ninand muley article

8/12/2019 Ninand Muley Article

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Review Article doi: 10.5577/intdentres.2012.vol2.no2.3

International Dental Research 2012 37

The Evolution of External and InternalImplant Abutment Connections: A Review

D.R. Prithviraj, Ninad Muley, Vikas Gupta1 MDS, Professor, Head of Dept. of Prosthodontics govt. Dental College and Research Institute, Bangalore, INDIA2 Post Graduate Student, Dept. of Prosthodontics govt. Dental College and Research Institute, Bangalore, INDIA3 Post Graduate Student, Dept. of Prosthodontics govt. Dental College and Research Institute, Bangalore, INDIA

Key WordsImplant abutment interface,external hexagon, internal hexagon,spline dental implant, morse taperimplant.

Correspondence:D.R. Prithviraj,Dept. of Prosthodontics govt.Dental College and ResearchInstitute, Bangalore, INDIA.

e-mail: [email protected]

Abstract

A study of the implant abutment connection is of great importancebecause it is the primary determinant of the strength and stability ofan implant-supported restoration, which, in turn, determines therestorations prosthetic stability. Traditionally, Brnemarks externalhexagon has been used, but significant complications, such asabutment screw loosening, rotational misfit at the implant abutmentinterface, and microbial penetration have led to modification of theexternal hexagon and the development of internal implant abutmentconnections. In this review, we describe various implant abutmentconnections that have evolved over time from the traditional externalhexagon.

(Int Dent Res 2012;2(2):37-42)

Introduction

The foundation of implant dentistry dates to theestablishment of the Brnemark Protocol in theUnited States in the 1980s. Since then, implantdentistry has evolved continuously from the originalprotocol to include various techniques andapplications (1,2). This evolution has been possible

because numerous investigators have documentedbiological factors, surgical procedures, andrestorative principles that influence the outcome ofimplant restorations, widening the application ofimplant dentistry from the restoration of a singletooth to the replacement of multiple missing teethwith predictable success (3,4). The mechanicalprinciples governing implant restorations have alsobeen defined clearly and are well understood (5,6).Improvement in restorative principles and betterunderstanding of the perceived outcome of implanttherapy have led to the development of the conceptof restoration-driven implant dentistry (7).

The original Brnemark Protocol involved a two -stage surgical procedure and was designed to

restore a completely edentulous mandibular arch(8). The first step involved the placement of atitanium screw into viable bone, followed by anundisturbed healing period of at least 3 months. Thenext step involved exposure of the implant,attachment of a transmucosal element, and the

connection of the implant to the prostheticcomponent of the restoration. In this protocol, theimplant abutment interface was an externalhexagon with a 0.7-mm height that served as atorque transfer coupling device (fixture mount)during the initial placement of the implant into thebone and the subsequent connection of thetransmucosal extension, which, when performed insequence, could effectively restore a completelyedentulous arch. Although the external hexagonserved these purposes, it was not an effective anti-rotation device (9) and was not designed towithstand intraoral forces directed at the crowns(10). These properties are required when implantsare used to restore partially edentulous arches or a
mailto:[email protected]:[email protected]


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External and Internal Implant Abutment Connections D.R. Prithviraj et al.

38 IDR Volume 2, Number 2, 2012

single missing tooth. Thus, implant manufacturerscompensated for these limitations by changing thetype of screw used (e.g. with regard to its geometry,height, and surface area), the precision of the fitover the hexagon, and the amount of torque used tosecure the screw (11-13).

To overcome the inherent deficiencies of theexternal hexagon, a variety of implant abutmentconnections have also been derived from the originaldesign. The goals of new designs have been toimprove connection stability throughout theplacement and functional periods, and to simplifythe armamentarium necessary for the clinician tocomplete the restoration. The implant abutmentinterface determines joint strength and lateral androtational stability (14), and joint stability is one ofthe most important parameters affecting the successof implant therapy.

Several implant abutment connection designsare now available, and the clinician faces thechallenge of choosing an appropriate implant systemand connection design. This literature reviewdiscusses the evolution of various implant abutmentconnections, from the traditional external hexagonalimplant to Morse taper implants, with the aim ofproviding the clinician with an overview ofcommercially available implant abutmentconnections.

Search strategy

The MEDLINE database was searched toidentify relevant articles published between 1980and 2011. Key words such as implant abutmentinterface, external hexagon implant, internalhexagon implant, and Morse taper implant wereused alone and in combination to search thedatabase. The related articles option was also used.The reference lists of review articles and the mostrelevant papers were also searched. This electronicsearch was supplemented by manual searches of

journals relevant to the field of implant dentistry,

such as the International Journal of Oral andMaxillofacial Implants, the Journal of OralImplantology, and Clinical Oral Implants and RelatedResearch.

