing either adenovirus coding for Nell-1 (AdNell-1) or control, Lac Z (AdLacZ). No cells were implanted. The 20 rats were sacrificed at 6 weeks for evaluation of spinal fusion.

METHODS

All animals underwent Faxitron radiographs at 2, 4, and 6 weeks, manual spine palpation at 6 weeks, and high-resolution micro computerized tomography (microCT) at 6 weeks. Spinal fusion rate was assessed by: 1) 6-week Faxitron images; 2) manual palpation by three independent observers; 3) microCT; and 4) histology. New bone formation was assessed by hematoxylin-eosin and Masson trichrome staining on decalcified, coronally sectioned spine segments.

RESULTS

All differences achieved statistical significance. After 6 weeks, direct application of adenoviral Nell-1 in a DBM carrier achieved significantly higher rates of spinal fusion over Lac Z controls: 60% Nell-1 versus 20% Lac Z by manual palpation and 70% Nell-1 versus 20% Lac Z by microCT and histology. Histological assessment of bone quality and maturity revealed more mature, higher quality bone in all the Nell-1 treated specimens relative to Lac Z at 6 weeks.

CONCLUSIONS

Spinal fusion is more accurately assessed by microCT and histology than manual palpation. Direct application of adenoviral Nell-1 in a DBM carrier achieved significantly higher rates of spinal fusion over Lac Z controls at 6 weeks. Direct application of adenoviral Nell-1 in a DBM carrier also achieved significantly higher rates of spinal fusion over other reports in the literature using direct adenoviral BMP application. Direct application of adenoviral BMP in an allograft carrier achieved 8% fusion for BMP-2 and 16% fusion for BMP-7 at 8 weeks. These results indicate that Nell-1 may be a potent osteoinductive molecule. In addition, the regulation of Nell-1 by the master bone regulatory gene, Runx2 suggests that Nell-1 may exert its effects more specifically in osteoblastic cells than BMPs which affect multiple cell types. Overall, Nell-1 may fulfil a current need for an osteoinductive factor.

The initial attachment and subsequent behavior regulation of osteoblasts by dental implant surface modification

The aim of this study was to investigate the influence of hydrophobic acid-etched (A) and coarse-blasted large-grit and acid-etched (SLA) surfaces as well as hydrophilic modified acid-etched (modA) and modified coarse-blasted large-grit and acid-etched (modSLA) surfaces on the behavior of MG63 cells grown on these surfaces through determination of cell attachment and cell proliferation, time-lapse microscopy of fluorescence-labeled cells, and determination of gene expression by reverse transcription-polymerase chain reaction (RT-PCR). No significant difference of cell attachment on various titanium surfaces was found. Increased cell proliferation was observed on the A surface and the SLA surface compared with the modA surface and the modSLA surface. After 2 days of incubation, on modSLA and modA surfaces a tendency of formation of cell clusters has been observed, which was most pronounced on modSLA surface. On the A and the SLA surface, cell cluster formation started after longer incubation periods. The expression level of the bone-associated genes (alkaline phosphatase, osteocalcin, type-I-collagen, osteoprotegerin, and glyceraldehyde-3-phosphate-dehydrogenase) detected by RT-PCR was highest on the modSLA surface. In conclusion it has been demonstrated that the modSLA surface results in an enhanced cluster formation of osteoblasts grown on this surface and in an increased expression of key osteogenic regulatory genes in osteoblasts.

Effect of various implant coatings on biological responses in MG63 using cDNA microarray

During the process of bone formation, titanium (Ti) surface is an important factor in the modulation of osteoblastic function. This study was conducted in order to determine the effects of different Ti surfaces on the biological responses of a human osteoblast-like cell line (MG63). MG63 cells were cultured on smooth (S), sandblasted large-grit and acid etching (SLA), hydroxyapatite (HA), hydroxyfluoride (HF), titanium nitrate (TIN), and diamond-like carbon (DLC) Ti. The morphology of these cells were assessed by SEM. The cDNAs prepared from the total RNAs of the MG63 were hybridized into a human cDNA microarray (1152 elements). The appearances of the surfaces observed by SEM were different on each of the six dental substrate types. The SLA and HA surfaces were determined to be rougher than the others. MG63 cells cultured on SLA and HA exhibited cell-matrix interactions. In the expression of genes involved in osseointegration, several genes, including bone morphogenetic protein, cadherin, integrin, and insulin-like growth factors, were upregulated on the different surfaces. Several genes, including fibroblast growth factor receptor 4, Bcl 2-related protein, and collagen, were downregulated on the different surfaces. The attachment and expression of key osteogenic regulatory genes were enhanced by the surface roughness of the dental materials used.

