Window Approach for Simultaneous Root Fragment Removal and Implant Placement: Two Case Reports.

INTRODUCTION: Root fracture during extraction is not uncommon due to the presence of multiple and thin roots, which are often divergent and curved. The retained root fragments (RF) are usually radiographic incidental findings and often asymptomatic without associated pathology. However, careful and conservative surgical strategies for the removal of RF must be incorporated to allow for simultaneous implant placement and to avoid potential complications such as compromised osseointegration or retrograde peri-implantitis. Conventional RF removal techniques may lead to a significant amount of bone removal, involving more trauma and a prolonged healing period. CASE PRESENTATION: In these two case reports, the Window Approach for Simultaneous Root Fragment Removal and Implant Placement (WASRIP) technique was used to extract RF in a minimally invasive fashion to preserve both the coronal and apical bone, which are critical components in providing mechanical stability for simultaneously placed implants. All implants presented in both cases showed adequate primary stability and successfully achieved osseointegration at a 3-month follow-up period. CONCLUSION: Through the buccal window, sufficient access was provided to remove RF atraumatically with maximal retention of surrounding bone that led to predictable implant placement.

Skeletal Protection and Promotion of Microbiome Diversity by Dietary Boosting of the Endogenous Antioxidant Response.

There is an unmet need for interventions with better compliance that prevent the adverse effects of sex steroid deficiency on the musculoskeletal system. We identified a blueberry cultivar (Montgomerym [Mont]) that added to the diet protects female mice from musculoskeletal loss and body weight changes induced by ovariectomy. Mont, but not other blueberries, increased the endogenous antioxidant response by bypassing the traditional antioxidant transcription factor Nrf2 and without activating estrogen receptor canonical signaling. Remarkably, Mont did not protect the male skeleton from androgen-induced bone loss. Moreover, Mont increased the variety of bacterial communities in the gut microbiome (α-diversity) more in female than in male mice; shifted the phylogenetic relatedness of bacterial communities (ß-diversity) further in females than males; and increased the prevalence of the taxon Ruminococcus1 in females but not males. Therefore, this nonpharmacologic intervention (i) protects from estrogen but not androgen deficiency; (ii) preserves bone, skeletal muscle, and body composition; (iii) elicits antioxidant defense responses independently of classical antioxidant/estrogenic signaling; and (iv) increases gut microbiome diversity toward a healthier signature. These findings highlight the impact of nutrition on musculoskeletal and gut microbiome homeostasis and support the precision medicine principle of tailoring dietary interventions to patient individualities, like sex. © 2020 American Society for Bone and Mineral Research (ASBMR).

Aminobisphosphonate-treated ewes as a model of osteonecrosis of the jaw and of dental implant failure.

BACKGROUND: Bisphosphonate (BP)-related osteonecrosis of the jaw (BRONJ) and dental implant failure are two negative side effects of chronic aminoBP treatment. METHODS: Eleven ovariectomized (OVX) ewes and four ewes subjected to sham surgery (SHAM) were treated as follows: OVX (n = 5): OVX plus saline solution; zoledronic acid-treated group (ZOL) (n = 6): OVX plus ZOL; SHAM (n = 4): SHAM plus saline solution. Extraction of the first upper molar was performed at 1 year, dental implant placement at 2 years, and sacrifice at 28 months. RESULTS: Implants remained in place in SHAM and OVX ewes but were lost in all ZOL ewes. ZOL sheep (2/6) showed inflammation and necrotic bone at mandibular region. No differences in serum calcium (Ca), inorganic phosphate (Pi) or 25-hydroxyvitamin D were observed, whereas bone alkaline phosphatase levels decreased in the three studied groups (P < 0.05). The significantly lowest levels of carboxy-terminal telopeptide of type I collagen were observed in ZOL (P < 0.05), and showed no differences between SHAM and OVX. OVX showed the lowest and ZOL the highest Ca and Pi contents in femur and maxilla (P < 0.05). Bone volume (BV/TV%) and iliac crest were similar at baseline and at month 4. At the end of the study, BV/TV%, proximal femur and hemi-mandible bone mineral content and bone mineral density, and trabeculae number were similar in SHAM and ZOL, and lower in OVX (P < 0.05). CONCLUSION: All ZOL-treated ewes on a schedule similar to that used in cancer patients showed extensive suppression of bone remodeling and implant failure. Some of the ZOL ewes developed BRONJ.

