A Novel Approach for the Treatment of Recurrent Oroantral Fistula Occurring at an Infected Sinus Augmentation Site.

Closing a recurrent oroantral fistula (OAF) that occurs at an infected sinus augmentation site is a challenge for clinicians. The recurrent OAF has a detrimental impact on bone regeneration and subsequent implant placement. This case report includes three cases in which sinus graft infection and OAF occurred after maxillary sinus augmentation (MSA). In these cases, treatments to control sinus infection were performed using an otolaryngologist; then, intraoral interventions comprising mucosal flap procedures, bone grafts, and barrier membrane applications were performed 2-5 times by oral surgeons. Nevertheless, OAF recurred persistently. The failure to stop OAF recurrence may be due to the inability to effectively block air pressure at the OAF site. Following a comprehensive debridement of the infected tissue at the previous sinus augmentation site, a pouch was created through sinus mucosal elevation. The perforated sinus mucosa at the OAF site was covered with a non-resorbable membrane in one case and with resorbable collagen membranes in the other two cases, followed by bone grafting within the pouch. Lastly, this procedure was completed by blocking the entrance of the pouch with a cortical bone shell graft and a resorbable collagen membrane. The cortical bone shell graft, obstructing the air pressure from the nasal cavity, facilitated bone formation, and, ultimately, allowed for implant placement. Within the limitations of the present case report, the application of a guided bone regeneration technique involving a cortical bone shell graft and a barrier membrane enabled the closure of the recurrent OAF and subsequent implant placement.

Odontoma mandibular inusual y su resolución: reporte de un caso / Unusual mandibular odontoma and its resolution: report of a case

Objetivo: El odontoma es una lesión hamartomatosa benigna formada por tejido dentario (cemento, esmalte, pul­ pa). Según su grado de diferenciación podrá ser clasificado en sus dos variantes: compuesto y complejo en una relación 2:1. El objetivo de este artículo es presentar un odontoma mixto de gran tamaño de localización mandibular y su resolución quirúrgica. Caso clínico: Se describe el caso de un paciente mascu­ lino de 16 años de edad, portador de ortodoncia, que presenta un odontoma mixto de gran tamaño de localización mandibular y su resolución quirúrgica utilizando planificación 3D y confección de placa de titanio customizada (AU)

Aim: Odontoma is a benign hamartomatous lesion formed by dental tissue (cementum, enamel, pulp). According to its degree of differentiation, it can be classified in its two variants: compound and complex in a 2:1 ratio. The objective of this article is to present a large mixed odontoma of mandi­ bular location and its surgical resolution. Clinical case: A 16-year-old male patient with ortho­ dontics, who presents a large mixed odontoma with mandibu­ lar location and its surgical resolution using 3D planning and customized titanium plate fabrication (AU)

Manejo interdisciplinario para una óptima rehabilitación oral / Interdisciplinary management for optimal oral rehabilitation

Las estrategias para el éxito en la rehabilitación bucal requieren de la interrelación de varias disciplinas que en conjunto logren resultados predecibles y duraderos. La visión individualizada de cada área de especialidad puede conllevar a no ofrecer la mejor alternativa de tratamiento, es por ello que la valoración, el diagnóstico y la planificación del caso clínico debe ser realizada por un equipo interdisciplinario para evitar esta situación y crear una sinergia en donde el «todo sea mayor que la suma de sus partes¼. El objetivo de este trabajo es presentar un caso clínico en el cual intervinieron varias áreas de especialidad: periodoncia, prostodoncia, cirugía oral y patología bucal, logrando devolver la función y la estética a través del manejo interdisciplinario (AU)

The strategies for success in oral rehabilitation require the interrelation of several disciplines, which together, achieve predictable and lasting results. The individualized view of each specialty area may lead to not offering the best treatment alternative, which is why the assessment, diagnosis, and planning of the clinical case must be carried out by an interdisciplinary team to avoid this situation and create a synergy in where the «whole is greater than the sum of its parts¼. The objective of this work is to present a clinical case where several areas of specialty intervened: periodontics, prosthodontics, oral surgery, and oral pathology, thus achieving the return of function and aesthetics through interdisciplinary management (AU)

Standing Sedation and Iocoregional Analgesia in Equine Dental Surgery.

