Artificial intelligence to support early diagnosis of temporomandibular disorders: A preliminary case study.

BACKGROUND: Temporomandibular disorders (TMDs) are disabling conditions with a negative impact on the quality of life. Their diagnosis is a complex and multi-factorial process that should be conducted by experienced professionals, and most TMDs remain often undetected. Increasing the awareness of un-experienced dentists and supporting the early TMD recognition may help reduce this gap. Artificial intelligence (AI) allowing both to process natural language and to manage large knowledge bases could support the diagnostic process. OBJECTIVE: In this work, we present the experience of an AI-based system for supporting non-expert dentists in early TMD recognition. METHODS: The system was based on commercially available AI services. The prototype development involved a preliminary domain analysis and relevant literature identification, the implementation of the core cognitive computing services, the web interface and preliminary testing. Performance evaluation included a retrospective review of seven available clinical cases, together with the involvement of expert professionals for usability testing. RESULTS: The system comprises one module providing possible diagnoses according to a list of symptoms, and a second one represented by a question and answer tool, based on natural language. We found that, even when using commercial services, the training guided by experts is a key factor and that, despite the generally positive feedback, the application's best target is untrained professionals. CONCLUSION: We provided a preliminary proof of concept of the feasibility of implementing an AI-based system aimed to support non-specialists in the early identification of TMDs, possibly allowing a faster and more frequent referral to second-level medical centres. Our results showed that AI is a useful tool to improve TMD detection by facilitating a primary diagnosis.

Non-impacted tooth extractions and antibiotic treatment: A RCT study.

OBJECTIVES: A controlled, single-blind, randomized clinical trial was performed to evaluate usefulness of antibiotics in preventing pain and complications after tooth extractions and benefits of probiotics in reducing gastro-intestinal symptoms associated with antibiotic therapy. MATERIALS AND METHODS: A total of 159 patients were enrolled in this trial. After tooth extractions, patients were allocated to one of the groups: group 1 received postoperatively amoxicillin + clavulanic acid; group 2 received the same antibiotic therapy with an adjunctive probiotic treatment; and group 3 received neither antibiotics nor probiotics. Follow-up visits were planned at 7, 14, and 21 days after tooth extractions (T1, T2, and T3), and parameters assessed were pain, presence of abscess, edema, fever, alveolitis, trismus, pain, difficulty in daily routine activities, and gastro-intestinal symptoms. RESULTS: The number of patients reporting pain at T1 was significantly higher in the control group when compared to group 2 (p = .016), while no difference for pain intensity was observed between groups. No surgical site infection was observed in any of the groups. Intestinal symptoms seemed to be tackled by probiotic administration. CONCLUSIONS: Pain was the most important symptom in the control group. Antibiotics were not necessary after non-impacted tooth extractions, and probiotics can reduce gastro-intestinal symptoms associated with antibiotics.

Antibiotic's effectiveness after erupted tooth extractions: A retrospective study.

OBJECTIVE: The purpose of this retrospective study was to assess the influence of antibiotics on the development of alveolitis after tooth extractions. MATERIALS AND METHODS: The study population consisted of patients who had erupted tooth extractions in 3 centers. The patients' medical records were collected for several parameters. Moreover, use of antibiotics was evaluated. The primary outcome was the development of alveolitis during the postoperative period. The secondary outcome measure was the possible associations between alveolitis and other patients' characteristics. RESULTS: A total of 1579 patient charts were screened. The patients enrolled in the study were 418 (159 males and 259 females). Alveolitis was reported for 12 extraction sites (2.87%). Six were in the group of patients that received antibiotics (2.14% out of 280 patients treated with antibiotics), and six were in the group of patients that did not receive antibiotics (4.35% out of 138 patients not receiving antibiotics). None of patient-level parameters showed any significant association with the development of alveolitis. CONCLUSION: In conclusion, this study showed that the use of antibiotics after erupted tooth extractions is not useful in preventing alveolitis. Larger, prospective, and randomized studies are needed before incorporating these findings into the daily clinical practice.

Bacterial adhesion on direct and indirect dental restorative composite resins: An in vitro study on a natural biofilm.

