Combination of Platelet-Rich Fibrin and Calcium Sulfate in Socket Augmentation
Phase: NA
Conditions: Tooth Extraction
Sponsor: University of Malaya

Study Protocol and Statistical Analysis Plan 
Official title: Combination of platelet-rich fibrin and calcium sulfate in socket 
augmentation: A randomized clinical study 
Document Date: 24 October 2018 
Uploaded date: 22 February 2019 
 

Study protocol 
This study was a randomized clinical trial conducted from March 2015 to November 2016. 
Ethical approval was obtained from the Ethics Committee, Faculty of Dentistry, University of 
Malaya, Kuala Lumpur [DF RD 1621/0076 (L)]. All patients were recruited from the outpatient 
department and oral and maxillofacial surgery department. The study was conducted in accordance 
with the Helsinki Declaration of 1975, as revised in 2000. All patients who fulfilled the inclusion 
criteria were included in the study. They received a detailed explanation of the treatment and gave 
their written informed consent. 
The inclusion criteria for the study was maxillary premolar teeth requiring extraction with 
neighboring mesial and distal sound/restored teeth, alveolar bone level (measured from periapical 
radiographs) more than 50% of the root length and age ranges from 25-55 years. The exclusion 
criteria was bony fenestration of the socket wall confirmed from CBCT scan, acute signs of 
infection, periodontally compromised teeth, absence of buccal plates, any systemic disease which 
may hinder the healing process e.g., diabetes, hypertension, bleeding disorders like 
thrombocytopenia, thalassemia, asthma, patients on long term steroids, osteoporosis, smokers, 
pregnant and lactating women and history of malignancy or radiotherapy and chemotherapy.  
All patients were randomly allocated to either PRF-CS (test) or PRF-xenograft (MinerOss® X 
syringe, Bio Horizons, Alabama, United States) (PRF-X) (control) group using coin-toss method. 
The sample size for this study was calculated using t tests of means difference between two 
independent groups, based on a power of 80% and a detectable difference between the two 
comparative groups of 0.05 where the mean differences for socket depth were 13.73 mm and 9.50 
mm with standard deviations of 3.00 and 3.08 respectively (17). The sample size was calculated 
as 10 subjects (5 subjects in each group).  

Pre-surgical preparation 
A day before extraction, clinical photographs and impressions of the jaw were performed. An 
acrylic stent (A) (to serve as a fixed reference point) for each patient was prepared using light 
cured material. A cone beam computerized tomography (CBCT) scan was performed for the 
planned extraction site using Kodak 9000C® (Carestream, United States) software. The selected 
scanning parameters were 70 kV; 10 mA; voxel size = 76µm; acquisition time = 10.8s. The 
parameters measured from the CBCT scan at baseline were mesial bone height (MBH), distal bone 
height (DBH), socket bone height (SH), buccal bone height (BBH), palatal bone height (PBH), 
horizontal bone width (W) and volume of bone. MIMICS® software (Materialise NV, Belgium, 
version 16.0) was used for the analysis of bone volume at baseline and at 5 months post-extraction. 
To measure the soft tissue profile changes from stone casts, another occlusal acrylic stent (stent B) 
was fabricated using light cure acrylic. Grooves were prepared to serve as fixed points for the 
periodontal probe. The parameters measured for clinical measurements were mesial soft tissue 
height (MSH), distal soft tissue height (DSH), buccal soft tissue height (BSH), and palatal soft tissue 
height (PSH). 
Extraction procedures 
Prior to extraction, 20ml of venous blood was collected in two sterile vacutainer tubes. The 
venous blood was quickly spun in the centrifugation machine (Process for PRF DUO® Centrifuge, 
France) at 1300 rpm for 8 mins and kept separate for 3-5 mins. After the completion of 
centrifugation, the fibrin clot was picked up using a tweezer while a pair of sterile scissors was 
used to separate the Red blood cell layer. Finally, the fibrin clot from 1 tube was placed in the PRF 
box (PRF processing, Nice, France) to form the PRF membrane whereas the fibrin clot from 
second tube was compressed to form the PRF plug. 

After atraumatic tooth extraction, the extraction socket was carefully curetted and irrigated with 
normal saline. In the control group, xenograft (MinerOss®X) (size 250-1000µ, 0.5cc) was mixed 
with PRF membrane (cut into pieces) and placed inside the socket. In the test group, calcium 
sulfate (CS) was mixed with PRF membrane (cut into pieces) and placed inside the socket. The 
graft materials were placed up to the level of crest of the extraction socket before being covered 
with the PRF plug. Simple interrupted sutures (black silk 4-0, Ethilon® Mersilk, Cornelia, 
Georgia) were applied on the mesial, middle and distal area. An antibiotic, Amoxicillin 500mg 
(capsule) every 8h for 5 days and an analgesic, Paracetamol 1g (tablet) every 8h for 3 days were 
then prescribed. The patients were advised to rinse with 0.12% chlorhexidine mouth rinse twice 
daily for a week. Patients were recalled after a week for suture removal followed by another recall 
5 months post-extraction for CBCT scans and planning of implant placement. 
 
 

Statistical analysis 
Descriptive statistics were achieved for data analysis (SPSS 22, IBM, USA). Mean with 
standard deviations were reported to demonstrate average bone resorption and percentage of 
changes (PoC). Since the assumptions of the normal distributions were fulfilled, parametric test 
was used to calculate the linear radiographic changes and for volumetric changes. The paired 
sample t test was performed to calculate the changes obtained within each group (intragroup) from 
baseline to 5 months. An independent samples t test was used for independent groups to assess the 
difference between the treatment groups. Because of the unmet criteria of normal distribution, non-
parametric test was used for clinical measurements and median values with interquartile range 
were used to calculate the P values. The Wilcoxon signed rank test was used to equate the median 
values in clinical parameters (MSH, DSH, BSH and PSH) at baseline and at 5 months within each 
group (intragroup). For intergroup changes from baseline and 5 months, the Mann-Whitney U test 
was used. Level of significance was set to 0.05.