Procedural sedation has become popular for describing a semiconscious state that allows patients to be comfortable during certain surgical or diagnostic procedures. Sedation may be enhanced by locoregional anesthetic techniques to produce sufficient analgesia and muscle relaxation for surgery to occur. Sedation and local anesthesia for standing diagnostic and surgical procedures on the horse's head circumvents the potential complications of general anesthesia (particularly, complications related to recovery). However, the implementation of a locoregional anesthetic technique requires a thorough understanding of the anatomy to maximize success and minimize possible complications.

Evaluation of Surgical Treatment of Oroantral Fistulae in Smokers Versus Non-Smokers.

Background and Objectives: Smoking has been found to interfere with wound healing processes. Therefore, the purpose of this study was to compare surgical treatment of oroantral fistulae (OAFs) in smokers and non-smokers. Materials and Methods: Medical records of all consecutive patients who underwent surgical closure of OAFs between 2003 and 2016 at the oral and maxillofacial surgery department, Rabin Medical Center, Israel were reviewed. Patients' demographic data, preoperative signs and symptoms, surgical method of repair, and postoperative complications were recorded. Results: The cohort consisted of 38 smokers and 59 non-smokers. Age and gender distributions were similar in both groups. The main etiology in both groups was tooth extraction, followed by pre-prosthetic surgery in smokers and odontogenic infection in non-smokers (p = 0.02). Preoperative conditions were not significantly different between smokers and non-smokers in terms of size of soft tissue fistula and bony defect, chronic sinusitis and foreign bodies inside the sinus. OAFs were repaired by local soft tissue flaps without consideration of smoking status. Smokers experienced more moderate-severe postoperative pain (p = 0.05) and requested more weak opioids (p = 0.06). Postoperative complications included infection, delayed wound healing, residual OAF, pain, sensory disturbances and sino nasal symptoms. These were mostly minor and tended to be more frequent in smokers (p = 0.35). Successful closure of OAFs was obtained in all patients except one smoker who required revision surgery. Conclusions: Smokers may be more susceptible to OAFs secondary to preprosthetic surgery. In this cohort, there was no statistically significant difference in outcome between smokers and non-smokers in terms of failure. However, smokers tended to have more severe postoperative pain and discomfort and to experience more postoperative complications. Further studies with larger sample sizes should be conducted to validate these results.

Implant-supported fixed hybrid acrylic complete dentures opposing fully restored mandibular metal ceramic restorations.

This report presents a full-mouth rehabilitation case. A patient came with a failing dentition in maxilla, and after the treatment, the patient had a shortened full-arch, implant-supported, screw-retained hybrid acrylic complete denture in the maxilla and full-arch metal ceramic restorations in the mandible. The report describes the steps involved in the prosthodontic rehabilitation; a cost-effective treatment plan, the restoration of vertical dimension, an immediate denture, an implant-level impression, a verified-master cast, the fabrication of definitive prosthesis, the occlusal scheme and multiple follow-ups in 6 months. We discussed the merits/demerits of screw-retained prosthesis, impression techniques and various types of fixed complete dentures. We learnt the difficulty in hygiene measures and dissatisfaction of the patient with the hygienic gaps under the acrylic fixed dentures.

Planificacion de tratamiento con software para cirugía guiada en implantologia oral / Treatment planning with software for guided surgery in implant dentistry

La planificación preoperatoria de la posición de los implantes constituye una parte importante de la coordinación quirúrgica y prostodóncica que se ha ido incrementando para conseguir resultados funcionales y estéticos. La cirugía guiada de implantes ha aumentado su popularidad, particularmente debido a los avances y a la utilización de la tomografia computarizada de haz cónico (CBCT) y a la planificación del tratamiento con implantes mediante programas informáticos 3D que valoran la localización del implante. De hecho, los pacientes edéntulos pueden ser diagnosticados con una CBCT y tratados con varios implantes por cirugía guiada y carga inmediata. La CBCT constituye un método no invasivo para describir las estructuras maxilofaciales evaluando la cantidad y calidad ósea de los rebordes alveolares. La incorporación de softwares específicos de implantología guiada puede mejorar la planificación virtual de la cirugía sin colgajo y los resultados de los implantes colocados con una férula quirúrgica guiada. En muchos casos, la carga inmediata optimiza el éxito de la técnica de cirugía guiada con muchos beneficios como la reducción del tiempo del tratamiento y el confort del paciente

