Mean, minimum, and maximum values of the measurements (mm) made on 31 and 41.
\r\n\t
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She worked as a post-doc and a visiting associate in the Biological Engineering Department at Massachusetts Institute of Technology. She is currently working as a full professor at Hacettepe University, Faculty of Pharmacy, Department of Pharmaceutical Toxicology. Her main study interests are clinical and medical aspects of toxicology, endocrine-disrupting chemicals, and oxidative stress. She has published more than 150 papers in national and international journals. 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Incisors",doi:"10.5772/intechopen.71341",slug:"identification-of-lower-central-incisors",body:'In dentistry, it is essential to have a wide knowledge of the dental anatomy. The study of basic anatomical characteristics combined with the extensive knowledge about the richness of details present in a single tooth is the factor that can differentiate a high-level dentist from other professionals.
In esthetic procedures, where there is a great need to know the morphology of each tooth, we have the anterior dental teeth acting as protagonists. Incisors and canines are the group of teeth that require most attention of dentists, since alterations in their anatomical structures are easy to perceive.
In this chapter, there is a search for a better understanding of the external shape and appearance of one of these components: the permanent lower central incisors.
It is already known that, unlike the other teeth, the permanent lower central incisors have their mesial surface shorter or equal compared to the distal surface (if observed by their free surfaces), converging to the cervix of the teeth [1]. Although being almost equal to the proximal surfaces, the distal one is more convex and with a clearer configuration. The mesial surface, on the other hand, is smaller (at least in weary teeth) and less inclined than the distal surface [1]. However, there is great symmetry between both surfaces of the permanent lower central incisor, with a tendency to parallelism, being difficult to distinguish the proximal surfaces [2]. Another feature that hinders the identification of the proximal surfaces is the intersection of the incisal margin with the mesial and distal margins of the proximal surfaces. This intersection occurs at almost right, very little rounded, or not rounded angles [2, 3].
The deciduous lower central incisor differs from the deciduous lower lateral incisor mainly because of the size, since the lateral incisor is larger than the central incisor. This difference in size is, in many people, more pronounced in deciduous than in permanent teeth [4].
The teeth that may be confused with the permanent lower central incisors during the individual study in dental anatomy classes are the permanent lower lateral incisors. However, the lower lateral incisor is slightly larger in all dimensions [2]. Its crown is not symmetrical bilaterally as the one of the central incisor [5]. Its proximal surfaces present greater convergence to the cervix, and the mesial surface is slightly higher than the distal one [1, 2, 5]. The almost right angles observed on the permanent lower central incisors are not present on the lateral incisors, but they have a distoincisal angle more rounded and obtuse [1, 2, 5]. The most significant difference between the permanent lower incisors is the projection of the distoincisal angle to the lingual surface of the lateral incisors, because the incisal edge is rotated to the distal-lingual direction. The cingulum, located on the lingual surface, also accompanies the edge rotation, with its greater prominence slightly distal. With respect to the roots, the lower lateral incisors present them longer, more robust, and with deeper grooves, with the apex angled to distal [2, 5].
Due to the absence of sufficient wear to alter the dental structure, in newly erupted teeth, the mesial surface is still larger than the distal one, although this condition is transient and, over time, the situation is reversed, since wear is more pronounced in the mesial part of the incisal margin [1, 2].
According to Madeira and Rizzolo [2], the cervical line describes a very closed curve, which extends incisally up to one-third of the length of the crown and is even more closed on the mesial side.
It was intended to facilitate the study of the anatomy of the lower central incisor for dentistry students that this study searched for a better way to differentiate the third quadrant element (31—permanent left lower central incisor) from the fourth quadrant element (41—permanent right lower central incisor).
This chapter had as a purpose to evaluate permanent lower central incisors of the didactic collection of the Discipline of Anatomy, Department of Morphology, School of Dentistry of Araraquara, São Paulo State University (UNESP) and to verify the presence of correlation between the structures mentioned below: proximal surface with the smallest cervical-incisal dimension, mesio-incisal and disto-incisal angles, cervical line on the proximal surfaces, the flattest proximal surface in the cervix region, root grooves, and root apex, intending to identify the proximal surfaces by those structures. Measurements of the cervical-incisal dimension of the crown, the root length, mesio-distal dimension of the crown and root, buccolingual dimension of the crown and root, and total tooth length were made. Besides, it was evaluated whether there was difference between 31 and 41.
This project was approved by the Ethics Committee of the School of Dentistry of Araraquara, São Paulo State University (UNESP) (CAAE 61522516.2.0000.5416).
One hundred permanent lower central incisors, with no information about sex and age, were evaluated, and those belong to the collection of the Laboratory of Anatomy of the Department of Morphology of the São Paulo State University (UNESP), School of Dentistry, Araraquara were evaluated. The teeth were cleaned with dental instruments and solution of hydrogen peroxide and ammonium hydroxide. The teeth were stored dry, without any solutions, in glass containers. Those teeth are routinely used in the dental anatomy classes.
The proximal faces were randomly determined with the letters A and B, and the following structures were evaluated by visual method:
Proximal surface with the smallest cervical-incisal dimension: A, B, or W (without identification, when no difference was observed between A and B).
The most pointed incisal angle: A, B, or W.
The greatest curvature of the cervical line: A, B, or W.
The flattest proximal surface in the cervix region: A, B, or W.
Surface with less deep root groove or a more convex surface: A, B or S.
Angulation of the root apex: A, B, or R (rectilinear).
Each tooth was identified by a number. The teeth were evaluated by two experienced anatomy professors who checked, at the same time, the classifications and reached a consensus.
From the evaluated features, the teeth were identified as 31 or 41 by the sum of the features observed in each surface, their association, and the most striking structures. The professors also classified the identification of the incisors as easy, moderate difficulty, and difficult, and they noted which features were considered to make the identification.
Subsequently, measurements were made on the same teeth by a single examiner using a digital caliper (Mitutoyo® Sul Americana LTDA).
The following measurements were performed:
Measurement of the cervical-incisal dimension of the crown (CIC): measurement from the cervical line to the incisal edge made on the buccal surface.
Measurement of the root length (RL): measurement of the most cervical region of the cervical line up to the root apex made on the buccal surface.
Measurement of the mesio-distal dimension of the crown (MDC): measurement on the incisal edge of the crown made on the buccal surface.
Measurement of the mesio-distal dimension of the root (MDR): measurement between the mesial and distal root surfaces in the dental cervix made on the buccal surface.
Measurement of the buccolingual dimension of the crown (BLC): measurement between the buccal and lingual surfaces of the crown in the dental cervix made on the mesial surface.
Measurement of the buccolingual dimension of the root (BLR): measurement between the buccal and lingual surfaces of the root in the dental cervix made on the mesial surface.
The measurement of total tooth length (TL) was obtained by the sum of the cervical-incisal dimension of the crown (CIC) and the measurement of the root length (RL).
Descriptive statistics was performed. The t-test was applied to evaluate the relation between the right lower first premolars and the left lower first premolars. A correlation study was performed using the Pearson correlation coefficient (r) among the six evaluated features.
Table 1 presents the mean, the minimum, and maximum values of the measurements made on 31 and 41. There was no statistically significant difference between the measurements made on 31 and 41 (p > 0.05; t-test; Table 1).
Measurements | 31 | 41 | p |
---|---|---|---|
CIC | |||
Minimum | 10.6 | 7.9 | |
Maximum | 15.7 | 11.3 | |
Mean | 9.4 | 9.3 | 0.4315 |
RL | |||
Minimum | 10.6 | 8.5 | |
Maximum | 15.7 | 15.1 | |
Mean | 12.9 | 12.5 | 0.2167 |
MDC | |||
Minimum | 4.4 | 4.7 | |
Maximum | 6.3 | 5.9 | |
Mean | 5.4 | 5.3 | 0.5 |
MDR | |||
Minimum | 3.1 | 3.1 | |
Maximum | 4.5 | 5.6 | |
Mean | 3.5 | 3.6 | 0.8224 |
BLC | |||
Minimum | 4.7 | 5.0 | |
Maximum | 7.0 | 6.7 | |
Mean | 5.8 | 5.8 | 0.8035 |
BLR | |||
Minimum | 4.6 | 4.8 | |
Maximum | 6.7 | 6.5 | |
Mean | 5.7 | 5.7 | 0.5133 |
TL | |||
Minimum | 19.4 | 16.7 | |
Maximum | 26.2 | 24.8 | |
Mean | 22.2 | 21.8 | 0.1366 |
Mean, minimum, and maximum values of the measurements (mm) made on 31 and 41.
