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CAD/CAM TECHNOLOGIES IN THESURGICAL AND PROSTHETIC TREATMENTOF THE EDENTULOUS PATIENT WITHBIOMYMETIC INDIVIDUALIZED APPROACHA. POZZI*, M. GARGARI**, A. BARLATTANI***

* DDS PhD, Private Practice in Rome, Italy** University of Rome Tor Vergata, Department of Odontostomatological Sciences*** MD DDS, Chief and Director Dental Degree & Department of Dentistry, University of Rome Tor Vergata

SUMMARYCAD/CAM technologies in the surgical and prosthetic treatment ofthe edentulous patient with biomymetic individualized approachBackground: The advent of modern endosseous implant design andimproved surface technology has allowed the development of newrestorative techniques that decrease patient’s total treatment time. Uti-lizing the latest scanning, CAD/CAM and manufacturing technolgies weare able to manufacture individualized dental restoration with high ac-curacy and a perfect precision of fit.Materials and methods: This report describes the rehabilitation of acompletely edentulous patient utilizing a CT-based implant planningwith computer-assisted surgical design, simultaneous CAD/CAM fabri-cation of a surgical template, a flapless surgical placement of the im-plants, and a prefabricated fixed complete denture for an immediatelyloaded restoration according to Nobel Biocare’s Teeth-in-an-Hour™(Nobel Biocare Goteborg, Sweden) protocol. This systematic approach to full mouth rehabilitation reduces thetime necessary for an edentulous patient to go from severely atroph-ic alveolar support to implant retained prosthetic restoration. Theseaspects of minimally invasive and simplified surgery, along with re-ducing the treatment time and postsurgical discomfort, are beneficialto the patient, and allowing for rehabilitation with the same level ofsuccess as in flap surgery. Conclusion: The Teeth-in-an-Hour protocol is a unique solution madepossible by the Procera System. With the aid of the CT scans and a vir-tual planning software, a custom fabricated precision drill guide and apre-manufactured prosthesis can be made before surgery. The execu-tion of implant placement is performed with a flapless procedure that re-sults in minimal surgical intervention. This results in a short and non-traumatic surgery with a minimum of postoperative complications, al-lowing the patient to leave the chair with a fixed prosthesis. Utilizing thelatest scanning, CAD/CAM and manufacturing technologies the dentalteam is able to develop individualized zirconia full arch framework withhigh accuracy and precision of fit.

Key words: Nobel Guide, CAD/CAM technology, zirconia full archframework.

RIASSUNTOLa tecnologia CAD/CAM nella riabilitazione implantoprotesica delpaziente edentulo con un approccio biomimetico individualizzatoBackground: l’introduzione di nuovi design implantari e di nuove su-perfici finalizzate al miglioramento delle capacità osteoinduttive ed’integrazione delle fixture ha stimolato i clinici a sviluppare nuoveprocedure restaurative che aumentino il comfort del paziente e ridu-cano il tempo complessivo di trattamento. Utilizzando le ultime tec-niche di scansione, in associazione con la tecnologia CAD-CAM,siamo in grado di produrre restauri protesici individualizzati con unalto grado di accuratezza e con una perfetta precisione, anche neicasi di riabilitazioni complete.Materiali e metodi: questo articolo descrive un protocollo di trattamen-to per la riabilitazione implantare immediata delle arcate completamen-te edentule. Il protocollo Teeth-in-an-Hour (Procera System, Nobel Bio-care) è una soluzione terapeutica unica, resa possibile da una piatta-forma di produzione che mette a disposizione del team implantoprote-sico, la tecnologia CAD/CAM nelle varie fasi di progettazione e realiz-zazione della riabilitazione su impianti. Il posizionamento dei pilastri im-plantari viene eseguito con una procedura chirurgica flapless mini-inva-siva; questo approccio conservativo risulta in una chirurgia atraumati-ca, di breve durata rispetto alle procedure convenzionali e pertanto ildolore e le complicanze locali nell’immediato post-operatorio (sangui-namento e gonfiore) sono minime, con grande beneficio per il pazien-te, garantendo le stesse percentuali di successo della chirurgia a cieloaperto. Il team implantoprotesico utilizzando la tecnologia CAD-CAM èin grado di progettare e realizzare la riabilitazione implantoprotesicacon un elevato grado di precisione e di accuratezza chirurgico-protesi-ca. UtIlizzando le ultime tecniche di scansione tattile-meccanica, l’ela-borazione CAD/CAM e tecnologie di produzione e controllo di tipo in-dustriale, è possibile ottenere restauri in ossido zirconio estesi a tuttal’arcata dentaria con un alto grado di accuratezza e precisione. Conclusioni: questo nuovo protocollo attraverso la pianificazionecomputerizzata virtuale protesico-chirugica dell’implantologia e larealizzazione di strutture CAD/CAM estremamente precise ed accu-rate, semplifica le procedure operative necessarie alla riabilitazionedelle arcate completamente edentule, facilitando il passaggio da unaprotesi totale insufficiente e scomoda per il paziente con grave rias-sorbimento osseo ad una riabilitazione fissa definitiva in circa 4 me-si di trattamento.

