Journal of Postgraduate Medicine, Education and Research, April-June 2012;46(2):81-89

81
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SYMPOSIUM
Biomaterials in Regenerative Medicine
Sumrita Bhat, Ashok Kumar
ABSTRACT
Limitations with the conventional methods have bought
biomaterials to the forefront for the repair and restoration of
tissue functions. Recent advances in the area of biomaterials
have revolutionized the field of tissue engineering and
regenerative medicine. According to the nature of polymers they
are divided into different classes and each one has found
applicability in the area of regenerative medicine. Each class of
biomaterials has a set of properties which makes them
appropriate for a specific application. The most important
property is the behavior of biomaterials when implanted in vivo.
It should not elicit any immune rejection reactions neither should
its byproducts be toxic to animal tissue. Any type of the
biomaterial can be fabricated into a three-dimensional scaffold
which can be used as housing for the initial growth and
proliferation of the specific cell type. In addition to the
conventional methods of scaffold fabrication few contemporary
methods include hydrogels and cryogels. These matrices
possess interconnected porous network which facilitates the
cell migration and proliferation. These gel matrices can be
fabricated from both natural and synthetic polymers and have
shown applicability in different areas of tissue engineering.
Biomaterials have shown applicability as cardiovascular
implants, orthopedic implants, dental implants, etc. Furthermore,
recent advances in the regenerative medicine have shown that
in addition to the use of autologous and allogenic sources, stem
cells can prove to be a very good alternative. Stem cells
interaction with biomaterials has shown applicability in the
regenerative medicine and thus can have an immense potential
in future.
Keywords: Biomaterials, Regenerative medicine, Tissue
engineering, Implants, Polymers.
How to cite this article: Bhat S, Kumar A. Biomaterials in
Regenerative Medicine. J Postgrad Med Edu Res 2012;46(2):
81-89.
Source of support: Nil
Conflict of interest: None declared
INTRODUCTION TO BIOMATERIALS
The advances of biomaterials as a science dates back to
approximately 50 years and the study of biomaterials is
called as biomaterial science. Considering the wide
explicabilities of biomaterials different authors have put
forward diverse definitions to it. In an introductory lecture
on Biomaterials by J eong-Yeol Yoon (http://
[Link] [Link]/~trouard/courses/bme516/
biomater_lec1.pdf)
1
various definitions of biomaterials have
been proposed by various authors. In general it can be any
material natural or synthetic that comprises whole or a part
of living structure or a biomedical device which performs,
amplifies or replaces the function that has been lost by either
accident or injury. According to Park and Lakes
10.5005/jp-journals-10028-1018
biomaterial is any synthetic material which is used to
replace part of a living system or to function in intimate
contact with the living tissue. In accordance to Clemson
University Advisory Board for Biomaterials it is a material
which is synthetically and pharmacologically inert and is
designed to be implanted within or incorporated with living
system. As proposed by Dee et al these are the materials
that constitutes part of medical implants, extracorporeal
devices and disposables those have been utilized in
medicine, surgery, dentistry and veterinary medicine as well
as in every aspect of patient health care. As stated by
National Institute of Health (NIH) it is any substance (other
than drug) or a combination of substances, synthetic or
natural in origin which can be used for any period of time
as a whole or as a part of a system which treats, augments,
or replaces any tissue, organ or function of the body.
According to Williams (1987), a biomaterial is a material
used in implants or medical device, intended to interact with
biological systems.
2
Talking from the perspective of the
bioengineering which is the application of concepts and
methods of physical science and mathematics in an
engineering approach toward solving problems in repair and
reconstruction of lost, damaged or deceased tissue and any
material that can be used for this purpose can be regarded
as a biomaterial.
2
Examples of biomaterials include the
common medical devices like substitute heart valves,
artificial hips and knee joints, dental implants, fracture
fixtures, skin regeneration templates, dialyzers to support
ailing kidneys, etc. Any material that can be used for these
medical applications must possess some specific properties
and most basic criteria are related to the material
biocompatibility. So, any material that is biocompatible with
the host tissue can be considered as a biomaterial.
3
Field of
biomaterials has evolved in many ways like its capacity to
study the various aspects like molecular biology and cell
biology at the implant host tissue interface which further
gives a detailed idea about the material biocompatibility.
