Cephalometric analysis (Tweed-Merrifield)
\\n\\n
IntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\\n\\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\\n\\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\\n\\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\\n\\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\\n\\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\\n\\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\\n\\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\\n\\nFeel free to share this news on social media and help us mark this memorable moment!
\\n\\n\\n"}]',published:!0,mainMedia:{caption:"",originalUrl:"/media/original/237"}},components:[{type:"htmlEditorComponent",content:'
After years of being acknowledged as the world's leading publisher of Open Access books, today, we are proud to announce we’ve successfully launched a portfolio of Open Science journals covering rapidly expanding areas of interdisciplinary research.
\n\n\n\nIntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\n\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\n\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\n\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\n\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\n\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\n\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\n\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\n\nFeel free to share this news on social media and help us mark this memorable moment!
\n\n\n'}],latestNews:[{slug:"intechopen-supports-asapbio-s-new-initiative-publish-your-reviews-20220729",title:"IntechOpen Supports ASAPbio’s New Initiative Publish Your Reviews"},{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"}]},book:{item:{type:"book",id:"7514",leadTitle:null,fullTitle:"Biofuels - Challenges and opportunities",title:"Biofuels",subtitle:"Challenges and opportunities",reviewType:"peer-reviewed",abstract:"Amongst concerns about climate change, energy security decline and depletion of fossil fuels, this book explores the high importance of and interests in alternative energy resources. Many studies have shown that biomass fuels are sustainable, environmentally friendly and can be the most appropriate replacement to the depleting crude oil. Additionally, they can expand green landscapes, create new job opportunities, be directly utilised in standard power systems and improve combustion performance. Biomass fuels can be limited due to production cost and competition with food. Therefore, plant and food wastes play an important role in reducing these costs and recycling dump bio-materials. Production of biofuels from non-food biomass has emerged as a sustainable option to tackle the problems associated with growing demands for energy.",isbn:"978-1-78985-536-4",printIsbn:"978-1-78985-535-7",pdfIsbn:"978-1-83962-071-3",doi:"10.5772/intechopen.76490",price:119,priceEur:129,priceUsd:155,slug:"biofuels-challenges-and-opportunities",numberOfPages:188,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"e8346cbab8dc0782736f2976dd8889f8",bookSignature:"Mansour Al Qubeissi",publishedDate:"March 13th 2019",coverURL:"https://cdn.intechopen.com/books/images_new/7514.jpg",numberOfDownloads:12335,numberOfWosCitations:11,numberOfCrossrefCitations:17,numberOfCrossrefCitationsByBook:1,numberOfDimensionsCitations:50,numberOfDimensionsCitationsByBook:3,hasAltmetrics:1,numberOfTotalCitations:78,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"March 21st 2018",dateEndSecondStepPublish:"April 11th 2018",dateEndThirdStepPublish:"June 10th 2018",dateEndFourthStepPublish:"August 29th 2018",dateEndFifthStepPublish:"October 28th 2018",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"241686",title:"Dr.",name:"Mansour",middleName:null,surname:"Al Qubeissi",slug:"mansour-al-qubeissi",fullName:"Mansour Al Qubeissi",profilePictureURL:"https://mts.intechopen.com/storage/users/241686/images/system/241686.png",biography:"Dr. Al Qubeissi is a Chartered Engineer, Fellow of the Higher Education Academy, member of several engineering organisations (including UnICEG, IAENG–ISME, IMechE and the Institute for Future Transport and Cities), and Senior Lecturer and Course Director for Master of Engineering programmes at CU. He is experienced in computational thermo-fluids, biofuels and energy systems. Other relevant expertise includes turbine combustion, PV/T and battery thermal management. His research efforts have been disseminated via 10s of publications in high impact refereed journals, conference proceedings and books. Since joining CU in 2015, Dr. Al Qubeissi has been involved in leading 10s of research projects and PhD theses. Prior to that role, he was a Lecturer at the University of Brighton, UK.",institutionString:"Coventry University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"Coventry University",institutionURL:null,country:{name:"United Kingdom"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"885",title:"Bioenergy",slug:"sustainable-energy-bioenergy"}],chapters:[{id:"65383",title:"Introductory Chapter: Biofuels - Challenges and Opportunities",doi:"10.5772/intechopen.84267",slug:"introductory-chapter-biofuels-challenges-and-opportunities",totalDownloads:1073,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:0,abstract:null,signatures:"Mansour Al Qubeissi",downloadPdfUrl:"/chapter/pdf-download/65383",previewPdfUrl:"/chapter/pdf-preview/65383",authors:[{id:"241686",title:"Dr.",name:"Mansour",surname:"Al Qubeissi",slug:"mansour-al-qubeissi",fullName:"Mansour Al Qubeissi"}],corrections:null},{id:"64671",title:"Valorization of Wastes for Biodiesel Production: The Brazilian Case",doi:"10.5772/intechopen.81879",slug:"valorization-of-wastes-for-biodiesel-production-the-brazilian-case",totalDownloads:1221,totalCrossrefCites:0,totalDimensionsCites:3,hasAltmetrics:0,abstract:"This chapter intends to bring an overview about the Brazilian researches and their contributions to the production of biodiesel from wastes. Currently, the main obstacles to spread the use of biodiesel are its high cost of production and the competition between biodiesel and food industries. So, the use of wastes plays an important role in reducing the biodiesel costs and reusing the materials that have no other applications, as deodorization residues, neutralization soap sticks, and animal fats, among others. Then, we present a review about Brazilian studies involving waste oils and fatty–acid-rich raw materials that helped the advancement in this field of knowledge during the last few years.",signatures:"Luís Adriano Santos do Nascimento, Deborah Terra de Oliveira, Alex\nNazaré de Oliveira, Luiza Helena de Oliveira Pires, Carlos Emmerson\nFerreira da Costa and Geraldo Narciso da Rocha Filho",downloadPdfUrl:"/chapter/pdf-download/64671",previewPdfUrl:"/chapter/pdf-preview/64671",authors:[null],corrections:null},{id:"63911",title:"Properties of Torrefied Palm Kernel Shell via Microwave Irradiation",doi:"10.5772/intechopen.81374",slug:"properties-of-torrefied-palm-kernel-shell-via-microwave-irradiation",totalDownloads:1180,totalCrossrefCites:0,totalDimensionsCites:3,hasAltmetrics:0,abstract:"This study describes the characteristic and thermal properties of torrefied palm kernel shell (PKS) by microwave irradiation pretreatment. The microwave power level (200, 300, 450, and 600 W) and processing time (4, 8, and 12 min) were used in this study. The pretreated samples were analyzed for mass and energy yield, calorific value, proximate and elemental composition, and thermal decomposition. Results showed that the characteristic of pretreated PKS was enhanced by increasing the microwave power level and processing the time. The oxygen content and O/C ratio of torrefied PKS were reduced by increasing the microwave power level. The carbon content of pretreated PKS, which was closed to the untreated MB coal properties with comparable calorific value, was obtained. The microwave power level of 450 W and processing time of 8 min were suitable to upgrade the PKS to a respectable quality feedstock. Thus, it can be concluded that the alteration in physical, chemical, and thermal properties of torrefied PKS discovered the potential of this feedstock to be applied in subsequent thermochemical conversion such as pyrolysis and gasification.",signatures:"Razi Ahmad, Mohd Azlan Mohd Ishak, Nur Nasulhah Kasim and\nKhudzir Ismail",downloadPdfUrl:"/chapter/pdf-download/63911",previewPdfUrl:"/chapter/pdf-preview/63911",authors:[null],corrections:null},{id:"63927",title:"Chemical Kinetic and High Fidelity Modeling of Transesterification",doi:"10.5772/intechopen.80008",slug:"chemical-kinetic-and-high-fidelity-modeling-of-transesterification",totalDownloads:872,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"The modeling and simulation of transesterification require an understanding of the chemical reactions that take place inside the reactor. The development of reaction mechanism of the multiple step triglyceride, triglycerides and mono-glycerides and their reversal reaction is beyond the interest of chemical or mechanical engineers, whose main interests are to assess the conversion overall and to establish performance process metrics. This chapter undertakes the transesterification conversion by firstly establishing and formulating the overall process kinetics as far as the rate constant and activation energy. Secondly, use the obtained kinetic values to carry out high fidelity reactive flow of the multiple species which are co-present inside the reactor and otherwise complex to capture experimentally. Following these two steps, this work provides qualitative and quantitative information on the concentration of the reactants, intermediates and the overall yield. This two-step-approach can also be utilized as reactor design tool and gaining in-depth insight on reaction progress and species distribution. Experimental results, high-fidelity numerical results, and parametric sensitivity studies will be introduced and discussed.",signatures:"Isam Janajreh and Manar Almazrouei",downloadPdfUrl:"/chapter/pdf-download/63927",previewPdfUrl:"/chapter/pdf-preview/63927",authors:[null],corrections:null},{id:"63045",title:"Measurement of Limited and Unlimited Emissions during Burning of Alternative Fuels in the Tractor’s Engines",doi:"10.5772/intechopen.79705",slug:"measurement-of-limited-and-unlimited-emissions-during-burning-of-alternative-fuels-in-the-tractor-s-",totalDownloads:913,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"This text is aimed at the basic analysis of diesel oil and rapeseed methyl ester and evaluation of limited and unlimited emission produced by their combustion. Thereafter, test results are compared, and the evaluation of emission—greenhouse gases, dangerous exhaust gases and strong carcinogens and their contents during fuel combustion—is done. In this chapter, results obtained from the application of biofuel to the machinery working in conditions sensitive to environmental contamination are presented. At present, our environment is excessively overloaded with all kinds of emission, and the idea of using fuel with a marginal impact on the environment is very important. Based on the evaluation of emission, it can be stated that it is very important to study not only limited but also unlimited emission that can be very dangerous, although in this work it was discovered that values of unlimited emission do not exceed the lethal limit.",signatures:"Juraj Jablonický, Danela Uhrínová, Juraj Tulík and Ján Polerecký",downloadPdfUrl:"/chapter/pdf-download/63045",previewPdfUrl:"/chapter/pdf-preview/63045",authors:[null],corrections:null},{id:"63352",title:"Development and Implementation of Virtual Instrumentation for the Measurement of Operating Parameters of an Engine Using Diesel-Biodiesel Mixtures",doi:"10.5772/intechopen.80533",slug:"development-and-implementation-of-virtual-instrumentation-for-the-measurement-of-operating-parameter",totalDownloads:1098,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"Through a reaction of alkaline transesterification of soybean oil using sodium methoxide, biodiesel denominated as B100 was obtained, with which four mixtures of diesel-biodiesel B2, B5, B10, and B20 were prepared. Kinematic viscosity and high heating value of the four blends, B100, and diesel were determined. The blends, B100, and diesel were used in a motor of four cylinders in-line engine, air intake at atmospheric pressure with a power of 250 hp and 6000 cm3, operating at a constant rate of 850 ± 50 rpm, a temperature of 25°C, and a relative