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Chem. Rev. 2008, 108, 47424753

Calcium Phosphate-Based Osteoinductive Materials

Racquel Zapanta LeGeros*
Department of Biomaterials and Biomimetics, New York University College of Dentistry, 345 East 24th Street, New York, New York 10010
Received July 2, 2008

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Publication Date (Web): November 12, 2008 | doi: 10.1021/cr800427g

Contents
1. Introduction
2. Bone and Its Properties
3. Calcium Phosphate-Based Biomaterials
3.1. Dental and Medical Applications
3.2. Composition
3.3. Properties of CaPs That Mimic Properties of
Bone (or Bone Mineral)
4. Osteoinductive Properties of Calcium
Phosphate-Based Biomaterials
4.1. Intrinsic Osteoinductivity
4.2. Engineered or Programmed Osteoinductivity
4.3. Challenges
5. Summary
6. Acknowledgments
7. References

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1. Introduction
This review focuses on calcium phosphate-based bone
substitute materials that are used (or can be used) for teeth
or bone replacement, bone repair, augmentation, or regeneration. This review will also include some properties of bone
(e.g., interconnected porosity, biodegradability, bioactivity,
osteoconductivity) that are being mimicked in the manufacture of calcium phosphate-based biomaterials and some of
the reported factors and strategies that can make the calcium
phosphate-based biomaterials acquire osteoinductive properties.
Archaeological findings showed that attempts to replace
missing teeth date back to the prehistoric period. The
materials used then included shells, corals, ivory (from
elephant tusks), metals, and human (from corpses) and animal
bones.1 Because of the practice of cremation in many
societies, not much is known about prehistoric materials used
to replace bones lost to accident or disease.
Presently, autografts (bones obtained from another anatomic site in the same subject) remain the gold standard for
bone repair, substitution, and augmentation followed by
allografts (bones from another subject, such as processed
cadaver bones). Autografts and allografts while having the
important advantage of being osteogenic or osteoinductive
(i.e., inducing bone formation), suffer from several disadvantages. With autografts the drawbacks include additional
expense and trauma to the patient, possibility of donor site
morbidity, and limited availability. In the case of allografts,
in addition to limited supply and high cost, potential viral
transmission and immunogenicity are of serious concern.2
Because of the high cost and limited availability of autografts
* To whom correspondence should be addressed. Phone: (212) 998-9580.
Fax: (212) 995-4244. E-mail: rzl1@nyu.edu.

Racquel Zapanta LeGeros received her Ph.D. degree from New York
University. She is currently a Professor and Associate Chair of the
Department of Biomaterials and Biomimetics at New York University
College of Dentistry. Her pioneering work was on substitution in the apatite
structure and effect on properties. Her research interests includes biologic
and synthetic apatites and related calcium phosphates, calcium phosphatebased biomaterials in the form of granules, scaffolds, cements, and
coatings, and implant surface modifications. Her current research is on
the development of calcium phosphate-based biomaterial for prevention
of bone loss induced by diseases (e.g., osteoporosis), therapy (e.g.,
radiation), condition (e.g., mineral deficiency, immobility), and recovery
of bone loss. She is married to Dr. John P. LeGeros and mother of
Bernard, David, Katherine, and Alessandra.

and allografts, there is a great need to develop synthetic

alternative biomaterials for bone replacement, repair, and
augmentation.
Current commercial substitute materials to replace or repair
teeth and bones include metals, polymers (natural or synthetic), corals, human bones (processed cadaver bones),
animal bones (processed cow bones), corals and coral
derived, synthetic ceramics (calcium phosphates, calcium
sulfates, calcium carbonate, bioactive glasses), and composites.3-28 It is interesting to note that several of the materials
used in prehistoric times are similar to the materials used
presently (e.g., coral and coral derived, animal bone derived,
metals).
Generally, depending on the ability to stimulate bone
tissue, materials for tooth or bone repair or replacement are
classified as bioinert or bioactive.3,4 Bioinert materials do
not stimulate bone formation but instead stimulate formation
of fibrous tissue and therefore do not directly bond to bone
and thus form a weak biomaterial-bone interface.4,29 Bioactive materials stimulate bone tissue formation and therefore
directly bond with bone and thus form a uniquely strong
biomaterial-bone interface.3-5,11,24 Bioinert materials include metals (e.g., titanium or titanium alloys, stainless steel,
cobalt-chromium, Co-Cr, alloys), some synthetic polymers
(e.g., PEEK, Teflon-type), and some ceramics (e.g., alumina,

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Calcium Phosphate-Based Osteoinductive Materials

zirconia, carbon). Bioactive materials include natural polymers (e.g., collagen, demineralized bone matrix), calcium
phosphates (synthetic or derived from biologic materials such
as corals, algae, bovine bone), calcium carbonate (natural
or synthetic), calcium sulfates, and bioactive glasses (silica
or nonsilica based).
The rational for the development of calcium phosphatebased (CaP) biomaterials is their similarity in composition
to the bone mineral6-8 (a calcium phosphate in the form of
carbonate apatite) and similarities in some properties of bone
that include biodegradability, bioactivity, and osteoconductivity. Interconnecting porosity, another important bone
property, can be introduced in the manufacture of CaP
biomaterials by addition of porogens. However, in spite of
these desirable properties, CaP biomaterials have low fracture
strength and are not suitable for load-bearing areas.6-8
Depositing CaP coatings on orthopedic and dental implants
combine the bioactivity of CaP and the strength of the metal.
A very important property of bone is the osteoinductivity
that allows the bone to repair and regenerate itself (up to a
point). The osteoinductive property of bone is due to bone
morphogenetic proteins (BMPs) and osteogenic proteins (e.g.,
collagen, osteonectin, osteopontin, bone sialoprotein) present
in the extracellular matrix.30-37
CaP biomaterials are not osteoinductive (does not form
bone de novo, for example, forming bone in nonosseous
sites).11 However, some CaP biomaterials have been described to have inherent osteoinductive property, while
others can be engineered to have this property. This will
be briefly discussed in section 3.

