È ¬È 

Ij[\Wd?^Z[
0RINCIPLESÈOFÈ"/)
9b_d_YWb"IY_[dj_\_Y"WdZFhWYj_YWb=k_Z[b_d[i
je*#::[djWb?cfbWdjebe]o
 È ¬È 

Ij[\Wd?^Z[

0RINCIPLESÈOFÈ"/)
9b_d_YWb"IY_[dj_\_Y"WdZFhWYj_YWb=k_Z[b_d[i
je*#::[djWb?cfbWdjebe]o

M_j^:L:

M_j^)..<_]kh[iWdZ.JWXb[i


3TEFANÈ)HDEÈ:h$
PW^dhpjb_Y^[Ab_d_a
:eh\fbWjp''
9>#.-)-=ecc_imWbZ

?I8D)#+*&#(',,+#&
Ifh_d][h8[hb_d>[_Z[bX[h]D[mOeha

B_XhWhoe\9ed]h[ii9edjhebDkcX[h0(&&*'&+.+.

J^_i meha _i ikX`[Yj je Yefoh_]^j$ 7bb h_]^ji Wh[ h[i[hl[Z" m^[j^[h j^[ m^eb[ eh fWhj e\ j^[ cWj[h_Wb _i
YedY[hd[Z" if[Y_ÒYWbbo j^[ h_]^ji e\ jhWdibWj_ed" h[fh_dj_d]" h[ki[ e\ _bbkijhWj_edi" h[Y_jWj_ed" XheWZYWij_d]"
h[fheZkYj_ededc_YheÒbcieh_dWdoej^[hmWo"WdZijehW][_dZWjWXWdai$:kfb_YWj_ede\j^_ifkXb_YWj_edeh
fWhjij^[h[e\_if[hc_jj[ZedbokdZ[hj^[fhel_i_edie\j^[=[hcWd9efoh_]^jBWme\I[fj[cX[h/"'/,+"_d_ji
Ykhh[djl[hi_ed"WdZf[hc_ii_ed\ehki[ckijWbmWoiX[eXjW_d[Z\hecIfh_d][h#L[hbW]$L_ebWj_ediWh[b_WXb[
\ehfhei[Ykj_edkdZ[hj^[=[hcWd9efoh_]^jBWm$

Ifh_d][h_iWfWhje\Ifh_d][hIY_[dY[!8ki_d[iiC[Z_W
ifh_d][hedb_d[$Yec

žIfh_d][h#L[hbW]8[hb_d>[_Z[bX[h](&&+
Fh_dj[Z_d=[hcWdo

J^[ki[e\][d[hWbZ[iYh_fj_l[dWc[i"h[]_ij[h[ZdWc[i"jhWZ[cWhai"[jY$_dj^_ifkXb_YWj_edZe[idej_cfbo"
[l[d_dj^[WXi[dY[e\Wif[Y_ÒYijWj[c[dj"j^WjikY^dWc[iWh[[n[cfj\hecj^[h[b[lWdjfhej[Yj_l[bWmiWdZ
h[]kbWj_ediWdZj^[h[\eh[\h[[\eh][d[hWbki[$

FheZkYj b_WX_b_jo0 J^[ fkXb_i^[hi YWddej ]kWhWdj[[ j^[ WYYkhWYo e\ Wdo _d\ehcWj_ed WXekj ZeiW][ WdZ
Wffb_YWj_ed YedjW_d[Z _d j^_i Xeea$ ?d [l[ho _dZ_l_ZkWb YWi[ j^[ ki[h ckij Y^[Ya ikY^ _d\ehcWj_ed Xo
Yedikbj_d]j^[h[b[lWdjb_j[hWjkh[$

:_iYbW_c[h0M^_b[j^[WZl_Y[WdZ_d\ehcWj_ed_dj^_iXeeaWh[X[b_[l[ZjeX[jhk[WdZWYYkhWj[Wjj^[j_c[
e\ikXc_ii_ed\ehfkXb_YWj_ed"d[_j^[hj^[Wkj^ehidehj^[fkXb_i^[hYWdWYY[fjWdob[]Wbh[ifedi_X_b_jo\eh
Wdo[hhehiehec_ii_edicWZ[_dWdofWhje\j^_iXeea$J^[cWj[h_Wbfh[i[dj[Z_dj^_iXeea_idej_dj[dZ[Z
jeh[fh[i[djj^[edboc[j^eZehWffb_YWj_edWffhefh_Wj[\ehj^[c[Z_YWbi_jkWj_ediZ_iYkii[ZXkjhWj^[h_i
_dj[dZ[Zjefh[i[djWdWffheWY^"l_[mfe_dj"ijWj[c[djehef_d_ede\j^[Wkj^ehi"m^_Y^cWoX[^[bf\kbje
ej^[him^e[dYekdj[hi_c_bWhYb_d_YWbi_jkWj_edi$
J^[ef_d_edi[nfh[ii[Z"ik]][ij_edicWZ[WdZWZl_Y[]_l[d_dj^_iXeeaWh[j^ei[e\j^[h[if[Yj_l[Wkj^ehi
WdZdejd[Y[iiWh_boj^ei[e\ehj^[fkXb_i^[h$J^[fkXb_i^[hWdZj^[Wkj^ehicWa[demWhhWdjo"[nfh[iieh
_cfb_[Z"m_j^h[if[YjjeWdocWj[h_WbYedjW_d[Zj^[h[_d$

;Z_jeh0=WXh_[b[IY^hZ[h">[_Z[bX[h]
:[ia;Z_jeh0CWhj_dW>_cX[h][h">[_Z[bX[h]
FheZkYj_ed0Fhe;Z_j=cX>">[_Z[bX[h]
9el[hZ[i_d]0<h_ZeIj[_d[d#8hee";IjkZ_e9WbWcWh"IfW_d
Jof[i[jj_d]0I:I"B[_c[d
Fh_dj_d]WdZ8_dZ_d]0Ij”hjp"M”hpXkh]

Fh_dj[ZedWY_Z#\h[[fWf[h(*%)'+&H[+*)('&
!CKNOWLEDGEMENTS
? mekbZ b_a[ je j^Wda Fhe\[iieh Le`_ibWl B[ael_³
WdZ :h$ PehWd 7b[ai_³ \eh j^[_h d[l[h#Y[Wi_d]
[dYekhW][c[dj je mh_j[ WdZ fkXb_i^ j^_i Xeea WdZ
\eh j^[ cWdo Yb_d_YWb _bbkijhWj_edi j^[o ie a_dZbo
f[hc_jj[Z c[ je ki[$ ? mekbZ Wbie b_a[ je j^Wda :h$
PehWd7b[ai_³\eh^_iWii_ijWdY[m_j^j^[ijWj_ij_YWb
[lWbkWj_edi WdZ m_j^ j^[ fh[fWhWj_ed e\ j^[
^_ijebe]_YWbif[Y_c[di$7bbijWj_ij_Yim[h[YWbYkbWj[Z
Xo:Wl_ZAef[Yaoe\:(Ci$h$e$"FhW]k[_d\e6Z(c$
Yp$?Wbiej^WdaFhe\[iieh>[hX[hjP_jj[hWjB[eX[d
Kd_l[hi_jo \eh Yh[Wj_d] j^[ H;C _cW][i$ 7dZ ?
mekbZ b_a[ je j^Wda co Ye#Wkj^ehi \eh j^[_h j_c[bo
Yeef[hWj_edm_j^j^[lWh_ekiY^Wfj[hi$
If[Y_Wb j^Wdai Wh[ Zk[ je Wbb co Yebb[W]k[i WdZ
ijkZ[dji m^e ^Wl[ Wii_ij[Z c[ _d Wii[cXb_d] j^[
cWdkiYh_fj WdZ m^ei[ ik]][ij_edi WdZ gk[ij_edi
^Wl[X[[dl[ho^[bf\kb$J^[_hifedjWd[ekih[WYj_edi
m[h[e\_cc[di[lWbk[WdZe\j[d^[bf[Zc[_Z[dj_\o
j^[l[hoi_cfb[XWi_Yij^WjWh[iee\j[dh[gk_h[Z\eh
j^ehek]^Yecfh[^[di_edWdZj^Wjm[h[_dYbkZ[Z_d
j^[ Xeea Xo j^[_h h[Yecc[dZWj_ed$ FWhj_YkbWhbo" ?
mekbZb_a[jej^Wda:h$:_[j[hI_d][h":h$AWjh_dJeij"
:h$ @[Wd#9bWkZ[ Ced_d WdZ :h$ <hWda#F[j[h IfW^d
\ehioij[cWj_YWbboh[l_[m_d]j^[cWdkiYh_fjWdZ\eh
e\\[h_d] lWbkWXb[ _di_]^ji [l[d j^ek]^ j^[o Wh[ dej
b_ij[ZWiYe#Wkj^ehi$J^Wdaije:h$Jeij\ehb[jj_d]c[
ki[WdkcX[he\_bbkijhWj_edi$7dZj^WdaijeHkii[bb
\ehYedjh_Xkj_d]j^[f_Yjkh[ie\j^[jh[[iWdZ\[dY[i$
8[oedZ Wbb j^_i" co if[Y_Wb j^Wdai Wh[ Zk[ je
j^[ j_h[b[ii Yh_j_Yi e\ j^[ 8E? jh[Wjc[dj m^e ^Wl[
[dYekhW][Zc[WdZcWdoej^[hfhWYj_Y_Wdie\XWiWb
eii[e_dj[]hWj_ed_cfbWdjebe]oje[dj[h_djeWdef[d
WdZYh_j_YWb[nY^Wd][m_j^j^[fhejW]ed_ijie\Yh[ijWb
_cfbWdjebe]o$J^[o^Wl[e\j[d\W_b[ZjeWffh[Y_Wj[WdZ
Yedj_dk[dejjeWffh[Y_Wj[j^[\kdZWc[djWbie\j^_i
jh[Wjc[djYedY[fj"WdZXoZe_d]ie^Wl[ij_ckbWj[Z
c[ je bWo ekj _d Z[jW_b j^[ j^[eh[j_YWb \ekdZWj_edi
e\ Xed[ X[^Wl_ekh \ebbem_d] 8E? j^[hWfo" XWi[Z ed
Wh[l_[me\j^[[njWdjb_j[hWjkh[WdZedcWdoo[Whi
e\ Yb_d_YWb [nf[h_[dY[" Zkh_d] m^_Y^ m[ ^WZ j^[
Y^WdY[jejh[Wj\Whceh[j^Wded[j^ekiWdZfWj_[dj
YWi[i$ 9ecfWhWj_l[ [nWc_dWj_ed e\ j^[ fh_dY_fb[i
WdZfheY[Zkh[ie\Yh[ijWb_cfbWdjebe]o^Wl[i^emd
j^Wjj^_iWh[W_ih[fb[j[m_j^j^[eh[j_YWbWdZfhWYj_YWb
_dYedi_ij[dY_[i$ J^_i Xeea m_bb fe_dj ekj i[l[hWb e\
j^[i[_dYedi_ij[dY_[i$
9b_d_YWbeXi[hlWj_ede\kd[nf[Yj[ZWdZkdZ[i_hWXb[
jh[Wjc[djekjYec[ifhel_Z[Zf[hcWd[djcej_lWj_ed
\eh \khj^[h h[i[WhY^ _dje j^[ fheY[Zkh[ e\ XWiWb
eii[e_dj[]hWj_ed f[h i[ WdZ e\ f[hj_d[dj _cfbWdji"
jeebi WdZ jh[Wjc[dj ijhWj[]_[i$ 9ehZ_Wb j^Wdai je
j^[ j[Wc Wj j^[ =ecc_imWbZ :[djWb 9b_d_Y" m^ei[
]eeZ_Z[WiWdZYecc_jc[dj^[bf[Zc[a[[fkfco
cej_lWj_edj^hek]^ekjWbbj^[i[o[Whi$
Ceij e\ Wbb" ? mekbZ b_a[ je j^Wda co \Wc_bo \eh
j^[_h kdZ[hijWdZ_d] WdZ ikffehj Wi ? mWi Z[[fbo
_cc[hi[Z _d j^_i [dZ[Wlekh" e\j[d kdZ[h ]h[Wj
j[di_ed WdZ Wbb jee e\j[d dej [l[d fh[i[dj$ CWo Wbb
ekh^ef[i\eh_cc_d[dj_cfhel[c[djedj^Wj\hedj
dejX[_dlW_d
7k]kij(&&* Ij[\Wd?^Z[
È

#ONTENTS

È 3TRUGGLESÈANDÈ3UCCESSESÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈ È *$'$' ;nj[hdWb?cfbWdji;: $$$$$$$$$$$$$$$$ ),

