**2.4 Analysis**

As the number of items in the achievement tests was not equal among different graders, the correct response rate for each grade was calculated as a proportion and hence the arc sine root transformation was applied to the correct response rates (Sheskin 2007). Since the number of children with developmental disorders was limited at each grade, we abandoned the analysis of variance using two levels of each independent variable. Instead, we created new variables using the four categories of items mentioned above.

Specifically, in order to examine the effect of orthographical demand (i.e. visual complexity), we averaged the correct response rate for (i) characters that consist of a small number of strokes and have only one pronunciation and (iii) characters that consist of a small number of strokes and have more than one pronunciation on one hand to create a variable representing the participants' performance for visually less complex characters, and averaged the correct response rate for (ii) characters that consist of many strokes and have only one pronunciation and (iv) characters that consist of many strokes and have more than one pronunciation on the other hand to create a variable representing the participants' performance for visually more complex characters. Two more variables representing their performance for phonologically less complex characters and their performance for phonologically more complex characters were created in a similar manner.

The mean correct response rate for typically developing children at each grade was further analyzed using the statistical tests according to its distribution after the test for the homogeneity of variance and the test for the normality of distribution. Since the mean correct response rates were not significantly different between the gender groups of typically developing children at each grade according to the Mann Whitney U test, we calculated the mean and the standard deviation of the entire group, containing both girls and boys. Using this mean and the standard deviation as the basis, we then calculated the Zscores for children with developmental disorders at each grade, although the proportion of males and females was different between typically developing children and children with developmental disorders.

#### **3. Results**

The result of the experiment seems to support the following three statements:

Assessing Orthographical and Phonological Impairments 75

Fig. 2. Overall correct response rate of writing by typically developing children.

Fig. 3 represents the Z scores for the correct response rate of both dyslexics and ADHD patients for the reading and writing achievement tests. The left side column shows the Z scores of the reading tests and the right side column shows those of the writing tests. Each row shows the Z scores of each grade. Filled data points in black represent the cases with

From those graphs we see that Z scores for writing tend to be low with both developmental disorders, that dyslexics' reading scores likewise tend to be low, but that ADHD patients' Z scores for reading tend to be close to normal (around -1.0 SD or above), suggesting relatively

The pattern of overall performance alone does not necessarily allow us to distinguish ADHD patients and dyslexics. In other words, some ADHD patients and some dyslexics show an indistinguishable pattern of overall performance, as we see with Case 4 (dyslexic) and Case 13 (ADHD) in Grade 3 and Case 12 (dyslexic), Case 16 (ADHD) and Case 17 (ADHD) in Grade 5. Thus, in order to distinguish the two types of disorders on the basis of reading and writing achievement tests, it is necessary to examine not only the overall performance of the children,

Fig. 4 reports the typically developing children at each grade's mean correct response rate for reading achievement tests as a function of orthographical complexity. Error bars indicate standard deviations. There was significant difference between the mean correct response rate for orthographically complex characters and that for orthographically simple characters at Grade 2. The correct response rate was higher when the character was orthographically complex than when the character was orthographically less complex (Z=2.51, *p*<.01, *r*=.27). The sampling distribution was similar between the levels of orthographical complexity in

**3.1.2 Overall performance by children with developmental disorders**

dyslexia whereas unfilled data points represent the cases with ADHD.

but also their performance for each of the four (two by two) question types.

**3.2.1 Orthographical performance by typically developing children**

**3.2 Performance as a function of orthographical complexity**

other grades, according to Wilcoxon's signed rank test.

minor impairment of reading abilities.

#### **3.1 Overall performance**

#### **3.1.1 Overall performance by typically developing children**

Fig. 1 reports the mean correct response rate of typically developing children at each grade for the reading achievement tests. Error bars indicate one standard deviation of uncertainty. The sampling distribution was similar among different grades, according to the Kruskal-Wallis test (*p* = .1).

