Effect of Different Suture Techniques on Early Healing of Peri-implant Soft Tissue Following Open-flap Implant Surgery in Esthetic Area: a Randomized Clinical Trial Comparing Horizontal and Vertical Mattress Sutures
Phase: NA
Conditions: Dental Implants, Wound Healing, Sutures
Sponsor: Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University

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Shanghai Ninth People’s Hospital, Shanghai
Jiao Tong University School of Medicine
Clinical Research Protocol
Project Name:
Effect of different suture techniques on
early healing of peri-implant soft tissue
following open-flap implant surgery in
esthetic area: a randomized clinical trial
comparing
horizontal
and
vertical
mattress sutures
Version Number:
V 1.0
Version Date:
2021/10/20
Project Manager:
Start
and
End
Dates:
2021/12 – 2022/12

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Researcher’s Statement and Protocol Signature Page
As the main person in charge of this research project, I will follow the
Measures for Ethical Review of Biomedical Research Involving Human
Subjects (2016), WMA Declaration of Helsinki (2013), CIOMS
International Ethical Guidelines for Biomedical Research Involving
Human Subjects (2002) and the ethical principles of the GCP. Under the
guidance of drug clinical trial quality management regulations, I will
conduct research in accordance with the requirements of this protocol
approved by the ethics committee to ensure the scientific nature of the
research and protect the health and rights of the subjects.
Name: __Prof. Maurizio Tonetti_
Signature:
Date:

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Research Protocol Contents
1.
Protocol Abstract................................................................................................................ 3
2.
Research Background......................................................................................................... 4
3.
Study Objectives.................................................................................................................5
3.1
Primary Objective........................................................................................................5
3.2
Secondary Objective....................................................................................................5
3.3
Additional Objective................................................................................................... 5
4.
Study Hypothesis................................................................................................................5
5.
Study Methods....................................................................................................................5
5.1
Overall Design of the Study........................................................................................ 5
5.2
Sample Size................................................................................................................. 5
5.3
Randomization and Concealment................................................................................6
5.4
Blinding.......................................................................................................................6
6.
The Selection, Withdrawal and Management of Subjects..................................................6
6.1
Inclusion Criteria.........................................................................................................6
6.2
Exclusion Criteria........................................................................................................6
6.3
Management of Subjects............................................................................................. 7
7.
Study Procedures................................................................................................................ 7
7.1
Treatment of Trial Participants....................................................................................7
7.2
Handing of study interventions................................................................................... 8
7.3
Course of Treatment and Visit Points......................................................................... 9
7.3.1 Screening and Enrollment..........................................................................................9
7.3.3 Baseline Assessments (presurgical measurements T0)............................................. 9
7.3.4 Follow-up Visits and evaluation..............................................................................10
8.
Outcomes and evaluations................................................................................................ 12
8.1
Outcomes...................................................................................................................12
8.1.1 Primary outcomes.................................................................................................... 12
8.1.2 Secondary outcomes................................................................................................ 12
9.
Safety Evaluation..............................................................................................................12
9.1
Adverse Events..........................................................................................................12
9.2
Follow-up for Adverse Events...................................................................................13
10.
Data Quality Assurance.................................................................................................13
10.1
Quality Control and Assurance................................................................................. 13

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10.1.1 Training and Calibration........................................................................................13
10.1.2 Protocol Deviations............................................................................................... 13
10.1.3 Regular Monitoring............................................................................................... 13
10.1.4 Record Keeping..................................................................................................... 13
10.1.5 Patient Scheduling................................................................................................. 14
10.1.6 Investigator assistance........................................................................................... 14
10.2
Data Management......................................................................................................14
11.
Statistical Analysis........................................................................................................ 15
11.1
Statistical Software and General Requirements........................................................ 15
11.2
Statistical analysis plan..............................................................................................15
12.
Ethics Requirements and Informed Consent.................................................................15
13.
References.....................................................................................................................15