2. Bone and Its Properties

Bone is a mineralized matrix, a complex composite of
biopolymer and biomineral. The biopolymer consists of
matrix proteins, mostly collagen (type 1) with some minor
but important noncollagenous proteins (e.g., proteoglycans),
minor amounts of lipids and osteogenic factors (e.g., bone
morphogenetic proteins, BMPs).30-33 Bone is formed by a
series of complex events rigorously orchestrated by different
types of bone cells interacting with each other and with the
extracellular matrix. The bone cells include (1) osteoblasts,
(2) osteoclasts, (3) osteocytes, and (4) bone-lining cells.
Osteoblasts are responsible for production and mineralization
of the bone matrix; osteoclasts maintain the bone matrix;
osteoclasts are responsible for bone resorption. Cell attachment, proliferation, and differentiation are important activities
involved in bone formation. The osteoblast (bone-forming)
cells attach, proliferate, and differentiate, leading to production of matrix proteins that include collagen (mostly type
1), osteopontin (OSP), bone sialoprotein (BSP), osteonectin
(ONN), osteocalcin (OSC), fibronectin (FN), and BMPs
before mineral deposition.30-37 BMPs and matrix proteins
induce bone formation in vitro and in vivo. Collagen, OSP,
and ONN have been shown in vitro to nucleate apatite
formation and also inhibit or modulate apatite crystal growth.
Important physicochemical properties of bone include (1)
interconnecting porosity, (2) biodegradability, (3) bioactivity,
(4) osteoconductivity, and (5) osteoinductivity. Pore size
ranges from 10 to 50 m and 100 to 300 nm in cortical bone
and 200 to 600 m in trabecular bone. The size and
interconnection of bone porosity is essential for vascularization, diffusion of nutrients and cells, and tissue ingrowths.
The bone architecture and composition allows cell attach-

Chemical Reviews, 2008, Vol. 108, No. 11 4743

ment, migration, proliferation, and differentiation, promoting

bone formation, repair, and regeneration.
The bone mineral was identified as an apatite based on its
similarity to the X-ray diffraction profiles of mineral apatites
and their similarities in composition with each other (principally calcium and phosphate ions).38-40 The mineral of
teeth and bones was idealized as calcium hydroxyapatite
(HA), Ca10(PO4)6(OH)2.41 However, biologic apatites contain
minor and trace elements and are therefore not pure HA.
The most important minor elements are carbonate (CO3),
magnesium (Mg), and sodium (Na). Systematic studies on
synthetic carbonate-substituted apatites and biologic apatites
using combined analytical methods (X-ray diffraction,
infrared spectroscopy and chemical analyses)42-46 led to the
conclusion that biologic apatites should be considered as
carbonate hydroxyapatite,47-49 CHA, approximated by the
formula (Ca, Na, Mg)10(PO4,HPO4,CO3)6(OH,Cl,F)2 (compared to pure hydroxyapatite, HA, Ca10(PO4)6(OH)2).
Bone apatite crystals are irregularly shaped platelets of
variable lengths and widths (30-45 nm) and thickness (average
about 5 nm) oriented with their c axis parallel to one another
and lies along the collagen fibrils.50 Biologic apatites of enamel
have considerably larger crystal size (about 2000 nm)
compared to that of either bone or dentin apatite, as indicated
by the well-defined diffraction peaks in the XRD profile of
enamel apatite47 and much broader diffraction peaks of either
bone or dentin apatite (Figure 1). The concentrations of Mg
and CO3 in enamel apatite are much lower than those in
either dentin or bone apatite.22,47,51 The mineral phase of
some fish enameloids (e.g., shark enameloid) have fluoride
(F-) ions replacing the hydroxyl (OH) groups in the apatite
structure.52 Differences in composition affect the lattice
parameters of the apatite hexagonal structure (a- and c-axis
dimensions), crystal size, and solubility of the biological and
synthetic apatites22,47 as demonstrated in the differences in
crystallite size and solubility of the biologic apatites in
enamel, dentin, and bone.22,47,51-55 For example, substitution
of CO32-(for PO43-) or Mg2+ or Sr2+ (for Ca2+) in the
apatite structure causes a decrease in crystallite size and an
increase in solubility, while incorporation of fluoride ions (Ffor OH- substitution in the apatite structure) causes an increase in
crystallite size and decrease in solubility.22,42,43,52-55
Other calcium phosphates also occur in biologic systems,
usually in pathologic calcifications (e.g., dental calculus,
urinary stones, soft-tissue calcifications) or diseased states
(e.g., dental caries).22,56,57 Biologic nonapatitic calcium
phosphates include amorphous calcium phosphate, Cax(PO4)y
zH2O (ACP), dicalcium phosphate dihydrate, CaHPO4
2H2O (DCPD), octacalcium phosphate, Ca8H2(PO4)6 5H2O
(OCP), Mg-substituted tricalcium phosphate, (Ca,Mg)3(PO4)2
(-TCMP or Mg-TCP), and calcium pyrophosphate dihydrate, Ca2P2O7 2H2O (CPPD), as summarized in Table 1.
However, while only CHA is present in normal calcified
tissues (teeth and bones), several types of CaPs coexist in
pathologic calcifications. For example, DCPD, OCP, -TCMP (or Mg-TCP), and CHA coexist in human dental
calculus.
Formation of different types of calcium phosphates in both
synthetic and biologic systems depends on the solution pH,
temperature, and composition. In biologic as well as synthetic
systems, calcium phosphates can transform from one form
to another depending on the pH and composition of the
synthetic solution or biologic microenvironment.22,57 For
example, ACP DCPD, and OCP can transform to CHA in

