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Review
. 2014 Feb;93(2):109-16.
doi: 10.1177/0022034513506445. Epub 2013 Oct 2.

Periosteum: biology and applications in craniofacial bone regeneration

Z Lin  1 , A Fateh, D M Salem, G Intini
Affiliations
Review

Periosteum: biology and applications in craniofacial bone regeneration

Z Lin et al. J Dent Res. 2014 Feb.

Abstract

The bone-regenerative potentials of the periosteum have been explored as early as the 17th century. Over the past few years, however, much has been discovered in terms of the molecular and cellular mechanisms that control the periosteal contribution to bone regeneration. Lineage tracing analyses and knock-in transgenic mice have helped define the relative contributions of the periosteum and endosteum to bone regeneration. Additional studies have shed light on the critical roles that BMP, FGF, Hedgehog, Notch, PDGF, Wnt, and inflammation signaling have or may have in periosteal-mediated bone regeneration, fostering the path to novel approaches in bone-regenerative therapy. Thus, by examining the role that each pathway has in periosteal-mediated bone regeneration, in this review we analyze the status of the current research on the regenerative potential of the periosteum. The provided analysis aims to inform both clinician-scientists who may have interest in the current studies about the biology of the periosteum as well as dental surgeons who may find this review useful to perform periosteal-harnessing bone-regenerative procedures.

Keywords: bone healing; osteoprogenitor cells; periosteum; regenerative surgery; stem cells; tissue engineering.

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Conflict of interest statement

The authors declare no potential conflicts of interest with respect to the authorship and/or publication of this article.

Figures

Figure 1.
Figure 1.
Cell populations present in the outer and inner layers of the periosteum. The outer more “fibrous” layer contains “elongated” fibroblasts and blood vessels. The inner “cambium” layer presents with skeletal progenitor cells, osteoblasts, small and isodiametric fibroblasts, and blood vessels. Because of its high vascularity, the periosteum contains a large number of endothelial pericytes surrounding the blood vessels.
Figure 2.
Figure 2.
During the fracture healing, cells from the periosteum contribute significantly to callus formation. Cells from other sources, such as stem cells from muscle and adipose tissue, and pericytes from the surrounding blood vessels, are involved in callus formation as well. Cells derived from the endosteum and the bone marrow are primarily responsible for the regeneration of the new endosteum and bone marrow. Endosteal and bone marrow cells do not participate in callus formation (adapted from Colnot et al., 2012).
Figure 3.
Figure 3.
Double-flap incision design, consisting of 2 layers, a superficial mucosal layer and a deep periosteal layer. The authors recommend separating the mucosal layer first by dissecting the tissue in a partial thickness manner; the periosteum layer is reflected subsequently. (A) Crestal incision on the edentulous ridge and one vertical releasing incision are outlined. (B) The double-flap incision design is made, leaving the periosteum on the edentulous ridge. (C, D) The mucosal layer of the double flap is elevated, leaving the periosteal layer. (E, F) The periosteal layer of the double flap is elevated, exposing the alveolar bone. (G) Occlusal view of the double flap. (H) The periosteal layer of the double flap is sutured to stabilize the grafted site. (I) Buccal view after final suturing (from Hur et al., 2010; with permission from the American Academy of Periodontology).
Figure 4.
Figure 4.
Modified vascularized interpositional periosteal-connective tissue technique. (A, B) The flap is elevated by a papilla preservation technique. (C) The palatal donor site preparation begins by extending the incision horizontally to the first molar, and a subepithelial split-thickness dissection is carried anteriorly toward the palatal area of the missing site. (D) A vertical incision is made internally through the connective tissue and periosteum distal to the palatal incision, and a pediculated graft is elevated carefully from the bone, exposing the periosteum. Then, the connective tissue pedicle is rotated over the surgical site (from Kim et al., 2012; with permission).
Figure 5.
Figure 5.
Periosteal pocket flap. (A) The first incision is made at the most coronal aspect of the bone crest at a 45-degree angle to the buccal wall. (B) Subsequently, a split-thickness flap on the buccal side separates the mucosa from the underlying periosteum. Vertical releasing is performed only within the mucosa, on both sides of the flap. A periosteal second incision follows, to create the periosteal pocket flap. (C) Bone-grafting material is inserted into the pocket flap to foster bone regeneration (from Steigmann et al., 2012; with permission).
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