*$'$( 7Xkjc[djiWdZ9ecfed[dji
'$' Ijhk]]b[i$$$$$$$$$$$$$$$$$$$$$$$$$$$$$'  \eh;nj[hdWb#J^h[WZ:[i_]di$$$$$$$$$$$ ).
'$( Ej^[hCW`eh9edi_Z[hWj_edi$$$$$$$$$$$$$ ( *$'$) Jeebi\eh;nj[hdWb#J^h[WZ?cfbWdji$$$$$*&
'$) 7dWjec_YWbBWdZcWhai *$'$* 9ecfWj_Xb[9h[ijWb?cfbWdjJof[i0
 WiCel_d]JWh][ji$$$$$$$$$$$$$$$$$$$$$$ )  AEIIoij[cWdZI?cfbWdji$$$$$$$$$$$$*&
'$* M_dZie\9^Wd][$$$$$$$$$$$$$$$$$$$$$$ ) *$'$+ I[c_#f[hcWd[dj8edZ_d]
'$+ J^[HeYaoHeWZjeIkYY[ii$$$$$$$$$$$$$$ *  ed;:?cfbWdji$$$$$$$$$$$$$$$$$$$$$$$*&
'$, IYef[e\J^_i8eea$$$$$$$$$$$$$$$$$$$$ , *$( ?dj[hdWb:[i_]dim_j^Wd
'$- ;l_Z[dY[WdZJhkij$$$$$$$$$$$$$$$$$$$$$ -  ;nj[hdWb>[nW]ed?:Ioij[c$$$$$$$$$$ *)
'$. J^[?dj[hd[j$$$$$$$$$$$$$$$$$$$$$$$$$$ - *$) ?dj[hdWb8E?:[i_]dim_j^Wd
'$/ H[ikbjiWdZEkjYec[i  ;nj[hdWbEYjW]ed$$$$$$$$$$$$$$$$$$$$$ *)
 7ffb[iWdZEhWd][i$$$$$$$$$$$$$$$$$$ . *$)$' ?dj[hdWb#J^h[WZ:[i_]di?:EIoij[c$$ *)
'$'& J^[L_i_ed$$$$$$$$$$$$$$$$$$$$$$$$$$$$ . *$* Jeebi\ehIkh][ho$$$$$$$$$$$$$$$$$$$$$**
'$'' B_ij[d_d]jeFWj_[djiÉ:[cWdZi$$$$$$$$$$ . *$+ ?dj[hdWbL[hiki;nj[hdWbJ^h[WZ:[i_]di $**

È (ISTORYÈASÈ$OCUMENTEDÈBYÈ0ATENTSÈ È %QUIPMENTÈÈ
È ANDÈ0ATENTÈ!PPLICATIONSÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈ È È ANDÈ3URGICALÈ4ECHNIQUES ÈÈÈÈÈÈÈÈÈÈÈÈÈ È

+$' FbWdiWdZEkjYec[iWdZj^[9e[n_ij[dY[
È -ORPHOLOGYÈOFÈ"/)È)MPLANTSÈÈ  8[jm[[dB_l_d]WdZ:[WZEX`[Yji $$$$$$$*/
È ANDÈ2ELATEDÈ$ESIGNS ÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈ È +$( =[d[hWb9edi_Z[hWj_edi $$$$$$$$$$$$$$$$*/
+$) ?hh_]Wj_ed $$$$$$$$$$$$$$$$$$$$$$$$$$$$ +(
)$' Cehf^ebe]oe\j^[J^h[WZ[ZF_d$$$$$$$ (+ +$* 9ed\_]khWj_ede\j^[BeWZ#JhWdic_jj_d]
)$( BeWZJhWdic_ii_edXo:_iaiehH_d]i$$$$ (-  Ikh\WY[WdZJ^h[WZ[ZF_d$$$$$$$$$$$$$$$+)
)$) :_ijWdY[8[jm[[d9h[ijWbWdZ8WiWb +$+ 9ecX_dWj_edm_j^IYh[m?cfbWdji
 BeWZ#JhWdic_jj_d]Ikh\WY[i$$$$$$$$$$$$ (-  WdZ8[dZ_d]e\8Wi[#FbWj[7h[Wi $$$$$$$$ +/
)$* I^Wf[e\8WiWbBeWZ#JhWdic_jj_d] +$, ?djhWef[hWj_l[8b[[Z_d] $$$$$$$$$$$$$$$$ ,'
 Ikh\WY[i$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ (. +$- C[Z_YWj_ed$$$$$$$$$$$$$$$$$$$$$$$$$$$ ,)
)$+ IjhkYjkhWbH[i_b_[dY[e\?cfbWdji$$$$$$$ (/ +$. ?cfbWdjFei_j_ed_d]
)$, 9ed\_]khWj_edWdZH[bWj_l[:_c[di_edi  \ehFheij^[j_YJh[Wjc[dj $$$$$$$$$$$$$$$ ,+
 e\j^[?cfbWdj9ecfed[dji$$$$$$$$$$$$ (/ +$/ ?d`khoje7Z`WY[djJ[[j^$$$$$$$$$$$$$$$ ,+
)$- Ikh\WY[7h[Wie\?cfbWdji $$$$$$$$$$$$$$ )& +$'& ?djhWef[hWj_l[L_i_ed $$$$$$$$$$$$$$$$$$,,
)$. ;bWij_YL[hikiIj_\\ +$'' 7dWboi_d]j^[9Wki[ie\?cfbWdjBeii$$$ ,-
 ?cfbWdj#H[ijehWj_edIoij[ci$$$$$$$$$$$$)'
)$/ H[j[dj_edIoij[ci\ehFheij^[j_Y
 Ikf[hijhkYjkh[i;:L[hiki?:Jof[i $$$ )( È $IAGNOSTICSÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈ È
)$'& 9edYbki_ed$$$$$$$$$$$$$$$$$$$$$$$$$$$ )*
,$' ?djheZkYj_ed$$$$$$$$$$$$$$$$$$$$$$$$$,/
,$'$' J^[IjhWj[]_YJWia$$$$$$$$$$$$$$$$$$$$,/
È )NSERTIONÈ4OOLSÈÈ ,$'$( ;nfbeh_d]j^[Jh[Wjc[djEX`[Yj_l[$$$$$$,/
È ANDÈ)MPLANTÈ$ESIGNSÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈ È ,$( Ehj^efWdjece]hWf^i$$$$$$$$$$$$$$$$$,/
,$) FWdehWc_YHWZ_e]hWf^e\j^[Iakbb$$$$$ -&
*$' ?di[hj_edJeebi\eh;nj[hdWb ,$* BWj[hWbJ[b[hWZ_e]hWf^i$$$$$$$$$$$$$$$$ -&
 J^h[WZ:[i_]di$$$$$$$$$$$$$$$$$$$$$$$$)+ ,$+ FWbfWjeho;nWc_dWj_ed$$$$$$$$$$$$$$$$ -&
L??? #ONTENTS

,$, <kdYj_edWb:_W]dei_i .$* F[Ykb_Wh_j_[i9edY[hd_d]?cfbWdji

 WdZH[ijehWj_l[7bj[hdWj_l[i $$$$$$$$$$$$$-'  _dF[h_eZedjWbbo?dlebl[ZJ_iik[$$$$$$$$'&'
,$,$' Ded#Yehh[YjWXb[:oi\kdYj_edi $$$$$$$$$$$-' .$+ IkccWho $$$$$$$$$$$$$$$$$$$$$$$$$$$$'&'
,$- IjehW][H[gk_h[c[dji$$$$$$$$$$$$$$$$$ -(
,$. Ioij[c_Y>[Wbj^:_W]dei_i$$$$$$$$$$$$$ -)
,$/ IjhkYjkhWb>_ijehoe\j^[?cfbWdjI_j[$$$ -) È &OUR $IMENSIONALÈ#ONSIDERATIONSÈÈ
,$'& :_W]dei_ie\If[[Y^ È OFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS ÈÈ
 WdZ>[Wh_d]<kdYj_ed$$$$$$$$$$$$$$$$$ -)
/$' Fhef[hj_[ie\8ed[J_iik[
 _dj^[EhWb;dl_hedc[dj $$$$$$$$$$$$$$$'&)
È 4REATMENTÈ0LANNINGÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈ È /$'$' 9ehj_YWb8ed[$$$$$$$$$$$$$$$$$$$$$$$$'&)
 I$?^Z[WdZJ$CW_[h /$'$( M^o:e[i8CK7Yj_lWj_edEYYkh5$$$$$$'&+
/$'$) ?dj[hWYj_edi8[jm[[d@e_dji
-$' IYef[e\J^[hWfo$$$$$$$$$$$$$$$$$$$$$ --  WdZ8ed[9^Wd][i$$$$$$$$$$$$$$$$$$$ '&-
-$( DkcX[he\?cfbWdji /$'$* >ehcedWbWdZC[Y^Wd_YWb?d\bk[dY[i
 \eh9ecfb[j[8h_Z][i $$$$$$$$$$$$$$$$$$ --  :kh_d]=hemj^WdZ7]_d]$$$$$$$$$$$$ '&-
-$($' CWn_bbWhoH[ijehWj_edi$$$$$$$$$$$$$$$$ -. /$'$+ :_iki[7jhef^o"8beeZIkffbo
-$($( CWdZ_XkbWhH[ijehWj_edi$$$$$$$$$$$$$$$ -/  WdZF[h_eZedjWbFheXb[ci$$$$$$$$$$$$ '&.
-$) M^_Y^@WmI^ekbZ8[H[ijeh[Z<_hij5$$$$.& /$'$, 7if[Yjie\F[h_eZedjWb:_i[Wi[$$$$$$$$ '&/
-$* M^[dI^ekbZj^[?cfbWdji8[BeWZ[Z5$$.& /$'$- Heb[e\:_h[Yj8ed[Ij_ckbWj_ed
-$+ =[d[hWb8_ec[Y^Wd_YWb9edi_Z[hWj_edi  _d9h[ijWb?cfbWdji$$$$$$$$$$$$$$$$$$$$''&
 _dJh[Wjc[djFbWdd_d]$$$$$$$$$$$$$$$$$$.' /$'$. <ehY[":[\ehcWj_ed"Fh[iikh[WdZ<bem$$'''
-$, 9[c[dj_d]L[hikiIYh[m_d]$$$$$$$$$$$$ .* /$'$/ J^[&Ä'Fhef[hjo
-$- H[ZkY_d]<kdYj_edWbWdZFWhW\kdYj_edWb  WdZj^[I[b\#JhWX[YkbWj_ed
 BeWZiXoFheij^[j_YJh[Wjc[dj$$$$$$$$$$ .*  CeZ[bÄC_YheceZ[bb_d]$$$$$$$$$$$$$$$'''
-$. H[ZkY_d]<kdYj_edWbBeWZi /$( <ehc<ebbemi<kdYj_ed $$$$$$$$$$$$$$$$ '')
 Xo:hk]Jh[Wjc[dj $$$$$$$$$$$$$$$$$$$$ .+ /$($' 9edYbki_edi $$$$$$$$$$$$$$$$$$$$$$$$$ '(*
-$.$' :eiW][$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$., /$) ?cfWYje\9ecfh[ii_edWdZJ[di_ed
-$.$( 7Zl[hi[;\\[Yji$$$$$$$$$$$$$$$$$$$$$$$.,  edj^[L[hj_YWb8ed[B[l[b$$$$$$$$$$$$$ '(,
-$.$) ?dZ_YWj_ediWdZHWj_edWb[ $$$$$$$$$$$$$$., /$)$' ?djheZkYj_ed$$$$$$$$$$$$$$$$$$$$$$$$ '(,
-$/ ;njhWYj_edL[hikiFh[i[hlWj_ed /$)$( 8WYa]hekdZ9edi_Z[hWj_edi
 e\DWjkhWbJeej^IjhkYjkh[i$$$$$$$$$$$$$ ..  H[]WhZ_d]L[hj_YWb8ed[=hemj^ $$$$$$$$'(-
-$'& J[cfehWhoH[ijehWj_edi$$$$$$$$$$$$$$$ .. /$)$) 9b_d_YWb7ffb_YWj_ed$$$$$$$$$$$$$$$$$$$'(/
-$'' IYef[e\H[ijehWj_l[Jh[Wjc[dj$$$$$$$$$ .. /$)$* IkccWho $$$$$$$$$$$$$$$$$$$$$$$$$$$$')&
-$'( J^[I_]d_\_YWdY[e\J^_hZCebWhi$$$$$$$./ /$* >ehcedWb?d\bk[dY[i
-$') IkccWho $$$$$$$$$$$$$$$$$$$$$$$$$$$$ /)  WdZ:hk]Jh[Wjc[dj$$$$$$$$$$$$$$$$$$$ ')'
-$'* <_dWb9ecc[dji $$$$$$$$$$$$$$$$$$$$$$ /) /$*$' ;\\[Yjie\>ehcedWb:[\_Y_ji$$$$$$$$$$$ ')'
/$*$( <hWYjkh[i7\j[h?cfbWdjJ^[hWfo $$$$$$$$')*
/$*$) <hWYjkh[iWdZEij[eco[b_j_i $$$$$$$$$$$$ ')+
È !SPECTSÈOFÈ"/)È4REATMENTÈ /$*$* FioY^eieY_Wb7if[Yji$$$$$$$$$$$$$$$$$$'),
È INÈ0ERIODONTALLYÈ)NVOLVEDÈ#ASES ÈÈÈÈ /$*$+ 9edYbki_ed$$$$$$$$$$$$$$$$$$$$$$$$$$$'),
 I$?^Z["L$B[ael_YWdZP$7b[ai_Y /$+ CWYheiYef_Y<kdYj_edWb7dWjeco $$$$$$$')-
/$+$' ?djheZkYj_ed$$$$$$$$$$$$$$$$$$$$$$$$$')-
.$' ?djheZkYj_edWdZ:[\_d_j_ed$$$$$$$$$$$$ /+ /$+$( 7][#H[bWj[Z9^Wd][i
.$( ?cc[Z_Wj[boBeWZ[Z8E?  _d@WmCehf^ebe]o$$$$$$$$$$$$$$$$$$$$')-
 WjF[h_eZedjWbbo?dlebl[ZI_j[i $$$$$$$$$$// /$+$) CWn_bbWhoCehf^ebe]o$$$$$$$$$$$$$$$$$').
.$($' ?djheZkYj_ed$$$$$$$$$$$$$$$$$$$$$$$$$// /$+$* J^[FheXb[ce\Iocc[jho
.$($( EX`[Yj_l[i$$$$$$$$$$$$$$$$$$$$$$$$$$$//  M^_Y^MWi<_hij0J^[>[dehj^[;]]5$').
.$($) CWj[h_WbiWdZC[j^eZi$$$$$$$$$$$$$$$$// /$+$+ IkccWho0Beea_d]_djej^[FWij $$$$$$$$')/
.$($* Ikh]_YWbFheY[Zkh[ $$$$$$$$$$$$$$$$$$$$// /$, C_YheiYef_Y7dWjeco
.$($+ Fheij^[j_YFhejeYeb$$$$$$$$$$$$$$$$$$$$//  WdZDkjh_[djIkffbo$$$$$$$$$$$$$$$$$$$')/
.$($, <ebbem#Kf$$$$$$$$$$$$$$$$$$$$$$$$$$ '&& /$,$' M^oWdZ>emÆ7bbJ^_d]i7h[_d<bknÇ$$$')/
.$($- H[ikbji$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ '&& /$,$( 9b_d_YWb9edi_Z[hWj_edi $$$$$$$$$$$$$$$$'*'
.$) Efj_cWbFei_j_ede\8E??cfbWdji /$,$) >eb_ij_Y9edi_Z[hWj_edied?cfbWdj
 _dj^[L_Y_d_joe\;njhWYj_edIeYa[ji$$$$$'&'  J^[hWfo_d<_[bZie\:_ijkhXWdY[$$$$$$ '*(
È #ONTENTSÈ ?N

