\r\n\tThis book intends to provide the reader with a comprehensive overview of the current state-of-the-art novel imaging techniques by focusing on the most important evidence-based developments in this area.
",isbn:null,printIsbn:null,pdfIsbn:null,doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"d9159ce31733bf78cc2a79b18c225994",bookSignature:"Dr. Gabriel Cismaru",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11867.jpg",keywords:"Hypertrophic Cardiomyopathy, Dilated Cardiomyopathy, Restrictive Cardiomyopathy, Transesophageal Echocardiography, Intracardiac Echocardiography, 3-Dimensional Echocardiography, Adult Congenital Heart Disease, Tetralogy of Fallot, Transposition of the Great Vessels, Coronary Artery Disease, Risk Stratification, Revascularization",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"April 21st 2022",dateEndSecondStepPublish:"May 19th 2022",dateEndThirdStepPublish:"July 18th 2022",dateEndFourthStepPublish:"October 6th 2022",dateEndFifthStepPublish:"December 5th 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"3 months",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Dr. Cismaru Gabriel is an Assistant Professor at the University of Medicine and Pharmacy Cluj-Napoca, certified in Cardiology. After completing his certification in cardiology, Dr. Cismaru began his electrophysiology fellowship at the Institut Lorrain du Coeur et des Vaisseaux Louis Mathieu. He has authored or co-authored peer-reviewed articles and book chapters in the field of cardiac pacing, defibrillation, electrophysiological study, and catheter ablation.",coeditorOneBiosketch:"Raluca Tomoaia is an MD, Ph.D. in novel techniques in Echocardiography at the University of Medicine and Pharmacy in Cluj-Napoca, Romania., assistant professor, and a researcher in echocardiography and cardiovascular imaging.",coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"191888",title:"Dr.",name:"Gabriel",middleName:null,surname:"Cismaru",slug:"gabriel-cismaru",fullName:"Gabriel Cismaru",profilePictureURL:"https://mts.intechopen.com/storage/users/191888/images/system/191888.png",biography:"Dr. Cismaru Gabriel is an assistant professor at the Cluj-Napoca University of Medicine and Pharmacy, Romania, where he has been qualified in cardiology since 2011. He obtained his Ph.D. in medicine with a research thesis on electrophysiology and pro-arrhythmic drugs in 2016. Dr. Cismaru began his electrophysiology fellowship at the Institut Lorrain du Coeur et des Vaisseaux Louis Mathieu, France, after finishing his cardiology certification with stages in Clermont-Ferrand and Dinan, France. He began working at the Rehabilitation Hospital\\'s Electrophysiology Laboratory in Cluj-Napoca in 2011. He is an experienced operator who can implant pacemakers, CRTs, and ICDs, as well as perform catheter ablation of supraventricular and ventricular arrhythmias such as ventricular tachycardia and ventricular fibrillation. He has been qualified in pediatric cardiology since 2022, and he regularly performs device implantation and catheter ablation in children. Dr. Cismaru has authored or co-authored peer-reviewed publications and book chapters on cardiac pacing, defibrillation, electrophysiological studies, and catheter ablation.",institutionString:"Iuliu Hațieganu University of Medicine and Pharmacy",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"7",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"Iuliu Hațieganu University of Medicine and Pharmacy",institutionURL:null,country:{name:"Romania"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"16",title:"Medicine",slug:"medicine"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:null},relatedBooks:[{type:"book",id:"5970",title:"Bedside Procedures",subtitle:null,isOpenForSubmission:!1,hash:"ba56d3036ac823a7155f40e4a02c030d",slug:"bedside-procedures",bookSignature:"Gabriel Cismaru",coverURL:"https://cdn.intechopen.com/books/images_new/5970.jpg",editedByType:"Edited by",editors:[{id:"191888",title:"Dr.",name:"Gabriel",surname:"Cismaru",slug:"gabriel-cismaru",fullName:"Gabriel Cismaru"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9064",title:"Epidemiology and Treatment of Atrial Fibrillation",subtitle:null,isOpenForSubmission:!1,hash:"1cd6bf2b3181eb82446347fbe478a2bc",slug:"epidemiology-and-treatment-of-atrial-fibrillation",bookSignature:"Gabriel Cismaru and Keith Andrew Chan",coverURL:"https://cdn.intechopen.com/books/images_new/9064.jpg",editedByType:"Edited by",editors:[{id:"191888",title:"Dr.",name:"Gabriel",surname:"Cismaru",slug:"gabriel-cismaru",fullName:"Gabriel Cismaru"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6550",title:"Cohort Studies in Health Sciences",subtitle:null,isOpenForSubmission:!1,hash:"01df5aba4fff1a84b37a2fdafa809660",slug:"cohort-studies-in-health-sciences",bookSignature:"R. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3092",title:"Anopheles mosquitoes",subtitle:"New insights into malaria vectors",isOpenForSubmission:!1,hash:"c9e622485316d5e296288bf24d2b0d64",slug:"anopheles-mosquitoes-new-insights-into-malaria-vectors",bookSignature:"Sylvie Manguin",coverURL:"https://cdn.intechopen.com/books/images_new/3092.jpg",editedByType:"Edited by",editors:[{id:"50017",title:"Prof.",name:"Sylvie",surname:"Manguin",slug:"sylvie-manguin",fullName:"Sylvie Manguin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{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"}}]},chapter:{item:{type:"chapter",id:"71271",title:"Flap Techniques in Dentoalveolar Surgery",doi:"10.5772/intechopen.91165",slug:"flap-techniques-in-dentoalveolar-surgery",body:'\nOral surgical flap by definition is the operation in which a portion of the mucoperiosteal tissue is surgically detached from the underlying bone for better access and visibility. Common principles have been applied for all flap designs. First, the base of the flap should be broader than the free end to ensure adequate blood supply. Second, the incision should be performed at a right angle to the underlying bone, avoiding any anatomical structures, and it should provide adequate visualization. Third, the flap should be wider than the anticipated underlying bone defect and delicately handled without tension. Fourth, the vertical releasing incision should start from the buccal vestibule and end up mesial or distal to the interdental papilla. Different flaps have been proposed for various intraoral surgeries, that is, third molar surgery, canine exposure, various periodontal surgery, dental implant preparation, endodontic surgeries, and repair of oroantrual communications. The review will focus on oral anatomy, classification, indications, complications of common oral flap techniques; common flap designs are illustrated, and their fundamental principles are highlighted.
\nThe flap design has considerable effects on primary wound healing in lower third molar surgery [1]. When the conventional sulcular flap design is used, 56% of the patients develop a disorder in primary wound healing [1]. The envelope flap is fixed anteriorly with intersulcular sutures. Notably, dehiscence can take place inconspicuously and unnoticed by the patient and may heal secondarily. The secondary wound healing can cause wedge-shaped defects of the gingiva distal to the second molar or can lead to a loss of attachment distal to the second molar. This periodontal complication after lower third molar surgery has been investigated by several studies [2, 3, 4, 5]. Dehiscence occurs in only 10% of cases of triangular flap design [1], and the triangular flap design decreases tension in the area distal to wound closure compared with the envelope flap technique. The vestibular triangular flap can be easily moved to the lingual, ensuring a wound closure that is almost tension-free. The mesial vestibular relieving incision, which is only adapted coronally by a single suture, allows depletion of the postoperative hematoma during masticatory movements. On the first postoperative day, a present hematoma is easy to relieve by spreading and compression. The advantage is that the release area has bone support. Such postoperative morbidity has important medical-legal and economic implications. Many surgical approaches, such as those with the use of surgical drains, different wound closure techniques, and various flap designs, have been tried to minimize the complications [6].
\nAn envelope flap with a sulcular incision from the first to the second molar and a distal relieving incision to the mandibular ramus is a widely used technique for lower third molar surgery (Figure 1).
\nEnvelope flap for the removal of the third molar.
The envelope flap is closed with two or three single button sutures distal to the second molar, with special attention to an exact repositioning in the area of the gingival margin. In addition, the flap is adapted with interdental sutures between the first and the second molars.
