American College of Rheumatology diagnostic criteria for Takayasu arteritis.
\r\n\tThere are a variety of approaches to reversing biodiversity loss, ranging from economic, to ecological and ethical. The utilitarian approach to conservation, bolstered by the concept of ecosystem services, can be utilized to improve the conservation case by supplementing the burgeoning biodiversity rhetoric. To address this issue, a pluralistic approach to biodiversity is required for conservation and sustainability.
",isbn:"978-1-80356-339-8",printIsbn:"978-1-80356-338-1",pdfIsbn:"978-1-80356-340-4",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,isSalesforceBook:!1,isNomenclature:!1,hash:"ab014f8ed1669757335225786833e9a9",bookSignature:"Dr. Gopal Shukla, Dr. Jahangeer Bhat and Dr. Sumit Chakravarty",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11460.jpg",keywords:"Ecosystem Services, Intrinsic Value, Global Trends in Biodiversity Loss, Convention on Biological Diversity, Utilitarian Value, Biodiversity Conservation, Perception, In Situ and Ex Situ Conservation, Nature Conservation, Sustainable Development Goals, Drivers of Degradation, Prioritizing Biodiversity",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 17th 2022",dateEndSecondStepPublish:"April 22nd 2022",dateEndThirdStepPublish:"June 21st 2022",dateEndFourthStepPublish:"September 9th 2022",dateEndFifthStepPublish:"November 8th 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"2 months",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Dr. Gopal Shukla, prior to becoming an assistant professor, has worked under NAIP (National Agricultural Innovation Project), NICRA ( National Innovations on Climate Resilient Agriculture), and SERB (Science and Engineering Research Board) projects. 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Bhat",coverURL:"https://cdn.intechopen.com/books/images_new/9841.jpg",editedByType:"Edited by",editors:[{id:"101105",title:"Dr.",name:"Gopal",surname:"Shukla",slug:"gopal-shukla",fullName:"Gopal Shukla"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1591",title:"Infrared Spectroscopy",subtitle:"Materials Science, Engineering and Technology",isOpenForSubmission:!1,hash:"99b4b7b71a8caeb693ed762b40b017f4",slug:"infrared-spectroscopy-materials-science-engineering-and-technology",bookSignature:"Theophile Theophanides",coverURL:"https://cdn.intechopen.com/books/images_new/1591.jpg",editedByType:"Edited by",editors:[{id:"37194",title:"Dr.",name:"Theophile",surname:"Theophanides",slug:"theophile-theophanides",fullName:"Theophile Theophanides"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3161",title:"Frontiers in Guided Wave Optics and Optoelectronics",subtitle:null,isOpenForSubmission:!1,hash:"deb44e9c99f82bbce1083abea743146c",slug:"frontiers-in-guided-wave-optics-and-optoelectronics",bookSignature:"Bishnu Pal",coverURL:"https://cdn.intechopen.com/books/images_new/3161.jpg",editedByType:"Edited by",editors:[{id:"4782",title:"Prof.",name:"Bishnu",surname:"Pal",slug:"bishnu-pal",fullName:"Bishnu Pal"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"371",title:"Abiotic Stress in Plants",subtitle:"Mechanisms and Adaptations",isOpenForSubmission:!1,hash:"588466f487e307619849d72389178a74",slug:"abiotic-stress-in-plants-mechanisms-and-adaptations",bookSignature:"Arun Shanker and B. 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"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"2270",title:"Fourier Transform",subtitle:"Materials Analysis",isOpenForSubmission:!1,hash:"5e094b066da527193e878e160b4772af",slug:"fourier-transform-materials-analysis",bookSignature:"Salih Mohammed Salih",coverURL:"https://cdn.intechopen.com/books/images_new/2270.jpg",editedByType:"Edited by",editors:[{id:"111691",title:"Dr.Ing.",name:"Salih",surname:"Salih",slug:"salih-salih",fullName:"Salih Salih"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"117",title:"Artificial Neural Networks",subtitle:"Methodological Advances and Biomedical Applications",isOpenForSubmission:!1,hash:null,slug:"artificial-neural-networks-methodological-advances-and-biomedical-applications",bookSignature:"Kenji Suzuki",coverURL:"https://cdn.intechopen.com/books/images_new/117.jpg",editedByType:"Edited by",editors:[{id:"3095",title:"Prof.",name:"Kenji",surname:"Suzuki",slug:"kenji-suzuki",fullName:"Kenji Suzuki"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"53805",title:"Nonatherosclerotic Peripheral Artery Disease",doi:"10.5772/67180",slug:"nonatherosclerotic-peripheral-artery-disease",body:'\nNonatherosclerotic peripheral artery disease (NAPAD) remains underappreciated compared to atherosclerotic peripheral artery disease (APAD) due to its low prevalence. Despite common symptoms such as claudication, rest pain, and tissue loss, most clinicians are unfamiliar with the diagnosis of NAPAD. NAPAD should be suspected clinically in younger patients, and in older patients with few atherosclerotic risk factors, few atherosclerotic features, or unusual lesion distributions. There is a broad spectrum of pathophysiologies in NAPAD, with the most common being arterial wall abnormalities, abnormal external and internal forces, spasm, vasculitis, and thrombophilia [1]. Under‐ or misdiagnosis of NAPAD can lead to serious adverse outcomes that, with awareness of its distinctive symptoms and signs, may be avoided or minimized [2–5]. Thus, this section briefly overviews vascular imaging, mainly invasive angiography, to optimize the management of NAPAD.
When there is a high clinical index of suspicion of NAPAD, the combination of blood examination (biochemical and serological tests) and vascular imaging is an integral part of the differential diagnosis process (Figure 1).
Approach to diagnosis of nonatherosclerotic peripheral artery disease.
In combination with vascular imaging, the assessment of macrocirculation by the ankle‐brachial index is important. Furthermore, in regard to microcirculation assessment, either skin perfusion pressure (SPP) or transcutaneous oxygen pressure (TcPO2) can be applied in patients with critically ischemic limbs. Limb ischemia in younger patients warrants a high clinical suspicion of NAPAD. Even in older patients, most cases of NAPAD may be underdiagnosed or misinterpreted as an atherosclerotic condition.
Fibromuscular dysplasia (FMD) is a noninflammatory disease that produces arterial narrowing, aneurysms, dissection, and occlusion. Although the cause is unknown, 90% of cases occur in females [6], most frequently in the renal and carotid arteries, followed by the mesenteric artery. Although lower extremity arteries are less commonly affected, FMD is one of the most significant causes of NAPAD [4, 7]. Pathologically, FMD can mainly be classified into three types, that is, intimal, medial, and perimedial. Angiographic classification identifies the multifocal type with multiple stenoses and the so‐called “string‐of‐beads” appearance, the tubular type, and the focal type. The “string‐of‐beads” sign that is frequently associated with the medial type is the most indicative of FMD, while the tubular and focal types may mimic atherosclerotic lesions [8] (Figure 2).
Fibromuscular dysplasia. (A) String‐of‐beads appearance in bilateral external iliac arteries (arrows). (B) Multiple string‐of‐beads appearances in the left crural artery (arrows).
There are isolated reports of FMD mimicking vasculitis such as polyarteritis nodosa, Takayasu\'s arteritis (TA), and other disorders such as Ehlers‐Danlos\'s syndrome, Alport\'s syndrome, and pheochromocytoma [9].
Adventitial cystic disease is characterized by a collection of mucin in the adventitial layer, typically in the popliteal artery. In rare cases, the external iliac artery or femoral artery can be affected. This disorder is typically observed in middle‐aged persons, with a male‐to‐female ratio of 5–15:1 [4, 10]. Duplex ultrasound is considered a reasonable first‐line method to diagnose adventitial cystic disease. Although stenotic lesions may develop into occlusion, the angiographic findings show a smooth, eccentric, and extrinsically narrowed appearance (Figure 3).
Adventitial cystic disease. (A) A 70‐year‐old male presenting moderate claudication. Enhanced CT shows focal stenosis in the midsegment of the right popliteal artery (arrow). (B) Ultrasonography revealed a low‐echoic cystic lesion along the vessel wall causing significant stenosis in the popliteal artery (arrows). (C) Angiography could confirm focal stenosis in the right popliteal artery (arrow).
Coarctation of the aorta is mostly located just distal to ligament arteriosum. Midaortic syndrome (MAS) is a rare condition characterized by coarctation of the abdominal aorta or distal descending thoracic aorta and thought to arise from an embryonic development disorder [2]. It is essential to differentiate MAS such as involvement of the abdominal aorta from other causes in large‐vessel vasculitis. In addition to idiopathic MAS, the association of MAS with neurofibromatosis, FMD, mucopolysaccharidosis, Alagille syndrome, and William\'s syndrome could be a genetic etiology. Others include tuberous sclerosis, retroperitoneal fibrosis, moyamoya disease, congenital rubella syndrome, epidermal nevus syndrome, and autosomal dominant supravalvar aortic stenosis syndrome [11, 12]. The most common anatomic type of MAS is suprarenal (60%), followed by intrarenal (25%) and infrarenal (15%) (Figure 4).
Idiopathic midaortic syndrome. A 51‐year‐old male presenting renovascular hypertension. Although the ABI was 0.70/0.67 (right/left), intermittent claudication was absent. (A) Enhanced CT showing suprarenal abdominal aortic coarctation below the origin of the superior mesenteric artery (arrow). (B) Lateral view demonstrates Winslow\'s pathway which is a collateral vessel developing from the subclavian arteries, internal thoracic (mammary) arteries, superior epigastric arteries, inferior epigastric arteries into the external iliac arteries (arrows). (C) Anteroposterior view AP view reveals the Arc of Riolan which is a mesenteric meandering artery between the superior and inferior mesenteric arteries (arrows).
It is usually discovered during workups for hypertension in children. Renal vessels, mesenteric vessels, or both may also be affected to varying degrees. According to previous reports, if the syndrome is left untreated, the majority of patients will die from complications of severe hypertension and ischemia by the age of 40 because of myocardial infarction, heart failure, intracranial hemorrhage, or aortic rupture [13, 14]. Recent study suggests that good long‐term outcomes of MAS can be obtained by medical management [15]. Intermittent claudication might be an uncommon clinical presentation compared to manifestation of hypertension.
