New Frontiers in Biomaterials R. Gilbert Triplett, pps, pho®*, Oksana Budinskaya, DDs‘ KEYWORDS ‘Tissue engineering * Regenerative medicine * Biomaterials * Angiogenesis * Nanophase biomaterial * Atmospheric cold plasma KEY POINTS ‘* Tissue loss due to trauma or pathology or for congenital purposes necessitates the replacement of form and function, and this has led to the development of tissue engineering and regenerative medi 2. ‘© Grafting materials and techniques have undergone a rapid evolution from simply replacing tissues to stimulating a response from the host. « These developments are promising in that previously unattainable resutts in skin, nerve, muscle, and specialized tissue bioengineering are within reach. INTRODUCTION A biomaterial in medical terminology is “any natu- ral or synthetic material (which includes polymer or metal) that is intended for introduction into living tissues as part of a medical device or implant (for example artificial heart or temporomandibular joint). Biomaterials from a health care perspective can be defined as “materials that possess some novel properties that makes them appropriate to come into immediate contact with the living tissue without eliciting an adverse immune rejection reaction.”’ Tissue loss in the craniomaxillofacial region oc- curs frequently from disease, trauma, and congen- ital abnormalities. This loss induces serious physiologic and psychological consequences for patients and their families.” Reconstruction of this area to an esthetic and functional state is the goal of the reconstructive surgeon, Historically, tissue replacement with biomate- rials in the craniomaxillofacial region focused on the physical properties of the material itself, such as inertness, malleability, and strength. Over the past 35 years, both the science and funding of biomaterials have seen incredible growth, Bioma- terial science has evolved through the research, clinical experience, and collaboration between re- searchers and surgeons. Recently research has redirected its focus on the biologic interactions of implant materials with the surrounding tissue and cells.® In the past, removable or implanted prostheses used to obturate and replace tissues in this region were fabricated with metals and ceramics Although they provided an improved esthetic and functional state, they had their limitations. These materials were believed “inert” and, therefore, incapable of eliciting an unfavorable reaction from the host tissue. It is now recognized that various “inert” materials can change physically and chemically after implantation and, from a bio- logical perspective, no material should be consid- ered truly inert.“ Disclosure Statement: The authors have nothing to disclose. * Department of Oral and Maxillofacial Surgery, Texas A&M — College of Dentistry, 3302 Gaston Avenue, Dal- las, Texas 75246, USA; ® Department of Surgery, Division of Dentistry, Baylor University Medical Center, Dallas, Texas, USA; ‘ Oral Diagnosis, Texas A&M ~ College of Dentistry, 3302 Gaston Ave,, Dallas, Tx 75246, USA * Corresponding author. E-mail address: Gtriplett@bcd.tamhscedu Oral Maxillofacial Surg Clin N Arm 29 (2017) 105-115 hitp:/dx.doi.org/10.1016/}.coms.2016.08.011 1042-3699/17/0 2016 Elsevier Inc. All rights reserved. oralmaxsurgery.theclinics.com106 Gilbert Triplett & Budinskaya Numerous advances have been made in the area of biomaterials and tissue engineering; how- ever, the complexity of human tissues and organs has not been simple to unscramble and mecha- nisms and interaction between the tissues, cells, and various factors are still being discovered. This atticle discusses the exciting and novel areas of discovery, first discussing the basic concepts of biomaterials, their development, and their poten- tial implementation to understand the endless possibilities in this field with their current limita- tions and shortcomings. BACKGROUND The first generation of biomaterials evolved during the 1960s and 1970s and initially served mainly as medical implants. Basic goals during the fabrica- tion of these biomaterials consisted in maintaining a balance between physical and mechanical prop- erties with minimal toxicity to host tissues.” Ideal properties of the first-generation biomaterials were (1) appropriate mechanical properties, (2) resistance to corrosion in an aqueous environ- ment, and (8) not eliciting toxicity or carcinogenic ity in living tissue. Second-generation biomaterials were developed to also be bioactive, Substantial progress was observed in the application for or- thopedic and dental use. Examples include bioac- tive glasses, ceramics, polymers, glass-ceramics, and composites. "° Current developments with biomaterial technol- ogy are now translating into the expansion of a third-generation of biomaterials that can stimulate a specific cellular response.’ This research is focused on the development and improvement of scaffolding, the delivery of site-specific cells, and the use of necessary growth factors and various molecules to an area needing regeneration, These scaffolds are used as extracellular matrixes (ECMs) to provide 3-D supporting structure to the cells, resulting in a “tissue construct.” Various biomaterial scaffolds are being investigated and include naturally occurring biodegradable poly- mers, synthetic organic biodegradable polymers, hydrogels, and synthetic bioactive glass and ceramics. These biomaterial scaffolds have been demon- strated to have an effect on the cellular activity of cells within and adjacent to a tissue construct and have been designed to provide a sustained local release of cytokines.’ Scatfolds consisting of natural polymers have recently been developed and have gained popularity. Natural polymers can be considered the first biodegradable biomaterials used in human clinical conditions.’ These natural materials, due to their bioactive properties, tend to have greater biological interaction with the cells, which allow them to perform better in biological systems. These polymers can be classified as pro- teins (silk, collagen, fibrinogen, elastin, keratin, actin, and myosin) and polysaccharides (cellulose, amylose, dextran, chitin, and glycosaminoglycans) ‘or polynucleotides (DNA and RNA). It is often beneficial for scaffolds to mimic the natural ECM because ECM components specif- ically modulate mesenchymal stem cell (MSC) adhesion, migration, proliferation, and osteogenic differentiation.’ Cell-derived decellularized ECM is also a promising approach to obtain ECM- based biomimetic material.” When the biomaterial is inserted into a living tis- sue, a cascade of events is initiated that starts with the adsorption of biomaterials to the material's surface. The immediate interaction of the biomate- rial with the in vivo environment is the surface charge and surface energy of the biomaterial. An increase in surface energy improves the wettability of the material surface facilitating the adsorption of serum proteins and other biomolecules, such as fibronectin.