Author details

Nawab Hussain1 \* and Iram Iqbal2

1 Department of Mathematics, King Abdulaziz University, Jeddah, Saudi Arabia

References

1435-1443

1380-1383

1-10

equation X ¼ Σm

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Contraction Mappings and Applications DOI: http://dx.doi.org/10.5772/intechopen.81571

[2] Lim Y. Solving the nonlinear matrix

i¼1MiXδi

[3] Berzig M, Samet B. Solving systems of nonlinear matrix equations involving Lipshitzian mappings. Fixed Point Theory and Applications. 2011;2011:

[4] Hussain N, Ahmad J, Ciric L, Azam A. Coincidence point theorems for generalized contractions with

application to integral equations. Fixed Point Theory and Applications. 2015:78

Krasnosel'skii-type fixed point theorems with applications to Volterra integral equations. Fixed Point Theory and

[6] Hussain N, Azam A, Ahmad J, Arshad M. Common fixed point results in complex valued metric spaces with application to integral equations. Filomat. 2014;28(7):1363-1380

[7] Hussain N, Parvaneh V, Roshan JR. Fixed point results for G-α-contractive maps with application to boundary value problems. The Scientific World Journal. 2014. Article ID 585964

[8] Hussain N, Salimi P, Vetro P. Fixed points for Suzuki-φ-ψ-contractions with applications to integral equations. Carpathian Journal of Mathematics.

[9] Hussain N, Kutbi MA, Roshan JR, Parvaneh V. Coupled and tripled

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[11] Hussain N, Khan AR, Agarwal RP. Krasnosel'skii and Ky Fan type fixed point theorems in ordered Banach spaces. Journal of Nonlinear and Convex

[12] Khan AR, Kumar V, Hussain N. Analytical and numerical treatment of Jungck-type iterative schemes. Applied Mathematics and Computation. 2014;

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2 Department of Mathematics, University of Sargodha, Sargodha, Pakistan

\*Address all correspondence to<EMAIL_ADDRESS>
© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Contraction Mappings and Applications DOI: http://dx.doi.org/10.5772/intechopen.81571


**6. Midwifery**

Midwifery students included in our study expressed their understanding that midwives were involved in the most intimate and vulnerable aspects of the lives of women and couples:

*Midwives "enter" the intimate sphere of human beings. (M4)*

*A midwife deals with the intimacy of a woman in her most frail moments. (M8)*

It is therefore of utmost importance to establish a safe and trustworthy relation:

### *Our work reaches to the very intimate sphere. It is up to us, how to approach the intimacy, in what way, showing respect. (M22)*

Midwives affect the lives of women, couples, babies, and families. Our respondents enumer‐ ated the facts that midwives give advice and teach about, for example, good relations in partnerships, sexual practices, the safety of intercourse, contraception, problems related to sexuality, family planning, healthy pregnancy, sexuality during pregnancy, labour, and parental roles. Knowing and understanding the type of partnership is a precondition of their work. Our respondents were aware that it was therefore important to respect the sexuality of women and couples they came into contact with in order to be able to provide relevant and high quality information and midwifery care.


In general, well-designed prospective clinical trials and non-interventional studies that investigate MRONJ management approaches in patients with cancer and bone metastases are lacking. Furthermore, inconsistent outcome measures (e.g., patient QoL scales, mucosal healing, and symptom improvement) are used in all studies [1]. This means that it is difficult to reach a consensus on the most effective MRONJ management approaches available. Patients who develop MRONJ should be referred to a maxillofacial surgeon or an oncologist [1]. A pragmatic approach to the management of patients with MRONJ should be adopted, with the management of malignant skeletal disease at the forefront of the care of each patient. Conservative management is recommended for the AAOMS I MRONJ stage, supplemented with appropriate surgical approaches for the most severe cases.

The current AAOMS guide recommends soft tissue debridement to treat irritation and infection in association with necrotic bone removal in stage 2, while bone resection at the necrotic area is considered in stage 3 [1]. The main problems related to surgery will consist of: temporary decrease in quality of life during convalescence, risks of relapse with extension of the necrosis with a second stage surgical need, possibility of complications (e.g., risk of infection or fracture), need for extended hospitalization, uncertain implications of interruptions necessary to chemotherapy and any cost per patient, and final treatment failure.