Effects of implant surface microtopography on osteoblast gene expression

AIM

The promotion of osteoblast attachment and differentiation has been evaluated on various implant surfaces. However, the effects of different implant surface properties on gene expression of key osteogenic factors are not fully understood.

OBJECTIVE

The objectives of this study were to evaluate how topographical effects on titanium surface alter the expression of bone-related genes and transcription factors.

METHODS

Osteoblasts were cultured on titanium disks prepared with a titanium dioxide grit blasting (TiOBlast) or grit blasted and etched with hydrofluoric acid (Osseospeed), grit blasted and etched (SLA-1), or grit blasted, etched and rinsed with N2 protection and stored in isotonic NaCl (SLA-2) commercially pure titanium implant discs. High-density cultures of human mesenchymal pre-osteoblastic cells (HEPM 1486, ATCC) were grown for 72 h and real-time PCR used for quantitative analysis of alkaline phosphatase (ALP), core-binding factor alpha1 (Cbfa1), Osterix, Type I Collagen, Osteocalcin and bone sialoprotein II gene expression.

RESULTS

Real-time PCR showed significant (P<0.001) increases in ALP gene expression in osteoblasts grown on SLA-2, relative to all other surfaces. Cbfa1/RUNX-2 gene expression was significantly (P<0.01) increased on Osseospeed and TiOBlast surface as compared with SLA-1 and SLA-2 surfaces. The expression of Osterix had a trend similar to that of Cbfa1.

CONCLUSION

In conclusion, implant surface properties may contribute to the regulation of osteoblast differentiation by influencing the level of bone-related genes and transcription factors in human mesenchymal pre-osteoblastic cells.

Effects of titanium particle size on osteoblast functions in vitro and in vivo

The formation of titanium (Ti)-wear particles during the lifetime of an implant is believed to be a major component of loosening due to debris-induced changes in bone cell function. Radiographic evidence indicates a loss of fixation at the implant-bone interface, and we believe that the accumulation of Ti particles may act on the bone-remodeling process and impact both long- and short-term implant-fixation strengths. To determine the effects of various sizes of the Ti particles on osteoblast function in vivo, we measured the loss of integration strength around Ti-pin implants inserted into a rat tibia in conjunction with Ti particles from one of four size-groups. Implant integration is mediated primarily by osteoblast adhesion/focal contact pattern, viability, proliferation and differentiation, and osteoclast recruitment at the implant site in vivo. This study demonstrates the significant attenuation of osteoblast function concurrent with increased expression of receptor activator of nuclear factor kappaB ligand (RANKL), a dominant signal for osteoclast recruitment, which is regulated differentially, depending on the size of the Ti particle. Zymography studies have also demonstrated increased activities of matrix metalloproteinases (MMP) 2 and 9 in cells exposed to larger Ti particles. In summary, all particles have adverse effects on osteoblast function, resulting in decreased bone formation and integration, but different mechanisms are elicited by particles of different sizes.

Analysis of the transforming growth factor-beta 1 gene promoter polymorphisms in early osseointegrated implant failure

