Ethics {9} {15}
The clinical trial was approved by the Ethics and Research Committee of Faculty of Medicine, Hasanuddin University, Makassar, Indonesia with code number 1063/UN4.6.4.5.31/PP36/2019. Participants will be recruited from general practices of Hasanuddin Dental Hospital and in the area around Makassar. The trial will be conducted in Hasanuddin Dental Hospital. All participants shall be asked to sign an informed consent. This study complies with the principles of the Declaration of Helsinki.
Study design {8} {6b} {11c} {12}
This is a single-center prospective control clinical trial, assessing the safety and feasibility of Ca-polyP-MP (Calcium-polyphosphate microparticles, CAS No.: 13477-39-9, EC No.: 236-769-6) as bone graft material in an alveolar cleft model. The average MP particle size diameter is 280 ± 120 nm (Müller WEG et al., 2018). A total of 8 patients will be included in the trial. Four patients (randomized) will receive Ca-PolyP MP as bone graft, and the other 4 patients will receive a combination of PolyP/BCP as graft material. The primary endpoint will be set at 6 months. At each follow-up visit, AE and/or SAEs will be documented, and clinical assessments will be performed at time points specified in the Intervention section (below). All patients will be monitored closely using lab test (Complete blood count (https://doi.org/10.1053/jpan.2003.50013), others if needed), radiographs, and periodic physical examination (Table1). After these six months, a bone biopsy will be taken during dental implant preparation and processed for histological/histomorphometric analysis. Finally, a report on safety, feasibility, and potential efficacy with regard to bone formation will be made and published.
Eligibility criteria {10}
Inclusion and exclusion criteria {26a}
After written informed consent will be obtained by research team member, the participant will be screened further for eligibility. Patients should be ≥ 15 years healthy old male or female patients with an alveolar cleft bone defect, non-smoker, with no history of previous grafting procedure(s), a normal blood count, and with an ASA1 regarding anesthetic risks.
Patients will be excluded when they have poor oral hygiene with mouth plaque, systemic or local infection, have systematic disease, or received radiotherapy, chemotherapy, immunosuppressive or anticoagulant therapy recently. Other exclusion criteria comprise having received bone morphogenetic protein (BMP) growth factors or other bone growth promoting factor therapy, obvious malnutrition, and active influenza.
Point {26b}:
N/A no additional consent is required at this level of the trial.
Intervention {11a}
Under general anesthesia, and after local infiltration with adrenaline 1:100,000, an incision will be made at the cleft margin to create a pocket-like tissue towards the nose and the mouth in order to reconstruct the nasal floor as well as the palatal tissue. The goal of this approach is to get rid of the oro-nasal fistula and to expose the bony edges on both sides of the cleft. Under sterile conditions, either Ca-polyP MP alone (NanotecMARIN GmbH, Mainz, Germany) or a combination of BCP (Straumann Bone Ceramic, Villeret, Switzerland) and PolyP will be mixed with normal saline or blood in a ratio 1g:3-5 ml and 1g:1g:5-7 ml respectively. A homogenous mixture should be reached before placing the graft material into the cleft defect. A good adaptation of bone graft material should be considered while placing it in cleft defect. No membrane will be used unless absolutely necessary. A different graft quantity will be considered for larger defects, however, with the same mixing ratios. Absorbable sutures with 3/0 vicryl for mucosa, and 4/0 vicryl for nasal reconstruction will be used for closure.
Post-operative, suitable antibiotic and painkillers will be prescribed to all patients.
Adverse Event (AE) and Serious Adverse Event (SAE) {11b} {11d} {30} {22}
Any adverse event will be graded with respect to intensity and classified as either serious or non-serious according to the World Health Organization Classification. Any change in health which occurs between screening examination and first administration of amorphous Ca-polyP microparticles or related procedures will be recorded as part of the subject’s medical history, and full medical care will be given to all participants. In the case of a SAE, the sponsor will be reported within 24 hours from the onset. If the SAE concerns severe toxicity or infection associated with the graft site, the trial will be terminated immediately.
Sample size {14} {18b}
Since this is a first-in-man trial, the current trial sample size has been limited to only 2x4 patients, with the primary goal to gain a first insight on the feasibility and safety of the treatment with polyp. The number of patients has been kept low in order to minimize the risk of the graft exposure in case of any adverse effect.
Randomization and treatment allocation {16a} {16b} {16c} {17b}
Because of this is a first in human study, it is not possible to keep all personnel and the participants to be blinded to assignment group. After written informed consent, randomization will be performed with regard to the treatment group, but the patients will be aware of the fact that they will be treated with polyp.
Blinding {17a} {23}
The radiologist and the histopathologist will be kept blinded to the treatment when evaluating the data (Figure 1).
Data collection {18a} {19} {27} {5d}
The rules and responsibilities will be provided to the research team. The doctors and nurses of the research team will collect the data according to the evaluation table 1. All research team members will receive training on how to collect data at all study visits. Each patient will be followed up for up to 6 months. The confidentiality of the participants will be well protected by the data manager.
Outcomes
Safety assessment based on physical examination and laboratory measurements
When a SAE occurs, it will be concluded that polyP is not (yet) safe in the current setting. For AEs, if they do not occur at a higher frequency than in patients treated with standard care (autologous bone) and/or can be resolved by non-invasive conventional methods (eg, analgesics, antibiotics), the polyP product will be considered safe. In all other cases, polyP will not be considered safe (yet).
Radiographic evaluation
The Chelsea scale will be used to evaluate the bone graft and the level of the bone in comparison with the adjacent teeth. This scale starts with drawing an imaginary midline between the two teeth on either side of the cleft site. Each of those teeth (mesial and distal roots) will be divided starting from cemento-enamel junction to the root apex in four parts. A 0 score is given when no bone is present up till the midline, a 0.5 score is given when there is bone, but it fails to reach the midline, and a 1 score is given when the bone extends from the root surface to the midline (Witherow H et al., 2002).
Histological and histomorphometric analysis {33}
The histological and histomorphometric analysis will be performed in at least 3 patients from each group. In those patients, the dental implant site will be prepared using a trephine burr (⌀ 2.0 mm × 10.0 mm in length) instead of a normal drill, thereby being able to collect a biopsy from the treated site without interfering with the normal procedure. The biopsies will be fixed in 10 % formalin and processed for embedding in methylmethacrylate for evaluation of hard tissue formation. After sectioning, different stainings (Goldner’s trichrome, Toluidin blue, Tartrate-resistand acid phosphatase (TRAP)) will be used, and histomorphometric parameters for bone formation will be analyzed. Two trained examiners, blinded for the treatment modality, will evaluate the images, and intra- and inter-observer reliabilities will be determined. In case of disagreement between observers, the specimen will be re-evaluated to reach consensus.
Monitoring {21a} {21b}
Monitoring will be done constantly by internal monitors of the Ethics and Research Committee of Faculty of Medicine, Hasanuddin University, since there is a negligible risk a data safety monitoring board will not be formed. A safety report will be provided to the Medical Research Ethics Committee of the Ethics and Research Committee of Faculty of Medicine, Hasanuddin University every year. An interim analysis will not be conducted.
Statistical analysis {20a}
A SPSS power analysis for parameter comparisons between the groups. A p-value less than 0.05 will considered statistically significant.
{20b, 20c, 31c, 25}: N/D
Those points are not applicable in safety and feasibility in this small sample study.