RADIOGRAPHIC EVALUATION OF CORALS vs.

AUTOGENOUS BONE GRAFT FOR FILLING CAVITIES

OF LARGE ENUCLEATED CYSTS OF THE JAWS

Khaled A. Elhayes*; Gehan A. Omar**; Walid A.Ghanem***

Abstract:
This study included 21 patients of both sexes (13 males & 8 females) aged 20 - 46 years, they were divided into 3
groups, each group contained 7 Patients, All patients in all groups were selected to have large cystic cavities in
their dental arches of different etiological factors, ranged in diameter 1 – 2.5 cm. and not approaching any vital
structures, they underwent surgical enucleations of these cystic cavities, Patients of group ( I ) have received
autogenous bone grafts that were harvested from the chin to fill the residual spaces of the cysts, wile Patients in
group (II) have received bone substitute in form of Algipore granules that were packed inside the bony cavities of
enucleated cysts till complete filling, and the Patients in group ( III ) have not received any grafting materials after
cysts enucleations. Radiographic evaluation of all patients was performed using digital radiography system
(Digora) by Soredex Orion Corporation version 1.51. Radiographs were taken preoperatively and at intervals of 1
week, 3 month, 6 months and 1 year postsurgically. Radiographs of the same region at the opposite side were
obtained for comparison. All radiographs were taken using long cone parallel technique with the help of bite blocks
to provide standardization of images. The mean density of pixels within the area of graft was recorded and other
normal side too. It was found that there was no significant difference between Autogenous group and Algipore
group at all time intervals, while there were significant increase in bone density in both groups compared with
control group at all these time intervals, the significant increase in bone density in control group seen only at 1 year
postoperatively compared with preoperative bone density, while there was no significant difference in bone density
between other time intervals. In other both groups, there was significant increase in bone density in all time
intervals compared with preoperative density, BUT, in Autogenous group, there was a significant decrease in bone
density at 3 months postoperatively compared with 1 week postoperatively while this decrease in bone density with
Algipore group was not significant. Furthermore, the bone density increased again significantly in Autogenous
group at 6 months postoperatively compared with 3 months postoperatively while this increase was not significant
in Algipore group. It was concluded that Algipore (CORALS) can be a dependable bone substitute material for
grafting bony defects in both jaws and preferred than Autogenous bone as there were no significant difference
between them throughout 1 year follow up period and taking the advantage of avoiding other surgical sites with
their morbidity.

Introduction:
Large bony spaces left after enucleation of large cystic cavities of the Jaws represent a
questionable issue for bone grafting procedures, so, different grafting procedures for these bony
spaces were performed in this research to study their effects on the net result of bone density
postsurgically.

Review of literature:
Roux FX. et al (1988) reported that Corals have the advantage of being cheap , easily sterilized,
inert (99% of calcium carbonate), biodegradable and well reossified. They shorten surgical
procedures by avoiding the use of iliac and/or costal grafts. No infectious complications have
been noted. (27)

‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
*Lecturer of Oral&Maxillofacial Surgery, Faculty of Oral&Dental Medicine, Cairo University.
**Lecturer of Radiology, Faculty of Oral&Dental Medicine, Cairo University.
***Lecturer of Oral&Maxillofacial Surgery, Faculty of Dentistry, Suez Canal University.

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Patat JL. and Guillemin G. (1989) mentioned that “Experimental studies commenced in 1977
and human clinical applications commenced in 1979, have largely demonstrated the
biocompatibility of the coral material and its entirely original nature. This biomaterial is
progressively and totally replaced by newly formed bone with the characteristics of the recipient
bone (after completion of the restoration process). (26)
Begley CT. et al (1995) in a comparison between Corals and others, said that “a layer of what
appeared as dense calcification was seen around the coral implant. Coral elicited no marked
inflammatory response, and this was attributed to the negligible amounts of protein present in
these materials.” (3)
Roux FX. et al (1995) mentioned that “Madreporic Coral graft implants can be recommended as
bone substitute in cranial base surgery: 1) The material simplifies the surgical procedure; 2)
Harvesting of autologous bone is no longer necessary; 3) Transmission of infections like AIDS,
Hepatitis C or Creutzfeld-Jacob-disease can be avoided with certainty.” (28)
Demers C. et al (2002) in their review for Corals as a bone substitute revealed that The
structure of the commonly used coral, is similar to that of cancellous bone and its initial
mechanical properties resemble those of bone, they are
biocompatible, osteoconductive, and biodegradable at variable rates, and they added “When
applied appropriately, natural coral exoskeletons have been found to be impressive bone graft
substitutes. (9)
Turhani D. et al (2005) concluded that the results of their study showed that Algipore obtained
from calcified red algae support the proliferation and differentiation of human osteoblast-like
cells on its surface. (33)
The autogenous bone used in this research was taken from the chin as it is a very common
donor site and beneficial source for autogenous bone grafts(8),presented better bone quality
than bone harvested from the ileum (21) and the mandibular Symphesis can be reliably selected
as the harvest site in a variety of oral and maxillofacial reconstructive procedures
(2,12,24,25,37).
Furthermore, convenient surgical access, proximity of donor and recipient sites, low morbidity,
availability of larger quantities of bone over other donor sites, minimal resorption, no
hospitalization, no cutaneous scar and minimal discomfort are some advantages of this
procedure over other sites (10, 11, 13, 22, 23, 31)