Transforming growth factor-beta 1 is a multifunctional cytokine involved in extracellular matrix deposition, reduction of inflammation, and promotion of wound healing. Single nucleotide polymorphisms in the promoter region of human transforming growth factor-beta 1 gene, C-509T and G-800A, have been shown to increase the transcriptional activity of this cytokine and have been associated with a variety of diseases. The objective of this study was to investigate the possible association between these single nucleotide polymorphisms and the early implant failure. A sample of 68 nonsmoking patients was divided into two groups: a test group comprising 28 patients with one or more early failed implants and a control group consisting of 40 individuals with one or more healthy implants. Genomic DNA from oral mucosa was amplified by polymerase chain reaction and analyzed by restriction fragment length polymorphism. The significance of the differences in observed frequencies of single nucleotide polymorphisms was assessed using the chi square test and Fisher's exact test. The cited single nucleotide polymorphisms in transforming growth factor-beta 1 were analyzed in combination as haplotype using the computer program ARLEQUIN. The authors did not observe significant differences in the allele and genotypes to both single nucleotide polymorphisms of transforming growth factor-beta 1 gene (C-509T and G-800A) between control and early implant failure groups. The distribution of the haplotypes arranged as allele and genotypes were similar between control and test groups. These results indicate that C-509T and G-800A polymorphisms in the transforming growth factor-beta 1 gene are not associated separately or in haplotype combinations with early implant failure, suggesting that the presence of those single nucleotide polymorphisms alone do not constitute a genetic risk factor for early implant failure in the Brazilian population.

Impact of IL-1 genotype and smoking status on the prognosis of osseointegrated implants

AIM

This study evaluated the impact of the IL-1 genotype and smoking status on the prognosis and development of complications of osseointegrated implants.

MATERIAL AND METHODS

The clinical charts of 180 consecutively admitted patients were analyzed with respect to the occurrence of biological complications in conjunction with oral implants. Biologic complications were defined as clinical conditions with suppuration from the peri-implant sulcus, development of a fistula or peri-implantitis with radiologic bone loss. All patients had received one or more ITI dental implants, which had been in function for at least 8 (range: 8-15) years. This patient population had received 292 implants. From these, 51 implants in 34 patients showed late (infectious) biologic complications, and 241 implants had survived without any biologic complications at all.

RESULTS

Of the 180 patients, 53 were smokers, who were subdivided in a series of classes according to their intensity of smoking and 127 were never smokers. Sixty-four of 180 (36%) patients tested positive for the IL-1 genotype polymorphism. This prevalence corresponds to previous reports for the prevalence of European descent populations. The results for the non-smoking group indicated no significant correlation between implant complications and a positive IL-1 genotype. However, there was a clear association for heavy smokers between a positive IL-1 genotype and implant complications. 6 of 12 or half of the heavy smokers and IL-1 genotype-positive patients had either an implant failure, i.e. loss of implant, or a biologic complication during the follow-up period.

CONCLUSIONS

These findings have led to the conclusion that there is a synergistic effect between a positive IL-1 genotype and smoking that puts dental implants at a significantly higher risk of developing biologic complications during function.

Analysis of MG63 osteoblastic-cell response to a new nanoporous implant surface by means of a microarray technology

Surface implant modifications have been shown to have a relevant importance in modifying cell response. Expression profiling by DNA microarray is a new molecular technology that allows the analysis of gene expression in a cell system. By using DNA microarrays containing 19,200 genes, we identified in osteoblast-like cells line (MG-63) on new implant surface (nanoPORE, Out-Link, Sweden and Martina, Due Carrare, Padova, Italy), several genes whose expressions were significantly down-regulated. The differentially expressed genes cover a broad range of functional activities: (a) immunity, (b) vesicular transport (c) apoptosis and cell cycle regulation. It was also possible to detect some genes whose function is unknown. The data reported are, to our knowledge, the first genetic portrait of an implant surface. They can be relevant to better understand the molecular mechanism of implant osseointegration and as a model for comparing other materials.

[Experimental pilot study on surface activation of implants with liposomal vectors]

BACKGROUND

Surface coating with mitogenic or morphogenic proteins can improve the healing of bone adjacent to implants and increase the bone-implant interface. Clinical surveys have shown liposome-mediated gene transfer to be a promising and safe new therapeutic method. The aim of our study was to evaluate an experimental model of new approaches for topical treatment of the implant surface and of periimplant defects by using DNA liposomes encoding for BMP-2 (bone morphogenetic protein).

