Bone Tissue Engineering
Strategies in Co-Delivery of Bone
Morphogenetic Protein-2
and Biochemical Signaling Factors
Sungjun Kim, Sangmin Lee, and Kyobum Kim
Abstract
Administration of bone morphogenetic pro-
tein-2 (BMP-2), which is commercially
approved by the food and drug administration
to damaged bone sites has been investigated
for the purpose of bone tissue regeneration.
BMP-2 can promote osteoblastic
differentiation of mesenchymal stem cells as
well as regeneration of bone formation in
early phase. This review highlights various
factors such as vitamin D, dexamethasone,
platelet-derived growth factor, placental
growth factor, BMP-7, and NEL-like protein-1
that enhance and stimulate angiogenesis, cell
differentiation, and bone regeneration. These
biochemical signals and growth factors (GFs)
accelerate bone repair and remodeling either
synergistically or individually. Delivery
systems and scaffolds are used for sustained
release of these cargo molecules and support
at damaged bone sites. Compared with direct
administration of BMP-2, current studies have
Sungjun Kim and Sangmin Lee have contributed equally
in this chapter.
S. Kim · K. Kim (*)
Division of Bioengineering, College of Life Sciences
and Bioengineering, Incheon National University,
Incheon, South Korea
e-mail: kyobum.kim@inu.ac.kr
S. Lee
Department of Bioengineering, Hanyang University,
Seoul, South Korea
© Springer Nature Singapore Pte Ltd. 2018
H. J. Chun et al. (eds.), Cutting-Edge Enabling Technologies for Regenerative Medicine, Advances
in Experimental Medicine and Biology 1078, https://doi.org/10.1007/978-981-13-0950-2_12
12
demonstrated that a combination of multiple
GFs and/or therapeutic chemical factors with
delivery platforms synergistically facilitates
bone regeneration. Therefore, in the future,
multiple combinations of various GFs, chemi-
cals, and materials could provide patients and
surgeons with non-invasive treatment options
without secondary surgery and pain. To the
end, this review summarizes the biological
functions and synergistic effects of dual
administration modalities involving BMP-2 as
well as recent developments in bone tissue
engineering applications.
Keywords
Bone morphogenetic Protein-2 · Co-delivery ·
Bone tissue engineering · Chemical supple-
ments · Cytokines · Osteogenesis
12.1 Introduction
Bone is a complex tissue including mineral, extra-
cellular matrices (ECM), blood vessels, and vari-
ous cell types such as osteoblasts (bone forming
cells), osteoclasts (bone resorbing cells), and
osteocytes (functional mature bony cells).
Although bone naturally regenerates in adult-
hood, natural bone healing is a complex and
dynamic process involving a myriad of cellular,
molecular, biochemical, and mechanical cues [11,
233
234
28]. Currently, bone fractures are a major occur-
rence worldwide, and grafting is commonly used
to treat the patients. However, bone grafting has
limitations such as pain, high cost, limited supply,
finite donor availability, potential donor site mor-
bidity, disease transmission, and immunogenic
response [53, 59]. Therefore, tissue engineering
approaches utilizing biodegradable materials,
stem cells, and exogenous growth factors (GFs)
have been intensively investigated for the devel-
opment of novel clinical applications [26, 27].
Biodegradable materials, especially synthetic bio-
polymers, have attracted great attention in the tis-
sue engineering field since degradability avoids
the common disadvantages of grafting and
ceramic or metallic device implantation [55]. In
addition, GFs and bioactive cytokines are often
administered in a scaffold or delivery system to
enhance osteoblastic differentiation of stem cell
population and bone regeneration [44]. Among a
series of GFs for exogenous delivery strategies in
bone repair, bone morphogenetic protein-2 (BMP-
2) is well known to promote osteogenesis of mes-
enchymal stem cells (MSCs). Additionally,
BMP-2 is commercially available and has been
approved by the US Food and Drug Administration
[5, 57]. Although a recent investigation reported a
minor limitation in exogenous BMP-2 adminis-
tration such as a side effect of high dose of
BMP-2 [23], BMP-2 mediated bone regeneration
approach have been researched in decades.
Recently, a co-delivery of BMP-2 and additional
therapeutic GF has also been investigated for the
development of more effective medical applica-
tions for bone repair [43].
