Relationships between Clinical and Non-Clinical Variables concerning Traumatic Dental Injuries in Deciduous Teeth Attended in a Children's Hospital.

This study aimed to describe Traumatic Dental Injuries (TDI) in a child population, with a discussion focused on the impact of non-clinical variables on TDI. A cross-sectional, descriptive, and relational study about TDI in deciduous dentition in a children's hospital was performed. A total of 166 patients were included, of which 51.8% were male and 48.2% were female. Subluxation was the most observed injury (37.5%), and high-severity lesions predominated (60.2%). Regarding non-clinical variables, 89.2% of the patients attended urgent care centers within 24 h, and 43.4% within the first 3 h. Pointed objects were the leading cause of TDI (47%). Most TDIs were concentrated between the ages of 2 and 4 (53.5%). Concerning the place of TDI occurrence, the school (41.6%) was associated with faster urgent dental care attendance, and the home (37.3%) was associated with TDI occurrence in children under 2 years of age. Previous TDI experience (24.1% of patients) did not generate differences in the time interval between the TDI and arrival at the hospital, compared with children without a TDI history. While the behavior of clinical variables agrees with the literature reviewed, several non-clinical variables show wide differences. There is a need to identify the non-clinical variables that can significantly interact with phenomena specific to the study population (social, demographic, and cultural). The study of these variables can be useful in applying health policies. In the group studied, the non-clinical data reveals the need to educate parents or guardians on the importance of timely care in TDI, the long-term consequences of traumatism affecting deciduous dentition, and the implication of the maturation of the child's motor skills in TDI.

Comparison of 0.12% Chlorhexidine and a New Bone Bioactive Liquid, BBL, in Mouthwash for Oral Wound Healing: A Randomized, Double Blind Clinical Human Trial.

Following surgery, healing within the oral cavity occurs in a hostile environment, and proper oral care and hygiene are required to accelerate recovery. The aim of the current study is to investigate and compare the bioreactivity characteristics of mouthwashes based on either chlorhexidine (CHX) or a novel bone bioactive liquid (BBL) in terms of oral healing within seven days application post-surgery. A randomized, double blind clinical trial was conducted in 81 patients, wherein the mouthwashes were applied twice a day for a period of 7 days. The visual analog scale (VAS) protocol was applied to determine pain index scores. Early wound healing index (EHI) score was determined for evaluating oral cavity healing progress. No adverse effects were observed using the mouthwashes, but CHX application resulted in stained teeth. Applications of both CHX and BBL were sufficient to reduce pain over a period of 7 days. However, the BBL group demonstrated a statistically significant reduction in VAS scores starting on day 4. The EHI scores were significantly higher in the BBL group compared with the CHX group, independent of tooth location. No differences in either VAS or EHI scores due to gender were observed. Compared with the commercially available CHX mouthwash, application of the BBL mouthwash reduced pain and accelerated oral cavity healing to a greater extent, suggesting it effectively improves the oral cavity microenvironment at the wound site in mediating soft tissue regeneration.

Tongue-tie: incidence and outcomes in breastfeeding after lingual frenotomy in 2333 newborns.

AIM: To determine the prevalence of ankyloglossia in newborns with breastfeeding problems and to assess the effectiveness of frenotomy in the maintenance of exclusive breastfeeding at 1 month, 3 months and 6 months in newborns at an Andorran Hospital. STUDY DESIGN: A descriptive, cross-sectional, population-based, retrospective study of newborns over a 5-year period (2016-2020) was performed. Nine medical history variables (presence or absence of ankyloglossia and type of frenulum, surgical intervention or not, first degree hereditary component, gender, Rh and blood group, type of breastfeeding, causes of cessation and duration of breastfeeding) related to perinatal and feeding history were collected confidentially and anonymously. The Coryllos classification was used for the diagnosis of ankyloglossia. Descriptive analysis of the data, Chi-square test and prevalence ratios were calculated. RESULTS: A total of 2333 newborns were included in the study (50.02% males and 49.98% females). The prevalence of ankyloglossia was 7.84% (n = 183). Of the infants examined, 136 underwent lingual frenotomy. The number of infants who maintained exclusive breastfeeding, both surgically and non-surgically treated, was no statistically significant differences at 1 month (p = 0.65), 3 months (p = 0.61) and 6 months (p = 0.49). CONCLUSIONS: Lingual frenotomy was only performed on patients with ankyloglossia associated with ineffective suction that causes BF difficulties. The realization or not of frenotomy was not a determining factor for the maintenance of breastfeeding at 1 month, 3 months and 6 months. On the contrary, it was a determining factor for the prolongation of mixed feeding. Ankyloglossia related to breastfeeding difficulties should be treated by a multidisciplinary team.

