Ex vivo biomechanical evaluation of 2.4 mm LCP plate rod constructs versus 2.7 mm LCP applied to the feline tibia.

OBJECTIVE: To compare the stiffness and strength of three plate and rod fixation constructs applied to a feline tibial gap model. STUDY DESIGN: Ex vivo study. SAMPLE POPULATION: Thirty-three unpaired tibiae obtained from skeletally mature cats. METHODS: The tibiae were randomly divided into three groups. The following implants were then applied to the feline tibiae prior to the creation of a 10 mm diaphyseal gap. Group 1: 2.4 mm locking compression plate (LCP) and 1.0 mm intramedullary pin (IMP). Group 2: 2.4 mm LCP and 1.6 mm IMP. Group 3: 2.7 mm LCP. Subsequently, each specimen was tested for torsion, axial compression, and axial load until construct failure. Student's t-tests were used to compare the torsional and axial stiffness, yield load, and maximum axial force. RESULTS: Group 2 had higher axial stiffness than group 3 (p = .013). Group 1 showed a lower maximum axial force and yield point than groups 2 and 3 (p < .01; p < .05, respectively). There were no among-group differences in torsional stiffness. CONCLUSION: Constructs with a 2.4 mm LCP and 1.6 mm IMP provided the strongest and most rigid constructs in a feline tibia gap model. CLINICAL SIGNIFICANCE: A plate-rod construct combining a 2.4 mm LCP and a 1.6 mm IMP is appropriate for achieving high implant stiffness and resisting maximum axial force in treatment of tibial fractures in cats.

Treatment of traumatic cranial fracture with sonic activated polymer pins and plates resorbable implants in a dog.

INTRODUCTION: The case report describes the use of ultrasound-activated resorbable implants for surgical repair of comminuted cranial fractures in a 10 years old medium sized mix-breed dog being injured from a horse kick.

INTRODUCTION: Ce rapport de cas décrit l'utilisation d'implants résorbables activés par ultrasons pour la réparation chirurgicale de fractures crâniennes comminutives chez un chien de race moyenne âgé de 10 ans, blessé par un coup de pied de cheval.

[Treatment of a hip and patella luxation in a toy dog]. / Behandlung einer Hüftgelenks- und Kniescheiben-Luxation bei einer Zwerghunderasse.

INTRODUCTION: The present case report describes the surgical treatment of a traumatic craniodorsal luxation of the hip and a concomitant medial congenital luxation of the patella (3rd grade) in an 11-year-old Yorkshire Terrier. First the hip luxation was corrected with a cemented hip prosthesis. The femoral stem was inserted in slight anteversion (15°) with respect to the preoperative condition (5°), this contributed contrasting the medial traction of the femoral quadriceps on the patella, improving patellar luxation from 3rd to 2nd grade. However, the persistent patellar luxation and intermittent lameness reduced limb function and made a second intervention necessary. Four weeks after prosthetic surgery, a femoral trocleoplasty and lateral transposition of the tibial crest were performed to definitively re-establish a correct replacement of the patella in the femoral trochlea. No perioperative complications were found. At the final examination the patient did not show any lameness or pain that could be evoked when manipulating the surgically corrected limb. The surgical treatment allowed a restoration of the hip function and the alignment of the extensor mechanism of the femoral quadriceps and ensured a complete return to normal motor activities.

INTRODUCTION: Nous décrivons le traitement chirurgical d'une luxation traumatique cranio-dorsale de la hanche et d'une luxation patellaire de degré 3 concomitante chez un chien Yorkshire Terrier âgé de 11 ans. La luxation de la hanche a d'abord été traitée avec une prothèse totale cimentée. L'insertion de la tige fémorale en légère antéversion (15°) par rapport à l'état préopératoire (5°) contrecarrait la traction médiale des muscles quadriceps sur la rotule et réduisait la luxation patellaire du degré 3 au degré 2. Cependant la présence d'une boiterie intermittente due à la luxation patellaire de degré 2 persistante a réduit la fonction du membre et a rendu nécessaire une seconde intervention chirurgicale. Quatre semaines après le remplacement total de la hanche, une trochléoplastie fémorale et une transposition latérale de la crête tibiale ont été réalisées afin d'établir définitivement un alignement correct de la rotule dans la trochlée fémorale. Aucune complication périopératoire n'a été rencontrée. Lors de dernier contrôle, le patient ne présentait pas de boiterie ni de douleur lors de la manipulation du membre opéré Le traitement chirurgical a permis de rétablir la fonction de la hanche et d'aligner correctement le mécanisme extenseur des muscles quadriceps, tout en garantissant un retour complet du patient à une activité physique normale.