STATEMENT OF PROBLEM: Both direct and indirect techniques are used for dental restorations. Which technique should be preferred or whether they are equivalent with respect to bacterial adhesion is unclear. PURPOSE: The purpose of this in vitro study was to determine the affinity of bacterial biofilm to dental restorative composite resins placed directly and indirectly. MATERIAL AND METHODS: Five direct composite resins for restorations (Venus Diamond, Adonis, Optifil, Enamel Plus HRi, Clearfil Majesty Esthetic) and 3 indirect composite resins (Gradia, Estenia, Signum) were selected. The materials were incubated in unstimulated whole saliva for 1 day. The biofilms grown were collected and their bacterial cells counted. In parallel, the composite resin surface morphology was analyzed with atomic force microscopy. Both bacterial cell count and surface topography parameters were subjected to statistical analysis (α=.05). RESULTS: Indirect composite resins showed significantly lower levels than direct composite resins for bacterial cell adhesion, (P<.001). No significant differences were observed within the direct composite resins (P>.05). However, within the indirect composite resins a significantly lower level was found for Gradia than Estenia or Signum (P<.01). A partial correlation was observed between composite resin roughness and bacterial adhesion when the second and particularly the third-order statistical moments of the composite resin height distributions were considered. CONCLUSIONS: Indirect dental restorative composite resins were found to be less prone to biofilm adhesion than direct composite resins. A correlation of bacterial adhesion to surface morphology exists that is described by kurtosis; thus, advanced data analysis is required to discover possible insights into the biologic effects of morphology.

Alveolar Ridge Preservation Procedures Performed with a Freeze-Dried Bone Allograft: Clinical and Histologic Outcomes in a Case Series: Part II

INTRODUCTION: Tooth extractions can result in alveolar bone dimensional changes, necessitating additional bone grafting for implant placement. Alveolar Ridge Preservation (ARP) aims to counteract post-extraction changes. This study evaluates the bone regenerative properties of a freeze-dried bone allograft (FDBA) and the clinical outcomes of implants in grafted extraction sites. MATERIALS AND METHODS: This case series enrolled 33 patients undergoing single/multiple tooth extractions followed by ARP. Biopsies were harvested during implant placement for histologic and histomorphometric analysis. Clinical outcomes included marginal bone loss and Pink Esthetic Score (PES). RESULTS: 25 patients completed the study. FDBA augmented sockets exhibited new bone formation adjacent to graft particles. Implants (n=25) showed 100% survival and success rates at 1 and 2 years. PES improved significantly over time (p<.001), while marginal bone loss did not significantly differ at 1 and 2 years (p=.096). Specimens showed trabecular bone, residual FDBA particles, and marrow spaces. High magnification revealed immature bone and woven bone bridges around graft particles. No inflammatory cells were observed. CONCLUSIONS: The case series provides valuable insights into ARP performed with FDBA; implants were placed after 3 months of healing without any additional bone augmentation, the histologic outcomes were favorable, and implants were successful after a 2-year period of follow-up.

Resonance Frequency Analysis to Assess the Stability of Immediate Implants: A Retrospective Clinical Trial.

Adequate implant primary stability is a key factor to obtain osseointegration and can be measured at insertion by insertion torque (IT) and at different timepoints with resonance frequency analysis (RFA), expressed as an implant stability quotient (ISQ). This retrospective study investigated the correlation between ISQ and IT at implant insertion. All patients who were eligible for this single-cohort retrospective clinical trial were treated with an immediate implant. IT parameters were recorded at implant insertion, and ISQ values were recorded at insertion and at 2-, 4-, and 12-month follow-ups. The study comprised 23 patients who received 32 implants. The mean IT value was 46.87 ± 9.66 Ncm (range: 25 to 65 Ncm), and the mean ISQ value at implant insertion was 71.45 ± 4.24 (range: 63 to 78); these values showed a statistically significant correlation (P < .0001). According to the present data and considering the implant design used in this trial, there is a statistically significant and positive correlation between IT and ISQ values. Thus, ISQ can be used as a reliable method to measure implant stability over time.

One-Year Clinical Performance of Activa™ Bioactive-Restorative Composite in Primary Molars.