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LeGeros
Table 2. Calcium Phosphate-Based Biomaterials: Commercial
calcium deficient apatite
(CDA)
hydroxyapatite (HA)
Ca10(PO4)6(OH)2

HA/polyethylene
HA/CaSO4
coralline HA (derived from
coral)
bovine bone Ap (unsintered)
bovine bone apatite (sintered)

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tricalcium phosphate (-TCP)

Ca3(PO4)2
biphasic calcium phosphates,
BCP (HA + -TCP)

BCP/collagen
BCP/fibrin
BCP/silicon
CHA/collagen

Figure 1. X-ray diffraction profiles of biologic apatites from (A)

bone, (B) dentin, and (C) enamel. The sharper diffraction peaks in
C compared to either B or A indicate that enamel apatite crystals
are much larger compared to either bone or dentin apatite crystals.
Table 1. Calcium Phosphates in Biologic Systems
calcium phosphates
amorphous calcium
phosphates, ACP
dicalcium phosphate dihydrate,
DCPD
octacalcium phosphate, OCP
Mg-substituted tricalcium
phosphate, -TCMP
carbonate hydroxyapatite,
CHA
carbonate fluorapatite, CFA
calcium pyrophosphate
dihydrate, CPPD

occurrence
soft-tissue calcifications
dental calculus, dental caries
dental calculus, urinary stone
dental calculus, soft tissue
calcifications
dental calculus, urinary stone,
mineral phases of enamel,
dentin, cementum, bone, fish
enameloids
fish enameloids
joints

neutral or basic pH in the presence of HCO3- or CO3 2ions or to -TCMP in acid, neutral, or basic pH in the
presence of Mg2+ ions, or (F,OH)-apatites in the presence
of F- ions.22

3. Calcium Phosphate-Based Biomaterials

As stated in the Introduction, the principal rationale for
developing calcium phosphate-based biomaterials and recommending their use as bone substitute materials in dentistry
(e.g., in oral maxillofacial reconstruction, tooth replacement)
and medicine (e.g., orthopedics) is the similarity of these

Osteogen (Impladent, NY)

Calcitite
Ostegraf (Ceramed,CO)
Bioroc (Depuy-Bioland,
France)
HAPEX (Gyrus, TN)
Hapset (LifeCore, MINN)
Interpore, ProOsteon
(Interpore, CA)
BioOss(EdGeitslich,
Switzerland)
Endobon (Merck, Germany)
Osteograf-N (Ceramed, CO)
Vitoss (Orthovita, PA)
MBCP (Biomatlante, France),
Triosite (Zimmer, IN)
Osteosynt (Einco Ltd., Brazil)
Tribone (Stryker, Europe)
Allograft (Zimmer, IN)
Tricos (Baxter
BioScience,France)
FlexHA (Xomed, FL)
Healos (Orquest Inc., CA)

materials to the composition of bone mineral, a calcium

phosphate in the form of carbonate apatite nanocrystals.
Carbonate apatite prepared at low temperature (25 or 37 C)
have similar morphology and size to that of bone apatite
(Figure 2). In addition, CaP biomaterials are similar to bone
mineral in its biodegradability, bioactivity, and osteoconductivity. Interconnecting porosity similar to that of bone
can be introduced during the manufacture.
While other materials (e.g., calcium carbonate, CaCO3;
calcium sulfate, CaSO4 2H2O; silica-based bioactive glasses
from the system CaO-Na2O-SiO2) are also bioactive,
biodegradable, and osteoconductive, they do not have the
chemical composition similar to that of the bone mineral.

