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ISSN 2047-4830

REVIEW ARTICLE
María Vallet-Regí et al.
A tissue engineering approach based on the use of bioceramics for bone repair
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Biomaterials
Science
REVIEW

A tissue engineering approach based on the use of

Cite this: Biomater. Sci., 2013, 1, 40 bioceramics for bone repair
Antonio J. Salinas,a,b Pedro Esbritc,d and María Vallet-Regí*a,b
Published on 01 October 2012 on http://pubs.rsc.org | doi:10.1039/C2BM00071G

Biomimetics takes advantage of natural strategies for the solution of technological problems, including
the proper design of biomaterials. Living bone exhibits a hierarchical porosity with both giant and nano-
metric pores which must be reproduced for the design of biomaterials for hard tissue repair. Bioactive
and degradable bioceramics are a good alternative for the manufacture of scaffolds. Tissue engineering
approaches to improve bone regeneration include strategies supporting endogenous osteoblast
adhesion, proliferation (osteoconduction), osteoinduction by growth factors, and osteoprogenitors.
Understanding the natural ossification mechanisms and the role of biomolecules involved in this process
is a requirement for the design of bone tissue scaffolds. Mesoporous bioactive ceramics, namely meso-
Received 15th June 2012,
porous silica and templated glasses with nanometric pores to host growth factors, conformed into 3D
Accepted 17th July 2012
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scaffolds with micrometric porosity by rapid prototyping, are a good option for bone regeneration. In
DOI: 10.1039/c2bm00071g
this regard, biomolecules such as well characterized bone morphogenetic proteins and others under
www.rsc.org/biomaterialsscience current research, such as osteostatin and osteoprogenitors, are promising strategies in bone tissue
engineering applications. Future developments in biomaterials will
a come in both micro- and nano- scales, and molecular and cell
Departamento de Química Inorgánica y Bioinorgánica, Facultad de Farmacia,
Universidad Complutense de Madrid, Madrid, Spain. E-mail: vallet@farm.ucm.es; biology approaches will provide suitable solutions to the demanding
Tel: +34 91 394 1861; Fax: +34 91 394 1786 needs of these compounds.
b
Networking Research Center on Bioengineering, Biomaterials and Nanomedicine
(CIBER-BBN), Madrid, Spain
c
Laboratorio de Metabolismo Mineral y Óseo, Instituto de Investigación Sanitaria
(IIS)-Fundación Jiménez Díaz, Madrid, Spain
d
Red Temática de Investigación Cooperativa en Envejecimiento y Fragilidad
(RETICEF), Instituto de Salud Carlos III, Madrid, Spain

Antonio Salinas graduated in Pedro Esbrit graduated in Chem-

Chemistry at the Universidad
Complutense de Madrid (UCM)
and PhD at the same university
in 1992. He is Associate Pro-
fessor of Inorganic Chemistry
and member of the Biomedical
Research Networking Center on
Bioengineering, Biomaterials
and Nanomedicine, CIBER-BBN.
He was visiting Professor at the
Universities of Florida, Aveiro
Antonio J. Salinas and Paris. Dr. Salinas has pub-
lished more than 100 articles
and books chapters most of them in the field of bioceramics and
participated in 22 research projects. He has more than 1,500
world-wide citations (ISI Web of Knowledge). Dr. Salinas is Corre-
sponding Academician of the Spanish Royal National Academy of
Pharmacy.
istry at Universidad Complu-
tense, and received his Ph.D. in
Biochemistry from Universidad
Autónoma, in Madrid, Spain. He
was a post-doc Fulbright fellow
at Barnes and Jewish Hospitals
(St. Louis, MO), and visiting
researcher at Veterans Adminis-
tration Hospital (West Haven,
CT). He currently holds an
Associate Chief position as Head
Pedro Esbrit of Bone and Mineral Metabolism
Laboratory at Instituto de Inves-
tigación Sanitaria-Fundación Jiménez Díaz, Madrid. Dr. Esbrit
has published >100 papers and several books in the field of bone
and mineral metabolism, particularly focusing on the actions of
PTHrP, in which he is one of the 10-top experts according to
BiomedExperts.