\nAdvantages
Good exposure during surgery
Mesial cut could be extended if cystic surgery or endosurgery is required
The envelope flap provides adequate soft tissues, covering for any bone defects
The envelope flap has a wider base, assuring vascularity up to the wound margins
Limitations
Inducing loss of the alveolar bone distal to the second molar probably due to wound dehiscence
Sulcular incision may lead to periodontal damage
The envelope flap leads to a total loss of the attached gingiva in this area after the operation, thus causing pocket formation and loss of attachment in the area of the second molar [1]
Dehiscence to the second molar [7]
Hypersensitivity in the area of the distally exposed root surface of the second molar
Alveolar osteitis and soft tissue abscess are severe complications
This technique was described by Szmyd [6]. The incision is conducted from the mandibular ramus to the distobuccal crown edge of the second molar, followed by a perpendicular incision obliquely into the mandibular vestibulum, with a length of about 10 mm. In contrast, the modified incision extends over the mucogingival borderline, and the periodontium of the second molar is only touched at the dentofacial edge (Figures 2 and 3). The flap is lingually based on the triangular flap [8].
\nTriangular flap for the removal of the third molar.
Modified triangular flap for removal of the third molar.
For suturing, the same suturing technique is used distally (envelop), whereas the perpendicular incision is only adapted with a single coronally placed suture. The main aim is exact repositioning of the gingival margin in the area of the second molar. The loose adaption in the apical portion allows easy relief of a hematoma.
\nAdvantages
Reduces the incidence of wound dehiscence
A suitable choice for compromised cases of nicotine exposure
This flap can be easily moved to the lingual, ensuring a wound closure that is almost tension-free [8]
Limitations
Swelling and trismus
Pain
No significant difference in postoperative complications between the lingually based triangular flap and the traditional buccally based triangular flap after surgery of the third molar [8]
Canines are among the most commonly impacted teeth after the third molar teeth. Different causes have been suggested and investigated in literature [9]. The impacted canines need to be either exposed or removed to avoid some possible complications. Untreated canines may cause tooth malalignment, root resorption of adjacent teeth, infections, and cystic changes.
\nThe location of an impacted canine will determine the access for surgical exposure or removal. About one-third of the impacted maxillary canines are positioned labially or within the alveolus, while two-thirds are located palatally [10]. Kokich [11, 12] suggested that the following four criteria related to tooth position within the alveolar bone housing need to be carefully evaluated before exposing the impacted canine:
The first criterion looks at the labial-palatal position of the impacted canine. When there is labial impaction, the treatment of choice is an open technique (gingivectomy or apically positioned flap). While impaction in the mid-alveolus requires an open or closed technique, a palatal impaction is usually treated using a closed technique.
The second criterion evaluates the impaction position relative to the mucogingival junction (MGJ) in an apical-coronal dimension. When the majority of the impacted crown is positioned coronal to the MGJ, the gingivectomy open technique can be conducted. If the crown is located at the MGJ level, an apically repositioned flap is used. When the crown is apical to the MGJ, a closed technique is generally utilized.
The third criterion involves the evaluation of the amount of keratinized gingiva (KG) mainly with facial impactions. When there is an abundance of KG, the impacted canine is positioned relatively close to the MGJ, and a gingivectomy procedure is recommended. However, if there is inadequate KG, an apically repositioned flap or closed technique is suggested.
The fourth criterion evaluates the mesial-distal position of the canine relative to the lateral incisor. If the canine crown is positioned distal to the mesial aspect of the lateral incisor, an open technique is performed. If the crown is positioned mesial to the lateral incisor, a closed technique for the pataltal eruption of canine.
Labial canine impaction is usually difficult to approach because aesthetic outcomes of final soft-tissue healing are a challenge. An inappropriate surgical technique or flap design may lead to compromised aesthetic results [12]. During the process of uncovering a labially impacted maxillary canine, mucogingival problems, such as an immersed clinical crown, limited keratinized gingiva, gingival recession, and scarring, may occur if an inappropriate surgical intervention is employed [13]. In addition, the vertical and horizontal locations of the impacted canine also greatly affect orthodontic tooth movements and soft-tissue responses. Therefore, it is critical to make the right decision about the choice of a proper surgical technique to expose labially impacted teeth.
\nThe proposed flap techniques include the window excision of the soft tissue (Figure 4), apically positioned flap, closed eruption technique, and sequential approach.
\nWindow excision at the labial soft tissue opposite to the crown of the impacted upper canine.
\nFigure 4 shows the window excision of the soft tissue when the canine crown is coronal to the mucogingival junction.
\nAdvantages
Directly expose the crown part
Easy to perform
Limitations
Sacrifice the gingival tissue
Require wider attached gingiva
\nFigures 5 and 6 show the apically positioned flap if there is insufficient attached gingiva.
\nAn apically repositioned flap: (a) outline of the flap; (b) flap repositioned apically to provide a collar of the attached gingiva around the exposed tooth.
Window is created (top image) labially opposite to the crown of the impacted canine, and (bottom image) the attached free gingival margin is placed apically.
Advantage
Preserve attached gingiva
Limitation
Not suitable in highly impacted canine
\nFigure 7 shows that highly impacted canine and the crown tip are properly aligned mesiodistally.
\nGingival margin flap with bracket and chain bond it to the crown of the impacted canine.
Advantage
The closed mucosal flap is more comfortable for patients
Limitation
Uncontrollable orthodontic forces on the nonvisible tooth during orthodontic extrusion
If a maxillary canine is highly impacted, its crown protrudes labially, or its cusp tip is displaced mesially (Figure 8), two-stage approaches may be indicated, in which exposure is carried out first (Figure 6) and mucogingival surgery such as gingivoplasty is performed at a later stage. Laterally sliding flap (Figure 9) provides additional keratinized tissue with natural color and consistency at the recipient site if adequate keratinized gingival is available over lateral incisor. Pedicle flap can be the second option and can be dissected from both the central and lateral incisor areas to transfer to cover the recipient bed (Figure 9).
\nMesially exposed impacted canine that may require two-stage surgery to achieve minimal attached gingiva.
The principle of lateral pedicle repositioned flap. R, recipient tooth; D, donor tooth; F, flap; S, split-thickness dissection.
Advantage
Achieve 3–4 mm keratinized gingiva in highly impacted canine [9]
Limitations
Two-stage surgery
Donor site morbidity is expected
The main objective of periodontal flap surgery is to eliminate and reduce the pocket depth that cannot be treated conservatively (evidence of bleeding, loss of attachment, or suppuration) with conventional periodontics treatment. Raising surgical flap facilitates removal of the inflamed tissue inside the pocket, provides access for tooth surface cleaning, and helps remove harmful plaque and calculus.
\nIndications
Provide access to the tooth’s root surface for instrumentation
Correction of gingival overgrowth by gingivectomy
Create new periodontal attachment
Improve aesthetics and function following gingival recession by the root coverage technique
Contra-indications
Poor plaque control
Uncontrolled systemic disease
Heavy smokers
Teeth with poor long-term prognosis
Raising full mucoperiosteum exposes the underlying bone. The modified Widman flap [14] is one example of this type of flap. It includes a scalloped incision 1 mm from the crevicular margin involving the interproximal area of the teeth, allowing the flap to be raised without releasing incision (Figure 10).
\nModified Widman flap technique. The image is adapted from The Hungarian higher education in dentistry in Hungarian, German, and English.
Advantages
Allow close adaptation of soft tissues to the root surface with minimal trauma
Less postoperative teeth sensitivity
Better aesthetic results
Allow root surface debridement
The pocket reduction is achieved by long junctional epithelial attachment to the root surface
Limitations
Not indicated if osseous surgery is planned
Cannot be used for full pocket removal
Reverse bevel incision is made at the attached gingiva angled to excise the periodontal pocket in a scalloped fashion. Two releasing incisions are made mesial and distal to the defect. After the flap is elevated, pocketing tissues are discarded, osseous surgery can be performed, and the flap is then apically repositioned and sutured in position as illustrated above in the canine exposure section (Figure 11).
\nApically repositioned flap for periodontal surgery. (a) The bevel, scalloped incision for pocket elimination. (b) The flap positioned apically.
Advantages
Expose the alveolar bone and allow osseous surgery to correct infrabony defects
Allow excellent access to the root surface for debridement
Limitation
Not applicable in the palatal tissue
Beveled incision excises the supra-gingival pocket and allows for gingival re-contouring.