MATERIAL AND METHODS

A total of 27 implants (3.5 x 14 mm) were placed in critically sized defects of the frontal skull bone of adult pigs (n=3). The bottom of the implant was placed in the base of the defect which guaranteed primary stability, whereas the superior part of the implant (10 mm) represented an implant in a defect area. Liposomes containing DNA encoding for BMP-2 and GFP (green fluorescence protein) were used. In a first trial GFP-DNA liposomes on a collagen matrix were directly applied to the periimplant defect. In a second stage, the surface of the implants was encoded with BMP-2 DNA liposomes. Subsequently, these implants were inserted in the manner described. The resulting bone samples were prepared for immunohistochemical staining. Staining for GFP was performed in the area of the defect and for BMP-2 on the bone-implant interface.

RESULTS

Immunohistochemical staining on day 3 postoperatively revealed an increased GFP expression in the periimplant defect. Therefore, the effectiveness of the liposomal vector was verified for the chosen animal model. On the surface of the implants encoded with BMP-2 DNA liposomes an increased BMP-2 expression was found. Thus, the liposomal vector system was validated also for BMP-2 DNA transfer in the chosen animal model. Further, the established system allows a sustainable and delayed release of BMP-2 in the area of the bone-implant interface.

CONCLUSIONS

As a result of the study we were able to collect data concerning the influence of implant surface conditioning on the bone-implant interface and on therapeutically relevant options for the treatment of periimplant defects. These approaches are currently being evaluated in a long-term study.

Analysis of MMP-1 and MMP-9 promoter polymorphisms in early osseointegrated implant failure

PURPOSE

Polymorphisms, such as a guanine inserted at position -1607 in the promoter region of human matrix metalloprotenase 1 (MMP-1) or a C-1562T substitution in the MMP-9 gene, have been shown to increase the transcriptional activity of these MMPs. The objective of this study was to investigate the possible relationship between these polymorphisms and early implant failure.

MATERIALS AND METHODS

Genomic DNA from oral mucosa was amplified by polymerase chain reactions (PCRs) and analyzed by restriction endonucleases. The significance of the differences in observed frequencies of polymorphisms was assessed by the chi-square and Fisher exact tests.

RESULTS

The test group comprised patients with early failure of osseointegrated oral implants. In the MMP-1 gene, 2G allele was observed in 25% of the control group and in 50% of the test group (P = .013). The genotype 1G/1G was found in 61.5% of the control group, while all patients in the test group had the genotype 1G/2G (P < .001). No differences were seen in the allele and genotype frequencies in the MMP-9 gene among the groups (P = .15 and P = .13, respectively).

DISCUSSION AND CONCLUSION

These results suggest that polymorphism in the promoter region of the MMP-1 gene may be associated with early implant failure, while polymorphism in the promoter region of the MMP-9 gene may not have a relationship with implant loss.

Analysis of Osteoblast-like MG63 Cells’ Response to a Rough Implant Surface by Means of DNA Microarray

Several features of the implant surface, such as composition, topography, roughness, and energy, play a relevant role in implant integration with bone. Little is known about the structural and chemical surface properties that may influence biological responses. Expression profiling by DNA microarray is a molecular technology that allows the analysis of gene expression in a cell system. By using DNA microarrays containing 19200 genes, we identified several genes whose expression was significantly down-regulated in osteoblast-like cell line MG63 on a new implant surface (titanium pull spray superficial [TPSS] surface, Oralplant, Cordenons, PN, Italy). The differentially expressed genes cover a broad range of functional activities: (1) signaling transduction, (2) translation, (3) cell cycle regulation, (4) structural and metabolic functions, and (5) apoptosis. It was also possible to detect some genes whose functions are unknown. The data reported can be relevant to better understand the role of the type of surface on the molecular mechanism of implant osseointegration and as a model for comparing other materials.

Molecular biologic comparison of new bone formation and resorption on microrough and smooth bioactive glass microspheres

