Calcium phosphate cements (CPCs) are frequently used to repair bone defects. Since their discovery in the 1980s, extensive research has been conducted to improve their properties, and emerging evidence supports their increased application in bone tissue engineering. Much effort has been made to enhance the biological performance of CPCs, including their biocompatibility, osteoconductivity, osteoinductivity, biodegradability, bioactivity, and interactions with cells. This review article focuses on the major recent developments in CPCs, including 3D printing, injectability, stem cell delivery, growth factor and drug delivery, and pre-vascularization of CPC scaffolds via co-culture and tri-culture techniques to enhance angiogenesis and osteogenesis.

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Calcium phosphate cements for bone engineering and their biological properties.

Autogenous bone graft is the gold standard bone graft material. However, due to limitations of supply and morbidity associated with autograft harvest, various bone substitutes have been considered. This article aims to review the properties of the bone graft and various bone substitutes currently available in orthopedic surgery. Synthetic bone substitutes consist of hydroxyapatite, tricalcium phosphate, calcium sulfate, or a combination of these minerals. Synthetic porous substitutes share several advantages over allografts, including unlimited supply, easy sterilization, and storage. However, they also have some disadvantages, such as brittle properties, variable rates of resorption, and poor performance in some clinical conditions. Recently, attention has been drawn to osteoinductive materials, such as demineralized bone matrix and bone morphogenetic proteins. Despite tremendous efforts toward developing autograft alternatives, a single ideal bone graft substitute has not been developed. The surgeon should understand the properties of each bone graft substitute to facilitate appropriate selection in each specific clinical situation.

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Review of bone graft and bone substitutes with an emphasis on fracture surgeries.

Brushite cements differ from apatite-forming compositions by consuming a lot of water in their setting reaction whereas apatite-forming cements consume little or no water at all. Only such cement systems that consume water during setting can theoretically produce near-zero porosity ceramics. This study aimed to produce such a brushite ceramic and investigated whether near elimination of porosity would prevent a burst release profile of incorporated antibiotics that is common to prior calcium phosphate cement delivery matrices. Through adjustment of the powder technological properties of the powder reactants, that is particle size and particle size distribution, and by adjusting citric acid concentration of the liquid phase to 800 mM, a relative porosity of as low as 11% of the brushite cement matrix could be achieved (a 60% reduction compared to previous studies), resulting in a wet unprecompacted compressive strength of 52 MPa (representing a more than 100% increase to previously reported results) with a workable setting time of 4.5 min of the cement paste. Up to 2 wt.% of vancomycin and ciprofloxacin could be incorporated into the cement system without loss of wet compressive strength. It was found that drug release rates could be controlled by the adjustable relative porosity of the cement system and burst release could be minimized and an almost linear release achieved, but the solubility of the antibiotic (vancomycin > ciprofloxacin) appeared also to be a crucial factor.

High strength resorbable brushite bone cement with controlled drug releasing capabilities

Periodontitis is a prevalent infectious disease worldwide, causing the damage of periodontal support tissues, which can eventually lead to tooth loss. The goal of periodontal treatment is to control the infections and reconstruct the structure and function of periodontal tissues including cementum, periodontal ligament (PDL) fibers, and bone. The regeneration of these three types of tissues, including the re-formation of the oriented PDL fibers to be attached firmly to the new cementum and alveolar bone, remains a major challenge. This article represents the first systematic review on the cutting-edge researches on the regeneration of all three types of periodontal tissues and the simultaneous regeneration of the entire bone-PDL-cementum complex, via stem cells, bio-printing, gene therapy, and layered bio-mimetic technologies. This article primarily includes bone regeneration; PDL regeneration; cementum regeneration; endogenous cell-homing and host-mobilized stem cells; 3D bio-printing and generation of the oriented PDL fibers; gene therapy-based approaches for periodontal regeneration; regenerating the bone-PDL-cementum complex via layered materials and cells. These novel developments in stem cell technology and bioactive and bio-mimetic scaffolds are highly promising to substantially enhance the periodontal regeneration including both hard and soft tissues, with applicability to other therapies in the oral and maxillofacial region.

https://www.mdpi.com/2073-4409/8/6/537/pdf

Periodontal Bone-Ligament-Cementum Regeneration via Scaffolds and Stem Cells

A review of bioceramic porous scaffolds for hard tissue applications: Effects of structural features

Calcium phosphate cements (CPCs) are injectable bone substitutes with a long clinical history because of their biocompatibility and osteoconductivity. Nevertheless, their cohesion upon injection into perfused bone defects as well as their long-term degradation behavior remain major clinical challenges. Therefore, the long-term degradation behavior of two types of α-tricalcium phosphate-based, apatite-forming CPCs was compared to a commercially available apatite-forming cement, that is HydroSet™ . Carboxyl methylcellulose (CMC) was used as cohesion promotor to improve handling properties of the two experimental cements, whereas poly (d, l-lactic-co-glycolic) acid (PLGA) microparticles were added to introduce macroporosity and stimulate CPC degradation. All three CPCs were injected into defects drilled into rabbit femoral condyles and explanted after 4, 12, or 26 weeks, after which the bone response was assessed both qualitatively and quantitatively. CPCs without PLGA microparticles degraded only at the periphery of the implants, while the residual CPC volume was close to 90%. On the contrary, bone ingrowth was observed not only at the periphery of the CPC, but also throughout the center of the implants after 26 weeks of implantation for the PLGA-containing CPCs with a residual CPC volume of approximately 55%. In conclusion, it was shown that CPC containing CMC and PLGA was able to induce partial degradation of apatite-forming CPCs and concomitant replacement by bone tissue.

Long-term evaluation of the degradation behavior of three apatite-forming calcium phosphate cements.

