Clinical Advances in Calcium Phosphate for Maxillomandibular Bone Regeneration: From Bench to Bedside

In this study, we report a new observation on the phase conversion that occurs during the sintering of hydroxyapatite (HA)-tricalcium phosphate (TCP) biphasic ceramics. During the sintering of the HA-TCP mixture powders, a large amount of TCP was converted into HA, as detected by X-ray diffraction. The amount of TCP transformed into HA was approximately 10-90% of that initially added. From the electron probe microscopy analysis, the HA transformed from TCP was found to be Ca-deficient with Ca/P ratios of 1.62-1.64. The dissolution behavior and osteoblastic responses in a series of HA-TCP biphasic ceramics (10-90% TCP) were assessed. The solubility of the HA-TCP biphasic ceramics was intermediate between that of the HA and TCP pure ceramics. However, in the case of the HA-90% TCP biphasic ceramic, the solubility was even higher than that of pure TCP. The cell proliferation and alkaline phosphatase activity of the cells on the biphasic ceramics were lower than those on pure HA, but higher than those on pure TCP. However, particularly in the HA-50% TCP biphasic composition, the cellular responses were significantly higher than those on pure HA. It is considered that the Ca-deficient apatite newly formed from the TCP may affect in some way the solubility and biological properties of the HA-TCP biphasic ceramics.

Critical bone defects are a major clinical challenge in reconstructive bone surgery. Polycaprolactone (PCL) mixed with bioceramics, such as hydroxyapatite (HA) and tricalcium phosphate (TCP), create composite scaffolds with improved biological recognition and bioactivity. Electrical stimulation (ES) aims to compensate the compromised endogenous electrical signals and to stimulate cell proliferation and differentiation. We investigated the effects of composite scaffolds (PCL with HA; and PCL with β-TCP) and the use of ES on critical bone defects in Wistar rats using eight experimental groups: untreated, ES, PCL, PCL/ES, HA, HA/ES, TCP, and TCP/ES. The investigation was based on histomorphometry, immunohistochemistry, and gene expression analysis. The vascular area was greater in the HA/ES group on days 30 and 60. Tissue mineralization was greater in the HA, HA/ES, and TCP groups at day 30, and TCP/ES at day 60. Bmp-2 gene expression was higher in the HA, TCP, and TCP/ES groups at day 30, and in the TCP/ES and PCL/ES groups at day 60. Runx-2, Osterix, and Osteopontin gene expression were also higher in the TCP/ES group at day 60. These results suggest that scaffolds printed with PCL and TCP, when paired with electrical therapy application, improve bone regeneration.

Calcium phosphates and glass composite coatings on zirconia for enhanced biocompatibility

Alloplastic calcium phosphate bone substitutes such as hydroxyapatite (HA) and tricalcium phosphate (TCP) have been studied extensively due to their composition closely resembling the inorganic phase of bone tissue. On the same way, by manipulating the HA/TCP ratio it may be possible to change the substitution rate and the bioactivity of these materials, an advantage which has brought them to clinical use in oral and orthopaedic surgery. In this work, we evaluated the histological response in bone of two biphasic calcium phosphate ceramics by varying the proportion of their components. All premolars of 6 beagle dogs were removed from both sides of the mandible. Three months later, four cylinders composed of 85% HA and 15% beta-TCP (BCP 1) were implanted in the right side of mandible and other four cylinders composed of 15% HA and 85% beta-TCP (BCP 2) were implanted in the left side of mandible of dogs for 4, 12 ad 26 weeks, respectively. Two dogs were used in each time point. The histological study indicated that both biphasic ceramic were biocompatible. The earlier and more quantity of bone formed in BCP 2 than in BCP 1 suggested that the first one had a higher osteoinductive potential than the second one in mandibular bone. The resorption of the phosphate phase and the subsequent migration of bone into the resorbed portions were detected in both biphasic ceramics although two processes appeared faster in BCP 2 than in BCP 1. These dates conclude that varying the components of our biphasic ceramic we improve its osteoinductive potential.