Three-dimensional computer-assisted corrective osteotomy with a patient-specific surgical guide for an antebrachial limb deformity in two dogs.

INTRODUCTION: We describe patient-specific surgical guide prototyping and surgical treatment of a complex antebrachial deformity in two skeletally mature dogs presented with chronic lameness. Computer-assisted surgery was elected to increase accuracy in the correction of the complex deformity. Radiographs and computed tomography (CT) scans revealed a biplane deformity with valgus, procurvatum and external torsion of the right radius in both cases. The pre-surgical planning started from the quantification of the angular deformity, followed by computer simulated correction and to end up with a rehearsal surgery on 3D printed bone models. During the surgery, the custom-made osteotomy guides closely fitted the bone, allowing for a precise corrective osteotomy, that was stabilized with two locking plates. Postoperative radiographs showed the successful correction of the deformity. Eight and 12 weeks postoperative follow up examinations showed improved lameness, weight-bearing and progression of bone healing in both dogs. Patient-specific surgical guides allowed for a satisfactory correction of the antebrachial deformity. Additional benefits of using customized surgical devices include standardization and reduced surgical time.

INTRODUCTION: Nous décrivons le prototypage d'une procédure chirurgicale spécifique au patient et le traitement chirurgical d'une déformation antébrachiale complexe chez deux chiens ayant atteint leur maturité squelettique et présentant une boiterie chronique. La chirurgie assistée par ordinateur a été choisie pour accroître la précision de la correction de la déformation complexe. Les radiographies et la tomodensitométrie (TDM) ont révélé une déformation dans deux plans avec valgus, procurvatum et torsion externe du radius droit dans les deux cas. La planification préopératoire a commencé par la quantification de la déformation angulaire, suivie par une correction simulée sur ordinateur et a abouti à une opération de répétition sur des modèles d'os imprimés en 3D. Pendant l'intervention, des guides d'ostéotomie sur mesure ont ajusté l'os de manière exacte, permettant ainsi une ostéotomie correctrice précise, stabilisée avec deux plaques de verrouillage. Les radiographies postopératoires ont montré la réussite de le correction de la déformation. Les examens de suivi postopératoires effectués à huit et douze semaines ont montré une amélioration de la boiterie et de la mise en charge ainsi que la progression de la cicatrisation des os chez les deux chiens. Les guides chirurgicaux spécifiques au patient ont ­permis une correction satisfaisante de la déformation antébrachiale. L'utilisation de matériel chirurgical personnalisé comporte d'autres avantages, tels que la standardisation et la réduction du temps de l'intervention chirurgicale.

[Arthroscopic-assisted stabilization of medial shoulder instability in a Miniature Poodle]. / Arthroskopisch-assistierte Stabilisation einer medialen Schulterinstabilität bei einem Zwergpudel.

INTRODUCTION: A 12-year old female miniature Poodle was presented because of a 4/4 right fore-limb lameness. The orthopedic examination demonstrated pain at palpation of the right shoulder and an abduction angle of 55 °. MRI examination confirmed injuries consistent with a traumatic medial shoulder instability with no evidence of shoulder dysplasia. A partial rupture of the subscapularis tendon and complete detachment of the cranial gleno- humeral ligament were confirmed with arthroscopy. The joint was successfully stabilized using an arthroscopic assisted prosthetic suture.

Retrospective evaluation of the efficacy of minimally invasive, fluoroscopic-assisted reduction and stabilisation of unicondylar humeral fractures.

