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112 The Journal of Craniofacial Surgery Volume 27, Number 1, January 2016
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery Volume 27, Number 1, January 2016 Eggshell-Derived Hydroxyapatite
TABLE 1. Showing Distribution of Subjects According to Groups and Sex TABLE 3. Showing the Size of the Lesion Preoperatively in Both the Groups
Sex SHA Group % EHA Group % Total % Size of the Lesion SHA EHA
Preoperatively Group % Group % Total %
Male 5 50.00 5 50.00 10 50.00
Female 5 50.00 5 50.00 10 50.00 <2 cm 5 50.00 2 20.00 7 35.00
Total 10 100.00 10 100.00 20 100.00 >2 cm 5 50.00 8 80.00 13 65.00
Total 10 100.00 10 100.00 20 100.00
EHA, eggshell-derived hydroxyapatite; SHA, synthetic hydroxyapatite.
EHA, eggshell-derived hydroxyapatite SHA, synthetic hydroxyapatite.
25–35
the literature, but in this study EHA is indigenously synthes-
ized by microwave processing. The EHA produced was chemically RESULTS
pure form of nanocrystalline calcium deficient hydroxyapatite with
eggshell origin alike any other SHA.22– 24
Clinical Observations
The sizes of cysts were ranged from 2 to 4 cm in diameter. All
Clinical and Radiologic Evaluation the patients were healed well without significant adverse clinical
The study was conducted in the Department of Oral and Max- observations irrespective of the size of the lesion in both the groups
illofacial Surgery in our institute after ethical committee approval. (Table 3). First day postsurgical clinical examination showed
The study registered in Clinical Trial Registry of India (CTRI) similar edema among patients in both the groups with reddish
retrospectively with CTRI numbers CTRI/2014/09/004947 and overlying mucosa in all the patients. At the time of suture removal,
CTRI/2014/12/005340. A total number of 20 patients aged between the mucosal color and contour was normal in all the patients.
20 and 45 years with periapical cyst/residual cyst of anterior Moreover, no flap dehiscence was observed.
maxilla, requiring cystectomy/apicoectomy, and grafting were
enrolled (Tables 1-2). All the patients were divided randomly into Digital Radiographic Observations
2 groups with 10 patients in each group. In Group-1 the cystic
Radiologic evaluation of surgical site outline and bone formation
defects were filled with SHA, whereas in Group-2 with EHA.
characteristics in both the groups were significant with time interval
All the patients were followed up during first and second week
(Table 4; Fig. 1), but on comparison between the groups both SHA
postsurgically to evaluate the signs and symptoms of infection or any
and EHA showed similar pattern of bone formation and bone healing
other complications related with the surgical procedure. During
characteristics along with the margin blend with material margin at
clinical evaluation mucosal color, postoperative pain or swelling
first, third, and second month’s interval (Table 5). The mean radio-
was noted. Pain measurements were carried out using visual analog
graphic density of grafted cystic bone defects were continued to
scale. The wound healed uneventfully in all the patients. Seventh day
increase until it reached its maximum at 24 weeks (Table 6). The
of postsurgery, suture removal was done. Infected patients were
mean density of SHA and EHA group were similar at third and sixth
excluded from the study. Bone regeneration was assessed postopera-
month’s interval. The formation of bone and bone margin blending
tively at first, second, third, and sixth month’s intervals using
with material margin were well correlated with density of bone
modified observer strategy.36,37 The radiographs were examined
formation. The radiographs shows well demarcation of both material
blindly by 2 examiners. In case of any gross inconsistency with
and bone margin during first month follow-up (Fig. 2 A-B), and was
observations, the third examiner observed the radiographs to prevent
invisible with passage of time (Figs. 3-5). At sixth month’s interval on
bias and the results were tabulated. Surrounding normal bone density
both the sides it showed trabecular appearance indicating complete
was also measured as a control since beginning and correlated till last
bone formation (Fig. 6). The observations of bone regeneration
follow-up for comparison using the variable intensity light.
parameters by both the examiners were in very good agreement with
each other (k: 0.81–0.92).
Statistical Analysis
Radiographic changes in surgical site outline, internal portion of
surgical site after surgery were statistically compared using Mann- TABLE 4. Showing the Comparison of Groups (Synthetic Hydroxyapatite,
Whitney test and Wilcoxon matched-pairs test. The kappa (k) Eggshell-Derived Hydroxyapatite) With Radiologic Evaluation of Surgical Site
correlation was taken into consideration to assess the degree of Outline at First, Second, Third, and Sixth Month by Wilcoxon Matched-Pairs Test
observer agreement for radiologic assessment. The mean values and Groups Treatments N t z P
standard deviations of each parameter were calculated. The Student
t-test used to evaluate the differences between the means; P < 0.05 SHA First month versus second month 10 0.00 2.8031 0.0051
was considered as significant. First month versus third month 10 0.00 2.0226 0.0431
First month versus sixth month 10 0.00 — —
TABLE 2. Showing Mean and Standard Deviation Age of Men and Women by Second month versus third month 10 15.00 1.2741 0.2026
Groups and Sex Second month versus sixth month 10 3.00 2.4973 0.0125
SHA Group EHA Group Total Third month versus sixth month 10 0.00 1.8257 0.0679
EHA First month versus second month 10 0.00 2.8031 0.0051
Sex Mean SD Mean SD Mean SD First month versus third month 10 0.00 2.0226 0.0431
First month versus sixth month 10 0.00 — —
Male 28.20 7.66 25.00 4.53 26.60 6.17 Second month versus third month 10 15.00 1.2741 0.2026
Female 34.40 4.98 29.60 14.06 32.00 10.26 Second month versus sixth month 10 3.00 2.4973 0.0125
Total 31.30 6.91 27.30 10.14 29.30 8.69 Third month versus sixth month 10 0.00 1.8257 0.0679
EHA, eggshell-derived hydroxyapatite; SD, standard deviation; SHA, synthetic EHA, eggshell-derived hydroxyapatite; SHA, synthetic hydroxyapatite.
hydroxyapatite.
Significant at (P < 0.05).
TABLE 5. Comparison of 2 Groups (Synthetic Hydroxyapatite, Eggshell-Derived Hydroxyapatite) With Radiologic Evaluation Surgical Site Outline, Bone Formation
and Bone Healing Patterns at First, Second, Third, and Sixth Month by Mann-Whitney Test
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery Volume 27, Number 1, January 2016 Eggshell-Derived Hydroxyapatite
FIGURE 3. Radiograph after one month of the grafting showing improved bone
formation at periapical area of right central incisor, right lateral incisor, left FIGURE 5. A, Radiograph after 3 months of synthetic hydroxyapatite grafting.
central incisor, and left lateral incisor. B, Radiograph after 3 months of eggshell-derived hydroxyapatite grafting.
ACKNOWLEDGMENT
The authors thank S.B. Javali for his continued support in
the research.
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