Parole chiave: Nobel Guide, tecnologia CAD/CAM, strutture estese inzirconio.

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The advent of modern endosseous implant designand improved surface technology has allowedthe development of new restorative techniquesthat decrease a patient’s total treatment time. Uti-lizing the latest scanning, CAD/CAM and manu-facturing technolgies we are able to manufactureindividualized dental restoration with high accu-racy and a perfect precision of fit. According tothe original Branemark protocol the time periodfor the osseointegration of an implant, prior torestoration, in preparation for loading was be-tween 3 and 6 months, depending on implant po-sition and bone quality (Branemark, 1983; Gaps-ki R., 2003). Changes in implant design and sur-face characteristics have led to the concept ofearly loading of implants, decreasing the un-loaded time to less than 2 to 4 weeks. The suc-cess of immediate and early loading of implantshas been well documented in multiple studies us-ing the latest generation fixtures (Ogawa T.,2003; Zechner W., 2003). Rigid cross-arch stabi-lization has been shown to successfully allow theimmediate loading of titanium implants in anedentulous ridge, allowing rapid sequence reha-bilitation of the arch involved. With the combina-tion of the new surface technology and cross-arch stabilization, immediate placement of animplant-supported fixed prosthesis following im-plant placement is now a predictable treatmentoption (Gapshi R., 2003; Tarnow D., 1997; Sad-owsky S.J., 1997; Harris D., 2002; ChatzistavrouM., 2003). There has been numerous treatment modalitiesdescribed for the immediate loading of implantsto achieve optimal prosthetic design during therehabilitation of the edentulous ridge such as theconversion prosthesis (Balshi, 1985), retrofittingan existing complete denture, providing relief inthe areas of the implants, by converting it into aprovisional restoration using acrylic resin oracrylic resin metal-reinforced frameworks (Zit-maqnn N.U., 1999). Laboratory fabricated transi-tional prosthesis can be processed following theplacement of the implants by making a tradition-al impression of the fixtures. Another treatmentis a laboratory-processed provisional utilizing aprecast framework and processed complete den-

ture that is connected intraorally after implantplacement (Rodrigues A.H., 2003). Creating a provisional prosthesis after the surgi-cal procedure can be difficult and time-consum-ing for both the patient and the clinician becauseof the extended time in the chair (RodriguesA.H., 2003).This report describes the rehabilitation of a com-pletely edentulous patientutilizing a CT-basedimplant planning with computer-assisted surgicaldesign, simultaneous CAD/CAM fabrication of asurgical template, a flapless surgical placementof the implants, and a prefabricated fixed com-plete denture for an immediately loaded restora-tion according to Nobel Biocare’s Teeth-in-an-Hour™ (Nobel Biocare Goteborg, Sweden) pro-tocol. This systematic approach to full mouth rehabili-tation reduces the time necessary for an edentu-lous patient to go from severely atrophic alveolarsupport to implant retained prosthetic restora-tion. These aspects of minimally invasive andsimplified surgery, along with reducing the treat-ment time and postsurgical discomfort, are bene-ficial to the patient (Malo P., 2003). and allowingfor rehabilitation with the same level of successas in flap surgery (Malo P., 2007). Using surgical software (NobelGuide; NobelBiocare AB) and a computerized tomographyscan (CT scan), data can be transferred into a 3-dimensional (3-D) implant planning program toallow for accurate planning and placement of im-plants (Marchack, 2005). A surgical template anda fixed acrylic resin implant supported prosthesisare fabricated, ensuring precision of transferfrom the virtual to the planned prosthesis, imme-diately after clinical implant placement through aflapless surgery, a prosthesis, manufactured priorto the implant surgery, was inserted.

