[Development and Challenges of Additive Manufactured Customized Implant].

Additive manufacturing (3D printing) technology aligns with the direction of precision and customization in future medicine, presenting a significant opportunity for innovative development in high-end medical devices. Currently, research and industrialization of 3D printed medical devices mainly focus on nondegradable implants and degradable implants. Primary areas including metallic orthopaedic implants, polyether-ether-ketone (PEEK) bone implants, and biodegradable implants have been developed for clinical and industrial application. Recent research achievements in these areas are reviewed, with a discussion on the additive manufacturing technologies and applications for customized implants. Challenges faced by different types of implants are analyzed from technological, application, and regulatory perspectives. Furthermore, prospects and suggestions for future development are outlined.

Electrohydrodynamic printing of submicron-microscale hybrid scaffolds with improved cellular adhesion and proliferation behaviors.

Electrohydrodynamic (EHD) printing has been considered as a mature strategy to mimic the hierarchical microarchitectures in native extracellular matrix (ECM). Most of the EHD-printed scaffolds possess single-dimensional fibrous structures, which cannot mimic the multi-dimensional architectures for enhanced cellular behaviors. Here we developed a two-nozzle EHD printing system to fabricate hybrid scaffolds involving submicron and microscale features. The polyethylene oxide- polycaprolactone (PEO-PCL) submicron fibers were fabricated via solution-based EHD printing with a width of 527 ± 56 nm. The PCL microscale fibers were fabricated via melt-based EHD printing with a width of 11.2 ± 2.3µm. The hybrid scaffolds were fabricated by printing the submicron and microscale fibers in a layer-by-layer manner. The microscale scaffolds were utilized as a control group. Rat myocardial cells (H9C2 cells) were cultured on the two kinds of scaffolds for the culturing period of 1, 3 and 5 d. Biological results indicated that H9C2 cells showed enhanced adhesion and proliferation behaviors on the hybrid scaffold than those on the pure microscale scaffold. This work offers a facile and scalable strategy to fabricate multiscale synthetic scaffolds, which might be further explored to regulate cellular behaviors in the fields of tissue regeneration and biomedical engineering.

Graphene-Based Material-Mediated Immunomodulation in Tissue Engineering and Regeneration: Mechanism and Significance.

Tissue engineering and regenerative medicine hold promise for improving or even restoring the function of damaged organs. Graphene-based materials (GBMs) have become a key player in biomaterials applied to tissue engineering and regenerative medicine. A series of cellular and molecular events, which affect the outcome of tissue regeneration, occur after GBMs are implanted into the body. The immunomodulatory function of GBMs is considered to be a key factor influencing tissue regeneration. This review introduces the applications of GBMs in bone, neural, skin, and cardiovascular tissue engineering, emphasizing that the immunomodulatory functions of GBMs significantly improve tissue regeneration. This review focuses on summarizing and discussing the mechanisms by which GBMs mediate the sequential regulation of the innate immune cell inflammatory response. During the process of tissue healing, multiple immune responses, such as the inflammatory response, foreign body reaction, tissue fibrosis, and biodegradation of GBMs, are interrelated and influential. We discuss the regulation of these immune responses by GBMs, as well as the immune cells and related immunomodulatory mechanisms involved. Finally, we summarize the limitations in the immunomodulatory strategies of GBMs and ideas for optimizing GBM applications in tissue engineering. This review demonstrates the significance and related mechanism of the immunomodulatory function of GBM application in tissue engineering; more importantly, it contributes insights into the design of GBMs to enhance wound healing and tissue regeneration in tissue engineering.

Embedded bioprinting for designer 3D tissue constructs with complex structural organization.