Fig. 1. Overall correct response rate of reading by typically developing children.

Fig. 2 represents the means of the correct response rate of typically developing children at each grade for the entire writing achievement tests. Error bars indicate one standard deviation over sampling distribution. The sampling distribution was significantly different among different grades, according to the Kruskal-Wallis test (p < .0001). The post hoc tests revealed that the mean correct response rate of Grade 4 and 5 was significantly lower than that of Grade 3 (U=3830.5, Z=-3.22, *r*=-.23; U=3652.0, Z=-4.07, *r*=-.28, respectively) after Bonferroni corrections.

First, while children with dyslexia had trouble both with writing and with reading, children with ADHD had trouble mainly with writing and not necessarily with

Second, compared to children with dyslexia, children with ADHD had more trouble writing Chinese characters which consist of many strokes and thus are visually more complex, although both children with ADHD and dyslexia seemed to have less trouble

Third, compared to children with ADHD, dyslexic children had more trouble reading (if not writing) Chinese characters which have more than one possible pronunciation

Fig. 1 reports the mean correct response rate of typically developing children at each grade for the reading achievement tests. Error bars indicate one standard deviation of uncertainty. The sampling distribution was similar among different grades, according to the Kruskal-

Fig. 1. Overall correct response rate of reading by typically developing children.

Fig. 2 represents the means of the correct response rate of typically developing children at each grade for the entire writing achievement tests. Error bars indicate one standard deviation over sampling distribution. The sampling distribution was significantly different among different grades, according to the Kruskal-Wallis test (p < .0001). The post hoc tests revealed that the mean correct response rate of Grade 4 and 5 was significantly lower than that of Grade 3 (U=3830.5, Z=-3.22, *r*=-.23; U=3652.0, Z=-4.07, *r*=-.28, respectively) after

a. Overall performance

b. Orthographic performance

c. Phonological performance

**3.1 Overall performance**

Wallis test (*p* = .1).

Bonferroni corrections.

reading visually more complex characters.

and are thus arguably phonologically more complex.

**3.1.1 Overall performance by typically developing children**

reading.

Fig. 2. Overall correct response rate of writing by typically developing children.

## **3.1.2 Overall performance by children with developmental disorders**

Fig. 3 represents the Z scores for the correct response rate of both dyslexics and ADHD patients for the reading and writing achievement tests. The left side column shows the Z scores of the reading tests and the right side column shows those of the writing tests. Each row shows the Z scores of each grade. Filled data points in black represent the cases with dyslexia whereas unfilled data points represent the cases with ADHD.

From those graphs we see that Z scores for writing tend to be low with both developmental disorders, that dyslexics' reading scores likewise tend to be low, but that ADHD patients' Z scores for reading tend to be close to normal (around -1.0 SD or above), suggesting relatively minor impairment of reading abilities.

The pattern of overall performance alone does not necessarily allow us to distinguish ADHD patients and dyslexics. In other words, some ADHD patients and some dyslexics show an indistinguishable pattern of overall performance, as we see with Case 4 (dyslexic) and Case 13 (ADHD) in Grade 3 and Case 12 (dyslexic), Case 16 (ADHD) and Case 17 (ADHD) in Grade 5. Thus, in order to distinguish the two types of disorders on the basis of reading and writing achievement tests, it is necessary to examine not only the overall performance of the children, but also their performance for each of the four (two by two) question types.


**3. Dyshomeostasis Ca2+ in neurons**

Signal unsettling influences and Ca2+ fixations have been recognized in different diabetic creature cell disengagement explores just as from diabetic patients. Ca2+ homeostasis variations from the norm have been found in most trial tissues, including bone, heart and smooth muscle, discharge cells, platelets, kidneys and osteoblasts. Diminished (in spite of the fact that not generally) and diminished upgrade evoked Ca2+ signals. Ca2+-dealing with disarranges have additionally been found in tangible neurons from creatures with diabetes [11, 40, 41].


