THE APPLICATION OF STEM CELLS IN THE ORTHODONTIC MAXILLARY EXPANSION
This invention relates to the method in which stem cells derived from bone marrow and adipose tissue are used in orthodontic maxillary expansion.
Maxillary narrowness is a unilateral or bilateral skeletal problem in the jaw bones. This problem may occur as a result of the reduction in the mandibular and maxillary width in terms of bone level. For the treatment of orthodontic patients with maxillary narrowness, the expansion apparatus supported by the teeth are used. The use of these apparatus enables the expansion of the maxilla. After the expansion treatment, new bone formation is expected to occur. The relapse of the achieved expansion is prevented through bone formation.
In the study by Wertz and Dreskin, it was stated that in individuals between the ages of 8 and 29 years, there was a mean increase of 6.5 mm between the molar teeth with the use of rapid maxillary expansion, and that during the stabilization and retention period, 30% of this increase was relapsed and besides, in the oldest patients, the relapse rate in the intermolar distance was reported to rise to 75% (1 ). In the technique, the relapse rates reported after the maxillary expansion were known to be very high.
Following the maxillary expansion, new bone formation is required for the maintenance of the achieved state and for the stabilization of the occlusion. Therefore, a reinforcement treatment is administered via movable or fixed appliances for 3 to 6 months (2, 3).
The shortening of the reinforcement period after the maxillary expansion is essential for the treatment success and patient cooperation. However, the shortening of this period is unlikely to be achieved due to the relapse occurring after the expansion. Moreover, the tendency to relapse after maxillary expansion may last for many years.
In order to obtain more effective results in a shorter period, it is important to evaluate the factors affecting bone healing and reorganization. For this reason, the quality and rate of new bone formation to occur between the surfaces of osteotomized bone segments are important factors to reduce early relapse. The shortening of this period will also shorten the time of long orthodontic treatment period and increase the patient cooperation.
Recently, in the technique, there are studies to increase bone formation in the suture and its quality, and thus protecting the stability (4-6). In fact, the importance of the bone formation in the suture is known long before. The maintenance of the increase achieved in the arch width by opening midpalatal suture is known to be enabled following a repair of the bone defect in the suture with a new bone.
Considering the fact that relapse can be reduced by speeding up the bone formation in the midpalatal suture, Saito and Shimizu (4) applied low-level laser therapy to the expanded sutura and determined that bone regeneration was increased. Uysal et al. showed that boron mineral in rabbits (7), vitamin E (8), vitamin D (9), vitamin C (10) and electrical stimulation (1 1) in rats increased the bone formation during the maxillary expansion. During these experimental studies, the osteogenic activities of the administered agents, and the cellular activities of stem cells in the bone formation in this region were not evaluated. In many studies to date, it has been demonstrated that mesenchymal stem cells derived from bone marrow and adipose tissue (BMMSCs. ATMSCs) considerably increased the bone regeneration. Since MSCs are of mesodermal origin, they have the potential to transform into bone tissues (12). Both bone marrow and adipose tissue are clinically easily isolatable tissues (13, 14). The re-transplantation of these isolated tissues to the same patient is called autologous transplantation. Bone marrow and adipose tissue transplantations are successfully applied in the clinical setting during the studies so far (15). The clinical use of these autologous stem cell resources are known not to cause any ethical problem.
United States Patent Application No. 20090148419, which is one of the known applications in the technique, refers to the use of a particular type of adipose tissue derived from mesenchymal stem cells in the treatment of the graft-versus- host disease.
International Patent document No. WO20080081 14, which is also a known application in the technique, refers to the use of stem cells derived from adipose tissue in the treatment of Krabbe disease.
International Patent document No. WO2009046346, which is also a known application in the technique, refers to the stem cell therapy to be used for the treatment of obesity.