Case report

A 60-year-old man presented with a mandibularcomplete denture (Fig. 1). The patient had beenedentulous since he was 50 years old. Because of

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over 10 years of removable complete dentureuse, the edentulous alveolar ridges have sufferedsevere resorption. The patient was never com-fortable with the mandiboular prosthesis andcomplained of ill-fitting mandibular prosthesis.The patient stated that he was interested in fixedprosthetic rehabilitation. The patient had a com-prehensive examination by an oral surgeon andprosthodontist to establish his candidacy for im-plant therapy with immediate loading of the den-tal implants. Patient selection is critical and may predicatesuccess of the surgery (Sadowsky S.J., 1997; Zit-maqnn N.U., 1999) host factors, implant design,and occlusal loads may all impact osseointegra-tion of the implants (Gapski R., 2003). The patient was reevaluated to determine andconfirm tooth position for aesthetics (Frush J.,1955), phonetics (Rothman, 1961), and appropri-ate vertical dimension (Swerdlow, 1965). For radiographic guide preparation, the patients’previously worn prosthesis was used, when ade-quate, or a new complete transitional lower den-tures was fabricated. When a new removable prosthesis was fabricated,an impression was made with an elastomeric im-pression material (polyether, Impregum Penta,3M Espe, Italy) to obtain the final casts. Maxillo-mandibular relation records, including the makingof an interocclusal record and a trial insertion ofthe tooth arrangement, were accomplished.

Once the appropriate setup was achieved themandibular arch rehabilitation started. If the fab-ricated transitional complete prosthesis is accept-able to the patient both functionally and aesthet-ically, the practitioner needs to confirm its sta-bility or a reline would be required. It is impera-tive at this stage that both the patient and practi-tioner are satisfied prior to proceeding with theprojected immediately loaded fixed prosthesis.This commits both the patient and practitioner tothe final restoration; otherwise a new setupshould be undertaken. In this procedure, the transitional denture is du-plicated into clear acrylic for use as a radiograph-ic guide. As with all duplications, confirming theseat of the duplicate radiographic guide is imper-ative. The same denture can also be used as a ra-diographic guide but it is important that it’s notreinforced with metal framework. Six buccal and3 palatal holes, 1.5 mm wide and 1 mm deep,were made randomly at different levels in the re-movable prosthesis and were filled with a radio-opaque marker (guttapercha; Obtura Spartan,USA) (Fig. 2).An interocclusal record was made as a radi-ographic index with a rigid vinyl polysiloxane(Zhermack SpA, Italy) at the patient’s-appropri-ate centric relation and occlusal vertical dimen-sion. The patient was prescribed for a mandi-boular computed tomography (CT), using a dou-

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Figure 1Patient with a mandibular complete denture func-tionally inadequate.

Figure 2Duplicate of transitional prosthesis used as radi-ographic guide with radio-opaque markers ran-domly positioned at different levels.