Endofibrosis typically involves the narrowing of the external iliac artery in young athletes such as cyclists, runners, triathletes, and skaters [16]. The disorder is characterized by intimal thickening and subsequent narrowing of the artery by collagen fibers, fibrous tissue, and smooth muscle proliferation [17]. The pathogenesis is presumed to involve repetitive vessel stretching during extreme hip flexion, external compression by psoas muscle hypertrophy, repeated vessel kinking during exercise, and shear stress during high cardiac output. This disorder is progressive and may lead to occlusion, frequently occurring (85%) unilaterally on the left. In addition to the external iliac artery (85%), the common femoral artery (5%) and superficial femoral artery (<5%) can be affected [4]. Since no specific angiographic findings are observed, a high clinical suspicion of this disorder is required for diagnosis and proper treatment.
Popliteal artery entrapment can be caused by compression of the popliteal artery in the popliteal fossa by adjacent or surrounding musculotendinous structures and ligaments. This disorder can occur bilaterally (30–67%) and is predominant in young males, although cases of elderly patients up to the age of 70 have been reported [4, 18]. The condition may become evident when the popliteal artery is abnormally positioned, or in cases of fibrous bands or abnormal muscle insertions or slips. There are six types of entrapment based on the anatomical compression of the popliteal artery [1]. Computed tomography (CT) angiography or magnetic resonance (MR) angiography may be useful techniques for identifying the structures causing external compression of the artery (Figure 5). Angiography may also reveal medial or occasionally lateral displacement of the popliteal artery if it is still patent. However, the position of the popliteal artery may be normal if the compression is due to the plantaris or popliteus muscles. In addition, pre‐stenotic or post‐stenotic dilatation can be associated with this disorder (Figure 5). Although popliteal artery narrowing induced by extension of the knee and dorsiflexion of the foot may support the diagnosis of this condition, there is some concern regarding the potential for false‐positive results since popliteal artery compression can occur with active plantar flexion even in healthy individuals [19].
Popliteal artery entrapment syndrome. A 30‐year‐old male presenting moderate claudication. (A) Enhanced CT revealed tight stenosis and post‐stenotic dilatation in the right popliteal artery (arrow). (B) Horizontal view of the CT showing compressed popliteal artery by the surrounding muscle (arrow). (C): Subsequent angiography revealed the progression to occlusion (arrows).
Adductor canal outlet syndrome involves the compression of the distal superficial femoral artery by the adductor canal. It is most commonly reported in runners and skiers, who present with exercise‐induced intermittent claudication symptoms and paresthesias. Symptoms are typically chronic but can progress to occlusion and cause acute limb ischemia due to thrombus. This condition may be rare but it is possible relationship to acute intimal injury and thrombosis should be considered in order to save limbs that may otherwise be lost [20–22].
Other conditions including neoplasma, pseudoxanthoma elasticum, and Baker\'s cyst can cause lower limb ischemia [4].
Vasospasm can occur even in the lower extremity arteries. There are a variety of causes, including idiopathic or certain vasospastic agents (e.g., ergotamine, cocaine, marijuana, and amphetamine) [23, 24]. The characteristic findings of drug‐induced vasospasm are bilateral, symmetric, and abrupt narrowing of any segment of a lower limb artery. Vasospasm can be resolved by discontinuing the offending drug or administering vasodilators (Figure 6).
Idiopathic vasospasm (Ref. 24). A 28‐year‐old male presenting claudication with subsequent acute limb ischemia. (A) Diagnostic enhanced CT angiogram showing tight narrowings in the bilateral femoropopliteal segments (large arrows) and disruptions in the bilateral anterior tibial arteries (small arrows). Also, the proximal segment in the superficial femoral artery seems to be spastic. (B) After initiation of medical treatment during hospitalization, complete recovery of the disruptive lesions is observed though the crural arteries are superimposed on the veins.
Vasculitis may confuse clinicians since it comprises a heterogeneous group of disorders characterized by inflammation and necrosis of blood vessels. However, the key to diagnosis when considering the possible presence of some type of vasculitis is to employ a multidisciplinary approach that involves rheumatologists as well as vascular specialists. Based on the size of the arteries involved and the underlying cause, vasculitis can be categorized as large vessel, medium vessel, or small vessel. The effects of vascular damage including arterial narrowing, thrombosis, or aneurysm formation become prominent over the course of these conditions. Invasive angiography is the gold standard for detecting such lesions and can be used to measure the trans‐lesional pressure gradient. However, there are some concerns regarding invasive angiography for vasculitis. First, sheath or catheter insertion may cause vascular injury in the presence of active inflammation. Second, the potential exists for hypersensitivity reactions to the contrast dye as well as contrast nephropathy and volume overload. Moreover, invasive angiography does not provide any information on changes in vasculitis activity.
\nTakayasu\'s arteritis and giant cell arteritis (GCA) are typical large‐ and medium‐vessel vasculitis that affect the aorta and its main branches, including the subclavian, carotid, vertebral, renal, mesenteric, and iliac arteries. The affected aortoiliac arteries may cause lower limb ischemia. Behcet\'s disease and Buerger\'s disease are representative conditions affecting various‐sized arteries and venous systems. Medium‐vessel vasculitis mainly comprise polyarteritis nodosa, anti‐neutrophil cytoplasmic antibodies (ANCA)‐related vasculitis (granulomatosis with polyangiitis (GPA), microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis), and Kawasaki disease. Assessment of the patient\'s clinical background and systemic examination are indispensable for the diagnosis of this vasculitis. They can also potentially emerge in an atypical vascular bed for each disorder, mimicking other types of vasculitis [25].
\nThis inflammatory vasculitis of large and medium elastic arteries, also called nonspecific aortitis, is characterized pathologically by giant cell infiltration and granuloma formation. Destruction of the entire vascular wall and progressive adventitial fibrosis can cause stenosis or dilatation that can be complicated with superimposed calcification at the chronic stage. This disorder is typically but not exclusively observed in young women of Asian or Latin descent. It primarily affects the aorta, its major branches, and the pulmonary arteries, including but not limited to the brachiocephalic, carotid (common carotid), vertebral, subclavian (proximal subclavian), renal, iliac, femoral, and coronary arteries. Clinically, it usually first presents in the second or third decade, but can occur at older ages. Many patients initially complain of fever, arthralgias, and malaise. Although the most common symptom of TA is arm claudication, observed in greater than 60% of cases, aortoiliac artery involvement can result in lower limb ischemic symptoms, and even the femoral artery may be involved [26, 27].
\nThere are no serological tests to identify TA. The diagnosis of TA is based on clinical findings in the presence of compatible vascular imaging abnormalities (Table 1) [1].
1990 criteria for the classification of Takayasu arteritis |
---|
|
American College of Rheumatology diagnostic criteria for Takayasu arteritis.
Takayasu arteritis is defined clinically if at least three of these six criteria are present. The presence of any three or more criteria yields a sensitivity of 90.5% and a specificity of 97.8%.
Angiography can reveal the extent of luminal narrowing, with or without dilatation/aneurysm, in order to differentiate TA from other diseases. While CT angiography or MR angiography can provide the whole image alternative to angiography, measurement of the pressure gradients is one of the major advantages of invasive angiography (Figure 7). It can also provide opportunities for surgical or endovascular intervention. However, in terms of evaluating vessel wall thickening and edema, duplex US, CT, and MR are more informative than angiography.
Takayasu arteritis. A 20‐year‐old female presenting mild claudication and renovascular hypertension. Invasive angiography revealed significant stenosis in the descending thoracic aorta (arrow). The pullback pressure gradient was 20 mmHg.
Although giant cell arteritis is pathologically similar to TA, this type of vasculitis commonly affects the temporal artery. The disorder is observed in men and women of around 50 and older, and is particularly prevalent in patients aged 70 and older. The arteries potentially affected include the aorta and its branches, with a predilection for the distal subclavian, axillary, and proximal brachial arteries, as well as the branches of the carotid arteries, in particular the ophthalmic artery. Therefore, headaches, jaw claudication, and visual impairment can occur in addition to arm claudication. Also, a normal erythrocyte sedimentation rate (ESR) is more useful in excluding giant cell arteritis than an elevated ESR is in diagnosing this disease [1] (Table 2).
1990 criteria for the classification of giant cell arteritis |
---|
|
American College of Rheumatology diagnostic criteria for giant cell arteritis.
Giant cell arteritis is defined clinically if at least three of these five criteria are present. The presence of any three or more criteria yields a sensitivity of 93.5% and a specificity of 91.2%.
Lower limb arteries can also be affected by this disorder [28, 29]. According to positron emission tomography scan studies, the iliac artery was involved in 37% of cases and the femoral artery in 37% (subclavian artery 70%, axillary artery 40%) [30]. Other studies have reported that superficial femoral artery was involved in 33%, common femoral artery in 14%, internal iliac artery 11%, deep femoral artery in 6%, and popliteal artery in 6% of cases [4, 31–34]. US studies have also detected the involvement of distal lower limb arteries such as the femoropopliteal, tibial, and peroneal arteries [35]. It is sometimes challenging to differentiate lesions from atherosclerosis in older patients.
\nFindings of arteritis from a temporal artery biopsy can be supportive but not essential for a diagnosis. An accurate diagnosis of GCA requires a comprehensive approach that includes assessment of clinical manifestations, physical examination, laboratory studies, vascular imaging, and arterial biopsies. Positive temporal artery biopsies can occasionally be seen in other types of arteritis and the ESR may be normal in up to 10% of GCA patients so that cautious interpretation is required. Differential diagnosis of GCA should include brain disease, infectious disease, and malignant disease. It should be noted that other vasculitis such as polyarteritis nodosa or ANCA‐related vasculitis may rarely present with temporal artery involvement. Polymyalgia rheumatic may also be included in this group of vasculitis as it is often regarded as one clinical entity with GCA.
\nAlthough angiography can confirm the extent of affected vessels, less invasive tools such as duplex US, CT angiography, and MR angiography should also be considered. In particular, CT is informative for the extent of calcification. The advantage of angiography is that it allows measurements of pressure gradients to identify hemodynamically significant lesions.
