Reuseable Software Components.
\r\n\tThe purpose of the book is to bring together the latest knowledge about genetic diversity by presenting the studies of some of the scientists who are engaged in development of new tools and ideas used to reveal genetic diversity, often from very different perspectives. The book should prove useful to students, researchers and experts in the area of biology, medicine and agriculture.
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It is used in embedded electronics, in flight dynamics, in ground and space data processing, and in the current generation of data products. For example, the National Aeronautics and Space Administration (NASA) Goddard Space Flight Center’s Innovative Partnerships Program Office offers licensing opportunities for software and technologies from a variety of areas relevant to the hardware and software requirements of Earth and space science missions and projects: aerospace/aeronautics, computer software, data processing/analysis, electromechanical devices, electronics, manufacturing equipment, mechanical technologies, nanotechnology, optics and photonics, sensor and detector technologies, subassemblies and components, telecommunications and internet, and test and measurement (IPP Office, 2009). Reuse of existing experience and artifacts eliminates having to “reinvent the wheel” and is a key element to achieving progress in many areas of complex aerospace system development.
\n\t\t\tOriginally, in the absence of vendor-provided solutions and commercial off-the-shelf software components, many data and information systems were designed and built as custom applications. However, as the practice of systems and applications development has matured, facilitating reuse of software and reusing previously developed software have been recognized as beneficial for meeting the challenges of developing and maintaining complex systems. Some of the challenges commonly faced by system developers can include dealing with very large quantities of data (e.g., terabytes per day), working with a distributed knowledge base, the expense and complexity of required technology infrastructure, and the need for domain-specific knowledge in software development (Samadi et al., 2007). In software development, reuse can assist today’s development teams in various aspects of the system development life cycle, especially when they share common goals (Samadi et al., 2007).
\n\t\t\tThe development of new systems can benefit from the efforts that contributed to the development of current and previous generations of systems. Considering the costs of building new systems, and the learning curve that contributes to such costs, leveraging the results of previous system development activities has the potential to reduce system development costs and improve capabilities for new development. Previously developed system components, such as plans, design requirements, system documentation, algorithms, and procedures, offer the results of previous design, testing activities, scientific algorithms, and learning experiences that were part of the initial systems development effort. Such legacy resources contain the evolved expertise of previous generations and can have continuing value if reused when building the next generation of systems or enhancing existing systems.
\n\t\t\tWhile the potential gains from software reuse appear quite promising, these gains also can be accompanied by costs and risks. Effectively preparing software components and other artifacts for potential reuse requires efforts to ensure that such artifacts can be reused in a manner that offers adopters efficiency gains that can be realized through reuse. Without such preparation efforts, adopters might not achieve the efficiency benefits anticipated for their reuse activities. However, the costs of preparing software for reuse could be small in comparison to the potential gains to be attained from reuse. For example, in cases where a planned or “forward-looking” approach to software reuse has been employed in the aerospace industry, improvements have been observed in terms of increasing the quality and reducing the costs of software reuse (Finnigan & Blanchette, 2008).
\n\t\t\tSimilarly, risks can be incurred through software reuse. The adoption of previously-developed software can pose risks for those who contribute software as well as for those who adopt software. For example, assumptions about the origination, validation, and verification of software can increase risks to software projects, especially if the software affects mission-critical operations or safety-critical systems (Orrego & Mundy, 2007). While costs can be controlled and risks can be mitigated, they need to be recognized and assessed to determine their potential effects on software reuse. Recognizing the existence of the possible costs and risks also enables the involved parties to engage in software reuse with grounded expectations. Taking a deliberate, planned, and systematic approach to software reuse will help producers and adopters of reusable software to attain the benefits of reuse while limiting its costs and managing its risks.
\n\t\t\tReuse has been shown to be effective in developing large and complex data systems to support space-based missions. One example is the National Polar-orbiting Operational Environmental Satellite System Preparatory Project where high levels of reuse have enabled system developers in the Science Data Segment, which provides ground systems that support data product assessment and quality verification, to reduce development effort as described by Samadi et al. (2007). Software reuse also contributes to flight software, such as the instrument manager software for the Mars Science Laboratory rover (Murray et al., 2009). This chapter describes how reuse activities can fit into building the next generation of aerospace data processing systems by providing guidance on methods for improving reuse practices in order to realize the benefits of reuse.
\n\t\tThe reuse of existing software and related artifacts is commonly referred to as software reuse. More specifically, the reuse of a software artifact is its integration into another context (Leyton, 2008). The reuse of software has been practiced informally and formally by software developers, since the practice offers potential benefits for developers and development organizations to attain improvements in productivity and software quality (Ajila & Wu, 2007; Mohagheghi & Conradi, 2007; Nazareth & Rothenberger, 2004). Decreases in software product development time and software development costs also have been reported (Frakes & Kang, 2005). In addition, systematic software reuse could provide additional benefits if the organization establishes incentives to motivate developers (Sherif et al., 2006).
\n\t\t\tThe results of surveying members of the Earth science community on their reuse practices and experiences showed that the reuse of existing technologies is most often performed in order to save time, save money, and ensure the reliability of the product (Marshall et al., 2006). When measuring potential gains in productivity, quality, and time-to-market from software reuse, metrics must be analyzed from the entire software development life cycle as well as from software maintenance efforts (Mascena et al., 2005). If such gains can be realized, then efforts to reuse software code and other artifacts should be pursued by software developers and their employing organizations. Likewise, such efforts should be documented to identify and measure actual benefits attained. Furthermore, measuring the benefits of software reuse can assist in benchmarking the activities that led to the measured gains and enable the identification of additional gains that can be compared to such benchmarks.
\n\t\t\tIn addition to the potential benefits previously described, reliability is another objective of software reuse (Frakes & Kang, 2005). NASA recognizes the value of reuse in providing “a lower likelihood that the item will fail tests and generate rework” (NASA, 2007). Anticipating potential uses of software artifacts should help to reduce failures of reusing such artifacts within new domains and operating environments (Suri & Garg, 2008). In addition, efforts to ensure the reliability of software for reuse within new environments should begin during the early stages of the software development process (Immonen & Niemela, 2008).
\n\t\t\tVarious software artifacts, in addition to source code, can be reused to the benefit of software developers and their organizations. Some reusable software components are listed in Table 1 (derived from Samadi et al., 2007, with additions).
\n\t\t\tReusable Software Components | \n\t\t\t\t\t
Operational source code | \n\t\t\t\t\t
Analysis and design specifications | \n\t\t\t\t\t
Plans (project management) | \n\t\t\t\t\t
Data (testing) | \n\t\t\t\t\t
Synthetic data generators and analysis tools | \n\t\t\t\t\t
Expertise/experience (life cycle model, quality assurance) | \n\t\t\t\t\t
Information used to create software and documentation | \n\t\t\t\t\t
Testing procedures | \n\t\t\t\t\t
Documentation | \n\t\t\t\t\t
System and user guides | \n\t\t\t\t\t
Use cases and user scenarios | \n\t\t\t\t\t
Reuseable Software Components.
In order to make use of reusable components, information about “how” they work must be included along with information about “what” they do (Neighbors, 1992). Additional work products, such as comments and other artifacts, also can contribute to the reusability of source code and are often needed to migrate software components between platforms, contexts, and projects. In many cases, documentation, such as user guides, installation guides, and other specifications, also is essential to facilitate the reusability of software components.
\n\t\t\tEstablishing reusability as a requirement for the development of software components can contribute to their potential for reuse. However, even in cases where reusability was not planned or originally intended during initial software development, an artifact may still be reused in domains and contexts similar to the original. In such cases, domain analysis may be required to facilitate reuse, even when the reuse is within an application or problem domain that is similar to the original. Domain analysis includes identifying, capturing, and organizing information that was used in developing the original system to facilitate its potential reuse within a new system (Preito-Diaz, 1990), enabling subsequent evolution of the original information infrastructure.
\n\t\tReusing previously developed components within a new system requires a directed effort. In some cases, a top-down and single-project life cycle model such as the “waterfall” model might not be appropriate for software reuse (Simos, 1988). Software reuse is not inherently top-down, and it needs a perspective which may be beyond the development activities of a single project or program. The reuse process needs to follow a structured approach such as the approach recommended by Basili et al. (1989):
\n\t\t\t1. Specifying the object to be created
2. Searching the project, domain, and general databases for reuse candidates
3. Evaluating the candidates to determine which (if any) should be used
4. Modifying, if necessary, to fit specific needs
5. Integrating the reusable components
6. Validating
7. Feeding back the knowledge regarding the payoff of reuse
Initially, potentially reusable components need to be identified through domain analysis, and the candidates for reuse need to be assessed in terms of how they might be reused. For example, a categorized list of sub-routines might inform current development activities even if the subroutines are not considered to be reusable. The extent of reuse could depend on common aspects between the original functionality of the reusable components and the planned purposes for their potential reuse. Also, developers need to determine whether the candidate reuse would be cost-effective when assessing how much preparation is required for potential reuse. The more mature the software is, in a reusability sense, the more cost-effective its reuse is likely to be. Less mature software is likely to take more time, cost, effort, etc. than building the software from scratch, and is less likely to provide cost-effective solutions.
\n\t\t\tIn addition to identifying candidates for reuse from current and legacy systems, other systems, either within the same organization or available externally, also should be considered when seeking reusable components. Developers from various fields are contributing to open source collections of software that are available for reuse by other adopters. SourceForge (2009) is one example of such a collection, and the site covers essentially all domains. Other collections may be focused on one or more particular domains, such as the Netlib for mathematics (2009) and the Space Telescope Science Institute’s list of software and hardware products for astronomy (2009).
\n\t\t\t\tThere are also collections for particular programming languages, tools/formats, and applications; some examples of these are the Comprehensive Perl Archive Network (2009), the software available at the HDF-EOS Tools and Information Center (2009), and the Comprehensive TeX Archive Network (2009). While adopters are most likely to find reusable components for their particular domain, programming language, tool/format, or application in these more specific collections, they should check the more general collections as well, since some components may be suitable candidates for reuse even if they were originally developed for a different domain.
\n\t\t\t\tOften, these open source resources are offered with non-restrictive licenses that allow and encourage others to reuse the components. Open source communities also encourage developers to share improvements to open source resources so that the resources and the adopters will benefit from enhancements that have been developed and offered by others.
\n\t\t\tVarious tools are available for systems developers when assessing the potential for reusing legacy resources in the development of a new system. One example is reuse readiness levels (Marshall & Downs, 2008), which can be used to assess the potential for existing software being considered for reuse. Reuse Readiness Levels (RRLs) also can be used to assess the value of software that is being developed and to determine areas where improvements could contribute to the reusability of the software, particularly through the use of the topic area levels from which the overall RRLs were developed. A brief introduction to this method of assessing the reusability maturity of software components follows.
\n\t\t\t\tAs described in Marshall & Downs (2008), the RRLs were developed by members of the Earth science data systems software development community through an iterative process. Initially, the needs of both software contributors and software adopters were considered in order to identify topic areas that could be important for measuring the reuse maturity of software components. Nine such areas were identified; alphabetically, they are documentation, extensibility, intellectual property issues, modularity, packaging, portability, standards compliance, support, and verification/testing. Nine teams, each consisting of at least two people who have been involved with software development, worked together to write a set of levels for these nine topic areas; descriptions of the topic level areas can be found in Marshall et al. (2008). Next, members of these teams looked across all topic areas at each level to draft summaries of the overall RRLs, combining key information from all topics at the same level. Based on feedback received from other members of the community, the overall RRLs and topic area levels were revised and improved. This process of revising the levels and obtaining additional feedback to use in further revisions is repeated as the community continues to improve the RRLs. A summary of the RRLs is presented in Table 2.
\n\t\t\t\tAdditional details on the RRLs and the topic area levels from which they were developed can be found in materials produced by the NASA Earth Science Data Systems Software Reuse Working Group, many of which are publicly available on the group’s web site (2009).
