Bone regeneration capacity of newly developed spherical magnesium phosphate cement granules.

OBJECTIVES: Magnesium phosphate-based cements begin to catch more attention as bone substitute materials and especially as alternatives for the more commonly used calcium phosphates. In bone substitutes for augmentation purposes, atraumatic materials with good biocompatibility and resorbability are favorable. In the current study, we describe the in vivo testing of novel bone augmentation materials in form of spherical granules based on a calcium-doped magnesium phosphate (CaMgP) cement. MATERIALS AND METHODS: Granules with diameters between 500 and 710 µm were fabricated via the emulsification of CaMgP cement pastes in a lipophilic liquid. As basic material, two different CaMgP formulations were used. The obtained granules were implanted into drill hole defects at the distal femoral condyle of 27 New Zealand white rabbits for 6 and 12 weeks. After explantation, the femora were examined via X-ray diffraction analysis, histological staining, radiological examination, and EDX measurement. RESULTS: Both granule types display excellent biocompatibility without any signs of inflammation and allow for proper bone healing without the interposition of connective tissue. CaMgP granules show a fast and continuous degradation and enable fully adequate bone regeneration. CONCLUSIONS: Due to their biocompatibility, their degradation behavior, and their completely spherical morphology, these CaMgP granules present a promising bone substitute material for bone augmentation procedures, especially in sensitive areas. CLINICAL RELEVANCE: The mostly insufficient local bone supply after tooth extractions complicates prosthetic dental restoration or makes it even impossible. Therefore, bone augmentation procedures are oftentimes inevitable. Spherical CaMgP granules may represent a valuable bone replacement material in many situations.

GDF-5 can act as a context-dependent BMP-2 antagonist.

BACKGROUND: Bone morphogenetic protein (BMP)-2 and growth and differentiation factor (GDF)-5 are two related transforming growth factor (TGF)-ß family members with important functions in embryonic development and tissue homeostasis. BMP-2 is best known for its osteoinductive properties whereas GDF-5-as evident from its alternative name, cartilage derived morphogenetic protein 1-plays an important role in the formation of cartilage. In spite of these differences both factors signal by binding to the same subset of BMP receptors, raising the question how these different functionalities are generated. The largest difference in receptor binding is observed in the interaction with the type I receptor BMPR-IA. GDF-5, in contrast to BMP-2, shows preferential binding to the isoform BMPR-IB, which is abrogated by a single amino acid (A57R) substitution. The resulting variant, GDF-5 R57A, represents a "BMP-2 mimic" with respect to BMP receptor binding. In this study we thus wanted to analyze whether the two growth factors can induce distinct signals via an identically composed receptor. RESULTS: Unexpectedly and dependent on the cellular context, GDF-5 R57A showed clear differences in its activity compared to BMP-2. In ATDC-5 cells, both ligands induced alkaline phosphatase (ALP) expression with similar potency. But in C2C12 cells, the BMP-2 mimic GDF-5 R57A (and also wild-type GDF-5) clearly antagonized BMP-2-mediated ALP expression, despite signaling in both cell lines occurring solely via BMPR-IA. The BMP-2- antagonizing properties of GDF-5 and GDF-5 R57A could also be observed in vivo when implanting BMP-2 and either one of the two GDF-5 ligands simultaneously at heterotopic sites. CONCLUSIONS: Although comparison of the crystal structures of the GDF-5 R57A:BMPR-IAEC- and BMP-2:BMPR-IAEC complex revealed small ligand-specific differences, these cannot account for the different signaling characteristics because the complexes seem identical in both differently reacting cell lines. We thus predict an additional component, most likely a not yet identified GDF-5-specific co-receptor, which alters the output of the signaling complexes. Hence the presence or absence of this component then switches GDF-5's signaling capabilities to act either similar to BMP-2 or as a BMP-2 antagonist. These findings might shed new light on the role of GDF-5, e.g., in cartilage maintenance and/or limb development in that it might act as an inhibitor of signaling events initiated by other BMPs.

Cryopreservation of autologous bone grafts: an experimental study on a sheep animal model.

