Isolation of human oral keratinocyte progenitor/stem cells.

Progenitor/stem cell populations of epithelium are known to reside in the small-sized cell population. Our objective was to physically isolate and characterize an oral keratinocyte-enriched population of small-sized progenitor/stem cells. Primary human oral mucosal keratinocytes cultured in a chemically defined serum-free culture system, devoid of animal-derived feeder cells, were sorted by relative cell size and characterized by immunolabeling for beta1 integrin, nuclear transcription factor, peroxisome proliferator-activated receptor-gamma, and cell-cycle analysis. Sorted cells were distinguished as progenitor/stem cells by functional assays and their ability to regenerate an oral mucosal graft. Small-sized cells demonstrated the lowest expression of peroxisome proliferator-activated receptor-gamma, the highest colony-forming efficiency, a longer long-term proliferative potential, an enriched quiescent cell population, and the ability to regenerate an oral mucosal graft, implying that the small-sized cultured oral keratinocytes contained an enriched population of progenitor/stem cells.

Development of an oral mucosa equivalent using a porcine dermal matrix.

We evaluated the suitability of a porcine acellular dermal matrix for the development of a 3-dimensional oral mucosal equivalent using an ex vivo-produced oral mucosal equivalent (EVPOME). Oral keratinocytes were seeded in a submerged model, and then in an air-liquid interphase model, using Transwell® inserts. EVPOME showed good cell viability and increased glucose consumption over time. Histological evaluation showed that stratified differentiated epithelium had formed in all matrices.

Biochemical indicators of implantation success of tissue-engineered oral mucosa.

Real-time (RT) determination of the health of in vitro tissue-engineered constructs prior to grafting is essential for prediction of success of the implanted tissue-engineered graft. In addition, the US Food and Drug Administration requires specific release criteria in RT prior to the release of tissue-engineered devices for human use. In principle, assessing the viability and functionality of the cellular component can be achieved by quantifying the secretion of growth factors and chemokines of tissue-engineered constructs. Ex vivo-produced oral mucosa equivalents (EVPOMEs) were fabricated under thermally stressed conditions at 43 °C for 24 h to create a functionally compromised EVPOME. We used microchannel enzyme-linked immunosorbent assay to evaluate the functionality of the cellular component, oral keratinocytes, of stressed and unstressed EVPOMEs by measuring the release of vascular endothelial growth factor (VEGF), interleukin-8 (IL-8), human ß-defensin 1 (hBD-1), and tissue inhibitor of metalloproteinase 1 and 2 (TIMP-1 and -2) into the spent medium, which was collected on the same day prior to graft implantation into severe combined immunodeficiency mice. Implanted EVPOMEs' histology on the seventh postimplantation day was used to correlate outcomes of grafting to secreted amounts of IL-8, hBD-1, VEGF, TIMP-1, and TIMP-2 from corresponding EVPOMEs. Our findings showed that significantly higher levels of IL-8, hBD-1, and TIMP-2 were secreted from controls than from thermally stressed EVPOMEs. We also found a direct correlation between secreted VEGF and IL-8 and blood vessel counts of implanted EVPOMEs. We concluded that measuring the constitutive release of these factors can be used as noninvasive predictors of healthy tissue-engineered EVPOMEs in RT, prior to their implantation.

Manufacturing and characterization of 3-d hydroxyapatite bone tissue engineering scaffolds.

Internal architecture has a direct impact on the mechanical and biological behaviors of porous hydroxyapatite (HA) implants. However, traditional processing methods provide very minimal control in this regard. This paper reviews a novel processing technique developed in our laboratory for fabricating scaffolds with controlled internal architectures. The preliminary mechanical property and in vivo evaluation of these scaffolds are also presented.

Microfibrillar collagen hemostatic pledgets.

The use of topical microfibrillar collagen hemostatic agents is increasing in many areas of clinical surgery. We have developed a method of preparing the hemostatic agent by which a pledget is formed in a syringe. This gives it a firm consistency and allows easier handling and application and can be done at the operating room table.

Development and characterization of a tissue-engineered human oral mucosa equivalent produced in a serum-free culture system.

