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 Table of Contents  
REVIEW ARTICLE
Year : 2013  |  Volume : 2  |  Issue : 3  |  Page : 159-167

Implant hygiene and soft tissue management: Dentist's perspective


1 Department of Prosthodontics, J. S. S. Dental College and Hospital, Mysore, Karnataka, India
2 Department of Orthodontics and Dentofacial Orthopedics, J. S. S. Dental College and Hospital, Mysore, Karnataka, India

Date of Web Publication25-Oct-2013

Correspondence Address:
S Meenakshi
Department of Prosthodontics, J. S. S. Dental College and Hospital, Mysore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.120584

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  Abstract 

Osseointegration is the treatment modality opted in the rehabilitation of partially or fully edentulous patients. However, the surrounding tissues may be subject to inflammatory conditions, similar to periodontal disease, and so requires maintenance. The dental personnel should have current knowledge about methods of safely instrumenting implants and knowledge of available products, which could be safely recommended to patients to initiate effective home care of implants. It can be challenging to achieve effective oral hygiene around dental implants over the long term, and the patient, dentist, and dental hygienist must exercise considerable effort to achieve the desired results. This article discusses the background, etiology, diagnosis of peri-implant diseases, maintenance, care of osseointegrated implants.

Keywords: Peri-implant mucositis, peri-implantitis, plastic probe, periotest, resonance frequency analysis


How to cite this article:
Meenakshi S, Raghunath N, Gujjari AK. Implant hygiene and soft tissue management: Dentist's perspective . Int J Health Allied Sci 2013;2:159-67

How to cite this URL:
Meenakshi S, Raghunath N, Gujjari AK. Implant hygiene and soft tissue management: Dentist's perspective . Int J Health Allied Sci [serial online] 2013 [cited 2022 Oct 2];2:159-67. Available from: https://www.ijhas.in/text.asp?2013/2/3/159/120584


  Introduction Top


Traditional implant maintenance in the past has included clinical assessment of plaque control and radiographic evaluation of the crestal bone levels. Additionally, it was important to determine the integrity of the connection of the prosthesis to the abutment and the abutment to the implant body. The advent of single tooth and cemented restorations, early and immediate loading, the variety of abutment designs, and a shift in focus to more cosmetically -acceptable restorations has necessitated the development of changes in the concepts of implant maintenance.

To ensure the continued maintenance of optimum intraoral health, the dental team must understand how to assess the health of the peri-implant tissues, the alveolar bone housing, and the common restorative components associated with dental implants.

Some of the important issues to be considered at every dental implant maintenance appointment are discussed below:


  Peri-Implant Anatomy Top


The integrity of the soft tissue with the implant is critical in sealing the intraoral environment from the endosseous part of the dental implant. [1] The clinician should understand the similarities and distinctions between the dental implant and the natural tooth. Subsequently, by examining the similarities and differences between a natural tooth and a dental implant, basic guidelines can be provided for maintaining the long-term health of dental implants. The biologic soft tissue seal (biologic width), which is analogous to the epithelial attachment of the tooth, protects the implant-bone interface by resisting the bacterial irritants and the mechanical trauma resulting from restorative procedures, masticatory forces, and oral hygiene maintenance. [2] The soft tissue that forms the coronal part of a dental implant is about 3 mm in corono-apical direction and consists of two zones, epithelium and connective tissue. The outer surface of the peri-implant mucosa generally is covered by keratinized stratified squamous epithelium that is analogous to the gingiva [Figure 1].
Figure 1: Peri-implant anatomy

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The vascular supply to the peri-implant mucosa is derived solely from the alveolar supraperiosteal blood vessels as there is no contribution from a periodontal ligament. The remaining 1-1.5 mm of soft tissue margin, between the apical portion of the epithelium and the alveolar crest bone, is composed of connective tissue. The connective tissue adjacent to the implant is rich in collagen and is relatively acellular and avascular, making it histologically similar to scar tissue. [3]