\nAdvantages
Suitable for gingival hypertrophy (supra-alveolar pocket)
Re-contouring severely damaged gingival tissues
Crown lengthening (Figure 12)
The stages for crown lengthening. (A) Internal beveling; (B) sulcular incision; (C) removal of excess tissues to expose the crown or the gingival overgrowth.
Limitations
Not indicated in case of deep “true” infrabony pocket
Not suitable for removal of intrabone lesions
Row wound exposes the root surface, making it sensitive and susceptible to caries
Because of the loss of the attached gingiva, some bone remodeling may occur
Mucogingival graft surgery aims at the correction of local gingival defects. It will be conducted if changing the morphology of gingival margin improves the plaque control, high frenal attachment, and severe gingival recession.
\nRaising partial soft tissues and leaving the mucoperiosteum attached to the bone are commonly used techniques to address such mucogingival problems. Moreover, pedicle flap includes either laterally, coronally, or double papilla repositioned flaps. The flaps are indicated in very narrow areas of isolated gingival recession or even in the presence of wide recession with adequate door tissues on either side [15].
\nTwo horizontal incisions are made on both mesial and distal sides of defects 1 mm away from the gingival margin of the adjacent tooth. Two vertical incisions are then made perpendicular to the initial incisions on either side, which extend into the alveolar mucosa. Partial-thickness pedicles are reflected on either side of the recession area (Figure 9). The reflection is carried out to a level that would permit free movements of the mesial and distal pedicle flaps. Both pedicles are rotated over the defect to make sure they would remain over the defect without any tension. Subsequently, both pedicles are sutured with 6-0 polypropylene sutures.
\nAdvantages
Minimal exposure of the underlying periosteum at the interdental donor sites
Rapid wound healing at the donor site
Limitations
Cannot be used in a generalized recession
Cannot be used if there is an inadequate amount of keratinized tissues at donor sites
A partial-thickness flap is raised around the defect with the help of two horizontal and two vertical incisions on either side of the defect without involving the marginal gingiva of adjacent teeth. To facilitate a tension-free coronal displacement, its base can be separated from the periosteum with the help of a periosteal releasing incision. The flap is then advanced coronally and sutured at the level of cementoenamel junction (CEJ) using 5-0 polypropylene sutures (Figures 13 and 14).
\nCoronally repositioned flap used to cover localized recession. The top image shows the recession area, and the incision line is done 4–5 mm from the gingival margin; the bottom image shows that partial-thickness flap is raised and sutured coronally.
Free gingival graft is applied to cover the root surface with less amount of attached gingiva.
This graft is a harvested tissue and is completely removed from the blood donor area, and it is used to augment the amount of the attached (keratinized) gingiva. This approach can be only used with the combination with another surgical approach.
\nTwo-stage surgical techniques use double pedicle flap with a connective tissue graft, followed by coronally advanced flap.
\nAdvantages
Treatment for a severe localized gingival recession
Excellent color matching and dual blood supply to graft
Very predictable results
Can be used if minimal keratinized tissue is present
Limitations
Requires good pedicel length
Two-stage surgery
A free graft is required
Two-stage flap techniques are commonly used for dental implant surgery and include a flapless (e.g., Punch or Half Punch) flap and full-thickness flap, such as mid-crest, double papilla preservation flap. Full-thickness flap might be more suitable for immediate implantation; the flapless flap is superior to full-thickness flap in cases of less inflammation and less morbidity, has shallower biological width, and shows better aesthetic results [16].
\nA small hole in the keratinized mucosa is required to be present on the crest of the ridge at the area of interest (Figure 14). This punch can be created using a blade or punch drill. Precise placement of the cut can be obtained using the surgical guide with the help of the planning software (Figure 15).
\nPunch flap (flapless) at mid-crest of ridge.
Advantages
Minimal surgery
Minimal postoperative pain/discomfort
Suitable for one-stage surgery
Limitations
Simultaneous bone grafting is not possible
Minimal exposure to the bone for thickness evaluation
Require sufficient keratinized mucosa
In the case of the presence of inadequate or deficient buccal tissues, half punch approach is used. Half punch flap is conducted with horizontal crestal incision and reflects full-thickness flap buccally. Subsequently, punch approach is used lingually or palatally to remove minimally required tissues for implant placement (Figure 16).
\nHalf punch flap used for implant bed preparation.
Advantage
One-stage implant surgery with possible simultaneous bone grafting
Mid-crestal incision is performed at the middle of the ridge bone, and buccal and lingual/or palatal flaps are then raised to expose the full surgical site (Figure 17).
\nThe edentulous ridge with minimal attached gingiva. Half punch flap is performed.
Advantages
This flap can be used for both one- and two-stage implant surgery
Buccal and palatal/lingual bone grafting is possible
Limitation
Requires sufficient buccal and palatal tissues
The incision is similar to mid-crestal incision; however, it is made more toward the palatal side/lingual. The flap is then raised to perform the bone preparation (Figure 18).
\nMid-crestal incision used during implant bed preparation.
Advantages
Suitable in cases when there are less buccal tissues available to raise full-thickness flap
Bone grafting can be performed buccally or palatally/lingually
Suitable for both one- and two-stage implant surgery
This flap is designed to maintain the interdental papilla for aesthetics in some cases.
\nIn this flap, vertical releasing incision distal to the papilla is made and is connected to a crestal incision on the other side of the defect. An intrasulcular incision on the distal tooth is performed, and the flap is raised, followed by implant bed preparation (Figure 19).
\nPlatatal crestal flap used for implant bed preparation.
Advantages
Good aesthetic results
Minimal surgery and soft tissue manipulation
Limitations
Not suitable if bone grafting is required
Used for the second stage of implant surgery to help get maximum aesthetic results by preserving the papilla
This flap is opposite to mesial preservation flap, and the aim is to preserve the distal side of the defect to allow bone grafting (Figures 20 and 21).
\nMesially papilla preserved incision for implant bed preparation.
Double papilla preservation with two vertical releasing incisions.
This flap is designed to preserve both mesial and distal papilla at the defect area. Two vertical incisions are performed and connected with lingual or palatal crestal incision, thus allowing the release of the mucoperiosteal flap toward the buccal aspect.
\nAdvantages
More aesthetic results
Suitable for the second stage of implant surgery where the mobilization of a good amount of tissues may be required
Limitation
Vascularity may be compromised in the narrow space
The buccal or lingual mucoperiosteal flap can be reflected, allowing an alveolar split to be done using thin osteotomes for alveolar ridge expansion if required.
\nAdvantages
Wide exposure allows observing the undercut lingually or buccally
Easy to lean and perform alveoloplasty
Easy to perform bone cutting and splitting
Limitations
Bone devitalization and subsequent remodeling resorption in narrow ridge [17].
Less predictable outcomes
This is a minimally exposed osteoperiosteal flap to overcome the limitation of full-thickness flap for the wide edentulous area when the resulting vascularity may jeopardize the outcomes (Figure 22).
\nFull ridge exposure using the full thickness flap buccally and lingually.
Advantages
Maintain the integrity of periosteum
Maintain bone vitality (vascularity)
Alveolar width stability, that is, minimal postoperative resorption compared with full-thickness flap
Limitations
The bone is cut blindly; therefore, the surgeon must have a good conceptualization of the alveolar anatomy to not miss the midpoint of the alveolus. The surgeon should avoid extending to the vestibular depth or palatally directed osteotomy
Requires extensive flap dissection [17]
Flap design in periapical surgery should be adequate for the planned surgical procedure, offering good access to the zone surrounding the affected apexes without altering the soft-tissue circulation. The flap should be a firm continuous incision and not cross an underlying bony defect. If a vertical incision is needed, it should be in the concavities between bone eminences. The vertical incision should not extend into the mesiobuccal fold, and its termination of the gingival crest must be at the mesial or distal line angle of the tooth. Additionally, the base of the flap must be at least equal to the width of its free end. The most frequently used flap in periapical surgery is the Luebke-Ochsenbein flap involving submarginal incision, with semilunar or Partsch flap variants.
