Does the Choice of Preparation Protocol for Platelet-Rich Fibrin Have Consequences for Healing and Alveolar Ridge Preservation After Tooth Extraction? A Meta-Analysis.

PURPOSE: Multiple preparation protocols for platelet-rich fibrin (PRF) are in use today, and clinical results are often heterogeneous. This study analyzes the impact of the chosen PRF preparation protocol on 1) wound healing and 2) alveolar ridge preservation. METHODS: For this systematic review and meta-analysis, eligible studies were identified in PubMed and Cochrane databases. Included were randomized controlled and controlled clinical trials with healthy patients treated with PRF after atraumatic tooth extraction compared to untreated socket(s), reporting at least one of the following outcome variables: pain, swelling, soft tissue healing, alveolar osteitis risk, horizontal and vertical bone loss, socket fill, and new bone formation. Main predictor variable was relative centrifugal force (RCF) comparing high RCF (high PRF), intermediate RCF (standard [S-PRF]), low RCF (advanced PRF), and various RCF settings (concentrated growth factor preparation [CGF]). The type of centrifugation tubes (silica-coated plastic and glass) was a secondary predictor. Weighted or standardized mean differences, risk ratio and corresponding 95% confidence intervals were calculated. RESULTS: Forty studies published between 2012 and 2022 were selected. The pooled effects of all outcomes were significant against untreated sockets. Within the subgroups high PRF or advanced PRF had the lowest efficacy for many outcome parameters. Pain reduction (in visual analog scale units) was highest for S-PRF (-1.18 [-1.48, -0.88], P < .00001) and CGF (-1.03 [-1.16, -0.90], P < .001). The risk ratio of alveolar osteitis (0.09 [0.01, 0.69], P < .02) and soft tissue healing (standardized mean difference = 2.55 [2.06, 3.03], P < .001) were best for CGF. No subgroup differences were found for bone-related outcomes. No meaningful analysis of the tube material effect was possible. CONCLUSION: This study confirms that PRF is associated with reduced postoperative complications but indicates that preparation protocol influences clinical outcomes. S-PRF and CGF protocols appear to be superior for several outcome parameters.

A novel resorption assay for osteoclast functionality based on an osteoblast-derived native extracellular matrix.

Osteoclasts are large, mobile, bone-resorbing cells and play a critical role in bone remodeling and catabolic bone diseases. The major function of osteoclasts is to hydrolyze inorganic hydroxyapatite and degrade organic bone matrix, mainly collagen. For evaluation of differentiation to fully functional osteoclasts in vitro, a quantitative functional resorption assay is essential. Currently available commercial test systems are either based on the organic or the inorganic part of the bone matrix. The novel resorption assay presented here is based on decellularized osteoblast-derived matrix. SaOS-2 cells were used for the synthesis of a densely mineralized extracellular bone matrix (ECM) in alpha-MEM medium, which strongly accelerates their matrix synthesis. After removal of the SaOS-2 cells, osteoclast precursors are plated on the osteoblast-derived matrix and stained by von Kossa. Subsequently, resorption pits were quantified by densitometry using an imaging program. Using this novel assay, we show that (i) RAW 264.7 cells resorbed the osteoblast-derived matrix continuously from day 6 until day 9 of culture, a process that is dose dependent on the macrophage colony-stimulating factor (M-CSF) concentration, (ii) the resorption performance of RAW 264.7 was dose-dependently inhibited by IFN-gamma, and (iii) the assay is working with primary human and mouse osteoclast precursors as well. In conclusion, this quantitative, functional, easy-to-use, inexpensive assay will advance analysis of osteoclast biology.

Response of osteoblast-like SAOS-2 cells to zirconia ceramics with different surface topographies.

