Tissue engineering of oral mucosa combines cells, materials and engineering to produce a three-dimensional reconstruction of oral mucosa. It is meant to simulate the real anatomical structure and function of oral mucosa. Tissue engineered oral mucosa shows promise for clinical use, such as the replacement of soft tissue defects in the oral cavity. These defects can be divided into two major categories: the gingival recessions (receding gums) which are tooth-related defects, and the non tooth-related defects. Non tooth-related defects can be the result of trauma, chronic infection or defects caused by tumor resection or ablation (in the case of oral cancer). Common approaches for replacing damaged oral mucosa are the use of autologous grafts and cultured epithelial sheets.
Autologous grafts Autologous grafts are used to transfer tissue from one site to another on the same body. The use of autologous grafts prevents transplantation rejection reactions. Grafts used for oral reconstruction are preferably taken from the oral cavity itself (such as gingival and palatal grafts). However, their limited availability and small size leads to the use of either skin transplants or intestinal mucosa to be able to cover bigger defects. Other than tissue shortage, donor site morbidity is a common problem that may occur when using autologous grafts. When tissue is obtained from somewhere other than the oral cavity (such as the intestine or skin) there is a risk of the graft not being able to lose its original donor tissue characteristics. For example, skin grafts are often taken from the radial forearm or lateral upper arm when covering more extensive defects. A positive aspect of using skin grafts is the large availability of skin. However, skin grafts differ from oral mucosa in: consistency, color and keratinization pattern. The transplanted skin graft often continues to grow hair in the oral cavity.
Normal oral mucosa
To better understand the challenges for building full-thickness engineered oral mucosa it is important to first understand the structure of normal oral mucosa. Normal oral mucosa consists of two layers, the top stratified squamous epithelial layer and the bottom lamina propria. The epithelial layer consists of four layers:
Stratum basale (basal layer) Stratum spinosum (spinous layer) Stratum granulosum (granular layer) Stratum corneum (keratinized/superficial layer) Depending on the region of the mouth the epithelium may be keratinized or non-keratinized. Non-keratinized squamous epithelium covers the soft palate, lips, cheeks and the floor of the mouth. Keratinized squamous epithelium is present in the gingiva and hard palate. Keratinization is the differentiation of keratinocytes in the granular layer into dead surface cells to form the stratum corneum. The cells terminally differentiate as they migrate to the surface (from the basal layer where the progenitor cells are located to the dead superficial surface). The lamina propria is a fibrous connective tissue layer that consists of a network of type I and III collagen and elastin fibers. The main cells of the lamina propria are the fibroblasts, which are responsible for the production of the extracellular matrix. The basement membrane forms the border between the epithelial layer and the lamina propria.
Tissue engineered oral mucosa
Partial-thickness engineered oral mucosa Cell culture techniques make it possible to produce epithelial sheets for the replacement of damaged oral mucosa. Partial-thickness tissue engineering uses one type of cell layer, this can be in monolayers or multilayers. Monolayer epithelial sheets suffice for the study of the basic biology of oral mucosa, for example its responses to stimuli such as mechanical stress, growth factor addition and radiation damage. Oral mucosa, however, is a complex multilayer structure with proliferating and differentiating cells and monolayer epithelial sheets have been shown to be fragile, difficult to handle and likely to contract without a supporting extracellular matrix. Monolayer epithelial sheets can be used to manufacture multilayer cultures. These multilayer epithelial sheets show signs of differentiation such as the formation of a basement membrane and keratinization. Fibroblasts are the most common cells in extracellular matrix and are important for epithelial morphogenesis. If fibroblasts are absent from the matrix, the epithelium stops proliferating but continues to differentiate. The structures obtained by partial-thickness oral mucosa engineering form the basis for full-thickness oral mucosa engineering.
Full-thickness tissue engineered oral mucosa With the advancement of tissue engineering an alternative approach was developed: the full-thickness engineered oral mucosa. Full-thickness engineered oral mucosa is a better simulation of the in vivo situation because they take the anatomical structure of native oral mucosa into account. Problems, such as tissue shortage and donor site morbidity, do not occur when using full-thickness engineered oral mucosa. The main goal when producing full-thickness engineered oral mucosa is to make it resemble normal oral mucosa as much as possible. This is achieved by using a combination of different cell types and scaffolds.
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