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 Table of Contents  
RESEARCH
Year : 2022  |  Volume : 22  |  Issue : 4  |  Page : 343-353

Impact of complete mouth rehabilitation following Pankey Mann Schuyler versus HOBO Philosophy on Oral Health-Related Quality of Life using Oral Health Impact Profile-14: A randomized clinical trial


Department of Dental Surgery and Oral Health Sciences, Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission27-May-2021
Date of Decision12-Mar-2022
Date of Acceptance30-Mar-2022
Date of Web Publication03-Oct-2022

Correspondence Address:
Poonam Prakash
Department of Dental Surgery and Oral Health Sciences, Armed Forces Medical College, Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jips.jips_252_21

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  Abstract 


Aim: Aim of this in vivo study was to assess the impact of two rehabilitation philosophies namely; Pankey Mann Schuyler (PMS) & Hobo Twin Stage (HOBO) on Oral Health-related Quality of life (OHRQoL) using Oral Health Impact Profile (OHIP 14).
Settings and Design: This was a randomized clinical trial.
Material and Methods: This study was designed based on the PICOT model. 40 patients were selected who need to undergo complete mouth rehabilitation. The intervention performed was complete mouth rehabilitation therapy and the results were compared with that of no intervention. The outcome was assessed in terms of improvement in mastication, phonetics, esthetics and overall OHRQoL (OHIP-14) over a period of 01 year at intervals of 48 hrs, 01 mon, 6 mon and 12 months. Patients were unaware of the treatment philosophy being used and were given a questionnaire (OHIP-14); at baseline (pre-treatment) and 48 hrs, 1, 6 and 12 months after completion of treatment (post-treatment) to evaluate OHRQoL. The data was collected by independent reviewers blinded to the regimen followed making the participants and the outcome assessors blinded to the procedure.
Statistical Analysis: Independent Student's t-test and Chi-Square test were used for analysis
Result: Analysis illustrated significant differences in scores obtained pre-treatment and post-treatment in both groups at 12 months (P < 0.05). At 12 months, OHIP-14 scores showed a mean percentage change of 51% in Group A (PMS); (P = 0.001) and a mean percentage change of 49% in group B (Hobo).
Conclusion: Complete mouth rehabilitation therapy for management of generalized attrition or mutilated dentition is a viable and effective treatment option and brings about definitive improvement in Oral Health Related Quality of Life (OHRQoL) and overall health status of an individual.

Keywords: HOBO Twin Stage, Oral Health Impact Profile 14, Oral Health-related Quality of Life, Pankey Mann Schuyler, randomised clinical trial


How to cite this article:
Prakash P, Singh K. Impact of complete mouth rehabilitation following Pankey Mann Schuyler versus HOBO Philosophy on Oral Health-Related Quality of Life using Oral Health Impact Profile-14: A randomized clinical trial. J Indian Prosthodont Soc 2022;22:343-53

How to cite this URL:
Prakash P, Singh K. Impact of complete mouth rehabilitation following Pankey Mann Schuyler versus HOBO Philosophy on Oral Health-Related Quality of Life using Oral Health Impact Profile-14: A randomized clinical trial. J Indian Prosthodont Soc [serial online] 2022 [cited 2022 Nov 30];22:343-53. Available from: https://www.j-ips.org/text.asp?2022/22/4/343/357795




  Introduction Top


“Two central goals of healthy people 2020 initiative are to attain high-quality, longer lives free of preventable disease disability, injury, and premature death; achieve health equity, eliminate disparities, and improve the health of all groups; create social and physical environments that promote good health for all; and promote quality of life, healthy development, and healthy behaviors across all life stages.”[1] Oral care is one of the twelve important topics included in the leading health indicators.[2] Lately, the assessment of improvements in living standards, assessed considering the oral status is becoming an indicator of the overall health status of an individual and also being included as an important domain in public health programs.

There is a wide range of oral conditions that require attention and management, however, generalized attrition or wearing away of the teeth is one such condition in which the remaining natural teeth are mutilated or worn off. It may or may not alter the vertical dimension of patient but results in altered function, esthetics, and overall health status of the individual.