The implant abutment interface

Implant abutment connections may be internalor external; external connections feature a distinctprojection external to the implant body (Fig. 1),whereas internal connections are recessed into theimplant body (Fig. 2).

Figure 1. An external implant abutment connection

Figure 2. An internal implant abutment connection

The connection can be characterised further as

a slip-fit joint, where a slight space exists betweenthe mating parts and the connection is passive, oras a friction-fit joint, where no space exists betweenthe mating components and the parts are literallyforced together.

The contact between mating surfaces ischaracterised further as a butt joint, which consistsof two flat surfaces contacting one another at a rightangle, or a bevel joint, where the surfaces areangled internally or externally. The joined surfacesmay also incorporate a rotational resistance andindexing feature and/or lateral stabilising geometry.

This geometry is further described as octagonal,hexagonal, conical, cylindrical hexagonal, or spline.


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D.R. Prithviraj et al. External and Internal Implant Abutment Connections


External implant abutment connections

Brnemarks original implant abutmentconnection was an external hexagon with a 0.7-mmheight that acted as a coupler and torque transferdevice. The original Brnemark Protocol was

developed for the restoration of completelyedentulous arches using a series of implantsconnected by a metal bar.8

The applications of implant dentistry haveexpanded from the original restoration of completelyedentulous arches to the use of fixed partialdentures, single-tooth replacement, maxillofacialrestoration, and a myriad of other applicationslimited only by the clinicians ingenuity and skill (15,16). Significant clinical complications ofBrnemarks external hexagonal connection (9,17,18) make it unsuitable for these applications.Thus, the external hexagon has evolved, bynecessity, into a prosthetic indexing and anti-rotational mechanism.

Since its introduction by Brnemark, theexternal hexagon has undergone a number ofmodifications and is now available in heights of 0.7,0.9, 1.0, and 1.2 mm and with flat flat widths of2.0, 2.4, 2.7, 3.0, 3.3, and 3.4 mm, depending onthe implant platform (8). Tapered hexagons,external octagons, and spline dental implants (19)are also now available.

Tapered hexagon

This design was developed with the aim ofimproving the fit between the implant and abutmentby incorporating a 1.5 taper to the flat surface ofthe hexagon and a corresponding close-tolerancehexagonal abutment recess that is friction-fittedonto the hexagon. It was first introduced as theSwede-Vent TL by Paragon Implant Company(Encino, CA, USA). The manufacturer claimed that itgreatly reduced the rotational freedom between theimplant and the abutment, thereby reducing theincidence of screw loosening.

External octagon

The external octagonal implant abutmentconnection was first marketed commercially as aone-piece implant with a narrow diameter (3.3 or3.5-mm; ITI Narrow Neck; designed to replace themandibular anterior teeth. The tall, octagonalextension allowed for 45 rotation. Themanufacturer claimed that the implant had goodlateral and rotational resistance and strength, but norelevant study supporting these claims is available.

Spline dental implant

The spline dental implant (19) system wasdeveloped in 1992 by Calcitek (Carlsbad, CA, USA).Six spline teeth project outward from the implantbody and fit into six grooves between the

projections from the corresponding abutment,providing a snug fit between the implant andabutment and excellent locational accuracy.

Internal implant abutment connections

Internal implant abutment connections weredeveloped to overcome the clinical complicationsassociated with external connections (9,17,18). Thegoals of the new designs were to improveconnection stability throughout the placement andfunctional periods, and to simplify thearmamentarium necessary for the clinician tocomplete the restoration. One of the first internalhexagonal implants, the Core-Vent implantdeveloped by Niznick in 1986, featured a 1.7-mm-deep hexagon below a 0.5-mm- wide 45 bevel(20,21). The design was demonstrated to distributeintraoral forces deep within the implant, therebyimproving implant abutment joint stability (20,21).

Internal connection implants can be subdividedinto the following groups for the purpose of

explanation.

Passive fit/slip-fit joint (space exists betweenmating components)

1)Six-point internal hexagona) Core-Vent, / Screw vent, Centerpulse Dental

Inc.b) Frialit-2, Dentsply Friadent

2) 12-point internal hexagona) Osseotite CERTAIN, 3i Implant Innovations,

Inc.

3) Internal tripoda) CAMLOG, Altatec Technologiesb) Replace Select, Nobel Biocare

4) Internal octagona) Omniloc, Sulzer Calcitek Inc.

