Tissue engineering of oral mucosa combines cells, materials and engineering to produce a three-dimensional reconstruction of oral mucosa. It is meant to simulate the real anatomical structure and function of oral mucosa. Tissue engineered oral mucosa shows promise for clinical use, such as the replacement of soft tissue defects in the oral cavity. [1] These defects can be divided into two major categories: the gingival recessions (receding gums) which are tooth-related defects, and the non tooth-related defects. Non tooth-related defects can be the result of trauma, chronic infection or defects caused by tumor resection or ablation (in the case of oral cancer). Common approaches for replacing damaged oral mucosa are the use of autologous grafts and cultured epithelial sheets.
Autologous grafts are used to transfer tissue from one site to another on the same body. The use of autologous grafts prevents transplantation rejection reactions. Grafts used for oral reconstruction are preferably taken from the oral cavity itself (such as gingival and palatal grafts). However, their limited availability and small size leads to the use of either skin transplants or intestinal mucosa to be able to cover bigger defects. [2]
Other than tissue shortage, donor site morbidity is a common problem that may occur when using autologous grafts. When tissue is obtained from somewhere other than the oral cavity (such as the intestine or skin) there is a risk of the graft not being able to lose its original donor tissue characteristics. For example, skin grafts are often taken from the radial forearm or lateral upper arm when covering more extensive defects. A positive aspect of using skin grafts is the large availability of skin. However, skin grafts differ from oral mucosa in: consistency, color and keratinization pattern. The transplanted skin graft often continues to grow hair in the oral cavity.
To better understand the challenges for building full-thickness engineered oral mucosa it is important to first understand the structure of normal oral mucosa. Normal oral mucosa consists of two layers, the top stratified squamous epithelial layer and the bottom lamina propria. The epithelial layer consists of four layers:
Depending on the region of the mouth the epithelium may be keratinized or non-keratinized. Non-keratinized squamous epithelium covers the soft palate, lips, cheeks and the floor of the mouth. Keratinized squamous epithelium is present in the gingiva and hard palate. [3] Keratinization is the differentiation of keratinocytes in the granular layer into dead surface cells to form the stratum corneum. The cells terminally differentiate as they migrate to the surface (from the basal layer where the progenitor cells are located to the dead superficial surface). The lamina propria is a fibrous connective tissue layer that consists of a network of type I and III collagen and elastin fibers. The main cells of the lamina propria are the fibroblasts, which are responsible for the production of the extracellular matrix. The basement membrane forms the border between the epithelial layer and the lamina propria.
Cell culture techniques make it possible to produce epithelial sheets for the replacement of damaged oral mucosa. Partial-thickness tissue engineering uses one type of cell layer, this can be in monolayers or multilayers. Monolayer epithelial sheets suffice for the study of the basic biology of oral mucosa, for example its responses to stimuli such as mechanical stress, growth factor addition and radiation damage. Oral mucosa, however, is a complex multilayer structure with proliferating and differentiating cells and monolayer epithelial sheets have been shown to be fragile, difficult to handle and likely to contract without a supporting extracellular matrix. Monolayer epithelial sheets can be used to manufacture multilayer cultures. These multilayer epithelial sheets show signs of differentiation such as the formation of a basement membrane and keratinization. [1] Fibroblasts are the most common cells in extracellular matrix and are important for epithelial morphogenesis. If fibroblasts are absent from the matrix, the epithelium stops proliferating but continues to differentiate. The structures obtained by partial-thickness oral mucosa engineering form the basis for full-thickness oral mucosa engineering.
With the advancement of tissue engineering an alternative approach was developed: the full-thickness engineered oral mucosa. Full-thickness engineered oral mucosa is a better simulation of the in vivo situation because they take the anatomical structure of native oral mucosa into account. Problems, such as tissue shortage and donor site morbidity, do not occur when using full-thickness engineered oral mucosa.
The main goal when producing full-thickness engineered oral mucosa is to make it resemble normal oral mucosa as much as possible. This is achieved by using a combination of different cell types and scaffolds.
To obtain the best results, the type and origin of the fibroblasts and keratinocytes used in oral mucosa tissue engineering are important factors to hold into account. Fibroblasts are usually taken from the dermis of the skin or oral mucosa. Kertinocytes can be isolated from different areas of the oral cavity (such as the palate or gingiva). It is important that the fibroblasts and keratinocytes are used in the earliest stage possible as the function of these cells decreases with time. The transplanted keratinocytes and fibroblasts should adapt to their new environment and adopt their function. There is a risk of losing the transplanted tissue if the cells do not adapt properly. This adaptation goes more smoothly when the donor tissue cells resemble the cells of the native tissue.