Enhancing degradation of poorly degrading injectable calcium phosphate (CaP) cements (CPCs) can be achieved by adding poly(lactic-co-glycolic acid) (PLGA) microparticles, generating porosity after polymer degradation. CPC-PLGA has proven to be biodegradable, although its long-term biological performance is still unknown. Optimization of injectability could be achieved via addition of carboxymethyl cellulose (CMC). Here, we evaluated the long-term in vivo performance of CPC-PLGA with or without the lubricant CMC in comparison to the devitalized bovine bone mineral (DBBM) predicate device Bio-Oss®. Rabbit femoral bone defects were injected with a CPC-formulation or filled with Bio-Oss® granules. Samples were retrieved at 6 and 26 weeks. Material degradation for Bio-Oss® was marginal, starting with 57% material remnants at implantation, 49% at 6 weeks, and 35% at 26 weeks, respectively. In contrast, CPC-PLGA and CPC-PLGA-CMC showed significant material degradation, starting with 100% material remnants at implantation, 56 and 78% at 6 weeks, and 8 and 21% at 26 weeks. Bone formation showed to be rapid for Bio-Oss®, with 24% at 6 weeks, and a similar value (27%) at 26 weeks. Both CPC-PLGA and CPC-PLGA-CMC showed a continuous temporal increase in bone formation, with 13 and 6% at 6 weeks, and 44 and 32% at 26 weeks. This study showed that CPC-PLGA induces favorable bone responses with >90% degradation and >40% new bone formation after an implantation period of 26 weeks.

https://iopscience.iop.org/article/10.1088/1748-605X/12/1/015009/pdf

Long-term biological performance of injectable and degradable calcium phosphate cement

Injectable, self-setting calcium phosphate cements (CPCs) are favorable bone substitutes due to their osteocompatibility. However, due to their brittleness and low toughness, their clinical application is limited to non-load-bearing sites. The incorporation of poly(vinyl alcohol) (PVA) fibers into cementitious materials is a successful strategy in civil engineering for improving the mechanical performance of cements. However, PVA fibers in particular have not yet been applied to reinforce CPCs. Therefore, the aim of this study is to investigate the effect of PVA fibers on the mechanical properties of CPCs. Second, the in vitro cytocompatibility of these fibers is studied using cell culture tests. Finally, the in vivo osteocompatibility of PVA fiber-reinforced CPCs is studied after a 6 and 12 week implantation period in the femoral condyle of rabbits. Results reveal that the incorporation of PVA fibers into CPCs is a highly effective strategy to strengthen and toughen CPCs, since the flexural strength and ...

Tough and Osteocompatible Calcium Phosphate Cements Reinforced with Poly(vinyl alcohol) Fibers.

Injectable, self-setting calcium phosphate cements (CPCs) are synthetic bone substitutes considered favorable for the repair and regeneration of bone due to their osteocompatibility and unique handling properties. However, their clinical applicability can be compromised due to insufficient cohesion upon injection into the body coupled with poor degradation rates that restricts new bone formation. Consequently, carboxymethyl cellulose (CMC) was incorporated into CPC formulations to improve their cohesion and injectability while poly (D,L -lactic-co-glycolic acid) (PLGA) porogens were added to introduce macroporosity and improve their biodegradation rate. Like most biomaterials, CPCs are gamma irradiated before clinical use to ensure sufficient sterilization. However, it is well known that gamma irradiation also reduces the molecular weight of CMC and PLGA via chain scission, which affects their material properties. Therefore, the aim of this study is to measure the effect that gamma irradiation has on the molecular weight of CMC at varying doses of 15, 40, or 80 kGy and investigate how this affects the handling (i.e., injectability, cohesion, washout, and setting times) and in vitro degradation behavior of CPC formulations. Results reveal that the molecular weight of CMC decreases with increasing gamma irradiation dose, thereby reducing the viscosifying capabilities of CMC, which causes CPCs to deteriorate more readily. Further, the addition of CMC seems to inhibit the degree of phase transformation during cement setting while the subsequent reduction in molecular weight of PLGA after gamma irradiation improves the in vitro degradation rate of CPCs due to the faster degradation rate of low molecular weight PLGA. © 2019 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 2216-2228, 2019.

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Sterilization effects on the handling and degradation properties of calcium phosphate cements containing poly ((D,L)-lactic-co-glycolic acid) porogens and carboxymethyl cellulose

Calcium phosphate bioceramics and cements are bone grafting materials that exhibit unique bioactive and osteoconductive properties that make them a viable alternative for bone regeneration from more traditional autograft and allograft techniques. More specifically, calcium phosphate cements stand out as a favorable material because they are biodegradable and have excellent handling properties (i.e., injectability, moldability, and cohesion). This gives them the added advantage of being employed in minimally invasive surgical techniques and the ability to be molded into irregularly shaped defect sites. Their ideal handling properties are attributed to their synthesis process, which involves mixing a powder and liquid phase to form a self-setting paste that eventually hardens in vivo. Strategies to improve these cements mechanically have been employed to expand their clinical applicability to more load-bearing sites. This chapter encompasses the fundamental properties of these cements (i.e., setting reactions, setting times, injectability, cohesion, and mechanical performance) and outlines strategies to modify and improve these properties. Finally, the clinical relevance of these cements is discussed.

Ralf-Peter Herber

Papers

Long-term evaluation of the degradation behavior of three apatite-forming calcium phosphate cements.

Long-term biological performance of injectable and degradable calcium phosphate cement

Tough and Osteocompatible Calcium Phosphate Cements Reinforced with Poly(vinyl alcohol) Fibers.

Sterilization effects on the handling and degradation properties of calcium phosphate cements containing poly ((D,L)-lactic-co-glycolic acid) porogens and carboxymethyl cellulose

Calcium Phosphate Bioceramics and Cements