BONE

REGENERATION
PRESENTED BY :AYA ADEL MEKKY
OUTLINES
• Definition
• Bone healing
• Bone graft
• GBR
• Tissue engineering
• Biologicaly mediated strategies
• Gene therapy
 DEFINITION
Bone regeneration is a complex, well-organized process of bone
formation.

• The most common

form of bone However, there are
regeneration complex clinical
normal bone conditions in which
healing normal bone
• Continuous regeneration is impaired
remodelling
throughout life.
 Bone regeneration is comprised of a well-organized series of
biological events of bone induction and conduction, involving a
number of cell types and intracellular and extracellular molecular
signalling pathways, in an effort to optimise skeletal repair and
restore skeletal function.
Unlike in other tissues, the majority of bony injuries (fractures)
heal without the formation of scar tissue, and bone is regenerated
with its pre-existing properties largely restored, and with the
newly formed bone being eventually indistinguishable from the
adjacent uninjured bone.
Histological stages of bone
healing. Histological
progression of bone
healing in rats.
Representative
photomicrographs
showing the least to the
most advanced stages of
bone healing , with regions
of hematoma (HE),
granulation tissue (GT), IM
woven bone (IWB), and
cortical bone (CB) labeled.
Sections were stained with
H&E, and images were
acquired at 10
magnification
There are cases of fracture healing in which bone regeneration is
impaired
In orthopaedic surgery and in oral maxillofacial surgery in which
bone regeneration is required in large quantity (beyond the
normal potential for self-healing)

1. Skeletal reconstruction of large bone defects created by

trauma, infection, tumour resection and skeletal
abnormalities
2. Cases in which the regenerative process is compromised,
including avascular necrosis and osteoporosis.
 BONE REGENERATION
BONE GRAFT
Bone grafting is a surgical
procedure to place bone or
bone substitute material into a
bone defect with the objective
of producing new bone and
possibly the regeneration of
periodontal ligament and
cementum
 autografts

The materials used

allografts
in bone grafting

xenografts

Synthetic and biologically based, tissue-engineered biomaterials

and combinations of these substitutes are other options .
 1 2

3 4
Bone regeneration can be accomplished through three different
mechanisms: osteogenesis, osteoinduction, and osteoconduction.

Osteogenesis is the formation and development of bone, even in the

absence of local undifferentiated mesenchymal stem cells. either present
in the recipient bone or coming from the graft material. This property is
mainly present in autogenous grafts as compared with allografts and
xenografts.
Osteoinduction is the capability of the graft materials to
induce formation of the bone-forming cells via differentiation of
multipotent mesenchymal stem cells (MSCs) of the surrounding host
tissues to produce osteoprogenitor cells followed by development of
osteoblasts. Such ability has been discovered in growth factors
including bone morphogenetic proteins (BMPs) such as BMP-2 and
BMP-7, transforming growth factor-β (TGF-β), fibroblast growth
factor (FGF), insulin-like growth factor (IGF), and platelet-derived
growth factor (PDGF).
Osteoconductionis a characteristic whereby the graft acts as a
permanent and resorbable scaffold, mechanically supporting
ingrowth of vessels and new bone from the borders of the defect into
and onto its surfaces. This characteristic initiates or induces new
bone formation
AUTOGRAFTS
AUTOGRAFTS ARE THE ‘GOLD STANDARD’ IN RECONSTRUCTING SMALL BONE DEFECTS

Is tissue transferred from one location to another within the same

individual, which can be obtained from intraoral or extraoral sites.
Advantage :
• They are the best materials for bone grafting, are very well
accepted by the body and may produce the fastest rate of
bone growth
• The patient is assured of protection from disease transmission
and/or immune reaction

Disadvatage :
• There is the potential risk of additional discomfort and a
secondary procedure.
Grafted autogenous bone can be trabecular (cancellous), cortical
or corticotrabecular.
cancellous bone has more osteogenic potential than cortical
bone due to presence of hematopoietic marrow and a greater
amount of pleuripotential cells in cancellous bone .
Cortical graft has fewer surviving osteogenic cells but provides
the most bone morphogenetic protein (BMP) .

