Socket Preservation Revisited: RCT to Study the Three-dimensional Changes of Hard and Soft Tissue Comparing Two Distinct Surgical Protocols
Phase: NA
Conditions: Ridge Preservation, Bone Regeneration
Sponsor: Harvard School of Dental Medicine

HLMA Research Protocol  
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Investigators
!
  Instructions: The purpose of this research protocol is to provide IRB members and reviewers with sufficient 
information to conduct a substantive review
.  If a separate sponsor’s protocol exists, submit it in addition to this 
document. 
Complete all of the sections below
.  For more detailed instructions, consult the Investigator’s Manual or IRB 
website (links provided below).  
1. Specific Aims 
The primary objective of this study is to assess two widely accepted surgical protocols (both used 
interchangeably as standard of care) that are used to maintain hard and soft tissue after a tooth extraction. 
It is currently unclear if one treatment is more effective than the other
. The two treatments being compared are: 
Treatment 1: A
 cross-linked membrane is used in secondary intention healing. 
Treatment 2: A
 non-cross-linked membrane is used in primary intentional healing.  
Non-Crosslinked Membrane: A
 collagen covering used to keep bacteria out, hold the bone graft in place, and to 
separate the gum and bone during healing. 
Crosslinked Membrane: A
 stronger more long lasting collagen covering which functions similarly to the non-
crosslinked membrane described above.  
Primary intention healing (submerged healing): The wound edges are brought together and closed (ie papercut).  
Secondary intention healing (non-submerged healing): The wound edges are not brought together (ie knee 
scrape).  
Treatment 1 
!
 
GENERAL I
NFORMATION
Protocol # (if assigned): IRB15-3772
Version Date: 5/6/2016
Version Number: 1.7
Principal Investigator: 
Eli Machtei DMD
Faculty Advisor (if PI is a student): N/A
Protocol Title: Dimensional changes of the keratinized gingiva and vestibular depth following 
socket preservation procedure using two surgical protocols
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Treatment 2 
!
 
