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ORIGINAL ARTICLE
Year : 2021  |  Volume : 25  |  Issue : 6  |  Page : 496-503  

Minimally invasive treatment of gingival recession by vestibular incision subperiosteal tunnel access technique with collagen membrane and advanced platelet-rich fibrin: A 6-month comparative clinical study


Department of Periodontology and Oral Implantology, ITS-Centre for Dental Studies and Research Center, Ghaziabad, Uttar Pradesh, India

Date of Submission09-Aug-2020
Date of Decision08-May-2021
Date of Acceptance09-May-2021
Date of Web Publication01-Nov-2021

Correspondence Address:
Kavya Sangal Jain
Department of Periodontology and Oral Implantology, ITS-Centre for Dental Studies and Research Center, Muradnagar Ghaziabad - 201 206, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisp.jisp_590_20

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   Abstract 


Aim: The study aimed to assess the minimally invasive Vestibular Incision Subperiosteal Tunnel Access (VISTA) technique for treatment of Millers Class I or Class II buccal gingival recession defects and to compare the effectiveness of a bioresorbable collagen membrane or advanced platelet rich fibrin (A-PRF). Methods and Material: 20 sites with Millers Class I or II gingival recession were recruited and allocated into 2 groups with 10 sites each. Group 1: VISTA with A-PRF, Group 2: VISTA with with bioresorbable collagen membrane (Healiguide)®. Standardized Clinical Parameters: Plaque Index (PI), Gingival Index (GI), Clinical attachment level (CAL )Pocket Probing Depth (PPD) Recession Height (RH ) and width of keratinized gingiva (WKG) were measured at baseline 3 months and 6 months. Results: Both groups showed significant improvement in clinical parameters. However reduction in recession height and mean root coverage percentage was greater in A-PRF group after 6 months. Conclusions: VISTA with both A-PRF and Healiguide showed good clinical outcomes but better results were obtained when A-PRF was used.

Keywords: Advanced platelet-rich fibrin, collagen, healiguide, minimally invasive, root coverage, vestibular incision subperiosteal tunnel access


How to cite this article:
Jain KS, Vaish S, Gupta SJ, Sharma N, Khare M, Nair MM. Minimally invasive treatment of gingival recession by vestibular incision subperiosteal tunnel access technique with collagen membrane and advanced platelet-rich fibrin: A 6-month comparative clinical study. J Indian Soc Periodontol 2021;25:496-503

How to cite this URL:
Jain KS, Vaish S, Gupta SJ, Sharma N, Khare M, Nair MM. Minimally invasive treatment of gingival recession by vestibular incision subperiosteal tunnel access technique with collagen membrane and advanced platelet-rich fibrin: A 6-month comparative clinical study. J Indian Soc Periodontol [serial online] 2021 [cited 2021 Dec 3];25:496-503. Available from: https://www.jisponline.com/text.asp?2021/25/6/496/329748




   Introduction Top


Gingival recession (GR) refers to exposure of the root surface in the oral cavity due to apical displacement of gingival margin from cementoenamel junction (CEJ). GR can be associated with one or more surfaces and is either localized or generalized.[1]

There are multiple causes of GR; these can be broadly categorized as being either: (a) Predisposing factors and (b) precipitating factors. Developmental factors such as tooth malposition, thin gingival biotype, inadequate keratinized gingiva, or frenal pull that may lead to GR are characterized as predisposing factors. The factors such as traumatic tooth brushing, smoking, plaque-induced inflammation, or dental treatments (which includes certain types of orthodontic tooth movement, subgingival restorations that may lead to GR) are precipitating factors.[2]

Due to exposure of root surface and deterioration in esthetics, GR is a concern for both patients and dental professionals. Treatment of recession has gained popularity due to increased demand for improved esthetics. At present, connective tissue graft (CTG) is considered to be the gold standard for the treatment of GR. That said, it has certain major disadvantages including need for distant donor site for harvesting, limited tissue availability, and increased risk for post harvesting morbidity. Due to these risks, root coverage using guided tissue regeneration (GTR) was developed in an attempt to overcome these limitations while providing comparable results.