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1.
Protocol Abstract
Project Name
Effect of horizontal and vertical mattress sutures on early healing
following open-flap implant surgery in esthetic area: a randomized
clinical trial
Version Number
1.0
Version Date
2021-10-20
Apply and Participating
Units
Shanghai Ninth People's Hospital
Research Nature
Randomized
clinical trial
Sample Size
20
Research Purposes
To compare the blood perfusion and early healing of horizontal
mattress suture with vertical mattress sutures following open-flap
implant surgery.
Participants
Patients want single implant replacement in esthetic area
Research Methods
A randomized, open-label, controlled clinical trial
Noninvasive procedures will be used to assess the primary and
secondary outcomes.
Inclusion Criteria
With sufficient bone width (≥6mm), With mesial-distal distance
over 8mm, age over 18, Willing to participate
Exclusion Criteria
Patients want multiple adjacent implant replacements in esthetic
area, Untreated periodontitis, Smokers, Diabetes mellitus
Research Progress Plan
The study is expected to last for 3 months including 1 months
follow-up period after implant surgery
Statistics
Analytical Methods
Descriptive statistics and inferential statistics performed in SPSS
software, version 26.0
Publication Form of
Research Results
Publication in international specialty Journal
Main Researcher
Maurizio
S. Tonetti
Title
Chair
Professor
Date of
Birth
18 May
1961
Major
Members
of the
Project
Name
Date of
Birth
Title
With or
Without GCP
Certificate
Responsibility
Prof. Lai
Hongchang
Professor
With GCP
Co-investigator
Dr. Junyu
Shi
Doctor
With GCP
Co-investigator
Dr. Deng
Ke
07 Oct
1991
Doctor
With GCP
Co-investigator/ study
coordinator
Dr. Shujiao
Qian
Doctor
With GCP
Co-investigator
Dr. Beilei
Liu
Doctor
With GCP
Co-investigator/ study
coordinator
Dr. Xiao
Zhang
Doctor
With GCP
Statistician

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2.
Research Background
Dental implant placement is a highly technique-sensitive procedure. Proper wound closure and
stabilization of wound margins in a desired position are critical events that influence the success
of the outcomes, particularly in more demanding surgeries such as esthetic and reconstructive
surgery.
Wound healing primarily depends on early formation of the blood clot and the establishment of an
attachment of the clot that is resistant to mechanical forces acting on the flap and opposing
surfaces participating in the wound closure. Suture is the major area of concern in situations where
mechanical stability of the flap is required.
Ideally, surgical suture should hold edges in
apposition until the wound has healed. Various types of sutures have been proposed to stabilize
and secure the surgical flap to promote the optimal healing.
For a wound that is deeper in nature, a mattress stitch can be placed, providing better strength. The
deeper penetration into the soft tissue layers minimizes tension and allowing for better closure at
the wound edges. Mattress sutures can be applied as vertical or horizontal subtypes. According to
a previous studies, mean maximum pulling force in a standardized model was 5.69 N (SD, 0.88),
7.25 N (SD, 1.33) and 8.11 N (SD, 1.00) for single interrupted suture, vertical and horizontal
mattress suture, respectively. In addition, the blood supply after implant surgery mainly comes
from the apex aspect due to the disruption of periosteal blood supply. Thus, the amount and
direction of tension of the different subtypes of mattress sutures can have a significant impact on
the blood supply after implant surgery.
So far, various studies have compared the effect of horizontal mattress suture (HMS) with vertical
mattress suture (VMS) on wound healing in different wound. A 1-year clinical study compared the
early healing following HMS with VMS after pancreaticogastrostomy. The result showed that
HMS was superior to VMS for preventing early postoperative complications and did not affect
pancreatic function. Another study evaluated the medical stitch in trans-osseous-equivalent rotator
cuff repair. The results showed that VMS failed at higher loads compared with HMS (568.9 ±
140.3 vs 451.1 ± 174.3 N; P = 0.025).
Laser Doppler flowmetry (LDF) is used to measure the tissue blood perfusion noninvasively and
has been widely used in the field of plastic surgery. It can detect circulatory disturbances at early
stages and predict surgical complications.
However, limited studies have evaluated the effect of the subtype of mattress sutures on the early
wound healing and microcirculation changes of peri-implant soft tissues following implant

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surgery using LDF. Therefore, it is important to understand the effect of different suture
techniques on early wound healing following implant surgery.
3.
Study Objectives
The overall aim of this study is to compare the microcirculation changes of peri-implant soft
tissues following open-flap implant surgery using different suture techniques. The study also aims
to monitor healing dynamics by means of observing volumetric alterations of the peri-implant soft
tissues following implant placement.
3.1 Primary Objective
To compare the peri-implant blood perfusion volume responses during healing with horizontal
mattress suture and vertical mattress sutures following open-flap implant surgery.
3.2 Secondary Objective
To compare the peri-implant blood oxygen saturation, blood flow velocity and haemoglobin count
during healing with horizontal mattress suture and vertical mattress sutures following open-flap
implant surgery.
3.3 Additional Objective
To compare three-dimensional soft-tissue volumetric changes, wound healing score and patient-
related outcomes (visual analogue scale) during healing with horizontal mattress suture and
vertical mattress sutures following open-flap implant surgery.
4.
Study Hypothesis
The effect of the different pressure directions of horizontal and vertical mattress sutures on the
soft tissue blood supply can be detected by laser Doppler flowmetry.
5.
Study Methods
5.1 Overall Design of the Study
This will be a parallel group, single‐centred, open-label, adaptive-design clinical trial with
balanced randomization.
5.2 Sample Size
Null hypothesis is that no significant difference of blood perfusion volume change (PU) can be
found at each time points between two groups. Alterative hypothesis is Significant difference of
blood perfusion volume change (PU) can be found at least one time point between two groups.

