Natural coral exoskeleton as a bone graft substitute: A review

Natural coral graft substitutes are derived from the exoskeleton of marine madreporic corals. Researchers first started evaluating corals as potential bone graft substitutes in the early 1970s in animals and in 1979 in humans. The structure of the commonly used coral, Porites, is similar to that of cancellous bone and its initial mechanical properties resemble those of bone. The exoskeleton of these high content calcium carbonate scaffolds has since been shown to be biocompatible, osteoconductive, and biodegradable at variable rates depending on the exoskeleton porosity, the implantation site and the species. Although not osteoinductive or osteogenic, coral grafts act as an adequate carrier for growth factors and allow cell attachment, growth, spread- ing and differentiation. When applied appropriately and when selected to match the resorption rate with the bone formation rate of the implantation site, natural coral exoskeletons have been found to be impressive bone graft substitutes. The purpose of this article is to review and summarize all the pertinent work that has been published on natural coral as a bone graft including in vitro, animal and clinical human studies. Preliminary report of our own experiments as well as our recommendations on the use of coral are also included.