Contemporary treatment of critical bone defect remains a significant challenge in the field of orthopedic surgery. Engineered biomaterials combined with growth factors have emerged as a new treatment alternative in bone repair and regeneration. Our approach is to encapsulate bone morphogenetic protein-2 (BMP-2) into a polymeric matrix in different ways and characterize their individual performance in a nude mouse model. The main objective of this study is to examine whether the PLGA/HAp composite fibrous scaffolds loaded with BMP-2 through electrospinning can improve bone regeneration. The hypothesis is that different loading methods of BMP-2 and different HAp contents in scaffolds can alternate the release profiles of BMP-2 in vivo, therefore modify the performance of scaffolds in bone regeneration. Firstly, mechanical strength of scaffolds and HAp nanoparticles distribution in scaffolds were investigated. Secondly, nude mice experiments extended to 6 weeks were carried out to test the in vivo performance of these scaffolds, in which measurements, like serum BMP-2 concentration, ALP activity, X-ray qualification, and H&E/IHC tissue staining were utilized to monitor the growth of new bone and the changes of the corresponding biochemical parameters. The results showed that the PLGA/HAp composite scaffolds developed in this study exhibited good morphology/mechanical strength and HAp nanoparticles were homogeneously dispersed inside PLGA matrix. Results from the animal experiments indicate that the bioactivity of BMP-2 released from the fibrous PLGA/HAp composite scaffolds is well maintained, which further improves the formation of new bone and the healing of segmental defects in vivo. It is concluded that BMP-2 loaded PLGA/HAp composite scaffolds are promising for bone healing.

The fabrication of biomaterial 3D scaffolds for bone tissue engineering applications involves the usage of metals, polymers, and ceramics as the base constituents. Notwithstanding, the composite materials facilitating enhanced osteogenic differentiation/regeneration are endorsed as the ideally suited bone grafts for addressing critical-sized bone defects. Here, we report the successful fabrication of 3D composite scaffolds mimicking the ECM of bone tissue by using ∼30 wt% of collagen type I (Col-I) and ∼70 wt% of different crystalline phases of calcium phosphate (CP) nanomaterials [hydroxyapatite (HAp), beta-tricalcium phosphate (βTCP), biphasic hydroxyapatite (βTCP-HAp or BCP)], where pH served as the sole variable for obtaining these CP phases. The different Ca/P ratio and CP nanomaterials orientation in these CP/Col-I composite scaffolds not only altered the microstructure, surface area, porosity with randomly oriented interconnected pores (80-450 μm) and mechanical strength similar to trabecular bone but also consecutively influenced the bioactivity, biocompatibility, and osteogenic differentiation potential of gingival-derived mesenchymal stem cells (gMSCs). In fact, BCP/Col-I, as determined from micro-CT analysis, achieved the highest surface area (∼42.6 m2 g-1) and porosity (∼85%), demonstrated improved bioactivity and biocompatibility and promoted maximum osteogenic differentiation of gMSCs among the three. Interestingly, the released Ca2+ ions, as low as 3 mM, from these scaffolds could also facilitate the osteogenic differentiation of gMSCs without even subjecting them to osteoinduction, thereby attesting these CP/Col-I 3D scaffolds as ideally suited bone graft materials.

Next-generation synthetic bone graft therapies will most likely be composed of resorbable polymers in combination with bioactive components. In this article, we continue our exploration of E1001(1k), a tyrosine-derived polycarbonate, as an orthopedic implant material. Specifically, we use E1001(1k), which is degradable, nontoxic, and osteoconductive, to fabricate porous bone regeneration scaffolds that were enhanced by two different types of calcium phosphate (CP) coatings: in one case, pure dicalcium phosphate dihydrate was precipitated on the scaffold surface and throughout its porous structure (E1001(1k) + CP). In the other case, bone matrix minerals (BMM) such as zinc, manganese and fluoride were co-precipitated within the dicalcium phosphate dihydrate coating (E1001(1k) + BMM). These scaffold compositions were compared against each other and against ChronOS (Synthes USA, West Chester, PA, USA), a clinically used bone graft substitute (BGS), which served as the positive control in our experimental design. This BGS is composed of poly(lactide co-ε-caprolactone) and beta-tricalcium phosphate. We used the established rabbit calvaria critical-sized defect model to determine bone regeneration within the defect for each of the three scaffold compositions. New bone formation was determined after 2, 4, 6, 8 and 12 weeks by micro-computerized tomography (µCT) and histology. The experimental tyrosine-derived polycarbonate, enhanced with dicalcium phosphate dihydrate, E1001(1k) + CP, supported significant bone formation within the defects and was superior to the same scaffold containing a mix of BMM, E1001(1k) + BMM. The comparison with the commercially available BGS was complicated by the large variability in bone formation observed for the laboratory preparations of E1001(1k) scaffolds. At all time points, there was a trend for E1001(1k) + CP to be superior to the commercial BGS. However, only at the 6-week time point did this trend reach statistical significance. Detailed analysis of the µCT data suggested an increase in bone formation from 2 through 12 weeks in implant sites treated with E1001(1k) + CP. At 2 and 4 weeks post-implantation, bone formation occurred at the interface where the E1001(1k) + CP scaffold was in contact with the bone borders of the implant site. Thereafter, during weeks 6, 8 and 12 bone formation progressed throughout the E1001(1k) + CP test implants. This trend was not observed with E1001(1k) + BMM scaffolds or the clinically used BGS. Our results suggest that E1001(1k) + CP should be tested further for osteoregenerative applications.