As there was no significant difference between 31 and 41, the measurements were presented together, without considering the sides.
The mean, the minimum, and maximum values of the measurements of all evaluated lower central incisors are shown in Table 2.
N | Minimum | Maximum | Mean | |
---|---|---|---|---|
CIC | 100 | 7.6 | 11.7 | 9.3 |
RL | 100 | 8.5 | 15.7 | 12.7 |
MDC | 100 | 4.4 | 6.3 | 5.3 |
MDR | 100 | 3.1 | 5.6 | 3.6 |
BLC | 100 | 4.7 | 7.4 | 5.8 |
BLR | 100 | 4.6 | 6.7 | 5.7 |
CTD | 100 | 16.7 | 26.2 | 22.0 |
Mean, minimum, and maximum values of the measurements (mm) made on the lower central incisors.
From the 100 permanent lower central incisors, one was not classified as 31 or 41, because the two professors considered more appropriate not to classify it due to the features presented of the tooth and the difficulty in identifying it.
Table 3 shows the frequency of the anatomical features observed on the lower inferior central incisors.
Anatomical features | Frequency | % |
---|---|---|
Proximal surface with the smallest cervical-incisal dimension | ||
Mesial | 57 | 57.6 |
Distal | 28 | 28.3 |
Without identification | 14 | 14.1 |
Total | 99 | 100 |
The most pointed incisal angle | ||
Mesial | 55 | 55.6 |
Distal | 22 | 22.2 |
Without identification | 22 | 22.2 |
Total | 99 | 100 |
Proximal surface with the greatest curvature of the cervical line | ||
Mesial | 51 | 51.5 |
Distal | 23 | 23.2 |
Without identification | 25 | 25.3 |
Total | 99 | 100 |
The flattest proximal surface | ||
Mesial | 65 | 65.7 |
Distal | 17 | 17.2 |
Without identification | 17 | 17.2 |
Total | 99 | 100 |
Surface with less deep root groove or a more convex surface | ||
Mesial | 74 | 74.7 |
Distal | 15 | 15.2 |
Without identification | 10 | 10.1 |
Total | 99 | 100 |
Angulation of the root apex | ||
Mesial | 6 | 6.1 |
Distal | 35 | 35.4 |
Rectilinear | 58 | 58.6 |
Total | 99 | 100 |
Frequency of the anatomical features observed on the lower inferior central incisors.
The professors verified that the most pointed incisal angle did not show reliability in the selection of the features for the identification of the proximal surfaces. Therefore, it was not included in the sum of the features for decision making. According to Madeira and Rizzolo [2], the incisal angles are almost right, very little rounded, or not rounded.
Thirty-one teeth were considered easy to identify by the anatomy professors, 22 were considered moderate difficulty, and 46 teeth were considered difficult to classify.
From the 31 teeth considered easy to classify, 19 incisors were identified by adding and associating 4 features, 8 by 3 features, and 4 by 5 features. From the 22 teeth considered with moderate difficulty, 13 were identified by 3 features, 7 by 2 features, and 2 by 4 features. From the difficult teeth, 29 incisors were identified by 2 features, 8 by 3 features, 2 by 4 features, and 7 teeth only by 1 feature.
From the teeth considered easy, most of them were chosen by adding the shortest proximal surface feature to the root features (surface with less deep root groove or a more convex surface and the angulation of the root apex), associated or not to the proximal surface with a cervical line with the greatest curvature, or a flatter proximal surface. Therefore, it was verified that the more items found which characterize a certain proximal surface according to the literature, the easier it becomes to identify them. Only five teeth from the 31 considered easy to identify, the shortest proximal surface did not help the identification of the proximal surfaces, and no root features were observed for the identification of four incisors.
The identification of the teeth became more difficult, when one or more features were contrary to the others or when it was not possible to verify differences between the surfaces. Therefore, the professors took into account the most striking elements.
The mesial surface presented the smallest cervical-incisal dimension in 57 teeth (Figures 1 and 2), followed by the distal surface (28), and 14 incisors the incisal edge was rectilinear, with mesial and distal surfaces with similar cervical-incisal dimension (Figure 2 and Table 3). The mesial edge of the buccal surface is usually smaller than the distal one (the inverse of what is observed on the other teeth) because the wear is more pronounced on the mesial half of the incisal edge [1, 6]. Due to the wear, a beveled shape is identified in the incisal edge of the mesial surface, which extends through the buccal surface [1, 2, 7]. The incisal edge is rectilinear and obliquely directed, from top to bottom, in the disto-mesial direction (at least in the teeth with certain wear); the mesial angle becomes more obtuse and the distal one becomes more acute [1]. Possibly, due to the presence of wear, it was observed in the present study that the most pointed incisal angle was the mesial one (55 incisors; Table 3). Pagano et al. [7] reported that the mesial and distal angles are slightly rounded or acute, with no significant differences between them.
Tooth 31 presenting the mesial surface with smaller cervical-incisal dimension compared to the distal surface.
Permanent lower central incisors. (A) Rectilinear incisal edge, (B) incisor with the distal surface with smaller cervical-incisal dimension, and (C) incisor with the mesial surface with smaller cervical-incisal dimension.
The cervical line presents a greatest curvature on the mesial surface according to Madeira and Rizzolo [2]. This feature was verified in 51.5% of the teeth in this study (Figure 3; Table 3).
Permanent lower central incisors. (A) The cervical line presents a greatest curvature on the mesial surface. (B) The cervical line presents a smaller curvature on the distal surface.
According to Picosse [6], the distal edge of the buccal surface is more angled, but it is difficult to notice. Della Serra and Ferreira [1] reported that the mesial surface is smaller and less inclined than the distal one. In the present study, it was observed that the distal surface was more inclined compared to the mesial surface, this being the flattest one (65.7%) (Figure 4 and Table 3).
Permanent lower central incisor. (A) Mesial surface is flatter than the distal surface in the cervix region.
Regarding the root grooves, the authors have reported that the lower central incisors have evident longitudinal grooves, the distal groove being the deepest one [2, 3, 4, 8]. In the present study, it was observed that the distal groove was the deepest one in many teeth. The mesial surface of the roots presented less deep grooves or a more convex surface (74.7%). However, the deepest groove was the mesial one on 15 teeth, and no difference was observed between the surfaces on 10 incisors (Table 3). According to Picosse [6], some teeth present the grooves so evident that they can separate the root, partially or totally, into two buccal and lingual segments. This feature described by Picosse [6] was not observed in any lower incisors of this study. Sanchez et al. [9] evaluated the presence of root concavities in the lower central incisors, improving the knowledge of tooth root morphology to result in a correct instrumentation and subsequent success in periodontal treatment. The authors observed that these concavities were present in 100% of the sample and were deeper and wider in the distal surface than in the mesial surface of the root. This feature coincides with the presence of deeper root grooves in the distal surface, already reported in the literature and also found in this study (Figure 5).
Permanent lower central incisor. (A) Mesial surface with a shallow root groove and (B) distal surface with a deeper root groove.
With the objective of understanding the morphology of the grooves present in the proximal surfaces of the roots of the upper and lower anterior teeth and its effect on the loss of periodontal insertion, Kaur et al. [10] evaluated 300 proximal surfaces of 150 teeth. The prevalence of proximal root grooves was 86.67%. The prevalence of grooves on maxillary teeth was 43.42% and on mandibular teeth was 56.67%. In mandibular teeth, it was 88% for mandibular central incisor, 90% for mandibular lateral incisor, and 80% for mandibular canines. Of the total 300 surfaces that were examined, 228 had grooves, of which 110 (48.24%) were mesial and 118 (51.75%) were distal. The mean width for maxillary central incisor and mandibular incisors was seen to be 1.97 mm and 2.20 mm, respectively. It was observed that the loss of periodontal insertion was higher in teeth that had root grooves than those that did not had grooves, and teeth with deeper grooves presented greater loss. The observations made in the study also support the hypothesis that proximal root grooves when present play a significant role in the loss of attachment.