Biomaterials have also evolved in terms of their applicability
and are now also being used as carriers to deliver small and
large bioactive molecules. These delivery molecules or
systems can be targeted to a specific tissue for its
regeneration.
4
HISTORY OF BIOMATERIALS
The introduction of nonbiological materials now called
as biomaterials for the benefit of human health was noted
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Sumrita Bhat, Ashok Kumar
far back in the prehistory. The Mayan people fashioned
nacre teeth from the sea shells around 600 AD and
apparently achieved what is now referred to as bone
integration. Additionally, linen sutures were used by the
early Egyptians for surgical purposes. I dea of the
construction of artificial heart and organ perfusion dates
back to 4th century BC, however, no one could construct
such apparatus during that time. Concept of contact lenses
dates back to year 1508 with the thoughts of Leobnardo Do
Vinci. The first hip replacement was performed in year 1891
by a German surgeon Theodor Gluck, who used cemented
ivory ball as an implant. Furthermore, improvements with
the technology developed chrome-based alloys and stainless
steel implants with better mechanical properties. Also,
experimentation with the dental implants dates back to 1809,
when Maggiolo implanted a gold postanchor into the fresh
extraction socket. Moreover, attempts to construct the
dialysis unit for kidney ailments dates back to year 1901
when J ohn J acob attempted to remove toxins from the
patient's blood. However, major advances in kidney dialysis
were made by Dr Scribner during 1921 to 2003 at the
University of Washington. Thomas Cornin and Frank Gerow
at the University of Texas invented the first silicon breast
implant during early 1960s. Furthermore, many variants
of this device have been tried over the years. First fully
implantable pacemaker was developed by the fusion of
engineering and medical concepts by Wilson Greatbatch
an engineer by profession and WM Chardack a cardiologist
in the year 1959.
CLASSES OF BIOMATERIALS
Biomaterials can be divided into three major classes as
follows:
1. Polymers (synthetic and natural);
2. Metals and
3. Ceramics (e.g. carbons, glass-ceramics and glasses)
Polymers
Polymeric biomaterials have many other applications in
addition to tissue regeneration or in regenerative medicine.
Some examples include poly (methyl methacrylate) which
has been used as bone cements, poly (glycolic acid) as
degradable surgical sutures, poly (glycolic-co-lactic acid)
as bone screws or poly (vinyl siloxane) as dental implants.
Furthermore, polymer like poly (hydroxyethyl methacrylate)
(PHEMA) is being used as soft contact lenses. Polymers
used as biomaterials can either be natural or synthetic and
both have shown applicability in the field of regenerative
medicine. These polymeric classes consist of large number
of small repeating units. Synthetic polymeric biomaterials
being used in the area of regenerative medicine include;
silicone rubber (SR), polyethylene (PE), polypropylene (PP),
poly (ethylene terephthalate) (PET), polytetrafluoroethylene
(PTFE), poly (methyl methacrylate) (PMMA), poly (vinyl
chloride) (PVC), PHEMA, poly (ethylene glycol) (PEG),
etc. PMMA which is a hydrophobic polymer has shown
applicability as bone cement for orthopedic applications.
Due to the excellent light transmittance of PMMA it has
proved to be a good material for intraocular lenses (IOLs)
and as hard contact lenses. For the fabrication of the soft
contact lenses poly (HEMA) is cross-linked with ethylene
glycol dimethacrylate (EGDMA). Cross linking helps to
retain the dimensional stability of the lens. Additionally
polymers like polymethacrylic acid in small quantities are
also incorporated into contact lens formulations to improve
the wetability. Polymers like polyacrylic acids are being
used as dental cements and also these polymers have shown
applicability as mucoadhesive additives in mucosal drug
delivery formulations. Polypropylene (PP) is a isotactic
crystalline polymer with high rigidity and good tensile
strength and has thus found applicability as surgical sutures
and in hernia repair. Polyvinyl alcohol (PVA) is being used
as tubing and blood storage bags in the area of biomedical
science. These tubing even include blood transfusion tubes,
dialysis tubing, etc. Biodegradable polymer like PLGA is
used as resorbable surgical sutures, drug delivery systems
and in orthopedic applications as fixation devices.
Furthermore, its intrinsic usage is enhanced as the
degradation products of PLGA are lactic acid and glycolic
acid which are as such nontoxic for the host. Copolymers
from various monomeric units represent an important class
of material design which has a significant applicability in
the area of biomedical science. A copolymer of
tetrafluoroethylene with small amount of hexafluoro-
proplylene (FEP Teflon) is used as a tubing connector and
as catheters.