Vasculitis is observed in less than one‐third of Behcet\'s disease cases. The etiology remains unclear and may involve both genetic and environmental factors. It can potentially be characterized by concomitant oral and genital ulcerations, skin lesions, uveitis, central nervous system, and gastrointestinal involvement. Approximately 80% of Behcet\'s disease patients have the human leukocyte antigen (HLA)‐B51 allele. However, since no symptoms or laboratory findings are pathognomonic for Behcet\'s disease, diagnosis depends on the patient meeting a set of established clinical criteria. The major histopathological features of this disorder are predominantly perivascular inflammatory infiltrates and a tendency to thrombus formation in both veins and arteries of every size. In particular, venous disease is characteristic, including superficial phlebitis, varices, and thrombosis of the deep veins, vena cava, and cerebral sinuses. Large vessels frequently show luminal narrowing, aneurysm, or rupture. Medium and small vessels may also be affected [36, 37] (Figure 8).
Behcet\'s disease. A 64‐year‐old male with a history of deep vein thrombosis and cerebral vein thrombosis presenting acute onset of rest pain and claudication in the right leg. Invasive angiography revealed right femorocrural occlusion. The proximal crural artery was reconstituted through the collateral vessels (arrows).
Buerger\'s disease, also known as thromboangiitis obliterans (TAO), was first reported by Winiwarter in 1879, and later described in detail by Buergers in 1908 [38, 39]. Although the etiology remains unclear, this disorder is a segmental inflammatory disease typically affecting small‐ to medium‐sized arteries of the upper and lower extremities, with occasional extension to the veins and nerves of the extremities [40–42]. Atypically, multiple large vessels can be affected [43]. This condition is more common in men than in women and is almost exclusively observed in patients who use tobacco so that it is widely recognized that tobacco is associated with the onset, progression, and recurrence of the disease. Symptoms can include claudication, rest pain, and ischemic tissue loss such as ulceration and gangrene. Unlike other vasculitis, inflammatory markers such as the ESR and C‐reactive protein are typically normal. Angiography is often required to evaluate lesion extent and runoff conditions since there is the potential for over‐ or underestimation of the lesion with MR and CT imaging. Angiographic findings include segmental arterial occlusions of small‐ and medium‐sized vessels while large arteries are typically spared (Figure 9) [44].
Buerger\'s disease. (A) Femorocrural occlusion beyond the right knee joint in a 38‐year‐old female presenting foot gangrene. (Ref. 44). (B) Crural artery occlusion in a 37‐year‐old male presenting right toe gangrene. Long total occlusions in the tibial arteries extending to the pedal arch.
The term “corkscrew” has recently been used to describe the appearance of collateral vessels in Buerger\'s disease patients. However, the original article attributes the corkscrew appearance to the recanalization of the affected native artery [45, 46]. Moreover, the corkscrew appearance is not pathognomonic for Buerger\'s disease as it may be seen in patients with other disorders including connective tissue disease. Thus, several different criteria have been proposed for the diagnosis of Buerger\'s disease (Tables 3 and 4) [40, 41].
|
Criteria of Buerger\'s disease by Shionoya [40].
|
Criteria of Buerger\'s disease by Olin [41].
Other rare diseases, including Cogan\'s syndrome and relapsing polychondritis, can cause vasculitis of large‐ or medium‐sized vessels. Small‐vessel vasculitides include cryoglobulinemic vasculitis, leukocytoclastic vasculitides such as Henoch‐Schonlein purpura and isolated cutaneous leukocytoclastic vasculitis, and vasculitis secondary to systemic autoimmune disease, including rheumatoid arthritis, systemic lupus erythematosus (SLE), and scleroderma [30, 47]. It is worth noting that there is the possibility of atypical lesion distribution for any type of vasculitides (Figures 10 and 11).
Systemic lupus erythematosus A 16‐year‐old female presenting claudication with subsequent acute limb ischemia as an initial clinical manifestation. Enhanced CT revealed severe femorocrural occlusion. Although the mid‐tibial arteries were reconstituted, the distal tibial and pedal arteries were occluded.
Scleroderma. An 80‐year‐old female presenting toe gangrene with a history of scleroderma. Invasive angiography showing multiple stenosis in the right crural artery.
For example, there have been case reports of large‐ or medium‐vessel vasculitis in patients with rheumatoid arthritis, SLE and ANCA‐related vasculitis [30, 47–62], and uncommon diseases including hypereosinophilic syndrome, Kimura disease, and angiolymphoid hyperplasia with eosinophilia can also mimic Buerger\'s disease [63–65]. Moreover, antiphospholipid syndrome (APS) can occur concomitantly with vasculitis secondary to systemic autoimmune disease (frequently SLE), and can develop into catastrophic APS [66–73] (Figure 10). Certain kinds of vasculitis can be complicated by thrombosis and potentially develop into thrombotic storm which has a devastating clinical course [74–77]. Radiation arteritis can occur years after high‐dose radiotherapy for pelvic malignant disease. In such cases, stenotic or occlusive disease can be seen within the radiation field. Thus, with typical and atypical cases in mind, a careful diagnostic workup is vital for vasculitis.
There are inherited and acquired disorders in which thrombosis develops in the arterial system. Inherited disorders include hyperhomocysteinemia/hyperhomocystinuria, antithrombin deficiency, protein S deficiency, and protein C deficiency, as well as gene polymorphisms such as Factor V Leiden. Acquired disorders are more common and can be caused by APS, malignancies, hormone therapy, and such myeloproliferative disorders as polycythemia vera, thrombocythemia, heparin‐induced thrombocytopenia, and thrombotic thrombocytopenic purpura (Figure 12) [78].
Primary antiphospholipid syndrome [
Thrombosis can be seen in vasculitis [74, 79]. In particular, inflammation‐induced thrombosis is considered to be a feature of certain kinds of vasculitis (systemic autoimmune diseases such as SLE, rheumatoid arthritis, and Sjogren\'s syndrome, and other vasculitis). Thus, primary or secondary APS concomitant with autoimmune diseases such as SLE can cause thrombosis and potentially develop into catastrophic APS [80–82].
Congenital malformations of the iliofemoral arterial system are rare, but accurate diagnosis is essential to avoid unnecessary revascularization treatment. Congenital absence or hypoplasty of the common iliac artery, external iliac artery, and SFA has been reported [83, 84]. Congenital variants of the external iliac artery have been classified into three groups [85]: group 1, anomalies in the origin or course of the artery; group 2, hypoplasia or atresia compensated for by persistent sciatic artery (PSA); and group 3, isolated hypoplasia or atresia. Although group 1 may not be associated with lower limb ischemia and is most often discovered at autopsy, group 2, the so‐called persistent sciatic artery, and group 3 are most likely to present with lower limb ischemia.
\nAbove all, PSA is a popular variant. Failure of regression of the sciatic artery during fetal development is often associated with superficial femoral artery hypoplasia, and the PSA then provides the dominant arterial inflow to the lower limb. Therefore, there is continuation of the internal iliac artery into the thigh through the greater sciatic notch. This variant can cause not only acute lower limb ischemia due to thromboembolism but also chronic lower limb ischemia, with a high incidence of aneurysm formation and arteriosclerosis of the sciatic artery (Figure 13) [4, 86].
Persistent sciatic artery. (A, B) A 64‐year‐old male. Enhanced CT incidentally found persistent sciatic artery (large arrows) in the right. The right external iliac artery connects with the hypoplastic superficial femoral artery (small arrows). (C) A 60‐year‐old female presenting acute limb ischemia. The left external iliac artery connects with the hypoplastic superficial femoral artery whereas the persistent sciatic artery through the left internal iliac artery is the dominant blood supply (small arrows). The distal part of the sciatic artery is occluded due to thromboembolism (large arrow).
Embolism can potentially cause manifestations of chronic lower limb ischemia, such as claudication and critical limb ischemia, but not acute limb ischemia in particular in the elderly population. Embolisms may have a number of sources including cardiac, aortic, and right‐to‐left shunts (paradoxical embolism from the venous circulation).
Orthopedic surgery or trauma may cause lower limb ischemia because of dissection or thrombotic occlusion [87]. Additionally, pediatric cardiac catheterization using the transfemoral approach could be a cause of iliofemoral occlusion or stenosis due to thrombosis formation or intimal hyperplasia (Figure 14). This disorder may be asymptomatic until adulthood, but long‐term uncorrected circulatory impairment can potentially cause limb growth retardation even in the absence of symptomatic evidence of ischemia [88–93].
Vascular injury following catheterization. A 4‐year‐old boy experienced a pale foot on the right following catheterization. Enhanced CT revealed a short occlusion due to puncture site thrombosis in the proximal segment of the right superficial femoral artery (arrows).
This section is intended to focus on vascular imaging, mainly invasive angiography, for NAPAD. From a clinical standpoint, an increase in opportunities to experience the symptoms and signs of APAD heightens the importance of the differential diagnosis of NAPAD in daily practice. NAPAD cannot benefit from a one‐size‐fits‐all approach compared to APAD. Thus, differentiation between NAPAD and APAD may be a challenging task but we clinicians need to increase our knowledge of the diversity of NAPAD so that such awareness can be translated into improved patient care.
Dental implant service is a life-changing treatment modality for many patients. Giving our patients a fixed restoration is a very rewarding procedure, especially if the patients have difficulties: gage reflex, bulky prostheses, lack in retention, stability, or support. Unfortunately, this is not applicable for all patients, especially patients who cannot afford multiple implants or bone grafting. By considering the strategic implants under the existing removable partial denture (RPD), we make implant treatment simple and affordable for more patients.
The removable partial denture (RPD) is the dental prostheses that the patient, who suffers the absence of some but not all the natural teeth, can readily insert and remove from his/her mouth. The prostheses restore the missing teeth as well as the gingiva and the missing bone if needed. Removable partial dentures (RPDs) are indicated for patients with a long edentulous span, too long for a fixed prosthesis. The RPD is indicated for a patient with no posterior abutment to support a fixed prosthesis, and the cantilever bridge is contraindicated. Also, it is preferred if excessive alveolar bone loss is encountered, especially in the esthetic zone. Those patients who are not indicated for bone grafting or unable to afford the costly treatment are good candidates for the removable denture (RD). The acrylic flang is a good approach to compensate for the bone and soft tissue deficiency within a short fabrication time and a less aggressive approach. Moreover, this treatment option allows the patient to remove his prostheses for easier intraoral access, subsequently, better oral hygiene. The RD enables the dentist to repair or adjust the prostheses easily.
