Robert Sader

Influence of β-tricalcium phosphate granule size and morphology on tissue reaction in vivo.

In this study the tissue reaction to five different β-tricalcium phosphate (β-TCP)-based bone substitute materials differing only in size, shape and porosity was analyzed over 60 days, at 3, 10, 15, 30 and 60 days after implantation. Using the subcutaneous implantation model in Wistar rats both the inflammatory response within the implantation bed and the resulting vascularization of the biomaterials were qualitatively and quantitatively assessed by means of standard and special histological staining methods. The data from this study showed that all investigated β-TCP bone substitutes induced the formation of multinucleated giant cells. Changes in size, shape and porosity influenced the integration of the biomaterials within the implantation bed and the formation of tartrate-resistant acid phosphatase (TRAP)-positive and TRAP-negative multinucleated giant cells, as well as the rate of vascularization. While a high porosity generally allowed cell and fiber in-growth within the center of the bone substitute, a lower porosity resulted in a mosaic-like integration of the materials, with the granules serving as place holders. The number of multinucleated giant cells located in the implantation bed positively correlated with the vascularization rate. These data emphasize that all biomaterials investigated were capable of inducing the formation of TRAP-positive multinucleated giant cells as a sign of biomaterial stability. Furthermore, these cells directly influenced vascularization by secretion of vascular endothelial growth factor (VEGF), as well as other chemokines. Based on these findings, the role of multinucleated giant cells in the foreign body reaction to biomaterials might need to be reconsidered. This study demonstrates that variations in the physical properties of a bone substitute material clearly influence the (extent of the) inflammatory reaction and its consequences.

Critical Evaluation of Piezoelectric Osteotomy in Orthognathic Surgery: Operative Technique, Blood Loss, Time Requirement, Nerve and Vessel Integrity

PURPOSE Piezo-osteotomy feasibility as a substitute for the conventional saw in orthognathic surgery was evaluated regarding operative technique, blood loss, time requirement, and nerve and vessel integrity. PATIENTS AND METHODS Fifty patients had orthognathic surgery procedures in typical distribution using piezosurgical osteotomy: 22 (44%) monosegment, 26 (52%) segmented Le Fort I osteotomies; 48 (48%) sagittal split osteotomies, 6 (12%) symphyseal, and 4 (4%) mandibular body osteotomies. Controls were 86 patients with conventional saw and chisel osteotomies: 57 (66%) monosegment, 25 (29%) segmented Le Fort I osteotomies, 126 (73%) sagittal split, and 4 (5%) symphyseal osteotomies. RESULTS Piezosurgical bone osteotomy permitted individualized cut designs, enabling segment interdigitation after repositioning. Angulated tools weakened the pterygomaxillary suture; auxiliary chisels were required in 100% of cases for the nasal septum, and lateral nasal walls as 46% pterygoid processes. After downfracture, the dorsal maxillary sinus wall and pterygoid processes were easily reduced. Hemorrhage was successfully avoided with average blood loss of 541 +/- 150 mL versus 773 +/- 344 mL (P = .001) for a conventional bimaxillary procedure. Sagittal mandibular osteotomy required considerable time (auxiliary saw in 13%); the lingual dorsal osteotomy was mostly performed tactile. Time investment remained unchanged: 227 +/- 73 minutes per bimaxillary standard osteotomy versus 238 +/- 61 minutes (P = .5); clinical courses and reossification were unobtrusive. Alveolar inferior nerve sensitivity was retained in 95% of the study collective versus 85% in the controls (P = .0003) at 3 months postoperative testing. CONCLUSIONS Piezoelectric osteotomy reduced blood loss and inferior alveolar nerve injury at no extra time investment. Single cases require auxiliary chiseling or sawing. Piezoelectric drilling for screw insertion and complex osteotomy designs may be developed to maintain bone contact or interdigitation after repositioning and minimize need for osteofixation.