Chemically Defined Conditions Mediate an Efficient Induction of Dental Pulp Pluripotent-Like Stem Cells into Hepatocyte-Like Cells.

Liver diseases are major causes of morbidity and mortality. Dental pulp pluripotent-like stem cells (DPPSCs) are of a considerable promise in tissue engineering and regenerative medicine as a new source of tissue-specific cells; therefore, this study is aimed at demonstrating their ability to generate functional hepatocyte-like cells in vitro. Cells were differentiated on a collagen scaffold in serum-free media supplemented with growth factors and cytokines to recapitulate liver development. At day 5, the differentiated DPPSC cells expressed the endodermal markers FOXA1 and FOXA2. Then, the cells were derived into the hepatic lineage generating hepatocyte-like cells. In addition to the associated morphological changes, the cells expressed the hepatic genes HNF6 and AFP. The terminally differentiated hepatocyte-like cells expressed the liver functional proteins albumin and CYP3A4. In this study, we report an efficient serum-free protocol to differentiate DPPSCs into functional hepatocyte-like cells. Our approach promotes the use of DPPSCs as a new source of adult stem cells for prospective use in liver regenerative medicine.

Histologic and Histomorphometric Evaluation of a New Bioactive Liquid BBL on Implant Surface: A Preclinical Study in Foxhound Dogs.

BACKGROUND: Bioactive chemical surface modifications improve the wettability and osseointegration properties of titanium implants in both animals and humans. The objective of this animal study was to investigate and compare the bioreactivity characteristics of titanium implants (BLT) pre-treated with a novel bone bioactive liquid (BBL) and the commercially available BLT-SLA active. METHODS: Forty BLT-SLA titanium implants were placed in in four foxhound dogs. Animals were divided into two groups (n = 20): test (BLT-SLA pre-treated with BBL) and control (BLT-SLA active) implants. The implants were inserted in the post extraction sockets. After 8 and 12 weeks, the animals were sacrificed, and mandibles were extracted, containing the implants and the surrounding soft and hard tissues. Bone-to-implant contact (BIC), inter-thread bone area percentage (ITBA), soft tissue, and crestal bone loss were evaluated by histology and histomorphometry. RESULTS: All animals were healthy with no implant loss or inflammation symptoms. All implants were clinically and histologically osseo-integrated. Relative to control groups, test implants demonstrated a significant 1.5- and 1.7-fold increase in BIC and ITBA values, respectively, at both assessment intervals. Crestal bone loss was also significantly reduced in the test group, as compared with controls, at week 8 in both the buccal crests (0.47 ± 0.32 vs 0.98 ± 0.51 mm, p < 0.05) and lingual crests (0.39* ± 0.3 vs. 0.89 ± 0.41 mm, p < 0.05). At week 12, a pronounced crestal bone loss improvement was observed in the test group (buccal, 0.41 ± 0.29 mm and lingual, 0.54 ± 0.23 mm). Tissue thickness showed comparable values at both the buccal and lingual regions and was significantly improved in the studied groups (0.82-0.92 mm vs. 33-48 mm in the control group). CONCLUSIONS: Relative to the commercially available BLT-SLA active implants, BLT-SLA pre-treated with BBL showed improved histological and histomorphometric characteristics indicating a reduced titanium surface roughness and improved wettability, promoting healing and soft and hard tissue regeneration at the implant site.