In a recent in vitro study, chemical microroughening of a bioactive glass surface was shown to enhance attachment of MG-63 osteoblastic cells to glass. The current study was designed to delineate the effects of microroughening on the gene expression patterns of bone markers during osteogenesis and new bone remodeling on bioactive glass surface in vivo. With the use of a rat model of paired comparison, a portion of the medullary canal in the proximal tibia was evacuated through cortical windows and filled with microroughened or smooth bioactive glass microspheres. The primary bone-healing response and subsequent remodeling were analyzed at 1, 2, and 8 weeks, respectively, by radiography, pQCT, histomorphometry, BEI-SEM, and molecular biologic analyses. The expression of various genes for bone matrix components (type I collagen, osteocalcin, osteopontin, osteonectin) and proteolytic enzymes (cathepsin K, MMP-9) were determined by Northern analysis of the respective mRNAs. Paired comparison showed significant differences in the mRNAs levels for specific bone matrix components at 2 weeks: osteopontin was significantly higher (p =.01) and osteonectin significantly lower (p =.05) in bones filled with microroughened microspheres than in those filled with smooth microspheres. Bones filled with microrough microspheres also showed significantly increased ratios of cathepsin K and MMP-9 (both markers of osteoclastic resorption) to type I collagen (p =.02 and p =.02, respectively) at 2 weeks and a significantly increased expression of MMP-9 at 8 weeks (p =.05). The pQCT, histomorphometric, and BEI-SEM analyses revealed no significant differences in the pattern of bone-healing response. Based on these results, microroughening of a bioactive glass surface could trigger temporal changes in the expression of specific genes especially by promoting the resorption part of new bone-remodeling processes. Future studies are needed to evaluate if the observed changes of gene expression are directly related to the microrough surface of any biomaterial or are biomaterial specific.

Different bone integration profiles of turned and acid-etched implants associated with modulated expression of extracellular matrix genes

PURPOSE

The manner in which surface roughness of Implants affects bone-implant integration remains unknown. This study correlated morphologic profiles of bone-implant integration and extracellular matrix (ECM) gene expression in response to the placement of implants with different surface topographies.

MATERIALS AND METHODS

T-shaped hollow implants with turned and dual acid-etched (DE) surfaces were placed into rat femurs. A bone integration curve (BIC) was created from serial histomorphometric measurements within the implant chamber. The mRNA expression pattern of ECM genes in bone healing with or without implants was examined using reverse transcriptase-polymerase chain reaction.

RESULTS

At week 2, the BIC of the DE implant increased near the implant surface, whereas that of the turned implant decreased. The bone-to-implant contact rate of the DE Implant was 6- and 2.5-fold higher than that of the tuned Implant at weeks 2 and 4, respectively. A spatially standardized histomorphometry revealed that, at week 2, the DE implant had a greater bone volume than the turned implant in a zone near the implant, but not in zones distant from the implant surface. The DE implant evoked an accelerated mRNA expression for osteonectin and osteocalcin compared with the turned Implant, along with an up-regulated expression for bone sialoprotein II, collagen III, and integrins in initial healing stages up to week 1.

DISCUSSION AND CONCLUSION

The results indicate that different histologic bone integration profiles associated with increased surface roughness may be explained, in part, by the modulated expression of the selected ECM-related genes. The data provide evidence supporting the fact that gene regulation occurs at local levels of implant surfaces in vivo.

[Gene transfer in cruciate ligament surgery. Natural science-based principles and possible clinical applications]

Current challenges in anterior cruciate ligament surgery include graft remodeling and tendon-to-bone healing. The development over the past few decades of methods for delivering genes to musculoskeletal tissues has stimulated interest in its application for orthopedic problems, including anterior cruciate ligament surgery. Despite substantial progress, a number of technical issues need to be addressed before gene transfer might be considered as an approach to improve the structural and functional properties of anterior cruciate ligament grafts. The aim of this review is to illustrate the principles of somatic gene transfer and to apply them to the cells that constitute the anterior cruciate ligament. Special characteristics that dictate the experimental strategies will be outlined.

[Standardized testing of skeletal implant surfaces with an osteoblast cell culture system. IV. Specific gene expression during differentiation]

Successful osseointegration of an implant depends on the properties of the material of which it is made. A standardized cell culture system for the assessment of the biological effect of material surfaces has already been described. In the present study, this system has been extended to include the quantitative analysis of the material-dependent osteoblast gene expression. Human foetal osteoblasts (hFOB 1.19) were cultured for 3 weeks on titanium surfaces of varying roughness, and on surfaces of chromium-cobalt-molybdenum alloy (CrCoMo). Using a real time RT-PCR technique, expressions of alkaline phosphatase, collagen 1 and osteocalcin were determined as parameters of osteoblast differentiation. In comparison with CrCoMo, differentiation was accelerated on titanium. While the smooth titanium surface leads to earlier cell growth, the rough surface induces more prolonged and stronger cell proliferation. Our results confirm at the molecular level the excellent clinical biocompatibility of titanium surfaces. The real-time RT-PCR provides a new method for the quantitative assessment of material-dependent osteoblastic differentiation.