3D bioprinting has been developed as an effective and powerful technique for the fabrication of living tissue constructs in a well-controlled manner. However, most existing 3D bioprinting strategies face substantial challenges in replicating delicate and intricate tissue-specific structural organizations using mechanically weak biomaterials such as hydrogels. Embedded bioprinting is an emerging bioprinting strategy that can directly fabricate complex structures derived from soft biomaterials within a supporting matrix, which shows great promise in printing large vascularized tissues and organs. Here, we provide a state-of-the-art review on the development of embedded bioprinting including extrusion-based and light-based processes to manufacture complex tissue constructs with biomimetic architectures. The working principles, bioinks, and supporting matrices of embedded printing processes are introduced. The effect of key processing parameters on the printing resolution, shape fidelity, and biological functions of the printed tissue constructs are discussed. Recent innovations in the processes and applications of embedded bioprinting are highlighted, such as light-based volumetric bioprinting and printing of functional vascularized organ constructs. Challenges and future perspectives with regard to translating embedded bioprinting into an effective strategy for the fabrication of functional biological constructs with biomimetic structural organizations are finally discussed. STATEMENT OF SIGNIFICANCE: It is still challenging to replicate delicate and intricate tissue-specific structural organizations using mechanically-weak hydrogels for the fabrication of functional living tissue constructs. Embedded bioprinting is an emerging 3D printing strategy that enables to produce complex tissue structures directly inside a reservoir filled with supporting matrix, which largely widens the choice of bioprinting inks to ECM-like hydrogels. Here we aim to provide a comprehensive review on various embedded bioprinting techniques mainly including extrusion-based and light-based processes. Various bioinks, supporting matrices, key processing parameters as well as their effects on the structures and biological functions of resultant living tissue constructs are discussed. We expect that it can provide an important reference and generate new insights for the bioprinting of large vascularized tissues and organs with biological functions.

Polyzwitterion Manipulates Remineralization and Antibiofilm Functions against Dental Demineralization.

Biomineralization technology has become a trend for the arrest and prevention of dental caries. In particular, the bioactivity and ability to release large amounts of Ca2+ and PO43- ions make amorphous calcium phosphate (ACP) for hard tissue remineralization are highly desired. However, the instability of ACP limits its clinical application. Under continuous bacterial challenge in the oral cavity, the currently developed ACP-based remineralization system lacks the ability to inhibit bacterial adhesion and biofilm formation. Here, a dual-functional nanocomposite with antibiofilm and remineralization properties was designed by combining zwitterionic poly(carboxybetaine acrylamide) (PCBAA) and ACP. The resulting nanocomposite was stable in solution for at least 3 days without any aggregation. The PCBAA/ACP nanocomposite exerted a significant inhibitory effect on the adhesion and biofilm formation of Streptococcus mutans and exhibited bactericidal activities under acidic conditions resulting from bacteria. Moreover, compared with fluoride, this nanocomposite demonstrated superior effects in promoting the remineralization of demineralized enamel and the occlusion of exposed dentinal tubules in vivo and in vitro. The present work provides a theoretical and experimental basis for the use of the PCBAA/ACP nanocomposite as a potential dual-functional agent for arresting and preventing caries.

Additive manufactured polyether-ether-ketone implants for orthopaedic applications: a narrative review.

Polyether-ether-ketone (PEEK) is believed to be the next-generation biomedical material for orthopaedic implants that may replace metal materials because of its good biocompatibility, appropriate mechanical properties and radiolucency. Currently, some PEEK implants have been used successfully for many years. However, there is no customised PEEK orthopaedic implant made by additive manufacturing licensed for the market, although clinical trials have been increasingly reported. In this review article, design criteria, including geometric matching, functional restoration, strength safety, early fixation, long-term stability and manufacturing capability, are summarised, focusing on the clinical requirements. An integrated framework of design and manufacturing processes to create customised PEEK implants is presented, and several typical clinical applications such as cranioplasty patches, rib prostheses, mandibular prostheses, scapula prostheses and femoral prostheses are described. The main technical challenge faced by PEEK orthopaedic implants lies in the poor bonding with bone and soft tissue due to its biological inertness, which may be solved by adding bioactive fillers and manufacturing porous architecture. The lack of technical standards is also one of the major factors preventing additive-manufactured customised PEEK orthopaedic implants from clinical translation, and it is good to see that the abundance of standards in the field of additive-manufactured medical devices is helping them enter the clinical market.

Microfluidic synthesis of composite cross-gradient materials for investigating cell-biomaterial interactions.