humidity of 50%. To monitor the emissions, rpm, fuel consumption, and temperature in the engine’s exhaust manifold, which operates with diesel-biodiesel mixtures, an integral instrument that uses the virtual instrumentation technology was developed in the programming platforms LabVIEW 2010 and ARDUINO. The development and implementation of the virtual instrument allow monitoring in real time the parameters of internal combustion engines and presents the versatility, flexibility, scalability, and capacity to function in equipment that operates with different liquid fuels at a lower cost than the one that conventional systems offered. These characteristics represent a significant benefit in comparison with the measurement and monitoring systems in the present market.",signatures:"Armando Pérez, Rogelio Ramos, Gisela Montero, Conrado García,\nMarcos Coronado, Héctor Campbell, René Delgado and Alejandro\nSuástegui",downloadPdfUrl:"/chapter/pdf-download/63352",previewPdfUrl:"/chapter/pdf-preview/63352",authors:[null],corrections:null},{id:"63170",title:"Engineering Microbial Consortia for Bioconversion of Multisubstrate Biomass Streams to Biofuels",doi:"10.5772/intechopen.80534",slug:"engineering-microbial-consortia-for-bioconversion-of-multisubstrate-biomass-streams-to-biofuels",totalDownloads:1339,totalCrossrefCites:8,totalDimensionsCites:12,hasAltmetrics:0,abstract:"Production of biofuels from nonfood biomass has emerged as a sustainable option to address the problems associated with growing enery demand for transportation, heating, and industrial processes, in the context of diminishing petroleum reserves and global climate change. Biomass resources such as lignocellulose-rich biomass and microalgae, despite being abundant pose several challenges for efficient bioconversion to biofuels. Major challenges that must be addressed are the chemical complexity of the biomass and the associated feedstock variability. In this chapter, the role of microbial consortium-based biocatalysis strategies that are being developed to address these issues are reviewed and discussed. Microbial coculture biocatalysts are systems that are engineered to specialize in the conversion of a general class of substrates present in the biomass hydrolysates into biofuel intermediates, providing the capability of adapting to the variable composition of the feedstock. The techniques being developed to understand the interactions between the members of the bioconversion consortia and the corresponding population dynamics of the engineered cocultures are also discussed.",signatures:"Fang Liu, Eric Monroe and Ryan W. Davis",downloadPdfUrl:"/chapter/pdf-download/63170",previewPdfUrl:"/chapter/pdf-preview/63170",authors:[null],corrections:null},{id:"63144",title:"Effect of Binary Fuel Blends on Compression Ignition Engine Characteristics: A Review",doi:"10.5772/intechopen.80566",slug:"effect-of-binary-fuel-blends-on-compression-ignition-engine-characteristics-a-review",totalDownloads:902,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Diversified research in alternate sources arises become necessity due to higher consumption of fossil fuels along with their adverse impacts on the environment, even to the point of complete elimination of diesel from compression-ignition (CI) engines. Binary fuel blend (a blend of low and high viscous fuel) is one of the best environmentally friendly alternative in CI engines. Blending of methyl ester with edible and nonedible oils in different volumetric ratios has the potency to give a stable mixture and that can be used as a fuel in diesel engines. The main motive for the blending of two fuels is that the inferior properties of one biofuel remunerate from improved properties of the other fuel considerably improves the physicochemical properties of the blend. The present study provides comprehensive information on the emission and performance characteristics of binary biodiesel-oil fuel blends. Most researchers had suggested optimum blends from their respective studies that support capability for complete elimination of diesel from CI engines. Some researchers have used this binary fuel blend with minor adjustments to the engine parameters. These investigations have provided positive results. The comprehensive review concluded that binary fuel approach has potential to completely eliminate diesel from CI engines.",signatures:"Paramvir Singh, S.R. Chauhan and Varun Goel",downloadPdfUrl:"/chapter/pdf-download/63144",previewPdfUrl:"/chapter/pdf-preview/63144",authors:[null],corrections:null},{id:"64099",title:"Comparison of Ethanol and Methanol Blending with Gasoline Using Engine Simulation",doi:"10.5772/intechopen.81776",slug:"comparison-of-ethanol-and-methanol-blending-with-gasoline-using-engine-simulation",totalDownloads:2436,totalCrossrefCites:5,totalDimensionsCites:19,hasAltmetrics:1,abstract:"During the last years, concerns regarding climate change, decline of energy security, and hydrocarbon reserves have resulted in a wide interest in renewable alternative sources for transportation fuels. Methanol and ethanol have been possible candidates as alternative fuels for the internal combustion engines because they are liquid and have several physical and combustion properties which resemble those of gasoline. Therefore, the aim of this study is to develop the one-dimensional model of a gasoline engine for predicting the effect of various fuel types on engine performances, specific fuel consumption, and emissions. Commercial software AVL BOOST was used to examine the engine characteristics for different blends of methanol, ethanol, and gasoline (by volume). A comparison was made between the results gained from the engine simulation of different fuel blends and those of gasoline. They show that when blended fuel was used, the engine brake power decreased and the BSFC increased compared to those of gasoline fuel. When blended fuel increases, the CO and HC emissions decrease, and there is a major increase in NOx emissions when blended fuel increases up to 30% M30 (E30). Increase in the percentage of ethanol and methanol leads to a significant increase in NOx emissions.",signatures:"Simeon Iliev",downloadPdfUrl:"/chapter/pdf-download/64099",previewPdfUrl:"/chapter/pdf-preview/64099",authors:[null],corrections:null},{id:"62841",title:"Biodiesel in Brazil Should Take Off with the Newly Introduced Domestic Biofuels Policy: RenovaBio",doi:"10.5772/intechopen.79670",slug:"biodiesel-in-brazil-should-take-off-with-the-newly-introduced-domestic-biofuels-policy-renovabio",totalDownloads:1301,totalCrossrefCites:1,totalDimensionsCites:8,hasAltmetrics:0,abstract:"Our planet’s climate has experienced changes mainly ascribed to the emission of carbon dioxide (CO2), which accumulates in the atmosphere and causes an increase in the Earth’s average temperature. In 2015, heads of state and scientists from several countries met in Paris to discuss measures aimed at curbing greenhouse gas emissions in order to limit that temperature rise to 2°C by the end of this century. As CO2 needs to be banned from our environment for the sake of our own planet, it is reasonable for biofuels to present themselves as clean alternatives for the gradual replacement of fossil fuels. Biodiesel stands as an option. After 2005, some public policies were created in Brazil as an attempt to establish biodiesel as a replacement for mineral diesel, mainly in the transport sector. Although moderately successful, none of them compare in scope and reach to RenovaBio, a domestic biofuels policy that will make the production and use of biodiesel take off, once and for all. Therefore, herein, we present a brief overview on the status of the biodiesel production and use before the enactment of this new biofuels policy and the forecast of what it is expected to happen after its implementation.",signatures:"Fernando C. De Oliveira and Suani T. Coelho",downloadPdfUrl:"/chapter/pdf-download/62841",previewPdfUrl:"/chapter/pdf-preview/62841",authors:[null],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"8871",title:"Renewable Energy",subtitle:"Resources, Challenges and Applications",isOpenForSubmission:!1,hash:"e00c59554fb355c16623c62064ecc3bb",slug:"renewable-energy-resources-challenges-and-applications",bookSignature:"Mansour Al Qubeissi, Ahmad El-kharouf and Hakan Serhad Soyhan",coverURL:"https://cdn.intechopen.com/books/images_new/8871.jpg",editedByType:"Edited by",editors:[{id:"241686",title:"Dr.",name:"Mansour",surname:"Al Qubeissi",slug:"mansour-al-qubeissi",fullName:"Mansour Al Qubeissi"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6784",title:"Biofuels",subtitle:"State of 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3092",title:"Anopheles mosquitoes",subtitle:"New insights into malaria vectors",isOpenForSubmission:!1,hash:"c9e622485316d5e296288bf24d2b0d64",slug:"anopheles-mosquitoes-new-insights-into-malaria-vectors",bookSignature:"Sylvie Manguin",coverURL:"https://cdn.intechopen.com/books/images_new/3092.jpg",editedByType:"Edited by",editors:[{id:"50017",title:"Prof.",name:"Sylvie",surname:"Manguin",slug:"sylvie-manguin",fullName:"Sylvie Manguin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"47810",title:"Non-Surgical Treatment of Class III with Multiloop Edgewise Arch-Wire (MEAW) Therapy",doi:"10.5772/59257",slug:"non-surgical-treatment-of-class-iii-with-multiloop-edgewise-arch-wire-meaw-therapy",body:'The incidence of class III malocclusion among the western population is low, but in Japan and South Korea is high and since many patients don`t accept orthognatic surgery, a conservative/camouflage treatment is often necessary. The MEAW (multiloop edgewise arch wire) was developed in 1967 by Dr. Young H. Kim to correct open bite malocclusions and was found to be extremely effective. Further development of Meaw technique extends its application to treat any type of malocclusion, especially Class III malocclusion.
The MEAWs are constructed with 0.016 x 0.022stainless steel (bracket 0.018 inch slot) or 0.017x0.025 stainless steel (bracket 0.022– inch slot). The arches have ideal arch form with five loops on each side of the arch.
Prof. Sadao Sato developed the use of MEAW and introduced different concepts about the etiology of malocclusions. According to Sato genetics may not be the only reason to class III malocclusion, the posterior discrepancy may be the major contributing factor to class III malocclusion.
The degree of basicranial flexion differs in the various types of malocclusion. According to Hooper (1986) the spheno-basilar articulation is the most important among the cranial bones and it is where the movement of flexion-extension occurs. The cranial base angles (Na-S-Ar) comes to approximately 124,2 ° in class I patterns.
From this average value a more obtuse (extension) angle indicates skeletal Class II and a more acute (flexion) angle means skeletal Class III.The rotating movement of the cranial base (flexion/extension) occurs at the spheno-occipital articulation and it is transmitted to the maxilla through the Vomer. This dynamic mechanism has a great influence on the growth pattern of an individual during the growth period.
When the sphenoid makes flexion the rotating force of the vomer is postero-inferior and the maxilla is strongly pushed down. This causes vertical elongation of the maxillary complex, short anteroposterior dimension and posterior crowding. This is related to the development of a class III skeletal frame (Sato 2001).
The posterior discrepancy increases the probability of wisdom teeth impaction and once their impaction occurs a “squeezing-out “effect may occur, causing an over-eruption of the adjacent teeth, flatten the posterior occlusal plane and an increase in the posterior occlusal vertical dimension. The over-erupted molars produce occlusal interferences that act as a fulcrum causing a mandibular forward adaptation with subluxation of the mandibular condyles and active remodeling of the condylar cartilage. The result is a mandibular prognathism.
The skeletal Class III relationships may be due to a lack of sagital development of maxillary or mandibular overdevelopment, or a combination of both.
Skeletal class III malocclusion is usually characterized by a steep mandibular plane angle, obtuse gonial angle, a small cranial base angle which may displace the glenoid fossa anteriorely to cause a forward positioning of the mandible, flat occlusal plane, short antero posterior diameter of the maxilla, increased vertical growth of the maxilla, labial tipping of the maxillary teeth, lingual tipping of the mandibular teeth.