/$- I_ckbjWd[ekiC_d[hWb_pWj_ed ''$($+ <WXh_YWj_d]<_n[Z8h_Z][i $$$$$$$$$$$$$$'-,

 WdZH[ceZ[bb_d]J[dZ[dY_[i$$$$$$$$$$ '** ''$($, Æ8heiWcb[Ç8h_Z][i$$$$$$$$$$$$$$$$$$$'-,
 <$AhWiiWdZI$?^Z[ ''$($- C[jWb9eh[WdZL[d[[h_d]$$$$$$$$$$$$$ '.&
''$($. H[i_dL[hiki9[hWc_YL[d[[h_d]$$$$$$$$ '.'

È &UNCTIONALÈ#ONSIDERATIONSÈASÈÈ È 2EPLACINGÈ-OLARSÈINÈ"OTHÈ*AWSÈÈÈÈÈÈÈÈÈ

È THEÈ'UIDINGÈ4REATMENTÈ0RINCIPLEÈÈÈÈÈÈÈ
'($' ?djheZkYj_ed$$$$$$$$$$$$$$$$$$$$$$$$$'.)
'&$' Bed]#J[hc<kdYj_ed '($( IYehj[YY_ÉiCkbj_#_cfbWdj9edY[fj$$$$$$$'.)
 H[gk_h[iF[hi_ij[dj8WbWdY[$$$$$$$$$$$ '*/ '($) 8E??cfbWdji9ecX_d[Zm_j^
'&$( ?djheZkYj_ed$$$$$$$$$$$$$$$$$$$$$$$$$'+&  DWjkhWbJ[[j^WdZ9h[ijWb?cfbWdji$$$$$$'.)
'&$) :[Yecf[diWj_ede\ '($* Bed]#J[hcEkjYec[
 j^[CWij_YWjeho7ffWhWjki$$$$$$$$$$$$$'+&  e\LWh_ekiJh[Wjc[dj
'&$)$' 7le_ZWdY[FWjj[hdi$$$$$$$$$$$$$$$$$$$$ '+'  CeZWb_j_[i_dj^[Feij[h_ehI[]c[dj $$$$$'.)
'&$)$( Kd_bWj[hWb9^[m_d]WdZI_Z[Im_jY^_d]$$ '+' '($*$' FWj_[dji$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$'.+
'&$)$) H[ijh_Yj[ZCel[c[dj$$$$$$$$$$$$$$$$$$ '+) '($*$( ?dZ_YWj_edi$$$$$$$$$$$$$$$$$$$$$$$$$$ '.,
'&$)$* Ded#f^oi_ebe]_YWb>ofeceX_b_jo:k[ '($*$) Jh[Wjc[djIY^[Zkb[WdZI[b[Yj_ed
 jeBWYae\7XhWi_ed$$$$$$$$$$$$$$$$$$$'+*  e\?cfbWdj:[i_]di$$$$$$$$$$$$$$$$$$$ '.,
'&$* 9b_d_YWb:_W]deij_Yi $$$$$$$$$$$$$$$$$$$ '++ '($*$* ?cfbWdjWj_edFheY[Zkh[$$$$$$$$$$$$$$ '.,
'&$+ N#HWo:_W]deij_Yi$$$$$$$$$$$$$$$$$$$$'+, '($*$+ Fheij^[j_YH[ijehWj_ed $$$$$$$$$$$$$$$$$'.-
'&$, H[bWn_d]@e_djiWdZCkiYb[i $$$$$$$$$$$$'+, '($*$, IjWj_ij_YWb7dWboi_iWdZH[ikbji$$$$$$$$$'.-
'&$- F[h_eZedjWb9edi[gk[dY[ie\<kdYj_ed$$'+, '($*$- :_iYkii_ed $$$$$$$$$$$$$$$$$$$$$$$$$$ './
'&$-$' CkiYb[Fem[hWdZ9^[m_d]FWjj[hd$$$$$'+- '($+ 9edYbki_edi $$$$$$$$$$$$$$$$$$$$$$$$$$ '/'
'&$. EYYbki_edL[hikiCWij_YWj_ed$$$$$$$$$$$'+/ '($, IjWj_ij_YWb:_W]hWci
'&$/ D[kheckiYkbWh9edjheb  WdZH[fh[i[djWj_l[F^eje]hWf^i $$$$$$$ '/(
 _d?cfbWdjFWj_[dji$$$$$$$$$$$$$$$$$$$ ',&
'&$'& H[\b[n[iWdZ;d]hWci$$$$$$$$$$$$$$$$ ',&
'&$'' H[YedijhkYj_d]j^[9^[m_d]<kdYj_ed $$$ ',' È !NTERIORÈ-ASTICATORYÈ0ATTERNSÈÈ
'&$'( ?cfbWdjJh[Wjc[djWi<_hij#B_d[ È ANDÈ#LASSÈ))È3KELETALÈ2ELATIONSÈÈÈÈÈÈÈÈÈÈ
 J^[hWfoe\CWij_YWj_ed $$$$$$$$$$$$$$$$ ','
'&$') HWj_edWb[e\9h[Wj_d] ')$' :[\_d_d]j^[FWj_[dj=hekf$$$$$$$$$$$$$'/-
 W8WbWdY[Z<kdYj_ed$$$$$$$$$$$$$$$$$$',( ')$( :[l[befc[dje\j^[CWij_YWjehoFWjj[hd$'/-
'&$'* CWij_YWj_edJ^[hWfo7bbemi ')$) 9ehh[Yj_d]9bWii??H[bWj_edi
 ;\\[Yj_l[8ed[CWdW][c[dj $$$$$$$$$$$$',)  XoFheij^[j_YJh[Wjc[dj$$$$$$$$$$$$$$(&&
'&$'+ 9edYbki_ed$$$$$$$$$$$$$$$$$$$$$$$$$$ ',* ')$* CW_djW_d_d]EYYbkiWb9bWii??H[bWj_edi
 :kh_d]Fheij^[j_YJh[Wjc[dj$$$$$$$$$$ (&'
')$+ L[hj_YWb:_c[di_ed$$$$$$$$$$$$$$$$$$ (&'
È 0ROSTHETICÈ4REATMENTÈÈ ')$, :_h[YjWdZ?dZ_h[Yj9edi[gk[dY[i
È #ONSIDERATIONS ÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈ  e\Jh[Wjc[dj$$$$$$$$$$$$$$$$$$$$$$$$ (&)
')$- 9edYbki_ed$$$$$$$$$$$$$$$$$$$$$$$$$$(&*
''$' Fheij^[j_YJh[Wjc[djIj[fi $$$$$$$$$$$$$',+
''$'$' 7Xkjc[djI[b[Yj_ed$$$$$$$$$$$$$$$$$$ ',,
''$'$( 9ebbWXehWj_edm_j^j^[BWXehWjeho$$$$$ ',, È "/)È4REATMENTÈINÈTHEÈ0RESENCEÈÈ
''$'$) Jof[ie\El[hbeWZ$$$$$$$$$$$$$$$$$$$$',- È OFÈ#LASSÈ)))È3KELETALÈ2ELATIONSÈÈÈÈÈÈÈÈÈÈÈ
''$'$* Fheij^[j_Y=k_Z[b_d[i$$$$$$$$$$$$$$$$$ '-&  I$?^Z[WdZL$AedijWdj_del_Y
''$'$+ Jh[Wjc[djEX`[Yj_l[i $$$$$$$$$$$$$$$$$ '-&
''$'$, J^[L[hj_YWb:_c[di_ed$$$$$$$$$$$$$$$$ '-' '*$' =[d[hWb9edi_Z[hWj_edi $$$$$$$$$$$$$$$ (&-
''$'$- 7dj[h_eh7bj[hWj_edi $$$$$$$$$$$$$$$$$$$'-( '*$( 9edl[dj_edWbIkh]_YWb7ffheWY^[i$$$$$ (&-
''$'$. 7[ij^[j_Y9edi_Z[hWj_edi$$$$$$$$$$$$$$'-( '*$) 7bj[hdWj_l[Jh[Wjc[dj
''$'$/ ?di[hj_ede\j^[H[ijehWj_ed $$$$$$$$$$$$'-)  m_j^8E??cfbWdji$$$$$$$$$$$$$$$$$$$(&.
''$'$'& J[cfehWho9edd[Yj_edi$$$$$$$$$$$$$$$'-* '*$* 9edYbki_ed$$$$$$$$$$$$$$$$$$$$$$$$$$(&/
''$( BWXehWjehoFheY[Zkh[i$$$$$$$$$$$$$$$$'-+
 DWp_hP[Y_h_
''$($' BWXehWjeho;gk_fc[dj\eh;:?cfbWdji$$'-+ È 4REATINGÈTHEÈ!TROPHIEDÈ-ANDIBLEÈÈÈÈÈ
''$($( H[#l[d[[h_d]e\8h_Z][<hWc[mehai$$$$$'-+
''$($) 9edd[Yj_d]j^[8h_Z][$$$$$$$$$$$$$$$$$'-, '+$' ?djheZkYj_ed$$$$$$$$$$$$$$$$$$$$$$$$$('+
''$($* 7[ij^[j_YiL[hiki7YY[ii_X_b_jo $$$$$$$$$$'-,
N #ONTENTS

'+$( Jme9edY[fji\eh:[Wb_d] '.$. JhekXb[i^eej_d]$$$$$$$$$$$$$$$$$$$$$ (,+

 m_j^8_ec[Y^Wd_YWbH[Wb_jo$$$$$$$$$$$$('+ '.$/ Cehf^ebe]_YWb7bj[hWj_edi
'+$($' Dkc[heki?cfbWdji_dj^[CWdZ_Xb[$$$$('+  _dj^[:_ijWbCWdZ_Xb[ $$$$$$$$$$$$$$$$(,,
'+$($( IjhWj[]_Y?cfbWdjFei_j_ed_d]$$$$$$$$$$$('- '.$'& HWZ_e]hWf^_Y9Wi[IjkZ_[i $$$$$$$$$$$$ (,.
'+$) ?d\hWd[hlWb?cfbWdjWj_ed$$$$$$$$$$$$$$ ('/ '.$'' JhW_d_d]\ehI_dkiFheY[Zkh[i$$$$$$$$$ (-*
'+$* 7if[Yjie\j^[IjhWj[]_YFei_j_ed_d] '.$'( 9edYbki_edi $$$$$$$$$$$$$$$$$$$$$$$$$ (-*
 e\8E??cfbWdji '.$') 9ecfb_WdY[$$$$$$$$$$$$$$$$$$$$$$$$$ (-+
 WdZFheXb[c#Iebl_d]IjhWj[]_[i$$$$$$$$ ((&
'+$+ J[cfehWhoH[ijehWj_ed$$$$$$$$$$$$$$$ ((+
'+$, 7if[Yjie\J[di_ed:_ijh_Xkj_ed$$$$$$$ ((+ È "ARÈ!TTACHMENTSÈONÈ"/)È)MPLANTSÈÈÈÈÈÈ
'+$- IkccWho $$$$$$$$$$$$$$$$$$$$$$$$$$$ ((,
'/$' ?dZ_YWj_edi$$$$$$$$$$$$$$$$$$$$$$$$$$ (--
'/$( 9eij9edi_Z[hWj_edi$$$$$$$$$$$$$$$$$$ (--
È 4UBEROPTERYGOIDÈ3CREWS ÈÈÈÈÈÈÈÈÈÈÈÈÈ '/$) 7[ij^[j_Y9edi_Z[hWj_edi$$$$$$$$$$$$$ (-.
'/$* ?cfbWdjFei_j_ed_d]\eh8Wh
',$' ?djheZkYj_ed$$$$$$$$$$$$$$$$$$$$$$$$ ((/  7jjWY^c[djiL[hiki<_n[Z8h_Z][i$$$$$$ (-.
',$( FWhWbb[b?cfbWdjFbWY[c[dj$$$$$$$$$$$$ ()( '/$+ ?cfbWdjI[b[Yj_ed
',$) IkccWho $$$$$$$$$$$$$$$$$$$$$$$$$$$$()+  \eh8WhH[ijehWj_edi $$$$$$$$$$$$$$$$$$ (-/
'/$, Kf]hWZ_d]CWdZ_XkbWh
 8WhH[ijehWj_edi $$$$$$$$$$$$$$$$$$$$$ (-/
È &UNCTIONALÈ0ROSTHODONTICÈ4REATMENTÈÈ
È ANDÈ2ESTORATIONÈOFÈÈ
È THEÈ6ERTICALÈ$IMENSIONÈÈ È !ESTHETICSÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈ
È INÈ#RANIOMANDIBULARÈ$ISEASEÈÈÈÈÈÈÈÈÈ
(&$' ?djheZkYj_ed$$$$$$$$$$$$$$$$$$$$$$$$ (.-
'-$' ?djheZkYj_ed$$$$$$$$$$$$$$$$$$$$$$$$ ()- (&$( 9Wi[IjkZ_[i?bbkijhWj_d]
'-$( 9b_d_YWb7ffheWY^$$$$$$$$$$$$$$$$$$$$ ()-  j^[Ki[e\=_d]_lWb;f_j^[i[i $$$$$$$$$$ (..
'-$) F[hiedWb_jo:_iehZ[hi (&$) =_d]_lWbLebkc[9ecf[diWj_ed
 WdZFeeh9ecfb_WdY[$$$$$$$$$$$$$$$$ ()/  XoF_da9[hWc_Yi$$$$$$$$$$$$$$$$$$$$ (./
'-$* 9C:#H[bWj[ZFheXb[ci7\\[Yj (&$* 9h[Wj_d]Wd;c[h][dY[Fhe\_b[$$$$$$$$$(/&
 j^[<kdYj_ed (&$+ 7[ij^[j_Y?cfWYj
 e\j^[M^eb[Ia[b[jWbIoij[c$$$$$$$$$$ ()/  e\<kdYj_edWb7ZWfjWj_edi$$$$$$$$$$$$(/&
'-$+ ?d_j_WbJh[Wjc[dj$$$$$$$$$$$$$$$$$$$$$(*& (&$, FWj_[djiÉ7[ij^[j_Y:[cWdZi
'-$, ?cfbWdjJh[Wjc[dj$$$$$$$$$$$$$$$$$$$ (*'  _d9b_d_YWbFhWYj_Y[ $$$$$$$$$$$$$$$$$$$$(/'
'-$- :[\_d_j_l[Fheij^[j_YH[YedijhkYj_ed$$$ (*)
'-$. :_iYkii_ed $$$$$$$$$$$$$$$$$$$$$$$$$$ (*-
'-$/ 9edYbki_ed$$$$$$$$$$$$$$$$$$$$$$$$$$(*/ È -ECHANICSÈ-EETSÈ"IOMECHANICSÈÈÈÈÈÈÈÈ