Estudio experimental aleatorizado de innovación docente que compara metodología mixta frente a presencial para la formación en soporte vital básico estándar del European Resuscitation Council / Standard basic life support training of the European Resuscitation Council versus blended training: a randomized trial of a new teaching method

Objetivo. Evaluar los resultados de la formación mixta frente a la presencial en un curso de soporte vital básico/desfibrilador externo automático (SVB/DEA), así como su retención a los 9 meses. Método. Estudio experimental aleatorizado que compara los resultados de la formación en SVB/DEA entre un grupo control (GC) que recibió formación presencial de 4 horas frente a un grupo experimental (GE) que recibió formación en metodología mixta: 2 horas virtuales y 2 horas presenciales. Resultados. Participaron 89 alumnos (45 del GC y 44 del GE). Después de la formación, el GC obtuvo mejores puntuaciones en conocimientos [8,6 (DE 0,9) frente a 8,0 (DE 1,14), p = 0,013]. El GE obtuvo mejores puntuaciones en las habilidades del tiempo en segundos de "hands off" y en el porcentaje de la rexpansión completa del tórax. Los conocimientos decaen a los 9 meses, pero sin diferencias entre los dos grupos. La retención global baja de 8,31 (DE 1,1) a 6,04 (DE 1,6) (p = 0,001), en 9 meses, pero de forma similar en ambos grupos. En las habilidades prácticas no hubo diferencias entre los dos grupos ni al finalizar el curso ni a los 9 meses. Conclusiones. Con la metodología virtual se obtienen mejores resultados en algunos parámetros de las habilidades

Objective. To evaluate the immediate and 9-month results of blended versus standard training in basic life support and the use of an automatic external defibrillator (BLS/AED). Methods. Randomized trial comparing the results of standard BLS/AED training to blended training. The control group received 4 hours of standard instruction from a trainer and the experimental blended-training group received 2 hours of virtual training and 2 hours of in-person instruction. Results. Eighty-nine students participated, 45 in the control group and 44 in the experimental group. The controls achieved better mean (SD) knowledge scores immediately after training (8.6 [0.9] vs 8.0 [1.14] in the experimental group, P=.013). The blended training group scored better on certain skill markers (hands-off time in seconds and compressions followed by complete chest recoil). Participant knowledge had decreased at 9 months without significant between-group differences. Overall, retention fell from a score of 8.31 (1.1) to 6.04 (1.6) (P=.001) in 9 months and the loss was similar in the 2 groups. No differences in practical skills between the groups were observed at the end of the course or 9 months later. Conclusions. The blended training method led to better results on some skill ítems

Standard basic life support training of the European Resuscitation Council versus blended training: a randomized trial of a new teaching method. / Estudio experimental aleatorizado de innovación docente que compara metodología mixta frente a presencial para la formación en soporte vital básico estándar del European Resuscitation Council.

OBJECTIVES: To evaluate the immediate and 9-month results of blended versus standard training in basic life support and the use of an automatic external defibrillator (BLS/AED). MATERIAL AND METHODS: Randomized trial comparing the results of standard BLS/AED training to blended training. The control group received 4 hours of standard instruction from a trainer and the experimental blended-training group received 2 hours of virtual training and 2 hours of in-person instruction. RESULTS: Eighty-nine students participated, 45 in the control group and 44 in the experimental group. The controls achieved better mean (SD) knowledge scores immediately after training (8.6 [0.9] vs 8.0 [1.14] in the experimental group, P=.013). The blended training group scored better on certain skill markers (hands-off time in seconds and compressions followed by complete chest recoil). Participant knowledge had decreased at 9 months without significant between-group differences. Overall, retention fell from a score of 8.31 (1.1) to 6.04 (1.6) (P=.001) in 9 months and the loss was similar in the 2 groups. No differences in practical skills between the groups were observed at the end of the course or 9 months later. CONCLUSION: The blended training method led to better results on some skill items.

OBJETIVO: Evaluar los resultados de la formación mixta frente a la presencial en un curso de soporte vital básico/desfibrilador externo automático (SVB/DEA), así como su retención a los 9 meses. METODO: Estudio experimental aleatorizado que compara los resultados de la formación en SVB/DEA entre un grupo control (GC) que recibió formación presencial de 4 horas frente a un grupo experimental (GE) que recibió formación en metodología mixta: 2 horas virtuales y 2 horas presenciales. RESULTADOS: Participaron 89 alumnos (45 del GC y 44 del GE). Después de la formación, el GC obtuvo mejores puntuaciones en conocimientos [8,6 (DE 0,9) frente a 8,0 (DE 1,14), p = 0,013]. El GE obtuvo mejores puntuaciones en las habilidades del tiempo en segundos de "hands off" y en el porcentaje de la rexpansión completa del tórax. Los conocimientos decaen a los 9 meses, pero sin diferencias entre los dos grupos. La retención global baja de 8,31 (DE 1,1) a 6,04 (DE 1,6) (p = 0,001), en 9 meses, pero de forma similar en ambos grupos. En las habilidades prácticas no hubo diferencias entre los dos grupos ni al finalizar el curso ni a los 9 meses. CONCLUSIONES: Con la metodología virtual se obtienen mejores resultados en algunos parámetros de las habilidades.