**Table 1.**

*Casting Processes and Modelling of Metallic Materials*

porosity in alloys with high Si content.

oxide films would result in the formation of large pores that are linked together. The end result can be explained in terms of the difference in eutectic solidification in unmodified and Sr-modified alloys [9, 10]. Dinnis et al. [11] examined the amount, distribution, and morphology of porosity in sand-cast plates of Sr-free and Sr-containing Al-(0–9 wr%) Si alloys. The authors found that no apparent differences in the amount, distribution, and morphology of porosity were observed between Sr-free and Sr-containing alloys with no Si (i.e. pure Al). However, Sr modification significantly changed the amount, distribution, and morphology of

Influence of oxides on porosity formation in Sr-treated alloys was investigated by Samuel et al. [12] in 319 and 356 alloys. Their findings show that porosity formation is frequently associated with strontium oxides (particles or films), as well as β-Al5FeSi phase platelets. The Al2SrO3 oxides are formed during melting by the high oxygen affinity of strontium. These oxides are difficult to be removed via degassing. Aluminum oxide films trapped in the molten metal result in the precipitation of coarser and deeper pores than those formed due to the strontium oxides [13]. According to Campbell and Tiryakioğlu [14], the beneficial effect of Sr as a modifying agent could be compromised by porosity development caused by the formation of oxide bifilms. The authors suggested an explanation in terms of the oxide population in the melt. A new multi-zone model is proposed by SkatTiedje et al. [15]. This model was developed by considering the effect of cooling rate on solidification and distribution of porosity in cast Al–Si alloys. The effect of Sr-modification on pore formation in reduced pressure and atmospheric conditions was studied by Miresmaeili et al. [16–18]. A new type of metallic cup with a riser was designed for use in a reduced pressure test as a mold. It was designed to improve directional solidification so that no macro shrinkage occurred in the test

Another parameter to be considered is the presence of Fe-based intermetallics, in particular β-Al5FeSi. Taylor et al. [19] investigated the role of iron in the formation of porosity in Al-Si-Cu-based casting alloys. Their analysis pointed to inadequacies in the existing theories regarding the role of iron and suggests that a new theory is required to understand the observed behavior. Effect of alloy composition on the stability of the β-AlFeSi phase and the role of the latter in porosity formation in 319 and 356 alloys was studied by Khalifa et al. [20]. The β-phase particles are potential sites for porosity formation regardless of the alloy composition and the type or size of the β particles. SrO and Al2Si2 Sr particles were observed to have contact with the β-AlFeSi platelets in the microstructure. Thus, with the addition of Sr, finer, better distributed pores appear in the microstructure. The alloy tensile properties are greatly improved by: (a) Sr addition in the range 200–400 ppm, (b) increasing the Mn/Fe ratio to 0.7, (c) addition of 0.08%Be, (d) addition of 0.08%

The present study was undertaken to emphasize the role of melt treatment parameters (stirring, degassing, Sr-modification, grain refining, hydrogen content, intermetallics) as well as alloy composition on porosity formation in Al-(6–11 wr%Si) cast alloys and their impact on the alloy hardness. The initial alloys were

**Table 1** lists the chemical composition of the as received ingots. The ingots of each alloy were cut, cleaned and melted in an electrical heated furnace using 6 kg SiC crucibles. The melting temperature was about 750°C ± 5 °C. Degassing was

unmodified and contained 0.0075%Ti and less than 0.2%Fe.

**114**

samples.

Be+0.02% Sr [21–23].

**2. Experimental procedure**

*Chemical composition of the as-received alloys (wt.%).*

carried out using a perforated graphite impeller turning at 135 rpm using pure Ar gas (0.492 cubic meter/hr) for about 30–40 minutes. The same impeller was also used as stirrer without gas. Strontium was added in the form of Al-10%Sr master alloy (waffles) whereas grain refiner was introduced as Al-5%Ti-15B master alloy in the form of short rods. It should be mentioned here that the manufacturing of the grain refiner produces Al2O3 which will increase in the amount of porosity. For this reason, the grain refiner in this study was added in the form of short rods (cold rolled) to minimize the presence of such oxides.

