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   Table of Contents    
ORIGINAL ARTICLE
Year : 2019  |  Volume : 23  |  Issue : 3  |  Page : 234-241  

Evaluation and comparison of hydroxyapatite crystals with collagen fibrils bone graft alone and in combination with guided tissue regeneration membrane


1 Department of Periodontology, Teerthanker Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh, India
2 Department of Periodontology, Indira Gandhi Government Dental College, Jammu, Jammu and Kashmir, India
3 Dr. Chugh's Dental Centre, New Delhi, India

Date of Submission05-Jun-2018
Date of Acceptance02-Oct-2018
Date of Web Publication2-May-2019

Correspondence Address:
Dr. Zoya Chowdhary
Department of Periodontology, Indira Gandhi Government Dental College, Jammu, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisp.jisp_386_18

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   Abstract 


Background: The combination of collagen in bone grafts is being used because of its properties that accentuate the degree of regeneration. Furcation involvement poses challenge to the prognosis of a tooth, the use of bone grafts and a combination of grafts and membranes have proved to be beneficial in the treatment of furcation defects. Thus, the aim of the present study was to clinically evaluate and compare the effectiveness of collagen fiber bone graft with and without a membrane in the treatment of mandibular Grade II furcation defects. Materials and Methods: A clinical split-mouth randomized control trial, which included ten patients having bilateral mandibular Grade II furcation defects, was randomly assigned to Group I, treated with bone graft of hydroxyapatite with collagen fibers, and Group II, treated with bone graft of hydroxyapatite with collagen fibers and guided tissue regeneration membrane of polyglycolide and polylactide copolymer, respectively. The clinical measurements were recorded at baseline and 6 months after surgery; and plaque and gingival index were recorded at baseline and at 3 and 6 months after surgery. The data obtained was statistically evaluated. Results: The overall results showed that the treatment procedures demonstrated statistically significant reduction in probing pocket depth, vertical defect fill, and horizontal depth of furcation, with a gain in clinical attachment level. On comparison of both the groups, Group II showed superior results with a statistically significant difference in all parameters except in gingival recession. Conclusion: The findings of the study demonstrated superior clinical results obtained with hydroxyapatite with collagen fibers, used in combination with polyglycolide and polylactide copolymer as compared to used alone in the treatment of Grade II furcation defects.

Keywords: Collagen, furcation, hydroxyapatite, membrane, regeneration


How to cite this article:
Mehrotra S, Chowdhary Z, Rastogi T. Evaluation and comparison of hydroxyapatite crystals with collagen fibrils bone graft alone and in combination with guided tissue regeneration membrane. J Indian Soc Periodontol 2019;23:234-41

How to cite this URL:
Mehrotra S, Chowdhary Z, Rastogi T. Evaluation and comparison of hydroxyapatite crystals with collagen fibrils bone graft alone and in combination with guided tissue regeneration membrane. J Indian Soc Periodontol [serial online] 2019 [cited 2019 Oct 16];23:234-41. Available from: http://www.jisponline.com/text.asp?2019/23/3/234/251768




   Introduction Top


Periodontitis is an inflammatory disease of the supporting tissues of the teeth that leads to crucial changes in the bone architecture.[1] The reconstitution of the lost form or tissues of the periodontium is the main aim of periodontal therapy.

Bone grafts have been used for long in periodontics for regeneration. Newer bone grafts have been introduced for regeneration over the years.[2],[3],[4] Recently, bone grafts have been introduced containing collagen fibers to increase the efficacy of the graft materials.