Sinus floor elevation using a new bovine bone grafting material: case report and bone grafting materials update / Actualización en materiales de relleno óseo: reporte de un caso clínico de elevamiento del piso del seno maxilar usando un nuevo material de relleno óseo bovino

Bone grafting is important to preserve the alveolar bone ridge height and volume for dental implant placement. Even though implant-supported overdentures present highly successful outcomes, it seems that a great number of edentulous individuals have not pursued implant-based rehabilitation. The cost of the treatment is one of the reasons of discrepancy between highly successful therapy and its acceptance. Therefore, the development of biomaterials for bone grafting with comparable characteristics and biological effects than those renowned internationally, is necessary. In addition, domestic manufacture would reduce the high costs in public health arising from the application of these biomaterials in the dental feld. The purpose of this clinical case report is to provide preliminary clinical evidence of the efficacy of a new bovine bone graft in the bone healing process when used for sinus floor elevation. (AU)

El uso de injertos óseos es importante para preservar la altura y el volumen de la cresta alveolar para la colocación de implantes dentales. Si bien las sobredentaduras implanto-soportadas presentan resultados altamente exitosos, la mayoría de las personas desdentadas no han sido rehabilitadas mediante implantes dentales. Uno de los principales motivos por los cuales los pacientes no aceptan este tipo de tratamiento, altamente exitoso, es el elevado costo del mismo. Por ello, es necesario el desarrollo de biomateriales de injerto óseo con características y efectos biológicos comparables a los reconocidos internacionalmente. Asimismo, la fabricación nacional reduciría los altos costos en Salud Pública derivados de la aplicación de estos biomateriales en el campo dental. El objetivo de esta comunicación es presentar un caso clínico a fin de proporcionar evidencia preliminar acerca de la eficacia de un nuevo injerto de hueso bovino en el proceso de cicatrización ósea en el levantamiento del piso del seno maxilar. (AU)

Preliminary study on the biocompatibility and osteoconductive properties of a new bovine bone graft / Estudio preliminar sobre las propiedades de biocompatibilidad y osteoconductividad de un nuevo injerto de hueso bovino

To prevent post-extraction resorption and preserve the integrity of the alveolar ridges, the placement of bone grafts at the time of extraction is recommended. Bovine bone grafts are biocompatibile and osteoconductive, allowing new bone apposition by osteoprogenitor cells. Although there are trademarks recognized internationally regarding bovine bone grafts, they are expensive and even difficult to acquire. Therefore, domestic industry development of high quality biomaterials will reduce the public health high costs in the dental field. Here, we evaluated and compared the effects of an Argentinean manufactured bovine bone graft (Synergy Bone Matrix) with a bovine bone graft recognized for its osteoconductive effects (Bio-Oss), on bone healing in an experimental model in rats. We created critical sized bone defects in rat tibiae and filled them with either one of the bovine bone grafts or control. Clinical responses, X-ray findings, bone mineral density, and histological parameters were evaluated. No abscess, encapsulation, suppuration or inflammation of lymphatic nodes were observed. Radiographically, all implants were amalgamated to the surrounding bony margins, suggesting proper healing. On the other hand, control tibiae exhibited no signs of recovery and remained either unfilled or showed fibrous tissue formation. No statistical differences were observed in BMC and BMD between tibiae filled with Synergy Bone Matrix or Bio-Oss. Histological analysis revealed particles of both bone grafts surrounded by laminar bone tissue indicating osteoconductivity, without any inflammatory sign. This preliminary study suggests that Synergy Bone Matrix, as well as Bio-Oss, present similar properties of biocompatibility and osteoconductivity. (AU)

Para prevenir la resorción post-exodoncia y preservar la integridad de los rebordes alveolares, se recomienda la colocación de injertos óseos en el momento de la extracción. Los injertos de hueso bovino son biocompatibles y osteoconductivos, permitiendo nueva aposición ósea por células osteoprogenitoras. Existen marcas internacionales de injertos de hueso bovino, pero resultan caros e incluso difíciles de adquirir. Por ello, la elaboración de biomateriales de alta calidad, nacionales, reduciría los altos costos de salud pública en odontología. En este estudio, se evaluaron y compararon los efectos de un injerto de hueso bovino fabricado en Argentina (Synergy Bone Matrix) versus un injerto de hueso bovino reconocido por sus efectos osteoconductivos (Bio-Oss), en el proceso de cicatrización ósea en un modelo experimental en ratas. Para ello, creamos un defecto óseo crítico en tibia de rata el cual se rellenó con uno de los injertos de hueso bovino o control. Se evaluó: respuesta clínica y radiográfica, densidad mineral ósea e histología. No se observaron abscesos, encapsulación, supuración o inflamación de los ganglios linfáticos. Radiográficamente, todos los implantes se integraron a los márgenes óseos circundantes, sugiriendo una cicatrización adecuada. Por el contrario, las tibias control no mostraron signos de recuperación con formación de tejido fibroso. No se observaron diferencias estadísticas en las BMC y BMD entre las tibias Synergy Bone Matrix o Bio-Oss. La histología reveló partículas de ambos injertos óseos rodeadas por tejido óseo laminar indicando osteoconductividad sin signos inflamatorios. Este estudio preliminar sugiere que Synergy Bone Matrix presenta propiedades similares de biocompatibilidad y osteoconductividad que Bio-Oss. (AU)

