Cytotoxicity of Multi-Purpose Solutions (MPS) is commonly tested on cells using diluted MPS or extracts from MPS soaked contact lenses. There is evidence that lens type will affect uptake and release of compounds contained in MPS. To assess the cytotoxicity of agents contained in MPS that would be released by contact lens, an in vitro “onlay” model was used, whereby MPS soaked silicone hydrogel lenses were directly set onto a confluent monolayer of corneal cells. Chapter 4 describes the impact of MPS released from contact lenses on immortalized human corneal epithelial cells. MPS-soaked lens interactions with cells were characterized by studying cell viability, cell adhesion and caspase assays. In Chapter 5, mechanisms of cell death induced by exposure to MPS from contact lenses were determined through evaluation of apoptotic markers, such as activation of caspase 3 and 9. In Chapter 6, the impact of the physical properties of silicone hydrogel lenses, specifically surface treatments, on cytotoxicity of MPS were investigated. The development of methods for characterizing the release of MPS from lenses, using absorbance spectra, is also described. The results indicate that exposure to contact lenses soaked in Opti-Free Express (OFX) and ReNu not only induces cell death in vitro, but also has an adverse effect on adhesion phenotype, suggesting that the remaining cells may have a compromised epithelial structure. Borate- buffered MPS were found to be more cytotoxic than phosphate-buffered base solutions. Investigation of the mechanisms of cell death revealed that ReNu and OFX induced corneal epithelial cell death in vitro using different pathways, whereby ReNu induced a necrotic pathway while OFX-induced cell death was mediated by the intrinsic pathway of apoptosis. The in vitro model was also able to identify differences between silicone hydrogels with different surface treatments: the different surface treatments and chemistries of silicone hydrogels lens will affect the release profile of MPS and hence their potential cytotoxicity. By investigating the induction of cell death processes by solution-lens combinations in vitro, we aim to prevent potential adverse effects in the cornea, which may ultimately compromise various visual and barrier functions. The findings indicate the wealth of information in vitro cytotoxicity testing can provide when evaluating the toxicological profile of MPS.

Numerous applications in neuroscience research and neural prosthetics, such as retinal prostheses, spinal-cord surface stimulation for prosthetics, electrocorticogram (ECoG) recording for epilepsy detection, etc., involve electrical interaction with soft excitable tissues using a surface stimulation and/or recording approach. These applications require an interface that is able to set up electrical communications with a high throughput between electronics and the excitable tissue and that can dynamically conform to the shape of the soft tissue. Being a compliant and biocompatible material with mechanical impedance close to that of soft tissues, polydimethylsiloxane (PDMS) offers excellent potential as the substrate material for such neural interfaces. However, fabrication of electrical functionalities on PDMS has long been very challenging. This thesis work has successfully overcome many challenges associated with PDMS-based microfabrication and achieved an integrated technology platform for PDMS-based stretchable microelectrode arrays (sMEAs). This platform features a set of technological advances: (1) we have fabricated uniform current density profile microelectrodes as small as 10 microns in diameter; (2) we have patterned high-resolution (feature as small as 10 microns), high-density (pitch as small as 20 microns) thin-film gold interconnects on PDMS substrate; (3) we have developed a multilayer wiring interconnect technology within the PDMS substrate to further boost the achievable integration density of such sMEA; and (4) we have invented a bonding technology---via-bonding---to facilitate high-resolution, high-density integration of the sMEA with integrated circuits (ICs) to form a compact implant. Taken together, this platform provides a high-resolution, high-density integrated system solution for neural and muscular surface interfacing. sMEAs of example designs are evaluated through in vitro and in vivo experimentations on their biocompatibility, surface conformability, and surface recording/stimulation capabilities, with a focus on epimysial (i.e. on the surface of muscle) applications. Finally, as an example medical application, we investigate a prosthesis for unilateral vocal cord paralysis (UVCP) based on simultaneous multichannel epimysial recording and stimulation.

No description available.