40 | Biomater. Sci., 2013, 1, 40–51 This journal is © The Royal Society of Chemistry 2013

Biomaterials Science
1. State of the art: the process of bone
regeneration and repair. How nature works
Bone regeneration after a fracture and the healing of small
bone defects are very effective processes. However, a challenge
arises with an increasing number of fractures associated with
poor healing through various causes such as osteoporosis,
fractures involving bone sites of poor vascularity or large bone
tissue loss.1 In this regard, the number of fractures related to
osteoporosis has doubled in the last decade, in part related to
the significant increase in life span in Western societies.2
Osteoporosis occurs frequently in women after menopause
Published on 01 October 2012 on http://pubs.rsc.org | doi:10.1039/C2BM00071G
due to the loss of estrogen, but bone loss is also known to
occur for both men and women with aging. In fact, the
increasing number of “non-union” fractures in the aging popu-
lation is a significant clinical problem. A number of other situ-
ations related to osteopenia/osteoporosis, namely diabetes
mellitus and glucocorticoid treatment, are known to affect
optimal skeletal healing after trauma or osteotomy.3–8 This
represents a major challenge to our health systems, and deter-
mines that bone regeneration following maxillo-facial and
orthopaedic surgery is an important clinical issue in regenera-
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tive medicine. Therefore, therapeutic strategies to improve
bone healing in these circumstances are of utmost impor-
tance. Therapies derived from a better knowledge of the cellu-
lar and molecular events in bone healing together with state-
María Vallet-Regí was born in
Las Palmas, Spain. She studied
Chemistry at the Universidad
Complutense de Madrid (Spain)
and received her PhD at the
same university in 1974. She is
full professor of Inorganic Chem-
istry and head of the research
group Smart Biomaterials in the
Department of Inorganic and
Bioinorganic Chemistry of the
Faculty of Pharmacy at Universi-
María Vallet-Regí dad Complutense de Madrid.
Prof. Vallet-Regí has written
more than 600 articles and several books. She was the most cited
Spanish scientist according to ISI Web of Knowledge, in the field
of Materials Science in these past decades. She is Fellow of Bioma-
terials Science and Engineering at the International College of
Fellows of Biomaterials Science and Engineering (ICF-BSE), Num-
bered Fellow of the Spanish Royal Academy of Engineering and the
Royal National Academy of Pharmacy. She has received the Prix
Franco-Espagnol 2000 from Societé Française de Chimie, the
Spanish Royal Society of Chemistry (RSEQ) award in Inorganic
Chemistry 2008, the Spanish National Research Award in Engin-
eering 2008, FEIQUE Research award 2011 and the RSEQ
Research Award and Gold Medal 2011.
This journal is © The Royal Society of Chemistry 2013
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Review
of-the-art biomaterials are being developed as bone tissue
engineering strategies to improve bone repair.
1.1 Bone: a model to imitate
Nature is an important source of inspiration in the develop-
ment of new implant materials. In this sense, the design of
these biomaterials relies on imitating the structure and func-
tion of biological systems (see Fig. 1). The biomimetic
approach is based on the fact that after billions of years of
evolution, nature has learned which systems are the most
appropriate in terms of optimal properties with minimal
resources.9,10 Thus, biomimetics take advantage of these
natural strategies for the solution of specific problems in all
branches of materials science and engineering.
Bone is formed by a series of biomineralization processes, a
sequence of physicochemical reactions that give rise to
organic–inorganic nanocomposites with exceptional mechan-
ical properties that would be impossible to reach with pure
materials.10 This tissue is made up of a cellular component
and an extracellular matrix consisting of an organic phase,
mainly type 1 collagen, and an inorganic ceramic phase of
calcium-deficient carbonated hydroxyapatite (CHA) nanocrys-
tals.11 As observed in Fig. 2, the main characteristics of biologi-
cal apatites are: variable composition, nanometric crystal size,
calcium deficiency, the presence of carbonate groups and
structural disorder. Another important feature of the apatite
structure is the ability to accommodate different ions in its
three ionic sublattices (calcium, phosphate and hydroxy).11
These apatite nanocrystals grow at ordered mineralization
sites of collagen molecules in bone.
More than 200 bone pieces with different lengths and
shapes constitute the human skeleton.12 However, all of them
present a hierarchical structure that ranges from the collagen-
CHA nanocomposite, the lamellae, lacunae and osteons to the
macroscopic material. Another important characteristic of
bone is its porosity. In this sense, bone tissue with less than
20% porosity is known as cortical (or compact) bone, whose
most important function is to provide mechanical support
Fig. 1 Nature is an ideal inspiration to solve technological problems associated
with implant materials.
Biomater. Sci., 2013, 1, 40–51 | 41