3.1. Dental and Medical Applications

The first application of a calcium phosphate material for
bone repair was reported in 1920 by Albee and Morrison,58
who used a chemical reagent marked tricalcium phosphate.
The first dental application was reported by Nery et al.59
more than 50 years later using a synthetic porous material
obtained by sintering a tricalcium phosphate reagent that
was originally described by the authors as tricalcium
phosphate or TCP but later demonstrated to consist of a
mixture of HA and -TCP.10 Such mixtures of HA and
-TCP is now referred to as biphasic calcium phosphates,
BCP.12,60 Current dental and medical applications of CaP
biomaterials include repair of periodontal defects, augmentation of alveolar bone, sinus lifts, tooth replacement, repair
of large bone defects caused by tumors, spine fusion, and
ear and eye implants.4-27,61-68 CaPs are used as scaffolds
in tissue engineering for bone or dentin regeneration69-73
or delivery systems for drugs73-77 or antibacterial agents.78-81
CaPs are used in the form of injectable cements17,82-84or as
coatings on titanium and titanium alloy implants85-89 to
combine the bioactivity of the CaP and the strength of the
metal.87-90 CaP (HA, BCP) are used as abrasives (instead
of alumina) to roughen metal implant surfaces.90,91

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Figure 2. Transmission electron microscopic (TEM) images of (A) bone apatite crystals and (B) synthetic carbonate apatite prepared at
37 C. (Reprinted with permission from ref 91. Copyright 1998 Woodhead Publishing.)

Figure 3. Scanning electron microscopic (SEM) images showing the difference in crystal sizes and microporosity among (A) synthetic
HA, (B) coralline HA, and (C) precipitated calcium deficient apatite, CDA. HA was prepared by precipitation and sintering at 1100 C,
coralline HA by hydrothermal conversion of coral (CaCO3) in (NH4)2HPO4 at 365 C, 200 psi, and CDA by precipitation at 95 C.

3.2. Composition
Commercialization of hydroxyapatite (HA) and beta-tricalcium phosphate (-TCP) started in the early 1980s6-9 and of
biphasic calcium phosphates (BCPs) in the 1990s.12 On the
basis of composition, current commercial calcium phosphates
for bone and tooth repair are classified as (1) calciumdeficient apatite, CDA (i.e., Ca/P molar ratio less than the
stoichiometric value of 1.67 for pure HA), (2) hydroxapatite
(HA), Ca10(PO4)6(OH)2, (3) beta-tricalcium phosphate (TCP), Ca3(PO4)2, and (4) biphasic calcium phosphate (BCP),
an intimate mixture of HA and -TCP of varying HA/TCP weight ratios (Table 2). Experimental calcium phosphatebased biomaterials include substituted apatites,92-95 substituted tricalcium phosphates,18,98,99 calcium phosphate glasses
(CPGs),21,100 and other CaPs such as OCP.86,101 CDA can
be prepared by precipitation6-8,22,42,43,108 or hydrolysis of
either CaHPO4 2H2O (DCPD)22,77 or CaHPO4 (DCP).22,42
HA is prepared by precipitation, hydrolysis, or hydrothermal
methods22,42,108 at high pH then sintering at 1000-1200 C.
Coral-derived HA (coralline HA) is prepared by the hydrothermal reaction of coral (CaCO3) and (NH4)2HPO4 at 375
C and 200 psi.106 Bovine-bone-derived apatite is obtained
by removing the organic phase with or without subsequent
sintering at 1000 C.10,14,22-24 BCP is obtained by sintering
CDA above 900 C with the resulting HA/-TCP weight
ratio depending on the Ca/P ratio of the CDA before
sintering.12,107 Substituted apatites or substituted TCPs are
prepared by precipitation, hydrolysis, hydrothermal, or solidstate reactions.12,22-24,42,107
The crystal size of synthetic apatite is controlled by the
solution composition, reaction pH, and temperature (37-100
C) and subsequent sintering temperature (900-1200 C).22-24
For example, apatite nanocrystals similar to bone or dentin
apatite crystals can be obtained at 25-37 C (Figure 2), while
larger crystals, similar to enamel apatite, are obtained at
80-95 C.22-24,42,43 The difference in preparation conditions
(e.g., coralline HA obtained by hydrothermal method vs

synthetic HA obtained by precipitation and sintering at

1000-1200 C) also affect crystal size, e.g., coralline HA
vs synthetic HA (Figure 3). Comparison of XRD profiles of
commercial bovine-derived apatite (nonsintered) and commercial HA is shown in Figure 4.

3.3. Properties of CaPs That Mimic Properties of

Bone (or Bone Mineral)
Protein Adhesion
Synthetic apatites readily facilitate protein adhesion as
evidenced by its use in chromatography.108 Protein adhesion
to synthetic surfaces is important for cell binding, proliferation, and differentiation.

Interconnecting Porosity
Interconnecting macroporosity (Figure 5) is introduced in
synthetic HA, -TCP, or BCP by adding porogens (e.g.,
naphthalene, H2O2, polymeric porogens) or using the foaming
method.105,109 Microporosity depends on sintering temperature or sintering program. Thus, CaP sintered at 1200 C
shows significantly less microporosity than that sintered at
1000 C and a dramatic change in crystal size12,107 (Figure
6). In the case of coralline HA or bovine-derived apatites,
the porosity of the original biologic material (coral or bovine
bone) is preserved during processing (Figure 5).