In adults patients,without growing ability, orthognatic surgery is indicated for severe skeletal class III malocclusion, but moderate class III cases (borderline cases) can be treated orthodontically if the patients refuse surgery. The MEAW is often used in skeletal class III treatment without orthognatic surgery or extraction of intermediate teeth.
The objectives of the treatment are: a) to eliminate posterior discrepancy, b) to intrude the posterior teeth and to upright them, c) reconstruction the occlusal plane (steepning the occlusal plane) which induces mandibular backward adaption. The entire lower dentition is moved distally and uprighted using a MEAW with short class III elastics after extraction of the third molars. The skeletal features of the class III malocclusions are closely related to the deviation in the vertical aspect of the occlusion. According to this correcting the occlusal plane by controlling the vertical dimension is extremely important in the treatment of class III malocclusion.
To eliminate the posterior discrepancy, the upper and lower third molars should be extracted prior to the onset of treatment. The upper second molars can be extracted, if the patient is young and if the the upper third molars have quality in terms of size, shape and direction of eruption. This approach will allow steepen the occlusal plane with the elimination of the “squeezing-out effect “at the upper molars. The treatment mechanics use tip back bend activations of the MEAW and vertical or short class III elastics (3/16 inch – 6 oz) on the anterior teeth.
The steps of treatment of the class III malocclusion are: a) Levelling, b) elimination of occlusal interference,,c) establishing mandibular position d) reconstruction of the occlusal plane, e) achieving a physiological occlusion.
Sassouni and Nanda (1964) proved the vertical disproportion were, in many cases, at the origin of anteroposterior dysplasias. Therefore, treatment strategies should focus on vertical control in order to correct anteroposterior disharmony.
Angle(1899) – The class III malocclusion occurred when lower teeth occluded mesial to their normal relationship by the width of one premolar or even more in extreme cases.The class III can be defined as a skeletal facial deformity characterized by a forward mandibular position with respect to the cranial base and/or maxilla.
Genetics-an example is the famous mandibular prognathism of Habsburg family.
Syndromes
Crouzon syndrome
Acromegaly
Gorlin and Goltz syndrome Hypertrophy
Cleido cranial dysplasia
Achondroplasia
Environmental factors-ex : thyroid deficiency cause large tongue, causing mandibular prognathism
Functional factors
Naso-respiratory diseases and enlarged tonsils
Mental diseases-compulsive habits of protruding the mandible
Posterior crowding – “The posterior squeezing out effect “
Moyers classified the class III malocclusion according the cause: osseous; muscular; dental.According to him, it was necessary to determine whether the mandible on closure was in centric relation or “convenient” anterior position.
In 1966 Charles Tweed divided class III malocclusion in pseudoclass III and skeletal class III. Tweed also divided the class III onto two distinct categories : The category A-the FMA ranges between 10° and 22°,with a large mandible ; underdeveloped maxilla and a ANB between 7° to 10° and the category B – FMA ranges between 30° to 50° with an obtuse gonial angle and a lower lip overactive.
The characteristics of Pseudoclass III are the following: normal mandible and underdeveloped maxilla, concave straight profile, skeletal pattern is class I, normal gonial angle and the retrusion of the mandible is possible.
The skeletal class III discrepancy may be the result of a large mandible, a small maxilla, a distally positioned maxilla or a combination of the three. Vertically the class III can be divided in high angle, average and low angle.
The class III subdivision is characterized by a class I molar relation on one side and a class III on the other side.
The diagnostic criteria for pseudo class III according to Rabie and Yan Gu (AJODO 2000) is the following : a) 72 % showed no family history; b) molar class I in CR and class III at habitual occlusion ; c)decreased midface length ; d) forward mandibular position with normal length ; e) retroclined upper incisors with normal lower incisors; f) presence of mandibular anterior sliding into a edge-to-edge or crossbite relationship due to premature tooth contact (with CO–CR discrepancy), absence of skeletal signs of class III malocclusion. The differential diagnosis of skeletal class III malocclusion with skeletal class I include the following differences:
In class III the SNA is lower
The SNB is greater in class III
The mean ANB angle in class III is negative
The gonial angle is more open in class III
The lower anterior facial height is increased
Cranial base angle is smaller in class III patients
The dentoalveolar class III malocclusion present a normal ANB angle and a lingual tipping of upper incisors and labial tipping of lower incisors. The skeletal class III malocclusion show a maxillary retrusion or mandibular protrusion, or both with negative ANB, increased mandibular length, increased gonial angle, labial tipping of upper incisors and lingual tipping of lower incisors.
There are three important diagnostic principles of class III such as:
To determine whether the mandible on closure is in centric relation or in a “convenient “ anterior position
Identify the nature of skeletal discrepancy
To evaluate the potential growth and development of a patient with a class III malocclusion
The ideal age to treat pseudo class III is between 6 to 9 years, because treating the pseudo class III during the mixed dentition has some advantages such as : the stability of correction is better, prevent unfavourable growth of skeletal frame,prevent deleterious habits.There are many options to treat the pseudo class III malocclusion such as : equilibration of occlusion, bionator appliance, fixed appliance, acrylic crowns, acrylic inclined planes, functional appliance therapy, and orthopaedic appliances.
During the primary, mixed and permanent dentition the growth is present and the treatment is different from when the growth is finished. The first step is to distinguish if the class III is due to maxillary undergrowth, mandibular overgrowth or both or a skeletal class I with anterior cross bite. When the class III is due to mandibular overgrowth the options of treatment are : chin cap therapy, reverse class III activator (to produce retrusive force on the mandible), low or high pull head gear (HPHG) to control posterior eruption.
When class III is due to maxillary undergrowth and/or retrognatic maxillary with a orthognatic mandible, it is necessary to promote the growth and protact the maxillary using a face mask (Delaire or Petit) or a functional appliance therapy (activator or Frankel III regulator).
The treatment of class III in adults and non growing patients can be a surgical treatment or a camouflage treatment. When a non growing patient is diagnosed as a class III malocclusion and has a strong skeletal component, the treatment of choice is usually orthodontic/orthognatic surgery. After determined that the surgery will be necessary the surgeon usually waits until the growth is finished. Maxillary growth may be completed at age 14-15 years, but mandibular growth may continue until 20 years. Then the orthodontist will decompensate the incisors and after that the surgery will be done.
Beyond the adolescent growth spurt, to correct a mild skeletal class III, teeth must be displaced relative to their supporting bone to mask the underlying class III discrepancy by dental compensation. This is termed camouflage treatment. A patient with class III malocclusion, with the growth completed, a slight skeletal class III, acceptable alignment of teeth and acceptable facial proportions is a good candidate for a camouflage treatment. Since 1967 the MEAW technique has proved to be an effective treatment camouflage and a non-surgical treatment of class III malocclusion. The extraction theraphy of premolars may have limited applicability in class III treatment, for example extractions in the lower arch will increase the lingual inclination of the incisors which were already inclined. Another contraindication to extract is the cases that combine orthodontics and surgery.
Many times during the diagnosis process the etiology of the malocclusion and the mechanism of its development are depreciated. The cephalometric analysis doesn`t clearly shows the cause of malocclusion, it only localizes the site of skeletal malocclusion and shows the degree of deviation. This means that current orthodontics many times identifies and treats symptoms rather than aiming the cause. Hence there is a need for the insertion of a new treatment philosophy based on the function rather than esthetic needs of the patient. It is necessary to understand the dynamic mechanism of development of malocclusion and to know the treatment technique for orthodontic occlusal reconstruction.
During the human evolution the cranial base was modified with the bipedalism and erect posture, producing a flexion of the cranial base and a displacement of the foramen occipitale magnum from one end to the middle of the skull. The result of this displacement, is a vertical growth pattern rather than horizontal. The degree of basicranial flexion is different according to the type of malocclusion. Thus a cranial base angle (Na-S-Ar) about 124,2 degrees is characteristic of class I pattern. When the angle is closed to 130 degrees (extension of cranial base) indicates a class II malocclusion and a more acute angle closer to 120 degrees (flexion) indicates a skeletal class III. If more severe is the class III pattern, more pronounced is the flexion of the cranial base and greater is the tendency of vertical growth. Thus the vertical component of class III malocclusion is very important, contrary to be considered just a sagital problem. According to this the use of chin cap, long class III elastics, premolar extraction, surgery are treatment approaches of skeletal class III malocclusion in the sagital direction, neglecting the vertical component. When the angle of cranial base presents a flexion, the rotating movement occurs at the spheno-occipital synchondrosis and it is transmitted to the maxillary through the vomer. This dynamic mechanism affects the growth pattern of the growing patients. With the flexion of the sphenoid, the rotating force of the vomer is posteroinferior and the maxillary is pushed dowm. This produce vertical elongation, undersized sagital dimension and posterior crowding of the maxillary. The lack of maxillary translation creates a deficit of space in the tuberosity, and a posterior crowding, that causes the “squeezing out effect “. The squeezing out effect is an over-eruption of the molars and modifies the inclination of the occlusal plane, making it flatter. Once the over-eruption of the molars occurs, then occlusal interferences appear and in order to avoid them, the mandible adapts forward.This mandibular forward movement, produces a distraction of the mandibular condyles and active reformulation of the condylar cartilage, resulting in mandibular prognathism.
The dynamic mechanism of the development of class III malocclusion
The class III malocclusion has the following characteristics:
Increased vertical dimension
short maxillary length
posterior crowding
Increased FH-MP angle
Labial tipping of maxillary teeth
lower anterior teeth are inclined lingually (dento-alveolar compensation)
ANB angle is negative
flexion of the cranial base
Skeletal frame is class III (APDI is more than 85)
It is very important to understand the dynamic mechanism of the development of class III malocclusion to establish a correct treatment plan. In the development of class III malocclusion the key point is the molar over-eruption (due to the posterior crowding) which is responsible for the flatness of the upper posterior occlusal plane.The upper posterior flat occlusal plane produces a forward mandibular adaptation. According to this there are two significant goals to attain with the treatement of class III:
Elimination of the posterior crowding
To Rebuilt the occlusal plane (to steepen the upper posterior occlusal plane)
The posterior crowding is usually solved, by extraction of third molars prior to the onset of the treatment. The upper second molars can be extracted if the patient is young and the third molars are too high in the tuberosity. Before the decision to extract the upper second molars, the third molars should be radiographically evaluated to check if they have correct size and shape as well as appropriate position and inclination to erupt properly, replacing the extracted second molars. Another significant goal to attain with the treatment of class III is the reconstruction of the occlusal plane, because the class III malocclusion requires a steeper occlusal plane for backward adaptation of the mandible. The tip back bends of the MEAW correct the premolars and molars to an upright position and intrude the molars. The correct treatment mechanics used are progressive tip back bends activations of 3° to 5° from the premolars teeth to molar area along with short class III elastics 3/16 inch, 6 oz) on the anterior teeth.