\nA horizontal incision is made in the attached gingival tissue about 3–4 mm above the gingival margin, with two vertical releasing incisions on either side of the flap located one or two teeth distal to where the lesion is located (Figure 23).
\nPartial-thickness flap before ridge expansion for future dental implant insertion.
Advantages
This type of flap is easy to detach
It is less aggressive with the gingival tissue than an intrasulcular incision flap
It is useful in patients with fixed prosthesis restorations because of less recession of the gingival margin and interdental papillae [17, 18, 19]
Limitation
It can leave a postsurgical scar if the repositioning sutures are not performed adequately [20]
The semilunar (Partsch) flap is a variant involving a submarginal incision in the alveolar mucosa to form a crescent- or semilunar-shaped flap (Figure 24). The semilunar flap is almost exclusively used for the maxillary canines [21]. Care is required to avoid performing the incision above the bone defect.
\nSubmarginal incision and two vertical incisions mesial and distal to the defect area.
Advantage
Small incision suitable for upper canine surgery
Limitations
\n\nThis flap involves intrasulcular incision in its triangular and trapezoidal versions and offers perfect access for periapical surgery, with sufficient access to the affected bone and lesion-related roots. The intrasulcular incision may be triangular or trapezoidal (Figure 25). The most common intrasulcular flap involves a triangular incision with a single vertical releasing incision located one or two teeth distal to the lesion (Figure 26). This flap is characterized by increased tension, and the traction forces increase especially at the fixed extremity. This technique allows for easy flap repositioning after periapical surgery.
\nLuebke-Ochsenbein flap is used clinically for periapical surgery.
Semilunar flap in a form of crescent.
Advantage
This technique allows easy flap repositioning after periapical surgery
Limitation
Increased tension and traction forces
This flap, which was originally described by Velvart, is characterized by a horizontal incision following the dental sulcus along the neck of the teeth and extending to the base of the papillae (Figure 27). The papillae adhere for posterior suturing of the flap. A vertical releasing incision is made to maximize the exposure.
\nClinical application of Partsch flap for periapical surgery.
Advantage
Produces less recession at the interdental papillary level than a sulcular incision [23]
Limitations
A surgically complicated flap requiring adequate surgeon experiences
Requires the presence of enough healthy attached gingiva for suturing
A horizontal incision is made following the dental sulcus to the dental papilla, and the vertical releasing incision is seated away from the papilla (Figures 28–33) [19].
\nTrapezoidal flap with two releasing incisions.
Triangular flap with a single releasing incision.
Clinical application for the intrasulcular trapezoidal flap.
The papilla adhered to the bone and the raised full mucoperiosteal flap.
The raised papilla preservation mucoperiosteal flap.
The raised palatal full mucoperiosteal flap for palatal periapical surgery.
Advantage
This flap is useful in teeth with a generous mesiodistal width, affording an adequate surgical field
Limitations
The narrow neck needs careful releasing, careful adaptation, and suturing
This flap may be not suitable in narrow mesiodistal distance between teeth
A festoon flap is performed at the gingival margins on the palatal side. This flap is used in periapical surgery of the palatal roots of the maxillary molars. Palatal releasing incisions are not necessary. If any such incisions are made, they should be performed between the canine and premolar, representing the vascularization limit between the nasopalatine artery and the anterior palatine artery, or distal to the second molar behind the emergence point of the anterior palatine artery [24].
\nAdvantage
Useful in cases in which the palatal roots of molars or lateral incisors require exposure
Limitations
If the flap needs to be expanded to gain greater visibility, the incision can be extended mesially to the canine
This flap may cause pain and discomfort for the patient postoperatively
Chance of hematoma formation may jeopardize the blood supply of the flap
Oroantral communication/fistula is an unnatural communication between the oral cavity and the maxillary sinus. These complications occur most commonly during the extraction of upper molar and premolar teeth (48%). The major reason is the anatomic proximity or projection of the roots within the maxillary sinus [25]. Other causes of oroantral communication/fistula include tuberosity fracture, dentoalveolar/periapical infections of molars, implant dislodgement, maxillary sinus, trauma (7.5%), presence of maxillary cysts or tumors (18.5%), osteoradionecrosis, flap necrosis, and dehiscence following implant failure [25, 26]. Two basic principles must be considered while operating for Oroantral communication/fistula. First, the sinus must be free of any types of infection with adequate nasal drainage. Second, closure must be tension-free and consists of broadly based, well-vascularized soft tissue flaps over the intact bone. Successful closure of the oroantral fistula should be preceded by the complete elimination of any sinus pathology, the fistulous tract, sinus infection, degenerated mucosa, and diseased bone [27].
\nThe most common flap procedures may be categorized into local flaps, distant flaps, and grafting. The flaps involving rotating or advancing soft tissues include buccal flap, palatal flap, submucosal tissue flap, and buccal fat pad and tongue flap [26]. The procedures utilizing buccal mucoperiosteal flap for closure include straight-advancement flap, rotation-advancement flap, transverse flap, and sliding flap techniques, and those utilizing palatal mucoperiosteum include straight-advancement flap, rotational advancement flap, hinged flap, and island flap procedures [26]. Double-layer closure utilizing local tissues includes the combination of inversion and rotational advancement flaps, double overlapping hinged flaps, double island flaps, and superimposition of reverse palatal and buccal flaps. However, the studies over the last 50 years point out the lack of consensus for a uniformly successful procedure [28].
\nHere we illustrate the most common flaps used for closure of oroantral communication/fistula: the buccal flap and the palatal pedicle flap techniques.
\nIt has been described [14, 29] the use of a buccal flap with a thin layer of buccinator muscle to close an oroantral defect. Later, [30] reported a buccal sliding flap technique, which is still in use, as a tool to close small to medium size (<1 cm) lateral or mid-alveolar fistulas, located either laterally or in the middle of the alveolar process. Krompotie and Bagatin [13] reported the immediate closure of an oroantral communication by a rotating gingiva-vestibular flap. This technique can also be employed for closing oroantral fistulas. It is a modification of a vestibular flap in order to avoid lowering of the vestibular sulcus, an event that takes place normally when using vestibular flaps. Two vertical release incisions are made to provide a flap with dimensions suitable for closure of the antral communication (Figure 34).
\nThe buccal advancement flap is used to close OAC (arrow).
Incision removal of the epithelial lining of the palatal mucosa behind the communication might also be required. The flap with a trapezoidal shape consists of both epithelium and connective tissues and is positioned over the defect using mattress sutures from the buccal flap to the palatal mucosa.
\nAdvantage
It is possibly utilized in cases of severly resorbed alvealr ridge, and the fistula is located in a more mesial area [31]
Limitation
Loss of vestibular depth buccally
The first procedure for closing oroantral fistulas using a palatal full-thickness flap was described by Ashley [26, 32]. After excising the epithelium from its edges and cutting the palatal fibro-mucosa, the flap is created with an axial stack with a posterior base, supplied by the greater palatine artery. The palatal flap with its total thickness laterally rotated must have a large base to include the greater palatine artery at the site of its exit from the foramen (Figure 35) [33, 34]. The anterior extension of the flap must exceed the diameter of the bony defect and have a length sufficient to allow its lateral rotation and replacement, and the suture has no exerting tension on the vestibular mucosa [35]. Further improvement of the techniques was advocated [35, 36] by adding a flap of mucosa to the connective tissue island to cover the raw area of the palatal bone. The bone is covered, and the island flap retains excellent mobility without causing bunching of the mucosa of the hard palate and recipient site.
\nThe palatal rotation flap used to close OAC (arrow).