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Published on 01 October 2012 on http://pubs.rsc.org | doi:10.1039/C2BM00071G
Fig. 2 Top: Schematic image of CHA nanocrystals reinforcing the triple helix of
collagen. Middle: Cancellous bone observed by scanning electron microscopy
and CHA nanocrystals by transmission electron microscopy. Bottom: Main fea-
tures of biological apatites.
(strength and stiffness). On the other hand, cancellous (trabecu-
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lar or spongy) bone can contain up to 90% of porosity. This type
of bone provides a large surface area which determines the key
role of the skeleton in ion homeostasis and haematopoiesis. Fur-
thermore, pores with different sizes, from one to several hundred
micrometers are present in bone; those below 1 μm in diameter
are responsible for bioactivities involving protein interactions.
This hierarchical porosity must be reproduced in the design of
new biomaterials for regeneration and repair of hard tissues.13
There is general agreement on both scaffolds required for
osteoconduction and osteogenic growth factors as key elements
for applications in bone repair and regeneration.14 The increas-
ing importance of the latter factors, mainly bone morphogenic
proteins and other growth factors, is illustrated in Fig. 3
showing the participation of different products in the US Ortho-
pedic Market in 2009.15 These agents represent 20% of this
global market, with an expected growth of 30–35% each year in
the next five years. This growth is 3-fold higher than that
expected for the US global market for orthopedic biomaterials.
1.2 Cell and molecular mechanisms underlying the process
of bone healing
Bone repair—a key process for resolution of orthopedic
trauma which causes bone disjunction—is a unique process
involving the interplay of complex cellular and molecular
events to generate new bone instead of a fibrous scar which is
the final outcome in other connective tissues. In contrast to
bone remodeling in adults, which requires a relatively long
period to complete at random sites (called “bone remodeling
units”) throughout the skeleton, bone repair occurs in a com-
pressed time frame and in a precise location. The latter basi-
cally recapitulates normal bone formation during
embryogenesis, except for some events such as inflammation,
the limited number of osteoprogenitors available and the key
42 | Biomater. Sci., 2013, 1, 40–51
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Biomaterials Science
Fig. 3 Economic impact of different products in US Orthopedic Biomaterials
market in 2009 (Adapted from ref. 15). “Others” category includes the big
markets for sealants, hemostats and anti-adhesion agents.
influence of mechanical stimuli that greatly influence bone
healing in adults.8 At the bone injury site, mesenchymal cells
interact with inflammatory cells in an orderly fashion by yet
poorly understood mechanisms.16 Recent evidence also
suggests that osteoclasts as well as osteoprogenitors might
have an active role in the early response to injury, as occurs in
the bone remodeling units in the bone surface.17,18
New bone formation is initiated by the condensation of
mesenchymal stem cells (MSCs), which then leads to either
the formation of a cartilage template in the bone marrow
(endochondral ossification) or direct differentiation into osteo-
blasts at the periostium (intramembranous or appositional ossi-
fication). The former ossification mechanism predominates in
most cases of fracture healing, but rigid fixation of the injury
causes primary bone apposition as the major repair mechan-
ism.8,19 The general pattern of endochondral ossification after
fracture includes several chronological phases (Fig. 4).
Immediately following trauma, vascular endothelium integ-
rity is lost, giving rise to disruption of the blood supply and
hematoma formation. This is accompanied by an inflamma-
tory response, related to the production of pro-inflammatory
cytokines—namely tumour necrosis factor-α, interleukin-1
(IL-1), and IL-6—from aggregated platelets, which have chemo-
tactic activity towards lymphocytes, monocytes-macrophages
and fibroblasts (inflammatory cells), and also endothelial
cells.20 Macrophages can also produce and secrete the afore-
mentioned cytokines and various growth factors, platelet-
derived growth factor, fibroblast growth factors, insulin-like
growth factors, the transforming growth factor-β superfamily,
including bone morphogenetic proteins (BMPs) and vascular
endotelial growth factor (VEGF), which induce angiogenesis and
bone formation from recruited periosteal progenitors, as well as
extracellular matrix synthesis.21–23
Neovascularization of injured tissue is key to successful
bone repair, providing oxygen, facilitating metabolic waste
removal, and delivering progenitor cells of haematopoietic
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Published on 01 October 2012 on http://pubs.rsc.org | doi:10.1039/C2BM00071G
Fig. 4 Phases of endochondral ossification in fracture healing. The well micro-
vascularized periostium is shown, consisting of an outer fibrous layer and the
inner cambium which is rich in osteoprogenitors. Immediately after injury,
hematoma formation and inflammation take place. Osteoprogenitors are then
recruited from the periosteum to differentiate into chondrocytes or osteoblastic
cells (depending on the oxygen supply). New bone is thus starting to be formed
at the borders of the injury site. Simultaneously, a callus mostly made up of
hypertrophic cartilage develops and begins to revascularize. Eventually, osteo-
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clast-mediated remodeling of the newly formed bone leads to the restoration of
structural bone integrity (modified from the Primer on the Metabolic Bone Dis-
eases and Disorders of Mineral Metabolism, 7th Edition. www.asbmrprimer.
org).
origin.8,24 Whereas mechanical stability preserves vascular
integrity and promotes osteogenesis, instability disrupts micro-
vessels producing hypoxic conditions that favor chondrogenesis,
as occurs in the central avascular region of the callus.25 This
determines that stabilized fractures have less cartilage and a
reduced callus volume. VEGF, which is expressed under the
control of hypoxia-inducible factor (HIF)-1α under low oxygen
tension, is a prototype osteogenic–angiogenic factor that can
expand the osteoprogenitor pool by interaction with the endo-
thelium.26 Osteogenic factors such as BMPs and parathyroid
hormone (PTH)-related protein (PTHrP) stimulate the expression
of VEGF by osteoblastic cells.27,28 The critical role of this factor
in bone repair has been well exemplified in mice with con-
ditional overexpression of HIF1α in mature osteoblasts (using
the osteocalcin promoter) undergoing distraction osteogenesis
to stimulate bone regeneration, showing a robust angiogenic
response closely related to new bone formation.1 The key final
step to correct the bone defect consists of newly formed woven
(or disorganized) bone replacement by lamellar bone through
the activity of osteoclasts and osteoblasts (bone remodeling).
Current evidence also points to the role of osteoclastogenesis
and osteoclast-mediated bone resorption during both early and
late stages of bone repair. Osteoprogenitors may activate osteo-
clast-mediated resorption of damaged bone, while osteoclasts
themselves can modulate osteoblast activity and thus contribute
to bone formation.19,29 This evidence can explain the reported
deleterious effects of bone resorption inhibitors, namely
bisphosphonates, on callus formation and remodeling.18,30
This journal is © The Royal Society of Chemistry 2013
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The proliferation and differentiation of osteoblasts from
pluripotent MSCs is a complex process under systemic and
local control. Many of the regulatory factors underlying this
control constitute a matter of investigation as putative targets
or therapies to stimulate bone repair.8,31 Of interest, these
factors appear to act through common intracellular signaling
pathways—namely mitogen-activated protein kinase (MAPK)
and Wnt/β-catenin pathways8—to induce proliferation of osteo-
progenitors and activation of Runx2, a key transcription factor
for osteoblast differentiation.32 The fact that MAPK signaling
acts as an important mediator of pro-inflammatory cytokines
determines that its therapeutic manipulation might be
restrained to the early phase in bone repair, which involves
inflammation.33 The canonical Wnt/β-catenin pathway has an
important role in bone formation, and recently, its impact on
bone regeneration has also been examined in mice. Thus, sys-
temic administration of an adenovirus expressing an inhibitor
of this pathway into transgenic mice was found to arrest the
program of tissue regeneration in the mouse tibia.34 On the
other hand, it has been suggested that pre-treatment of bone
marrow cells with Wnt/β-catenin pathway activators may
increase their osteogenic capacity;35 a particularly relevant
manoeuvre in conditions associated with a low number of
osteoprogenitors (e.g., aging and diabetes mellitus).
A reduction in the number of osteoprogenitors as well as a
decreased proliferative and differentiation capacity of pre-
osteoblasts to osteoblasts, associated with an overall remodel-
ing capacity decline, correlates with old age.36–38 Alterations in
osteoblast function related to aging might be accounted for at
least in part by increased oxidative stress and inflammation
status.39,40 Several recent studies have explored the putative
age-related alterations in the temporal pattern of gene
expression during bone regeneration in rats and humans.18,41
In old rats, the machinery of bone healing based on the gene
profile seems to be conserved with age despite the delay in
new bone formation to bridge the fracture gap.41 In the callus
after hip fracture in elder human subjects, the expression of
inflammation-related genes is highest at the earlier phase, and
it shifts towards bone remodeling genes later on after frac-
ture.18 Interestingly, expression of Sost—the sclerostin-encod-
ing gene, a key modulator of bone remodeling—was rapidly
reduced in the callus, suggesting that this would allow osteo-
blasts to escape from its inhibitory effect to promote bone for-
mation.18 These observations provide new insights for specific
interventions targeting excessive inflammation and Sost to
promote bone regeneration in elder subjects.42,43
2. Bioceramics to promote bone
regeneration. From the raw materials to
scaffolds
Synthetic materials used for bone repair can be divided into:
ceramics, polymers, metals and composites where at least two
classes of materials are combined together.44 Ceramics have a
Biomater. Sci., 2013, 1, 40–51 | 43

