Modulating macrophage polarization with divalent cations in nanostructured titanium implant surfaces.

Nanoscale topographical modification and surface chemistry alteration using bioactive ions are centrally important processes in the current design of the surface of titanium (Ti) bone implants with enhanced bone healing capacity. Macrophages play a central role in the early tissue healing stage and their activity in response to the implant surface is known to affect the subsequent healing outcome. Thus, the positive modulation of macrophage phenotype polarization (i.e. towards the regenerative M2 rather than the inflammatory M1 phenotype) with a modified surface is essential for the osteogenesis funtion of Ti bone implants. However, relatively few advances have been made in terms of modulating the macrophage-centered early healing capacity in the surface design of Ti bone implants for the two important surface properties of nanotopography and and bioactive ion chemistry. We investigated whether surface bioactive ion modification exerts a definite beneficial effect on inducing regenerative M2 macrophage polarization when combined with the surface nanotopography of Ti. Our results indicate that nanoscale topographical modification and surface bioactive ion chemistry can positively modulate the macrophage phenotype in a Ti implant surface. To the best of our knowledge, this is the first demonstration that chemical surface modification using divalent cations (Ca and Sr) dramatically induces the regenerative M2 macrophage phenotype of J774.A1 cells in nanostructured Ti surfaces. In this study, divalent cation chemistry regulated the cell shape of adherent macrophages and markedly up-regulated M2 macrophage phenotype expression when combined with the nanostructured Ti surface. These results provide insight into the surface engineering of future Ti bone implants that are harmonized between the macrophage-governed early wound healing process and subsequent mesenchymal stem cell-centered osteogenesis function.

Positive modulation of osteogenesis- and osteoclastogenesis-related gene expression with strontium-containing microstructured Ti implants in rabbit cancellous bone.

This study investigated the in vivo osteoblast and osteoclast gene expression in the peri-implant bone tissue of the strontium (Sr)-incorporated microstructured Ti implants (SLA/Sr) in order to evaluate whether local Sr delivery to the implant surface as in the form of SrTiO(3) also exerts original bone healing enhancement effect of Sr that take place through the dual modes of action of a stimulation of osteogenesis and an inhibition of osteoclastogenesis. The in vivo mRNA expression of osteoblast- and osteoclast-related genes in the peri-implant bone and removal torque forces of the SLA/Sr implants were compared with a chemically modified super-hydrophilic SLA implants (SLActive®) in rabbit cancellous bone after 2 weeks of implantation. There was no significant difference in the removal torque values between the two groups. Both the torque-tested SLA/Sr and SLActive implants exhibited a considerable quantity of bone attached to the surface. Real-time PCR analysis revealed notably increased mRNA expression of osteoblast genes (Runx2, osterix and osteocalcin) in the peri-implant bone of the SLA/Sr implants compared with the SLActive implants (p < 0.05), whereas osteoclast phenotype gene (TRAP) expression was markedly decreased in the SLA/Sr implant (p < 0.05). The results at the molecular level suggest that local Sr delivery as in the form of the Sr-incorporated Ti oxide layer favors early osseointegration of microrough Ti implants via a positive modulation of bone healing, that is, a promotion of osteoblast differentiation and suppression of osteoclastogenesis, in the bone-implant interface of cancellous bone.

Role of subnano-, nano- and submicron-surface features on osteoblast differentiation of bone marrow mesenchymal stem cells.

Subnano, nano and sub-micron surface features can selectively activate integrin receptors and induce osteoblast differentiation of bone marrow mesenchymal stem cells. Although it is widely accepted that nanoscale titanium surface roughness may promote differentiation of various osteoblast lineages, there has been no clear report on the threshold dimension of surface features and the optimized dimensions of surface features for triggering integrin activation and stem cell differentiation. This study systematically controlled titanium surface features from the sub-nano to sub-micron scales and investigated the corresponding effects on stem cell responses, such as integrin activation, cyclins, key transcriptional genes of osteoblast differentiation and osteoblastic phenotype genes. Surface features with sub-nano surface dimensions were insufficient to increase integrin activation compared to pure nanoscale titanium surface features. Although both pure nanoscale and nano-submicron hybrid scales of titanium surface features were sufficient for activating integrin-ligand proteins interactions through the α integrin subunits, only nano-submicron hybrid titanium surface features significantly accelerated subsequent osteoblast differentiation of primary mouse bone marrow stromal cells after 2 weeks. In addition, live cell analysis of human bone marrow mesenchymal stem cells on transparent titanium demonstrated rapid cytoskeletal re-organization on the nanoscale surface features, which ultimately induced higher expression of osteoblast phenotype genes after 3 weeks.