Preoperative planning of the implant position as part of a coordinated prosthetic and surgical concept is becoming increasingly important regarding function and esthetics. Guided implant surgery is increasing in popularity, particularly due to advances and increased usage of cone beam computed tomography (CBCT) and dental implant treatment planning software allowing three-dimensional assessment of the implant site. In fact, edentulous patients can be diagnosed by a CBCT and treated with several implants for rehabilitation with guided surgery and immediate loading. The CBCT provides a noninvasive method to describe maxillofacial structures and assess bone volume and density of alveolar ridges. The introduction of specific softwares of guided implant dentistry can improve the virtual planning of flapless surgery and outcomes of dental implant placed in edentulous alveolar ridges by template guided surgery. In many cases, the immediate-loading protocol maximises the sucess of the guided surgery techniques with many benefits, such as short time and maximum patient comfort

Regeneración horizontal en sector anterosuperior con injerto en bloque vs particulado / Horizontal guide bone regeneration in anterior maxilla with autogenous bone block or particulated xenograft

La regeneración ósea horizontal tiene por objeto solventar las deficiencias de volumen óseo vestíbulopalatino o lingual, previa o simultáneamente a la colocación de implantes dentales. Hoy en día, existen diferentes técnicas para realizar una regeneración ósea, su selección depende de las características del caso clínico que se vaya a realizar. Los injertos óseos, se pueden clasificar según su origen y según su forma. Atendiendo a su origen, se distinguen en injertos autólogos, aloinjertos, materiales aloplásicos y xenoinjertos. En función de la forma se distinguen en bloque o particulados, siendo principalmente autoinjertos y xenoinjertos, respectivamente. Los primeros estudios sobre el tema preconizaban el uso de los autoinjertos en bloque como el Gold Standard en la regeneración ósea previa a la colocación de implantes. El propósito de esta revisión bibliográfica fue comparar los resultados obtenidos en cuanto a ganancia de hueso horizontal tras la regeneración del sector anterior de un maxilar atrófico, con injerto en bloque autólogo versus xenoinjerto particulado. Se realiza una actualización bibliográfica sobre técnicas de aumento de volumen óseo horizontal previas a la colocación de implantes, con el fin de comparar las dos técnicas más utilizadas hoy en día

The purpose of horizontal bone regeneration is to resolve the deficiencies/shortcomings of the buccal or palatal volume, prior or simultaneously to the placement of dental implants. Nowadays, there are different techniques to perform a bone regeneration, its selection depends on the characteristics of the clinical case that is going to be performed. Bone grafts can be classified according to their origin and their shape. Based on their origin, they are distinguished in autologous grafts, allografts, alloplastic materials and xenografts. Depending on the shape, they are distinguished in block or particulate, being mainly autografts and xenografts, respectively. The first studies on the subject, advocated the use of block autografts such as the Gold Standard in bone regeneration prior to implant placement. The purpose of this literature review was to compare the results obtained in terms of horizontal bone gain after regeneration of the anterior sector of an atrophic maxilla, with autologous block graft versus particulate xenograft. A bibliographic update is made on techniques of horizontal bone volume increase prior to the placement of implants, in order to compare the two techniques most used today

Osteotomía segmentaria con injerto interposicionado en región anterior de la mandíbula: reporte de un caso / Segmental osteotomy with interpositional graft in anterior mandible: report of a case

La pérdida de dientes por lo general resulta en defectos de la cresta alveolar, dificultando la colocación de implantes. La corrección de estos defectos es un desafío para los cirujanos orales. La técnica de osteotomía segmentaria con injerto óseo interposicionado también conocida como osteotomía en «sándwich¼ ha demostrado ser efectiva para estos problemas. Se describe un caso clínico con la utilización de esta técnica para el aumento óseo vertical en la región anterior mandibular y la colocación de implantes (AU)

The loss of teeth usually results in defects of the alveolar ridge, making it diffi cult to place implants. The correction of these defects is a challenge for oral surgeons. The segmental sandwich technique with interpositional bone graft has proven to be predictable for these problems. We describe a clinical case with the use of this technique for vertical bone augmentation in the mandibular anterior region and the placement of dental implants (AU)

Novel electrical conductivity device for osteotomy preparation for dental implants placement: A cadaver study.