A sheep animal model was used to investigate the clinical behavior of autologous bone transplants after cryopreservation. The aim of the present study was to compare fresh, cryopreserved and deep-frozen bone transplants in terms of their osseointegration. We used a serum-free cryopreservation protocol with DMSO as cryoprotectant for the bone transplants, which were harvested from the iliac crest of the sheep. The bicortical iliac bone grafts were either cryopreserved or immediately frozen to -80 degrees C for 4 weeks. Four, 8, 12 and 16 weeks after the autologous transplantation of the cryopreserved, fresh or deep-frozen bone transplants to the contralateral iliac crest, the animals were sacrificed and the bone specimens were evaluated clinically, by staining for hematoxylin/eosin and for tartrate-resistant acid phosphatase, by quantified computed tomography, immunohistochemistry (Ki67) and polychrome sequential labeling. The best results were obtained for the fresh specimens with 83% bone healing compared with 75% (cryopreserved bone) and 50% (deep frozen bone). All parameters indicate that bone formation and remodeling processes take place in fresh and cryopreserved transplants. The deep-frozen specimens displayed no fluorochrome uptake in the sequential labeling. These findings indicate that osseointegration of the fresh transplants was the most successful and that osteogenic effects in fresh and cryopreserved transplants are located in the surface area, whereas only the osteoconductive effects are important in the center of the transplants. Thus, cryopreservation is a useful method for the clinical routine because it keeps the osteogenic cells viable, making it superior to deep freezing of abundant bone.

Low temperature fabrication of magnesium phosphate cement scaffolds by 3D powder printing.

Synthetic bone replacement materials are of great interest because they offer certain advantages compared with organic bone grafts. Biodegradability and preoperative manufacturing of patient specific implants are further desirable features in various clinical situations. Both can be realised by 3D powder printing. In this study, we introduce powder-printed magnesium ammonium phosphate (struvite) structures, accompanied by a neutral setting reaction by printing farringtonite (Mg(3)(PO(4))(2)) powder with ammonium phosphate solution as binder. Suitable powders were obtained after sintering at 1100°C for 5 h following 20-40 min dry grinding in a ball mill. Depending on the post-treatment of the samples, compressive strengths were found to be in the range 2-7 MPa. Cytocompatibility was demonstrated in vitro using the human osteoblastic cell line MG63.

Development and Bone Regeneration Capacity of Premixed Magnesium Phosphate Cement Pastes.

Magnesium phosphate cements (MPC) have been demonstrated to have a superior bone regeneration capacity due to their good solubility under in vivo conditions. While in the past only aqueous MPC pastes have been applied, the current study describes the fabrication and in vitro/in vivo testing of an oil-based calcium doped magnesium phosphate (CaMgP) cement paste. Premixed oil-based pastes with CaMgP chemistry combine the advantages of conventional MPC such as high mechanical strength and good resorbability with a prolonged shelf-life and an easier clinical handling. The pastes set in an aqueous environment and predominantly form struvite and achieve a compressive strength of ~8-10 MPa after setting. The implantation into a drill-hole defect at the distal femoral condyle of New Zealand white rabbits over a course of 6 and 12 weeks demonstrated good biocompatibility of the materials without the formation of soft connective tissue or any signs of inflammation. In contrast to a hydroxyapatite forming reference paste, the premixed CaMgP pastes showed subsequent degradation and bony regeneration. The CaMgP cement pastes presented herein are promising bone replacement materials with excellent material properties for an improved and facilitated clinical application.

Fabrication and cytocompatibility of spherical magnesium ammonium phosphate granules.

Magnesium phosphate compounds, as for example struvite (MgNH4PO4·6H2O), have comparable characteristics to calcium phosphate bone substitutes, but degrade faster under physiological conditions. In the present work, we used a struvite forming calcium doped magnesium phosphate cement with the formulation Ca0.75Mg2.25(PO4)2 and an ammonium phosphate containing aqueous solution to produce round-shaped granules. For the fabrication of spherical granules, the cement paste was dispersed in a lipophilic liquid and stabilized by surfactants. The granules were characterized with respect to morphology, size distribution, phase composition, compressive strength, biocompatibility and solubility. In general, it was seen that small granules can hardly be produced by means of emulsification, when the raw material is a hydraulic paste, because long setting times promote coalescence of initially small unhardened cement droplets. Here, this problem was solved by using an aqueous solution containing both the secondary (NH4)2HPO4 and primary ammonium phosphates NH4H2PO4 to accelerate the setting reaction. This resulted in granules with 97 wt.% having a size in the range between 200 and 1,000 µm. The novel solution composition doubled the compressive strength of the cement to 37 ± 5 MPa without affecting either the conversion to struvite or the cytocompatibility using human fetal osteoblasts.

Tissue engineering of human oral mucosa on different scaffolds: in vitro experiments as a basis for clinical applications.