Combinatorial material synthesis is a powerful approach for creating composite material libraries for the high-throughput screening of cell-material interactions. Although current combinatorial screening platforms have been tremendously successful in identifying target (termed "hit") materials from composite material libraries, new material synthesis approaches are needed to further optimize the concentrations and blending ratios of the component materials. Here we employed a microfluidic platform to rapidly synthesize composite materials containing cross-gradients of gelatin and chitosan for investigating cell-biomaterial interactions. The microfluidic synthesis of the cross-gradient was optimized experimentally and theoretically to produce quantitatively controllable variations in the concentrations and blending ratios of the two components. The anisotropic chemical compositions of the gelatin/chitosan cross-gradients were characterized by Fourier transform infrared spectrometry and X-ray photoelectron spectrometry. The three-dimensional (3D) porous gelatin/chitosan cross-gradient materials were shown to regulate the cellular morphology and proliferation of smooth muscle cells (SMCs) in a gradient-dependent manner. We envision that our microfluidic cross-gradient platform may accelerate the material development processes involved in a wide range of biomedical applications.

In-situ re-melting and re-solidification treatment of selective laser sintered polycaprolactone lattice scaffolds for improved filament quality and mechanical properties.

Selective laser sintering (SLS) is a promising additive manufacturing technique that produces biodegradable tissue-engineered scaffolds with highly porous architectures without additional supporting. However, SLS process inherently results in partially melted microstructures which significantly impair the mechanical properties of the resultant scaffolds for potential applications in tissue engineering and regenerative medicine. Here, a novel post-treatment strategy was developed to endow the SLS-fabricated polycaprolactone (PCL) scaffolds with dense morphology and enhanced mechanical properties by embedding them in dense NaCl microparticles for in-situ re-melting and re-solidification. The effects of re-melting temperature and dwelling time on the microstructures of the SLS-fabricated filaments were studied. The results demonstrated that the minimum requirements of re-melting temperature and dwelling time for sufficient treatment were 65 °C and 5 min respectively and the size of the SLS-fabricated filaments was reduced from 683.3 ± 28.0 µm to 601.6 ± 17.4 µm. This method was also highly effective in treating three-dimensional (3D) PCL lattice scaffolds, which showed improved filament quality and mechanical properties after post-treatment. The treated PCL scaffolds with an initial compressive modulus and strength of 3027.8 ± 204.2 kPa and 208.8 ± 14.5 kPa can maintain their original shapes after implantation in vivo for 24 weeks. Extensive newly-grown tissues were found to gradually penetrate into the porous regions along the PCL filaments. Although degradation occurred, the mechanical properties of the implanted constructs stably maintained. The presented method provides an innovative, green and general post-treatment strategy to improve both the filament quality and mechanical properties of SLS-fabricated PCL scaffolds for various tissue engineering applications.

Electrohydrodynamic 3D printing of layer-specifically oriented, multiscale conductive scaffolds for cardiac tissue engineering.

Mimicking the hierarchical microarchitecture of native myocardium in vitro plays an important role in cardiac tissue engineering. Here we present a novel strategy to produce multiscale conductive scaffolds with layer-specific fiber orientations for cardiac regeneration by combining solution-based and melt-based electrohydrodynamic (EHD) printing techniques. Polycaprolactone (PCL) microfibers were printed by melt-based EHD printing and the fiber orientation was flexibly controlled in a layer-by-layer manner according to user-specific design. The as-printed microfibrous scaffolds can provide the seeded cells necessary contact cues to guide layer-specific cellular alignments. Sub-microscale conductive fibers were simultaneously incorporated inside the well-organized PCL scaffolds by solution-based EHD printing, which significantly improved the conductivity as well as the cellular adhesion and proliferation capacity. The multiscale conductive scaffolds can further direct the multiple-layer alignments of primary cardiomyocytes and facilitate cardiomyocyte-specific gene expressions, which exhibited enhanced synchronous beating behavior compared with pure microfibrous scaffolds. It is envisioned that the proposed hybrid EHD printing technique might provide a promising strategy to fabricate multifunctional micro/nanofibrous scaffolds with biomimetic architectures, electrical conductivity and even biosensing properties for the regeneration of electroactive tissues.

Three-Dimensional Printing PEEK Implant: A Novel Choice for the Reconstruction of Chest Wall Defect.

