• The Pankey-Mann and Schuyler philosophies are two classic approaches to full mouth rehabilitation (FMR). Pankey-Mann emphasizes a quadrant-by-quadrant approach using the Pankey-Mann instrument and the "cross-arch" stabilization concept. Schuyler focused on occlusal equilibration. Indications include severe wear, multiple missing teeth, and collapsed VDO; contraindications include poor periodontal support and uncontrolled parafunctional habits.

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Pankey-Mann-Schuyler (PMS) Philosophy of Full Mouth Rehabilitation (FMR)

What is PMS Philosophy?

1. Existence of a physiologic rest position of the mandible (constant)
2. Recognition of a variable vertical dimension of occlusion (VDO)
3. Acceptance of a dynamic, functional centric occlusion

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The Four Steps of PMS Philosophy

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Occlusal Principles of PMS

• Freedom in centric occlusion (long centric incorporated in lingual surfaces of maxillary incisors)
• Group function on the working side
• Absence of non-working side (balancing) contacts - balancing contacts considered deleterious in natural dentition
• Maxillary cuspids in good functional contact
• Incisal guidance is the predominating factor for selecting posterior guiding tooth inclines (over condylar guidance)
• Antero-posterior freedom of movement incorporated in restorations

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Schuyler's Contribution (Freedom in Centric Concept)

• Balancing contacts are deleterious and must be avoided in natural dentition
• Incisal guidance should be established first as the initial step of occlusal rehabilitation
• Antero-posterior freedom (long centric) must be incorporated
• Cusp-to-surface (rather than cusp-to-fossa) relationship - though this limits chewing efficiency (the main limitation of Schuyler's concept)

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INDICATIONS for PMS-Based FMR

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CONTRAINDICATIONS for PMS-Based FMR

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Limitations of PMS Technique

• Cusp-to-fossae/marginal ridge contacts may complicate occlusal design
• Use of wax FGP techniques can cause errors (wax distortion)
• The PM instrument was based on the non-arcon Monson articulator - may not accurately record eccentric movements at increased VDO
• In practice, the PM instrument itself is rarely used in clinical case reports (none of the 15 cases in the systematic review actually used it)

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PMS Suitability for COMBINATION CASES: Natural Teeth + Implant-Supported FMR

Why PMS Works Well in Combination (Tooth + Implant) FMR

• Natural teeth have a periodontal ligament (PDL) with proprioceptive feedback and some mobility (50-200 micrometers)
• Implants are ankylosed (osseointegrated) with no PDL and negligible mobility (3-5 micrometers)

Key Clinical Modifications for Implant Cases within PMS

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Summary Comparison: PMS vs Schuyler's Contribution

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Evidence Base

• PMS is the most widely applied FMR philosophy (57.69% of cases)
• Primary indication: Turner & Missirlian Category 1 (anterior guidance disturbed)
• Age range of treated patients: 18-75 years (broad applicability)
• Recent 2025 case report (IJOHD, Kumar et al.) demonstrates PMS success in partial edentulism with severe wear
• Implant + tooth-supported FMR using PMS philosophy is an established contemporary practice, integrating centric relation, anterior guidance, and harmonious posterior disclusion

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Hobo's Twin Table Technique & Twin Stage Procedure - FMR Philosophy

Background

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The Two Techniques: Key Distinction

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Occlusal Principles of Hobo's Philosophy

• Mutually protected occlusion - anteriors protect posteriors in excursions; posteriors protect anteriors in centric
• Posterior disocclusion during all eccentric mandibular movements (lateral, protrusive) - this is the hallmark
• Precise anterior guidance established before posterior restorations
• Condylar path and incisal guidance are dependent variables - changing one affects the other
• Bennett angle: fixed at 15° (simplified, does not need to reproduce the Fisher angle)
• Immediate mandibular translation (Bennett movement) does not need to be produced
• Anterior guide table: triangular gutter shape, adjustable for both sagittal inclination and lateral wing angles

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INDICATIONS for Hobo's Twin Table / Twin Stage FMR

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CONTRAINDICATIONS for Hobo's Philosophy

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Advantages of Hobo's Approach

• Posterior disocclusion minimizes harmful lateral forces on restorations, TMJ, and periodontal tissues
• Applicable to FPD, implants, and dentures - versatile
• Evidence-based - grounded in research on the interdependence of anterior guidance and condylar path
• Semi-adjustable articulator suffices - no need for fully adjustable articulator (unlike gnathological approach)
• Twin Stage is CAD/CAM and digital workflow compatible - a major advantage in modern prosthodontics
• Easier to learn than full gnathological techniques; simpler than PMS for certain case types
• Bennett angle standardized at 15° reduces operator-dependent variability

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Limitations

• Not suitable for cases with abnormal posterior tooth inclinations (extreme Curve of Spee/Wilson, rotation)
• Limited long-term studies on posterior disocclusion reproducibility
• Less widely used than PMS in classical literature (7.69% Twin Table; 34.61% Twin Stage)
• Wax-up technique demands operator skill for accurate articulator programming
• Cusp-to-fossa occlusal scheme requires careful execution

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Comparison: Hobo vs PMS at a Glance

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Summary

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DIGITALIZATION IN PROSTHODONTICS

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CONTENTS

1. Introduction & Historical Perspective
2. Fundamentals of Digital Workflow
3. Digital Technologies - Core Components
4. Digitalization in Complete Denture (CD)
5. Digitalization in Removable Partial Denture (RPD)
6. Digitalization in Fixed Partial Denture (FPD)
7. Digitalization in Full Mouth Rehabilitation (FMR)
8. Digitalization in Implant Prosthodontics
9. Digitalization in Maxillofacial Prosthetics
10. Digitalization in Dental Materials
11. Artificial Intelligence (AI) in Prosthodontics
12. Virtual Articulator & Digital Occlusion
13. Advantages, Limitations & Future Directions
14. References