On the other hand, RD is less secure with limited retention and stability than fixed prostheses. RD metal clasp may compromise the final esthetic result. It may act as a gum stripper and accelerate alveolar bone resorption. These drawbacks in the RD can be managed by upgrading the RD using strategic implants, which are “the implants that change the prosthetic support type to a more favorable configuration” [1].
In this chapter the folllowing points is going to be discussed:
Classification as a systematic approach for communication and planning:
Kennedy classification system
Steffel classification and modified Steffel classification
Implant-Corrected Kennedy (ICK) Classification System for Partially Edentulous Arches
Strategic mini dental implants (MDI) and standard dental implant (SDI) under existing RPD, how many implant?
The abutment prosthetic value
Immediate and delayed restoration/loading, what is the difference?
Why strategic implant?
Mini-implant-assisted removable partial denture
Conclusion
A classification is a systematic approach in which the items or units are categories in groups or subgroups according to specific criteria. This approach facilitates the discussion regarding the most suitable treatment options, eases the communication between the dentist and the technician. The classification also allows for visualization and differentiation between the RPD support types: tooth-supported, tooth tissue-supported, tissue-supported, implant-supported, implant tissue-supported, and implant tooth-supported.
In 1925 Dr. Edward Kennedy introduced his approach of categorizing partially edentulous arches into four classes. He categorized the partially edentulous arches in a way that considered the edentulous area position in the arch and if it was surrounded with teeth or not. This approach was beneficial in visualizing the cases and reaching the decisions regarding the RPD designs.
The following is the Kennedy classification:
Class I: Edentulous free-end areas located on both sides (bilateral), posterior to the remaining teeth (Figure 1).
Class I maxillary arch.
Class II: Edentulous free-end area located on one side (unilateral), posterior to the remaining teeth (Figure 2).
Class II maxillary arch.
Class III: Edentulous bounded area with natural teeth remaining both anterior and posterior to it (Figure 3). The area is located on one side (unilateral).
Class III maxillary arch.
Class IV: Edentulous bounded area with natural teeth remaining posterior to it. The area is located anteriorly and crossing the mid-line (Figure 4).
Class IV maxillary arch.
In 1965 Applegate’s added eight rules to the classification. The rules can be summarized by the following: The categorization (classification) is always determined by the most posterior edentulous region (or regions). Any additional edentulous area (other than those that define the categorization) is considered a modification (Figures 6 and 7). If the teeth posterior to the edentulous area are not used to support the RPD, the edentulous area is classified as a free end (Figures 5 and 7), and vice versa (Figures 6 and 7). If the posterior free end edentulous region is not going to receive artificial teeth, it will not be considered in the classification (Figures 6–8), and vice versa. Putting the design and the structure of the RPD into consideration is a cornerstone in giving the correct RPD classification. Subsequently, the classification will be the start point making the best clinical decision regarding the number and the position of strategic implants under the RPD.
No rest is going to be costructed on # 38 or 37 ➔ the arch has two free end areas ➔ Class I mandibular arch.
Direct retainer is going to be constructed on 37. No artificial teeth is going to replace 46, 47 or 48 ➔ no free end ➔ Class III mod 1 mandibular arch.
No artificial teeth is going to replace, 48. Direct retainer is going to be constructed on 37 but not on 47 ➔ one free end ➔ Class II mod 3 mandibular arch.
No artificial teeth is going to replace, 38, 37, 36, 47 or 48. Class IV mandibular arch.
In 1962 Steffel described six support possibilities that can be encountered in RPD.[2] He labeled the classification categories from A to F based on the fulcrum, and the number and distribution of the abutments, Figure 9. The fulcrum line is a hypothetical line formed between abutments, teeth or implants. The RPD may rotate somewhat around the fulcrum during function.
Steffel classification.
ICK I (# 25).
In this chapter, we suggest a modification to this classification to simplify the communication and decision-making regarding the strategic implant under the existing RPD. In the modification, B, C, and D will be labeled together.
The following is the
Punctual-support, only one abutment.
Linear-support, two abutments; separated with edentulous area or at least one tooth.
Triangular-support, three well-distributed abutments; separated with edentulous area or at least one tooth. One of the abutments should be on the opposite quadrant.
Quadrangular-support, two well-distributed abutments on every quadrant.
Providing the patient with a stable prosthesis is a crucial target for the dentist. However, the RPD is not rigidly attached to the intraoral hard (teeth) and soft (mucosa) tissues, which have different levels of compressibility and mobility. Subsequently, the chewing and occlusal forces may generate different levels of tissue stress and prosthesis mobility. Both (stress and mobility) should be within the physiological level and cause no harm or trauma. Achieving this critical goal depends on the clinician’s understanding of the biomechanics and the different design solutions. The RPD design should consider the unique nature of each clinical case and counter the expected RPD movement in response to loading. The design also should minimize the potentially destructive forces that may affect the supporting tissues; teeth, mucosa, and bone. That can be achieved by avoiding a long lever system, good selection for the RPD supporting elements, and wide symmetrical distribution of the functional forces [3, 4]. Many of the previous points (if not all) can be achieved (fully or partially) by delivering an RPD with quadrangular-support type.
According to the modified Steffel classification, there are four types of prosthetic support: punctual, linear, triangular, and quadrangular. The RPD support improves gradually as the classification change from I to IV. Classification IV provides the best support to the RPD with the highest resistance of rotation. The strategic implant aims to change the prosthetic support type to a more favorable configuration.
One of the simple classification systems for RPD supported with implants or implants and natural teeth is Implant-Corrected Kennedy (ICK) classification system for partially edentulous arches by Al-Johany et al.[5] The ICK is based on the Kennedy classification system and the Applegate eight rules (Applegate–Kennedy system).[6] According to the ICK classification system coding guidelines, the Kennedy classification comes first, followed by the number of modification spaces (Applegate rules). Finally, round brackets enclose # followed by the implant’s or implants’ position will be added, Figures 10–18.
ICK II mod 2 (# 33, 36). Direct retainer is going to be constructed on 28.
ICK II mod 3 (# 13, 23). Direct retainer is going to be constructed on 28.
Meeting our patient’s expectations is a priority. That cannot be reached if the dentist did not provide the patient with a full straightforward clarification for the treatment plan. The clarification should cover the advantages, disadvantages, risks, time, cost, and alternatives. The explanation should be done in a way that helps both the patient first and the dentist second to reach the decision that best matches the patients’ needs, health status, and financial ability, as well as respect the patient’s chief complaint and consideration. Generally speaking, teeth-implant- or implant-supported removable dentures reduce (and in many cases eliminate) traditional denture problems.[1, 7, 8, 9] It helps the dentist widen his options to meet the patient’s needs and expectations by inserting one or few implants in strategic positions, but how many implants?
The needed number of mini dental implants (MDIs) or standard dental implants (SDIs) under existing RPD is a multifactorial process (see paragraph 2.5) and taken on the quadrant level. To give the patient an RPD with acceptable retention, stability, and support, the abutments should be well distributed. Two abutments on every quadrant in symmetrical position as possible are needed. On every quadrant, the sum of the abutments prosthetic value should be ≥2, Table 1 and Figure 19.
ICK II mod 1 (# 16, 13, 23).
The abutments prosthetic value | ||
---|---|---|
Teeth | Upper or lower incisor or lateral incisor | 0–0.5* |
Upper or lower canine | 1.3** | |
Upper or lower premolar or molar | 1*** | |
MDI | Upper MDI | 0.5–0.7**** |
lower MDI | 1 | |
SDI | Upper Standard Implant | 1 |
Lower Standard Implant | 1 |
The prosthetic value of the available teeth and the planned MDIs and SDIs. The recommendations are on the quadrant level.
The numbers represent the prosthetic value if abutment rest is planned; if not, the value will be 0.
If the four natural anterior abutment teeth are missing (11, 12, 13, 14), strategic implant/s is recommended even if all posterior teeth are available, and vice versa.
If there is no space ( edentulous area or at least one natural tooth) between the abutment teeth, the prosthetic value will decrease to 0.5 for each abutment.
Bone quality impacts the MDI prosthetic value.
ICK II (# 35, 33, 43).
For partially edentulous patients, the abutments can be implants or natural teeth and should be well-distributed with a sum of the prosthetic value ≥2 on quadrant level.
ICK III mod 3 (# 41).
In the course of formulating the prosthodontic plan, not all teeth or abutments have the same prosthetic value. The prosthetic value stands for the importance of the tooth or implant from a specific prosthodontic point of view. The last first molar (#36) in Figure 20 has a very high prosthetic value than the lateral incisor #32. Extracting #36 shifts the treatment modality (if an implant is not feasible) from fixed partial denture to removable partial denture. Suppose the dentist changes his prosthodontic point of view by selecting RPD as a treatment modality. In that case, the prosthetic value of #36 will be reduced a little for this specific treatment modality. However, the prosthetic value for the same tooth (#36, Figure 20) and the same treatment modality (RPD) will be very high if the patient has a knife-edge thin, sensitive mucosa. Usually, this type of patient can tolerate tooth-tooth-supported RPD better than tooth tissue-supported RPD. Therefore, it can be concluded that:
ICK III mod 1 (# 34, 42).
ICK III mod 1 (# 13, 23).
ICK IV (# 33, 43). Direct retainers are going to be constructed on 36 and 47. No artificial teeth are going to replace 37 or 38.
(A1 upper jaw and A2 lower jaw to G1 upper jaw): The recommended number of strategic standard implants (SDIs) or mini dental implants (MDIs) under existing RPD.
The #36 has a very high prosthetic value because the extracting change the treatment modality (if implant is not feasible) from fixed partial denture to removable partial denture.
The SDI #23 and MDI #33 have very high esthetic value as they help the dentist avoiding anterior metal clasps. #27 and MDI 35 have relatively high prosthetic value as they shift the RPD from tooth tissue supported to more implant tooth-supprted or implat implant-supported RPD.
Upgrading the existing clasp retained lower RPD by inserting strategic mini-implants, immediate restoration with immediate loading/soft material. A- Intraoral image with lower RPD before implantation. B- Partial edentulous lower jaw before implantation. C- Tissue surface of the RPD before implantation. D- Four strategic mini-implants in the interforaminal region, tooth 32 was extracted. E- Tissue surface of the RPD after implantation, soft relining in the areas opposing the implants’ head. F- Tissue surface of the RPD after 4 months, the matrix pick-up (housings). G- Intraoral image with lower RPD after the housing, clasps in esthetic zone were removed.