Restorative procedures for caries affecting primary molars are a daily challenge for pediatric dentistry, and one of the main factors influencing the results of these restorative procedures is the choice of dental material used: bioactive materials were recently introduced, combining the strength of composites and the benefits of glass ionomers. The present study's objective is to clinically evaluate the aesthetic, functional and biological properties of Activa™ Bioactive composite in approximal and occlusal carious lesions for 1 year using the FDI criteria for evaluating direct dental restorations. Forty-five children with occlusal or approximal caries in first or second primary molars were included in the study: the cavities were then randomized to be restored with either Activa BioActive or SDR Bulk-fill and evaluated over time according to Federation Dentaire Internationale (FDI) criteria. Results showed that Activa BioActive composite has similar performance over time compared to Bulk-fill composite, for both functional and aesthetic properties. Thus, within the limitations of this study, including the short follow-up period, it can be concluded that bioactive materials might be the material of choice to restore primary molars. A longer follow-up period is desirable to confirm these findings.

Histologic Evaluation of Soft Tissues around Dental Implant Abutments: A Narrative Review.

The basis for dental implant success comes not only with the titanium implant osseointegration but also depends on other factors such as the development of a soft tissue barrier, which protects the peri-implant bone from the oral environment. The characteristics of surfaces in contact with peri-implant soft tissues may affect the capacity of peri-implant mucosal cells to create a tight seal around the implant, thus influencing long-term implant success. Many histological studies on animals have been conducted on different materials to better understand their influence on peri-implant soft tissues, with the limitation that results from animal studies cannot be fully translated in humans. The aim of this review paper was to analyze the literature focusing on histological clinical studies in humans which have examined different materials or different surface treatments and their effects on peri-implant soft tissues. The research was conducted according to the following PICO question: "Do different implant/abutment materials affect peri-implant soft tissues adhesion and health?". Nine articles were analyzed in this review. The results of this review show the influence of different abutment materials on the peri-implant soft tissues, and the need of further research regarding the effect that abutment materials, surface treatments, and surface properties have on soft tissues.

Maxillary sinus augmentation with three different biomaterials: Histological, histomorphometric, clinical, and patient-reported outcomes from a randomized controlled trial.

BACKGROUND: Lateral maxillary sinus augmentation (MSA) is a predictable bone regeneration technique in case of atrophy of the posterior-upper maxilla. Aimed at obtaining quantity and quality of bone suitable for receiving osseointegrated implants, its success is largely due to the skill of the surgeon, but also to the characteristics of the biomaterial used. METHODS: Twenty-four patients needing MSA were included in the study. The patients were randomly allocated to three different groups: anorganic bovine bone mineral as control, tricalcium phosphate with or without hyaluronic acid (HA) as test groups. Nine months after MSA, bone biopsies were harvested for the histomorphometric analysis. Secondary outcomes were mean bone gain, intraoperative and postoperative complications, implant insertion torque, implant failure, and patient-reported outcome measures. RESULTS: Although the percentage of new bone was not statistically different between the three groups (P = .191), the percentages of residual biomaterial was significantly higher (P < .000) and nonmineralized tissue significantly lower (P < .000) in the control than in the test groups. Test groups did not differ significantly from each other for all histomorphometric parameters. The implant insertion torque was significantly higher in the control group (P < .0005). The rest of the secondary outcomes were not significantly different between the groups. CONCLUSION: MSA is a safe and predictable procedure in terms of histological, clinical, and PROAMs, regardless of the biomaterial used. The addition of HA did not influence the outcomes.

Atomic force microscopy in vitro study of surface roughness and fractal character of a dental restoration composite after air-polishing.

BACKGROUND: Surface roughness is the main factor determining bacterial adhesion, biofilm growth and plaque formation on the dental surfaces in vivo. Air-polishing of dental surfaces removes biofilm but can also damage the surface by increasing its roughness. The purpose of this study was to investigate the surface damage of different conditions of air-polishing performed in vitro on a recently introduced dental restorative composite. METHODS: Abrasive powders of sodium bicarbonate and glycine, combined at different treatment times (5, 10 and 30 s) and distances (2 and 7 mm), have been tested. The resulting root mean square roughness of the surfaces has been measured by means of atomic force microscopy, and the data have been analyzed statistically to assess the significance. Additionally, a fractal analysis of the samples surfaces has been carried out. RESULTS: The minimum surface roughening was obtained by air-polishing with glycine powder for 5 s, at either of the considered distances, which resulted in a mean roughness of ~300 nm on a 30 × 30 µm2 surface area, whereas in the other cases it was in the range of 400-750 nm. Both untreated surfaces and surfaces treated with the maximum roughening conditions exhibited a fractal character, with comparable dimension in the 2.4-2.7 range, whereas this was not the case for the surfaces treated with the minimum roughening conditions. CONCLUSIONS: For the dental practitioner it is of interest to learn that use of glycine in air polishing generates the least surface roughening on the considered restorative material, and thus is expected to provide the lowest rate of bacterial biofilm growth and dental plaque formation. Furthermore, the least roughening behaviour identified has been correlated with the disappearance of the surface fractal character, which could represent an integrative method for screening the air polishing treatment efficacy.

