JICDRO is a UGC approved journal (Journal no. 63927)

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ORIGINAL RESEARCH
Year : 2020  |  Volume : 12  |  Issue : 2  |  Page : 154-165

Canal Localization in Dry Mandibles: Two-Dimensional versus Three-Dimensional Imaging


1 Department of Oral and Maxillofacial Surgery, Sathyabama Dental College and Hospital, Chennai, India
2 Department of Prosthodontics and Crown and Bridge, SB Patil Dental College and Hospital, Bidar, Karnataka, India
3 Department of Oral and Maxillofacial Surgery, Sree Mookambika Institute of Dental Sciences, Kanyakumari, India
4 Department of Prosthodontics and Crown and Bridge, Santosh Dental College and Hospital, Ghaziabad, Uttar Pradesh, India
5 Department of Prosthodontics and Crown and Bridge, Rajas Dental College and Hospital, Tirunelveli, Tamil Nadu, India
6 Department of Conservative Dentistry and Endodontics, Saraswati Dhanwantari Dental College and Hospital and Postgraduate Research Institute, Parbhani, Maharashtra, India
7 Department of Oral Medicine and Radiology, Saraswati Dhanwantari Dental College and Hospital and Postgraduate Research Institute, Parbhani, Maharashtra, India

Date of Submission11-Sep-2019
Date of Decision18-Sep-2019
Date of Acceptance13-Sep-2020
Date of Web Publication14-Dec-2020

Correspondence Address:
Dr. Abhishek Singh Nayyar
Department of Oral Medicine and Radiology, Saraswati-Dhanwantari Dental College and Hospital and Postgraduate Research Institute, Parbhani, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicdro.jicdro_29_19

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   Abstract 


Context and Aim: Dental implants are widely used for the rehabilitation of edentulous arches. Yet, placement of oral implants in the mandible is associated with numerous complications, including hemorrhage and neurosensory disturbances. Enumerating precise information concerning the vital structures of the mandible, thus, becomes all the more important before the placement of implants. The aim of the present study was to determine the efficiency and accuracy of digital orthopantomography (OPG) and cone-beam computed tomography (CBCT) in determining the location of mandibular canal in preoperative assessment of the mandibles for implant placement. Materials and Methods: Ten dry edentulous mandibles of adult humans were selected for this study which comprised two phases, namely a radiographic phase and an in vitro phase. The radiographic phase was based on the obtaining digital orthopantomographs and cone-beam computed tomograms. During the in vitro phase, all the mandibles were sectioned at an angle of 90° to the inferior border of the mandible, and in vitro measurements were obtained. Statistical Analysis Used: Statistical analysis was done using IBM SPSS statistics 20 (Chicago, IL, USA). Paired and unpaired t-tests were used to do a comparative analysis of the two modalities used. P < 0.05 was considered to be statistically significant. Results: The results of the present study revealed that the measurements of both the vertical (D1 and D2) and the buccolingual distances of the mandible (D3 and D4) obtained by CBCT were in accordance with the ones obtained with the help of in vitro measurements, and there was no statistically significant difference in the studied variables (D1, D2, D3, and D4) between the two measurements. On the contrary, there was a significant statistical difference between the values obtained from digital OPG (D1 and D2) when compared to the values obtained by in vitro measurements. Conclusion: The findings of the present study implied that CBCT is the most efficient and accurate diagnostic tool available to locate the course of mandibular canal in the selection of potential implant sites. The accuracy of the CBCT was found to be superior to the digital panoramic images in the present study because of multiplanar three-dimensional reconstructions.

Keywords: Cone-beam computed tomography, digital orthopantomography, dry mandibles, localization, mandibular canal


How to cite this article:
Chandran A, Kattimani PT, Nachiappan S, Joevitson MA, Chatterjee S, Rajambigai AM, Das M, Nayyar AS. Canal Localization in Dry Mandibles: Two-Dimensional versus Three-Dimensional Imaging. J Int Clin Dent Res Organ 2020;12:154-65

How to cite this URL:
Chandran A, Kattimani PT, Nachiappan S, Joevitson MA, Chatterjee S, Rajambigai AM, Das M, Nayyar AS. Canal Localization in Dry Mandibles: Two-Dimensional versus Three-Dimensional Imaging. J Int Clin Dent Res Organ [serial online] 2020 [cited 2021 Jan 25];12:154-65. Available from: https://www.jicdro.org/text.asp?2020/12/2/154/303403




