Faleh Tamimi

Dicalcium phosphate cements: Brushite and monetite

Dicalcium phosphate cements were developed two decades ago and ever since there has been a substantial growth in research into improving their properties in order to satisfy the requirements needed for several clinical applications. The present paper presents an overview of the rapidly expanding research field of the two main dicalcium phosphate bioceramics: brushite and monetite. This review begins with a summary of all the different formulae developed to prepare dicalcium phosphate cements, and their setting reaction, in order to set the scene for the key cement physical and chemical properties, such as compressive and tensile strength, cohesion, injectability and shelf-life. We address the issue of brushite conversion into either monetite or apatite. Moreover, we discuss the in vivo behavior of the cements, including their ability to promote bone formation, biodegradation and potential clinical applications in drug delivery, orthopedics, craniofacial surgery, cancer therapy and biosensors.

Local controlled release of VEGF and PDGF from a combined brushite-chitosan system enhances bone regeneration.

The two growth factors VEGF and PDGF are involved in the process of bone regeneration. For this reason, we developed a brushite-chitosan system which controls the release kinetics of incorporated VEGF and PDGF to enhance bone healing. PDGF (250 ng) was incorporated in the liquid phase. Alginate microsphere-encapsulated VEGF (350 ng) was pre-included in small cylindrical chitosan sponges. VEGF and PDGF release kinetics and tissue distribution were determined using iodinated ((125)I) growth factor. In vivo, PDGF was more rapidly delivered from these systems implanted in rabbit femurs than VEGF. 80% of PDGF was released by the end of two weeks while only 70% of VEGF was delivered after a period of three weeks. Both GFs released from the brushite-chitosan constructs remained located around the implantation site (5 cm) with negligible systemic exposure. A PDGF bone peak concentration of approximately 5 ng/g was achieved on the 4th day. Thereafter, PDGF concentrations stayed higher than 2 ng/g during the first week. These scaffolds also provided a local VEGF bone concentration above 3 ng/g during a total of 4weeks, with a peak concentration of 5.5 ng/g on the 7th day. The present work demonstrates that our brushite-chitosan system is capable of controlling the release rate and localization of both GFs within a bone defect. The effect on bone formation was considerably enhanced with PDGF loaded brushite-chitosan scaffolds as well as with the PDGF/VEGF combination.

Craniofacial vertical bone augmentation: a comparison between 3D printed monolithic monetite blocks and autologous onlay grafts in the rabbit.

Onlay autografting is amongst the most predictable techniques for craniofacial vertical bone augmentation, however, complications related to donor site surgery are common and synthetic alternatives to onlay autografts are desirable. Recent studies have shown that the acidic calcium phosphates, brushite and monetite, are osteoconductive, osteoinductive and resorb faster in vivo than hydroxyapatite. Moreover, they can be 3D printed allowing precise host bone-implant conformation. The objectives of this study were to confirm that craniofacial screw fixation of 3D printed monetite blocks was possible and to compare the resulting vertical bone augmentation with autograft. 3D printed monolithic monetite onlay implants were fixed with osteosynthesis screws on the calvarial bone surface of New Zealand rabbits. After 8 weeks, integration between the implant and the calvarial bone surface was observed in all cases. Histomorphometry revealed that 42% of the monetite was resorbed and that the new bone formed within the implant occupied 43% of its volume, sufficient for immediate dental implant placement. Bone tissue within the autologous onlay occupied 60% of the volume. We observed that patterns of regeneration within the implants differed throughout the material and propose that this was due to the anatomy and blood supply pattern in the region. Rapid prototyped monetite being resorbable osteoconductive and osteoinductive would appear to be a promising biomaterial for many bone regeneration strategies.

Resorption of monetite granules in alveolar bone defects in human patients

Bone grafting is often required to restore mandibular or maxillary bone volume prior to prosthetic tooth root implantation. Preclinical animal models are often used to study the in vivo properties of new bone graft products designed for human use. Although animal studies may offer valuable data regarding bioperformance, materials do not necessarily perform the same in human patients. In this study we implanted bovine hydroxyapatite (BH), a widely used porous apatite granule, and dicalcium phosphate anhydrous (monetite) granules, bilaterally in human patients post extraction alveolar sockets. After six months, histomorphometrical analysis of the biopsies revealed that the amount of bone regenerated with monetite (59.5 +/- 13%) was significantly higher than that obtained with BH (33.1% +/- 4.9), while the amount of unresorbed graft was higher in the sockets treated with BH (37.8 +/- 6.1) than in those implanted with monetite (25.8 +/- 14.3). Resorption of calcium phosphate ceramics is discussed by applying the Hixon-Crowell dissolution model.