Review
structure which mimics that of natural bone and thus were
considered attractive materials in this respect.45,46 This cat-
egory of materials includes oxides, phosphates, carbonates,
nitrides, carbides, carbons and glasses. Those designed to
interact with living tissues are called bioceramics,46,47 and
they are the subject of this review.
The so-called bioinert bioceramics elicit a foreign body
reaction which gives rise to a non-adherent fibrous capsule iso-
lated from surrounding bone, which accounts for the aseptic
loss of many implants.48 For this reason, research efforts at
the end of the past century were devoted to biodegradable and
bioactive bioceramics, sometimes denoted as second gener-
Published on 01 October 2012 on http://pubs.rsc.org | doi:10.1039/C2BM00071G
ation bioceramics. Biodegradable bioceramics are designed to
fulfil specific functions for a given time period, helping in the
self-repair processes of the living organism, and are sub-
sequently resorbed. The critical aspect in the design of these
bioceramics is their relatively fast degradation rate, with the
loss of their mechanical properties, compared to the slower
new bone formation process. Bioactive bioceramics can react
with physiological fluids, but only at surface level, giving rise
to a sequence of surface reactions producing a strong bond
between the material and bone.47 Several calcium phosphates
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such as tricalcium phosphates (alpha or beta polymorphs) or
calcium sulphates are good examples of biodegradable
bioceramics. Likewise, well known bioactive ceramics are
hydroxyapatite (HA) and certain compositions of glasses and
glass-ceramics. Bioactive and biodegradable bioceramics are
clinically used as bone fillers, bone cements or for coating
metallic implants.47 Fig. 5 shows representative bioceramics of
each category. Because the in vivo reactivity of these materials
depends on its surface area, one single material such as HA
can be classified in different categories depending on its par-
ticle size.
Present research in bioceramics is based mainly on biologi-
cal criteria since it pursues bone tissue “regeneration” rather
than its mere “replacement”. Thus, current efforts are devoted
towards the synthesis of bioceramics—so-called third gener-
ation bioceramics49—which are able to induce a cell response
leading to osteogenesis.50 In this regard, research has mainly
focused on porous resorbable or bioactive bioceramics that are
used to manufacture porous scaffolds able to host cells and
bioactive agents (growth factors, hormones, peptides). The
signals triggered by these biomolecules should promote bone
formation. Moreover, advanced bioceramics such as ordered
mesoporous silica-based materials or organically modified bio-
ceramics are now under investigation in this respect.51–53
2.1 Second generation bioceramics
Most widely used second generation bioceramics are calcium
salts—phosphates and sulphates—and silica (SiO2)-based bio-
ceramics which are extensively used in orthopaedics and den-
tistry because of their biocompatibility and capacity to
promote osteointegration. Many of these bioceramics are also
osteoconductive, meaning their ability to provide the appropri-
ate surface to support osteoblast adhesion and proliferation
and therefore, bone formation.50 Furthermore, the presence of
44 | Biomater. Sci., 2013, 1, 40–51
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Biomaterials Science
Fig. 5 Main bioceramics classified as a function of its reactivity with living
tissues.
silicon in the structure of bioactive bioceramics appears to
confer them osteoinduction features.49 However, a major draw-
back of calcium phosphates and silica-based bioceramics is
their poor mechanical strength, namely brittleness and low
resistance to fatigue. They exhibit excellent features for filling
small bone defects, but their brittleness is a drawback for
repairing large bone defects. This is especially so in highly
porous bioceramics and scaffolds with high porosity percen-
tages and pores larger than 100 μm in diameter. Consequently,
for bone substitution and repair, these bioceramics, are
mainly used as fillers in non-load bearing applications or as
coatings of metallic prostheses, but also can be proposed for
the manufacture of scaffolds, as will be described in the fol-
lowing section.
Next, the major features of some calcium phosphates
including synthetic apatites, biphasic mixtures, bone cements
and coatings, and silica-based materials including bioglasses,
mesoporous ordered silica-based materials and templated
glasses will be described. Of all the synthetic apatites, HA
[Ca10(PO4)6(OH)2], is the most widely studied for its structural
and chemical similarities with the inorganic component of
bone.54,55 HA is biocompatible, bioactive and osteoconductive.
To mimic biological apatites, synthetic apatites must present
nanometric particle size and contain 4–8 wt% of CO32−
ions.56,57 HA structure can accept the inclusion of many ions,
such as Na+, K+, Mg2+, Sr2+, Cl−, F−, HPO42−, etc.57 This can be
exploited in the design of HA with specific surface structure
and electric charge in order to improve the material behaviour
in biological environments. In addition, the presence of
certain elements (i.e., strontium, zinc or silicate) that can be
released in the regenerating bone environment might facilitate
the process of bone healing. Carbonate and strontium ions
also facilitate apatite dissolution and implant resorption. Sili-
cate ions increase the mechanical strength of apatite and
accelerate its bioactive response. Thus, the synthesis of substi-
tuted apatites is a current research trend.