A problem maxillofacial surgeons face is a lack of sufficient autogenous oral mucosa for reconstruction of the oral cavity. Split-thickness or oral mucosa grafts require more than one surgical procedure and can result in donor site morbidity. Skin has disadvantages of adnexal structures and a different keratinization pattern than oral mucosa. In this study, we successfully assembled, ex vivo, a human oral mucosa equivalent, consisting of epidermal and dermal components, in a defined, essential-fatty-acid-deficient, serum-free culture medium without a feeder layer, that could be used for intra-oral grafting in humans. Autogenous oral keratinocytes were seeded onto a cadaveric dermis, AlloDerm. The oral mucosa equivalent was cultured at an air-liquid interface for 2 wks. The resulting equivalent had a well-stratified parakeratinized epithelial layer similar to native oral keratinized mucosa. Expression of differentiation markers, filaggrin and cytokeratin 10/13, suggested a premature keratinized state. The presence of proliferation markers, proliferating cell nuclear antigen (PCNA) and Ki-67, suggested a state of hyperproliferation. Fatty acid composition of the equivalent was similar to that of in vitro cultured oral keratinocytes but differed from the that of in vivo native tissue, showing a lower content of 18:2 and 20:4, and a higher content of 16:1 and 18:1 fatty acids, respectively. The keratinocytes of the equivalent appeared to be in a more active and proliferative state than native keratinized mucosa. The dynamic nature of the cell population on the oral mucosa equivalent may be beneficial for intra-oral grafting procedures and for transfection of the keratinocytes.

CT-generated porous hydroxyapatite orbital floor prosthesis as a prototype bioimplant.

Hydroxyapatite bioceramic was used for the manufacture of an orbital floor prosthesis from spiral CT data acquired transaxially at 1-mm beam collimation, pitch of 1, and 0.2-mm reconstruction intervals. CT data were converted to vector file format for subsequent prosthesis manufacture on a stereo-lithography machine. The orbital floor prosthesis was engrafted onto an acrylic model of the orbit as a qualitative indication of its overall accuracy. High anatomic accuracy was achieved, as determined by visual inspection. Cross-hatching of the vector file data allowed a porous internal architecture of the prosthesis. Refinements in chemical structure of the hydroxyapatite bioceramic are expected to enhance mechanical properties.

Radiographic and histological analysis of tooth eruption through calcium phosphate ceramics in the cat.

The effect of implanting calcium phosphate ceramics (CPC) into metabolically active sites within kitten mandibles during permanent premolar tooth eruption was examined. Forty kittens, 3-4 months of age were used: the deciduous second and third mandibular premolars were extracted and their sockets implanted with autologous blood clot, autogenous cancellous marrow, and the calcium phosphate ceramics, non-porous beta-tricalcium phosphate or porous hydroxylapatite. Animals were killed at 1, 2, 3, 4 and 5 months after implantation and undermineralized sagittal sections were evaluated by light microscopy. Eighty percent of hydroxylapatite implanted mandibles showed delay in tooth eruption concurrent with distortion in crown development, and a dense cellular fibro-proliferative response within the follicle of unerupted teeth. This response occurred in only one specimen with tricalcium phosphate, whereas normal eruptive patterns and crown development were routinely noted. Both the tricalcium phosphate and hydroxylapatite were integrated into the surrounding alveolar bone without evidence of an inflammatory response. Thus hydroxylapatite initiated a dense cellular fibrous network within the dental follicle preventing formation of an eruptive pathway, delaying tooth eruption and causing crown deformation. This was rarely seen with tricalcium phosphate, and may be due to the resorbability of tricalcium phosphate when compared to hydroxylapatite. Hydroxylapatite should therefore be used with caution for implanting into areas containing unerupted teeth with a metabolically active dental follicle.

Primary synovial chondromatosis of the temporomandibular joint with suspected traumatic etiology. Report of a case.

Synovial chondromatosis (SC) of the temporomandibular joint (TMJ) is a rare disease that is characterized by the development of nodules of cartilage within the synovial connective tissues of articulating joints. Reports of extracapsular TMJ SC are rare. A case is presented of primary SC of the TMJ with extension to the pterygoid plates, with a suspected traumatic etiology. The differences between primary and secondary SC are discussed.

Intraoral grafting of an ex vivo produced oral mucosa equivalent: a preliminary report.

The objective of this study was to assess the efficacy of the use of an ex vivo produced oral mucosa equivalent (EVPOME) for intraoral grafting procedures. Autogenous keratinocytes were harvested from a punch biopsy 4 weeks prior to surgery, placed in a serum-free culture system and seeded onto a human cadaveric dermal equivalent, AlloDerm. Thirty patients with either a premalignant or cancerous lesion were triaged into two groups, depending on the stage of disease: Group 1: EVPOME or Group 2: AlloDerm, control without an epithelial layer. Clinically, EVPOME grafts were easy to handle and showed excellent compliance on grafting. Both, EVPOME and AlloDerm grafts, showed a 100% take rate. At 6 days post-grafting, the EVPOME clinically showed changes indicating vascular ingrowth and had cytologic evidence of the persistence of grafted cultured keratinocytes on the surface. The EVPOME grafts had enhanced maturation of the underlying submucosal layer associated with rapid epithelial coverage when compared to the AlloDerm grafts at biopsies taken at 28 days post-grafting. In summary, EVPOME appears to be an acceptable oral mucosal substitute for human intraoral grafting procedures and results in a more favorable wound healing response than AlloDerm alone.