Madeira and Rizzolo [2] describe the root of the lower central incisor as rectilinear, with no angulation. However, anatomical variation is observed in teeth and also in other anatomical structures. In this study, the root was rectilinear in 58.6% of the lower central incisors; in 35.4%, the root apex was angled to distal, which would not be an uncommon situation; and in 6.1%, there was a mesial inclination of the root apex (Figure 6 and Table 3). According to Della Serra and Ferreira [1], the root inclines to the distal approximately one degree, as well as for Figun and Garino [8], who reported that there is a slight radicular deviation to the distal side. Della Serra and Ferreira [1] cited a study in which rectilinear roots were observed in 66.7% of the lower central incisors, 12.5% presented an angled distal root apex, 2% presented an angled mesial root apex, and in 18.8%, the root apices were inclined to the buccal side. In the present study, no inclination to the buccal side of the root apex was observed.
Permanent lower central incisor. (A) Rectilinear root, (B) root apex angled to distal, and (C) root apex angled to mesial.
In this study, we evaluated the measurement of the cervical-incisal dimension of the crown (CIC). The mean value was 9.3 mm (ranging from 7.6 to 11.7 mm; Table 2). Della Serra and Ferreira [1] cited a variation from 6.7 to 11.5 mm, and Woelfel and Scheid [5] found a minimum value of 6.3 mm and a maximum value of 11.6 mm (mean 8.8 mm). The same result (8.8 mm) was found by Figun and Garino [8]. Sicher [11] reported a mean of 9.4 mm for the length of the dental crown. According to Picosse [6], the mean of the dental crown length of the lower central incisors in men was 8.51 mm, and in women, it was 7.95 mm. These results are lower than those found in our study and in the other reported studies.
Regarding the measurement of the root length (RL), the mean value was 12.7 mm (ranging from 8.5 to 15.4 mm; Table 2). Others authors reported a range from 8.8 to 16 mm [1], from 7.7 to 17.9 mm (mean value of 12.6 mm) [5], and 11.9 mm [8]. Picosse [6] verified that the mean of the root length was 12.27 mm in men and 12.65 in women. Sanchez et al. [9] measured the root length both on the distal and mesial surfaces. The authors found a mean value of 13.88 ± 1.4 mm on the distal surface and 13.76 ± 1.5 mm on the mesial surface, with no statistically significant difference between them. Besides we have made the same measurement on the buccal surface of the root, our results as well as those cited by Sanchez et al. [9] are within the standards.
Observing the mesio-distal dimension of the dental crown (MDC), we found in the literature a variation from 5.0 to 6.5 mm [1]; 4.4 to 6.7 mm [5]; and a maximum value of 6.87 mm [2]. In the present study, the same measurement ranged from 4.4 to 6.3 mm, with a mean value of 5.3 mm (Table 2). A mean value of 5.4 mm for the mesio-distal distance of the lower central incisors was cited by some authors [6, 8, 11].
It was observed that the mean value of the measurement of the mesio-distal dimension of the root (MDR) was 3.6 mm (ranging from 3.1 to 5.6 mm) (Table 2). Similar values were observed by Woelfel and Scheid [5] (mean value of 3.5 mm, ranging from 2.7 to 4.6 mm) and 3.9 mm by Sicher [11].
The buccolingual dimension of the crown (BLC) ranged from 4.7 to 7.4 mm (mean value of 5.8 mm; Table 2). In the literature, it was found a range from 6 to 8 mm [1] and from 4.8 to 6.8 mm, with a mean value of 5.7 mm [5].
A mean value of 5.7mm (ranging from 4.6 to 6.7mm, Table 2) was observed regarding the buccolingual dimension of the root (BLR). A dimension of 5.9 mm was cited by Sicher [11] and 5.4 mm (ranging from 4.3 to 6.5 mm) by Woelfel and Scheid [5]. According to Picosse [6], the mean of the maximum buccolingual dimension of the lower central incisors was 5.7 mm in men and 5.46 in women. Figún and Garino [8] found a buccolingual distance of 6 mm.
The measurement of total tooth length (TL) ranged from 16.7 to 26.2 mm (mean value of 22 mm) (Table 2). Others authors reported a range from 15.5 to 27.5 mm [1], from 16.6 to 26.7 mm (mean value of 20.8 mm) [5], 21.4 mm [11], 20.7 mm [8], and 20.78 mm in men and 20.6 mm in women [6].
According to Picosse [6], the mean of the measurements of the lower central incisors was higher in men than in women, except for the measurement of the root length. In our study, there was no information about sex and age. This is a limitation of this study because it was not possible to make associations between the measurements and those criteria.
The Pearson correlation coefficient between six anatomical features (21 possible associations) observed in the lower central incisors showed a weak positive correlation between the features: 1 and 2 (r = 0.366, p = 0.0001), 1 and 3 (r = 0.327, p = 0.0016), 1 and 4 (r = 0.347, p = 0.0004), 1 and 5 (r = 0.412, p < 0.0001), and 2 and 5 (r = 0.309, p = 0.0018) and weak negative for 2 and 6 (r = −0.419, p < 0.0001). The other associations were not significant. Therefore, it was verified that the evaluated features do not repeat in the same way in all incisors, demonstrating anatomical variation. Some patterns described in the literature were confirmed, but the percentage of anatomical variations was high for all studied features.
This makes the study of the lower central incisor quite difficult, especially for the first-year Dentistry graduation student. The lower central incisor is the smallest and most symmetrical tooth of the permanent dentition. Its anatomical elements, such as grooves and ridges, are the least evident [2].
The purpose of this study was to verify features that could facilitate the identification of the proximal surfaces of the lower central incisor. It was verified that the standard anatomical features described in the literature could not be observed in all teeth. However, the observation of the mentioned anatomical features, the sum of the features, the association of them, and the observation of the most striking structures consist of a method that assists in the identification of the permanent lower central incisors.
It was verified that the evaluated anatomical features do not repeat in the same way in all lower central incisors, demonstrating the presence of anatomical variation. However, the systematic methodology used for the evaluation of the incisors in this study facilitated the identification of the teeth. Therefore, the observation of the anatomical features mentioned in the literature, the sum and the association of the features, and the observation of the most striking structures are methods that facilitated to differentiate the third quadrant element (31—permanent left lower central incisor) from the fourth quadrant element (41—permanent right lower central incisor).
It was verified that there was no statistically significant difference between the measurements of 31 and 41. Distinguishing the right from the left central incisor is difficult, even for experienced practitioners. We could observe that the measurements do not facilitate the identification of teeth of different quadrants. Therefore, the anatomical features are relevant for the study of the dental anatomy in the identification of the lower central incisors.
The portal hypertension is caused by an increased resistance to venous flow in portal vein. Which leads to an increase to pressure in the portal circulation. It is a result of chronic liver disease, obstruction of portal vein, or portosystemic shunt, which leads to hyperdynamic circulation.
The normal hepatic venous pressure gradient (HVPG) correlates with normal portal pressure which is 1–4 mm Hg. A pressure gradient of more than 10 mm Hg links to esophageal varices. The pressure 12 mm Hg predicts the risk of active bleeding. [1]
The most common complication of pediatric portal hypertension is acute variceal bleeding. The grading system of the Japanese Research Society for Portal Hypertension of esophageal varices is as follows: grade 1: flattened by insufflation, grade 2: not flattened by insufflation but is not circumferential, grade 3: not flattened and is circumferential. [2]
The three main venous embryo systems will be recognizable by the end of the 3rd week of gestation.