Collagen is a natural component of the body and is significant in maintaining the integrity of the tissues. It has a triple helical structure which prevents breaking down by enzymatic activity enabling adhesiveness of cells.[5] Furthermore, collagen's porous structure, permeability, and stability make it a suitable scaffold for the deposition of osteoblasts.[6]

Collagen by interaction with platelets can form a hemostatic plug which fastens wound healing as well as stabilizes the clot within the wound.[7] Thus, making collagen useful for bone grafting and regeneration. A combination of hydroxyapatite crystals with collagen fibers acts as an osteoconductive matrix with prolonged stability, providing a desired scaffold for new bone formation.[8]

The use of membranes along with bone grafts has become popular owing to the properties of the membrane. The membranes play a significant role in stabilizing the graft material within the defects, stabilizing the wound, and preventing the epithelial downgrowth.[8],[9],[10] These factors allow the pluripotent cells from the adjacent wound margins to repopulate the defect resulting in regeneration.[9]

The furcation is an area of complex anatomic morphology and is difficult to maintain by routine oral healthcare measures.[1] Bone replacement grafts and a combination of grafts and membranes have shown to increase bone level in the treatment of Grade II furcation.[2],[3],[4] However, several studies have shown superior treatment outcomes with the combination of bone graft and guided tissue regeneration (GTR) procedures than either of them used alone.[11],[12],[13],[14],[15]

Constant efforts are being made to increase the efficacy of bone grafts, and the addition of collagen fibers to hydroxyapatite particles has been made to improve the efficacy of the graft material. Furthermore, collagen has similar property to a membrane regarding clot stabilization by reacting with platelets to form a hemostatic plug, and since collagen triple helical structure prevents it from breakdown by enzymatic activity, it acts as a suitable scaffold which further helps in space maintenance which is also a similar property of a membrane. Hence, the present study was undertaken to evaluate the regenerative capacity of the bone graft material-containing hydroxyapatite with collagen fibers and to compare it with a combination of a membrane.


   Materials and Methods Top


A clinical split-mouth randomized control trial was conducted in the Department of Periodontology at Teerthanker Mahaveer Dental College and Research Centre. A total number of ten patients having bilateral mandibular Grade II furcation defects (20 sites), both male and female, with an average age ranging from 25 to 55 years participated in the study.

Inclusion criteria

  1. Patients having bilateral mandibular Grade II furcation defects (Glickman's classification) involving the buccal plate, evident on the radiograph
  2. Defects with a minimum of 3 mm of horizontal probing depth of furcation defect
  3. Patients with no previous periodontal surgical treatment within 6 months before the study were included in the study.


Exclusion criteria

  1. Medically compromised patients
  2. Smokers
  3. Pregnant and lactating women
  4. Patients having untreated nonvital teeth
  5. Teeth having more than Grade I mobility


Study design

A randomized split-mouth clinical study was conducted to evaluate the regenerative capacity of the bone graft material-containing hydroxyapatite with collagen fibers and compared along with the use of a membrane.

The study was conducted in accordance with the Helsinki declaration[16] approved by the Institutional Ethics Committee (TMU/EC/511). An informed written consent was obtained from the included patients before the treatment.

Site selection

The selected patients having bilateral mandibular Grade II furcation defects were divided randomly into two groups by the toss of a coin, with one site among the bilateral defects per patient serving as Group I and the other as Group II.

  1. Group I – The site treated with bone graft of hydroxyapatite with collagen fibers (OSTOFORM™) alone
  2. Group II – The site treated with bone graft of hydroxyapatite with collagen fibers (OSTOFORM™) with guided tissue regeneration (GTR) membrane of copolymer of polyglycolide and polylactide (BioMesh-S™) in combination.


Radiographic standardization

The radiographs were standardized with paralleling cone technique using extension-cone paralleling radiograph holder, and a mesh grid was used with calibration of one millimeter for appreciating any radiographical changes seen preoperatively [Figure 1] and postoperatively.
Figure 1: Preoperative radiograph showing Grade II furcation defect in mandibular molar of (a) Group I and (b) Group II

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Clinical parameters

After oral hygiene instructions and the Phase I therapy, the patients were recalled for surgery after 4 weeks, and the following parameters were assessed for the evaluation of treatment results:

  1. Plaque index (PI) (Silness and Loe, 1964)[17]
  2. Gingival index (GI) (Loe and Silness, 1963).[17]


The following clinical parameters at the site of the furcation were recorded after placing the stent in position using UNC-15 probe. The probe was placed along the groove made, on an acrylic stent made on a model cast, at the mid-buccal aspect of the furcation area of the selected site, the groove made in the stent helps in maintaining the same position, and angulation of the probe while recording of the parameters preoperatively and postoperatively [Figure 2] and [Figure 3].
Figure 2: Preoperative clinical measurements of Group I (a) showing recording of measurement using the stent, and (b) showing recording of the horizontal depth of furcation measurement

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Figure 3: Preoperative clinical measurements of Group II (a) showing recording of measurement using the stent, and (b) showing recording of the horizontal depth of furcation measurement

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  1. Gingival recession (GR) (from cementoenamel junction [CEJ] to gingival margin)
  2. Probing pocket depth (PPD) (from gingival margin to base of sulcus)
  3. Clinical attachment level (CAL) (PPD plus GR)
  4. Vertical depth of furcation (VDF) (from gingival margin to base of the defect using transgingival probing)
  5. Horizontal depth of furcation (HDF) was measured using a UNC-15 probe by inserting the probe horizontally, just apical to the fornix area (transgingival probing).
  6. All the parameters were assessed and recorded at baseline and at 6 months postoperatively; except GI and PI, which were assessed at baseline, at 3 months and at 6 months postoperatively, by the same operator (S. M).


Surgical procedure

The extraoral and intraoral disinfection was performed using savlon (3% w/v cetrimide; 1.5% v/v chlorhexidine) and betadine (2% and 5% povidone-iodine, respectively) solution. The surgical area was then anesthetized using local anesthesia (lignocaine hydrochloride 2% with 1:80,000 adrenaline).

A sulcular incision was given using Bard-Parker (BP) blade no. 12, and a releasing incision using BP blade no. 15 was given where required. After raising a full-thickness flap, complete debridement of the furcation defect along with scaling and root planing (SRP) was done. The furcation defect in Group I [Figure 4] was completely filled with bone graft.
Figure 4: Surgical procedure in Group I (a) shows after reflection of the flap and debridement of the defect, and (b) shows the placement of the OSTOFORM™ (hydroxyapatite with collagen fibers) bone graft at the site of furcation defect

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In Group II [Figure 5], after the reflection of the flap, a template was made according to which the membrane was cut and trimmed with scissor to adapt to the size of the furcation defect. After the defect was completely filled with bone graft, the membrane was stabilized against the tooth over the defect area using 5-0 resorbable polyglactin suture material (Vicryl™, Ethicon, Johnson and Johnson Ltd.) with the margins of the membrane overlapping on the alveolar bone, about 3 mm in all directions.
Figure 5: Surgical procedure in Group II (a) shows after reflection of the flap and debridement of the defect, (b) shows the placement of the OSTOFORM™ (hydroxyapatite with collagen fibers) bone graft at the site of furcation defect, and (c) shows the placement of BioMesh-S™ (polyglycolide and polylactide copolymer) guided tissue regeneration membrane secured with using 5-0 resorbable polyglactin suture material (Vicryl™, Ethicon, Johnson and Johnson Ltd.) at the site of furcation defect

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The flap was positioned at the CEJ to completely cover the membrane and secure the graft in place using a 4-0 silk suture material (Mersilk™, Ethicon, Johnson and Johnson Ltd.). A periodontal dressing (COE-PAK™, GC America Inc. USA) was given over the surgical area. The patient has prescribed a combination of amoxicillin 500 mg and clavulanic acid 125 mg thrice daily, paracetamol 500 mg at every 8 h, and 0.2% chlorhexidine gluconate mouthwash twice daily for 1 week postsurgically along with postoperative and oral hygiene instructions.

The patient was asked to refrain from mechanical plaque control for 1 week at the surgical site and was recalled after the first 24 h to assess any postoperative complications. Sutures and periodontal pack were removed after 1 week.