BMP differentiates host mesenchymal cells into osteoblasts. In

addition, BMP provides more resistance to the graft structure
resorption, which impedes soft tissue in-growth but also may
prolong the time needed for blood vessels to infiltrate the graft.
SEM ultramicrographs of microstructure of natural bone grafts. (A) Trabecular or cancellous bone graft.
Note the porous honey comb-like microstructure of cancellous bone graft. ( B) Cortico-cancellous bone
graft. ( C) Cortical or compact bone graft (scalebars ( A - C) 100 μm).
ALLOGRAFTS
consist of tissue transferred from one individual to another
genetically dissimilar individual of the same species.
Disadvatage :
• The age and health of the donor can affect the rate of bone
regeneration.
• The risk of disease transmission
The allografts are freeze-dried at ultra-low temperatures and dried
under high vacuum. They are available either demineralized or
non-demineralized.
Unlike synthetic bone, which only provides scaffolding for
osteoconduction, allografts include growth factors which are also
osteoinductive. Allografts induce bone growth and provide an
environment that increases the body’s regenerative process.
Cortical cancellous
crushed

cancellous crushed

block
XENOGRAFTS
Xenografts are tissue grafts obtained from a species other than the
host species.
The representative xenograft materials are natural hydroxyapatite
(HA) and deorganified bovine bone (anorganic bone matrix or
ABM). These graft materials are inert osteoconductive filler
material, which serves as a scaffold for new bone formation.
Disadvantages
• Increased risk of a host-immune response
• They have low resorption rate may negatively impact the
healing of the grafted site and compromise the mechanical and
biological properties of the regenerated bone.
In cases where bone grafts from human or animal sources are not
feasible, synthetic graft materials (alloplasts) are used.
 GBR (GUIDED BONE
REGENRATION )
is a surgical procedure that uses barrier
membranes with or without particulate bone
grafts or/and bone substitutes.
Osseous regeneration by GBR depends on
the migration of pluripotential and osteogenic
cells (e.g. osteoblasts derived from the
periosteum and/or adjacent bone and/or bone
marrow) to the bone defect site and exclusion
of cells impeding bone formation(e.g.
epithelial cells and fibroblasts) .
To accomplish the regeneration of a bone
defect, the rate of osteogenesis extending
inward from the adjacent boney margins must
exceed the rate of fibrogenesis growing in
from the surrounding soft tissue.
 Surgical procedures for ridge augmentation are designed based on biological principles of bone regeneration. First, space-
maintenance where new bone formation is needed is achieved by use of grafts and/or membranes. In order for bone formation to
occur, grafts need to be osteoconductive acting as a scaffold onto which bone resorption and deposition occurs. Most graft materials
allow for their resorption by osteoclasts prior to bone deposition by osteoblasts ( A ). Since the turnover rate of soft tissues is higher
than that of bone, grafts are used alone when their surfaces have low resorption rates, or in combination with membranes that
separate the graft from soft tissues, when their surfaces have high resorption rates; This approach ensures that soft tissues are
prevented from occupying the space where bone formation is intended ( B ); Bone deposition by osteoblasts is facilitated by
adequate blood flow through the graft and osteoinductive properties of the graft that provide the growth factors necessary for
osteoblast differentiation and function ( C ). Some grafts (autologous) act as osteogenic materials when they contain sufficient
amount of osteoblasts precursors and growth factors
SEQUANCE OF EVENTS
1. Within the first 24 hours after a bone graft, the graft material/barrier
created space is filled with the blood clot
2. blood clot releases growth factors (e.g., platelet derived growth
factor) and cytokines (e.g., IL-8) to attract neutrophils and
macrophages.
3. The clot is absorbed and replaced with granulation tissue which is
rich in newly formed blood vessels.
4. Through these blood vessels, nutrients and mesenchymal stem
cells capable of osteogenic differentiation can be transported and
contribute to osteoid formation.
5. Mineralization of osteoid forms woven bone , which later serves as
a template for the apposition of lamellar bone .
6. This transformation of primary sponge work would eventually
constitute both compact and reticular bone with mature bone
marrow.
7. These events occur 3 to 4 months post-surgery
TISSUE ENGINEERING
Tissue engineering is defined as ‘a process that affects the
structure and architecture of any viable and non-viable tissue
with the aim to increase the effectiveness of the construct in
biologic environments.

Tissue engineering involve the use of scaffolds, healing

promotive factors (e.g., growth factors), and stem cells .