OBJECTIVES: To evaluate the accuracy, safety, and anticipation effect of a novel electrical conductivity device (SG) in maxillary osteotomy preparation for placement of dental implants. MATERIALS AND METHODS: Thirty-seven osteotomies were prepared by three operators with different levels of expertise, using the SG protocol in the maxilla of six fresh frozen cadavers. A pre-op CT measurement of the length of bone in the desired implant location was taken and compared with the final length of the osteotomy created using SG during surgery. A comparison was made between the results of the different operators. RESULTS: The pre-op CT bone length measurements and the final depth assessment of the osteotomy with SG had a very high correlation level (0.977) with a significant mean difference of 0.639 mm (P < .0001), with the pre-op CT measurements being longer. The least experienced operator had placed the implants 0.924 mm less deep than the pre-op CT length measurements while the most experienced operator had placed the implants 0.244 mm less deep than the pre op CT length measurements. All implants were placed in the correct position and no breach of the sinus/nasal floor or buccal/palatine bone plates was detected. CONCLUSIONS: The SG electrical conductivity device offers the operator real-time monitoring during the surgical procedure. It provides a simple, safe, and sensitive method of detecting breaches, making it simple and safe for oral surgeons with different levels of expertise to use, with promising results.

Piezoelectric surgery versus conventional drilling for implant site preparation: a meta-analysis.

PURPOSE: To answer the PICO question: "Among patients to whom an implant is placed, does the piezoelectric surgery (PS) compared to the conventional drilling (CS) achieve higher implant stability, increase surgical time or improve implant survival rate?" STUDY SELECTION: Two independent authors screened the literature through MEDLINE, Cochrane Library and Scopus. Randomized or non-randomized controlled trials, prospective and retrospective cohort studies comparing implant stability and/or clinical outcomes with PS versus CS used for implant site preparation published in the last 10 years were included in the search. RESULTS: Five of the 177 articles initially found were included in the meta-analysis. No statistically significant differences were found between PS and CS for implant stability quotient (ISQ) at baseline (SMD: 0.31; 95 %CI: -0.59 to 1.20; p=0.5). However, ISQ values were significantly higher at 2 months (SMD: 0.52; 95 %CI: 0.03-1.00; p=0.04) and at 3 months (SMD: 0.74; 95 %CI: 0.17-1.32; p=0.01) for CS. PS needed significantly more time than CS (SMD: 1.74; 95 %CI: 0.42-3.06; p=0.01) in order to be performed. No differences for implant survival rates were found when comparing both techniques (RR: 0.52; 95 %CI: 0.09-2.88; p=0.45). CONCLUSIONS: PS has not demonstrated superiority to conventional drilling for implant stability during the healing period. PS needs significantly longer surgery time than CS. Differences for implant survival rate were not found between the two techniques.

Implant stability using piezoelectric bone surgery compared with conventional drilling: a systematic review and meta-analysis.

The aim of this systematic review was to assess the primary and secondary stability of dental implants placed at sites prepared with piezoelectric bone surgery (PBS) and conventional drilling (CD). The PubMed/MEDLINE and Cochrane Library databases were searched without date or language restriction up to June 2017. Controlled clinical trials in which each patient received implants placed at sites prepared with both PBS and CD were selected. Implant stability had to be measured on day 0 and during the osseointegration period. Methodological quality was assessed using the Cochrane Collaboration tool. A meta-analysis was performed to compare primary stability (on day 0) and secondary stability (after 2 and 3months) between the two groups. The studies included were determined to have a high risk of bias. There was no significant difference between the two groups for primary stability (on day 0) (P=0.51). After 2 and 3months, secondary stability was statistically higher in implants placed with PBS preparation (P=0.04 and P=0.01, respectively). The implant survival rate was 97.5% in the CD group and 100% in the PBS group. PBS preparation improves secondary stability after 2 and 3months in comparison to CD, with similar implant survival rates. Further studies are needed to determine whether implant osseointegration periods could be shortened with PBS preparation.

Endoscopically controlled flapless transcrestal sinus floor elevation with platelet-rich fibrin followed by simultaneous dental implant placement: A case report and literature review.