   Results Top


Periodontal probing depth

[Table 1] shows the mean value in Group I of PPD at baseline, i.e., 3.20 ± 0.63 which after treatment reduced to 2.30 ± 0.48 with a mean difference of 0.90 ± 0.73. This was statistically significant (P < 0.01) whereas, in [Table 2], the mean value in Group II of PPD at baseline was 3.30 ± 0.48 which after treatment reduced to 1.80 ± 0.42 with a mean difference of 1.50 ± 0.52, and this was also statistically significant (P < 0.01).
Table 1: Comparison of pre- and post-clinical parameter values at the site of furcation in Group I

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Table 2: Comparison of pre- and post-clinical parameter values at the site of furcation in Group II

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Gingival recession

The results in Group I show no statistical difference in GR after treatment [Table 1] whereas, in Group II, the mean value of GR at baseline was 1.60 ± 0.51 which after treatment was reduced to 1.10 ± 0.32 with a mean difference of 0.52 ± 0.53, this reduction in values of GR was statistically significant (P < 0.01) [Table 2].

Clinical attachment level

The mean value for Group I at baseline was 4.80 ± 0.91, which was reduced to 3.70 ± 0.82 after treatment, the mean difference of CAL pre- and post-treatment was 1.10 ± 0.99, this difference in values of CAL is statistically significant (P < 0.01) as shown in [Table 1]. In [Table 2], the mean value for Group II at baseline was 4.90 ± 0.74 which was reduced to 2.90 ± 0.57 after treatment, the mean difference of CAL was 2.00 ± 0.82, and this too is statistically significant (P < 0.01).

Vertical depth of furcation

The mean values of VDF at baseline in both the groups were 2.80 ± 0.42, which reduced to 1.80 ± 0.42 and 1.10 ± 0.32 after treatment in Group I and Group II, respectively. The change in values is statistically significant (P < 0.01) [Table 1] and [Table 2].

Horizontal depth of furcation

The mean value at baseline for both the groups was 4.30 ± 0.48, which reduced to 2.40 ± 0.52 and 1.60 ± 0.70 after treatment in Group I and Group II, respectively, the mean difference is statistically significant (P < 0.01) [Table 1] and [Table 2].

Plaque index

[Table 3] and [Graph 1] show the mean value of PI scores at baseline, 3 months, and 6 months, with a mean PI score of 1.33 ± 0.20, 1.30 ± 0.15, and 1.29 ± 0.11, respectively. The mean difference in values of baseline versus 3 months, baseline versus 6 months, and 3 months versus 6 months was 0.03 ± 0.15, 0.04 ± 0.22, and 0.01 ± 0.20, respectively. The results were statistically insignificant (P > 0.05).
Table 3: Comparison of mean values of plaque index at baseline, 3 months, and 6 months

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Gingival index

[Table 4] and [Graph 2] show the mean value of GI scores at baseline, 3 months, and 6 months, with a mean GI score of 0.80 ± 0.07, 0.79 ± 0.06, and 0.78 ± 0.07, respectively. The mean difference in values of baseline versus 3 months, baseline versus 6 months, and 3 months versus 6 months was 0.01 ± 0.01, 0.02 ± 0.01, and 0.01 ± 0.01, respectively. The results were statistically insignificant (P > 0.05).
Table 4: Comparison of mean values of gingival index at baseline, 3 months, and 6 months

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Out of the total patients included, 70% (7) were male, and 30% (3) were female, with an average ranging from 25 to 55 years. [Figure 6] show the improvement in the clinical parameters postoperative in Group I and Group II after 6 months but, on comparing the groups, Group II, i.e., bone graft and GTR membrane show better results than Group I, i.e., bone graft alone.
Figure 6: Postoperative photographs of Group I (a) show recording of the horizontal depth of furcation measurement postoperatively at 6 months, and (b) shows the 6-month postoperative radiograph of the site treated