Surface characteristics and primary bone marrow stromal cell response of a nanostructured strontium-containing oxide layer produced on a microrough titanium surface.

Strontium (Sr) has been successfully used for the treatment of osteoporotic bone, increasing new bone formation while reducing bone resorption by stimulating proliferation and differentiation of osteoblastic cells and inhibiting osteoclast function. In this study, Sr-incorporated Ti oxide layer was produced on clinically relevant osteoconductive implant surface, that is, a grit-blasted microrough Ti surface, by a simple hydrothermal treatment with the expectation of utilizing the osteoblast response enhancement effect of Sr for the future applications as a more osteoconductive surface of the permanent load-bearing endosseous implants, without altering the original microrough surface features of grit-blasted Ti at the micron-scale. This surface exhibits a hierarchical structure (i.e., a nanoscale surface architecture of the Sr-incorporated Ti oxide layer (SrTiO(3)) imposed on micron-scale rough Ti structure) and Sr ion release into physiological solution. In vitro experiments using primary mouse bone marrow stromal cells (BMSCs) revealed that the hydrothermally produced SrTiO(3) coating promotes both the early and late cell response of BMSCs grown on a microrough Ti surface, with notably enhanced attachment, spreading, focal adhesion, alkaline phosphatase activity, and expression of critical integrins and osteoblastic phenotype genes. These results indicate that a hydrothermally produced SrTiO(3) coating improves the osteoconductivity of the microrough Ti surface by enhancing both the early and late cell response of BMSCs.

Increased new bone formation with a surface magnesium-incorporated deproteinized porcine bone substitute in rabbit calvarial defects.

This study investigated the effects of magnesium ion (Mg) incorporation into the surface of deproteinized porcine cancellous bone in the bone healing of rabbit calvarial defects with the expectation of utilizing the integrin-ligand binding enhancement effect of Mg, and compared its bone healing capacity with that of untreated porcine cancellous bone and deproteinized bovine bone (Bio-Oss). Hydrothermal treatment was performed to produce Mg-incorporated porcine bone using an alkaline Mg-containing solution. The surface morphology and chemical composition of the samples were investigated using scanning electron microscopy, energy-dispersive X-ray spectrometry, and X-ray photoelectron spectroscopy. Defects 7 mm in diameter were created in the calvaria of 14 adult male New Zealand White rabbits and were filled with (1) untreated porcine bone (PB), (2) Bio-Oss, and (3) Mg-containing porcine bone (MG). The percentage of newly formed bone (NB%) was evaluated histomorphometrically at 2 and 4 weeks after implantation. Hydrothermal treatment resulted in a Mg-containing surface in porcine bone covered with nanostructures ~100 nm in size. The MG group supported better new bone formation compared with the other groups. Osteoconductive new bone formation was observed in the central defect area in the MG group at an early healing time-point. Histomorphometric analysis revealed significantly greater NB% in the MG group when compared with the untreated PB and Bio-Oss groups at 4 weeks (p < 0.05). The Mg-incorporated porcine bone with surface nanostructures achieved rapid new bone formation in the osseous defects of rabbit calvaria compared with untreated xenografts of porcine and bovine origin.

Effect of the pore structure of bioactive glass balls on biocompatibility in vitro and in vivo.

We prepared porous bioactive glass (BG) balls with various pore architectures using a modified version of a polymer templating technique which is generally used for the synthesis of mesoporous BG. Sol-gel derived porous BG is an excellent candidate as a graft material for bone tissue regeneration due to its good bone forming bioactivity and biodegradability. The biodegradability is largely related to the pore architecture and affects its biocompatibility. The pore architecture of the BG balls was controllable by changing the reaction time in chloroform. The relationship between the pore architecture of the BG balls and biocompatibility were studied using MC3T3-E1 pre-osteoblast cells in vitro and the rabbit calvarial model in vivo 8 weeks after implantation. The mesoporous BG balls (BG0) and porous BG beads with a hierarchical pore structure on the nano- to microscale (BG0.5 and BG2) showed a good cell proliferation response and differentiation behavior in vitro and in vivo without serious toxicity. These hierarchically porous structures also enhanced osteoconductivity. However, the existence of too many microscale pores in the BG balls (BG24) led to their rapid biodegradation and, consequently, to serious negative effects in vitro and in vivo. The pore architecture of the BG balls greatly influenced their biocompatibility, as well as bone formation, and should be carefully controlled when designing new materials for use in bioapplications. The porous BG balls with hierarchical pores on the nano- to microscale exhibit favorable biocompatibility in vitro and promise excellent potential applications in the field of biomaterials, such as tissue regeneration and drug storage.

