|Year : 2017 | Volume
| Issue : 2 | Page : 110-118
TAD – transpalatal arch-MOD combination system: An effective tool in the nonsurgical management of individuals with vertical facial patterns and gummy smiles
Department of Orthodontics and Dento-facial Orthopaedics, Apollo Clinic, Kolkata, West Bengal, India
|Date of Submission||24-Aug-2016|
|Date of Acceptance||20-Dec-2016|
|Date of Web Publication||17-Apr-2017|
Great Lakes Multispeciality Dental Clinic and Orthodontic Centre, 27, Janak Road, Behind Lake Mall, Kolkata - 700 029, West Bengal
Source of Support: None, Conflict of Interest: None
The treatment of vertical facial patterns with gummy smiles in adults has long been a challenge to the orthodontist. Before the advent of microimplants, correction of such complex skeletal problems in adults was only possible with the help of orthognathic surgery. Orthognathic surgery in such situations aimed at LeFort I impaction of the maxillary dentoalveolar segment followed by counterclockwise rotation of the mandible, thereby improving the gummy smile and chin prominence. With the introduction of skeletal anchorage systems and microimplants in the last decade and the promising results that it has shown over the years, we as orthodontist now believe that surgery can definitely be avoided in selected cases when temporary anchorage devices are used – orthognathic surgery such as orthodontics. Microimplants have therefore expanded the envelope of discrepancy on which the orthodontist can work on. This case report focuses on the use of the TAD – Transpalatal arch-MOD combination system for nonsurgical management of adults with vertical facial pattern and gummy smile and details of the biomechanical perspectives associated with it.
Keywords: Biomechanics of vertical correction, gummy smile, long face, microimplants, orthognathic surgery such as orthodontics, vertical growth pattern
|How to cite this article:|
Ghosh A. TAD – transpalatal arch-MOD combination system: An effective tool in the nonsurgical management of individuals with vertical facial patterns and gummy smiles. J Indian Orthod Soc 2017;51:110-8
|How to cite this URL:|
Ghosh A. TAD – transpalatal arch-MOD combination system: An effective tool in the nonsurgical management of individuals with vertical facial patterns and gummy smiles. J Indian Orthod Soc [serial online] 2017 [cited 2019 Feb 21];51:110-8. Available from: http://www.jios.in/text.asp?2017/51/2/110/204605
| Introduction|| |
The introduction of skeletal anchorage to orthodontic practice has made it possible to correct malocclusions which were otherwise difficult or even impossible to be corrected by regular conventional mechanics.
Among the skeletal anchorage devices which include microimplants, miniplates, or even dental implants, the most popular has been the microimplants, thanks to its low-cost, easy surgical placement, removal, and very few anatomic limitations for its placement.
Microimplants have been effective in bringing tooth movement in all three dimensions of space,,,,,, whether it is anterior tooth retraction, whole arch retraction, whole arch intrusion, single tooth intrusion, molar protraction, or even bringing about skeletal changes in maxillomandibular relationships while maintaining absolute anchorage.,, It has therefore brought about a revelation in the field of orthodontics in the past decade.
Microscrews have also been significantly effective in the correction of occlusal canting,, skeletal anterior open bite,,,,,,, and gummy smiles. This makes us believe that full-arch maxillary dentoalveolar intrusion with slow counterclockwise rotation of the mandible is possible with our own preferred system which would cater to the objectives of the treatment.
TAD – Transpalatal arch (TPA)-mod combination system is used for full-arch maxillary dentoalveolar intrusion [Figure 1].,,,
The components of this system involve the use of five microimplants and modified TPA for full-arch intrusion of the maxillary dentoalveolar segment. Of the five microimplants, four are placed in the buccal segment and one in the mid-palatal region (in adults). The buccal microimplants are placed mesial to the maxillary canine and in between the second premolar and the first molars, bilaterally. The purpose of the anterior TADs is to provide an intrusive force to the anterior maxillary dentoalveolar unit while the posterior implants help in the retraction of the anteriors and intrusion of the posterior segment.