In addition to the therapeutic efficacy of mul-
tiple GFs, a regenerative capacity of other bio-
chemical supplanted factors also facilitate the
activation of native and/or delivered stem cell
population to differentiate into osteoblasts as
well as a subsequent bone regeneration in
physiological microenvironment. Various
biochemical factors such as chemical compounds,
bioactive cytokines, and drugs can synergistically
promote osteogenesison the top of regenerative
efficacy of BMP-2 [23]. For instance, vitamin D3
and dexamethasone (Dex) are important chemical
compounds to maintain calcium and phosphorous
S. Kim et al.
balance in the body and to promote osteogenic
differentiation of MSCs in vitro, respectively [14,
32, 50, 52]. Other bioactive cytokines including
platelet-derived growth factor (PDGF) and
placental growth factor (PLGF) involve in
inducing angiogenesis and vascularization [2].
Moreover, BMP-7 can be also used as a substitute
for BMP-2 [6, 9, 57] and NEL-like protein-1
(NELL-1), a secretory signal peptide sequence, is
considered as co-delivery factor for BMP-2
mediated bone regeneration strategies [30, 60]. In
order to maximize the therapeutic functionality
and overcome the limitations of the current
BMP-2 delivery, co-administration of these
biochemical factors with BMP-2 could achieve
an enhanced healing efficacy. To this end, a
variety of interactions among biochemical
factors, scaffolds, and delivery systems must be
considered to ensure successful bone regeneration
(Fig.  12.1) [49]. Therefore, this mini review
summarizes recent tissue engineering
developments in (1) co-delivery strategies using
BMP-2 and multiple biochemical signals using
various delivery applications and (2) the
synergistic therapeutic effect of the co-delivery
applications, especially for bone tissue repair.
12.2 Co-Delivery of BMP-2
and Chemical Supplements
Vitamin D3 is an effective chemical supplement
to enhance BMP-2 mediated therapeutic effects
on osteogenic differentiation of stem cells [19,
52, 56]. Song et al., reported a synergistic effect
of BMP-2 and vitamin D3 on in vitro osteogenic
differentiation of adipose derived stem cells
(ADSCs) [52]. In the case of vitamin D3 single
delivery, ALP expression and mineralization of
ADSCs upregulated by increasing the dose of
vitamin D3 up to 10−6  M per 30,000 cells in a
well of 48 well plates. For a co-delivery, a
combination of 50 ng/mL of BMP-2 and 10−7 M
of vitamin D3 achieved an optimal dose for the
differentiation of ADSCs over 14  days, and the
synergistic effect (i.e., a higher osteoblastic
phenotypes of ADSCs) was observed as compared
with any single delivery. In addition, a
12  Bone Tissue Engineering Strategies in Co-Delivery of Bone Morphogenetic Protein-2… 235

Fig. 12.1  Various and complex combination of bioactive factors with delivery systems for bone tissue engineering
applications being developed recently. (Reproduced with permission from Ref. [49])

t­ime-­dependent therapeutic manner of BMP-2
and vitamin D3 also indicated the optimal
administration timings. Based on the experimental
results, it could be concluded that vitamin D3
treatment throughout the 14  days of culture
period with the addition of BMP-2  in the later
period is an effective and economical way for the
induction of osteogenic differentiation of ADSCs.
In addition, Dex is another chemical com-
pounds to induce bone regeneration and
enhance the regenerative effect of BMP-2 [4].
Recently, Li et  al., suggested a controlled co-
delivery of BMP-2 and Dex using bovine serum
albumin (BSA) nanoparticle-embedded electros-
pun poly(ε-caprolactone)-co-­poly(ethylene gly-
col) (PCE) nanofibers [35]. Specifically, BMP-2
incorporated BSA nanoparticles were first syn-
thesized by desolvation, and the final particles
were stabilized by chitosan-mediated electro-
static self-assembly (Fig.  12.2a). Chitosan-
stabilized nanoparticles and Dex were mixed
with PCE polymers and electospun to result
nanofibrous scaffold systems (Fig.  12.2b). The
bioactivity of incorporated BMP-2 and Dex were
maintained in an in vitro condition. A relatively
faster release of Dex and more sustained release
of BMP-2 were observed, and this nanofibrous
scaffold released both cargos over 35 days. The
synergistic effect of co-delivery was determined
by ALP expression and Alizarin Red S staining of
murine mesenchymal stem cells (MSCs) cultured
onto the nanofibers. Moreover, a co-delivery of
BMP-2 and Dex using nanofibrous composite
scaffolds facilitated in vivo bone regeneration as
well. Implanted scaffolds containing both
BMP-2 and Dex in critical-sized rat calvarial
defect exhibited the best repair efficacy over
12 weeks, determined by radiograms of the X-ray
detection, Masson’s trichrome staining, and
osteocalcin(OCN) immunehistochemical stain-
ing. Although it is known that Dex generally pro-
motes early calcified bone formation while
BMP-2 is beneficial for a long-term new bone
formation, this research suggested a controlled
and sustained release of BMP-2 and Dex using
engineered delivery platforms could activate
bone regeneration processes. Furthermore,
Fig.  12.3 indicates a possible mechanism of in
vivo osteogenesis promoted by this dual-drug-
loaded nanofibrous scaffold [20, 21, 35].