Biodegradability
In vitro biodegradation is determined by suspending the
material in acidic buffer and monitoring the release of Ca2+
ions with time.54,110,111 The acidic buffer, to some extent,
mimics the acidic environment during osteoclastic activity
(bone resorption).112 In vitro or in vivo degradation of CaPs
depends on their composition, particle size, crystallinity
(reflecting crystal size), porosity, and preparation condi-

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4746 Chemical Reviews, 2008, Vol. 108, No. 11

Figure 4. X-ray diffraction profiles of (A) synthetic HA and (B)

bovine bone apatite. The difference in the sharpness of the
diffraction peaks indicates the vast difference in their crystallite
sizes. Synthetic HA was prepared by precipitation and sintering at
1000 C. Bovine bone apatite was prepared by removing the organic
component at 37 C.

tions.113 Such experiments have demonstrated that the

degradation or rate of dissolution proceeds in the following
decreasing order: -TCP . bovine bone Ap (unsintered) .
bovine bone Ap (sintered) > coralline HA > HA. In the
case of BCPs, degradation depends on the HA/ -TCP ratio:
the higher the ratio, the lower the degradation rate.107
Comparing different synthetic CaPs (unsintered), the solubility decreases in the order ACP > DCPD > OCP > CDA.
Incorporation of different ions apatite can increase (e.g.,
CO3-2, Mg2+, or Sr2+) or decrease (e.g., F-) the solubility
of the apatite.22,51-55 The solubility of -TCP is decreased
by incorporation of either Mg2+ or Zn2+ ions.12,114 In vitro
the effect of composition observed for solution-induced or
cell-induced degradation is similar. For example, osteoclastic
resorption and the rate of dissolution was observed to be
greater for CHA compared to CFA.93,115

Bioactivity
Bioactivity, the property of the material to directly bond
with the new forming bone, was first observed and described
by Hench et al. in special silica-based bioactive glasses.3 In
contrast, an unmineralized fibrous tissue forms at the interface
of the new bone and bionert materials.4 For example, direct
bone attachment is observed on a plasma-sprayed HA-coated
Ti alloy surface, while fibrous tissue encapsulates the
uncoated surface.116 The Ti alloy surface grit blasted with
apatitic abrasive showed direct bone attachment, while the
fibrous tissue interface was observed on the surface grit
blasted with alumina (Figure 7), suggesting that grit blasting
with bioactive apatitic abrasive rendered the surface more
bioactive than grit blasting with bioinert alumina.91

LeGeros

The newly formed bone bonds directly with bioactive

materials through a carbonate apatite (CHA) layer at the
bone-material interface.5,119 HA nanocrystals (similar in
dimensions to bone apatite nanocrystals) growing on HA
ceramic implanted in nonosseous site (Figure 8) was first
reported by Heughebaert et al.117 In vitro a greater amount
of CHA nanocrystals was observed on the coralline HA
surface compared to that on the synthetic dense HA surface
after immersion in fetal bovine serum.118
Presently, in vitro bioactivity (assumed to predict in vivo
bioactivity) is usually tested by immersing the material in
simulated body fluid (SBF) with electrolyte composition
similar to that of serum.119 In vitro CHA formation on CaP
surfaces occurs in the presence of proteins (e.g., in serum)118
or the absence of proteins (e.g., in mineralizing solution or
in SBF).119 In vitro CHA formation on CaP-based materials
in SBF (pH 7.4) or other calcifying or mineralizing solution
or in serum is a precipitation process as evidenced by the
uptake of calcium and phosphate ions from the serum118 and
from the SBF. However, formation of CHA on CaP ceramic
surfaces in vivo in nonosseous sites or osseous sites (Figure
8) is a cell-mediated dissolution/precipitation process.120,121
In vivo the cellular activity (e.g., by macrophages or
osteoclasts) associated with acidic environment results in
partial dissolution of the CaP ceramic, causing liberation of
calcium (Ca2+) and phosphate (HPO42-, PO43-) ions onto
the microenvironment. The liberated ions increase the
supersaturation condition of the biologic fluid, causing
precipitation of CHA incorporating Ca2+, HPO42-, PO43-,
and other ions (Mg2+, Na+, CO32-) present in the biologic
fluid (Figure 10).120,121 Infrared spectroscopic analyses
demonstrated that these nanocrystals were intimately associated with an organic component (probably proteins) that may
also have originated from the biologic fluid or serum.117,118
Bone apatite nanocrystals are also intimately associated with
organic component.
The population of the CHA nanocrystals on the surface
of CaP material appear to depend on its dissolution property.
For example, when coralline HA and synthetic HA were
immersed in FBS, much more CHA nanocrystals were
observed associated with the coralline HA compared with
those with synthetic HA.118 The higher solubility of coralline
HA compared to synthetic HA may be due to its smaller
size (Figure 3) and its CO3 and Mg contents. These ions
incorporated in synthetic apatites were shown to increase
their solubilities. In vivo BCPs with lower HA/TCP were
associated with greater population of the CHA nanocrystals:
15HA/85TCP. 60HA/40TCP.120 Biodegradation of BCP
depends on the HA/-TCP ratio: the higher the ratio, the
less the biodegradation. This is explained by the greater
solubility of -TCP hich is hence more easily biodegraded
than HA. Therefore, the amount of CHA formed associated
with CaP biomaterials in vitro and in vivo is directly related
to the solubility of the material.

Osteoconductivity
Osteoconductivity, when referring to biomaterials, is the
ability of the material to serve as a scaffold or template
to guide formation of the newly forming bone along their
surfaces.122 In vivo the CHA layer that forms on CaP
biomaterial surfaces adsorbs circulating proteins (from the
biologic environment) on which bone cells attach, migrate,
proliferate, and differentiate, leading to matrix production

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Figure 5. (A) Bovine bone-derived HA. (B and C) Biphasic calcium phosphate, BCP. The original interconnecting macroporosity in bone
was preserved in A. Macroporsity in B and C was introduced using porogens before sintering. C shows the presence of concavities.