Les cellules dérivées de la moelle osseuse, principalement les cellules endothéliales progénitrices, sont réduites chez les patients souffrant de maladies cardiovasculaires. Leur mobilisation et leur incorporation aux sites de lésion vasculaire sont des évènements prépondérants dans l’accélération des processus de réendothélialisation. Dans un modèle murin, le 17β-estradiol favorise les processus de guérison vasculaire par la mobilisation et le recrutement des cellules endothéliales progénitrices dérivées de la moelle osseuse. Il existe présentement plusieurs stratégies afin d’augmenter la mobilisation des cellules progénitrices ainsi que leur incorporation à la paroi vasculaire. Cependant, peu d’études privilégient la livraison locale d’un nombre élevé de cellules progénitrices fonctionnelles par un véhicule biodégradable et leur maintien au site de lésion afin de favoriser la réendothélialisation ciblée. Un polymère d’intérêt pour cette application s’avère être le chitosan. Ce biopolymère non toxique et biodégradable est couramment utilisé dans l’ingénierie tissulaire et, depuis peu, est utilisé dans la guérison vasculaire. Le chitosan complexé à la phosphorylcholine voit sa solubilité s’accroître dans les solutions aqueuses ainsi que sa biocompatibilité cellulaire en condition physiologique. Le projet de ce mémoire visait donc : 1) à étudier in vitro, la capacité d’un polymère de chitosan complexé à la phosphorylcholine à influencer l’adhésion, la survie, la différenciation et la fonctionnalité cellulaire dans un modèle murin de culture mixte de cellules dérivées de la moelle osseuse et 2) de déterminer l’impact de la présence du 17β-estradiol sur ces mêmes comportements cellulaires. Nos travaux démontrent que la matrice de chitosan-phosphorylcholine s’avère compatible avec notre modèle de culture cellulaire. En effet, ce polymère est capable de promouvoir l’organisation et le développement des cellules dérivées de la moelle osseuse de façon comparable à la matrice normalement utilisée dans la croissance in vitro des cellules endothéliales progénitrices, la fibronectine. De plus, ce polymère n’a nullement compromis l’activité migratoire des cellules, laissant supposer qu’il pourrait éventuellement être un véhicule approprié pour effectuer une livraison cellulaire à un site de lésion. Il s’avère que le 17β-estradiol, lorsqu’ajouté au milieu de culture ou complexé au polymère de chitosan phosphorylcholine, est capable de moduler le comportement cellulaire, et ce, de façon différente. Le 17β-estradiol complexé au polymère de chitosan-phosphorylcholine démontre, par rapport à sa forme soluble, une plus grande aptitude à accroître le nombre de cellules hématopoïétiques ainsi que des cellules endothéliales progénitrices dérivées de la moelle osseuse in vitro. De plus, le 17β-estradiol complexé au polymère de chitosan-phosphorylcholine permet une amplification marquée des cellules endothéliales progénitrices et leur offre un support adéquat afin de favoriser la guérison vasculaire. L’ensemble de nos travaux suggère que le polymère de chitosan complexé à la phosphorylcholine en présence ou non de 17β-estradiol est une matrice compatible avec les cellules progénitrices dérivées de la moelle osseuse in vitro. Le 17β-estradiol complexé au polymère est toutefois plus efficace que sa forme soluble à promouvoir l’amplification du nombre de cellules progénitrices. Ce polymère représente un outil thérapeutique attrayant et une matrice de livraison d’agent bioactif prometteuse pour le recrutement cellulaire dans l’accélération de la guérison vasculaire. / Bone marrow derived cells, including endothelial progenitor cells, are reduced in numbers in patient with cardiovascular disease or risk factors. Mobilization and incorporation of these cells at the vascular lesion site are important events in the reendothelialization process. 17β-estradiol was shown in a mouse model of injury, to favour this healing process through mechanisms which involve the mobilization and incorporation of endothelial progenitor cells derived from the bone marrow. At the moment, there are many strategies to increase endothelial progenitor cells mobilization as well as recruitment into the vascular wall. However, few studies favour local delivery of a large number of functional progenitor cells on a biodegradable scaffold and to maintain them at the lesion site in order to promote reendothelialization. An interesting biopolymer for this application is chitosan. This non toxic and biodegradable biopolymer is commonly used in tissue engineering and was recently used in vascular healing. Phosphorylcholine modified chitosan can increase the water solubility and cell biocompatibility of the biopolymer in physiological condition. This master project was thus designed to :1) evaluate, in vitro, the capacity of phosphorylcholine modified chitosan to influence cell adhesion, survival, differentiation and functionality in a mouse model of