MC3T3-E1 cell differentiation and in vivo bone formation induced by phosphoserine.

Bone formation induced by phosphoserine was investigated in vitro and in vivo using MC3T3-E1 cells and a rabbit calvarial osseous defect model. MC3T3-E1 cells supplemented by phosphoserine displayed two-fold higher alkaline phosphatase activity and mineralization nodule formation, and calvarial defects treated with phosphoserine showed statistically significant new bone formation compared with the control (P < 0.05).

Improved pre-osteoblast response and mechanical compatibility of ultrafine-grained Ti-13Nb-13Zr alloy.

OBJECTIVE: Metallic implantation materials having high yield strength, low elastic modulus, and non-cytotoxic alloying elements would be advantageous for the long-term stability of implants. This study assessed the surface and mechanical properties, and also in vitro osteoconductivity of ultrafine-grained (UFG) Ti-13Nb-13Zr alloy produced by dynamic globularization without any severe deformation for future biomedical applications as an endosseous implant material. MATERIAL AND METHODS: The surface characteristics and mechanical properties were investigated by orientation image microscopy, contact angle measurements, optical profilometry, and uniaxial tension tests. Mouse calvaria-derived pre-osteoblastic cell (MC3T3-E1) attachment, spreading, viability, alkaline phosphatase (ALP) activity, and quantitative analysis of osteoblastic gene expression on UFG Ti-13Nb-13Zr alloy were compared with coarse-grained (CG) Ti-13Nb-13Zr and CG Ti-6Al-4V alloys. RESULTS: Dynamic globularized Ti-13Nb-13Zr alloy has an ultrafine grain size (0.3 µm) and an excellent combination of yield strength and elastic modulus compared with CG alloys, which displayed significantly lower water contact angles compared with CG alloys (P<0.05). The UFG and CG Ti-13Nb-13Zr alloys displayed significantly increased cellular attachment compared with CG Ti-6Al-4V alloy (P<0.05). The UFG Ti-13Nb-13Zr supported better cell spreading and more numerous focal adhesions. ALP activity (P<0.05) and mRNA expressions of the osteoblast transcription factor genes (osterix, Runx2) and marker gene for osteoblast differentiation (osteocalcin) were markedly increased in cells grown on the UFG substrate compared with CG substrates at early incubation timepoints. CONCLUSION: Enhanced pre-osteoblast response to UFG Ti-13Nb-13Zr substrate is attributable to the non-cytotoxic alloying elements and the submicron scale grain size contributes to the superior surface hydrophilicity and abundant grain boundaries favorable for cell behavior. These findings indicate that dynamic globularized UFG Ti-13Nb-13Zr alloy is promising for load-bearing endosseous implant material because of excellent mechanical and biological compatibilites.

Osteoblast response to magnesium ion-incorporated nanoporous titanium oxide surfaces.