It has been commonly noted that with this biomechanical system, there is a chance of palatal cusp hang in the first and the second molars which ultimately hinders the true intrusion process. To counteract this, a modified TPA with two inbuilt helices close to the two first molar bands is placed. An additional mid-palatal microimplant is also placed to provide an intrusive component of force from the palatal aspect (helix of the mod TPA) and to negate the moment generated from the buccal microimplants causing the palatal cusp hang [Figure 2].
The full-arch maxillary intrusion process with subsequent slow counterclockwise rotation of the mandible demands the elimination of the posterior most fulcrum, i.e., the third molars if they are in occlusion, banding and bonding of all dental units both in upper and lower arch, and the use of light, optimum intrusive forces during the course of the treatment.,, Extraction of third molars can be considered as an option if during the treatment process, the clinician finds that it is hampering the autorotation process of the mandible.
It is to be clearly understood that this biomechanical system becomes complex when the full-arch intrusion is associated with anterior teeth retraction (e.g., in premolar extraction case or a case of spaced anterior teeth). The application of the intrusive force both in the anterior and posterior segment should then be adjusted according to the retraction biomechanics to bring about the intrusion retraction process simultaneously. Slight imbalance in force magnitude and vector can bring about unwanted side effects such as posterior open bite, anterior deep bite, and render suboptimal results.
Therefore, understanding the biomechanical perspective is mandatory which makes us look at three different situations to effectively bring about true intrusion of anteriors and posteriors with retraction of the anteriors simultaneously.
Situation A: Retraction force at the level of center of resistance (CR) of the anterior dentoalveolar unit [Figure 3].
Since retraction force is delivered from the posterior buccal microimplant at the level of the CR, no moments are generated both in the anterior or the posterior maxillary dentoalveolar segment due to the force. Therefore, for full-arch intrusion, similar intrusive forces need to be applied from the anterior labial, posterior buccal, and palatal microimplants in each quadrant (80 g from each implant in the posterior and 50 g from each implant in the anterior). It may be taken into note that in some instances, application of retraction force at the level of the CR may not be feasible as the power arm may encroach in the buccal vestibule of the patient and may cause significant discomfort.
Situation B: Retraction force is below the level of CR of the anterior dentoalveolar unit [Figure 4].
Since retraction force is delivered below the level of CR, clockwise moment of forces is generated both in the anterior and posterior dentoalveolar segment, therefore having an extrusive component in the anteriors and an intrusive component in the posteriors. Therefore, for full-arch intrusion in such a situation, the active intrusive force in the anterior has to be of a greater duration while the active intrusive force in the posterior (buccally) may be marginally decreased as compared to situation A. The palatal intrusive force may then be altered accordingly to prevent palatal cusp hang and bring about true intrusion. Maintaining similar intrusive force levels such as situation A may lead to the development of posterior open bite and anterior deep bite.
Situation C: Retraction force is below the level of CR of the anterior dentoalveolar unit at the level of the archwire [Figure 5].
Here, the retraction force is significantly below the level of the CR at the archwire level (if preformed archwires are used). Significant clockwise moments are generated both in the anterior and the posterior segment due to this force system which has a high extrusive component in the anteriors and intrusive component in the posteriors. Therefore, for full-arch intrusion, the active intrusive force in the anterior has to be of a significantly greater duration while the active intrusive force in the posterior (buccally) may not be required. The palatal force component should be maintained accordingly to counteract the moment generated by the buccal intrusive component preventing palatal cusp hang.
The efficiency of this system lies in the meticulous execution of its intricate biomechanics as the whole system is dependent on the quantum and duration of the force applied from each unit.
| Case Report|| |
An adult female patient of 27 years age reported with a chief complaint of spacing and forwardly placed upper front teeth. She was also concerned about her unnatural facial appearance on smile.
- Extraoral examination: Revealed a dolichocephalic head type, a leptoprosopic facial pattern with apparently normal facial symmetry. There was increased incisal exposure at rest and excessive gingival display on spontaneous smile. Lips were incompetent, and lower lip was curled and everted. The profile showed a posterior divergence with significant convexity and a double chin (golf ball chin). The 45° view also substantiated similar findings [Figure 6]
- Intraoral examination: Revealed Angle's Class I malocclusion with spacing of 11 mm in the upper arch and 6 mm in the lower arch. Other dental findings include bilateral single tooth scissor bite in relation to 14 and 24, increased overjet of 6 mm, and overbite of 60%. Occlusal photographs suggest apparent asymmetry of arches and broad upper and lower dental arch. The tongue is large with crenation present in the lateral borders on either side [Figure 7].