OBJECTIVES: Zirconia is a suitable biomaterial for use in medicine (stomatology, orthopaedics) due to its good biocompatibility and outstanding mechanical properties. This study compares the effect of (i) zirconia to the widely used titanium and (ii) zirconia with two different surface topographies (sandblasted and sandblasted/etched) on the adhesion, proliferation and differentiation of SAOS-2 osteoblasts. METHODS: SAOS-2 cells were cultured on either sandblasted or sandblasted/etched zirconia and compared with sandblasted/etched titanium. 2 and 24 h after plating, cell morphology was investigated by scanning electron microscope (SEM) and fluorescence imaging. At 24 and 48 h, cell number-relevant parameters were determined. Alkaline phosphatase (ALP) activity and mineral accumulation were measured at days 8, 11, 15 and day 22 of culture, respectively. RESULTS: SEM and fluorescence images revealed a faster spreading as well as higher number of adherent cells after 24 h incubation on zirconia compared with titanium. Also, the cellular metabolic activity after 24 h and the proliferation rate after 48 h is higher with zirconia compared with titanium. Zirconia had a more pronounced effect compared with titanium on the differentiation of SAOS-2 cells: ALP activity, an early differentiation marker increased earlier and mineralization, a late differentiation marker was increased. Only minor differences were found between zirconia with two different surface topographies; etched zirconia promoted slightly greater the differentiation of SAOS-2 cells. CONCLUSIONS: These data indicate that zirconia mediates a pronounced stronger effect on the adhesion, proliferation and differentiation compared with titanium; and that topographical differences of zirconia have minor effects on osteoblast biology.

Success and side effects of different treatment options in the low current attack of bacterial biofilms on titanium implants.

The long-term success of peri-implantitis treatments is generally insufficient. Attacking the bacteria on the titanium implant surface using electrochemical polarization could be an alternative approach. In this study an E. coli biofilm in phosphate buffered saline was treated with low current densities (0.25 to 2 mA/cm2) using anodic, cathodic, or combined polarization regimes, either alone or with the antiseptic chlorhexidine. The antibacterial effect was assessed using LIVE/DEAD® staining and through quantification of viable bacteria, sample surfaces were characterized pre- and post-treatment with electrochemical impedance spectroscopy. All polarization treatments had an antibacterial effect that increased with current density, with at least 1 mA/cm2 necessary to reduce colony forming units by four orders of magnitude. Cathodic treatment was slightly superior to anodic treatment, and there was no difference between alternating polarization and single-type polarization. Neither treatment resulted in a significant detachment of bacteria, but combination with chlorhexidine improved the antibacterial effect synergistically. The use of chloride containing electrolytes is not recommended in this context. The low current densities used here were not sufficient to generate adequate bactericidal chlorine reactive species, but first signs of pitting corrosion were already detected for anodic polarization at 1 mA/cm2.

Osteoclast and osteoblast response to strontium-doped struvite coatings on titanium for improved bone integration.

To develop implants with improved bone ingrowth, titanium substrates were coated with homogeneous and dense struvite (MgNH4PO4·6H2O) layers by means of electrochemically assisted deposition. Strontium nitrate was added to the coating electrolyte in various concentrations, in order to fabricate Sr-doped struvite coatings with Sr loading ranging from 10.6 to 115 µg/cm2. It was expected and observed that osteoclast activity surrounding the implant was inhibited. The cytocompatibility of the coatings and the effect of Sr-ions in different concentrations on osteoclast formation were analyzed in vitro. Osteoclast differentiation was elucidated on morphological, biochemical as well as on gene expression level. It could be shown that moderate concentrations of Sr2+ had an inhibitory effect on osteoclast formation, while the growth of osteoblastic cells was not negatively influenced compared to pure struvite surfaces. In summary, the electrochemically deposited Sr-doped struvite coatings are a promising approach to improve bone implant ingrowth.

Sodium alendronate loaded poly(l-lactide- co-glycolide) microparticles immobilized on ceramic scaffolds for local treatment of bone defects.

Bone tissue regeneration in critical-size defects is possible after implantation of a 3D scaffold and can be additionally enhanced once the scaffold is enriched with drugs or other factors supporting bone remodelling and healing. Sodium alendronate (Aln), a widely used anti-osteoporosis drug, exhibits strong inhibitory effect on bone resorption performed by osteoclasts. Thus, we propose a new approach for the treatment of bone defects in craniofacial region combining biocompatible titanium dioxide scaffolds and poly(l-lactide-co-glycolide) microparticles (MPs) loaded with Aln. The MPs were effectively attached to the surface of the scaffolds' pore walls by human recombinant collagen. Drug release from the scaffolds was characterized by initial burst (24 ± 6% of the drug released within first 24 h) followed by a sustained release phase (on average 5 µg of Aln released per day from Day 3 to Day 18). In vitro tests evidenced that Aln at concentrations of 5 and 2.5 µg/ml was not cytotoxic for MG-63 osteoblast-like cells (viability between 81 ± 6% and 98 ± 3% of control), but it prevented RANKL-induced formation of osteoclast-like cells from macrophages derived from peripheral blood mononuclear cells, as shown by reduced fusion capability and decreased tartrate-resistant acid phosphatase 5b activity (56 ± 5% reduction in comparison to control after 8 days of culture). Results show that it is feasible to design the scaffolds providing required doses of Aln inhibiting osteoclastogenesis, reducing osteoclast activity, but not affecting osteoblast functions, which may be beneficial in the treatment of critical-size bone tissue defects.

