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Whole Tooth Regeneration As a Future Dental Treatment 14 Whole Tooth Regeneration as a Future Dental Treatment 14 Masamitsu Oshima and Takashi Tsuji Abstract Dental problems caused by dental caries, periodontal disease and tooth injury compromise the oral and general health issues. Current advances for the development of regenerative therapy have been infl uenced by our understanding of embryonic development, stem cell biology, and tissue engineering technology. Tooth regenerative therapy for tooth tissue repair and whole tooth replacement is currently expected a novel therapeutic concept with the full recovery of tooth physiological functions. Dental stem cells and cell-activating cytokines are thought to be candidate approach for tooth tissue regeneration because they have the potential to differentiate into tooth tissues in vitro and in vivo. Whole tooth replace- ment therapy is considered to be an attractive concept for next generation regenerative therapy as a form of bioengineered organ replacement. For realization of whole tooth regeneration, we have developed a novel three- dimensional cell manipulation method designated the “organ germ method”. This method involves compartmentalisation of epithelial and mesenchymal cells at a high cell density to mimic multicellular assembly M. Oshima , Ph.D. Department of Oral Rehabilitation and Regenerative Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences , Okayama University , Okayama 700-8525 , Japan RIKEN Center for Developmental Biology , Kobe , Hyogo 650-0047 , Japan e-mail: [email protected] T. Tsuji , Ph.D. (*) RIKEN Center for Developmental Biology , Kobe , Hyogo 650-0047 , Japan Research Institute for Science and Technology , Tokyo University of Science , Noda Chiba , 278-8510 , Japan Organ Technologies Inc , Tokyo 101-0048 , Japan e-mail: [email protected] © Springer International Publishing Switzerland 2015 255 L.E. Bertassoni, P.G. Coelho (eds.), Engineering Mineralized and Load Bearing Tissues, Advances in Experimental Medicine and Biology 881, DOI 10.1007/978-3-319-22345-2_14 256 M. Oshima and T. Tsuji conditions and epithelial-mesenchymal interactions in organogenesis. The bioengineered tooth germ generates a structurally correct tooth in vitro, and erupted successfully with correct tooth structure when transplanted into the oral cavity. We have ectopically generated a bioengineered tooth unit composed of a mature tooth, periodontal ligament and alveolar bone, and that tooth unit was engrafted into an adult jawbone through bone inte- gration. Bioengineered teeth were also able to perform physiological tooth functions such as mastication, periodontal ligament function and response to noxious stimuli. In this review, we describe recent fi ndings and tech- nologies underpinning whole tooth regenerative therapy. Keywords Whole tooth regeneration • Tooth replacement • Dental tissue engineering • Organ germ • Tooth germ • Stem cells 14.1 Introduction treat tooth loss (Brenemark and Zarb 1985 ; Burns et al. 2003 ). Although these artifi cial therapies Oral functions regarding mastication, swallowing have been widely applied to rehabilitation of tooth and speech are an important aspect of good health loss, it is anticipated that further technological and quality of life (Proffi t et al. 2004 ). The tooth developments based on biological fi ndings are is an ectodermal organ whose development is needed to restore tooth physiological functions regulated by reciprocal epithelial-mesenchymal (Tucker and Sharpe 2004 ). interactions (Jussila et al. 2013 ; Tucker and Recent regenerative therapies have been devel- Sharpe 2004 ; Ikeda and Tsuji 2008 ) and contains oped based on our understanding of embryonic distinctive hard tissue structure composed of development, stem cell biology and tissue engi- enamel, dentin and cementum (Avery 2002 ; Nanci neering technology (Korbling and Estrov 2003 ; 2012 ). Teeth also have soft connective tissues Brockes and Kumar 2005 ; Watt and Hogan 2000 ; such as pulp and periodontal ligament (PDL) that Langer and Vacanti 1999 ; Atala 2005 ). One con- include peripheral nerve fi bres and blood vessels cept in regenerative therapies rely on the cell to maintain tooth homeostasis and physiological transplantation of purifi ed tissue-derived stem functions (Avery 2002 ; Nanci 2012 ). Tooth physi- cells or embryonic stem (ES) or induced pluripo- ological functions are exerted effi ciently by the tent stem (iPS) cells. These stem cell transplanta- characteristic three-dimensional multicellular tion, which targets structural and functional structure that establishes functional synergy with diseases such as malignant diseases, neurological the maxillofacial region (Avery 2002 ; Nanci disorders, myocardial infarction, and hepatic dys- 2012 ). Tooth loss due