The tip back bends of MEAW
Levelling
Elimination of occlusal interferences
Establishig mandibular position
Occlusal plane reconstruction
Obtain a physiologic occlusion
The MEAW’s are constructed with.016x.022 stainless steel (bracket 0.018 – inch slot) or.017x.025 ss (bracket 0.022 – inch slot).
The arches have ideal arch form with five loops on each side of the arch.
Patient female 13 years old and 3 months of age, with skeletal class III and dental class III on a normodivergent face pattern, mandibular prognathism, overbite (0 mm), overjet (0 mm), flat occlusal plane in the upper molar area producing interference in the posterior area. The patient began the treatment with 13 years old and 3 months and the duration of the treatment was 18 months. The type of appliance was an edgewise multi-bracket 0,022x0,028 slot, 0° torque, 0° angulation and MEAWs arch wires. The appliance was removed in January 2013 (14Y+11M).
The purpose of the treatment for this patient with class III malocclusion was to provide a steep occlusal plane in order to achive a posterior adaptative repositioning of the mandible, to correct the crowding and improve the occlusion by uprighting and alignment the dentition. First the impacted upper and lower third molars should be removed, but she refused. It was explained to the patient and the parents, that without the extractions the probability of relapse was high. It was then accepted to extract the teeth later, after the end of treatment.During the last control visit (one year after the end of treatment) the patient was informed that she should extract the third molars and she agreed.
The steps of the treatment:
a-Leveling; b-Elimination of occlusal interferences ; c-Establishing mandibular position ; d-Reconstruction of the occlusal plane; e-Achieving a physiological occlusion.
Step one-Levelling – The levelling was performed using 0.016 SS wire arches.
Step two-Elimination of occlusal interferences-0,017x0,025 multiloop edgewise archs wire (MEAW) were incorporated in both dental arches. The alignment and intrusion began through progressive tipback of 3° to 5°,from premolars to the molar area along with the use of short class III (3/16 inch, 6oz) elastics on both sides.
Step three-Establishing mandibular position: At the end of this phase the molar occlusion was in class one.
Step four/five-Reconstruction of the occlusal plane and achieving a physiological occlusion: In this step the tipback in molar area was removed and the occlusal plane in the molar area was steepen. A stable occlusion was obtained after 18 months of treatment the retention phase was done with maxillary Hawley plate for night time use (6months) and bonded lingual wire from 33 to 43.
Pre-treatment extraoral (A-C) and intraoral (D-F) photographs
Post-treatment results show an improved profile, occlusion and a pleasant smile. The intra-oral photos show a class I molar relationship and a correct overbite and overjet. The mandibular superposition shows a slight mandibular posterior shift.
\n\t\t\t | \n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t
FMIA | \n\t\t\t67º+- 3 | \n\t\t\t71 | \n\t\t\t77 | \n\t\t\t75 | \n\t\t
FMA | \n\t\t\t25º+- 3 | \n\t\t\t27 | \n\t\t\t28 | \n\t\t\t28 | \n\t\t
IMPA | \n\t\t\t88º+- 3 | \n\t\t\t82 | \n\t\t\t75 | \n\t\t\t77 | \n\t\t
SNA | \n\t\t\t82º+- 2 | \n\t\t\t85 | \n\t\t\t86 | \n\t\t\t86 | \n\t\t
SNB | \n\t\t\t80º+- 2 | \n\t\t\t85 | \n\t\t\t84 | \n\t\t\t84 | \n\t\t
ANB | \n\t\t\t2º-+ 2 | \n\t\t\t0 | \n\t\t\t2 | \n\t\t\t2 | \n\t\t
Ao-Bo | \n\t\t\t2mm | \n\t\t\t-2mm | \n\t\t\t3mm | \n\t\t\t3mm | \n\t\t
OP | \n\t\t\t10º-14º | \n\t\t\t6 | \n\t\t\t5 | \n\t\t\t5 | \n\t\t
Z | \n\t\t\t75º+-5 | \n\t\t\t91 | \n\t\t\t88 | \n\t\t\t88 | \n\t\t
PFH | \n\t\t\t45mm | \n\t\t\t45 | \n\t\t\t46 | \n\t\t\t46 | \n\t\t
AFH | \n\t\t\t65mm | \n\t\t\t62 | \n\t\t\t64 | \n\t\t\t66 | \n\t\t
INDEX | \n\t\t\t0,69 | \n\t\t\t0,73 | \n\t\t\t0,72 | \n\t\t\t0,70 | \n\t\t
Cephalometric analysis (Tweed-Merrifield)
\n\t\t\t | \n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t|||
ODI | \n\t\t\tMP/AB 60 | \n\t\t\t60 | \n\t\t\t60 | \n\t\t\t60 | \n\t\t\t60 | \n\t\t\t60 | \n\t\t
FH/PP 0 | \n\t\t\t0 | \n\t\t\t0 | \n\t\t||||
APDI | \n\t\t\tHF/FP 95 | \n\t\t\t93 | \n\t\t\t94 | \n\t\t\t87 | \n\t\t\t92 | \n\t\t\t87 | \n\t\t
FP/AB -02 | \n\t\t\t-05 | \n\t\t\t-05 | \n\t\t||||
HF/PP 0 | \n\t\t\t-2 | \n\t\t\t0 | \n\t\t||||
CF | \n\t\t\tODI+APDI | \n\t\t\t153 | \n\t\t\t\n\t\t\t | 147 | \n\t\t\t\n\t\t\t | 147 | \n\t\t
Cephalometric analysis (Kim)
pre-treatment records (A-C)
Photos during the treatment (A –M)
post-treatment extraoral (A-C) and intraoral (D-F) photos
Post-treatment records (A-D),superimpositions (E-F)
post-retention extra oral photos (A-C) and intraoral photos (D-F)
post-retention records (A – C)
superimpositions (A-C)
Patient female (15 years old/10 months), with skeletal class III (ANB-2°, APDI 91)and dental class III on a hypodivergent face pattern (FMA 22°), mandibular prognathism, open bite tendency (ODI 55); overjet (0 mm), flat occlusal plane in the molar area producing interference in the posterior area.
The z angle of 85° confirms an unbalanced face which is based on a prognathic chin.
According to Kym’s analysis, the ODI (55°) indicates a openbite skeletal pattern. The APDI (91°).indicates a class III skeletal pattern and the CF (combination factor of 146) indicates a skeletal pattern requiring extraction of permanent teeth (third molars). The posterior crowding was solved by extraction of third lower molars and upper second molars prior to the onset of the treatment. The upper second molars were extracted because the third molars were too high in the tuberosity. Before the decision to extract the upper second molars, the third molars were radiographically evaluated to check if they had correct size and shape as well as appropriate position and inclination to erupt properly, replacing the second molars.
Treatment began with age (15/10), 0.016 ss arch wires were inserted for levelling and alignment of both dental arches.
Pre-treatment extraoral(A-B-C) and intraoral (D-E-F) photos
After 2 months, the use of MEAW and short class III elastics (3/16 inch, 6 oz) started. The elastics were used 24 hours per day and were removed only for brushing the teeth and to eat. The correct treatment mechanic used was progressive tip back bends activations of 3° to 5° from the premolars teeth to molar area along with short class III elastics (3/16 inch, 6 oz) on the anterior teeth.
This treatment lasted 18 months. At the end of the treatment, the maxillofacial disharmony and the profile were improved. The patient displayed a pleasant smile, a normal canine and molar class I relationship, the overbite and overjet were corrected.
The lower incisors were lingually tipped (IMPA 85°) and the lower molars were moved distally.
Pre-treatment records (A-C)
\n\t\t\t | \n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t
FMIA | \n\t\t\t67º+- 3 | \n\t\t\t68 | \n\t\t\t74 | \n\t\t\t74 | \n\t\t
FMA | \n\t\t\t25º+- 3 | \n\t\t\t22 | \n\t\t\t21 | \n\t\t\t22 | \n\t\t
IMPA | \n\t\t\t88º+- 3 | \n\t\t\t90 | \n\t\t\t85 | \n\t\t\t84 | \n\t\t
SNA | \n\t\t\t82º+- 2 | \n\t\t\t73 | \n\t\t\t75 | \n\t\t\t75 | \n\t\t
SNB | \n\t\t\t80º+- 2 | \n\t\t\t75 | \n\t\t\t74 | \n\t\t\t74 | \n\t\t
ANB | \n\t\t\t2º-+ 2 | \n\t\t\t-2 | \n\t\t\t1 | \n\t\t\t1 | \n\t\t
Ao-Bo | \n\t\t\t2mm | \n\t\t\t-7mm | \n\t\t\t-2mm | \n\t\t\t-2mm | \n\t\t
OP | \n\t\t\t10º-14º | \n\t\t\t3 | \n\t\t\t3 | \n\t\t\t3 | \n\t\t
Z | \n\t\t\t75º+-5 | \n\t\t\t85 | \n\t\t\t80 | \n\t\t\t81 | \n\t\t
PFH | \n\t\t\t45mm | \n\t\t\t\n\t\t\t | \n\t\t\t | \n\t\t |
AFH | \n\t\t\t65mm | \n\t\t\t\n\t\t\t | \n\t\t\t | \n\t\t |
INDEX | \n\t\t\t0,69 | \n\t\t\t\n\t\t\t | \n\t\t\t | \n\t\t |
Cephalometric analysis (Tweed-Merrifield)
The general superimposition shows that the entire lower dental arch was moved distally and uprighted.
The final ODI of 63° show that the vertical aspect of the occlusion (open bite tendency) was improved. This case shows a successful orthodontic treatment of a skeletal class III malocclusion, eliminating the posterior crowding and reconstructing the occlusal plane using the MEAW technique.
Photos during the treatment.(A-P) with MEAW upper and lower and short class III elastics (6 oz, 3/16 inch).
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ODI | \n\t\t\tMP/AB 60 | \n\t\t\t55 | \n\t\t\t67 | \n\t\t\t63 | \n\t\t\t67 | \n\t\t\t63 | \n\t\t
FH/PP -5 | \n\t\t\t-4 | \n\t\t\t-4 | \n\t\t||||
APDI | \n\t\t\tHF/FP 92 | \n\t\t\t91 | \n\t\t\t92 | \n\t\t\t90 | \n\t\t\t92 | \n\t\t\t90 | \n\t\t
FP/AB 4 | \n\t\t\t2 | \n\t\t\t2 | \n\t\t||||
HF/PP -5 | \n\t\t\t-4 | \n\t\t\t-4 | \n\t\t||||
CF | \n\t\t\tODI+APDI | \n\t\t\t146 | \n\t\t\t\n\t\t\t | 153 | \n\t\t\t\n\t\t\t | 153 | \n\t\t
cephalometric analysis (Kim)
Post-treatment extraoral photos (A-C) and intraoral photos (D-F)
Post-treatment records
superimpositions (D – E)
Post-retention extraoral photos (A-C) and intraoral photos (D-F)
post-retention records (A –E)
The MEAW technique proved to be effective in the treatment of class III malocclusion. The MEAW is a valid alternative in the treatment of class III malocclusion, when patients refuse surgery and when the disharmony of the skeletal structure is not harsh. The MEAW used correctly can properly reconstruct the occlusal plane, allowing toachieve a correct and stable occlusion, improving the profil and facial balance.