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1. INTRODUCTION & HISTORICAL PERSPECTIVE

• 1st generation (1985-2000): Chairside single-unit CAD/CAM (CEREC)
• 2nd generation (2000-2015): Laboratory CAD/CAM systems, 3D cone beam CT, intraoral scanners (IOS)
• 3rd generation (2015-present): Integrated full digital workflows, additive manufacturing (3D printing), virtual reality, AI-driven diagnostics, and photogrammetry

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2. FUNDAMENTALS OF THE DIGITAL WORKFLOW

DATA ACQUISITION → DIGITAL DESIGN → MANUFACTURING (CAM)
    (Scanning)         (CAD Software)    (Milling / 3D Printing)

Three Clinical Workflow Models (Abduo, 2026 - PMC12747636)

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3. DIGITAL TECHNOLOGIES - CORE COMPONENTS

A. Digital Data Acquisition

• Eliminate conventional impressions (polyether/PVS)
• Accuracy: <50 µm for single units; accuracy decreases in full-arch scans
• Grande et al. (2025, J Dent - PMID 40675250): Reviewed factors influencing IOS accuracy in implant scanning - adjacent teeth, scan strategy, and scanner type all affect trueness

• Scan conventional impressions or stone casts
• High accuracy (10-20 µm); used in laboratory digital workflows
• Examples: 3Shape D2000, Dental Wings

• 3D volumetric imaging of hard tissues
• Superimposed with IOS data (surface scan) for virtual patient creation
• Indispensable for implant planning, bone assessment, and maxillofacial prosthetics

• Captures spatial positions of implants via photogrammetric cameras
• Pozzi et al. (2025, Clin Implant Dent Relat Res - PMID 40481748): Systematic review and meta-analysis comparing photogrammetry vs IOS in complete-arch implant cases - photogrammetry showed superior accuracy for complete-arch implant impressions

B. CAD Software

• Prosthesis design, occlusal analysis, virtual articulation
• Key software: 3Shape Dental System, exocad, CEREC SW, Planmeca Romexis
• STL (Standard Tessellation Language) is the universal file format

C. CAM - Manufacturing

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4. DIGITALIZATION IN COMPLETE DENTURE (CD)

Digital Complete Denture Protocols

• Visit 1: IOS or conventional impression + jaw relation records digitized
• Visit 2: Delivery of milled/printed denture
• Eliminates try-in appointment

• Entire workflow completed in a single extended visit using chairside CAD/CAM

Manufacturing Methods for Digital CDs

• Denture base: milled from pre-polymerized PMMA disc (e.g., Ivoclar IvoBase CAD, VITA CAD-Waxx)
• Artificial teeth: milled separately and bonded, OR monolithic milled (AvaDent, DENTCA)
• Superior trueness of fit compared to conventional and 3D-printed dentures
• Srinivasan et al. (2021, J Dent - PMID 34400250): Systematic review and meta-analysis - CAD/CAM CDs showed comparable/superior trueness of fit, better mechanical properties, and greater color stability vs conventional dentures

• Stereolithography (SLA), Digital Light Processing (DLP), or FDM
• Faster and cheaper than milling; allows complex geometries
• Zandinejad et al. (2024, J Prosthodont - PMID 38666691): Systematic review and meta-analysis - milled and 3D-printed dentures showed comparable clinical outcomes to conventional dentures; patient satisfaction was similar across groups

Virtual Teeth Arrangement

• Software arranges denture teeth according to arch form, VDO, and esthetic parameters
• Eliminates waxing and trial denture fabrication steps

Advantages of Digital CDs

• Archival capability - digital files stored; replication possible without re-impression
• Reduced polymerization shrinkage in milled dentures
• Better dimensional stability and surface hardness
• Reduced chairside time and patient burden
• Avelino et al. (2024, J Prosthet Dent): Systematic review - digital dentures showed favorable patient-reported outcomes and clinical performance

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5. DIGITALIZATION IN REMOVABLE PARTIAL DENTURE (RPD)

Digital RPD - Framework Fabrication

1. CAD/CAM milling - cobalt-chrome frameworks milled from metal blocks
2. Selective Laser Sintering/Melting (SLS/SLM) - powder bed fusion 3D printing of cobalt-chrome or titanium frameworks (most widely adopted for RPD digitization)
3. Stereolithography (SLA) patterns - resin patterns for investment casting (semi-digital)

• CAD/CAM and 3D-printed frameworks showed comparable or improved fit accuracy vs conventional casting
• Mean gap at rest seats ranged 50-150 µm across digital techniques

• Adequate fit accuracy for clinical use
• Comparable mechanical strength to cast frameworks
• Potential for personalized design with improved esthetic components

Digital RPD Workflow

IOS / Cast scan → Framework design (CAD) → SLM/SLS printing 
→ Sandblasting/finishing → Try-in → Artificial teeth setting 
→ Denture base (digital/conventional) → Delivery

• Digital impressions for RPD are clinically acceptable
• Jaw relation records using digital means are reliable for RPD cases
• Challenges remain in capturing undercuts and flexible denture areas

Digital Clasp Design

• CAD software allows precise clasp angulation, thickness, and position optimization
• Reduces technician skill dependency
• Korkes et al. (2024, J Prosthodontics) - seating accuracy of digital RPD frameworks was comparable to conventional

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6. DIGITALIZATION IN FIXED PARTIAL DENTURE (FPD)

Digital Workflow for FPD

Tooth preparation → IOS → Virtual die trimming (CAD) 
→ Crown/Bridge design → Milling/Printing → Try-in → Cementation