OBJECTIVE: This study evaluated the proficiency in executing closed, fluoroscopic-assisted reduction of unicondylar humeral fractures. The following were hypothesised: experienced surgeons would be highly successful in performing closed reduction; body weight, time to surgery and surgeon experience would influence the reduction method; and the reduction method would not affect technical aspects of the repair. METHODS: All unicondylar humeral fractures stabilised between January 2007 and January 2017 were reviewed. Signalment and time to surgery, experience of the attending surgeon, and the initial and definitive reduction methods were recorded. Initial and subsequent postoperative radiographs were used to assess fracture reduction, implant placement and complications. Univariate polychotomous logistic regressions, Fisher's exact test, Kruskal-Wallis rank sums non-parametric test or equivalence tests were used to compare parameters evaluated based on the approach employed (P < 0.05 significant). RESULTS: A total of 36 dogs with 37 fractures were identified (median weight: 5.4 kg; median time to surgery: 3 days). Of these, 11 of 15 attempted closed reductions were successful. Successful closed reductions had shorter times to surgery than limited open or open reductions (P = 0.009). Age, weight and surgeon experience did not influence the definitive reduction method. Technical aspects of reduction and stabilisation were similar among the reduction methods. Surgery times were shorter for closed reductions (P = 0.034). Of the fractures, 75% healed without complications and 85% had excellent long-term function. CONCLUSION: The results suggested that closed, fluoroscopic-assisted reduction is a proficient (73% successful) and efficient (shorter surgery times with comparable technical results compared with other limited open and open reduction) means of stabilising acute unicondylar humeral fractures.

Radiosurgery-assisted gingival displacement: a proof of concept technique to enhance the efficiency of intraoral digital impression.

Nowadays, an increasing number of dentists are using intraoral scanners (IOS) in their daily practice as an alternative to conventional impression taking. One of the main concerns is related to the capability of scanning the subgingival anatomy of the die, usually very challenging due to the limited operative field and the presence of oral fluids. The radiosurgery assisted gingival displacement technique (RAGD) may enhance the intraoral optical scanning of the finish line and neighbor tooth anatomy. The contour of the interim prosthesis is used to drive the tip of radiosurgery electrode along the tooth surface and open selectively the gingival crevice with a prosthetically-driven and minimally invasive approach. The clinical implication of this technique is related to increasing the efficiency and accuracy of the digital impression technique in the critical zone of the prosthetic shoulder.

The role of sentinel lymph node mapping in small animal veterinary medicine: A comparison with current approaches in human medicine.

The relevance of regional lymph node (LN) assessment to quantify the metastatic spread of cancer is well recognized in veterinary oncology. Evaluation of LNs is critical for tumour staging. However, sampling the correct LN may not be possible without sentinel lymph node (SLN) mapping. Methods for diagnostic imaging and intraoperative detection of SLNs are well established in human medicine, in particular, the combination of lymphoscintigraphy and intraoperative application of blue dyes. Nevertheless, alternative imaging techniques are available and have gained increasing interest. Successful implementation of these techniques in dogs have been reported in both clinical and experimental studies. This review aims to provide an overview of SLN mapping techniques in human and veterinary medicine.

Surgical treatment of a proximal diaphyseal tibial deformity associated with partial caudal and cranial cruciate ligament deficiency and patella baja.

INTRODUCTION: Caudal cruciate ligament injury can be a complication following tibial plateau leveling osteotomy (TPLO) (Slocum und Slocum, 1993) especially if the post-operative Tibial Plateau Angle (TPA) is less than 5 degree. We describe a case of negative TPA associated with partial cranial and caudal ligament rupture treated with a center of rotation of angulation (CORA) based cranial tibial opening wedge osteotomy and tibial tuberosity transposition. A 13 kg, mixed breed dog was presented for right pelvic limb lameness. Radiographically a bilateral patella baja and a malformed tibia tuberosity along with a bilateral TPA of -8 degree were detected. Arthroscopically a partial rupture of the cranial and caudal cruciate ligaments were found. A cranial tibial opening wedge osteotomy of 23 degree and a fibular ostectomy were performed. The osteotomy was fixed with a 8 holes ALPS 9 (KYON, Switzerland) and a 3-holes 2.0mm UniLock plate (Synthes, Switzerland). Then a proximal tibial tuberosity transposition of 10mm was performed and fixed with a pin and tension band construct. The postoperative TPA was 15 degree. The radiographic controls at 6, 10 weeks, 6 months and 1 year after surgery revealed an unchanged position of the implants and progressive healing of the osteotomies. At the 6 and 12 months recheck evaluation the dog had no evidence of lameness or stifle pain and radiographs revealed complete healing of the osteotomy site and no implant failure. The diaphyseal CORA based osteotomy allowed accurate correction of a proximal tibial deformity associated with negative TPA.