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ble-scan technique (van Steenberghe D., 2002)which allowed views of different objects at dif-ferent densities. The first scan was of the patientwith the interim denture, which included the ra-diopaque markers and the interocclusal record.The second scan was of the denture only with thesame orientation as in the mouth. The CT datawas converted into a file format compatible withthe planning program, having the two sets ofscans superimposed upon each other. One scanwas of the osseous tissues and the other of thecomplete denture, which showed the position ofthe planned denture teeth in relation to the bone.The reformatted data was returned to the surgicaland restorative team to determine and plan forthe implant positions. A 3-dimensional implantplanning software program the Procera SoftwarePlanning program (Nobel Biocare AS), follow-ing the Procera Cad-Design procedure, allowedthe clinicians to evaluate the osseous tissues inrelation to the ideal prosthetic position of thedenture teeth (Fig. 3). From this information, the

sizes and positions of the dental implants weredigitally evaluated and virtually placed (Ver-streken K., 1996) (Fig. 4). The surgical place-ment data was transferred to a milling center(Procera; Nobel Biocare) that fabricated and de-livered the surgical template (Nobel Guide, No-bel Biocare, AB) (Fig. 5) to guide the surgeon asto the precise positions of each dental implant(Parel S.M., 1991).

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Figure 3Procera Software Planning Program allows forprosthetic guided implant positioning.

Figure 5CAD/CAM manufactured surgical template.

Figure 4A 3-dimensional Procera Cad-design of surgicaltemplate after implant virtual positioning.

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Dental laboratory

The laboratory process consisted of fabricating aworking cast connecting implant replica to thesurgical stent and mounting the cast onto an ar-ticulator with the opposing cast using the origi-nal interocclusal record and radiographic guide.A new interocclusal record was made betweenthe surgical template and the opposing arch onthe articulator to facilitate positioning and totransfer the centric relation and occlusal verticaldimension information to the patient during sur-gery. Therefore an acrylic resin fixed completedenture reinforced with metal frame work toguarantee cross-arch stabilization of implantswas fabricated.

Surgical procedure

The surgical template was oriented in the patientusing a surgical index fitted to the opposing arch(Fig. 6) and stabilized with anchor pins (NobelBiocare AB). After placement of the surgical tem-plate, flapless implant surgery was performed, fol-lowing the manufacturer’s instructions, using adrill protocol (NobelGuide; Nobel Biocare AB).The surgical procedure was performed accordingto the Teeth-in-an-Hour concept (Nobel BiocareAB). The flapless surgery was performed underlocal anesthetic (Rocci A., 2003). The surgicaltemplate was inserted and positioned with the cen-tric relation interocclusal record. While the patientwas closed into the interocclusal record, friction-fitted horizontal stabilization pins (Procera; NobelBiocare) were used to help maintain the accurateposition of the surgical template during the surgi-cal procedure. The three horizontal stabilizationpins were placed through the surgical template ina preplanned horizontal direction into the osseoustissues.The l.5-mm twist drill was used to create reten-tive holes for the stabilization pins. The pinswere positioned, securing the surgical template,

and the patient was allowed to open his mouth.The first osteotomy site was prepared, adjacentto the most anterior implant site, using the appro-priate drilling guides and twist drills. The pre-planned length and diameter of the implant wasplaced using the implant guide. After insertion ofthe implant (Nobelspeedy Groovy®, Nobel Bio-care AB) with an oxidized surface (TiUnite; No-bel Biocare AS) a template abutment was insert-ed, which connected the surgical template to theplaced implant, providing additional stability tothe template. The next implant was inserted inthe opposite side of the arch, also adjacent to themost anterior implant to guarantee the cross sta-bilization of the surgical guide. After the implantwas placed, a second template abutment was in-serted. The three horizontal stabilization pins,and the two template abutments, ensured the sur-gical template’s stability and accurate position.The remaining implants were placed, using thesame drilling guides and twist drills (Fig. 7). Furthermore, there is consensus on the impor-tance of achieving adequate primary stability byplacing implants at insertion torque values of 35to 45 Ncm (Malo P., 2003). However, in moredense bone (classes D1 and 02, Lekholm andZarb index), insertion torque should not exceed50 Ncm to avoid bone overcompression and in-crease the risk of crestal bone loss. The minimal-ly-invasive approach of Nobel Guide surgicalprocedure allowed no bleeding or pain perform-ing surgery, and a healthy aspect of soft tissue af-ter implant placement (Fig. 8).

Figure 6Surgical template oriented in the mouth using asurgical index fitted to the opposing arch and sta-bilized with anchor pins.