Materials for Digital FPD

Fit Accuracy

• Marginal gap (clinically acceptable ≤ 120 µm): CAD/CAM-milled crowns consistently achieve this threshold
• Abduo et al. (2023, J Prosthodontics): Marginal accuracy of monolithic and veneered zirconia crowns - digital workflows produced clinically acceptable marginal gaps
• Sanchez-Lara et al. (2023): CEREC Omnicam CAD/CAM showed horizontal marginal discrepancy <100 µm; conventional technique showed <100 µm internal discrepancy - both clinically acceptable

Time & Cost Analysis

• Digital FPD fabrication reduces lab turnaround time
• J Prosthet Dent (2024): Systematic review - digital workflows show comparable or reduced overall treatment time for FPDs with potential cost savings in the long term

CEREC (Chairside CAD/CAM)

• Single-visit crown fabrication
• IOS → software design → chairside milling (15-20 min) → staining/glazing → cementation
• Long-term survival rate of CEREC restorations: >90% at 10 years (Krämer et al.)

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7. DIGITALIZATION IN FULL MOUTH REHABILITATION (FMR)

Digital Planning for FMR

• IOS captures pre-operative dentition
• CAD software designs the ideal occlusal scheme, VDO, tooth morphology
• Exported as STL → 3D-printed mock-up or provisional restorations
• Eliminates analogue wax-up on stone casts

• Facial photographs + video + IOS integrated
• 2D/3D smile simulation before any irreversible treatment
• Patient-specific esthetic planning with photo-realistic previews
• Software: DSD App, 3Shape Smile Design, Planmeca Romexis

• CBCT + IOS + jaw tracking device (e.g., ARCUSdigma, JMT) → virtual patient
• Condylar path inclination, Bennett angle recorded digitally
• Virtual articulator (exocad, 3Shape) simulates mandibular movements
• Prosthetic occlusion designed and verified digitally before fabrication

Occlusal Analysis - T-Scan System

• Measures occlusal force distribution and timing digitally
• Identifies prematurities, lateral interferences in real-time
• Essential for FMR to establish simultaneous bilateral contacts and anterior guidance

Digital FMR Workflow - Step by Step

1. Facial scan + IOS + CBCT → 3D virtual patient
2. Digital Smile Design
3. Virtual diagnostic wax-up
4. 3D-printed provisional restorations (try-in phase)
5. Patient approval → transfer to definitive workflow
6. Definitive IOS or impression scan
7. CAD design of all restorations
8. Phased milling/printing (zirconia, e.max, titanium)
9. Virtual occlusal check + T-scan verification
10. Delivery and adjustment

Advantages in FMR

• Predictability - patient can visualize outcome before treatment
• Replication of proven provisional occlusion in definitive restorations
• Reduces number of clinical try-ins
• Digital records enable retreatment without data loss

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8. DIGITALIZATION IN IMPLANT PROSTHODONTICS

A. Digital Implant Treatment Planning

• CBCT provides bone volume, density, neurovascular anatomy
• IOS provides tooth/soft tissue surface data
• Superimposition creates a "virtual patient" for precise implant positioning

• Prosthetically-driven implant placement
• Ideal prosthesis designed first (CAD) → optimal implant position derived

B. Computer-Guided Implant Surgery

• 3D-printed (SLA/SLM) surgical stent derived from digital implant plan
• Controls implant depth, angulation, and position
• Shi et al. (2023, Int J Implant Dent - PMID 37875645): Systematic review of digital surgical guide accuracy - mean deviation at entry point: 0.6-1.2 mm; apex: 0.8-1.5 mm; angulation: 2-4°; clinically acceptable in most studies

• Real-time tracking of handpiece position during surgery (e.g., X-Guide, Navident)
• GPS-like guidance; allows angulation adjustment intraoperatively
• Does not require pre-fabricated stent

C. Digital Implant Impressions

• Scan body placed on implant fixture or abutment
• IOS records 3D position → virtual abutment placement in software
• Eliminates conventional open/closed tray impressions
• Accuracy limitations: IOS accuracy decreases with increasing number of implants and arch length

• Pozzi et al. (2025, PMID 40481748): Meta-analysis showed photogrammetry has superior accuracy over IOS for complete-arch implant cases
• Key for full-arch implant bridges (All-on-4, All-on-6) where passive fit is critical

D. Digital Implant Prosthetic Components

• Titanium or zirconia abutments milled to precise anatomy
• Superior fit over stock abutments
• Eliminates human error in lab fabrication

• Monolithic zirconia (milled) - preferred for implant-supported FPD
• No veneering porcelain → eliminates chipping risk
• Papaspyridakos et al. (2025, J Prosthodontics): 115 edentulous jaws treated with zirconia full-arch implant prostheses - high survival rates with manageable complications

CBCT + IOS → Backward planning → Guided surgery 
→ Immediate provisional (pre-made digital) → Final IOS/photogrammetry 
→ Full-arch zirconia bridge (CAD/CAM) → Torque-verified delivery

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9. DIGITALIZATION IN MAXILLOFACIAL PROSTHETICS

Facial/Extraoral Prosthetics

• Structured light scanners (e.g., Artec Eva) or photogrammetry capture defect anatomy
• Eliminates invasive conventional impression techniques in compromised patients
• Particularly beneficial for patients with trismus, anxiety, or neurologic involvement

• Mirroring software uses the contralateral unaffected side to design the prosthesis (ear, nose, orbit)
• STL exported for 3D printing of prosthesis or mold

