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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 1  |  Page : 12-20

Evaluation of Intermaxillary Fixation (IMF) Screw Therapy with Craniomandibular Index Analysis for Chronic Recurrent Dislocation in the Temporomandibular Joint


Department of Oral, Maxillofacial Surgery, Atatürk University Faculty of Dentistry, Erzurum, Turkey

Date of Submission08-Mar-2021
Date of Acceptance02-Jul-2021
Date of Web Publication19-Jan-2022

Correspondence Address:
Dr. Y E Ascl
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ataturk University, Erzurum - 25520
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_107_21

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   Abstract 


Background: Temporomandibular joint (TMJ) hypermobility is classified as a subluxation, complete (luxation), unilateral, or bilateral, acute, chronic protracted, or chronic recurrent dislocation. Aims: This controlled randomized clinical study aims to evaluate the effectiveness of intermaxillary fixation (IMF) screw application and autologous blood injections in the treatment of chronic recurrent dislocation of TMJ in comparison with the placebo group. Patients and Methods: The patients who were admitted to the Faculty of Dentistry of the Atatürk University between October 2018 and January 2020 were evaluated. Three hundred patients diagnosed with bilateral chronic recurrent dislocation of TMJ based on clinical findings and radiographs were included in the study. The patients were randomly divided into three groups according to the evaluation criteria. Group 1 received IMF, group 2 received autologous blood injection, and group 3 (placebo group) received an intraarticular saline injection. Results: The results of the patients who received IMF, autologous blood injection, and saline injection were evaluated by the craniomandibular index. The IMF group showed significant improvement after 1 month and 6 months (P < 0.001), while the patients who received autologous blood injection and saline injection showed no significant improvement (P > 0.05). The data were analyzed with IBM SPSS V23. The significance level was P < 0.05. Conclusion: In our study, the IMF gave the best results among all the study groups. The IMF technique can be used in patients with protracted chronic recurrent dislocation in whom autologous blood injection has failed.

Keywords: Dislocation, maxillomandibular fixation, temporomandibular joint dislocation


How to cite this article:
Ertas U, Ascl Y E, Yalcin E, Urvasizoglu G. Evaluation of Intermaxillary Fixation (IMF) Screw Therapy with Craniomandibular Index Analysis for Chronic Recurrent Dislocation in the Temporomandibular Joint. Niger J Clin Pract 2022;25:12-20

How to cite this URL:
Ertas U, Ascl Y E, Yalcin E, Urvasizoglu G. Evaluation of Intermaxillary Fixation (IMF) Screw Therapy with Craniomandibular Index Analysis for Chronic Recurrent Dislocation in the Temporomandibular Joint. Niger J Clin Pract [serial online] 2022 [cited 2022 Nov 30];25:12-20. Available from: https://www.njcponline.com/text.asp?2022/25/1/12/335978




   Introduction Top


Temporomandibular joint (TMJ) hypermobility is the displacement of the head of the condyle from its normal position in the glenoid fossa to the anterior of articular eminence during the mandibular opening. TMJ hypermobility is defined as the abnormal displacement of the condyle. In patients with this joint problem, the condyle head moves in front of the articular eminence during laughter, flexion, and wide mouth opening movements. Although hypermobility is generally classified as acute and chronic, many different definitions such as habitual dislocation, subluxation, and recurrent dislocation are also included in the subgroupings of TMJ dislocation.[1],[2],[3],[4]

TMJ hypermobility represents 3% of all the reported hypermobile joints in the body.[5] TMJ hypermobility is classified as a subluxation, complete (luxation), unilateral, or bilateral, acute, chronic protracted, or chronic recurrent dislocation.[6]

The terms 'chronic recurrent and habitual' are used for recurrent episodic dislocations. The term “chronic recurrent” is used for cases with dislocation that is repetitive and lasts for more than 1 month.[7] Trauma, abnormal chewing habits, TMJ ligament capsule laxity, and chewing muscle disorders seem to play a role in the pathogenesis of chronic recurrent dislocation of TMJ. Some drugs such as phenothiazine or neurological disorders leading to muscle hyperactivity (e.g. Parkinson's disease) have a well-known important role in TMJ dislocation.[8] The first method to reduce acute TMJ dislocation was described by Hippocrates (500 BC). Today, modern techniques are based on this description.[9] Chronic recurrent dislocation of TMJ can be treated conservatively. There are different treatment methods for chronic recurrent dislocation of TMJ, which can be divided into two groups: surgical and non-surgical methods.[10]