They include (1) the 2 cardinal veins which drain the embryo blood (intraembryonic system). To the sinus venosus (primitive atrium). The other two are extraembryonic systems, one of them transports the blood from the yolk sac to the heart (sinus venosus) which is called (2) the vitelline veins (two pairs). Finally, (3) the 2 umbilical veins transport the oxygenated blood from the placenta to the embryo’s heart. [3]
The hepatic bud starts branching off from the caudal end of the foregut, which expands into the transversum septum (Mesenchymal tissue in the pericardiac area). The cephalic part of the hepatic bud will eventually form the liver. And the caudal part will form the biliary tree and the gall bladder. During liver development, the primitive liver tissue in the transversum septum is in close contact with the two extraembryonic venous systems (Figure 1).
Schematic drawing represents the relation between the primitive hepatic bud and the major fetal venous systems. (Courtesy of Collardeau-Frachon and Scoazec et al. [4]. All the rights reserved).
The portal circulation of the liver develops between the 4th and 6th weeks, which is the result of a complex interaction between a primitive liver and a pair of vitelline veins and umbilical veins.
Initially, the vitelline veins form 4 sites of anastomoses between each other in their way to the sinus venosus, which are the caudal-ventral anastomosis, middle dorsal (they named according to their relation to the foregut), subhepatic, and finally the subdiaphragmatic anastomosis.
A net of smaller anastomoses between the right and the left vitelline veins extend in the area between the subdiaphragmatic and the subhepatic anastomoses in the same site where the hepatic bud will proliferate and develop to form the liver (the caudal part of the septum transversum). Synchronously, the umbilical veins in their way to the sinus venosus each vein are divided into 2 branches. One runs in parallel to the primitive liver and the other one ends in the liver parenchyma. The right umbilical vein and its branches atrophy in the 4th week. Also, the direct branch to the sinus venosus disappears in the same period. But the left branch of the umbilical vein to the liver parenchyma persists. It increases in size gradually inside liver parenchyma till communicates with the left end of the subhepatic anastomosis of the vitelline veins. That is known as a portal sinus. So, all the oxygenated blood is conveyed to the liver via the left umbilical vein. Due to massive blood influx to the liver, one of the anastomosing veins between the subhepatic and subdiaphragmatic anastomoses increases in size tremendously (Ductus venosus) to accommodate the oxygenated blood from the portal sinus to sinus venosus via a subdiaphragmatic anastomosis. [4]
The future portal vein is formed of the inferior section of the left vitelline vein, middle dorsal anastomosis, and the superior section of the right vitelline vein. By end of this process in the 6th week, the S-shape portal vein starts to appear. By this, the definitive fetal portal circulation is formed. [4]
The next major event happens at birth when the umbilical blood flow ceases. Subsequently, intravascular pressure in the umbilical vein and the ductus venosus drop and obliterating of these veins start within minutes after birth, which usually takes 15–20 days for complete closure. [3]
The portal vein is formed by the union of the superior mesenteric and the splenic veins behind the neck of the pancreas. It passes behind the first part of the duodenum, then it runs in the free edge of the lesser momentum posterior to the common bile duct (on the right side) and hepatic artery proper (on the left side) up to the porta hepatis where it divides into right and the left portal veins. Both main branches continue breaking down up to the sinusoids.
There is a specific pattern of the breakdown of the portal vein, the biliary duct, and hepatic arteries within the liver parenchyma, which does not correlate with the liver surface anatomy.
The Cantlie’s line extends from the inferior vena cava to the fundus of the gall bladder, which divides the liver into right and left lobes. Cantlie’s line represents the true surgical division of the liver into right and left lobes. [5]
The description of further portal triad breakdowns and its correlation with hepatic veins is delineated by a French surgeon and anatomist “Claude Couinaud”, depending on his framework that every half further divides into sectors, and a hepatic sector according to Couinaud system (Figure 2) is a region bounded by 2 hepatic veins or a hepatic vein and the hepatic edge. And the segment in the region of the liver that has an independent portal triad (separate branches from the portal vein, the hepatic artery, and the biliary duct) supplies it. These anatomical facts guide the hepatobiliary surgeons to execute the hepatectomy (right or left) and segmentectomy precisely. [7]
Drawing represents the Couinaud system and the relation of left portal vein to ligamentous teres in the umbilical fissure. (Courtesy of John E. Skandalakis et al. [6], All rights reserved).
The location of the Rex recess has an important surgical application in pediatric portal hypertension. That is where a branch from the left portal branch lies in the porto-umbilical fissure between the left lateral sector (segments II, III) and the left medial sector (segment IV). In intrauterine life, the left portal branch in the recess of Rex was communicating with the left umbilical vein. The fibrous remnant of the left umbilical postnatally known as ligamentous teres can be used as a reliable anatomical landmark for the recess of the Rex, which is surgically accessible and connecting it to the mesenteric vessel (superior mesenteric vein) via graft to bypass the portal occlusion and avoid the cavernoma, which is a net of collaterals formed after the portal obstruction in the area of porta hepatis. A portal vein occlusion is the commonest cause of portal hypertension in the pediatric age group.
Another important anatomical aspect of portal hypertension is the collateral anastomoses [8] between the portal and systemic circulations. Under normal circumstances, the mesenteric vein returns to the liver via the portal vein, then to the inferior vena cava (systemic circulation) via the hepatic veins to reach finally, the right atrium of the heart. This normal pathway would be interrupted in portal hypertension where the resistance to blood flow in the portal circulation is increased. This forces the blood to use the porto-systemic anastomoses as alternative pathways to reach the systemic circulation, which are negligible in normal situations. But in portal hypertension, these anastomoses increase in size with the increased potentiality of hemorrhage (ex: esophageal varices).
These anastomoses are as follows:
The esophageal branches of the left gastric vein (a tributary of the portal circulation) anastomose with esophageal branches of hemiazygos vein (systemic circulation).
The anastomosis between the superior rectal vein (portal circulation) with the middle and inferior rectal veins (systemic circulation) in the anal canal.
Paraumbilical anastomoses (caput medusa) are the communication between tributaries of portal vein which run in the falciform with the superficial veins of the anterior abdominal wall.
The communications between veins of ascending colon, descending colon, and duodenum (portal circulation) with the left renal vein (systemic circulation).
The veins of Retzius connect retroperitoneally between tributaries of inferior vena cava and tributaries of the superior and inferior mesenteric veins.
The accessory portal system of sappey is a set of diaphragmatic veins connecting the portal system to the systemic system.
The spectrum of causes is arranged in the pre-hepatic, the hepatic, and the post-hepatic lesions.
Pre-hepatic lesions: Extra-hepatic portal vein obstruction is the commonest cause of portal hypertension. The underlying cause of portal thrombosis is unidentifiable in most cases. [9] But it links to the predisposing factors. They are an injury to the portal vein in the cannulation of the umbilical vein, dehydration, abdominal sepsis, omphalitis, and hypercoagulable state. Another factor is the extra-mural compression like enlarged lymph node due to inflammation or malignancy. [10]
The portosystemic shunt is another cause of portal hypertension which can be surgical or iatrogenic cause or congenital shunts. Lautz et al. proposed a classification for congenital portosystemic shunts which divide them into 2 types. Type I with no intrahepatic portal venous flow. Type II with some intrahepatic portal venous flow. [11]
Hepatic lesions: Hepatic cellular injury of any cause (e.g. Biliary atresia, Schistosomiasis) stimulates collagen deposition via activated stellate cells, which leads to an increase resistance to venous outflow. [12]
Post-hepatic lesions: They include the hepatic veno-occlusive disease. [13] Busulfan containing regimes use for a bone marrow ablation in the bone marrow transplant considered are risk factors for hepatic veno-occlusive disease, because of hepatic and endothelial cellular injuries, which cause hepatic venules obstruction leading to venous congestion and eventually, to portal hypertension. Budd-Chiari syndrome is another cause of post-hepatic obstruction. Although it is uncommon in the pediatric age group, Budd-Chiari syndrome does occur in children. The level of obstruction can be at any level from the hepatic veins up to the level of the aortocaval junction. The most underlying cause of Budd-Chiari syndrome in children is the hypercoagulable state (Protein C, S deficiency, antithrombin III deficiency). [14]
How the pediatric patient with portal hypertension is presented depends on 2 essential factors: (1) the site of the obstruction (2) whether the patient has liver cirrhosis or not.