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Prosthetic procedure

After all implants were placed, the pre-fabricatedtemporary prosthesis framework was inserted(Fig. 9). Vertically adjustable abutments (NobelBiocare AB) were used, which allowed for dis-crepancies in the z-axis. The adjustable abutmentis an interlocking cylinder sleeve with two piecesthat slide within one another. The sliding cylindersof the abutment allow for slight variations in the z-

axis position of the implant, allowing a passivelyfitting framework. Once the prosthesis was insert-ed, postoperative radiographs were made to con-firm the fit of the prosthesis (Fig. 10a-b-c). The re-taining screws were torqued at 35 Ncm into place,the occlusion was evaluated and adjusted to havesimultaneous centric relation contact and a canineprotected occlusal scheme (van Steenberghe D.,2002). In addition, provisional prostheses withnarrow occlusal platforms, flat cusps, and light oc-clusal contacts to minimize the lateral forces arerecommended (Rocci A., 2003) (Morton D., 2004)(Rangert B.R., 1997). The access holes weresealed with a cotton pellet and gutta-percha.

After surgery follow-up

Following the procedure, the patient was dis-charged home. The patients was enrolled in animplant maintenance program (Table I) and in-structed to eat a soft diet for 2 months. To beclassified as surviving, the implants were re-quired to fulfill the following criteria: clinicalstability, patient reported function without anydiscomfort, absence of suppuration, infection, orradiolucent areas around the implants at 10 daysand 2-4 months, post-surgically.

Figure 78 fixtures positioned and seated correctly on thesleeve of surgical template.

Figure 8Minimally invasive guided surgery results in min-imal postsurgical trauma of periimplant soft tis-sue.

Figure 9The pre-fabricated temporary prosthesis frame-work passively fitted on implants.

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Periapical radiographs were made at implant in-sertion and after 4 months. A conventional radi-ograph holder (Rinn RX Holder; Dentsply, Italy)was used, and its position was manually adjustedfor an estimated orthogonal position of the film.The reference point for the reading was the im-plant platform (the horizontal interface betweenthe implant and the abutment), and marginalbone remodeling was defined as the difference inmarginal bone level relative to the bone level attime of surgery. After 3 months, if the implants were judged sta-ble (Fig. 11) a conventional protocol was fol-lowed to take an impression for manufacturingthe definitive prosthesis. An impression using areversible hydrocolloid was made for a study castpoured in a gypsum stone. This study cast wasused to fabricate an open-top custom tray from alight-cured resin. At a subsequent appointment

impression copings (Nobel Biocare 29073) weretorqued (15 Ncm) to the implant. If the impres-sion copings seating could not be confirmed byvisual inspection, a radiograph was taken to ver-ify the seating prior to impression taking. Astone-impression is made using an impressionplaster (Snow White Plaster 2, Kerr) to obtainrigid splinting of impression copings and accu-rate reproduction of the soft tissue anatomy forthe fabrication of the master cast (Fig. 12). Lab-oratory analogs (Nobel Biocare 29108) were at-tached to the impression copings, and a soft tis-sue and stone master cast was fabricated. The es-thetics and phonetics of the definitive prosthesiswas dictated by the interim denture. The fullbridge was produced using CAD/CAM technolo-gy following Procera Zirconia Implant Bridgeprotocol. The full bridge framework was mod-eled with a wax-up procedure using an acrylic

Figure 10Postoperative radiographs were made to confirm thefit of the prosthesis, with vertically adjustable abut-ments seated on implant platforms.

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low shrinkage resin (Leocryl, Leone spa, Italy)(Fig. 13). The CAD design of the framework(Fig. 14) was obtained by tactile scan and relateddata was sent to the milling Center to produce de-finitive bridge from one blank of zirconia. Pro-cera Bridge Zirconia has a very high flexuralstrength and fracture toughness, these make zir-

conia very resistant to masticatory forces, stillwith mainteined exact precision of fit (SierraaltaM., 2006) (Fig. 15, 16).The biocompatibility of zirconia improve soft tis-sue healing and guarantees a soft tissue sealaround the neck of the implant (Fig. 17). The zirconia framework was prepared for porce-

Table 1 - Postsurgical protocol.