A short description of the invention
The purpose of this invention is to enable new bone formation in the midpalatal suture after maxillary expansion by using stem cells from both adipose tissue and bone marrow. The other puipose of the invention is to administer a stem cell therapy which prevents patients from having to use apparatus for a long period of time during the maxillary expansion treatment. Another purpose of the invention is to administer a stem cell therapy which shortens the treatment period for the patients undergoing maxillary expansion.
Yet another purpose of the invention is to administer a stem cell therapy which enables an increase in the area and quality of the newly formed bone structures.
A detailed description of the invention
The figures showing the results obtained from the experimental studies conducted in order to reach the goal of this invention are enclosed and are as follows: Figure 1 - In vitro morphological appearances of ATMSCs (a) and BMMSCs (b).
Figure 2 - Osteocalcin staining: a. ATMSCs, b. BMMSCs; Collagen type 1 staining, c. ATMSCs and d. BMMSCs - The appearances of the differentiation experiment results of ATMSCs and BMMSCs.
Figure 3 - a. ATMSCs and b. BMMSCs - The appearances of premaxillary tissue under fluorescence microscopy.
Figure 4 - A. Osteoblasts (ob), osteoclasts (oc) and vessels (v) formed through the application of BMMSCs in the mid-sutural region. B. Osteoblasts (ob), osteoclasts (oc) and vessels (v) formed through the application of ATMSCs in the mid-sutural region; the appearances of the new bone formations in the mid-palatal suture region.
Figure 5 - The appearance of the histomorphometric analysis of the new bone formation in the mid-palatal suture region; a. The comparison of the bone formation in the suture region; b. The comparison of the number of osteoblasts in the suture region; c. The comparison of the number of vessels in the suture region.
The experimental study and its results providing a basis for the developed model are indicated below.
The isolation and characterization of stem cells
The isolation of BMMSCs and ATMSCs from 3-month-old Wistar rats was conducted with known applications in the technique ( 16, 17). In order to characterize the obtained stem cells, they were analyzed through flow cytometry and then, their in vitro bone-forming potentials were shown.
Maxillary expansion in rats
30 male Wistar rats were distributed in three equal groups. In each group, one single helix of 2 mm in diameter bent from stainless steel wire of 0.014 inches and a spring with arms of 10 mm each were used to expand mid-palatal suture. The activation was made on a millimetric paper and was adjusted to apply a strength of 30 grams.
Under general anesthesia, upper two incisors were drilled with holes on front and back sides at the level of gingival edges (papilla) and the expansion apparatus was placed into these holes from the front of the teeth.
Injection of the Stem Cells
Twenty-four hours following the placement of the expansion apparatus, ATMSCs in the group 1 , BMMSCs in the group 2 and normal saline in the group 3 (control group) were injected into the mid-palatal suture region. Stem Cells were prepared in 100 μΐ of PBS (Phosphate-Buffered Saline) and then injected using insulin needles into the mid-palatal suture region (1 million cells per rat). Following an expansion period of five days, the expansion apparatus was removed and brackets were placed in the holes drilled on the incisors for reinforcement. Following a reinforcement period of 10-14 days, the animals were sacrificed by applying high doses of anesthetics.
Histomorphometric Assessment For the evaluation of hard tissue, the upper jaws of ten animals each from the control and experimental groups were dissected (elimination of the soft tissues) and fixated in a solution of 10% formalin. After the fixation, the brackets used for the reinforcement purposes were removed and the premaxilla was decalcified in 5% formic acid. The sections were obtained at vertical angles to the sagittal plane. The reference points were determined as the apex and 4 mm apical to the alveolar crest. The line passing through the reference planes is along the centre of the incisor crown at the level of gingiva. The samples were embedded in paraffin blocks and serial sections of 5 μπι thickness were obtained. The histological sections were stained with hematoxylin-eosin and then the histomorphometric assessment was conducted.