Upper GI bleeding: It is a frightening and common presenting symptom of portal hypertension in the pediatric age group. About 70% of the extra-hepatic portal hypertension cases present with upper GI bleeding, which is the common cause of pediatric portal hypertension presented. [10] But since the liver parenchyma and functions are preserved for decades in the extra-hepatic portal hypertension at the time of the presentation almost all the patients have a normal liver function. For this reason, most of these patients recovered without serious complications with a low mortality rate. This is true for all patients with compensated liver function presented with upper GI bleeding. Unfortunately, this is not the case for patients with decompensated liver disease (cirrhosis). Mathieu Duche et al. in their study reported that 1/5 of patients with cirrhosis developed life-threatening complications after upper GI bleeds. [15]
Portal hypertensive gastropathy: It is gastric lesions related to portal hypertensive disease. It ranges from erythema to diffuse gastritis. It is an occasional cause of upper GI bleeding. But it most commonly causes iron deficiency anemia due to chronic blood loss, which also may manifest as melena. [16]
Splenomegaly and hypersplenism: Splenomegaly alone could be the presenting symptom in the extra-hepatic portal hypertension, in this scenario usually there are no other hepatic signs and symptoms, which necessitates excluding hematologic causes. If the patient has cirrhosis, the signs, and symptoms of liver disease (e.g. spider naevi, jaundice, ascites) will be presented with splenomegaly. Splenomegaly imposes a significant risk in adolescent patients due to the type of sports and activities involved in this age group. It may lead to a spleen rupture and catastrophic bleeding. Splenectomy may be the only option in these patients, who do not complaint about avoiding contact sports. Also, these patients may develop hypersplenism (splenomegaly, with thrombocytopenia and leukopenia). [17] Although the hepatomegaly is not common in pediatric portal hypertension. But it could be associated with Budd-Chiari syndrome and congenital hepatic fibrosis. [14, 18]
Encephalopathy: It is a known complication of liver cirrhosis. But it can be associated with normal liver function in the extra-hepatic portal hypertension patients caused by port-systemic shunts, whether it is congenital or systemic shunts. It could be manifested as learning difficulties and behavior abnormalities. [19]
Pulmonary related disorders: Pulmonary hypertension is associated with portal hypertension with or without liver disease. [20] It is caused by increased vascular resistance due to pulmonary vasoconstriction as a result of shunting vasoactive substance to the systemic circulation whether is due to prehepatic shunting or inability of the liver to process the proteins (liver cirrhosis). And the hepatopulmonary syndrome is the contrast to pulmonary hypertension, which present with dyspnea and hypoxia resulting from pulmonary arteriovenous shunting and partial oxygenation of the blood due to massive capillary dilation as a response to vasodilators proteins bypassed to the systemic circulation. [21]
Patients with portal hypertension may present with signs of liver disease if the underlying cause of portal hypertension is the damage of liver parenchyma. For example, Ascites develops due to 2 important factors: (1) protein synthesis failure in the liver which impairs the intravascular oncotic pressure (2) dilated abdominal vascular capillaries and lymphatic microcirculation as a result of the increased portal hydrostatic pressure. [22] Jaundice is another sign of decompensated liver function. It happens due to the inability of the liver to process the bilirubin as one product of hemoglobin breakdown. [23]
Blood investigation:
Complete blood count (CBC): It is useful to identify the presence of and type of anemia. Also, it is essential in the management of acute variceal bleeding. The presence of thrombocytopenia and leukopenia in portal hypertension investigation usually indicate hypersplenism.
Liver function test: It assesses the functionality of the liver. That will help to point toward the underlying cause of portal hypertension with help of other investigation modalities (see later). Low protein level (albumin) and prolonged coagulation profile indicate the impaired synthetic ability of the liver. The increased bilirubin level and hepatic enzymes indicate hepatocellular damage.
Renal function test: It assesses dehydration especially in acute variceal bleeding, and impaired renal function test associated with liver diseases, like congenital hepatic fibrosis which linked to polycystic kidney disease.
Other investigations are requested according to the clinical status of the patients. Blood glucose will be low in decompensated liver cirrhosis and it is low in glycogen storage disease. Also, the ammonia level is indicated to confirm the diagnosis of encephalopathy. The coagulation screen in liver cirrhosis is prolonged. But in the extra-hepatic portal thrombosis, the coagulation profile shows secondary hypercoagulable abnormalities. [24] It will be reversed after the obstruction is overcomed.
Endoscopy: It is an essential tool in portal hypertension management. It confirms the presence of varices in the esophagus and the stomach and identifies the cause of the upper GI bleeding whether from varices or other origins like hemorrhagic gastritis or Mallory-Weiss syndrome. Also, in cases of acute upper GI bleeding are not responsive to medical management, endoscopy offers an important therapeutic option to control the variceal bleeding whether via variceal banding or sclerotherapy. [25]
Radiological modalities: The first radiological modality in use as part of the diagnosis armamentarium is an abdominal ultrasound with Doppler. It provides a lot of important and useful information, which include the size, echogenicity of the liver, and presence of the cysts or nodules. It also delineates the status of the intra and extra biliary tree, the patency of the portal vein, and the presence of the cavernoma in the porta hepatis. The size and echogenicity of the spleen are demonstrated in the abdominal ultrasound. And by assessing the vascularity of the abdomen it can provide valuable information for the surgical team such as the patency of the superior mesenteric, renal, and splenic veins. The neck Doppler ultrasound plays an important role in planning for surgical intervention, by confirming the patency of Jugular veins. This allows using one of them as an autologous graft provided both veins are patent. [26] Furthermore, the distance between the veins can assess the possibility of shunting between them like the distance between the renal and the spleen veins to assess the possibility of the splenorenal shunting. It may also pick up the portosystemic shunting. But the computed tomography angiography and magnetic resonance angiography are more accurate to pick up such anomalies. The later radiological modalities are usually the second step in the work up to delineate the anatomy more accurately. Invasive radiological investigations are required in specific cases. For example, the wedged hepatic venography is required in the congenital porto-systemic shunts [27] and to check the patency of the left portal vein tributary in the Rex recess to assess the possibility of Rex shunt.
The upper GI bleeding can be the first presenting symptom of pediatric portal hypertension, especially when the extra-hepatic portal vein thrombosis is the underlying cause of portal hypertension. The mortality risk from the first variceal bleeding is less than 1% in pediatric portal hypertension. [28] This is due to 2 facts. First, portal hypertension in children develops early in course of the pathology, which leads subsequently to early variceal formation in children who have well-compensated liver function. Thus, the ability of the children’s recover is better comparing with adults (adult mortality rate ranging from 7 to 15%). Secondly, improved medical management reduce the mortality rate in all age groups. [12]
The management of acute variceal bleeding should start with securing the airway. Insertion 2 large cannulas withdraw the blood simultaneously for urgent investigations, which should include complete blood count, blood crossmatch, urea and electrolytes, liver function test, and blood clotting profile. The other blood tests as the medical situation are mandatory. [12]
The volume replacement should start as soon as possible with crystalloids and packed red blood cells aiming to maintain the hemoglobin at or above 7 g/dL. [25] This strategy prevents tissue hypoxia which reduces lactic acid accumulation in the tissues and blood. Therefore, blood acidosis becomes less likely. Eventually, the impairment of clotting factors (proteins) function also becomes less likely. This strategy hinders the slipping towards deleterious complications of disseminated intravascular coagulopathy. The insertion of the nasogastric tube is also beneficial in observing the continuity of the bleeding and evacuating the blood of the stomach. Evacuation of the blood from the stomach has significant importance in cirrhotic patients to prevent encephalopathy. The octreotide is a synthetic analogue of somatostatin, which reduces the portal venous inflow by constriction of the splanchnic arterioles via a direct effect on the arteriole smooth muscles. It is started as a bolus dose (1 mcg/kg) followed by infusion (1 mcg/kg/H) usually for 4–5 days, which is often followed endoscopy after controlling the bleeding. [29] The only accepted situations to use endoscopic sclerotherapy in children should be acute bleeding not responding to the medical management with technical difficulty to apply band and infant’s cases where there is no banding device available for them. There is a randomized trial showing the administration of erythromycin intravenously by 30 minutes before the endoscopy improves visibility and reduces the time of the procedure. [30] In a situation where medical management (including the endoscopy) fails to stop the bleeding, urgent shunt surgery or trans-jugular intrahepatic portosystemic shunt (TIPS) should be performed. The optimal environment for the management of these patients is the intensive care unit, where all the vital signs are monitored closely.