OBJECTIVES: The lack of oral mucosa in oral and maxillofacial surgery for intraoral grafting after trauma or tumor resection can be balanced by tissue-engineered oral mucosa. The aim of this study was to generate a tissue-engineered oral mucosa equivalent (OME). STUDY DESIGN: First, primary oral fibroblasts were cultured for 7 days on different materials: Tissufoil E (TFE), dermal regeneration template (DRT), and Vicryl. Then, cocultures were established by seeding of primary oral keratinocytes and culturing for another 7-14 days. Immunohistochemical staining for CD90, cytokeratin 14 and collagen IV as well as gene expression analysis using reverse-transcription quantitative polymerase chain reaction were used to get information about cell architecture and basal membrane formation. RESULTS: Vicryl showed good mechanical stability but mixed cell growth. TFE provided the best cell growth with good cell architecture and basal membrane formation but showed degradation. The best results for the above-mentioned criteria were seen with DRT. CONCLUSIONS: It was possible to create OMEs on all 3 scaffolds. The arrangement of the cells strongly depends on the texture of the material.

In vivo degradation of low temperature calcium and magnesium phosphate ceramics in a heterotopic model.

Bone replacement using synthetic and degradable materials is desirable in various clinical conditions. Most applied commercial materials are based on hydroxyapatite, which is not chemically degradable under physiological conditions. Here we report the effect of a long-term intramuscular implantation regime on the dissolution of various low temperature calcium and magnesium phosphate ceramics in vivo. The specimens were analysed by consecutive radiographs, micro-computed tomography scans, compressive strength testing, scanning electron microscopy and X-ray diffractometry. After 15months in vivo, the investigated materials brushite (CaHPO(4)·2H(2)O), newberyite (MgHPO(4)·3H(2)O), struvite (MgNH(4)PO(4)·6H(2)O) and hydroxyapatite (Ca(9)(PO(4))(5)HPO(4)OH) showed significant differences regarding changes of their characteristics. Struvite presented the highest loss of mechanical performance (95%), followed by newberyite (67%) and brushite (41%). This was accompanied by both a distinct extent of cement dissolution as well as changes of the phase composition of the retrieved cement implants. While the secondary phosphate phases (brushite, newberyite, struvite) completely dissolved, re-precipitates of whitlockite and octacalcium phosphate were formed in either particulate or whisker-like morphology. Furthermore, for the first time the possibility of a macropore-free volume degradation mechanism of bioceramics was demonstrated.

Face perception in patients with unilateral cleft lip and palate and patients with severe Class III malocclusion compared to controls.

Although there is principal agreement that increased facial asymmetry is associated with decreased facial attractiveness, there are no studies analysing face perception in patients with a unilateral cleft lip and palate (CLP) (uCLP) compared to orthognathic Class III patients. To this end, three-dimensional (3D) data on the faces of 30 adults with a complete uCLP, 20 orthognathic patients with a severe skeletal Class III, and 20 adults with a skeletal Class I as a control group were generated. The 3D asymmetry of the facial soft-tissue was analysed. These data were compared with subjective ratings for attractiveness carried out by 100 laypersons. Compared to the controls, uCLP patients and orthognathic patients had a significantly higher facial asymmetry. No difference was found between uCLP patients and orthognathic patients. The attractiveness ratings showed that uCLP patients and orthognathic patients were rated less attractive compared to the controls. However, although there were no differences in the facial asymmetry between uCLP patients and orthognathic patients, the uCLP patients were rated significantly less attractive. This leads to the conclusion that not only the extent of asymmetry has an influence on attractiveness but also the location of asymmetry. For clinical use, these findings underline the importance of accurate as possible surgical reconstruction of the nasal morphology in uCLP patients.

Phase composition, mechanical performance and in vitro biocompatibility of hydraulic setting calcium magnesium phosphate cement.