Management of such cases warrants a well-planned treatment protocol aimed at restoration of the lost tooth structure and maintains integrity of remaining dentition. Various treatment approaches and philosophies mentioned in the literature can be utilized in complete mouth rehabilitation of lost tooth structure that varies in terms of treatment sequence, treatment time, and use of instruments.

The term complete mouth rehabilitation applies to the restoration of teeth, with or without dental implants; with fixed dental prostheses in the maxillae and mandible.[3] Complete mouth rehabilitation produces a distinguished improvement in patient's life irrespective of the philosophy followed. However, comparison of outcome of various treatment philosophies has not been attempted. Earlier, there was a scarcity of objective measurement tools to evaluate the improvements in the quality of life after a particular treatment instituted.

However, today there is a far extensive scope with availability of various tools for the same.[4] Oral Health Impact Profile 14 (OHIP-14) is one of the instruments that dictates individuals perceptivity of oral health status on their well-being.[5] The OHIP consist of 14 questions formulated under seven domains based on Locker's scale [Figure 1].[5],[6],[7] Two most commonly employed philosophies for complete mouth rehabilitation are Pankey Mann Schuyler (PMS) and Hobo Twin Stage (HOBO).[8],[9]
Figure 1: Locker's conceptual model of oral health

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In PMS, area of freedom between CRCP and IP (<0.5 mm), anterior guidance determines restoration of anterior followed by lower posteriors. Wax patterns of upper posteriors are fabricated using functionally generated path technique to achieve simultaneous contact of all posterior teeth.[10] The absence of balancing side contact and group function on working side.[11] Fully adjustable articulator is not required.

Hobo-Twin-stage concept is a two stage methodical approach based on the theory of disclusion. First, anterior segment is removed and occlusal pattern of posterior teeth is fabricated keeping cusp angle same as that of standard value of effective cusp angle produced (condition I). Second, with anterior segment in position, morphology and guidance is established to create definitive disclusion (Condition 2).[12]

This randomized clinical trial aims to evaluate the impact of complete mouth rehabilitation therapy on Oral Health-Related Quality of life (OHRQoL) using OHIP-14.[13] The primary objective was to evaluate the influence of treatment on OHRQoL using short form of OHIP-14 measured on the Likert Scale.[14] The secondary objectives were to compare the impact of rehabilitation using PMS versus Hobo on the OHRQoL and to comment on the seven domains that result in summated OHIP-14 scores.

Null hypothesis was that that there will be no definitive improvements in patients, posttreatment and similar effect on OHRQoL would be obtained in both the groups (PMS and HOBO).


  Methodology Top


Ethical clearance was obtained from the Institutional Ethical committee Review Board, Armed Forces Medical College, Pune, India, (IEC/2020/193 date July 15, 2020). Forty patients who reported to Department of Dental Surgery and Oral Health Sciences AFMC, Pune and needed to undergo complete mouth rehabilitation were selected to participate in the randomized clinical trial based on the inclusion and exclusion criteria. Patients with generalized attrition, severely mutilated dentition, multiple missing teeth who complained of difficulty in chewing, and speech, pain, and generalized sensitivity were selected. Subjects with no wear facets or with single or few teeth missing were excluded from the study.

Based on the clinical and radiological findings, treatment plan was formulated and discussed with the patients. The PIS (patient information sheet) was provided, purpose of study explained and all participating patients were made to sign informed consent (ICF).

The sample size was calculated considering the power of the study as 80%, confidence interval at 95%, difference in group means to be 20%. Sample size of 40 was derived (i.e., 20 in each group) [Figure 2].
Figure 2: Flow diagram depicting patient selection and random allocation in two groups

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The selected forty patients were divided into two groups depending upon the mode of rehabilitation planned. Group A: Twenty patients who would be rehabilitated following PMS philosophy. Group B: Twenty patients who would be rehabilitated following HOBO Twin Stage philosophy. Based on the longest held occupation, measurement of social class was made. Patients were categorized according to the Modified Kuppuswamy Scale.[15] Patients were also categorized based on the age in two groups (Group A-20–40 years and Group B-40–60 years) and gender into male and female [Table 1].
Table 1: Baseline characteristics of study participants

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Patients in each group were treated using standardized care based on treatment protocol but were blinded to the philosophy being followed. The protocol followed was the occlusal plane analysis, determination of existing vertical dimension, evaluation of loss of vertical dimension if any and need for restoration and occlusal splint therapy if required based on the assessment. Each patient from the group A was rehabilitated using PMS philosophy and Group B using Hobo Twin Stage philosophy following the standard treatment protocol. All operative treatment was conducted by postgraduates in prosthodontic clinics under similar working conditions with similar armamentarium and material. All the restorations were fabricated in the same dental laboratory to rule out any bias in the outcome.