The primary prophylaxis aims to prevent the first variceal bleeding. The efficiency of the primary prophylaxis is well established in adult by screening the portal hypertension patients and identify the high-risk elements for variceal bleeding like the large size of varices (Grade 2,3), presence of the red wale on varices’ surface, and the severity of the liver disease. [31] Using the endoscopic banding and/or non-selective beta-blockers which act by decreasing the portal pressure via un-opposed action of alfa-receptor on the splanchnic arterioles and decreasing the cardiac output. Sclerotherapy is not recommended for primary prophylaxis because of increased mortality in one randomized study which is forced the discontinuity of this study. [32] Regarding the children, there is no consensus about the primary prophylaxis in the pediatric age group because there is no substantial data to decide which patients need screening and what are the predictive factors for variceal presence. [28] Some studies indicate that the presence of varices in children should be related to low albumin levels, increased size of the spleen, and thrombocytopenia. But there is a need for larger, well designed randomized studies to standardize these predictive factors for children. Also, the necessity for general anesthesia for endoscopic sessions in children is another worrying point. The deleterious effect of general anesthesia on the neurodevelopment of children is well documented. [33] And the recurrence of esophageal varices after eradication is common if the underlying cause of portal hypertension is not treated. There is increased incidence of gastric varices and portal hypertensive gastropathy after eradication of esophageal varices. The same is true regarding the non-selective beta-blocker. There is no properly designed randomized study to assess the therapeutic doses and the safety of the drug in children [34]. Taking into account the mortality rate due to the first variceal bleeding is exceedingly low (1%). All these points together came against standardizing the primary prophylaxis in children. But in special circumstances, the primary prophylaxis in children is justifiable like the child living away from the medical facilities which may necessitate primary prophylaxis.
The secondary prophylaxis is the prevention of recurrence of variceal bleeding after the first variceal bleeding. Secondary prophylaxis is recommended in children due to the high recurrence rate after the first bleeding and enough data supporting the efficiency and safety of endoscopic banding and superior to endoscopic sclerotherapy therapy. As in the primary prophylaxis, no enough data support the safety and efficiency of non-selective beat-blockers. [28, 35]
TIPS refers to an establishment of intrahepatic portosystemic by inserting a stent (a communication) between the portal and hepatic veins. [36] It can be used in acute variceal bleeding uncontrolled by other means. Also, it is considered a good option for bridging to liver transplant for patients who have cirrhosis to improve the severe symptoms (e.g. Massive ascites). In this scenario, TIPS is considered an ideal option by avoiding abdominal operation with subsequent adhesions and fibrosis, which makes the liver transplant operation much easier. [26]
This technique is considered as a non-selective shunt where most of the portal blood diverted to the systemic circulation which participates in encephalopathy. Also, TIPS has potential complications, which are shunt stenosis/thrombosis, bleeding, and dislodge of the stent to the right atrium. [26, 34]
The type of surgery depends on the level of obstruction (pre-hepatic, hepatic. Post-hepatic).
Pre-hepatic portal vein thrombosis with suitable anatomy means a patent left portal vein in the umbilical fissure and the patent superior mesenteric vein. They connect via graft whether synthetic or autologous, but as a rule in pediatric surgery, the use of autologous graft is always preferred whenever it is possible due to the fact the graft grows with the child. The most used autologous graft is one of the internal jugular veins after making sure the contralateral one patent pre-operatively by doppler ultrasound. After the anastomosis has been established, the porto-systemic circulation is re-established. Another important point that the liver parenchyma in the extrahepatic portal thrombosis is preserved for a long time. Based on this fact the functionality of the liver is expected to recover after re-establishing the porto-systemic circulation. Fortunately, the data of the surgical outcome confirms this concept. The secondary coagulation abnormalities, hepatopulmonary syndrome, liver adenomas, encephalopathy, and neurocognitive all will be reverted after successful Rex shunt. [37] And for the congenital portosystemic shunt the surgical ligation of the shunt when it is technically feasible. [27]
When the cause of portal hypertension is liver cirrhosis in the modern era the suitable option is a liver transplant. [38]
There are other surgical options for portal hypertension which are considered palliative rather than therapeutic: (1) Selective shunt: the technique is known as distal splenorenal shunt (Warren shunt). The principle of this technique is diverting part of the portal circulation to the systemic circulation by dividing the splenic vein and anastomosing the distal end to the left renal vein. It helps to reduce gastroesophageal variceal pressure subsequently reducing the bleeding potentials. Also, hypersplenism and encephalopathy are improved. But the issue with this shunt is that with time the selective shunt becomes non-selective due to the formation of collaterals. [26]
(2) Non-selective shunt: its principle is based on diverting the whole portal circulation to systemic circulation by mobilization of the superior mesenteric vein and creation of side to side anastomosis with inferior vena cava or by used graft to connect the 2 veins whether synthetic or autologous grafts. This technique is not preferred in children because of the high-risk encephalopathy and deleterious effect on the cognitive ability of the children. [38]
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\\n\\nThe Author shall obtain in writing all consents necessary for the reproduction of any material in which a third-party right exists, including quotations, photographs and illustrations, in all editions of the Work worldwide for the full term of the above licenses, and shall provide to IntechOpen, at its request, the original copies of such consents for inspection or the photocopies of such consents.
\\n\\nThe Author shall obtain written informed consent for publication from those who might recognize themselves or be identified by others, for example from case reports or photographs.
\\n\\nThe Author shall respect confidentiality during and after the termination of this Agreement. The information contained in all correspondence and documents as part of the publishing activity between IntechOpen and the Author and Co-Authors are confidential and are intended only for the recipients. The contents of any communication may not be disclosed publicly and are not intended for unauthorized use or distribution. Any use, disclosure, copying, or distribution is prohibited and may be unlawful.
\\n\\nAUTHOR'S WARRANTY
\\n\\nThe Author and Co-Authors confirm and warrant that the Work does not and will not breach any applicable law or the rights of any third party and, specifically, that the Work contains no matter that is defamatory or that infringes any literary or proprietary rights, intellectual property rights, or any rights of privacy.
\\n\\nThe Author and Co-Authors confirm that: (i) the Work is their original work and is not copied wholly or substantially from any other work or material or any other source; (ii) the Work has not been formally published in any other peer-reviewed journal or in a book or edited collection, and is not under consideration for any such publication; (iii) Authors and any applicable Co-Authors are qualifying persons under section 154 of the Copyright, Designs and Patents Act 1988; (iv) Authors and any applicable Co-Authors have not assigned, and will not during the term of this Publication Agreement purport to assign, any of the rights granted to IntechOpen under this Publication Agreement; and (v) the rights granted by this Publication Agreement are free from any security interest, option, mortgage, charge or lien.
\\n\\nThe Author and Co-Authors also confirm and warrant that: (i) he/she has the power to enter into this Publication Agreement on his or her own behalf and on behalf of each Co-Author; and (ii) has the necessary rights and/or title in and to the Work to grant IntechOpen, on behalf of themselves and any Co-Author, the rights and licences in this Publication Agreement. If the Work was prepared jointly by the Author and Co-Authors, the Author confirms that: (i) all Co-Authors agree to the submission, license and publication of the Work on the terms of this Publication Agreement; and (ii) the Author has the authority to enter into this biding Publication Agreement on behalf of each Co-Author. The Author shall: (i) ensure each Co-Author complies with all relevant provisions of this Publication Agreement, including those relating to confidentiality, performance and standards, as if a party to this Publication Agreement; and (ii) remain primarily liable for all acts and/or omissions of each Co-Author.