Anquiloglosia y problemas de succión, tratamiento multidisciplinar: terapia miofuncional orofacial, sesiones de lactancia materna y frenotomía / Ankyloglossia and breastfeeding problems, multidisciplinary management: Orofacial myofunctional therapy, breastfeeding sessions and frenotomy

Introducción. La limitación de la movilidad lingual en neonatos puede ocasionar problemas en la lactancia, entre ellos: dolor-grietas-mastitis en la madre, mal progreso de peso del neonato y duración excesivamente larga de las tomas. El objetivo de este trabajo es evaluar la efectividad de los tratamientos realizados en los pacientes con anquiloglosia y trastornos de succión. Material y métodos. Estudio descriptivo preliminar de la efectividad del circuito establecido entre los servicios de Cirugía Oral y Maxilofacial, Logopedia y Rehabilitación Orofacial y Lactancia Materna para el tratamiento de los pacientes que acuden con problemas de lactancia materna y se les diagnostica anquiloglosia. Resultados. Se trató a 61 pacientes de edades entre 0 y 6meses con anquiloglosia asociada a problemas clínicos relacionados con la lactancia: 20 niñas (32.8%) y 41 niños (67.2%). Se establecieron 3 grupos según el tratamiento realizado: grupo1 (n=6) únicamente las sesiones de lactancia materna (SLM), grupo2 (n=19) terapia miofuncional (TMF) y asesoramiento en SLM, y grupo3 (n=36) frenotomía y siguieron TMF y asesoramiento de SLM. La anquiloglosia tipoiii es el frenillo lingual más frecuente (57.4%). En el total de la muestra se observaron mejorías en los parámetros que valoran la efectividad y el confort de la lactancia materna. Conclusiones. Mejorar la succión es posible; se recomienda estimular la succión con terapia miofuncional antes y después de la frenotomía, y también en aquellos casos en los que no será necesaria la cirugía (AU)

Introduction. The limitation of lingual mobility in newborns can cause problems in lactation. Among these problems are, soreness, cracked nipples or mastitis in the mother, poor weight gain of the newborn, and an excessively prolonged period of time in each breastfeed. The aim of this study is evaluate the effectiveness of the treatment received by the newborns with breastfeeding problems and ankyloglossia. Material and methods. A preliminary study of the effectiveness of the circuit established between the Oral and Maxillofacial Surgery, Speech Therapy and Orofacial Rehabilitation and the Breastfeeding Department to treat patients that attended the hospital with breastfeeding problems and were diagnosed with ankyloglossia. Results. A total of 61 patients with ages between 0 and 6 months had ankyloglossia were seen due to clinical problems related to breastfeeding. Of these, 20 (32.8%) were girls and 41 (67.2%) were boys. Three groups were established in accordance with the treatment carried out: group1 (n=6) solely from the Breastfeeding Sessions (BFS), group2 (n=19) Myofunctional Therapy (MFT) and BFS, and group3 (n=36) Frenotomy, followed by MFT and BFS. Ankyloglossia type3 was the most frequent lingual frenulum (57.4%). From the total sample, improvements were observed in the parameters that assessed the effectiveness and comfort of breastfeeding. Conclusions. Improving breastfeeding is possible, and in some cases, surgery should not be necessary. If surgery is required, it is recommended to stimulate suction before and after the frenotomy with myofunctional therapy (AU)

Implant-supported fixed prostheses in a Patient with Osteogenesis Imperfecta: A 4-year follow-up.

