In situ bone regeneration of large cranial defects using synthetic ceramic implants with a tailored composition and design.

The repair of large cranial defects with bone is a major clinical challenge that necessitates novel materials and engineering solutions. Three-dimensionally (3D) printed bioceramic (BioCer) implants consisting of additively manufactured titanium frames enveloped with CaP BioCer or titanium control implants with similar designs were implanted in the ovine skull and at s.c. sites and retrieved after 12 and 3 mo, respectively. Samples were collected for morphological, ultrastructural, and compositional analyses using histology, electron microscopy, and Raman spectroscopy. Here, we show that BioCer implants provide osteoinductive and microarchitectural cues that promote in situ bone regeneration at locations distant from existing host bone, whereas bone regeneration with inert titanium implants was confined to ingrowth from the defect boundaries. The BioCer implant promoted bone regeneration at nonosseous sites, and bone bonding to the implant was demonstrated at the ultrastructural level. BioCer transformed to carbonated apatite in vivo, and the regenerated bone displayed a molecular composition indistinguishable from that of native bone. Proof-of-principle that this approach may represent a shift from mere reconstruction to in situ regeneration was provided by a retrieved human specimen, showing that the BioCer was transformed into well-vascularized osteonal bone, with a morphology, ultrastructure, and composition similar to those of native human skull bone.

Monocytes and pyrophosphate promote mesenchymal stem cell viability and early osteogenic differentiation.

Pyrophosphate-containing calcium phosphate implants promote osteoinduction and bone regeneration. The role of pyrophosphate for inflammatory cell-mesenchymal stem cell (MSC) cross-talk during osteogenesis is not known. In the present work, the effects of lipopolysaccharide (LPS) and pyrophosphate (PPi) on primary human monocytes and on osteogenic gene expression in human adipose-derived MSCs were evaluated in vitro, using conditioned media transfer as well as direct effect systems. Direct exposure to pyrophosphate increased nonadherent monocyte survival (by 120% without LPS and 235% with LPS) and MSC viability (LDH) (by 16-19% with and without LPS). Conditioned media from LPS-primed monocytes significantly upregulated osteogenic genes (ALP and RUNX2) and downregulated adipogenic (PPAR-γ) and chondrogenic (SOX9) genes in recipient MSCs. Moreover, the inclusion of PPi (250 µM) resulted in a 1.2- to 2-fold significant downregulation of SOX9 in the recipient MSCs, irrespective of LPS stimulation or culture media type. These results indicate that conditioned media from LPS-stimulated inflammatory monocytes potentiates the early MSCs commitment towards the osteogenic lineage and that direct pyrophosphate exposure to MSCs can promote their viability and reduce their chondrogenic gene expression. These results are the first to show that pyrophosphate can act as a survival factor for both human MSCs and primary monocytes and can influence the early MSC gene expression. Graphical abstract.

Three-Dimensional Insights into Interfacial Segregation at the Atomic Scale in a Nanocrystalline Glass-Ceramic.

The distribution of dopant atoms plays a key role in the effectiveness of doping, thereby requiring delicate characterizations. In this study, we found that energy-dispersive X-ray spectroscopy (EDX) and electron energy loss spectroscopy (EELS) techniques in scanning transmission electron microscopy (STEM) were not adequate to reveal the distribution of yttrium and the chemical composition of the ZrO2/SiO2 heterophase interface in an yttrium-doped ZrO2-SiO2 nanocrystalline glass-ceramic. Atom probe tomography (APT) is rarely utilized to characterize ceramics due to some inherent difficulties. However, we successfully revealed the three-dimensional distribution of ZrO2 nanocrystallites and SiO2 matrix at the atomic scale with APT under optimized and well-controlled conditions. We also found that the ZrO2 nanocrystallites had a special core-shell structure, with a thin Zr/Si interfacial layer as a shell and a ZrO2 solid solution as a core. Yttrium dopants showed interfacial segregation at both ZrO2 grain boundaries and the ZrO2/SiO2 heterophase interfaces.

In vivo safety assessment of a bio-inspired bone adhesive.