('$' =[d[hWb9edi_Z[hWj_edi $$$$$$$$$$$$$$$ (/+

È )MPLANTÈ4REATMENTÈÈ ('$( <ebbem#Kfe\<hWYjkh[Z8E??cfbWdji$$(/,
È !LONGÈTHEÈ-AXILLARYÈ3INUS ÈÈÈÈÈÈÈÈÈÈÈÈ ('$($' 9edYbki_ed$$$$$$$$$$$$$$$$$$$$$$$$$$(/,
 L$AedijWdj_del_YWdZI$?^Z[ ('$) <;C7dWboi_i
 e\:_\\[h[djBeWZ_d]I_jkWj_edi$$$$$$$$ (/-
'.$' L_[miWdZIf[YkbWj_edi $$$$$$$$$$$$$$$$(+' ('$)$' 9edYbki_ed$$$$$$$$$$$$$$$$$$$$$$$$$$ (/-
'.$( >_ijeh_YWbH[l_[m$$$$$$$$$$$$$$$$$$$$ (+( ('$* M[X8Wh:[i_]d
'.$) DWjkh[e\j^[CWn_bbWhoI_dki$$$$$$$$$$$(+)  WdZIjh[ii:_ijh_Xkj_ed$$$$$$$$$$$$$$$(//
'.$* 8_ec[Y^Wd_YiL[hikiL[dj_bWj_ed $$$$$$$$(+) ('$*$' 9edYbki_ed$$$$$$$$$$$$$$$$$$$$$$$$$$(//
'.$+ ?cfbWdjebe]_YWb7ffheWY^[i
 jej^[I_dki7h[W$$$$$$$$$$$$$$$$$$$$ (+-
'.$+$' 7k]c[djWj_ed#8Wi[Z?di[hj_ed È 0RIMARYÈ!UGMENTATIONÈÈ
 e\8E??cfbWdji$$$$$$$$$$$$$$$$$$$$$ (+- È 5SINGÈ"/)È)MPLANTSÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈ
'.$+$( IjhWj[]_YJhWdi#i_dki?di[hj_ed  J$CW_[h"L$AedijWdj_del_Y"WdZI$?^Z[
 e\8E??cfbWdji$$$$$$$$$$$$$$$$$$$$$ (+.
'.$, IfWj_Wb<_dZ_d]i7\j[hDed#Wk]c[dj[Z (($' ?djheZkYj_ed$$$$$$$$$$$$$$$$$$$$$$$$ )&)
 ?cfbWdjWj_ed$$$$$$$$$$$$$$$$$$$$$$$$ (,( (($( Fh_cWho7k]c[djWj_ed0
'.$- I[YedZWho?cfbWdjFbWY[c[dj  9b_d_YWbFheY[Zkh[$$$$$$$$$$$$$$$$$$$ )&)
 7bed]j^[CWn_bbWhoI_dki$$$$$$$$$$$$$ (,* (($) 9edYbki_ed$$$$$$$$$$$$$$$$$$$$$$$$$$ )&*
È #ONTENTSÈ N?

È (ISTOLOGYÈOFÈ"/)È)MPLANTS ÈÈÈÈÈÈÈÈÈÈÈÈÈ È ,EGALÈ!SPECTSÈOFÈ4HERAPEUTICÈÈ

È !LTERNATIVESÈANDÈ#OSTSÈÈ
()$' >_ijebe]_YWbIjkZ_[i$$$$$$$$$$$$$$$$$$ )&- È #OURTÈ$ECISIONSÈÈ
()$'$' ?djheZkYj_ed$$$$$$$$$$$$$$$$$$$$$$$$ )&- È ANDÈ(EALTHÈ)NSURERSÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈ
()$'$( >_ijebe]_YWbIf[Y_c[di$$$$$$$$$$$$$$$ )&-  C_Y^W[bPWY^
()$'$) >_ijebe]_YWbH[ikbji
 \eh8E??cfbWdji$$$$$$$$$$$$$$$$$$$$$ )&/ (+$' ?djheZkYj_ed$$$$$$$$$$$$$$$$$$$$$$$$$)+)
()$'$* >_ijebe]_YWbH[ikbji (+$( IYh[m?cfbWdji9ecX_d[Z
 \eh9h[ijWb?cfbWdji $$$$$$$$$$$$$$$$$$$)'&  m_j^?b_WY9h[ij8ed[=hW\jiÄ
()$'$+ :_iYkii_edWdZ9b_d_YWb7ffb_YWj_ed$$$$$)'&  Ij_bbÆj^[IjWj[e\j^[7hjÇ5$$$$$$$$$$$$$)+)
()$'$, 9edYbki_edi $$$$$$$$$$$$$$$$$$$$$$$$$$)'* (+$) ?cfbWdjebe]_ijiWdZ8E?:_iYbeikh[0
()$( >WhZ#J_iik[>[Wb_d]  J^[=[hcWdB[]WbI_jkWj_ed$$$$$$$$$$$ )+,
 WdZ?cc[Z_Wj[BeWZ_d]$$$$$$$$$$$$$$$)'. (+$* 9eijH[_cXkhi[c[djXo=[hcWd
()$($' ?djheZkYj_ed$$$$$$$$$$$$$$$$$$$$$$$$$)'.  Fh_lWj[>[Wbj^?dikh[hi$$$$$$$$$$$$$$$$)+.
()$($( ?cc[Z_Wj[BeWZ_d]L[hiki
 ?cc[Z_Wj[?cfbWdjWj_ed $$$$$$$$$$$$$$$)'/
()$($) ?cc[Z_Wj[BeWZ_d]L[hiki È -AINTENANCE ÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈ
 :[bWo[ZBeWZ_d] $$$$$$$$$$$$$$$$$$$$$ )(&
()$($* IjhWj[]_[ije7Y^_[l[?dj[]hWj_ed (,$' H[YWbb$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$),'
 _dLWh_ekiBeYWj_edi$$$$$$$$$$$$$$$$$$)(' (,$'$' ?djheZkYj_ed$$$$$$$$$$$$$$$$$$$$$$$$$),'
()$($+ ?cc[Z_Wj[BeWZ_d]WdZj^[D[[Z (,$'$( ?cfbWdjH[YWbb9^[Yab_ij $$$$$$$$$$$$$$$),'
 \eh9edj_dkekiFheij^[j_Y7Z`kijc[dji $ )(( (,$'$) ?dZ_YWj_ed\ehHWZ_e]hWf^i$$$$$$$$$$$$ ),(
()$($, EdboBeWZ[Z8E??cfbWdji (,$'$* IW\[]kWhZ?d\ehcWj_edWdZJ^[hWf[kj_Y
 9WdIj_ckbWj[j^[8ed[ $$$$$$$$$$$$$$$$)()  ?d\ehcWj_ed:kh_d]H[YWbb$$$$$$$$$$$$ ),(
()$($- IkccWho $$$$$$$$$$$$$$$$$$$$$$$$$$$$)() (,$'$+ EYYbkiWb7Z`kijc[dji
()$) Ceh[>_ijebe]_YWb<_dZ_d]i  WdZ9ecf[diWj_ede\9^Wd][i
 WdZ9b_d_YWb9edi_Z[hWj_edi $$$$$$$$$$$ )(*  _dj^[8ed[Cehf^ebe]o $$$$$$$$$$$$$$ ),)
()$)$' ?djheZkYj_ed$$$$$$$$$$$$$$$$$$$$$$$$ )(* (,$'$, If[Y_Wb9edi_Z[hWj_ediM^[d?di[hj_d]
()$)$( Eii[eWZWfjWj_edWdZ=Wf@kcf_d]$$$$$ )(*  WI[YedZHekdZe\?cfbWdji$$$$$$$$$$$ ),+
()$)$) H[bWj_l[Cel[c[dj (,$'$- J^[CeX_b_joe\;:?cfbWdji
 e\Fheij^eZedj_YWbboBeWZ[Z?cfbWdji$$$)(+  7]W_dij7Xkjc[dji$$$$$$$$$$$$$$$$$$$ ),,
()$)$* ?d\bk[dY[e\Ikh\WY[Fhef[hj_[i (,$'$. 9edYbki_ed$$$$$$$$$$$$$$$$$$$$$$$$$$ ),-
 edj^[:[]h[[e\?dj[]hWj_ed$$$$$$$$$$ )(, (,$( JhekXb[i^eej_d]$$$$$$$$$$$$$$$$$$$$$ ),-
()$)$+ ?di[hj_d]?cfbWdjiD[Wh (,$($' J^[h[7h[Ceh[Iebkj_edi
 eh?di_Z[:[djWbHeeji$$$$$$$$$$$$$$$$ )(,  J^WdFheXb[ci$$$$$$$$$$$$$$$$$$$$$$ ),-
()$)$, J[jhWYoYb_d[<bkeh[iY[dY[;lWbkWj_ed $$$ )(, (,$($( <hWYjkh[iWjj^[J^h[WZ[ZF_d$$$$$$$$$ )-(
()$)$- HWZ_ebe]_YWb7dWboi_i (,$($) F[d[jhWj_ede\j^[CkYeiWXoW:_ia$$$ )-(
 e\j^[>_ijebe]_YWbI[Yj_edi$$$$$$$$$$$ )(, (,$($* 9edYbki_ed$$$$$$$$$$$$$$$$$$$$$$$$$$ )-(
()$)$. :_h[Yj_ede\?cfbWdj?dj[]hWj_ed $$$$$$$$)(- (,$) Beiie\IjWX_b_joWdZH[_dj[]hWj_ed$$$$$ )-(
()$)$/ :_iYkii_ed $$$$$$$$$$$$$$$$$$$$$$$$$$$)(- (,$)$' H[Wiedi\eh?cfbWdjBeii$$$$$$$$$$$$$ )-(
()$)$'& IkccWho $$$$$$$$$$$$$$$$$$$$$$$$$$$$))) (,$)$( 7le_Z_d]F[hcWd[dj8ed[:[\[Yji$$$$$ )-,
()$)$'' M^Wj_ij^[Yb_d_YWbi_jkWj_ed (,$)$) IkccWho $$$$$$$$$$$$$$$$$$$$$$$$$$$ ).&
 m[YWd[nY[fjW\j[h_cfbWdjWj_ed (,$* 7ZZ_j_edWbIkh]_YWbFeij#jh[Wjc[dj$$$$$ ).&
 WdZfheij^[j_Yjh[Wjc[dj5 $$$$$$$$$$$$$ )). (,$*$' ?djheZkYj_ed$$$$$$$$$$$$$$$$$$$$$$$$ ).&
(,$*$( I[YedZWho7k]c[djWj_ed$$$$$$$$$$$$$$).'
(,$*$) <h[[CkYeiWb=hW\ji $$$$$$$$$$$$$$$$$$ ).(
È #OUNSELLINGÈANDÈ#ASEÈ!CCEPTANCEÈÈÈÈÈÈ (,$*$* ?cfbWdjH[fbWY[c[dj:k[
 C_Y^W[bPWY^  jeIe\j#J_iik[FheXb[ci$$$$$$$$$$$$$$$ ).(
(,$*$+ 7ZZ_j_edWb7if[Yji
(*$' ?d\ehc[Z9edi[djje  e\Feij#_cfbWdjWj_ed$$$$$$$$$$$$$$$$$$).)
 ?cfbWdj#8Wi[Z:[djWbJh[Wjc[dj$$$$$$$$)*' (,$+ 9ecfb_WdY["9ecfb_YWj_edi
(*$( 7hX_jhWj_ed7]h[[c[dj$$$$$$$$$$$$$$$ )*+  WdZBed]#j[hcJh[Wjc[djIkYY[ii$$$$$$).)
(*$) :[djWbJh[Wjc[dj9edjhWYj (,$+$' 9ecfb_WdY[WdZ9ecfb_WdY[=hekfi0
 ?cfbWdjJh[Wjc[dj$$$$$$$$$$$$$$$$$ )*-  7:[\_d_j_ed$$$$$$$$$$$$$$$$$$$$$$$$$$).)
(*$* 9^[Ya#KfH[fehj$$$$$$$$$$$$$$$$$$$$ )+& (,$+$( ?d_j_Wb9ecfb_WdY[$$$$$$$$$$$$$$$$$$$ ).*
(*$+ :[dj_ijÉiMWhhWdjoE\\[h$$$$$$$$$$$$$$$ )+' (,$+$) Jof_YWbH[ikbji
 _d:_\\[h[dj9ecfb_WdY[=hekfi$$$$$$$$).+
N?? #ONTENTS