A scaffold or matrix serves as a temporary supporting structure (extracellular matrix), the initial architecture, on which the cells can grow three-dimensionally into the desired tissue. A scaffold must provide the environment needed for cellular growth and differentiation; it must provide the strength to withstand mechanical stress and guide their growth. Moreover, scaffolds should be biodegradable and degrade at the same rate as the tissue regenerates to be optimally replaced by the host tissue.[ citation needed ] There are numerous scaffolds to choose from and when choosing a scaffold biocompatibility, porosity and stability should also be held into account. [4] Available scaffolds for oral mucosa tissue engineering are:
Fibroblast-populated Skin Substitutes are scaffolds which contain fibroblasts that are able to proliferate and produce extracellular matrix and growth factors within 2 to 3 weeks. This creates a matrix similar to that of a dermis. Commercially available types are for example:
Gelatin is the denatured form of collagen. Gelatin possesses several advantages for tissue-engineering application: they attract fibroblasts, are non-immunogenic, easy to manipulate and boost the formation of epithelium. There are three types of gelatin-based scaffolds:
Glucan is a polysaccharide with antibacterial, antiviral and anticoagulant properties. Hyaluronic acid is added to improve the biological and mechanical properties of the matrix. [1]
Collagen is the primary component of the extracellular matrix. Collagen scaffolds efficiently support fibroblast growth, which in turn allows keratinocytes to grow nicely into multilayers. Collagen (mainly collagen type I) is often used as a scaffold because it is biocompatible, non-immunogenic and available. However, collagen biodegrades relatively rapidly and is not good at withstanding mechanical forces. Improved characteristics can be created by cross-linking collagen-based matrices: this is an effective method to correct the instability and mechanical properties. [6]
Compound collagen-based scaffolds have been developed in an attempt to improve the function of these scaffolds for tissue engineering. An example of a compound collagen scaffold is the collagen-chitosan matrix. Chitosan is a polysaccharide that is chemically similar to cellulose. Unlike collagen, chitosan biodegrades relatively slowly. However, chitosan is not very biocompatible with fibroblasts. To improve the stability of scaffolds containing gelatin or collagen and the biocompatibility of chitosan is made by crosslinking the two; they compensate for each other's shortcomings. [4] [6]
Collagen-elastine membrane, collagen-glycosaminoglycane (C-GAG) matrix, cross-linked collagen matrix Integra and Terudermis are other examples of compound collagen scaffolds. [7]
Allogeneic cultured keratinocytes and fibroblasts in bovine collagen (Gintuit) is the first cell-based product made from allogeneic human cells and bovine collagen approved by the US Food and Drug Administration (FDA). [8] It is an allogeneic cellularized scaffold product and was approved for medical use in the United States in March 2012. [9]
Fibrin-based scaffolds contain fibrin which gives the keratinocytes stability. Moreover, they are simple to reproduce and handle. [1]
A hybrid scaffold is a skin substitute based on a combination of synthetic and natural materials. Examples of hybrid scaffolds are HYAFF and Laserskin. These hybrid scaffolds have been shown to have good in-vitro and in-vivo biocompatibilities and their biodegradability is controllable. [7]
The use of natural materials in scaffolds has its disadvantages. Usually, they are expensive, not available in large quantities and they have the risk of disease transmission. This has led to the development of synthetic scaffolds. When producing synthetic scaffolds there is full control over their properties. For example, they can be made to have good mechanical properties and the right biodegradability. When it comes to synthetic scaffolds thickness, porosity and pore size are important factors for controlling connective tissue formation. Examples of synthetic scaffolds are:
Historical use of electrospinning to produce synthetic scaffolds dates back to at least the late 1980s when Simon showed that technology could be used to produce nano- and submicron-scale fibrous scaffolds from polymer solutions specifically intended for use as in vitro cell and tissue substrates. This early use of electrospun lattices for cell culture and tissue engineering showed that various cell types would adhere to and proliferate upon polycarbonate fibers. It was noted that as opposed to the flattened morphology typically seen in 2D culture, cells grown on the electrospun fibers exhibited a more rounded 3-dimensional morphology generally observed of tissues in vivo. [10]