Using tissue engineering techniques, it is possible to design new

scaffolds and tissue grafts aiming to decrease the disadvantages
of traditional grafts and improve graft incorporation,
osteogenicity, osteoconductivity, and osteoinductivity
 Tissue engineering combines bone marrow cells or MSC, synthetic
scaffolds and molecular signals (growth or differentiating factors) to
form hybrid constructs.
Steps :
In a classical approach, bone tissue engineering consists of
harvesting bone marrow from a patient,
1. Isolating MSC by adherence to tissue culture plastic
2. Expanding and differentiating MSC in culture.
3. Seeding them onto a suitable synthetic scaffold.
4. Implantation into the same patient .
It has been shown that from a small volume (0.1–3 ml) aspirate,
alveolar bone marrow stromal cells (BMSC) expand by 70%.
Although this raises few ethical issues, harvesting of cells from
bone marrow is still an invasive procedure, and in addition stem
cell numbers may decrease significantly with the age of the
individual.

The search for more readily accessible sources of pluripotent

cells has led to investigation of other tissues
1. peripheral blood
2. umbilical cord blood and
3. more recently, periodontal ligament and deciduous and
permanent teeth.
4. Dental pulp tissue is also a readily accessible source of pulp‐
derived MSC (PDSC) and can be easily isolated
Scaffolds
are the most important issue in tissue engineering and could be
divided into two main categories
biological (natural or synthetic (artificial)
organic) such as materials such as
collagen type ceramics

General characteristics, including

• porosity
• suitable pore size and shape
• fiber alignment and orientation
• fiber density
• internal and external architecture
• hydrophilicity, and hydrophobicity, including water uptake, binding,
and delivery.
Alginate (A), alginate-chitosan (B), chitosan (C), chitosan-
collagen (D), mesenchymal stem cells cultured on the scaffold
collagen (C)-DL-lactic acid-glycolic acid (PLGA) (P) medium (E),
and synthesized porous HA scaffold (F). The scaffolds used for
bone tissue engineering must be porous
Healing promotive factors
Healing promotive factors such as growth factors have been
extensively used to treat bony defects and for osteoinduction.
Some growth factors such as (VEGF), TGF-β, PDGF, and BMPs
such as BMP-2, BMP-7, and IGF are present in the healthy bone
matrix and are expressed during bone healing.
These factors can regulate vascularization and induce
proliferation and differentiation of the osteoblasts and their
precursors, so they can be useful in improving the healing
processes .
Bone morphogenetic protein-2 (BMP-2) is a potent osteoinductive
cytokine that plays a critical role during bone regeneration and
repair
BIOLOGICALLY
MEDIATED STRATEGIES
Biologically mediated strategies include materials, such as
.enamel matrix protein
• Premixed with vehicle solution.
• Topical application onto exposed root surfaces or bone to
treat intrabony defects and furcations due to moderate or
severe periodontitis.

These bone morphogenetic proteins help to initiate a

cascade of events leading to the differentiation of progenitor
cells into phenotypes involved in periodontal regeneration.
GENE THERAPY
• Gene therapy consists of transfer of genetic information to
the target cells and may introduce a safe and effective
strategy to induce bone healing.
• Gene therapy can be used for delivery of growth factors in
tissue engineering.
• The vehicle for gene delivery can be either viral (adenovirus,
retrovirus, and adeno-associated virus) or non-viral
(liposomes) .
• The gene vector may be delivered
 In vivo
 direct injection
 using gene activated matrix (GAM).
 Ex vivo by using genetically modified cells.
Limitation of gene therapy

• Trans-infection of the target cells with the foreign genes .

• An unresolved issue of gene therapy is to target the right gene at
the right location in the right cells and express it for sufficiently
long at the right time, while minimizing adverse reactions .
• A short controlled expression is desirable and often sufficient to
accelerate bone healing, while achieving permanent or long-term
expression of a therapeutic gene is more difficult.
• Therefore, providing controlled and sufficient expression by
adaptation of gene therapy to tissue engineering is a key and
critical aspect in this field.
REFERANCES
• Bone Regeneration Stewart, S., Bryant, S. J., Ahn, J., &
Hankenson, K. D. (2015)
• Bone regenerative medicine: classic options, novel
strategies, and future directions Published: 17 March 2014
• Mechanisms of Guided Bone Regeneration: A Review Jie
Liu and David G Kerns Published online 2014 May 16
• Orbans text book