Utilizing DNA for functionalization of biomaterial surfaces.

DNA sequences are widely used for gene transfer into cells including a number of substrate surface-based supporting systems, but due to its singular structure property profile, DNA also offers multiple options for noncanonical applications. The special case of using DNA and oligodeoxyribonucleotide (ODN) structures for surface functionalization of biomedical implants is summarized here with the major focus on (a) immobilization or anchoring of nucleic acid structures on substrate surfaces, (b) incorporation of biologically active molecules (BAM) into such systems, and (c) biological characteristics of the resulting surfaces in vitro and in vivo. Sterilizations issues, important for potential clinical applications, are also considered.

One step 3D printing of surface functionalized composite scaffolds for tissue engineering applications.

their surface properties. A main challenge in this area is the development of processing routes enabling for a simple but efficient surface design of complex shaped geometries. Against this background, this work aimed at the implementation of self-assembly principles for surface functionalization of 3D-printed poly(lactic-co-glycolic acid) (PLGA)-based constructs with macro- and microporous geometries via precision extruding deposition. METHODS: Three-component melts from PLGA, CaCO3 and amphiphilic polymers (poly(2-oxazoline) block copolymer) were printed and their bulk and surface properties were studied. RESULTS: Melts with up to 30 mass % of CaCO3 could be successfully printed with homogeneously distributed mineral particles. PLGA degradation during the printing process was temperature and time dependent: the molecular weight reached 10 to 15% of the initial values after ca. 120 min of heat exposure. Filament surfaces from melts containing CaCO3 show an increasing microroughness along with increasing CaCO3 content. Surface roughness and amphiphilic polymer content improve scaffold wettability with both factors showing synergistic effects. The CaCO3 content of the melts affected the inner filament structure during in vitro degradation in PBS, resulting in a homogeneous mineral particle-associated microporosity for mineral contents of 20 mass % and above. CONCLUSIONS: These results provide novel insights into the behavior of three-component melts from PLGA, CaCO3 and amphiphilic polymers during precision extruding deposition and show for the first time that self-assembly processes can be used to tailor scaffolds surface properties under such processing conditions.

Osteogenic nanostructured titanium surfaces with antibacterial properties under conditions that mimic the dynamic situation in the oral cavity.

The study aim was to assess the impact of different surface nanofeatures on otherwise smooth titanium surfaces on bacterial adhesion as well as on their osteogenic potential. Bacterial adhesion was assessed in the presence of saliva under static and dynamic conditions to approximate both sub- and supragingival conditions in the oral cavity as the gingival seal will be affected by implantation. The ultimate goal was to develop a surface that will reduce biofilm formation but still support osseointegration in vivo. To this end nanotubular or nanopitted surfaces were created on electropolished titanium via electrochemical anodization procedures. Sandblasted/acid etched surfaces (SBAE) were used as a microrough reference. Bacterial adhesion was studied using saliva-precoated samples with S. sanguinis as a typical early colonizer of the oral cavity; osteogenic differentiation was assessed with human bone marrow stromal cells. While bacterial adhesion was reduced on all microsmooth surfaces to an average of 17% surface coverage compared to 61% on SBAE under static conditions, under dynamic conditions the nanopitted surface had a significant impact on bacterial adhesion. Here fluid flow removed all bacteria. By comparison, the reduction on the nanotubular surface was only similar to that of the SBAE reference. We hypothesise the underlying cause to be an effect of the surface morphology on the structure and composition of the saliva precoating that reduces its stability, giving rise to a self-cleaning effect. In addition, no negative influence on the osteogenic potential of the nanopitted surface could be determined by alkaline phosphatase activity, mineralization behaviour or gene expression; it remained on a par with the tissue culture plastic control. Thus, nanopitting seems to be a promising surface treatment candidate for dental implants to reduce infection related complications without compromising the implant integration.

Investigation of the mechanical and chemical characteristics of nanotubular and nano-pitted anodic films on grade 2 titanium dental implant materials.