\\n\\nThe Author agrees to indemnify IntechOpen harmless against all liabilities, costs, expenses, damages and losses, as well as all reasonable legal costs and expenses suffered or incurred by IntechOpen arising out of, or in connection with, any breach of the agreed confirmations and warranties. This indemnity shall not apply in a situation in which a claim results from IntechOpen's negligence or willful misconduct.
\\n\\nNothing in this Publication Agreement shall have the effect of excluding or limiting any liability for death or personal injury caused by negligence or any other liability that cannot be excluded or limited by applicable law.
\\n\\nTERMINATION
\\n\\nIntechOpen has the right to terminate this Publication Agreement for quality, program, technical or other reasons with immediate effect, including without limitation (i) if the Author and/or any Co-Author commits a material breach of this Publication Agreement; (ii) if the Author and/or any Co-Author (being a private individual) is the subject of a bankruptcy petition, application or order; or (iii) if the Author and/or any Co-Author (as a corporate entity) commences negotiations with all or any class of its creditors with a view to rescheduling any of its debts, or makes a proposal for, or enters into, any compromise or arrangement with any of its creditors.
\\n\\nIn the event of termination, IntechOpen will notify the Author of the decision in writing.
\\n\\nIntechOpen’s DUTIES AND RIGHTS
\\n\\nUnless prevented from doing so by events beyond its reasonable control, IntechOpen, at its discretion, agrees to publish the Work attributing it to the Author and Co-Authors.
\\n\\nUnless prevented from doing so by events beyond its reasonable control, IntechOpen agrees to provide publishing services which include: managing editing (editorial and publishing process coordination, Author assistance); publishing software technology; language copyediting; typesetting; online publishing; hosting and web management; and abstracting and indexing services.
\\n\\nIntechOpen agrees to offer free online access to readers and use reasonable efforts to promote the Publication to relevant audiences.
\\n\\nIntechOpen is granted the authority to enforce the rights from this Publication Agreement on behalf of the Author and Co-Authors against third parties, for example in cases of plagiarism or copyright infringements. In respect of any such infringement or suspected infringement of the copyright in the Work, IntechOpen shall have absolute discretion in addressing any such infringement that is likely to affect IntechOpen's rights under this Publication Agreement, including issuing and conducting proceedings against the suspected infringer.
\\n\\nIntechOpen has the right to include/use the Author and Co-Authors names and likeness in connection with scientific dissemination, retrieval, archiving, web hosting and promotion and marketing of the Work and has the right to contact the Author and Co-Authors until the Work is publicly available on any platform owned and/or operated by IntechOpen.
\\n\\nMISCELLANEOUS
\\n\\nFurther Assurance: The Author shall ensure that any relevant third party, including any Co-Author, shall execute and deliver whatever further documents or deeds and perform such acts as IntechOpen reasonably requires from time to time for the purpose of giving IntechOpen the full benefit of the provisions of this Publication Agreement.
\\n\\nThird Party Rights: A person who is not a party to this Publication Agreement may not enforce any of its provisions under the Contracts (Rights of Third Parties) Act 1999.
\\n\\nEntire Agreement: This Publication Agreement constitutes the entire agreement between the parties in relation to its subject matter. It replaces all prior agreements, draft agreements, arrangements, collateral warranties, collateral contracts, statements, assurances, representations and undertakings of any nature made by, or on behalf of, the parties, whether oral or written, in relation to that subject matter. Each party acknowledges that in entering into this Publication Agreement it has not relied upon any oral or written statements, collateral or other warranties, assurances, representations or undertakings which were made by or on behalf of the other party in relation to the subject matter of this Publication Agreement at any time before its signature (known as the "Pre-Contractual Statements"), other than those which are set out in this Publication Agreement. Each party hereby waives all rights and remedies which might otherwise be available to it in relation to such Pre-Contractual Statements. Nothing in this clause shall exclude or restrict the liability of either party arising out of any fraudulent pre-contract misrepresentation or concealment.
\\n\\nWaiver: No failure or delay by a party to exercise any right or remedy provided under this Publication Agreement or by law shall constitute a waiver of that or any other right or remedy, nor shall it preclude or restrict the further exercise of that or any other right or remedy. No single or partial exercise of such right or remedy shall preclude or restrict the further exercise of that or any other right or remedy.
\\n\\nVariation: No variation of this Publication Agreement shall have effect unless it is in writing and signed by the parties, or their duly authorized representatives.
\\n\\nSeverance: If any provision, or part-provision, of this Publication Agreement is, or becomes invalid, illegal or unenforceable, it shall be deemed modified to the minimum extent necessary to make it valid, legal and enforceable. If such modification is not possible, the relevant provision or part-provision shall be deemed deleted. Any modification to, or deletion of, a provision or part-provision under this clause shall not affect the validity and enforceability of the rest of this Publication Agreement.
\\n\\nNo partnership: Nothing in this Publication Agreement is intended to, or shall be deemed to, establish or create any partnership or joint venture or the relationship of principal and agent or employer and employee between IntechOpen and the Author or any Co-Author, nor authorize any party to make or enter into any commitments for, or on behalf of, any other party.
\\n\\nGoverning law: This Publication Agreement and any dispute or claim, including non-contractual disputes or claims arising out of, or in connection with it, or its subject matter or formation, shall be governed by and construed in accordance with the law of England and Wales. The parties submit to the exclusive jurisdiction of the English courts to settle any dispute or claim arising out of, or in connection with, this Publication Agreement, including any non-contractual disputes or claims.
\\n\\nPolicy last updated: 2018-09-11
\\n"}]'},components:[{type:"htmlEditorComponent",content:'When submitting a manuscript, the Author is required to accept the Terms and Conditions set out in our Publication Agreement – Monographs/Compacts as follows:
\n\nCORRESPONDING AUTHOR'S GRANT OF RIGHTS
\n\nSubject to the following Article, the Author grants to IntechOpen, during the full term of copyright, and any extensions or renewals of that term, the following:
\n\nThe foregoing licenses shall survive the expiry or termination of this Publication Agreement for any reason.
\n\nThe Author, on his or her own behalf and on behalf of any of the Co-Authors, reserves the following rights in the Work but agrees not to exercise them in such a way as to adversely affect IntechOpen's ability to utilize the full benefit of this Publication Agreement: (i) reprographic rights worldwide, other than those which subsist in the typographical arrangement of the Work as published by IntechOpen; and (ii) public lending rights arising under the Public Lending Right Act 1979, as amended from time to time, and any similar rights arising in any part of the world.
\n\nThe Author, and any Co-Author, confirms that they are, and will remain, a member of any applicable licensing and collecting society and any successor to that body responsible for administering royalties for the reprographic reproduction of copyright works.
\n\nSubject to the license granted above, copyright in the Work and all versions of it created during IntechOpen's editing process, including all published versions, is retained by the Author and any Co-Authors.
\n\nSubject to the license granted above, the Author and Co-Authors retain patent, trademark and other intellectual property rights to the Work.
\n\nAll rights granted to IntechOpen in this Article are assignable, sublicensable or otherwise transferrable to third parties without the specific approval of the Author or Co-Authors.
\n\nThe Author, on his/her own behalf and on behalf of the Co-Authors, will not assert any rights under the Copyright, Designs and Patents Act 1988 to object to derogatory treatment of the Work as a consequence of IntechOpen's changes to the Work arising from the translation of it, corrections and edits for house style, removal of problematic material and other reasonable edits as determined by IntechOpen.
\n\nAUTHOR'S DUTIES
\n\nWhen distributing or re-publishing the Work, the Author agrees to credit the Monograph/Compacts as the source of first publication, as well as IntechOpen. The Author guarantees that Co-Authors will also credit the Monograph/Compacts as the source of first publication, as well as IntechOpen, when they are distributing or re-publishing the Work.
\n\nThe Author agrees to:
\n\nThe Author will be held responsible for the payment of the agreed Open Access Publishing Fee before the completion of the project (Monograph/Compacts publication).