  Peri-Implant Disease Top


Implants, like teeth, are susceptible to bacterial plaque accumulation and calculus formation. Lack of connective tissue fiber insertion and decreased vascular supply around the implant, there may be greater susceptibility to plaque-induced inflammation. [4] Plaque will form on implant surfaces as soon as they are exposed to the oral cavity. The initial pellicle formation on implants is similar to that on natural teeth. Data suggests that periodontal pathogens such as spirochetes may be transmitted from residual teeth to implants within 6 months of implant placement. [5],[6] Proliferation of these pathogens can result in an inflammatory response and may lead to peri-implant infections.

The mucosa surrounding the implant exhibits an inflammatory response to plaque formation in a similar fashion as the gingiva that surrounds the natural teeth. Although the formation of biofilm and the initial inflammatory response between the dento-gingival structures and the gingivo-implant structures are similar, studies have shown that the pattern of spread of inflammation differs. [7] The presence of smaller numbers of fibroblasts in peri-implant tissues, resulting in the inflammatory cell infiltrate extending into the bone marrow spaces of the alveolus. Thus, it has been suggested that the peri-implant mucosa is less effective than the gingiva in preventing further progression of the plaque-induced lesion into the surrounding bone. This progression can lead to peri-implantitis and potential failure of the implant. [8]

Osseointegration is defined as the direct anchorage of an implant to alveolar bone, which provides a foundation to support a dental prosthesis and in turn transmits occlusal forces to the alveolar bone. [9] The focus of implant dentistry involves obtaining osseointegration, which is highly predictable, together with the long-term maintenance of health of the peri-implant hard and soft tissues. This can be achieved by a combination of appropriate professional care and patient cooperation via effective home care. [10] Patients must accept the responsibility for implant maintenance. Therefore, the patient selection process should take into account the patient's willingness to maintain the fixture and restoration.


  Dental Implant Maintenance and Recording Top


The purpose of the maintenance appointment should be to identify if there is a problem or potential problem that needs attention. Proper monitoring and maintenance is essential to ensure the longevity of the dental implant and its associated restoration through a combination of appropriate professional care, evaluation, and effective patient oral hygiene. A proper referral can be made with comprehensive recording and will benefit in arriving at a correct diagnosis and treatment. Periodic evaluation of the dental implant is vital to its long-term success. The following factors must be evaluated at each maintenance appointment:

Presence of plaque and calculus

Evidence from animal studies has showed that the main predisposing factor in the etiology and pathogenesis of peri-implant disease is microbial colonization. [11] Therefore, it is logical to monitor oral hygiene habits by routinely assessing plaque accumulation around dental implants. The peri-implant tissues cascade from peri-mucositis to peri-implantitis in a similar progression to that of gingivitis and periodontitis around the natural tooth. [12] However, peri-implant infections can progress more rapidly than infection around natural teeth, a key consideration in the recommended three-month implant maintenance appointments, especially in the first year following placement of an implant

prosthesis [13] [Figure 2].
Figure 2: Presence of calculus

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Examination of peri-implant soft tissue (Visual soft tissue assessment)

The clinical appearance of peri-implant tissues is another evaluation that should be completed during a routine maintenance visit. Redness, swelling, and alterations of color, contour, and consistency of the marginal tissues may be signs of peri-implant disease. A study recommends the use of the 0'Leary index, a visual measure for periodontal tissue condition. Usage of index is important rather than the choice of index. [14] Assessment and any tissue changes should be recorded in the patient's records as well as intra-oral photographs should be taken. This photograph or digital image can be used to help educate the patient about what healthy tissue looks like and, if any inflammation is present, can be an excellent visual tool to reinforce the importance of good home-care.