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Because actual difference of primary outcome between two groups may vary. An adaptive design
is adopted to adjust planned sample size, type of comparison according to actual statistics
calculated from 20 subjects. If the revised sample size is within the planned sample size then the
planned sample size is not to be adjusted. If the revised sample size is larger than planned sample
size then the revised sample size will be considered. The study population, intervention and
primary outcome will stay the same throughout this study.
5.3 Randomization and Concealment
The patients will be randomized to one of the two groups: vertical mattress suture (test group) and
horizontal mattress suture (control group) on a 1:1 ratio. Randomization will be performed by
computer generated random codes. Allocation will be concealed to the surgeon until completion of
all surgical steps except for suturing by opaque envelopes.
5.4 Blinding
As it is not possible to blind the therapist and examiner for the suture, an open-label design will be
used in this study
6.
The Selection, Withdrawal and Management of Subjects
6.1 Inclusion Criteria
Consecutive patients fulfilling the following inclusion criteria will be invited to participate in the
study:

Aged 18 and above

Subjects want single implant treatment in esthetic area (premolar to premolar) in maxilla

With sufficient bone width (≥6mm)

With mesial-distal distance over 8mm
Evidence of subject ability to achieve good oral hygiene and control periodontitis in the whole
of the dentition (FMPS<20% and FMBS<20%)
Ability to understand study procedures and to comply with them for the entire length of the
study. Ability and willingness to give written informed consent.
6.2 Exclusion Criteria
All candidates meeting any of the following exclusion criteria at baseline will be excluded from
study participation:

Subjects want multiple adjacent implant treatment

Patients with inadequate bone volume where major bone augmentation would be required at
implant location.

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
Subjects with untreated periodontitis

Current smokers

Subjects with diabetes mellitus.

Pregnant females
Participation in another intervention trial
Inability or unwillingness of individual to give written informed consent.
6.3 Management of Subjects
(1) Study Enrollment Procedures
Consecutive subjects will be screened for eligibility in the Department of Implant Dentistry of
Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine. Potentially
eligible patients will be provided information about the study objectives by one of the
investigators and full informed consent will be sought from potentially interested subjects.
(2) Informed Consent Process
The participant must personally sign and date the latest approved version of the informed consent
form before any study specific procedures are performed. Documental consent form will be
provided to patient, with verbal explanation by one of the investigators. The procedure would be
done at the beginning of the study after verification of inclusion and exclusion criteria.
Written and verbal versions of the participant information and Informed consent will be presented
to the participants detailing no less than: the exact nature of the study; the implications and
constraints of the protocol; the known side effects and any risks involved in taking part. It will be
clearly stated that the participant is free to withdraw from the study at any time for any reason
without prejudice to future care, and with no obligation to give the reason for withdrawal.
The participant will be allowed as much time as wished to consider the information, and the
opportunity to question the investigators to decide whether they will participate in the study.
Written Informed Consent will then be obtained by means of participant dated signature and dated
signature of the investigator who presented and obtained the informed consent. A copy of the
signed informed consent will be given to the participants. The original signed form will be
retained at the study site.
7.
Study Procedures
7.1 Treatment of Trial Participants
7.1.1 Control of periodontitis (if needed)
Standard periodontal treatment needs to be completed in the dentition before the patient can be

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enrolled into the study. The patient needs to show evidence of good oral hygiene (FMPS<20%)
and control of bleeding on probing (FMBS<20%).
7.1.2 Surgical procedures
One experienced specialist in Implant Dentistry will perform the implant surgeries for all patients.
Surgery will be standardized, and the same procedures/materials will be employed to ensure
consistency.

Local anesthesia will be performed by infiltration at the buccal vestibular sulcus and the
palatal side of the alveolar ridge.