\n\t\t\t\tRRL | \n\t\t\t\t\t\t\tSummary | \n\t\t\t\t\t\t
1 | \n\t\t\t\t\t\t\tLimited reusability; the software is not recommended for reuse. | \n\t\t\t\t\t\t
2 | \n\t\t\t\t\t\t\tInitial reusability; software reuse is not practical. | \n\t\t\t\t\t\t
3 | \n\t\t\t\t\t\t\tBasic reusability; the software might be reusable by skilled users at substantial effort, cost, and risk. | \n\t\t\t\t\t\t
4 | \n\t\t\t\t\t\t\tReuse is possible; the software might be reused by most users with some effort, cost, and risk. | \n\t\t\t\t\t\t
5 | \n\t\t\t\t\t\t\tReuse is practical; the software could be reused by most users with reasonable cost and risk. | \n\t\t\t\t\t\t
6 | \n\t\t\t\t\t\t\tSoftware is reusable; the software can be reused by most users although there may be some cost and risk. | \n\t\t\t\t\t\t
7 | \n\t\t\t\t\t\t\tSoftware is highly reusable; the software can be reused by most users with minimum cost and risk. | \n\t\t\t\t\t\t
8 | \n\t\t\t\t\t\t\tDemonstrated local reusability; the software has been reused by multiple users. | \n\t\t\t\t\t\t
9 | \n\t\t\t\t\t\t\tDemonstrated extensive reusability; the software is being reused by many classes of users over a wide range of systems. | \n\t\t\t\t\t\t
Reuse Readiness Levels.
The Earth science data systems development community also has identified a number of potential uses for the RRLs. As metadata for reusable software components stored in catalogs and repositories, RRLs provide a guide to software adopters. They can help adopters quickly asses the maturity of candidate components for their reuse efforts, narrowing down the number of possible solutions they must consider in detail. The RRLs, and the RRL topic area levels in particular, can serve as an indicator of areas to focus on when creating reusable components, as a guide to contributors. Each topic area was selected because it was identified as an important factor that contributes to the reusability of software. By assessing their software components in each of the topic areas, contributors can identify the strengths and weaknesses of their components and work to improve the reusability of the components by using the levels as a guide. The RRLs are being evaluated and work is in progress to develop specific use cases for the RRLs, for both software contributors and software adopters.
\n\t\t\t\tIt also has been recognized that RRLs could eventually become part of requests for proposals or contracts, which require a reuse approach or explanation of how components are being made reusable. Projects could undertake reusability improvement efforts, indicating that software that begins at one RRL will be developed to and released at a higher RRL. By maturing the reusability of the software, the chances of it being reused would be higher, enabling more projects to benefit from previous efforts. Projects that involve new software development could propose to make their resulting work available for reuse and indicate the planned RRL that would be targeted for release of the software. Projects that will be reusing software could indicate the RRLs of the component(s) being considered for reuse and demonstrate how this reuse provides benefits to the proposed work (e.g., by reducing development time and costs).
\n\t\t\t\tTools such as the RRLs can be very helpful in both creating and adopting reusable software components. Developers are advised to take advantage of such tools when possible.
\n\t\t\tCreating reusable software and other components also offers benefits for system developers and their employing organizations. In addition to the benefits of reusing software, system developers also need to recognize the potential value that their current system development activities could have for future system development efforts. Besides contributing to the new system that is being developed, the results of current system development projects also can contribute to the development of future systems that are created by the same organization or by other organizations. Considering the potential value of reusable components for future systems, building software components so that they can be reused could be economically beneficial for organizations involved in software development. There is evidence that reuse offers cost reduction, cost avoidance, and increased profit even though there can be additional costs involved in developing software for reuse (Lim, 1998). Furthermore, building software components to be reusable should be considered good business practice (Stephens, 2006), enabling organizations to reduce redundancy, avoid increasing maintenance costs, and meet evolving requirements.
\n\t\t\tOther factors also motivate individual developers to create reusable software components, either for reuse within the same organization that originally created the software or for reuse by others. Open source software developers can be motivated both intrinsically, for altruistic reasons, and extrinsically, for potential gains (Hars & Ou, 2002; Wu et al., 2007). Such motivations can be complementary for individual software developers (Roberts et al., 2006) and also could evolve (Shah, 2006). However, extrinsic factors, such as improving reputation and self-development, could be more motivating than intrinsic factors, such as altruism (Oreg & Nov, 2008). Factors motivating an individual developer’s involvement in open source Internet communications software development projects include personal software needs, expectations of skill development, reputation enhancement, and enjoyment (Xu et al., 2009). Community factors such as leadership effectiveness and interpersonal relationships also were found to be motivators for involvement in these software development projects (Xu et al., 2009).
\n\t\t\t\tWhile systems development technology and available resources and tools can be expected to change, the purposes for developing future systems could have many aspects in common with the systems that are being developed today. In addition, as techniques and capabilities for developing reusable components improve, future systems could gain even more from current software development efforts. Software development organizations also could contribute to the motivations of their employees to engage in software reuse activities by providing the resources to create an infrastructure that facilitates software reuse (Sherif et al., 2006). Commitment to reuse by the top management of the organization also could be a contributing factor (Morisio et al., 2002).
\n\t\t\tPlanning is necessary when developing systems components for potential reuse. In some cases, initial efforts to ensure the reusability of system components can offer future benefits without adding to development costs. If additional development costs will be required to produce reusable components, these must be weighed against the potential benefits and cost savings of reusing the components in other projects in the future. If a small additional expenditure on the current project can save a larger amount of money in future projects, it would be justified. However, if the organization developing the reusable components is not expected to be the one to reap the benefits of reusing the components in the future, it may be more difficult to justify the additional cost of preparing components for future reuse. Engaging in a planned, systematic approach to software reuse, including the identification of its benefits, can reduce the potential risks of software reuse (Frakes & Isoda, 1994).
\n\t\t\t\tCertainly, many of the activities that foster reusability, such as effectively documenting the work, should be conducted routinely during system development even if reuse is not planned to ensure that enhancements can be completed efficiently. While seemingly trivial and sometimes overlooked by software developers, adding comments to source code can assist in its subsequent analysis and reuse. Furthermore, the inclusion of comments was found to be a success factor for module design that contributed to reuse in large-scale systems at NASA (Selby, 2005).
\n\t\t\t\tDeveloping to standards also can facilitate reuse by others. By developing to established standards for software (see, for example, Baldo et al., 1997 and IEEE, 2004) and data (Baxter et al., 2006), reuse of both software and data can be fostered.
\n\t\t\t\tFurthermore, establishing standards for system components enables others to develop to such standards and potentially foster reuse of components that meet the standards. For example, NASA has proposed an open architecture standard for software-defined radio systems that could facilitate the reuse of design expertise as well as software code, offering potential gains in efficiency for future development and modification efforts (Reinhart et al., 2008).
\n\t\t\t\tIndependent of whether components have been developed to meet established standards, it is necessary to provide sufficient information about resources available for reuse so that they can be identified and assessed for adoption by potential adopters. In addition, enabling reuse also requires developers to grant appropriate intellectual property rights to eliminate legal barriers to reuse, as described in the following section on contributing components for reuse.
\n\t\t\tContributing reusable system components to open source software collections and catalogs can enable others to reuse such components if they are licensed as shareable resources that foster reuse by others. Enabling others to reuse system components can contribute to the pool of resources available for all members of the open source community and result in further improvements to these resources by others. If there are barriers to adoption, it will be more difficult for potential adopters to reuse software and other available components. Such barriers can appear at the individual level or the organizational level, and the interaction of barriers at the organizational level can create barriers at the individual level (Sherif & Vinze, 2003). It is important for software developers to consider the potential barriers that exist at all levels and to take the steps that are necessary to address such barriers in order for their software components and related artifacts to be reused more easily by potential adopters.
\n\t\t\tPotential adopters of reusable components need to be authorized to reuse components that they identify for potential adoption. Without the legal rights to adopt available components, it would be imprudent for potential adopters to incur potential risks by adopting components that they have not been authorized to use. Furthermore, considering the effort involved in adopting reusable components and integrating such components into systems, such investments would not be recommended without first ensuring that the rights for reuse have been obtained. Given these considerations, it is necessary for contributors of components to grant the intellectual property rights necessary for others to adopt components that have been developed for reuse. In addition, it also is necessary to adequately communicate information about the rights for reuse so that potential adopters can easily determine whether they have the right to adopt a particular component and determine any conditions for reuse that might be associated with the adoption.
\n\t\t\t\tSeveral licensing options are available for system and software developers to authorize others to utilize components that have been developed for reuse. One such option is open source, for which there are a number of available licenses; see, for example, Open Source Initiative (2009) for a list. However, prior to considering the available choices for granting rights for reuse, developers should identify any policies or rules within their own organization that might govern their choices. Some organizations have policies that prevent granting rights to others. In such cases, a waiver might have to be obtained from the appropriate authority within the organization so that authorization for reuse can be granted. Organizations also might be concerned about liability and could require review to ensure that granting rights for reuse does not expose the organization to such liability. In some cases, organizations that routinely create reusable components might have stock licensing statements available for developers to offer components for reuse. Such licensing and liability statements should be reviewed by an attorney.
\n\t\t\tAdopters of reusable software should consider sharing any enhancements that they have made to reusable software so that others also may benefit from their improvements. The changes that one organization finds useful might also be useful for other organizations. In addition, other software developers could evaluate the contributed changes and improve them even further. Likewise, such improvements might be considered valuable by the original adopters who had shared their enhancement. In such cases, the original adopters might decide to adopt the new version that includes the improvements to their original enhancements. These kinds of scenarios could be compounded as the community that adopts and contributes enhancements, for a particular reusable resource, continues to grow. Such cycles of individual contributions can improve libraries of software components, offering benefits to the software development community that participates in the software reuse process.
\n\t\t\tThe reuse of software components and other artifacts offers potential benefits for software developers of aerospace systems and other systems. However, a planned and systematic approach to software reuse is recommended for software developers and software development organizations to realize the benefits of software reuse while minimizing potential costs and risks of reuse. The tools and techniques for software reuse that have been described offer options for developing the capabilities to engage in software reuse as contributors and adopters of reusable software and related artifacts. In addition, suggestions for improving software reuse practices have been offered for software contributors and for software adopters.
\n\t\tThe authors appreciate the contributions of the current and previous members of the National Aeronautics and Space Administration (NASA) Earth Science Data Systems Software Reuse Working Group to some of the work presented here, and very much appreciate the support received from the NASA for the work reported in this paper, including the support for Robert Downs under Contract NAS5-03117.
\n\t\tPeri-implant soft tissue (PST) thickness and width of keratinized mucosa (KM) have a major impact on the esthetic appearance, stability, and health of implant/prosthetic reconstruction. Dental implants were introduced 50 years ago as a treatment modality for edentulous patients and, later on, for partially edentulous patients with shortened arches and single-tooth gaps [1]. Until lately, the success of implant treatment was based on implant survival rates, prosthetic stability, radiographic bone loss, and absence of infection [2, 3]. Today, patients’ implant treatment expectations have changed. They have shifted from healthy and functional to healthy, functional, esthetic, and natural-looking tooth replacement [4]. Consequently, the PST augmentation procedure became a fundamental part of implant treatment algorithms.
There are two main objectives of soft tissue augmentation around implants—(1) to restore an adequate width of KM and (2) to increase the volume of peri-implant soft tissue [5].
The displacement and loss of the KM can be a consequence of—(1) flap mobilization in order to achieve primary flap closure during horizontal or vertical bone augmentation procedures and (2) vertical bone resorption and reduction of distance between the bone crest and mucogingival line [6].
Today, the vast majority of published evidence supports the necessity of at least 2 mm of keratinized mucosa width around the implant.
The presence of an adequate amount of KM around implants (>2 mm) will facilitate maintenance of oral hygiene, which can lead to less plaque accumulation and lower incidence of peri-implant mucositis. Furthermore, KM can be associated with soft and hard tissue stability, resulting in decreased incidence in the recession of peri-implant mucosa, marginal bone resorption, and attachment loss (Figure 1) [5, 7, 8, 9, 10, 11, 12, 13].