Extraoral radiographic findings
Lateral cephalogram [Figure 8] reveals normal structure maxilla and mandible underlying a Class II skeletal base with the presence of bidental protrusion. The profile is convex with interlabial gap of 8 mm at rest.
Orthopantomogram (OPG) [Figure 9] reveals normal bony structure of the maxilla and mandible with normal height and contour of interdental bone. The structure and shape of the condyles look apparently normal. There is a generalized spacing in the upper and the lower dental arch with fully erupted third molars in occlusion.
Cephalometric analysis - Pretreatment [Table 1]
Composite cephalometric analysis reveals normal sized but slightly retropositioned maxilla with small-sized and retropositioned mandible. The skeletal parameters (ANB: 7°) reveal significant difference in skeletal base position between maxilla and mandible with vertical facial pattern (FMA - 28°, lower anterior facial height of 70 mm). The dental parameters suggest normally inclined but forwardly placed upper incisors, and when assessed with respect to the palatal plane, they are grossly extruded (upper incisor to NF: 33 mm, upper molar to NF: 25 mm) probably accounting partly to the gummy smile apart from the vertical growth pattern. The lower incisors are severely proclined and forwardly placed with lower vertical parameters (lower incisor to MP: 42 mm, lower molar to MP: 36 mm) relatively normal. Soft-tissue parameters reveal an acute nasolabial angle and an increased lip strain (NLA - 80°, lip strain - 8 mm) [Table 1].
The patient was diagnosed with Angle's Class I malocclusion underlying a Class II skeletal base with spacing in upper and lower arch, increased overjet, overbite, and gummy smile with vertical growth pattern. Other significant findings include forwardly placed upper and lower incisors, bilateral single tooth scissor bite in relation to 14 and 24, wide maxillary and mandibular asymmetric dental arches, large tongue, increased lip strain, and convex facial profile.
(1) To attend to the chief complaint of the patient by correction of the proclined incisors. (2) To resolve the spacing and scissor bite in relation to the upper and lower dental arch. (3) To correct the gummy smile by intrusion of the anterior and posterior maxillary segment with respect to the upper lip at smile and rest. (4) To aid in autorotation of the mandible which would improve the chin prominence and correct the chin–throat angle. (5) To establish ideal static/functional occlusion with normal overbite and overjet. (6) To achieve ideal esthetic outcome, including correction of nasolabial angle, concavity of profile, chin prominence, and vertical facial height.
- Decompensation (nonextraction) and surgical option (maxillary LeFort I impaction): which include correction of spacing with coordination (involving correction of dental scissor bite) of upper and lower dental arches followed by orthognathic surgery involving maxillary LeFort I impaction and simultaneous counterclockwise autorotation of the mandible. This shall enable correction of initial dental problems such as spacing and proclination followed by correction of gummy smile, lower anterior facial height, chin prominence, and chin–throat angle
- Camouflage treatment (nonextraction) (microimplants): which involves correction of the initial spacing in upper and lower dental arches followed by the use of microimplants (five in number) – four in the buccal and labial maxillary dentoalveolar segment and one in the mid-palate with the use of modified TPA for slow impaction of the entire maxillary dentoalveolar units [Figure 1]. This would then replicate orthognathic surgery such as orthodontics (avoid orthognathic surgery) but still address to the complaints of the patient which includes – spacing, long face, gummy smile, and reduced chin prominence.
Treatment plan and sequential progress
The choice of treatment plan was made in a joint discussion with the patient and the orthodontist, and the second treatment alternative was chosen.