In our study, we developed a new protocol for the treatment of patients in stage 2 and stage 3 MRONJ causing segment fracture or showing high-risk for fracture. In MRONJ treatment there is a contraposition between two requirements: One is to remove the necrotic bone area, the other one is to prevent new necrosis by avoiding periosteal elevation in affected the area. To solve these two opposite requirements, we developed a new technique where bone resection was performed and fixation of the fractured bone segments in the affected area or preventive fixation of the resected area at risk of fracture was performed by our epi-mucosa fixation technique. This technique was already validated and published for jaw reducible fractures; because of the similar condition for reducible jaw fractures in MRONJ cases and in non-affected patients, we adopted this technique in the two reported cases. It was the first time the technique was adopted in MRONJ cases, hence the scientific relevance. In this way, it was possible to avoid periosteal elevation with a subsequent bone nutrition impairment and necrosis extension risk. In this new technique, the fixation is performed in closed surgery by fixing the bone plates over the mucosa using self-locking screws, as in an external fixation system. Conservative treatment by autologous PRF is also used in combination, to enhance and promote soft tissue and exposed bone area healing.

We developed the epi-mucosal fixation technique for reducible or well aligned fractures of the jaw; in these cases, fixation of the two bone segments is performed after close reduction of the fracture, avoiding surgical trauma and periosteal elevation, thereby preserving bone nutrition. In this way, we can ensure less surgical trauma with earlier healing of the lesion for the patient.

As shown in our previous study, the main indications for this technique were in well aligned fractures of the jaws (especially in elderly edentulous patients when minimally invasive techniques are needed) or in dislocated jaw fractures that can be reduced by closed manipulation without any incision. Particular indication for this technique is in case of multi segmented fractures with high risks for bone resorption and infection in case of periosteum elevation because of lack of nutrition of the bone fragments [9]. Long threadednecked screws and plates are used, avoiding plate compression on the muco-periosteum and bone fragments, thus using a self-locking screws and plates system like external fixers. The bone fractures are fixed in position, after the reduction, by a rigid fixation system without compression that joins the insertion of the screw into the bone fragment on one side and the insertion of the thread screw neck in the holes of the plates on the other, obtaining a three-dimensional rigid system without any incision [8,10].

The main advantages of this technique are the minimum surgical trauma suitable for elderly patients, avoiding the risk of devascularization of the fragment even in comminuted or multifocal fractures; in this way, the quality and speed of the healing process is improved [9].

Other advantages are an easier removal of fixing devices, avoiding further surgical time, unlike in current techniques with sub-periosteal miniplates and screws, and no risk of periodontal damage, unlike in ferule methods, with lower costs and greater benefits of results [9,11]. It is conceivable to develop this technique and apply a double-plate fixation system for each fracture line in case greater stability is required, such as in unfavorable jaw line fractures, particularly in larger fractured areas [9].

With the use of this new epi-mucosa fixation technique, we were able to shorten the healing time with minimal surgical impact on the patients affected by MRONJ with fractured or weakened bone segments. In conclusion, the intraoral epi-mucosal fixation system is comparable to external fixation devices, with the advantages of avoiding transcutaneous pins or cumbersome devices with aesthetic and functional impairment. For the minimum device size, intraoral placement of the system is also possible for the molar areas using a ratchet screwdriver and contra-angle tips. Particular attention must be paid to the selection of the screw insertion sites in the interalveolar bone septa, avoiding damage to the dental roots.

#### **5. Conclusions**

Analyzing the result of the two cases treated by our technique, it was possible to achieve good results, combining the most effective treatment, even for advanced cases of MRONJ (stage 3). Excellent results were obtained, limiting risks and disadvantages, also in cases with high-risk for bone fracture or cases of effective fractured segment in necrotic bone segments.

The advantages are: Non-invasive surgical procedure; ability to stabilize a bone segment at risk for pathologic fracture; limited risks for necrosis extension; ability in solving pain and necrosis related symptoms achieving mucosa healing.

In our cases, we did not find any complications related to pain during plate and screw fixation, and there was no infection around the sites of screw insertion and no screw weakening or plate mobilization.

Even if the epi-mucosal fixation procedures are already used in close reducible maxillofacial fractures, the number of cases was limited, and additional studies with a larger number of cases are needed to finally assess the reliability and effectiveness of this procedure in MRONJ patients, even if showing promising results in our cases.

**Author Contributions:** Conceptualization, A.C. (Antonio Cortese); Data curation, A.C. (Antonio Cortese); Formal analysis, A.C. (Antonio Cortese), A.C. (Antonio Casarella), C.M.H. and P.P.C.; Writing—original draft, A.C. (Antonio Cortese), A.C. (Antonio Casarella), C.M.H. and P.P.C.; Writing review & editing, A.C. (Antonio Cortese), A.C. (Antonio Casarella), C.M.H. and P.P.C. All authors have read and agreed to the published version of the manuscript.

**Funding:** Candace M. Howard is partially supported by the National Institute of General Medical Sciences of the National Institutes of Health under Award Number 1U54GM115428. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki, and was approved by the Comitato Etico dell' Universita' di Salerno (38/06, 14 April 2006).

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** Data is available upon reasonable request.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**

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