Recession of the marginal mucosa caused by inadequate width of KM.
KM is fundamental in maintaining health around implants in erratic maintenance compliers patients. Less than 2 mm of KM around implants is erratic compliers seems to be associated with a higher incidence of peri-implantitis [12, 14].
In literature, the suggested PIS thickness is at least 2 mm. PIS thickness has a major influence on two factors—(1) esthetic appearance of the implant/prosthetic rehabilitation and (2) marginal bone stability [13, 15].
The color, texture, volume, level of mucosal margin of the PIS, and presence of papilla has a major influence on the overall esthetical outcome. The aforementioned elements must be in line with those of soft tissue around adjacent teeth in order to obtain a harmonious and natural-looking restoration. These parameters are influenced mainly by soft tissue thickness. Several indexes were developed to objectively evaluate the esthetical appearance of the implant/prosthetic restoration [16].
In literature, the suggested PIS thickness is at least 2 mm [15].
Inadequate PIS volume can be improved with soft tissue augmentation techniques. Furthermore, thick soft tissue can even mask and hide alveolar bone loss on the buccal side of implants [12, 13, 15]. Therefore, soft tissue augmentation is recommended in esthetical regions where a certain amount of buccal bone remodeling is expected, like immediate implant placement in situations with thin biotype or thin buccal bone plate [17, 18].
PIS thickness is essential for concealing the color of the prosthetic restoration and preventing PIS discoloration caused by prosthetic material. In cases with thin PIS (< 2 mm) titanium abutments will cause a visible color change of the buccal PIS (Figure 2) [12, 19, 20, 21].
Visible discoloration of the thin marginal mucosa caused by titanium abutment in the region of the lower right canine.
PIS has a predetermined thickness of 2.5–4 mm, termed biologic width [22]. PIS is formed after healing abutment installation. In case when soft tissue is thinner than 2 mm, peri-implant marginal bone resorption will be initiated in order to establish sufficient space for the biological width [22, 23]. Augmentation of PIS volume with soft tissue grafts can prevent marginal bone resorption in the case of thin PIS [5, 14, 24].
After transplantation to the recipient region, the soft tissue graft depends on plasmatic imbibition in order to receive sufficient nourishment. In the later stages, after 3–4 days, the soft tissue graft will be transvascularized with newly formed blood vessels. Blood vessel anastomoses will be formed between vessels of the recipient site and vessels already present in the graft [21, 25, 26, 27, 28, 29]. In order to achieve plasmatic imbibition and transvascularization certain factors must be met:
Rigid immobilization of the graft-excessive movement can hamper plasmatic imbibition and transvascularization of the flap
Intimate contact of the graft with the recipient site—decreased distance for the plasmatic diffusion or for new blood vessels to reach the graft will result in faster and complete nourishment of the graft. Furthermore, the formation of a blood clot or active hemorrhage between the vascular surface of the recipient site and graft can compromise the nourishment of the graft
Vascularity of the recipient site—the root surface of the tooth and the surface of the implant are avascular surfaces. In those situations, the survival of the graft will be accomplished either by using a larger graft than the avascular surface in order to obtain nourishment from the adjacent vascularized surfaces, preparing a split-thickness flap in order to assure nourishment from both sides of the flap, or by using a pedicle graft.
The PIS grafting procedure should begin with the preparation of the recipient site in order to decrease the time between graft harvest and graft transfer into recipient bed [21, 25, 26].
Most of the aforementioned conditions are met when the periosteum is used as a recipient site. The periosteum is well irrigated and it is immobile (Figure 3) [25, 30].
Stabilization and intimate contact of the autologous soft tissue graft (free gingival graft) in the recipient site achieved with simple interrupted and cross mattress sutures. After the dissection and apical displacement of the mucosal flap, only the exposed periosteal surface is present in the recipient site. The periosteum is well irrigated and immobile surface, suitable for graft nutrition and stabilization.
Likewise, to achieve those factors care must be taken while harvesting the soft tissue graft. The graft should be of uniform thickness to ensure even intimate contact of the inner surface of the graft and the recipient site [25, 26].
The composition of the graft can influence the nourishment of the graft—adipose and glandular tissue may hinder the nourishment of the rest of the graft so they should be dissected from the graft [26, 31].
The first description in literature of the use of connective tissue graft was by Alan Edel in 1974 for increasing the width of gingiva [32]. Since than the indications and the use of CTG graft increased significantly. Today, CTG is still regarded as the gold standard for most soft tissue augmentation treatments. It is indicated for:
Increasing the width of the keratinized gingiva [33]
Treatment of single and multiple gingival recession around teeth [34]
Treatment of mucosal recession around implants [35]
Furcation treatment [36]
Regeneration of infrabony defects [37]
Augmentation of edentulous alveolar ridge defects [38]
Augmentation of PIS [39]
Some of the aforementioned indications are overlapping with those of the FGG. The main advantage of the CTG over FGG is the superior esthetic outcome in terms of color and texture of the augmented area (Figure 4) [25, 26, 40, 41, 42].
Connective tissue graft.
The harvesting technique of the CTG has a direct influence on the graft dimension, histological composition, harvesting complications, morbidity, healing dynamics of the donor site, healing dynamics of the recipient site, and outcome of the grafting procedure. The ideal technique should enable the maximum volume and quality of the graft to be harvested, while concurrently limiting trauma, postoperative morbidity, and possible complications connected with CTG harvesting [43]. A variety number of techniques have been described in the literature for connective tissue graft harvesting. All the techniques can be divided into two groups—(1) connective tissue harvesting with the preparation of the primary flap (offend referred to as subepithelial connective tissue graft, sCTG) and (2) free gingival graft harvesting with extraoral de-epithelization. The first group can be further subdivided into free CTG or pedicle CTG depending if the CTG is completely dissected or remains attached by one side of the palatal soft tissue [26, 40, 42, 43, 44, 45].
The palate is the most frequent site donor site for CTG or FGG harvesting [40]. Histologically, it is composed of different layers—the most superficial epithelial layer, covering a dense connective tissue layer (lamina propria). The submucosal layer is located below the lamina propria and above the periosteum, containing fatty and glandular tissue. Preferably, the CTG should consist only or mostly of the lamina propria layer, with little or no submucosa [26, 46]. Fatty and glandular tissue can hinder or slow the revascularization of the graft after its transplantation [31]. Furthermore, they can be responsible for the increased shrinkage rate of the CTG during healing, influencing the outcome of the grafting procedure [40, 47, 48].
Palatal soft tissue thickness differs greatly among the various areas of the palate and among individuals [49, 50, 51].
Limited data in the literature suggest that patients with thick palatal soft tissue have increased thickness mainly of the submucosal layer while the dimensions of lamina propria remain unchanged [49]. It could be hypothesized that CTG harvesting with the primary flap techniques in thick palatal soft tissue would always result in a graft composed of a lower percentage of lamina propria. The only layer that would have increased share in graft thickness would be the submucosal layer [49].
In the case of thin palatal soft tissue, there is not enough connective tissue thickness to prepare the primary flap and the CTG. The result of CTG harvesting with the primary flap in those situations can lead either to (1) primary flap necrosis if the primary flap is prepared to thin in order to increase the composition of the lamina propria inside CTG, or (2) CTG with a decreased thickness and composition of lamina propria which can result in the improper outcome of the harvesting procedure [48].
To overcome the aforementioned drawbacks, a new harvesting procedure was described—harvesting of an FGG and afterward, intra- or extra-oral de-epithelization of the FGG. As a consequence of the de-epithelization, the epitel layer is removed and the FGG graft is converted into CTG. With this harvesting procedure, the most valuable tissue (lamina propria) is almost completely inside the graft regardless of the initial thickness of the palatal soft tissue. In contrast, when the primary flap is used, a varying percentage of the lamina propria remains unutilized, attached to the inner side of the primary flap [40, 49, 52]. Furthermore, CTG obtained with the new harvesting procedure (de-epithelized FGG) is firmer and easier to manage during the grafting procedure with less variations in compositions among different CTG [48, 49].
The main disadvantage of the de-epithelized FGG procedure is the secondary intention healing of the donor site resulting in a slower healing process related to a higher percentage of complications linked to the donor site (pain and bleeding). Patients who underwent CTG graft harvesting experienced a lower incidence of donor site pain in the early postoperative period compared to FGG graft harvesting patients (Table 1) [49, 52, 53, 54, 55].
Harvesting techniques of free CTG | ||
---|---|---|
CTG with primary flap (subepithelial connective tissue graft) | de-epithelized FGG | |
Advantages | Primary healing of the donor site | Larger graft dimensions |
Faster healing with less complications (pain, bleeding) | Higher quality of graft composition | |
Better patient acceptance | Easier management of the graft | |
Lower percentage of graft contraction during healing | ||
Disadvantages | Reduced graft dimensions | Secondary healing of the donor site |
Lower quality of graft composition | Slower healing with more complication | |
Higher percentage of contraction during healing | Lower patient acceptance | |
Poor handling properties |
Advantages and disadvantages of CTG harvesting techniques: CTG with the primary flap and de-epithelized CTG.
The main purpose of the primary flap is the protection of the donor wound region. At the end of the surgical procedure, the primary flap is repositioned and sutured in its original position, completely covering the wound area beneath it. Thus, thanks to the primary flap, the wound area is healing with primary intention. This will result in a reduced time of haling and postoperative morbidity. In case when the primary flap has reduced vascularity as a consequence of a surgical error during flap preparation (flap thinner than 1 mm, perforation of the flap) it will necrotize, leaving the donor area unprotected and left to heal with secondary intention 26, 25, 40, 42, 43, 47, 52 (Figure 5).
sCTG harvesting. After the harvesting procedure of the sCTG the primary flap is repositioned in its original position. The primary flap protects the wound beneath it, enabling primary healing of the donor area.
The donor area for CTG graft harvesting is located in the palatal masticatory mucosa extending:
Mesiodistally: the donor iste is extending from the distal line angle of the canine to the mesial line angle of the platal root of the first molar. In this region, the soft tissue thickness is suitable for the CTG harvesting procedure.
Apically the donor area is limited with a zone containing blood vessels. The average distance between blood vessels and CEJ of adjacent teeth is 12 mm. The recommended apical limit of the donor area is set at 10 mm from CEJ, leaving 2 additional millimeters of the safety zone between the apical border of the CTG and the blood vessels.
The coronal incision is displaced 2 mm from the CEJ to prevent soft tissue recession on the palatal side of the adjacent teeth.
In patients with a flat palate, the palatine artery is closer to the CEJ, located 7 mm apically of the CEJ of adjacent teeth resulting in a limited height of the CTG [25, 26, 56, 57, 58, 59].
Another limiting factor for CTG harvesting with the preparation of the primary flap is the palatal soft tissue thickness. The palatal soft tissue should be at least 3 mm thick, to allow the preparation of primary flap thick 1.0–1.5 mm and harvesting of 1.5–2.0 mm thick CTG. Therefore, before starting the grafting procedure, it is advisable to examine the thickness of the donor area [42, 60, 61, 62, 63].
In case when inadequate palatal soft tissue thickness is present, three different solutions are available—(1) two-step procedures: Augmentation of the palatal soft tissue with the collagen sponge and after 8 weeks harvesting of the sCTG from the thickened donor site [60, 61, 62], (2) different grafting techniques of the CTG (de-epithelized CTG) [42, 48, 64], and (3) use of a substitutional soft tissue graft (allogenic or xenogenic soft tissue substitute graft) [65, 66, 67, 68].
