INTRODUCTION:

Periodontitis is the most common chronic inflammatory disease that occur in periodontal tissue and can lead to alveolar bone resorption.¹ Periodontitis is characterized by the destruction within connective tissue and alveolar bone resorption in the periodontal tissue which occurs due to the inflammatory response triggered by periodontal bacterias.²

The prevalence of chronic periodontitis is ranging from 60% worldwide.³ Based on the previous study, there are about 80% patients suffering from chronic periodontitis experience alveolar bone defect.⁴ Furthermore, alveolar bone resorption in periodontitis can lead to tooth loss.^5-7This indicates that alveolar bone defect therapy is quite challenging and it still requires a potent and effective treatment.^6-8

The existing treatment for chronic periodontitis with alveolar bone defect through tissue engineering approach is by bone grafts.^7-8 Nevertheless, this kind of therapy is lack of growth factor and cells that can accelerate alveolar bone remodeling.Based on this reason, we suggested a better approach for periodontitis with alveolar bone defect treatment by using combination of Mesenchymal Stem Cells (MSCs) and Scaffold. MSCs possessed good proliferation ability aand osteogenic differentiation.⁸ In addition, MSCs secrete various growth factors and advantageous metabolite that may help during wound healing.⁹ Gingival Mesenchymal Stem Cells (GMSCs) and Chitosan scaffold may be promising to overcome the periodontitis. This treatment approach has various advantages such as GMSCs is easily isolated, able to proliferate lineage multipotent mesenchymal differentiation, and able to accelerate osteogenic differentiation in alveolar bone defect.^10-14 Meanwhile, the chitosan scaffold was chosen because it is easy to obtain, biocompatible, non-toxic, and good material for tissue engineering.⁶ The combination of GMSCs and chitosan scaffold may accelerate osteogenic differentiation and induce endogenous mesenchymal stem cell within periodontal tissue to proliferate and differentiate which is expected to be able to form the basis of bone defect reconstruction.^6,9-14This narrative review summarized the potential combination of GMSC and Chitosan scaffold to ameliorate alveolar bone defect in periodontitis.

PERIODONTITIS:

Periodontitis is a chronic inflammatory disease that occurrs in periodontal tissue.¹⁵ A chronic periodontitis may be cause by the poor oral health (e.g. the presence of plaque/calculus), unhealthy habits (e.g. smoking), systemic disorders (e.g. diabetes).^16,17 In addition, some specific genes such as Interleukin-1 (IL-1), IL-6, Tumor Necrosis Factor-α (TNF-α), Fc Fragment Of IgG Receptor IIa (FCGR2A), Complement (C5), Cluster Differentiation (CD14), and WNT5A are predicted to have an important role in periodontitis.^18,-20 The most common opportunist bacteria in the periodontal tissue that cause periodontitis are Porphyromonas gingivalis, Treponema denticola, Tannerella forsythia.²¹ These bacteria are gram-negative anaerobic bacteria that turn into pathogens when there is an imbalance condition in oral cavity microenvironment and unhealthy or disturbance for host immune responses.²²

ALVEOLAR BONE DEFECTS IN PERIODONTITIS:

Alveolar bone defects are the advance form due to the prolong alveolar bone resorption in chronic periodontitis. There are many conditions which can form alveolar bone defects. The immune system and inflammatory response during periodontitis can interfere the regulation of bone formation that can lead to alveolar bone defects.²⁴ Meanwhile, macrophage precursors, Tumor Necrosis Factor-a (TNF-a), Interleukin (IL)-1b, Prostaglandin E2 (PGE2) and the other inflammatory cytokine response can enhance osteoclasts and activate them, thus, the alveolar bone resorption can occur in periodontitis. Furthermore, pro-inflammatory cytokines such as IL-6, IL-11, IL-17, TNF-a are mediators that can also trigger alveolar bone resorption in periodontitis.²⁴ TNF and IL are pro-inflammatory cytokines expressed by the chronic inflammatory cells such as monocytes/macrophages and lymphocytes. TNF-a has an important role in bone cells and bone resorption regulation. Finally, the increased TNF-a can enhance osteoclasts in large numbers, therefore, it can cause alveolar bone resorption in periodontitis.^23,24