Advantages
Good vascularization, adequate thickness, and optimal tissue quality
The use of mucous membrane from the hard palate. In 1980, Ehrl demonstrated the possibility of employing this technique with wide fistulas 1 cm in diameter [37]
This method allows replacement of the denture a short time after the wound healing
Limitation
It is only indicated if the fistula is located at the area of the premolar to avoid excessive rotation of the flap
The area of the palatal flap will heal by secondary epithelialization, which causes pain and discomfort
Necrosis of the flap can happen if excessive rotation to the flap is performed
Since Egyedi reported the BFP flap as a suitable method to close the OAC, oronasal communication, and maxillary postsurgery defects, the technique has been widely used. In addition, according to the study by Rapidis et al. [38], the BFP can be used as a free flap to close oral defects. Tideman et al. described the detailed anatomy, vascularization, and operative techniques of BFP [39]. The pedunculated BFP has been employed for the reconstruction of an oral defect of moderate size following surgical removal of a malignant lesion [38]. A gentle dissection with fine curved artery forceps exposes the yellowish-colored buccal fat. The buccal fat pad flap, especially the pedicled type, has been used most commonly for the closure of the OAF due to the location of the buccal fat pad, which is anatomically favorable, and due to the easy and minimal dissection, with which it can be harvested and mobilized.
\nAdvantages
\n\nLimitations
Mild reduction in the vestibular height
A second surgery is required in order to achieve closure if there is a low rate of recurrence of fistulas
This technique designs the palatal inversion flap on the basis of the greater palatine vessels after measuring the bone defect, but not the soft-tissue defect, as shown in Figure 35. Once the flap is raised, the residual palatal raw surface is left to heal by secondary intension with the formation of the granulation tissue. The horizontal palatal flap is then inverted so that the oral palatal epithelial surface covers the bone defect and faces the maxillary sinus. Subsequently, it will be covered by the buccal advancement flap that is released by extending the incision inside the cheek from the gingivolabial sulcus to have a wide base and ensure a good blood supply, as shown in Figure 34.
\nAdvantages
Indicated if there is an increased risk of wound breakdown and recuurant oroantrual defect
It provides epithelial covering to both the superior and inferior surfaces
Blood perfusion of the palatal flap is better than that of the single technique
Limitations
It has a risk of subsequent pathology
Perfusion of buccal flaps is poor
Narrowing of the gingivobuccal sulcus may occur
BFP is anatomically favorable, and the easy and minimal dissection of the fat tissue from the buccal pad of fat and then harvesting and mobilization made it a popular technique (Figure 36). Furthermore, it has excellent blood supply. A quick surgical technique is preferred due to fact that BFP and the defects to be covered are located in the same surgical field, and a good rate of epithelialization allows for replacement of the mucoperiosteal flap without loss of vestibular depth.
\nIntraoral photograph shows the harvested buccal fat and is adapted to the defect in the molar and premolar/molar areas.
Advantages
Low rate of complications
Minimal donor site morbidity
Easy and versatile technique
No loss of vestibular depth
Limitations
While harvesting BFP, perforation or/and shrinkage may occur
The amount of BFP is inadequate in some cases
This technique combines BFP and buccal advancement or skin flaps. BFP can be covered by the partial thickness skin flap [41] or buccal advancement flap, especially for defects larger than 5 × 1 cm2. This technique can also be better managed with the use of BFP with buccal advancement flap than BFP alone [42] (Figure 37).
\nIllustration shows harvesting BFP from the buccal tissue, and the buccal advancement flap is then sutured.
Advantages
Provides more stability
Can be used when there is a deficient BFP for closure
Can be used in cases where a trapezoidal flap is raised for some reasons and in cases with perforation and shrinkage of BFP [43, 44, 45]
Used to minimize the risk of shallow sulcus [42]
Limitations
More time is needed to perform the surgery
An experienced surgeon may be needed
It requires high patient’s compliance
A wide variety of intraoral flaps and their modifications have been reported in the literature. This chapter illustrates some familiar flap techniques, as well as their advantages and limitations. The application and design of each flap should be tailored to the patient’s diagnosis and needs. Surgeons should be aware of patient diagnosis, the anatomical limitation, and the application of different flap’s designs. Careful planning, implications, and selection of suitable flap designs would affect final aesthetic outcomes or postoperative morbidity, which may have important medical-legal and economic impacts.
\nThe authors declare no conflict of interest.
At the end of 2019, a new type of previously unidentified coronavirus appeared in the Chinese city of Wuhan, then known as the novel coronavirus 2019, which was renamed SARS-CoV-2, severe acute respiratory syndrome coronavirus 2. The disease it causes is officially named Coronavirus Disease-2019 (COVID-19). The first cases of infection with this virus spread from animals to humans, presumably at the seafood market in the Chinese city of Wuhan, causing a terrible epidemic in many cities in China [1, 2]. Due to the growing rate of reporting cases in Chinese and international locations, on January 30, 2020, the WHO Emergency Committee declared a global health emergency [2].
To slow the spread of COVID-19 and prevent health systems from becoming overloaded, many countries around the world have implemented restrictions on population movement and complete or partial lockdowns, police-enforced curfew, strict travel bans and shutted borders [3]. All of this has affected the established way of human life and caused a major psychological impact on people around the world, posing a serious threat to mental health [3].
The severity of the COVID-19 pandemic poses a new challenge to mental health. The World Health Organization defines mental health as a state of well-being in which an individual achieves his potential, can cope with normal life stress, can work productively and is able to contribute to the community. The definition of mental health leads to the conclusion that it is more than just the absence of mental illness, ie that good functioning within one’s own family, good relationships with other people and expressing life satisfaction are qualities of a person who is mentally healthy [4]. People with good mental health are often sad, sick, angry or unhappy, and that is part of a fully lived life for a human being. Nevertheless, mental health is often conceptualized as a purely positive impact, marked by a sense of happiness and a sense of having control over one’s environment [4].
With the outbreak of COVID-19, people faced a series of situations that changed their lives, but also the lives of their loved ones. Closing in houses, distancing oneself from other people, death of close people and general uncertainty are situations to which people were not used until then [3, 5]. The continuing stress associated with a pandemic can have serious consequences for their mental health. Stress involves physiological and psychological reactions to stressors that come from the environment, and people very often have no control over these causes of stress [6].
Depression, anxiety, and stress have been identified as basic negative indicators of mental health and some of the major health problems, and research interest has focused on understanding their nature, causes, and treatments [7]. An individual’s depression is characterized by experiences of dysphoria, hopelessness, devaluation of oneself and life as a whole, impoverishment of social life and anhedonia. Anxiety is a mental state characterized by a subjective experience of anxiety, a feeling of helplessness and a high level of arousal of the organism. Negative stress is a state of high arousal of the organism that occurs as a result of one or more threatening events, with strong negative emotions on the mental level [7]. People who are generally prone to anxiety, as a rule, often express symptoms of depression, and vice versa. Stress is also associated with depression and anxiety [7].
Studies assessing stress, anxiety and depression during quarantine caused by the spread of SARS-CoV-2 have revealed the presence of severe psychological distress and psychopathological factors and have shown that the COVID-19 pandemic is associated with very significant levels of stress, which in many cases could reach the threshold of clinical importance [8].
Further in the text of this book chapter, a more detailed review of the existing literature on mental health and associated factors during the COVID-19 pandemic will be reported, ie the prevalence of symptoms of depression, anxiety and other forms of psychological distress. After that, the roles of preventive factors related to mental health will be identified, with a focus on resilience and capacity for mentalizing.
The outbreak of the COVID-19 pandemic caused an increase in the prevalence of mental disorders by a massive 25%. The most common and important of these disorders are depression, anxiety and various types of psychological distress, which are described in more detail in this book chapter. In addition to the COVID-19 pandemic, multiple factors also caused a “pandemic of mental disorders”, ie a massive increase in mental health problems.
One of the main explanations for the increase in mental health problems is the unprecedented multiple stress caused by the social isolation resulting from the pandemic. Related to this were limitations in people’s ability to work, seek support from loved ones and engage in their communities, loneliness, fear of infection, suffering and death for themselves and loved ones, grief after bereavement, and financial worries. These are all stressors that lead to the fundamental mental problems of anxiety and depression. Among healthcare workers, who belong to a group particularly vulnerable to the COVID-19 pandemic, exhaustion and burnout syndrome have been main triggers for suicidal thoughts [3, 5].
Numerous studies on the mental health status of people around the world have been published during the COVID-19 pandemic, reporting on different rates of mental health problems. Some differences can be attributed to methodological issues such as different instruments for measuring mental health indicators such as depression, anxiety and distress, and the range of outcomes used, while other differences probably stemmed from cultural factors about discovering mental health problems [9].