• Silicone 3D printing (emerging): Direct silicone printing with intrinsic pigmentation
• Mold fabrication from 3D-printed masters → poured with medical-grade silicone
• Chao et al. (2025, Spec Care Dentist - PMID 40525869): Review of digital technology for prosthetic nasal rehabilitation - digital workflow reduced prosthesis fabrication time, improved symmetry and patient outcomes

Intraoral Maxillofacial Prosthetics

• CBCT + IOS → digital obturator design
• Milled PMMA or 3D-printed obturators
• Better adaptation to defect margins vs conventional technique
• Hollow obturators with complex internal geometry - only achievable with additive manufacturing

• Custom ocular prostheses designed from 3D facial scan
• Digital iris reproduction with photographic matching
• 3D-printed sclera with iris image embedded

• Mirror imaging from contralateral ear
• Titanium bar frameworks with CAD/CAM implant abutments for retention
• 3D-printed silicone molds

• Non-invasive data acquisition for compromised patients
• Superior symmetry through mirroring algorithms
• Archival - prosthesis can be replicated from digital file
• Integration with surgical planning (VSP - Virtual Surgical Planning)

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10. DIGITALIZATION IN DENTAL MATERIALS

A. Zirconia - The Digital Material Par Excellence

• Zirconia milling requires pre-sintering (white stage) - milled in larger dimensions to compensate for ~20% sintering shrinkage
• High-speed sintering (Ivoclar SpeedFire): Full sintering in 17 min → enables same-day zirconia restorations

B. Lithium Disilicate (e.max CAD)

• Available in blocks for CAD/CAM milling in partially crystallized (blue stage)
• Post-milling crystallization firing transforms to full-strength glass-ceramic (400 MPa)
• Ideal for anterior/posterior single units and short-span FPDs

C. CAD/CAM PMMA (Polymethyl Methacrylate)

• Pre-polymerized, homogeneous blanks → no residual monomer
• Superior mechanical properties vs heat-cured conventional PMMA
• Applications: Provisional restorations, complete denture bases, surgical templates
• Key material: Telio CAD (Ivoclar), VITA CAD-Temp

D. 3D Printing Resins

• Photopolymer resins (Class I, II, IIa biocompatibility)
• Types: Surgical guide resin, provisional resin, model resin, occlusal splint resin
• Prpic et al. (2020, J Prosthodont): 3D-printed denture base resins showed lower flexural strength vs milled PMMA - material selection must consider clinical requirements

E. Titanium (Grade 4 and Grade 5 Ti-6Al-4V)

• Milled or SLM-printed for implant abutments, full-arch frameworks, subperiosteal implants
• El-Sawy & Hegazy (2024): Systematic review on digitally constructed subperiosteal implants - promising outcomes for severely resorbed ridges where conventional implants are not feasible

F. Cobalt-Chrome via Selective Laser Melting (SLM)

• RPD frameworks, metal copings, implant bars
• No casting defects; controlled microstructure
• Better corrosion resistance than cast Co-Cr

G. PEEK (Polyetheretherketone)

• High-performance polymer; tooth-colored alternative to metal frameworks
• CAD/CAM milled from PEEK blocks
• Used for RPD frameworks, implant abutments, provisional restorations
• Tooth-colored, metal-free, MRI-compatible

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11. ARTIFICIAL INTELLIGENCE (AI) IN PROSTHODONTICS

• Deep learning algorithms can detect carious lesions, periapical pathology, and bone loss on radiographs with accuracy comparable to specialists
• AI-driven automated tooth preparation detection and margin identification on IOS scans
• Automated crown design - AI models generate crown morphology based on adjacent teeth with minimal operator input
• Occlusal contact prediction - AI algorithms analyze occlusal contact patterns and suggest adjustments

Applications of AI:

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12. VIRTUAL ARTICULATOR & DIGITAL OCCLUSION

• Replicates semi-adjustable or fully adjustable articulator within CAD software
• Jaw movement data input from: jaw tracking devices (ARCUSdigma, JMT Zebris), CBCT condylar anatomy, or standardized values
• Enables dynamic occlusal simulation before fabrication

• Ultrasonic (ARCUSdigma), electromagnetic, or optical systems
• Records condylar path inclination, Bennett angle, lateral border movements
• Data imported into virtual articulator → personalized occlusal design

• Digital occlusal analysis system
• 6-micron-thin sensor placed in occlusion → records force distribution in N and timing in milliseconds
• Identifies prematurities and interferences invisible to articulating paper
• Particularly valuable in FMR to verify simultaneous bilateral contacts and canine guidance establishment

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13. ADVANTAGES, LIMITATIONS & FUTURE DIRECTIONS

Advantages of Digital Prosthodontics

Limitations

Future Directions

1. Fully digital complete denture workflow - photographic skin tone matching for base color, AI-driven tooth selection
2. 4D printing - shape-memory materials that adapt to tissue changes over time
3. Real-time digital articulators with haptic feedback
4. AI-powered autonomous crown design reducing technician role
5. Augmented Reality (AR) in clinic - virtual prosthesis overlay on patient face for live esthetic preview
6. Intraoral 3D printers - direct intraoral printing of restorations
7. Nanomaterial-reinforced 3D printing resins - approaching the mechanical properties of glass-ceramics