236 S. Kim et al.

Fig. 12.2  Schematic diagram for preparation chitosan spun for the repair of bone defects. (Reproduced with per-
stabilized BMP-2 loaded BSA nanoparicle (A) and DEX/ mission from Ref. [35])
BNP embedded electrospun PCE nanofiber using electro-

Fig. 12.3  Schematic illustration of signaling pathway simultaneously released, and enhance more new bone for-
that accelerated by DEX and BMP-2. In the early phase, mation and mineralized bone formation. After 6  weeks,
DEX initially burst released and, it is promote osteogene- BMP-2 plays important role for bone regeneration.
sis for 2  weeks. From 2 to 6  weeks, DEX and BMP-2 (Reproduced with permission from Ref. [35])
12  Bone Tissue Engineering Strategies in Co-Delivery of Bone Morphogenetic Protein-2…
Fig. 12.4  In vivo 125I-rhBMP-2 intensity from the scaf-
fold that containing rhBMP-2 and ZA in the rat models
during 4 weeks via SPECT. Control tube was located on
Similarly, Choi et  al., developed core-shell
microcapsules for a co-delivery of BMP-2 and
Dex [7]. In this study, the size and shape of core-­
shell microcapsules could be modulated by con-
trolling nozzle size, applied voltage, the
volumetric feeding ratio of poly(L-lactide-co-­
glycolide) (PLGA) and alginate, feeding rate,
and polymer concentrations via a coaxial electro-­
dropping method. 100 μg of BMP-2 was encap-
sulated into the inner PLGA core while 10 mg of
Dex was incorporated in the 0.5  wt.% alginate
outer shells. A release profile exhibited a signifi-
cantly different temporal pattern of both cargos.
The result showed an initial burst of Dex over
5  days, followed by a sustained release pattern
during the remaining time period (until 30 days)
while a release of BMP-2 was more sustained.
When rat bone marrow stromal cells were encap-
sulated with these core-shell microcapsules into
alginate hydrogels, released BMP-2 and Dex
induced osteogenic marker gene expression
including ALP, OCN, and osteopontin after
4 weeks of in vitro culture. The results indicated
that co-delivery of BMP-2 and Dex using core-
shell type microcapsules could maintain the
osteogenic potential of stem cells. Moreover,
Raina et al., also reported a synergistic effect of
co-administration of BMP-2 and zoledronic acid
(ZA) for inducing ostoeclast cells death and
osteogenesis [46]. In this study, a composite
cryogel with gelatin/hydroxyapatite/calcium
237
the bottom side to compensate for tracer radiation decay.
(Reproduced with permission from Ref. [46])
s­ ulfate was fabricated for a delivery platform. In
vitro assays demonstrated that cryogels with
recombinant human BMP-2 (rhBMP-2) induced
proliferation of MC3T3-E1 cells as well as
expressions of osteoblastic gene markers includ-
ing alkaline phosphate, osteric and osteocalcein.
For evaluation of in vivo osteogenesis, rat abdom-
inal muscle pouch model was utilized. In vivo
X-ray and micro-CT results showed that signifi-
cantly higher mineralization was observed in
gelswith both 10 μg of rhBMP-2 and 10 μg of ZA
as compared gels containing the same dosage of
cargos in commercially available absorbable col-
lagen sponge. Histological analysis also indi-
cated a higher new bone formation in a dual
delivery group of rhBMP-2 and ZA than a single
delivery of rhBMP-2. In order to track the release
of both rhBMP-2 and ZA in in vivo physiological
environment, 125I labeled BMP-2 was tracked via
single photon emission computed tomography
imaging (Fig. 12.4) while 14C labeled ZA release
was detected by a scintillation counting.