The preclinical study aimed to compare the healing of segmental bone defects treated with biodegradable hyaluronic acid and tricalcium phosphate-based hydrogel with the established autologous spongioplasty. Another aim was to evaluate the hydrogel as a scaffold for osteoinductive growth factor of bone morphogenetic protein-2 (BMP-2) and stem cells. The study was conducted in an in vivo animal model. A standardized rabbit model of a 15 mm long segmental bone defect of left radius was used. A total of 40 animals were divided into 5 groups of 8 individuals. In the KO- (negative control) group, the created defect was left to heal spontaneously. In the KO+ (positive control) group, the defect was filled with morselized bone autograft prepared from the resected segment. In the study group A, the defect was filled with hydrogel based on hyaluronic acid derivative and tricalcium phosphate. In the study group B, the defect was filled with hydrogel based on hyaluronic acid derivative, tricalcium phosphate and bone marrow aspirate. In the study group C, the defect was filled with hydrogel based on hyaluronic acid derivative, tricalcium phosphate, bone marrow aspirate and BMP-2. Healing was assessed using radiographs at 1, 6, and 12 weeks postoperatively and histology specimens were collected at 16 weeks postoperatively. Altogether 35 rabbits survived (KO- 7, KO+ 7, A 7, B 6, C 8) until the end of the study. As concerns the radiographic assessment, the best results were achieved by the groups KO+ and C, where new bone formation across the entire width of the bone defect was clearly seen at 6 and 12 weeks and the osteotomy line was completely healed too. At 12 weeks, complete bone remodelling was observed in all animals in the group KO+, whereas in the group C, bone remodelling was fully completed in 5 animals and partially completed in 3 animals. In terms of histological assessment, however, the best results were achieved by the group C, where the bone defect was completely remodelled into lamellar bone in 7 specimens, while in 1 specimen it healed with bony callus formation. In the group KO+, the defect was healed in 4 specimens by cartilaginous callus with loci of remodelling into bony callus, in 2 specimens the bony callus was predominant with cartilaginous callus areas, and only one defect was completely remodelled into lamellar bone. Compared to autografts that manifest osteogenic, osteoinductive and osteoconductive properties, the biodegradable hyaluronic acid and tricalcium phosphate-based hydrogel has osteoconductive properties only. Thus, it was also tested in our study as a scaffold for bone marrow cells and BMP-2 osteoinductive growth factor. Thanks to its semi-liquid properties, the biodegradable hyaluronic acid and tricalcium phosphate-based hydrogel is a promising material for use in 3D printing. The preclinical study in an in vivo animal model confirmed the beneficial effect of the biodegradable hyaluronic acid and tricalcium phosphate-based hydrogel on the healing of critical-size segmental bone defects. Better healing of these defects was also confirmed for filling composed of hydrogel and BMP-2 osteoinductive growth factor. The benefit of bone marrow aspirate mixed with hydrogel was not confirmed. bone defect, non-union, rabbit, hyaluronic acid, calcium phosphate, stem cells, BMP-2, scaffold, bone healing, spongioplasty.

