Tissue engineering 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 biolog ...

oral mucosa 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 des ...

combines cells, materials and engineering to produce a

three-dimensional Three-dimensional space (also: 3D space, 3-space or, rarely, tri-dimensional space) is a geometric setting in which three values (called ''parameters'') are required to determine the position of an element (i.e., point). This is the informa ...

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. These defects can be divided into two major categories: the

gingiva The gums or gingiva (plural: ''gingivae'') consist of the mucosal tissue that lies over the mandible and maxilla inside the mouth. Gum health and disease can have an effect on general health. Structure The gums are part of the soft tissue lin ...

l 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 Oral cancer, also known as mouth cancer, is cancer of the lining of the lips, mouth, or upper throat. In the mouth, it most commonly starts as a painless white patch, that thickens, develops red patches, an ulcer, and continues to grow. When on ...

). Common approaches for replacing damaged oral mucosa are the use of autologous

grafts Grafting refers to a surgical procedure to move tissue from one site to another on the body, or from another creature, without bringing its own blood supply with it. Instead, a new blood supply grows in after it is placed. A similar techniqu ...

and cultured epithelial sheets.

Autologous grafts

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 Reconstruction may refer to: Politics, history, and sociology *Reconstruction (law), the transfer of a company's (or several companies') business to a new company *'' Perestroika'' (Russian for "reconstruction"), a late 20th century Soviet Unio ...

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. 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 Radial is a geometric term of location which may refer to: Mathematics and Direction * Vector (geometric), a line * Radius, adjective form of * Radial distance, a directional coordinate in a polar coordinate system * Radial set * A bearing f ...

forearm The forearm is the region of the upper limb between the elbow and the wrist. The term forearm is used in anatomy to distinguish it from the arm, a word which is most often used to describe the entire appendage of the upper limb, but which in ...

lateral Lateral is a geometric term of location which may refer to: Healthcare *Lateral (anatomy), an anatomical direction * Lateral cricoarytenoid muscle * Lateral release (surgery), a surgical procedure on the side of a kneecap Phonetics *Lateral co ...

upper arm In human anatomy, the arm refers to the upper limb in common usage, although academically the term specifically means the upper arm between the glenohumeral joint (shoulder joint) and the elbow joint. The distal part of the upper limb between th ...

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.

Normal oral mucosa

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: *

Stratum basale The ''stratum basale'' (basal layer, sometimes referred to as ''stratum germinativum'') is the deepest layer of the five layers of the epidermis, the external covering of skin in mammals. The ''stratum basale'' is a single layer of columnar or ...

(basal layer) *

Stratum spinosum The stratum spinosum (or spinous layer/prickle cell layer) is a layer of the epidermis found between the stratum granulosum and stratum basale. This layer is composed of polyhedral keratinocytes. These are joined with desmosomes. Their spiny (La ...

(spinous layer) *

Stratum granulosum The stratum granulosum (or granular layer) is a thin layer of cells in the epidermis lying above the stratum spinosum and below the stratum corneum ( stratum lucidum on the soles and palms).James, William; Berger, Timothy; Elston, Dirk (2005) '' ...

(granular layer) * Stratum corneum (keratinized/superficial layer) Depending on the region of the mouth the epithelium may be keratinized or non-keratinized. Non-keratinized squamous epithelium covers the

soft palate The soft palate (also known as the velum, palatal velum, or muscular palate) is, in mammals, the soft tissue constituting the back of the roof of the mouth. The soft palate is part of the palate of the mouth; the other part is the hard palate. ...

, lips, cheeks and the floor of the mouth. Keratinized squamous epithelium is present in the gingiva and

hard palate The hard palate is a thin horizontal bony plate made up of two bones of the facial skeleton, located in the roof of the mouth. The bones are the palatine process of the maxilla and the horizontal plate of palatine bone. The hard palate spans t ...

. Keratinization is the differentiation of

keratinocyte Keratinocytes are the primary type of cell found in the epidermis, the outermost layer of the skin. In humans, they constitute 90% of epidermal skin cells. Basal cells in the basal layer (''stratum basale'') of the skin are sometimes referre ...

s 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 cell A progenitor cell is a biological cell that can differentiate into a specific cell type. Stem cells and progenitor cells have this ability in common. However, stem cells are less specified than progenitor cells. Progenitor cells can only differ ...

s 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 A fibroblast is a type of biological cell that synthesizes the extracellular matrix and collagen, produces the structural framework ( stroma) for animal tissues, and plays a critical role in wound healing. Fibroblasts are the most common cells ...

, which are responsible for the production of the

extracellular matrix In biology, the extracellular matrix (ECM), also called intercellular matrix, is a three-dimensional network consisting of extracellular macromolecules and minerals, such as collagen, enzymes, glycoproteins and hydroxyapatite that provide s ...