The use of platelet concentrates generated from autologous blood, which is a recent advancement, has gained popularity because of its low cost, relatively simple acquisition, and suturing suitability. Advanced platelet-rich fibrin (A-PRF) is a type of PRF based on low speed centrifugation concept (LSCC) by Choukroun and Ghanaati[3] which utilizes reduced relative centrifugation forces with modification in time for increasing the total number of cells within the top layer of PRF. A-PRF is an ideal provider of autologous cells, and the cells have been found to be more evenly distributed throughout the clot.[4]

Dr Zadeh[5] developed a new technique for root coverage known as vestibular incision subperiosteal tunnel access (VISTA) to overcome some potential complications of intrasulcular tunnelling procedures. This technique has gained popularity by providing a minimally invasive alternative to treatment of GR and promising results in root coverage.

The present study was conducted to assess the VISTA technique for the treatment of Millers Class I or Class II buccal GR defects and to compare the effectiveness of a bioresorbable collagen membrane or A-PRF.


   Materials and Methods Top


The present clinical study was conducted in the Department of Periodontology and Oral Implantology, ITS-CDSR, Muradnagar, Ghaziabad. The sample size was calculated using software OpenEpi Open Source Epidemiologic Statistics for Public Health version 2.3 (developed by AG Dean, KM Sullivan, MM Soe, Cambridge, United States) with a statistical formula having 5% α value, 80% power, and 95% confidence interval. The clinical study was structed as a parallel mouth, single-blinded randomized controlled clinical trial. For the study, a total of 20 sites in eight patients in an age group of 18–50 years with at least 2 sites with Miller's Class I or Class II buccal GR were selected. In the selected patients, 10 sites were randomly assigned by toss of a coin as Group 1 and 10 sites as Group 2. The inclusion criteria were systemically healthy willing individuals with good oral hygiene compliance and no history of smoking for the last 5 years. The exclusion criteria were nonvital teeth, sites with noncervical carious lesions, participants who had taken antibiotics in the past 3 months, participants on immunosuppressant drugs or on any medication known to cause gingival enlargement, participants with active infectious diseases, pregnant and lactating mothers, presence of high frenal attachment and participants who had previously undergone any type of periodontal surgical procedure or regenerative therapy in the past 1 year [Figure 1].
Figure 1: Consort flow diagram showing study design; N - number of sites; VISTA - Vestibular Incision Subperiosteal Tunnel Access technique; APRF - Advanced Platelet Rich Fibrin

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All the selected participants underwent Phase I therapy and were evaluated after 1 week. Only those maintaining optimum oral hygiene assessed as participants with bleeding on probing <20% and full mouth plaque score <20% were selected for surgical therapy. Group 1 participants comprising of 10 sites were treated with VISTA with A-PRF and Group 2 participants comprising of 10 sites were treated with VISTA with bioresorbable collagen membrane (Healiguide®, Advanced Biotech Products Ltd, under technology from Encol, Fremont USA). The study protocol was found to comply with the principles of the declaration of Helsinki and was thus approved by the University Ethical Committee. All the participants in the study signed an informed consent before the surgery. The study was prospectively registered with clinical trials registry (CTRI/2020/1/022679).

Clinical parameters

Clinical parameters were recorded at baseline (just prior to the surgery) as well as at the 3rd month and 6th month follow-up for Group 1 and Group 2 using a UNC-15 probe. Custom-made self-cured acrylic stents grooved in an occluso-apical direction corresponding to the mid-buccal area as a fixed reference point was fabricated to provide reproducible alignments of the probe for each patient. The clinical parameters assessed were as follows: Plaque index (PI), gingival index (GI), relative attachment level (RAL measured from fixed point on custom made stent to the most apical part of the sulcus.), pocket probing depth (PPD) (PPD measured from free gingival margin to the most apical part of the sulcus), recession height (RH from CEJ to the crest of marginal gingiva), and width of keratinized gingiva (WKG measured at the mid buccal point from the free gingival margin to the mucogingival junction).

The mean root coverage (MRC) percentage was measured from the following formula:



Surgical procedure

Local anesthesia was administered in patients following oral scrubbing with betadine (Povidone iodine 5%). In both groups (Group 1 and Group 2), the preparation of the recipient site was common using VISTA technique given by Dr Zadeh. First based on sites being treated a vestibular access incision was given. Following this, facial osseous plate and root dehiscence were exposed through a subperiosteal tunnel created using Abs gingival elevator 1 and 2 [Figure 2]. For proper coronal repositioning, the tunnel was extended through the gingival sulci and beyond the mucogingival junction and also at least one tooth beyond the teeth which required root coverage. In Group 1, the A-PRF was prepared by centrifugation of 10 ml blood withdrawn from the patient at 1500 rpm for 14 min. The freshly prepared A-PRF membrane was trimmed and inserted inside the subperiosteal tunnel. Gentle pressure for 3 min was applied for stabilization of the membrane followed by suturing [Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7],[Figure 8]. In Group 2, a surgical template was used to measure the size of defect and the bioresorbable collagen membrane (Healiguide®) was trimmed to fit the dimensions of the surgical area. The collagen membrane was inserted in the subperiosteal tunnel, and the membrane and mucogingival complex were sutured after proper positioning of the membrane [Figure 9],[Figure 10],[Figure 11],[Figure 12],[Figure 13],[Figure 14]. The suturing technique in VISTA is a specialized coronally anchored suturing technique which was the same for both Group 1 and Group 2. The teeth were etched to provide good bonding of composite to the surface. Following this, a horizontal mattress suture was given spanning the width of the tooth and about 2–3 mm apical to the gingival margin of each tooth. It was then coronally advanced and bonded to the tooth surface using composite [Figure 7] and [Figure 13]. This rigid fixation of gingival margins reduces micromotion and provides more favourable outcome. After 1 week, patients were recalled for the removal of midline sutures. The composite bonded sutures were removed 3 weeks postsurgery.
Figure 2: Abs gingival elevators used for subperiosteal tunnel access

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Figure 3: Preoperative picture of Group 1 with Miller's class I buccal recession defect seen in relation to 11, 12, 13, 14 and 15

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Figure 4: Measurement of clinical parameters using custom made acrylic stent

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Figure 5: Preparation of subperiosteal tunnel through a vertical incision given apical to mucogingival junction. Prepared advanced platelet-rich fibrin was inserted in the prepared tunnel

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Figure 6: Insertion of advanced platelet-rich fibrin in subperiosteal tunnel

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Figure 7: Coronally anchored bonded sutures given in relation to 11, 12, 13, 14 and 15

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Figure 8: 6 months postoperative picture of Group 1 with root coverage achieved in 11, 12, 13, 14, 15

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Figure 9: Preoperative picture of Group 2 with Miller's class I buccal recession defect seen in relation to 23 and 24

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Figure 10: Measurement of clinical parameters using custom made acrylic stent

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Figure 11: Preparation of subperiosteal tunnel through a vertical incision given apical to mucogingival junction. Bioresorbable collagen membrane was inserted in the prepared tunnel

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Figure 12: Insertion of bioresorbable collagen membrane in subperiosteal tunnel

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Figure 13: Coronally anchored bonded sutures given in relation to 23 and 24

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Figure 14: 6 months postoperative picture of Group 2 with root coverage achieved in 23 and 24

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   Results Top


A significant decrease in PPD from baseline to 6 months, i.e., for Group 1: 0.90 ± 0.32 mm to 0.70 ± 0.26 mm; and for Group 2, 0.90 ± 0.32 mm to 0.50 ± 0.00 mm was observed. Gain in WKG was significant from baseline to 6 months, i.e., 4.40 ± 1.17 mm to 5.00 ± 1.55 mm in Group 1 and 4.30 ± 0.95 mm to 5.15 ± 2.35 mm in Group 2, respectively. However, the difference in mean WKG between Group 1 and Group 2 at baseline, 3 months and 6 months was not significant [Table 1]. The difference in mean RAL between Group 1 and Group 2 at baseline, 3 months and 6 months was not significant; however, a significant gain in RAL was observed in both the groups from baseline to 6 months. The mean RH at baseline for Group 1 and Group 2 was 2.05 ± 0.83 mm and 2.00 ± 0.33 mm, respectively, and decreased at 3 months to 0.65 ± 0.63 mm and 0.55 ± 0.50 mm and at 6 months to 0.35 ± 0.53 mm and 0.80 ± 0.59 mm at respectively [Table 1]. The mean difference in RH from baseline to 6 months and between 3 months and 6 months was significantly more in Group 1 as compared to Group 2 [Table 2]. The MRC after 6 months for Group 1 was 77.50 ± 46.58% and for Group 2 was 61.67 ± 25.20% [Table 3] which was significantly more in Group 1.
Table 1: Inter group comparison of clinical parameters at various time intervals

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Table 2: Inter group comparison of difference in clinical parameters at various time intervals

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Table 3: Inter group comparison of mean root coverage percentage