Impact of Concave/Convergent vs Parallel/ Divergent Implant Transmucosal Profiles on Hard and Soft Peri-implant Tissues: A Systematic Review with Meta-Analyses.

PURPOSE: To systematically review the literature comparing marginal bone loss (MBL) and pink esthetic scores of implants with convergent or concave transmucosal profiles vs divergent or parallel profiles. MATERIALS AND METHODS: A PICO question was defined, and an electronic search was carried out in the MEDLINE/PubMed and Cochrane Oral Health Group databases. Studies documenting type of transmucosal profile (either tissue-level profiles or abutments) and soft and/or hard tissue outcomes of implants were considered eligible. Studies were selected on the basis of the inclusion criteria and quality assessments. A meta-analysis with subgroup analyses was performed. RESULTS: Five papers fulfilled the inclusion criteria, and four were eligible for meta-analysis. Significantly less MBL was found in concave/convergent groups, with a mean difference of 0.772 (95% confidence interval [CI]: 0.450 to 1.095; P < .001). In the subgroup analyses for platform-switching and platform-matching connections, a significant effect in favor of concave/convergent was detected, with a standardized difference in means of 1.135 (95% CI: 0.688 to 1.583, P < .001) when platform switching was considered. No significant effects were found for platform-matching connections. CONCLUSION: Within the limitations of this review, it is suggested that concave/convergent implant transmucosal profiles result in less MBL. No statistically significant results were obtained for soft tissue-related outcomes or for the platform-matching connection subgroup.

Tissue level implants in healthy versus medically compromised patients: a cohort comparative study.

BACKGROUND: Dental implants placed in medically compromised patients have predictable outcomes and a high rate of survival, compared to those placed in healthy patients. The aims of this study were to observe and compare implant survival/success rates and soft tissue response to tissue-level implants placed in healthy and medically compromised patients with a 1-year follow-up. METHODS: Seventy-two patients, 36 healthy patients (20 females and 16 males) and 36 medically compromised patients (18 females and 18 males) affected by cardiovascular diseases (arrythmia, hypertension, atrial fibrillation, bypass and pacemaker surgery), depression, endocrine metabolic diseases (hypercholesterolemia, type II diabetes, Hashimoto's thyroiditis), gastrointestinal diseases (gastritis, hiatal hernia, gastric ulcers), asthma, osteoporosis or glaucoma received one tissue-level implant. Measurements for primary and secondary outcomes were collected immediately after implant placement and at 1 year from implant insertion. RESULTS: Three were failed and two were survived out of a total of 72 implants. Among healthy patients, two implants failed while one was classified as survived; among Medically compromised patients one implant failed and another one was classified as survived. No statistically significant difference was found between the two groups in terms of success rate or survival rate. No statistically significant differences between the two groups' marginal bone level was observed. In healthy patients a mean loss of keratinized tissue (-0.1±0.6 mm) was reported, while in medically compromised patients a mean gain was reported (+0.5±0.8 mm). CONCLUSIONS: In terms of success, failure and survival rates, tissue level implants placed in healthy and in medically compromised individuals showed no short-term (1 year) differences.

Application of IBM Watson to Support Literature Reviews: A Preliminary Experience in Restorative Dentistry.

Literature reviews are crucial in the choice of the best personalized material type and restauration type in restorative dentistry. We developed an IBM-Watson based system to support literature search for restorative dentistry, and compared its results to a literature search performed by a trained professional. We found that our system could assist the researcher in performing a literature review, but the grounding semantic model needs to be refined in order to provide more extensive results.

Relationship between human periodontitis and type 2 diabetes at a genomic level: a data-mining study.