BACKGROUND: The purpose of this study is to use 3-dimensional printing (3DP) polyetheretherketone (PEEK) implants for skeletal reconstructions after wide excision of chest wall. 3DP PEEK implants were expected to provide a better physiological simulation than traditional ones because of a closer elastic modulus to cortical bone and similar biomechanical properties. METHODS: Eighteen patients (mean age 44.5 years), comprising 6 males and 12 females, underwent adequate radical wide excision for tumors and chest wall reconstruction using 3DP PEEK implants. Surgical data, which include patient demographic characteristics, implant preparation parameters, and preoperative and postoperative pulmonary function test results, were collected and analyzed. RESULTS: Ten patients with rib tumors and 8 patients with sternum tumors were selected for the study. The mean chest wall defect size was 173.6 ± 151.5 cm2 (range, 55 to 625 cm2). The mean weight of a single 3DP PEEK rib and sternum was 28 g and 104 g, respectively. The flexural and tensile strength of PEEK implants were 141 ± 7 MPa and 89 ± 3 MPa, respectively. Preoperative and postoperative pulmonary function tests revealed that mean forced vital capacity was from 2.79 ± 0.68 L to 2.40 ± 0.70 L with a reduction of 14.0% (p < 0.001). No side effects were observed 6 to 12 months after the operation. CONCLUSIONS: These findings suggest that 3DP PEEK implant is a safe and effective alternative in the reconstruction of chest wall defects. The pulmonary function of the patient may be preserved effectively after surgery.

Custom design and biomechanical analysis of 3D-printed PEEK rib prostheses.

A tumour resection normally involves a large tissue resection and bone replacement. Polyether ether ketone (PEEK) has become a suitable candidate for use in various prostheses owing to its lightness in weight, modulus close to that of natural bone, and good biocompatibility, among other factors. This study proposes a new design method for a rib prosthesis using the centroid trajectory of the natural replaced rib, where the strength can be adjusted by monitoring the cross-sectional area, shape, and properties. A custom-designed rib prosthesis was manufactured using fused deposition modelling (FDM) manufacturing technology, and the mechanical behaviour was found to be close to that of a natural rib. A finite element analysis of the designed rib was carried out under similar loading conditions to those used in mechanical testing. The results indicate that the centroid trajectory derived from a natural rib diaphysis can provide reliable guidance for the design of a rib prosthesis. Such methodology not only offers considerable design freedom in terms of shape and required strength, but also benefits the quality of the surface finishing for samples manufactured using the FDM technique. FDM-printed PEEK rib prostheses have been successfully implanted, and good clinical performances have been achieved.

Electrohydrodynamic 3D printing of microscale poly (ε-caprolactone) scaffolds with multi-walled carbon nanotubes.

Electrohydrodynamic 3D printing is a promising strategy to controllably fabricate hierarchical fibrous architectures that mimic the structural organizations of native extracellular matrix. However, most of the existing investigations are mainly based on viscous melted biopolymers which make it difficult to uniformly incorporate bioactive or functional nanobiomaterials into the printed microfibers for functionization. Here we investigated the feasibility of employing solution-based electrohydrodynamic 3D printing to fabricate microscale poly (ε-caprolactone) (PCL) scaffolds with multi-walled carbon nanotubes (MWCNTs). The effect of polyethylene oxide (PEO) content in the acetic acid solution of PCL on the 3D profile and dimension of the electrohydrodynamically printed walls was studied for an optimal PEO-PCL composition. When the contents of PEO and PCL are 8 w/v % and 5 w/v %, respectively, 3D fibrous lactic structures with different MWCNTs content could be stably printed with the fiber diameter about 10 µm, close to the size of living cells. Biological experiments showed that although the addition of MWCNTs negatively affected cellular attachment compared with PEO-PCL scaffolds, the electrohydrodynamically printed PEO-PCL-MWCNT scaffolds facilitated cell alignment. It is envisioned that the presented electrohydrodynamic 3D printing might provide a new strategy to flexibly incorporate various nanobiomaterials into microscale fibrous structures for specific functionality or mimicking of hierarchically organized nanocomposites in vivo.

Development of melt electrohydrodynamic 3D printing for complex microscale poly (ε-caprolactone) scaffolds.