RATIONALE: In this case study, a modified transcrestal approach was applied to the patient of extremely atrophic posterior maxilla. We analysis the Implant Stability Quotient values (ISQ) to monitor implant stability, and the cone-beam computer tomography (CBCT) to evaluate the bone regeneration. PATIENT CONCERN: A 26-year-old female patient visited our hospital with no contraindications for dental implants and a loss of the maxillary right first molar. DIAGNOSE: Examination by CBCT demonstrated the posterior maxilla was extremely atrophic, the residual bone height (RBH) of #16 was 3.5 mm. INTERVENTION: Patient underwent a endoscopically controlled flapless sinus floor elevation. The maxillary sinus membrane was elevated by two-step, and an implant of 12 mm length was placed simultaneously. OUTCOMES: Twelve weeks post-surgery, the implant-level impression was finished and a full-ceramic crown was placed thereafter. LESSONS: The modified transcrestal approach can be applied to augment maxillary sinus with a residual bone height less than 4 mm.

[Analysis of the prevalence of dental diseases requiring prosthodontic treatment among the rural population of the Omsk region]. / Analiz rasprostranennosti stomatologicheskikh zabolevanii, trebuiushchikh ortopedicheskogo lecheniia, sredi sel'skogo naseleniia Omskoi oblasti.

The aim of the study was to evaluate the prevalence of dental diseases requiring prosthetic treatment among rural population of Omsk region. The study involved 1247 residents from 12 rural areas of the Omsk region at the age of 18 to 87 years. Partial absence of teeth was found in 69.4±1.30%, 7.5±0.75% had a complete absence of teeth on one jaw and 3.8±0.54% on both jaws. Malocclusion is present in 29.5±1.29% of rural residents, the pathology of dental hard tissues, clinical symptoms of TMJ dysfunction, increased dental abrasion were revealed in 63.8±1.36%, 12.0±0.92% and 8.7±0.80%, respectively. Thus the study showed high prevalence of dental pathology that require prosthetic dental rehabilitation in rural areas of the Omsk region.

A New Technique in Alveolar Cleft Bone Grafting for Dental Implant Placement in Patients With Cleft Lip and Palate.

OBJECTIVE: To evaluate 2 iliac corticocancellous-block grafting techniques for dental implant placement in residual alveolar clefts. DESIGN: Nonrandomized prospective clinical trial between March 2010 and December 2014. SETTING: National Hospital of Odonto-Stomatology, Hanoi, Vietnam. PARTICIPANTS: Thirty-two patients (23 female, 9 male; mean age, 21.28 years; range, 16-31 years) with unilateral complete alveolar cleft after reconstructive surgery for cleft lip and palate (CLP). INTERVENTIONS: Harvested iliac crest bone was cut into 2 corticocancellous blocks. The smaller block was adapted against the sutured nasal mucoperiosteum and overlaid with cancellous bone; the larger one overlapped the labial cleft margin and was fixed with screws. Endosteal dental implants were placed after 4 to 6 months, and final restorations were delivered 6 months later. MAIN OUTCOME MEASURES: Flap statuses were assessed clinically. Bone formation was assessed using the Enemark scale. Cone-beam computed tomography was used for graft height and width measurements. Implant health was assessed by the Misch criteria. RESULTS: The mean postgrafting follow-up period was 36.7 ± 10.4 (range, 18-53) months. Three patients (9.4%) showed flap dehiscence but no infection 7 days after bone grafting. Twenty-nine patients (90.6%) had 75% to 100% bone fill (Enemark score of 1). The mean graft height and width were 11.4 ± 2.4 and 6.1 ± 1.0 mm, respectively. Sufficient bone for implant placement was noted in 29 patients (90.6%); the others required partially fixed prostheses. All implants functioned for at least 18 months. CONCLUSION: The proposed technique is reliable to reconstruct the alveolar cleft for implant placement in CLP patients.

Dental Implants: The Last 100 Years.

The present article on the history of dental implants spans beyond the past 100 years of the American Association of Oral and Maxillofacial Surgeons. It was not until the materials and methods became less traumatic to the bone that implants could become firmly attached to the surrounding bone. This phenomenon is now used to replace single and multiple teeth and restore the patient to function and well-being. Many of the methods used to increase denture function are still used with modifications to augment the environment for an implant. These technological changes have allowed patients to be treated efficiently, with the same need for a good treatment plan and physical evaluation by the clinician.