2. Background 
2.1  Provide the scientific background and rationale for the study 
HARD TISSUE DIMENSIONAL CHANGES 
Socket preservation procedures have been developed with the aim of avoiding or reducing dimensional 
shrinkage of alveolar bone after tooth extraction which in turn will facilitate subsequent prosthetic treatment 
using dental implants or fixed partial denture. Both preclinical and clinical studies have investigated the changes 
which occur after tooth extraction when the site is left to heal on its own and when socket preservation 
procedures have been performed. 
Preclinical Studies 
Cardaropoli et al. 2003 1 utilized the canine model to study hard tissue remodeling after tooth extraction and 
demonstrated that the socket is initially occupied by a coagulum which is then sequentially replaced by 
provisional connective tissue matrix, woven bone and lamellar bone.  
During remodeling, the hard tissue undergoes dynamic changes which include a crestal height reduction of the 
buccal and lingual walls (greater on the buccal wall) and alveolar width resorption from the surfaces of the outer 
buccal and lingual walls (Araujo et al. 2005) 2. 
Fickl et al. 2008 3 compared post extraction resorption rates after socket preservation to untreated controls in 
canines.  All treatment groups displayed contour shrinkage of the buccal plate but socket preservation was able 
to limit hard tissue alterations.  Utilizing a xenograft, Araujo et al. 2009 
4, found that the percent change in 
surface area of the marginal portion of the extraction site was -35% in the negative control group and -12% in 
the grafted group.  The placement of bone graft into an extraction socket counteracted the marginal ridge 
reduction by serving as a scaffold for modified tissue modeling.  
Conversely
, other canine studies were unable to find significant merit in the use of socket preservation 
procedures.  Rothamel et al. 2008 5 examined the use of a nano crystalline hydroxyapatite paste on dimensional 
ridge alterations and found no statistically significant difference between the test and control groups.  Araujo et 
al. 2011 
6 compared the use of autologous bone with inorganic bovine bone and demonstrated that  
autologous bone did little to prevent hard tissue contraction (-25%) while bovine derived graft material showed 
a +3.6% change with delayed hard tissue healing.  The -25% change (Araujo et al. 2011) 
6 was similar to the 
-30% ridge reduction found in non-grafted sites in a previous study (Araujo et al. 2005) 
7. 
Araujo et al. 2005 noted that in addition to internal resorption of the extraction site, external resorption occurred 
from the outer surfaces of the buccal and lingual walls.  Fickl et al 2008 
8 examined external boney resorption 
associated with surgical trauma.  The combined internal and external osteoclastic resorption resulted in 
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significantly greater hard tissue shrinkage. Thus, avoiding muco-periosteal flap elevation and allowing healing 
by secondary intention can minimize crestal bone loss.  
Clinical Studies 
Considering the variations within individuals and differences in anatomic sites, a considerable 11-22% of 
alveolar height loss and a 29-63% decrease in alveolar width were reported during the first 6 months after 
extraction when the site is allowed to heal un-assisted (Tan et al. 2012) 
9.  When socket preservation therapies 
were applied to extraction sites, they demonstrated statistically significant reduction of post-extraction 
dimensional changes. Vignoletti et al. in 2012 10 found a 1.83mm decrease in resorption of the alveolar ridge 
width and 1.47mm decrease in alveolar height resorption.  Meta-analysis by Avila-Ortiz et al. 2014 11 revealed a 
similar picture: ridge resorption in the socket preservation group was 1.89 mm less than in the control group. 
Also, less vertical resorption was found at the midbuccal (2.07mm), midlingual (1.18mm), medial (0.48mm), 
and distal (0.24mm) aspects.  Willenbacher et al. 2015 
12 found that 1.31-1.54mm of alveolar width and 
0.91-1.12mm of bone height could be preserved with socket preservation therapy
.  
SOFT TISSUE DIMENSIONAL CHANGES 
Untreated extraction sites have exhibited soft tissue thickness increase of 0.4-0.5mm (Iasella et al. 2003 13 ) and 
keratinized tissue width increase of 0.7mm (Barone et al. 2014 14). When indicated, the maintenance of hard and 
soft tissue at the newly edentulous site can preserve the contours and structure of existing bony walls, reduce the 
need for future augmentation procedures, and improve the final esthetic results.  
In comparison to sites that healed unassisted, those that had undergone ridge preservation surgery exhibited 
changes in gingival thickness, width and vestibular depth.  Gingival thickness differences between test group 
and untreated control were only statistically significant in buccal sites (Vignoletti et al. 2011 
10). Gingival width 
has been found to have a larger coronal shift of 1.1mm after socket preservation when compared to 0.7mm in 
unassisted healing (Barone et al. 2014 14).  In a study of the long-term stability of soft tissue after socket 
preservation, Roccuzzo et al. 2014 15 found that with maintenance, the risk of soft tissue recession around 
implants is less than 1.0mm after 10 years.  
Vestibular Depth Dimensional Changes 
Alveolar bone resorption often in combination with coronally repositioned flaps can contribute to a reduction in 
vestibular depth.  Halperin-Sternfeld et al. (in press) 16 have found that shallow vestibules (<4mm) were 
associated with increased recession, relative attachment level, and bleeding on probing as well as decreased 
keratinized tissue width around implants. The effect of socket preservation upon vestibular depth has seldom 
been studied, but its effect on keratinized tissue and vestibular depth can be important in esthetics, hygiene 
maintenance, and functionality of the final prosthesis. 
SURGICAL TECHNIQUES AND MATERIALS 
A
 number of surgical techniques can be utilized to preserve soft and hard tissues post-extraction.  These include: 
(1) flapped or flapless access, (2) primary or secondary intention wound healing and, (3) graft material, 
membrane barrier, or a combination of both. When compared to a flapless surgical approach, full thickness flap 
reflection has a disruptive effect on the osteogenic potential of the periosteum (Araujo et al. 2005 
7). However a 
flapped surgical procedure has greater potential for achieving primary wound closure; an important technique 
for preventing bacterial invasion of the socket that has been shown to reduce the horizontal bone changes 
(Vignoletti et al. 2011 
10).  In all cases, an atraumatic extraction, whenever possible, is an essential part of the 
protocol.   
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THE ROLE OF MEMBRANE BARRIERS IN SOCKET PRESERVATION 
Barrier membranes facilitate cell exclusion, maintain the space and stabilize the graft and blood clot in socket 
preservation; therefore, their biodurability during healing is crucial (Tal et al. 2008 17). Among the surgical 
techniques regarding barriers are the use of membranes alone or in conjunction with bone grafting. Meta-
analysis by Oregas et al. 2013 
18 found that the use of barrier membranes alone can improve normal wound 
healing after extraction. Vignoletti et al. 2012 10 found that the use of barrier membranes with or without bone 
graft reduced horizontal bone resorption. 
Non-resorbable barriers such as expanded polytetrafluoroethylene (ePTFE) membranes require a surgical 
reentry for membrane retrieval and, if exposed to the oral environment, become colonized with bacteria thus 
requiring early removal with considerable diminished bone formation (Machtei 2001 
19). In contrast to ePTFE 
membranes, bioabsorbable barriers obviate the need for a re-entry to remove the membrane and if exposed, are 
less likely to become infected. When exposed, both cross-linked and non-crosslinked membranes are degraded 
by bacterial collagenolytic enzymes which can result in some bone graft resorption (Moses et al 2005 20).   
Kodama et al. 1989 21 have found a negative correlation between the degree of collagen cross-linking and 
membrane resorption rate. Several different techniques for achieving collagen cross-linking involve ultraviolet 
light radiation, glutaraldehyde, imides or ribose (Tal et al 2006 
17). Ribose sugar mediated cross-linking shows 
prolonged barrier functionality
, no adverse tissue reactions, and can enable high degrees of cross-linking 
(Friedmann et al 2002 
22).  
Cross-linked membranes have the advantage of greater structural integrity which enable 4-6 months of 
functionality compared to 4-6 weeks from a non-cross-linked membrane (Moses et al. 2005 
20, Zitzmann et al. 
1997 23).  Moses et al. 2005 
20 found that while cross-linked and non-cross-linked membranes have the same 
exposure rate, 69% of cross-linked collagen barriers had soft tissue healing over exposures when compared to 
12% of non-cross-linked collagen barriers. 
2.2  Describe the significance of the research, and how it will add to existing knowledge 
If Treatment 1proves to have significantly better soft and hard tissue outcomes, it could become the new 
standard of care.  Even if both treatments have similar outcomes, then the simplicity of the surgical technique of 
Treatment 1 might become the new preferred standard of care resulting in simpler and less traumatic surgical 
procedures.  
3. Study Setting  
1. 
Identify the sites or locations where the research will be conducted.  
This study will be conducted at the Harvard School of Dental Medicine located at 188 Longwood Ave., Boston, 
MA
 02115. 
2. 
Describe the Principal Investigator’s experience conducting research at study site(s) and 
familiarity with local culture 
The PI, Eli Machtei DMD, is a seasoned periodontist with years of experience with regenerative techniques such 
as the one being employed in this study
. 
3. 
Is the research conducted outside the United States?   
  