The chemical composition of synthetic bone substitutes influences tissue reactions in vivo: histological and histomorphometrical analysis of the cellular inflammatory response to hydroxyapatite, beta-tricalcium phosphate and biphasic calcium phosphate ceramics

Bone substitute material properties such as granule size, macroporosity, microporosity and shape have been shown to influence the cellular inflammatory response to a bone substitute material. Keeping these parameters constant, the present study analyzed the in vivo tissue reaction to three bone substitute materials (granules) with different chemical compositions (hydroxyapatite (HA), beta-tricalcium phosphate (TCP) and a mixture of both with a HA/TCP ratio of 60/40 wt%). Using a subcutaneous implantation model in Wistar rats for up to 30 days, tissue reactions, including the induction of multinucleated giant cells and the extent of implantation bed vascularization, were assessed using histological and histomorphometrical analyses. The results showed that the chemical composition of the bone substitute material significantly influenced the cellular response. When compared to HA, TCP attracted significantly greater multinucleated giant cell formations within the implantation bed. Furthermore, the vascularization of the implantation bed of TCP was significantly higher than that of HA implantation beds. The biphasic bone substitute group combined the properties of both groups. Within the first 15 days, high giant cell formation and vascularization rates were observed, which were comparable to the TCP-group. However, after 15 days, the tissue reaction, i.e. the extent of multinucleated giant cell formation and vascularization, was comparable to the HA-group. In conclusion, the combination of both compounds HA and TCP may be a useful combination for generating a scaffold for rapid vascularization and integration during the early time points after implantation and for setting up a relatively slow degradation. Both of these factors are necessary for successful bone tissue regeneration.

Advanced Platelet-Rich Fibrin: A New Concept for Cell-Based Tissue Engineering by Means of Inflammatory Cells

Choukrouns platelet-rich fibrin (PRF) is obtained from blood without adding anticoagulants. In this study, protocols for standard platelet-rich fibrin (S-PRF) (2700 rpm, 12 minutes) and advanced platelet-rich fibrin (A-PRF) (1500 rpm, 14 minutes) were compared to establish by histological cell detection and histomorphometrical measurement of cell distribution the effects of the centrifugal force (speed and time) on the distribution of cells relevant for wound healing and tissue regeneration. Immunohistochemistry for monocytes, T and B -lymphocytes, neutrophilic granulocytes, CD34-positive stem cells, and platelets was performed on clots produced from four different human donors. Platelets were detected throughout the clot in both groups, although in the A-PRF group, more platelets were found in the distal part, away from the buffy coat (BC). T- and B-lymphocytes, stem cells, and monocytes were detected in the surroundings of the BC in both groups. Decreasing the rpm while increasing the centrifugation time in the A-PRF group gave an enhanced presence of neutrophilic granulocytes in the distal part of the clot. In the S-PRF group, neutrophils were found mostly at the red blood cell (RBC)-BC interface. Neutrophilic granulocytes contribute to monocyte differentiation into macrophages. Accordingly, a higher presence of these cells might be able to influence the differentiation of host macrophages and macrophages within the clot after implantation. Thus, A-PRF might influence bone and soft tissue regeneration, especially through the presence of monocytes/macrophages and their growth factors. The relevance and feasibility of this tissue-engineering concept have to be proven through in vivo studies.

Scaffold vascularization in vivo driven by primary human osteoblasts in concert with host inflammatory cells.

Successful cell-based tissue engineering requires a rapid and thorough vascularization in order to ensure long-term implant survival and tissue integration. The vascularization of a scaffold is a complex process, and is modulated by the presence of transplanted cells, exogenous and endogenous signaling proteins, and the host tissue reaction, among other influencing factors. This paper presents evidence for the significance of pre-seeded osteoblasts for the in vivo vascularization of a biodegradable scaffold. Human osteoblasts, cultured on silk fibroin micronets in vitro, migrated throughout the interconnected pores of the scaffold and produced extensive bone matrix. When these constructs were implanted in SCID mice, a rapid and thorough vascularization of the scaffold by the host blood capillaries occurred. This profound response was not seen for the silk fibroin scaffold alone. Moreover, when the pre-cultivation time of human osteoblasts was reduced from 14 days to only 24 h, the significant effect these cells exerted on vascularization rate in vivo was still detectable. From these studies, we conclude that matrix and soluble factors produced by osteoblasts can serve to instruct host endothelial cells to migrate, proliferate, and initiate the process of scaffold vascularization. This finding represents a potential paradigm shift for the field of tissue engineering, especially in bone, as traditional strategies to enhance scaffold vascularization have focused on endovascular cells and regarded osteoblasts primarily as cell targets for mineralization. In addition, the migration of host macrophages and multinucleated giant cells into the scaffold was also found to influence the vascularization of the biomaterial. Therefore, the robust effect on scaffold vascularization seen by pre-culturing with osteoblasts appears to occur in concert with the pro-angiogenic stimuli arising from host immune cells.