Friction fit (no space between matingcomponents)

5) Locking taper/Morse tapera) 8 taper (IT I Straumann, Avana, 3i TG,

Ankylos)b) 11 taper (Astra) c) 1.5 tapered rounded channel (Bicon).


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Six-point internal hexagon

This design is the most common type ofcommercially available internal implant abutmentconnection. It consists of a hexagon recessed intothe body of the implant. Because the internal

geometry is hexagonal, the abutment can fit overthe implant at every 60 of rotation, but not at anintermediate angle. Thus, abutment positioning ispossible at six different implant positions.

This type of implant abutment connection isavailable commercially from several manufacturers.Centerpulse Dental Inc.offers screw-vent implantswith a 1.2-mm-long internal connection. Thistapered implant has evolved from the original core-vent implant and has a hollow basket design. Themanufacturer claims that this new design simplifiesinsertion and increases initial stability in soft bonewhen used according to a patented surgicalprotocol, in which the tapered implant is insertedinto a straight socket.

An internal hexagonal connection (Frialit-2)is also available commercially from DentsplyFriadent. The manufacturers claim that the Frialit-2system combines the advantages of a cylindricalimplant and an internal connection. The cylindricalconnection is claimed to provide lateral loadresistance, resistance to joint opening, protection ofthe abutment screw, and high strength, and theinternal hexagonal connection is claimed to provide60 indexing and rotational resistance.

12-point internal hexagon

The 12-point internal hexagonal design, alsomarketed by some manufacturers as an offsethexagonal design, provides the greatest freedomduring abutment placement over the implant. The12-point double internal hexagon provides anopportunity to place the abutment on the implant atevery 30 of rotation, and is thus useful when usingangled abutments. It provides a greater opportunityto correct off-axis angulation of the abutment withrespect to the implant. One such implant, theOsseotite CERTAIN, is marketed by 3i ImplantInnovations, Inc., (Palm Beach Gardens, FL, USA).

Internal tripod

This type of implant abutment connectionhas a triangular internal geometry. A majordisadvantage of this system is that it allows forabutment positioning over the implant only at 120of rotation. This type of implant abutmentconnection was introduced by Nobel Biocare as theReplace Select tri-channel implant system. It isavailable in four diameters (3.5, 4.3, 5, and 6 mm)and is colour-coded for ease of identification. It is

claimed to provide a precise fit of the abutment overthe implant and to have excellent lateral stability.

The CAMLOG implant system (AltatecTechnologies), is an internal tripod implant abutment connection. The length of the internalconnection is 5.4 mm. It is claimed to have a tube

in tube effect that provides an accurate,mechanically secure implant abutment connectionwith anti-rotational stability.

Internal octagon

The internal octagonal implant systemallows for implant positioning over the abutment atevery 45 of rotation. The internal octagonalconnection was introduced as the Omniloc systemby Sulzer Calcitek Inc.. The octagonal connectionhas thin walls, a 0 6-mm length, and a small

diameter that create a geometric profile similar tothat of a circle, offering minimal rotational andlateral resistance during function. Because of thesedisadvantages, it is no longer marketed.

Friction fit (Morse taper implants)

The Morse taper implant abutmentconnection features a tapered projection from theabutment that fits into a tapered recess in theimplant (Fig. 3). The implant abutment interface isformed by a cold-welded friction-fit joint, which is

necessary to eliminate rotation at the implant abutment interface and subsequent abutment screwloosening (6).

Figure 3. A Morse taper implant abutmentconnection


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D.R. Prithviraj et al. External and Internal Implant Abutment Connections


The original concept of the Morse taper implantincluded two tapers (2 and 4) and was designedto provide a precise fit without self-locking threads.

8 Morse taper implants

In dentistry, the concept of the Morse taper orcone-screw tapered connection was first used by theITI group (Switzerland) (22). The rationale was thata tapered connection would yield a mechanicallystable, sound, and self-locking interface. It basicallycreates a friction lock similar to the Morse taperused generally in mechanical engineering andrelated industries.

A further modification of the ITI-Straumannimplant design is the Synocta design. Although theoriginal implant design allowed for a precise fitbetween the implant and the abutment, it did not

allow for rotation of the abutment over the implantor fit at a different angulation. Wiskott & Belsersupplemented the Morse taper connection byintroducing an internal hexagon at its centre,thereby enabling abutment repositioning and theprecise transfer of the implant position to the mastercast. As a result, only one transfer system and oneanalogue are required.