P. gingivalis bacteria have a fimbriae structure that can bind some chemokine such as CXC-Chemokine Receptor 4 (CXCR4) and can inhibit the host's immune system reaction on the infected tissue.^21,22,25 CXCR4 is one of the receptors which plays a role in the occurrence of alveolar bone resorption in the periodontitis process because CXCR4 can express osteoclasts as cells that play an important role in the process of bone resorption. The interaction between P. gingivalis’ LPS can enhance CX Chemokine Ligand 12 (CXCL12) interaction with CXCR4 in periodontitis which can lead to alveolar bone resorption and in some more severe condition becomes an alveolar bone defect.²⁶

Alveolar bone defects occur as a progressive complication of periodontitis.²⁵ Periodontal pathogen bacteria is able to disrupt homeostasis between resorption and bone formation; thus, alveolar bone defects occur.²² Periodontal pathogens induce osteotropic by releasing various inflammatory cytokine response. Furthermore, as osteoclast increases, alveolar bone defects occur.²² In chronic periodontitis, T cell, B cell, macrophages, and neutrophils will be stimulated.^24,25 Nuclear Factor Associated T cells 1 (NFATC1) and Sclerostin are important factor to active osteoclasts.²⁶ Thus, osteoclast secrete Carbonic Anhydrase (CA) II, Cathepsin K, and Tartrate Resistant Acid Protein to damage bone lacuna by changing the acidity gradient in the cell and bone surface.^25,26

MESENCHYMAL STEM CELL:

Mesenchymal Stem Cell (MSC) is a multipotent cell which can differentiate to mesenchymal lineage.¹⁴ MSC can be obtained from the mature tissues and proliferate to osteoblast, chondrocyte, and adipocyte by in vivo or in vitro form. Based on the previous study, MSCs can be isolated from adipose, hair follicle, or even the oral tissues such as dental pulp, periodontal ligament, and free margin gingiva.^7,8,27-30

MSC can be isolated from various tissues. MSCs have potential ability in self-renewal also proliferation potent.⁹ Therefore, MSC is often used as the first choice for tissue engineering.²⁹ MSC is expected to express the surface markers, such as cluster of differentiation (CD) in form of CD73, CD90, and CD105; but less expression of CD14, CD34, CD45, CD11b, CD79a, CD19, human leukocyte antigen-antigen D related (HLA-DR) markers on their surface.²⁹ MSC which is isolated from orofacial tissue probably has more potency of regeneration than Bone Marrow MSC (BMMSC). These potential abilities of MSC may be promising to accelerate bone remodeling of alveolar bone defect in the chronic periodontitis patient.^30,31

GINGIVAL MESENCHYMAL STEM CELL:

Gingiva is a part of periodontal tissue which supports the teeth with periodontal ligament, alveolar bone, and cementum. Gingival Mesenchymal Stem Cell (GMSC) is a MSC which is isolated from gingival tissue in the oral cavity.^33,34 GMSCs can be easily isolated with minimum invasive method.³⁵ GMSC should express CD44, CD73, CD90, CD105 but not CD14, CD19, CD34, CD45 surface marker.³⁰ GMSC can differentiate in form of osteoblast and chondroblast by expressing the molecular marker in vitro.³⁴ Osteogenic differentiation of GMSC happens on RNA level which GMSC is able to express the specific bone marker Runt Related Gene 2 (Runx2), collagen I (COL 1), collagen III (COL 3), alkaline phosphatase (ALP), osteonectin (ON), osteopontin (OP), and osterix.^{10-13, 37-39}

CHITOSAN SCAFFOLD:

In the tissue engineering field, scaffold has an important role. Scaffold can be structured by the natural or synthetic material which is intended for medical treatment.⁶ Chitosan is a polymer of D-glucosamine and attached to N-acetyl-D-glucosamine which is soluble to any acid solution. Chitosan scaffold in form of fibers, films, sponges, and hydrogel can be used for tissue engineering.⁴⁰

Chitosan used for scaffold is a natural biopolymer which can be found on shell of crustacea. Chitosan is a derivative of acetylated chitin and has a similar structure to glycosaminoglycan (GAG).⁶ Therefore, chitosan has some characteristics such as biocompatible, biodegradable, osteo-inductive, osteoconductive and osteo-template. Based on the previous research, chitosan scaffold is a promising scaffold that can enhance the osteogenic differentiation of MSC.⁴⁰