The treatments for TMJ chronic recurrent dislocation are surgical applications (condylectomy, articular eminence increase, the lateral pterygoid muscle removal, miniplate applications, etc.) and non-surgical applications (occlusal splint use, intermaxillary fixation, autologous blood injections, botulinum toxin injections, dextrose prolotherapy, exercise, etc.).[1],[2],[3],[4],[11],[12]

Prolotherapy with autologous blood injection (ABI) is one of the non-surgical treatment methods. It has come to the fore after being reintroduced by Hasson and Nahlieli in their recent study.[13] Prolotherapy, a treatment modality for TMJ dislocations, was firstly reported by Schultz in 1937, however, the studies on the effectiveness of TMJ prolotherapy have not involved comparison with the placebo group.[14] Prolotherapy with ABI is also known as “regenerative injection therapy” and “growth factor activator injection therapy.” Traditionally, it is thought to be a method to strengthen loose ligaments by injecting various types of sclerosing or proliferating solutions.[15.16]

Craniomandibular Index (CMI) is designed to measure changes in craniomandibular problems to be used in studies evaluating the effectiveness and success of therapeutic strategies. This index, by using visual analog scales, includes symptom severity multidimensional aspects and extent of symptoms, pain frequency. This index can be applied to patients with different diagnoses, different ages, and genders. CMI is used to compare the absence or presence of symptoms related to a craniomandibular problem or to differentiate different stages of a disorder. CMI appears to be valid and reliable for use in clinical trials.[17.18]

No study evaluating the success of IMF screw treatment in patients with TMJ chronic recurrent dislocation at the end of the literature review was found.

In this study, the craniomandibular index was used to evaluate the long-term clinical effects in patients who received IMF screw therapy, ABI, and saline injection.


   Patients and Methods Top


This clinical study included adult patients with TMJ chronic recurrent dislocation admitted to the Faculty of Dentistry of Atatürk University. The Ethics committee approval was obtained for this study and informed consent forms were obtained from all patients. The study protocol was approved by the Ataturk University Faculty of Medicine Clinical Research Ethics Committee (date of approval 26.06.2020, approval number B.30.2.ATA.0.01.00/333). A total of 300 patients who were admitted to the Faculty of Dentistry of Atatürk University between October 2018 and January 2020 were evaluated.

Three hundred patients diagnosed with bilateral chronic recurrent dislocation of TMJ based on clinical findings and radiographs were included in the study. The patients were selected according to the evaluation criteria. The patients were randomly divided into three groups;

Group 1 received only intermaxillary fixation with IMF screw for 3 weeks.

Group 2 received only ABI.

Group 3 was selected as a placebo group and received only saline injection to TMJ.

The inclusion criteria for this study were the presence of a diagnosed painful subluxation or a chronic recurrent dislocation of TMJ that may significantly interfere with the willingness to follow the instructions in the absence of a medical condition that may significantly affect healing. Chronic recurrent dislocation of TMJ was diagnosed based on the history of the patient and the clinical recognition of excessively abnormal displacement of the condyle where it slips over the joint superiority, exceeds its height a short while ago, and then, returns to the fossa by self-reduction or medical assistance.

The clinical diagnosis was confirmed by the radiographic view of the position of the mandibular condyle anterior to the joint superiority. The association between the condyle and the glenoid fossa in the TMJ radiographs of the patients was examined, and the position of the condyle was evaluated radiologically. The condylar head located in the anterior of the glenoid fossa, the dislocation findings lasting for more than 6 months, the presence of at least TMJ dislocation per month were considered as chronic recurrent dislocation of the TMJ [Figure 1]a and [Figure 1]b.
Figure 1: (a) CBCT sagittal section view with mouth open and closed. (b) CBCT 3D image with mouth open and closed

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The inclusion criteria were as follows:

ASA 1 and ASA 2 patients were selected (medically healthy adults)

18–46 years old

Patients with bilateral dislocation for at least 6 months

At least 3 TMJ dislocations per month

Patients who correct the dislocation by manual reduction.