Multi-Visceral Transplantation in a 21-Year-Old Man with Prior Pancreatoblastoma.

Organ transplantation in patients with prior malignancy increases the risk of tumor recurrence post-transplantation due to immunosuppression. Only two cases of liver transplantation have so far been reported in children with hepatic metastases from pancreatoblastoma, a rare malignant neoplasm originating from the epithelial exocrine cells of the pancreas. Herein, we describe a case of a successful multi-visceral transplant in a man with intestinal failure after surgical resection of pancreatoblastoma.

Endoscopic Single Approach Forearm Fasciotomy for Chronic Exertional Compartment Syndrome: Long Term Follow-up.

BACKGROUND: Chronic exertional compartment syndrome of the forearm is an uncommon condition, occurring in some populations such as athletes. The standard surgical treatment for professional athletes who cannot avoid trigger activity is an open forearm fasciotomy, which may require a long recovery time. The aim of this study is to present a new endoscopic single approach forearm fasciotomy technique and outcomes of at least 3 years follow up. METHODS: We performed the endoscopic single approach forearm fasciotomy in 4 forearms in 3 men with the mean age of 25 years. All of the patients were evaluated at a mean follow up of 46 months using the Visual Analog Scale (VAS) for pain and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. RESULTS: DASH improved from 21.71 to 5.39, VAS score improved too All the patients referred pain absence after the stress test performed at 20 kilos and 40 kilos. In our series no post-operative complications were observed. CONCLUSIONS: The new mini-invasive technique has proved to be safe, reliable in a long-term follow-up. The main advantage is the shortening of the recovering time, that leads to a faster return to the professional activity.

Hand Injury in Rock Climbing: Literature Review.

With the amazing increasing in number of participants, rock climbing has become a popular sport in the last decade. A growing number of participants, with different skill level, inevitably leads to an increased number of injuries related to this practice. The kind of lesions that can be observed in rock-climbers is very specific and often involves the hand. For this reason is very important for any hand surgeon that is exposed to sport injuries to know which and the most common injuries related to this sport and which are the basic principles for the treatment of those. The aim of this article is to review the literature that has been published in the last ten year in this topic. On the NCBI database 22 articles where found that where related to rock climbing lesion affecting the hand or the whole body. Differences where found according to kind of rock climbing activity that was analyzed, alpine climb leads to more serious injuries, often affecting the lower limb, while in sport and recreational rock climbing the upper limb and the hand are definitely the most affected parts. Flexor pulley lesions, followed by fractures and strains are the most common lesions affecting the hand that are related to this practice.

Plate failure by bending following tibial fracture stabilisation in 10 cats.

OBJECTIVE: To describe the clinical findings and management of tibial fractures in cats in which osteosynthesis failed due to plate bending. METHODS: Case records and radiographs of cat tibial fracture repairs from five referral centres were reviewed for signalment and to assess incidence of plate failure by bending. Cats that sustained plate bending following plate or plate-rod fixation were reviewed for fracture configuration, repair method, initial postoperative and postfailure tibial alignment, revision treatment and outcome. RESULTS: The incidence of plate bending in cat fractures managed with plate and plate-rod fixation in the four referral centres where the overall number could be established was 13% (8/60). In the 10 cats in which plates bent, initial fractures were generally oblique or spiral with mild comminution and located in the middle or distal third of the tibia. Mean time to implant failure was 24 days (range 2 to 56 days). Mean tibial valgus angle increased from 12·9° to 30·9° following bending of the plate. Short-term outcome following revision surgery using orthogonal plating or stacked medial plates was favourable with improvement in tibial valgus in all five fractures with follow-up data. CLINICAL SIGNIFICANCE: Plate bending following tibial fracture stabilisation in these 10 cats resulted in tibial valgus deformation. Consideration of plate and/or intramedullary rod selection and application should be given to avoid a plate strain environment that exceeds the yield point of the plate.

Integrin α1ß1 protects against signs of post-traumatic osteoarthritis in the female murine knee partially via regulation of epidermal growth factor receptor signalling.