In addition to synthetic polymers, natural polymers also
have shown applications in the area of biomedical science
and regenerative medicine. Although several naturally
occurring polymeric materials can be fabricated into the
potential tissue engineering scaffolds, commonly
investigated materials include alginate, collagen, hyaluronic
acid, fibrin gels, etc.
5
Alginate consists of repeating
monosaccharide units, i.e. L-guluronic acid and
D-mannuronic acid. Exposure of these polysaccharides to
calcium ions results in the formation of a three-dimensional
gel. This gel can be used for the encapsulation of growth
factors or specific cell type. Alginate has shown applicability
in the area of cartilage regeneration, as chondrocytes are
reported to maintain their phenotype in the alginate gels.
Alginate gels also have shown immense applicability for
the storage of chondrocytes, as cells can survive for up to
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8 months in these gels.
6
Natural polymer like collagen has
shown a huge potential in the area of skin regeneration as it
is a natural component of human skin. Bovine collagen
combined with cellular components like human autologous
keratinocytes and fibroblasts has shown good results when
applied to severe burn victims.
7
Collagen is also being used
in the form of bilayered artificial skin for the purpose of
skin regeneration.
8
This template is acellular and is
composed of collagen and glycosaminoglycans which is
commercially available as integra artificial skin or
integra.
9,10
Other types of skin regeneration templates, e.g.
matriderm uses bovine dermal collagen type I, III and
elastin.
11
Additionally natural polymer like hyaluronan as
such lacks desirable characteristics to be used as a scaffold
for tissue regeneration. Few limitations include high water
solubility and fast clearance time from the host tissue.
12
Few limitations can be answered by chemically modifying
its structure to increase its stability. One example of such
modified hyaluronan derivatives HYAFF 11; it is formed
from the complete esterification of all free carboxylic groups
with benzyl alcohol. This modified form has been utilized
as a degradable scaffold biomaterial for tissue regeneration.
These scaffolds have shown considerable promise for
cartilage repair.
12,13
Fibrin is a natural component of animal
skin and plays a major role during the process of wound
healing. So fibrin in the form of a biomaterial has a potential
to be utilized as a scaffold for tissue regeneration. Major
disadvantage with fibrin gels is their fast biodegradation
which occurs due to the phenomenon of fibrinolysis.
13
So
modifications with its structure have resulted in the gels
those remain intact for longer periods of time and these
gels are commercially available as Tissucol.
5
Such modified
fibrin gels have been used for the development of
extracellular matrix by chondrocytes. Other natural
polymers those has shown potential to be used as scaffolding
materials for regenerative medicine include cellulose,
agarose, chitosan, gelatin, etc.
Metals
Metallic implants have a significant economic impact in
the biomaterials field. Examples of metallic implants include
steels 316, 316L, vitallium, silver, tantalum, cobalt, F-75
and alloys of Ti, Cr +Co, Cr +Co +Mo, etc. Metallic
implants have certain disadvantages like low
biocompatibility, susceptibility to corrosion under
physiological environment and large variations in the
mechanical properties from the biological tissue.
14
Metallic
implants have a enormous applicability in the area of
biomedical science as they are used as staples, plaques and
wires. They are also being used as tooth implants, penis
implants and can be used as mesh for facial reconstruction.
15
Ceramics
Ceramics, glasses and glass-ceramics comes under the broad
range of inorganic/nonmetallic composites. This class has
shown applicability as eye glasses, diagnostics instruments,
chemical ware, thermometers, etc. In general, ceramics show
characteristics like high biocompatibility, high resistance
to corrosion, low electrical and thermal conductivity which
makes them suitable as implants.
16
Ceramics like
hydroxyapatite (HAp) has reported to play an important role
in the formation of new bone tissue. Other examples of
ceramics used as biomaterials include aluminum oxide,
calcium aluminates, titanium oxides, calcium phosphate,
carbon, bioglass, etc. Disadvantages associated with
ceramics include low impact resistance, processing and
fabrication difficulties, etc. Major applications of ceramics
in biomedical area include as dental parts, coatings, bone
fillings, ontological implants, medical tools and implants,
etc. Furthermore ceramic composites, i.e. metals with
ceramic coatings or materials coated with carbon have found
applicability in the area of biomedical science. Their high
biocompatibility and resistance to corrosion make them
appropriate implanting devices. But their disadvantages like
the lack of consistency and difficulties in the fabrication
process limits their explicabilities to the area of biomaterials.