The exclusion criteria were as follows:

Patients with acute dislocation

Patients with hematologic, rheumatologic, or neurological diseases, or patients with malocclusion due to trauma, distraction procedure, patients who had undergone orthognathic surgery or TMJ surgery, individuals with psychological or mental problems, and patients with malignant disease in the head and neck region were not included in this study.

The patients were subjected to craniomandibular index analysis in the preoperation period, in the postoperative first day, and in the postoperative sixth month. Panoramic radiographs and lateral TMJ radiographs of the patients were taken in the preoperation period and the postoperative sixth month.

The records and clinical examination data of the patients included in the study were analyzed. Data were obtained with a preoperative craniomandibular index. Craniomandibular index data were obtained after 1 month and 6 months and the results were evaluated.

IMF operative technique

The patients underwent intraoral IMF under local anesthesia. After the infiltration anesthesia with 1.8 mL 4% articaine with 1:100,000 epinephrine (Ultracain DS forte, Sanofi-Aventis, Germany), titanium monocortical miniplates and mini-screws were inserted between the canine and lateral tooth roots in all intraoral quadrants in the affected side. Care was taken to prevent the miniplates and mini-screws from getting in contact with the tooth roots [Figure 2]c The screw insertion areas were washed with serum. After the IMF screw, the corresponding screws were connected with chain elastic [Figure 2]a and [Figure 2]b. The patients were given a soft diet for 1 week and prescribed antibiotics and non-steroid anti-inflammatory drugs for 7 days depending on their allergic status. The IMF screw treatment was applied for 3 weeks. In the postoperative follow-ups, it was seen that there was no serious bleeding or complication and the wound healing was completed smoothly. After the IMF, the screws remained in the mouth for 3 weeks. They were removed after 3 weeks of IMF.
Figure 2: (a and b) IMF screw application. (c) Panoramic view of IMF screw application

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Autologous blood injection technique

This technique can be applied with the patient under local anesthesia, combined sedation, and local anesthesia or general anesthesia. The skin over the TMJ was cleaned with an antiseptic solution. Then, an imaginary line that extends from the tragus of the ear to the lateral canthus of the eye was used. The articular fossa point (AF) is located on this line, 10 mm anterior to the tragus of the ear, and 2 mm inferior to the line. Local anesthesia was administered to the auriculotemporal nerve of the patients, and a 19-gauge needle was inserted into the AF point. After the injection of 4% articaine (Ultracain DS forte, Sanofi-Aventis, Germany), 3 cc saline was injected, causing distention of the superior compartment. The correct location of the needle was confirmed by the protrusive movement of the mandible during the saline injection. The 19-gauge needle was left in the AF point and then a 5 cc blood sample was taken from the cubital fossa of the patients. A syringe was inserted into the already inserted needle and autologous blood was injected (4 cc into the superior joint space and 1 cc into the pericapsular tissue) [Figure 3]. After the procedure, the patients were instructed to restrict their jaw movements for 7 days. They were given a soft diet for 1 week and prescribed antibiotics and non-steroid anti-inflammatory drugs for 7 days depending on their allergic status.
Figure 3: Autologous blood injection intraoperative view

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Saline injection technique: (Placebo group)

The skin over the TMJ was flushed with an antiseptic solution. Then, an imaginary line that extends from the tragus of the ear to the canthus of the eye was used. The AF point is located on this line, 10 mm anterior to the tragus of the ear, and 2 mm inferior to the line. Local anesthesia was administered to the auriculotemporal nerve of the patients, and local anesthesia was administered to the auriculotemporal nerve, and a 19-gauge needle was inserted into the AF point. After the injection of 4% articaine (Ultracain DS forte, Sanofi-Aventis, Germany), 3 cc saline was injected. After the procedure, the patients were instructed to restrict their jaw movements for 7 days. The patients were given a soft diet for 1 week and prescribed antibiotics and non-steroid anti-inflammatory drugs for 7 days depending on their allergic status.