No Yes:  If yes; describe site-specific regulations or customs affecting the research, local  
  
scientific and ethical review structure 
No 
3.4.    Are there any permissions that have been or will be obtained from cooperating institutions,        
community leaders, or individuals, including approval of an IRB or research ethics committee?  
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No Yes:  If yes; provide a list of the permissions (also include copies with the application, if 
  
available)  
Yes: IRB 
4. Study Design 
1. 
Describe the study design type  
The present study will be a prospective, parallel-arm, human, randomized clinical study
. Participants who are 
screened and accepted into the study will be randomized into Treatment 1 and Treatment 2 groups using a web-
based randomization tool: randomizer
.org.   
2. 
Indicate the study’s duration - and the estimated date of study completion 
Individual participants are anticipated to be involved in the study for 5 months. The study’s overall anticipated 
duration is 18 months with an estimated completion date: May 2017.  
3. 
Indicate the total number of participants (if applicable, distinguish between the number of 
participants who are expected to be screened and enrolled, and the number of enrolled 
participants needed) 
In the present study
, no more than 60 participants are expected to be screened and no more than 30 participants 
will be enrolled. This allows for a 15% withdrawal rate which will not require supplemental recruitment. If more 
than 15% withdraw
, then supplemental recruitment will be initiated after approval of an increase in the 
enrollment number from the IRB via modification.  
4. 
List inclusion criteria  
•Within the age range of 20-80 years old.  
•Healthy (ASA
 I or ASA
 II) with no conditions which alter wound healing. 
•Has a tooth requiring extraction with two neighboring teeth on either side of it and intact bony walls. 
•Willing to participate in the study and sign the informed consent. 
•Patient intends to have an implant to replace the tooth.  
5. 
List exclusion criteria 
•Outside of the range of 20-80 years old.  
•The patient has systemic conditions that could alter wound healing. 
•Patient does not wish for the extraction site to be reentered surgically (i.e. no intention to get an implant) 
•Based on visual examination the patient has: 
o Tooth anatomy requiring aggressive bone removal or flap reflection as part of its extraction.   
o Severe local infection at the extraction site. 
o Tooth exhibiting resorption of buccal or lingual plates. 
o Absence of keratinized tissue buccal to the tooth to be extracted. 
o Reduced vestibular depth ≤3mm buccal to the tooth to be extracted. 
6. 
Describe study procedures  
Study Procedures
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Screening
Patients seen in the Harvard Dental Center pre-doctoral and resident clinics will be approached to 
gauge their interest in participating in the study
. Patients will be informed of the general aim of 
the  study
,  
the  overall  cost,  materials,  procedure,  and  
timeline  of  
their  
involvement.  Interested 
patients will be screened for eligibility by visual inspection of their tooth. If the patient agrees to 
participate, informed consent will be obtained.  If the patient would like time to decide on 
his/her  participation,  
they  will  be  given  a  copy  of  
the  
informed  consent  
to  
take  home. 
Patients that do not yet sign the informed consent at this visit will do so at Visit #1. 
Visit #1
• Dental CT Scan: This is an additional scan that is not commonly done in private practice but 
can be standard of care at HSDM depending on the specific case. This scan will be required for 
participation in this study
. 
Visit #2
Patients will be randomized into Treatment 1 or Treatment 2 using randomizer
.org. 
Prior to the surgery measurements will be taken:
• Pre-Operative measurements will be taken of teeth, gums and bone before tooth extraction 
after the patient has been numbed.  
• Gums will be measured by placing a periodontal probe (a small ruler) on top of the tissue. 
• Gum thickness will be measured with a thin needle and rubber stopper
.  
• Intra-operative dimensional measurements will be taken during tooth extraction.  The patient 
will still be numb.  
• Bone width will be measured with a caliper (an instrument that gently goes around the 
bone). 
• Teeth and bone will be measured by placing a periodontal probe (small ruler) on top of the 
structures. 
Visit #4
Six week post-operative follow-up. Will examine site for treatment side effects including intra-
oral findings and patient report. No measurements will be taken; only visual inspection to ensure 
normal healing. 
Visit #5
At the time of implant placement (by the patient’s own dentist) as per the standard of care, the 
study team will only be involved in the collection of the following data: 
• Dental impressions will be taken. 
• Pre-Operative and Intra-operative measurements will be repeated.
Standard of Care Procedures (for Information Purposes)
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7. 
Does the study involve the collection of data/specimens (including the use of existing data/
specimens)?  
  