Visual examination upon probing

Peri-implant probing depth should be measured routinely during maintenance appointments. [15] Measurement of probing depth around implants is more sensitive to force variation than around natural teeth. [16] Therefore, less probing force (0.2-0.3 N) is recommended around implants. Some implant surgeons recommend not probing the implant, or waiting three months, following abutment attachment to avoid disrupting the peri-mucosal seal. The peri-mucosal seal is fragile, and penetration during probing can introduce pathogens and jeopardize the success of the implant [Figure 3].
Figure 3: Probing the gingival sulcus around natural teeth

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The advantages of probing are:

Simplicity of the method, the immediate availability of results and helps to demonstrate topographic disease patterns, thus making probing an indispensable part of implant maintenance assessment. [17]

Guidelines to be followed when probing the tissue surrounding the implant;

  1. Flexible plastic probe is recommended to reduce the risk of scratching the implant's surface [Figure 4]. The probe is placed parallel to the long axis of the implant [Figure 5] and [Figure 6]
  2. Flexible plastic probe reduces the potential trauma to the peri-mucosal seal [Figure 7]
  3. Usage of the probe as a measuring device - Use of a fixed reference point on the implant abutment or prosthesis for a reliable measurement of attachment levels.
Figure 4: Use of plastic probe

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Figure 5: Proper per implant probing

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Figure 6: Iatrogenic pseudo pocket

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Figure 7: Measuring the keratinized gingiva. The metal probe should not be used to probe the implant

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Successful implants generally have a probing depth of 3 mm, whereas pockets of 5 mm or more serve as a protected environment for bacteria and can exhibit signs of peri-implantitis. [18] Peri-implant probing attachment level correlates with radiographically measurable peri-implant bone changes. It is recommended that probing should be a part of each maintenance recall appointment. [19]

Bleeding on probing

Another suggested parameter for evaluation of the status of the implant during maintenance is the presence of exudates or bleeding on probing. Bleeding on probing indicates inflammation of soft tissue, whether around natural teeth or implants. Though bleeding on probing has been found to be a poor predictor of progression of periodontal disease, its absence at successive maintenance visits is a good positive indicator of lack of attachment loss. [20]

Radiographic examination

Radiographic interpretation of peri-implant alveolar bone has proven to be one of the most valuable measures of implant success. [21] Radiographic interpretations is particularly important:

  1. To evaluate initial osseointegration
  2. Seating of abutments [Figure 8]
  3. Fit of prostheses
  4. Baseline bone level evaluation following completion of prosthetic treatment
  5. Longitudinal evaluation of bone levels.
Figure 8: Radiograph of implant with seated restoration clearly in focus

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A combination of peri-apical and panoramic radiographs could be recommended. [20] In the final analysis, the choice of imaging modality must be tailored to the clinical and anatomic circumstances of the individual patient. A stable landmark has to be identified for each fixture evaluated. For one-stage transmucosal implant systems, the implant shoulder or the collar contour is taken as the stable landmark or apical termination of the cylindrical portion of the implant for two-stage submerged implant systems. [21] The implant threads on the screw-type fixtures can be used as a reference to compare osseous peri-implant dimensional changes between on-going series of radiographs. When making measurements form radiographs, allowance must be made for dimensional distortion, which may vary considerably. [22]

Normally, a post-operative radiograph is taken immediately after implant placement to verify position and to provide benchmark for future comparisons. The recommended intervals at which the radiographs have to be made are at 1, 3, and 5 years with films obtained thereafter based on the clinical situation. [20] Progressive bone loss around a dental implant that exceeds these averages may be indicative of an ailing or failing implant.