Following anesthesia, a mid-crestal ridge incision will be started and continue with sulcular
incisions around both adjacent teeth to the implant bed using blades #.11 or No.12.

A full-thickness mucoperiosteal flap will be raised and soft tissue remnants will be removed
to fully expose the alveolar ridge.

A standardized dental implant (Nobel Active) will be placed according to the manufacturer’s
instructions. Cover screws will be used.

Different suture techniques will be used according to the group allocation to achieve wound
closure after opening the envelope.

The sutures will be removed after 7 days.
7.1.3 Post-surgical instruction

Post-operative pain and oedema will be controlled with analgesics (Ibuprofen, TSKF, 600mg,
2 times, interval 6-8 hours). Antibiotic regimen will also be performed (amoxicillin, Xinya
Co, 2g, 60 minutes before surgery).

Rinsing with 0.12% chlorhexidine will be prescribed 3 times/day for the first 2 weeks

Another single clinician, blind with respect to the group assignment, will perform all
measurements.
7.2 Handing of study interventions
Allocation will be concealed to the surgeon until completion of all surgical steps except for
suturing. Thereafter, vertical mattress sutures (test group) or horizontal mattress sutures (control
group) will be performed according to the group allocation to achieve wound closure after opening
the envelope.
(1) Control group
In the control group, the participants will receive the following sutures to achieve wound closure:

One mesial single interrupted suture (1 mm from the mesial teeth, 2-3mm from needle-in
points to the incision)

One distal single interrupted suture (1mm from the distal teeth, 2-3mm from needle-in points
to the incision)

One horizontal mattress suture (5-6mm from needle-in points to the incision, 3-4mm from
needle-in to needle-out points)

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(2) Test group
In the test group, the participants will receive the following sutures to achieve wound closure:

One mesial single interrupted suture (1mm from the mesial teeth, 2-3mm from needle-in
points to the incision)

One distal single interrupted suture (1mm from the distal teeth, 2-3mm from needle-in points
to the incision)

One mesial and one distal vertical mattress sutures (5-6mm from needle-in points to the
incision which are in keratinized tissues, 2-3mm from needle-out points to the incision, 3-4
mm from mesial and distal sutures)
7.3 Course of Treatment and Visit Points
7.3.1 Screening and Enrollment
Screening evaluations for this study will be performed in the Department of Implant Dentistry of
Shanghai Ninth People’s Hospital. Clinical and radiographic assessment will be performed for
treatment plan. Subjects fulfilling the inclusion and exclusion criteria will be invited to participate
in the study and receive an explanation of the study, its objectives, benefits and risks by the
investigator in the context of informed consent. The following information will be collected and
recorded after the inclusion of the participants.
(a) Demographics
The date of birth, gender and drinking habits will be recorded.
(b) Medical History
Details of medical, including diabetes mellitus, cardiovascular diseases and other systemic diseases
will be recorded.
(c) Concomitant Medication
All over-the-counter or prescription medication, vitamins, and/or herbal supplements will be
recorded on CRFs.
7.3.3 Baseline Assessments (presurgical measurements T0)
Baseline assessment will be performed by another trained clinician, blind with respect to the group
assignment, including:
(1)
Clinical photographs
(2)
Clinical measurements including:

The full-mouth plaque score (FMPS), full mouth bleeding score (FMBS)

Probing pocket depth (PPD) and clinical attachment level (CAL) for the two adjacent
teeth to the treatment site

Amount of keratinized tissue (KT) measured on the mid buccal of the treatment site