Craniomandibular index

The CMI was developed to measure the standard severity of mandibular movement (hypermobility and hypomobility), TMJ tone, muscle, and joint sensitivity problems [Table 1] and [Table 2]. The CMI is designed to provide clearly defined objective criteria, simple clinical methods, and ease of scoring; CMI is divided into two as Dysfunction Index (DI) and Palpation Index (PI). It supports the reliability of CMI in epidemiological and clinical studies related to CMI. For this reason, the CMI index was preferred in our study.
Table 1: Final clinical examination form: Mandibular movement and TMJ noise

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Table 2: Final examination form: Muscle and TMJ palpation

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The CMI is used clinically and contains data from articles referred to in the literature successively as symptoms of craniomandibular pain and dysfunction. The CMI is divided into DI, which evaluates jaw-joint functions, and PI, which evaluates capsule-muscle sensitivity. DI includes elements related to limits in the range of motion, deviation in movements, pain in the range of motion, and TMJ sound in the range of motion. PI includes intraoral and extraoral maxillary muscles, neck muscles, and sensitizing agents by palpation of the TMJ capsule. The sensitivity is limited to substances that have the potential to change over a period of time or with treatment. The score of CMI is the sum of the positive responses related to mandibular movement and TMJ sound divided by the total number of items. PI is the sum of the total responses divided by the total number of items related to the palpation of extraoral and intraoral jaw muscles, neck muscles, and TMJ capsule. So, CMI is the sum of DI and PI divided by 2 (CMI = DI + PI/2) [Table 2].

The construct validity requires that the index used conforms to a predetermined heuristic concept. In this study, if the scores of the index improved as expected in response to successful treatment, construct validity would be supported.[19] The index was applied by a single person in order to be objective. The examiner used the CMI exam form and audiological guidelines.

Statistical analysis

The data were analyzed with IBM SPSS V23. The conformity to normal distribution was examined with the Kolmogorov–Smirnov test. The Chi-square test was used to compare categorical variables by groups. The one-way analysis of variance was used to compare the data with normal distribution by groups, and the Kruskal–Wallis test was used to compare the data without normal distribution by groups. The Friedman test was used to compare the data without normal distribution by time. The analysis results were given as mean ± standard deviation and median (minimum–maximum) for quantitative data, while they were given as frequency (percentage) for categorical data. The significance level was P < 0.05.


   Results Top


In this study, 111 patients who had TMJ chronic recurrent dislocation and who had undergone IMF were diagnosed with clinical examination and cone beam computed tomography (CBCT), and their average age was 31.1 ± 5.48. (1.group). ABI was applied to 100 patients diagnosed with chronic recurrent dislocation of TMJ by clinical and CBCT. The average age of these patients was 30.91 ± 5.47. (2.group).

The saline injection was applied to 89 patients diagnosed with chronic recurrent dislocation of TMJ by clinical and CBCT. The average age of these patients was 30.99 ± 5.7 (3.group).

There was no difference in the distribution of sex and diagnosis between the groups (P > 0.050) [Table 3]; 72.1% of those in the IMF group, 72% of those in the ABI group, and 74.2% of those in the saline injection group were females [Table 3]. There was no statistically significant difference in the average age of the patients between the groups (P = 0.969).
Table 3: Comparison of gender and diagnosis by groups

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In our study, of the 111 patients in group 1, 80 (72.1%) were females and 31 (27.93%) were males. The majority (51.35%) of the patients were aged between 18 and 25 years; 16.22% of them were above 37 years. In our study, of the 100 patients in group 2, 72 (72.0%) were females and 28 (28%) were males; 48% of the patients were aged between 18 and 25 years; 26% of the patients were above 37 years. In our study, of the 89 patients in group 3, 66 (74.2%) were females and 23 (25.8%) were males; 36% of the patients were aged between 18 and 25 years. 29% of the patients were above 37 years [Table 4]. Panoramic radiographs were performed on the patients before and after the IMF. Lateral joint radiographs were taken before and after IMF as well [Figure 4]a and [Figure 4]b.
Figure 4: (a) Preop TMJ lateral radiography view (b) Postop TMJ lateral radiography view

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Table 4: Comparison of age by groups

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The results of the patients who received IMF, ABI, and saline injection in our study were evaluated by the craniomandibular index. The IMF group showed significant improvement after 1 month and 6 months (P < 0.001), while the patients who received ABI and saline injection showed no significant improvement (P > 0.05).