Brushite (CaHPO(4) x 2H(2)O)-forming calcium phosphate cements are of great interest as bone replacement materials because they are resorbable in physiological conditions. However, their short setting times and low mechanical strengths limit broad clinical application. In this study, we showed that a significant improvement of these properties of brushite cement could be achieved by the use of magnesium-substituted beta-tricalcium phosphate with the general formula Mg(x)Ca((3-x))((PO(4))(2) with 0 < x < 3 as cement reactants. The incorporation of magnesium ions increased the setting times of cements from 2 min for a magnesium-free matrix to 8-11 min for Mg(2.25)Ca(0.75)(PO(4))(2) as reactant. At the same time, the compressive strength of set cements was doubled from 19 MPa to more than 40 MPa after 24h wet storage. Magnesium ions were not only retarding the setting reaction to brushite but were also forming newberyite (MgHPO(4) x 3H(2)O) as a second setting product. The biocompatibility of the material was investigated in vitro using the osteoblast-like cell line MC3T3-E1. A considerable increase of cell proliferation and expression of alkaline phosphatase, indicating an osteoblastic differentiation, could be noticed. Scanning electron microscopy analysis revealed an obvious cell growth on the surface of the scaffolds. Analysis of the culture medium showed minor alterations of pH value within the physiological range. The concentrations of free calcium, magnesium and phosphate ions were altered markedly due to the chemical solubility of the scaffolds. We conclude that the calcium magnesium phosphate (newberyite) cements have a promising potential for their use as bone replacement material since they provide a suitable biocompatibility, an extended workability and improved mechanical performance compared with brushite cements.

3D powder printed calcium phosphate implants for reconstruction of cranial and maxillofacial defects.

BACKGROUND: The aim of this study was to investigate the processing and the possible use of 3D powder printed calcium phosphate implants for the reconstruction of cranial and maxillofacial defects. MATERIALS: The fabrication of the implants was carried out with a commercial 3D powder printing system. Diluted phosphoric acid was printed onto tricalcium phosphate powder, leading to the formation of dicalcium phosphate dihydrate (Brushite). Hydrothermal conversion of the brushite matrices led to the formation of dicalcium phosphate anhydrous (Monetite). METHOD: Bony defects were generated using a human cadaver skull. The implants were computer-aided designed (CAD) using a mirror imaging procedure following computed tomography of the skull. Specific implants were manufactured by the 3D powder printing rapid prototyping technique. RESULT: The processing chain from data acquisition to printing of the implants proved to be practical and uncomplicated. The individual implants showed a high degree of accuracy of fit. Mechanical and physical investigations revealed suitable characteristics. CONCLUSION: 3D powder printing of calcium phosphate cement material provides a promising new method for the manufacturing of biodegradable synthetic patient-specific craniofacial implants.

Multi-directional Le Fort III midfacial distraction using an individual prefabricated device.

BACKGROUND: Midfacial distraction following Le Fort III osteotomy has become an established procedure for midfacial advancement of syndromic craniosynostosis patients. A frequent difficulty is the precise three dimensional (3D) alignment of the distracted midface and the proper fixation of the distraction device in the midfacial area. In this study we present an individual modification method for commercial distraction devices comprising the establishment of prefabricated fixation plates and parallel connecting pins. MATERIAL: Individual prefabricated fixation plates for the zygomatic buttress were combined with two commercial distraction devices. METHOD: The fixation plates were made by a casting technique using individual cranial models as templates. The latter were fabricated by the rapid prototyping technique of 3D powder printing. For precise realization of the distraction vector, two commercial devices were combined and attached rigidly to the fixation plates by two parallel pins. RESULT: In the clinical routine, the 3D powder printing technique enables the simple fabrication of precise individual cranial models, which are required for manufacturing individual fixation plates. The combination of two commercial distraction devices facilitates the appropriate transfer of complex distraction vectors into the midfacial area. CONCLUSION: The technique presented should be useful for a precise multi-directional midfacial distraction following Le Fort III osteotomy.

Biological activity of a genetically modified BMP-2 variant with inhibitory activity.

BACKGROUND: Alterations of the binding epitopes of bone morphogenetic protein-2 (BMP-2) lead to a modified interaction with the ectodomains of BMP receptors. In the present study the biological effect of a BMP-2 double mutant with antagonistic activity was evaluated in vivo. METHODS: Equine-derived collagenous carriers were loaded with recombinant human BMP-2 (rhBMP-2) in a well-known dose to provide an osteoinductive stimulus. The study was performed in a split animal design: carriers only coupled with rhBMP-2 (control) were implanted into prepared cavities of lower limb muscle of rats, specimens coupled with rhBMP-2 as well as BMP-2 double mutant were placed into the opposite limb in the same way. After 28 days the carriers were explanted, measured radiographically and characterized histologically. RESULTS: As expected, the BMP-2 loaded implants showed a typical heterotopic bone formation. The specimens coupled with both proteins showed a significant decreased bone formation in a dose dependent manner. CONCLUSION: The antagonistic effect of a specific BMP-2 double mutant could be demonstrated in vivo. The dose dependent influence on heterotopic bone formation by preventing rhBMP-2 induced osteoinduction suggests a competitive receptor antagonism.