Due to the high affinity of Sr to react with oxygen to form SrO oxides, Sr was added during the last 10 minutes of degassing. As for varying the hydrogen level, small pieces of raw potato were added at the end of degassing, (in this case, Sr was not used) followed by AlScan™ measurement. In addition, reduced pressure test (RPT) samplings were taken from the melts. **Figure 1** shows examples of RPT samples sectioned in half to examine the porosity observed under different melt conditions. In all cases, samples for chemical analysis were also obtained from each melt prior to pouring.

Following melt treatment, the molten metal was poured in L-shaped metallic molds (75 mm × 35 mm × 30 mm). The molds were coated with fine grained boron nitride and were preheated at 450°C **Figure 2**. **Table 2** summarizes the sample codes and their melt treatment whereas **Table 3** shows complete analysis of A356.0 alloy as an example.

Samples for metallographic examination were sectioned from the middle of the cast bars (25 mm × 25 mm) and polished following standard procedures [24]. Porosity characteristics were evaluated using a Clemex image analyzer in conjunction with an optical microscope. Measurements were carried out at 100× as shown in **Figure 3**. For each sample at least 100 fields were scanned to enhance the accuracy of measurements. Selected samples were examined using an electron probe microanalyzer (EPMA) equipped with EDS and WDS systems, operating at 20 kV.

In order to quantify the effect of melt treatment parameters, hardness measuremnts were carried out on the sample surface shown in **Figure 2** using Brinell hardness testing machine using a 10 mm diameter steel ball and 500 kgf force. For each condition, an average of 8 readings was reported. The samples of A319.0

**Figure 1.** *RPT test taken from: (a) as received alloy, (b) after degassing, (c) 0.25 ml/100 g H2.*

#### **Figure 2.**

*L-Shape castings: (a) L-shape mold, (b) geometry of the L-shape casting, (c) cutting sequence of L-shaped casting to produce smaller rectangular bars, and (d) hardness test bars.*

#### **Table 2.**

*Codes of the used alloy s and their melt treatment.*

alloy were solution heat treated at 510°C for 8 h followed by water quenching. The samples thereafter were aged at various temperatures for 5 h followed by air cooling.


**1. Introduction**

**\***

> One alternative to addressing the overly narrow residual ridges of the mandible is the use of dental mini implants (with a diameter below 3 mm) [1], which represent an important therapeutic option in cases in which reconstructive surgeries are contraindicated or as an alternative to other surgical procedures that present greater morbidity [2]. For these cases, the use of alloys with improved mechanical properties is desired for use in dental implants [3]. In this context, grade V titanium mini transitional implants (MTIs) can be a better alternative in these clinical cases because of their high mechanical resistance. These procedures allow the clinician to perform restoration and maintenance work in the vertical dimension with the use of mini implants in conjunction with implant surgical therapy,

**Citation:** Beltrán, V.; Weber, B.; Lillo, R.; Manzanares, M.; Sanzana, C.; Fuentes, N.; Acuña-Mardones, P.; Valdivia-Gandur, I. Histomorphometric Analysis of Osseointegrated Grade V Titanium Mini Transitional Implants in Edentulous Mandible by Backscattered Scanning Electron Microscopy (BS-SEM). *Metals* **2021**, *11*, 2. https://dx.doi.org/10.3390/met1101 0002

Received: 30 October 2020 Accepted: 27 November 2020 Published: 22 December 2020

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/ licenses/by/4.0/).

which is considered to be an effective method to provide the patient with an immediate and comfortable transitional appliance [4].