Effect of platelet-rich plasma on sinus lifting: a randomized-controlled clinical trial.

OBJECTIVE The combination of anorganic bovine bone (ABB) with platelet-rich plasma (PRP) has been widely used in bone regeneration procedures although its benefits are still unclear. The purpose of this study was to evaluate whether or not PRP improves the efficacy of ABB in sinus floor augmentation. In addition, we have investigated the effect of residual bone height and tobacco on implant survival in sinus augmentation procedures. PATIENT AND METHODS Eighty-seven patients recruited for this study underwent 144 sinus floor augmentation procedures using ABB alone or ABB plus PRP (ABB+PRP) in a randomized clinical trial. A total of 286 implants were placed in the augmented bone, and their evolution was followed up for a period of 24 months. In order to investigate on a histological level and any adjunctive effects, we performed an ancillary study in five edentulous patients with a symmetrical severely resorbed maxilla. In these patients, a bilateral sinus augmentation was randomly performed using ABB or ABB+PRP in a split-mouth design, and after 6 months, bone biopsies were taken from the implant sites for histological and histomorphometric analysis. RESULTS Overall, 96.2% of ABB and 98.6% of ABB+PRP implant success were obtained during the monitoring period and differences were not found between sites grafted with and without PRP in the 87 patients studied. Densitometry assessments and graft resorption were similar in both experimental groups. However, the histological and histomorphometrical analysis in the five edentulous patients revealed that bone augmentation was significantly higher in sites treated with ABB+PRP (p <or= 0.05). Another outcome from our study is that the lack of initial bone support (p <or= 0.05) and smoking (p=0.05) appeared to have a negative effect on the treatment success, which was accentuated when both circumstances coincided. CONCLUSIONS PRP is not a determining factor for implant survival in sinus lifting procedures. However, this study revealed that PRP can improve the osteoconductive properties of ABB by increasing the volume of new bone formed. Moreover, in sinus augmentation procedures the implants survival rate appears to be more influenced by the residual bone height or by tobacco than by the type of bone graft.

Hydrogen peroxide whitens teeth by oxidizing the organic structure

OBJECTIVES The mechanism of tooth bleaching using peroxide oxidizers is not fully understood. It is unknown whether peroxide radicals make teeth whiter by deproteinizing, demineralizing, or oxidizing tooth tissues. This study was designed to define the mechanism of tooth bleaching and determine which of tooth enamel chemical components is/are affected by bleaching. METHODS Sixty sound teeth were collected from adult patients. The teeth were divided into 6 equal groups (n=10). Groups 1, 2, 3 and 4 were treated for 4 days with one of the following solutions: deproteinizing (NaOH) that removes organic content, demineralizing (EDTA) that decalcifies the mineral content, oxidizing (H(2)O(2)) and distilled water (control). Group 5 and 6 were pre-treated with either deproteinizing or demineralizing solutions before treating them with oxidizing solutions for 4 days. Changes in enamel elemental ratios, crystallinity index and tooth shade parameters of the treated teeth were examined by means of EDS, Raman spectroscopy and shade-spectrophotometry. The data obtained was analysed with Wilcoxon Signed-Ranks Test, and the statistical significance was set at p<0.05. RESULTS Tooth deproteinization increased the lightness by 4.8 ± 2.7°, tooth demineralization resulted in 8.5 ± 5.6° decrease in the lightness and tooth oxidization induced 19.9 ± 6.5° increase in the lightness. Oxidization of the deproteinized teeth did not influence shade parameters, but oxidation of the demineralized teeth resulted in 10.7 ± 5.8° increase in the lightness. CONCLUSION Hydrogen peroxide does not induce significant changes in tooth enamel organic and inorganic relative contents, and it whitens teeth just by oxidizing their organic matrix. These findings are of great clinical significance since they explain the mechanism of tooth bleaching, and help understanding its limitations and disadvantages.