An image-based approach for designing and manufacturing craniofacial scaffolds.

Bone tissue engineering (BTE), which combines biomaterial scaffolds with biologically active factors, holds tremendous promise for reconstructing craniofacial defects. A significant challenge in craniofacial reconstructive BTE applications is the complex patient-specific geometry that must be reconstructed. In this paper, we present an image-based approach for designing and manufacturing patient-specific craniofacial biomaterial scaffolds directly from CT or MRI data. In this approach, voxel density distribution is used to define scaffold topology. The scaffold design topology is created using image processing techniques. This voxel density distribution is then converted to data that can be used to drive a Solid Free-Form Fabrication machine to either directly build the scaffold or build a mold for the scaffold. Several preliminary applications for craniofacial surgery, including a mandibular condyle scaffold, an orbital floor scaffold, and a general mandibular defect scaffold, are illustrated. Finally, we show applications to in vivo models.

Use of local tissues for temporomandibular joint surgery disc replacement.

The CTM flap offers the oral and maxillofacial surgeon an excellent graft material that can be used to replace, anatomically and functionally, a nonrestorable TMJ disc or failed alloplastic implant. It has numerous advantages over the existing autogenous, allogeneic, and alloplastic materials currently available. In addition, the anatomic location of the flap makes the logistics of harvesting the graft much easier.

A putative in vitro organotypic model of molting with human skin explants.

We report finding a simple method to partially reproduce the characteristic process of molting that takes place in invertebrates using human skin explants in vitro. In this method, human skin explants discarded from regular plastic surgery procedures were kept, submersed, in regular growth medium for 10 days at 4°C. After that period, the skin explants were cultured at the air-liquid interface for another 10 days. Histological analysis of the skin revealed the formation of one full epidermal structure and an additional intermediate epidermal structure containing a putative stratum corneum, superimposed one of top of the other, in which we consider an equivalent model of "molting" or "ecdysis". Basic analysis of cell proliferation and differentiation of the explants at different stages of the process are briefly presented. We believe this model can be used in the study of certain human skin diseases as well as in comparative animal physiology.

Bisphosphonates inhibit expression of p63 by oral keratinocytes.

Osteonecrosis of the jaw (ONJ), a side-effect of bisphosphonate therapy, is characterized by exposed bone that fails to heal within eight weeks. Healing time of oral epithelial wounds is decreased in the presence of amino-bisphosphonates; however, the mechanism remains unknown. We examined human tissue from individuals with ONJ and non-bisphosphonate-treated control individuals to identify changes in oral epithelium and connective tissue. Oral and intravenous bisphosphonate-treated ONJ sites had reduced numbers of basal epithelial progenitor cells, as demonstrated by a 13.8±1.1% and 31.9±5.8% reduction of p63 expression, respectively. No significant differences in proliferation rates, vessel density, or macrophage number were noted. In vitro treatment of clonal and primary oral keratinocytes with zoledronic acid (ZA) inhibited p63, and expression was rescued by the addition of mevalonate pathway intermediates. In addition, both ZA treatment and p63 shRNA knock-down impaired formation of 3D Ex Vivo Produced Oral Mucosa Equivalents (EVPOME) and closure of an in vitro scratch assay. Analysis of our data suggests that bisphosphonate treatment may delay oral epithelial healing by interfering with p63-positive progenitor cells in the basal layer of the oral epithelium in a mevalonate-pathway-dependent manner. This delay in healing may increase the likelihood of osteonecrosis developing in already-compromised bone.

Development of an in vitro model for radiation-induced effects on oral keratinocytes.

Changes in epithelial cell activity and the production of pro-inflammatory cytokines were examined utilizing an organotypic culture system as an in vitro model to study the effects of radiation on oral keratinocytes to simulate what is thought to occur in radiation-induced oral mucositis. Monolayer cultures of oral keratinocyte were irradiated by varying the dose. Cell injury was assessed using a colony forming efficiency (CFE) assay. Third passage oral keratinocytes were seeded onto AlloDerm to form a 3D construct of an ex vivo produced oral mucosa equivalent (EVPOME) which was irradiated with 0, 1, 3 and 8Gy. Formalin-fixed sections of the EVPOME were used for histology and immunohistochemistry to examine proliferative capacity. Epithelial cell viability of EVPOME was measured by MTT assay. Spent culture medium was used to determine post-radiation pro-inflammatory cytokine production. Basal cells became more swollen and pyknotic as radiation increased, implying loss of cell viability also determined by MTT assay. The number of Ki-67 immunopositive cells and CFE showed negative correlation with radiation, indicating loss of cell proliferative capacity. The production of pro-inflammatory cytokines, IL-1alpha and IL-8, tended to increase in a radiation dose dependent manner. The EVPOME lacking submucosal cellular components was a useful model.