\n\nAll payments shall be due 30 days from the date of issue of the invoice. The Author or whoever is paying on behalf of the Author and Co-Authors will bear all banking and similar charges incurred.
\n\nThe Author shall obtain in writing all consents necessary for the reproduction of any material in which a third-party right exists, including quotations, photographs and illustrations, in all editions of the Work worldwide for the full term of the above licenses, and shall provide to IntechOpen, at its request, the original copies of such consents for inspection or the photocopies of such consents.
\n\nThe Author shall obtain written informed consent for publication from those who might recognize themselves or be identified by others, for example from case reports or photographs.
\n\nThe Author shall respect confidentiality during and after the termination of this Agreement. The information contained in all correspondence and documents as part of the publishing activity between IntechOpen and the Author and Co-Authors are confidential and are intended only for the recipients. The contents of any communication may not be disclosed publicly and are not intended for unauthorized use or distribution. Any use, disclosure, copying, or distribution is prohibited and may be unlawful.
\n\nAUTHOR'S WARRANTY
\n\nThe Author and Co-Authors confirm and warrant that the Work does not and will not breach any applicable law or the rights of any third party and, specifically, that the Work contains no matter that is defamatory or that infringes any literary or proprietary rights, intellectual property rights, or any rights of privacy.
\n\nThe Author and Co-Authors confirm that: (i) the Work is their original work and is not copied wholly or substantially from any other work or material or any other source; (ii) the Work has not been formally published in any other peer-reviewed journal or in a book or edited collection, and is not under consideration for any such publication; (iii) Authors and any applicable Co-Authors are qualifying persons under section 154 of the Copyright, Designs and Patents Act 1988; (iv) Authors and any applicable Co-Authors have not assigned, and will not during the term of this Publication Agreement purport to assign, any of the rights granted to IntechOpen under this Publication Agreement; and (v) the rights granted by this Publication Agreement are free from any security interest, option, mortgage, charge or lien.
\n\nThe Author and Co-Authors also confirm and warrant that: (i) he/she has the power to enter into this Publication Agreement on his or her own behalf and on behalf of each Co-Author; and (ii) has the necessary rights and/or title in and to the Work to grant IntechOpen, on behalf of themselves and any Co-Author, the rights and licences in this Publication Agreement. If the Work was prepared jointly by the Author and Co-Authors, the Author confirms that: (i) all Co-Authors agree to the submission, license and publication of the Work on the terms of this Publication Agreement; and (ii) the Author has the authority to enter into this biding Publication Agreement on behalf of each Co-Author. The Author shall: (i) ensure each Co-Author complies with all relevant provisions of this Publication Agreement, including those relating to confidentiality, performance and standards, as if a party to this Publication Agreement; and (ii) remain primarily liable for all acts and/or omissions of each Co-Author.
\n\nThe Author agrees to indemnify IntechOpen harmless against all liabilities, costs, expenses, damages and losses, as well as all reasonable legal costs and expenses suffered or incurred by IntechOpen arising out of, or in connection with, any breach of the agreed confirmations and warranties. This indemnity shall not apply in a situation in which a claim results from IntechOpen's negligence or willful misconduct.
\n\nNothing in this Publication Agreement shall have the effect of excluding or limiting any liability for death or personal injury caused by negligence or any other liability that cannot be excluded or limited by applicable law.
\n\nTERMINATION
\n\nIntechOpen has the right to terminate this Publication Agreement for quality, program, technical or other reasons with immediate effect, including without limitation (i) if the Author and/or any Co-Author commits a material breach of this Publication Agreement; (ii) if the Author and/or any Co-Author (being a private individual) is the subject of a bankruptcy petition, application or order; or (iii) if the Author and/or any Co-Author (as a corporate entity) commences negotiations with all or any class of its creditors with a view to rescheduling any of its debts, or makes a proposal for, or enters into, any compromise or arrangement with any of its creditors.
\n\nIn the event of termination, IntechOpen will notify the Author of the decision in writing.
\n\nIntechOpen’s DUTIES AND RIGHTS
\n\nUnless prevented from doing so by events beyond its reasonable control, IntechOpen, at its discretion, agrees to publish the Work attributing it to the Author and Co-Authors.
\n\nUnless prevented from doing so by events beyond its reasonable control, IntechOpen agrees to provide publishing services which include: managing editing (editorial and publishing process coordination, Author assistance); publishing software technology; language copyediting; typesetting; online publishing; hosting and web management; and abstracting and indexing services.
\n\nIntechOpen agrees to offer free online access to readers and use reasonable efforts to promote the Publication to relevant audiences.
\n\nIntechOpen is granted the authority to enforce the rights from this Publication Agreement on behalf of the Author and Co-Authors against third parties, for example in cases of plagiarism or copyright infringements. In respect of any such infringement or suspected infringement of the copyright in the Work, IntechOpen shall have absolute discretion in addressing any such infringement that is likely to affect IntechOpen's rights under this Publication Agreement, including issuing and conducting proceedings against the suspected infringer.
\n\nIntechOpen has the right to include/use the Author and Co-Authors names and likeness in connection with scientific dissemination, retrieval, archiving, web hosting and promotion and marketing of the Work and has the right to contact the Author and Co-Authors until the Work is publicly available on any platform owned and/or operated by IntechOpen.
\n\nMISCELLANEOUS
\n\nFurther Assurance: The Author shall ensure that any relevant third party, including any Co-Author, shall execute and deliver whatever further documents or deeds and perform such acts as IntechOpen reasonably requires from time to time for the purpose of giving IntechOpen the full benefit of the provisions of this Publication Agreement.
\n\nThird Party Rights: A person who is not a party to this Publication Agreement may not enforce any of its provisions under the Contracts (Rights of Third Parties) Act 1999.
\n\nEntire Agreement: This Publication Agreement constitutes the entire agreement between the parties in relation to its subject matter. It replaces all prior agreements, draft agreements, arrangements, collateral warranties, collateral contracts, statements, assurances, representations and undertakings of any nature made by, or on behalf of, the parties, whether oral or written, in relation to that subject matter. Each party acknowledges that in entering into this Publication Agreement it has not relied upon any oral or written statements, collateral or other warranties, assurances, representations or undertakings which were made by or on behalf of the other party in relation to the subject matter of this Publication Agreement at any time before its signature (known as the "Pre-Contractual Statements"), other than those which are set out in this Publication Agreement. Each party hereby waives all rights and remedies which might otherwise be available to it in relation to such Pre-Contractual Statements. Nothing in this clause shall exclude or restrict the liability of either party arising out of any fraudulent pre-contract misrepresentation or concealment.
\n\nWaiver: No failure or delay by a party to exercise any right or remedy provided under this Publication Agreement or by law shall constitute a waiver of that or any other right or remedy, nor shall it preclude or restrict the further exercise of that or any other right or remedy. No single or partial exercise of such right or remedy shall preclude or restrict the further exercise of that or any other right or remedy.
\n\nVariation: No variation of this Publication Agreement shall have effect unless it is in writing and signed by the parties, or their duly authorized representatives.
\n\nSeverance: If any provision, or part-provision, of this Publication Agreement is, or becomes invalid, illegal or unenforceable, it shall be deemed modified to the minimum extent necessary to make it valid, legal and enforceable. If such modification is not possible, the relevant provision or part-provision shall be deemed deleted. Any modification to, or deletion of, a provision or part-provision under this clause shall not affect the validity and enforceability of the rest of this Publication Agreement.
\n\nNo partnership: Nothing in this Publication Agreement is intended to, or shall be deemed to, establish or create any partnership or joint venture or the relationship of principal and agent or employer and employee between IntechOpen and the Author or any Co-Author, nor authorize any party to make or enter into any commitments for, or on behalf of, any other party.
\n\nGoverning law: This Publication Agreement and any dispute or claim, including non-contractual disputes or claims arising out of, or in connection with it, or its subject matter or formation, shall be governed by and construed in accordance with the law of England and Wales. The parties submit to the exclusive jurisdiction of the English courts to settle any dispute or claim arising out of, or in connection with, this Publication Agreement, including any non-contractual disputes or claims.
\n\nPolicy last updated: 2018-09-11
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