Figure 6. SEM of BOP sintered at (A) 105 000 and (B) 1200 C. Note the presence of microporosities in A and not in B.

Figure 7. Bone growth and attachment on Ti alloy cylinder grit blasted with apatitic abrasive on one side (A) and alumina abrasive on the
other side (B). The side grit blasted with apatitic abrasive showed direct bone attachment (A), while the side grit blasted with alumina
showed indirect bone attachment through a nonmineralized fibrous layer. (Reprinted with permission from ref 91. Copyright 1998 Woodhead
Publishing.)

and biomineralization. The newly forming bone follows the

outline of the bioactive CaP surface (Figure 10).
All bioactive materials are also osteoconductive. Bioactive (and therefore osteoconductive) biomaterials, unlike
bioinert materials, actively participate in the dynamic
activity occurring at the bone-biomaterial interface.

Cellular Response to CaPs

Cells attach to and engulf the CaPs, causing them to
biodegrade in vitro and in vivo123 (Figure 11). CaPs allow
osteoblast cells to attach, proliferate, and differentiate.
Differentiating osteoblast cells produce collagen (type 1),

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LeGeros

Figure 8. Formation of carbonate hydroxypatite (CHA) on CaP surfaces under different conditions: (A) on HA after immersion in
simulated body fluid; (B) on coralline HA after immersion in fetal bovine serum; (C) associated with HA implanted in nonosseous
sites; and (D) associated with BCP implanted in sites. Biodegradation of HA and BCP is evident in C and D. Deposition is observed
on A and B.

Figure 9. Schematic representation of the dissolution/precipitation process involved in formation of CHA on CaP surfaces in vivo.
Acid environment caused by cellular (macrophages, osteoclasts) activity causes partial dissolution of CaP, causing increased
supersaturation of the biologic or physiological fluid, causing precipitation of CHA incorporating 003 and other ions and organic
molecules (protein).

Figure 10. Osteoconductive property SEM images showing new

bone (NB) growing along the surfaces of Mg-substituted tricalcium
phosphate (-TCMP) after implantation in osseous site.

alkaline phosphatase, proteoglycans (decorin, lumican, biglycan), and matrix proteins (osteocalcin, osteopontin, bone

sialoprotein) known to signify bone formation27,28,34 as

shown in Figure 12. Cellular response is affected by the
composition of CaP. For example, zinc (Zn) from zinccontaining tricalcium phosphate (Zn-TCP)18,114,124 or fluoride (F) from F-apatite125 or carbonate-F-apatite (CFA)93,115
has been shown to inhibit osteoclastic activity. On the other
hand, F in FAP125 or Mg or Zn and/or F or combination of
the three ions in carbonate apatite matrix126 was shown in
vitro to promote collagen production and phenotypic expression of proteoglycans and matrix proteins associated with
bone mineralization (Figure 12).
Factors that affect cellular response to CaPs include surface
topography (roughness),127,128 composition,93,116,125,126 and
particle size.129

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Calcium Phosphate-Based Osteoinductive Materials

Chemical Reviews, 2008, Vol. 108, No. 11 4749

Figure 11. SEM (A-C) and TEM (D) images showing cellular response to CaP: (A) proliferation of chondrocytes on BCP, (B) attachment
on coralline HA, and phagocytosis of HA particles (C) in vitro and (D) in vivo.

4.1. Intrinsic Osteoinductivity

Figure 12. Response of human osteoblast cells to carbonate

hydroxyapatite of different composition:51-54 production of collagen type I (col 1), expression of alkaline phosphatase (AP), matrix
protein, osteocalcin (OSO), and proteoglycans (lumican, decorin,
biglycan).

4. Osteoinductive Properties of Calcium

Phosphate-Based Biomaterials
Osteoinductivity is the ability of the material to induce de
novo bone formation without the presence of osteogenic factors.
The osteoinductive property of a material is usually demonstrated by bone formation after implantation in nonosseous sites
(e.g., subcutaneously or in intramuscular sites). Induction of
bone formation by demineralized bone matrix, DBM (bone
decalcified with hydrochloric acid), after implantation in muscles
of different animals was first reported by Urist in 1965.130 Urist
et al. later131 demonstrated that proteins (specifically, bone
morphogenetic protein, BMPs) that were originally present
in the DBM were the osteoinductive factors. This conclusion
was confirmed by others.132-134
A recent review by Wozney133 and de Bruijn et al.134
summarized the bone formation cascade associated with
BMPs as follows: chemotaxis of undifferentiated mesenchymal cells f cell proliferation, differentiation into chondroblasts and chondrocytes f formation of cartilaginous
extracellular matrix f maturation and subsequent mineralization of hypertropic chondrocytes f removal of calcified
cartilage by osteoclasts f production of bone matrix by
osteoblasts f bone remodeling. Osteoinductivity may be
intrinsic or engineered.