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14. REFERENCES

1. Mörmann WH, Brandestini M. The CEREC concept: computerized preparation of direct ceramic inlays in 1 session. Quintessenz. 1987;38(3):457-470.
2. Srinivasan M, Kamnoedboon P, McKenna G, et al. CAD-CAM removable complete dentures: A systematic review and meta-analysis of trueness of fit, biocompatibility, mechanical properties, surface characteristics, color stability, time-cost analysis, clinical and patient-reported outcomes. J Dent. 2021 Oct;113:103768. [PMID: 34400250]
3. Zandinejad A, Floriani F, Lin WS, Naimi-Akbar A. Clinical outcomes of milled, 3D-printed, and conventional complete dentures in edentulous patients: A systematic review and meta-analysis. J Prosthodont. 2024 Oct;33(8):736-747. [PMID: 38666691]
4. Ahmed N, Abbasi MS, Haider S, et al. Fit Accuracy of Removable Partial Denture Frameworks Fabricated with CAD/CAM, Rapid Prototyping, and Conventional Techniques: A Systematic Review. Biomed Res Int. 2021;2021:5554101. [PMID: 34532499]
5. Takaichi A, Fueki K, Murakami N, et al. A systematic review of digital removable partial dentures. Part II: CAD/CAM framework, artificial teeth, and denture base. J Prosthodont Res. 2022 Jan;66(1):19-28. [PMID: 33504722]
6. Fueki K, Inamochi Y, Wada J, et al. A systematic review of digital removable partial dentures. Part I: Clinical evidence, digital impression, and maxillomandibular relationship record. J Prosthodont Res. 2022 Jan;66(1):9-18. [PMID: 33504721]
7. Revilla-León M, Gómez-Polo M, Vyas S, et al. Artificial intelligence models for tooth-supported fixed and removable prosthodontics: A systematic review. J Prosthet Dent. 2023 Feb;129(2):214-222. [PMID: 34281697]
8. Shi Y, Wang J, Ma C, et al. A systematic review of the accuracy of digital surgical guides for dental implantation. Int J Implant Dent. 2023 Oct;9(1):42. [PMID: 37875645]
9. Pozzi A, Arcuri L, Carosi P, et al. Photogrammetry Versus Intraoral Scanning in Complete-Arch Digital Implant Impression: A Systematic Review and Meta-Analysis. Clin Implant Dent Relat Res. 2025 Jun. [PMID: 40481748]
10. Grande F, Nuytens P, Zahabiyoun S, et al. Factors influencing the intraoral implant scan accuracy: a review of the literature. J Dent. 2025 Oct. [PMID: 40675250]
11. Chao D, Murtha MLJ, Jayanetti J, et al. Enhancing Prosthetic Nasal Rehabilitation Through Digital Technology. Spec Care Dentist. 2025 May-Jun. [PMID: 40525869]
12. Tommasato G, Piano S, Casentini P. Digital planning and bone regenerative technologies: A narrative review. Clin Oral Implants Res. 2024 Aug. [PMID: 38591734]
13. Abduo J, et al. Digital Workflows in Prosthodontics. PMC12747636. 2026.
14. Abduo J, Ho G, Centorame A, et al. Marginal Accuracy of Monolithic and Veneered Zirconia Crowns Fabricated by Conventional and Digital Workflows. J Prosthodontics. 2023;32:706-713.
15. Papaspyridakos P, Sinada N, Ntovas P, et al. Zirconia Full-Arch Implant Prostheses: Survival, Complications, and Prosthetic Space Dimensions. J Prosthodontics. 2025;34:271-280.
16. Prpic V, Schauperl Z, Catic A, et al. Comparison of mechanical properties of 3D-printed, CAD/CAM, and conventional denture base materials. J Prosthodont. 2020;29(6):524-528.
17. Dawson PE. Functional Occlusion: From TMJ to Smile Design. Mosby; 2007.
18. Carr AB, Brown DT. McCracken's Removable Partial Prosthodontics. 13th ed. Elsevier; 2016.
19. Rosenstiel SF, Land MF, Fujimoto J. Contemporary Fixed Prosthodontics. 5th ed. Elsevier; 2015.
20. Zarb G, Hobkirk J, Eckert S, Jacob R. Prosthodontic Treatment for Edentulous Patients. 13th ed. Elsevier; 2012.

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Word of advice for exam performance: In a 50-marker, divide your answer into clearly labeled sections with subheadings. Use comparison tables wherever possible (examiners reward structured, concise comparative data). Always cite at least 3-4 recent (post-2020) peer-reviewed references. Mention the CEREC system historically, zirconia generations, photogrammetry vs IOS for implants (Pozzi 2025), and AI - these are high-yield points that demonstrate awareness of cutting-edge developments. End with future directions to show depth of knowledge.This is a complete, PG-level 50-marker answer. Here is a quick guide to how to use it effectively in your exam:

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How to Score Maximum Marks - Quick Strategy

• CD: Milled vs 3D-printed, 2-visit protocol, Srinivasan 2021 meta-analysis
• RPD: SLM framework printing, Ahmed 2021 systematic review fit accuracy
• FPD: Zirconia generations table, marginal gap ≤120 µm threshold, CEREC survival >90% at 10 years
• FMR: DSD + virtual wax-up + T-Scan triad
• Implants: Backward planning + guided surgery + photogrammetry (Pozzi 2025) - this is a HIGH YIELD point
• Maxillofacial: Mirror imaging, hollow obturators by additive manufacturing
• Materials: Zirconia generation table (3Y/4Y/5Y-TZP), PEEK, CAD/CAM PMMA

PROSTHETICALLY DRIVEN IMPLANTOLOGY

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CONTENTS

1. Introduction & Definition
2. Historical Evolution - Classic Articles
3. Philosophy & Conceptual Framework
4. Pre-Surgical Prosthetic Planning
5. Implant Position - The 3D Framework (Mesiodistal, Buccolingual, Apicocoronal)
6. Emergence Profile & Soft Tissue Management
7. Abutment Selection & Design
8. Surgical Execution - Guided Surgery
9. Loading Protocols
10. Occlusion in Implant Prosthodontics
11. Prosthetic Connections - Screw vs. Cement Retained
12. Full Arch Rehabilitation (All-on-4)
13. Prosthetically Driven Approach in Special Situations
14. Complications & How Prosthetic Planning Prevents Them
15. Future Directions
16. References

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1. INTRODUCTION & DEFINITION

"Begin with the end in mind - design the restoration first, then plan the implant placement to support it."