Calcium phosphates are among the most common biomaterials employed in orthopaedic and dental surgery. The efficacy of such systems as bone substitutes and bioactive coatings on metallic prostheses has been proved by several clinical studies. Among these materials, hydroxyapatite (HA) and tricalcium phosphate (TCP) play a prominent role in medical practice since the '80s. In the last years, numerous attempts to combine HA or TCP with bioactive glasses have been made. There are two main motivations for sintering calcium phosphates with a glassy phase: on the one hand, it is possible to tune the dissolution of the final system and to enhance its biological response through the synergistic combination of two bioactive phases; on the other hand, the glass acts as a sintering aid with the aim to increase the densification of the composite and thus its mechanical strength. In this sense, TCP and HA are penalized by their relatively poor fracture toughness and tensile strength compared to natural bone, which makes it impossible to use them in load-bearing applications. Moreover, the bioactivity index of pure calcium phosphates is typically lower with respect to that of many bioactive glasses. In this review, the state of the art and current applications of composites, based on HA or TCP with bioactive glass as second phase, are presented and discussed. A special emphasis is given to the processing and mechanical behaviour of these systems, together with their biological implications, as a function of the composition of the glass employed as second phase.

Glutaraldehyde-crosslinking chitosan scaffolds reinforced with calcium phosphate spray-dried granules for bone tissue applications.

Low-temperature plasma effect-induced enhancement of osteogenic activity in calcium phosphate ceramics.

Objects with complex shape and functions have always attracted attention and interest. The morphological diversity and complexity of naturally occurring forms and patterns have been a motivation for humans to copy and adopt ideas from Nature to achieve functional, aesthetic and social value. Biomimetics is addressed to the design and development of new synthetic materials using strategies adopted by living organisms to produce biological materials. In particular, biomineralized tissues are often sophisticate composite materials, in which the components and the interfaces between them have been defined and optimized, and that present unusual and optimal chemical-physical, morphological and mechanical properties. Moreover, biominerals are generally produced by easily traceable raw materials, in aqueous media and at room pressure and temperature, that is through cheap process and materials. Thus, it is not surprising that the idea to mimic those strategies proper of Nature has been employed in several areas of applied sciences, such as for the preparation of liquid crystals, ceramic thin films computer switches and many other advanced materials. On this basis, this PhD thesis is focused on the investigation of the interaction of biologically active ions and molecules with calcium phosphates with the aim to develop new materials for the substitution and repair of skeletal tissue, according to the following lines: I. Modified calcium phosphates. A relevant part of this PhD thesis has been addressed to study the interaction of Strontium with calcium phosphates. It was demonstrated that strontium ion can substitute for calcium into hydroxyapatite, causing appreciable structural and morphological modifications. The detailed structural analysis carried out on the nanocrystals at different strontium content provided new insight into its interaction with the structure of hydroxyapatite. At variance with the behaviour of Sr towards HA, it was found that this ion inhibits the synthesis of octacalcium phosphate. However, it can substitute for calcium in this structure up to 15 atom %, in agreement with the increase of the cell parameters observed on increasing ion concentration. A similar behaviour was found for Magnesium ion, whereas Manganese inhibits the synthesis of octacalcium phosphate and it promotes the precipitation of dicalcium phosphate dehydrate. It was also found that Strontium affects the kinetics of the reaction of hydrolysis of α-TCP. It inhibits the conversion from α-TCP to hydroxyapatite. However, the resulting apatitic phase contains significant amounts of Sr2+ suggesting that the addition of Sr2+ to the composition of α-TCP bone cements could be successfully exploited for its local delivery in bone defects. The hydrolysis of α-TCP has been investigated also in the presence of increasing amounts of gelatin: the results indicated that this biopolymer accelerates the hydrolysis reaction and promotes the conversion of α-TCP into OCP, suggesting that its addition in the composition of calcium phosphate cements can be employed to modulate the OCP/HA ratio, and as a consequence the solubility, of the set cement. II. Deposition of modified calcium phosphates on metallic substrates. Coating with a thin film of calcium phosphates is frequently applied on the surface of metallic implants in order to combine the high mechanical strength of the metal with the excellent bioactivity of the calcium phosphates surface layers. During this PhD thesis, thank to the collaboration with prof. I.N. Mihailescu, head of the Laser-Surface-Plasma Interactions Laboratory (National Institute for Lasers, Plasma and Radiation Physics – Laser Department, Bucharest) Pulsed Laser Deposition has been successfully applied to deposit thin films of Sr substituted HA on Titanium substrates. The synthesized coatings displayed a uniform Sr distribution, a granular surface and a good degree of crystallinity which slightly decreased on increasing Sr content. The results of in vitro tests carried out on osteoblast-like and osteoclast cells suggested that the presence of Sr in HA thin films can enhance the positive effect of HA coatings on osteointegration and bone regeneration, and prevent undesirable bone resorption. The possibility to introduce an active molecule in the implant site was explored using Matrix Assisted Pulsed Laser Evaporation to deposit hydroxyapatite nanocrystals at different content of alendronate, a bisphosphonate widely employed in the treatments of pathological diseases associated to bone loss. The coatings displayed a good degree of crystallinity, and the results of in vitro tests indicated that alendronate promotes proliferation and differentiation of osteoblasts even when incorporated into hydroxyapatite. III. Synthesis of drug carriers with a delayed release modulated by a calcium phosphate coating. A core-shell system for modulated drug delivery and release has been developed through optimization of the experimental conditions to cover gelatin microspheres with a uniform layer of calcium phosphate. The kinetics of the release from uncoated and coated microspheres was investigated using aspirin as a model drug. It was shown that the presence of the calcium phosphate shell delays the release of aspirin and allows to modulate its action.