OHRQoL was assessed based on OHIP-14 questionnaire which consists of 14 questions covered under seven domains namely functional limitation, pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap. The questionnaire was allocated by an independent research reviewer at starting point (pretreatment), 48 h, 1 month, 6 months, and12 months after intervention (posttreatment).[16]

The research reviewer and all patients were blinded to the group allocation, making it a double blind study. For each of the 7 domains with 14 OHIP questions, patients were assessed for the outcome of treatment on various aspects of life as mentioned earlier, in the preceding 12 months (at the intervals of 48 h, 1 month, 6 months, and12 months after the completion of treatment). Responses were recorded on a 5-point Likert scale and coded as 5 = “very often,” 4 = “fairly often,” 3 = “occasionally,” 2 = “hardly ever” and 1 = “never.” Impact of treatment on OHRQoL was used as the primary outcome measure. A collective report of negative impacts stating reduction in OHIP-14 score indicates an improved OHRQoL.

All the data were compiled in excel sheet and subjected to statistical analysis. ANCOVA was used for the repeated measures. Inter-group statistical differences in common variables were assessed using independent sample t-test and RMANOVA was used for intra-group statistical differences. Linear models and logistic regression (binary and ordinal) models were used to assess relationships between the treatment groups and mean summary OHIP-14 and OHIP-14 domain scores. Demographic variables (including age, gender, and social class) were considered as covariants. All variables recorded were presented by time-point and by treatment group. This study design was implemented to avoid any bias and to prevent any uncertainty in randomization process.


  Results Top


Oral Health Impact Profile-14 summary scores

Forty participants completed the randomized clinical trial after 12 months. Mean OHIP-14 scores for all participants were recorded and mentioned in [Table 2]. ANCOVA for repeated measures was applied fitted to OHIP-14 scores [Table 3]. The record of categorical variables is presented as n (% of cases), whereas continuous variables were depicted as mean and standard deviation among two study groups. Inter-group statistical comparison of distribution of categorical variables was assessed using the Chi-square test. Inter-group statistical comparison of means of continuous variables was assessed with Independent sample t-test. Fixed factors in the model were treatment group, time point, i.e., (before treatment, at 48 h, 1 month, 6 months, and 12 months), social class, age, and gender. Covariants used were starting point values and age. Two-level interactions between treatment group and each of time point, social class, gender and age were considered for inclusion. Statistical Package for the Social Sciences (SPSS version 21.0, IBM Corporation, USA) for MS Windows was used for analysis and P < 0.05 were considered to be statistically significant.
Table 2: Inter-group comparison of mean pretreatment and posttreatment Oral Health Impact Profile-14 scores of cases studied

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Table 3: Mixed model analysis of covariance for repeated measures fitted to Oral Health Impact Profile-14 summary score

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There was an interaction between treatment group and time-point (P < 0.0001). Therefore, any difference in OHIP-14 summary scores between groups over time was not the same. The group effect, time-point effect, and any of their two-level interactions cannot be interpreted in isolation. Groups were compared at each of the 4 timepoints separately. This analysis illustrated that Group A (PMS) technique had improved OHIP-14 scores compared to Group B (HoBo) by mean scores of 1.58 at 48 h, 1.12 at 1 month (P = 0.014), 1.02 at 6 months (P = 0.004) and 1.02 at 12 months. Group A exhibited better OHIP-14 scores with a percentage change of 51%, showing significant differences at 1 month posttreatment with P value (0.014) and at 6 months posttreatment with P value (0.004). Group B recorded percentage change of 49%. The model indicated that there was no difference in results between social classes (P = 0.508) or genders recorded (P = 0.459) or age (P = 0.391) [Table 3].