The radiograph should reveal bone in close opposition to the implant body. Anticipated crestal bone loss for the first year after insertion is approximately 1 mm, with an average of 0.1 mm subsequent bone loss per year [Figure 9].
Figure 9: Radiograph documentation of peri-implant bone loss

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Rapid bone loss, which may not be radiographically evident, may be associated with fractured fixtures, initial osseous trauma during insertion, stress concentrated at the marginal bone by over tightening of fixtures during placement, trauma from occlusion, poor adaptation of prosthesis to abutment, normal physiologic resorption, and plaque-associated infection. [23]

Platform switching is the new concept used to preserve alveolar bone levels around dental implants. The concept refers to placing restorative abutments of narrower diameter on implants of wider diameter, rather than placing abutments of similar diameters, referred to as platform matching[24] [Figure 10].
Figure 10: Platform switching

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Occlusal evaluation

The occlusal status of the implant and its prosthesis must be evaluated on a routine basis. Occlusal overload could result in loosening of abutment screws, implant failure, and prosthetic failure. The occlusion also should be evaluated at every maintenance appointment. It has been established that abnormal occlusal loading will negatively affect the various components of the implant-supported prosthesis. [25] Any signs of occlusal disharmonies, such as premature contacts or interferences, should be identified and corrected to prevent occlusal overload. The implant-protected occlusion should have light centric contact with no contacts on lateral excursions. A check of occlusion should hold shim stock only with hard clinched teeth. Excessive concentrated force can result in rapid and substantial peri-implant bone loss.

Mobility

Specific clinical criteria associated with dental implants that should be monitored for an indication of early implant failure have not been clearly defined. Currently, the presence of fixture mobility is the best indicator of implant failure. [26] As stated earlier, healthy dental implants exhibit no mobility because of the absence of a periodontal ligament. Therefore, healthy implants should demonstrate lack of mobility, even in the presence of peri-implant bone loss, if an adequate amount of supporting alveolar bone still exists. An electronic mobilometer called the PERIOTEST is available from Siemens, Germany. This instrument indicates levels of mobility of root form implants. Readings from -7 to +18 are representative of movement too imperceptible to be clinically detectable. When mobility readings are +9 and above, implants with even the best of radiographic findings must be evaluated and treated. The Periotest offers a more reliable method of diagnosing implant status by measuring levels of subclinical mobility. [27]

Resonance frequency analysis

The implant stability could also be measured through a user-friendly, non-invasive, reliable, and clinically applicable technique called resonance frequency analysis (RFA) invented by Meredith and co-workers in 1996. [28]

A commercially available electronic device, based on RFA, with the trade name OSSTELL, is used widely for clinical and experimental purposes.

The results are presented as the implant stability quotient. The implant stability quotient unit is based on the underlying resonance frequency and ranges from 1 (lowest stability) to 100 (highest stability). [28]

Subjective symptoms

It is important to discuss patient comfort and function at each maintenance appointment. Pain or discomfort may be one of the first signs of a failing implant, usually presenting with mobility. [29] A fractured or loosened screw should be the first suspicion when a patient complains of a loose implant or discomfort.

Patient should be placed on a regularly scheduled, individually designed maintenance program including monitoring of the peri-implant-supported prosthesis and plaque control. [27] An established protocol suggests 3-month recall visits to limit disease progression and to allow treatment of disease at an early stage, especially if the patient has lost teeth because of periodontal disease. After the first year, the maintenance interval can be extended to 6 months if the clinical situation seems stable. [30] The clinician must be cognizant of each patient's level of home care effectiveness, systemic health, and status of the peri-implant tissues when determining these intervals.


  Maintenance of Dental Implant Top


Implants and implant prosthetic devices and suprastructures are different from normal gingival and tooth contours and relationships and produce a situation that demands special, detailed instruction and stressing of optimal home care procedures.

Thomson-neal and others have evaluated the effects of different prophylactic modalities on different implant surfaces such as commercially pure titanium (CPT), titanium alloy, and hydroxyapatite-coated titanium. They found that metal or ultrasonic instruments caused the titanium and hydroxyapatite-coated surfaces to be scarred and pitted in a random fashion, whereas anti-microbials and hand or motorized tooth brushes produced little change in surface appearance from the original unused surfaces. [27]

Based on the condition of the tissue and the assessment of the presence of plaque and calculus around implants, a thorough review of oral hygiene instructions should be implemented. Ideally, a home care assessment should be made before the implant fixture is placed surgically. It is important to use and recommend home care aids that do not alter the implant abutment surface and are safe and effective with daily use. [30] The clinical situation and the type of implant influence the timing of initiating home care measure.