(,$+$* IkccWho $$$$$$$$$$$$$$$$$$$$$$$$$$$ )., (-$)$' 9edikbjWdjiHkb[$$$$$$$$$$$$$$$$$$$$$ )/)

(,$, ?bb#7Zl_i[Z8E?FWj_[dji$$$$$$$$$$$$$$ ).- (-$)$( 7kj^eh_pWj_ed$$$$$$$$$$$$$$$$$$$$$$$ )/)
(-$)$) ;lWbkWj_ede\j^[9ecfb[j[
 Jh[Wjc[djFheY[ii$$$$$$$$$$$$$$$$$$$ )/*
È &ROMÈ+NOWLEDGEÈÈ (-$* FheX_d]WiW:_W]deij_Y7Z`kdYj$$$$$$$ )/*
È ANDÈ3KILLÈTOÈ!CTION ÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈ (-$*$' FheX_d]WiW:_W]deij_YC[Wikh[
 7hekdZDWjkhWbJ[[j^
(-$' GkWb_jo7iikhWdY[H[gk_h[i7jj[dj_ed  WdZ9h[ijWb?cfbWdji
 je:[jW_b $$$$$$$$$$$$$$$$$$$$$$$$$$$$$)/'  ;7I?7ii[iic[dj $$$$$$$$$$$$$$$$$$$ )/*
(-$( 8E?9edi[diki$$$$$$$$$$$$$$$$$$$$$$ )/( (-$*$( FheX_d]d[Wh8E?$$$$$$$$$$$$$$$$$$$$ )/,
(-$($' :[\_d_j_ed$$$$$$$$$$$$$$$$$$$$$$$$$$ )/( (-$*$) IkccWho $$$$$$$$$$$$$$$$$$$$$$$$$$$ )/-
(-$($( 7kj^eh_pWj_ed$$$$$$$$$$$$$$$$$$$$$$$ )/(
(-$($) 9edikbjWdji$$$$$$$$$$$$$$$$$$$$$$$$$$)/'
(-$($* Fh[fWhWj_ede\j^[?cfbWdj8[Z $$$$$$$$ )/( È 2EFERENCES ÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈ
(-$($+ 8E??cfbWdji9ecX_d[Z
 m_j^DWjkhWbJ[[j^
 WdZ9h[ijWb?cfbWdji$$$$$$$$$$$$$$$$$ )/( È !NHANGÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈ È
(-$($, BeWZ_d]XoFheij^[j_YIjhkYjkh[i$$$$$$ )/(
(-$($- ?dZ_YWj_edi\ehj^[H[celWb
 e\8WiWbEii[e_dj[]hWj[Z?cfbWdji$$$$$ )/( È 3UBJECTÈ)NDEX ÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈÈ È
(-$) 9ecc[djiedj^[8E?9edi[diki $$$$$$ )/(
È

6IDEOS

Fh[i[djWj_ed'0?djheZkYj_ed ', J^h[[8E?_cfbWdjiWdZed[IJ9_cfbWdj

Fh[i[djWj_ed(0CW_dj[dWdY[
 ' ?di[hj_ede\8E?_cfbWdjiWdZAEI
 \ehXWh#ikffehj[Zh[ijehWj_ed
 ( 8b[[Z_d]ed8E?_cfbWdj_di[hj_ed"
 Wdj[h_ehcWdZ_Xb[
 ) 7d_cWj_ed0;bWij_Y8E?_cfbWdj
 * 7d_cWj_ed0Jof['YYedijhkYj_ed
 + 7d_cWj_ed0Jof['\YedijhkYj_ed
 , 7d_cWj_ed0Jof[']YedijhkYj_ed
 - FbWY[c[dje\8E?_cfbWdjiX[bemj^[
 cWdZ_XkbWhd[hl[$
 . Ikffehj_d]_cfbWdj"cWn_bbW
 / JhWdi#i_dki_cfbWdjfbWY[c[dj
'& ?di[hj_ede\fh[#X[dj8E?_cfbWdj
'' Ikffehj_d]_cfbWdj_dj^[cWn_bbW
'( 8[dZ_d]Wdj[h_eh_cfbWdjkfmWhZ"
 fbkic[cXhWd[
') ?di[hj_ede\?:EJ_cfbWdj
'* 8E?_cfbWdj_di[hj_ed_dj^[Z_ijWb
 cWdZ_Xb[
'+ AEIiYh[mi_cfbWdjiWdZ8E?_cfbWdji
 _dj^[cWdZ_Xb[
 _dj^[cWn_bbW
'- CW_djW_dWdY[W\j[hj^[_dijWbbWj_ed
 e\j^[Xh_Z][
'. 9^Wd][e\Y^[m_d]fWjj[hd?
'/ 9^Wd][e\Y^[m_d]fWjj[hd??
(& 9^Wd][e\Y^[m_d]fWjj[hd???
(' 8E?_cfbWdji_dj^[kff[h`Wm"
 X[dZ_d]e\l[ij_XkbWhijhkji
(( 8E?_cfbWdjiWdZAEIiYh[m_cfbWdji
 _dj^[kff[h`Wm
() FbWY[c[dje\WjkX[hefj[ho]e_ZiYh[m
(* H[fbWY[c[dje\W\hWYjkh[Z8E?_cfbWdj
(+ 9ehh[Yj_ede\[WhboYedjWYji_dZ_ijWbWh[W
(, <W_bkh[e\W8E?_cfbWdjZk[jec_ii_d]
 cWij_YWjehoYehh[Yj_ediWdZl[hj_YWb
 Xed[]hemj^
 Wih[ifedi[je\kdYj_ed
(- <W_bkh[e\8E?_cfbWdjiZk[jec_ii_d]
 cWij_YWjehoYehh[Yj_edi
(. 8_Xb_e]hWf^oedbWj[hWb_cfbWdji
(/ Fh[fWhWj_ede\W\_Xh_dc[XhWd[
È

!UTHORS

$RÈ3TEFANÈ)HDE $RÈ4HOMASÈ-AIER
?cfbWdjebe]_ij"F[h_eZedjebe]_ij ?cfbWdjebe]_ij
PW^dhpjb_Y^[FhWn_i 8W^d^e\ijh$-"-)**-EX[haeY^[d"=[hcWdo
:eh\fbWjp''".-)-=ecc_imWbZ [#cW_b0Zh$cW_[h#pW^daeic[j_a6j#edb_d[$Z[
Im_jp[hbWdZ
[#cW_b0Zh$_^Z[6_cfbWdj$Yec .AZIRÈ:ECIRI
:[djWbJ[Y^d_Y_Wd
>[hh[dWYa[hijhWii[(.".-)&KpdWY^"Im_jp[hbWdZ
#ONTRIBUTORS [#cW_b0dp[Y_h_6_cfbWdj$Yec

$RÈ:ORANÈ!LEKSIC -ICHAELÈ:ACH
8[b]hWZ[IY^eebe\:[dj_ijho"F[h_e:fj$ 7jjehd[oWjBWm
:hIkXej_Yijh* ;_Ya[d[hIjh$.)"*'&,'CY^[d]bWZXWY^"=[hcWdo
''&&&8[b]hWZ["I[hX_WWdZCedj[d[]he [#cW_b0_d\e6h[Y^jiWdmWbj#pWY^$Z[
[#cW_b0ZhWb[ai_Y6fjj$ok

0ROFESSORÈ$RÈ6ITOMIRÈ3È+ONSTANTINOVIC %NGLISHÈTRANSLATION
9^_[\e\:[fWhjc[dj
CWn_bbe\WY_WbIkh][hoe\IjecWjebe]_YWb<WYkbjo 0ERÈ.È$ÚHLER
e\8[b]hWZ[Kd_l[hi_jo" Jh_WYec"8Wh[dZeh\%B”d[Xkh]"=[hcWdo
''&&&8[b]hWZ["I[hX_WWdZCedj[d[]he
[#cW_b0lial_jW6[kd[j$ok -AGÈ7ILFRIEDÈ0REINFALK
C[ZmehZ"L_[ddW"7kijh_W
$RÈ&LORIANÈ+RASS
H_]_Xb_Yaijh$''-",)+)M[]]_i"Im_jp[hbWdZ
[#cW_b0ie\jYWh[6]cn$d[j

0ROFÈ$RÈ6OJISLAVÈ,EKOVIC
8[b]hWZ[IY^eebe\:[dj_ijho"F[h_e:fj$
:hIkXej_Yijh*
''&&&8[b]hWZ["I[hX_WWdZCedj[d[]he
[#cW_b0le`Wb[a6[kd[j$ok

#(!04%2È
3TRUGGLESÈANDÈ3UCCESSES

MJLF
DIFTT

HPWFSOFE
CZ
UIF
MBXT
PG


CVU
XF
LOPX
UIBU


IPOFTU
BOE
QBUJFOU
"EBQUFE
GSPN
8BSSJPS

È
3TRUGGLES
M^[d jee cWdo f[efb[ W]h[[ ed j^[ iWc[ ikX`[Yj"
_j _i ^_]^ j_c[ je YWbb _j _dje gk[ij_ed$ <[m ej^[h
Wh[Wi e\ c[Z_Y_d[ Wh[ X[jj[h Y^WhWYj[h_p[Z Xo j^_i
ijWj[c[dj j^Wd Z[djWb _cfbWdjebe]o$ M^o5 8[YWki[
Xej^ WYWZ[c_Y Æh[i[WhY^[hiÇ WdZ fhWYj_j_ed[hi
\eYki j^[_h [\\ehji ieb[bo ed Yh[ijWb _cfbWdji$ ?d
ej^[h mehZi" j^[o Yecfb[j[bo _]deh[ Wdo Z[i_]di eh
YedY[fji ej^[h j^Wd iYh[mi WdZ Yob_dZ[hi" m^_Y^
]k_Z[ j^[ cWij_YWjeho \ehY[i" _dje Xed[ Wh[Wi j^Wj
cW_dbo Yedi_ij e\ YWdY[bbeki j_iik[$ ?\ j^[ WlW_bWXb[
l[hj_YWb Xed[ ikffbo _i _dik\\_Y_[dj" c[Wikh[i Wh[
jWa[djeh[Xk_bZj^[cehf^ebe]oe\j^[Xed[j_iik[
Ä m^[j^[h Xo jhWdifbWdjWj_ed" Xo Wk]c[djWj_ed eh
Xo _dZkY[Z ]hemj^$ Kdb[ii W[ij^[j_Y Yedi_Z[hWj_edi
fbWo W cW`eh heb[" j^[i[ ceZ_\_YWj_edi e\ j^[ Xed[
i_jkWj_edWh[f[h\ehc[Zieb[boje\WY_b_jWj[j^[ki[e\
Yh[ijWb_cfbWdji"m^_Y^mekbZX[_cfeii_Xb[je_di[hj
ej^[hm_i[$ ?d cWdo YWi[i" j^[i[ WZ`klWdj c[Wikh[i
Wh[ Yedi_Z[hWXbo ceh[ j_c[#Yedikc_d] WdZ ceh[
[nf[di_l[ j^Wd j^[ fWj_[dj YWd W\\ehZ$ C[Wdm^_b["
de _cfbWdj jh[Wjc[dj _i f[h\ehc[Z m^Wjie[l[h"
WdZ j^[ fWj_[dj _i b[\j m_j^ekj Wd WZ[gkWj[ \_n[Z
h[ijehWj_ed$ 7j j^[ iWc[ j_c[" j^[ \eYki e\ Z[djWb
_cfbWdj jh[Wjc[dj j[dZi je i^_\j WmWo \hec j^[
Z[djWb e\\_Y[i Wi j^[i[ WZ`klWdj c[Wikh[i ]W_d
h[if[YjWX_b_jo" jemWhZi j^[ if[Y_Wb_iji YWfWXb[ e\
f[h\ehc_d]j^[c$:k[jej^[WZZ_j_edWbYeije\j^[i[
WZ`klWdj c[Wikh[i" cWdo fWj_[dji Wh[ kdWXb[ je
W\\ehZWZ[gkWj[_cfbWdjjh[Wjc[dj$J^[Yedi[gk[dY[
_ij^Wjj^[_hcWij_YWjeho\kdYj_edYWddejX[h[ijeh[Z
_dWjhkboYecfh[^[di_l[cWdd[h$
J^[_cfbWdjj[Y^d_gk[e\ÆXWiWbeii[e_dj[]hWj_edÇ
8E?^WiX[[dZ[l[bef[Zm_j^Wl_[mjeWZZh[ii_d]
j^[i_jkWj_ediekjb_d[ZWXel["Wced]ej^[hfheXb[ci$
?dj^_iXeeam[Wh[]e_d]je[nfbW_dm^obWj[hWbWYY[ii
jej^[`WmXed[i^ekbZX[j^[ijWdZWhZj[Y^d_gk[_d
Z[djWb _cfbWdjebe]o$ 9edl[dj_edWb _cfbWdj Z[i_]di
YWd eYYWi_edWbbo X[ ki[Z Wi WZZ_j_edWb jh[Wjc[dj
efj_edi$
Iec[Z[djWbÆ[nf[hjiÇ"i^Wh_d]d[_j^[hj^[l_i_ed
deh j^[ [nf[h_[dY[ e\ 8E? ki[hi" ^Wl[ _d j^[ fWij
hW_i[Z leYWb effei_j_ed je j^_i ioij[c$ ?j _i dej
kdYecced \eh jhWZ_j_edWb_iji" m^e edY[ hei[ je
 ¬ 
*NQMBOUPMPHZ
JT
/BUVSF
8F
DBOOPU
TFF
PVS
PQQPOFOU
TIF
JT
GBJS
PG
UIF
-JHIU