OBJECTIVE: This study investigated the surface characteristics and in vitro osteoconductivity of a titanium (Ti) surface incorporated with the magnesium ions (Mg) produced by hydrothermal treatment for future application as an endosseous implant surface. MATERIAL AND METHODS: Mg-incorporated Ti oxide surfaces were produced by hydrothermal treatment using Mg-containing solution on two different microstructured surfaces--abraded minimally rough (Ma) or grit-blasted moderately rough (RBM) samples. The surface characteristics were evaluated using scanning electron microscopy, thin-film X-ray diffractometry, X-ray photoelectron spectroscopy, optical profilometry, and inductively coupled plasma atomic emission spectroscopy (ICP-AES). MC3T3-E1 pre-osteoblast cell attachment, proliferation, alkaline phosphatase (ALP) activity, and quantitative analysis of osteoblastic gene expression on Ma, RBM, Mg-incorporated Ma (Mg), and Mg-incorporated grit-blasted (RBM/Mg) Ti surfaces were evaluated. RESULTS: Hydrothermal treatment produced an Mg-incorporated Ti oxide layer with nanoporous surface structures. Mg-incorporated surfaces showed surface morphologies and surface roughness values almost identical to those of untreated smooth or micro-rough surfaces at the micron scale. ICP-AES analysis showed Mg ions released from treated surfaces into the solution. Mg incorporation significantly increased cellular attachment (P=0 at 0.5 h, P=0.01 at 1 h) on smooth surfaces, but no differences were found on micro-rough surfaces. Mg incorporation further increased ALP activity in cells grown on both smooth and micro-rough surfaces at 7 and 14 days of culture (P=0). Real-time polymerase chain reaction analysis showed higher mRNA expressions of the osteoblast transcription factor gene (Dlx5), various integrins, and the osteoblast phenotype genes (ALP, bone sialoprotein and osteocalcin) in cells grown on micro-rough (RBM) and Mg-incorporated (Mg and RBM/Mg) surfaces than those on Ma surfaces. Mg incorporation further increased the mRNA expressions of key osteoblast genes and integrins (α1, α2, α5, and ß1) in cells grown on both the smooth and the micro-rough surfaces. CONCLUSION: These results indicate that an Mg-incorporated nanoporous Ti oxide surface produced by hydrothermal treatment may improve implant bone healing by enhancing the attachment and differentiation of osteoblastic cells.

Enhanced osteoblast response to hydrophilic strontium and/or phosphate ions-incorporated titanium oxide surfaces.

OBJECTIVE: This study investigated the surface characteristics and in vitro biocompatibility of titanium (Ti) surfaces incorporated with strontium ions (Sr) and/or phosphate ions (P) produced by hydrothermal treatment for future applications as endosseous implant surfaces. MATERIAL AND METHODS: Sr and/or P-incorporated Ti oxide surfaces were produced by hydrothermal treatment. The surface characteristics were evaluated by scanning electron microscopy, thin-film X-ray diffractometry, X-ray photoelectron spectroscopy, contact angle and surface energy measurements, inductively coupled plasma atomic emission spectroscopy, and profilometry. MC3T3-E1 pre-osteoblast cell attachment, morphology of spread cells, viability, and quantitative analysis of osteoblastic gene expression on grit-blasted microrough (RBM), P-incorporated (P), and P- and Sr-incorporated (SrP) Ti surfaces were evaluated. RESULTS: Microstructured P and SrP surfaces showed significantly higher wettability and surface energy compared with RBM surfaces (P<0.01). After immersion in Hank's balanced salt solution, considerable apatite deposition was observed on the P and SrP surfaces. Sr incorporation significantly increased cellular attachment and viability compared with other surfaces (P<0.05). Real-time polymerase chain reaction analysis showed markedly higher mRNA expressions of the osteoblast transcription factor gene (Runx2) and the osteoblast phenotype genes (alkaline phosphatase, osteopontin, bone sialoprotein, and osteocalcin) in cells grown on the P and SrP surfaces compared with those on the RBM surface. CONCLUSIONS: These results demonstrate that Sr- and P-incorporated Ti oxide surfaces may improve implant bone healing by enhancing attachment, viability, and differentiation of osteoblastic cells.

Healing of rabbit calvarial bone defects using biphasic calcium phosphate ceramics made of submicron-sized grains with a hierarchical pore structure.

OBJECTIVES: This study investigated the efficacy of new bone graft substitutes - biphasic calcium phosphates (BCP) made of submicron-sized grains with fully interconnected wide-range micron-scale pores in two different macrodesigns: donut shaped with a 300-400 microm central macropore (n-BCP-1) or rod-shaped (n-BCP-2)--in the healing of rabbit calvarial defects, and compared their bone-healing properties with those of various commercial bone substitutes, which included substitutes with similar BCP composition (MBCP and Osteon), anorganic bovine bone (Bio-Oss), and beta-TCP (Cerasorb). MATERIAL AND METHODS: The surface morphology of the bone substitutes was investigated using scanning electron microscopy (SEM). Defects 8 mm in diameter were created in the calvaria of 30 adult male New Zealand White rabbits and were filled with six types of bone substitutes. The percentage of newly formed bone (NB%) was evaluated histomorphometrically 4 and 8 weeks after implantation. RESULTS: SEM observation showed submicron-sized grains with fully interconnected micropore structures in the n-BCP-1 and n-BCP-2 groups; these groups also showed considerable new bone formation in inner micropores as well as on the outer surfaces. The n-BCP-1 group exhibited enhanced new bone formation and direct ingrowth of bone tissue with blood vessels into central pores. Histomorphometric analysis showed significantly greater NB% in the n-BCP-1 group when compared with the other groups at 4 and 8 weeks (P<0.05). CONCLUSION: A new BCP ceramics made of submicron-sized grains with a hierarchical pore structure was an effective osteoconductive material for the treatment of osseous defects of rabbit calvaria.