Chitosan scaffold has more advantages than any other material such as gelatin, alginate, collagen, or even blood clot. Chitosan scaffold can be used for reconstructing some tissues such as nerve, bone, and accelerating the wound healing.⁴⁰ Chitosan scaffold acts like an extracellular matrix as media of interaction between cells to proliferate and differentiate which may support proliferation and differentiation of GMSC. The use of chitosan as a natural biomaterial of scaffold can interact between cells and biological systems better than synthetic biopolymers such as poly-l-lactide, polyurethane, or polyethylene glycol.^40-41

OSTEOGENESIS:

Osteogenesis is a compact postpartum bone formation process. Osteogenesis process is conducted by osteoblast. Meanwhile, bone remodeling and bone resorption are organized by osteoclast. On extracellular bone matrix formation, osteoblast and osteoclast have important role during bone remodeling. Osteogenesis and bone remodeling processes are crucial mechanism for compact bone development, structure repairment on fracture bone and bone defect, and maintenance for the bone as a whole.^41,42

Osteogenesis process is affected by internal and external factors such as hormone, growth factor, transcription factors, and signaling pathways. The bone formation process starts with proliferation, extracellular matrix maturation, and mineralization. On each phase of bone formation, there are specific bone expression markers founded, consist of Runx2, collagen type 1 (COL 1), alkaline phosphatase (ALP), collagen and non-collagen bone matrix such as osteocalcin (OC), dan osteonectin (ON).⁴² Runx2 and osterix play an important transcription marker on osteogenesis process which is also active on osteoblast cell marker activation.⁴³

ROLE OF GINGIVAL MESENCHYMAL STEM CELLS FOR ALVEOLAR BONE DEFECT REMODELLING:

MSCs was selected and proposed as an alveolar bone defect regeneration due to periodontitis therapy because it has good multipotent, plasticity and proliferation ability, immunomodulators, immunoregulator and endogenous stem cell stimulator.^7,8 GMSC is one of the MSCs which is abundant, most accessible dental tissues, and it can be easily isolated by minimal invasive methods.^10-14 GMSC can be isolated from medical waste after gingivectomy, then it is revitalized until the connective tissue remains.³⁰ In obtaining GMSCs, gingiva tissue then cultured by tissue culture method and passage for 2-4 weeks.^{30,35, 36}

GMSC has the ability to proliferate mesenchymal lineages like MSC in general.³³³⁴ This is evidenced at the mRNA expression level of specific induced osteogenic, adipogenic, and chondrogenic lineages in the compatible media for 28 days.GMSC also has a faster proliferative ability compared to BM-MSC³⁴. Based on the previous study, GMSC proves to be able to reconstruct the calvaria and mandibular defects in mice. This shows that GMSC has promising potential for bone and tissue repair.³¹ The differentiation ability of GMSC into osteoblasts is observed microscopically through Alizarin Red staining after being cultured on Osteogenic Differentiation Medium (ODM) for 15 days and the results reveal the expression of bone markers in the form of Runx2, osteocalcin, osteoprotegrin, and osteonectin which are osteogenic differentiation marker.^10-14 Runx2 is a T cell specific transcriptional regulator that acts as a key regulator of osteoblast differentiation.⁴¹Runx2 acts as an activator for transcription of osteocalcin which is the most specific gene in osteoblasts and induces the expression of several gene markers in osteoblast such as osteopontin, bone sialoprotein (BSP) type 1 and alpha 1 (Col 1α1).^10,13,45 The ability of GMSC to express transcriptional regulators in osteoblasts, especially Runx2, can help to increase the rate of osteoblast differentiation.^10,44,45

CONCLUSION:

Based on our narrative review, we can conclude that combination of GMSC and Chitosan scaffold may be a promising approach and therapy in alveolar bone defect due to periodontitis by accelerating alveolar bone remodeling. Further research is needed for further investigation that analyze the combination of GMSC and chitosan scaffold to accelerate bone remodeling. This latest innovation is expected to be implemented in real terms and can be a therapy for alveolar bone defects in periodontitis patient.

REFERENCE:

1. Suh JS, Kim S, Boström KI, Wang CY, Kim RH, Park NH. Periodontitis-induced systemic inflammation exacerbates atherosclerosis partly via endothelial–mesenchymal transition in mice. International Journal of Oral Science. 2019;11:21.

2. Mounika S, Gopinath G. Periodontitis as a Risk Factor of Atherosclerosis. Research J. Pharm. and Tech. 2016; 9(11): 2017-2019.