"
NBOVBM
CZ
1BVMP
$PFMIP
\Wc[ Xo ki_d] if[Y_\_Y c[j^eZi" je [W][hbo effei[
j^[eXieb[iY[dY[e\j^[_hademb[Z][XoeXijhkYj_d]
fhe]h[iiWYj_l[bo$?dj^[_hYWfWY_joWiYekhj#Wffe_dj[Z
[nf[hji"j^[oYWdb_j[hWbboXeoYejjd[mjh[Wjc[dji\eh
Wbed]j_c[$
:k[ je Wd Wbceij h[b_]_eki X[b_[\ _d iY_[dj_\_Y
c[Z_Y_d[ Ä _j ^Wi X[[d Wh]k[Z j^Wj j^_i X[b_[\ _i W
ikXij_jkj[ \eh h[b_]_ed _ji[b\ B”jp (&&( Ä fWj_[dji
Wh[ e\j[d kdWXb[ je _d\ehc j^[ci[bl[i _d W
h[Wb_ij_Y cWdd[h WXekj del[b jh[Wjc[dj ceZWb_j_[i$
D[l[hj^[b[ii"8E?_cfbWdji^Wl[X[Yec[_dYh[Wi_d]bo
fefkbWh_dh[Y[djo[Whi$7iWh[ikbje\j^[^_]^Z[]h[[
e\ fWj_[dj iWj_i\WYj_ed" j^[ fWj_[dji kbj_cWj[boÆlej[
m_j^j^[_h\[[jÇ$
De ZekXj" jh[Wjc[dj m_j^ 8E? _cfbWdji YWd
edbo X[ f[h\ehc[Z WdZ _ji ekjYec[ [lWbkWj[Z
_d W Yecf[j[dj cWdd[h Xo ki[hi m^e ^Wl[ X[[d
j^ehek]^bo jhW_d[Z _d j^[ j[Y^d_gk[ WdZ Wh[ kf je
ZWj[edj^[Ykhh[dj[nf[h_[dY[$7doed[h[`[Yj_d]j^[
j[Y^d_gk[ ekj e\ ^WdZ m_bb e\ Yekhi[ d[l[h X[ WXb[
jeWYgk_h[WdZcWij[h_j$M[i^Wbbj^[h[\eh[fh[i[dj
j^[ 8E? j[Y^debe]o _d j^_i Xeea" Z[cedijhWj[ _ji
fhWYj_YWX_b_jo"WdZZeYkc[dj_jiikYY[ii\kbekjYec[
XWi[Zedif[Y_\_YYWi[h[fehji$
:[dj_iji m^e f[h\ehc 8E? jh[Wjc[dji Wh[ ij_bb
h[gk_h[Z je ^Wl[ WZZ_j_edWb ieb_Z jhW_d_d]$ M^Wj
m[ Wh[ Ykhh[djbo eXi[hl_d] _i j^Wj ceh[ WdZ ceh[
kd_l[hi_j_[iWh[X[Yec_d]WYj_l[_dj^_i\_[bZ"^Wl_d]
\_hij WYgk_h[Z j^[ j[Y^d_gk[ j^[ci[bl[i$ I_dY[ j^[
kd_l[hi_j_[iÉ hW_ied ZɅjh[ _i j^[ fhefW]Wj_ed e\
ademb[Z][" j^_i Z[l[befc[dj e\ Yekhi[ Z[i[hl[i
fhW_i[$ 8o YedjhWij m_j^ ceij Ykhh[dj j[WY^_d]i _d
j^[h[Wbce\Yh[ijWb_cfbWdjebe]o"j^[fhefW]Wj_ede\
ademb[Z][WXekjj^[h[Wb#b_\[fhef[hj_[ie\Xed[WdZ
_jiX[^Wl_ekhfbWoWfhec_d[djheb[_d8E?$E\[gkWbbo
]h[Wj_cfehjWdY[Wh[fheij^eZedj_YYedY[fjiWdZj^[
j[WY^_d] e\ ^em je h[ijeh[ j^[ ^kcWd cWij_YWjeho
\kdYj_ed$CWdokd_l[hi_j_[im[h[jeebWj[][jj_d]ed
j^[ 8E? jhW_d$ Ed[ c_]^j m[bb Wia ^em j^_i YekbZ
^Wl[^Wff[d[ZÄi[l[hWb\WYjehiYec[jec_dZ0
v 7Yecfh[^[di_l[YedY[fje\cWij_YWj_ed_iWXi[dj
\hec j^[ WYWZ[c_Y j[WY^_d] Ykhh_Ykbkc$ Iec[
kd_l[hi_j_[iZedejYkhh[djboj[WY^j^_i\_[bZWjWbb"
m^_b[ej^[hij[WY^gk_j[Z_l[h][djl_[mi$
v J^[j[WY^_d]WdZfhWYj_Y[e\Z[djWb_cfbWdjebe]o_i
ifh[WZWYheiii[l[hWbZ[fWhjc[dji0fheij^eZedj_Y
( 9^Wfj[h'È 3TRUGGLESÈANDÈ3UCCESSES
Z[fWhjc[dji_cfbWdjÆi_cfb[hÇYWi[i"Z[fWhjc[dji
e\ ehWb ikh][ho _cfbWdj Æceh[ Z_\\_YkbjÇ YWi[i"
WdZ j^[ cWn_bbe\WY_Wb ikh][edi Wh[ ^ebZ_d] j^[_h
emd m^[d _j Yec[i je cW_djW_d_d] j^[_h d_Y^[
_d cWn_cWbbo _dlWi_l[ Xed[ jhWdifbWdjWj_edi$
;l[dehj^eZedj_ijieYYkfoWicWbbh[]_edm_j^_d
Z[djWb_cfbWdjebe]oh[bWj[Zje[deiiWbWdY^ehW][$
D[[Zb[ii je iWo" Wbb j^[i[ Z[fWhjc[dji \_]^j [WY^
ej^[h\ehWYY[iijej^[\[mfWj_[djiWdZjej^_hZ#
fWhjoh[i[WhY^]hWdji$
v ?dWmWo"8E?_cfbWdjebe]o_iWfWhje\Wbbe\j^[i[
ikX\_[bZi"Wd_dj[hZ_iY_fb_dWho[dZ[Wlekh"\eYkii_d]
ed\kdYj_edWbj^[hWfoWdZm_j^Wijhed]ikh]_YWb
Wif[Yj$FioY^e#ieY_WbWdZ[Yedec_YWbWif[YjiWbie
fbWo W heb[0 Dej edbo _i j^[ 8E? fheY[Zkh[ j^[
\Wij[ij WdZ iW\[ij jh[Wjc[dj fheY[Zkh[ _d Z[djWb
_cfbWdjebe]ojeZWo"_j_iWbiej^[Y^[Wf[ij$
v Iec[ kd_l[hi_j_[i _dYh[Wi_d]bo h[Wb_p[ j^Wj feij#
]hWZkWj[ _dijhkYj_ed _d 8E? _cfbWdjebe]o _i Wd
_cc[di[\_[bZj^Wjc_]^jl[hom[bb][d[hWj[^k][
Wcekdji e\ \_dWdY_Wb h[iekhY[i$ IjkZ[dji \hec
Wbb j^[ ikX#Z_iY_fb_d[i Y_j[Z WXel[ d[[Z iec[
jhW_d_d]_d8E?_cfbWdjebe]oÄWdZkbj_cWj[boWbb
WYj_l[eh\kjkh[Z[dj_iji$
:kh_d] co 8E?#h[bWj[Z jhWl[bb_d] WYj_l_j_[i" ? ^Wl[
\ekdZ j^Wj \[bbem Z[dj_iji _d j^[ [n#9ecckd_ij
Yekdjh_[i Wh[ ckY^ ceh[ \Wc_b_Wh m_j^ j^[ XWi_Yi
e\ Xed[ f^oi_ebe]o WdZ cWij_YWj_ed j^[hWfo j^Wd
Z[dj_iji _d j^[ \ehc[h M[ij[hd Yekdjh_[i$ >em[l[h"
_dj[hZ_iY_fb_dWhojhW_d_d]i[[cijeX[iYWhY[Wjiec[
_dij_jkj_edi$
7YYehZ_d] je IYehj[YY_ (&&'" // e\ fWj_[dji
dej [b_]_Xb[ \eh jh[Wjc[dj m_j^ iYh[m _cfbWdji YWd
X[ jh[Wj[Z Xo 8E? m_j^ekj Xed[ jhWdifbWdjWj_ed$
J^_i^_]^ikYY[iihWj[_i_dWYYehZWdY[m_j^ekhemd
[nf[h_[dY[$
7jfh[i[dj"_dikhWdY[YecfWd_[iWh[X[]_dd_d]je
\_dZekjj^Wj8E?jh[Wjc[dj_iXo\Whceh[iW\["\Wij[h
WdZ Y^[Wf[h j^Wd Yedl[dj_edWb Xed[ Wk]c[djWj_ed
\ebbem[ZXoYh[ijWb_cfbWdjWj_ed$Edj^[ej^[h^WdZ"
j^[Wff[WhWdY[e\8E?edj^[ijW][c[Wdij^Wjceh[
fWj_[dji m_bb kdZ[h]e jh[Wjc[dj ceh[ h[WZ_bo0 W
]h[Wj dkcX[h e\ fWj_[dji m^e ^Wl[ jeo[Z m_j^ j^[
_Z[W e\ _cfbWdj jh[Wjc[dj X[\eh[ Xkj i^_[Z WmWo
\hecXed[jhWdifbWdjWj_edehfhebed][ZY^W_hj_c[i
Wh[ X[]_dd_d] je i[[ W h[Wb_ij_Y Y^WdY[ e\ eXjW_d_d]
\_n[Z h[ijehWj_edi ed _cfbWdji m_j^_d Wd WYY[fjWXb[
j_c[\hWc[$
?j _i d[Y[iiWho WdZ \W_h je c[dj_ed j^Wj Z_ia
_cfbWdjebe]o WdZ j^[ 8E? j[Y^d_gk[" b_a[ Wbb Z[djWb
_cfbWdj j[Y^d_gk[i" m[dj j^hek]^ Wd [Whbo f^Wi[
e\ jh[Wjc[dj \W_bkh[i m_j^ _cfbWdji WdZ fheij^[j_Y
ikf[hijhkYjkh[iX[_d]beij$J^[iWc[b[Whd_d]Ykhl[
^WZjeX[cWij[h[Z_dj^[Z[l[befc[dje\Wbbej^[h
_cfbWdj j[Y^d_gk[i eh" \eh j^Wj cWjj[h" Wdo ej^[h
c[Z_YWb jh[Wjc[dj$ CWdo fheXb[ci _d Yedd[Yj_ed
m_j^ XWiWb eii[e_dj[]hWj_ed Whei[ \hec j^[ \WYj
j^WjWdkcX[he\l_[miedfheY[Zkh[i"X[b_[l[iWdZ
jh[Wjc[dj WffheWY^[i m[h[ WZefj[Z \hec kdj[ij[Z
Yh[ijWb _cfbWdjebe]o$ J^[o m[h[ WZefj[Z m_j^ekj
adem_d]j^[h[Wiedim^oj^[eh_]_dWbj[Y^d_gk[^WZ
WYjkWbbo meha[Z" eh dej meha[Z" _d if[Y_\_Y YWi[i$
?d ekh l_[m" iec[ e\ j^[Æhkb[iÇ j^Wj [lebl[Z \hec
j^[ b_j[hWjkh[ ed Yh[ijWb _cfbWdjebe]o Wh[ Z[\_d_j[bo
mhed]$Iec[e\j^[cYWddejX[][d[hWb_p[ZXkjWh[
XWi[Z ieb[bo ed [cf_h_YWb eXi[hlWj_edi j^Wj cWo
feii_Xbo Wffbo je Yh[ijWb _cfbWdji$ 7domWo ceij e\
j^[c^WZjeX[h[l_i[Z_dj^[fWijZ[YWZ[$
È
/THERÈ-AJORÈ#ONSIDERATIONS
B[Whd_d]j^[ikh]_YWbfheY[Zkh[_idejZ_\\_Ykbjf[hi[
_\]eeZ_dijhkYj_ed_ifhel_Z[Z$JhW_d[[i^Wl[jed[[Z
je i^Wa[ e\\ i[l[hWb fh[`kZ_Y[i j^Wj Wh[ Yedi_Z[h[Z
m_Z[bojeX[\WYji$
'$ 7Yeccedc_iYedY[fj_edjeZWo_ij^Wjj^[bWj[hWb
eij[ejeco \eh 8E? YWddej X[ Yh[Wj[Z m_j^ j^[
iWc[ bem#if[[Z _dijhkc[dji Wi Yeccedbo ki[Z
_d Yh[ijWb _cfbWdjebe]o$ H[]WhZb[ii" ^em[l[h"
j^[h[ Wh[ ]h[Wj WZlWdjW][i _d ki_d] ^_]^#if[[Z
_dijhkc[dji WdZ kbjhWied_Y jeebi dej edbo ed
j[[j^"XkjWbie_dj^[Xed[$
($ J^[ YbW_c j^Wj j^[ j[cf[hWjkh[i WiieY_Wj[Z m_j^
^_]^#if[[Z_dijhkc[djim_bbW\\[YjXed[^[Wb_d]_i
Z[\[Wj[ZXoYb_d_YWb[nf[h_[dY[$
)$ J^[ YedY[fj e\ _cc[Z_Wj[ beWZ_d] m_j^ 8E?
_cfbWdji _i Yedj_dkWbbo Z_iYkii[Z kdZ[h \Wbi[