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The most popular biphasic mixtures of calcium phosphates
are based on HA and β-tricalcium phosphate, β-Ca3(PO4)2,
(β-TCP) mixtures that evolve to CHA under physiological con-
ditions.58 The dissolution of resorbable β-TCP acts as a source
for new bone by the increase of Ca2+ and PO43− ion concen-
tration in the local environment, simultaneously creating extra
porosity that favours a suitable in vivo behaviour of the
material. This biphasic material can be injected, used as a
coating or as bulk in bone replacement. Other biphasic mix-
tures are under investigation including calcium phosphates,
bioactive glasses, and calcium sulphates, etc.
Bone cements based on calcium salts, mainly phosphates,
Published on 01 October 2012 on http://pubs.rsc.org | doi:10.1039/C2BM00071G
carbonates or sulphates, present excellent biocompatibility
and bone-repair properties.59,60 Most of the injectable calcium
phosphate-based cements evolve to calcium phosphate apatite
during the setting reaction. These cements harden in situ and
can be slowly resorbed. During this gradual process, the bone
grows and replaces the cement. Research is under way to
shorten the curing time and improve the mechanical
toughness.
Coatings of calcium phosphates over metallic substrates
have been used to overcome the main limitation of calcium
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phosphates as bioceramics: their poor mechanical properties.
Common substrates are titanium alloys, Ti6Al4V and commer-
cially pure Ti. Calcium phosphate coatings are usually pro-
duced by plasma spray because of the rapid deposition rate at
a relatively low cost.61,62 However, this method presents several
drawbacks: (i) the presence of highly soluble amorphous
calcium phosphate in the coatings produce resorption pro-
blems; (ii) the poor adherence of the bioceramic-substrate; (iii)
the instability of HA at high temperatures; and (iv) the phase
transition of titanium at high temperatures. Nowadays,
alternative techniques to obtain calcium phosphate coatings
are under investigation including physical vapor deposition,
chemical vapor deposition, magnetron sputtering, electrophor-
etic deposition, pulsed laser deposition and dip coating. Some
of these techniques permit higher control of the coating thick-
ness and crystallinity or can take place at low temperatures, an
interesting advantage compared with plasma spray. In Fig. 6,
different uses of calcium phosphate bioceramics are
presented.
For silica-containing bioceramics, bioglasses were the first
synthetic materials for which bioactivity was described.63 They
contain silica as the network former together with other met-
allic oxides as modifiers. Among them, Bioglass® 45S5 (45%
SiO2 24.5% NaO2, 24.5% CaO and 6% P2O5), obtained by tra-
ditional “quenching-of-a-melt” method, is the best character-
ized and used bioceramic of this group.63
In the 1990s, the synthesis of porous bioactive bioglasses by
the sol–gel method began.64–67 This technique requires lower
temperatures, which facilitates the possible incorporation of
biologically active molecules or living cells into the bioglasses.
These bioglasses exhibited high surface areas and porosity as
well as an abundance of surface silanol (Si–OH) groups, which
greatly improves their bioactive response. Nowadays, the most
promising application of bioactive bioglasses is in bone tissue
This journal is © The Royal Society of Chemistry 2013
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Fig. 6 Different uses of calcium phosphate bioceramics.
engineering as 3D scaffolds in association with osteogenic
agents, as will be detailed later. These bioactive matrices
present osteoconduction and osteoinduction.
In recent years, silica-based ordered mesoporous biocera-
mics attracted interest as templates for drug delivery appli-
cations.68 These mesoporous materials have the same
chemical composition, namely silica, and are denoted by
different acronyms, e.g., MCM-41, SBA-15, MCM-48, among
others. Mesoporous silica-based bioceramics exhibit a high
surface area (ca. 1000 m2 g−1), high pore volume (ca. 1 cm3
g−1), narrow pore size distribution in the mesopore region
(2–50 nm), and a pore channel system homogeneously orga-
nized in 2D or 3D arrangements. The surface of these
materials covered with silanol groups should govern
their interaction with the host tissue, although the kinetics of
the nanoapatite layer formation is slow.69 Therefore, in the last
few years a great interest was devoted towards the so-called
templated glasses,70 which exhibit analogous textural proper-
ties to mesoporous materials but a greater bioactivity response
that made them very attractive in bone regeneration
technologies.
2.2 3D bioceramic scaffolds for bone tissue engineering
In bone tissue engineering, synthetic scaffolds should fulfil
various requirements—they must provide mechanical stability
as well as an appropriate environment for new bone formation;
e.g., they must favour cell attachment as well as cell growth
and differentiation.71–75 Bioceramics can be manufactured as
scaffolds in this regard. The in vivo behaviour of such scaffolds
depends on both the intrinsic properties of the bioceramic
and specific features resulting from their fabrication
method.76–78
One advantage of bioceramic scaffolds lies in the fact that
they usually have hierarchical porosity with highly intercon-
nected pores analogous to bone. Pores can be classified in
three categories depending on the role they play. Those with
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diameters in the range 150 to 400 μm and larger are needed