There was a statistically significant difference in the median postoperative DI values between the groups (P < 0.001). The median DI was 0.35 in the IMF group, 0.73 in the ABI group, and 0.73 in the saline injection group. This difference resulted from the fact that the median DI in the IMF group was lower than that of other groups. There was a statistically significant difference in the median postoperative sixth-month DI values between the groups (P < 0.001). The median DI was 0.31 in the IMF group, 0.69 in the ABI group, and 0.69 in the saline injection group. This difference resulted from the fact that the median ID in the IMF group was lower than that of the other groups. There was a statistically significant difference in the median postoperative PI values between the groups (P < 0.001). The median PI was 0.22 in the IMF group, 0.47 in the ABI group, and 0.47 in the saline injection group. This difference resulted from the fact that the median PI in the IMF group was lower than that of other groups. There was a statistically significant difference in the median values of postoperative sixth-month PI values between the groups (P < 0.001). The median PI was 0.17 in the IMF group, 0.44 in the ABI group, and 0.47 in the saline injection group. This difference resulted from the fact that the median ID in the IMF group was lower than that of the other groups. There was a statistically significant difference in the median postoperative CMI values between the groups (P < 0.001). The median CMI was 0.29 in the IMF group, 0.61 in the ABI group, and 0.62 in the saline injection group. This difference resulted from the fact that the median CMI in the IMF group was lower than that of the other groups. There was a statistically significant difference in the median postoperative sixth-month CMI values between the groups (P < 0.001). The median CMI was 0.23 in the IMF group, 0.57 in the ABI group, and 0.58 in the saline injection group. This difference resulted from the fact that the median CMI in the IMF group was lower than that of the other groups [Table 5].
Table 5: Comparison of parameters between and within groups

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There was a statistically significant difference in the median postoperative CMI values of the IMF group by time (P < 0.001). The preoperative median was 0.7, the postoperative median was 0.29, and the postoperative sixth-month median was 0.23. There was no statistically significant difference in the median CMI values of the ABI group by time (P > 0.05). The median preoperative CMI was 0.7, the median postoperative CMI was 0.61, and the median postoperative sixth-month CMI was 0.57. There was no statistically significant difference in the median CMI values of the saline injection group by time (P > 0.05). The pre-operative median CMI was 0.7, the postoperative median CMI was 0.62, and the postoperative sixth-month median CMI was 0.58.

When the 300 patients were evaluated, many patients had TMJ sounds, despite internal derangements of the temporomandibular joint. In addition to this symptom, the patient suffered from pain upon opening the mouth wide, locking the jaw in an open or closed position, moving the lower jaw, in the anterior of the face, in the jaw joint, in the cheek, and the temporal. Joint sounds and tinnitus and headaches as subjective symptoms and the number of bruxism (teeth grinding) were found to be very close to each other in both genders.


   Discussion Top


ABI was first used by Brachmann as a treatment method for TMJ hypermobility.[20] Schulz was the first person who reported the use of ABI for the treatment of recurrent TMJ dislocation in 1973.[14] ABI involves the injection of autologous blood into the pericapsular area and the superior joint scape. During the ABI procedure, bleeding in the pericapsular area from the introduction of the needle will cause fibrous tissue formation. ABI was first reported by Schultz in 1937, however, the studies on the effectiveness of TMJ prolotherapy have not involved comparison with the placebo group.[14] In the studies on ABI, the success of ABI was evaluated mostly based on the comparison with medicines currently in use. Our study evaluated the IMF and ABI procedures in comparison with a placebo group (saline injection).