PTHrP-Derived Peptides Restore Bone Mass and Strength in Diabetic Mice: Additive Effect of Mechanical Loading.

There is an unmet need to understand the mechanisms underlying skeletal deterioration in diabetes mellitus (DM) and to develop therapeutic approaches to treat bone fragility in diabetic patients. We demonstrate herein that mice with type 1 DM induced by streptozotocin exhibited low bone mass, inferior mechanical and material properties, increased bone resorption, decreased bone formation, increased apoptosis of osteocytes, and increased expression of the osteocyte-derived bone formation inhibitor Sost/sclerostin. Further, short treatment of diabetic mice with parathyroid hormone related protein (PTHrP)-derived peptides corrected these changes to levels undistinguishable from non-diabetic mice. In addition, diabetic mice exhibited reduced bone formation in response to mechanical stimulation, which was corrected by treatment with the PTHrP peptides, and higher prevalence of apoptotic osteocytes, which was reduced by loading or by the PTHrP peptides alone and reversed by a combination of loading and PTHrP peptide treatment. In vitro experiments demonstrated that the PTHrP peptides or mechanical stimulation by fluid flow activated the survival kinases ERKs and induced nuclear translocation of the canonical Wnt signaling mediator ß-catenin, and prevented the increase in osteocytic cell apoptosis induced by high glucose. Thus, PTHrP-derived peptides cross-talk with mechanical signaling pathways to reverse skeletal deterioration induced by DM in mice. These findings suggest a crucial role of osteocytes in the harmful effects of diabetes on bone and raise the possibility of targeting these cells as a novel approach to treat skeletal deterioration in diabetes. Moreover, our study suggests the potential therapeutic efficacy of combined pharmacological and mechanical stimuli to promote bone accrual and maintenance in diabetic subjects. © 2016 American Society for Bone and Mineral Research.

Control of Bone Anabolism in Response to Mechanical Loading and PTH by Distinct Mechanisms Downstream of the PTH Receptor.

Osteocytes integrate the responses of bone to mechanical and hormonal stimuli by poorly understood mechanisms. We report here that mice with conditional deletion of the parathyroid hormone (PTH) receptor 1 (Pth1r) in dentin matrix protein 1 (DMP1)-8kb-expressing cells (cKO) exhibit a modest decrease in bone resorption leading to a mild increase in cancellous bone without changes in cortical bone. However, bone resorption in response to endogenous chronic elevation of PTH in growing or adult cKO mice induced by a low calcium diet remained intact, because the increased bone remodeling and bone loss was indistinguishable from that exhibited by control littermates. In contrast, the bone gain and increased bone formation in cancellous and cortical bone induced by daily injections of PTH and the periosteal bone apposition induced by axial ulna loading were markedly reduced in cKO mice compared to controls. Remarkably, however, wild-type (WT) control littermates and transgenic mice overexpressing SOST injected daily with PTH exhibit similar activation of Wnt/ß-catenin signaling, increased bone formation, and cancellous and cortical bone gain. Taken together, these findings demonstrate that Pth1r in DMP1-8kb-expressing cells is required to maintain basal levels of bone resorption but is dispensable for the catabolic action of chronic PTH elevation; and it is essential for the anabolic actions of daily PTH injections and mechanical loading. However, downregulation of Sost/sclerostin, previously shown to be required for bone anabolism induced by mechanical loading, is not required for PTH-induced bone gain, showing that other mechanisms downstream of the Pth1r in DMP1-8kb-expressing cells are responsible for the hormonal effect. © 2016 American Society for Bone and Mineral Research.

Avenanthramides Prevent Osteoblast and Osteocyte Apoptosis and Induce Osteoclast Apoptosis in Vitro in an Nrf2-Independent Manner.