65.3 ± 15.2% of 125I labeled BMP-2 was released
for 28 days from abdominal muscle pouch while
an initial burst release (i.e., 43.2 ± 3% release in
the first day of implantation) of 14C labeled ZA
was observed in a dual delivery group. Taken
together, the results demonstrated that a combi-
nation of BMP-2 and ZA into composite cryogels
could promote both in vitro and in vivo osteogen-
esis than commercial collagen sponges.
238 S. Kim et al.

12.3 Facilitated Osteogenesis varial defect models [8]. In this study, cartilage
by Co-Administration oligomeric matrix protein-angiopoietin 1
of BMP-2 and Various (COMP- Ang1), a synthetic and soluble variant
Cytokines of Ang-1, was administrated using absorbable
collagen sponges in a critical sized defect (5 mm
In addition to a dual delivery of BMP-2 and stim- in diameter) of C57BL/6 mice. Dual delivery
ulus chemical compounds, bioactive cytokines group using BMP-2 and COMP- Ang1 facilitated
have also been co-administrated with BMP-2 to vascular formation, determined by the highest
achieve a facilitated osteogenic differentiation expression of CD31(an endothelial cell marker)
and bone regeneration. For example, angiogenic and NG2 (a specific marker of pericyte) in
stimulants could support a physiological regen- immunofluorescence analysis. In addition,
erative process during bone healing by upregulat- increased migration, osteogenic differentiation of
ing angiogenesis and blood vessel formation in pericytes, upregulated expression of osteoblast-­
the bony defect sites. In addition to vascular specific genes including bone sialoprotein (BSP),
endothelial growth factor (VEGF), a well-known OCN, osterix (OSX), and phosphorylation of
angiogenic cytokine, placental growth factor-2 Smad/1/5/8 were also observed. The same
(PGF-2) is a multitasking cytokine to enhances co-delivery group also significantly increased in
angiogenesis, recruitment/activation of bone vivo bone repair volume as compared to the
marrow-derived cells, and bone remodeling [17, control, presumably by angiogenesis via
22, 38, 40]. recruitment of MSC-like pericytes and
Therefore, Liu et  al., suggested a heparin-­ osteoblastic differentiation of native stem cell
based nanocomplex for a sustained co-delivery of population. Hence, this research suggested that
BMP-2 and PGF-2 [36, 37]. For a fabrication of the improvement of reconstruction of large
this nanocomplex, a positively charged N-(2-­ craniofacial defects could be obtained by
hydroxyl)propyl-3-trimethyl ammonium co-administration of BMP-2 and Ang-1.
chitosan chloride (HTCC) interacted with a mix- Neural epidermal growth factor-like protein-1
ture of heparin/BMP-2/PGF-2 via electrostatic (NELL-1) is a multi-functional cytokine involved
complexation. The loading efficiency of both in osteogenesis[24, 31, 61], stabilization of the
cargo molecules was over 97% and the size of the intervented spine [13, 33], chonrogenic
nanocomplex was around 485 nm. Cumulative % differentiation of perivascular stem cells [34],
release of BMP-2 over 21 days was 9% and that and odontoblastic differentiation of dental pulp
of PGF-2 was 16%, respectively. The in vitro cells [36, 37]. As a potent osteoinductive factor,
results indicated that proliferation and osteogenic this cytokine recruit immature cells and stimulate
differentiation of MC3T3-E1 preosteoblasts was them to become preosteoblasts through the Wnt,
effectively stimulated by co-delivery, as com- Hedgehog, and MAPK pathway [42]. Binding of
pared with any single administration. Moreover, NELL-1 to its specific integrin-β1 receptor
PlGF-2 could enhance osteogenic differentiation stimulates β-catenin nuclear localization and
at a lower loaded lose (i.e., 0.5 μg) as compared subsequent transcription of Runx2 and OSX,
with 1.0  μg of BMP-2  in the case of a single through intermediate intracellular ERK/JNK
delivery. activation. Zhu et al., reported a rapid distraction
Another angiogenic cytokine for enhanced osteogenesis of rabbit tibia by co-delivery of
osteogenesis with the aid of BMP-2 is BMP-2 and NELL-1 [62]. Distraction
angiopoietin1 (Ang-1). This cytokine could osteogenesisis an effective medical technique to
promote vascularization and maturation by create new bone via the gradual separation of two
stimulating the Tie2 receptor/PIK3/AKT pathway bony fragments from each other after their
[54]. Therefore, Choi et  al., investigated the surgical division, especially for longitudinal bone
enhanced therapeutic effect of Ang-1 variant on lengthening (Fig. 12.5). However, this technique
BMP-2 induced cranial bone regeneration in cal- still results in a considerable morbidity. Thus,
12  Bone Tissue Engineering Strategies in Co-Delivery of Bone Morphogenetic Protein-2…
Fig. 12.5  Macroscopic description of a self-constructed
external fixator with four self-taping screws (a).