The changes in the superior joint space due to autologous blood could not fully be understood, however, it was concluded that it might cause adhesions between tissues. The restriction of the movement of the mandible is considered a success. When the literature was reviewed, it was seen that some researchers have preferably used IMF following an ABI procedure.[13.14] The study by Hasson et al. reported that ABI into the superior joint space and pericapsular tissues eliminated TMJ dislocations, causing scar formation and fibrous tissue formation.[14] The study by Candrl et al. to evaluate the histopathology of ABI in rabbit TMJ found no evidence of degeneration in the articular cartilage and only fibrin deposits in the tissue samples.[21] In our study, the IMF method and ABI method were used in two distinct groups. The IMF group showed significant improvement after 1 month and 6 months (P < 0.001), while the patients who received ABI showed no significant improvement (P > 0.001).

ABI can be used repeatedly with minimum complications,[22] however, the IMF cannot be used repeatedly. One of the major complications of both is the development of fibrosis or osseous ankylosis. In some cases, there are concerns about degenerated articular cartilage.[21.22] The anatomic region where the IMF screws will be inserted is selected according to the position of the teeth, the extent of surgical exposure, and the presence and quality of the bone. Canine-premolar regions and anterior vestibular regions of the maxilla and mandible are considered ideal. Because these regions are conveniently accessible and provide an appropriate bone stock away from tooth roots. The dense approximation areas of the dental roots in the lower front and in the dorsal portion of the alveolar quadrants, especially between the molars, are the areas at the highest risk for complication.[23]

ABI to the TMJ may cause pain and bleeding in the joint region due to needle trauma. Many patients typically have peak pain at the end of 72 h after the ABI procedure and they respond well to acetaminophen.[24] In our study, since other non-steroidal anti-inflammatory medicines mostly inhibit prostaglandin E2 production, they were not prescribed after the operation.

In chronic recurrent dislocation of the TMJ, IMF can be used alone or in a combination with other treatments. In the former case, a restriction period of 3–6 weeks is recommended.[25.26] In our study, we have taken the lower limit (3 weeks) to eliminate the risk of ankylosis. Some studies reported that fibrous or osseous ankylosis occurred when the patient was left in IMF for more than 6 weeks. Besides, no typical satisfactory results were obtained when the IMF was performed alone or in combination with sclerosing substances.[25] However, our study yielded contrary findings. Our study had a larger sample as well as a placebo group. In our study, the IMF alone gave statistically better results than the ABI alone. The most important disadvantage of IMF is the requirement for patient compliance and the need for patient tolerance. Da Cunha et al. administered intra-articularly 1.0 mg of morphine, 50 mg of tramadol, or 1 cc of saline (placebo) to patients with internal derangement of TMJ.[27] In our study, 3 cc saline was injected into the superior joint space and pericapsular tissue in the patients in the placebo group with chronic recurrent dislocation of TMJ. The improvement in the saline group was not statistically significant.

In a study by Hegab on patients with chronic recurrent dislocation, the patients in a group were left in IMF only for 3 weeks. The other group received ABI alone and the third group received a combination of IMF and ABI. This study concluded that the group which received IMF alone had better improvement than the group which received ABI.[26] Our study also supported this study.

The study by Da Cunha et al. on patients with rheumatoid arthritis confirmed that temporomandibular disorders can be determined by comparing the Helkimo and CMI indexes. In our study, the CMI was preferred since it can determine temporomandibular disorders.[27]


   Conclusion Top


In our study, the IMF gave the best results among all the study groups. The IMF technique can be used in patients with protracted chronic recurrent dislocation of TMJ in whom ABI has failed. However, it should be noted that patient compliance is crucial in the IMF screw technique. The clinical examination and craniomandibular index results showed that the IMF therapy can be successfully applied in patients with chronic recurrent dislocation of the TMJ. In the literature, there are not enough studies about the IMF. Its importance will be better understood by more comprehensive studies on this subject.

Ethical approval

The study was conducted, according to the principles outlined in the experimentation involving human subjects in the Declaration of Helsinki from the World Medical Association (2008). The study protocol was reviewed and approved by the Atatürk Unıversıty Medıcal Faculty Clınıcal Research Ethics Committee (protocol CAAE B.30.2.ATA.0.0 1.00/333- Date: 26.06.2020- Decision No: 24).

Informed consent

Informed consent was obtained from all individual participants included in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

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



 

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