The first part of the harvesting procedure consists of the preparation of the primary flap. The dissection of the primary flap starts with a horizontal incision 1.0–1.5 mm deep, 2 mm apical from the cementoenamel junction, and perpendicular to the mucosal surface. The blade angulation is changed to approximately 135° and a split-thickness flap is prepared in the apical direction. With the progression of the flap preparation, the angle of the blade is flattened until it becomes parallel with the gingival surface. The dissection is controlled from the external aspect of the flap in order to prevent flap perforation. The partial-thickness flap preparations end after reaching 8 mm from the first horizontal incision, this is 10 mm apically from the cementoenamel junction, leaving a safe zone with 2 mm of distance from the possible location of blood vessels. This will result in the maximal apico-coronal graft dimension of 8 mm.
The primary flap is prepared with the sharp dissection, in a split-thickness manner. During the partial-thickness preparation, the blade is oriented parallel with the mucosal surface to prevent perforations or overthinning of the primary flap. Care must be taken to leave the minimum residual thickness of the primary flap at least 1.5 mm, otherwise it could be necrotized.
After finishing its dissection, the primary flap is partially reflected and the connective tissue graft is dissected just beneath it. It is suggested to place the coronal dissection line 1.0–1.5 mm apical from the coronal incision line of the primary flap. This will result in a 1.0–1.5 mm connective tissue band along the coronal incision line, improving the healing of the primary flap, but at the same reducing the apico-coronal dimension of the connective tissue graft from the maximal 8 to 7 or 6.5 mm [26, 44, 69, 70, 71].
The connective tissue graft can be harvested with or without the periosteum layer depending on if it is inner surface is prepared with sharp or blunt dissection. The CTG with the periosteum has better mechanical stability and better clinical handling. On the other hand, leaving a periosteal surface on the bone in the donor area will improve the healing of the primary flap. In clinical situations where the primary flap was prepared with reduced thickness (equal or less than the lower value of the recommended thickness) or perforated during dissection, it could be advisable to leave the periosteum covering the bone surface [26, 44, 69, 70, 71].
After the completion of the harvesting procedure, the primary flap is repositioned and sutured in its original position. Although, cross matters or a combination of parallel and cross sutures were recommended [26, 69, 70], it seems that the suturing technique does not have an influence on early wound healing in the donor area [72].
Once the CTG is harvested it must be kept in a moist environment, usually draped in wet gauze, until is transferred to the recipient site [26, 69, 70, 71].
Connective tissue can be harvested from the palatal donor site as a free graft or pedicle graft. Free grafts are completely dissected from the donor site while pedicle flaps remain attached by one part to the donor site. In that way, they retain the vascularization of the donor site which will influence positively the graft volume stability reducing the shrinkage of the graft postoperatively and improving the outcome of the augmentation procedure [44, 45, 73].
Pedicle palatal connective tissue was first described in 1980 [74].
The preparation of the primary flap is equal to the primary flap for the free connective tissue graft. The only difference is the length of the primary flap which can be elongated if the defect is located in the frontal region [45]. The main variation to conventional free connective tissue graft is the harvesting of the CTG. During the preparation of the pedicle, the connective tissue graft below the primary flap is freed from the rest of the palatal tissue on three sides, while one side remains attached to it [45, 73, 75, 76, 77].
Different modifications of this technique have been described, which can be divided into two groups—roll techniques and vascularized interpositional periosteal connective tissue flap. In the first group, the pedicle is attached by its coronal part to the buccal flap and rolled under the buccal flap. This flap is used mostly for minor augmentation of the buccal PIS during the single implant uncovering procedure [78, 79, 80]. Other indications include soft tissue augmentation for pontic site development [81, 82] and multiple implants PIS augmentation and pontic site development at implant uncover procedure (Figures 6–11) [83].
Palatal roll technique for PIS augmentation around the single implant at uncovering procedure. Initial situation.
The primary flap has been prepared.
The CTG remains attached to the buccal flap, while it is dissected from the adjacent palatal soft tissue on the apical, mesial, and distal side.
The CTG pedicle graft has been rotated beneath the buccal flap and sutured in this position. The thickness of the buccal PIS has been visibly augmented.
Definitive zircon-ceramic screw-retained crown 14.
Two years follow up.
The vascularized interpositional periosteal connective tissue flap (VIP-CTG) consists of a connective tissue pedicle that remains attached to the palatal tissue on the distal or mesial side, depending on the defect location. It can be used for more pronounced soft-tissue defect augmentation (horizontal and vertical), allowing grafting of large soft tissue defects with only one procedure. Furthermore, VIP-CTG can be used for simultaneous soft and hard tissue augmentation procedures, reducing patient treatment time and morbidity. This procedure is indicated before implant placement, concomitant with implant placement, or during the implant osseointegration period [45, 75, 76] or pontic site development (Figures 12–18) [44, 73, 74, 84].
VIP-CTG for the treatment of the vertical soft-tissue defect in an esthetical demanding situation. Initial situation.
The incision line of the primary flap is extending mesially until the defect site is located in the region of the central incisor. The VIP-CTG is dissected from the rest of the palatal soft tissue on three sides (distal, coronal, apical) and rolled over the buccal soft tissue in order to determine the size of the buccal pouch that will be prepared. The mesial side of the VIP-CTG will remain attached to the adjacent palatal soft tissue.
With the help of two horizontal mattress sutures the VIP-CTG will be positioned and stabilized inside the pouch.
Suturing of the donor and defect area. The donor and the defect sites will heal by primary intention.
Final appearance of the PIS after soft tissue conditioning with provisional crowns-frontal view.
Final appearance of the PIS after soft tissue conditioning with provisional crowns-occlusal view.
Final screw-retained zirconia-ceramic crowns 21, 11.
The recipient site can be prepared with different surgical techniques. The techniques can be categorized in three groups:
Tunnel technique: The recipient site is prepared without vertical incisions and papilla incisions [21].
Coronally advanced flap without vertical incisions [85]
Single or double vertical incisions [86]
The vertical incision can compromise the vascular supply of the flap and cause an esthetical appearance. Incision through the papilla can cause papilla height reduction after healing, a likewise vertical incision can cause scare formation. On the other hand, the vertical incisions will facilitate the coronal advancement of the flap or the correct positioning and the stabilization of the graft [25].
Soft tissue graft consisting of epithelial and connective tissue layer which is completely detached from the rest of the palatal soft tissue is defined as a free gingival graft (FGG) [40].
The FGG was introduced in 1966 [87]. Historically, FGG was used to expand the band of keratinized gingiva around teeth [32], cover exposed root surfaces [88], soft tissue augmentation of edentulous ridges [89, 90], and expand the band of keratinized tissue around implants [91]. Since the esthetic appearance of the augmented tissue is poor due to inadequate color blending with the adjacent soft tissue and a “patch” like appearance, today FGG grafts are used mostly to increase the band of keratinized mucosa around implants in nonesthetic areas. Other indications for FGG are seldom performed only in nonesthetic areas 38, 40. The combination of apically positioned flap and autogenous graft is considered the gold standard technique for increasing the width of keratinized mucosa around implants [15].
The recipient site is prepared with the apically positioned flap technique.
A split-thickness flap is prepared along the mucogingival border. Usually, the flap design consists of a horizontal incision and two vertical incisions that are elongated to or apically to the mucogingival border depending on the amount of the apical displacement of the partial-thickness flap. The split-thickness flap is prepared with sharp dissection in the apical direction taking care to leave intact periosteal surface covering the bone; a 15C or 12D blade is used. In order to prevent perforations of the flap, the blade is oriented parallel with the mucosal surface during the dissection. Additionally, the progression of the flap dissection is monitored from the external flap surface. Muscle attachment, loose connective tissue fibers are removed from the periosteal surface. Care is taken to prepare an even surface that will allow an intimate contact of the graft with the vascularized surface. After the partial-thickness flap has been prepared, the flap is sutured in a new apical position. Sutures must engage the flap and the rigid periosteal surface in order to stabilize the flap [59]. The FGG is stabilized on the exposed periosteal surface with sutures or cyanoacrylate [40, 92]. After stabilization, the graft must be completely immobile, intimately adapted to the periosteal surface with no dead space remaining between the inner surface of the graft and the periosteal surface otherwise plasmatic imbibition and neovascularization bill be hindered. Furthermore, care must be taken to harvest an FGG with an even thickness to allow even precise adaptation to the recipient site throughout the inner surface of the graft. If present, fat tissue should be cut out from the FGG as it can slow down or prevent revascularization of the flap [25, 31, 40, 64].
The palatal masticatory mucosa is the most used donor site for FGG harvesting. Usually, the donor site is located inside the premolar and molar areas. The anterior palatal region where rugae are present is usually avoided since the rugae will remain present inside the FGG and will be transplanted to the recipient site, further deteriorating the appearance of the grafted site. The presence of the rugae can render the harvesting of the FGG challenging, especially in situations where the thin (1.0–1.5 mm) FGG grafts are harvested.
The harvesting procedure can be done freehand or with the help of a template.
The design of the flap consists of four incisions outlining the graft—coronal horizontal incision, mesial and distal vertical incision, and apical horizontal incision. Usually, the goal is to harvest an FGG which thickness is not exceeding 1.5 mm. For depth orientation during the performance of the outlining incision of the future graft, only the beveled part of the blade can be used which dimensions are approximately 1 mm [25, 44].
During healing, FGG undergoes contraction of around 30% of initially gain keratinized tissue band [7, 40, 93]. This fact should be taken into consideration while determining the dimension of the graft, which should be 30% larger than the site needing augmentation (Figures 19–22) [40].
Figure loss of vestibular depth and coronal and palatal displacement of keratinized mucosa after guided bone regeneration.
Apically positioned flap-the recipient site has been prepared with the apical displacement of a split-thickness buccal flap. The exposed periosteal surface is present in the recipient site.
Free gingival graft stabilized in the recipient site, on the exposed periosteal surface, with the help of sutures.
Final three-unit screw-retained bridge. On the buccal side a wide zone of KM and deepen vestibule is present.
After completion of graft dissection, the wound in the donor site is protected. Different techniques have been proposed—sutures, absorbable gelatin sponge, cyanoacrylate bioadhesive, periodontal dressing, palatal stents, platelet-rich fibrin, or a combination of some of the aforementioned techniques (Figures 23–34) [25, 26, 48, 53, 94, 95].
Two months after implant insertion in the region 36. Visible loss of keratinized mucosa-lateral view.
Two months after implant insertion in the region 36. Visible loss of keratinized mucosa-occlusal view.
Recipient site preparation—Apically positioned flap was prepared in the recipient region. The partial-thickness flap was stabilized in the new apical position using resorbable sutures. The height of the recipient site was measured.
Recipient site preparation—Apically positioned flap was prepared in the recipient region. The partial-thickness flap was stabilized in the new apical position using resorbable sutures. The width of the recipient site was measured.
Initial incisions outlining the future FGG—The dimensions of the graft were determined based on the measurements of the recipient site. The donor site was located in the region of the first molar, posterior to the rugae area. To avoid exercise bleeding during FGG preparation, the last outlining incision (horizontal apical incision) was done at the end of the procedure.
1–1.5 mm thick flap was prepared, starting from the coronal horizontal incision extending apically until reaching the imaginary line connecting the apical end of the two vertical incisions. The preparation of the FGG was terminated with the horizontal apical incision which completely dissected the FGG from the rest of the palatal soft tissue.
FGG after harvesting.
Donor site protection—Absorbable gelatin sponge and compressive crossed mattress sutures.
Dimensions of the harvested FGG.
Thickness of the harvested FGG—The thickness of the graft should not exceed 1.5 mm in order to reduce the postoperative morbidity associated with the donor site.
Initial stabilization of the FGG in the recipient site—The stabilization of the graft is initiated by applying simple interrupted sutures on the coronal part of the graft. Afterward, one to two additional simple interrupted sutures are applied on the mesial and distal vertical border of the flap- stretching the flap over the exposed periosteal surface in the donor area. In order to stabilize the graft, the needle must engage the graft and the periosteal surface.
Final graft stabilization—Mattress crossed sutures extending from the coronal to the apical part of the recipient site are used to secure even contact throughout the inner surface of the graft and the periosteal surface.