   Introduction Top


Dental implants are widely used for the rehabilitation of edentulous arches. Yet, placement of oral implants in the mandible is associated with numerous complications, including hemorrhage and neurosensory disturbances.[1],[2],[3] Enumerating precise information concerning the vital structures of the mandible, thus, becomes all the more important before the placement of implants.[4] A precise knowledge of the anatomy and their disparities is important to execute suitable surgical procedures and to secure the vital structures of the patient.[5],[6],[7] Dentomaxillofacial imaging is based either on conventional or digital techniques. Digital imaging has many advantages including a significant reduction of radiation exposure and feasibility of image manipulation and analysis among the many which improve sensitivity and diminish errors inbuilt in conventional imaging. For preimplant assessment, orthopantomography (OPG) and cone-beam computed tomography (CBCT) are the routinely used digital imaging modalities.[8] Measurements obtained through the comparison of digital OPG and CBCT with dry edentulous mandibles can help supplement the data about the estimation of the efficiency and accuracy of these imaging modalities in identifying the vital structures including the mandibular canal. The aim of the present study was to determine the efficiency and accuracy of digital OPG and CBCT in determining the location of the mandibular canal in the preoperative assessment of the mandibles for implant placement.


   Materials and Methods Top


Ten dry edentulous mandibles of adult humans were selected for this study [Figure 1] and [Figure 2]. Mandibles with any evidence of fractures, teeth, and socket spaces were excluded from the study before starting the examination protocol [Figure 3]. The study comprised two phases, namely a radiographic phase [Figure 4] and [Figure 5] and an in vitro phase [Figure 6],[Figure 7],[Figure 8]. The radiographic phase was based on obtaining digital orthopantomographs [Figure 9],[Figure 10],[Figure 11] and cone-beam computed tomograms [Figure 12],[Figure 13],[Figure 14],[Figure 15],[Figure 16]. Areas with 5, 15, and 25 mm distance from the distal margin of the mental foramen were marked as A, B, and C on both the right and left sides of the dry mandibles. Care was taken to maintain symmetry in both sides of the mandible. Radiopaque markers in the form of 2.54 mm steel ball bearings were placed on the above-described A, B, and C positions with the help of modeling wax to calculate the magnification error. Digital panoramic images were obtained with KODAK 8000C panoramic unit [Figure 4] at 60 kVP and 2 mA exposure parameters, with an exposure time of 13.63 s. Dry mandibles embedded with radiopaque marker were placed in the focal trough of the digital panoramic unit by maintaining the reference lines parallel to the symphysis menti and mesial aspect of the mental foramen with the support of bite plane and insulating tape. Digital images were acquired and stored in the computer. The following distances were measured on the acquired images:
Figure 1: samples used in the study

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Figure 2: a dry mandible used in the study-magnified view

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Figure 3: armamentarium used in the study

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Figure 4: digital Panoramic Machine-Kodak 8000C

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Figure 5: i-CAT cone-beam computed tomography unit

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Figure 6: sectioned dry mandible at A, B, and C region

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Figure 7: slices of the mandible

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Figure 8: in vitro measurements made from the sections of dry mandible

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Figure 9: digital panoramic image used for the localization of mandibular canal

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Figure 10: assessment of distance from the alveolar crest to the inferior border of the mandible (D1) with the help of digital orthopantomography (magnified)

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Figure 11: assessment of distance from the alveolar crest to the superior border of the mandibular canal (D2) with the help of digital orthopantomography (magnified)

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Figure 12: cone-beam computed tomography three-dimensional view of mandible-lateral view

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Figure 13: cone-beam computed tomography three-dimensional view of mandible-antero-posterior view

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Figure 14: assessment of distance from the alveolar crest to the inferior border of the mandible (D1) with the help of cone-beam computed tomography

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Figure 15: assessment of distance from the alveolar crest to the superior border of the mandibular canal (D2) with the help of cone-beam computed tomography

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Figure 16: corresponding cross-sectional views for the assessment of distance of buccolingual width 5 mm under mandibular crest (D3) and buccolingual width at the circumference of the mandibular canal (D4) with the help of cone-beam computed tomography

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  • D1: The distance from the alveolar crest to the inferior border of mandible (mm)
  • D2: The distance from the alveolar crest to the superior border of mandibular canal (mm).