CaP biomaterials are generally known to be osteoconductive but not osteoinductive.22 However, several CaP materials
have been reported to have the ability to form bone in
nonbony sites of different animals without addition of
osteogenic factors. These CaP materials have included porous
synthetic HA,135-138 coralline HA,139,140 -TCP,141 porous
BCP,142 calcium phosphate cements,143,144 and OCP coatings
on Ti alloy.86,145
Since this osteoinductive property was observed in some
CaP materials but not in others of similar composition, these
materials were described to have intrinsic osteoinductivity.
This inductive phenomenon for some CaP materials was
attributed to the topography, geometry, composition, macropore
size, and percent porosity of the CaP. Such geometry was
believed to allow entrapment and concentration of circulating
bone growth factors (BMPs) and osteoprogenitor cells
imparting osteoinductive properties to the CaP materials.
More recently, combination of interconnecting macro- and
microporosities146-151 and concavities146 (Figures 5 and 6)
were demonstrated to be important features of CaPs because
these features allow adsorption, entrapment, and concentration of circulating BMPs and osteogenic factors and/or
osteoprogenitor cells, thus imparting osteoinductive properties to these materials. Ripamonti146 demonstrated that BMPs
were concentrated on the concavities of the HA scaffolds.
Zhang et al.136 demonstrated that HA with pore dimensions
of 75-550 m and 60% porosity promoted more bone
formation in nonosseous (muscle) and osseous sites. Yuan
et al.147 demonstrated that HA with microporosity on the
macropore walls implanted in dogs dorsal muscle induced
bone formation compared to BCP without microporosity.
LeNihouannen et al.,142 using microporous/macroporous
BCP, demonstrated bone growth not only inside the pores
(as shown by others using macroporous HA) but also on the
outer surface of the BCP particles after 6 months implantation
in sheeps dorsal muscles (Figure 13). Ripamonti146 also
reported that demonstration of inductive property of certain

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LeGeros

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Figure 13. Osteoinductivity. (A) Histologic and (B) polarized pictures of new bone (NB) formation inside macroporous BCP (BCP)
granule after implantation in goat muscle for 6 months. (A) New bone is shown in the lighter color.142 (Photos courtesy of Prof. G.
Daculsi.)

CaPs depends on the animal models: highly reproducible

in primates, minimal in dogs and absent in rabbits and
rodents. This animal dependency of osteoinductivity is
believed to be due to the difference in the amount of
circulating growth factors in each of the species. In addition,
implantation time may also be a factor: porous and nonporous
HA and calcium phosphate cement (CPC) implanted intramuscularly in rabbit showed bone formation after 1 year.143
OCP coated on titanium implants was also reported to
exhibit osteoinductive property.86,148 This may be due not
to the OCP composition but to the microporosities between
OCP crystals and OCP,22 bundles that allow entrapment and
concentration of bone growth factors (BMPs) and/or osteogenic proteins.
The amount of carbonate hydroxyapatite (CHA) formed
on the BCP surface depends on the HA/-TCP ratio in the
BCP: the lower the ratio, the greater the amount of CHA
formed due to the preferential dissolution of the -TCP.120
The CHA forms by a dissolution/precipitation process.120,121
The Ca2+ and phosphate (HPO4- and PO43-) ions released
from the dissolving -TCP (due to the acid environment
created by the macrophages and osteoclasts) increase the
supersaturation of the biologic fluid (containing electrolytes
and proteins), leading to precipitation of CHA (Figures 8
and 9) intimately associated with an organic entity (probably,
protein). OCP when exposed to carbonate-containing solution
(e.g., biologic fluid) can easily transform to CHA.22
The CHA layer that forms on the CaP (or any bioactive
material) after implantation facilitates adhesion of proteins
on which the osteoprogenitor cells can attach, proliferate,
differentiate, and produce extracellular matrix that eventually
leads to biomineralization or bone formation.
The so-called intrinsic osteoinductive property of CaP
materials is based on their geometry, topography, interconnecting macroporosity, and microporosity (e.g., combination
of Figures 5 and 6A), which allows entrapment and
concentration of circulating BMPs in the biologic fluid. In
addition, the CHA layer (bone apatite-like) associated with
protein forming on the surface of CaP materials as a result
of dissolution/precipitation processes is recognized by osteoprogenitor cells as bone apatite (CHA intimately associated with protein); these cells then attach, proliferate, and
differentiate, producing extracellular matrix that leads to bone
formation.
It should be noted that certain CaP materials with
architectural features described above as having inherent
osteoinductivity cannot be compared with osteoinductive
materials like demineralized bone matrix or autografts or
allografts. These latter materials originally contained the

osteogenic factors (e.g., BMPs) which are later released.

The CaP materials, by virtue of their architecture, acquired
the osteogenic factors circulating in the environment (osseous
or nonosseous sites) and later release these factors that
eventually resulted in bone formation.