OBJECTIVE: To investigate the role of integrin α1ß1 in the progression of post-traumatic osteoarthritis (PTOA), and elucidate the contribution of epidermal growth factor receptor (EGFR) signalling to the mechanism by which integrin α1ß1 might control PTOA. We hypothesised that integrin α1ß1 plays a protective role in the course of PTOA and that the effect of PTOA (e.g., synovitis, loss of cartilage and growth of osteophytes) would be exacerbated in mice lacking integrin α1ß1 at every time point post destabilisation of medial meniscus (DMM). METHODS: DMM or sham surgery was performed on integrin α1-null and wild type (WT) mice and the progression of PTOA analysed at 2, 4, 8 and 12 weeks post-surgery (PS) using micro-computed tomography (microCT), histology, and immunohistochemistry. In addition, the effects of EGFR blockade were examined by treating the mice with the EGFR inhibitor erlotinib. RESULTS: Integrin α1-null female, but not male, mice showed earlier cartilage degradation post DMM surgery compared to WT controls. Furthermore, erlotinib treatment resulted in significantly less cartilage damage in integrin α1-null but not WT mice. Independent of genotype, erlotinib treatment significantly mitigated the effects of PTOA on many tissues of female mice including meniscal and fabella bone volume, subchondral bone thickness and density and cartilage degradation. In contrast, reduced EGFR signalling had little effect on signs of PTOA in male mice. CONCLUSION: Integrin α1ß1 protects against PTOA-induced cartilage degradation in female mice partially via the reduction of EGFR signalling. Furthermore, reduction of EGFR signalling protects against the development of PTOA in female, but not male mice.

Management of an infected cementless cup with prosthetic retention and antibiotic therapy in a dog.

A two-year-old Rottweiler presented for acute onset of a right hindlimb lameness 20 weeks after a cementless total hip replacement (THR) and 16 weeks after open reduction to address luxation of the THR. Radiographs revealed periosteal proliferation of the medial acetabulum and a stable implant. Synovial fluid cytology was consistent with inflammatory joint fluid. Treatment consisted of surgical debridement and intravenous and oral antibiotics. THR implants were not removed. Culture of tissue removed from the THR site yielded growth of Pseudomonas and Staphylococcus species. Lameness resolved 2 months after surgery. Twenty months after surgery, the dog was exercising normally with no clinical lameness and pelvic radiographs revealed no evidence of implant loosening and markedly decreased periosteal reaction. To the authors' knowledge, this is the first report of an infected THR site successfully treated without prosthesis explantation in the dog.

Arthroscopic-guided ulnar distraction for the correction of elbow incongruency in four dogs.

Four skeletally immature, small breed dogs (five elbows) with elbow incongruency were evaluated for forelimb lameness. Findings on clinical examination included pain, effusion and decreased range of motion of the affected elbow. Radiography, computed tomography and arthroscopy demonstrated elbow incongruency in all dogs. Fragmented medial coronoid process was diagnosed arthroscopically in three dogs (four elbows). Arthroscopic subtotal coronoidectomy was performed in all cases of fragmented medial coronoid process. Incongruency was corrected with acute ulnar lengthening under arthroscopic visualisation. The ulna was stabilised with a plate following correction. In two elbows an ostectomy of the anconeal process was performed to prevent impingement against the olecranon fossa. All dogs demonstrated improvement in lameness scores and client-scored visual analogue scale scores. Postoperative computed tomography showed significant improvement in elbow incongruency in all dogs. Arthroscopic-guided ulnar lengthening may be considered as a valid treatment in severe cases of elbow incongruency.

Aldosterone deficiency prevents high-fat-feeding-induced hyperglycaemia and adipocyte dysfunction in mice.

AIMS/HYPOTHESIS: Obesity is associated with aldosterone excess, hypertension and the metabolic syndrome, but the relative contribution of aldosterone to obesity-related complications is debated. We previously demonstrated that aldosterone impairs insulin secretion, and that genetic aldosterone deficiency increases glucose-stimulated insulin secretion in vivo. We hypothesised that elimination of endogenous aldosterone would prevent obesity-induced insulin resistance and hyperglycaemia. METHODS: Wild-type and aldosterone synthase-deficient (As (-/-)) mice were fed a high-fat (HF) or normal chow diet for 12 weeks. We assessed insulin sensitivity and insulin secretion using clamp methodology and circulating plasma adipokines, and examined adipose tissue via histology. RESULTS: HF diet induced weight gain similarly in the two groups, but As (-/-) mice were protected from blood glucose elevation. HF diet impaired insulin sensitivity similarly in As (-/-) and wild-type mice, assessed by hyperinsulinaemic-euglycaemic clamps. Fasting and glucose-stimulated insulin were higher in HF-fed As (-/-) mice than in wild-type controls. Although there was no difference in insulin sensitivity during HF feeding in As (-/-) mice compared with wild-type controls, fat mass, adipocyte size and adiponectin increased, while adipose macrophage infiltration decreased. HF feeding significantly increased hepatic steatosis and triacylglycerol content in wild-type mice, which was attenuated in aldosterone-deficient mice. CONCLUSIONS/INTERPRETATION: These studies demonstrate that obesity induces insulin resistance independently of aldosterone and adipose tissue inflammation, and suggest a novel role for aldosterone in promoting obesity-induced beta cell dysfunction, hepatic steatosis and adipose tissue inflammation.