Osteogenesis Imperfecta (OI) is a rare autosomal dominant connective tissue disorder in wich, the bone quality and density is affected. OI includes some metabolic disorders and have a wide range of clinical presentations. In Osteogenesis Imperfecta bone has a very low density and it is a disorder currently treated with bisphosphonates. Quality and quantity of bone is important for establishment of osseointegration in dental implants. There are few reported cases in the literature. This is a case report of a 61 year-old man with grade IV OI, rehabilitated with implant-supported fixed prostheses in the posterior right and left mandible, whithout bone grafts. At the 4-year follow-up, clinical and imaging study showed no evidence of pathology in the peri-implant tissues. The final outcome is a correct occlusion and masticatory function. This case shows that dental implants may be a treatment option in this patients, however there is still quite limited scientific evidence. Key words:Osteogenesis imperfecta, osteoporotic bone, dental implants, bone fragility, bisphosphonates, drilling technique.

Management of Ankyloglossia and Breastfeeding Difficulties in the Newborn: Breastfeeding Sessions, Myofunctional Therapy, and Frenotomy.

The problems of suction in newborns give rise to multiple consequences for both the mother and the newborn. The objective of this paper is to present a case of ankyloglossia ("tongue-tie") and the suction problems that were treated by a multidisciplinary team. The subject is a 17-day-old male patient, with ankyloglossia and suction problems during breastfeeding (pain in the breastfeeding mother, poor weight gain, and long breastfeeds). The patient followed the circuit established in our centre between the services of Oral and Maxillofacial Surgery and Breastfeeding and Speech Therapy and Orofacial Rehabilitation (CELERE). The evolution following the breastfeeding sessions, the myofunctional stimulation, and the lingual frenotomy was very favourable, thereby solving the suction problems that the newborn presented. All our patients receive breastfeeding sessions and myofunctional therapy as treatment. We know that a frenotomy is not always necessary and we believe that the stimulation of sucking before and after the surgical intervention is important in order to improve the final result.

Multidisciplinary management of ankyloglossia in childhood. Treatment of 101 cases. A protocol

BACKGROUND: Partial ankyloglossia is a limitation which restricts the possibility of protrusion and elevation of the tip of the tongue due to the shortness of either the lingual frenulum or the genioglossus muscles or both. The principal objective of this paper is to present our protocol of action for the treatment of ankyloglossia. The specific objectives are to study patients with ankyloglossia treated by the Service of Maxillofacial Surgery and the Service of Speech Therapy of our pediatric Hospital, describe the diagnostic procedures, the pre-surgical intervention, the surgical technique undertaken and the post-surgical rehabilitation taking into account the level of collaboration of the patients, and finally, describe the surgical complications and the referral of patients. MATERIAL AND METHODS: This is a descriptive study of healthy patients, without any diagnosis of syndrome, ranging between 4 and 14 years that have been surgically treated and rehabilitated post-surgery within a period of 2 years. RESULTS: 101 frenectomies and lingual plasties have been performed and patients have been treated following the protocol of action that we hereby present. After the surgical intervention, the degree of ankyloglossia has been improved, considering correction in 29 (28%) of the patients (95% CI: 20%, 38%), reaching, with the post-surgical orofacial rehabilitation, a correction of 97 (96%) of the participants (95% CI: 90%, 98%). CONCLUSIONS: The chosen surgical technique for moderate-severe ankyloglossia in our centre is the frenectomy and lingual plasty. The myofunctional training begins one week before the surgical intervention so that the patients learn the exercises without pain

Multidisciplinary management of ankyloglossia in childhood. Treatment of 101 cases. A protocol.

BACKGROUND: Partial ankyloglossia is a limitation which restricts the possibility of protrusion and elevation of the tip of the tongue due to the shortness of either the lingual frenulum or the genioglossus muscles or both. The principal objective of this paper is to present our protocol of action for the treatment of ankyloglossia. The specific objectives are to study patients with ankyloglossia treated by the Service of Maxillofacial Surgery and the Service of Speech Therapy of our pediatric Hospital, describe the diagnostic procedures, the pre-surgical intervention, the surgical technique undertaken and the post-surgical rehabilitation taking into account the level of collaboration of the patients, and finally, describe the surgical complications and the referral of patients. MATERIAL AND METHODS: This is a descriptive study of healthy patients, without any diagnosis of syndrome, ranging between 4 and 14 years that have been surgically treated and rehabilitated post-surgery within a period of 2 years. RESULTS: 101 frenectomies and lingual plasties have been performed and patients have been treated following the protocol of action that we hereby present. After the surgical intervention, the degree of ankyloglossia has been improved, considering correction in 29 (28%) of the patients (95% CI: 20%, 38%), reaching, with the post-surgical orofacial rehabilitation, a correction of 97 (96%) of the participants (95% CI: 90%, 98%). CONCLUSIONS: The chosen surgical technique for moderate-severe ankyloglossia in our centre is the frenectomy and lingual plasty. The myofunctional training begins one week before the surgical intervention so that the patients learn the exercises without pain.