Their major biomedical applications include heart valve
implants, knee implants, hip implants, etc.
17,18
PROPERTIES OF BIOMATERIALS
Properties of the biomaterials depend on the class to which
it belongs. But, key properties include surface properties,
corrosion, mechanical properties and degradation.
Surface Properties
As interactions between biomaterial and host tissue is a
surface phenomenon, so surface properties of an implant
material/biomaterial is of great importance. Material surface
is the termination of normal three-dimensional structure of
a particular biomaterial. Ceramics are typically electrical
and thermal insulators. The strong ionic and covalent bonds
make them hard and brittle. Furthermore, thermal behavior
of polymeric biomaterials is influenced by the factors like
composition of the backbone and side groups. A change in
the polymer composition or structure that increases the
relative movement of chains in turn increases the strength
and decreases the plasticity of the material.
Corrosion
Metallic implants are subjected to the phenomenon of
corrosion under physiological conditions. During the
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process of corrosion, metallic biomaterials have a tendency
to release the ions which reduces the biocompatibility of
the implant and can also jeopardize the fate of the implant.
So metallic implants like 316L stainless steel performs
satisfactorily in short term applications but are susceptible
to corrosion when implanted for longer periods of time.
Degradation
Other classes of biomaterials like ceramics and polymers
do not undergo corrosion, but they are susceptible to the
degradation under physiological conditions. An ideal
biomaterial should possess a regulated rate of degradation,
which should match with the formation of the neotissue.
During the process of degradation, byproducts released from
the implant may induce adverse local and systemic host
reactions. This release is a concern for materials like bone
cements, poly (vinyl alcohol), etc. Among the biodegradable
polymers poly (lactic acid) and poly (glycolic acid) or their
copolymers degrade majorly into lactic acid which is
removed by the normal metabolic processes of the body.
Mechanical Properties
Mechanical properties of an implant depend on several
factors like fabrication process and the type of metal used.
Mechanical properties of any biomaterial implant should
be at par with the native tissue. So for bone implants they
should possess modulus that is of higher magnitude than
that of the bone. Metallic implants like stainless steel or
Co-Cr alloys have Youngs modulus in the range of
190 to 253 GPa. But biomaterials like ceramics and glasses
are brittle and have poor tensile properties. Among the
biomedical ceramics, alumina has the highest mechanical
properties, but its tensile properties are still lower than those
of metallic implants. Furthermore, ceramics like calcium
phosphate and bioactive glasses are unsuitable as load
bearing implants due to their inferior mechanical properties.
In case of polymeric biomaterials, mechanical properties
depend on the composition and structure of the
macromolecular chains. Compared to the metals and
ceramics polymers have much lower mechanical strength
and moduli. So polymers are generally not used in
biomedical applications that are meant for bearing the heavy
loads. But out of the polymers ultra-high-molecular weight
polyethylene is an exception and is thus used as a bearing
surface in hip and knee replacements.
EVALUATION OF BIOMATERIALS FOR
CLINICAL USE
For any biomaterial to be used for regenerative medicine,
the first perquisite is to evaluate its biocompatibility under
in vitro conditions and then in vivo. Evaluation of the
material under in vitro conditions provides a rapid and
inexpensive approach on the interaction of biomaterial with
a particular cell type. But results obtained from in vitro
experiment may not be relevant, if a biomaterial is meant
for the in vivo implantation. So, lab animals are used for
testing the in vivo biocompatibility of a newly designed
biomaterial. First important step is the selection of model
system which offers a similar anatomy and physiology to
that of humans.