‘ This initial wetting (flash spread) that is accompanied by the adsorption of biomolecules is one of the most important preconditions for cells, or molecules to become attached to the material surface and to establish tissue contact with the biomaterial. Surface energy and charge depend largely on the material composition and the sur- face texture. Metals and mineralized materials commonly have a negative surface charge under physiologic conditions due to the presence of ox- ide molecules on their surface. This results in the adsorption of positively charged molecules to the biomaterial surface, Polymers, such as polylactic, acid, have a low surface energy and, therefore, a hydrophobic surface characteristic. The higher surface energy of many metals and ceramics and hydrophilic surfaces can enhance tissue integra- tion, The surface texture of the biomaterial also af- fects the interaction between itself and the living tissues. Microrough surfaces enhance cellular attachment and differentiation and increased sur- face roughness increases surface energy and im- proves wettability.’ Another positive effect on cellular behavior is mediated through the microtexture itself as evi- denced by surface modification of titanium im- plants.’ Different degrees of surface roughness have been shown to modify cellular production of receptors that mediate adhesion to titanium sur- faces and increase secretion of osteogenic factors, that induce differentiation of cells in contact with the microtextured surface. This leads to the pro- duction of cytokines involved in bone formation.° ‘Theses finding demonstrate how material sciencecan contribute to the success of tissue engineering by optimizing immediate and late interactions be- tween seeded cells in vitro and living tissue in vivo after implantation. Tissues in the cranio- maxillofacial region are varied in composition but essentially consist of a matrix and various cell types. The matrix represents a 3-D structure for cells (scaffolds), which provides them with a spe- cific environment and architecture for a given function © It is broadly agreed that a scaffold (-D matrix) should have the following properties: (1) biocom- patibility, including degradation products, both of which must not elicit an inflammatory response; 2) noneytotoxicity, including both the material it- self and its degradation products, (3) being noncarcinogenic; (4) being sterilizable; (6) pre- dictable physical and mechanical properties, including elasticity, load bearing, and shear stress capacity that are appropriate to the tissue they intend to replace; (6) favorable surgical manipulation properties, including suturing as required for soft tissue implantation and being able to be drilled and hold screws and hardware as required for bone and cartilage scaffolds; (7) porosity with at least an open pore size of 100 hum to 200 um to allow cellular migration and vascularization and permeation of nutrients, cyto- kines, and waste; (8) histoconductivity, which guides and stimulates proliferation of autogenous progenitor cells that migrate from surrounding tissues into the scaffold; (9) histoinductivity that induces proliferation and differentiation of autog- enous progenitor cells that have migrated from surrounding tissues into the scaffold; and (10) having sites for cellular binding as well as in vivo drug delivery, including growth factors and genes.“ VASCULARIZATION AND FABRICATION TECHNIQUES The vascularization problem associated with larger tissue constructs is complex and has limited the clinical use of prefabricated tissue constructs Scaffolds should have an interconnected pore structure and high porosity to ensure cellular pop- ulation and adequate diffusion of nutrients to cells within the construct and to the ECM formed by these cells. Interconnection of the pores is neces- sary to allow diffusion of waste products from the scaffold because the products of scaffold degra- dation should be able to exit without interference with other tissues. The mean pore size of the construct is critically important because the cells interact with scaffolds via ligands on the material surface.” New Frontiers in Biomaterials Scaffolds with pore sizes larger than 200 um require a preformed vascular network to supply adequate nutrients, gas exchange, and the removal of waste from the cells within the scaf- fold.® Several different fabrication techniques have been in use to create such scaffolds, including particle leaching, freeze drying, phase separation, fiber mesh formation using melt-spum or solution-spun techniques, electro- spinning fiber formation, and solid free-form fabrication.”-"? The purpose of these different fabrication techniques is to create a scaffold with adequate porosity to accommodate vascular networking used in combination with endothelial progenitor cells. If successful, this technique pro- duces a performed vascular tissue, ex vivo, which can eventually be implanted." "* Biofabrication of living structures with desired topology and functionality requires an interdisci= plinary effort of practitioners of the physical, bio- logical, and engineering sciences. Such efforts are being undertaken in many laboratories around the world. Numerous approaches are pursued, such as those based on the use of natural or arti- ficial scaffolds, decellularized cadaveric extracel- lular matrices, and bioprinting. To be successful it is crucial to provide in vitro microenvironmental clues for the cells resembling those in the organ- ism. Scaffolds populated with differentiated cells or stem cells of increasing complexity and sophis- tication are being fabricated. No matter how so- Phisticated scaffolds are, they can still cause problems stemming from their degradation, elicit- ing immunogenic reactions and other unforeseen complications. It is now realized that ultimately the best approach might be to rely on the natural self-assembly and self-organizing properties of cells and tissues and the innate regenerative capa- bility of the organism itself. There are different stra~ tegies for the fabrication of 3-D biological structures, in particular bioprinting, which uses a biological, scatfoldless, print-based engineering approach that includes self-assembling multice!- lular units as bioink particles and early develop mental morphogenetic principles, such as cell sorting and tissue fusion. 1° Self organizing vascular constructs are among the most promising scaffoidiess engineered tis- sues currently in preclinical and clinical studies. Initial successes with in vitro studies on cell sheet engineering of human vascular tissue led to the development of self-organizing vascular constructs. "° Self-organization in tissue engineering refers to engineered tissues, which exhibit the generation of distinct structures or gross morphology re- miniscent of native tissues without exogenous 107