Osteoblast response and osseointegration of a Ti-6Al-4V alloy implant incorporating strontium.

This study investigated the surface characteristics, in vitro and in vivo biocompatibility of Ti-6Al-4V alloy implants incorporating strontium ions (Sr), produced by hydrothermal treatment using a Sr-containing solution, for future biomedical applications. The surface characteristics were evaluated by scanning electron microscopy, thin-film X-ray diffractometry, X-ray photoelectron spectroscopy, optical profilometry, contact angle and surface energy measurement and inductively coupled plasma-mass spectroscopy (ICP-MS). Human osteoblast-like cell (MG63) attachment, proliferation, alkaline phosphatase (ALP) activity, and quantitative analysis of osteoblastic gene expression on Sr-containing Ti-6Al-4V surfaces were compared with untreated Ti-6Al-4V surfaces. Fifty-six screw implants (28 control and 28 experimental) were placed in the tibiae and femoral condyles of seven New Zealand White rabbits. The osteoconductivity of Sr-containing Ti-6Al-4V implants was evaluated by removal torque testing and histomorphometric analysis after 4weeks implantation. Hydrothermal treatment produced a crystalline SrTiO(3) layer. ICP-MS analysis showed that Sr ions were released from treated surfaces into the solution. Significant increases in ALP activity (P=0.000), mRNA expressions of key osteoblast genes (osterix, bone sialoprotein, and osteocalcin), removal torque values (P<0.05) and bone-implant contact percentages (P<0.05) in both cortical and cancellous bone were observed for Sr-containing Ti-6Al-4V surfaces. The results indicate that the Sr-containing oxide layer produced by hydrothermal treatment may be effective in improving the osseointegration of Ti-6Al-4V alloy implants by enhancing differentiation of osteoblastic cells, removal torque forces and bone apposition in both cortical and cancellous bone.

Effects of phosphoric acid treatment of titanium surfaces on surface properties, osteoblast response and removal of torque forces.

This study investigated the surface characteristics and biocompatibility of phosphate ion (P)-incorporated titanium (Ti) surfaces hydrothermally treated with various concentrations of phosphoric acid (H(3)PO(4)). The surface characteristics were evaluated by scanning electron microscopy, thin-film X-ray diffractometry, X-ray photoelectron spectroscopy, optical profilometry, contact angle and surface energy measurement and inductively coupled plasma mass spectroscopy (ICP-MS). MC3T3-E1 cell attachment, spreading, proliferation and osteoblastic gene expression on different surfaces were evaluated. The degree of bony integration was biomechanically evaluated by removal torque testing after 4 weeks of healing in rabbit tibiae. The H(3)PO(4) treatment produced micro-rough Ti surfaces with crystalline P-incorporated Ti oxide layers. High concentration H(3)PO(4) treatment (1% and 2%) produced significantly higher hydrophilic surfaces compared with low H(3)PO(4) treatment (0.5%) and untreated surfaces (P<0.01). ICP-MS analysis showed P ions were released from P-incorporated surfaces. Significant increased cell attachment (P<0.05) and notably higher mRNA expressions of Runx2, alkaline phosphatase, osteopontin and osteocalcin were observed in cells grown on P-incorporated surfaces compared with cells on untreated machined surfaces. P-incorporated surfaces showed significantly higher removal torque forces compared with untreated machined implants (P<0.05). Ti surfaces treated with 2% H(3)PO(4) showed increasing tendencies in osteoblastic gene expression and removal torque forces compared with those treated with lower H(3)PO(4) concentrations or untreated surfaces. These results demonstrate that H(3)PO(4) treatment may improve the biocompatibility of Ti implants by enhancing osteoblast attachment, differentiation and biomechanical anchorage.

Enhanced osteoblast response to an equal channel angular pressing-processed pure titanium substrate with microrough surface topography.