• Implant position errors of even 1-2 mm or 5-10° angulation can render the prosthetic outcome functionally compromised, aesthetically unacceptable, or biomechanically unfavorable
• The ITI Consensus (2009) confirmed that prosthetic position is the primary determinant of implant esthetic and functional success - not merely osseointegration

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2. HISTORICAL EVOLUTION - CLASSIC ARTICLES

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3. PHILOSOPHY & CONCEPTUAL FRAMEWORK

The "Begin with the End" Principle

STEP 1: Define ideal prosthesis (shape, emergence, occlusion, aesthetics)
        ↓
STEP 2: Determine ideal implant 3D position to support this prosthesis
        ↓
STEP 3: Assess bone volume at that ideal position
        ↓
STEP 4: If bone is deficient → regenerate bone FIRST (GBR, sinus lift)
        ↓
STEP 5: Place implant at ideal prosthetic position
        ↓
STEP 6: Design abutment and restoration to replicate planned prosthesis

Contrast: Bone-driven vs. Prosthetically Driven

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4. PRE-SURGICAL PROSTHETIC PLANNING

A. Comprehensive Examination

• Smile line analysis (high, medium, low)
• Lip dynamics, facial midline
• Occlusal vertical dimension (OVD), centric relation
• Opposing arch condition and occlusal scheme
• Periodontal status of remaining teeth
• TMJ evaluation

• CBCT (Cone Beam CT): 3D bone volume, bone density, proximity to vital structures (inferior alveolar nerve, maxillary sinus, nasal floor)
• Bone quality classification (Lekholm & Zarb, 1985): Type I-IV (cortical to trabecular) guides implant selection and loading protocol

B. Diagnostic Wax-up / Digital Smile Design

• Defines ideal tooth position, size, emergence, and occlusal contacts
• Identifies restorative space requirements
• Serves as template for surgical stent fabrication
• Digital equivalent: virtual diagnostic wax-up (CAD software)

C. The Radiographic / Diagnostic Stent (Dual Scan Protocol)

• Superimposition of prosthetic position (stent) over bone anatomy (CBCT)
• Creates the virtual patient - essential for backward planning
• Planning software (Nobel Clinician, Simplant, coDiagnostix, DTX Studio): virtual implant placement in ideal prosthetic position, checked against bone availability

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5. IMPLANT POSITION - THE 3D FRAMEWORK

A. Mesiodistal Position

• Minimum 1.5 mm from adjacent natural tooth
• Minimum 3.0 mm between two adjacent implants (to preserve interproximal bone and papilla)
• Centered under the planned crown contact area
• Clinical significance: Too close to adjacent tooth → interproximal bone loss → loss of papilla → "black triangle" deformity

B. Buccolingual (Labiopalatal) Position

• Implant platform should be positioned 1-2 mm palatal/lingual to the planned buccal surface of the crown (esthetic zone)
• Avoids buccal plate perforation
• Provides space for soft tissue emergence and natural-looking transition
• "Comfort zone" (Buser): ≥1 mm buccal bone maintained at platform level

C. Apicocoronal (Depth) Position

• Implant platform: 2-4 mm apical to the planned free gingival margin of the restoration
• Respects the biologic width (Hermann et al., 2000): ~3-4 mm of biological dimension needed around the implant platform
• Too shallow: biologic width violation → bone loss, soft tissue recession
• Too deep: increases probing depth, peri-implant maintenance difficulty, excessive subcrestal position

Summary Table - 3D Position Criteria

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6. EMERGENCE PROFILE & SOFT TISSUE MANAGEMENT

Types of Emergence Angles

Development of Emergence Profile

• Dynamic compression technique (Wittneben et al., 2013): Progressively adds composite to the provisional over weeks to expand the soft tissue collar naturally
• Neale & Chee (1994) - "Development of implant soft tissue emergence profile" - foundational technique paper

• Custom impression coping method (directly from provisional)
• Intraoral scan of emergence profile with provisional in place
• Copy-milling technique (Conejo et al., 2020)

Biotype Considerations

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7. ABUTMENT SELECTION & DESIGN

1. Emergence profile requirements
2. Restoration type (cement vs. screw retained)
3. Esthetic demand (anterior vs. posterior)
4. Interarch space
5. Implant angulation

Types of Abutments

"One Abutment, One Time" Protocol

• Final abutment placed at stage 2 surgery (or implant placement)
• Remains in place throughout healing - NOT replaced at impression or delivery
• Evidence shows superior peri-implant soft tissue stability
• Reduces mucosal trauma from repeated disconnection/reconnection cycles

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8. SURGICAL EXECUTION - GUIDED SURGERY

A. Static Guided Surgery (Surgical Templates)

• Pilot drill guided: Only initial osteotomy guided
• Partially guided: 2-3 steps guided
• Fully guided (stackable): All drilling steps controlled for depth, angulation, position

• Mean deviation at entry point: 0.6-1.2 mm
• Mean deviation at apex: 0.8-1.5 mm
• Mean angular deviation: 2-4°
• Tooth-supported guides more accurate than mucosa-supported
• Fully guided more accurate than partially guided

B. Dynamic Navigation (Real-time)

• Optical or electromagnetic tracking of surgical handpiece
• Real-time GPS-like feedback on implant position
• Panchal N et al. (2019, Oral Maxillofac Surg Clin North Am - PMID 31563194): Dynamic navigation for dental implant surgery review
• Advantages: No pre-fabricated stent needed; adjustable intraoperatively
• Block MS (2023, J Oral Maxillofac Surg - PMID 36481276): How to avoid errors using navigation for implant placement
• Mean accuracy similar to static guides (0.5-1.2 mm entry, 1.0-1.5 mm apex)