for cell colonization and vascularisation.79 Another group of
pores under 20 μm is necessary for capillary ingrowths and
cell-matrix interactions. In the case of scaffolds made of meso-
porous ordered silica-based bioceramics or templated glasses,
pores of a few nanometers are present, which allow the
inclusion of osteogenic factors to decorate the scaffold. This
confers a very important added value to the resulting scaffold:
the capacity of hosting drugs for locally treating different bone
morbidities and pathologies, such as bone infection, osteo-
porosis or cancer. The scaffold processing method should thus
preserve the original mesoporosity combined with macropor-
Published on 01 October 2012 on http://pubs.rsc.org | doi:10.1039/C2BM00071G

osity. Fig. 7 shows the different pore sizes required for several
physiological functions of bone tissue.
Several conformation methods are available to obtain
scaffolds at room temperature, a manoeuvre that permits the
Fig. 8 Bone regeneration and local drug delivery by mesoporous-based 3D
inclusion of different biomolecules in the material. An appro- scaffolds.
priate and useful method to produce scaffolds as bone
implants is rapid prototyping (RP) 3D printing,80,81 which
makes possible the design of the correct scaffold structure
the loading solution (including pH) are all parameters that
based on tomography information of the bone tissue to repair.
highly affect the adsorption capacity of the bioceramics
Then, with a computer-assisted design, suitable scaffolds with
scaffolds.83 However, this capacity can be improved by pre-
Downloaded on 26 March 2013