For the purpose of getting cone-beam computed tomograms, dry mandibles were placed in a 12 cm × 12 cm × 10 cm plastic box filled with water. The position of the mandibles in the water was maintained at a constant during the procedure for obtaining CBCT images. The plastic box was then placed within the focal trough of the i-CAT CBCT unit [Figure 5]. i-CAT is a CBCT unit which is an extended field of view model (Imaging Sciences International, Hatfield, PA, USA). In the present study, the i-CAT CBCT unit was used while the images were obtained at 120 kVp and 5 mA exposure parameters with a rotation time of 26.3 s by software addition of two different rotational scans using two different fields of view, covering the craniofacial complex and maxilla/mandible. In addition to D1 and D2, the following distances were measured on computed tomograms:

  • D3: Buccolingual (BL) width 5 mm under mandibular crest (mm)
  • D4: BL width at the circumference of the mandibular canal (mm).


The measurements of D1, D2, D3, and D4 were made with the help of Vernier calipers. During the in vitro phase, all the mandibles were sectioned at an angle of 90° to the inferior border of the mandible along the regions of A, B, and C using the bone cutter tool. On the sectioned mandibles, the measurements of D1, D2, D3, and D4 were then obtained [Figure 6],[Figure 7],[Figure 8]. The following formula was used to calculate the actual bone height (ABH) from the radiographic measurements obtained using digital OPG:

ABH = ADB × RBH/RDB

where in ABH available for implant placement; ADB = Actual diameter of the metal ball bearings; RBH = Radiographic bone height available for implant placement as measured from the radiograph; and RDB = Diameter of the metal ball bearings on radiograph.

Statistical analysis used

Statistical analysis was done using IBM SPSS statistics 20 (Chicago, IL, USA). Paired and unpaired t-tests were used to do a comparative analysis of the two modalities used. P < 0.05 was considered to be statistically significant.

Ethical Clearance

The structure and plan of the study was sent to the Ethics Committee of the Institution before the start of the study and their approval sought via. Institutional Ethics Committee Letter approval no SDDC/IEC/01-39-2018.


   Results Top


[Table 1] shows the descriptive statistics of dried mandibles with CBCT, while [Table 2],[Table 3],[Table 4] show the same for digital OPG (magnified), digital OPG (calculated), and in vitro measurements, respectively. [Table 5] shows the descriptive statistics for the included measurements, viz., D1, D2, D3, and D4 by groups. When considering in vitro measurements from dry mandibles as the gold standard, the results of the present study clearly revealed that the mean values of D1, D2, D3, and D4 (15.52, 7.53, 11.20, and 10.97 mm) obtained with the help of CBCT [Table 1] and [Table 5] were very close to the direct gold standard in vitro measurement values of 15.47, 7.51, 11.18, and 10.97 mm, respectively [Table 4] and [Table 5]. Similar measurements obtained with the help of digital OPG (magnified) for D1 and D2 (19.10 and 9.16 mm) [Table 2] and [Table 5] and digital OPG (calculated) for D1 and D2 (16.19 and 7.77 mm) [Table 3] and [Table 5] were, on the contrary, found to be much higher than the in vitro measurement values (15.47 and 7.51 mm) [Table 4] and [Table 5]. [Table 6] shows the Pearson’s correlation coefficients for CBCT for all the studied variables, D1, D2, D3, and D4. Similarly, [Table 7] shows the Pearson’s correlation coefficients for the measurements made with the help of digital OPG, while [Table 8] shows the Pearson’s correlation coefficients for in vitro measurements. The Pearson’s correlation coefficients obtained showed that there was a direct positive linear relationship evident between distance measurements for D1 (r = 0.999, P < 0.01), D2 (r = 0.998, P < 0.01), D3 (r = 0.993, P < 0.01), and D4 (r = 0.996, P < 0.01) in the CBCT [Table 6]. A similar positive relationship, also, existed between distance measurements for D1 (r = 0.998, P < 0.01) and D2 (r = 0.996, P < 0.01) in OPG [Table 7] as well as between distance measurements for D1 (r = 0.997, P < 0.01), D2 (r = 0.998, P < 0.01), D3 (r = 0.991, P < 0.01), and D4 (r = 0.992, P < 0.01) in case of in vitro measurements [Table 8]. The Pearson’s correlation coefficient values for CBCT ranged from 0.980 to 1, indicating an excellent correlation among all the measurements made with CBCT [Table 6]. Likewise, for digital OPG [Table 7] and in vitro measurements [Table 8], r-values ranged from 0.995 to 1 and 0.980 to 1, respectively, indicating an excellent correlation among all the measurements made with digital OPG and in vitro measurements, implying a significant positive correlation among them. [Table 9] and [Table 10] show the comparison done in between the in vitro and digital OPG (magnified) and in vitro and digital OPG (calculated) measurements by distance, respectively, with the help of Duncan’s t-test. Likewise, [Table 11] and [Table 12] show the comparison done in between CBCT and digital OPG and in vitro and CBCT measurements by distance with the help of Duncan’s t-test. The results of the present study revealed that the measurements of both the vertical (D1 and D2) and the BL distances of the mandible (D3 and D4) obtained by CBCT were in accordance with the ones obtained with the help of in vitro measurements, and there was no statistically significant difference in the studied variables (D1, D2, D3, and D4) between the two measurements. On the contrary, there was a significant statistical difference between the values obtained with the help of digital OPG (D1 and D2) as against the same values obtained with the help of in vitro measurements. [Table 13] and [Table 14] show the descriptive statistics for average magnification with digital OPG (magnified) versus digital OPG (calculated) and average magnification with digital OPG (magnified) versus in vitro measurements.
Table 1: Descriptive statistics of dried mandibles with cone-beam computed tomography