bone marrow mixed culture and 2) determine the impact of 17β-estradiol on these cell behaviours. Our results suggest an adequate biocompatibility of phosphorylcholine modified chitosan with our cell culture system. Indeed, this polymer was able to promote cell organization and development of bone marrow derived cells in the same way that fibronectin, the most commonly matrix used in the progenitor cells in vitro culture. Moreover, cell migratory activity was not compromised by the chitosan polymer. It appears that 17β-estradiol, when added to cell culture media or attached on phosphorylcholine modified chitosan is able to modulate differently cell behaviour. Our data suggest that 17β-estradiol coupled to the chitosan polymer was superior to increase the number of haematopoietic and endothelial progenitor cells derived from bone marrow in vitro compared to the soluble form. 17β-estradiol coupled to the polymer of phosphorylcholine modified chitosan allowed an increased amplification of progenitor cell number and provided adequate scaffold to favour vascular healing. We propose that phosphorylcholine modified chitosan in presence or not of 17β-estradiol is a compatible matrix with bone marrow derived progenitor cells in vitro. 17β-estradiol enhances the amplification of progenitor cell in vitro when associated to the polymer compared to its soluble form. This biopolymer may be an attractive matrix and a promising vehicle in a drug delivery therapeutic system for progenitor cells recruitment and to promote vascular healing.

La transplantation d’îlots chez des sujets diabétiques permet la normalisation de leur glycémie mais nécessite l’utilisation d’immunosuppresseurs. Afin d’éliminer l’utilisation de ceux-ci, une capsule d’alginate capable d’immunoprotéger l’îlot a été proposée. Cependant, un problème persiste : la survie de l’implant est limitée. Deux moyens afin d’améliorer ce facteur seront présentés dans ce mémoire: l’utilisation d’alginate purifié et la co-encapsulation des îlots avec des cellules canaliculaires pancréatiques. La première étude rapporte un aspect nouveau : les effets directs de l’alginate non-purifié, versus purifié, sur la survie d’îlots encapsulés. Ceci est démontré in vitro sur la viabilité à long terme des îlots, leur fonction et l’incidence de leur mort cellulaire par apoptose et nécrose. Ces investigations ont permis de conclure que l’alginate purifié permet de maintenir à long terme une meilleure survie et fonction des îlots. De plus, cette étude ajoute un autre rôle aux contaminants de l’alginate en plus de celui d’initier la réaction immunitaire de l’hôte; celle-ci étant indirectement reliée à la mort des îlots encapsulés. La deuxième étude consiste à déterminer les impacts possibles d’une co-encapsulation d’îlots de Langerhans avec des cellules canaliculaires pancréa-tiques. Les résultats obtenus démontrent que cette co-encapsulation n’améliore pas la survie des îlots microencapsulés, par des tests de viabilité et de morts cellulaires, ni leur fonction in vivo testée par des implantations chez un modèle murin immmunodéficient. Pour conclure, la survie des îlots encapsulés peut être améliorée par la purification de l’alginate mais reste inchangée lors d’une co-encapsulation avec des cellules canaliculaires pancréatiques. / Islets transplantation can normalize glycaemia in diabetic patients but only with the use of immunosuppressive drugs. The elaboration of an alginate microcapsule to immunoprotect the islets has been developed to overcome the use of those harmful drugs. However, one problem still subsists: the limited survival of the transplant. Two different aspects to overcome this problem will be discussed in this thesis: the use of purified alginate and the co-encapsulation of islets with pancreatic duct cells. The first study investigated a new proposition: the direct effects of non-purified alginate, compared to the purified one, on the survival of encapsulated islets. This was demonstrated by in vitro studies on the islets long-term viability, function and the incidence of their death by apoptosis and necrosis. These investigations helped us to conclude that purified alginate can maintain a better long-term survival and function of encapsulated islets. This investigation also demonstrated that alginate contaminants have a direct influence on encapsulated cells besides their role in immune cell activation; which have an indirect implication in the encapsulated islets death. The second study investigated the possible effects of pancreatic duct cells when co-encapsulated with islets of Langerhans. The results showed no significant effects on the viability of co-encapsulated islets, by viability and cellular death assays, and neither on their function in vivo tested with implantations in a mouse immmunodeficient model. To conclude, alginate purification appeared to improve the survival of encapsulated islets while pancreatic duct cells failed to do the same.