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(3)
Intra-oral scanning
Intraoral digital impressions of the alveolar ridge, buccal/palatal soft tissues and at least two
adjacent teeth will be conducted using an intraoral scanner (3Shape trios 3,) by a single
trained and calibrated examiner. The digitized 3D impressions will be saved and exported in
the Standard Tessellation Language (STL) file format.
(4)
Tissue perfusion assessment (LEA measurements)
A laser Doppler flowmetry machine (LDF) (LW1111, LEA) will be used to measure the
tissue perfusion. The machine can provide the following 4 types of measurements: 1) blood
perfusion volume, 2) blood flow velocity, 3) haemoglobin count, 4) blood oxygen saturation.
The diameter of the measurement probe will be 3mm. Two surgical stents with 6
measurement holes will be fabricated to ensure the measurement are repeatable. The small
hole with the same diameter of the LDF probe will be created on the buccal and palatal sides
of the incisions. LDF probe will be held at a standardized position perpendicular to the tissue
and at a distance of 0.5-1 mm from the gingiva and remain fixed during repetitive LDF
measurements.
The recordings of the probe of the LDF will be made through holes. The followin64 region of
interests (ROIs) will be measured: 1) central buccal: the area in the central of buccal aspect, 2)
central palatal: the area in the central of palatal aspect, 3) mesial buccal: the area in the
buccal aspect and 2.5mm from the mesial tooth, 4) distal buccal: the area in the buccal aspect
and 2.5mm from the distal tooth, 5) mesial palatal: the area in the palatal aspect and 2.5mm
from the mesial tooth, 6) distal palatal: the area in the palatal aspect and 2.5mm from the
distal tooth.
The LDF measurements at the test and control group will be performed on the day of the
surgery before the injection of the local anaesthesia (baseline), 1min following local
anaesthesia induction, immediately following completion of the surgical procedure, post-
operative hours 1,2,6 and on post- operative days 1, 3, 7, 14, 30.
(5)
Suture tension (Flap Tension Meter)
Immediately after suture, the tension exerted on the flap margins with the respective sutures
was measured using a highly sensitive electronic tension/pressure device (Flap Tension
Meters, Imedico GmbH, Zurich ZH, Switzerland). Tension was read to an accuracy of
0.001N (0.1 g).
7.3.4 Follow-up Visits and evaluation
Follow-up assessment will be performed by the same trained clinician, blind with respect to the
group assignment, additional assessments including:
(1)
Soft tissue thickness

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The thickness of the soft tissue will be performed with calipers 2 mm from incision margin in
both buccal and palatal side.
(2)
Clinical wound healing assessment
EHI index will be used for clinical wound healing assessment: a) complete flap closure – no
fibrin line in the interproximal area; b) complete flap closure – fine fibrin line in the
interproximal area; c) complete flap closure – fibrin clot in the interproximal area; d)
incomplete flap closure – partial necrosis of the interproximal tissue; e) incomplete flap
closure – complete necrosis of the interproximal tissue.
(3)
Patient-reported outcomes
Visual analogue scale (0-10) will be used to evaluate the post-operative pain.
Immediate after anesthesia – T1

LEA measurement

Soft tissue thickness (after flap elevation)
Immediate after suture – T2

LEA measurement

Intra-oral scanning

Suture tension

PROMs
1 hour after surgery – T3

LEA measurement

Intra-oral scanning
2 hours after surgery – T4

LEA measurement

Intra-oral scanning
6 hours after surgery – T5

LEA measurement

Intra-oral scanning

PROMs
24 hours after surgery – T6

LEA measurement

Intra-oral scanning

Clinical wound healing assessment

PROMs
72 hours after surgery – T7

LEA measurement

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
Intra-oral scanning

Clinical wound healing assessment

PROMs
7 days after surgery – T8

LEA measurement

Intra-oral scanning

Suture removal

Clinical wound healing assessment

PROMs
14 days after surgery – T9

LEA measurement

Intra-oral scanning

Clinical wound healing assessment
30 days after surgery – T10

LEA measurement

Intra-oral scanning

Clinical wound healing assessment
8.
Outcomes and evaluations
8.1 Outcomes
8.1.1 Primary outcomes

Blood perfusion volume (PU) change during the observation period
8.1.2 Secondary outcomes

Blood flow velocity change during the observation period

Hemoglobin count change during the observation period

Blood oxygen saturation change during the observation period

Three-dimensional soft-tissue volumetric changes during the observation period

Changes in clinical wound healing score during the observation period

PROMs (VAS)
9.
Safety Evaluation
9.1 Adverse Events
The collective evidence from numerous clinical trials reveals consistent findings that implant
surgery is a safe and the most effective approach for missing tooth replacement. No adverse events

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have been reported. Sometimes implant failure happens, but a second implant placement can be
performed after healing.
9.2 Follow-up for Adverse Events
Adverse events (AE), if any, will be managed according to current standard of care for the specific
condition. The principal investigators will assess and manage the condition to the best of his
knowledge and refer to specialist care if appropriate and in the best interest of the participant. AE
will be considered resolved once the principal investigators concur that to be the case.
10.
Data Quality Assurance
10.1
Quality Control and Assurance
10.1.1 Training and Calibration
All investigators involved in this study will be trained appropriately for the standard operating
procedures including the implant surgery and measurements

The examiner will be trained and calibrated with the LEA measurements and intra-oral
scanning before the start of the study.

The therapist, who will deliver the implant surgery, will be an experienced specialist in
implant dentistry fulfilling the Shanghai requirements.