No Yes:  If yes; indicate how
, when, where and from whom specimens or data will be obtained 
Yes: Data in the form of clinical measurements, radiographs and CT scans will be collected directly from 
participants.  All data will be collected at baseline and again at 4 months post operatively as per standard of care. 
If there are existing radiographs in the patient’s dental record, they will not be repeated at Visit #1 and that 
existing data will be used in the study 
8. 
Is there a data and safety monitoring plan (required for greater than minimal risk studies)? 
  
No Yes:  If yes; describe the plan 
Yes: To determine that participants remain safe during the study
, each visit will include an examination of 
possible treatment side effects including both intra-oral findings and patient reports. Treatment side effects 
would all be expected side effects of the standard of care and can include infections during healing, difficulty in 
wound clotting, discomfort during healing or swelling or bruising after surgery
.  There are no specific risks 
concerning the non-standard of care research components of the study (ie Pre-Operative and Intra-operative 
measurements, six week follow-up exam). Safety information will be collected on case report forms (CRF) at 
each study visit. If serious severe adverse events (SAE) occur (i.e. infection, excessive bleeding or allergic 
reaction), then the study will recall all patients within the same treatment protocol for thorough examination for 
any potential adverse effects. Potential SAE will be found via patient report and visual inspection during follow-
up exams. All treatment materials that will be utilized in the present study are FDA
 approved; the likelihood of 
an SAE arising from this treatment are slim. 
Visit #1
Patients will sign the treatment informed consent, receive oral hygiene instruction,  
Baseline data will be obtained (unless already on file in the dental record). 
• Full mouth X-Ray series 
• Intra-oral photo series 
• Dental impression (to be turned into stone cast) 
Patients will then be scheduled for the next visit.
Visit #2
Surgical Treatment (One treatment option would be chosen and performed) 
Treatment 1  
• Atraumatic extraction (without gum respositioning aka “flap elevation”). 
• Freeze-Dried Bone Allograft (RegenerOss®) placed. 
• Crosslinked collagen membrane (OssixPlus®) placed. 
• Secondary closure (with sutures). 
Treatment 2  
• Atraumatic extraction (with gum repositioning aka “full thickness flap elevation”). 
• Full thickness flap elevation. 
• Freeze-Dried Bone Allograft (RegenerOss®) placed. 
• Non-crosslinked collagen membrane (Bio-Gide®) placed. 
• Primary closure (with sutures). 
All patients will be given post-operative instructions in written and verbal forms.
Visit #3
Two  week  suture  removal  and  post-operative  follow  up.  Will  examine  site  for  treatment  side 
effects  including  intra-oral  findings  and  patient  report.  No  measurements  will  be  taken;  only 
visual inspection to ensure normal healing.
Visit #5
Four month post-operative implant placement performed by the patient’s own dentist not the 
study staff. 
• Peri-apical radiographs will be taken.  
• CT scan will be taken.
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9. 
Are there any anticipated circumstances under which participants will be withdrawn from the 
research without their consent? 
  