to dental caries, periodontal function, has been attempted to repair damaged disease and traumatic injury causes fundamental tissues (Copelan 2006 ; Lindvall and Kokaia 2006 ; problems for oral functions and associated gen- Segers and Lee 2008 ; Wang et al. 2003 ). In den- eral health issues (Proffi t et al. 2004 ). To restore tistry, basic research of stem/progenitor cells have the occlusal function or aesthetic condition after provided new insights concerning tooth tissue- tooth loss, several dental therapies that replace the derived stem cells, including dental pulp stem tooth with artifi cial materials such as fi xed dental cells (DPSCs), stem cells from human exfoliated bridges and removable dentures have been per- deciduous teeth (SHED) and stem cells from api- formed conventionally (Rosenstiel et al. 2001 ; cal papilla (SCAP) that have been isolated from Pokorny et al. 2008 ). Recently, osseointegrated the dental pulp tissue (Huang et al. 2009 ; Gronthos dental implants that can restore function without et al. 2000 ; Miura et al. 2003 ; Sonoyama et al. affecting the healthy teeth have been adopted to 2008 ). These stem cells are thought to be a poten- 14 Whole Tooth Regeneration as a Future Dental Treatment 257 tial resource for stem cell-mediated tissue repair, a lost or damaged tooth with a bioengineered including dentin or pulp regeneration, based on tooth reconstructed from stem cells and with the their high proliferation and multi-differentiation potential to generate a functional tooth unit capacity (Mantesso and Sharpe 2009 ; Yen and including the whole tooth and periodontal tissue Sharpe 2008 ). Also, periodontal ligament-derived surrounding the alveolar bone (Purnell 2008 ; stem cells (PDLSCs), which can differentiate into Volponi et al. 2010 ; Sharpe and Young 2005 ). It is all periodontal cell types after transplantation, anticipated that whole tooth replacement therapy have also been identifi ed, and have been attempted will be established in the near future as a success- to develop cell sheet-engineering using PDLSCs ful biological treatment that will provide essen- for clinical use in periodontal tissue regeneration tial functional recovery of lost teeth to satisfy (Seo et al. 2004 ). Although these treatments con- aesthetic and physiological requirements tribute to partial tissue repair, many researchers (Volponi et al. 2010 ; Sharpe and Young 2005 ) anticipate the development of further therapeutic (Fig. 14.1 ). Over the past three decades, many technologies using dental stem cells that can approaches for replacing lost teeth have been regenerate lost teeth (Mantesso and Sharpe 2009 ; studied, including three-dimensional bioengi- Yen and Sharpe 2008 ). neered teeth and tooth germ generation using Organ replacement regenerative therapy, biodegradable materials and cell aggregation unlike stem-cell transplantation, holds great methods (Sharpe and Young 2005 ; Duailibi et al. promise for the replacement of dysfunctional 2006 ). Recently, the fi rst studies of fully func- organs via a regenerative strategy by reconstruct- tioning bioengineered tooth replacement with the ing a fully functional bioengineered organ using correct tooth structure, masticatory performance, three-dimensional cell manipulation in vitro responsiveness to mechanical stress and percep- (Atala 2005 ; Seo et al. 2004 ). It is expected that tive potential following transplantation into a bioengineering technology will eventually enable tooth-loss region were reported (Nakao et al. the reconstruction of fully functional organs 2007 ; Ikeda et al. 2009 ; Oshima et al. 2011 ). In in vitro through the proper arrangement of sev- this chapter, we describe novel technologies for eral cell components. In the dental fi eld, tooth whole tooth replacement therapy that have the regenerative therapy involves the replacement of potential to provide functional recovery and Fig. 14.1 Concepts of dental regenerative therapy. Recent approaches to developing technologies for tooth regenerative therapy have included tissue repair and whole-tooth replacement 258 M. Oshima and T. Tsuji entirely replace the current dental treatments genes e.g. Msx1 , Msx2 , Lhx8 and Barx1 and based on artifi cial materials. secretory molecules including fi broblast growth factors (FGFs) and bone morphogenetic pro- teins (BMPs) (Ikeda and Tsuji 2008 ; Thesleff 14.2 Developmental Process 2003 ; Bei 2009 ; Nakatomi et al. 2010 ). At ED of Tooth Formation 11.5, oral epithelium invaginates into the mes- enchymal region, and then tooth bud is formed Ectodermal organs, including the teeth, hair and by the condensation of mesenchyme that is salivary glands, arise from their respective organ derived from neural crest cells. At ED 13.5– germs through the reciprocal epithelial- 14.5, a transient
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