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Table 2: Descriptive statistics of dried mandibles with digital orthopantomography (magnified)

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Table 3: Descriptive statistics of dried mandibles with digital orthopantomography (calculated)

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Table 4: Descriptive statistics of dried mandibles with in vitro measurements

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Table 5: Descriptive statistics for D1, D2, D3, and D4 by groups

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Table 6: Pearson's correlation coefficients for cone-beam computed tomography

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Table 7: Pearson's correlation coefficients for digital orthopantomography

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Table 8: Pearson's correlation coefficients for in vitro measurements

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Table 9: Duncan's t-test for all in vitro and digital orthopantomography (magnified) measurements by distance

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Table 10: Duncan's t-test for all in vitro and digital orthopantomography (calculated) measurements by distance

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Table 11: Duncan's t-test for all cone-beam computed tomography and digital orthopantomography measurements by distance

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Table 12: Duncan's t-test for all in vitro and cone-beam computed tomography measurements by distance

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Table 13: Descriptive statistics for average magnification with digital orthopantomography (magnified) versus digital orthopantomography (calculated)

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Table 14: Descriptive statistics for average magnification with digital orthopantomography (magnified) versus direct in vitro measurements

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   Discussion Top


Presurgical implant area assessment is an important aspect in any successful implant procedure. A great deal of risk is involved in the placement of dental implants because of inaccurate determination of the bone height and the subsequent use of implants that exceed the extent of the bone available. Such risks have their consequences in the form of either transient or permanent neurosensory disturbances, due to inferior alveolar nerve impingement.[9],[10],[11] With proper assessment of the location of the mandibular canal before dental implant procedures, the chances of occurrence of such nerve injuries are significantly reduced. Although conventional computed tomography (CT) imaging can accurately assess the cortical bone thickness of the remaining alveolar bone, it requires high dose of radiation. CBCT (dental CBCT), which requires a lower radiation dose, is frequently used in diagnosis and treatment planning in such cases. In addition to lower doses of radiation, dental CBCT provides greater spatial resolution than CT, making it an ideal presurgical assessment tool for dental implant surgeries.[12] The aim of the present study was to determine the efficiency and accuracy of digital OPG and CBCT in determining the location of mandibular canal in the preoperative assessment of mandibles for implant placement. The results of the present study were found to be in accordance with the study conducted by Angelopoulos et al.,[13] who compared CBCT reformatted panoramic images (i-CAT; Imaging Sciences, Hatfield, PA, USA), direct (charge-coupled device-based) panoramic radiographs (DIMAX; Planmeca, Helsinki, Finland), and digital panoramic radiographs based on a storage phosphor system (DENOPTIX; Gendex, Chicago, IL, USA), for the identification of the mandibular canal as part of the preimplant assessment. That study concluded CBCT to be the most reliable method for presurgical implant assessment and also to have added advantages simultaneously in the form of reduced radiation exposure. The images acquired with the help of CBCT were free from any magnification errors and superimpositions of the neighboring structures. This was in accordance with the results of the study conducted by Yim et al.,[14] who reported that no magnification of images was found in the images acquired by CBCT (Panoramic CT) when compared with the digital OPG (Planmeca panoramic images). The results of the present study were, also, found to be in accordance with the study conducted by Kamburoglu et al.,[15] who compared measurements obtained from CBCT of the skull by direct digital caliper and observed that all CBCT measurements were highly accurate and in accordance with the measurements obtained by the digital caliper. Similar results were obtained in the study conducted by Tantanapornkul et al.,[16] who concluded CBCT to be an accurate method of assessment in such situations, observing that the level of accuracy for determining the sensitivity and specificity was 93% and 77% for CBCT and 70% and 63% for digital panoramic images, respectively. Georgescu et al.