The uterus is an organ with a particular anatomic situation localized with the uterine body intraperitoneally, the isthmus extra-peritoneally, and the cervix can be considered visible intravaginal organs. The uterine body is coated by the visceral peritoneum, which intimately adheres to its sides. In front, the visceral peritoneum reflects it on the bladder and in the back to the rectum. On the lateral side, the visceral uterine peritoneum detaches from the two sides of the uterus into two sheets that are joined to each other but are anatomically distinct and surgically separable, forming
The uterus is maintained in anatomical position inside the pelvis by two systems: a
The suspension and orientation system of the uterus consists of
The
The supporting system reunites all the elements that work together to maintain the uterus in its intrapelvic anatomical position and resist the descending tendency generated by the weight of the intestines at rest or under effort.
Biomechanical studies show that the support of the uterus and the upper part of the vagina are provided by the
The supporting system anchors the uterus and vagina to the pelvic brim: the
The cardinal ligament consists of three segments: Proximal and intermediate segments containing the mesenteric elements and the terminal ureter and a common segment with the homologous uterosacral ligament, which is the main support element of the pericervical ring.
Cardinal ligaments provide reliable support for the vascular and lymphatic axes that converge or emerge in the uterus. Their fibers dissipate in the pubocervicovesical fascia towards the cervix uteri and superior vagina at the level of the cervical ring, and the fascial and areolar structures towards the pelvic walls, structures that cover the pelvic diaphragm, the obturator pelvic fascia, and the tendinous arch of the pelvis (arcus taendineus fascia pelvis-ATFP). (Campbell).
Like the cardinal ligaments, the uterosacral ligaments defined three segments: a proximal segment that merges with the cardinal ligament, an intermediate segment that represents the structure that can be used as a suspension element, and a distal segment that merges with the presacral fascia. Sacrouterine ligaments contain nervous fibers from the superior hypogastric plexus. Those innervating the urinary bladder are of particular importance in nerve-sparing surgery for cervical cancer (Figure 3).
Definition of three segments of uterosacral ligaments. MRI reconstruction -spatial disposition of posteriorly oriented uterosacral ligaments (in green) and cardinal ligaments oriented vertically (in beige yellow), P = pubis arch, Isch = ischion, Il = ilion, S = sacrum.
Vaginal hysterectomy consists of disconnection from below of all elements that maintain the uterus in anatomical position.
From the vaginal point of view, the uterus suspension-supporting system consists of three main connective-vascular pedicles; lower, middle, and upper pedicles.
like abdominal hysterectomy, where the lower pedicle is most difficult to approach, vaginal hysterectomy solves this operative step as the first maneuver of the disconnection of the uterus.
Lower Pedicle
On the caudal side, the cervix and uterine isthmus provide insertion for two fibrous-connective structures: anteriorly,
The juxta vesical ureter, surrounded by fatty tissue, is located in the thickness of each pillar. The
The
The uterosacral ligaments on the lateral sides, towards their sacral insertion, are flanked by the hypogastric nerve, which, along with the pelvic nerves, will be part of the inferior hypogastric plexus. For this reason, sectioning the uterosacral ligaments in radical vaginal hysterectomy as close as possible to the sacral insertion bears the risk of urinary disorders occurring through bladder denervation. Laterally and caudally, the uterosacral ligaments continue with the superior paracolpium, and a division of them achieves the upper level of suspension of the vagina (Delancey).
Campbell identified three distinct histologic regions of the uterosacral ligament. At the cervical attachment, the ligament was made up of carefully packed bundles of smooth muscle, abundant medium-sized and small blood vessels, and small nerve bundles. The intermediate third of the ligament was composed of predominantly connective tissue and only a few scattered smooth muscle fibers, nerve elements, and blood vessels. The sacral third was almost entirely composed of loose strands of connective tissue and intermingled fat, few vessels, nerves, and lymphatics.
The mechanical strength of the uterosacral ligaments is remarkable. The cervical and intermediate portions of the uterosacral ligament supported more than 17 kg of weight before failure. (Nichols) (Figure 4).
Middle Pedicle
The middle connective-vascular pedicle consists of the cardinal ligaments and a variable contingent of fibers that are part of the uterosacral ligaments. Vaginally, each cardinal ligament has a fibrous-connective segment consisting of inferior fibers of the uterosacral ligament and a cranially located vascular segment, which consists of the superior bundle of the cardinal ligament and uterine vascular pedicle. The two segments can be surgically treated as a single pedicle or as separate depending on the thickness and insertion area of the uterine edge (Shiff).
On its cranial aspect, the cardinal ligament is crossed by the ureter under the crossing-point with the uterine artery. The distance between the lateral side of the cervix and isthmus and the wall of the pelvis is approximately 4–5 cm. The ureter crosses the cardinal ligament halfway, approximately 2–2.5 cm from the cervix. The ureteral risk is reduced in vaginal hysterectomy because, once the lower pedicle is cut, the cardinal ligament is elongated, removing the ureter from the operator’s field. (Kovak) (Figure 5).
Upper Pedicle
The upper pedicle consists of
The primary vascular element of the upper pedicle is the
A. Lower connective-vascular pedicle (cardinal uterosacral complex -CUSC the first pedicle in vaginal hysterectomy). 1 = cervicovesical ligament, 2 = uterosacral ligaments, 3 = cardinal ligament. Redline mark where the same pedicle might secure bladder pillar, uterosacral ligaments, and cardinal ligaments. B. Lower connective pedicle at vaginal hysterectomy with distinct uterosacral ligament (USL) and cardinal ligament (CL) in the same pedicle.
Middle pedicle. 1 = uterine artery, 2 = cardinal ligament, 3 = inferior pedicle cut, 4 = parametrial ureter. Once cut, the uterosacral ligament’s traction on the cervix makes the cardinal ligament elongated and removes the ureter from the surgical field.
The uterus is a highly vascular organ with two arterial and two venous systems intertwined.
The primary arterial system is composed of the
Between the
The venous system is composed of the
The arterial blood supply is provided by three different sources: the
The origin of the uterine artery can be encountered most often in a common trunk with the umbilical artery, which arises as to the terminal branch from the previous division of the hypogastric artery. However, there is also the anatomic variant of direct origin from the hypogastric artery. From its origin, the uterine artery follows a 3–5 cm intrapelvic trajectory, approaching the cervix at a constant distance of approximately 2–2.5 cm without coming into contact.
The level where the uterine artery enters the uterine body, regardless of the shape or size of the uterus, corresponds to the level of the internal cervical orifice (Figure 6).
The point where the uterine artery reaches the uterus is constant at the level of the internal cervical orifice. ICO = internal cervical orifice, UP = uterine point. 1 = main uterine artery, 2 = ascending branch of the uterine artery, three = descending branches of the uterine artery. 4 = Beliaeva triangle.
In its trajectory, the uterine artery has three distinct segments:
In the
The
The uterine artery reaches the uterus in a triangular zone near the isthmus (Beliaeva triangle) situated at the base of the broad ligaments at three o clock for the right side and nine o clock for the left side (from the vaginal point of view). The descending uterine artery supplies the isthmus, cervix, and upper vagina. The ascending uterine artery supplies the body of the uterus. The ascending uterine artery is tortuous and gives rise to 10–12 arcuate arteries that course between the outer and middle thirds of the myometrium.
The crossing point of the uterine artery with the ureter is located sideways, approximately 20 mm away from the cervix and 10–12 mm cranially from the lateral vaginal fornix. At this level, there are two venous currents, one in front and another in the back of the ureter, which is predisposed to bleed during maneuvers to unroof the parametrial ureter (Figure 7).
Arterial supply of uterus and vagina. 1 = arterial trunk of hypogastric artery, 2 = Main trunk of the uterine artery, 3 = the ascending branch of the uterine artery, 4 = the descending branch of uterine artery (superior vaginal artery), five = inferior vaginal artery, 6 = umbilical vesical artery, 7 = ureteral branches from the uterine artery, 8 = middle hemorrhoidal artery, nine = ovarian artery, ten = ovarian arch between ovarian and uterine branches, 11 = tubal arch between ovarian and uterine branches, 12 = fundal branch of the uterine artery, 13 = arcuate arteries from right side, 14 = anastomotic branch between the uterine artery and ovarian arch, 15 = funicular branch (round ligament) artery.
The
Between the right and left sides of the uterine body, the arcuate arteries are anastomosed by collateral and small, direct branches. At the uterine fundus, approximately 15 mm away from the insertion of the tube, the ascending uterine artery divides into two branches:
A branch from the uterine artery.
The vaginal artery.
The middle hemorrhoidal artery.
The source of the uterine artery is composed of vesicovaginal and cervicovaginal branches and ensures the blood flow for the upper part of the vagina. The correct vaginal artery (lower vaginal artery or large vaginal artery) originates from the hypogastric artery. The artery from both sides anastomose in the midline and forms the longitudinal artery from the cervix to the vulva named the
The
The
The bilateral ligature of the anterior trunk of hypogastric arteries cannot stop the blood flow into the pelvis. Two primary sources ensure arterial collateral circulation of the pelvis:
Iliolumbar arteries
Lateral sacral arteries
Middle hemorrhoidal arteries
Lumbar arteries
Middle sacral artery
Superior hemorrhoidal arteries
Venous blood from the uterine body comes from the veins located in the thickness of the myometrium, which is venous sinuses with reduced endothelial cover. Venous blood drains into two collecting veins on each side of the uterus, with anastomoses in between. The collateral venous blood supply is significant concerning the alternative route for blood flow in case of significant obstruction of main venous branches.
Collateral venous circulation of the uterus can be done in three main ways:
The
The
The
The venous blood supply of the vagina consists of veins that come from each side of the vagina and anastomose on the median line on the same path as the azygos arteries. The blood flow is oriented to uterine veins at the level of the cervix.
Veins are mainly located on the sides of the vagina and anastomose each other at the extremities of the vaginal canal. In the middle region of the vagina, anastomoses are carried out in the azygous arteries draining the blood to the uterine veins at the level of the cervix. The uterine veins are anastomosis with the average hemorrhoidal veins, which, in turn, communicate with the upper hemorrhoids, forming at this level a porta-cave anastomose. The
Vaginal hysterectomy has as its first step the disconnection of the upper vagina from the cervix and uterine body. As a result, the anastomotic flow between the uterus and vagina is interrupted.
After the middle pedicles are cut, due to caudal traction of the cervix in the vaginal canal, the transversal segment of the uterine artery elongates, and it can be secured by occluding both the ascending and descending branch. After that, all the maneuverers in the uterus, until the upper pedicles, are bloodless.
If the diameter of the uterus exceeds the lower pelvic brim, as the uterus is released, the bleeding is stopped by compressing the vessels on the hard plane of the pelvis.
After extracting a large uterus, important bleeding may occur, caused by either ligature sliding or from the tearing of veins in the broad ligament.