Harvesting autogenous free grafts from the tuberosity are linked to different advantages compared to the classical palatal donor sites—the presence of a lower percentage of fatty/glandular tissue within the graft, higher percentage of collagen fibers within the graft, increased thickness of soft tissue in the donor area, and reduced patient morbidity and a lower percentage of other postoperative complications [26, 47, 96].
Soft tissue grafts from the tuberosity undergo minimal shrinkage during healing as a result of a higher quality of harvested soft tissue [47, 97]. A lower level of pain after tuber soft tissue graft harvesting may be explained by the faster rate of donor site healing compared to palatal donor sites. Additionally, the tuberosity donor site is less prone to masticatory friction [47, 96, 97, 98].
The presence of the fully erupted or semi-impacted third molar can prevent soft tissue grafting from the tuber region. In seldom clinical cases, hyperplastic response during haling of tuberosity CTG was observed, leading to an esthetic results (Figures 35–38) [47, 96].
CTG harvesting from the tuberosity. Autologous graft has been harvested as a free gingival graft. Note the increased thickness and the absence of the fatty tissue inside the CTG.
After extraoral de-epithelization: Epithelial layer (left part of the picture) removed from the rest of CTG (right part of the picture).
The CTG from the tuberosity is stabilized beneath the buccal flap with horizontal matrasses suture.
Flap adaptation around healing abutments.
Although the results of PIS grafting with substitutional grafts, at the present are inferior to the results obtained after autogenous soft tissue grafting [5, 8, 65, 66, 93, 99], the absence of the donor site makes this treatment modality appealing to the patient and practitioners, as well [26, 42, 100].
The elimination of the harvesting procedure [25, 65] will lead to the reduction of surgical time [65], simplify the surgical procedure [42, 100], decrease the patient morbidity [26, 42, 65, 93], allow the unlimited supply of the soft tissue graft [26, 101, 102], and increase patient acceptance for the procedure [42, 65, 100, 103].
The augmentation procedure with substitutional soft tissue grafts will result in PIS with perfect color and texture blending to the adjacent soft tissue [65, 101].
Two types of substitutional grafts are available—xenogenic and allogeneic soft tissue grafts. Both of the grafts can be used for augmenting the volume and the width of keratinized mucosal band [25, 26, 65, 93, 99, 104].
The substitutional grafts are deprived of vital cells. During the manufacturing procedure, cells and antigenic components are removed, preserving only the extracellular matrix consisting mainly of collagen and elastin fibers. The three-dimensional structures of the aforementioned scaffold will promote fibroblast and keratinocyte migration and vascular ingrowth from the surrounding tissue [105, 106, 107]. This will result in an excellent color match since the keratinocytes are derived from the surrounding tissue. Nevertheless, compared to autogenous soft tissue grafts, they do not possess the ability to promote keratinization, limiting their application for increasing the width of KM [105, 106]. To overcome this drawback, a combination of an FGG graft with reduced apico-coronal dimensions to 2 mm and an XCM was proposed [6].
When used to augment PIS thickness, substitutional grafts are less resistant to compression of the overlaying flap compared to CTG. Loss of the initial volume of the substitutional graft can lead to the compromised outcome of the grafting procedure. To overcome this drawback, a volume stable collagen matrix was developed [105]. As a result of the cross-linking process of the collagen fibers, the collagen matrix becomes more volume stable and prone to withstand soft-tissue pressure [108, 109]. At the moment there is a lack of literature on the long-term stability of augmented PIS with the substitutional grafts (Figures 39–66) [105].
Initial situation—Lateral view.
Initial situation.
Surgical stent.
Dehiscence bone defects around implant 16 and 15.
GBR: A composite bone graft was used consisting of 50% autogenous and 50% xenogenic graft. The bone graft was applied in two layers—The internal layer which is covering the exposed implant surface, is made out of autogenous bone and the external layer is consisting of a xenogenic bone graft.
GBR: Native collagen membrane stabilized with resorbable sutures.
Suturing in three layers;(1) palatal-apical position—Mattress sutures for membrane stabilization, (2) buccal-apical—Mattress sutures for initial closing of the flap, and (3) bucco-coronal—Simple interrupted suture for the final closure of the flap.
Four months after the GBR, the palatal displacement of the mucogingival line is evident. Occlusal view.
Four months after the GBR, the palatal displacement of the mucogingival line is evident. Lateral view.
The surgical stent was used to determine the dimensions of the flap.
The flap incision is made not at the mucogingival junction but 4 mm within the keratinized mucosa, therefore the buccal split-thickness flap will include a band of keratinized mucosa which is 4 mm wide.
Finalized preparation of the buccal split-thickness flap. The most coronal part of the partial-thickness flap consists of keratinized mucosa.
Apically positioned flap—Stabilization of the buccal partial-thickness flap in the new apical position. The exposed periosteal surface is completely surrounded by keratinized mucosa.
The exposed periosteal surface is covered with xenogenic collagen matrix (Mucoderm, Botiss gmbh, Berlin).
Healing two months after the keratinized mucosa widening procedure. The gain of the keratinized mucosa is evident but the thickness of the gained tissue is unsatisfactory. Occlusal view.
Healing two months after the keratinized mucosa widening procedure. The gain of the keratinized mucosa is evident but the thickness of the gained tissue is unsatisfactory. Lateral view.
During the implant uncovering procedure, a primary flap was prepared on the palatal side. The minimal thickness of 1.5 mm of the primary flap was respected, and the connective tissue was exposed.
Mesial, distal and apical incisions were made inside the connective tissue graft in order to completely dissect the CTG from the rest of the adjacent soft tissue.
The CTG is completely dissected from the rest of the adjacent soft tissue.
On the left: CTG harvested from the palate (the harvesting procedure was displayed on the previous pictures), on the right additional CTG harvested from the tuberosity on the same side.
Appearance of the palatal and tuber donor site after CTG harvesting.
Appearance of the regenerated bone on the buccal side of the implants.
Both of the CTG grafts were stabilized with sutures to the buccal flap.
Final stabilization of the CTG grafts to the inner aspect of the buccal flap.
Final suturing of the flap.
After 2 months of healing adequate quantity (soft tissue thickness) and quality (width of keratinized mucosa) of soft tissue surrounding the healing abutments.
Screw retained abutments.
Three units screw-retained bridge.
PIS augmentation procedure has become an integral part of implant-prosthetic rehabilitation. The aim of PIS augmentation is adequate quality and quantity of PIS—at least 2 mm of the width of peri-implant KM and 2 mm or more, of the thickness of PIS. These dimensions of PIS will result in stable peri-implant hard and soft tissue, better esthetical outcome and facilitate oral hygiene maintenance around the implant.
The use of autogenous soft tissue graft for PIS augmentation is considered the gold standard. FGG is primarily used for increasing the KM width and CTG for increasing the thickness of PIS. Different techniques have been developed for the harvesting of the CTG graft. The grafting technique and the choice of the donor site can influence different aspects of the procedure, from patient discomfort in the postoperative period to the quality and dimension of the graft. The choice of the grafting technique should be addressed individually based on the parameters of the specific clinical case (patient desire for decreased morbidity, anatomical limitations of the donor site, dimensions, and quality of the required graft).
The use of substitutional soft tissue grafts has different advantages—reduced length, the complexity of the procedure and patient morbidity, availability of the unlimited amount of the graft, and better patient acceptance. At the moment, the results of the use of substitutional grafts are inferior compared to soft tissue autografts. There is a lack of published long-term results of PIS augmentation with substitutional soft tissue grafts. Therefore, they should be used in cases where patient denial for soft tissue autografts would lead to rejection of the PIS augmentation procedure. In all other cases, priority should be given to soft tissue autografts.
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However, conventional fuzzy inference systems may suffer from either too sparse, too complex or imbalanced rule bases, given that the data may be unevenly distributed in the problem space regardless of its volume. Fuzzy interpolation addresses this. It enables fuzzy inferences with sparse rule bases when the sparse rule base does not cover a given input, and it simplifies very dense rule bases by approximating certain rules with their neighbouring ones. This chapter systematically reviews different types of fuzzy interpolation approaches and their variations, in terms of both the interpolation mechanism (inference engine) and sparse rule base generation. Representative applications of fuzzy interpolation in the field of control are also revisited in this chapter, which not only validate fuzzy interpolation approaches but also demonstrate its efficacy and potential for wider applications.",book:{id:"5883",slug:"modern-fuzzy-control-systems-and-its-applications",title:"Modern Fuzzy Control Systems and Its Applications",fullTitle:"Modern Fuzzy Control Systems and Its Applications"},signatures:"Longzhi Yang, Zheming Zuo, Fei Chao and Yanpeng Qu",authors:[{id:"167084",title:"Dr.",name:"Fei",middleName:null,surname:"Chao",slug:"fei-chao",fullName:"Fei Chao"},{id:"198988",title:"Dr.",name:"Longzhi",middleName:null,surname:"Yang",slug:"longzhi-yang",fullName:"Longzhi Yang"},{id:"200974",title:"Dr.",name:"Yanpeng",middleName:null,surname:"Qu",slug:"yanpeng-qu",fullName:"Yanpeng Qu"},{id:"200975",title:"Mr.",name:"Zheming",middleName:null,surname:"Zuo",slug:"zheming-zuo",fullName:"Zheming Zuo"}]},{id:"54790",doi:"10.5772/67989",title:"A Model for Evaluating Soil Vulnerability to Erosion Using Remote Sensing Data and A Fuzzy Logic System",slug:"a-model-for-evaluating-soil-vulnerability-to-erosion-using-remote-sensing-data-and-a-fuzzy-logic-sys",totalDownloads:1860,totalCrossrefCites:4,totalDimensionsCites:6,abstract:"Soil vulnerability is the capacity of one or more of the ecological functions of the soil system to be harmed. It is a complex concept which requires the identification of multiple environmental factors and land management at different temporal and space scales. The employment of geospatial information with good update capabilities could be a satisfactory tool to assess potential soil vulnerability changes in large areas. This chapter presents the application of two land degradation case studies which is simple, synoptic, and suitable for continuous monitoring model based on the fuzzy logic. The model combines topography and vegetation status information to assess soil vulnerability to land degradation. Topographic parameters were obtained from digital elevation models (DEM), and vegetation status information was derived from the computation of the normalized difference vegetation index (NDVI) satellite images. This spectral index provides relevance and is updated for each scene, evidences about the biomass and soil productivity, and vegetation density cover or vegetation stress (e.g., forest fires, droughts). Modeled output maps are suitable for temporal change analysis, which allows the identification of the effect of land management practices, soil and vegetation regeneration, or climate effects.",book:{id:"5883",slug:"modern-fuzzy-control-systems-and-its-applications",title:"Modern Fuzzy Control Systems and Its Applications",fullTitle:"Modern Fuzzy Control Systems and Its Applications"},signatures:"Ignacio Meléndez-Pastor, Jose Navarro Pedreño, Ignacio Gómez\nLucas and Antonis A. Zorpas",authors:[{id:"109913",title:"Dr.",name:"Ignacio",middleName:null,surname:"Melendez-Pastor",slug:"ignacio-melendez-pastor",fullName:"Ignacio Melendez-Pastor"},{id:"137040",title:"Prof.",name:"Jose",middleName:null,surname:"Navarro-Pedreño",slug:"jose-navarro-pedreno",fullName:"Jose Navarro-Pedreño"},{id:"137041",title:"Prof.",name:"Ignacio",middleName:null,surname:"Gómez Lucas",slug:"ignacio-gomez-lucas",fullName:"Ignacio Gómez Lucas"},{id:"205104",title:"Prof.",name:"Antonis A.",middleName:null,surname:"Zorpas",slug:"antonis-a.