Ovariectomy hinders the early stage of bone-implant integration: histomorphometric, biomechanical, and molecular analyses

Postmenopausal osteoporosis is a contributing factor to alveolar bone atrophy associated with tooth loss in the elderly. The use of dental titanium implants has been increasingly adapted to treat these edentulous patients. This study examines whether female gonadal hormone deficiency interferes with the critical integration process between bone and implants. Two types of experimental titanium implants with acid-treated surfaces were placed in the femurs of ovariectomized (ovx) and sham-operated control rats: T-cell implants with a hollow chamber for histomorphometric and steady-state mRNA expression assays, and unthreaded cylindrical implants for biomechanical push-in tests. At week 2, less bone area was found in the ovx-implant group (p = 0.0495) than in the sham-implant group. The implant push-in test showed that the ovx-implant group had approximately half of the withstanding value of the sham-implant group (p = 0.009). However, these differences between the ovx and sham groups became diminished at week 4. Total RNA samples were examined by a reverse transcriptase-polymerase chain reaction assay for col1a1, col3a1, bone sialoprotein (bSP) II, osteonectin, osteopontin, osteocalcin, integrin beta1 and integrin beta3. In untreated bones and in created bone defects without implant placement, ovx did not affect the steady-state levels of the mRNAs tested. When implants were placed, significant upregulation of these genes was observed in the sham-implant group; however, only osteocalcin and integrins were upregulated in the ovx-implant group. The results suggest a biphasic effect of female gonadal hormone deficiency that may temporarily interfere with the early implant-tissue integration process, and which may be associated with a failure to upregulate a selected set of bone extracellular matrix genes. Once established, however, functional bone-implant integration can be achieved even in ovx rats.

Messenger ribonucleic acid expression of 16 matrix metalloproteinases in bone-implant interface tissues of loose artificial hip joints

Matrix metalloproteinases (MMPs) have been reported to be the major factors responsible for aseptic loosening of artificial hip joints. So far, messenger ribonucleic acid (mRNA) expression patterns of seven MMPs have been reported, but that of many other MMPs which have been newly discovered or recently considered to be responsible for prosthetic loosening is still unknown. In this study, mRNA expression pattern of 16 different types of MMPs were analyzed to evaluate which MMPs were locally produced and contributed to prosthetic loosening. Synovium-like interface tissues between bone and prosthesis were collected from 18 cases of aseptic loose artificial hip joint at revision surgery. Six cases of normal synovium were used as controls. Total RNA was extracted by single-step acid guanidinium-thiocyanate-phenol-chloroform procedure. mRNA expression of MMPs was analyzed by semiquantitative reverse transcription-polymerase chain reaction. Based on local expression pattern of MMPs at the mRNA level, aseptic loose artificial hip joint was characterized by elevated expression of MMP-1, MMP-9, MMP-10, MMP-12, and MMP-13; moderate expression of MMP-2, MMP-7, MMP-8, MMP-11, membrane type (MT)1-MMP (MMP-14), MT2-MMP (MMP-15), MT3-MMP (MMP-16), MT4-MMP (MMP-17), and MMP-19; lower expression of MMP-3; and little significance of MMP-20. The MMPs detected in this study can potentially degrade almost all components of the periprosthetic extracellular matrix. Thus, many MMP type enzymes possibly contribute to prosthetic loosening and osteolysis through pathologic extracellular matrix degradation and connective tissue/bone remodeling around prostheses.