Grade V titanium alloy is widely used to fabricate medical and dental implants due to its superior physical, mechanical [5,6], and biological properties compared to other available biomedical metals and alloys. Specifically, its resistance to corrosion, excellent biocompatibility, lightweight, and superior tribological properties make this material far superior to other metals and alloys and highly useful for dental application [7,8]. Moreover, various authors have demonstrated its osseointegration [9–11]. Complications related to biocompatibility [12] or toxicity [13] of titanium alloys have been reported, including a mildly increased inflammatory response in direct contact to skeletal muscle [14]. Still, the evidence that includes human biopsies is scant.

Ultrastructural bone analysis has been performed by backscattered scanning electron microscopy (BS-SEM). This is an effective technique for studying the osseointegration of dental implants [15]; however, there is scarce evidence regarding the osseointegration of grade V titanium dental implants in humans when considering transitional implants immediately loaded and associated with overdenture. The purpose of this study is to assess the use of grade V titanium MTIs as immediately loaded implants for temporary overdenture, performing the analysis of the bone tissue close to the implant surface in human biopsies.

#### **2. Materials and Methods**

#### *2.1. Patients and Surgical Procedure*

The study was approved by the Ethics Committee of the University Mayor, Chile (Protocol Nº246/006). Four female patients (60–68 years of age, health compatible with treatment) who were non-smokers, users of acrylic removable dentures over the completely edentulous mandible, and with horizontal atrophy of the anterior area were selected for treatment using an overdenture which was fixed temporally by MTIs. Prior to implant placement, all patients signed for informed consent regarding description of the placement and removal of the MTIs. The surgical protocol involved the simultaneous placement of submerged regular implants (4.0 mm Titamax EX or 4.3 mm Alvim Morse Taper) and MTIs for immediate loading in the edentulous lower mandible. The submerged regular implants that were not loaded were maintained and controlled for their osseointegration in the traditional way (6–8 months to implant osseointegration).

Each patient received two MTIs (2.9 mm in diameter and 12 mm long, Facility Neodent with Neoporos, Curitiba, Brazil) that were placed in the canine mandible region with O-rings for fixation of the overdentures. The MTIs were placed with a mandatory insertion torque of at least 35 Ncm and maximum 45 Ncm measured by a drill unit (W&H Implant Med). The suture was performed using polyglactin 910 4.0 (Vicryl®, Ethicon Endo-Surgery Inc., Greensboro, NC, USA). Immediately after the surgery, MTIs were loaded with a removable overdenture following the loading protocol under the Schnitman concept [16]. Then, patients were controlled at 2, 7, 30, 60, and 90 days.

After 8 months, the MTIs were extracted with a trephine bur of 3.5 mm in diameter, and the samples were conditioned for histomorphometric analysis by BS-SEM (Figure 1).

**Figure 1.** Bone sample with mini transitional implants (MTIs) obtained by trephine. A cut was made to obtain two samples (SA and SB) for backscattered scanning electron microscopy (BS-SEM) analysis. MTI = mini transitional implant; SA and SB = Segments A and B obtained after the cut.

#### *2.2. Histomorphometric Analysis of Samples by BS-SEM*

The MTIs were surgically removed using a trephine bur (implant plus its bone segment, Figure 1). They were subsequently fixed in 10% neutral buffered formaldehyde for 48 h. Later, the bone segments were prepared for their inclusion in light-curing resin (Technovit®). Posteriorly, the included samples were cut following the central longitudinal axis of the implant (Figure 1) using an Exact® diamond band saw (0.2 mm thick) and treated for BS-SEM analysis following the procedure described in the literature [17,18].

During BS-SEM analysis, several microphotographs were obtained (50× to 150×). The area of tissue between two threads of the implant surface was established as a study unit (Figure 2), referred to as the "bone area fraction occupancy" (BAFO). The following parameters were analyzed in the BAFOs:

In accordance with the variables described above, we performed quantitative valuation and qualitative analysis. Quantification of tissue areas was performed using the software ImageJ. The SPSS statistical software was used for the analysis of the quantitative results. The ANOVA or Kruskal–Wallis tests were applied and the *p*-value < 0.05 was considered significant.