  Oral Hygiene Instructions - Levels of Therapy Top
[31],[32]

Together with the hygiene armamentarium, the home care techniques used to maintain endosseous dental implants are also equally important. Patients should be taught the modified bass technique of brushing using a medium-sized head, soft-bristled toothbrush. Instructions should be given regarding the proper use of interdental brushes. The plastic-coated wire brush is the only type of interdental brush to be used with dental implants, since these brushes will not scratch the implant surface. At different levels of surgical and post-surgical phase, the oral hygiene instructions vary depending on the needs and dexterity of the patient.

Level 1

During healing periods, when mechanical plaque control is contraindicated, chemical agents (chlorhexidine) should be used.

Level 2

In level 2, implant is exposed and healing cuff is placed to promote tissue maturity. At this stage, rinsing with chlorhexidine twice-daily together with the implementation of mechanical debridement with tooth brush is recommended.

Level 3

When tissue has healed and final restoration is delivered, modify and reinforce home care principles-depending on the access to implant, dexterity of patient, and design of final restoration. A variety of devices, including soft-bristled brushes, dental floss, and interproximal brushes with a nylon-coated core wire, may be used [Figure 11].
Figure 11: Use of soft bristled brush

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Patients with limited dexterity - There are evidence that certain electromechanical brushes may be superior to manual brushing for many patients. [33]

Interdental aids

Depending on the accessibility to implants-smaller-diameter toothbrush heads such as end-tufted brushes or tapered rotary brushes may be of benefit in difficult-to- assess areas [Figure 12].
Figure 12: Interdental brush for maintenance of implant-based fixed prosthesis

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Dental floss: Proxy-Floss (AIT Dental, USA) is an elastomeric material made up of hundreds of semi-circular flanges that bend and flex to remove plaque and debris or to apply chemotherapeutic agents. The elastomeric nature of this product prevents it from collapsing, snagging, or shredding. [34] The floss can be used to deliver chlorhexidine by inserting it around the buccal surface of implant, threaded around the lingual aspect and crossed back to buccal to completely surround the abutment [Figure 13],[Figure 14] and [Figure 15].
Figure 13: A length of floss has been threaded through the mesial contact point between the implant crown and the adjacent natural tooth and looped back through the distal contact point

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Figure 14: The ends of the floss are crossed over on the labial aspect to encircle the implant crown

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Figure 15: By apically directing the ends of the floss, a slight sawing action, the floss penetrates the sulcus of the peri-implant mucosa to effect the sub-mucosal debridement

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In wide embrasures- gauze strips yarn/thicker dental floss assist in plaque control [Figure 16].
Figure 16: Tufted floss

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Plaque control in a single tooth replacement is simple. Adequate oral hygiene is required for all natural teeth to maintain health and to prevent pathogens emergence that can rapidly destroy the delicate peri-implant tissue.

A prosthesis that is fixed to implants and cannot be removed requires more detailed home care. Access to implants is limited by esthetic demands. Powered tooth brushes, floss with threaders, interdental aids can be used to deliver chemotherapeutics in inaccessible areas [31] [Figure 12].

Patient self-care of implants in case of removable implant-supported prosthesis - Both implant and prosthetic attachments could be cleaned as part of oral hygiene program. A nylon flossing cord is abrasive enough to remove calculus and is indicated for abutment surface, ball attachments, and ridge bar. All surface of prosthesis should be cleaned with stiff nylon denture brush daily. [32]

In addition to the evaluation, the maintenance appointment also should include:

  1. A thorough review of oral hygiene reinforcement and modifications
  2. Deposit removal from implant/prosthesis surfaces
  3. Appropriate use of anti-microbials
  4. Re-evaluation of the present maintenance interval, with modification as dictated by the clinical presentation.