Narrow bone can be treated with bone grafting. Unfortunately, this is not always feasible. A- Biomechanically, the narrow implant is not always the best approach, see paragraph 5. B- Osteoplasty is used to insert a wider implant by increasing the bone width, which will impact the crown-implant ratio negatively and may place the implant near vital anatomical structure. C- One-piece mini-implant with ball attachment and preferable crown-implant ratio can be used to stabilize a complete removable denture or partial removable denture.
Upgrading the existing double crown retained upper RPD by inserting strategic mini-implants, immediate restoration, and delayed loading. A- Partial edentulous upper jaw before implantation. B- Tissue surface of the RPD before implantation. C- Five strategic mini-implants. D- Tissue surface of the RPD after implantation, recesses (empty notches) against the mini-implants. E- Tissue surface of the RPD after 4 months, the matrix pick-up (housings). The palate coverage was reduced. F- Intraoral image with the RPD after the housing.
Upgrading the existing double crown retained lower RPD by inserting strategic mini-implants, immediate restoration and immediate loading. A- Partial edentulous lower jaw before implantation. B- Tissue surface of the RPD before implantation. C- Two strategic mini-implants. D- Tissue surface of the RPD after implantation, the matrix pick-up (housings) inserted in the same implantation session. E- Intraoral image with the RPD in place after implantation.
The hidden #23 MDI under the saddle (Figure 21) has a very high esthetic value as it helps the dentist avoid metal clasp in the esthetic zone. In some cases, strategic implants enable the dentist to reduce or remove the flange to achieve a better esthetic result by reducing lip protrusion. In other cases, it gives the dentist the ability to minimize the RPD size (palate, Figure 24) and increase patient acceptance.
The prosthetic value (importance) for each abutment is estimated according to Table 1 and mainly the following points: [11, 12, 17, 18].
Periodontal status, mobility, and bone level around the abutment.
Crown-root ratio.
Tooth vitality, size of the defect (caries), size, and type of the restoration.
The shape and number of the abutment roots.
Occlusion, parafunctional activity and opposite jaw status: natural teeth, implant, fixed partial denture, complete denture, or partial denture.
In 1981 Albrektsson et al. suggested a protocol in which the implants are left to heal in situ for at least 3 to 4 months without loading.[19] He considered the non-loading phase a crucial period to achieve successful osseointegration and avoid fibrous tissue formation between the implant surface and the bone. On the other hand, many clinical studies proved that immediate restoration, immediate loading, or early loading are acceptable treatment modalities.[20, 21] These studies were in response to the social and psychological needs of many patients. The immediate or early treatment modalities aim to reduce the overall recovery time between the surgical intervention and the insertion of the final restoration. These approaches are known as immediate restoration protocol, immediate loading protocol, and early loading protocol.
Patients typically are uncomfortable and, in many cases, refuse to stay without their RPD for a long time, especially if it restores a lot of missing teeth or teeth in the esthetic zone. The immediate protocols can reduce the patient concerns related to the final restoration by reducing the waiting period. In some cases, a temporary restoration is immediately delivered to give the patient a hint on the form, size, and position (in some cases, the shade) of the final restoration. Moreover, the second surgical intervention can be averted through immediate protocols. To achieve a good success rate in this treatment modality, a good understanding of the topic, terminology, limitation, and biology is essential. These topics will be discussed in other chapters, but it is crucial to clarify a few terms.
The loading can be classified into four categories:
Conventional loading: The implants are left without loading for around two to three months.
Delayed loading: If the loading on the implant is applied after the conventional loading time, it is classified as delayed. That can be indicated if the tissue needs more healing time, such as external sinus lift with bone grafting. In such cases, the final restoration and implant loading may be applied after six to nine months.
Early loading: The implant is loaded by placing dental restoration in contact with opposing dentition at any time after one week but within two months after implant insertion.
Immediate loading: The dental restoration is inserted intraorally and placed in contact with opposing dentition within one week after the surgical intervention.
The timing of dental restoration can also be categorized to:
Conventional restoration in which the implant is left without temporary or final restoration for around two to three months.
Immediate restoration: The temporary or final restoration is placed within one week after surgical intervention.
Early restoration: The temporary or final restoration is placed any time after one week but within two months after implant insertion.
Delayed restoration: If the dental restoration is placed intraorally after the conventional loading time, the restoration is classified as delayed restoration.
According to the previous classifications, the dentist has different types of intervention. For example, he can go for immediate restoration with conventional loading or implement early restoration with delayed loading.
In the case of the strategic implant under existing RPD, there are seven scenarios: immediate restoration with one of the four loading types, or early restoration with early, conventional, or delayed loading. The decision regarding the best approach is multifactorial: age, esthetic expectations, oral hygiene level, bone quality and quantity, and treatment expenses. According to the 2018 census supported by the International Team for Implantology (ITI), the most critical factors that may impact the loading protocol selection are patient-related factors, especially patient’s general health, implant primary stability (ISQ), bone grafting, the size and shape of the implant, and the doctor skills and experience.[22] Moreover, the ITI tried to unify the two classifications (loading and restoration timing) to make it less complicated for the clinician and easier for the researchers to perform clinical studies and compare their results. They described four protocols:
Immediate loading: Within one week after implant placement, dental implants are linked to a prosthesis in occlusion with the opposing arch.
Immediate restoration: Within one week after implant placement, dental implants are linked to the dental restoration and are kept out of occlusion.
Early loading: Between one week and two months following implant placement, dental implants are linked to the prosthesis.
Conventional loading: dental implants are linked to the prosthesis after two months of implantation.
Improving dental treatment output by using implants to enhance the functional performance of the complete denture is a well-known approach in prosthodontics. The McGill Consensus Statement stated that the first option in treating the lower jaw edentulous patient should be two implants retained overdenture and not lower jaw conventional complete denture (CD).[23] Overwhelming scientific evidence supports the statement.[23] The evidence emphasized the superiority of two implants retained overdenture treatment modality on the conventional CD in many aspects, such as patients’ chewing efficiency, positive modification in patients’ diet, patients’ satisfaction with the CD stability, retention, and comfort as well as quality of life.[23] Although a lot of scientific evidence highlighted the positive impact of inserting implants under existing RPD, no similar Consensus Statement is available regarding implant-retained or implant-assisted removable partial denture. [24, 25, 26].
Not all patients are suitable for implant-supported fixed dental prostheses. For example, many patients are unwilling to have an extra surgical intervention (bone grafting, sinus lifting, bone splitting, or expansion). Other patients are not suitable for such intervention because they are medically compromised or do not have adequate financial flexibility. As an alternative to inserting multiple implants, the dentist can improve the quality of the prosthodontic treatment by changing the support type of the RPD to the quadrangular-support type. The improvement can be achieved by inserting one/two standard implants or one/two/three mini-implants per quadrant to reach a symmetrical quadrangular-support type. The prostheses will be tooth implant-supported RPD instead of tooth tissue-supported RPD. This prosthodontic approach is affordable to many patients.
The strategic implant is “the implant that can change the prosthetic support type to a more favorable configuration”.[1] It is a reliable way of treatment with an implant survival rate of 91.7–100%.[4] Also, it can support both the RPD and the other abutments effectively. In two clinical studies with 2 and 3 years follow-up, the survival rate of the natural teeth abutments was 100%.[9, 24].
Moreover, it can improve the survival rate of the RPD. The 10-year survival rate of RPDs; clasp-retained removable partial dentures, conical crown-retained dentures, or a combination of conical crown and clasp-retained dentures is 71.3%.[27] On the other hand, clinical studies with observation periods between 1 and 12.2 years reported survival rates of 90–100% for the implant-assisted removable partial denture prostheses.[7, 28, 29, 30, 31] This remarked difference in the survival rate plays an essential role in formulating the prosthodontic plan.
Many clinical studies have shown that implant placement in strategic locations under an existing RPD can enhance chewing efficiency, dental health-related quality of life, and patient satisfaction with speaking and eating, as well as RPD retention, stability, and support.[1, 8, 32] Above that, it gives the dentist the ability to reduce the tissue coverage and reduce the size of the RPD, which can positively impact the patient’s acceptance of the RPD, especially if he suffers hyperactive gag reflex, Figure 24. Also, it can improve the final esthetic result by avoiding the traditional metal clasp, Figures 19 and 22.
Unfortunately, inserting a standard implant under the existing RPD is not always feasible. The patient may have a very narrow bone that prevents inserting a standard implant without bone grafting. A procedure that is not suitable or acceptable by some patients. In this case, mini-implants can be considered a good alternative, Figures 22 and 25 [1, 8, 16].
In 1976, the U.S. Food and Drug Administration (FDA) approved the 3 mm root-form dental implant. With time, dental implants proved to be a predictable and reliable prosthodontic treatment modality with a high success rate.[33, 34, 35] After 21 years, the approval was cleared for implants less than 3 mm. The approval widens the spectrum of the patients treated with dental implants, particularly the cases with reduced bone width.
In literature, there is no standardization regarding the terminology of dental implant diameter.[36] For example, some authors considered the implants with diameters from 1.8 to 2.9 mm as small implants; others call them mini-implants.[37] Some authors defined the mini-implant as the implant with 2.2 mm.[38] Al-Johany et al. proposed a classification scheme and used four terms: Extra-narrow <3.0 mm, Narrow ≥3.0 mm to <3.75 mm, Standard 3.75 mm to <5 mm, and Wide ≥5 mm.[36] In this text, we will follow the lead of Resnik et al. and Schiegnitz et al. by considering the mini-implant as the implant with a diameter < 3.0 and the narrow-diameter implant as the implant with a diameter ≤ 3.5.[25, 37] This implant type is mainly used in heavily atrophic jaws but with sufficient bone height. The mini-implant gives the dentist the ability to avoid bone augmentation procedure, which is considered a time and cost-consuming surgical intervention. Avoiding additional surgical procedures can reduce morbidity and possible complications such as nerve trauma, hemorrhage, postoperative pain, or infection.[25] The infection may lead to the failure of bone grafting.[25] Above that, it is less invasive than the standard implant as it requires a smaller implant bed and no flap in a considerable number of cases.[26] Therefore, it is more appropriate for the compromised or elderly patients. Moreover, it is cost-effective and affordable. On the other hand, the small diameter of the implant may create a shear load to the crestal bone. That may increase the risk of bone resorption.[37, 39] Narrow -implant has been linked to biomechanical risk factors as implant fatigue or fracture, particularly when used in the canine area where high occlusal loads are applied or in parafunctional habits patients.[40].