A review of research literature from China, India, Nepal, Iran, Iraq, Japan, Nigeria, the United Kingdom, Italy and Spain showed that the average prevalence of depression in 14 studies with a sample size of 44,531 people was 33.7%, the prevalence of anxiety in 17 studies with a sample size of 63,439 was 31.9%, while stress rates in 5 studies with a total sample size of 9074 individuals were 29.6% [10].
When it comes to the results of research conducted in Europe, similar findings have been obtained. The first study in Serbia examining the mental health status of the general adult population found that of the 1057 participants in the study, 28.9% reported moderate to severe depression, 36.9% moderate to severe anxiety, and 38.1% moderate to severe symptoms of stress. Fear about COVID-19 news, feelings of helplessness, the likelihood of impending death, and the presence of COVID-19 symptoms were associated with higher levels of depression, anxiety, and stress. Current smoking status was associated with a higher risk of depression and stress. Higher socioeconomic status was significantly associated with lower levels of depression, anxiety and stress, while students had significantly higher levels of depression and stress [3].
Isolation, reduced social contacts, the duration of quarantine and restrictions, and significant changes in access to higher education in response to the global COVID-19 pandemic have played an important role in increasing negative emotional symptoms and stress in students. A study conducted on a sample of 338 students in Serbia during the state of emergency due to the COVID-19 pandemic examined the relationship between depression, anxiety, stress and procrastination [11]. The results showed that the average values of depression, anxiety and stress among students were significantly higher compared to the findings of research conducted on a sample of university students before the pandemic in Serbia, but also in other European countries [11].
The psychological impact of COVID-19 on the university community has also been demonstrated in research conducted in Spain, Greece and France. According to research conducted in Spain during the first weeks of the introduction of curfew due to the pandemic, students showed higher scores on the scales of depression, anxiety and stress, compared to the situation before the COVID-19 pandemic [12]. The authors, who conducted research in Greece during the state of emergency due to the COVID-19 pandemic, pointed to an increase in anxiety, depression and psychological distress in students compared to the time before the pandemic [13]. A cross-sectional study aimed at assessing the prevalence of anxiety and identifying anxiety-related factors among French students during the outbreak of COVID-19 found that of the 3936 students, 15.2% experienced moderate anxiety. Female gender and having relatives or acquaintances who were hospitalized for COVID-19 were major risk factors for anxiety [14].
Systematic review of three electronic databases (Google Scholar, PubMed and Medline), with 13 studies from different European countries that published data on the prevalence of anxiety, depression and stress in students, showed that the overall combined prevalence rate was 55% for anxiety, 63% for depression and 62% for stress [15]. A significant increase in anxiety, depression and stress has been identified among university students across Europe, but the long-term effect of this will need to be monitored. Governments, universities and other higher education service providers should take into account students’ mental health and provide strategies to support their mental well-being [15].
A study examining mental health during the COVID-19 pandemic and key risk factors in the adult population in Croatia, on a nationally representative sample of 1201 participants, shows that 9.8% of respondents were at risk of adjustment disorders, 7.7% were at risk of developing depressive disorder, and 7.8% were at risk for anxiety disorder. In addition, 7.2% experienced high levels of stress. Key risk factors for specific negative mental health outcomes varied, but common predictive factors for some of the mental health problems included younger age, current health status, previous diagnosis of mental disorder, having an below-average income, and over-following COVID-19 news. Together, the key risk factors identified in this study indicate the need for public health interventions that address the mental health of the general population, but also for specific risk groups [16].
COVID-19 has a serious impact on the mental health of both the general population and healthcare workers who belong to a special risk group during a pandemic [3, 17]. The psychological impact of the outbreak of acute infections on health workers has caused significant concern to the government, the public and medical professionals. The psychological impact of COVID-19 on health workers working during a pandemic is an important consideration, as chronic exposure to stressors leads to burnout syndrome and various mental health problems [17].
One study on psychological distress, which included 958 health workers from the city of Wuhan in China, indicates that more than half of the respondents had symptoms related to depression and anxiety. Specifically, 54% of the total sample had symptoms of anxiety and 58% of depression, with the prevalence of stress being higher than previously detected in healthcare workers battling the SARS virus [18]. In the study which involved 1257 healthcare workers from China, of which 760 from Wuhan, 71.5% of respondents showed symptoms of stress, 44.6% anxiety, 50.4% depression and 34% insomnia. These symptoms were more severe in nurses, front-line staff, and those working in Wuhan, the epicenter of the COVID-19 pandemic outbreak [19]. Similar results have been found in European countries, such as Germany, where healthcare professionals, especially nurses, have reported a high prevalence of stress, emotional fatigue and depressive symptoms [20].
A study conducted in China found that healthcare workers at the frontline of the pandemic and who deal directly with patients confirmed or suspected of having COVID-19 have higher levels of various mental health problems than those working in regular clinical settings. In addition, these two groups had comparatively low rates of behavior seeking help and treatment for their mental health problems. Data from that study showed that the mental health of healthcare workers at the frontline is of particular concern. The rate of mental health problems, such as anxiety, depression and insomnia, has increased significantly among healthcare workers working on the front lines of the fight against COVID-19, compared to those without direct contact with COVID-19 [21].
Compared to non-frontline healthcare workers, frontline healthcare workers can be exposed to much greater physical and mental stress, which can contribute to a higher rate of mental health problems. For example, frontline healthcare workers had to be especially careful when working in respiratory units or infectious wards, ensuring that suspicious patients were identified in a timely manner and transferred to a particular hospital to reduce the risk of exposure to others [21]. These results showed poor mental health among healthcare workers at the frontline of the fight against COVID-19 [21], but contrary to expectations, no significantly higher rates of seeking help or treatment of mental health problems were observed among these individuals. The phenomenon that healthcare professionals have difficulty accepting and detecting emotions is not unique to the outbreak of the COVID-19 pandemic [22]. Emotional stress is common among hospital physicians, many of whom do not seek professional help or support from their colleagues because they either think they did not need it or are uncomfortable seeking help and are concerned about confidentiality [22]. These findings remind us that in the future, providers of psychological interventions should pay more attention to healthcare workers who have mental health problems.
Study examining healthcare workers before and during the outbreak of the COVID-19 pandemic [23], which included both those working on the front lines and those with unclear COVID-19 exposure, found that the incidence of anxiety, depression and insomnia increased over time. However, it is unclear whether the respondents were the same at both time points. During the outbreak of COVID-19, one in four healthcare professionals reported at least mild anxiety, depression or insomnia [23].
One meta-analysis showed that twenty-two studies reported one or more variables related to mental health problems in healthcare workers during the COVID-19 pandemic [24]. The most common risk factors correlated with an increased risk of mental health problems were exposure to patients with COVID-19, females [24] and concerns of health professionals that they would be infected with coronavirus [21, 24]. In three studies, concern that family members were infected was a risk factor [24]. When it comes to anxiety, data from 22 studies showed that the percentage of healthcare workers with anxiety ranged from 9 to 90% with a median of 24% [24]. For depression, there were data from 19 studies. The percentage of respondents with depression ranged from 5 to 51%, with a median of 21%. For sleep problems, there were data from six studies. The percentage of sleep problems ranged from 34 to 65%, with a median of 37%. For psychological distress, there were data from 13 studies. The percentage with distress ranged from 7 to 97%, with a median of 37% [24].
The aforementioned studies conducted around the world during the COVID-19 pandemic highlighted mental health problems and unmet needs of medical staff during the pandemic. There is an urgent need to provide further strategies to alleviate the mental health problems of health workers, and long-term monitoring of the mental health of health workers, both those at the first line and those at the secont line of the COVID-19 pandemic [21].
In addition to COVID-19-related mental health risk factors, which mainly include the following: female gender and age under 40 [25, 26, 27], student status, unemployment, poor economic status, lower level of education and unemployment [3, 27, 28, 29], presence of chronic illness and history of medical or psychiatric illness [20, 30, 31], as well as frequent exposure to social media and news related to COVID-19 [3, 26, 32], and inadequate information about the virus [5, 33], several studies have also identified factors that protect individuals from symptoms of mental disorders during the COVID-19 pandemic. These factors associated with COVID-19 mainly include the timely dissemination of up-to-date and accurate health information regarding COVID-19 by the competent authorities [29], the active implementation of precautionary measures to reduce the risk of infection, such as frequent hand washing, wearing masks and less contact with people, [29], as well as more social support [34], and rest time during a pandemic [35].