BACKGROUND: The leader gene approach is a data-mining method based on the systematic search for the genes involved in a specific process and their ranking according to the interconnections with the other genes identified. The application of this algorithm to human periodontitis gave promising results. The present study used this algorithm to formulate new hypotheses about the association between periodontitis and type 2 diabetes. METHODS: The genes involved in a given process were identified via interrelated queries of several databases. The interactions among such genes were mapped and given a significance score. The weighted number of links (sum of weighted scores for every interaction in which a gene is involved) was calculated for each gene. Genes were clustered according to this parameter; those in the highest cluster were termed leader genes. This algorithm was applied to diabetes and sinusitis. Sinusitis was chosen as a control because it is an inflammatory infectious disease like periodontitis. The results were compared to those previously calculated for periodontitis. RESULTS: Periodontitis and diabetes share four leader genes; all leader genes are linked in a complex map of interactions. Periodontitis and sinusitis share no leader genes; no interactions were identified. CONCLUSIONS: Even with the limitations of ab initio analyses, these theoretical results might suggest the existence of some common genomic pathways between periodontitis and type 2 diabetes, despite the different pathogenesis of these diseases. In particular, the shared leader genes could have an important role in this relationship, which may be investigated further with targeted experimentation.

Twelve-year longitudinal clinical evaluation of bonded indirect composite resin inlays.

OBJECTIVE: This prospective clinical study evaluated the clinical performance of one-, two- and multi-surface composite resin inlays over a 12-year period on premolars and molars. METHOD AND MATERIALS: One clinician placed 113 indirect composite resin inlays (Signum, Heraeus Kulzer) in 30 patients that were bonded using a three-step bonding system and composite resin luting cement. Evaluations were made at 3 and 12 years by another clinician who was not involved in the placement of the restorations, using the modified US Public Health Service (USPHS) criteria. Data were analyzed using a nonparametric statistical test (Mann-Whitney U test) followed by Bonferroni correction (alpha = .05). RESULTS: Fourteen patients could not be followed, yielding to the follow-up of 99 restorations. After 12 years, compared to the 3-year follow-up, tooth integrity, secondary caries, and sensitivity criteria showed significant change, while other parameters did not show significant difference (P > .05). Parameters such as loss of marginal integrity, loss of restoration integrity, loss of surface polish, and secondary caries received more frequently delta scores. At the 3-year follow-up, the clinical performance of one- or two-surface inlays did not show significant difference from multi-surface ones (P = .6317), but at the 12-year follow-up, the results were more favorable for multi-surface inlays. Overall, the failure rate at 12 years was 12%. CONCLUSIONS: Adhesively bonded indirect composite resin inlays showed acceptable long-term clinical results in terms of function, but surface and margin characteristics changed over time.

Effectiveness of Calcium Phosphate Desensitising Agents in Dental Hypersensitivity Over 24 Weeks of Clinical Evaluation.

BACKGROUND: Calcium phosphate-based compounds are used to treat dental hypersensitivity (DH). Their long-term clinical behaviour needs further research. This study compared the 24-week effectiveness of Teethmate Desensitizer (TD), a pure tetracalcium phosphate (TTCP) and dicalcium phosphate dihydrate (DCPD) powder/water, to that of Dentin Desensitizer (DD), and Bite & White ExSense (BWE), both of calcium phosphate crystallites. METHODS: A total of 105 subjects were selected. A random table was utilised to form three groups of 35 subjects. DH was evaluated using the evaporative sensitivity, tactile sensitivity tests, and the visual analogue scale (VAS) of pain. Response was recorded before the application of the materials (Pre-1), immediately after (Post-0), at 1 week (Post-1), 4 weeks (Post-2), 12 weeks (Post-3) and 24 weeks (Post-4). The non-parametric distribution was assessed with the Shapiro-Wilk statistical test. Intra-group differences for the six time points were evaluated with the Friedman statistical test and the Kruskal-Wallis test. RESULTS: All the materials decreased DH after 24 weeks in comparison to Pre-1. However, the TTCP/DCPD cement showed the greatest statistical efficiency. CONCLUSIONS: The significant decrease of VAS scores produced by TD in the long term suggest the material as the most reliable in the clinical relief of DH.

Clinical outcomes of implants placed in ridge-preserved versus nonpreserved sites: A 4-year randomized clinical trial.