No Yes:  If yes; describe the circumstances as well any associated procedures to ensure orderly 
  
termination 
Yes: Conditions that will require patient removal include failure to show up for study visits, changes in medical 
condition that might alter wound healing, or severe abscess in the surgical site. The patient would then be 
referred for continued care to their existing dentist (who would be located in the same clinic for a seamless 
transition).  
5. Data/Statistical Analyses Plan 
1. 
Briefly describe the plan for data analysis (including the statistical method if applicable) 
Statistical analysis: Descriptive analysis will be performed on the differences in primary (gingival width) and 
secondary (vestibular depth, gingival thickness, radiographic and clinical alveolar height, alveolar width) 
outcome variables all of which will be measured in millimeters on a continuous scale.  Two sample t-tests for 
independence samples will be used to compare mean values between treatment groups to evaluate statistical 
significance. A
 standard significance level of 0.05 will be chosen determined significance. All statistical analysis 
will be performed using STATA
 software version 12. 
2. 
Is there a sample size/power calculation? 
  
No Yes:  If yes; describe the calculation and the scientific rationale, and, if applicable, by site 
  
and key characteristics such as participant demographics 
Using a power of 90%, alpha of 0.05 with mean intergroup difference of 1.0mm a sample of 15 in each group 
will be required.  
6. Recruitment Methods 
1. 
Does the study involve the recruitment of participants? 
  
No:  If no, skip to 7.1 
Yes:  If yes; indicate how
, when, where, and by whom participants will be recruited 
Patients who are currently in treatment with Harvard School of Dental Medicine pre-doctoral and resident 
clinics will be initially invited to join the study by research staff, whom are not their treating dentist. If their 
dentist is a member of this research project, a different study staff member will recruit, consent, and enroll the 
participant. As per the culture of an academic dental setting, attendings routinely check on students’
 progress. As 
the study staff encounters cases that seem to meet the study inclusion criteria (i.e., need a tooth removed and 
intend to get an implant) during these checks, they will approach those patients as appropriate for the study
. 
Those who qualify to participate (via a visual exam based on the Eligibility Checklist) and who might wish to 
enter the study will be provided with information about the nature of the study
, any potential side effects and 
alternative treatment options. This will be provided in the form of oral conversation referring to the consent 
form which they will be allowed to take home for their information. All recruitment activities will occur at a 
private dental chair at the time of their dental visit.  
2. 
Are there any materials that will be used to recruit participants, e.g., emails, posters, and 
scripts? 
  
No Yes:  If yes; provide a list of the materials (also include copies with the application) 
Yes: Recruitment Script  
 
 
7. Available Resources 
1. 
Describe the feasibility of recruiting the required number of participants within the recruitment 
period  
Due to the relative frequency of patients seeking dental treatment at the HSDM Periodontology division who 
require tooth extraction as part of their therapies, recruiting the expected number of participants is feasible 
within the timeline that we have highlighted above (12 months).  
2. 
Describe how the Principal Investigator will ensure that a sufficient amount of time will be 
devoted to conducting and completing the research. 
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The PI will dedicate 50% of his clinical time for the study
. The Co-PI will compliment this. The investigator will 
be dedicated to patient recruitment and monitoring thought the study
.  
3. 
Are there research staff members, in addition to the Principal Investigator?  
  
No:  If no, skip to 7.5 
Yes:  If yes; outline training plans to ensure that research staff members are adequately 
informed about the protocol and study-related duties 
Yes: The Co-Investigator, David Kim DMD, is a seasoned periodontist with years of experience with 
regenerative techniques such as the one being employed in this study
. Other study team members, Heather Wong 
DDS and Chia-Yu Chen DDS, are both graduate students in the department of Periodontology at HSDM. All 
research staff members will be adequately informed about the protocol and study-related duties. All research 
staff members will be able to obtain informed consent. The PI and Co- PI will be performing the surgery
.   
4. 
Describe the minimum qualifications for each research role (e.g., RN, social worker) their 
experience in conducting research, and their knowledge of local study sites and culture  
To be on the research team, one needs to have DMD/DDS license.  
5. 
Briefly describe how the research facilities and equipment at the research site(s) support the 
protocol’s aims, e.g., private rooms available for interviews, etc. 
The Periodontology clinic at the Harvard School of Dental Medicine is equipped with dental chairs, surgical 
materials, and surgical instrumentation which support periodontal surgical procedures and exams.   
6. 
Are there provisions for medical and/or psychological support resources (e.g., in the event of 
incidental findings, research-related stress)? 
  
No Yes:  If yes; describe the provisions and their availability 
No 
8. Vulnerable Populations 
1. 
Are there any potentially vulnerable populations (e.g., children, pregnant women, human 
fetuses, neonates, prisoners, elderly
, economically disadvantaged, employees or students of the 
investigator or sponsor
, undocumented, terminally ill, cognitively impaired or mentally ill, etc.)? 
  