fh[c_i[i"WiceijYedY[fjie\Yh[ijWb_cfbWdjebe]o
h[bo ed kdbeWZ[Z eii[e_dj[]hWj_ed e\ _cfbWdji$
9h[ijWb _cfbWdji" [if[Y_Wbbo _d j^[ cWn_bbW" Wh[
_di[hj[Z _d Xed[ Wh[Wi j^Wj Yedi_ij cW_dbo e\
YWdY[bbeki j_iik[$ J^[i[ Wh[Wi Wh[ dej YWfWXb[ e\
WYY[fj_d] WdZ jhWdic_jj_d] cWij_YWjeho beWZi _d
j^[[Whbof^Wi[ie\jh[Wjc[dj$J^_iedboX[Yec[i
feii_Xb[edY[j^[Xed[j_iik[^WiX[[dWZ[gkWj[bo
YedZ_j_ed[Z Xo j^[ [dZeii[eki _cfbWdj ikh\WY[$
9^Wfj[hi/WdZ()m_bbfhel_Z[j^[h[WZ[hm_j^j^[
d[Y[iiWho XWYa]hekdZ je m[_]^ kf j^[ fhei WdZ
Yedie\_cc[Z_Wj[beWZ_d]ceh[h[Wb_ij_YWbbo$
*$ J^[ YbW_c j^Wj _cfbWdj fbWY[c[dj _i YedjhW#
_dZ_YWj[Z _d f[h_eZedjWbbo _dlebl[Z Wh[Wi _i Wbie
XWi[Z ed \Wbi[ fh[c_i[i$ ?d Yh[ijWb _cfbWdjebe]o
ij[h_b[ _di[hj_ed _i W cW`eh h[gk_h[c[dj i_dY[ de
]Wf _i b[\j \eh ikffkhWj_ed$ Fh[#[n_ij_d] h[i_ZkWb
eij[_j_i m_j^_d j^[ Xed[ eh c_Yhe#eh]Wd_ici
_djheZkY[Z Zkh_d] j^[ _di[hj_ed YWd Xh_d]
jh[Wjc[dj m_j^ Yh[ijWb _cfbWdji je Wd [dZ l[ho
gk_Yabo$ 8E? _cfbWdji" Xo YedjhWij" Wh[ ^_]^bo
h[i_ijWdj je _d\[Yj_ed$ J^[ h[WZ[h _i h[\[hh[Z je
9^Wfj[hi.WdZ()\ehWZ[jW_b[ZZ_iYkii_ede\j^_i
_iik[$
È È !NATOMICALÈ,ANDMARKSÈASÈ-OVINGÈ4ARGETSÈ
È
!NATOMICALÈ,ANDMARKSÈASÈ-OVINGÈ4ARGETS
J^[ 8E? j[Y^d_gk[ h[gk_h[i dej edbo W j^h[[#
Z_c[di_edWbYedY[fje\j^[ijhkYjkh[ie\j^[^kcWd
iakbb"XkjWbieWdej_ede\j^[cehf^ebe]_YWbY^Wd][i
j^Wj j^[ iakbb m_bb kdZ[h]e Xej^ m_j^ W][ WdZ Wi W
h[ikbje\j^[fbWdd[Zjh[Wjc[dj$J^[[nf[h_[dY[m_j^
8E? _cfbWdji ^Wi o_[bZ[Z [cf_h_YWb ]k_Z[b_d[i j^Wj
fh[Z_Yj m^[h[ Wd _cfbWdj i^ekbZ X[ fbWY[Z" ^em _j
i^ekbZ X[ fkj _dje \kdYj_ed Xo fheij^[j_Y c[Wdi
WdZm^Wjjof[ie\jh[Wjc[djm_bb[dikh[WikYY[ii\kb
ekjYec[$
;l[d j^ek]^ W ikijW_dWXb[ _cfbWdj i_j[ cWo
X[ kdkiWXb[ Wj j^[ j_c[ e\ \_hij _cfbWdjWj_ed" j^[
jh[Wjc[djYWdij_bbX[fbWdd[Z_dikY^WmWoj^Wjj^[
h[gk_h[Z Xed[ lebkc[ m_bb X[ Xk_bZ_d] kf kdZ[h W
bed]#j[hc j[cfehWho h[ijehWj_ed$ Jh_Yao YedY[fji
b_a[j^[i[Wh[WY^Wbb[d][_dekh[l[hoZWofhWYj_Y["Xkj
kbj_cWj[boj^[oWh[be]_YWb$J^[ikYY[ii_l[jh[Wjc[dj
ij[fiWh[[Wiojef[h\ehc_dj^[^WdZie\m[bb#l[hi[Z
fhWYj_j_ed[hi$
7ZZ_j_edWb Z_\\_Ykbj_[i Wh_i[ _d i_jkWj_edi m_j^ W
c_d[hWb_pWj_ed fWjj[hd dej Yedi_ij[dj m_j^ je m^Wj
mekbZÆdehcWbboÇX[[nf[Yj[Z"ehm_j^WdWZ[gkWj[
Xed[ lebkc[ dej X[_d] fh[i[dj Wj ijhWj[]_YWbbo
\WlekhWXb[_cfbWdjfei_j_edi$J^_icWoeYYkhWjj^[
X[]_dd_d] e\ eh Zkh_d] W jh[Wjc[dj$ Kbj_cWj[bo" j^[
]eWbe\jh[Wjc[dj_ijeYh[Wj[ijWXb[YedZ_j_edi[l[d
j^ek]^ j^[ \kdYj_edWb fej[dj_Wb Wj j^[ X[]_dd_d]
e\ jh[Wjc[dj cWo X[ ikY^ j^Wj ijWX_b_jo YWddej X[
WjjW_d[Z_cc[Z_Wj[bo$
È
7INDSÈOFÈ#HANGE
7j W j_c[ m^[d YWhi Wh[ Xk_bj je bWij" m_j^ \kbbo
]WblWd_p[Z eh Wbb#Wbkc_d_kc Y^Wii_i \eh Yehhei_ed
fhej[Yj_edÄ_j_iZ_\\_Ykbjje[nfbW_djeiec[fWj_[dji
j^Wj Z[\_d_j_l[ fheij^[j_Y h[ijehWj_edi" edY[ j^[o
^Wl[X[[d_di[hj[Z_dj^[cekj^"d[[ZjeX[WZ`kij[Z
f[h_eZ_YWbbo je [dikh[ j^[_h bed][l_jo _d W l_iYe#
[bWij_Y _djhW#ehWb [dl_hedc[dj j^Wj _i ikX`[Yj je
Yedj_dkekic[Y^Wd_YWbWdZijWj_YY^Wd][i$7bie"j^[
\WYjj^Wj_cfbWdjjh[Wjc[djiWh[h[bWj_l[bo[nf[di_l[
b[WZifWj_[djijeX[b_[l[j^Wjj^[oYWd[nf[YjWijWXb[
Z[\_d_j_l[fheZkYj_dh[jkhd\ehj^[_hced[om_j^de
d[[Z\ehikXi[gk[djcW_dj[dWdY[j^[hWf_[i$FWj_[dji
mekbZ b_a[ je j^_da j^Wj j^[_h emd YebbWXehWj_ed
_i de bed][h W cW`eh \WYjeh _d j^[ ekjYec[ e\
j^[ Xed[#_cfbWdj#h[ijehWj_ed Yecfb[n edY[ j^[
_dijWbbWj_ed f^Wi[ ^Wi X[[d Yecfb[j[Z$ J^[o j[dZ
jeel[hbeeaj^WjYWhi"jee"d[[Zh[]kbWhcW_dj[dWdY[
WdZ Y^[Ya_d] WdZ Wh[ f[h_eZ_YWbbo \_jj[Z m_j^ d[m
)
joh[ijeh[i_ijWc[Y^Wd_YWbbo^eij_b[[dl_hedc[dj$?d
YWhi"j^[cW_dj[dWdY[YeijiWh[WikXijWdj_Wbfehj_ed
e\j^[WYgk_i_j_edYeij$
?cfbWdj#Xehd[ h[ijehWj_edi d[[Z cW_dj[dWdY[
WdZ ie Ze j^[ _cfbWdji j^[ci[bl[i$ J^[ \h[gk[dYo
e\j^[i[l_i_jim_bbZ[f[dZed^emkdkikWbj^[YWi[
mWi Wj j^[ j_c[ e\ fh[i[djWj_ed WdZ ^em \Wij j^[
cWij_YWjeho ioij[c YWd X[ ]k_Z[Z XWYa je h[]kbWh
\kdYj_ed$
IkijW_dWXb[ _cfbWdjebe]_YWb h[ikbji YWd edbo
X[ eXjW_d[Z _\ j^[ _cfbWdji _dYehfehWj[Z _dje j^[
\kdYj_edWb Yecfb[n e\ j^[ iakbb Ze dej W\\[Yj j^[
\kdYj_edWb cehf^ebe]_YWb Y^Wd][i e\ j^[ `WmXed[$
Fh[\[hWXbo"j^[oi^ekbZX[fbWY[Z_dWh[Wim^[h[j^[
Xed[_iiW\[\hech[iehfj_ed"iej^Wj[dek]^lebkc[
m_bbX[WlW_bWXb[\ehcWdoo[WhijeYec[$J^[i[iW\[
h[]_edi _dYbkZ[ dej edbo j^[ cWdZ_XkbWh Wdj[h_eh
i[]c[dj Xkj ej^[h Wh[Wi Wi m[bb$ 9h[ijWb _cfbWdji"
^em[l[h"YWddejX[fbWY[Z_dj^[i[Wh[Wi[$]$X[YWki[
e\j^[cWdZ_XkbWhd[hl[eh"WjX[ij"h[gk_h[WmamWhZ
WZ`klWdj fheY[Zkh[i je X[ _di[hj[Z$ ?d j^[i[ YWi[i"
8E? _cfbWdji Wh[ W i_cfb[ Wbj[hdWj_l[ je h[Wb_p[ W
\_n[Z h[ijehWj_ed W\j[h Wbb$ Beij Xed[ ijhkYjkh[i m_bb
h[Xk_bZ Xo j^[ci[bl[i m^[h[l[h \kdYj_edWb beWZi
_dZkY[j^[cjeh[Xk_bZeh"\ehj^WjcWjj[h"m^[h[l[h
j^[ Z[dj_ij _d][d_ekibo Z_h[Yji j^[i[ \kdYj_edWb
beWZi$J^[h[\eh["j^[bed]#j[hcikYY[iie\jh[Wjc[dj
_d j[hci e\ Xed[ ]W_d m_bb Z[f[dZ ckY^ ceh[
ed j^[ fheij^[j_Y h[ijehWj_ed j^Wd ed j^[ ikh]_YWb
fheY[Zkh[e\_cfbWdj_di[hj_ed$?cfbWdji_j[ij^WjWh[
XWi_YWbbo ijWXb[ cWo ÆikZZ[dboÇ bei[ j^[_h ijWX_b_jo
_\ j^[ \kdYj_edWb fWjj[hd e\ j^[ cWij_YWjeho ioij[c
Y^Wd][i WZl[hi[bo$ J^[i[ _dj[hWYj_edi Wh[ dej i[b\#
[nfbWdWjeho$J^[h[WZ[h_ih[\[hh[Zje9^Wfj[hi/WdZ
'&\ehWZ[jW_b[ZZ_iYkii_ed$
;nj[di_l[ Xed[ Wk]c[djWj_ed fheY[Zkh[i"
Wbj^ek]^ h[Wbbo kdd[Y[iiWho" Wh[ ij_bb X[_d] f[h#
\ehc[Z$J^[f[hi_ij[djki[WdZfhefW]Wj_ede\j^ei[
j[Y^d_gk[i^Wi_d[\\[YjX[Yec[W^WbbcWhae\Z[djWb
_cfbWdjebe]o$ 7bceij Wbb fWj_[dji mekbZ X[ [b_]_Xb[
\eh \_n[Z h[ijehWj_edi _\ edbo j^[ _cfbWdji m[h[
i[b[Yj[ZjecWjY^j^[Xed[$J^[[\\[Yj_l[d[iie\8E?
Wi W jh[Wjc[dj efj_ed ^Wi X[[d m[bb [ijWXb_i^[Z \eh
W bed] j_c[$ >[h["Æ[\\[Yj_l[d[iiÇ c[Wdi j^[ WX_b_jo
je h[ijeh[ W XWbWdY[Z cWij_YWjeho \kdYj_ed$ J^[
gk[ij_edm^[j^[hj^_ieX`[Yj_l[YWdX[WY^_[l[ZWdZ
cW_djW_d[Z Yedij_jkj[i j^[ edbo XWi_i \eh l[h_\o_d]
j^[Z[i_h[ZÆ[\\[YjÇ$J^[]eWbckijX[jec_d_c_p[j^[
dkcX[he\ikh]_YWbfheY[Zkh[iWdZje[dikh[W]eeZ
cWij_YWjeho \kdYj_ed XWi[Z ed \_n[Z h[ijehWj_edi Wj
Wbbj_c[i"[l[dZkh_d]Z_\\_Ykbjjh[Wjc[djf^Wi[i$
7 ieb_Z kdZ[hijWdZ_d] e\ j^[ 8E? j[Y^d_gk[
h[gk_h[i W \_hc ]hekdZ_d] _d X_ec[Y^Wd_Yi" Xed[
\kdYj_ed WdZ cWij_YWj_ed$ M_j^ j^_i _d c_dZ" j^[
h[WZ[hcWomWdjjeh[WZ9^Wfj[hi/"'&WdZ()\_hij$
* 9^Wfj[h'È 3TRUGGLESÈANDÈ3UCCESSES