After carefully analyzing the case both clinically and looking through the cephalometric parameters, the treatment progressed as follows:
- Considering the available space in the upper and the lower dental arch, the amount of proclination, and the presence of a large tongue (retention issues), a nonextraction camouflage plan was proposed to the patient
- The appliance system (0.022 × 0.028 MBT), metal brackets, was placed in all the dental units (except the third molars) together with the modified TPA anchored to the maxillary first molars on either side. The TPA has a helix bilaterally, close to the soldered joint to provide a point of attachment for the intrusive force from the mid-palatal screw
- After the initial leveling and alignment process with sequential change of arch wires starting with the 0.014 nickel-titanium (NiTi), 0.016 NiTi, 0.016 Australian Special plus SS wire, and ending with 0.018 Australian special plus SS wire, maxillary canine retraction was started. Lower leveling and alignment was also performed in the same way. The dental scissor bite (14 and 24 regions) corrected automatically with the coordination of arches. Posterior bite blocks were placed during the coordination process to aid in quickness of the correction
- End mass retraction process was started in the lower arch on 19 × 25 SS wire when the canine retraction process was in progress in the upper arch on a 0.018 SS Australian wire
- After canine retraction was completed in the maxillary arch and adequate space was achieved for the placement of the anterior microimplants, 19 × 25 NiTi wire followed by 19 × 25 SS posted wire was placed to start the intrusion retraction process (absolute anchorage) (Refer to situation – C)
- Microimplants were then placed in the upper anterior labial segment mesial to the canine buccally between the second premolars and first molar and in the mid-palatal region to aid in full-arch intrusion and retraction process. The labial and buccal microimplants were of 1.5 mm × 8 mm while the palatal implant was 2 mm × 6 mm in dimension [Figure 1]
- The microimplants were immediately loaded after placement and active intrusion, and retraction forces were applied. The intrusive forces were light, optimum, and maintained within biologic limits (40 g per side). Increased intrusive forces applied onto teeth in adult patients increase the chances of root resorption.,,, The retraction forces were maintained to about 100 g per side. E-chains were used as force components. NiTi coil spring was not used as they are not self-limiting and have less force decay. In case of missed appointments, this could be an issue as monitoring the intrusion process was vital in achieving differential intrusion between the anteriors and posteriors for changing occlusal plane relationship
- The intrusion retraction process continued for about 8–10 months, in which selectively more intrusion was done in the anterior than in the posterior, which aided in correction of the deep overbite and gummy smile. Posterior intrusion was monitored on the basis of the improving chin prominence. Once the acceptable chin prominence and the correction of the posterior gummy smile were addressed to, posterior intrusion was discontinued. Anterior intrusion retraction process was continued till the deep bite, and anterior gummy smile was addressed beyond which the anterior screws were removed
- After about 24 months of treatment, maxillary full-arch intrusion was completed together with slow counterclockwise rotation of the mandible leading to the development of an ideal overjet and overbite, closure of the mandibular plane, reduction in vertical facial height, and improvement in upper incisal show at rest and increased gum exposure on spontaneous smile [Figure 10] and [Figure 11]
- The case was finally finished with Class I molar and Class I canine relationship with ideal overjet and overbite
- Retention protocol involved bonded lingual retainers together with removal thermoplastic retainers in both upper and lower arches. The rationale for the usage of full-arch thermoplastic retainers lies in the use of controlled bite forces in maintaining the vertical correction achieved [Figure 12].
Treatment results [Table 2]
|Table 2: Peer Assessment Rating index for assessment of treatment changes|
Click here to view
- The final treatment results achieved were extremely pleasing. The case was finished with Class I molar and canine relationship and good intercuspation in static occlusion. The upper and the lower dental midlines perfectly coincided. The overjet and the overbite were within standard limits. Functional occlusion was also well-established posttreatment [Figure 10]
- The extraoral features posttreatment was equally pleasing. The frontal face was symmetric, and the competency of the lip was established. The smile was consonant, and there was ideal incisal exposure at rest and on spontaneous smile. There was complete elimination of the unaesthetic gummy smile seen before the treatment. The 45° view also suggested the same. The profile was straight, the reduced chin was prominent, and the acuteness of the nasolabial angle was significantly reduced, therefore, providing in all dimensions an overall balanced face. The chin–throat angle also improved significantly during the course of the treatment [Figure 11] and [Table 2].
Posttreatment extraoral radiographic findings
- Of the extraoral radiographs, lateral cephalogram suggested that all the objectives of the treatment set were achieved and thereafter included intrusion and retraction of upper incisors, retraction of lower incisors, and change in vertical skeletal and dental parameters. [Table 1] and [Figure 13]
- The OPG showed full complement of teeth present with no significant root resorption in the upper anterior segment. The root parallelism in the maxillary and the mandibular dentition was appreciably normal with progressive mild divergence from anterior to posterior [Figure 14].