the appropriate shape and porosity can be obtained for

different clinical requirements. Generally, biodegradable or
bioactive bioceramics are used for this purpose; a bioceramic
paste is prepared to load in the injector and to mould the
scaffold with a previously designed macroporosity. A combi-
nation of different methods, such as sol–gel chemistry, double
polymer templating and RP, has lead to 3D mesoporous bio-
glass-based scaffolds exhibiting hierarchical pore networks,
with giant (30–1000 μm), macro- (10–30 μm) and meso- (5 nm)
porosity.
An attractive strategy in bone tissue engineering has been
the incorporation of osteogenic factors with the aim to
improve the osteoinductive properties of the scaffolds (Fig. 8).
Incorporation of these factors relies on conventional impreg-
nation techniques using manufactured scaffolds.82 The type of
pore and exposed (inner and outer) surface, and the quality of
Fig. 7 Porosity features involved in the design of scaffolds for bone tissue
engineering.
vious chemical functionalization of scaffold mesopores with
different organic groups tailored to interact with a particular
factor of interest.53 This approach allows fine control over the
drug load and a predictable release pattern.83,84
The efficacy of local administration of osteoinductive
agents, e.g., peptides and growth factors, may be improved by
their covalent grafting to the scaffolds, which determines a
sustained exposure in the bone microenvironment.85,86 These
osteoinductive agents would act as attracting signals for bone
cells.
3. Symbiosis between nature and materials
A traditional approach in tissue engineering strategies involves
the implantation of different types of osteogenic cells seeded
onto suitable templates, including bioceramics. Cells of the
osteoblastic lineage with different differentiation status can be
used to drive bone tissue regeneration.87,88 In addition,
different sources of osteoprogenitors have been tested for their
capacity to regenerate bone (reviewed in ref. 31 and 89). MSCs
—defined as adherent multipotent cells capable of differentiat-
ing into osteogenic cells90—have distinctive and interesting
features such as immunosuppressive, cell protective, and
angiogenic activities.91 Current data support the notion that
MSCs are indeed pericytes residing on blood vessels; in this
context, an insult causing vasculature disruption would make
these cells available to help regenerate the resulting damaged
tissue.92,93 MSCs are relatively abundant in the bone marrow
from which they can be easily isolated and expanded in cul-
tures for use in different bone tissue engineering schemes.
The major drawback of MSCs from various origins, however,
lies in their limited quantity and/or differentiation

46 | Biomater. Sci., 2013, 1, 40–51 This journal is © The Royal Society of Chemistry 2013