Besides to these factors that are specific to the COVID-19 pandemic, it has been shown that psychological symptoms during a pandemic may be related to some personality traits, such as temperament, positive stress coping mehanisms [36, 37], secure and avoidant attachment styles [29, 37], resilience [33, 38, 39, 40, 41], and capacity for mentalizing [42].
There are significant individual differences in adapting to stressful situations such as the COVID-19 pandemic, which depends on personality characteristics and psychological resources, such as resilience. Previous studies have found that mental health during the pandemic has been associated with positive psychological traits such as psychological resilience [38, 39] and hope [40], and that resilience positively stabilizes mental health during the COVID-19 pandemic [41].
Interest in psychological resilience has increased in recent decades [43]. Numerous scientific disciplines deal with resilience, starting from psychiatry and psychology, through sociology to medicine, genetics and neuroscience. Nevertheless, by reviewing the existing literature and the definition of this term, the only consensus exists, and that is the question “how some people can endure discomfort without negative physical and psychological consequences” [44]. This is exactly how the simplest definition of the resilience construct can be formulated - as the ability of people to function well in difficult situations, that is, to cope with the stress that often accompanies them. Synonyms such as hardiness, resistance, psychoimmunity and toughness further clarify the qualities that resilience implies. Simply put, resilience implies successful adaptation and the ability to maintain or regenerate mental health despite obstacles [45]. In addition, it can be characterized as a process of evolution of positive attitudes and strategies [46], but also as an individual’s ability to “go back to the old” [43, 47]. Multidisciplinarity in approaching this problem has made definitions change and evolve as scientific understanding and cognition changes.
When resilience is perceived as a personality trait, it refers to an individual’s ability to return to a state of normal mental functioning after stressful or threatening events, without lasting negative consequences [43].
When resilience is defined as a complex capacity of an individual, then it is understood as the result of all protective factors that act to maintain or improve an individual’s mental health after circumstances that may cause severe distress or mental trauma. These protective factors can be: 1) individual factors, such as e.g. ways of overcoming stress, cognitive capacity and strength of an individual’s character, 2) factors arising from an individual’s social network, such as e.g. emotional or material support provided by family or close friends, and 3) support from the wider community, such as support provided by government agencies, businesses, and social organizations [43, 48].
Previous studies have shown that resilience is negatively correlated with depression and anxiety [49, 50, 51]. Even before the COVID-19 pandemic, high resilience was cited as a complex trait that allows people to easily recover from a variety of difficulties, which can be acquired through an appropriate training program [52, 53, 54]. Resilience is also cited as a trait that can reduce the association between burnout syndrome and mental health difficulties, and which acts as a moderator as a moderator by alleviating the association between burnout syndrome and subjective well-being [48, 55, 56].
The results of a study examining the links between resilience, hope, preventive behavior, subjective well-being and mental health in 220 adults, in the early stages of the COVID-19 pandemic, showed that hope and resilience have significant direct effects on mental health and subjective well-being. Preventive behavior showed no significant effect on these two variables other than resilience. These results suggest that more attention needs to be paid to hope and resilience to develop and improve well-being and mental health in times of crisis [40].
Research has found that resilience characteristics are associated with lower levels of anxiety and depression symptoms [57] and that resilience has mediated the relationship between stress, anxiety and depression symptoms [58]. Generally speaking, people with a higher degree of resilience also have a higher degree of well-being, and a lower degree of depression, anxiety and negative self-evaluation [54, 59].
Good capacity for mentalizing is considered to play a preventive role in maintaining mental health. Mentalizing is a form of imaginative mental activity that consists of interpreting perceived human behavior based on intentional mental states such as needs, desires, feelings, beliefs, goals, purposes, and reasons. The term imaginative mental activity indicates that this process is performed by a person using imagination in his/her mind. Mentalizing is a process that enables individuals to correctly understand their own and other people’s behavior in interpersonal relationships, as well as to regulate their own emotions and impulses well [60, 61, 62].
Capacity for mentalizing the individual develops in childhood and is highly associated with a secure affective attachment to primary caregivers. Mentalizing implies at least the following four dimensions: the first refers to the question of whose behavior is being mentalized - one’s own or someone else’s; the second refers to the question of the extent to which the individual controls mentalization - at one end it is automatic and implicit, and at the other end of that dimension it is conscious, voluntary or explicit mentalization; the third dimension refers to the use of cognitive and emotional processes, on the one hand there is the possibility to recognize mental phenomena, name and describe their causes and consequences in words, on the other is the possibility to experience these phenomena as feelings without the use of words; the fourth dimension refers to the contents that are mentalized, at one end of this dimension are the contents observed during direct communication with another person, either verbal or nonverbal channel, at the other end are assumptions that depend on the previous experience of the person being mentalizing, which among other things, is influenced by the socio-cultural environment in which that person lives [60, 61, 62]. In direct contact with another person, the basic mental actions that an individual performs when mentalizing are to make assumptions about the mental states that determine behavior and check them. Then the individual is aware that intentional mental states cannot be seen with the naked eye. During mentalization, an individual has a not knowing stance about intentional mental states and a sincere curiosity that helps him/her discover them in cooperation with another person [60, 61, 62].
Weak capacity for mentalizing has been found in patients with borderline personality disorder, but other mental disorders also include difficulties in mentalization [62, 63]. Also, in the non-clinical population, forms of impaired capacity for mentalizing were examined. Two such forms were investigated in these studies: hypomentalizing and hypermentalizing. These are two qualitatively different phenomena, not extremes of the same [42].
Hypomentalizing refers to the lack or absence of consideration of the phenomena of mental life that determine behavior, and by making assumptions and checking them in interpersonal interaction. Hypomentalizing can be a consequence of a lack of faith in one’s own ability to know the mental world, or as a consequence of mistaken beliefs that behavior is determined by external forces, not mental states. Among other things, it manifests as uncertainty in the ability to accurately assess the mental states underlying behavior [61, 64].
Hypermentalizing refers to making too many assumptions about intentional mental states, some of which are uncritically accepted as true, even though they are not true. The hypermentalizing of an individual occurs as a consequence of his/her erroneous beliefs that other persons have identical intentional mental states as himself. It manifests itself as excessive certainty in the accuracy of one’s own beliefs about the nature of mental states that underlie one’s behavior [61, 64].
There are findings that indicate that a good capacity for mentalizing allows a correct understanding of one’s own and others’ behavior in stressful situations, which helps to overcome stress [62, 65]. Authors [65] examined the relationship between global distress, capacity for mentalizing and well-being in a sample of German teachers, and found that mentalizing is positively associated with well-being and that mentalizing mitigates the negative impact of stress and psychological symptoms on well-being. In Spain, a study was conducted that examined the association between capacity for mentalizing and burnout syndrome in a sample of entrepreneurs. Research conducted in Spain has shown that the capacity for mentalizing reduces the degree of burnout syndrome in entrepreneurs by reducing emotional exhaustion and cynicism (depersonalization), and that hypomentalizing was a statistically significant positive predictor of emotional exhaustion and cynicism in entrepreneurs [64].
Good capacity for mentalizing is key to resilience - the ability of an individual to return to a state of normal mental functioning after stressful or threatening events, without lasting negative consequences [43]. The first study in the world that linked capacity for mentalizing and resilience to burnout syndrome in a sample of healthcare workers during the COVID-19 pandemic, revealed that there were negative correlations between resilience and burnout dimensions - emotional exhaustion and depersonalization, and positive correlations between resilience and personal achievement. Also, hypomentalizing has been shown to be a significant positive predictor of emotional exhaustion and depersonalization as a dimensions of burnout syndrome [42]. Good capacity for mentalizing means that empathy, active listening and authentic curiosity about mental states, both one’s own and the interlocutor’s, are expressed during direct communication. Hypomentalizers, instead of revealing objective facts about the reasons for their behavior through open communication with others, usually judge intentional mental states by “guessing”, referring to general laws and their previous experience, which leads to wrong conclusions. Lack of mentalizing reduces the ability of people to understand their own and others’ behavior, which leads to interpersonal misunderstandings, conflicts, dissatisfaction and professional frustrations. This is consistent with previous findings proving that good mentalizing ability is a protective factor of mental health [60, 63, 64].