3. Tonetti MS, Jepsen S, Jin L, Otomo-Corgel J. Impact of the global burden of periodontal diseases on health, nutrition and wellbeing of mankind: A call for global action. J Clin Periodontol. 2017; 00: 1–7.

4. Divyadharsini V, Sankari M. Effect of Smoking on Interleukin- 1 and Reactive Oxygen Species in Periodontitis. Research J. Pharm. and Tech. 2018; 11(3):1247-1250.

5. Sahar H, Al-Hindawi, Noori, Luaibi, Batool H, Al-Ghurabi. Estimation of Alkaline Phosphatase level in the Serum and Saliva of Hypothyroid Patients with and without Periodontitis. Research J. Pharm. and Tech. 2018; 11(7): 2993-2996.

6. Rezkita F, Wibawa KGP, Nugraha AP. Curcumin loaded Chitosan Nanoparticle for Accelerating the Post Extraction Wound Healing in Diabetes Mellitus Patient: A Review. Research J. Pharm. and Tech. 2020;13(2):1039.

7. Prahasanti C, Nugraha Ap, Saskianti T, Suardita K, Riawan W, Ernawati DS. Exfoliated Human Deciduous Tooth Stem Cells Incorporating Carbonate Apatite Scaffold Enhance BMP-2, BMP-7 and Attenuate MMP-8 Expression During Initial Alveolar Bone Remodeling in Wistar Rats (Rattus norvegicus). Clinical, Cosmetic and Investigational Dentistry 2020: 12 79–85

8. Sari DS, Maduratna E, Ferdiansyah, Latief FDE; Satuman, Nugraha AP, Sudiana K, Rantam FA. Osteogenic Differentiation and Biocompatibility of Bovine Teeth Scaffold with Rat Adipose-derived Mesenchymal Stem Cells. Eur J Dent. 2019;13(2): 206-212.

9. Nugraha AP, Purwati, Susilowati H, Hendrianto E, Karsari D, Ertanti N, Dinaryanti A, Ihsan IS, Narmada IB, Ernawati DS, Rantam FA. Medicinal Signaling Cells Metabolite Oral Based as a Potential Biocompatible Biomaterial Accelerating Oral Ulcer Healing ( in vitro study). Eur Dent J. 2019; 13(3): 432–436.

10. Nugraha AP, Narmada IB, Ernawati DS, Dinaryanti A, Hendrianto E, Ihsan IS, et al. Osteogenic potential of gingival stromal progenitor cells cultured in platelet rich fibrin is predicted by core‑binding factor subunit‑α1/Sox9 expression ratio (in vitro). F1000Research. 2018;7:1134.

11. Nugraha AP, Narmada IB, Ernawati DS, Dinaryanti A, Hendrianto E, Riawan W, Rantam FA. Bone alkaline phosphatase and osteocalcin expression of rat’s Gingival mesenchymal stem cells cultured in platelet-rich fibrin for bone remodeling (in vitro study). Eur J Dent. 2018;12: 566-73.

12. Nugraha AP, Narmada IB, Ernawati DS, Dinaryanti A, Hendrianto E, Ihsan IS, Susilowati H, Rantam FA. Somatic Cells Acceleration by Platelet Rich Fibrin. Indian Vet J. 2019; 94(04): 30-34.

13. Nugraha AP, Narmada IB, Ernawati DS, Dinaryanti A, Hendrianto E, Ihsan IS, Rantam FA. In vitro bone sialoprotein-I expression in combined gingival stromal progenitor cells and platelet rich fibrin during osteogenic differentiation. Tropical Journal of Pharmaceutical Research. 2018; 17 (12): 2341-2345.

14. Nugraha AP, Rezkita F, Putra KG, Narmada IB, Ernawati DS, Rantam FA. Triad Tissue Engineering: Gingival Mesenchymal Stem Cells, Platelet Rich Fibrin and Hydroxyapatite Scaffold to ameliorate Relapse Post Orthodontic Treatment. Biochem. Cell. Arch. 2019; 19(2): 3689-3693.

15. Shreya S, Gheena. The General Awareness among People about the Prevalence of Periodontitis. Research J. Pharm. and Tech. 2015; 8(8): 1119-1124.

16. John J, Emmadi P, Ambalavanan N, Verma E. Comparative Evaluation of Adjunctive Use of Locally Delivered Tetracycline Fiber (Actisite) With Scaling and Root Planning in the Treatment of Chronic Periodontitisa Clinical Study. Research J. Pharm. and Tech. 2013; 6(1): 90-95.