A new implant introduced by Osteo-Ti knownas the Combi implant, has a mechanism for accuratepositioning and friction fit similar to that of theSynocta design, and combines the features of aninternal hexagonal implant and a Morse taperimplant. Other manufacturers marketing 8 Morsetaper implants are Avana , 3i TG , and Ankylos .

11.5 Morse taper implant

This implant is marketed by Astra Tech . Thefixture and abutment are strongly connected at an11.5 angle by a conical seal design, which seals theconnection and decreases micro-movement andmicroleakage. The implant has a micro-threadedconical neck and a TiO 2-blasted surface.Microthreads on the fixture top prevent theconcentration of stress around the alveolar ridgecrest and reduce marginal bone loss.

1.5 Morse taper implant

This true Morse taper implant is available fromBicon Implants . The Bicon locking taper abutmenthas no screw, but like a screw-retained abutment, itrelies on friction to keep it intact. Assembly isachieved by driving the 1.5 Morse taper into thematching socket in the implant, which generates ahigh clamping force between abutment and implant.The high friction force is the result of relative slipbetween the two friction surfaces occurring at highcontact pressure. This results in the breakdown of

surface oxide layers, causing cold welding at theimplant abutment interface.

Discussion

This review describes changes in implant abutment connections, from Brnemarks 0.7 -mm-high traditional external hexagon and its variousmodifications to the development of Morse taperimplant abutment connections. The externalhexagonal connection, which served as a couplingand torque t ransfer device in Brnemarks Protocol,was adequate to restore a completely edentulousarch with a series of implants connected by a metalbar6. With better understanding of the concept ofosseointegration and the development andrefinement of surgical protocols in implant dentistry,the horizons of implant dentistry applications havebroadened.

Dental implants are now used in a myriad ofapplications, from the restoration of a completely orpartially edentulous arch to single tooth replacementand the use of fixed bridges (18,19). With theseever-increasing applications, the requirements ofimplant abutment connections have also increased;they must now serve anti-rotational and prostheticindexing functions8. These functions are mostimportant in the restoration of single posterior teethby implants because they are the most difficult toretain (23).

Thus, Brnemarks external hexagonalimplant abutment connection required modificationto prevent complications, such as abutment screwloosening and fracture, which occurred commonlywhen the external hexagon was used in single-toothimplant restorations. Various manufacturers havedeveloped design modifications, including theincreased height and flat flat width of the matingsurfaces of the implant abutment connection (8).The tapered hexagon and spline dental implant (19)have also been developed in attempts to overcome

the limitations of Brnemarks external hexagon. The search for a new implant abutmentconnection design that overcomes the limitations ofthe external hexagon has resulted in thedevelopment of the internal hexagonal design, whichhas been modified further into the internal tripod,12-point internal hexagon, and internal octagon. Thebasic clinical significance of these various implant abutment connections is the freedom of abutmentpositioning over the implant, which is maximal forthe 12-point internal hexagon and minimal for theinternal tripod.

This review describes various commerciallyavailable implant abutment connections, highlightsthe manufacturers claims, and supports them with


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published data, where available. With this review,we aim to help the clinician to make an informeddecision as to which implant system and implant abutment interface to use.

ConclusionThe implant abutment interface determines

the lateral and rotational stability of the implant abutment joint, which, in turn, determines theprosthetic stability of the implant-supportedrestoration. This review describes the evolution ofvarious implant abutment connections and seeks toinform the clinician regarding the variouscharacteristics associated with external and internaldesigns. It also enlightens the clinician about theclinical applications of contemporary implant

designs.

Acknowledgments

The authors deny an y conicts of interestrelated to this study.