A new class of materials, bone adhesives, could revolutionise the treatment of highly fragmented fractures. We present the first biological safety investigation of a bio-inspired bone adhesive. The formulation was based upon a modified calcium phosphate cement that included the amino acid phosphoserine. This material has recently been described as substantially stronger than other bioresorbable calcium phosphate cements. Four adhesive groups with the active substance (phosphoserine) and two control groups without phosphoserine were selected for in vitro and in vivo biocompatibility testing. The test groups were subject for cell viability assay and subcutaneous implantation in rats that was followed by gene expression analysis and histology assessment after 6 and 12 weeks. All adhesive groups supported the same rate of cell proliferation compared to the α-TCP control and had viability between 45-64% when compared to cell control. There was no evidence of an increased immune response or ectopic bone formation in vivo. To conclude, this bio-inspired bone adhesive has been proven to be safe, in the present study, without any harmful effects on the surrounding soft tissue.

Gentamicin loading of calcium phosphate implants: implications for cranioplasty.

BACKGROUND: Surgical site infections (SSI) are a significant risk in cranioplasty, with reported rates of around 8-9%. The most common bacteria associated with these nosocomial infections are of the Staphylococcus species, which have the ability to form biofilm. The possibility to deliver antibiotics, such as gentamicin, locally rather than systemically could potentially lower the early postoperative SSI. Various antibiotic dosages are being applied clinically, without any true consensus on the effectiveness. METHODS: Drug release from calcium phosphate (CaP), polyetheretherketone (PEEK), and titanium (Ti) samples was evaluated. Microbiological studies with Staphylococcus aureus (SA) and Staphylococcus epidermidis (SE) including strains from clinical infection were used to establish clinically relevant concentrations. RESULTS: The CaP samples were able to retain and release gentamicin overtime, whereas the Ti and PEEK samples did not show any drug uptake or release. A gentamicin loading concentration of 400 µg/ml was shown to be effective in in vitro microbiological studies with both SA and SE. CONCLUSIONS: Out of the three materials studied, only CaP could be loaded with gentamicin. An initial loading concentration of 400 µg/ml appears to establish an effective gentamicin concentration, possibly translating into a clinical benefit in cranioplasty.

Thromboinflammation as bioactivity assessment of H2O2-alkali modified titanium surfaces.

The release of growth factors from platelets, mediated by the coagulation and the complement system, plays an important role in the bone formation around implants. This study aimed at exploring the thromboinflammatory response of H2O2-alkali soaked commercially pure titanium grade 2 discs exposed to whole human blood, as a way to assess the bioactivity of the discs. Commercially pure titanium grade 2 discs were modified by soaking in H2O2, NaOH and Ca(OH)2. The platelet aggregation, coagulation activation and complement activation was assessed by exposing the discs to fresh whole blood from human donors. The platelet aggregation was examined by a cell counter and the coagulation and complement activation were assessed by ELISA-measurements of the concentration of thrombin-antithrombin complex, C3a and terminal complement complex. The modified surface showed a statistically significant increased platelet aggregation, coagulation activation and complement activation compared to unexposed blood. The surface also showed a statistically significant increase of coagulation activation compared to PVC. The results of this study showed that the H2O2-alkali soaked surfaces induced a thromboinflammatory response that indicates that the surfaces are bioactive.

Ultrastrong Translucent Glass Ceramic with Nanocrystalline, Biomimetic Structure.