17. Abraham C, Malaiappan S, Savitha G. Association of Hematological and Periodontal Parameters in Healthy, Chronic and Aggressive Periodontitis Patients – A Cross Sectional Study. Research J. Pharm. and Tech. 2019; 12(1): 74-78.

18. Pavithra RS, Varghese S. Gingival Tissue Level of Interleukin-1 in Diabetic Patient with Chronic Periodontitis. Research J. Pharm. and Tech. 2017; 10(12): 4442-4444.

19. Kumar S. Evidence-based update on diagnosis and management of gingivitis and periodontitis. Dental Clinics of North America. 2018: 63(1): 69-81.

20. Abd FG. Polymorphism of IL-4 (-590) and IL-6 (-174) is not associated with Chronic Periodontitis in Babylonian Population. Research J. Pharm. and Tech. 2018; 11(1): 275-280.

21. Hajishengallis G. Periodontitis: from microbial immune subversion to systemic inflammation. Nature Reviews Immunology. 2015;15(1): 30-44.

22. Zhang W, Ju J, Rigney T, Tribble G. Porphyromonas gingivalis infection increases osteoclastic bone resorption and osteoblastic bone formation in a periodontitis mouse model. BMC Oral Health. 2014, 14:89

23. Wisitrasameewong W, Kajiya M, Movila A, Rittling S, Ishii T, Suzuki M, Matsuda S,. Mazda Y, Torruella MR, Azuma MM, Egashira K, Freire MO, Sasaki H, Wang CY, Han X, Taubman MA, Kawai T. DC-STAMP is an osteoclast fusogen engaged in periodontal bone resorption. Journal of Dental Research. 2017: 1-9.

24. Hienz SA, Paliwal S, Ivanovski S. Mechanisms of bone resorption in periodontitis. Journal of Immunology Research. 2015; 2015:1-10.

25. Nagashima H, Shinoda M, Honda K, Kamio N, Hasuike A, Sugano N, Arai Y, Sato S, Iwata K. CXCR4 signaling contributes to alveolar bone resorption in Porphyromonas gingivalis-induced periodontitis in mice. Journal of Oral Science. 2017; 59(4): 571-577.

26. Hermawan RW, Narmada IB, Djaharu’ddin I, Nugraha AP, Rahmawati D. The Influence of Epigallocatechin Gallate on the Nuclear Factor Associated T Cell-1 and Sclerostin Expression in Wistar Rats (Rattus novergicus) during the Orthodontic Tooth Movement. Research J. Pharm. and Tech. 2020; 13(4): 1730-1734.

27. Suciadi SP, Nugraha AP, Ernawati DS, Ayuningtyas NF, Narmada IB, Prahasanti C, Dinaryanti A, Ihsan IS, Hendrianto E, Susilowati H, Rantam FA. The Efficacy of Human Dental Pulp Stem Cells in regenerating Submandibular Gland Defects in Diabetic Wistar Rats (Rattus novergicus). Research J. Pharm. and Tech. 2019; 12(4): 1573-1579.

28. Narmada IB, Laksono V, Nugraha AP, Ernawati DS, Winias S, Prahasanti C, Dinaryanti A, Susilowati H, Hendrianto E, Ihsan IS, Rantam FA. Regeneration of Salivary Gland Defects of Diabetic Wistar Rats Post Human Dental Pulp Stem Cells Intraglandular Transplantation on Acinar Cell Vacuolization and Interleukin-10 Serum Level. Pesquisa Brasileira em Odontopediatria e Clínica Integrada 2019; 19(e5002): 1-10.

29. Rantam FA, Nugraha AP, Ferdiansyah F, Purwati P, Bumi C, Susilowati H, Hendrianto E, utomo DN, Suroto H, Sumartono C, Setiawati R, Prakoeswa CR, Indramaya DM. A Potential Differentiation of Adipose and Hair Follicle-derived Mesenchymal Stem Cells to Generate Neurons Induced with EGF, FGF, PDGF and Forskolin. Research J. Pharm. and Tech. 2020; 13(1): 275-281

30. Rantam FA, Nugraha AP, Narmada IB, Ernawati DS, Widodo ADW, Lestari P, et al. Gingival mesenchymal stem cells from wistar rat’s gingiva (Rattus Novergicus) - Isolation and characterization (In Vitro Study). J Int Med Res. 2018;11:694-9.