Cephalometric analysis: Posttreatment [Table 1]
- Composite cephalometric analysis reveals change in the linear and angular position of the maxillary dentoalveolar segment (SNA - 79°, NPr-A - 2mm) suggestive of remodeling in the Point A region due to the intrusion and the retraction process. The position of the mandible changed posttreatment (SNB - 74°, NPr-Pog - 9 mm) due to mild counterclockwise rotation as a positive side effect toward maxillary dentoalveolar impaction. Therefore, the ANB angle changed from 7° (pretreatment) to 5° (posttreatment) therefore accounting for reduction in convexity of the profile
- There was significant reduction in vertical parameters (FMA - 26°, SN Go-Gn - 32°, LAFH - 68 mm) which was brought about by the slow impaction of the maxillary dentoalveolar segment
- The maxillary dental parameters suggest significant intrusion and retraction of the upper anteriors associated with intrusion of the posterior segment too (upper incisor to NA - 22°/2 mm, upper incisor to NF - 27 mm, upper incisor to NF - 23 mm). The mandibular dental parameters suggest significant retraction of the lower anteriors (lower incisor to NB - 32°/4 mm)
- As a result of vertical and sagittal dentoalveolar changes, there were changes in soft-tissue parameters also in which the nasolabial angle increased to 97° and the lip strain reduced to 1 mm. The sagittal position of the lip also changed – the upper lip to S-line reduced to 1 mm and lower lip to S-line reduced to 2 mm [Table 1].
| Discussion|| |
The treatment of skeletal vertical malocclusions with gummy smiles revolves basically around two protocols of surgery and camouflage with microimplants/skeletal anchorage systems. With most patients opting out of the surgical option, the orthodontist is left with only one option, i.e., microimplants.
With the advent of different protocols and mechanics associated to the correction of gummy smile and long face with microimplants, it was the need of the hour to develop a standardized protocol based on sound biomechanical standpoints which would deliver clinically predictable results. Hence the T-T technique was innovated. In the context of this case, the T-T technique brought about significant change in the anterior maxillary overall dentoalveolar height (change - 2 mm), to a lesser extent posterior maxillary overall dentoalveolar height (change - 2 mm), together with closure of the mandibular plane angle (change - 2°), thereby reducing the facial height and positioning the mandible forward. This improved the gummy smile and improved the profile to a significant degree [Figure 15] and [Figure 16].
This exactly replicates the probable changes that would have taken place had maxillary impaction surgery been performed on the patient.,
It has to be taken into note that in case of severe anteroposterior deficiency or excessive vertical dimension of the maxilla, surgery of the maxilla is necessary. Impaction of the maxilla with orthognathic surgery has more potential than intrusion of the posterior teeth with microimplants and associated orthodontic treatment. However, 2–3 mm of intrusion of the posterior teeth and more in the anteriors can be obtained easily and precisely with microimplants,,,, and these vertical movements can significantly change the overall esthetic outcome. Treatment with microimplant is less invasive and less expensive and causes less postoperative discomfort compared with maxillary surgical impaction.,
Maxillary surgery is inevitable in certain clinical situations and cannot be avoided, but whenever there are options to negate it with the use of microimplants, this method be seriously taken as an additional option considering the quality of the results achieved.
| Conclusion|| |
The advent of microimplants in the last decade has changed the paradigms of orthodontic treatment and broadened its scope. Treatments which would not have been possible in the yesteryears without surgery can now be attempted with orthodontics alone with predictable treatment outcomes. Correction of gummy smiles with vertical facial pattern is one such instance. However, for consistent clinical outcomes, the biomechanical perspectives need to be taken proper care of, with strict adherence to structured treatment protocols.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Creekmore TD, Eklund MK. The possibility of skeletal anchorage. J Clin Orthod 1983;17:266-9.
Kanomi R. Mini-implant for orthodontic anchorage. J Clin Orthod 1997;31:763-7.
Park HS. The skeletal cortical anchorage using titanium micro-screw implants. Korean J Orthod 1999;29:699-706.