Transparent/translucent glass ceramics (GCs) have broad applications in biomedicine, armor, energy, and constructions. However, GCs with improved optical properties typically suffer from impaired mechanical properties, compared to traditional sintered full-ceramics. We present a method of obtaining high-strength, translucent GCs by preparing ZrO2-SiO2 nanocrystalline glass ceramics (NCGCs) with a microstructure of monocrystalline ZrO2 nanoparticles (NPs), embedded in an amorphous SiO2 matrix. The ZrO2-SiO2 NCGC with a composition of 65%ZrO/35%SiO2 (molar ratio, 65Zr) achieved an average flexural strength of 1 GPa. This is one of the highest flexural strength values ever reported for GCs. ZrO2 NPs bond strongly with SiO2 matrix due to the formation of a thin (2-3 nm) amorphous Zr/Si interfacial layer between the ZrO2 NPs and SiO2 matrix. The diffusion of Si atoms into the ZrO2 NPs forms a Zr-O-Si superlattice. Electron tomography results show that some of the ZrO2 NPs are connected in one direction, forming in situ ZrO2 nanofibers (with length of ∼500 nm), and that the ZrO2 nanofibers are stacked in an ordered way in all three dimensions. The nanoarchitecture of the ZrO2 nanofibers mimics the architecture of mineralized collagen fibril in cortical bone. Strong interface bonding enables efficient load transfer from the SiO2 matrix to the 3D nanoarchitecture built by ZrO2 nanofibers and NPs, and the 3D nanoarchitecture carries the majority of the external load. These two factors synergistically contribute to the high strength of the 65Zr NCGC. This study deepens our fundamental understanding of the microstructure-mechanical strength relationship, which could guide the design and manufacture of other high-strength, translucent GCs.

The Monetite Structure Probed by Advanced Solid-State NMR Experimentation at Fast Magic-Angle Spinning.

We present a solid-state nuclear magnetic resonance (NMR) spectroscopy study of the local 31 P and 1 H environments in monetite [CaHPO 4 ; dicalcium phosphate anhydrous (DCPA)], as well as their relative spatial proximities. Each of the three 1 H NMR peaks was unambiguously assigned to its respective crystallographically unique H site of monetite, while their pairwise spatial proximities were probed by homonuclear 1 H- 1 H double quantum-single quantum NMR experimentation under fast magic-angle spinning (MAS) of 66 kHz. We also examined the relative 1 H- 31 P proximities among the inequivalent {P1, P2} and {H1, H2, H3} sites in monetite; the corresponding shortest internuclear 1 H- 31 P distances accorded well with those of a previous neutron diffraction study. The NMR results from the monetite phase were also contrasted with those observed from the monetite component present in a pyrophosphate-bearing calcium phosphate cement, demonstrating that while the latter represents a disordered form of monetite, it shares all essential local features of the monetite structure.

Stem cell-mediated functionalization of titanium implants.

Prosthetic implants are used daily to treat edentulous people and to restore mobility in patients affected by skeletal defects. Titanium (Ti) is the material of choice in prosthetics, because it can form a stable bond with the surrounding bone following implantation-a process known as osseointegration. Yet, full integration of prosthetic implants takes time, and fails in clinical situations characterized by limited bone quantity and/or compromised regenerative capacity, and in at-risk patients. Intense research efforts are thus made to develop new implants that are cost-effective, safe, and suited to every patient in each clinical situation. In this study, we tested the possibility to functionalize Ti implants using stem cells. Human induced pluripotent stem cell-derived mesenchymal progenitor (iPSC-MP) cells were cultured on Ti model disks for 2 weeks in osteogenic conditions. Samples were then treated using four different decellularization methods to wash off the cells and expose the matrix. The functionalized disks were finally sterilized and seeded with fresh human iPSC-MP cells to study the effect of stem cell-mediated surface functionalization on cell behavior. The results show that different decellularization methods produce diverse surface modifications, and that these modifications promote proliferation of human iPSC-MP cells, affect the expression of genes involved in development and differentiation, and stimulate the release of alkaline phosphatase. Cell-mediated functionalization represents an attractive strategy to modify the surface of prosthetic implants with cues of biological relevance, and opens unprecedented possibilities for development of new devices with enhanced therapeutic potential.

Template-free synthesis of phosphate-based spheres via modified supersaturated phosphate buffer solutions.

Modified supersaturated phosphate buffer solutions were used to synthesize phosphate-based spheres, including calcium phosphate (CaP), strontium phosphate (SrP) and barium phosphate (BaP). A series of ions concentrations in the modified phosphate buffer solutions were investigated in order to study their effects in precipitates morphologies. During synthesis, it was found that magnesium was the key factor in sphere formation. The morphologies of calcium phosphate, strontium phosphate and barium phosphate precipitates varied as the concentration of magnesium ions varied. When sufficient magnesium was provided, the precipitates appeared spherical, and the diameter was in range of 0.5-2 µm. The morphologies, compositions and structure of spheres were characterized by x-ray diffraction (XRD), scanning electron microscopy (SEM), transmission electron microscopy (TEM) and N2 adsorption analysis. Moreover, the application of magnesium substituted calcium phosphate spheres in dentin tubules occlusion was investigated.