A systematic review and meta-analysis reported that mini-implants (diameter < 3.0 mm) performed substantially worse than standard diameter implants with survival rates of 94.7 ± 5%.[25] However, narrow implants with a diameter (3–3.5 mm) have a better survival rate of 97.7 ± 2.3%.[25] Therefore, some researchers believe the best approach for a thin bone is bone augmentation.[37] If this is not feasible, narrow implant, osteoplasty and standard implant, or one-piece mini-implant with ball attachment and removable denture can be considered, Figure 23.
The small diameter implant is used to replace missing individual teeth in the anterior region, lower and upper jaw [41, 42]. Mini-implant is used as an orthodontic implant or transitional or provisional implant to support interim prostheses during the healing period after extensive implantations or augmentations and bone grafting.[43] The one-piece mini-implant with ball attachment is used as assisting / anchoring element under the removable denture.[1] Strategic min-implant under existing RPD and CD proved to be a reliable and straightforward approach.[1, 8, 44] New studies reported that the one-piece mini-implant with ball attachment has a significant advantage on the final prosthodontic treatment.[1, 8].
The one-piece implant mimics nature by having a solid unibody structure with no microgaps between the implant and the abutment. As a result, the possible biological complication (bone resorption) and structural flaw are reduced. Also, the flap or flapless single-stage surgery allows the dentist to implement immediate loading or immediate restoration.[42] Moreover, delayed loading is possible by preparing a recess against the mini-implant in the RPD’s tissue surface. The treatment protocol can be conventional or delayed loading. However, the recess (cavity) distorts the fit of the RPD’s, Figure 24.
On the other hand, if the mini-implants are inserted in a healthy, not compromised patent with insertion torque ≥35 Ncm, immediate loading can be considered. The immediate restoration with immediate loading can be implemented through one of two forms:
immediate loading using soft relining material, Figure 22.
immediate loading using the matrix pick-up (housings), Figure 25.
After implantation, soft relining material can restore the fit of the RPD, ease tissue pressure, and give the patient a secure feeling because the relining material encircles the implant head and minimizes RPD rocking. If all mini-implants have a high insertion torque, the patient can receive the final restoration with matrix pick-up (housings). Subsequently, no additional session for adjusting the RPD is needed. In this approach, the patient can directly feel and recognize the significant improvement in the RPD in many domains especially, retention, support stability, and chewing.[1, 8].
Studies proved that inserting strategic implants under existing RPD improves patient satisfaction on short- and medium-term follow-up (3-years).[1, 43] The improvement can be explained by the symmetrical distribution of the abutments and the increased number of the rests/abutments.[1, 17] Gorai S, et al. study reported a correlation between the rests number and denture usage.[17].
To sum it up, using strategic implants under existing RPD upgrade the design to more favorable support type and improve patient satisfaction with the RPD on several domains like speaking, chewing, retention, stability, and support of the RPD. This improvement could be reached earlier if the patient received immediate loading.[1].
In many cases, after putting into consideration the patient’s main complaint, expectation, desire, general health, intraoral/extraoral findings, evaluating the risks (do no harm) and the benefits of bone grafting and several implants, the dentist is able to provide his patient with one or few strategic standard or mini-implants that can satisfy the patients’ needs
Strategic implants can also improve chewing ability, stabilize the occlusion, increase bite force and improve patient oral health-related quality of life. Moreover, better distribution of occlusal forces that may reduce bone resorption may be gained. Furthermore, strategic implants can improve comfort, confidence, and esthetics by reducing the RPD size and removing metal clasps from the esthetic zone.
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He has both an MS and Ph.D. in Biomedical Engineering. He was previously a research scientist at the University of California Los Angeles (UCLA) and visiting professor and researcher at the University of North Dakota. He is currently working in artificial intelligence and its applications in medical signal processing. In addition, he is using digital signal processing in medical imaging and speech processing. Dr. Asadpour has developed brain-computer interfacing algorithms and has published books, book chapters, and several journal and conference papers in this field and other areas of intelligent signal processing. He has also designed medical devices, including a laser Doppler monitoring system.",institutionString:"Kaiser Permanente Southern California",institution:null},{id:"169608",title:"Prof.",name:"Marian",middleName:null,surname:"Găiceanu",slug:"marian-gaiceanu",fullName:"Marian Găiceanu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/169608/images/system/169608.png",biography:"Prof. Dr. Marian Gaiceanu graduated from the Naval and Electrical Engineering Faculty, Dunarea de Jos University of Galati, Romania, in 1997. He received a Ph.D. (Magna Cum Laude) in Electrical Engineering in 2002. Since 2017, Dr. Gaiceanu has been a Ph.D. supervisor for students in Electrical Engineering. He has been employed at Dunarea de Jos University of Galati since 1996, where he is currently a professor. Dr. Gaiceanu is a member of the National Council for Attesting Titles, Diplomas and Certificates, an expert of the Executive Agency for Higher Education, Research Funding, and a member of the Senate of the Dunarea de Jos University of Galati. He has been the head of the Integrated Energy Conversion Systems and Advanced Control of Complex Processes Research Center, Romania, since 2016. He has conducted several projects in power converter systems for electrical drives, power quality, PEM and SOFC fuel cell power converters for utilities, electric vehicles, and marine applications with the Department of Regulation and Control, SIEI S.pA. (2002–2004) and the Polytechnic University of Turin, Italy (2002–2004, 2006–2007). He is a member of the Institute of Electrical and Electronics Engineers (IEEE) and cofounder-member of the IEEE Power Electronics Romanian Chapter. He is a guest editor at Energies and an academic book editor for IntechOpen. He is also a member of the editorial boards of the Journal of Electrical Engineering, Electronics, Control and Computer Science and Sustainability. Dr. Gaiceanu has been General Chairman of the IEEE International Symposium on Electrical and Electronics Engineering in the last six editions.",institutionString:'"Dunarea de Jos" University of Galati',institution:{name:'"Dunarea de Jos" University of Galati',country:{name:"Romania"}}},{id:"4519",title:"Prof.",name:"Jaydip",middleName:null,surname:"Sen",slug:"jaydip-sen",fullName:"Jaydip Sen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/4519/images/system/4519.jpeg",biography:"Jaydip Sen is associated with Praxis Business School, Kolkata, India, as a professor in the Department of Data Science. His research areas include security and privacy issues in computing and communication, intrusion detection systems, machine learning, deep learning, and artificial intelligence in the financial domain. He has more than 200 publications in reputed international journals, refereed conference proceedings, and 20 book chapters in books published by internationally renowned publishing houses, such as Springer, CRC press, IGI Global, etc. Currently, he is serving on the editorial board of the prestigious journal Frontiers in Communications and Networks and in the technical program committees of a number of high-ranked international conferences organized by the IEEE, USA, and the ACM, USA. He has been listed among the top 2% of scientists in the world for the last three consecutive years, 2019 to 2021 as per studies conducted by the Stanford University, USA.",institutionString:"Praxis Business School",institution:null},{id:"320071",title:"Dr.",name:"Sidra",middleName:null,surname:"Mehtab",slug:"sidra-mehtab",fullName:"Sidra Mehtab",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00002v6KHoQAM/Profile_Picture_1584512086360",biography:"Sidra Mehtab has completed her BS with honors in Physics from Calcutta University, India in 2018. She has done MS in Data Science and Analytics from Maulana Abul Kalam Azad University of Technology (MAKAUT), Kolkata, India in 2020. Her research areas include Econometrics, Time Series Analysis, Machine Learning, Deep Learning, Artificial Intelligence, and Computer and Network Security with a particular focus on Cyber Security Analytics. Ms. Mehtab has published seven papers in international conferences and one of her papers has been accepted for publication in a reputable international journal. She has won the best paper awards in two prestigious international conferences – BAICONF 2019, and ICADCML 2021, organized in the Indian Institute of Management, Bangalore, India in December 2019, and SOA University, Bhubaneswar, India in January 2021. Besides, Ms. Mehtab has also published two book chapters in two books. Seven of her book chapters will be published in a volume shortly in 2021 by Cambridge Scholars’ Press, UK. Currently, she is working as the joint editor of two edited volumes on Time Series Analysis and Forecasting to be published in the first half of 2021 by an international house. Currently, she is working as a Data Scientist with an MNC in Delhi, India.",institutionString:"NSHM College of Management and Technology",institution:null},{id:"226240",title:"Dr.",name:"Andri Irfan",middleName:null,surname:"Rifai",slug:"andri-irfan-rifai",fullName:"Andri Irfan Rifai",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/226240/images/7412_n.jpg",biography:"Andri IRFAN is a Senior Lecturer of Civil Engineering and Planning. He completed the PhD at the Universitas Indonesia & Universidade do Minho with Sandwich Program Scholarship from the Directorate General of Higher Education and LPDP scholarship. He has been teaching for more than 19 years and much active to applied his knowledge in the project construction in Indonesia. His research interest ranges from pavement management system to advanced data mining techniques for transportation engineering. He has published more than 50 papers in journals and 2 books.",institutionString:null,institution:{name:"Universitas Internasional Batam",country:{name:"Indonesia"}}},{id:"314576",title:"Dr.",name:"Ibai",middleName:null,surname:"Laña",slug:"ibai-lana",fullName:"Ibai Laña",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314576/images/system/314576.jpg",biography:"Dr. Ibai Laña works at TECNALIA as a data analyst. He received his Ph.D. in Artificial Intelligence from the University of the Basque Country (UPV/EHU), Spain, in 2018. He is currently a senior researcher at TECNALIA. His research interests fall within the intersection of intelligent transportation systems, machine learning, traffic data analysis, and data science. He has dealt with urban traffic forecasting problems, applying machine learning models and evolutionary algorithms. He has experience in origin-destination matrix estimation or point of interest and trajectory detection. Working with large volumes of data has given him a good command of big data processing tools and NoSQL databases. He has also been a visiting scholar at the Knowledge Engineering and Discovery Research Institute, Auckland University of Technology.