No:  If no, skip to 9.1 
Yes:  If yes; identify all vulnerable populations 
No 
2. 
Describe safeguards to protect their rights and welfare  
N/A
 
9. Consent Process 
1. 
Will consent to participate be obtained? 
No:  
If no, skip to 9.5 
Yes:  If yes; describe the setting, role of individuals involved, timeframe(s), and steps to 
minimize coercion/undue influence during the consent process (at the time of initial consent and 
throughout the study) 
Yes: Participants will be initially invited to join the study by the research staff who will provide them with 
information about the nature of the study
, any potential side effects, and alternative treatments. This will be done 
in the form of oral conversation and further elaborated in a written consent form. Participants will be able to take 
a copy of the consent form home. 
2. 
Are there any special populations?  
  
No Yes:  If yes; describe the process to obtain consent, permission or assent  
No 
3. 
Will consent of the participants be documented in writing?  
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Yes No:  If no; describe the rationale for requesting a waiver or alteration of documentation of 
  
consent (and/or parental permission) 
Yes 
4. 
Will participants be provided with a copy of their signed consent form or information sheet 
(when a consent form is not signed)? 
  
Yes No:  If no; explain any extenuating circumstances that make it impossible or inappropriate 
  
to meet this requirement, ie, doing so may place participants at increased risk, if inadvertently 
  
disclosed 
Yes 
5. 
Is a waiver or alteration of consent (and/or parental permission) being requested?  
  
No Yes:  If yes; describe the rationale for the request. If the alteration is because of deception or 
  
incomplete disclosure, explain whether and how participants will be debriefed (include any 
  
debriefing materials with the application) 
No 
10.Risks  
1. 
Are there any reasonably foreseeable risks, discomforts, and inconveniences to participants 
and/or groups/communities? 
  
No Yes:  If yes; indicate probability
, magnitude, and duration of each (note that risks may be 
  
physical, psychological, social, legal, and/or economic) 
Yes, the list of side effects below associated with any oral surgical procedure is to be expected; however, the 
treatments are Standard of Care, as are the risks: 
• Swelling of face and gums 
• Bruising of skin at the area of tooth removal 
• Discomfort at the surgery site 
• Minor bleeding from the tooth removal site 
• During tooth extraction, infection, communication with sinuses (upper teeth) and nerve injury (lower 
teeth) are rare occurrences that pose a minimal risk of surgery
.  
Inconveniences that are specific to research activities include: 
• Probe measurements may produce minimal discomfort as a small ruler is placed into gum pockets.  
• Dental impressions can be slightly but temporarily uncomfortable.  
• The time required to attend the six week post-operative visit.  
• Due to the collection of identifiable data, a breach in confidentiality is a possible but minimal risk.   
• An additional CT scan is also a foreseeable inconvenience but has benefits to enable better 
understanding of the nature of the healed site to much better plan the future implant. As with all CT 
scans, minimal radiation is produced. This additional scan is not commonly done in private practice but 
can be standard of care at HSDM depending on the specific case. This scan will be required for 
participation in this study
.  
2. 
Identify whether any of the information collected, if it were to be disclosed outside of the 
research, could reasonably place the participant at risk of criminal or civil liability or be 
damaging to the participant’s financial standing, employability or reputation. 
The collection of medical information could potentially cause embarrassment (i.e. the knowledge of tooth 
extraction, implant placement). 
3. 
Outline provisions in place to minimize risk 
To minimize risk, all standard of care procedures will be carried out according to the standard operating 
procedure for tooth extraction and socket preservation. All the surgical procedure will be performed by the PI or 
the Co-PI both very experienced in these procedures.  
Non standard of care procedures will carefully monitored to reduce risk as follows: 
• Probe discomfort will be managed with gentle patient interactions and open communication. 
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Investigators
!
• Dental impression will be done in an efficient and gentle manner
.  
• Breaches of confidentiality will be avoided by keeping all medical and patient related information in a 
locked cabinet within a locked room. No medical record numbers will be recorded. All radiographs will 
be taken with lead aprons utilizing the radiation safety principle: ALARA
 (as low as reasonably 
achievable).  
11. Benefits  
1.
Describe potential benefits of study participation (indicate if there is no direct benefit) 
Study participants are likely to benefit from this study regardless of the group that they will be assigned to as 
both modalities are likely to yield positive and significant results and would have been done regardless of the 
research study as a part of improving their dental health. 
2. 
Describe potential benefits of the research to the local community and/or society 
If Treatment 1proves to have significantly better soft and hard tissue outcomes, it could become the new 
standard of care.  Even if both treatments have similar outcomes, then the simplicity of the surgical technique of 
Treatment 1 might become the new preferred standard of care resulting in simpler and less traumatic surgical 
procedures.  
12. Reportable Events 
1. 
Outline plans for communicating reportable events (e.g., adverse events, unanticipated 
problems involving risks to participants or others, breach of confidentiality) 
Reportable events will be reported to the IRB in accordance with IRB policies within 5 business days from the 
time the study team becomes aware of the information. Reportable events will also be communicated to the 
sponsor within the same time frame.  
13. Research Related Injuries (this section must be completed for any greater than minimal risk 
research) 
13.1 Are there provisions for medical care and compensation for research-related injuries? 
No Yes:  If yes; outline these provisions (Please note that although Harvard’s policy is not to 
provide compensation for physical injuries that result from study participation, medical 
treatment should be available including first aid, emergency treatment and follow-up care as 
needed. If the research plan deviates from this policy
, provide appropriate justification.) 
If physical injury resulting from participation in this research should occur, although Harvard’s 
policy is not to provide compensation, medical treatment will be available including first aid, 
emergency treatment and follow-up care as needed, and your insurance carrier may be billed for the 
cost of such treatment. In making such medical treatment available, or providing it, the persons 
conducting this research project are not admitting that your injury was their fault. 
14. Participant Privacy 
1. 
Describe provisions to protect participants’ privacy (their desire to control access of others to 
themselves, e.g., the use of a private interview room) and to minimize any sense of intrusiveness 
that may be caused by study questions or procedures 
Patient’s private information will be obtained in a private environment (private dental chair) and recorded in the 
CRF that is not available to anyone outside of the study investigators. Surgeries and follow up visits will be 
performed within the same private dental environment where patients generally receive care.  
15. Data Confidentiality 
1. 
Will the information that is obtained be recorded in such a manner that participants can be 
identified, directly or through identifiers linked to the participants?  
  