In bone grafting procedures, Many methods were used for measurement of bone density as
dual X-ray absorptiometry (5, 16, 20) peripheral quantitative computed tomography (pQ-CT)
(7)Micro-computed tomography (micro CT) (17, 18) cutting torque measurements(15) and many
other techniques.
Sivarajasingam V. et al (2001) have measured Optical density of iliac and tibial grafts using a
computerized densitometer, and compared them at 6 days, 6 weeks, and 3 months. (30)
Mankani MH. et al (2004) Concluded that the use of quantitative CT offers a practical approach
for the noninvasive determination of new bone formation in mineralizing bone marrow stromal
cells and hydroxyapatite-tricalcium phosphate(HA-TCP) transplants. (19)
Beltrame F. et al (2005) have presented an innovative calibration algorithm for a semi-
quantitative analysis of non-standardized digitized X-ray images to investigate the progression
of the new bone deposition and the osteo-integration at the bone-implant interface. (4)
Sanchez AR. et al (2005) have measured the bone mineral density (BMD) and bone mineral
content (BMC) by peripheral dual x-ray absorptiometry densitometer. (29)
Thorwarth M. et al (2005) using micro-radiography analysis for mineralization of autogenous
bone grafts harvested from different sites concluded that the differences in mineralization
depending on the origin of autogenous bone. Even after 6 months, these values could still be
correlated to the transplants origin. (32)
Vossen M. et al (2005) have studied Bone quality pre- and post-transplant using other
modalities by measuring acoustic velocity and density and by calculating elastic coefficients. (36)
2
Aim:
1- Evaluation of Coral material as a bone substitute grafting material for filling large bony
cavities created by enucleation of large Cysts of the Jaws.
2- Comparison between this material and autogenous bone from the chin.
3- Comparison between grafting and non-grafting procedures of these cavities.
Material &Methods:
This study included 21 patients of both sexes (13 males & 8 females) aged 20 - 46 years, they
were divided into 3 groups.
Group I (Autogenous Group) : Contained 7 patients (4 males & 3 females) of average age 31.1
years.
Group II (Algipore Group) : Contained 7 patients ( 4 males & 3 females) of average age 30.7
years.
Group III (Control Group) : Contained 7 patients ( 5 males & 2 females) of average age 31.4
years.
All patients in all groups were selected to have large cystic cavities in their dental arches of
different etiological factors, ranged in diameter 1 – 2.5 cm. and not approaching any vital
structures.
All patients underwent surgical enucleations of these cystic cavities using either pyramidal flaps
or semilunar flaps according to the location of the cyst in relation to the crest of the ridge.
Root canal treatments were performed to the related affected teeth during the surgical
procedures.
Patients of group ( I ) have received autogenous bone grafts to fill the residual spaces of the
cysts, they were harvested from the chin of the same patients in forms of bone blocks and
cancellous particulates; the blocks were cut and prepared to customize the size and anatomy of
the graft bed. The available amount of cancellous bone was then curetted from the bed of the
harvested bone using molt curette leaving the harvesting bed with intact lingual cortical plate.
Then, the bone block was prepared by removal of cancellous bone from its ventral surface
using end cutting bone rongeur, the total cancellous bone was then mixed with saline or blood
sample from the patient and packed inside the bony cavity of enucleated cyst. The cortical plate
of the bone block was then segmented according to the need of the area to be grafted, and
covered the cancellous particulate. (Fig. 1)
Patients in group ( II ) have received bone substitute in form of Algipore granules that were
mixed with a blood sample from the patient , then, packed inside the bony cavities of enucleated
cysts till complete filling of these cavities. (Fig. 2)
Patients in group ( III ) have not received any grafting materials after cysts enucleations.
Suturing of the flaps for all patients was performed using 000 black silk suture without
placement of any guided bone regeneration membranes, then, postoperative regimen of
medications was prescribed for the patients.
Radiographic evaluation of all patients was performed using digital radiography system (Digora)
by Soredex Orion Corporation version 1.51. Radiographs were taken preoperatively and at
intervals of 1 week, 3 month, 6 months and 1 year postsurgically. Radiographs of the same
region at the opposite side were obtained for comparison. All radiographs were taken using long
cone parallel technique with the help of bite blocks to provide standardization of images.
The density measurement window displayed the radiographs, and a rectangular area is marked
on the image in the area of the bony defects and area measuring is performed. The mean
density of pixels within the area was recorded. The same was performed in bilateral images.
Results were displayed as numeric statistical information, as a histogram showing density
distribution, and a density profile. (Fig. 3)

The data were then collected, tabulated and statistically analyzed.