**Figure 2.** In the upper part, the types of bone tissue studied in the samples are shown; in the lower part, the bone area fraction occupancy (BAFO) used as an analysis unit in this study is shown (delimited by the blue broken line between two implant threads). Samples of Bone to Implant Contact (BIC) area are shown in the boxes inside the inferior images. cl = cellular lacunae; ms = medullar space; vs = vascular space; MTI = mini transitional implant (surface).


**5. Sacrospinous colpopexy**

reflexes and patellar reflexes. Cardiovascular examination should be done to rule out lower

Simple primary care clinical tests are an integral part of initial evaluation. Pelvic Floor Distress Inventory-Short Form 20 (PFDI-20), the Pelvic Floor Impact Questionnaire-7 (PFIQ-7) and the ICIQ-VS score can be used to evaluate the quality of life and severity of symptoms. The most

The management options of recurrent pelvic organ prolapse is almost always surgical. It is to be realized that surgical options are the first choice as they provide a long-term relief. Surgical measures should always be accompanied by pelvic muscle strengthening exercises

The surgical procedure must be case based. If the initial repair was vaginal hysterectomy with pelvic floor repair the subsequent repair can be sacrospinous colpopexy or sacrospinous fixation. If the initial repair was sacrohysteropexy the recurrent prolapse can be managed by vaginal hysterectomy, anterior colporrhaphy and posterior colpoperineorrhaphy along with

extremities edema and feature of congestive heart failure [15–17].

common questionnaire used is the PFDI-20 questionnaire [18–20].

**3.5. Simple primary care tests**

62 Pelvic Floor Disorders

**4. Management options**

McCall's culdoplasty.

in the postoperative period for best outcome.

**Table 1.** Corrective surgery for vaginal vault prolapse.

Access to sacrospinous ligament is obtained through the Para rectal space in posterior approach and through the paravesical space in the anterior approach. The right ischial spine is localized digitally and after retractor positioning the ligament is made visible through blunt dissection. Two permanent sutures (Prolene 1.0, Ethicon, Somerville, NJ, USA) are placed through the right sacrospinous ligament at least 2 cm from the ischial spine. Pulley sutures are used to anchor the undersurface of the anterior vaginal cuff (anterior sacrospinous suspension) or posterior cuff (posterior sacrospinous suspension) along the sacrospinous ligament medially and laterally. During both techniques, the medial and lateral fixation sutures are placed at least 2 cm apart along the ligament. Hereafter an additional anterior and/or posterior colporrhaphy or incontinence surgery can be performed. The procedure is acceptable with few complications [22]. Sacrospinous Fixation can be done using Miya hook or Capio (**Figure 3**).

There are two ways to access the sacrospinous ligament: the anterior approach and the posterior approach. In the anterior approach the sacrospinous ligament is accessed after dissecting the paravaginal and paravesical spaces and the anterior vaginal cuff is anchored to the sacrospinous ligament. In the posterior approach the pararectal fossa is opened after dissected the posterior vaginal wall from the rectovaginal fascia. And the posterior cuff of vagina is anchored to the sacrospinous ligament.

In the posterior approach the vaginal mucosa is incised transversely at the posterior fourchette and the posterior vaginal mucosal flap is raised above from rectovaginal fascia. The assistant deflects the rectum medially while the surgeon palpates the ischial spine and identifies the sacrospinous ligament. A Miya hook passed through the sacrospinous ligament. The Miya hook is threaded with the suture and the sutures are carried and anchored to the vaginal vault. The permanent sutures are placed through the posterior side of the vagina in the posterior approach. The lower two thirds of posterior vaginal wall is closed with absorbable sutures (Vicryl 2, Eticon Somerville, NJ, USA). The permanent sutures are now tightened and the remaining one third of the vaginal wall is also closed (**Figures 3(a)**–**(c)**). The same principal is applied for sacrospinous hysteropexy in an intact uterus. The posterior sacrospinous approach is less invasive but the vaginal axis is slightly downwards as compared to the physiological axis of vagina. This predisposes to anterior compartment defects as the raised intraabdominal pressures are now directly transmitted to the anterior vaginal wall.