[17] demonstrated that CBCT is more efficient and accurate when compared to digital OPG, with added advantages in the form of easier and faster transformation of data, allowing direct volumetric reconstructions and a high level of accuracy and reproducibility. Similar results were obtained by Yun-Long and Chang-Fu,[18] who analyzed the application of CBCT and digital OPG in presurgical implant assessment and concluded that CBCT not only can evaluate the preoperative alveolar bone volume more accurately but also can indicate the peri-implant bone volume and quality clearly. In the present study, CBCT images were taken with the soft tissue equivalent (water) to avoid soft tissue burn-out. Hence, overestimation of vertical distances was excluded. This methodology was adopted in accordance with the study conducted by Suomalainen et al.,[19] who used sucrose solutions to minimize the chances of soft tissue burn-out. According to that study, the error of linear measurements with CBCT was found to be even smaller than that obtained with the multi-slice computed tomography (MSCT) during presurgical implant planning. They concluded CBCT to be a reliable tool for implant planning measurements when compared with the MSCT. These findings were, however, not in accordance with the study conducted by Potter et al.,[12] who showed overestimation in the measurement of distance between the inferior alveolar canal and alveolar crest, whereas the tomograms overestimated 3.06% of the distances. Further, these findings were, again, in contrast with the findings of the study conducted by Peltola and Mattila,[20] where an underestimation of the measured distance was found due to burn-out of the soft tissues in the mandible crest area, leading to difficulty in the identification and errors in the tracing.


   Conclusion Top


The present study evaluated the efficiency and accuracy of digital OPG and CBCT in determining the location of mandibular canal in the preoperative assessment of mandibles for implant placement. The findings of the present study implied that CBCT is the most efficient and accurate diagnostic tool available to locate the course of the mandibular canal in the selection of potential implant sites. The accuracy of the i CAT was found to be superior to the digital panoramic images in the present study because of multiplanar three-dimensional (3D) reconstructions, which are not possible with 2D panoramic images. 2D panoramic images do not provide information on bone thickness or location of vital structures in a BL direction, whereas the 3D images accurately display the size and BL direction of the mandibular canals and density of the remaining alveolar ridges. The efficiency of digital panoramic image is, further, reduced due to the possibility of magnification errors. However, panoramic radiographs are still valuable in daily practice with the skill and knowledge of the experienced surgeons.

Limitations of the present study

The present study does have certain limitations in the form of smaller sample size and with the study being on dry mandibles which are certainly different from that of a patient. Furthermore, the collected sample could not be correlated with the information associated with age and gender parameters that might lead to potential bias. Further studies are, therefore, warranted to validate the accuracy of the results obtained in the present study using larger sample size. The present study was, also, limited only to the posterior mandible. Thus, studies pertaining to other areas of mandible might, also, be considered to assess the efficiency of the studied imaging modalities in the accurate assessment of different parameters on dry or, otherwise, in vivo studies on mandibles.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Potter BJ, Shrout MK, Russell CM, Sharawy M. Implant site assessment using panoramic cross-sectional tomographic imaging. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:436-42.  Back to cited text no. 12
    
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Angelopoulos C, Thomas SL, Hechler S, Parissis N, Hlavacek M. Comparison between digital panoramic radiography and cone-beam computed tomography for the identification of the mandibular canal as part of pre-surgical dental implant assessment. J Oral Maxillofac Surg 2008;66:2130-5.  Back to cited text no. 13
    
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Yun-Long Z, Chang-Fu L. Application of orthopantomography and cone beam computed tomography in dental implant: A comparative study. Chin J Tissue Eng Res 2012;16:2332-5.  Back to cited text no. 18
    
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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], [Figure 15], [Figure 16]
 
 
    Tables

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



 

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