The replication of native hierarchical structures into synthetic scaffolds is important to direct cell growth and tissue regeneration. However, most of the existing scaffold strategies lack the capability to simultaneously realize the controlled fabrication of macroscopic geometries as well as microscale architectures with the scale similar to living cells. Here we developed a melt electrohydrodynamic printing platform and verified its feasibility to fabricate three-dimensional (3D) tissue-engineered scaffolds with complex curved geometries and microscale fibrous structures. Melting temperature was studied to stably print poly (ε-caprolactone) (PCL) filaments with the size of about 10 µm, which was precisely stacked into 3D straight walls with fine surface quality. By adjusting stage moving speed and directions, 3D PCL scaffolds with curved contours and predefined fiber orientations or spacing were successfully printed. Biological experiments showed that the printed microscale scaffolds had good biocompatibility and facilitated cellular proliferation and alignment in vitro. It is envisioned that the melt electrohydrodynamic printing can potentially provide an innovative tool to fabricate hierarchical scaffolds that mimic the native tissue architectures in a multiscale level.

Design and fabrication of biomimetic multiphased scaffolds for ligament-to-bone fixation.

Conventional ligament grafts with single material composition cannot effectively integrate with the host bones due to mismatched properties and eventually affect their long-term function in vivo. Here we presented a multi-material strategy to design and fabricate composite scaffolds including ligament, interface and bone multiphased regions. The interface region consists of triphasic layers with varying material composition and porous structure to mimic native ligament-to-bone interface while the bone region contains polycaprolactone (PCL) anchor and microchanneled ceramic scaffolds to potentially provide combined mechanical and biological implant-bone fixation. Finite element analysis (FEA) demonstrated that the multiphased scaffolds with interference value smaller than 0.5 mm could avoid the fracture of ceramic scaffold during the implantation process, which was validated by in-vitro implanting the multiphased scaffolds into porcine joint bones. Pull-out experiment showed that the initial fixation between the multiphased scaffolds with 0.47 mm interference and the host bones could withstand the maximum force of 360.31±97.51 N, which can be improved by reinforcing the ceramic scaffolds with biopolymers. It is envisioned that the multiphased scaffold could potentially induce the regeneration of a new bone as well as interfacial tissue with the gradual degradation of the scaffold and subsequently realize long-term biological fixation of the implant with the host bone.

Design and optimization of the fixing plate for customized mandible implants.

Customized mandible implants are used as the most effective surgical option for the reconstruction of the mandible after resection, and have become more prevalent, especially with the development of reverse engineering and rapid prototyping (RP). The fixing plate is the most important and complicated part; however, improper structures of the fixing plate often cost unnecessary workloads during surgery and might lead to fracture failure eventually. The fillet radius, cross-section, and countersinks distribution of the fixing plate are the three most significant factors to affect the strength of the implant. The fillet radius on the plate-body transition determines the amount of grinding bone and can also affect the strength of the fixing plate. In addition, both the different cross-sections of the fixing plate and the different distributions of the countersinks can influence the strength and anti-bending capacity of the fixing plate. Various structures of the fixing plate have been designed, and theoretical calculations and finite element analysis on its strength have been conducted in this study, and results presented an optimized design of the structure of the fixing plate. Moreover, for validation purposes, several clinical applications were successfully implemented with the optimized structure.

[Fabrication and in vivo implantation of ligament-bone composite scaffolds based on three-dimensional printing technique].

OBJECTIVE: To solve the fixation problem between ligament grafts and host bones in ligament reconstruction surgery by using ligament-bone composite scaffolds to repair the ligaments, to explore the fabrication method for ligament-bone composite scaffolds based on three-dimensional (3-D) printing technique, and to investigate their mechanical and biological properties in animal experiments. METHODS: The model of bone scaffolds was designed using CAD software, and the corresponding negative mould was created by boolean operation. 3-D printing techinique was employed to fabricate resin mold. Ceramic bone scaffolds were obtained by casting the ceramic slurry in the resin mould and sintering the dried ceramics-resin composites. Ligament scaffolds were obtained by weaving degummed silk fibers, and then assembled with bone scaffolds and bone anchors. The resultant ligament-bone composite scaffolds were implanted into 10 porcine left anterior cruciate ligament rupture models at the age of 4 months. Mechanical testing and histological examination were performed at 3 months postoperatively, and natural anterior cruciate ligaments of the right sides served as control. RESULTS: Biomechanical testing showed that the natural anterior cruciate ligament of control group can withstand maximum tensile force of (1 384 +/- 181) N and dynamic creep of (0.74 +/- 0.21) mm, while the regenerated ligament-bone scaffolds of experimental group can withstand maximum tensile force of (370 +/- 103) N and dynamic creep of (1.48 +/- 0.49) mm, showing significant differences (t = 11.617, P = 0.000; t = 2.991, P = 0.020). In experimental group, histological examination showed that new bone formed in bone scaffolds. A hierarchical transition structure regenerated between ligament-bone scaffolds and the host bones, which was similar to the structural organizations of natural ligament-bone interface. CONCLUSION: Ligament-bone composite scaffolds based on 3-D printing technique facilitates the regeneration of biomimetic ligament-bone interface. It is expected to achieve physical fixation between ligament grafts and host bone.