**Figure 3.** (a) The anatomical identification of sacrospinous ligaments as viewed from above and laterally. (b) The vaginal vault is anchored to the sacrospinous ligaments with delayed absorbable or nonabsorbable sutures. (c) The vaginal mucosa is anchored and closed.

with anterior sacrospinous fixation to achieve the best outcome. Postoperative strengthening

**Figure 4.** Anterior v/s posterior sacrospinous vault fixation: Postoperative comparison based on pelvic organ prolapse . Solid line: Anterior sacrospinous vault fixation, dashed line: Posterior sacrospinous fixation. (a): Lateral view of Vaginal axis after anterior and posterior bilateral sacrospinous fixation. (b): Anterior posterior view of vaginal axis after anterior

Recurrent Pelvic Organ Prolapse

65

http://dx.doi.org/10.5772/intechopen.76669

In vault prolapse the endopelvic fascia surrounding the vagina is broken at specific points. A site-specific repair and anchoring to the stumps of uterosacral ligaments will restore the suspension. Three principles are identification of the fascia defect, reducing the enterocele sac and closure of the fascia defect. Finally the vagina is anchored to the Level 1 support of uterosacral ligament making the procedure most anatomically close to physiologically correct vaginal axis. Vaginal apex is grabbed with two Allis clamps. The vaginal mucosa over the enterocele is incised. The enterocele sac is identified and dissected till the base or neck of the sac. The enterocele sac is opened carefully and contents are reduced taking care of adhesions. The excessive peritoneum is excised. A Deaver retractor is placed anteriorly and used to pack the abdominal

The uterosacral ligament stumps are identified; remnants are usually believed to be present at 5 0'clock and 7 0'clock position. The ureter position is confirmed by palpating the pelvic sidewall. The ureter is usually placed 2–3 cm lateral and ventral to the ischial spine. A nonabsorbable Prolene 1/0 suture is placed on the uterosacral remnant on left side passing the needle from lateral to medial side to avoid injuring the ureter. The rectum is then deflected away by the non-dominant hand. A second suture is placed further high and medially on the left uterosacral ligament for better anchoring. The peritoneum is included in the stich and now the stich is passed in the opposite uterosacral ligament taking the needle from lateral to medial side. Now these sutures are tied and this obliterates the cul-de-sac (**Figure 5**). Anterior

colporrhaphy or sling procedures if required are performed at this stage now.

of perineal muscles by structured pelvic exercises is effective.

**6. Uterosacral vaginal vault suspension**

and posterior bilateral sacrospinous fixation.

contents anteriorly.

The anterior approach was developed subsequently to overcome the shortcomings of posterior approach. In the anterior approach a vertical anterior vaginal incision is made for retro pubic entry and paravaginal and paravesical space is dissected. The sacrospinous ligament is identified and the anterior cuff of vagina is anchored with two polytetrafluoroethylene (00) sutures. The two sutures are placed 2 cm apart on sacrospinous ligament. The same procedure is performed on the contralateral sacrospinous ligament.

The anterior suspension technique positions the vaginal vault in a more capacious anatomic space, in comparison to the relatively narrow pararectal area occupied by the upper vagina after posterior sacrospinous vault suspension (**Figure 4(a)** and **(b)**). After anterior sacrospinous vaginal vault suspension, vaginal length and apical suspension are slightly increased. The axis of the suspended vagina appears more physiological. There are less chances of recurrent anterior compartment prolapse as compared with the posterior sacrospinous vaginal vault suspension procedure. The upper vaginal lumen caliber and sexual function are adequately preserved in both techniques [23]. The posterior vaginal wall laxity, on the contrary, is more common after anterior sacrospinous vault suspension.