31. Ansari S, Seagrove JT, Chen C, Shah K, Aghaloo T, Wu BM, Bencharit S, Moshaverinia A. Dental and orofacial mesenchymal stem cells in craniofacial regeneration: The prosthodontist’s point of view. J Prosthet Dent. 2017;118(4): 455-461.

32. Liu J, Yu F, Sun Y, Jiang B, Zhang W, Yang J, Xu GT, Liang A, Liu S. Concise Reviews: Characteristics and Potential Applications of Human Dental Tissue-Derived Mesenchymal Stem Cells. An Overview of Human Dental Tissue-Derived MSCs. Stem Cells. 2015;33(3): 627-38.

33. Fawzy El-Sayed K, Dörfer C. Gingival Mesenchymal Stem/Progenitor Cells: A Unique Tissue Engineering Gem. Stem Cells International. 2016;2016: 1-16.

34. Nugraha AP, Narmada IB, Ernawati DS, Dinaryanti A, Susilowati H, Hendrianto E, Ihsan IS, Riawan W, Rantam FA. Somatic Cells Acceleration by Platelet Rich Fibrin. Indian Vet J 2019;96(04): 30-34.

35. Nugraha AP, Narmada IB, Ernawatı DS, Dınaryantı A, Hendrıanto E, Ihsan IS, Riawan W, Rantam FA: The aggrecan expression post platelet rich fibrin administration in gingival medicinal signaling cells in Wistar rats (Rattus novergicus) during the early osteogenic differentiation (in vitro). Kafkas Univ Vet Fak Derg. 2019; 25 (3): 421-425.

36. Ramamoorthi M, Bakkar M, Jordan J, Tran SD. Osteogenic Potential of Dental Mesenchymal Stem Cells in Preclinical Studies: A Systematic Review Using Modified ARRIVE and CONSORT Guidelines. Stem Cells International. 2015; 1-28.

37. Mao X, Liu Y, Chen C, Shi S. Mesenchymal Stem Cells and Their Role in Dental Medicine. Dental Clinic of North America. 2017;61(1): 161-172.

38. Girijaa DM, Raob SR, Kalachaveeduc M, Subbarayand R. Osteogenic differentiation of Human Gingival Mesenchymal Stem cells by Aristolochia bracteolata supplementation through enhanced Runx2 expression. Journal of Cellular Physiology. 2017: 1-15.

39. Vázquez MR, Ruiz BV, Zúñiga RR, Koppel DAS, Olvera LFQ. Chitosan and its potential use as a scaffold for tissue engineering in regenerative medicine. BioMed Research International. 2015; 2015: 1-16

40. Li X, Ding J, Zhuang X, Chang F, Wang J, Chen X. Chitosan-based scaffolds for cartilage regeneration. Springer Series on Polymer and Composite Materials. 2016: 61-82.

41. Rutkovskiy A, Stensløkken K, Vaage IJ. Osteoblast Differentiation at a Glance. Medical Science Monit Basic Res. 2016; 22: 95-106.

42. Sitasari PI, Narmada IB, Hamid T, Triwardhani A, Nugraha AP, Rahmawati D. East Java green tea methanolic extract can enhance RUNX2 and Osterix expression during orthodontic tooth movement in vivo. J Pharm Pharmacogn Res 2020; 8(4): 290–298.

43. Libro R, Scionti D, Diomede F, Marchisio M, Grassi G, Pollastro F, Piattelli A, Bramanti P, Mazzon E, Trubiani O. Cannabidiol Modulates the Immunophenotype and Inhibits the Activation of the Inflammasome in Human Gingival Mesenchymal Stem Cells. Frontier’s in Physiology. 2016; 7(559): 1-17.

44. Du L, Yang P, Ge S. Two-stage reconstruction of the severely deficient alveolar ridge: bone graft followed by alveolar distraction osteogenesis. International Association of Oral and Maxillofacial Surgeons. 2017;47: 117-124.

45. Tomasello L, Mauceri R, Coppola A, Pitrone M, Pizzo G, Campisi G, Pizzolanti G, Giordano C. Mesenchymal stem cells derived from inflamed dental pulpal and gingival tissue: a potential application for bone formation. Stem Cell Research & Therapy. 2017;8(179): 1-15.

Received on 06.07.2019 Modified on 21.09.2019

Research J. Pharm. and Tech 2020; 13(5):2502-2506.

DOI: 10.5958/0974-360X.2020.00446.1