Oats contain unique bioactive compounds known as avenanthramides (AVAs) with antioxidant properties. AVAs might enhance the endogenous antioxidant cellular response by activation of the transcription factor Nrf2. Accumulation of reactive oxygen species plays a critical role in many chronic and degenerative diseases, including osteoporosis. In this disease, there is an imbalance between bone formation by osteoblasts and bone resorption by osteoclasts, which is accompanied by increased osteoblast/osteocyte apoptosis and decreased osteoclast apoptosis. We investigated the ability of the synthethic AVAs 2c, 2f and 2p, to 1-regulate gene expression in bone cells, 2-affect the viability of osteoblasts, osteocytes and osteoclasts, and the generation of osteoclasts from their precursors, and 3-examine the potential involvement of the transcription factor Nrf2 in these actions. All doses of AVA 2c and 1 and 5 µM dose of 2p up-regulated collagen 1A expression. Lower doses of AVAs up-regulated OPG (osteoprotegerin) in OB-6 osteoblastic cells, whereas 100 µM dose of 2f and all concentrations of 2c down-regulated RANKL gene expression in MLO-Y4 osteocytic cells. AVAs did not affect apoptosis of OB-6 osteoblastic cells or MLO-Y4 osteocytic cells; however, they prevented apoptosis induced by the DNA topoisomerase inhibitor etoposide, the glucocorticoid dexamethasone, and hydrogen peroxide. AVAs prevented apoptosis of both wild type (WT) and Nrf2 Knockout (KO) osteoblasts, demonstrating that AVAs-induced survival does not require Nrf2 expression. Further, KO osteoclast precursors produced more mature osteoclasts than WT; and KO cultures exhibited less apoptotic osteoclasts than WT cultures. Although AVAs did not affect WT osteoclasts, AVA 2p reversed the low apoptosis of KO osteoclasts. These in vitro results demonstrate that AVAs regulate, in part, the function of osteoblasts and osteocytes and prevent osteoblast/osteocyte apoptosis and increase osteoclast apoptosis; further, these regulatory actions are independent of Nrf2.

Low protein intake magnifies detrimental effects of ovariectomy and vitamin D on bone.

Protein-induced changes in bone and calcium homeostasis could potentially be greater in the elderly and in women at risk for osteoporosis. We hypothesize that a low protein intake would magnify the negative changes in bone metabolism seen in vitamin D (vitD) insufficiency and/or estrogen deficiency. The present study was undertaken to better understand how a low protein diet along with vitD insufficiency could affect bone metabolism using a rodent ovariectomized (OVX) model. Rats (n = 60) underwent ovariectomy (OVX) or sham operation. The first 15 days after surgery, all rats were fed a standard rodent diet. Thereafter, rats (n = 10/group) were fed a low protein diet (LP; 2.5 %) or a control diet (NP; 12.5 %) with 100 IU% vitD (+D; cholecalciferol) or without vitD (-D) for 45 days. The groups were as follows: SHAM + NP + D (control); SHAM + LP + D; SHAM + LP - D; OVX + NP + D; OVX + LP + D; OVX + LP - D. Body weight (BW) of control and OVX + NP + D groups increased while those feeding the LP diet, independently of vitD feedings, decreased (p < 0.05). The OVX + LP - D group presented the lowest serum Ca, phosphorus and osteocalcin levels and the highest CTX levels (p < 0.05). At the end of the study, total skeleton bone mineral content, proximal tibia bone mineral density, bone volume and trabecular number levels decreased as follows: SHAM + NP + D (controls) > SHAM + LP + D > OVX + NP + D > SHAM + LP - D > OVX + LP + D > OVX + LP - D (p < 0.05). A low protein diet negatively affected bone mass and magnified the detrimental effects of vitD and/or estrogen deficiencies.

Salivary bone turnover markers in healthy pre- and postmenopausal women: daily and seasonal rhythm.

No studies had investigated circadian and circannual rhythms of bone biomarkers in whole saliva. We evaluated the salivary daily and seasonal rhythm of carboxy-terminal telopeptide of type I collagen (CTX) and bone alkaline phosphatase (b-ALP). Forty clinical and oral healthy ambulatory pre- and postmenopausal women from two southern Argentine cities: Comodoro Rivadavia (latitude 45º S) and Ushuaia (latitude 54º S) were included in the study. CTX levels were evaluated in serum, urine, and saliva, and b-ALP levels were measured in serum and saliva. In both groups of women, salivary CTX showed a maximum percentage of change early in the morning (80%) and a minimum in the late afternoon (45%), similarly to the pattern observed in urinary samples. No daily rhythm was observed in serum or salivary b-ALP. 25-Hydroxyvitamin D levels decreased in winter vs. summer (p < 0.01) without differences between the two studied groups. Conversely, parathormone reached higher levels in winter (p < 0.05) which induced a slight non-significant increment in salivary CTX and b-ALP levels. The results showed that, as in serum and urinary samples, salivary CTX exhibits daily and a slight seasonal rhythmicity. Whole non-stimulated saliva is a useful tool to detect several oral and systemic diseases because it has important advantages compared to serum and urinary samples. Then, it may also be a promising sample to test changes in bone metabolism contributing to diagnose and to monitor the therapy of several metabolic bone diseases.