However, these differences are likely to be influenced by differences in levator muscle tone and degree of perineal support. So a posterior colporrhaphy may be concurrently performed

**Figure 4.** Anterior v/s posterior sacrospinous vault fixation: Postoperative comparison based on pelvic organ prolapse . Solid line: Anterior sacrospinous vault fixation, dashed line: Posterior sacrospinous fixation. (a): Lateral view of Vaginal axis after anterior and posterior bilateral sacrospinous fixation. (b): Anterior posterior view of vaginal axis after anterior and posterior bilateral sacrospinous fixation.

with anterior sacrospinous fixation to achieve the best outcome. Postoperative strengthening of perineal muscles by structured pelvic exercises is effective.


**6. Observation of rare earth element soil distributions in missouri**

#### **6.1 Study area**

Summers are hot and humid with a mean July temperature of 26°C and winter temperatures are mild with a mean January temperature of 2°C. The mean annual precipitation of 1.19 m is seasonally distributed, with greater rainfall in spring. Vegetation is either a mixed hardwood forest or land that has been cleared of vegetation, land-graded, and employed in row-crop agriculture.

#### **6.2 Soils**

The alred series (loamy-skeletal over clayey, siliceous, semiactive, mesic Typic Paleudalfs) consists of very deep, well-drained soils formed in cherty hillslope sediments and the underlying clayey residuum. The Alred has an A-E-Bt-2Bt horizon sequence. The rueter series (loamy-skeletal, siliceous, active, mesic Typic Paleudalfs) consists of very deep, somewhat excessively drained soils formed in colluvium and residuum from cherty limestone. The Rueter has an A-E-Bt-2Bt horizon sequence. The Menfro series (Fine-silty, mixed, superactive, and mesic Typic Hapludalfs) consists of very deep, well-drained soils formed in thick loess deposits on uplands. The Menfro has an A-E-BE-Bt-C horizon sequence. The Kaintuck soil series in Missouri (coarseloamy, siliceous, superactive, nonacid, mesic Typic Udifluvents) are very deep and well-drained floodplain soils formed from loamy alluvium and have an Ap-C horizon sequence.

### **6.3 Protocols**

An aqua regia digestion was employed to obtain a near-total estimation of elemental abundance associated with all but the most recalcitrant soil chemical environments. Aqua regia does not appreciably degrade quartz, albite, orthoclase, anatase, barite, monazite, sphene, chromite, ilmenite, rutile, and cassiterite; however, anorthite and phyllosilicates are partially digested. Homogenized samples (0.75 g) were equilibrated with 0.01 liter of aqua regia (3 mole nitric acid: 1 mole hydrochloric acid) in a 35°C incubator for 24 hours. Samples were shaken, centrifuged, and filtered (0.45 μm), with a known aliquot volume analyzed using inductively coupled plasma mass spectrometry (ICP-MS). Aide and Fasnacht [43] reviewed the application of the aqua regia digestion protocol.


*5.7.4 Cadherin related family member 23 (Cdh23Ahl)*

*Cdh23*Ahl is characterized as a hypomorphic allele for a calcium-dependent cell adhesion protein, otocadherin. It helps in the organization of stereocilia bundle and vestibular hair cells and is required for maintaining this organization in later stages of life [178]. Based on the association of *Cdh2*3Ahl with ARHL in mice, GWAS on a large cohort of Han Chinese population was performed to investigate the role of *CDH23* in ARHL in humans. This study demonstrated that SNPs in *CDH23* do not cause ARHL in humans [179]. However, another study on the methylation patterns in *CDH23* showed a positive correlation between an increase in methylation of the gene and ARHL [180].