4.2. Engineered or Programmed Osteoinductivity

Independent of geometry, architecture, or unique porosity,
CaPs or CaP-based composite scaffolds combined with
osteoprogenitor cells (stem cells, marrow cells, dental pulp
cells, chondrocytes), bone growth factors (BMPs), and
bioactive proteins (e.g., collagen, Ops, fibrin) or peptides
(based on amino acid fragments of bone sialoprotein
structure) have been shown to promote enhanced bone
formation.69-73,130-134,150-157 The commonly used peptide
is the amino acid sequence Arg-Gly-Asp (RGD).70,146,151,157
The rationale for combining CaPs or grafting metal implants
with bioactive proteins is to enhance cell adhesion, differentiation, matrix formation, and biomineralization.26,70,151,157
In tissue engineering, BCP seeded with dental pulp cells
was shown to promote dentin formation.69 Chondrocytes
were observed to proliferate, mature, and differentiate on
BCP.158 Adult mesenchymal stem cells seeded on BCPs were
shown to facilitate bone formation depending on the HA/
TCP ratio: 20/80 . 60/40 . 100HA or 100TCP.71,72 The
structure, geometry, macroporosity, microporosity, particle
size, and composition are important features of CaP materials
to enhance their efficacy as carriers of the osteogenic factors
for bone formation. Porosity was found to be more important
than the composition of the scaffold as a property of growth
factor carrier.158
De Bruijn et al.148 demonstrated that tantalum cylinders
coated by coprecipitating octacalcium phosphate (OCP) with
rhBMP2 implanted in intramuscular sites in dogs showed
osteoinductive properties, while the uncoated cylinders did
not.
Engineered osteoinductivity by grafting bone growth
factors, osteogenic proteins, or peptides is especially important to apply to metal implants used in orthopedic and
dentistry. This will allow accelerated bone formation and
enhanced osseointegration (direct bone bonding) of the
implants with bone,134,152 minimizing implant loosening that
could lead to implant failure.
It is projected that CaP materials with intrinsic or
engineered osteoinductive properties will be able to replace
autografts and allografts in bone repair and bone regeneration.

Calcium Phosphate-Based Osteoinductive Materials

4.3. Challenges
For the CaP materials with inherent osteoinductivity, the
challenge is to determine the appropriate architecture (appropriate combination of microporosity and macroporosity)
in fabricating the CaP materials to optimize the ability to
entrap and concentrate osteogenic factors (growth factors and/
or osteoprogenitor cells) and then be able to fabricate CaP
materials with such architecture reproducibly.
For CaP materials with engineered osteoinductivity, the
challenge is to determine the appropriate scaffold or carrier,
the appropriate dosage of the osteogenic factors (BMPs, Ops,
RGDs), and the appropriate controlled release of these factors
for maximum efficiency.

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5. Summary
Calcium phosphate-based bone substitute materials (CaPBSMs) in different forms (granules, blocks, composites) or
as cements or coatings on orthopedic and dental implants
are used in many medical and dental applications. They can
also be used as scaffolds in tissue engineering for dentin or
bone regeneration. CaPs are similar to bone in composition
and having bioactive (ability to directly bond to bone, thus
forming a uniquely strong interface) and osteoconductive
(ability to serve as a template or guide for the newly forming
bone) properties. Interconnecting porosity (macroporosity and
microporosity) similar to that of bone can be introduced by
chemical or physical methods. The bioactive property
promotes formation of a carbonate hydroxyapatite layer,
which attracts protein to which cells bind or adhere,
proliferate, and differentiate, leading to matrix production
and biomineralization or formation of new bone.
CaP materials, by themselves, are not osteoinductive (i.e.,
do not have the ability to induce de novo bone formation as
evidenced by bone formation nonskeletal sites such as
subcutaneous or intramuscular sites). However, osteoinductive properties can be introduced to CaP materials by two
methods: (1) designing the CaPs with appropriate geometry,
topography, combined appropriate macroporosity/microporosity and concavities that will allow the entrapment and
concentration of circulating growth factors or osteoprogenitor
cells responsible for bone formation or (2) combining CaP
with growth factors (BMPs, mesenchymal cells) or bioactive
proteins (collagen, OPs, or peptides based on osteonectin
and bone sialoprotein). In the latter case, microporosity/
macroporosity, composition, and particle size affect the
efficacy of the CaP scaffold or carrier. Introducing osteoinductive property to CaP materials will enhance their application in bone repair and regeneration for medical and
dental applications.
Two ways of introducing osteoinductive properties to CaPBSMs include (1) designing the CaPs with appropriate
geometry, topography, combined macroporosity/microporosity and concavities or that will entrap and concentrate the
circulating growth factors or (2) combining CaP with growth
factors (BMPs, mesenchymal cells) or bioactive proteins
(collagen, OPs, or peptides based on osteonectin and bone
sialoprotein). In the latter case, microporosity/macroporosity,
composition, and particle size affect the efficiency of the
CaP scaffold or carrier.
The concept of introducing osteoinductive properties to
biomaterials is an exciting one. However, it has the appropriate architectural features of the materials or scaffolds
with intrinsic osteoinductivity, and the reproducibility of

Chemical Reviews, 2008, Vol. 108, No. 11 4751

producing these features in the manufactured is yet to be

determined. In the case of engineered osteoinductivity, the
properties of the scaffolds or carriers, the mode of incorporating the osteogenic factors, their dosage, and controlled
release rate have yet to be determined and optimized.
Nevertheless, such materials would potentially replace the
use of autografts and allografts with their attendant
shortcomings.

6. Acknowledgments
The author gratefully acknowledges the professional
collaboration of Profs. G. Daculsi, J. P. LeGeros, A. M. Gatti,
C. Frondoza, A. Ito, Y.-K. Lee, R. Kijkowska, C. Texeira,
R. Rohanizadeh, and T. Sakae, Drs. D. Mijares and I. Orly,
the technical assistance of Ms. F. Yao, and the support of
research grants from NIH/NIDCR and NIH/NIBIB for some
of the authors work cited here.

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