3
 (Fig. 1) Bone graft of case in Autogenous group
A) Removal of cystic lesion B) Autogenous bone in place

(Fig. 2) Surgical steps for bone grafting procedures in Algipore group

A) Removal of cystic lesion B) Files in place for R.C.T
C) Apecectomy D) Algipore in place

4
(Fig. 3) measurement of bone density by DIGORA

5
Results:

All the cases had passed uncomplicated surgically except for one case of Algipore group that
showed 1 week postoperative infection and had been considered as a failure case and had
been replaced by an other successful one.
There was no significant difference between Autogenous group and Algipore group at all time
intervals, while there were significant increase in bone density in both groups compared with
control group at all these time intervals except preoperative period at Algipore group.
In Control group, there was a significant increase in bone density seen only at 1 year
postoperatively compared with preoperative bone density, while there was no significant
difference in bone density between other time intervals.
In other both groups, there was significant increase in bone density in all time intervals
compared with preoperative density, BUT, in Autogenous group, there was a significant
decrease in bone density at 3 months postoperatively compared with 1 week postoperatively
while this decrease in bone density with Algipore group was not significant.
Furthermore, the bone density increased again significantly in Autogenous group at 6 months
postoperatively compared with 3 months postoperatively while this increase was not significant
in Algipore group.

Statistical table showing the means of bone densities readings of all groups at al time intervals to study
the effect of time and the effect of grafting material

Control Autogenous Algipore F ratio Prob. LSD

Preop. 88.14 34.86 66.29 4.16923 0.032519 38.978

1W 69.57 189.71 181.57 38.58566 3.1E-07 32.114
3M 76.29 144.86 160.14 16.7871 7.68E-05 32.388
6M 97.57 179.71 169.00 18.62057 4.14E-05 30.748
12 M 130.57 189.71 171.29 11.32844 0.000653 26.716
F ratio 4.380 53.210 15.293
Prob. 0.007 3.37-13 6.35-07
LSD 32.963 26.033 34.874

Horizontally : evaluating effect of material used on bone density in each interval

Vertically : evaluating effect of time on bone density in each group separately
LSD = Least Significant Difference at p < 0.05

6
 Bone Density

200

150

100

50

0
Preoperative 1 W. 3 M. 6 M. 12 M.

Autogenous Algipore Control Time Intervals

Bone Density
200

150

100

50

0
Preoperative 1W 3M 6M 12 M

Autogenous Algipore Control Time Intervals

7
(Fig. 4) (A) Preoperative & (B) 3 months postoperative radiographs of patient in Autogenous group

(Fig. 5) (A) Preoperative & (B) 3 months postoperative radiographs of patient in Algipore group

8
Discussion:
The corals were selected for this research as they are more available and cheaper than many
other grafting materials, at the same time, the differences between corals and these various
grafting materials were not significant. (34)
Both Autogenous and Algipore groups had demonstrated better bone density than Control
group during all follow up periods that was in agreement with Sanchez AR. et al who have found
that the bony defects where demineralized freeze-dried bone graft (DFDBG) was used, either
with or without platelet-rich plasma (PRP), did demonstrate slightly greater Bone Mineral
Density (BMD) and Bone Mineral Content (BMC) than those left untreated. (29) Although, there
was no significant difference in bone density between autogenous bone graft and Algipore
groups throughout all postoperative time intervals that was in agreement with Block MS. et al
(6)
The significant decrease in bone density at the first 3 months postoperatively with Autogenous
bone group indicating that this period is resorpative in nature while the next 3 months were
depositive in nature as explained by the significant increase in bone density at the end of 6
months postoperatively. This disagreed with Verhoeven JW. et al who concluded that the first
half year being dominated by bone resorption, mainly confined to the cortex of the graft,
whereas the second half year is characterized by an increase in bone density in the (remaining)
cortex as well as the lower spongeous parts of the graft. (35)
Density measurement using digital radiography is used for providing an accurate measuring of
gray scale values than the human eye can. The density of an image refers to its brightness. The
maximum density value is 255, which corresponds to white. The minimum density value is zero,
which corresponds to black. The different shades of gray have density values from 1 to 254
(A.Wenzel, 1993) (1)
There were some few unexplained readings during this study that did not affect the net results
of this research, this was explained by Jeffecoat 1993 (14) who claimed that digital radiography
could detect minute changes in density, but the actual images in this study sometimes showed
unexplained readings, these readings could be explained by the relative depth or buccolingual
dimension of the osseous defect and the frequent superimposition of anatomical structures over
the bony defect. This also agreed Young et al 1996 (38) who measured the density changes in
marginal bone around implants, the authors found some unclear changes because of the fact
that radiographs only measure the mesial and distal marginal bone loss but not the buccal and
lingual sides.
Conclusions:
Algipore (CORALS) can be a dependable bone substitute material for grafting bony defects in both jaws
and preferred than Autogenous bone as there were no significant difference between them throughout 1
year follow up period and taking the advantage of avoiding other surgical sites with their morbidity.

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