OBJECTIVE: The objective of this study was to investigate the reproducibility, mechanical integrity, surface characteristics and corrosion behavior of nanotubular (NT) titanium oxide arrays in comparison with a novel nano-pitted (NP) anodic film. METHODS: Surface treatment processes were developed to grow homogenous NT and NP anodic films on the surface of grade 2 titanium discs and dental implants. The effect of process parameters on the surface characteristics and reproducibility of the anodic films was investigated and optimized. The mechanical integrity of the NT and NP anodic films were investigated by scanning electron microscopy, surface roughness measurement, scratch resistance and screwing tests, while the chemical and physicochemical properties were investigated in corrosion tests, contact angle measurement and X-ray photoelectron spectroscopy (XPS). RESULTS AND DISCUSSION: The growth of NT anodic films was highly affected by process parameters, especially by temperature, and they were apt to corrosion and exfoliation. In contrast, the anodic growth of NP film showed high reproducibility even on the surface of 3-dimensional screw dental implants and they did not show signs of corrosion and exfoliation. The underlying reason of the difference in the tendency for exfoliation of the NT and NP anodic films is unclear; however the XPS analysis revealed fluorine dopants in a magnitude larger concentration on NT anodic film than on NP surface, which was identified as a possible causative. Concerning other surface characteristics that are supposed to affect the biological behavior of titanium implants, surface roughness values were found to be similar, whereas considerable differences were revealed in the wettability of the NT and NP anodic films. CONCLUSION: Our findings suggest that the applicability of NT anodic films on the surface of titanium bone implants may be limited because of mechanical considerations. In contrast, it is worth to consider the applicability of nano-pitted anodic films over nanotubular arrays for the enhancement of the biological properties of titanium implants.

Influence of modified extracellular matrices on TI6AL4V implants on binding and release of VEGF.

Besides osteoconductive and osteoinductive signals, angiogenesis plays a crucial role in bone development and regeneration and consequently in the integration of implants. Therefore we investigated in this study the binding and release behaviour of vascular endothelial growth factor (VEGF) from Ti6Al4V surfaces coated with 3-dimensional collageneous matrices, some additionally modified with heparin. The heparin was incorporated using different methods: a) adsorptive immobilization b) crosslinking with N-(3-dimethylaminopropyl)-N'-ethylcarbodiimide (EDC) or c) incorporating during self-assembly of fibrils followed by cross-linking. For unmodified samples, maximum VEGF adsorption was reached with 85 ng VEGF/cm(2). On all 3d-collagen coated surfaces studied (with or without heparin), no saturation could be observed in the range of 0-256 ng VEGF/cm(2).Improved release kinetics were observed for the modified coatings. The initial burst of VEGF within the first 24 h was diminished. From the third day of delivery heparinized matrices showed a higher release of VEGF than the pure collagen matrix and the unmodified reference surface, respectively. In vitro, the proliferation of human dermal microvascular endothelial cells was increased with released VEGF from all investigated samples compared to a VEGF-free control. After 7 days highest increases in cell numbers were observed with solutions from heparinized matrices. It is concluded that functionalization of Ti6Al4V surfaces with heparinized collageneous matrices and VEGF leads to advantageous properties concerning the impact on angiogenesis and thus may improve bone regeneration in the microenvironment of implants.

Application of Lateral and Distance Spacers in an Oligonucleotide Based Immobilization System for Bioactive Molecules onto Titanium Implants.

Immobilization of bioactive molecules (BAMs) on a nanometer scale is of great interest for functionalization of implant and scaffold surfaces in current biomaterials research. A system for immobilization of one or more compounds is described, which is based on nanomechanical fixation of single-stranded nucleic acids into an anodic titanium oxide layer and their subsequent hybridization with BAMs conjugated to the respective complementary strands. This paper focuses on further development and in depth understanding of the immobilization system, as some of the major findings established for common sensor applications for immobilization of single-stranded DNA onto gold surfaces cannot be transferred to the TiO2 surface. The first approach concerning the influence of the internal spacer sequence revealed the best performance for a polyadenine based sequence out of four homologous spacer sequences (A30, T30, C30, and G30). This overall best performance of the A30 spacer is attributed to an increased contour length by nucleotide staggering, which resulted in the best protection of the hybridization sequence from unfavorable interactions with the surface or damaging attacks by reactive oxygen species. The second approach comprises the implementation of a lateral spacer, also based on a homologous sequence of A30. Simultaneous as well as sequential adsorption of anchor strands and spacer strands were performed, and it could be shown that a preadsorption with high density of the spacer was most effective to increase hybridization efficiency.