This study investigated the surface characteristics and in vitro biocompatibility of ultrafine-grain pure titanium substrates produced by equal channel angular pressing (ECAP) using MC3T3-E1 pre-osteoblast cells, compared with those of conventional coarse-grain pure titanium (CP) and Ti-6Al-4V (Ti64) substrates. All Ti surfaces were grit-blasted with hydroxyapatite particles to produce microrough surfaces. The surface characteristics were evaluated by electron back-scattered diffractometry, scanning electron microscopy, contact angle and surface energy measurements, and optical profilometry. The morphology of spread cells, cell attachment, viability, alkaline phosphatase (ALP) activity, quantitative analysis of osteoblastic gene expression and mineralization nodule formation on different surfaces were evaluated. ECAP-processed substrates showed a significantly lower water contact angle and higher surface energy compared with coarse-grain CP and Ti64 substrates (p<0.05). They also showed enhanced cell spreading, attachment, viability and ALP activity compared with the CP and Ti64 surfaces (p<0.05). Real-time polymerase chain reaction analysis showed notably higher ALP, osteopontin and osteocalcin mRNA levels in cells grown on the ECAP surfaces than on the CP and Ti64 surfaces, and the ECAP surfaces showed significantly greater mineralization nodule formation compared with the CP and Ti64 substrates (p<0.05). These results demonstrate the superior osteoblast cell compatibility of microroughened Ti surface made of ECAP-processed ultrafine-grain pure Ti substrates over coarse-grain pure Ti and Ti64 substrates.

Osteoconductivity of hydrophilic microstructured titanium implants with phosphate ion chemistry.

This study investigated the surface characteristics and bone response of titanium implants produced by hydrothermal treatment using H(3)PO(4), and compared them with those of implants produced by commercial surface treatment methods - machining, acid etching, grit blasting, grit blasting/acid etching or spark anodization. The surface characteristics were evaluated by scanning electron microscopy, thin-film X-ray diffractometry, X-ray photoelectron spectroscopy, contact angle measurement and stylus profilometry. The osteoconductivity of experimental implants was evaluated by removal torque testing and histomorphometric analysis after 6 weeks of implantation in rabbit tibiae. Hydrothermal treatment with H(3)PO(4) and subsequent heat treatment produced a crystalline phosphate ion-incorporated oxide (titanium oxide phosphate hydrate, Ti(2)O(PO(4))(2)(H(2)O)(2); TiP) surface approximately 5microm in thickness, which had needle-like surface microstructures and superior wettability compared with the control surfaces. Significant increases in removal torque forces and bone-to-implant contact values were observed for TiP implants compared with those of the control implants (p<0.001). After thorough cleaning of the implants removed during the removal torque testing, a considerable quantity of attached bone was observed on the surfaces of the TiP implants.

Bone formation with various bone graft substitutes in critical-sized rat calvarial defect.

OBJECTIVE: This histomorphometric study compared the efficacy of a new bone graft substitute (N-HA) derived from hen eggshell, consisted of submicron scale porous hydroxyapatite structure, in the healing of 8 mm diameter critical size defects in rat calvaria. We compared N-HA alone or in combination with calcium sulfate (CS), with a commercial bone substitute, anorganic bovine bone (Bio-Oss, BO). MATERIAL AND METHODS: Critical size defects were created in calvaria of 56 adult Sprague-Dawley rats. Animals were divided into four groups and treated with (1) unfilled defects, (2) N-HA grafts, (3) BO grafts and (4) N-HA/CS grafts. The percentage of new bone formed (NB%) was evaluated histomorphometrically after 6 and 12 weeks. RESULTS: The N-HA group exhibited more new bone formation compared with other groups at 6 and 12 weeks. Histomorphometric analysis showed greater NB% in N-HA group (11.2% at 4 weeks and 19.2% at 12 weeks) compared with those in unfilled (3.9% at 6 weeks and 6.4% at 12 weeks), BO-treated (6.4% at 6 weeks and 8.2% at 12 weeks) and N-HA/CS-treated (6.3% at 6 weeks and 12.6% at 12 weeks) groups. The N-HA group showed significant differences in NB% compared with unfilled group at 6 weeks (P=0.016), unfilled and BO-treated groups at 12 weeks (P=0.001). The addition of CS did not enhance the NB% compared with defects grafted with N-HA alone. CONCLUSION: N-HA was an osteoconductive bone substitute for treating osseous defects in critical size defects of rat calvaria.