Day of surgery(Day 1) Evaluation of occlusion; instructions to avoid prosthesis overload; explana-

tion of treatment phases and maintenance procedures to the patient; oralhygiene procedures: administration of chlorhexidine mouthwash and applica-tion of chlorhexidine gel after surgery for 10 days; periapical radiographs

Day 10 Evaluation of occlusion;control of suppuration by finger pressure; instruc-tions to avoid prosthesis overload; oral hygiene procedures.

Day 45 Panoramic radiographs; removal of prosthesis for cleaning and disinfecting;evaluation for fracture or loosening of prosthetic components; control of sup-puration by finger pressure; instructions to avoid prosthesis overload; oralhygiene procedures.

Month 3 Evaluation of occlusion; evaluation for inflammation/infection; removal ofprosthesis for cleaning and disinfecting; impression; periapical radiographs;oral hygiene procedures

Month 4 Definitive prosthesis placement; panoramic and periapical radiographs.

Maintenance Protocol Periapical annual radiographs; oral hygiene procedures every 4-6 months wi-thout removal of prosthesis.

Figure 11Periimplant soft tissue healing at 3 months aftersurgery and immediate loading.

Figure 12Stone impression of the implants with an open topimpression tray.

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lain application and the definitive prosthesis wasseated in the mouth and torqued with special zir-conia screws at 35 Ncm (Fig. 18a-b-c).

Discussion

The Teeth-in-an-Hour protocol is a unique solu-tion made possible by the Procera System. Withthe aid of the CT scans and a virtual planningsoftware, a custom fabricated precision drill

Figure 14The CAD design of the framework obtained by tac-tile scan.

Figure 15Procera Zirconia Implant Bridge made with CAD/CAM tecnology.

Figure 13The full bridge framework was modeled with awax-up procedure using an acrylic low shrinkageresin.

Figure 16High precision and accuracy of fitting on implantplatform of Zirconia implant Bridge.

Figure 17Full arch Zirconia framework try-in.

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guide and a pre-manufactured prosthesis can bemade before surgery. During the clinical and dig-ital planning stage most treatment decisions aremade with regard to prosthesis design and im-plant placement. The execution of implant place-ment is performed with a flapless procedure thatresults in minimal surgical intervention. This re-sults in a short and non-traumatic surgery with aminimum of postoperative complications, allow-ing the patient to leave the chair with a fixedprosthesis. The patient was elated with the shortsurgery time and remarked postoperatively at theuneventful short recovery with minimal discom-fort. Flapless surgery means less chance ofswelling, less pain, and faster initial healingtimes. Surgical complications can include plan-ning and placement of the implants too deeply in-to the osseous tissues, making it difficult to seatthe prosthesis. It is critical to ensure the osseoustissue is cleared around the placed implant, al-lowing the abutment to be completely seated.

This procedure may be contraindicated for pa-tients with limited oral opening. The surgical ar-mamentarium is longer than traditional drill kitsand access may be difficult. Utilizing the latest scanning, CAD/CAM andmanufacturing technologies the dental team isable to develop individualized dental restorationwith high accuracy and precision of fit (Fig. 19a-b-c). This new protocol simplifies the operativeprocedure of total arch reconstruction and allowstransition from severe ridge resorption and fail-ing conventional dentures to an implant fixed de-finitive prosthesis within 4 months (Fig. 20).

Acknowledgement

The authors wish to thank Mr. Alberto Bonaca,Dental technician, Perugia (Italy), for his preci-sion and accuracy in performing all the laborato-ry phases of the treatment.

Figure 18Completed Procera Zirconia Implant Bridge interoc-clusal lateral and frontal view: ideal implant position-ing respecting volume emergence profile of definitiveprosthesis.

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Figure 19Periapical radiographs made to confirm the fit andthe accuracy of definitive Procera Zirconia ImplantBridge prosthesi.

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Figure 20Final radiograph.

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Correspondence: Dott. Alessandro PozziViale Liegi 4400198 RomeE-mail: info@studioalessandropozzi.comWebsite: www.studioalessandropozzi.com

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