  Dental Implant Instrumentation Top


Proper implant instrumentation includes removing microbial deposits without altering the implant surfaces or adversely affecting biocompatibility. Scratches and gouges may affect the titanium-oxide layer, reducing the corrosion-resistant nature of a titanium implant. The implant surface can also become contaminated with trace elements from the scaler material that remains, which can compromise the long-term osseointegration of the implant. [33] Plastic graphite and titanium scalers are all within safe limits for instrumenting on implant surfaces [31],[33],[34] [Figure 17].
Figure 17: Plastic scaler graphite scaler gold tipped metal scaler

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An ultrasonic tip may be used only with a plastic covering that prevents gouging and disturbing the titanium surface. Polishing of the visible portion of the implant can be accomplished with rubber cups and non-abrasive paste of tin oxide. Scaling should be with short working strokes and light pressure to prevent trauma to delicate peri-implant sulcus. Blades should be engaged apically with the strokes extending coronally. [34],[35],[36],[37]

A 6-month study was conducted to examine the effect of a 0.3% triclosan/2% copolymer dentifrice on oral biofilms and gingival inflammation (GI) on dental implants and peri-implant tissues. It was concluded that usage of a triclosan/copolymer dentifrice twice-daily may enhance dental implant maintenance by reducing dental plaque and gingival inflammation. [38]

Antiseptic mouth rinses containing phenol-based therapeutic ingredients have been found to reduce plaque, gingivitis, and bleeding of peri-implant tissues significantly but do not improve probing depth or attachment level. [29],[31],[32]


  Conclusion Top


The long-term success of the dental implants requires the maintenance of healthy peri-implant tissues. Periodic clinical assessment of the implant fixture, prosthesis, and surrounding tissue is critical to clinical success. [36] For this reason, good oral hygiene and regular professional care are essential to maintain implants. The patient along with the clinician should involve in the maintenance of implants by following stringent home care for the long-term success of dental implants. [37] Together with the surgical phase of treatment, implant maintenance and effective home care can be considered as two other factors for implant success. It seems prudent to recommend the routine implementation of an active maintenance program tailored to the circumstances of each individual patient.

 
  References Top

1.Lindhe J, Berglundh T. The interface between the mucosa and the implant. Peri 1998;17:47-54.  Back to cited text no. 1
    
2.Sclar AG. Beyond osseintegration. Soft tissue and esthetic considerations in implant therapy. Chicago: Quintessence Publishing Co.; 2003.  Back to cited text no. 2
    
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4.Lindhe J, Berglundh T, Ericsson I, Liljenberg B, Marinello C. Experimental breakdown of peri-implant and periodontal tissues. Clin Oral Implants Res 1992;3:9-16.  Back to cited text no. 4
    
5.Aspe P, Ellen RP, Overall CM, Zarb GA. Microbiota and crevicular fluid collagenase activity in the osseintegrated dental implant sulcus: A comparison of sites in edentulous and partially edentulous patients. J Peridontal Res 1989;24:96-105.  Back to cited text no. 5
    
6.Quirynen M, Listgarten MA. Distribution of bacterial morphotypes around natural teeth and titanium implants ad modum Branemark. Clin Oral Implants Res 1990;1:8-12.  Back to cited text no. 6
    
7.Berglundh T, Lindhe J, Marinello C, Ericsson I, Liljenberg B. Soft tissue reaction to denovo plaque formation at implants and teeth. An experimental study in the dog. Clin Oral Implants Res 1992;3:1-8.  Back to cited text no. 7
    
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38.Sreenivasan PK, Vered Y, Zini A, Mann J, Kolog H, Steinberg D, et al. A 6-month study of the effects of 0.3% triclosan/copolymer dentifrice on dental implants. J Clin Periodontol 2011;38:33-42.  Back to cited text no. 38
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17]



 

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