Unusual anchor pins placement and protocol deviations during computer-based implant placement in a patient with severe mandibular bone atrophy. A case report.

The aim of the study was to describe an unusual method to stabilize the surgical template during the treatment of a severely resorbed edentulous mandible by means of computer-guided implant surgery. Pre-operative computer-based planning revealed the difficulty to stabilize the surgical template in a 67-year-old healthy woman. A deviation of the original NobelGuide™ protocol was performed to ensure the stability of the surgical template: four anchor pins were used to stabilize the surgical template, two in the buccal side of the anterior template and two unusual pins were placed in the lingual site. Four straight TiUnite® Nobel Biocare™ implants were then placed, according to a modified All-on-4™ concept procedure, to avoid graft procedures and to reduce the cumulative chair-side treatment time and costs. A temporary restoration was placed immediately after implant placement. Three months later a definitive, full acrylic restoration was delivered.

Minimally invasive repair of central tarsal bone luxation in a dog.

OBJECTIVES: To describe the use of closed reduction and minimally invasive fixation for treatment of a central tarsal bone luxation in a six-year-old spayed female, mixed breed dog with acute onset non-weight bearing right hindlimb lameness. METHODS: Physical examination and tarsal radiographs resulted in a diagnosis of central tarsal bone luxation. Closed reduction and minimally invasive screw stabilization were performed with fluoroscopic guidance. External coaptation for six weeks was followed by a gradual return to full function. RESULTS: Follow-up examination at 34 months post-surgery revealed the patient to be fully functional on the surgically repaired limb. Radiographs revealed ankylosis of the intertarsal joints. CLINICAL SIGNIFICANCE: Minimally invasive ankle surgery is commonly performed in humans but is uncommon in dogs. Based on the results of this single case, minimally invasive reduction and stabilization of central tarsal bone luxation is feasible.

Computer-assisted virtual treatment planning combined with flapless surgery and immediate loading in the rehabilitation of partial edentulies.

It has been suggested that for success with immediate loaded dental implants it is necessary that, prior to their placement, bone quality and quantity as well as the biomechanical environment in which the implants are to function be evaluated.However, conventional techniques currently used for immediate implant placement lack sufficient precision and are usually accomplished by opening flap procedures. Nowadays computer-guided flapless surgery for implant placement using stereolithographic templates is gaining popularity among clinicians and patients. The advantages of this surgical protocol are its minimally invasive nature, accuracy of implant placement, predictability, less post-surgical disconfort and reduced time required for definitive rehabilitation. The introduction of digital planning programs has made it possible to place dental implants in preplanned positions and being immediately functionally loaded by using prefabricated prostheses. The surgical guide is used, infact, to develop a master model and fabricate the provisional bridge that will be secured to the implants immediately after their placement using the guided surgery template. In this way patients are able to achieve, in the same day of the surgery, a comfortable fixed rehabilitation needing only minor occlusal adjustments. Job S. et al during the three-month period, have demonstrated that the average reduction of crestal bone height around the implants placed with flapless surgery (0.06 mm) is not statistically significant, while the average reduction of crestal bone height around the implants placed using flap surgery (0.4 mm) is statistically significant, concluding that the use of stereolithographic appliances in accordance with flapless surgery makes immediate placement of the implants more predictable. However, the documentation of this technique in partial rehabilitations is limited. PURPOSE of this paper is to report the benefit of sophisticated pre-operative diagnostic implant planning and a flapless surgical approach with immediate loading in the rehabilitation of partial edentulies.