BACKGROUND: Consistent bone changes occur after tooth removal, often compromising the success of implants placed within the socket left to natural healing The long-term effect of ridge preservation on implant outcomes is still unclear. PURPOSE: The aim of the study was to assess success and survival rates of implants placed in extraction sockets, with spontaneous healing, or grafted with cortical porcine bone, or collagenated corticocancellous porcine bone. MATERIALS AND METHODS: Ninety patients in need for a single premolar/molar tooth extraction and an implant treatment were selected for the present study. Patients were randomly distributed among 3 groups: sites that healed naturally (ctrl), or sites that received ridge preservation with either cortical (cort) or collagenated corticocancellous porcine bone (coll). Three months after, all the experimental sites were reentered to insert implants. Marginal bone levels were recorded; soft tissues were analyzed and summarized with the Pink Esthetic Score (PES). Forty-two patients out of 90 (initial cohort study) completed the entire follow-up of 4 years. RESULTS: Cumulative survival and success rates for all implants were 100% at a 4-year evaluation. Mean marginal bone loss (MBL) was 1.14 ± 0.23 mm in the cort group, 1.13 ± 0.29 mm in the coll group, and 1.92 ± 0.07 mm in the ctrl group. There were no significant differences between the 2 grafting materials but MBL was significantly greater in the nongrafted sites (P value < .001). The PES resulted significantly better (9.42 ± 0.75) for the cort group than for the coll group (8.53 ± 1.18) and ctrl group (6.07 ± 1.89) at 4-year evaluation. CONCLUSIONS: Ridge preservation was more effective than natural healing in preserving marginal bone and in achieving better esthetic outcomes around implants 4 years after placement. The cortical porcine bone showed better clinical outcomes than collagenated corticocancellous porcine bone.

Stiffness effect of using polywave or monowave LED units for photo-curing different bulk fill composites.

We investigated three bulk fill composites (Mat1, Mat2, Mat3) cured by two polywave (Poly1, Poly2) and one monowave (Mono) lamps. We used infrared spectroscopy, nanoindentation and atomic force microscopy to assess degree of conversion (DC), stiffness, and roughness after polishing, respectively. Mat2 exhibited the highest DC with Poly1 and second highest with Mono, however was the less stiff. Both Mat1 and Mat3 showed highest DC with Poly2, while Poly1 scored better than Mono. Mat3 scored better than Mat1 and was the third highest when cured with Poly2. For each composite cured by different lamps the stiffness ranked same as the DC. However, roughness did not correlate with hardness. Absolute stiffness value depends on composite formulation. Polywave lamps work better than monowave but not in all cases, as Mat2 showed higher DC with Mono than with Poly2. However, all lamps guarantee a DC≥50% but Mono for Mat1.

Local viscoelastic response of direct and indirect dental restorative composites measured by AFM.

We investigated the viscoelastic response of direct and indirect dental restorative composites by the novel technique of AM-FM atomic force microscopy. We selected four composites for direct restorations (Adonis, Optifil, EPH, CME) and three composites for indirect restorations (Gradia, Estenia, Signum). Scanning electron microscopy with micro-analysis was also used to support the results. The mean storage modulus of all composites was in the range of 10.2-15.2 GPa. EPH was the stiffest (p<0.05 vs. all other composites but Adonis and Estenia), while no significant difference was observed between direct and indirect group (p≥0.05). For the loss tangent, Gradia had the highest value (~0.3), different (p<0.05) from Optifil (~0.01) and EPH (~0.04) despite the large coefficient of variation (24%), and the direct composites showed higher loss tangent (p<0.01) than the indirect composites. All composites exhibited minor contrast at the edge of fillers, showing that these are pre-polymerized, as confirmed by EDS.

A novel approach to treat gingival recession and non-caries cervical lesion combined defects: Restoration guided creeping attachment (RGCA) technique. A case report.

Gingival recessions have multifactorial etiology and are often associated with non-caries cervical lesions. Different surgical techniques have been proposed over the years for their treatment, according to the severity of the recession. A novel technique, called restoration guided creeping attachment (RGCA), for the treatment of combined gingival recession and non-caries cervical lesion is presented. RGCA aims at treating Miller class I and II recessions using a specifically designed composite restoration and a minimally invasive approach. A clinical case describing the technique and forming the basis for further studies is presented. Although the results obtained are encouraging, a wider number of patients and longer follow-ups are needed to assess the reliability of this technique.