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"314575",title:"Dr.",name:"Jesus",middleName:null,surname:"L. Lobo",slug:"jesus-l.-lobo",fullName:"Jesus L. Lobo",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314575/images/system/314575.png",biography:"Dr. Jesús López is currently based in Bilbao (Spain) working at TECNALIA as Artificial Intelligence Research Scientist. In most cases, a project idea or a new research line needs to be investigated to see if it is good enough to take into production or to focus on it. That is exactly what he does, diving into Machine Learning algorithms and technologies to help TECNALIA to decide whether something is great in theory or will actually impact on the product or processes of its projects. So, he is expert at framing experiments, developing hypotheses, and proving whether they’re true or not, in order to investigate fundamental problems with a longer time horizon. He is also able to design and develop PoCs and system prototypes in simulation. He has participated in several national and internacional R&D projects.\n\nAs another relevant part of his everyday research work, he usually publishes his findings in reputed scientific refereed journals and international conferences, occasionally acting as reviewer and Programme Commitee member. Concretely, since 2018 he has published 9 JCR (8 Q1) journal papers, 9 conference papers (e.g. ECML PKDD 2021), and he has co-edited a book. He is also active in popular science writing data science stories for reputed blogs (KDNuggets, TowardsDataScience, Naukas). Besides, he has recently embarked on mentoring programmes as mentor, and has also worked as data science trainer.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"103779",title:"Prof.",name:"Yalcin",middleName:null,surname:"Isler",slug:"yalcin-isler",fullName:"Yalcin Isler",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRyQ8QAK/Profile_Picture_1628834958734",biography:"Yalcin Isler (1971 - Burdur / Turkey) received the B.Sc. degree in the Department of Electrical and Electronics Engineering from Anadolu University, Eskisehir, Turkey, in 1993, the M.Sc. degree from the Department of Electronics and Communication Engineering, Suleyman Demirel University, Isparta, Turkey, in 1996, the Ph.D. degree from the Department of Electrical and Electronics Engineering, Dokuz Eylul University, Izmir, Turkey, in 2009, and the Competence of Associate Professorship from the Turkish Interuniversity Council in 2019.\n\nHe was Lecturer at Burdur Vocational School in Suleyman Demirel University (1993-2000, Burdur / Turkey), Software Engineer (2000-2002, Izmir / Turkey), Research Assistant in Bulent Ecevit University (2002-2003, Zonguldak / Turkey), Research Assistant in Dokuz Eylul University (2003-2010, Izmir / Turkey), Assistant Professor at the Department of Electrical and Electronics Engineering in Bulent Ecevit University (2010-2012, Zonguldak / Turkey), Assistant Professor at the Department of Biomedical Engineering in Izmir Katip Celebi University (2012-2019, Izmir / Turkey). He is an Associate Professor at the Department of Biomedical Engineering at Izmir Katip Celebi University, Izmir / Turkey, since 2019. In addition to academics, he has also founded Islerya Medical and Information Technologies Company, Izmir / Turkey, since 2017.\n\nHis main research interests cover biomedical signal processing, pattern recognition, medical device design, programming, and embedded systems. He has many scientific papers and participated in several projects in these study fields. He was an IEEE Student Member (2009-2011) and IEEE Member (2011-2014) and has been IEEE Senior Member since 2014.",institutionString:null,institution:{name:"Izmir Kâtip Çelebi University",country:{name:"Turkey"}}},{id:"339677",title:"Dr.",name:"Mrinmoy",middleName:null,surname:"Roy",slug:"mrinmoy-roy",fullName:"Mrinmoy Roy",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/339677/images/16768_n.jpg",biography:"An accomplished Sales & Marketing professional with 12 years of cross-functional experience in well-known organisations such as CIPLA, LUPIN, GLENMARK, ASTRAZENECA across different segment of Sales & Marketing, International Business, Institutional Business, Product Management, Strategic Marketing of HIV, Oncology, Derma, Respiratory, Anti-Diabetic, Nutraceutical & Stomatological Product Portfolio and Generic as well as Chronic Critical Care Portfolio. A First Class MBA in International Business & Strategic Marketing, B.Pharm, D.Pharm, Google Certified Digital Marketing Professional. Qualified PhD Candidate in Operations and Management with special focus on Artificial Intelligence and Machine Learning adoption, analysis and use in Healthcare, Hospital & Pharma Domain. Seasoned with diverse therapy area of Pharmaceutical Sales & Marketing ranging from generating revenue through generating prescriptions, launching new products, and making them big brands with continuous strategy execution at the Physician and Patients level. Moved from Sales to Marketing and Business Development for 3.5 years in South East Asian Market operating from Manila, Philippines. Came back to India and handled and developed Brands such as Gluconorm, Lupisulin, Supracal, Absolut Woman, Hemozink, Fabiflu (For COVID 19), and many more. In my previous assignment I used to develop and execute strategies on Sales & Marketing, Commercialization & Business Development for Institution and Corporate Hospital Business portfolio of Oncology Therapy Area for AstraZeneca Pharma India Ltd. Being a Research Scholar and Student of ‘Operations Research & Management: Artificial Intelligence’ I published several pioneer research papers and book chapters on the same in Internationally reputed journals and Books indexed in Scopus, Springer and Ei Compendex, Google Scholar etc. Currently, I am launching PGDM Pharmaceutical Management Program in IIHMR Bangalore and spearheading the course curriculum and structure of the same. I am interested in Collaboration for Healthcare Innovation, Pharma AI Innovation, Future trend in Marketing and Management with incubation on Healthcare, Healthcare IT startups, AI-ML Modelling and Healthcare Algorithm based training module development. I am also an affiliated member of the Institute of Management Consultant of India, looking forward to Healthcare, Healthcare IT and Innovation, Pharma and Hospital Management Consulting works.",institutionString:null,institution:{name:"Lovely Professional University",country:{name:"India"}}},{id:"310576",title:"Prof.",name:"Erick Giovani",middleName:null,surname:"Sperandio Nascimento",slug:"erick-giovani-sperandio-nascimento",fullName:"Erick Giovani Sperandio Nascimento",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0033Y00002pDKxDQAW/ProfilePicture%202022-06-20%2019%3A57%3A24.788",biography:"Prof. Erick Sperandio is the Lead Researcher and professor of Artificial Intelligence (AI) at SENAI CIMATEC, Bahia, Brazil, also working with Computational Modeling (CM) and HPC. He holds a PhD in Environmental Engineering in the area of Atmospheric Computational Modeling, a Master in Informatics in the field of Computational Intelligence and Graduated in Computer Science from UFES. He currently coordinates, leads and participates in R&D projects in the areas of AI, computational modeling and supercomputing applied to different areas such as Oil and Gas, Health, Advanced Manufacturing, Renewable Energies and Atmospheric Sciences, advising undergraduate, master's and doctoral students. He is the Lead Researcher at SENAI CIMATEC's Reference Center on Artificial Intelligence. In addition, he is a Certified Instructor and University Ambassador of the NVIDIA Deep Learning Institute (DLI) in the areas of Deep Learning, Computer Vision, Natural Language Processing and Recommender Systems, and Principal Investigator of the NVIDIA/CIMATEC AI Joint Lab, the first in Latin America within the NVIDIA AI Technology Center (NVAITC) worldwide program. He also works as a researcher at the Supercomputing Center for Industrial Innovation (CS2i) and at the SENAI Institute of Innovation for Automation (ISI Automação), both from SENAI CIMATEC. He is a member and vice-coordinator of the Basic Board of Scientific-Technological Advice and Evaluation, in the area of Innovation, of the Foundation for Research Support of the State of Bahia (FAPESB). He serves as Technology Transfer Coordinator and one of the Principal Investigators at the National Applied Research Center in Artificial Intelligence (CPA-IA) of SENAI CIMATEC, focusing on Industry, being one of the six CPA-IA in Brazil approved by MCTI / FAPESP / CGI.br. He also participates as one of the representatives of Brazil in the BRICS Innovation Collaboration Working Group on HPC, ICT and AI. He is the coordinator of the Work Group of the Axis 5 - Workforce and Training - of the Brazilian Strategy for Artificial Intelligence (EBIA), and member of the MCTI/EMBRAPII AI Innovation Network Training Committee. He is the coordinator, by SENAI CIMATEC, of the Artificial Intelligence Reference Network of the State of Bahia (REDE BAH.IA). He leads the working group of experts representing Brazil in the Global Partnership on Artificial Intelligence (GPAI), on the theme \"AI and the Pandemic Response\".",institutionString:"Manufacturing and Technology Integrated Campus – SENAI CIMATEC",institution:null},{id:"1063",title:"Prof.",name:"Constantin",middleName:null,surname:"Volosencu",slug:"constantin-volosencu",fullName:"Constantin Volosencu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/1063/images/system/1063.png",biography:"Prof. Dr. Constantin Voloşencu graduated as an engineer from\nPolitehnica University of Timișoara, Romania, where he also\nobtained a doctorate degree. He is currently a full professor in\nthe Department of Automation and Applied Informatics at the\nsame university. Dr. Voloşencu is the author of ten books, seven\nbook chapters, and more than 160 papers published in journals\nand conference proceedings. He has also edited twelve books and\nhas twenty-seven patents to his name. He is a manager of research grants, editor in\nchief and member of international journal editorial boards, a former plenary speaker, a member of scientific committees, and chair at international conferences. His\nresearch is in the fields of control systems, control of electric drives, fuzzy control\nsystems, neural network applications, fault detection and diagnosis, sensor network\napplications, monitoring of distributed parameter systems, and power ultrasound\napplications. He has developed automation equipment for machine tools, spooling\nmachines, high-power ultrasound processes, and more.",institutionString:"Polytechnic University of Timişoara",institution:{name:"Polytechnic University of Timişoara",country:{name:"Romania"}}},{id:"221364",title:"Dr.",name:"Eneko",middleName:null,surname:"Osaba",slug:"eneko-osaba",fullName:"Eneko Osaba",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/221364/images/system/221364.jpg",biography:"Dr. Eneko Osaba works at TECNALIA as a senior researcher. He obtained his Ph.D. in Artificial Intelligence in 2015. He has participated in more than twenty-five local and European research projects, and in the publication of more than 130 papers. He has performed several stays at universities in the United Kingdom, Italy, and Malta. Dr. Osaba has served as a program committee member in more than forty international conferences and participated in organizing activities in more than ten international conferences. He is a member of the editorial board of the International Journal of Artificial Intelligence, Data in Brief, and Journal of Advanced Transportation. He is also a guest editor for the Journal of Computational Science, Neurocomputing, Swarm, and Evolutionary Computation and IEEE ITS Magazine.