In vitro antibacterial properties and UV induced response from Staphylococcus epidermidis on Ag/Ti oxide thin films.

Implanted materials are susceptible to bacterial colonization and biofilm formation, which can result in severe infection and lost implant function. UV induced photocatalytic disinfection on TiO2 and release of Ag(+) ions are two promising strategies to combat such events, and can be combined for improved efficiency. In the current study, a combinatorial physical vapor deposition technique was utilized to construct a gradient coating between Ag and Ti oxide, and the coating was evaluated for antibacterial properties in darkness and under UV light against Staphylococcus epidermidis. The findings revealed a potent antibacterial effect in darkness due to Ag(+) release, with near full elimination (97%) of viable bacteria and visible cell lysis on Ag dominated surfaces. The photocatalytic activity, however, was demonstrated poor due to low TiO2 crystallinity, and UV light irradiation of the coating did not contribute to the antibacterial effect. On the contrary, bacterial viability was in several instances higher after UV illumination, proposing a UV induced SOS response from the bacteria that limited the reduction rate during Ag(+) exposure. Such secondary effects should thus be considered in the development of multifunctional coatings that rely on UV activation.

Cytotoxicity of modified glass ionomer cement on odontoblast cells.

Recently a modified glass ionomer cement (GIC) with enhanced bioactivity due to the incorporation of wollastonite or mineral trioxide aggregate (MTA) has been reported. The aim of this study was to evaluate the cytotoxic effect of the modified GIC on odontoblast-like cells. The cytotoxicity of a conventional GIC, wollastonite modified GIC (W-mGIC), MTA modified GIC (M-mGIC) and MTA cement has been evaluated using cement extracts, a culture media modified by the cement. Ion concentration and pH of each material in the culture media were measured and correlated to the results of the cytotoxicity study. Among the four groups, conventional GIC showed the most cytotoxicity effect, followed by W-mGIC and M-mGIC. MTA showed the least toxic effect. GIC showed the lowest pH (6.36) while MTA showed the highest (8.62). In terms of ion concentration, MTA showed the largest Ca(2+) concentration (467.3 mg/L) while GIC showed the highest concentration of Si(4+) (19.9 mg/L), Al(3+) (7.2 mg/L) and Sr(2+) (100.3 mg/L). Concentration of F(-) was under the detection limit (0.02 mg/L) for all samples. However the concentrations of these ions are considered too low to be toxic. Our study showed that the cytotoxicity of conventional GIC can be moderated by incorporating calcium silicate based ceramics. The modified GIC might be promising as novel dental restorative cements.

Synthesis of Ag doped calcium phosphate particles and their antibacterial effect as additives in dental glass ionomer cements.

Developing dental restorations with enhanced antibacterial properties has been a constant quest for materials scientists. The aim of this study was to synthesize silver doped calcium phosphate particles and use them to improve antibacterial properties of conventional glass ionomer cement. The Ag doped monetite (Ag-DCPA) and hydroxyapatite (Ag-HA) were synthesized by precipitation method and characterized using X-ray diffraction, scanning electron microscope and X-ray fluorescence spectroscopy. The antibacterial properties of the cements aged for 1 day and 7 days were evaluated by direct contact measurement using staphylococcus epidermis Xen 43. Ion concentrations (F- and Ag+) and pH were measured to correlate to the results of the antibacterial study. The compressive strength of the cements was evaluated with a crosshead speed of 1 mm/min. The glass ionomer cements containing silver doped hydroxyapatite or monetite showed improved antibacterial properties. Addition of silver doped hydroxyapatite or monetite did not change the pH and ion release of F-. Concentration of Ag+ was under the detection limit (0.001 mg/L) for all samples. Silver doped hydroxyapatite or monetite had no effect on the compressive strength of glass ionomer cement.

Simvastatin and zinc synergistically enhance osteoblasts activity and decrease the acute response of inflammatory cells.