In vitro Analysis for the Determination
of Biocompatibility
For any new polymeric biomaterial or implant device to be
utilized for the regenerative medicine, first important
assessment is to check its cytotoxicity on the model cell
line. Term cytotoxicity refers to any toxic effect (death,
alteration in cellular permeability, etc.) induced by the
material at the cellular level. Any biomaterial can be tagged
as toxic if it kills the cells either directly or indirectly. So
any biomaterial intended to be used as a medical implant
should be initially assayed for its cytotoxicity in the in vitro
conditions. After the cytotoxicity profile has been analyzed,
then more specific tests are performed to assess the overall
biocompatibility of the implant. During the assay methods,
test material may be placed directly on the cells or may be
extracted in a solution that is then placed on the cells. Based
on how the assay is performed there are three major methods
to analyze the biocompatibility of any material i.e. direct
contact, agar diffusion and elution. Out of all these method
direct contact method is majorly used in the area of tissue
engineering and regenerative medicine. This assay is done
by taking a near confluent monolayer of L-929 cells
(mammalian fibroblast cells). Culture media is removed and
fresh media is added to the plate. Specimen (biomaterial or
implant) is placed carefully in the culture plates and
incubated for 24 hours at 37C under humid atmosphere.
Following the incubation, cell line is stained with
cytochemical stains, e.g. hematoxyline and eosin or by live
fluorescent stains, e.g. fluorescein diacetate (FDA). Toxicity
is evaluated by the absence of stained cells under and around
the specimen. Other direct contact assay is 3-(4,5-
dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide
assay (MTT assay). In this assay cells are allowed to grow
on the biomaterial for few days. On the day of the assay,
media is removed from the wells followed by the addition
of MTT reagent. This assay involves the conversion of
tetrazolium salt MTT by viable proliferating cells to an
insoluble product, purple formazan after 4 hours of
incubation time. These formazan crystals can be solubilized
in an organic solvent like DMSO and the resultant colored
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complex can be quantified by checking the optical density
spectrophotometrically at 570 nm.
In vivo Analysis for the Determination
of Biocompatibility
Main aim of in vivo assessment is to determine the
biocompatibility of new biomaterial/medical device in a
biological environment under physiological conditions.
Animal models for the in vivo assessment of medical
devices:
Device classification Animals
1. Cardiovascular
Heart valves Sheep
Vascular grafts Dog, pig
Artificial heart Calf
2. Orthopedic/bone
Bone regeneration/ Rabbit, dog, pig,
substitutes mouse, rat
Total hip/knee joint Dog, goat
replacements
Vertebral implants Sheep, goat, baboon
3. Neurological
Peripheral nerve Rat, cat
regeneration Nonhuman primates
Electrical stimulation Rat, cat, nonhuman
primates
4. Ophthalmological
Contact lens Rabbit
Intraocular lens Rabbit, monkey
In vivo assessment is done by the following methods:
Implantation
A newly designed biomaterial is implanted surgically or is
placed into an implant site in an animal model. Evaluation
of the pathological effect is then carried out at both gross
and microscopic levels.
Hemocompatibility
This test evaluates the effect of a medical implant on the
blood components. According to ISO standards five test
categories are indicated for hemocompatability, i.e.
thrombosis, coagulation, platelets, hematology and
immunology (complement and leukocytes).
Biodegradation
This test determines the amount of degradation during a
given period of time, i.e. kinetics of degradation. It is done
by the implantation of a biomaterial in experimental animal.
This test further gives an idea about the nature of released
by products during the process of degradation. An ideal
biomaterial should have an optimized rate of degradation
and should not be degraded into any toxic byproducts.
NEW CLASSES OF SCAFFOLDS FOR
BIOMEDICAL APPLICATIONS
The traditional biomaterials as discussed before can be
fabricated into a desired three-dimensional scaffold which
acts as a housing for the initial cell growth and proliferation.
These biomaterials can be fabricated into scaffolds using
different fabrication technologies like:
1. Solvent casting in combination with particulate leaching;
2. Fiber networking;
3. Phase separation in combination with freeze drying
4. Solid free form fabrication.
19
But these scaffold
fabrication technologies have associated limitations like
lack of interconnectivity, desired pore size, etc. and thus
new scaffold fabrication technologies are emerging.
Hydrogels as Tissue Engineering Scaffolds
Hydrogel is a colloidal gel in which water is the dispersion
medium. They have emerged as important scaffolding
biomaterials as they resemble the native tissue. Aqueous
nature of hydrogels closely resembles the cells in body. They
possess a good porosity which allows the nutrient and waste
exchange. Both natural and synthetic polymers can be
fabricated into hydrogel scaffolds those are then used for
the purpose of tissue regeneration.