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m.nih.gov/pubmed/19053930http://www.ncbi.nlm.nih.gov/pubmed?term=%22Kazor%20C%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Cianciola%20LJ%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Barboza%20E%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Barboza%20E%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Silc%20J%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Misch-Dietsh%20F%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Misch%20CE%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=Evaluation%20of%20the%20ITI%20Morse%20taper%20implant%2Fabutment%20design%20with%20an%20internal%20modification.%20Ding%20TA%2C%20Woody%20RD%2C%20Higginbottom%20FL%2C%20Miller%20BH.%20Int%20J%20Oral%20Maxillofac%20Implants.%202003%20Nov-Dec%3B18(6)%3A865-72.%20%20%20http://www.ncbi.nlm.nih.gov/pubmed?term=Evaluation%20of%20the%20ITI%20Morse%20taper%20implant%2Fabutment%20design%20with%20an%20internal%20modification.%20Ding%20TA%2C%20Woody%20RD%2C%20Higginbottom%20FL%2C%20Miller%20BH.%20Int%20J%20Oral%20Maxillofac%20Implants.%202003%20Nov-Dec%3B18(6)%3A865-72.%20%20%20http://www.ncbi.nlm.nih.gov/pubmed?term=%22Miller%20BH%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Higginbottom%20FL%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Woody%20RD%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Ding%20TA%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/9108742http://www.ncbi.nlm.nih.gov/pubmed/9108742http://www.ncbi.nlm.nih.gov/pubmed?term=Implant%20abutment%20screw%20rotations%20and%20preloads%20for%20four%20different%20screw%20materials%20and%20surfaces%20Will%20C.%20Martin%2C%20(J%20Prosthet%20Dent%202001%3B86%3A24-32.http://www.ncbi.nlm.nih.gov/pubmed?term=Implant%20abutment%20screw%20rotations%20and%20preloads%20for%20four%20different%20screw%20materials%20and%20surfaces%20Will%20C.%20Martin%2C%20(J%20Prosthet%20Dent%202001%3B86%3A24-32.http://www.ncbi.nlm.nih.gov/pubmed?term=%22Miller%20AW%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Miller%20BH%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Woody%20RD%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Martin%20WC%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=Binon%20P.P%20.Implants%20and%20components%20%3A%20entering%20the%20new%20millennium.%20International%20journal%20of%20oral%20and%20maxilloafacial%20implants%3A%20Volume%2015%2C%20number%201%20%2C%202000.%20%20http://www.ncbi.nlm.nih.gov/pubmed?term=Binon%20P.P%20.Implants%20and%20components%20%3A%20entering%20the%20new%20millennium.%20International%20journal%20of%20oral%20and%20maxilloafacial%20implants%3A%20Volume%2015%2C%20number%201%20%2C%202000.%20%20http://www.ncbi.nlm.nih.gov/pubmed?term=Compend%20Contin%20Educ%20Dent.%201995%20Aug%3B16(8)%3A796%2C%20798-802%2C%20804.%20Restoration-driven%20implant%20placement%20with%20restoration-generated%20site%20development.%20Garber%20DA%2C%20Belser%20UC.%20Source%20http://www.ncbi.nlm.nih.gov/pubmed?term=Compend%20Contin%20Educ%20Dent.%201995%20Aug%3B16(8)%3A796%2C%20798-802%2C%20804.%20Restoration-driven%20implant%20placement%20with%20restoration-generated%20site%20development.%20Garber%20DA%2C%20Belser%20UC.%20Source%20http://www.ncbi.nlm.nih.gov/pubmed?term=%22Belser%20UC%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Garber%20DA%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=Mechanics%20of%20the%20implant-abutment%20connection%3A%20an%208-degree%20taper%20compared%20to%20a%20butt%20joint%20connection.%20%20%20http://www.ncbi.nlm.nih.gov/pubmed?term=Mechanics%20of%20the%20implant-abutment%20connection%3A%20an%208-degree%20taper%20compared%20to%20a%20butt%20joint%20connection.%20%20%20http://www.ncbi.nlm.nih.gov/pubmed?term=%22Belser%20UC%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Hunenbart%20S%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Merz%20BR%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=Khraisat%20Et.al%20Stability%20of%20implant%20abutment%20joint%20in%20a%20single%20tooth%20external%20hexagon%20system%20%3A%20clinical%20and%20mechanical%20review%3A%20Clinical%20oral%20implants%20and%20related%20research%3B%206%2C%20number%204%2C%202004.http://www.ncbi.nlm.nih.gov/pubmed?term=Khraisat%20Et.al%20Stability%20of%20implant%20abutment%20joint%20in%20a%20single%20tooth%20external%20hexagon%20system%20%3A%20clinical%20and%20mechanical%20review%3A%20Clinical%20oral%20implants%20and%20related%20research%3B%206%2C%20number%204%2C%202004.http://www.ncbi.nlm.nih.gov/pubmed?term=%22Dar-Odeh%20N%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Dar-Odeh%20N%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Al-Kayed%20AM%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Abu-Hammad%20O%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Khraisat%20A%22%5BAuthor%5D


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C o p y r i g h t o f I n t e r n a t i o n a l D e n t a l R e s e a r c h i s t h e p r o p e r t a n d i t s c o n t e n t m a y n o t b e c o p i e d o r e m a i l e d t o m u l t i p l e s it h e c o p y r i g h t h o l d e r ' s e x p r e s s w r i t t e n p e r m i s s i o n . H o w e ve m a i l a r t i c l e s f o r i n d i v i d u a l u s e .

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