Several ceramic biomaterials have been suggested as promising alternatives to autologous bone to replace or restore bone after trauma or disease. The osteoinductive potential of most scaffolds is often rather low by themselves and for this reason growth factors or drugs have been supplemented to these synthetic materials. Although some growth factors show good osteoinductive potential their drawback is their high cost and potential severe side effects. In this work the combination of the well-known drug simvastatin (SVA) and the inorganic element Zinc (Zn) is suggested as a potential additive to bone grafts in order to increase their bone regeneration/formation. MC3T3-E1 cells were cultured with Zn (10 and 25 µM) and SVA (0.25 and 0.4 µM) for 10 days to evaluate proliferation and differentiation, and for 22 days to evaluate secretion of calcium deposits. The combination of Zn (10 µM) and SVA (0.25 µM) significantly enhanced cell differentiation and mineralization in a synergetic manner. In addition, the release of reactive oxygen species (ROS) from primary human monocytes in contact with the same concentrations of Zn and SVA was evaluated by chemiluminescence. The combination of the additives decreased the release of ROS, although Zn and SVA separately caused opposite effects. This work shows that a new combination of additives can be used to increase the osteoinductive capacity of porous bioceramics.

Porosity prediction of calcium phosphate cements based on chemical composition.

The porosity of calcium phosphate cements has an impact on several important parameters, such as strength, resorbability and bioactivity. A model to predict the porosity for biomedical cements would hence be a useful tool. At the moment such a model only exists for Portland cements. The aim of this study was to develop and validate a first porosity prediction model for calcium phosphate cements. On the basis of chemical reaction, molar weight and density of components, a volume-based model was developed and validated using calcium phosphate cement as model material. 60 mol% ß-tricalcium phosphate and 40 mol% monocalcium phosphate monohydrate were mixed with deionized water, at different liquid-to-powder ratios. Samples were set for 24 h at 37°C and 100% relative humidity. Thereafter, samples were dried either under vacuum at room temperature for 24 h or in air at 37 °C for 7 days. Porosity and phase composition were determined. It was found that the two drying protocols led to the formation of brushite and monetite, respectively. The model was found to predict well the experimental values and also data reported in the literature for apatite cements, as deduced from the small absolute average residual errors (<2.0%). In conclusion, a theoretical model for porosity prediction was developed and validated for brushite, monetite and apatite cements. The model gives a good estimate of the final porosity and has the potential to be used as a porosity prediction tool in the biomedical cement field.

Novel Calcium Phosphate Promotes Interbody Bony Fusion in a Porcine Anterior Cervical Discectomy and Fusion Model.

STUDY DESIGN: Experimental porcine anterior cervical discectomy and fusion (ACDF) model: a proof-of-concept study. OBJECTIVE: The effect of monetite synthetic bone graft containing calcium pyrophosphate (Ca-PP) and ß-tricalcium phosphate (ß-TCP) on cervical spinal fusion in a non-instrumented two-level large animal model. SUMMARY OF BACKGROUND DATA: ACDF is the gold standard surgical technique for the treatment of degenerative cervical spinal diseases. However, pseudarthrosis associated with increased patient morbidity occurs in approximately 2,6% of the surgeries. Synthetic bone graft (SBG) may enhance bony fusion and subsequently decrease the risk of pseudarthrosis. Recent studies on monetite-based synthetic bone grafts for use in large cranial defects in humans have shown promising bone healing results, necessitating further investigation of their use in cervical spinal fusion. METHODS: Four adult female Danish Göttingen mini-pigs received partial cervical anterior discectomy and intervertebral defects at an upper and lower level. One defect was filled with SBG and the other was left empty. Bony fusion was evaluated using computed tomography (CT) at three-month intervals for 12 months. Fifteen months post-surgery, the animals were euthanized for further ex vivo qualitative histopathological and micro-CT evaluations. Fusion rates were compared using Fisher´s exact test at each time point. RESULTS: Increased interbody bony fusion rates were observed at synthetic bone graft levels (4/4) compared with control levels (0/4) evaluated by CT at 6- and 9-months post-surgery ( P = 0.029). Fusion was observed at all synthetic bone graft levels 12 months post-surgery and at only one control level. Histopathological evaluation confirmed high-quality interbody bony fusion at all synthetic bone graft levels, and fusion by spondylosis at one control level. CONCLUSION: This proof-of-concept study provides preliminary evidence of a novel, Ca-PP -and ß-TCP-containing monetite SBG that promotes bony fusion compared to a negative control in a clinically relevant porcine model of ACDF. LEVEL OF EVIDENCE: N/A.