Correlation between salivary and serum markers of bone turnover in osteopenic rats.

BACKGROUND: Previously, we measured bone alkaline phosphatase (b-ALP) and terminal C-telopeptide of collagen type I (CTX) in saliva. The present longitudinal experimental study sought to determine whether salivary concentrations of b-ALP and CTX have the same response as in serum samples under different conditions: normal, increased, and reduced bone remodeling. METHODS: Thirty rats were ovariectomized (OVX) to induce osteopenia 60 days after surgery, and 10 rats were sham operated. Then, the rats were divided into four groups and treated as follows for 45 days: group 1 (G1) = SHAM + vehicle; group 2 (G2) = OVX + 8 microg olpadronate (OPD)/100 g of body weight; group 3 (G3) = OVX + 4 microg OPD/100 g of body weight; and group 4 (G4) = OVX + vehicle. Saliva and serum CTX and b-ALP were determined at 60 days (baseline) and at 75 days (T(75)). Lumbar spine and proximal tibia bone mineral density (BMD) was determined using dual-energy x-ray absorptiometry at baseline and at 105 days. RESULTS: SHAM baseline and T(75) salivary b-ALP and CTX levels correlated with serum concentrations (P <0.01 and P <0.004, respectively). A correlation was observed between saliva and serum concentrations of b-ALP and CTX in OVX at baseline (P <0.0001 and P <0.004, respectively). Baseline salivary b-ALP and CTX levels were lower in SHAM animals compared to OVX groups (P <0.01). After treatment, T(75) saliva and serum CTX remained higher in G4 compared to G1 (P <0.05), was lower in G2 than in G1 (P <0.01) and G3 (P <0.01), and was similar in G1 and G3. Changes in BMD were the result of variations in salivary CTX levels due to OPD treatment (P <0.05). CONCLUSIONS: Saliva determinations may prove to be practical and reliable for the detection of systemic signs of increased bone remodeling, particularly in cases involving pediatric, obese, and elderly patients, and in screening large populations. Moreover, saliva CTX may be one of the best candidate markers to detect the activity and severity of periodontal disease.

Vitamin D insufficiency reduces the protective effect of bisphosphonate on ovariectomy-induced bone loss in rats.

The present study was carried out to obtain an experimental model of vitamin D (vit D) insufficiency and established osteopenia (experiment 1) to then investigate whether vit D status, i.e. normal or insufficient, interferes with bone mass recovery resulting from bisphosphonate therapy (experiment 2). Rats (n = 40) underwent OVX (n = 32) or a sham operation (n = 8). The first 15 days post-surgery, all groups were kept under fluorescent tube lighting and fed a diet containing 200 IU% vit D (+D). They were then assigned during an additional 45 days to receive either +D or a diet lacking vit D (-D) and kept under 12 h light/dark cycles using fluorescent or red lighting. Serum 25HOD was significantly lower in -D rats (P < 0.0001). The type of lighting did not induce differences in 25OHD, calcium (sCa), phosphorus (sP), bone alkaline phosphatase (b-AL), CTX, bone density or histology. No osteoid was observed in undecalcified bone sections. Experiment 2 (105 days): rats were fed either +D or -D according to experiment 1 and were treated with either placebo or 16 mug olpadronate (OPD)/100 g rat/week during the last 45 days. Whereas 25HOD was significantly lower (P < 0.0001) in -D/OPD than in +D/OPD rats, no significant differences in sCa, sP, b-AL or CTX were observed. OPD prevented the loss of lumbar spine (LS) and proximal tibia (PT) BMD and the decrease in bone volume (BV/TV) (P < 0.05) and in the number of trabeculae observed in untreated rats. However, +D/OPD animals presented significantly higher values of LS BMD, PT BMD and BV/TV than -D/OPD rats (P < 0.05). No osteoid was observed in undecalcified sections of bone. In summary, this is the first experimental study to provide evidence that differences in vit D status may affect the anticatabolic response to bisphosphonate treatment. However, the molecular mechanism through which vit D insufficiency reduces the effect of the aminobisphosphonate remains to be defined.