Abstract der Posterpräsentation: Xerogele basierend auf Silikat und Kollagen wurden als lasttragendes Knochenersatzmaterial entwickelt. Das Materialkonzept [1] wurde durch den Zusatz verschiedener Calciumphosphate modifiziert. Das Ziel der Arbeit – die Bioaktivität der Komposite und somit das Zellverhalten zu beeinflussen – wird in Verbindung gesetzt zur derzeitigen kritischen Diskussion der Bioaktivität von Biomaterialien [2]. Die Xerogele wurden durch Nutzung eines Sol-Gel-Prozesses hergestellt, der durch die Änderung des pH-Wertes beim Mischen von Kieselsäure und einer Kollagenlösung initiiert wird. Hydroxylapatit (HAp), a-Tricalciumphosphat (TCP), Brushit und ein selbst entwickelter organisch modifizierter HAp wurden als Pulver sowie Ostim® als pastöse Komponente zur Kollagensuspension hinzugefügt. Die Xerogele wurden in Medien verschiedener Calciumkonzentrationen inkubiert. Die Charakterisierung erfolgte durch biochemische Methoden und Rasterelektronenmikroskopie. Der Einfluss der Xerogelbioaktivität auf die osteogene Differenzierung humaner mesenchymaler Stammzellen wurde biochemisch und durch konfokale Laser-Scanning-Mikroskopie analysiert. Die Zugabe von HAp, Ostim® oder TCP führte zu einer beschleunigten Apatitabscheidung auf den Xerogelen aus simulierter Körperflüssigkeit ebenso wie aus Zellkulturmedium (a-MEM). Im Gegensatz dazu verursachen organisch modifizierter HAp oder Brushit eine initiale Calciumfreisetzung aus den Xerogelen. Diese Freisetzung kompensiert das bioaktive Verhalten in gewissem Maße, was durch die Einlagerung in Calcium-freiem a-MEM bestätigt wurde. Die gesteigerte Bioaktivität der Xerogele entspricht einem verringerten Calciumgehalt im Medium, der wiederum einen nachteiligen Effekt auf die Proliferation hat und zur Inhibierung der Matrixmineralisation führt.

Objetivo: avaliar a biocompatibilidade de materiais indicados como protetores pulpar no tecido subcutâneo de ratos ao longo do tempo. Métodos: Implantes padronizados de Hidróxido de Cálcio (HC), Cimento de Ionômero de Vidro (CIV) e Adesivo Dentinário Fotoativado (ADF) foram colocados cirurgicamente no dorso de ratos Wistar e deixados por 15 e 30 dias (cada grupo com 5 animais) e os respectivos grupos sham (S). Após a experimentação os animais foram sacrificados e material do dorso dos animais foi retirado para estudo ao microscópio de luz com estereologia e imuno-histoquímica para &#945;-actina de músculo liso (ACML, detecção de miofibroblastos). As pastilhas e a superfície das cápsulas fibrosas foram analisadas quanto a textura, em microscopia eletrônica de varredura (MEV) com microanálise. Resultados: Houve diferenças na fibrose e no número de mastócitos na região peri-implante dependente do tipo de implante. Não foram detectados miofibroblastos expressando ACML. O menor valor de densidade volumétrica de fibrose intersticial (Vv[f]) ocorreu no grupo HC, e o maior no grupo ADF (diferença significativa em relação ao grupo S, nos dois tempos experimentais, p<0,05). Entretanto, aos 30 dias, houve acréscimo de 30% de Vv[f] do grupo ADF, determinando, neste período, diferença significativa em relação ao grupo HC. Quanto a densidade numérica de mastócitos por área (NA[mastócito]) o menor valor ocorreu no grupo HC sem diferença para o grupo S, mas diferença para o grupo ADF (este com o maior valor de NA[mastócito] nos dois tempos experimentais). O grupo CIV apresentou, para Vv[f] e NA[mastócito], durante toda a experimentação, resultados intermediários aos grupos HC e ADF. Houve fibrose discreta e restrita a área cirúrgica com poucos mastócitos juntos aos vasos no grupo S. Houve correlação positiva para Vv[f] e NA[mastócito], no grupo ADF. Ao MEV viu-se interação, no grupo HC, entre o material da pastilha e sua cápsula fibrótica, mas não nos grupos ADF e CIV. Conclusão: Os materiais estudados induziram a formação de fibrose e migração de mastócitos de modo diferenciado. Os resultados sugerem o HC como o material mais compatível biologicamente dentre os testados neste trabalho. / Purpose: to evaluate the biocompatibility of some pulpar protecting materials in the subcutaneous tissue of rats along the time. Methods: standardized implants of Calcium Hydroxide (CH), Glass Ionomer Cement (GIC) and Light-cured Dentin Adhesive (LDA) surgically were put in the back of Wistar rats and left by 15 and 30 days (each group with 5 animals) and the respective sham groups (S). After the experimentation the animals were sacrificed and material from the back of the animals was removed for study with light microscope, stereology and immunohistochemistry for smooth muscle alfa-actin (SMAA, myofibroblast detection). The implants and the fibrous capsule surfaces were analyzed with the scanning electronic microscopy (SEM) adapted with microanalysis. Results: the fibrosis and the number of mastocytes were different in the implant area depending of the implant type. Myofibroblasts were not detected expressing SMAA. The smallest value of the volume density of interstitial fibrosis (Vv[f]) occured in the CH group, and the largest in the LDA group (the difference was significant in relation to the S group, in the two experimental times, p < 0.05). However, to the 30 days, the Vv[f] of the LDA group increase 30%, being different from the CH group in this period. The numerical density of mastocytes per area (NA[mastocyte]) was smaller in the CH group without difference for the S group, but with difference from the LDA group (this group had the largest NA[mastocyte] value in the two experimental times). The GIC group had, for Vv[f] and NA[mastocyte] all experimentation time, intermediary values ranging from CH to LDA values. There was discreet and restricted fibrosis in the surgical area with few mastocytes associated to vessels in the S group. There was positive correlation for Vv[f] and NA[mastocyte] in the LDA group. In the CH group the SEM observed interaction between the implant material and its fibrotic capsule, but not in the LDA and GIC groups. Conclusion: The studied materials induced the fibrosis formation and mastocytes migration in a differentiated way. The results suggest that CH as the most biologically compatible material among the materials tested in this work.

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No. of bitstreams: 1 TesePRGA.pdf: 5283158 bytes, checksum: c57ad9ff767d07147f784d369b1084cf (MD5) Previous issue date: 2015-03-27 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / Millions of bone fractures occur annually worldwide and the consequent bone repair process is complex, involving many biological events until it reaches the restoration of the tissue integrity. During that process some problems can occur due to delays in the bone healing, which does not allow the proper joining of the tissue. Thus, it is necessary to search for new technologies that work in restoring the integrity of the bone tissue and that promote the osteoconduction and the osteoinduction. In this sense, the use of bioactive materials in the bone repair process is a promising alternative. Following this, two studies (I and II) were developed in order to investigate a new fibrous glassy scaffold, and these studies were based in three lines of research: (i) the characterization of the new fibrous glassy scaffold; (ii) the biocompatibility evaluation of this bioactive material; (iii) the analysis of the biological performance of this new scaffold in the bone repair. More specifically, in the study I the developed scaffolds were characterized in terms of porosity, mineralization and morphological features. Additionally, fibroblast and osteoblast cells were seeded in contact with extracts of the scaffolds to assess cell proliferation and genotoxicity after 24, 72 and 144 h. Finally, scaffolds were placed subcutaneously in rats for 15, 30 and 60 days. In regards to study II, the morphological structure of the scaffolds upon incubation in phosphate buffered saline (PBS) (via scanning electron microscope) was assessed after 1, 7 and 14 days and, also, the in vivo tissue response to the new biomaterial was evaluated using implantation in rat tibial defects. The histopathological, immunohistochemistry and biomechanical analyzes after 15, 30 and 60 days of implantation were performed to investigate the effects of the material on bone repair. The scaffolds presented interconnected porous structures (porosity of ~75%), and the precursor bioglass could mineralize a hydroxycarbonate apatite (HCA) layer in SBF after only 12 h. The PBS incubation indicated that the fibers of the glassy scaffold degraded over time. With regards to the biological investigations, the biomaterial elicited increased fibroblast and osteoblast cell proliferation, and no DNA damage was observed. The in vivo experiment showed degradation of the biomaterial