Brushite–collagen composites for bone regeneration

Brushite-based biomaterials are of special interest in bone regeneration due to their biocompatibility and biodegradability; on the other hand, collagen is a well-known osteoconductive biomaterial. In the present study a new brushite-collagen composite biomaterial is reported. This new biomaterial was prepared by combining citric acid/collagen type I solutions with a brushite cement powder. The obtained biomaterial was a cement paste, with improved handling properties. The effect of collagen on the setting reaction of brushite cement was studied, and was found to speed up the cement setting reaction. The cement paste set into a hard ceramic material within 18.5+/-2.1min and had compressive strength similar to that of spongeous bone (48.9+/-5.9MPa in dry conditions and 12.7+/-1.5MPa in humid conditions). The combination of collagen with citric acid revealed an interesting synergistic effect on the compressive strength of the composite material. Moreover, this new biomaterial had excellent cohesion properties (ninefold better than brushite cement), and high cellular adhesion capacity (threefold higher than brushite cement). The composite biomaterial described in this study combines good handling properties, compressive strength, cohesion and cell adhesion capacity, along with the osteoconductive and biodegradable properties inherent in brushite and in collagen-based biomaterials.

Biocompatibility of magnesium phosphate minerals and their stability under physiological conditions

Magnesium phosphates such as newberyite (MgHPO(4)·3H(2)O) are formed in vivo and are known to be biodegradable and nontoxic after implantation. Indeed, magnesium apatites have been shown to support osteoblast differentiation and function, and bone formation can occur around metallic magnesium implants. However, very little is known regarding the precipitation and stability of magnesium phosphates in physiological environments. In order to address this, the aqueous formation of magnesium phosphate as a function of pH, temperature and ion concentration is reported. Physicochemical characterization of the precipitates was carried out; additionally, biocompatibility and gene expression of osteoblast differentiation markers for bone formation via an in vitro cell culture assay were determined. Precipitation conditions for newberyite, tribasic magnesium phosphate pentahydrate, holtedahlite, bobierrite and cattiite were determined. Under physiological conditions of pH, temperature and magnesium phosphate concentration, no precipitates were formed. However, at concentrations 10-100 times higher than physiological, magnesium phosphate precipitates of cattiite and newberyite were formed. These two minerals demonstrated biocompatibility with osteoblast cultures and induced osteoblast adhesion and differentiation. The pattern of expression of OCN and CollA1 genes in the presence of newberyite crystals was comparable to that of calcium phosphate bioceramics. In our experiments, we have shown that certain magnesium phosphate phases such as newberyite and cattiite are able to promote in vivo osteogenic activity in a similar way to calcium phosphates such as hydroxyapatite and brushite. This confirms the great potential of magnesium phosphate ceramics in the development of new biomaterials for bone regeneration.

Bone regeneration in rabbit calvaria with novel monetite granules

The aim of this study was to evaluate whether local application of monetite granules would induce bone regeneration in critical size defects on rabbits calvaria. Novel monetite granules were synthesized by thermal conversion of preset brushite cement. Twelve female New Zealand rabbits were used for this study. Two identical 10-mm-diameter bicortical cranial defects were created in each animal. One of the defects was grafted with monetite granules while the contralateral was left unfilled as negative control. Animals were sacrificed at 4 and 8 weeks after surgery, and biopsies were taken for histological and histomorphometrical evaluation under light microscopy. Wilcoxon test was used for statistical analysis. The histological observations showed signs of graft resorption as newly formed bone tissue grew surrounding and penetrating the monetite granules. Histomorphometric evaluation showed that the augmented bone volume as well as the augmented mineral tissue was higher in the defects treated with monetite granules (p < 0.05) 8 weeks after the intervention. In this animal model, local application of the novel monetite granules in bone defects enhances bone healing significantly.

The effect of autoclaving on the physical and biological properties of dicalcium phosphate dihydrate bioceramics: brushite vs. monetite.

Dicalcium phosphate dihydrate (brushite) is an osteoconductive biomaterial with great potential as a bioresorbable cement for bone regeneration. Preset brushite cement can be dehydrated into dicalcium phosphate anhydrous (monetite) bioceramics by autoclaving. This heat treatment results in changes in the physical characteristics of the material, improving in vivo bioresorption. This property is a great advantage in bone regeneration; however, it is not known how autoclaving brushite preset cement might improve its capacity to regenerate bone. This study was designed to compare brushite bioceramics with monetite bioceramics in terms of physical characteristics in vitro, and in vivo performance upon bone implantation. In this study we observed that monetite bioceramics prepared by autoclaving preset brushite cements had higher porosity, interconnected porosity and specific surface area than their brushite precursors. In vitro cell culture experiments revealed that bone marrow cells expressed higher levels of osteogenic genes Runx2, Opn, and Alp when the cells were cultured on monetite ceramics rather than on brushite ones. In vivo experiments revealed that monetite bioceramics resorbed faster than brushite ones and were more infiltrated with newly formed bone. In summary, autoclaving preset brushite cements results in a material with improved properties for bone regeneration procedures.