Although it has not yet been commercialized for clinical use clinical studies have been done on intra- and extra-oral treatments with full-thickness engineered oral mucosa. Full-thickness engineered oral mucosa is mainly used in maxillofacial reconstructive surgery and periodontal peri-implant reconstruction. Good clinical and histological results have been obtained. For example, there is vascular ingrowth and the transplanted keratinocytes integrate well into the native epithelium. Full-thickness engineered oral mucosa has also shown good results for extra-oral applications such as urethral reconstruction, ocular surface reconstruction and eyelid reconstruction. [1]
Biopolymers are natural polymers produced by the cells of living organisms. Like other polymers, biopolymers consist of monomeric units that are covalently bonded in chains to form larger molecules. There are three main classes of biopolymers, classified according to the monomers used and the structure of the biopolymer formed: polynucleotides, polypeptides, and polysaccharides. The Polynucleotides, RNA and DNA, are long polymers of nucleotides. Polypeptides include proteins and shorter polymers of amino acids; some major examples include collagen, actin, and fibrin. Polysaccharides are linear or branched chains of sugar carbohydrates; examples include starch, cellulose, and alginate. Other examples of biopolymers include natural rubbers, suberin and lignin, cutin and cutan, melanin, and polyhydroxyalkanoates (PHAs).
In humans, the vocal cords, also known as vocal folds, are folds of throat tissues that are key in creating sounds through vocalization. The length of the vocal cords affects the pitch of voice, similar to a violin string. Open when breathing and vibrating for speech or singing, the folds are controlled via the recurrent laryngeal branch of the vagus nerve. They are composed of twin infoldings of mucous membrane stretched horizontally, from back to front, across the larynx. They vibrate, modulating the flow of air being expelled from the lungs during phonation.
The integumentary system is the set of organs forming the outermost layer of an animal's body. It comprises the skin and its appendages, which act as a physical barrier between the external environment and the internal environment that it serves to protect and maintain the body of the animal. Mainly it is the body's outer skin.
A mouth ulcer (aphtha), or sometimes called a Canker sore, is an ulcer that occurs on the mucous membrane of the oral cavity. Mouth ulcers are very common, occurring in association with many diseases and by many different mechanisms, but usually there is no serious underlying cause. Rarely, a mouth ulcer that does not heal may be a sign of oral cancer. These ulcers may form individually or multiple ulcers may appear at once. Once formed, an ulcer may be maintained by inflammation and/or secondary infection.
Epithelium or epithelial tissue is a thin, continuous, protective layer of cells with little extracellular matrix. An example is the epidermis, the outermost layer of the skin. Epithelial (mesothelial) tissues line the outer surfaces of many internal organs, the corresponding inner surfaces of body cavities, and the inner surfaces of blood vessels. Epithelial tissue is one of the four basic types of animal tissue, along with connective tissue, muscle tissue and nervous tissue. These tissues also lack blood or lymph supply. The tissue is supplied by nerves.
Tissue engineering is a biomedical engineering discipline that uses a combination of cells, engineering, materials methods, and suitable biochemical and physicochemical factors to restore, maintain, improve, or replace different types of biological tissues. Tissue engineering often involves the use of cells placed on tissue scaffolds in the formation of new viable tissue for a medical purpose, but is not limited to applications involving cells and tissue scaffolds. While it was once categorized as a sub-field of biomaterials, having grown in scope and importance, it can be considered as a field of its own.
The epidermis is the outermost of the three layers that comprise the skin, the inner layers being the dermis and hypodermis. The epidermis layer provides a barrier to infection from environmental pathogens and regulates the amount of water released from the body into the atmosphere through transepidermal water loss.
The lamina propria is a thin layer of connective tissue that forms part of the moist linings known as mucous membranes or mucosae, which line various tubes in the body, such as the respiratory tract, the gastrointestinal tract, and the urogenital tract.
Wound healing refers to a living organism's replacement of destroyed or damaged tissue by newly produced tissue.