-zorpas",fullName:"Antonis A. Zorpas"}]},{id:"56033",doi:"10.5772/68126",title:"A Fuzzy Logic Approach for Separation Assurance and Collision Avoidance for Unmanned Aerial Systems",slug:"a-fuzzy-logic-approach-for-separation-assurance-and-collision-avoidance-for-unmanned-aerial-systems",totalDownloads:1414,totalCrossrefCites:3,totalDimensionsCites:5,abstract:"In the coming years, operations in low altitude airspace will vastly increase as the capabilities and applications of small unmanned aerial systems (sUAS) continue to multiply. Therefore, finding solutions to managing sUAS in highly congested airspace will facilitate sUAS operations. In this study, a fuzzy logic-based approach was used to help mitigate the risk of collisions between aircraft using separation assurance and collision avoidance techniques. The system was evaluated for its effectiveness at mitigating the risk of mid-air collisions between aircraft. This system utilizes only current state information and can resolve potential conflicts without knowledge of intruder intent. The avoidance logic was verified using formal methods and shown to select the correct action in all instances. Additionally, the fuzzy logic controllers were shown to always turn the vehicles in the correct direction. Numerical testing demonstrated that the avoidance system was able to prevent a mid-air collision between two sUAS in all tested cases. Simulations were also performed in a three-dimensional environment with a heterogeneous fleet of sUAS performing a variety of realistic missions. Simulations showed that the system was 99.98% effective at preventing mid-air collisions when separation assurance was disabled (unmitigated case) and 100% effective when enabled (mitigated case).",book:{id:"5883",slug:"modern-fuzzy-control-systems-and-its-applications",title:"Modern Fuzzy Control Systems and Its Applications",fullTitle:"Modern Fuzzy Control Systems and Its Applications"},signatures:"Brandon Cook, Tim Arnett and Kelly Cohen",authors:[{id:"200830",title:"Mr.",name:"Brandon",middleName:"Matthew",surname:"Cook",slug:"brandon-cook",fullName:"Brandon Cook"},{id:"200833",title:"Mr.",name:"Timothy",middleName:null,surname:"Arnett",slug:"timothy-arnett",fullName:"Timothy Arnett"},{id:"200834",title:"Dr.",name:"Kelly",middleName:null,surname:"Cohen",slug:"kelly-cohen",fullName:"Kelly Cohen"}]},{id:"54614",doi:"10.5772/67899",title:"A Fuzzy Belief-Desire-Intention Model for Agent-Based Image Analysis",slug:"a-fuzzy-belief-desire-intention-model-for-agent-based-image-analysis",totalDownloads:1373,totalCrossrefCites:2,totalDimensionsCites:4,abstract:"Recent methods of image analysis in remote sensing lack a sufficient grade of robustness and transferability. Methods such as object-based image analysis (OBIA) achieve satisfying results on single images. However, the underlying rule sets for OBIA are usually too complex to be directly applied on a variety of image data without any adaptations or human interactions. Thus, recent research projects investigate the potential for integrating the agent-based paradigm with OBIA. Agent-based systems are highly adaptive and therefore robust, even under varying environmental conditions. In the context of image analysis, this means that even if the image data to be analyzed varies slightly (e.g., due to seasonal effects, different locations, atmospheric conditions, or even a slightly different sensor), agent-based methods allow to autonomously adapt existing analysis rules or segmentation results according to changing imaging situations. The basis for individual software agents’ behavior is a so-called believe-desire-intention (BDI) model. Basically, the BDI describes for each individual agent its goal(s), its assumed current situation, and some action rules potentially supporting each agent to achieve its goals. The chapter introduces a believe-desire-intention (BDI) model based on fuzzy rules in the context of agent-based image analysis, which extends the classic OBIA paradigm by the agent-based paradigm.",book:{id:"5883",slug:"modern-fuzzy-control-systems-and-its-applications",title:"Modern Fuzzy Control Systems and Its Applications",fullTitle:"Modern Fuzzy Control Systems and Its Applications"},signatures:"Peter Hofmann",authors:[{id:"199778",title:"Dr.",name:"Peter",middleName:null,surname:"Hofmann",slug:"peter-hofmann",fullName:"Peter Hofmann"}]},{id:"54682",doi:"10.5772/68050",title:"Use of Fuzzy Logic for Design and Control of Nonlinear MIMO Systems",slug:"use-of-fuzzy-logic-for-design-and-control-of-nonlinear-mimo-systems",totalDownloads:1599,totalCrossrefCites:3,totalDimensionsCites:4,abstract:"Standard analytical methods are often ineffective or even useless for design of nonlinear control systems with imprecisely known parameters. The use of fuzzy logic principles presents one possible way to control such systems which can be used both for modeling and design of the control. The advantage of using this method consists in its simplicity and easy way of developing the algorithm, which in the phase of designing the controllers and also for modeling the features of the designed structures, allows the use of computer technology. Simplicity of the proposed structure (usually with the PI controllers) and determination of their parameters without any need for complex mathematical description present another considerable advantage of the used method. This chapter presents two typical examples of designing the control of nonlinear multi‐input multi‐output (MIMO) systems from the field of mechatronic systems based on fuzzy logic principles.",book:{id:"5883",slug:"modern-fuzzy-control-systems-and-its-applications",title:"Modern Fuzzy Control Systems and Its Applications",fullTitle:"Modern Fuzzy Control Systems and Its Applications"},signatures:"Pavol Fedor and Daniela Perduková",authors:[{id:"199777",title:"Prof.",name:"Daniela",middleName:null,surname:"Perdukova",slug:"daniela-perdukova",fullName:"Daniela Perdukova"},{id:"205024",title:"Prof.",name:"Pavol",middleName:null,surname:"Fedor",slug:"pavol-fedor",fullName:"Pavol Fedor"}]}],mostDownloadedChaptersLast30Days:[{id:"54537",title:"Fuzzy Logic Application, Control and Monitoring of Critical Machine Parameters in a Processing Company",slug:"fuzzy-logic-application-control-and-monitoring-of-critical-machine-parameters-in-a-processing-compan",totalDownloads:1880,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"The processing company under study found out that the boiler was the key machine and needs artificial intelligence monitoring and control. It was simulated under Matlab software and oil level, and pressure and temperature were to be modelled and controlled using the programmable logic controller (PLC) with a fuzzy logic controller as the main brain of control. The company is for processing of fruits to produce juice.",book:{id:"5883",slug:"modern-fuzzy-control-systems-and-its-applications",title:"Modern Fuzzy Control Systems and Its Applications",fullTitle:"Modern Fuzzy Control Systems and Its Applications"},signatures:"Tawanda Mushiri",authors:[{id:"198749",title:"Dr.",name:"Tawanda",middleName:null,surname:"Mushiri",slug:"tawanda-mushiri",fullName:"Tawanda Mushiri"}]},{id:"65167",title:"Functional Safety of FPGA Fuzzy Logic Controller",slug:"functional-safety-of-fpga-fuzzy-logic-controller",totalDownloads:816,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"In this paper we describe a methodology to implement a fuzzy logic controller in FPGA. The implementation of fuzzy logic controller (FLC) in FPGA requires a qualitative and a quantitative analysis to define the system safety integrity level (SIL). This level can be defined by the quantification of the probability of failure on demand (PFDavg). We propose to analyze the implementation advance safety architecture of fuzzy logic controllers with 1-out-of-2 controllers (1oo2) in FPGA using the reliability block diagram (RBD) and the Markov model. We demonstrate how from hardware characteristics parameters, such as rate of dangerous detected failure and undetected failure, the diagnostic coverage, proof test interval and other parameters to evaluate the PFDavg.",book:{id:"7656",slug:"fuzzy-logic",title:"Fuzzy Logic",fullTitle:"Fuzzy Logic"},signatures:"Mohammed Bsiss and Amami Benaissa",authors:[{id:"241400",title:"Prof.",name:"Mohammed",middleName:null,surname:"Bsiss",slug:"mohammed-bsiss",fullName:"Mohammed Bsiss"},{id:"286059",title:"Prof.",name:"Benaissa",middleName:null,surname:"Amami",slug:"benaissa-amami",fullName:"Benaissa Amami"}]},{id:"67797",title:"The Fuzzy Logic Methodology for Evaluating the Causality of Factors in Organization Management",slug:"the-fuzzy-logic-methodology-for-evaluating-the-causality-of-factors-in-organization-management",totalDownloads:789,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"The paper is concerned with solving the problem of factor causality using the tools of the fuzzy set theory. The paper formulates the problem of causal relations in a broad sense and analyzes the methods for its solution with an emphasis on the socioeconomic aspects. For this purpose, the system approach, comparative experiment, economic and mathematical modeling, and other general scientific methods are used. The authors suggest that the causality of factors be studied based on the theory of fuzzy binary relations using the mathematical tools of Goguen’s fuzzy implication. As an example, the paper describes the effect of organizational culture indicators under the Denison’s model on the key performance indicators of an organization.",book:{id:"7656",slug:"fuzzy-logic",title:"Fuzzy Logic",fullTitle:"Fuzzy Logic"},signatures:"Nazarov Dmitry Mikhailovich",authors:[{id:"278819",title:"Dr.",name:"Dmitrii",middleName:null,surname:"Nazarov",slug:"dmitrii-nazarov",fullName:"Dmitrii Nazarov"}]},{id:"55096",title:"EMG-Controlled Prosthetic Hand with Fuzzy Logic Classification Algorithm",slug:"emg-controlled-prosthetic-hand-with-fuzzy-logic-classification-algorithm",totalDownloads:1891,totalCrossrefCites:2,totalDimensionsCites:3,abstract:"In recent years, researchers have conducted many studies on the design and control of prosthesis devices that take the place of a missing limb. Functional ability of prosthesis hands that mimic biological hand functions increases depending on the number of independent finger movements possible. From this perspective, in this study, six different finger movements were given to a prosthesis hand via bioelectrical signals, and the functionality of the prosthesis hand was increased. Bioelectrical signals were recorded by surface electromyography for four muscles with the help of surface electrodes. The recorded bioelectrical signals were subjected to a series of preprocessing and feature extraction processes. In order to create meaningful patterns of motion and an effective cognitive interaction network between the human and the prosthetic hand, fuzzy logic classification algorithms were developed. A five-fingered and 15-jointed prosthetic hand was designed via SolidWorks, and a prosthetic prototype was produced by a 3D printer. In addition, prosthetic hand simulator was designed in Matlab/SimMechanics. Pattern control of both the simulator and the prototype hand in real time was achieved. Position control of motors connected to each joint of the prosthetic hand was provided by a PID controller. Thus, an effective cognitive communication network established between the user, and the real-time pattern control of the prosthesis was provided by bioelectrical signals.",book:{id:"5883",slug:"modern-fuzzy-control-systems-and-its-applications",title:"Modern Fuzzy Control Systems and Its Applications",fullTitle:"Modern Fuzzy Control Systems and Its Applications"},signatures:"Beyda Taşar and Arif Gülten",authors:[{id:"198982",title:"Ph.D. Student",name:"Beyda",middleName:null,surname:"Tasar",slug:"beyda-tasar",fullName:"Beyda Tasar"},{id:"201773",title:"Dr.",name:"Arif",middleName:null,surname:"Gulten",slug:"arif-gulten",fullName:"Arif Gulten"}]},{id:"64740",title:"Some Topological Properties of Intuitionistic Fuzzy Normed Spaces",slug:"some-topological-properties-of-intuitionistic-fuzzy-normed-spaces",totalDownloads:865,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"In 1986, Atanassov introduced the concept of intuitionistic fuzzy set theory which is based on the extensions of definitions of fuzzy set theory given by Zadeh. This theory provides a variable model to elaborate uncertainty and vagueness involved in decision making problems. In this chapter, we concentrate our study on the ideal convergence of sequence spaces with respect to intuitionistic fuzzy norm and discussed their topological and algebraic properties.",book:{id:"7656",slug:"fuzzy-logic",title:"Fuzzy Logic",fullTitle:"Fuzzy Logic"},signatures:"Vakeel Ahmad Khan, Hira Fatima and Mobeen Ahmad",authors:[{id:"276104",title:"Dr.",name:"Vakeel A.",middleName:null,surname:"Khan",slug:"vakeel-a.