over time, with soft tissue ingrowth into the degraded area and the presence of multi-nucleated giant cells around the implant. At day 60, the scaffolds were almost completely degraded, and an organized granulation tissue filled the area. Additionally, the histological analysis of the implants in the bone defects revealed a progressive degradation of the material with increasing implantation time and also its substitution by granulation tissue and woven bone. Histomorphometry showed a higher amount of newly formed bone area in the control group (CG) compared to the biomaterial group (BG) 15 days post-surgery. After 30 and 60 days, CG and BG showed a similar amount of newly formed bone. The novel biomaterial enhanced the expression of RUNX-2 and RANK-L, and also improved the mechanical properties of the tibial callus at day 15 after surgery. These results indicate that the new fibrous glassy scaffold is bioactive, non-cytotoxic, biocompatible and promising for using in bone tissue engineering. / Milhões de fraturas ósseas ocorrem anualmente no mundo todo e o processo de reparo é complexo, envolvendo muitos eventos biológicos até que se atinja a restauração da integridade do tecido. Problemas nessa regeneração podem ocorrer, levando a não união óssea. Assim, faz-se necessária a busca por novas tecnologias que atuem na restauração da integridade do tecido ósseo e promovam a osteocondução e a osteoindução. Para tanto, uma alternativa promissora é a utilização de materiais bioativos para o reparo ósseo. Seguindo essa linha, foram realizados dois estudos (I e II) acerca de um novo scaffold vítreo fibroso, sendo estes estudos baseados em três linhas de investigação: (i) caracterização do novo scaffold vítreo fibroso; (ii) avaliação da biocompatibilidade desse material bioativo e (iii) análise do desempenho biológico desse novo scaffold no reparo ósseo. Mais especificamente, no estudo I foi feita a caracterização dos scaffolds em termos de porosidade, mineralização e características morfológicas. Adicionalmente, fibroblastos e osteoblastos foram cultivados em contato com extratos dos scaffolds para avaliação da proliferação celular e genotoxicidade após 24, 72 e 144 h. Finalmente, nesse mesmo estudo, os scaffolds foram implantados subcutaneamente em ratos por 15, 30 e 60 dias. No que se refere ao estudo II, foram feitas avaliações da estrutura morfológica dos scaffolds (via microscopia eletrônica de varredura) imersos em tampão fosfato salino (PBS) após 1, 7 e 14 dias, além de investigações do efeito no reparo ósseo do novo scaffold utilizando implantação do mesmo em defeitos ósseos tibiais em ratos. Análises histopatológicas, imunohistoquímicas e biomecânicas foram realizadas 15, 30 e 60 dias após a implantação. Os scaffolds apresentaram estruturas altamente porosas (porosidade de ~75%) e interconectadas, e o biovidro precursor mineralizou uma camada de hidroxicarbonatoapatita (HCA) em SBF (simulated body fluid) após o curto período de 12 h. A incubação em PBS indicou que as fibras do scaffold apresentaram sinais de degradação com o passar do tempo. Sobre os testes biológicos, o novo biomaterial levou a um aumento da proliferação de fibroblastos e osteoblastos, e nenhum dano ao DNA foi observado. Os experimentos de implantação do material no subcutâneo indicaram degradação do biomaterial acompanhada do crescimento interno de tecido mole e presença de células gigantes multinucleadas ao redor do implante. Após 60 dias, os scaffolds estavam quase completamente absorvidos e um tecido de granulação organizado preenchia a área de implantação. Adicionalmente, as análises histológicas dos scaffolds em defeitos ósseos revelaram uma degradação progressiva do biomaterial e substituição do mesmo por tecido de granulação e tecido ósseo neoformado. A histomorfometria mostrou uma maior quantidade de osso neoformado no grupo controle (CG) comparado ao grupo biomaterial (BG) 15 dias após a cirurgia. No entanto, depois de 30 e 60 dias, CG e BG apresentaram quantidades similares de osso neoformado. Além disso, o novo biomaterial aumentou a expressão de RUNX-2 e RANK-L, e também melhorou as propriedades mecânicas do calo tibial 15 dias após a cirurgia. Os resultados indicam que o novo scaffold vítreo fibroso é bioativo, não-citotóxico, biocompatível e promissor para utilização na engenharia do reparo ósseo.

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