Pharmacological retention of oral mucosa progenitor/stem cells.

Oral mucosa progenitor/stem cells reside as a small-sized cell population that eventually differentiates concurrently with an increase in cell size. Activation of the mammalian target of rapamycin (mTOR) leads to an increase in cell size. We hypothesized that rapamycin, a specific inhibitor of mTOR, will maintain primary human oral keratinocytes as a small-sized, undifferentiated cell population capable of retaining their proliferative capacity. Primary, rapamycin-treated (2 nM, 20 nM) oral keratinocytes showed a diminished cell size that correlated with a higher clonogenicity, a longer-term proliferative potential, and a slower cycling cell population concurrent with decreased expression of a differentiation marker when compared with untreated cells. Only the 2-nM rapamycin-treated oral keratinocytes maintained their ability to regenerate oral mucosa in vitro after 15 weeks of culture. Rapamycin, a Food and Drug Administration-approved drug, may have applicability for use in creating a highly proliferative cell population for use in regenerative medicine.

Computed tomography-based tissue-engineered scaffolds in craniomaxillofacial surgery.

INTRODUCTION: Tissue engineering provides an alternative modality allowing for decreased morbidity of donor site grafting and decreased rejection of less compatible alloplastic tissues. METHODS: Using image-based design and computer software, a precisely sized and shaped scaffold for osseous tissue regeneration can be created via selective laser sintering. Polycaprolactone has been used to create a condylar ramus unit (CRU) scaffold for application in temporomandibular joint reconstruction in a Yucatan minipig animal model. Following sacrifice, micro-computed tomography and histology was used to demonstrate the efficacy of this particular scaffold design. RESULTS: A proof-of-concept surgery has demonstrated cartilaginous tissue regeneration along the articulating surface with exuberant osseous tissue formation. Bone volumes and tissue mineral density at both the 1 and 3 month time points demonstrated significant new bone growth interior and exterior to the scaffold. CONCLUSION: Computationally designed scaffolds can support masticatory function in a large animal model as well as both osseous and cartilage regeneration. Our group is continuing to evaluate multiple implant designs in both young and mature Yucatan minipig animals.

Engineering craniofacial scaffolds.

OBJECTIVE: To develop an integrated approach for engineering craniofacial scaffolds and to demonstrate that these engineered scaffolds would have mechanical properties in the range of craniofacial tissue and support bone regeneration for craniofacial reconstruction. EXPERIMENTAL VARIABLE: Scaffold architecture designed to achieve desired elasticity and permeability. Scaffold external shape designed to match craniofacial anatomy. OUTCOME MEASURE: Final fabricated biomaterial scaffolds. Compressive mechanical modulus and strength. Bone regeneration as measured by micro-CT scanning, mechanical testing and histology. SETTING: Departments of Biomedical Engineering, Oral/Maxillofacial Surgery, and Oral Medicine, Pathology and Oncology at the University of Michigan. RESULTS: Results showed that the design/fabrication approach could create scaffolds with designed porous architecture to match craniofacial anatomy. These scaffolds could be fabricated from a wide range of biomaterials, including titanium, degradable polymers, and degradable calcium phosphate ceramics. Mechanical tests showed that fabricated scaffolds had compressive modulus ranging 50 to 2900 MPa and compressive strength ranging from 2 to over 56 MPa, within the range of human craniofacial trabecular bone. In vivo testing of designed scaffolds showed that they could support bone regeneration via delivery of BMP-7 transduced human gingival fibroblasts in a mouse model. Designed hydroxyapatite scaffolds with pore diameters ranging from 400 to 1200 microns were implanted in minipig mandibular defects for 6 and 18 weeks. Results showed substantial bone ingrowth (between 40 and 50% at 6 weeks, between 70 and 80% at 18 weeks) for all scaffolds, with no significant difference based on pore diameter. CONCLUSION: Integrated image-based design and solid free-form fabrication can create scaffolds that attain desired elasticity and permeability while fitting any 3D craniofacial defect. The scaffolds could be manufactured from degradable polymers, calcium phosphate ceramics and titanium. The designed scaffolds supported significant bone regeneration for all pore sizes ranging from 300 to 1200 microns. These results suggest that designed scaffolds are clinically applicable for complex craniofacial reconstruction.