-khan",fullName:"Vakeel A. 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He is an academic staff member of the Department of Reproduction and Artificial Insemination, Selçuk University, Turkey. He manages several studies on sperms and embryos and is an editorial board member for several international journals. His studies include sperm cryobiology, in vitro fertilization, and embryo production in animals.",institutionString:"Selçuk University, Faculty of Veterinary Medicine",institution:null},{id:"90846",title:"Prof.",name:"Yusuf",middleName:null,surname:"Bozkurt",slug:"yusuf-bozkurt",fullName:"Yusuf Bozkurt",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/90846/images/system/90846.jpg",biography:"Yusuf Bozkurt has a BSc, MSc, and Ph.D. from Ankara University, Turkey. He is currently a Professor of Biotechnology of Reproduction in the field of Aquaculture, İskenderun Technical University, Turkey. His research interests include reproductive biology and biotechnology with an emphasis on cryo-conservation. He is on the editorial board of several international peer-reviewed journals and has published many papers. Additionally, he has participated in many international and national congresses, seminars, and workshops with oral and poster presentations. He is an active member of many local and international organizations.",institutionString:"İskenderun Technical University",institution:{name:"İskenderun Technical University",country:{name:"Turkey"}}},{id:"61139",title:"Dr.",name:"Sergey",middleName:null,surname:"Tkachev",slug:"sergey-tkachev",fullName:"Sergey Tkachev",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/61139/images/system/61139.png",biography:"Dr. Sergey Tkachev is a senior research scientist at the Institute of Fundamental Medicine and Biology, Kazan Federal University, Russia, and at the Institute of Chemical Biology and Fundamental Medicine SB RAS, Novosibirsk, Russia. He received his Ph.D. in Molecular Biology with his thesis “Genetic variability of the tick-borne encephalitis virus in natural foci of Novosibirsk city and its suburbs.” His primary field is molecular virology with research emphasis on vector-borne viruses, especially tick-borne encephalitis virus, Kemerovo virus and Omsk hemorrhagic fever virus, rabies virus, molecular genetics, biology, and epidemiology of virus pathogens.",institutionString:"Russian Academy of Sciences",institution:{name:"Russian Academy of Sciences",country:{name:"Russia"}}},{id:"310962",title:"Dr.",name:"Amlan",middleName:"Kumar",surname:"Patra",slug:"amlan-patra",fullName:"Amlan Patra",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/310962/images/system/310962.jpg",biography:"Amlan K. Patra, FRSB, obtained a Ph.D. in Animal Nutrition from Indian Veterinary Research Institute, India, in 2002. He is currently an associate professor at West Bengal University of Animal and Fishery Sciences. He has more than twenty years of research and teaching experience. He held previous positions at the American Institute for Goat Research, The Ohio State University, Columbus, USA, and Free University of Berlin, Germany. His research focuses on animal nutrition, particularly ruminants and poultry nutrition, gastrointestinal electrophysiology, meta-analysis and modeling in nutrition, and livestock–environment interaction. He has authored around 175 articles in journals, book chapters, and proceedings. Dr. Patra serves on the editorial boards of several reputed journals.",institutionString:null,institution:{name:"West Bengal University of Animal and Fishery Sciences",country:{name:"India"}}},{id:"53998",title:"Prof.",name:"László",middleName:null,surname:"Babinszky",slug:"laszlo-babinszky",fullName:"László Babinszky",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/53998/images/system/53998.png",biography:"László Babinszky is Professor Emeritus, Department of Animal Nutrition Physiology, University of Debrecen, Hungary. He has also worked in the Department of Animal Nutrition, University of Wageningen, Netherlands; the Institute for Livestock Feeding and Nutrition (IVVO), Lelystad, Netherlands; the Agricultural University of Vienna (BOKU); the Institute for Animal Breeding and Nutrition, Austria; and the Oscar Kellner Research Institute for Animal Nutrition, Rostock, Germany. In 1992, Dr. Babinszky obtained a Ph.D. in Animal Nutrition from the University of Wageningen. His main research areas are swine and poultry nutrition. He has authored more than 300 publications (papers, book chapters) and edited four books and fourteen international conference proceedings.",institutionString:"University of Debrecen",institution:{name:"University of Debrecen",country:{name:"Hungary"}}},{id:"201830",title:"Dr.",name:"Fernando",middleName:"Sanchez",surname:"Davila",slug:"fernando-davila",fullName:"Fernando Davila",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/201830/images/5017_n.jpg",biography:"I am a professor at UANL since 1988. My research lines are the development of reproductive techniques in small ruminants. We also conducted research on sexual and social behavior in males.\nI am Mexican and study my professional career as an engineer in agriculture and animal science at UANL. Then take a masters degree in science in Germany (Animal breeding). Take a doctorate in animal science at the UANL.",institutionString:null,institution:{name:"Universidad Autónoma de Nuevo León",country:{name:"Mexico"}}},{id:"309250",title:"Dr.",name:"Miguel",middleName:null,surname:"Quaresma",slug:"miguel-quaresma",fullName:"Miguel Quaresma",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/309250/images/9059_n.jpg",biography:"Miguel Nuno Pinheiro Quaresma was born on May 26, 1974 in Dili, Timor Island. He is married with two children: a boy and a girl, and he is a resident in Vila Real, Portugal. He graduated in Veterinary Medicine in August 1998 and obtained his Ph.D. degree in Veterinary Sciences -Clinical Area in February 2015, both from the University of Trás-os-Montes e Alto Douro. He is currently enrolled in the Alternative Residency of the European College of Animal Reproduction. He works as a Senior Clinician at the Veterinary Teaching Hospital of UTAD (HVUTAD) with a role in clinical activity in the area of livestock and equine species as well as to support teaching and research in related areas. He teaches as an Invited Professor in Reproduction Medicine I and II of the Master\\'s in Veterinary Medicine degree at UTAD. Currently, he holds the position of Chairman of the Portuguese Buiatrics Association. He is a member of the Consultive Group on Production Animals of the OMV. He has 19 publications in indexed international journals (ISIS), as well as over 60 publications and oral presentations in both Portuguese and international journals and congresses.",institutionString:"University of Trás-os-Montes and Alto Douro",institution:{name:"University of Trás-os-Montes and Alto Douro",country:{name:"Portugal"}}},{id:"38652",title:"Prof.",name:"Rita",middleName:null,surname:"Payan-Carreira",slug:"rita-payan-carreira",fullName:"Rita Payan-Carreira",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRiFPQA0/Profile_Picture_1614601496313",biography:"Rita Payan Carreira earned her Veterinary Degree from the Faculty of Veterinary Medicine in Lisbon, Portugal, in 1985. She obtained her Ph.D. in Veterinary Sciences from the University of Trás-os-Montes e Alto Douro, Portugal. After almost 32 years of teaching at the University of Trás-os-Montes and Alto Douro, she recently moved to the University of Évora, Department of Veterinary Medicine, where she teaches in the field of Animal Reproduction and Clinics. Her primary research areas include the molecular markers of the endometrial cycle and the embryo–maternal interaction, including oxidative stress and the reproductive physiology and disorders of sexual development, besides the molecular determinants of male and female fertility. She often supervises students preparing their master's or doctoral theses. She is also a frequent referee for various journals.",institutionString:null,institution:{name:"University of Évora",country:{name:"Portugal"}}},{id:"283019",title:"Dr.",name:"Oudessa",middleName:null,surname:"Kerro Dego",slug:"oudessa-kerro-dego",fullName:"Oudessa Kerro Dego",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/283019/images/system/283019.png",biography:"Dr. Kerro Dego is a veterinary microbiologist with training in veterinary medicine, microbiology, and anatomic pathology. Dr. Kerro Dego is an assistant professor of dairy health in the department of animal science, the University of Tennessee, Institute of Agriculture, Knoxville, Tennessee. He received his D.V.M. (1997), M.S. (2002), and Ph.D. (2008) degrees in Veterinary Medicine, Animal Pathology and Veterinary Microbiology from College of Veterinary Medicine, Addis Ababa University, Ethiopia; College of Veterinary Medicine, Utrecht University, the Netherlands and Western College of Veterinary Medicine, University of Saskatchewan, Canada respectively. He did his Postdoctoral training in microbial pathogenesis (2009 - 2015) in the Department of Animal Science, the University of Tennessee, Institute of Agriculture, Knoxville, Tennessee. Dr. Kerro Dego’s research focuses on the prevention and control of infectious diseases of farm animals, particularly mastitis, improving dairy food safety, and mitigation of antimicrobial resistance. Dr. Kerro Dego has extensive experience in studying the pathogenesis of bacterial infections, identification of virulence factors, and vaccine development and efficacy testing against major bacterial mastitis pathogens. Dr. Kerro Dego conducted numerous controlled experimental and field vaccine efficacy studies, vaccination, and evaluation of immunological responses in several species of animals, including rodents (mice) and large animals (bovine and ovine).",institutionString:"University of Tennessee at Knoxville",institution:{name:"University of Tennessee at Knoxville",country:{name:"United States of America"}}},{id:"251314",title:"Dr.",name:"Juan Carlos",middleName:null,surname:"Gardón Poggi",slug:"juan-carlos-gardon-poggi",fullName:"Juan Carlos Gardón Poggi",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/251314/images/system/251314.jpeg",biography:"Juan Carlos Gardón Poggi received University degree from the Faculty of Agrarian Science in Argentina, in 1983. Also he received Masters Degree and PhD from Córdoba University, Spain. He is currently a Professor at the Catholic University of Valencia San Vicente Mártir, at the Department of Medicine and Animal Surgery. He teaches diverse courses in the field of Animal Reproduction and he is the Director of the Veterinary Farm. He also participates in academic postgraduate activities at the Veterinary Faculty of Murcia University, Spain. His research areas include animal physiology, physiology and biotechnology of reproduction either in males or females, the study of gametes under in vitro conditions and the use of ultrasound as a complement to physiological studies and development of applied biotechnologies. Routinely, he supervises students preparing their doctoral, master thesis or final degree projects.",institutionString:null,institution:{name:"Valencia Catholic University Saint Vincent Martyr",country:{name:"Spain"}}},{id:"309529",title:"Dr.",name:"Albert",middleName:null,surname:"Rizvanov",slug:"albert-rizvanov",fullName:"Albert Rizvanov",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/309529/images/9189_n.jpg",biography:'Albert A. Rizvanov is a Professor and Director of the Center for Precision and Regenerative Medicine at the Institute of Fundamental Medicine and Biology, Kazan Federal University (KFU), Russia. He is the Head of the Center of Excellence “Regenerative Medicine” and Vice-Director of Strategic Academic Unit \\"Translational 7P Medicine\\". Albert completed his Ph.D. at the University of Nevada, Reno, USA and Dr.Sci. at KFU. He is a corresponding member of the Tatarstan Academy of Sciences, Russian Federation. Albert is an author of more than 300 peer-reviewed journal articles and 22 patents. He has supervised 11 Ph.D. and 2 Dr.Sci. dissertations. Albert is the Head of the Dissertation Committee on Biochemistry, Microbiology, and Genetics at KFU.\nORCID https://orcid.org/0000-0002-9427-5739\nWebsite https://kpfu.ru/Albert.Rizvanov?p_lang=2',institutionString:"Kazan Federal University",institution:{name:"Kazan Federal University",country:{name:"Russia"}}},{id:"210551",title:"Dr.",name:"Arbab",middleName:null,surname:"Sikandar",slug:"arbab-sikandar",fullName:"Arbab Sikandar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/210551/images/system/210551.jpg",biography:"Dr. Arbab Sikandar, PhD, M. Phil, DVM was born on April 05, 1981. He is currently working at the College of Veterinary & Animal Sciences as an Assistant Professor. He previously worked as a lecturer at the same University. \nHe is a Member/Secretory of Ethics committee (No. CVAS-9377 dated 18-04-18), Member of the QEC committee CVAS, Jhang (Regr/Gen/69/873, dated 26-10-2017), Member, Board of studies of Department of Basic Sciences (No. CVAS. 2851 Dated. 