Macroscopic (b) and representative radiograph (c) of sub-
this study emphasized a combinatorial effect of
co-delivery of BMP-2 and NELL-1 on enhanced
bone regeneration through improvement of callus
structure/organization and mechanical strength,
as evidenced by histology, mechanical testing,
and μ-CT examination. The result demonstrates
that BMP-2 and NELL-1 could enhance each
other’s functionality in tibia osteo-distraction as
compared with either agent alone, and that the
addition of NELL-1 might reduce the clinical
dose of BMP-2 as well as unintended side effects.
Although another recent study reported that the
osteogenic potential of a single delivery of
NELL-1 is less significant than BMP-2
administration [15], a co-administration of
BMP-2 and NELL-1 could synergistically facili-
tate bone repair process.
Wnt1-inducible signaling pathway protein 1
(WSIP1, also known as CCN4) is a member of
CCN protein family to enhance bone regeneration,
as an osteoblastic signal regulator. In general,
CCN family proteins participate in biological
processes related to development, tissue repair,
and tumor suppression. Wnt signaling pathway is
239
periosteal osteotomy to the fibula in rabbit model.
(Reproduced with permission from Ref. [62])
closely involved in developmental process [10],
and oncogenesis [45]. In the process of bone
regeneration, noncanonical Wnt signaling
regulates osteogenic differentiation, enhances
bone development, and maintain bone
homeostasis [3, 41]. Therefore, Kohara et  al.,
investigated the effect of co-administration of
BMP-2 and WSIP1 on ectopic osteoid formation
[29]. Subcutaneous implantation of gelatin/β-­-
tricalcium phosphate sponges incorporating both
BMP-2 and WSIP1 exhibited homogeneous
osteoid formation around the implant in middle-­
aged mice with decreased ability of bone
formation (i.e., 38 weeks old).
In addition, platelet-rich plasma (PRP) could
be also utilized to improve osteogenic
differentiation of stem cells, treat bone defects,
and support microfracture surgery in
osteochondral lesions [18, 39, 47]. As a dual
delivery application, Fernandes et  al. reported
that a controlled release of PRP in alginate beads
along with BMP2 could significantly promote in
vitro proliferation, osteogenic differentiation,
and mineralization activity of MSCs [16]. As
240
PRP is a blood derivative containing a series
of osteoinductive and angiogenic bioactive cyto-
kines such as platelet derived growth factor
(PDGF), transforming growth factor (TGF)-beta,
platelet factor-4, interleukin-1, platelet-derived
angiogenesis factor, VEGF, epithelial cell growth
factor, insulin-like growth factor, fibrinogen,
vitronectin, fibronectin, osteocalcin, and
osteonectin, even a single delivery of PRP itself
could promote ex-vivo bone regeneration using
isolated femur bones of C57BL/6 mice and
calvarial suture closure [16]. Similarly, PDGF,
one of the components in PRP, has also used in a
co-delivery with BMP-2 for critical-size calvarial
bone reconstruction [51]. In this study, Shah et al.
hypothesized that rapid bone formation in large,
critical-sized defects could be induced by
simultaneous delivery of BMP-2 and
PDGF-BB.  Both GFs were incorporated into
polyelectrolye multilayer coating onto PLGA/
alendronate membranes. Histological evaluation
and μ-CT imaging demonstrated that mature
bone formation with sufficient mechanical
properties was observed in a co-administration
group, with a greater number of vascular channels
and higher cell density within regenerated bone
area. This result indicated a mitogenic role of
PDGF-BB in the bone formation process in
craniomaxillofacial defects.
12.4 Combination of Other
Bioactive Growth Factors
for Enhanced Bone Repair
Other members of BMP superfamily such as
BMP-6 and BMP-7 are also potentially used in
clinical bone repair. These GFs improve bone
mass or quality, repair damage to bone and joints,
and treat diseases of skeletal overgrowth [48].
Recent studies investigated their potential bone
tissue engineering applications along with a
variety of delivery platforms. For example,
Demirtas et  al. evaluated osteoblastic
differentiation of pre-osteoblastic cells by a
co-administration of BMP-6 and PDGF-BB [12].