Many vaginal hysterectomies may result in insignificant bleeding as compared to those in abdominal hysterectomies.
Unlike abdominal hysterectomy, regardless of the method, open or laparoscopic, vaginal hysterectomy produces a particularly favorable effect by reducing bleeding, especially in the case of large uteri due to special hemodynamic conditions. During a vaginal hysterectomy, a series of hemodynamic events occur concerning the uterine circulation, especially for a large uterus:
Traction exerts on the cervix of a large uterus almost throughout the operation, so that blood flow is significantly diminished. After the bilateral ligature of the uterine arteries, which can affect both the ascending and the descending branches, the blood flow is completely stopped, allowing maneuvers for dimensional reduction of the uterus with no risk of significant bleeding.
During the vaginal hysterectomy, after the ligature of uterine arteries, visible bleeding does not come from vascular pedicles but from blood stored in the myometer.
In cases where labia minora are hypertrophic and hinder access to the vaginal introit, they are anchored laterally by suture or by using the Richter retractor. The surgical area is bounded by a set of fields isolating the anterior vulval-perineal region (Figure 8).
Pericervical infiltration with saline solution. The cervix is grasped with 2 Pozzi clamps, and a magenta dye marks the limit of the anterior and posterior incision. Infiltrating is strictly submucosal.
The course of the future colpotomy is infiltrated submucosally with a vasoconstrictive solution. (1/200,000 epinephrine, 4 ml of ropivacaine, and up to 20 ml of saline solution). When there are contraindications for administering the epinephrine, saline solution alone may be used. Through infiltration with saline solution, a hydric dissection of the tissues is achieved, which determines the opening of the cleavage spaces, and the local anesthesia blocks the nervous transmission from the receptor level.
Accidental intravascular injection should be avoided.
The incision of the vaginal wall can be done with a cold or electric scalpel.
The incision of the vagina around the cervix is circular, with the anterior limit in the first transversal fold of the vaginal mucosa from its insertion into the cervix (
The incision includes the entire thickness of the vaginal wall, anteriorly and posteriorly. Laterally only the epithelium is interested. In this way, with the ligature of the first pedicle, the vagina will remain anchored sideways to the uterosacral ligaments, ensuring the prevention of the vaginal vault prolapse (Figure 9).
The incision of the anterior wall of the vagina 1.5–2 cm away from the external cervical orifice includes the entire thickness of the vaginal wall. Posteriorly, the incision is placed at the level of the first posterior rugae of the vaginal wall.
Entry into the anterior cleavage space starts with opening the vesicouterine space by cutting the
To expose the cervico-vesical septum, the cervix is pulling down and the cutting edge of the vaginal wall in the opposite direction. The sectioning of the cervicovesical septum is done with scissors facing the mass of the cervix.
The anterior cleavage space is open. Bladder pillars delineate the spatial side of anterior cleavage space. The dissection of the vesicouterine space is done by the progression of the index on the median line.
The peritoneal vesicouterine fold remains up as long as the uterus keeps its connections with the superior connective vascular pedicle. For this reason, its opening is not an immediate objective once the bladder has been detached from the uterus.
In our basic technique, opening the vesicouterine pouch becomes extremely simple after the disconnection of the inferior pedicle if the uterus is not enlarged or deformed. After sectioning the inferior pedicle, the uterus descends 3–4 cm, where the white-pearly transversal fold of the peritoneal vesicouterine fold can be observed. It is grasped with a clamp and cut where it enters the pelvis. The surgeon digitally explores the anterior side of the uterus and inserts a Briesky-Navratil retractor in this space, discharging the bladder upward (Figure 12).
A. Identifying and opening the real vesicovaginal fold (white arrow). The black arrow marks the cervical insertion of the peritoneal fold (false fold). B. the vesicovaginal fold opens.
Unlike with anterior colpoceliotomy, entering the rectovaginal cleavage space and opening the pouch of Douglas can be done at the same time. The level of posterior vaginal incision described above is significant to ensure a good entry into the rectovaginal space. The edge of the posterior vaginal wall incision is grasped with Allis clamps, and the rectovaginal space is entered by sharp or blunt dissection. After entering the rectovaginal space and pressing the rectum down, the peritoneal cul-de-sac may be observed swelling when the cervix is moved in or out. After opening the pouch of Douglas, the posterior side of the uterus, uterosacral ligaments, and the posterior leaf of the broad ligaments can be explored digitally (Figures 13 and 14).
Developing rectovaginal cleavage space. Allis clamps grasp the vaginal cutting edge, and the space is open by sharp dissection. The posterior aspect of the cervix is pulled upward, and the dissection is carried out using a Sims retractor.
The rectovaginal fold is open, and the posterior side of the uterus is visible. (arrow).
In difficult cases, a particular variant can be used to avoid the creation of an excessively sizeable retroperitoneal space between the vagina and the rectum. (see Chapter 6).
The lower pedicle is represented by the uterosacral ligament posteriorly and the vesicouterine ligament anteriorly. For the disconnection of the inferior pedicle, it is not mandatory to open the rectouterine pouch, and the maneuver can be done extra-peritoneally.
The bladder is removed cranially with a Briesky-Navratil retractor, placing the two vesical pillars under tension, and the rectum is depressed with a posterior Sims retractor (Figures 15 and 16).
Right lower pedicle. A dotted line separates the bladder pillar (blue arrow) from the uterosacral ligament (blue light arrow). Clamping the inferior part of the bladder pillar and uterosacral ligament together form the right lower pedicle.
A. Right lower pedicle secured by Vicryl 2/0. B. the left lower pedicle is clamped prepared to cut.
Using a Wertheim clamp, one of the uterosacral ligaments and the homologous bladder pillar are loaded together, after which, the pedicle is cut and ligated. The maneuver is repeated on the opposite side. In many situations, after cutting the pedicle, the pouch of Douglas opens spontaneously near the uterine edge.
The middle pedicle is represented by the cardinal ligament that contains the main uterine vascular supply for the uterus and cervix. By caudal traction on the cervix, the vascular pedicle has a parallel direction on the uterine edge, removing the ureters from the surgical field (Figure 17).
Right middle pedicle formed by cardinal ligament and uterine artery and veins clamped and cut. Left middle pedicle clamped. Arrow mark the uterine artery. In our technique, the pediculisation of uterine vessels is not useful as long as the clamping of the pedicle is done strictly parallel to the uterine side. The risk to the ureter’s damage is reduced if the lower pedicle is previously sectioned. (see chapter 2).
For this reason, during the vaginal hysterectomy, the urethral risk is lower than with the abdominal approach. After clamping, the pedicle is cut and ligated with 2–0 Vicryl.
In some situations, the cardinal ligament can be well represented and cannot be clamped at a single time. In this case, a second clamping and cutting should be cautiously be done. There is the risk of clamping and cutting a part of the superior pedicle and, in the maneuver, tilting the uterus. If so, the latter might break, causing some unwanted bleeding.
For vaginally delivering the uterus, securing the superior connective vascular pedicle is the most important and sometimes the most difficult step of vaginal hysterectomy.
In most cases, the superior pedicle can be brought into the surgical field by tilting the uterus. The uterus can be tilted anteriorly (Doderlain-Kronig maneuver) or posteriorly (Heaney maneuver).
When the uterus is highly mobile and small, its release from the pelvis can also be done without tilting.
For the uterus weighing up to 200–280 g, access to the superior pedicle is done by tilting, a maneuver that brings the superior pedicle into the surgical field, which consists in anatomical order of the round ligament, fallopian tube, and homologous utero-ovarian ligament. This pedicle includes the anastomotic branch of the uterine artery and the tubo-ovarian vascular arch.
The main disadvantage of the tilting maneuvers is that it forces the vaginal opening through which the uterus is pulled, which can lead to the slipping of ligatures placed on the anteriorly cut and ligated connective vascular pedicles (Figures 18–20).
Disconnection of upper pedicle by posterior tilting (Heaney maneuver).
Disconnection of the superior pedicle. In this case, the uterus is hemisected previously. The pedicle is hooked by the index finger and then clamped.
Clamped left upper pedicle. We can see what it is made of 1 = round ligament, 2 = utero-ovarian ligament, 3 = tube.
Anterior tilting (Doderlain-Kronig maneuver). After anterior colpoceliotomy, the anterior side of the uterus is evident. Using Pozzi forceps, the uterine fundus is extracted, and the superior pedicle can be clamped and cut.
The cervix is forcefully pulled caudally to expose as much as possible the anterior side of the uterus. Using a Pozzi clamp, the mass of the uterine body is clamped on the median line as high up as possible. It is gradually pulled, without sudden moves that lead to the rupture of the myometrium. At the same time, the cervix is left free without traction or pushed cranially and posteriorly with the Pozzi clamp. Along with the uterus’s progress into the surgical field, using another Pozzi clamp, the mass of the uterine tissue is escalated as high up as possible until the uterine fundus and one or two superior pedicles appear in the surgical field. At this time, the cervix is pulled cranially to place the pedicle under tension. The index finger of the surgeon’s left hand cranially and caudally loads the superior uterine pedicle, while the right-hand loads the pedicle into the arms of the Wertheim clamp.
After clamping and cutting, the pedicle is ligated, and the ends of the threads are kept as benchmarks. For the contralateral side, the maneuver for clamping the pedicle simplifies because, by pulling onto the cervix, the pedicle will be well exposed. Cutting and ligating the pedicles gives rise to the extraction of the uterus. The pedicle can be completely clamped or the round ligament isolated when one aims to perform the adnexectomy.
Posterior tilting (Heaney maneuver) is the most frequently used maneuver to access the superior pedicle for non-prolapsed uteruses weighing more than 180 g. Posterior tilting has the main advantage of being able to rotate the uterus in a much larger space, represented by the sacral concavity.
The cervix is forcefully pulled cranially while the assistant depresses the rectum using a Sims retractor to reveal as much as possible of the posterior side of the uterus. The surgeon places a Pozzi clamp on the dorsal middle bottom of the uterus, as close as possible to the uterine pouch. Relaxing the tension exerted on the cervix, it is pulled progressively by the clamp while the assistant tries to extract the uterus using the posterior retractor. When uterus progression is observed, the position of the uterus pulling clamp is changed to become as cranial as possible, and the releasing maneuvers are continued until the uterine fundus appears in the surgical field (Figures 22 and 23).
Posterior tilting (Heaney maneuver). Clamping the left superior pedicle. The cervix is pulled cranially at the same time that the uterine fundus is pulled hard caudally.
The Heaney maneuver. The right pedicle is clamped ˝a la Vue easily. ˝.
Unlike anterior tilting, the superior pedicle does not become visible. To be able to identify it, the surgeon places a Briesky retractor in the area between the lateral wall of the vagina and the uterine horn, usually on the left side, where access is more accessible. As an aiding maneuver, the clamp anchoring the uterine fundus is repositioned as close as possible to the externalized uterine horn. Thus, by simultaneously pulling the cervix and uterine fundus and maneuvering the Briesky-Navratil retractor laterally, the superior pedicle is revealed at its insertion into the uterus. With the medius of the left hand, the surgeon loads the pedicle in a cranial position to clamp the pedicle in a caudal place with the right hand using a Wertheim clamp.