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The postoperative clinical parameters comparisons at the site of furcation between Group I and Group II, [Table 5], and [Graph 3]a show the mean value of PPD in Group I after the treatment was 2.30 ± 0.48 whereas in 1.80 ± 0.42 with a mean difference of 0.50 ± 0.52 which was statistically significant (P < 0.05), thus showing an increased improvement in PPD in Group II as compared to Group I; and the mean value of GR after treatment was 1.20 ± 0.42 whereas in Group II was 1.10 ± 0.32 with a mean difference of 0.10 ± 0.73 which was statistically insignificant. The mean value of CAL in Group I after treatment was 3.70 ± 0.82 whereas in Group II was 2.90 ± 0.57 with a mean difference of 0.80 ± 0.91, which was statistically significant (P < 0.05, thus showing an increased improvement in CAL in Group II as compared to Group I) [Table 5] and [Graph 3]a. The mean value of VDF and HDF in Group I after treatment was 1.80 ± 0.42 and 2.40 ± 0.52, whereas in Group II was 1.1. +0.32 and 1.60 ± 0.70 with a mean difference of 0.70 ± 0.67 and 0.80 ± 0.42, respectively, which was statistically significant (P < 0.05) as shown in [Table 5] and [Graph 3]b, thus showing an increased improvement in VDF and HDF in Group II as compared to Group I.
Table 5: Comparison postclinical parameter values at the site of furcation in Groups I and II

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   Discussion Top


Collagen is a natural component of the body and comprises a large percentage of bone matrix protein.[18],[19] Owing to its triple helical and porous structure[19], collagen is resistant to break down by enzymatic activity which increases its adhesiveness for cells,[5] permeability, and stability making it a suitable scaffold for the deposition of osteoblasts.[6]

Collagen by interaction with platelets can form a hemostatic plug which fastens wound healing as well as stabilizes the clot within the wound.[7] Thus, making collagen useful for bone grafting and regeneration. A combination of hydroxyapatite crystals with collagen fibers acts as an osteoconductive matrix with prolonged stability, providing a desired scaffold for new bone formation.[8]

The combined effect of collagen with hydroxyapatite crystals provides synergistic properties of osteoinduction and osteoconduction, thereby increasing the effect of bone regeneration and bone remodeling.[20] The combination of collagen with hydroxyapatite crystals is being used in an attempt to increase the effectiveness of bone graft materials.

In the present study, OSTOFORM™ (Sark Healthcare Pvt. Ltd., Korea) bone graft has been used, which is a natural/bovine, porous, resorbable hydroxyapatite with collagen fibers, with a particle size of 400 microns, which resorbs completely over a period of 9–12 months.[21]

Even, with the various attempts to increase the efficacy of bone grafts in periodontal regeneration, the role of gingival epithelium in masking the effect of amount of regeneration cannot be overlooked.

In the present study, a polylactic acid (PLA) and polyglycolic acid (PGA) polymer resorbable barrier membrane has been used, which is widely being applied in clinical practice today.[22],[23] These polymer barriers are synthesized by copolymerization of different forms of PLA, PGA, or mixture of PLA and PGA.[22],[24] Barrier degeneration occurs by hydrolysis of ester bonds, a process that initiates at about 30-60-plus days depending on the polymeric composition of the material, and complete degradation occurs by about 6 months.[22],[25],[26],[27],[28] BioMesh-S™ (Samyang corp., Korea) GTR membrane is a biodegradable polyglycolide (poly-d, l-lactide-co-glycolide), polylactide (poly-L-lactide) copolymer membrane which is available as a yellowish-white microporous membrane in a dimension of 20 mm × 25 mm.

Membranes have an additional significance of preventing the growth of epithelial cells and their corresponding connective tissue into the defect area. This allows the wound to be healed by the cells of its original constitution and promotes regeneration to a greater extent.[8] The membrane helps in stabilizing blood clots and containing the graft materials within the defects.[29],[30] Similarly, effects of collagen have been demonstrated because of its triple-helix design which gives it strength and rigidity, and it also attracts platelets to form a hemostatic plug.[14],[31],[32],[33],[34] Collagen also stimulates fibroblastic and osteoblastic activity.[6]

Hence, this study was conducted to evaluate and to compare the efficacy of collagen-based bone graft for the treatment of mandibular Grade II furcation alone and in combination with a barrier membrane.