C. Flapless vs. Flap Surgery

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9. LOADING PROTOCOLS

Classification of Loading Protocols (ITI Consensus 2013)

• Immediate and early loading comparable to conventional in terms of implant survival when selection criteria are met
• Patient-reported outcomes favor immediate loading (reduced edentulous period)

Primary Stability - Measurement

• Measures implant stability quotient (ISQ) - scale 1-100
• ISQ ≥70: Immediate loading indicated
• ISQ 60-69: Early loading
• ISQ <60: Conventional loading

• ≥35 Ncm: Prerequisite for immediate loading in most protocols

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10. OCCLUSION IN IMPLANT PROSTHODONTICS

Key Biologic Differences: Implant vs. Natural Tooth

Occlusal Principles for Implant Restorations

• Bilateral simultaneous contacts in CR = MI
• Implant crown in slightly lighter contact than natural teeth in centric (shimstock)
• Rationale: implant's lack of PDL mobility means it receives disproportionate force if in heavy contact

• Reduce occlusal table width by 20-30% compared to natural tooth equivalent
• Reduces bending moment at implant-bone interface (reduces Class III lever mechanics)

• Flatter cusps → reduced lateral force components
• Reduces non-axial loading

• Posterior implants: centric stop, no lateral contacts
• Anterior implants: guidance on natural anteriors preferred (cuspid-protected / mutually protected)
• Eliminate all prematurities and balancing side contacts on implants

• Forces directed along the long axis of the implant
• Minimize cantilever extensions - each mm of cantilever multiplies force at the distal implant

• For implant-supported prostheses: mutually protected occlusion preferred
• Posterior implants: disocclude in lateral excursions
• If group function necessary: distribute across multiple implants, not single implant

• Natural teeth have ~25x more mobility than implants
• In combination cases: establish centric contacts on natural teeth first; implants brought into contact slightly lighter
• Avoid centric contacts that would transfer disproportionate load to the implant

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11. PROSTHETIC CONNECTIONS: SCREW vs. CEMENT RETAINED

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12. FULL ARCH REHABILITATION - ALL-ON-4 / ALL-ON-X

All-on-4 Concept

• Number of implants (4, 5, 6 - "All-on-X")
• Angulation of posterior implants (30°, 45°)
• Prosthetic platform height (for acrylic-metal hybrid or full zirconia)
• Lip support (need for flanged vs. flangeless prosthesis)
• Prosthetic space requirements (minimum 12-15 mm for hybrid acrylic-metal; 8-10 mm for zirconia)

Digital Workflow for Full Arch

Facial scan + IOS (existing denture/dentition) → Digital Smile Design
→ CBCT superimposition → Virtual implant planning (backward from prosthesis)
→ 3D-printed guided surgery stent
→ Guided flapless surgery → Immediate implant placement
→ Pre-fabricated provisional (designed before surgery from digital plan)
→ Attached to implants same day (immediate loading)
→ Healing phase (3-6 months) → Final IOS / photogrammetry
→ Full-arch zirconia bridge (CAD/CAM milled) → Delivery

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13. PROSTHETICALLY DRIVEN APPROACH IN SPECIAL SITUATIONS

A. Esthetic Zone (Anterior Maxilla)

• Timing of implant placement: Type 1 (immediate) to Type 4 (late) based on Buser et al. (2017, Periodontology 2000) - bone grafting almost always needed in Type 1/2
• Critical dimensions: Buccal plate ≥2 mm; platform 2-3 mm palatal to future buccal gingival zenith; depth 3-4 mm subcrestal
• Pink esthetics: PES (Pink Esthetic Score - Fürhauser 2005) evaluates mesial/distal papilla, soft tissue level, contour, color, texture
• White esthetics: WES (White Esthetic Score - Belser 2009) evaluates crown form, outline, color, translucency, texture

B. Posterior Single Tooth Replacement

• Less esthetic demand; greater occlusal load
• 3D position: centered in edentulous space, crestal, axially loaded
• Occlusal scheme: mutually protected occlusion with posterior disclusion

C. Implant in Growing Patients

• Contraindicated until skeletal maturity (girls 17+; boys 18-20 years)
• Implant acts as an ankylosed tooth - does not grow with the jaw → infraocclusion over time

D. Implant-Tooth-Supported FPD (Combination Prosthesis)

• Generally contraindicated by most implant systems - mobility mismatch between PDL tooth and rigid implant
• If unavoidable: use non-rigid connectors on the tooth side to accommodate differential mobility
• Prosthetic planning must account for long-term tooth intrusion risk under the rigid implant connection

E. Implant Overdentures

• Locator, ball, bar, magnetic attachments chosen based on retention needs, OVD, patient dexterity
• 2-4 mandibular implants (Feine et al. McGill Consensus 2002: minimum 2 implants for mandibular overdenture)
• Pre-prosthetic planning determines inter-arch space for attachment housing

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14. COMPLICATIONS & HOW PROSTHETIC PLANNING PREVENTS THEM

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15. FUTURE DIRECTIONS

1. AI-guided implant planning: Machine learning algorithms that analyze bone density, adjacent anatomy, and prosthetic requirements to suggest optimal implant position automatically (PMC12467394)
2. Augmented Reality (AR) in surgery: Real-time holographic overlay of planned implant position over surgical field - eliminates need for physical surgical stent
3. Intraoral photogrammetry: Full-arch passive fit verification intraorally
4. One-visit implantology: CBCT + IOS + AI planning + guided surgery + immediate CAD/CAM crown - true same-day implant crown delivery
5. Digital biomechanical simulation: Finite element analysis integrated with planning software to predict stress distribution before prosthesis fabrication
6. Smart implants: Embedded sensors monitoring bone stress and peri-implant health in real time