20
Synthetic hydrogel
scaffolds used in the area of regenerative medicine are
polyurethanes (PU), poly (ethylene oxide) (PEO), poly (N-
isopropylacrylamide) (PNIPAAm), poly (vinyl alcohol)
(PVA), poly (acrylic acid) (PAA) and poly (propylene
furmarate-co-ethylene glycol) [P(PF-co-EG)]. Naturally
derived polymers fabricated into tissue engineering scaffolds
include agarose, alginate, chitosan, collagen, fibrin, gelatin
and hyaluronic acid (HA).
21
Cryogels as Tissue Engineering Scaffolds
Cryogels are the gel matrices synthesized by the process of
cryogelation which synthesizes the scaffolds at sub-zero
temperature from natural or synthetic polymers without the
use of inorganic solvents (Fig. 1). Scaffolds generated by
the process of cryogelation have advantage over other types
of scaffolds. As cryogel scaffolds can be fabricated in
diverse formats like disk, sheets and monoliths with variable
dimensions. Cryogelation generates the matrices those
possess large and interconnected pores. During the process
of cryogelation most of the solvent gets frozen while part
of the solvent is left unfrozen (unfrozen liquid microphase),
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Sumrita Bhat, Ashok Kumar
where monomeric or polymeric precursors concentrate and
undergo chemical reactions. This chemical reaction in the
liquid microphase leads to gel formation that is converted
into porous scaffold on thawing the frozen part which acts
as porogens. Cryogel matrices facilitate the unhindered
diffusion of solutes and nutrients due to the presence of
interconnected macropores.
22
Cryogels possess continuous
interconnected pores up to 200 mm that provide a surface
for the proliferation of most of the cell types making these
matrices suitable for tissue engineering applications.
23
The potential of cryogel matrices have been explored
widely in the areas of tissue engineering/regenerative
medicine, bioseparation and therapeutic protein production,
etc. In the area of tissue engineering cryogels have shown
potential for the regeneration of cartilage, bone, skin and
liver, etc.
24-26
These scaffolds have the potential to be
utilized for other biomedical applications which can be
explored further.
APPLICATION IN REGENERATIVE MEDICINE
Cardiovascular Devices and Implants
Cardiac replacement valves fall into two general types, i.e.
mechanical and biological. Mechanical valves can further
be categorized into three subclasses, i.e. caged ball, single
tilting disk and bileaflet.
27
Biological valves are divided
according to the source of tissue material, e.g. homograft
biological valves and heterograft bioprosthetic valve.
Homograft biological valves are preserved human aortic
valve or pulmonary valves those are surgically placed within
the recipient.
28
Heterograft bioprosthetic valves are derived
from animal sources like porcine heart valves or bovine
pericardial tissue those are formed into valves over a support
structure.
27
Additional types of cardiovascular implants are
stents and stent grafts. Stents can be divided into two main
groups and this classification is based on the method of
expansion. First type is balloon-expandable stents those
arrive premounted on a balloon angioplasty catheter or can
be mounted by the surgeon before the procedure (Figs 2A
and B). Next type of stent is self-expanding which comes
premounted or sheathed. During the procedure sheath can
be pulled back allowing the stent to expand to its
predetermined diameter.
29
Artificial RBC Cell Substitutes
Research work toward the development of red cell
substitutes has the applicability in blood replacement
therapies, either for perioperative hemodilution or for
resuscitation from hemorrhagic blood loss. Unlike true
blood, artificial blood is intended for the sole purpose of
transporting oxygen and carbon dioxide throughout the
body. The ideal artificial blood product should possess the
following characteristics; it must be safe to use and
compatible within the human body with different blood
types. It must be able to transport oxygen throughout the
body and release it where it is needed and lastly it must be
shelf stable. It should be used as an alternative and/or
supplement to homologous and autologous transfusion, or
in combination with the use of erythropoietin. Depending
on the type of artificial blood that is made, various raw
materials are used. The two significantly different products,
i.e. perfluorocarbons (PFC) and hemoglobin-based products
are under development as blood substitutes. They differ
primarily in the way that they carry oxygen and have been
used for perfusional protection of organs. PFC products
involve a polymerization reaction. PFC is chemically inert
compound consisting of fluorine substituted hydrocarbons.
Unlike Hb-based substitutes, PFCs have the following
advantages:
1. They do not react with oxygen or other gases.
2. I ncrease the oxygen solubility in the plasma
compartment.