In certain situations (early endometrial cancer, interventions under local anesthesia), it is necessary to release the uterus with minimum trauma, without tilting or morcellation. Direct access to the superior pedicle is possible mainly in multiparous women with perineal relaxation and small uteruses with a weakly represented bearing system. In these cases, clamping and section of the pedicle are done without any difficulties. Clamping the superior pedicle can be done safely by successively escalating the elements included in the utero-adnexal pedicle.
After extracting the uterus, gauze is inserted through the vaginal opening and into the pelvic cavity, pushing the bowels and leaving the pelvic-subperitoneal space open to view. The posterior wall of the vagina is retracted with an auto-static retractor. The vesicouterine peritoneum is revealed using a Briesky-Navratil retractor. The basis of the parameter is shown on the appropriate side, pulling the thread locating the superior pedicle. Bleeding at the end of the intervention is usually profuse, and its primary source is the vaginal cutting edges. In the case of active arterial bleeding from parameters, the surgical field is flooded, and the primary sources, such as the uterine arteries or the utero-ovarian arches, are to be found immediately.
At the end of a vaginal hysterectomy, the surgical field is rarely “dry” until the vaginal cuff is closed.
In the technique we used for a vaginal hysterectomy for a non-prolapsed uterus, we adopted the Wertheim manner of closing the peritoneal cavity and the remaining vaginal edges. The main drawback of this maneuver is the closing of the surgical field without controlling the hemostasis until the end of the operation. We modified the technique, closing down the pelvic-peritoneal space and anchoring the superior vagina to the remaining cuffs of the inferior pedicle containing the most substantial elements of suspension – the uterosacral ligaments. With this procedure, the prevention of vaginal vault prolapse is done like the McCall procedure.
The manner we proposed is done in three distinct times:
Closure of the pelvic-subperitoneal posterior space
Closure of the pelvic-subperitoneal anterior space
Full closure of the vaginal cuff
Closure of the pelvic-subperitoneal posterior space
Closing down the pelvic-subperitoneal space is done by running a suture with Vicryl nr. 0 to close the edge of the vagina and the posterior visceral peritoneum, starting from the lower pedicle on one side to the similar pedicle on the other side (Figure 24).
Closure of the pelvic-subperitoneal anterior space
This step usually is not necessary, but when the dissection of the bladder wall is difficult or in the case of an inadvertent wound, closing the space between the bladder and vagina is the best alternative. By joining the wall of the vagina with the visceral vesical peritoneum using a running suture, space is closed down.
Full closure of the vaginal cuff
The vaginal cuff can be fully closed by sutures with separate suture points. The closure of the vaginal cuff is done with Vicryl 0 and with suture points in a figure of eight that starts at the center of the section and goes out towards each lateral vaginal commissure (Figure 25).
Prophylactic apical support
The technique described above refers to the unprolapsed uterus where post-hysterectomy vault prolapse occurs very rarely. For this reason, we do not include in the operative procedure an appropriate step addressed for it. The prevention of vaginal vault prolapse is necessary in case of an association of early forms of uterovaginal prolapse. By the technique described by us, the means of suspension of the upper vagina are preserved as long as the circular (Figure 26).
Closing the posterior pelvic-subperitoneal space by running suture. The edge of the vagina (green arrow) is sutured together with the visceral posterior peritoneum (yellow arrow).
The final closing of the vaginal vault by separate suture points, from middle to lateral.
Superficial incision of the lateral aspect of the vagina allows the section of the lower connective vascular pedicle to anchor the vaginal wall to uterosacral ligaments making prophylaxis of vaginal vault prolapse. (yellow arrows – Vaginal wall).
The incision in the cervix is of interest only to the vaginal mucosa. For cases where early apical prolapse is present, McCall culdoplasty is an excellent way to resuspend the upper vagina at the first level (DeLancey).
The presented technique of vaginal hysterectomy resulted from combining several variants tried by authors over the years of more than 4500 vaginal hysterectomies. From each variant of the technique, we chose the most efficient and safe method to achieve each operator time as a confirmation of the validity of the succession of operating times proposed by us, the International Society of Endoscopic Surgery (ISGE) published in 2020 a set of recommendations on the technique of vaginal hysterectomy on the unprolapsed uterus.
Six recommendations were established similar to the standard technique proposed by us:
Circular incision at the level of the cervical-vagina junction is recommended (grade IC).
Posterior peritoneum should be opened first (grade IC).
Clamping and cutting the uterosacral and cardinal ligaments before or after getting access to the anterior peritoneum are recommended (grade IC).
Routine closure of the peritoneum during vaginal hysterectomy is not recommended (grade IB).
Vertical or horizontal closure of the vaginal vault following vaginal hysterectomy is recommended (grade IC).
To insert the vaginal plug following vaginal hysterectomy is not recommended (grade IB).
..,
There is no standard technique for vaginal hysterectomies. Every case poses different strategical problems. It is not necessary to follow every step of the operation in order as described elsewhere in literature or even in this chapter. The surgeon can treat every operation as a distinct one with a specific strategy.
The disconnection of the leading vascular pedicles causes fewer problems than delivering the uterus from the upper connective vascular pedicle. For large uteri, this operative step is time-consuming and challenging to work for the surgeon.
If during the first steps of the operation, incidental bleeding begins that cannot be managed, the surgeon should not hesitate to convert the vaginal operation to an open abdominal or laparoscopic one. Every minute lost means 250 ml of blood lost from each uterine artery.
In many cases, there is significant blood loss until the uterus is released, and after that, the drama begins. In some cases, the abrupt withdrawal of the uterus from the pelvis causes the sliding of ligatures from a uterine artery. If the bleeding seems to be to one side, you have to look for it on the opposite side.
The most important thing is to finish this partially blind operation without any doubt regarding the safety of the patient.
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His studies in robotics lead him not only to a PhD degree but also inspired him to co-found and build the International Journal of Advanced Robotic Systems - world's first Open Access journal in the field of robotics.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"441",title:"Ph.D.",name:"Jaekyu",middleName:null,surname:"Park",slug:"jaekyu-park",fullName:"Jaekyu Park",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/441/images/1881_n.jpg",biography:null,institutionString:null,institution:{name:"LG Corporation (South Korea)",country:{name:"Korea, South"}}},{id:"465",title:"Dr.",name:"Christian",middleName:null,surname:"Martens",slug:"christian-martens",fullName:"Christian Martens",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Rheinmetall (Germany)",country:{name:"Germany"}}},{id:"479",title:"Dr.",name:"Valentina",middleName:null,surname:"Colla",slug:"valentina-colla",fullName:"Valentina Colla",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/479/images/358_n.jpg",biography:null,institutionString:null,institution:{name:"Sant'Anna School of Advanced Studies",country:{name:"Italy"}}},{id:"494",title:"PhD",name:"Loris",middleName:null,surname:"Nanni",slug:"loris-nanni",fullName:"Loris Nanni",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/494/images/system/494.jpg",biography:"Loris Nanni received his Master Degree cum laude on June-2002 from the University of Bologna, and the April 26th 2006 he received his Ph.D. in Computer Engineering at DEIS, University of Bologna. On September, 29th 2006 he has won a post PhD fellowship from the university of Bologna (from October 2006 to October 2008), at the competitive examination he was ranked first in the industrial engineering area. He extensively served as referee for several international journals. He is author/coauthor of more than 100 research papers. He has been involved in some projects supported by MURST and European Community. 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From 1985 to 1986, he was a Research Fellow in the Research Institute for Electronic Equipment, ZZU AD, Plovdiv, Bulgaria. In 1986, he joined the Department of Control Systems, Technical University of Sofia at the Plovdiv campus, where he is presently a Full Professor. He has held long-term visiting Professor/Scholar positions at various institutions in South Korea, Turkey, Mexico, Greece, Belgium, UK, and Germany. And he has coauthored one book and authored or coauthored more than 80 research papers in conference proceedings and journals. 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Over periods of time, some of these norms become standards that all members of the community are expected to adhere to. Deviance from these standards is seen as absurd, wrong, or frankly abnormal. However, many of these cultural mores have no scientific basis and, some of them actually promote behaviors with negative health consequences. This chapter examines the cultural practices of some communities in Africa and their health consequences and, explores ways to address the challenges.",book:{id:"9138",slug:"public-health-in-developing-countries-challenges-and-opportunities",title:"Public Health in Developing Countries",fullTitle:"Public Health in Developing Countries - Challenges and Opportunities"},signatures:"Radiance Ogundipe",authors:[{id:"302308",title:"Dr.",name:"Radiance",middleName:null,surname:"Ogundipe",slug:"radiance-ogundipe",fullName:"Radiance Ogundipe"}]},{id:"44569",title:"Health Care Waste Management – Public Health Benefits, and the Need for Effective Environmental Regulatory Surveillance in Federal Republic of Nigeria",slug:"health-care-waste-management-public-health-benefits-and-the-need-for-effective-environmental-regulat",totalDownloads:8837,totalCrossrefCites:9,totalDimensionsCites:22,abstract:null,book:{id:"3432",slug:"current-topics-in-public-health",title:"Current Topics in Public Health",fullTitle:"Current Topics in Public Health"},signatures:"Nkechi Chuks Nwachukwu, Frank Anayo Orji and Ositadinma\nChinyere Ugbogu",authors:[{id:"85404",title:"Dr.",name:"Nkechi Chuks",middleName:null,surname:"Nwachukwu",slug:"nkechi-chuks-nwachukwu",fullName:"Nkechi Chuks Nwachukwu"},{id:"120194",title:"Dr.",name:"Orji",middleName:null,surname:"Frank Anayo",slug:"orji-frank-anayo",fullName:"Orji Frank Anayo"},{id:"161783",title:"Dr.",name:"Ositadinma Chinyere",middleName:null,surname:"Ugbogu",slug:"ositadinma-chinyere-ugbogu",fullName:"Ositadinma Chinyere Ugbogu"}]},{id:"71667",title:"Health Promotion and Its Challenges to Public Health Delivery System in Africa",slug:"health-promotion-and-its-challenges-to-public-health-delivery-system-in-africa",totalDownloads:1511,totalCrossrefCites:1,totalDimensionsCites:2,abstract:"The chapter examines the place and role of health promotion in the drive for sustainable and effective public health delivery in Africa. It conceptualizes health promotion from a multifaceted and multi-professional perspective hinged on the empowerment of communities and individuals to play active roles and adopt behaviour consistent with the goals of good health. The paper drawing on documentary data sees health promotion as critical to the achievement of health goals in the continent and equally reflects on the theories of health promotion, strategies for health promotion and challenges to health promotion in Africa. It argues that health promotion in the continent can be strengthened through such measures as appropriate legislations, robust funding, gender inclusiveness, stepping up research, regular needs assessment and evaluation, setting needs-driven priorities and building capacity of health promotion to