No:  If no, skip to 16.1 
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HLMA Research Protocol  
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Investigators
!
Yes:  If yes; either state that participants will be told that their data will be public or describe 
provisions to maintain the confidentiality of identifiable data, e.g., use of password protections  
(please refer to the Harvard Research Data Security Policy (HRDSP), at http://vpr
.harvard.edu/
pages/harvard-research-data-security-policy, for additional information about required data 
security measures) [NOTE: The HRDSP
 does not always apply if data are not being stored at 
Harvard facilities.  Please consult the HRDSP
 for additional information.] 
Yes: Confidentiality will be maintained via the following. No electronic data will be kept except CDs of the CT 
scans. Standard of care data will remain in the Axium system. All research data (the CDs and the hard copy 
CRFs) will be will be stored within in a locked cabinet in a locked room (the Periodontology Residents room at 
HSDM). 
2. 
Describe i) whether data will be transmitted, and if so how; ii) how long it will be stored; and 
iii) plans for the data at the end of the storage period (how will it be destroyed, or will it be 
returned to data provider) 
i) There will be no transmission of identifiable data. 
ii) Standard of care data will be protected under the Axium software firewall. Research data (hardcopies) will be 
stored in a locked cabinet within a locked office.  
iii) At the end of the study period, the clinical data will be moved to an offsite storage facility for HSDM 
research data which will then be destroyed after 10 years unless otherwise instructed. 
3. 
Indicate how research team members and/or other collaborators are permitted access to 
information about study participants  
Only three researchers will have access to the identifiable data information which will be kept in a locked 
cabinet within a locked office.  
PI: Eli Machtei DMD 
Co-Investigator: David Kim DMD 
Other Study Team Member: Heather Wong DDS 
Other Study Team Member: Chia-Yu Chen DDS 
4. 
If future use of data, data sharing, ie, required of NIH-funded studies using/generating large-
scale human genomic data, or future open access, ie, free availability and unrestricted use, of 
data is planned or likely
, indicate how data will be shared/released.  
N/A
 
16. Costs and Payments  
1. 
Identify any costs that participants may incur during the study
, including transportation costs, 
childcare, or other out-of-pocket expenses 
There are no additional study related expenses other than what the patient (or their insurance) would pay for the 
standard of care.  The cost will be approached (and possibly billed to insurance) as any other standard of care 
procedures at the dental clinic. 
Costs that participants may incur during the study 
i)
Transportation costs (i.e. parking, gas, public transportation) 
ii)
Opportunity costs (i.e. patients time will be forfeit where they might normally be at work) 
iii)
The tooth extraction will also be charged to the patient as is usual in standard of care.  
iv) 
The first CT scan will be charged to the patient.  The second CT scan will be done for free. The cost 
of at least one CT scan is normally charged as a part of the standard of care. 
Patients will receive the following for free (which are normally charged for as part of the standard of care) 
i)
Socket preservation surgery 
ii)
Bone graft material 
iii)
Collagen membrane  
iv) 
Additional X-rays 
v) 
The second CT scan 
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Investigators
!
2. 
Is there any payment or reimbursement that participants may receive during the study?  
  