Similar to a combination of BMP-2 and
PDGF-BB described in a previous section, a
S. Kim et al.
co-delivery of BMP-6 and PDGF-BB effectively
stimulated in vitro proliferation and osteogenic
differentiation of MC3T3-E1 cells via dual
capacities of osteogenic and mitogenic activation.
Moreover, a recent study comparatively evaluated
osteoinductive bioactivity of BMPs combined
with human plasma fibronectin (FN/BMP)
delivered using titanium-hydroxyapatite (TiHA)
[1]. This research demonstrated that each member
of BMP superfamily possessed a different
molecular binding strength with fibronectin and
variant paracrine effect of BMPs around the FN/
BMPs functionalized TiHA implant surfaces.
Therefore, it could be emphasized that BMP-6
could be an alternative bioactive signal to develop
a biomimetic microenvironment to induce
osteogenic activity, especially when incorporated
with a FN/TiHA engineered scaffold system.
In addition, BMP-7 has also been investigated
to enhance the therapeutic capacity of BMP-2 via
co-administration [25, 58]. In order to a sequential
delivery of BMP-2 and BMP-7, Jo et  al.,
suggested a heparinization of collagen
membranes by a simple EDC/NHS chemistry
(Fig.  12.6) [25]. Briefly, a collagen membrane
surface was heparinzed by the generation of
amine-reacitve NHS-ester. BMP-7 was first
incorporated with heparin and subsequently
BMP-2 was physically absorbed onto collagen
surfaces. In this study, to evaluate in vivo
performance of co-administration of BMP-2 and
BMP-7, either 5 μg of any single GF or 2.5 μg of
dual BMP-2/BMP-7 was applied into a
10  mm  ×  10  mm collagen membrane which
covered a circular, transosseous, 8 mm defect in
the middle of the cranium of Sprague-Dawley
rats. Burst release of BMP-2 and sustained
release of BMP-7 exhibited a significantly
induced new bone formation after 8  weeks of
transplantation, as compared with other single
delivery formulations. A similar application was
also developed using chitosan-based scaffolds for
bone tissue engineering [58]. Yilgor et  al.,
developed a sequential GF delivery system using
synthetic polymer nanocapsules and chitosan-­
polyethyle oxide scaffolds. Here, BMP-2 and
BMP-7 was incorporated into PLGA
nanoscapsules while BMP-7 was loaded with
12  Bone Tissue Engineering Strategies in Co-Delivery of Bone Morphogenetic Protein-2… 241

Fig. 12.6  Schematic illustration for the fabrication of heparinized collagen membranes containing BMP-2 on the sur-
face and heparin bound BMP-7. (Reproduced with permission from Ref. [25])

poly(3-hydroxybutyrate-co-3-hydroxyvalerate) BMP-2 is the most proven and studied GF for

(PHBV) nanocapsules, respectively. This
research also achieved a similar release profile of
BMPs (i.e., the early release of BMP-2 and
longer term release of BMP-7). While a
simultaneous delivery of both BMPs was not
particularly effective on in vitro proliferation and
ALP activity of bone marrow MSCs, a sequential
delivery of BMP-2 and BMP-7 exhibited to the
highest normalized ALP activity indicating the
synergistic effect of co-administration by
modulating their release patterns.
12.5 Summary
Bone healing is a complex process involving cell
interaction, ECM production, mineralization, and
vascularization. Surgical procedures are limited
and disadvantageous. Therefore, development of
delivery systems that are injectable,
biocompatible, and biodegradable is required.
bone regeneration. However, a biodegradable
mechanism that provides mechanical strength
must be developed. Administration of sufficient
dosages of BMP-2 could have clinical side effects
such as inflammation, radiculopathy, ectopic
bone formation, osteolysis, urogenital events,
and wound complications [23]. Thus,
circumstantial proper treatment of BMP-2 could
eliminate the need for complex bone grafting
procedures and have long-term healing effects.
Many recent studies have demonstrated the
synergistic effect of a combination of BMP-2
with other GFs or other factors. BMP-2 promotes
osteogenic differentiation in the early stage, and
other GFs or factors accelerate and support later
in vivo bone regeneration. ECM mimicking the
structure of delivery materials for stable and
sustained release of GFs must be considered. To
this end, successful fabrication and manufacturing
of injectable and/or transplantable biomaterials
as a multiple GF delivery system could be a
242 S. Kim et al.

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