. The basement membrane forms the border between the epithelial layer and the lamina propria.

Tissue engineered oral mucosa

Partial-thickness engineered oral mucosa

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 A growth factor is a naturally occurring substance capable of stimulating cell proliferation, wound healing, and occasionally cellular differentiation. Usually it is a secreted protein or a steroid hormone. Growth factors are important for regul ...

addition and

radiation damage Radiation damage is the effect of ionizing radiation on physical objects including non-living structural materials. It can be either detrimental or beneficial for materials. Radiobiology is the study of the action of ionizing radiation on livin ...

. 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. Fibroblasts are the most common cells in extracellular matrix and are important for epithelial

morphogenesis Morphogenesis (from the Greek ''morphê'' shape and ''genesis'' creation, literally "the generation of form") is the biological process that causes a cell, tissue or organism to develop its shape. It is one of three fundamental aspects of deve ...

. 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.

Full-thickness tissue engineered oral mucosa

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 Studies that are ''in vivo'' (Latin for "within the living"; often not italicized in English) are those in which the effects of various biological entities are tested on whole, living organisms or cells, usually animals, including humans, and ...

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. * Lamina propria: is mimicked by seeding oral fibroblasts, producing extracellular matrix, into a

biocompatible Biocompatibility is related to the behavior of biomaterials in various contexts. The term refers to the ability of a material to perform with an appropriate host response in a specific situation. The ambiguity of the term reflects the ongoing de ...

(porous) scaffold and culturing them in a fibroblast differentiation medium. * Basement membrane: containing

type IV collagen Collagen IV (ColIV or Col4) is a type of collagen found primarily in the basal lamina. The collagen IV C4 domain at the C-terminus is not removed in post-translational processing, and the fibers link head-to-head, rather than in parallel. Also, ...

laminin Laminins are a family of glycoproteins of the extracellular matrix of all animals. They are major components of the basal lamina (one of the layers of the basement membrane), the protein network foundation for most cells and organs. The laminins ...

fibronectin Fibronectin is a high- molecular weight (~500-~600 kDa) glycoprotein of the extracellular matrix that binds to membrane-spanning receptor proteins called integrins. Fibronectin also binds to other extracellular matrix proteins such as collage ...

and

integrins Integrins are transmembrane receptors that facilitate cell-cell and cell-extracellular matrix (ECM) adhesion. Upon ligand binding, integrins activate signal transduction pathways that mediate cellular signals such as regulation of the cell cycle, ...

. Ideally, the basement membrane must contain a

lamina lucida The lamina lucida is a component of the basement membrane which is found between the epithelium and underlying connective tissue (e.g., epidermis and dermis of the skin). It is a roughly 40 nanometre wide electron-lucent zone between the plasma ...

and a

lamina densa The lamina densa is a component of the basement membrane zone between the epidermis and dermis of the skin, and is an electron-dense zone between the lamina lucida and dermis, synthesized by the basal cells of the epidermis, and composed of (1) ...

. * Stratified squamous epithelium: is simulated by oral keratinocytes cultured in a medium containing keratinocyte growth factors such as the epidermal growth factor (EGF). 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.

Scaffolds

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. There are numerous scaffolds to choose from and when choosing a scaffold biocompatibiltiy,

porosity Porosity or void fraction is a measure of the void (i.e. "empty") spaces in a material, and is a fraction of the volume of voids over the total volume, between 0 and 1, or as a percentage between 0% and 100%. Strictly speaking, some tests measur ...

and stability should also be held into account. Available scaffolds for oral mucosa tissue engineering are:

Naturally derived scaffolds

* Acellular Dermis. An acellular dermis is made by removing the cells (epidermis and dermal fibroblasts) from split-thickness skin. It has two sides: one side has a basal lamina suitable for the epithelial cells, and the other is suitable for fibroblast infiltration because it has intact vessel channels. It is durable, able to keep its structure and does not trigger immune reactions (non-immunogenic). * Amniotic Membrane. The

amniotic membrane The amnion is a membrane that closely covers the human and various other embryos when first formed. It fills with amniotic fluid, which causes the amnion to expand and become the amniotic sac that provides a protective environment for the develo ...

, the inner part of the

placenta The placenta is a temporary embryonic and later fetal organ that begins developing from the blastocyst shortly after implantation. It plays critical roles in facilitating nutrient, gas and waste exchange between the physically separate mate ...

, has a thick basement membrane of collagen type IV and laminin and avascular connective tissue.