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   Discussion Top


The objective of treatment of gingival tissue recession is complete coverage of exposed root surface and regeneration of all the supporting components of the periodontium resulting in improved esthetics. Recently, there has been research for minimally invasive and aesthetically superior techniques for root coverage therefore, the VISTA was developed Dr Zadeh[5] in 2011 which involves a single vestibular incision through which multiple recession in the anterior can be accessed using specialized instruments and coronal advancement of the gingiva can be done. Although considered the gold standard in the treatment of GR, subepithelial CTG (SCTG) has some disadvantages such as technique sensitivity, two surgical sites, and patient compliance. GTR was thus utilised in root coverage procedures in an attempt to overcome these limitations. At present, collagen is the most commonly used GTR membrane with many auspicious biological activities such as hemostatic ability, attraction and activation of periodontal ligament, and gingival fibroblast cells. That said, these membranes have a few disadvantages such as unpredictable degradation profile, risk of disease transmission, ethical concerns among patients on their use as well as expense. A search for better material for periodontal regeneration led to the development of a new class of biomaterials is generated from autologous blood. Recently, LSCC has been proposed by Choukroun and Ghanaati.[3] which includes A-PRF. It states that reducing the relative centrifugation forces with modification in time increases the total number of cells left contained within the top layer of PRF enabling a higher number of leukocytes “trapped” within the fibrin matrix.[3] In the present study, a comparison between A-PRF and collagen was done in recession defects.

No significant difference in mean PI and GI between Group 1 and Group 2 at baseline, 3 months and 6 months was observed. These results may be attributed to reinforcement of oral hygiene and also elucidates successful patient motivation and compliance to the instructions rendered.

The mean PPD was significantly more in Group 1 as compared to Group 2 at 6 months. Similar results were obtained by Pini Prato et al.[6] in PPD in a 4-year follow-up study and by Romagna-Genon[7] who compared CTG to bioabsorbable bilayer collagen membrane with GTR. A possible reason was given that GTR may create a more resistant attachment than does the graft. Similarly, in the present study, a resistant attachment in collagen group might be responsible for significantly less PPD as compared to the A-PRF group.

A significant gain in WKG of 0.80 ± 0.67 mm from baseline to 3 months and 0.60 ± 0.94 mm from baseline to 6 months was observed in A-PRF group [Table 4]. Jankovic et al.[8] reported a similar gain in WKG when PRF was used in the treatment of buccal GR. A significant gain of WKG of 0.85 ± 0.88 mm was also observed from baseline to 6 months in the collagen group similar to the results obtained by Shieh et al.[9] and Pini Prato et al.[6]
Table 4: Intra group comparison of mean difference in clinical parameters at various time intervals in Group 1 and Group 2

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The gain in RAL was significant from baseline to 3 months and baseline to 6 months in A-PRF group [Table 4]. Using CAF with PRF for root coverage, Gupta et al.[10] observed a similar gain in attachment. The decrease in PPD and increased recession coverage can attribute to the gain in clinical attachment. Another possible reason can be the formation of new connective tissue attachment and secretion of the growth factors by PRF which lead to better attachment of cells in the overlying flap to membrane and of the membrane to the underlying root surface, thereby resulting in the prevention of the flap shrinkage.[11]

There was a significant reduction in recession height in intragroup comparison at all time intervals in both the groups [Table 4]. However, the mean difference in RH was significantly more in A-PRF as compared to collagen group. Furthermore, the MRC percentage after 6 months for Group 1 was 77.50% ± 46.58% and for Group 2 was 61.67% ± 25.20%. The results are comparable to those obtained by Mansouri et al.[12] who reported an MRC of 70.69% in VISTA for root coverage. It was less than the MRC obtained by Gupta et al.,[13] S Rajeswari et al.[14] and Chatterjee et al.[15] who reported a 97.22%, 94.17%, and 92%, respectively, using VISTA technique. Recent study by Mohamed and Marssafy.[16] demonstrated better MRC with VISTA technique which was 92.43% as compared to tunnelling technique with MRC 82.58%. The collagen group showed an MRC of 61.67 ± 25.20% which is similar to results obtained by Praveen et al.[17] who reported 64.50% MRC and Trombelli et al.[18],[19] who showed a MRC percentage of 55%–65%. The low predictability of regeneration is the main shortcoming of all second-generation GTR membranes which might have attributed to lower reduction in recession height and lower MRC% in collagen group.[20] Space preservation in recession defects is often difficult to achieve because the morphology of the dehiscence tends to allow collapse of membrane against root surface,[9] which probably explains the less MRC% in collagen group.