Control of plaque and gingivitis is important in clinical studies because both vary in their association with periodontitis and affect the response to therapy. In the present study, after oral hygiene instructions and initial therapy of SRP, difference in mean plaque values at baseline (1.33 ± 0.20) was statistically insignificant as compared to 3 months (1.30 ± 0.20) and 6 months (1.29 ± 0.11) postoperatively, which shows that the subjects had maintained oral hygiene throughout the study, along with a significant reduction in GI mean values at baseline (0.80 ± 0.07), 3 months (0.79 ± 0.06), and 6 months (0.78 ± 0.07); the effect of which is reflected in the improvement of the clinical parameters at the site of furcation.

The clinical parameters at the site of furcation defects treated in Group I showed statistically significant improvement. A reduction in VDF, with a difference in mean value of 1.00 ± 0.47, was statistically significant (P < 0.001). A reduction in HDF, with a difference in mean value of 1.90 ± 0.57, was also statistically significant (P < 0.001), as observed postoperatively at an interval of 6 months.

With the reduction in VDF, a reduction in PPD with a difference in mean value of 0.90 ± 0.73, statistically significant (P < 0.01), was observed at 6 months, along with a gain in CAL with a difference in mean value of 1.10 ± 0.99, was also statistically significant (P < 0.01). However, there was no change in the level of gingival margin.

Similarly, the clinical parameters at the site of furcation defects treated in Group II showed statistically significant improvement. A reduction in VDF with a mean difference in value of 1.07 ± 0.48 which was statistically significant (P < 0.001), along with a reduction in HDF with a mean difference in the value of 2.70 ± 0.48, also statistically significant (P < 0.001) was observed postoperatively at 6 months.

A gain in CAL with a difference in mean value of 2.00 ± 0.82 was statistically significant (P < 0.001) was also observed at 6 months, with a reduction in PPD with difference in mean value of 1.50 ± 0.52, statistically significant (P < 0.001), and also a gain in the level of gingival margin, with a difference in mean value of 0.50 ± 0.53, statistically significant (P < 0.015), was seen at 6 months.

Furcation defects treated in Group II [Figure 7] showed better clinical improvement as compared to furcation defects treated with Group I [Figure 6], which were statistically significant regarding VDF (mean difference of 0.70 ± 0.67; P < 0.001), HDF (mean difference of 0.80 ± 0.42; P < 0.009), PPD (mean difference of 0.50 ± 0.52; P < 0.024), CAL (mean difference of 0.80 ± 0.91; P < 0.02), and with no significant difference in GR between the two groups (mean difference of 0.10 ± 0.73; P < 0.55).
Figure 7: Postoperative photographs of Group II (a) show recording of horizontal depth of furcation measurement postoperatively at 6 months, and (b) shows the 6-month postoperative radiograph of the site treated

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Corroborating the results of the present study, it can be concluded that, even though the use of collagen fibers in bone graft substitutes shows significant positive results owing to the properties of collagen. However, additional benefits of membrane application are obvious. Despite collagen fibers help in accelerating wound healing, hemostasis, and stabilizing the graft material within the defect sites, the role of epithelial cells in limiting the amount of regeneration cannot be overlooked.

With advancements in graft materials and introduction of newer regenerative materials, such as growth factors and other natural components of the tissue, the extent of regeneration has certainly improved; however, membranes still play a crucial role in limiting the epithelial cells from interfering with the regenerative process. Thus, it can be said that the application of membranes definitely yields more promising results than a single entity of any graft material.


   Conclusion Top


The overall results of the present study demonstrate that hydroxyapatite plus collagen (bone graft) alone or with polyglycolide and polylactide copolymer (barrier membrane) are efficient in the treatment of mandibular Grade II furcation defects. However, the combined use of the graft and membrane shows better results for the management of mandibular Grade II furcation defects as compared to graft alone.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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