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"275829",title:"Dr.",name:"Esther",middleName:null,surname:"Villar-Rodriguez",slug:"esther-villar-rodriguez",fullName:"Esther Villar-Rodriguez",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/275829/images/system/275829.jpg",biography:"Dr. Esther Villar obtained a Ph.D. in Information and Communication Technologies from the University of Alcalá, Spain, in 2015. She obtained a degree in Computer Science from the University of Deusto, Spain, in 2010, and an MSc in Computer Languages and Systems from the National University of Distance Education, Spain, in 2012. Her areas of interest and knowledge include natural language processing (NLP), detection of impersonation in social networks, semantic web, and machine learning. Dr. Esther Villar made several contributions at conferences and publishing in various journals in those fields. Currently, she is working within the OPTIMA (Optimization Modeling & Analytics) business of TECNALIA’s ICT Division as a data scientist in projects related to the prediction and optimization of management and industrial processes (resource planning, energy efficiency, etc).",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"49813",title:"Dr.",name:"Javier",middleName:null,surname:"Del Ser",slug:"javier-del-ser",fullName:"Javier Del Ser",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49813/images/system/49813.png",biography:"Prof. Dr. Javier Del Ser received his first PhD in Telecommunication Engineering (Cum Laude) from the University of Navarra, Spain, in 2006, and a second PhD in Computational Intelligence (Summa Cum Laude) from the University of Alcala, Spain, in 2013. He is currently a principal researcher in data analytics and optimisation at TECNALIA (Spain), a visiting fellow at the Basque Center for Applied Mathematics (BCAM) and a part-time lecturer at the University of the Basque Country (UPV/EHU). His research interests gravitate on the use of descriptive, prescriptive and predictive algorithms for data mining and optimization in a diverse range of application fields such as Energy, Transport, Telecommunications, Health and Industry, among others. In these fields he has published more than 240 articles, co-supervised 8 Ph.D. theses, edited 6 books, coauthored 7 patents and participated/led more than 40 research projects. He is a Senior Member of the IEEE, and a recipient of the Biscay Talent prize for his academic career.",institutionString:"Tecnalia Research & Innovation",institution:null},{id:"278948",title:"Dr.",name:"Carlos Pedro",middleName:null,surname:"Gonçalves",slug:"carlos-pedro-goncalves",fullName:"Carlos Pedro Gonçalves",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRcmyQAC/Profile_Picture_1564224512145",biography:'Carlos Pedro Gonçalves (PhD) is an Associate Professor at Lusophone University of Humanities and Technologies and a researcher on Complexity Sciences, Quantum Technologies, Artificial Intelligence, Strategic Studies, Studies in Intelligence and Security, FinTech and Financial Risk Modeling. He is also a progammer with programming experience in:\n\nA) Quantum Computing using Qiskit Python module and IBM Quantum Experience Platform, with software developed on the simulation of Quantum Artificial Neural Networks and Quantum Cybersecurity;\n\nB) Artificial Intelligence and Machine learning programming in Python;\n\nC) Artificial Intelligence, Multiagent Systems Modeling and System Dynamics Modeling in Netlogo, with models developed in the areas of Chaos Theory, Econophysics, Artificial Intelligence, Classical and Quantum Complex Systems Science, with the Econophysics models having been cited worldwide and incorporated in PhD programs by different Universities.\n\nReceived an Arctic Code Vault Contributor status by GitHub, due to having developed open source software preserved in the \\"Arctic Code Vault\\" for future generations (https://archiveprogram.github.com/arctic-vault/), with the Strategy Analyzer A.I. module for decision making support (based on his PhD thesis, used in his Classes on Decision Making and in Strategic Intelligence Consulting Activities) and QNeural Python Quantum Neural Network simulator also preserved in the \\"Arctic Code Vault\\", for access to these software modules see: https://github.com/cpgoncalves. He is also a peer reviewer with outsanding review status from Elsevier journals, including Physica A, Neurocomputing and Engineering Applications of Artificial Intelligence. Science CV available at: https://www.cienciavitae.pt//pt/8E1C-A8B3-78C5 and ORCID: https://orcid.org/0000-0002-0298-3974',institutionString:"University of Lisbon",institution:{name:"Universidade Lusófona",country:{name:"Portugal"}}},{id:"241400",title:"Prof.",name:"Mohammed",middleName:null,surname:"Bsiss",slug:"mohammed-bsiss",fullName:"Mohammed Bsiss",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241400/images/8062_n.jpg",biography:null,institutionString:null,institution:null},{id:"276128",title:"Dr.",name:"Hira",middleName:null,surname:"Fatima",slug:"hira-fatima",fullName:"Hira Fatima",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/276128/images/14420_n.jpg",biography:"Dr. Hira Fatima\nAssistant Professor\nDepartment of Mathematics\nInstitute of Applied Science\nMangalayatan University, Aligarh\nMobile: no : 8532041179\nhirafatima2014@gmal.com\n\nDr. Hira Fatima has received his Ph.D. degree in pure Mathematics from Aligarh Muslim University, Aligarh India. Currently working as an Assistant Professor in the Department of Mathematics, Institute of Applied Science, Mangalayatan University, Aligarh. She taught so many courses of Mathematics of UG and PG level. Her research Area of Expertise is Functional Analysis & Sequence Spaces. She has been working on Ideal Convergence of double sequence. She has published 17 research papers in National and International Journals including Cogent Mathematics, Filomat, Journal of Intelligent and Fuzzy Systems, Advances in Difference Equations, Journal of Mathematical Analysis, Journal of Mathematical & Computer Science etc. She has also reviewed few research papers for the and international journals. She is a member of Indian Mathematical Society.",institutionString:null,institution:null},{id:"414880",title:"Dr.",name:"Maryam",middleName:null,surname:"Vatankhah",slug:"maryam-vatankhah",fullName:"Maryam Vatankhah",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Borough of Manhattan Community College",country:{name:"United States of America"}}},{id:"414879",title:"Prof.",name:"Mohammad-Reza",middleName:null,surname:"Akbarzadeh-Totonchi",slug:"mohammad-reza-akbarzadeh-totonchi",fullName:"Mohammad-Reza Akbarzadeh-Totonchi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Ferdowsi University of Mashhad",country:{name:"Iran"}}},{id:"414878",title:"Prof.",name:"Reza",middleName:null,surname:"Fazel-Rezai",slug:"reza-fazel-rezai",fullName:"Reza Fazel-Rezai",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"American Public University System",country:{name:"United States of America"}}},{id:"302698",title:"Dr.",name:"Yao",middleName:null,surname:"Shan",slug:"yao-shan",fullName:"Yao Shan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Dalian University of Technology",country:{name:"China"}}},{id:"125911",title:"Prof.",name:"Jia-Ching",middleName:null,surname:"Wang",slug:"jia-ching-wang",fullName:"Jia-Ching Wang",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"National Central University",country:{name:"Taiwan"}}},{id:"357085",title:"Mr.",name:"P. Mohan",middleName:null,surname:"Anand",slug:"p.-mohan-anand",fullName:"P. Mohan Anand",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}},{id:"356696",title:"Ph.D. Student",name:"P.V.",middleName:null,surname:"Sai Charan",slug:"p.v.-sai-charan",fullName:"P.V. Sai Charan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}},{id:"357086",title:"Prof.",name:"Sandeep K.",middleName:null,surname:"Shukla",slug:"sandeep-k.-shukla",fullName:"Sandeep K. Shukla",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}},{id:"356823",title:"MSc.",name:"Seonghee",middleName:null,surname:"Min",slug:"seonghee-min",fullName:"Seonghee Min",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Daegu University",country:{name:"Korea, South"}}},{id:"353307",title:"Prof.",name:"Yoosoo",middleName:null,surname:"Oh",slug:"yoosoo-oh",fullName:"Yoosoo Oh",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:"Yoosoo Oh received his Bachelor's degree in the Department of Electronics and Engineering from Kyungpook National University in 2002. He obtained his Master’s degree in the Department of Information and Communications from Gwangju Institute of Science and Technology (GIST) in 2003. In 2010, he received his Ph.D. degree in the School of Information and Mechatronics from GIST. In the meantime, he was an executed team leader at Culture Technology Institute, GIST, 2010-2012. In 2011, he worked at Lancaster University, the UK as a visiting scholar. In September 2012, he joined Daegu University, where he is currently an associate professor in the School of ICT Conver, Daegu University. Also, he served as the Board of Directors of KSIIS since 2019, and HCI Korea since 2016. From 2017~2019, he worked as a center director of the Mixed Reality Convergence Research Center at Daegu University. From 2015-2017, He worked as a director in the Enterprise Supporting Office of LINC Project Group, Daegu University. His research interests include Activity Fusion & Reasoning, Machine Learning, Context-aware Middleware, Human-Computer Interaction, etc.",institutionString:null,institution:{name:"Daegu Gyeongbuk Institute of Science and Technology",country:{name:"Korea, South"}}},{id:"262719",title:"Dr.",name:"Esma",middleName:null,surname:"Ergüner Özkoç",slug:"esma-erguner-ozkoc",fullName:"Esma Ergüner Özkoç",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Başkent University",country:{name:"Turkey"}}},{id:"346530",title:"Dr.",name:"Ibrahim",middleName:null,surname:"Kaya",slug:"ibrahim-kaya",fullName:"Ibrahim Kaya",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Izmir Kâtip Çelebi University",country:{name:"Turkey"}}},{id:"419199",title:"Dr.",name:"Qun",middleName:null,surname:"Yang",slug:"qun-yang",fullName:"Qun Yang",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Auckland",country:{name:"New Zealand"}}}]}},subseries:{item:{id:"40",type:"subseries",title:"Ecosystems and Biodiversity",keywords:"Ecosystems, Biodiversity, Fauna, Taxonomy, Invasive species, Destruction of habitats, Overexploitation of natural resources, Pollution, Global warming, Conservation of natural spaces, Bioremediation",scope:"