No Yes:  If yes; specify the amount, method and timing of disbursement. (Please refer to Harvard 
  
University Financial Policy on Human Subject Payments at 
 
 http://policies.fad.harvard.edu/pages/human-subject-payments) 
No 
17. Multi-site Study Management  
1. 
Is this a multi-site study? 
  
    No Yes:  If yes; describe plans for communication among sites regarding adverse events, interim 
results, protocol modifications, monitoring of data, etc. 
No 
18. Investigational Drug/Biologic/Device 
1. 
Does this study involve an Investigational Drug/Biologic/Device? 
  
    No: If no; skip to 19.1 
Yes: If yes; identify and describe the drug/biologic/device (e.g., marketing status: Is there an 
IND/IDE, classification of a device as significant vs. non-significant risk) 
No 
2. 
Describe its administration or use 
N/A
 
3. 
Compare the research drug/biologic/device to the local standard of care 
N/A
 
4. 
Describe plans for receiving, storage, dispensing and return (to ensure that they will be used 
only for participants and only by authorized investigators) 
N/A
 
5. 
If proven beneficial, describe anticipated availability and cost to participants post-study; plans 
(if applicable) to make available 
N/A
 
19. HIPAA
 Privacy Protections 
1. 
Are HIPAA
 privacy protections required? Please note that only Harvard University Health 
Services and Harvard School of Dental Medicine are covered entities at Harvard.  Harvard is 
otherwise not a HIPAA
 covered entity
.  If, however
, data is derived from a Covered Entity (e.g. 
a hospital or community health center), mark ‘yes’ and address the items below
. 
  
    No: If no; skip to 20.1 
Yes: If yes; include at least one of the following: 
Describe plans for obtaining authorization to access protected health information 
Provide the rationale for a waiver of authorization or limited waiver of authorization 
request 
Yes, the study will be conducted at the Harvard School of Dental Medicine, which is HIPAA
 covered entity at 
Harvard. Consent for authorization to access protected health information is included in the Consent Form and 
will be obtained at enrollment into the study
.  
20. Data and Specimen Banking 
1. 
Does the study include Data and Specimen Banking?  
  
    No: If no; skip to 21.1 
 Yes: If yes; identify what will be collected and stored, and what information will be associated 
with the specimens 
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HLMA Research Protocol  
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Investigators
!
Yes: Data that will be obtained will be that of clinical and radiographic nature which is considered not to be 
sensitive information.  
2. 
Describe where and how long the data/specimens will be stored and whether participants’ 
permission will be obtained to use the data/specimens in other future research projects 
During the duration of the study
, a CRF will be collected and stored under locked cabinet in the Periodontology 
resident’s room. At the end of the study period, the clinical data will be moved to an off-site storage facility for 
HSDM research data which will then be destroyed after 10 years unless otherwise instructed. Data will not be 
used in the future.  
3. 
Identify who may access data/specimens and how 
Only four researchers will have access to the identifiable research data information which will be kept in a 
locked cabinet within a locked office.  
PI: Eli Machtei DMD 
Co-Investigator: David Kim DMD 
Other Study Team Member: Heather Wong DDS 
Other Study Team Member: Chia-Yu Chen DDS 
Any standard of care data in the dental record will be available to those who would normally have access.  
4. 
Will specimens and/or data be sent to research collaborators outside of Harvard? 
  
     No Yes:  If yes; describe the plan 
No 
5. 
Will specimens and/or data be received from collaborators outside of Harvard? 
  
     No Yes:  If yes; describe the plan 
No 
21. Sharing Study Results 
1. 
Is there a plan to share study results with individual participants? 
  
    No Yes:  If yes; describe the plan 
No 
2. 
Is there a plan to disseminate aggregate results to the community where the research is 
conducted? 
  
    No Yes:  If yes; describe the plan 
De-identified data will be used for statistical analysis and eventually be submitted for publication in a peer 
review journal in aggregate 
22. Regulatory Compliance 
1. 
Describe plan for monitoring regulatory compliance, in order to ensure proper record keeping 
and retention of required regulatory documents 
Patients’
 private information will be obtained in a private environment and recorded in the CRF that is not 
available outside of the study investigators. These booklets will be kept within a locked cabinet inside of a 
locked room.  At the end of the study period, the clinical data will be moved to an off-site storage facility for 
HSDM research data which will then be destroyed after 10 years unless otherwise instructed. Study staff will 
be responsible for ensuring that regulatory documentation is being kept compliant and will monitor this 
process at each study visit. 
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