The investigator who performs interventions for the test/control groups will be trained in a
standardized session including the spacing of the mattress sutures and tension of the knotting.
10.1.2 Protocol Deviations
The study will be conducted in accordance with the current approved protocol, ICH GCP, relevant
regulations and standard operating procedures. Protocol deviations will be assessed during regular
monitoring.
10.1.3 Regular Monitoring
Regular monitoring for assuring protocol compliance, and data quality at the clinical site,
including review of source documents and records, consent forms, etc will be performed by an
investigator trained in both GCP and the specific procedures. Furthermore, the clinical research
coordinator will audit the case report forms for the first few patients to ensure correct filling of
forms. The study will also be monitored by the compliance office of the National Clinical
Research Center of Oral Diseases and Clinical Research Center of the 9th People Hospital.
10.1.4 Record Keeping
All investigators are required to keep complete clinical records, clinical samples, study data for all
the patients included in the study. Radiographs and intraoral scanning images should be archived

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in digital format and stored securely both as part of the patient clinical record and as part of the
study records. The study coordinator will collect a copy of all digital files. All research-related
records will be retained for at least 5 years after study completion.
10.1.5 Patient Scheduling
In order to improve compliance with protocol, all subjects participating in the study will have an
alert in their patient record identifying them as participant to this protocol in order to alert
administrative staff on the need to follow a stringent timing of follow-up appointments.
10.1.6 Investigator assistance
Investigators can contact the principal investigators for any question, doubt or problem that could
emerge. For clinical, protocol, patient care and adverse event reporting, investigators should
contact Dr. Shi at the following numbers:
Dr. Shi
Tel
13636340883
10.2
Data Management
(1) Overview of Data Management Methods
Primary data will be stored and retrieved from the Shanghai Ninth People Hospital. The
participants will be identified by a study specific participant number and/or code in the
secondary database after retrieving data from primary database for data analysis. CRF will be
in written format with identifiers removed and assigned with identifying codes. Codes will be
stored safely and separated from data. The name and any other identifying detail will NOT
be included in any secondary study data electronic file. All documents will be stored securely
and only accessible by trial staff and authorized personnel.
The investigators will archive source documents for each patient entered in the study, signed
and witnessed informed consent forms, patient questionnaires. Furthermore, the investigators
will maintain a study patient list that will allow matching Case Reports with source
documents, a screening log, the investigator manual, digital radiographs, intraoral scanning
images and clinical samples.
(2) Internal Analysis Plan of Data
N/A
(3) The Frequency of Data Security and Monitoring Reports Submitted to the Ethics
Committee
Given the low risk profile of the study, data safety and monitoring reports will be submitted to
the Ethics committee every 6 months.

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11.
Statistical Analysis
11.1
Statistical Software and General Requirements
Data analysis will be performed in SPSS software, version 26.0 (IBM Corp., Armonk, NY, USA).
The level of statistical significance will be set at 0.01 for all tests.
11.2
Statistical analysis plan
(1) Descriptive statistics will be run to describe the demographic, clinical and biological
characteristics of the study population. Means with standard deviations (SD) or medians with
interquartile range (IQR) will be used to describe continuous variables. Frequencies will be
used to describe categorical variables.
(2) The normality of clinical and biological parameters at baseline and each re-evaluation visit
will be tested for normality using the Kolmogorov-Smirnov test. The homogeneity of the
clinical and biological parameters at baseline and each re-evaluation visit will be tested using
Levene’s test.
(3) The differences over time within groups for data will be analyzed with the non-parametric
Wilcoxon’s Signed Ranks tests or Paired t-tests according to the data normality and
homogeneity.
(4) The comparison of parameters between the control and the test group at baseline and each re-
evaluation visit will be performed with the Mann–Whitney U test or Student t test according
to the data normality and homogeneity, respectively.
12.
Ethics Requirements and Informed Consent
The Investigators will ensure that this study is conducted in full conformity with the current
revision of the Declaration of Helsinki (last amended October 2013). The Investigators will ensure
that this study is conducted in full conformity with relevant regulations and with the ICH
Guidelines for Good Clinical Practice E6 (R1) July 1996. The protocol, informed consent form and
participant information sheet will be submitted to an appropriate Research Ethics Committee (REC)
for written approval. A signed consent form will be obtained from each participant. The consent
form will describe the purpose of the study, the procedures to be followed, and the risks and
benefits of participation. A copy will be given to each participant and this fact will be documented
in the participant’s record. The trial staff will ensure that the participants’ anonymity is maintained.
13.
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