Fibroblast-populated skin substitutes

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: * Dermagraft™ * Apligraf™ * Orcel™ * Polyactive™ * Hyalograf 3D™

Gelatin-based scaffolds

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: * Gelatin-oxidized dextran matrix * Gelatin-chitosan-oxidized dextran matrix * Gelatin-glucan matrix * Gelatin-hyaluronate matrix * Gelatin-chitosan hyaluronic acid matrix. Glucan is a polysaccharide with

antibacterial An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention ...

antiviral Antiviral drugs are a class of medication used for treating viral infections. Most antivirals target specific viruses, while a broad-spectrum antiviral is effective against a wide range of viruses. Unlike most antibiotics, antiviral drugs do no ...

and anticoagulant properties. Hyaluronic acid is added to improve the biological and mechanical properties of the matrix.

Collagen-based scaffolds

Pure collagen scaffolds

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.

Compound collagen scaffolds

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 Chitosan is a linear polysaccharide composed of randomly distributed β-(1→4)-linked D-glucosamine (deacetylated unit) and ''N''-acetyl-D-glucosamine (acetylated unit). It is made by treating the chitin shells of shrimp and other crustacean ...

is a polysaccharide that is chemically similar to

cellulose Cellulose is an organic compound with the formula , a polysaccharide consisting of a linear chain of several hundred to many thousands of β(1→4) linked D-glucose units. Cellulose is an important structural component of the primary cell w ...

. 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. Collagen-elastine membrane, collagen-glycosaminoglycane (C-GAG) matrix, cross-linked collagen matrix Integra™ and Terudermis® are other examples of compound collagen scaffolds.

Fibrin-based scaffolds

Fibrin-based scaffolds contain fibrin which gives the keratinocytes stability. Moreover, they are simple to reproduce and handle.

Hybrid scaffolds

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 Biodegradation is the breakdown of organic matter by microorganisms, such as bacteria and fungi. It is generally assumed to be a natural process, which differentiates it from composting. Composting is a human-driven process in which biodegradati ...

is controllable.

Synthetic scaffolds

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

. When it comes to synthetic scaffolds thickness, porosity and pore size are important factors for controlling connective tissue formation. Examples of synthetic scaffolds are: * Polyethylene terephthalate membranes (PET membranes) * Polycarbonate-permeable membranes (PC membranes) * Porous polylactic glycolic acid (

PLGA PLGA, PLG, or poly(lactic-''co''-glycolic acid) is a copolymer which is used in a host of Food and Drug Administration (FDA) approved therapeutic devices, owing to its biodegradability and biocompatibility. PLGA is synthesized by means of ring-op ...

) 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 produced 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''.

Clinical applications: full-thickness engineered oral mucosa

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 Histology, also known as microscopic anatomy or microanatomy, is the branch of biology which studies the microscopic anatomy of biological tissues. Histology is the microscopic counterpart to gross anatomy, which looks at larger structures vis ...

results have been obtained. For example, there is

vascular The blood vessels are the components of the circulatory system that transport blood throughout the human body. These vessels transport blood cells, nutrients, and oxygen to the tissues of the body. They also take waste and carbon dioxide away f ...

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 The urethra (from Greek οὐρήθρα – ''ourḗthrā'') is a tube that connects the urinary bladder to the urinary meatus for the removal of urine from the body of both females and males. In human females and other primates, the urethra con ...

reconstruction,

ocular Eyes are organs of the visual system. They provide living organisms with vision, the ability to receive and process visual detail, as well as enabling several photo response functions that are independent of vision. Eyes detect light and con ...

surface reconstruction and

eyelid An eyelid is a thin fold of skin that covers and protects an eye. The levator palpebrae superioris muscle retracts the eyelid, exposing the cornea to the outside, giving vision. This can be either voluntarily or involuntarily. The human eye ...

reconstruction.

References

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''Tissue-engineered Oral Mucosa: a Review of the Scientific Literature''
JDR Journal of Dental Research Eline Deboosere
''Tissue engineering van de orale mucosa''
Universiteit Gent Sung-Pei Tsai et al (2006)
''Preparation and Cell Compatibility Evaluation of Chitosan/Collagen Composite Scaffolds Using Amino Acids as Crosslinking Bridges''
Journal of Applied Polymer Science Ulrich Meyer et al (2009), ''Fundamentals of Tissue Engineering and Regenerative Medicine'', p. 368, {{ISBN, 978-3-540-77754-0 Luiz Carlos Junquiera et al (2005), ''Basic Histology'', p. 282, {{ISBN, 0-07-144116-6 Berillo D., Volkova N. (2014), ''Preparation and physicochemical characteristics of cryogel based on gelatin and oxidised dextran'', Journal of Materials Science 49 (14), P. 4855-4868 {{doi, 10.1007/s10853-014-8186-3 Berillo D. et al (2012), ''Oxidized Dextran as Crosslinker for Chitosan Cryogel Scaffolds and Formation of Polyelectrolyte Complexes between Chitosan and Gelatin'', Macromolecular bioscience 12 (8), P. 1090-1099 {{doi, 10.1002/mabi.201200023 Tissue engineering