Influence of pulse ratio on codeposition of copper species with calcium phosphate coatings on titanium by means of electrochemically assisted deposition.

Aim of this study was to combine the well-known biocompatibility and ostoeconductivity of thin calcium phosphate coatings on titanium with proangiogenic signals from codeposited copper species. Copper species could be integrated in mineral layers based on hydroxyapatite by means of electrochemically assisted deposition from electrolytes containing calcium, phosphate, and copper ions. Different combinations of duration and intensity of galvanostatic pulses result in different amounts of deposited calcium phosphate and of copper species even for the same applied total charge. Absolute amounts of copper varied between 2.1 and 6.9 µg/cm², and the copper was distributed homogeneously as shown by EDX mapping. The presence of copper did not change the crystalline phase of deposited calcium phosphate (hydroxyapatite) but provoked a significant decrease in deposited amounts by factor 3 to 4. The copper was deposited mainly as Cu(I) species with a minor fraction of basic copper phosphates. Reduction of copper occurred not only at the surface of titanium but also within the hydroxyapatite coating due to the reaction with hydrogen produced by the electrolysis of water during the cathodic polarization of the substrate.

Physicochemical and cell biological characterization of PMMA bone cements modified with additives to increase bioactivity.

Polymethylmethacrylate (PMMA) bone cement is the most widely used material in surgery to fix joint replacements in the bone. In this study, we propose a new approach to generate bioactive PMMA surfaces directly at the site of implantation by adding the amphiphilic molecule phosphorylated 2-hydroxyethylmethacrylate (HEMA-P) to commercial PMMA bone cement, both with or without addition of 1-5% soluble calcium and carbonate salts. The setting behavior as well as the mechanical properties, the bonding quality at the metal/cement interface, mineral deposition, and cellular response for different cement modifications were investigated in vitro. The addition of HEMA-P resulted in entirely positive effects with respect to proliferation and differentiation of osteoblast-like cells (SaOs-2) and a very tight contact at the metal/cement interface. No detrimental changes of other properties were detected. The additional incorporation of salts provoked an increased deposition of calcium phosphate minerals but no further improvement in SaOs-2 cell differentiation. A significant decrease in polarization resistance for cements with high salt content (5%) was attributed to debonding between metal and cement. The results suggest an improved clinical performance of PMMA/HEMA-P composites, which might be further enhanced by small amounts of the soluble salts.

Progression of osteogenic cell cultures grown on microtopographic titanium coated with calcium phosphate and functionalized with a type I collagen-derived peptide.

BACKGROUND: The functionalization of metallic surfaces aims at promoting the cellular response at the biomaterial-tissue interface. This study investigates the effects of the functionalization of titanium (Ti) microtopography with a calcium phosphate (CaP) coating with and without peptide 15 (P-15), a synthetic peptide analog of the cell-binding domain of collagen I, on the in vitro progression of osteogenic cells. METHODS: Sandblasting and acid etching (SBAE; control) Ti microtopography was coated with CaP, enabling the loading of two concentrations of P-15: 20 or 200 µg/mL. A machined Ti was also examined. Rat calvarial osteogenic cells were cultured on Ti disks with the surfaces mentioned above for periods up to 21 days (n = 180 per group). RESULTS: CaP coating exhibited a submicron-scale needle-shaped structure. Although all surfaces were hydrophobic at time zero, functionalization increased hydrophilicity at equilibrium. Microtopographies exhibited a lower proportion of well-spread cells at 4 hours of culture and cells with long cytoplasmic extensions at day 3; modified SBAE supported higher cell viability and larger extracellular osteopontin (OPN) accumulation. For SBAE and modified SBAE, real-time polymerase chain reaction showed the following results: 1) lower levels for runt-related transcription factor 2 at 7 days and for bone sialoprotein at days 7 and 10 as well as higher OPN levels at days 7 and 10 compared to machined Ti; and 2) higher alkaline phosphatase levels at day 10 compared to day 7. At 14 and 21 days, modified SBAE supported higher proportions of red-dye-stained areas (calcium content). CONCLUSION: Addition of a CaP coating to SBAE Ti by itself may affect key events of in vitro osteogenesis, ultimately resulting in enhanced matrix mineralization; additional P-15 functionalization has only limited synergistic effects.