Hemidesmosomes are very small stud-like structures found in keratinocytes of the epidermis of skin that attach to the extracellular matrix. They are similar in form to desmosomes when visualized by electron microscopy; however, desmosomes attach to adjacent cells. Hemidesmosomes are also comparable to focal adhesions, as they both attach cells to the extracellular matrix. Instead of desmogleins and desmocollins in the extracellular space, hemidesmosomes utilize integrins. Hemidesmosomes are found in epithelial cells connecting the basal epithelial cells to the lamina lucida, which is part of the basal lamina. Hemidesmosomes are also involved in signaling pathways, such as keratinocyte migration or carcinoma cell intrusion.
The basal lamina is a layer of extracellular matrix secreted by the epithelial cells, on which the epithelium sits. It is often incorrectly referred to as the basement membrane, though it does constitute a portion of the basement membrane. The basal lamina is visible only with the electron microscope, where it appears as an electron-dense layer that is 20–100 nm thick.
Loose connective tissue, also known as areolar tissue, is a cellular connective tissue with thin and relatively sparse collagen fibers. They have a semi-fluid matrix with lesser proportions of fibers. Its ground substance occupies more volume than the fibers do. It has a viscous to gel-like consistency and plays an important role in the diffusion of oxygen and nutrients from the capillaries that course through this connective tissue as well as in the diffusion of carbon dioxide and metabolic wastes back to the vessels. Moreover, loose connective tissue is primarily located beneath the epithelia that cover the body surfaces and line the internal surfaces of the body. It is also associated with the epithelium of glands and surrounds the smallest blood vessels. This tissue is thus the initial site where pathogenic agents, such as bacteria that have breached an epithelial surface, are challenged and destroyed by cells of the immune system.
The basement membrane, also known as base membrane, is a thin, pliable sheet-like type of extracellular matrix that provides cell and tissue support and acts as a platform for complex signalling. The basement membrane sits between epithelial tissues including mesothelium and endothelium, and the underlying connective tissue.
The oral mucosa is the mucous membrane lining the inside of the mouth. It comprises stratified squamous epithelium, termed "oral epithelium", and an underlying connective tissue termed lamina propria. The oral cavity has sometimes been described as a mirror that reflects the health of the individual. Changes indicative of disease are seen as alterations in the oral mucosa lining the mouth, which can reveal systemic conditions, such as diabetes or vitamin deficiency, or the local effects of chronic tobacco or alcohol use. The oral mucosa tends to heal faster and with less scar formation compared to the skin. The underlying mechanism remains unknown, but research suggests that extracellular vesicles might be involved.
A stratified squamous epithelium consists of squamous (flattened) epithelial cells arranged in layers upon a basal membrane. Only one layer is in contact with the basement membrane; the other layers adhere to one another to maintain structural integrity. Although this epithelium is referred to as squamous, many cells within the layers may not be flattened; this is due to the convention of naming epithelia according to the cell type at the surface. In the deeper layers, the cells may be columnar or cuboidal. There are no intercellular spaces. This type of epithelium is well suited to areas in the body subject to constant abrasion, as the thickest layers can be sequentially sloughed off and replaced before the basement membrane is exposed. It forms the outermost layer of the skin and the inner lining of the mouth, esophagus and vagina.
Histology is the study of the minute structure, composition, and function of tissues. Mature human vocal cords are composed of layered structures which are quite different at the histological level.
The dermal equivalent, also known as dermal replacement or neodermis, is an in vitro model of the dermal layer of skin. There is no specific way of forming a dermal equivalent, however the first dermal equivalent was constructed by seeding dermal fibroblasts into a collagen gel. This gel may then be allowed to contract as a model of wound contraction. This collagen gel contraction assay may be used to screen for treatments which promote or inhibit contraction and thus affect the development of a scar. Other cell types may be incorporated into the dermal equivalent to increase the complexity of the model. For example, keratinocytes may be seeded on the surface to create a skin equivalent, or macrophages may be incorporated to model the inflammatory phase of wound healing.
In periodontology, gingival grafting, also called gum grafting or periodontal plastic surgery, is a generic term for the performance of any of a number of surgical procedures in which the gingiva is grafted. The aim may be to cover exposed root surfaces or merely to augment the band of keratinized tissue.
Allogeneic cultured keratinocytes and fibroblasts in bovine collagen, sold under the brand name Gintuit, is a cellular therapy used for the treatment of mucogingival conditions.
A tissue membrane is a thin layer or sheet of cells that covers the outside of the body, the organs, internal passageways that lead to the exterior of the body, and the lining of the moveable joint cavities. There are two basic types of tissue membranes: connective tissue and epithelial membranes.