A hydroxyapatite and tricalcium phosphate nanocomposite containing 5% silica was developed for dental applications. The biomaterial was prepared by one-step synthesis via the wet route. The resulting dry material consisted of hydrated calcium phosphate agglomerates with sizes of up to 200 μm. The presence of silica was found to lower the phase transformation temperature of the calcium phosphates and increase the open porosity of the biomaterial compared to that of hydroxyapatite. The hydrated calcium phosphate transformed into hydroxyapatite (HA) and beta tricalcium phosphate (TCP) at approximately 682 °C. After 2 h of calcination at 900 °C, the volume ratios of HA and TCP in the nanocomposite were 84 and 16%, respectively. The open porosity in the triphasic nanocomposite and in the HA was 46.35% and 41.52%, respectively, after 3 h of sintering at 1 100 °C. Samples of grade 2 titanium were sandpapered and etched with an acid solution of HCl/H2SO4 prior to deposition of the calcined nanocomposite. The particles were deposited homogeneously and reduced the contact angle of the titanium surface.

Interface of synthetic inorganic biomaterials and bone regeneration

Background In this study, the properties of the water glass (WG, sodium-silicate glass) were utilized to control the biodegradability of the beta tricalcium phosphate materials by the WG coating on the tricalcium phosphate disc surface with various coating thickness, chemistry, and heat-treatment. Methods Four types of disc specimens were prepared. A sample group A consisted of pure hydroxyapatite (HA) as a negative resorption control; a sample group B consisted of pure beta tricalcium phosphate as a positive resorption control; a sample group C consisted of beta tricalcium phosphate coated with WG as an early resorption model; and a sample group D consisted beta tricalcium phosphate coated with WG and heat-treated at 500°C as a delayed resorption model. Using human bone marrow-derived mesenchymal stem cells, for the analysis of cellular attachment and proliferative activity, 4-6-Diamidino-2-Phenylindole fluorescence technique was used. For the analysis of osteteogenic differentiation, alkaline phospastase (ALP) activity was measured. Results The mean z-scores of four groups (A, B, C, and D) in cellular attachment at 4 h after seeding were -1.21, -0.15, 0.42, and 0.94, respectively, and statistically significantly different in all groups respectively. Seven days after seeding, the mean z-scores of cellular proliferation were 1.97, 0.71, 1.48, and 1.83 in the four groups, respectively. The mean z-scores of the ALP activity per the mean z-scores of cell numbers of respective groups on the seventh day were 0.40, -1.51, 0.12, and 0.06, respectively, in four groups. Conclusion Initial cellular attachment is better on beta tricalcium phosphate than on HA and is enhanced by WG coating, especially with sintering at the high temperature. Cellular proliferation is considered to be increased by maintaining its attachment site through reduced dissolution of beta tricalcium phosphate by WG coating. Osteogenic differentiation in in-vitro study on the WG-coated beta tricalcium phosphate is thought to be as the result of increased silicon ion release from the WG.