Long-Term Effects of Bone Morphogenetic Protein-2-Loaded Calcium Phosphate on Maxillary Sinus Lift Surgery for Delayed and Simultaneous Dental Implantation.

Maxillary sinus lift surgery (MSLS) is considered to be a useful treatment method for patients with atrophic alveolar bone. Choosing a suitable surgical procedure to simultaneously decrease graft absorption and obtain long-term survival of dental implants is still a challenge. In this study, 20 patients received MSLS with graft of bone morphogenetic protein 2 (BMP2)-loaded calcium phosphate. Dental implants were placed simultaneously in 10 patients receiving MSLS (1-stage group), and in 10 patients receiving dental implants with a 3 to 6 months delay (2-stage group). The effects were evaluated based on clinical and radiographic examination during a 4 to 5 years follow-up. The results showed that only 1 perforation of the maxillary sinus mucosa was observed in 1-stage group, and was patched with a collagen membrane. An average bone gain of 6.8 mm was observed, and all implants exhibited no looseness, peri-implantitis, or fracture, all of which were stable during the follow-up and exhibited nice dental function during a 4 to 5 years follow-up. The loss of peri-implant bone height was 1.12 ±â€Š0.47 and 1.10 ±â€Š0.39 mm, the probing depth of periodontal pocket was 1.79 ±â€Š0.62 and 1.81 ±â€Š0.71 mm, the sulcular bleeding index was 1.63 ±â€Š0.47 and 1.72 ±â€Š0.54 in 1-stage group and 2-stage group, respectively, and no significant differences existed between these 2 groups. These findings implied that BMP2-loaded calcium phosphate may be a suitable material for MSLS, especially for patients with minimal bone height. Clinicians can use the 1- or 2-stage technique based on clinical condition, patients' choice and clinicians' experience. In patients where implants cannot be stabilized for patients with minimal bone height, 2-stage surgery may be more suitable.

Bone Resorption During Submerged Healing After Guided Bone Regeneration: A Prospective Case Series.

OBJECTIVE: The aim of this study was to evaluate bone resorption quantitatively during the healing period subsequent to ridge augmentation. MATERIALS AND METHODS: Sixteen patients requiring vertical ridge augmentation before implant placement were recruited in the study. The study used an allograft and nonresorbable membrane. A custom acrylic stent was used to measure changes in bone volume. Augmented bone was compared with remaining bone 6 months after guided bone regeneration (α = 0.05 by means of the paired t test). RESULTS: All sites following the six months post-surgery were analyzed. Overall changes in alveolar bone were observed with a mean resorption rate of 19.8% (p<0.001). The vertical bone measurement indicated a mean resorption rate of 22.8% (range = 18.5% - 26.5%). The horizontal measurement indicated a mean resorption rate of 18.7% (range = 12.6% - 26.0%). Among the sixteen sites, four sites with post-operative complications including membrane exposure showed an average of 42.1% resorption rates. CONCLUSION: Loss in graft quantity was observed after ridge augmentation using an allograft and nonresorbable membrane during submerged healing before implant placement. Further studies with larger sample sizes are recommended to confirm its findings.

Effect of Simplifying Drilling Technique on Heat Generation During Osteotomy Preparation for Dental Implant.

OBJECTIVES: To test the hypothesis that there would be no difference in heat production by reducing the number of drills during the implant site preparation relative to conventional drilling sequence. METHODS: A total of 120 implant site preparations with 3 different diameters (3.6, 4.3, and 4.6 mm) were performed on bovine ribs. Within the same diameter group, half of the preparations were performed by a simplified drilling procedure (pilot drill + final diameter drill) and other half using the conventional drilling protocol (pilot drill followed by graduated series of drills to widen the site). Heat production by different drilling techniques was evaluated by measuring the bone temperature using k-type thermocouple and a sensitive thermometer before and after each drill. RESULTS: Mean for maximum temperature increase during site preparation of the 3.6, 4.3, and 4.6-mm implants was 2.45, 2.60, and 2.95° when the site was prepared by the simplified procedure, whereas it was 2.85, 3.10, and 3.60° for the sites prepared by the conventional technique, respectively. No significant difference in temperature increase was found when implants of the 3 different diameters were prepared either by the conventional or simplified drilling procedure. CONCLUSIONS: The simplified drilling technique produced similar amount of heat comparable to the conventional technique that proved the initial hypothesis.