In vivo tracking of the transplanted stem cells
In order to determine the vitality of transplanted stem cells in the mid-palatal suture region, the bone marrow- and adipose tissue-derived stem cells were marked with PKH67 green (Sigma) cell membrane dye and then injected into the rats. After the conclusion of the experiment, the premaxilla dissected from the rats was frozen on dry ice and then serial sections were obtained with cryotome. The obtained sections were fixated and examined under fluorescence microscopy, and then the presence of the marked stem cells was identified. Results of the experiment
The stem cells obtained from 3-month-old Wistar rats were demonstrated to be similar to MSCs (Mesenchymal Stem Cells) through flow cytometry (Table 1) and differentiation experiments. Table 1. The characterization of ATMSCs and BMMSCs through flow cytometry
MSC markers Hematopoietic markers
The results of the flow cytometry showed that ATMSCs and BMMSCs are positive for MSC markers and negative for hematopoietic markers.
When ATMSCs and BMMSCs were examined under in vitro microscope, it was observed that they had classic MSC morphology (Figure 1 ).
The potentials of ATMSCs and BMMSCs to differentiate into bone cells were shown and it was also shown that these cells produced bone markers - collagen type 1 and osteocalcin proteins - as a result of the differentiation (Figure 2).
10-14 days following the application of ATMSCs and BMMSCs into the rats that had undergone maxillary expansion, the dissected premaxillary tissue was examined under the microscope and the presence of the marked stem cells was identified in the premaxillary tissue (white areas are injected cells a. ATMSCs and b. BMMSCs) (Figure 3).
The newly formed osteoblasts (ob), osteoclasts (oc) and vessels (v) in the mid- palatal suture region in the groups that had undergone stem cell application were identified through the histological assessment (Figure 4). The histomorphometric assessment of the new bone formation in the mid-palatal suture region showed that the stem cell application provided a more effective bone foiTnation compared to the negative control group (in which only normal saline was applied). The application of ATMSCs and BMMSCs enabled faster bone formation in the mid- palatal suture region following the maxillary expansion, and it also increased the number of osteoblasts and vessels in the mid-palatal suture region (Figure 5).
The fact that it was experimentally proved that the application of ATMSCs and BMMSCs accelerated the new bone formation in the mid-palatal suture region and that those stem cells were directly involved in the bone structures through the process of new bone formation paved the way for the new treatment methods. This invention with the obtained findings can be applied to all mammals including humans.
The shortening of the orthodontic treatment period with stem cell therapies, reduction of the relapse rate and thus achieving more stable results and improving the comfort of both patients and physicians are the advantages of this invention. The orthodontic treatment period, which gives a hard time for the patients since having to wear an apparatus during the treatment is esthetically unpleasant and also causes discomfort in their mouths, will be shortened with this application.
Furthermore, the discomfort the patients are having will be relieved and a healthy relationship of the teeth to the jaw will be established. In addition to these, the completion of the treatment will be ensured to take place at a high level of patient cooperation. Thanks to this invention, bone marrow- and adipose tissue-derived stem cells applied following the maxillary expansion - a frequently used method for the orthodontic treatment - made favorable contributions to the healing of the expanded bone tissue. The relapse occurring after the maxillary expansion treatment can be avoided by speeding up the bone healing time and increasing the quality of the bones. Thanks to this application, a shorter treatment period for patients undergoing the maxillary expansion treatment will be ensured and the patients will not have to use apparatus for a long period of time.
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1. A method for the orthodontic maxillary expansion treatment that includes the following steps: the isolation of the stem cells, maxillary expansion and the injection of the stem cells.
2. A method applied with bone marrow-derived stem cells as in claim 1.
3. A method applied with adipose tissue-derived stem cells as in claim 1.
4. A method as in claim 1 or 3, in which the stem cells were injected in the suture region at a dose of 1 million cells per rat.
5. A method applied with adipose tissue-derived mesenchymal stem cells (ATMSCs) as in claim 3. 6. A method applied with bone marrow-derived mesenchymal stem cells
(BMMSCs) as in claim 2.