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16. REFERENCES

Classic Articles (Foundational)

1. Branemark P-I. Intra-osseous anchorage of dental prosthesis - experimental studies. Scand J Plast Reconstr Surg. 1977;11:1-132. (FOUNDING CLASSIC)
2. Adell R, Lekholm U, Rockler B, Branemark P-I. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg. 1981;10:387-416. (CLASSIC - First long-term evidence)
3. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of currently used dental implants: a review and proposed criteria of success. Int J Oral Maxillofac Implants. 1986;1(1):11-25. (CLASSIC - Success criteria)
4. Garber D, Belser U. Restoration-driven implant placement with restoration-generated site development. Compend Contin Educ Dent. 1995;16:796-804. (FOUNDING ARTICLE - prosthetically driven concept)
5. Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the anterior maxilla: anatomic and surgical considerations. Int J Oral Maxillofac Implants. 2004;19(Suppl):43-61. (CLASSIC - 3D position criteria)
6. Hermann JS, Buser D, Schenk RK et al. Biologic width around titanium implants: a physiologically formed and stable dimension over time. Clin Oral Implants Res. 2000;11(1):1-11.
7. Neale D, Chee WW. Development of implant soft tissue emergence profile: a technique. J Prosthet Dent. 1994;71:364-368.
8. Gross MD. Occlusion in implant dentistry: a review of the literature of prosthetic determinants and current concepts. Aust Dent J. 2008 Jun;53 Suppl 1:S60-8. [PMID: 18498587]

Recent Evidence-Based Articles

1. Gallucci GO, Hamilton A, Zhou W, Buser D, Chen S. Implant placement and loading protocols in partially edentulous patients: a systematic review. Clin Oral Implants Res. 2018 Oct;29(Suppl 16):106-134. [PMID: 30328194]
2. Huynh-Ba G, Oates TW, Williams MAH. Immediate loading vs. early/conventional loading of immediately placed implants in partially edentulous patients from the patients' perspective: A systematic review. Clin Oral Implants Res. 2018 Oct;29(Suppl 16):255-269. [PMID: 30328205]
3. Schrott A, Riggi-Heiniger M, Maruo K et al. Implant loading protocols for partially edentulous patients with extended edentulous sites: a systematic review and meta-analysis. Int J Oral Maxillofac Implants. 2014;29(Suppl):239-255. [PMID: 24660201]
4. Gallucci GO, Hamilton A, Akhondi S. Current state of evidence for implant placement and loading in partially edentulous patients: a systematic review. Clin Implant Dent Relat Res. 2026 Feb. [PMID: 41574557] (Most recent)
5. Mojaver S, Patel N, Sarmiento H. Under pressure: Unraveling the impact of occlusal overload on peri-implant health - a systematic review. J Prosthodont. 2025 Oct. [PMID: 40571905]
6. Shi Y, Wang J, Ma C et al. A systematic review of the accuracy of digital surgical guides for dental implantation. Int J Implant Dent. 2023 Oct;9(1):42. [PMID: 37875645]
7. D'haese J, Ackhurst J, Wismeijer D. Current state of the art of computer-guided implant surgery. Periodontol 2000. 2017 Feb;73(1):121-133. [PMID: 28000275]
8. Karami D, Alborzinia HR, Amid R. In-Office Guided Implant Placement for Prosthetically Driven Implant Surgery. Craniomaxillofac Trauma Reconstr. 2017 Sep;10(3):243-249. [PMID: 28751952]
9. Panchal N, Mahmood L, Retana A. Dynamic Navigation for Dental Implant Surgery. Oral Maxillofac Surg Clin North Am. 2019 Nov;31(4):539-547. [PMID: 31563194]
10. Block MS. How to Avoid Errors When Using Navigation to Place Implants - A Narrative Review. J Oral Maxillofac Surg. 2023 Mar;81(3):338-346. [PMID: 36481276]
11. Greenstein G, Albeshri S, Majeed-Saidan A. Surgical and prosthetic criteria for selecting prefabricated vs custom implant abutments. Gen Dent. 2025 May-Jun. [PMID: 40258252]
12. Wittneben JG, Buser D, Belser UC, Braegger U. Peri-implant soft tissue conditioning with provisional restorations in the esthetic zone: the dynamic compression technique. Int J Periodontics Restorative Dent. 2013;33:447-455.
13. Brugnami F, Caleffi C. Prosthetically driven implant placement. How to achieve the appropriate implant site development. Keio J Med. 2005;54:172-178.
14. Nulty A. A literature review on prosthetically designed guided implant placement and the factors influencing dental implant success. Br Dent J. 2024 Feb. [PMC10853061]
15. Zarb GA, Schmitt A. Prosthodontic Treatment for Edentulous Patients. 13th ed. Mosby-Elsevier; 2012.
16. Misch CE. Contemporary Implant Dentistry. 3rd ed. Mosby; 2008.
17. Brånemark P-I, Zarb GA, Albrektsson T. Tissue-Integrated Prostheses: Osseointegration in Clinical Dentistry. Quintessence; 1985. (Foundational Textbook)

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EXAM SCORE-MAXIMIZING SUMMARY

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Mark Distribution Guide (50 marks)

1. Citing Garber & Belser 1995 and Buser 2004 as the founding classics
2. Using exact 3D position measurements (≥1.5 mm, ≥3 mm, 2-4 mm depth)
3. Connecting occlusal overload to peri-implant bone loss with Mojaver 2025 systematic review