Biomaterials Science
capacity;94,95 these hurdles are presently a subject of intense
investigation through different approaches.96,97 In addition,
elucidating the true role of the host contribution to bone
tissue regeneration is paramount to optimize tissue engineer-
ing approaches. Of interest in this line, MSCs and more com-
mitted cells of the osteoblast lineage appear to have a different
capability to recruit host endothelial cells and, therefore, to
increase vascularization.93,97
Osteopromotion can be achieved by using factors which
enhance the healing process. Thus, a common strategy to
promote bone healing relies on the use of osteogenic factors
which are either directly implanted as recombinant proteins or
Published on 01 October 2012 on http://pubs.rsc.org | doi:10.1039/C2BM00071G
embedded in a suitable carrier such as bioceramics previous
to implantation.98,99 Osteoinduction properties are conferred
to these biomaterials by growth factors which can induce
differentiation of MSCs along the bone repair process.31
BMP-2 and BMP-7 in particular, have been widely used in
animal models and also in randomized clinical trials for
healing fractures and stimulating spine fusion. BMP-2 has
proven essential for MSCs recruitment and expansion; it is the
only United States Food and Drug Administration (FDA)-
approved molecular therapy for use in the management of
fracture repair and spine non unions.100 In fact, BMP-2 rep-
Downloaded on 26 March 2013
resented 18% of the US orthopaedic biomaterials market in
2009 (See Fig. 3). However, some concerns have recently been
raised due to the poor outcomes of BMP-2 administration in
some cases.101,102
Recently, our group has started to explore the advantage of
the small peptide osteostatin, consisting of the 107–111
domain (Thr-Arg-Ser-Ala-Trp) of PTHrP, to promote bone
healing. Fig. 9 shows the comparison of some biological
characteristics of osteostatin and BMP-2. As can be seen, local
application of osteostatin is expected to bring significant
advantages with respect to BMP-2. We have recently demon-
strated that osteostatin loading onto silica-based ceramics con-
ferred osteogenic features to these materials, including
stimulation of osteoblastic cell growth and differen-
tiation.103,104 Moreover, osteostatin has recently been proven to
increase the osteogenic efficacy of fibroblast growth factor-2 as
coated onto Si-doped hydroxyapatite by enhancing its angio-
genic potential in vitro.105 These data are consistent with the
recently described anabolic features of the native peptide,
PTHrP107–139, independent of its concomitant inhibitory effect
on bone resorption.106,107 Attractive properties of osteostatin
lie in the fact that it can affect bone cells at <nM concen-
trations and its structure is not likely to be degraded by pro-
teolysis. This prompted us to further investigate whether
osteostatin-coated bioceramics might be able to improve
osteointegration and accelerate bone repair after a cavitary
defect in the femoral epiphysis of healthy rabbits. This in vivo
model, in which trabecular bone damage predominates, has
been proven to be suitable for testing biomaterials. Histologi-
cal analysis revealed the absence of significant inflammation
or bone resorption within the time of study (4 and 8 weeks)
after implantation.104 At 8 weeks, microcomputerized tomogra-
phy (μCT) analysis showed that osteostatin-loaded biomaterials
This journal is © The Royal Society of Chemistry 2013
View Article Online
Review
Fig. 9 A comparison between bioactivities of osteostatin and BMP-2.
were highly osteoconductive and osteoinductive by promoting
infiltration of proliferating osteogenic precursor cells and con-
nective tissue formation (Fig. 10). In addition, these biocera-
mics induced revascularization of the defect, related to an
increased immunostaining for VEGF in the healing bone
tissue.104 More recently, these biomaterials were also found to
improve the early stage of bone healing in the same bone frac-
ture model in osteoporotic rabbits.108 Thus, these osteostatin-
loaded bioceramics appear to be an attractive approach for
bone tissue engineering applications even in the setting of
osteopenia.
4. Future perspectives
Second generation bioceramics including those bioactive and
resorbable bioceramics are being used today as implants for
bone regeneration and repair in Orthopedics and Dental appli-
cations. Third generation bioceramics, those driving bone
regeneration in various bone tissue engineering schemes, are
now under intense research in the hope of significant develop-
ments in the near future.
A representative picture of the current research interests in
biomaterials can be obtained from the program of the Nine
World Biomaterials Congress that took place in Chengdu
(China) from the 1st to the 5th of June 2012. The central topic
of the Congress was: “Innovative Biomaterials and Crossing
Frontiers in Biomaterials and Regenerative Medicine”. Over
3,000 communications were classified in 87 Symposia that
were divided into 167 scientific sessions. The main topic was
“scaffolds”, which was included in 12 sessions, followed by
“cell-materials interactions”, which were discussed in 8 ses-
sions. In addition, the following topics were present in 6 ses-
sions: “nanomaterials, gene delivery and hydrogels”. Other 5
sessions were devoted to “tissue inducing biomaterials, bio-
mimetics, and molecular imaging”, while four more sessions
dealt with “bioinorganics and bioceramics, surface modifications,
hybrid materials and polymer design”. These 12 topics rep-
resented almost 50% of all scientific sessions of the Congress.
Biomater. Sci., 2013, 1, 40–51 | 47
 View Article Online

Review Biomaterials Science

Acknowledgements
Funding for the authors came from grants by Comisión Inter-
ministerial de Ciencia y Tecnología (CICYT, Spain) (MAT2008-
736 and CSO2010-11384-E), Comunidad Autónoma de Madrid
(CAM; S2009/MAT-1472), Instituto de Salud Carlos III
(RETICEF RD06/0013/1002) and Fundación de Investigación
Médica Mutua Madrileña.
Published on 01 October 2012 on http://pubs.rsc.org | doi:10.1039/C2BM00071G

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