A very recent modification of VISTA called modified VISTA advocates the use of a volume-stable porcine collagen matrix with volumetric stability and histomorphometric properties similar to SCTG. This modified VISTA has the potential to overcome the disadvantages of normal collagen membranes but needs further validation.[21] A-PRF group showed a greater reduction in recession height and greater MRC%. Garg et al.[22] also demonstrated that addition of PRF with VISTA give better outcome in the root coverage. This result might be attributed to the effect of fibroblast proliferation in periodontal ligaments and gingival connective tissues with the influence of PRF's various growth factors and spacing effect.[23]

The results of the present study suggest that both A-PRF and bioresorbable collagen membrane (Healiguide®) can produce predictive root coverage with VISTA technique. Although the use of A-PRF offers greater advantage in the present study, it is important to note that all surgical procedures have their advantages and disadvantages as well as indications and contraindications. The variation in the results suggest that root coverage procedures are technique sensitive, and success of root coverage may be influenced by the condition of surgical sites, such as soft-tissue thickness.[24] Certain limitations of our study were small sample size, short follow-up period, and absence of histological analysis. Furthermore, the thickness of soft tissue or gingival biotype was not assessed in this study. Hence, the ability to directly compare the percent of root coverage between this study and previous human clinical trials is limited.


   Conclusion Top


Within the limitations of the present study, it can be concluded that VISTA technique can be successfully used for root coverage in the treatment of Miller's Class I and II GR defects. In the present study, VISTA with both A-PRF and Healiguide® showed good clinical outcomes, but better results were obtained when A-PRF was used. However, these findings are still not sufficient to advocate the true clinical effect of VISTA technique with A-PRF or bioresorbable collagen membrane (Healiguide®) on the treatment of buccal recession defects. Long-term clinical trials with larger sample size are recommended to evaluate the stability of root coverage using the VISTA technique.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Smith RG. Gingival recession. Reappraisal of an enigmatic condition and a new index for monitoring. J Clin Periodontol 1997;24:201-5.  Back to cited text no. 1
    
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Masuki H, Okudera T, Watanebe T, Suzuki M, Nishiyama K, Okudera H, et al. Growth factor and pro-inflammatory cytokine contents in platelet-rich plasma (PRP), plasma rich in growth factors (PRGF), advanced platelet-rich fibrin (A-PRF), and concentrated growth factors (CGF). Int J Implant Dent 2016;2:19.  Back to cited text no. 4
    
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Romagna-Genon C. Comparative clinical study of guided tissue regeneration with a bioabsorbable bilayer collagen membrane and subepithelial connective tissue graft. J Periodontol 2001;72:1258-64.  Back to cited text no. 7
    
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Jankovic S, Aleksic Z, Klokkevold P, Lekovic V, Dimitrijevic B, Kenney EB, et al. Use of platelet-rich fibrin membrane following treatment of gingival recession: A randomized clinical trial. Int J Periodontics Restorative Dent 2012;32:e41-50.  Back to cited text no. 8
    
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Gupta S, Banthia R, Singh P, Banthia P, Raje S, Aggarwal N. Clinical evaluation and comparison of the efficacy of coronally advanced flap alone and in combination with platelet rich fibrin membrane in the treatment of Miller Class I and II gingival recessions. Contemp Clin Dent 2015;6:153-60.  Back to cited text no. 10
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Mansouri S, Moghaddas O, Torabi N, Ghafari K. Vestibular incisional subperiosteal tunnel access versus coronally advanced flap with connective tissue graft for root coverage of Miller's class I and II gingival recession: A randomized clinical trial. J Adv Periodontol Implant Dent 2019;11:12-20.  Back to cited text no. 12
    
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Gupta G, Puri K, Bansal M, Khatri M, Kumar A. Platelet-rich fibrin–reinforced vestibular incision subperiosteal tunnel access technique for recession coverage. J Clin Adv Periodont 2015;5:248-53.  Back to cited text no. 13
    
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Schulze-Späte U, Lee CT. Modified vestibular incision subperiosteal tunnel access procedure with volume-stable collagen matrix for root coverage: Report of three cases. Int J Periodontics Restorative Dent 2019;39:e181-7.  Back to cited text no. 21
    
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Garg S, Arora SA, Chhina S, Singh P. Multiple gingival recession coverage treated with vestibular incision subperiosteal tunnel access approach with or without platelet-rich fibrin – A case series. Contemp Clin Dent 2017;8:464-8.  Back to cited text no. 22
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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