Figs 2A and B: (A) A typical heart valve, (B) a balloon catheter
and inflation pump (reproduced with permission from Gage and
Wagner, 2002)
29
Figs 1A to C: Process of cryogelation (A), digital images of the
cryogels in different shapes (monoliths and disks) (B), and scanning
electron microscopy image of the cryogel showing interconnected
porous network (C) (reproduced with permission from Kumar et al
2011)
23
A B
A
B C
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3. The dissolved oxygen is not subject to the effects of
temperature, pH, 2,3-DPG, etc. (thus, the oxygen
dissociation curve is linear)
4. Facilitate effortless transfer of oxygen from red cells
to the tissue. The final goal of any transfusion service
is to create a transfusion system with no side effects
and with more effective medical care. Although
current system of homologues blood is working well
with low cost, acceptable efficacy and relatively less
side effects.
30
Extracorporeal Artificial Organs
These devices are used to process the patients blood outside
the body before it is returned to the circulation. Examples
of these devices include gas and heat exchangers, dialyzers,
apheresis devices, bioartificial liver, etc. All these devices
are designed to optimize the flux of material between body
fluids and other fluids separated from each other by a
membrane. Bioartficial liver devices are used to support
the patients suffering with acute liver failure. These devices
either use hepatocytes in bioreactor which provides both
exchange and synthetic functions or uses nonliving
components which remove toxins accumulated due to liver
failure. These devices are used to assist the patient till
transplantation. These devices use natural or synthetic
polymers like collagen in case of hollow fiber system.
31
Orthopedic Applications/Dental Implants/
Cartilage Implants
In addition to the metallic implants naturally derived
matrices made from hyaluronic acid, chitosan, collagen,
fibrinogen, etc. have also been used in bone tissue
engineering. But the disadvantage with the use of these
matrices is that they are difficult to sterilize and can also
elicit immune response in the host. Synthetic polymers like
poly(a-hydroxy acid), polypropylene fumarate,
polyethyleneglycol, etc. have an advantage that they can
be fabricated with desired parameters, but they degrade into
toxic components. Wide range of bioactive inorganic
materials is showing potential in bone tissue engineering,
e.g. bioactive glass, hydroxyapatite, porous coralline,
tricalcium phosphate, etc. Further work is being focused
on enhancing the bio-functionality of the scaffold by the
incorporation of osteinductive cues which can enhance
osteoblast proliferation on these scaffolds.
32
Scaffolds
fabricated from natural and synthetic polymers are being
used in cartilage tissue engineering. Examples of natural
polymers include agarose, alginate, chitosan, collagen,
fibrin, hyaluronan, etc. and synthetic polymers are poly (a-
hydroxy ester), polylactic acid (PLA), polyglycolic acid
(PGA) and their copolymers, etc.
24
Dental implants those
are designed for the commercial applications can be divided
into two categories:
a. Endosteal or endosseous, these implants extend into
the bone tissue while.
b. Subperiosteal systems are in contact with the exterior
bone surfaces (Figs 3A and B). The endosteal
implants, e.g. root forms (cylinders, screws), blades
(plates), transossious or staples or endodontic
stabilizers are placed into the bone. But superiosteal
devices are fitted to the bone surface in the form of
customized shapes. Furthermore bone plates are
placed into bone under periosteum and are fixed with
the help of endosteal screws.
33
Synthetic materials
used for root form devices include valuable metals
like gold, platinum, iridium and palladium. Other
commonly used biomaterials or dental implants
include titanium and its alloys, aluminum oxide and
surface coatings of hydroxyapetite.
Surgical Sutures/Surgical Adhesives
Surgical sutures can be classified as follows:
a. Natural sutures: Major examples include catgut suture
which is derived from bovine intestines serosa or from
the submucosa of sheep or goat intestines. Primary
constituent of the catgut suture is collagen.
b. Synthetic nonabsorbable sutures: Examples include
polysester sutures those are based on poly (ethyl-
eneterephthalate) (PET), poly (butylenes terephthalate)
(PBT) and polybutester. Other example of synthetic
suture is polyamide sutures which includes nylon-6,
6 and nylon-6.
c. Synthetic absorbable sutures: All the major absorbable
sutures are made from one or more of the five different
cyclic monomers, i.e. glycolide (GA), L-lactide (LLA),
trimethyl carbonate (TMC), p-dioxanone and
-caprolactone. Primary mode of degradation for natural
materials is enzymolysis while for synthetic materials it
is hydrolysis. Adhesive is a general term that covers
designations like cement, glue, paste, fixative, etc.