A novel silk-TCP-PEEK construct for anterior cruciate ligament reconstruction: an off-the shelf alternative to a bone-tendon-bone autograft.

Bone-tendon-bone autograft represents a gold-standard for anterior cruciate ligament (ACL) reconstruction but at the cost of a secondary surgical site that can be accompanied by functional impairment and discomfort. Although numerous in vitro and in vivo studies have investigated tissue engineering alternatives to autografting, the achievement of a functional histological transition between soft and hard tissue has remained elusive. To bridge this gap we developed and tested a novel multiphase scaffold of silk, tricalcium phosphate (TCP) and polyether ether ketone for ACL reconstruction. We present in vitro biomechanical tests demonstrating that the construct recapitulates native ACL function under typical physiological loads. A pilot in vivo experiment in two pigs with a three-month follow-up showed a robust histological transition between regenerated fibrous tissue and the margins of the bone tunnel, with histological features similar to the native ACL to bone insertion. These histological observations suggest that the construct was stably anchored until TCP incorporation to the host tissues. On the strength of these preliminary results, we conclude that the described approach may offer a promising alternative to autograft for ACL reconstruction. This study thus provides proof for a concept that warrants further development.

A novel silk-based artificial ligament and tricalcium phosphate/polyether ether ketone anchor for anterior cruciate ligament reconstruction - safety and efficacy in a porcine model.

Loss of ligament graft tension in early postoperative stages following anterior cruciate ligament (ACL) reconstruction can come from a variety of factors, with slow graft integration to bone being widely viewed as a chief culprit. Toward an off-the-shelf ACL graft that can rapidly integrate to host tissue, we have developed a silk-based ACL graft combined with a tricalcium phosphate (TCP)/polyether ether ketone anchor. In the present study we tested the safety and efficacy of this concept in a porcine model, with postoperative assessments at 3months (n=10) and 6months (n=4). Biomechanical tests were performed after euthanization, with ultimate tensile strengths at 3months of ∼370N and at 6months of ∼566N - comparable to autograft and allograft performance in this animal model. Comprehensive histological observations revealed that TCP substantially enhanced silk graft to bone attachment. Interdigitation of soft and hard tissues was observed, with regenerated fibrocartilage characterizing a transitional zone from silk graft to bone that was similar to native ligament bone attachments. We conclude that both initial stability and robust long-term biological attachment were consistently achieved using the tested construct, supporting a large potential for silk-TCP combinations in the repair of the torn ACL.

Cartilage repair and subchondral bone migration using 3D printing osteochondral composites: a one-year-period study in rabbit trochlea.

Increasing evidences show that subchondral bone may play a significant role in the repair or progression of cartilage damage in situ. However, the exact change of subchondral bone during osteochondral repair is still poorly understood. In this paper, biphasic osteochondral composite scaffolds were fabricated by 3D printing technology using PEG hydrogel and ß-TCP ceramic and then implanted in rabbit trochlea within a critical size defect model. Animals were euthanized at 1, 2, 4, 8, 16, 24, and 52 weeks after implantation. Histological results showed that hyaline-like cartilage formed along with white smooth surface and invisible margin at 24 weeks postoperatively, typical tidemark formation at 52 weeks. The repaired subchondral bone formed from 16 to 52 weeks in a "flow like" manner from surrounding bone to the defect center gradually. Statistical analysis illustrated that both subchondral bone volume and migration area percentage were highly correlated with the gross appearance Wayne score of repaired cartilage. Therefore, subchondral bone migration is related to cartilage repair for critical size osteochondral defects. Furthermore, the subchondral bone remodeling proceeds in a "flow like" manner and repaired cartilage with tidemark implies that the biphasic PEG/ß-TCP composites fabricated by 3D printing provides a feasible strategy for osteochondral tissue engineering application.