Schwarzer et al. [65] found that the presence of stress negatively affected subjective assessments of well-being, while the capacity for mentalizing had an indirect and positive effect on an individual’s assessments of health. Evidence suggests that impaired capacity for mentalizing, typical of various mental illnesses, can be improved by psychotherapeutic intervention, leading to a reduction in psychological symptoms [66]. Relying on clinical relevance, there has been a shift towards focusing on capacity for mentalizing as a mediating capacity to promote health in non-clinical populations [60, 62, 63, 65]. Most important in this context is the idea that preventive or early interventions that encourage good capacity for mentalizing can protect the individual from the influence of distress factors [67], thus enabling more resilient adaptation to life stressors and protecting the mental health of the individual.
Concerns about the potential increase in mental disorders have led countries around the world to include psychosocial support in their COVID-19 response plans, among other measures to combat COVID-19, but major shortcomings and concerns remain [68].
The outbreak of COVID-19 has caused enormous psychological impact worldwide and poses an unprecedented threat to mental health. The extant scientific literature, which reports on mental health status and the prevalence of psychological disorders during the COVID-19 pandemic, warns that the level of depression, anxiety and stress among citizens around the world has reached alarming proportions.
Given that the COVID-19 pandemic marks a global public health crisis unseen in the last century, there is an urgent need to implement measures and strategies to minimize the impact of the COVID-19 pandemic on mental health. As resilience and capacity for mentalizing have been shown to play a very important preventive role when it comes to mental health, it is essential to develop and implement strategies to encourage resilience and strengthen capacity for mentalizing to counteract psychological stress during public health emergencies, including response to COVID-19.
In addition to combating the spread of the Sars-CoV-2 virus, mitigating the devastating effects of COVID-19 on the mental health of both general population and vulnerable groups should be an international public health priority.
This book chapter sought, in addition to reviewing the prevalence of mental disorders during the COVID-19 pandemic and the role of preventive mental health factors such as resilience and good capacity for mentalizing, to emphasize a wake-up call to all countries to pay more attention to mental health and work better to support the mental health of their populations.
The authors declare no conflict of interest.
The authors want to thank and dedicate this book chapter to their parents who have always taught them to hope in life and never give up.
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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:{name:"Association for Computing Machinery",country:{name:"United States of America"}}},{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:"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:'"Politechnica" University Timişoara',institution:null},{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:{name:"Tecnalia",country:{name:"Spain"}}},{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:"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:null,institution:null},{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:"417317",title:"Mrs.",name:"Chiedza",middleName:null,surname:"Elvina Mashiri",slug:"chiedza-elvina-mashiri",fullName:"Chiedza Elvina Mashiri",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Midlands State University",country:{name:"Zimbabwe"}}},{id:"352140",title:"Dr.",name:"Edina",middleName:null,surname:"Chandiwana",slug:"edina-chandiwana",fullName:"Edina Chandiwana",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Midlands State University",country:{name:"Zimbabwe"}}},{id:"342259",title:"B.Sc.",name:"Leonard",middleName:null,surname:"Mushunje",slug:"leonard-mushunje",fullName:"Leonard Mushunje",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Midlands State University",country:{name:"Zimbabwe"}}},{id:"347042",title:"Mr.",name:"Maxwell",middleName:null,surname:"Mashasha",slug:"maxwell-mashasha",fullName:"Maxwell Mashasha",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Midlands State University",country:{name:"Zimbabwe"}}},{id:"2941",title:"Dr.",name:"Alberto J.",middleName:"Jorge",surname:"Rosales-Silva",slug:"alberto-j.-rosales-silva",fullName:"Alberto J. Rosales-Silva",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Instituto Politécnico Nacional",country:{name:"Mexico"}}},{id:"437913",title:"Dr.",name:"Guillermo",middleName:null,surname:"Urriolagoitia-Sosa",slug:"guillermo-urriolagoitia-sosa",fullName:"Guillermo Urriolagoitia-Sosa",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Instituto Politécnico Nacional",country:{name:"Mexico"}}},{id:"435126",title:"Prof.",name:"Joaquim",middleName:null,surname:"José de Castro Ferreira",slug:"joaquim-jose-de-castro-ferreira",fullName:"Joaquim José de Castro Ferreira",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Aveiro",country:{name:"Portugal"}}},{id:"437899",title:"MSc.",name:"Miguel Angel",middleName:null,surname:"Ángel Castillo-Martínez",slug:"miguel-angel-angel-castillo-martinez",fullName:"Miguel Angel Ángel Castillo-Martínez",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Instituto Politécnico Nacional",country:{name:"Mexico"}}},{id:"289955",title:"Dr.",name:"Raja",middleName:null,surname:"Kishor Duggirala",slug:"raja-kishor-duggirala",fullName:"Raja Kishor Duggirala",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Jawaharlal Nehru Technological University, Hyderabad",country:{name:"India"}}}]}},subseries:{item:{id:"10",type:"subseries",title:"Animal Physiology",keywords:"Physiology, Comparative, Evolution, Biomolecules, Organ, Homeostasis, Anatomy, Pathology, Medical, Cell Division, Cell Signaling, Cell Growth, Cell Metabolism, Endocrine, Neuroscience, Cardiovascular, Development, Aging, Development",scope:"Physiology, the scientific study of functions and mechanisms of living systems, is an essential area of research in its own right, but also in relation to medicine and health sciences. The scope of this topic will range from molecular, biochemical, cellular, and physiological processes in all animal species. Work pertaining to the whole organism, organ systems, individual organs and tissues, cells, and biomolecules will be included. Medical, animal, cell, and comparative physiology and allied fields such as anatomy, histology, and pathology with physiology links will be covered in this topic. Physiology research may be linked to development, aging, environment, regular and pathological processes, adaptation and evolution, exercise, or several other factors affecting, or involved with, animal physiology.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/10.jpg",hasOnlineFirst:!1,hasPublishedBooks:!1,annualVolume:11406,editor:{id:"202192",title:"Dr.",name:"Catrin",middleName:null,surname:"Rutland",slug:"catrin-rutland",fullName:"Catrin Rutland",profilePictureURL:"https://mts.intechopen.com/storage/users/202192/images/system/202192.png",biography:"Catrin Rutland is an Associate Professor of Anatomy and Developmental Genetics at the University of Nottingham, UK. She obtained a BSc from the University of Derby, England, a master’s degree from Technische Universität München, Germany, and a Ph.D. from the University of Nottingham. She undertook a post-doctoral research fellowship in the School of Medicine before accepting tenure in Veterinary Medicine and Science. Dr. Rutland also obtained an MMedSci (Medical Education) and a Postgraduate Certificate in Higher Education (PGCHE). She is the author of more than sixty peer-reviewed journal articles, twelve books/book chapters, and more than 100 research abstracts in cardiovascular biology and oncology. She is a board member of the European Association of Veterinary Anatomists, Fellow of the Anatomical Society, and Senior Fellow of the Higher Education Academy. Dr. Rutland has also written popular science books for the public. https://orcid.org/0000-0002-2009-4898. www.nottingham.ac.uk/vet/people/catrin.rutland",institutionString:null,institution:{name:"University of Nottingham",institutionURL:null,country:{name:"United Kingdom"}}},editorTwo:null,editorThree:null,series:{id:"10",title:"Physiology",doi:"10.5772/intechopen.72796",issn:"2631-8261"},editorialBoard:[{id:"306970",title:"Mr.",name:"Amin",middleName:null,surname:"Tamadon",slug:"amin-tamadon",fullName:"Amin Tamadon",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002oHR5wQAG/Profile_Picture_1623910304139",institutionString:null,institution:{name:"Bushehr University of Medical Sciences",institutionURL:null,country:{name:"Iran"}}},{id:"251314",title:"Dr.",name:"Juan Carlos",middleName:null,surname:"Gardón Poggi",slug:"juan-carlos-gardon-poggi",fullName:"Juan Carlos Gardón 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