Figs 3A and B: (A) Modern dental implant and (B) a endosseous
dental implants (reproduced with permission from http://
[Link] [Link]/[Link])
33
B A
88
JAYPEE
Sumrita Bhat, Ashok Kumar
Examples include cyanoacrylates derived from methyl-
2-cyanoacrylate. This liquid monomer polymerizes
rapidly even in the presence of moisture and blood. Other
examples include protein glues, hydrogels, tooth and
bone cements, etc.
INTERACTIONS OF BIOMATERIALS
WITH STEM CELLS
Regenerative medicine and tissue engineering intend to
generate a functional tissue or organ. Following section of
this review discusses about the developments in biomaterials
and knowledge of the stem cell biology for their applicability
in the area of regenerative medicine.
Stem Cell Niche
During the tissue damage sometimes there is a loss of deeper
layers that contains the stem cell niches. In such cases
biomaterials could be useful tool for reestablishment of the
niche functionality.
34
In comparison to the standard
two-dimensional (2-D) culture systems a three-dimensional
(3-D) scaffolds based model would facilitate a spatial
distribution of the different cells resulting in the structural
organization which may resemble the in vitro tissue
organization.
35
Bone Tissue
Both autografts and allograft therapies for the bone
regeneration have several drawbacks, so alternative
approaches are being explored. One such approach is the
isolation and expansion of the mesenchymal stem cells
(MSCs) from the patient and their seeding onto the porous
three-dimensional scaffolds. During the in vitro cultivation
as the stem cells are exposed to signaling molecules supplied
in the media, MSCs differentiate toward osteogenic lineage.
This engineered tissue can then be implanted at the defect
site to regenerate the new bone as scaffold degrades.
36
Nervous Tissue
Treatment of the nervous tissue particularly in spinal cord
injuries require new medical therapies as axons do not have
regenerative capacity in the native environment. Current
strategy is the use of nerve autografts, but due to the
limitations like donor site morbidity, etc. this strategy does
not provide a promising solution for the repair. Alternative
therapy consists of use of nerve guidance conduit that could
provide a pathway for nerve out-growth and could also
promote nerve regeneration. Recently it has been shown
that design of surface topography may stimulate stem cell
differentiation toward the neural lineage. In this direction
hydrogenated amorphous carbon (a-C:H) groove
topographies with the width/spacing ridges ranging from
80/40 m, 40/30 m, 30/20 m and depth of 24 nm were
used as a single mechanotransducer stimulus to generate
neural cells from hBM-MSCs in vitro.
37
Skeletal and Cardiac Muscles
Traumatic injuries can interrupt muscle contraction by
causing damage to the skeletal muscles and peripheral
nerves. Natural healing may result in scar tissue formation.
Therefore, use of three-dimensional scaffolds will trigger
muscle cell elongation, orientation, fusion and striation.
Electrospun chitosan microfibers have been used as novel
biomaterials for muscle repair. Classical porous scaffolds
may be inadequate as they do not reproduce typical
myocardial environment. Considering the significance of
topography in this process, one approach is to mimic the
microenvironment of the native tissue. In this direction,
microfabricated scaffolds were created with soft lithography
technique using bioartificial blend, based on alginate, gelatin
and a novel poly (N-isopropyl acrylamide) based copolymer.
This scaffold showed anisotropic mechanical properties
which resembles the native tissue.
38
ACKNOWLEDGMENT
The authors would like to acknowledge Department of
Biotechnology (DBT), Department of Science and
Technology (DST), Ministry of Science and Technology,
Government of India for financial support for our projects
in this area.
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ABOUT THE AUTHORS
Sumrita Bhat
Postdoctoral Fellow, Department of Biological Sciences and
Bioengineering, Indian Institute of Technology Kanpur, Kanpur
Uttar Pradesh, India
Ashok Kumar (Corresponding Author)
Professor, Department of Biological Sciences and Bioengineering
I ndian I nstitute of Technology Kanpur, Kanpur-208016
Uttar Pradesh, India, Phone: +91-512-2594051, Fax: +91-512-2594010
e-mail: ashokkum@[Link]