Gingival bleeding of a high-flow mandibular arteriovenous malformation in a child with 8-year follow-up.

Intraosseous arteriovenous malformations (AVMs) in the head and neck region are uncommon. There are several types and they can have a wide range of clinical presentations. Depending on the blood flow through the AVM, the treatment may be challenging for the attending team and may lead to life-threatening hemorrhages. A clinical case report is presented. A 9-year-old girl, seen for gingival bleeding during oral hygiene, was found to have a high-flow AVM located within and around the mandible. Two-stage treatment consisted of intra-arterial embolization followed by intraoral injection of a sclerosing agent 8 weeks later. At the 8-year follow-up, imaging study showed no evidence of recurrent lesion inside or outside the bone. The final outcome is a correct occlusion with a symmetric facial result. This case shows that conservative treatment may be the first treatment option mostly in children. Arteriography and transcortical injection were enough to control the AVM.

A descriptive study of 113 unerupted supernumerary teeth in 79 pediatric patients in Barcelona

Unerupted supernumerary teeth, depending on the morphology, number and distribution can give rise to various alterations in the eruption and development of those permanent teeth to which they are related. Objectives: We aimed to make an epidemiological and descriptive study of the clinical characteristics of patients in Barcelona, their surgical treatment and how said treatment was hindered. Materials and methods: A descriptive study including 113 supernumerary teeth from 79 healthy pediatric patients between 5 and 19 years of age, which underwent surgery in our hospital during a 2 year period (May 2005 / May 2007), taking into account the variables of personal data, gender, age, location, number, morphology, positionaxis, radiological study, surgical treatment, related pathologies, and surgical complications. Results: Male patients (51) were more frequently affected than female (28) patients mainly within the central incisors-mesiodens (53.16%), in which the unique form (68.52%) predominates in conoid morphology (69.62%). Surgical treatment was done by palatal/lingual extraction (49.37%), with few surgical complications (only 1 case of post-surgical bleeding). Conclusion: Incidence in supernumerary teeth is higher among male patients (ratio M:F of 1.82:1). They are most frequently located in the maxilla (82%), specifically, in the premaxilla (77%). Most cases presented only one supernumerary tooth (68.5%) and, in multiple cases, the premolar region is predominant. The conoid shape is the commonest morphology (69.62%). Surgical extraction, was done by palatal/lingual in 49.37% of the cases, as opposed to the vestibular approach in 45.57% (AU)

A descriptive study of 113 unerupted supernumerary teeth in 79 pediatric patients in Barcelona.

UNLABELLED: Unerupted supernumerary teeth, depending on the morphology, number and distribution can give rise to various alterations in the eruption and development of those permanent teeth to which they are related. OBJECTIVES: We aimed to make an epidemiological and descriptive study of the clinical characteristics of patients in Barcelona, their surgical treatment and how said treatment was hindered. MATERIALS AND METHODS: A descriptive study including 113 supernumerary teeth from 79 healthy pediatric patients between 5 and 19 years of age, which underwent surgery in our hospital during a 2 year period (May 2005 / May 2007), taking into account the variables of personal data, gender, age, location, number, morphology, position-axis, radiological study, surgical treatment, related pathologies, and surgical complications. RESULTS: Male patients (51) were more frequently affected than female (28) patients mainly within the central incisors-mesiodens (53.16%), in which the unique form (68.52%) predominates in conoid morphology (69.62%). Surgical treatment was done by palatal/lingual extraction (49.37%), with few surgical complications (only 1 case of post-surgical bleeding). CONCLUSION: Incidence in supernumerary teeth is higher among male patients (ratio M:F of 1.82:1). They are most frequently located in the maxilla (82%), specifically, in the premaxilla (77%). Most cases presented only one supernumerary tooth (68.5%) and, in multiple cases, the premolar region is predominant. The conoid shape is the commonest morphology (69.62%). Surgical extraction, was done by palatal/lingual in 49.37% of the cases, as opposed to the vestibular approach in 45.57%.