Park HS, Bae SM, Kyung HM, Sung JH. Micro-implant anchorage for treatment of skeletal class I bialveolar protrusion. J Clin Orthod 2001;35:417-22.
Shapiro PA, Kokich VG. Uses of implants in orthodontics. Dent Clin North Am 1988;32:539-50.
Park HS, Kwon TG, Sung JH. Nonextraction treatment with microscrew implants. Angle Orthod 2004;74:539-49.
Takano-Yamamoto T, Kuroda S. Titanium screw anchorage for correction of canted occlusal plane in patients with facial asymmetry. Am J Orthod Dentofacial Orthop 2007;132:237-42.
Park HS, Kim JY, Kwon TG. Occlusal plane change after intrusion of maxillary posterior teeth by microimplants to avoid maxillary surgery with skeletal class III orthognathic surgery. Am J Orthod Dentofacial Orthop 2010;138:631-40.
Umemori M, Sugawara J, Mitani H, Nagasaka H, Kawamura H. Skeletal anchorage system for open-bite correction. Am J Orthod Dentofacial Orthop 1999;115:166-74.
Park YC, Lee SY, Kim DH, Jee SH. Intrusion of posterior teeth using mini-screw implants. Am J Orthod Dentofacial Orthop 2003;123:690-4.
Vaden JL. Nonsurgical treatment of the patient with vertical discrepancy. Am J Orthod Dentofacial Orthop 1998;113:567-82.
Sugawara J. Orthodontic reduction of lower facial height in open bite patients with skeletal anchorage system: Beyond traditional orthodontics. World J Orthod 2005;6:Suppl:24-6.
Tanaka E, Iwabe T, Kawai N, Nishi M, Dalla-Bona D, Hasegawa T, et al.
An adult case of skeletal open bite with a large lower anterior facial height. Angle Orthod 2005;75:465-71.
Park HS, Kwon TG, Kwon OW. Treatment of open bite with microscrew implant anchorage. Am J Orthod Dentofacial Orthop 2004;126:627-36.
Lee HA, Park YC. Treatment and post treatment changes following maxillary posterior teeth with miniscrew implants for open-bite correction. Korean J Orthod 2008;38:31-40.
Klontz HA. Facial balance and harmony: An attainable objective for the patient with a high mandibular plane angle. Am J Orthod Dentofacial Orthop 1998;114:176-88.
Park HS, Bae SM, Kyung HM, Sung JH. Simultaneous incisor retraction and distal molar movement with microimplant anchorage. World J Orthod 2004;5:164-71.
Melsen B, Fotis V, Burstone CJ. Vertical force considerations in differential space closure. J Clin Orthod 1990;24:678-83.
Upadhyay M, Yadav S, Nanda R. Vertical-dimension control during en-masse retraction with mini-implant anchorage. Am J Orthod Dentofacial Orthop 2010;138:96-108.
Abhisek G, Rajib S, Surana A. Skeletal Anchorage Mediated Slow Auto-rotation of Mandible: Orthognathic Surgery Like Orthodontics for Correction of Vertical Maxillary Excess with TAD-Open Hyrax Combination System: A Clinical Innovation/Case Report. RUJODS, Ranchi University 2013;2:66-75.
Ari-Demirkaya A, Masry MA, Erverdi N. Apical root resorption of maxillary first molars after intrusion with zygomatic skeletal anchorage. Angle Orthod 2005;75:761-7.
Carrillo R, Rossouw PE, Franco PF, Opperman LA, Buschang PH. Intrusion of multiradicular teeth and related root resorption with mini-screw implant anchorage: A radiographic evaluation. Am J Orthod Dentofacial Orthop 2007;132:647-55.
Daimaruya T, Nagasaka H, Umemori M, Sugawara J, Mitani H. The influences of molar intrusion on the inferior alveolar neurovascular bundle and root using the skeletal anchorage system in dogs. Angle Orthod 2001;71:60-70.
Daimaruya T, Takahashi I, Nagasaka H, Umemori M, Sugawara J, Mitani H. Effects of maxillary molar intrusion on the nasal floor and tooth root using the skeletal anchorage system in dogs. Angle Orthod 2003;73:158-66.
[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]
[Table 1], [Table 2]