Oral Health Impact Profile-14 domains

Functional limitation

Pretreatment mean values for Group A (PMS) and Group B were 2.35. At 12 months, post treatment mean values for both the groups were 1.15 (P = 0.001). However, statistically significant differences in mean value were found at 48 h posttreatment (P = 0.007). Mean percentage change in scores over a period of 12 months was 50.66% in Group A and 49.21% in Group B which indicates more improvement in Group A by 1% as compared to Group B in this particular domain [Figure 3] and [Figure 4].
Figure 3: Inter-group comparison of mean pretreatment and posttreatment functional limitations score of cases studied

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Figure 4: Intra-group comparison of mean pre- and post-treatment functional limitations score of cases studied

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Physical pain

Pretreatment mean value was 3.10 for Group A (PMS) and 3.15 for Group B (Hobo). Posttreatment, mean value was 1.00 (P = 0.001) for both the groups. Mean percentage change in scores over a period of 12 months was 65.33% in Group A and 67.28% in Group B which indicates more improvement in Group B by 2% as compared to Group A in this particular domain [Figure 5] and [Figure 6].
Figure 5: Inter-group comparison of mean pretreatment and posttreatment physical pain scores of cases studied

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Figure 6: Intra-group comparison of mean pretreatment and posttreatment physical pain scores of cases studied

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Psychological discomfort

Pretreatment mean value was 3.20 for Group A (PMS) and 3.60 for Group B (HOBO). Posttreatment mean value was 1.00 (P = 0.001) for both groups. Mean percentage change in scores over a period of 12 months was 65.44% in Group A and 70.36% in Group B which indicates more improvement in Group B by 5% as compared to Group A [Figure 7] and [Figure 8].
Figure 7: Inter-group comparison of mean pretreatment and posttreatment psychological discomfort score of cases studied

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Figure 8: Intra-group comparison of mean pretreatment and posttreatment psychological discomfort score of cases studied

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Physical disability

Pretreatment mean value for Group A (PMS) was 3.45 and 3.65 for Group B (HOBO). Posttreatment mean value was 1.00 (P = 0.001) for both the groups. However, statistically significant differences in mean value were found at 6 months posttreatment with the P value (0.036). Mean percentage change in scores over a period of 12 months was 69.31% in Group A and 71.83% in Group B which indicates more improvement in Group B by 2% [Figure 9] and [Figure 10].
Figure 9: Inter-group comparison of mean pretreatment and posttreatment physical disability scores of cases studied

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Figure 10: Intra-group comparison of mean pretreatment and posttreatment physical disability scores of cases studied

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Psychological disability

Pretreatment mean score was 3.25 for Group A (PMS) and 3.40 for Group B (Hobo). Posttreatment mean value for psychological disability score was 1.00 (P = 0.001) for both groups. However, statistically significant differences in mean values were found at 1 month and 6 months posttreatment with the P value (0.048). Mean percentage change in scores over a period of 12 months was 66.11% in Group A and 67.5% in Group B which indicates more improvement in Group B by 1% as compared to Group A in this particular domain [Figure 11] and [Figure 12].
Figure 11: Inter-group comparison of mean pretreatment and posttreatment psychological disability scores of cases studied

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Figure 12: Intra-group comparison of mean pretreatment and posttreatment psychological disability score of cases studied

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Social disability

Pretreatment mean value for social disability score was 2.95 for Group A (PMS) and 2.90 for Group B (Hobo). Posttreatment mean value was 1.00 (P = 0.001) for both groups. Mean percentage change in scores over a period of 12 months was 61.84% in Group A and 62.53% in Group B which indicates more improvement in group B by 1% as compared to Group A [Figure 13] and [Figure 14].
Figure 13: Inter-group comparison of mean pretreatment and posttreatment social disability score of cases studied

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Figure 14: Intra-group comparison of mean pretreatment and posttreatment social disability score of cases studied

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Handicap

Pretreatment mean value for handicap score was 2.30 for Group A (PMS) and 2.35 for Group B (Hobo). Posttreatment mean value was 1.00 (P = 0.001) for Group A (PMS) and 1.05 Group B (Hobo). Mean percentage change in scores over a period of 12 months was 50.14% in Group A (PMS) and 47.92% in Group B (Hobo) which indicates more improvement in Group A by 3% as compared to Group B in this particular domain [Figure 15] and [Figure 16].
Figure 15: Inter-group comparison of mean pretreatment and posttreatment handicap score of cases studied