Nanoscale size control of protein aggregates.

Herein, a novel method to synthesize soluble, sub-micrometer sized protein aggregates is demonstrated by mixing native and denatured proteins without using bacteria and contaminating proteins. Ovalbumin (OVA) is employed as a model protein. The average size of the formed aggregates can be controlled by adjusting the fraction of denatured protein in the sample and it is possible to make unimodal size distributions of protein aggregates. OVA aggregates with a size of ∼95 nm are found to be more immunogenic compared to native OVA in a murine splenocyte proliferation assay. These results suggest that the novel method of engineering size specific sub-micrometer sized aggregates may constitute a potential route to increasing the efficacy of protein vaccines. The protein aggregates may also be promising for use in other applications including the surface functionalization of biomaterials and as industrial catalysis materials.

Influence of particle size on hardening and handling of a premixed calcium phosphate cement.

Premixed calcium phosphate cements (pCPC) have been developed to circumvent problems related to mixing and transfer of cements in the operating room. In addition, by using pCPC the short working times generally associated with conventional water-mixed cements are avoided. In this work, the influence of particle size on handling and hardening characteristics of a premixed monetite cement has been assessed. The cements were evaluated with respect to their injectability, setting time and compressive strength. It was found that cements with smaller particle sizes were more difficult to inject and had higher compressive strength. Regarding setting time, no clear trend could be discerned. The addition of granules made the cements easier to inject, but setting time was prolonged and lower strengths were obtained. The main findings of this work demonstrate that particle size can be used to control handling and physical properties of premixed cements and that previous knowledge from water-based CPC, regarding effects of particle size, is not directly applicable to premixed CPC.

Laser induced surface structuring and ion conversion in the surface oxide of titanium: possible implications for the wetability of laser treated implants.

In the present study, commercially pure titanium was irradiated with UV-light with varying wavelengths using a Q-switched Nd:YAG-laser. This was performed in order to investigate if a laser treatment can be employed to rapidly introduce hydrophilic properties to titanium surfaces, which is believed to facilitate protein adsorption and cell attachment. It was demonstrated that irradiation with 355 nm light (10 Hz, 90 mJ/shot) for 1 min or more caused an ion conversion of Ti(4+) to Ti(3+) sites in the surface oxide which lead to an increase in hydrophilicity of the surface. Furthermore, shorter irradiation times at 355 nm caused a surface structuring that gave rise to an unexpected and unstable hydrophobic state at the surface. Irradiation with 266 nm light (10 Hz, 40 mJ/shot) did not introduce any ion conversion in the surface oxide, nor did it give rise to any hydrophobicity of the surface.

Bone without borders - Monetite-based calcium phosphate guides bone formation beyond the skeletal envelope.

Calcium phosphates (CaP) represent an important class of osteoconductive and osteoinductive biomaterials. As proof-of-concept, we show how a multi-component CaP formulation (monetite, beta-tricalcium phosphate, and calcium pyrophosphate) guides osteogenesis beyond the physiological envelope. In a sheep model, hollow dome-shaped constructs were placed directly over the occipital bone. At 12 months, large amounts of bone (∼75%) occupy the hollow space with strong evidence of ongoing remodelling. Features of both compact bone (osteonal/osteon-like arrangements) and spongy bone (trabeculae separated by marrow cavities) reveal insights into function/need-driven microstructural adaptation. Pores within the CaP also contain both woven bone and vascularised lamellar bone. Osteoclasts actively contribute to CaP degradation/removal. Of the constituent phases, only calcium pyrophosphate persists within osseous (cutting cones) and non-osseous (macrophages) sites. From a translational perspective, this multi-component CaP opens up exciting new avenues for osteotomy-free and minimally-invasive repair of large bone defects and augmentation of the dental alveolar ridge.