Genetic potential of interfacial guided osteogenesis in implant devices

The purpose of this review is to summarise recent advances in the design and composition of bioactive surface layers of implantabile biomaterials, and thus the genetic potential of osteoprogenitor cells to recognize and respond to these diverse implanted biomaterials. Changes applied to a biomaterial's surface, in general, could improve its biocompatibility, osseointegration and durability properties, which are required for long-term implantation in the living body. In this review, the implant-bone interface was evaluated and interpreted on the basis of osteoblast cell cultures, i.e., on the genetic potential of osteoblasts to express different phenotype markers depending on the type of biomaterials used. The interface formed by in vitro-grown osteoblasts may be used to identify components of the in vivo implant-bone interface. Over the years, a large number of implant systems consisting of many different biomaterials have been introduced in dentistry and orthopaedics. This paper discusses the performance of currently used metals and other biomaterials, by focusing on the events which occur immediately after implantation and on their impact on the bone-implant interface. The review demonstrates that continuous improvements in composition, surface modality and design of implants may benefit osseointegration and clinical longevity of such implants. No load-bearing conditions or clinical status are discussed. Titanium (Ti) and calcium phosphate ceramics are regarded as the most biocompatible synthetic substances known to be used in hard tissue implantation. These biomaterials are osteoconductive, and do not induce ectopic bone formation. Nonetheless, they provide a physical matrix which is suitable for the deposition of new bone and may guide both the growth and extension of the bone. Comparative investigation evaluated that Ti implant systems appear to be apposed by more bone than ceramic systems, although alternatives concerning the type of Ti alloy and bioactive surface layer engineering, generate extremely diverse osseointegration results. Manufacturers have created an extensive range of inorganic or ceramic coatings on Ti implants in order to achieve better bone healing and osteoconduction. Biologically active molecules, added to the implant surface, represent breakthroughs in guided interfacial osteogenesis. This methodology offers an enormous potential of genetic controlling and promoting osteogenesis. The bone growth factors are not fully understood, but most researchers agree that the contact between the bioactive surface layer of the implant and bone is not static but dynamic and that the above factors may maximise the implant osseointegration.

Gene expressions of antiinflammatory mediators in THR retrieved interfacial membranes

We investigated gene expression of antiinflammatory mediators in the interfacial membranes retrieved at hip revision arthroplasty using reverse transcription-polymerase chain reaction (RT-PCR). Levels of RT-PCR products were compared with those of synovial tissue from patients with osteoarthrosis or rheumatoid arthritis. Antiinflammatory mediators such as type II interleukin (IL)-1 receptor, IL-4, IL-10, IL-1 receptor antagonist, and transforming growth factor-beta 1 (TGF-beta 1) were expressed in the interfacial membrane. In interfacial tissue, the level of IL-10 was lower, but that of the IL-1 receptor antagonist higher than in diseased synovial tissue.

Molecular methods of enhancing lumbar spine fusion

OBJECTIVE

An optimal method for spinal fusion would induce rapid growth of bone via an osteoconductive and osteoinductive implant. This study examines the spinal fusion enhancement potential of some osteoconductive and osteoinductive biomaterials.

METHODS

Four similar canines received unilateral posterolateral fusions on the left side at T13-L1 and L4-L5 and on the right side at L2-L3 and L6-L7. The experiments were grouped as follows: Group A, autogenous bone harvested from the iliac crest; Group B, autogenous bone and collagen; Group C, no implant; and Group D, autogenous bone, collagen, and recombinant human bone morphogenetic protein-2. Radiographic assessment, three-dimensional computed tomographic volumetric analysis, and biomechanical testing were performed at each level.

RESULTS

For Groups A and B, the fusions demonstrated moderate bone formation at 6 and 12 weeks postoperatively. Group D fusions exhibited earlier and more dramatic increases in volume and radiodensity and eventually were comparable in size to the vertebral bodies. Average fusion volumes computed from three-dimensional computed tomographic analysis were: Group A = 1.243 cc, Group B = 0.900 cc, Group C = 0.000 cc, and Group D = 6.668 cc (P = 0.003 compared to Group A). Group D exhibited flexion and extension biomechanical properties much greater than controls. The addition of recombinant human bone morphogenetic protein-2 consistently yielded the strongest fused segments and, on average, enhanced extension stiffness by 626% and flexion stiffness by 1120% over controls.

CONCLUSION

The most advantageous spinal fusion implant matrix consisted of recombinant human bone morphogenetic protein-2, autogenous bone, and collagen. Future investigators, however, need to examine the appropriate quantities of the individual components and clarify the efficacy of the matrix for the various types of spinal fusion approaches.