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Figure 16: Intra-group comparison of mean pretreatment and posttreatment handicap score of cases studied

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  Discussion Top


The life expectancy of individuals is approximately 78.6 years, based on the survey report of National Center for Health Statistics 2020. According to a report published by National Health and Nutrition Examination Survey, 63% of adults aging 18–64 years visit dental clinics in past years (2020).[17] Adult individuals visit the dental specialists for sensitivity of teeth or difficulty in mastication or compromised esthetics which is a result of loss of tooth surface material. The loss can be due to generalized attrition or mutilated dentition that is one of the most common dental diseases of adulthood which progresses till early old age among dentate individuals. The impact of such diseases on their daily life makes them considerably important.

Complete mouth rehabilitation of such patients is a challenging task as the clinical and symptomatic presentation is unique in every case and does not always fall into the defined category of diagnosis and treatment planning. Due to availability of numerous options in terms of philosophies, techniques and concepts, there are different schools of thoughts regarding the selection of treatment strategy for complete mouth rehabilitation. The mutilated dentition affects various aspects of life in the form of physical disability, psychological disability, functional limitation, pain, psychological discomfort, social disability and, handicap, thereby deteriorating the overall quality of life for an individual.[18] So the management aims at providing optimum levels of restoration in individual domains along with improvement in the overall quality of life.

Complete mouth rehabilitation creates a state of synchronous harmony between teeth and their periodontal structures along with para-oral structures such as muscles of mastication and Temporomandibular joint (TMJ), so as to result in optimum functional and biologic efficiency.[19] Meticulous assessment of the patient's occlusion, dietary habits and various disorders, is required to formulate a definitive diagnosis and establish a treatment planning.[9] Outcome and prognosis of the treatment is also affected by variables such as, Etiology, Clinical situation, Signs and symptoms, Treatment philosophy employed, age, gender, and socioeconomic status.[20],[21]

This randomized clinical trial is an attempt to assess and compare the changes in oral health related quality of life (OHRQoL) at pre and post rehabilitation process under various domains. It also attempts to compare the effects between two most commonly utilized philosophies for full mouth rehabilitation i.e., PMS and HOBO Twin Stage in order to derive a conclusion whether any substantial amount of difference exists between various techniques used in terms of impact of the treatment on the overall OHRQoL with the help of a validated measurement tool; OHIP-14 (since no data exists comparing the effects of various treatment philosophies). This will guide the clinicians to adopt an appropriate rehabilitation philosophy for each patient. The scores have been summated at a considerable amount of follow up period of 12 months which gives patients an appropriate amount of time to assess the outcome of the treatment instituted, considering various domains.

OHRQoL dictates the impact of oral status on everyday life and general health of the patient. OHIP is a tool that evaluates individuals perception of the well being based on impact of various oral disorders. The OHIP-49 used earlier was shortened from 49 to 14 items and these 14 questions were conceptually formulated that are based on Locker's theoretical model [Figure 1]. The other measurement tools used to assess OHRQoL are LORQV3, GOHAI.[22],[23]

For each of the 14 OHIP questions, people were asked how frequently they had experienced the impact in the preceding 12 months. Responses were made on a 5 point Likert scale and coded 5 = “very often,” 4 = “fairly often,” 3 = “occasionally,” 2 = “hardly ever” and A = “never.” For this report, descriptive statistics were created by computing the mean of the coded response for each item which is described as the severity score for each item. OHIP-14 used in this study has been validated in various languages and it allows collection of informative data, which increases its reliability.[5]

Cases selected for this clinical trial were in which vertical dimension was maintained and space was available with the clinical symptoms of sensitivity and signs of generalized attrition. The occlusal scheme utilized was group function and full coverage PFM restorations were given.

In the clinical trial conducted, significant improvements were observed under all the seven domains of life postoperatively. The study shows that the pain relief was foremost followed by an instant and obvious change or improvement in the esthetics. The results of this study also validate that mastication, speech, social interactions and sleep improved measurably post dental treatment.