Effect of Er:YAG, CO2 and diode laser irradiation on surface properties of zirconia endosseous dental implants

Zirconia implants (ZI) are becoming more popular in implant dentistry, as a result of their favorable esthetic outcome. However, little is known about the impact laser application has on this material in the course of peri‐implantitis treatment. The objective of this investigation was to analyze the influence of Er:YAG, CO2 and diode laser irradiation on polished ZI.

Investigation on plasma immersion ion implantation treated medical implants.

In this work the biocompatibility of osteosynsthesis plates treated with plasma immersion ion implantation (PIII) was tested using a rat model. Small rods (Ø 0.9 mm, and length 10 mm) prepared from different materials-pure Ti, anodised Ti, and two NiTi alloys (SE 508, and SM 495)-were implanted with oxygen by PIII to form a rutile surface layer and subsequently inserted into rat femurs, together with a control group of untreated samples. The results of the biomechanical tests correlate with the histological results, and show that plasma immersion ion implantation leads to an increase of biocompatibility and osseointegration of titanium and NiTi, albeit no improvement of the (bad) biocompatibility of the anodised Ti. Despite the layer thickness of up to 0.5 microm a strong influence of the base material is still present.

Evaluation of the tissue reaction to a new bilayered collagen matrix in vivo and its translation to the clinic

This study evaluates a new collagen matrix that is designed with a bilayered structure in order to promote guided tissue regeneration and integration within the host tissue. This material induced a mild tissue reaction when assessed in a murine model and was well integrated within the host tissue, persisting in the implantation bed throughout the in vivo study. A more porous layer was rapidly infiltrated by host mesenchymal cells, while a layer designed to be a barrier allowed cell attachment and host tissue integration, but at the same time remained impermeable to invading cells for the first 30 days of the study. The tissue reaction was favorable, and unlike a typical foreign body response, did not include the presence of multinucleated giant cells, lymphocytes, or granulation tissue. In the context of translation, we show preliminary results from the clinical use of this biomaterial applied to soft tissue regeneration in the treatment of gingival tissue recession and exposed roots of human teeth. Such a condition would greatly benefit from guided tissue regeneration strategies. Our findings demonstrate that this material successfully promoted the ingrowth of gingival tissue and reversed gingival tissue recession. Of particular importance is the fact that the histological evidence from these human studies corroborates our findings in the murine model, with the barrier layer preventing unspecific tissue ingrowth, as the scaffold becomes infiltrated by mesenchymal cells from adjacent tissue into the porous layer. Also in the clinical situation no multinucleated giant cells, no granulation tissue and no evidence of a marked inflammatory response were observed. In conclusion, this bilayered matrix elicits a favorable tissue reaction, demonstrates potential as a barrier for preferential tissue ingrowth, and achieves a desirable therapeutic result when applied in humans for soft tissue regeneration.

Accuracy and precision of the three-dimensional assessment of the facial surface using a 3-D laser scanner

Three-dimensional (3-D) recording of the surface of the human body or anatomical areas has gained importance in many medical specialties. Thus, it is important to determine scanner precision and accuracy in defined medical applications and to establish standards for the recording procedure. Here we evaluated the precision and accuracy of 3-D assessment of the facial area with the Minolta Vivid 910 3D Laser Scanner. We also investigated the influence of factors related to the recording procedure and the processing of scanner data on final results. These factors include lighting, alignment of scanner and object, the examiner, and the software used to convert measurements into virtual images. To assess scanner accuracy, we compared scanner data to those obtained by manual measurements on a dummy. Less than 7% of all results with the scanner method were outside a range of error of 2 mm when compared to corresponding reference measurements. Accuracy, thus, proved to be good enough to satisfy requirements for numerous clinical applications. Moreover, the experiments completed with the dummy yielded valuable information for optimizing recording parameters for best results. Thus, under defined conditions, precision and accuracy of surface models of the human face recorded with the Minolta Vivid 910 3D Scanner presumably can also be enhanced. Future studies will involve verification of our findings using test persons. The current findings indicate that the Minolta Vivid 910 3D Scanner might be used with benefit in medicine when recording the 3-D surface structures of the face

Dual-Energy CT Applications in Head and Neck Imaging

OBJECTIVE Dual-energy scanning is a breakthrough in CT technology that has several applications in chest and abdominal imaging. Dual-energy CT also has potential for head and neck imaging. This review describes the role of dual-energy CT in head and neck imaging. CONCLUSION As with other body regions, both image fusion and material characterization dual-energy applications can be used for head and neck imaging. Early results are promising, and further research is encouraged.