12-04-13, and No. CVAS, 9024 dated 20/11/17), Member of Academic Committee, CVAS, Jhang (No. CVAS/2004, Dated, 25-08-12), Member of the technical committee (No. CVAS/ 4085, dated 20,03, 2010 till 2016).\n\nDr. Arbab Sikandar contributed in five days hands-on-training on Histopathology at the Department of Pathology, UVAS from 12-16 June 2017. He received a Certificate of appreciation for contributions for Popularization of Science and Technology in the Society on 17-11-15. He was the resource person in the lecture series- ‘scientific writing’ at the Department of Anatomy and Histology, UVAS, Lahore on 29th October 2015. He won a full fellowship as a principal candidate for the year 2015 in the field of Agriculture, EICA, Egypt with ref. to the Notification No. 12(11) ACS/Egypt/2014 from 10 July 2015 to 25th September 2015.; he received a grant of Rs. 55000/- as research incentives from Director, Advanced Studies and Research, UVAS, Lahore upon publications of research papers in IF Journals (DR/215, dated 19-5-2014.. He obtained his PhD by winning a HEC Pakistan indigenous Scholarship, ‘Ph.D. fellowship for 5000 scholars – Phase II’ (2av1-147), 17-6/HEC/HRD/IS-II/12, November 15, 2012. \n\nDr. Sikandar is a member of numerous societies: Registered Veterinary Medical Practitioner (life member) and Registered Veterinary Medical Faculty of Pakistan Veterinary Medical Council. The Registration code of PVMC is RVMP/4298 and RVMF/ 0102.; Life member of the University of Veterinary and Animal Sciences, Lahore, Alumni Association with S# 664, dated: 6-4-12. ; Member 'Vets Care Organization Pakistan” with Reference No. VCO-605-149, dated 05-04-06. :Member 'Vet Crescent” (Society of Animal Health and Production), UVAS, Lahore.",institutionString:"University of Veterinary & Animal Science",institution:{name:"University of Veterinary and Animal Sciences",country:{name:"Pakistan"}}},{id:"311663",title:"Dr.",name:"Prasanna",middleName:null,surname:"Pal",slug:"prasanna-pal",fullName:"Prasanna Pal",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/311663/images/13261_n.jpg",biography:null,institutionString:null,institution:{name:"National Dairy Research Institute",country:{name:"India"}}},{id:"202192",title:"Dr.",name:"Catrin",middleName:null,surname:"Rutland",slug:"catrin-rutland",fullName:"Catrin Rutland",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/202192/images/system/202192.png",biography:"Catrin Rutland is an Associate Professor of Anatomy and Developmental Genetics at the University of Nottingham, UK. She obtained a BSc from the University of Derby, England, a master’s degree from Technische Universität München, Germany, and a Ph.D. from the University of Nottingham. She undertook a post-doctoral research fellowship in the School of Medicine before accepting tenure in Veterinary Medicine and Science. Dr. Rutland also obtained an MMedSci (Medical Education) and a Postgraduate Certificate in Higher Education (PGCHE). She is the author of more than sixty peer-reviewed journal articles, twelve books/book chapters, and more than 100 research abstracts in cardiovascular biology and oncology. She is a board member of the European Association of Veterinary Anatomists, Fellow of the Anatomical Society, and Senior Fellow of the Higher Education Academy. 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Samir worked as a member of different local projects on E-learning and he is a board member of the African Association of Veterinary Anatomists and of anatomy societies and as an associated author at local and international journals. Orcid: https://orcid.org/0000-0002-6180-389X",institutionString:null,institution:{name:"Alexandria University",country:{name:"Egypt"}}},{id:"246149",title:"Dr.",name:"Valentina",middleName:null,surname:"Kubale",slug:"valentina-kubale",fullName:"Valentina Kubale",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/246149/images/system/246149.jpg",biography:"Valentina Kubale is Associate Professor of Veterinary Medicine at the Veterinary Faculty, University of Ljubljana, Slovenia. Since graduating from the Veterinary faculty she obtained her PhD in 2007, performed collaboration with the Department of Pharmacology, University of Copenhagen, Denmark. She continued as a post-doctoral fellow at the University of Copenhagen with a Lundbeck foundation fellowship. She is the editor of three books and author/coauthor of 23 articles in peer-reviewed scientific journals, 16 book chapters, and 68 communications at scientific congresses. Since 2008 she has been the Editor Assistant for the Slovenian Veterinary Research journal. She is a member of Slovenian Biochemical Society, The Endocrine Society, European Association of Veterinary Anatomists and Society for Laboratory Animals, where she is board member.",institutionString:"University of Ljubljana",institution:{name:"University of Ljubljana",country:{name:"Slovenia"}}},{id:"258334",title:"Dr.",name:"Carlos Eduardo",middleName:null,surname:"Fonseca-Alves",slug:"carlos-eduardo-fonseca-alves",fullName:"Carlos Eduardo Fonseca-Alves",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/258334/images/system/258334.jpg",biography:"Dr. Fonseca-Alves earned his DVM from Federal University of Goias – UFG in 2008. He completed an internship in small animal internal medicine at UPIS university in 2011, earned his MSc in 2013 and PhD in 2015 both in Veterinary Medicine at Sao Paulo State University – UNESP. Dr. Fonseca-Alves currently serves as an Assistant Professor at Paulista University – UNIP teaching small animal internal medicine.",institutionString:null,institution:{name:"Universidade Paulista",country:{name:"Brazil"}}},{id:"245306",title:"Dr.",name:"María Luz",middleName:null,surname:"Garcia Pardo",slug:"maria-luz-garcia-pardo",fullName:"María Luz Garcia Pardo",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/245306/images/system/245306.png",biography:"María de la Luz García Pardo is an agricultural engineer from Universitat Politècnica de València, Spain. She has a Ph.D. in Animal Genetics. Currently, she is a lecturer at the Agrofood Technology Department of Miguel Hernández University, Spain. Her research is focused on genetics and reproduction in rabbits. The major goal of her research is the genetics of litter size through novel methods such as selection by the environmental sensibility of litter size, with forays into the field of animal welfare by analysing the impact on the susceptibility to diseases and stress of the does. Details of her publications can be found at https://orcid.org/0000-0001-9504-8290.",institutionString:null,institution:{name:"Miguel Hernandez University",country:{name:"Spain"}}},{id:"350704",title:"M.Sc.",name:"Camila",middleName:"Silva Costa",surname:"Ferreira",slug:"camila-ferreira",fullName:"Camila Ferreira",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/350704/images/17280_n.jpg",biography:"Graduated in Veterinary Medicine at the Fluminense Federal University, specialist in Equine Reproduction at the Brazilian Veterinary Institute (IBVET) and Master in Clinical Veterinary Medicine and Animal Reproduction at the Fluminense Federal University. She has experience in analyzing zootechnical indices in dairy cattle and organizing events related to Veterinary Medicine through extension grants. I have experience in the field of diagnostic imaging and animal reproduction in veterinary medicine through monitoring and scientific initiation scholarships. I worked at the Equus Central Reproduction Equine located in Santo Antônio de Jesus – BA in the 2016/2017 breeding season. I am currently a doctoral student with a scholarship from CAPES of the Postgraduate Program in Veterinary Medicine (Pathology and Clinical Sciences) at the Federal Rural University of Rio de Janeiro (UFRRJ) with a research project with an emphasis on equine endometritis.",institutionString:null,institution:null},{id:"41319",title:"Prof.",name:"Lung-Kwang",middleName:null,surname:"Pan",slug:"lung-kwang-pan",fullName:"Lung-Kwang Pan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/41319/images/84_n.jpg",biography:null,institutionString:null,institution:null},{id:"125292",title:"Dr.",name:"Katy",middleName:null,surname:"Satué Ambrojo",slug:"katy-satue-ambrojo",fullName:"Katy Satué Ambrojo",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/125292/images/system/125292.jpeg",biography:"Katy Satué Ambrojo received her Veterinary Medicine degree, Master degree in Equine Technology and doctorate in Veterinary Medicine from the Faculty of Veterinary, CEU-Cardenal Herrera University in Valencia, Spain.Dr. Satué is accredited as a Private University Doctor Professor, Doctor Assistant, and Contracted Doctor by AVAP (Agència Valenciana d'Avaluació i Prospectiva) and currently, as a full professor by ANECA (since January 2022). To date, Katy has taught 22 years in the Department of Animal Medicine and Surgery at the CEU-Cardenal Herrera University in undergraduate courses in Veterinary Medicine (General Pathology, integrated into the Applied Basis of Veterinary Medicine module of the 2nd year, Clinical Equine I of 3rd year, and Equine Clinic II of 4th year). Dr. Satué research activity is in the field of Endocrinology, Hematology, Biochemistry, and Immunology in the Spanish Purebred mare. She has directed 5 Doctoral Theses and 5 Diplomas of Advanced Studies, and participated in 11 research projects as a collaborating researcher. She has written 2 books and 14 book chapters in international publishers related to the area, and 68 scientific publications in international journals. Dr. Satué has attended 63 congresses, participating with 132 communications in international congresses and 19 in national congresses related to the area. Dr. Satué is a scientific reviewer for various prestigious international journals such as Animals, American Journal of Obstetrics and Gynecology, Veterinary Clinical Pathology, Journal of Equine Veterinary Science, Reproduction in Domestic Animals, Research Veterinary Science, Brazilian Journal of Medical and Biological Research, Livestock Production Science and Theriogenology, among others. Since 2014 she has been responsible for the Clinical Analysis Laboratory of the CEU-Cardenal Herrera University Veterinary Clinical Hospital.",institutionString:null,institution:null},{id:"201721",title:"Dr.",name:"Beatrice",middleName:null,surname:"Funiciello",slug:"beatrice-funiciello",fullName:"Beatrice Funiciello",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/201721/images/11089_n.jpg",biography:"Graduated from the University of Milan in 2011, my post-graduate education included CertAVP modules mainly on equines (dermatology and internal medicine) and a few on small animal (dermatology and anaesthesia) at the University of Liverpool. After a general CertAVP (2015) I gained the designated Certificate in Veterinary Dermatology (2017) after taking the synoptic examination and then applied for the RCVS ADvanced Practitioner status. After that, I completed the Postgraduate Diploma in Veterinary Professional Studies at the University of Liverpool (2018). My main area of work is cross-species veterinary dermatology.",institutionString:null,institution:null},{id:"291226",title:"Dr.",name:"Monica",middleName:null,surname:"Cassel",slug:"monica-cassel",fullName:"Monica Cassel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/291226/images/8232_n.jpg",biography:'Degree in Biological Sciences at the Federal University of Mato Grosso with scholarship for Scientific Initiation by FAPEMAT (2008/1) and CNPq (2008/2-2009/2): Project \\"Histological evidence of reproductive activity in lizards of the Manso region, Chapada dos Guimarães, Mato Grosso, Brazil\\". Master\\\'s degree in Ecology and Biodiversity Conservation at Federal University of Mato Grosso with a scholarship by CAPES/REUNI program: Project \\"Reproductive biology of Melanorivulus punctatus\\". PhD\\\'s degree in Science (Cell and Tissue Biology Area) \n at University of Sao Paulo with scholarship granted by FAPESP; Project \\"Development of morphofunctional changes in ovary of Astyanax altiparanae Garutti & Britski, 2000 (Teleostei, Characidae)\\". She has experience in Reproduction of vertebrates and Morphology, with emphasis in Cellular Biology and Histology. She is currently a teacher in the medium / technical level courses at IFMT-Alta Floresta, as well as in the Bachelor\\\'s degree in Animal Science and in the Bachelor\\\'s degree in Business.',institutionString:null,institution:null},{id:"442807",title:"Dr.",name:"Busani",middleName:null,surname:"Moyo",slug:"busani-moyo",fullName:"Busani Moyo",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Gwanda State University",country:{name:"Zimbabwe"}}},{id:"439435",title:"Dr.",name:"Feda S.",middleName:null,surname:"Aljaser",slug:"feda-s.-aljaser",fullName:"Feda S. 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