Patients in Group A and Group B showed boost in OHRQoL scores throughout the 12 month with marked improvement in 48 h and 1 month post treatment followed by gradual improvement in all the domains of OHIP-14. Thus, benefits of complete mouth rehabilitation therapy were highest at 48 h posttreatment which gradually stabilized over a period of 12 months.

These results strongly suggest that management of generalized attrition or mutilated dentition with complete mouth rehabilitation has definite impact on the physical, social and psychological levels thereby resulting in overall improvement in OHRQoL. It was also observed that the improvement is consistent regardless of the treatment philosophy employed for complete mouth rehabilitation; PMS or HOBO Twin stage.

PMS exhibits better cumulative results when compared with HOBO in terms of seven domains of OHIP-14. Out of the 7 domains assessed, PMS showed better results in functional limitation score and handicap score, whereas Hobo technique showed better values in terms of physical pain, psychological discomfort, physical disability, psychological disability, and social disability. This could be attributed to the fact that vertical dimension is restored and sequential therapy allows rebuilding of the masticating surfaces at the stage of temporisation. Furthermore, the occlusal surfaces are in perfect harmony with the anatomical structures due to utilization of Broadrick's occlusal plane analyzer for mandibular posterior segment and incorporation of functionally generated path for maxillary posteriors, thereby bringing the entire stomatognathic system in anatomical and functional (dynamic) harmony.

In the literature, previous randomized clinical trials conducted on children and partially dentate individual showed statistically significant positive differences post full mouth rehabilitation. However, the terms full mouth rehabilitation and oral rehabilitation have been interpreted as treatment with restorations and removable partial denture and shortened dental arch with adhesive resin-bonded bridge work.[24],[25],[26],[27]

Strengths

The strengths of this clinical trial are as mentioned

  1. Random allocation was done which eliminated the selection bias
  2. Double-blind study (patient, research reviewer, and data analyst were blinded)


  3. Follow-up with the OHIP-14 was done at multiple time lines not just pre- and posttreatment. Which gave the patients sufficient time to evaluate consistent improvements in quality of life
  4. Further sources of bias were eliminated by carrying out clinical part of the therapy by operators at same treatment center and the laboratory procedures at same lab using similar materials
  5. Patient reported outcome measures were recorded thus eliminating the reviewer's bias
  6. Lack of comparative studies in the literature.


Limitations

The limitations of the present study are the unavoidable variables such as the clinical situation, age, gender, occupation, habits and patient's dietary habits that play an important role in the occurrence as well as the prognosis and success of the therapy instituted.

Most pertinent point is that no two cases of mutilated dentition of generalized attrition are same in terms of amount of tooth surface loss; amount of vertical dimension discrepancy, available freeway space, space available for restoration, so actual comparison between different philosophies is not practically possible.


  Conclusions Top


Patients with severely worn out dentition requiring rehabilitation can be managed with different philosophies and techniques available. However, it is observed that most commonly used philosophies are PMS and HOBO. Till today, there are no clear guidelines for the selection of the technique indicating superiority of results obtained with therapy or technique. This clinical trial is an attempt to achieve quantifiable results in terms of various domains of oral health leading to improvement in OHRQoL. The trial conducted exhibits following conclusive results.

  1. FMR has definitive positive outcome posttreatment as compared to pretreatment (statistically significant)
  2. PMS gives better results in two out of 7 domains, namely functional limitation score and handicap score, whereas Hobo technique showed higher values in terms of physical pain, psychological discomfort, physical disability, psychological disability, and social disability. Although HOBO shows better results in terms of five domains as compared to PMS which shows better results in two out of seven domains. These significant results shown by HOBO are at intermittent stage of the treatment and not at the final outcome stage
  3. Overall improvement in OHRQoL based on assessment of seven domains of OHIP-14 was seen better with PMS.


The results of this clinical trial are in consonance with the advantages of the PMS Philosophy mentioned in the literature, namely maintaining patients vertical dimension, establishing occlusal morphology to achieve optimum occlusion. Hence, the results can be generalized to the population when treatment protocols are planned and executed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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McKenna G, Allen F, Woods N, O'Mahony D, Cronin M, DaMata C, et al. Cost-effectiveness of tooth replacement strategies for partially dentate elderly: A randomized controlled clinical trial. Community Dent Oral Epidemiol 2014;42:366-74.  Back to cited text no. 27
    


    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]



 

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