target vulnerable and marginal members of the society, among others.",book:{id:"9138",slug:"public-health-in-developing-countries-challenges-and-opportunities",title:"Public Health in Developing Countries",fullTitle:"Public Health in Developing Countries - Challenges and Opportunities"},signatures:"Edlyne Eze Anugwom",authors:[{id:"293469",title:null,name:"Edlyne Eze",middleName:null,surname:"Anugwom",slug:"edlyne-eze-anugwom",fullName:"Edlyne Eze Anugwom"}]},{id:"67091",title:"Health Literacy: An Intervention to Improve Health Outcomes",slug:"health-literacy-an-intervention-to-improve-health-outcomes",totalDownloads:1904,totalCrossrefCites:2,totalDimensionsCites:4,abstract:"WHO has defined health literacy as the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make basic health decisions for themselves and their loved ones. The purpose of this article is to outline the scope of low health literacy as a concept and explore some appropriate interventions that researchers and healthcare professionals may use to reduce its negative impact on health outcomes such as mortality. The authors conclude by identifying areas of research that are needed to advance the conceptualization of health literacy in reducing hospital mortality and morbidity.",book:{id:"7158",slug:"strategies-to-reduce-hospital-mortality-in-lower-and-middle-income-countries-lmics-and-resource-limited-settings",title:"Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs) and Resource-Limited Settings",fullTitle:"Strategies to Reduce Hospital Mortality in Lower and Middle Income Countries (LMICs) and Resource-Limited Settings"},signatures:"Monique Ann-Marie Lynch and Geovanni Vinceroy Franklin",authors:[{id:"276834",title:"Dr.",name:"Monique",middleName:"Ann-Marie",surname:"Lynch",slug:"monique-lynch",fullName:"Monique Lynch"},{id:"289629",title:"MSc.",name:"Geovanni",middleName:null,surname:"Franklin",slug:"geovanni-franklin",fullName:"Geovanni Franklin"}]},{id:"69468",title:"The Global Burden and Perspectives on Non-Communicable Diseases (NCDs) and the Prevention, Data Availability and Systems Approach of NCDs in Low-resource Countries",slug:"the-global-burden-and-perspectives-on-non-communicable-diseases-ncds-and-the-prevention-data-availab",totalDownloads:2760,totalCrossrefCites:7,totalDimensionsCites:19,abstract:"The burden of non-communicable diseases (NCDs) is growing swiftly in low-resourced countries resulting in deleterious health resembling the NCDs burden in high-resourced countries. Despite the availability of information on the escalating adverse economic and health effects of NCDs globally, specific strategies designed to address the growing burden of NCDs in low-resourced countries remain substandard. Research engines like EBSCOhost, Science Citation Index, CINAHL database, PsycINFO, Cochrane Database of Systematic Reviews, published and unpublished abstracts and a hand search of reference lists and table of contents of relevant journals and books were searched from January 2011 to June 2019. In total, 84 studies met the inclusion criteria. Most studies confirm that low-resourced countries compared with high-resourced countries battle to implement NCDs prevention strategies; fail to record data on the risk factors of NCDs; medical records and surveillance data are unavailable. Due to a lack of knowledge and skill, low-resourced countries show no urgency to implement a systems approach for NCDs management. 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He also obtained an MSc in Molecular and Genetic Medicine, and a Ph.D. in Clinical Immunology and Human Genetics from the University of Sheffield, UK. He also completed a short-term fellowship in Pediatric Clinical Immunology and Bone Marrow Transplantation at Newcastle General Hospital, England. Dr. Rezaei is a Full Professor of Immunology and Vice Dean of International Affairs and Research, at the School of Medicine, Tehran University of Medical Sciences, and the co-founder and head of the Research Center for Immunodeficiencies. He is also the founding president of the Universal Scientific Education and Research Network (USERN). Dr. Rezaei has directed more than 100 research projects and has designed and participated in several international collaborative projects. He is an editor, editorial assistant, or editorial board member of more than forty international journals. He has edited more than 50 international books, presented more than 500 lectures/posters in congresses/meetings, and published more than 1,100 scientific papers in international journals.",institutionString:"Tehran University of Medical Sciences",institution:{name:"Tehran University of Medical Sciences",country:{name:"Iran"}}},{id:"180733",title:"Dr.",name:"Jean",middleName:null,surname:"Engohang-Ndong",slug:"jean-engohang-ndong",fullName:"Jean Engohang-Ndong",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/180733/images/system/180733.png",biography:"Dr. Jean Engohang-Ndong was born and raised in Gabon. After obtaining his Associate Degree of Science at the University of Science and Technology of Masuku, Gabon, he continued his education in France where he obtained his BS, MS, and Ph.D. in Medical Microbiology. He worked as a post-doctoral fellow at the Public Health Research Institute (PHRI), Newark, NJ for four years before accepting a three-year faculty position at Brigham Young University-Hawaii. Dr. Engohang-Ndong is a tenured faculty member with the academic rank of Full Professor at Kent State University, Ohio, where he teaches a wide range of biological science courses and pursues his research in medical and environmental microbiology. Recently, he expanded his research interest to epidemiology and biostatistics of chronic diseases in Gabon.",institutionString:"Kent State University",institution:{name:"Kent State University",country:{name:"United States of America"}}},{id:"188773",title:"Prof.",name:"Emmanuel",middleName:null,surname:"Drouet",slug:"emmanuel-drouet",fullName:"Emmanuel Drouet",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/188773/images/system/188773.png",biography:"Emmanuel Drouet, PharmD, is a Professor of Virology at the Faculty of Pharmacy, the University Grenoble-Alpes, France. As a head scientist at the Institute of Structural Biology in Grenoble, Dr. Drouet’s research investigates persisting viruses in humans (RNA and DNA viruses) and the balance with our host immune system. He focuses on these viruses’ effects on humans (both their impact on pathology and their symbiotic relationships in humans). He has an excellent track record in the herpesvirus field, and his group is engaged in clinical research in the field of Epstein-Barr virus diseases. He is the editor of the online Encyclopedia of Environment and he coordinates the Universal Health Coverage education program for the BioHealth Computing Schools of the European Institute of Science.",institutionString:null,institution:{name:"Grenoble Alpes University",country:{name:"France"}}},{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},{id:"332819",title:"Dr.",name:"Chukwudi Michael",middleName:"Michael",surname:"Egbuche",slug:"chukwudi-michael-egbuche",fullName:"Chukwudi Michael Egbuche",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/332819/images/14624_n.jpg",biography:"I an Dr. Chukwudi Michael Egbuche. I am a Senior Lecturer in the Department of Parasitology and Entomology, Nnamdi Azikiwe University, Awka.",institutionString:null,institution:{name:"Nnamdi Azikiwe University",country:{name:"Nigeria"}}},{id:"284232",title:"Mr.",name:"Nikunj",middleName:"U",surname:"Tandel",slug:"nikunj-tandel",fullName:"Nikunj Tandel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/284232/images/8275_n.jpg",biography:'Mr. Nikunj Tandel has completed his Master\'s degree in Biotechnology from VIT University, India in the year of 2012. He is having 8 years of research experience especially in the field of malaria epidemiology, immunology, and nanoparticle-based drug delivery system against the infectious diseases, autoimmune disorders and cancer. He has worked for the NIH funded-International Center of Excellence in Malaria Research project "Center for the study of complex malaria in India (CSCMi)" in collaboration with New York University. The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. Received the CSIR-SRF (Senior Research Fellow) award-2018, FIMSA (Federation of Immunological Societies of Asia-Oceania) Travel Bursary award to attend the IUIS-IIS-FIMSA Immunology course-2019',institutionString:"Nirma University",institution:{name:"Nirma University",country:{name:"India"}}},{id:"334383",title:"Ph.D.",name:"Simone",middleName:"Ulrich",surname:"Ulrich Picoli",slug:"simone-ulrich-picoli",fullName:"Simone Ulrich Picoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334383/images/15919_n.jpg",biography:"Graduated in Pharmacy from Universidade Luterana do Brasil (1999), Master in Agricultural and Environmental Microbiology from Federal University of Rio Grande do Sul (2002), Specialization in Clinical Microbiology from Universidade de São Paulo, USP (2007) and PhD in Sciences in Gastroenterology and Hepatology (2012). She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"333753",title:"Dr.",name:"Rais",middleName:null,surname:"Ahmed",slug:"rais-ahmed",fullName:"Rais Ahmed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333753/images/20168_n.jpg",biography:null,institutionString:null,institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. He has authored and reviewed a number of journal articles and book chapters.",institutionString:"National Veterinary Research Institute",institution:{name:"National Veterinary Research Institute",country:{name:"Nigeria"}}},{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",biography:"Professor Dr. Shailendra K. Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. He is also an international opinion leader/expert in vaccination for Japanese encephalitis by IPIC (UK).",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",country:{name:"India"}}},{id:"94928",title:"Dr.",name:"Takuo",middleName:null,surname:"Mizukami",slug:"takuo-mizukami",fullName:"Takuo Mizukami",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94928/images/6402_n.jpg",biography:null,institutionString:null,institution:{name:"National Institute of Infectious Diseases",country:{name:"Japan"}}},{id:"233433",title:"Dr.",name:"Yulia",middleName:null,surname:"Desheva",slug:"yulia-desheva",fullName:"Yulia Desheva",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/233433/images/system/233433.png",biography:"Dr. Yulia Desheva is a leading researcher at the Institute of Experimental Medicine, St. Petersburg, Russia. She is a professor in the Stomatology Faculty, St. Petersburg State University. She has expertise in the development and evaluation of a wide range of live mucosal vaccines against influenza and bacterial complications. Her research interests include immunity against influenza and COVID-19 and the development of immunization schemes for high-risk individuals.",institutionString:'Federal State Budgetary Scientific Institution "Institute of Experimental Medicine"',institution:null},{id:"238958",title:"Mr.",name:"Atamjit",middleName:null,surname:"Singh",slug:"atamjit-singh",fullName:"Atamjit Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/238958/images/6575_n.jpg",biography:null,institutionString:null,institution:null},{id:"252058",title:"M.Sc.",name:"Juan",middleName:null,surname:"Sulca",slug:"juan-sulca",fullName:"Juan Sulca",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/252058/images/12834_n.jpg",biography:null,institutionString:null,institution:null},{id:"191392",title:"Dr.",name:"Marimuthu",middleName:null,surname:"Govindarajan",slug:"marimuthu-govindarajan",fullName:"Marimuthu Govindarajan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/191392/images/5828_n.jpg",biography:"Dr. M. Govindarajan completed his BSc degree in Zoology at Government Arts College (Autonomous), Kumbakonam, and MSc, MPhil, and PhD degrees at Annamalai University, Annamalai Nagar, Tamil Nadu, India. He is serving as an assistant professor at the Department of Zoology, Annamalai University. His research interests include isolation, identification, and characterization of biologically active molecules from plants and microbes. He has identified more than 20 pure compounds with high mosquitocidal activity and also conducted high-quality research on photochemistry and nanosynthesis. He has published more than 150 studies in journals with impact factor and 2 books in Lambert Academic Publishing, Germany. 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