È
4HEÈ2OCKYÈ2OADÈTOÈ3UCCESS

JeZWo" _cfbWdjebe]_YWb jh[Wjc[dj ]eWbi YWd

X[ WY^_[l[Z ceh[ h[b_WXbo" ceh[ [Wi_bo WdZ b[ii
[nf[di_l[boj^Wd[l[h$M[bb#l[hi[ZfhWYj_j_ed[hi^Wl[
j^[ efj_ed e\ ki_d] 8E? _cfbWdji" m^_Y^ Wh[ j^[
ijWj[#e\#j^[#Whj Z[iY[dZWdji e\ j^[ \_hij#][d[hWj_ed
J):i"' j^[ i[YedZ#][d[hWj_ed Z_ia _cfbWdji$ M_j^
8E?_cfbWdji"\_n[Zh[ijehWj_ediYWdX[fbWY[Z[l[d_d
i[l[h[boYecfhec_i[ZWbl[ebWhh_Z][i$<khj^[hceh["
j^[o YWd X[ _cc[Z_Wj[bo beWZ[Z _d j^[ cW`eh_jo
e\ YWi[i$ I_dY[ 8E? _cfbWdji kj_b_p[ j^[ ^eh_pedjWb
Z_c[di_ede\j^[h_Z][m^_Y^_iWbmWoi_djWYj"j^[
&IGÈÈ 7ZlWdY[Z 9D9 c_bb_d] cWY^_d[i Wh[ YWfWXb[ e\
l[hj_YWbXed[h[gk_h[c[dj_il[hoicWbb$
i^Wf_d] cWdo Z_\\[h[dj 8E? Z[i_]di m_j^ Z[\_d[Z fhef[hj_[i
?d j^[ bWj[ '/.&i" Z_ia _cfbWdjebe]o mWi ij_bb \hecWi_d]b[XWhe\cWii_l[j_jWd_kc
Z_ic_ii[Z Wi Wd kdYecced j[Y^d_gk[ ki[Z edbo
Xo ekji_Z[hi$ <khj^[h Z[l[befc[dji" ^em[l[h" ^Wl[
]_l[d h_i[ je j^[ 8E? j[Y^d_gk[" m^_Y^ jeZWo _i j^[
ceij \h[gk[djbo ki[Z h[ijehWj_l[ c[j^eZ je jh[Wj
WZlWdY[Z h_Z][ h[iehfj_ed _d W i_d]b[ fheY[Zkh["
dejb[WijX[YWki[_j_ij^[edboj[Y^d_gk[Wbbem_d]W
][dk_d[boed[#ij[fikh]_YWbWffheWY^$J^[j[Y^d_gk[
^Wi h[WY^[Z Wd [njhWehZ_dWho Z[]h[[ e\ cWjkh_jo
X[YWki[_j^WiX[[dZ[l[bef[Z"el[hZ[YWZ[i"ekji_Z[
7YWZ[c_W Xo fhWYj_j_ed[hi edbo$ 7bie" j^[ \WYj j^Wj
cWdk\WYjkh[hi ^Wl[ [cXhWY[Z j^[ _dfkj \hec
Yb_d_YWbki[hiZ_h[YjboWdZm_j^ekjZ[bWo^Wi]h[Wjbo
WYY[b[hWj[Zj^[Z[l[befc[dje\j^[cWj[h_WbiWim[bb
Wie\j^[c[j^eZ$
C[Wdm^_b[" j^[ fhe]h[ii cWZ[ _d Yh[ijWb
_cfbWdjebe]o^WiX[[d_dYehfehWj[Zjej^[X[d[\_je\
8E?Wim[bb"j^[Z[l[befc[dji_dikh\WY[j[Y^debe]o
X[_d]ed[[nWcfb[$
7dej^[h Wif[Yj je a[[f _d c_dZ _i j^Wj j^[
cWdk\WYjkh[ e\ 8E? _cfbWdji X[YWc[ W\\ehZWXb[
edbo h[Y[djbo Xo WZlWdY[Z 9D9#Yedjhebb[Z
j[Y^debe]o$ J^_i j[Y^debe]o WdZ j^[ ief^_ij_YWj[Z
cWdk\WYjkh_d] j[Y^d_gk[i WiieY_Wj[Z m_j^ _j ^Wl[ &IGÈÈ L_[me\j^[cWdk\WYjkh_d]Y^WcX[he\W9D9c_bb_d]
Yh[Wj[Zj^[feii_X_b_jojeZ[i_]dijWXb[WdZZ[b_YWj[bo cWY^_d[
i^Wf[Z _cfbWdji \hec j_jWd_kc _d]eji m_j^ ademd
XWi_Y fhef[hj_[i m_j^ekj i_]d_\_YWdjbo Wbj[h_d] j^[
ijhkYjkh[ e\ j^[ cWj[h_Wb <_]i$'$'Ä'$-$ M[ Wh[ cWn_bbWWdZcWdZ_Xb[$M^[d[l[hehWbYedZ_j_ediWh[
_dZ[Xj[Z je j^[ [d]_d[[hi m^e m[h[ ia_b\kb [dek]^ b[iij^Wd_Z[Wb\ehYh[ijWb_cfbWdji"j^[WZlWdjW][ie\
jejhWdibWj[ekhh[gk[ijiYedY[hd_d]_cfbWdjZ[i_]d j^[8E?WffheWY^Wh[eXl_eki0
_dje\_d_i^[ZfheZkYji$ v Bem Z[]h[[ e\ _dlWi_l[d[ii de Wk]c[djWj_ed"
9h[ijWb _cfbWdjebe]o de ZekXj e\\[hi efj_cWb Z_ijhWYj_edehjhWdifbWdjWj_ed
mWoi e\ h[ijehWj_l[ jh[Wjc[dj _d i_jkWj_edi m^[h[ v½ Ed[#ij[ffheY[Zkh[
j^[_cfbWdjiYWdX[_di[hj[Zm_j^ekjZ[bWoWdZm_j^ v I_cfb[h[fW_h_dYWi[e\fheXb[ci
de d[[Z \eh WZ`klWdj fheY[Zkh[i$ Kd\ehjkdWj[bo" W v 9ecX_dWj_edm_j^dWjkhWbj[[j^feii_Xb[
]h[WjcWdofWj_[djiZedejc[[jj^[i[Yh_j[h_W$J^_i v 9ecX_dWj_edm_j^Yh[ijWb_cfbWdjifeii_Xb[
_ifWhj_YkbWhbojhk[e\j^[feij[h_ehi[]c[djie\j^[ v CWdW][WXb[ioij[c\[mYecfed[dji
v I_cfb[bWXehWjehoj[Y^d_gk[
v ;njh[c[bo^_]^ikYY[iihWj[i
' J^[\_hijjh_Z_c[di_edWb_cfbWdjim[h[Z[i_]dWj[ZÆJ):ÇXo
@[Wd#CWhY@kbb_[j$
È È 4HEÈ2OCKYÈ2OADÈTOÈ3UCCESSÈ
&IGÈÈ ?j_i_cfeii_Xb[jemWjY^j^[c_bb_d]ij[fiZk[jej^[
[nj[di_l[Yeeb_d]h[gk_h[c[dji
&IGÈÈ Iec[ 8E? Z[i_]di d[[Z je X[ WZ`kij[Z _d W i[YedZ
WdZj^_hZij[fXoWXhWi_l[_dijhkc[dji$<ehj^_ifkhfei["j^[o
Wh[cekdj[Zed_dZ_l_ZkWbjhWoYecfWhjc[dji
:_iWZlWdjW][ie\j^[8E?ioij[c_dYbkZ[0
v J^[ ijeYa#a[[f_d] h[gk_h[c[dji Wh[ ]h[Wj[h
j^Wd _d Yh[ijWb _cfbWdjebe]o" _$[$ _j m_bb WbmWoi
X[d[Y[iiWhojea[[fW\[mceh[_cfbWdji^WdZo
je Wle_Z [nj[di_l[ fbWdd_d] _dYbkZ_d] j^h[[#
Z_c[di_edWb[nfbehWj_ede\Xed[YedZ_j_edi$
v J^[ j[Y^d_gk[ fei[i ikXijWdj_Wb Y^Wbb[d][i"
\eh _dijhkYjehi WdZ ki[hi Wb_a[" Wi \Wh Wi j^[
ikh]_YWb WdZ fheij^[j_Y jh[Wjc[dj ijW][i WdZ
j^[ ikXijWdj_Wb ademb[Z][ h[gk_h[c[dji _d j^[
\_[bZi e\ X_ec[Y^Wd_Yi WdZ Xed[ f^oi_ebe]o Wh[
YedY[hd[Z$
+
&IGÈÈ J^[ iWc[ jh_fb[#Z_ia 8E? Z[i_]d _d Z_\\[h[dj ijW][i
e\fheY[ii_d]
&IGÈÈ 7bj^ek]^ 9D9 c_bb_d] cWY^_d[i Wh[ [njh[c[bo
WYYkhWj[WdZfh[Y_i["[WY^if[Y_c[d_ij^ehek]^bo_dif[Yj[Z
<hec W Xki_d[ii f[hif[Yj_l[" ^em[l[h" j^[i[ Z_i#
WZlWdjW][ijkhdekjjeX[WZlWdjW][iW\j[hWbb"i_dY[
cWij[h_d] j^[ b[Whd_d] Ykhl[ m_bb ]_l[ Z[dj_iji W
Yec\ehjWXb[ [Z][ el[h Wdo Yecf[j_jehi _d j^[ \_[bZ
e\_cfbWdjebe]o$
J^[ gk[ij_ed m^o j^[ ekjYec[ e\ 8E? _cfbWdji
_i ie ckY^ X[jj[h j^Wd j^[ h[ikbji m_j^ Yh[ijWb
_cfbWdji Ä m^_Y^ if[Y_\_YWbbo _dYbkZ[i j^[ ikhl_lWb
hWj[iWim[bbÄh[cW_dijeX[YedYbki_l[boWdim[h[Z$
Fh[ikcWXbo"j^[fhe]dei_ie\8E?_cfbWdji_iX[jj[h
\hec j^[ ijWhj" Wi j^[ XbeeZ ikffbo je j^[ Xed[
h[cW_dibWh][bo_djWYjWiWh[ikbje\j^[Æia[b[j_p[ZÇ
[deiiWb _cfbWdj \_njkh[$ Ikh\WY[#[d^WdY[Z Yh[ijWb
_cfbWdji Wh[ ikiY[fj_Xb[ je f[h_#_cfbWdj_j_i" m^_Y^
, 9^Wfj[h'È 3TRUGGLESÈANDÈ3UCCESSES
cWo b[WZ je fhe]h[ii_l[ h_Z][ h[iehfj_ed$ M_j^ j^[
8E? j[Y^d_gk[" j^_i _i b[ii e\ W fheXb[c Zk[ je
j^[ dWhhem feb_i^[Z [c[h][dY[ e\ j^[ _cfbWdji$ ?d
WZZ_j_ed" j^[ i_j[ e\ XWYj[h_Wb _dlWi_ed _i \Wh WmWo
\hecj^[i_j[e\\ehY[jhWdic_ii_ed$>[dY[j^[Xed[
_i dej XkhZ[d[Z m_j^ jme jWiai Wj j^[ iWc[ j_c[$
9hWj[h#ijob[ YebbWfi[i Wh[ kikWbbo Wle_Z[Z j^_i mWo$
Ceh[el[h"j^[_cfbWdjWh[Wim^[h[beWZjhWdic_ii_ed
jWa[i fbWY[ Wh[ _dj[]hWj[Z _d ikY^ W mWo j^Wj j^[
eij[e][d[j_Y WdZ eij[efhej[Yj_l[ fhef[hj_[i e\ j^[
Yehj_YWbXed[Wh[efj_cWbbokj_b_p[Z$
?d8E?ioij[ci"j^[\Wj[e\j^[Wbl[ebWhh_Z][_idej
b_da[Zjej^[\Wj[e\j^[_cfbWdj#h[ijehWj_edYecfb[n"
i_dY[ j^[ Wh[Wi m^[h[ beWZ jhWdic_ii_ed jWa[i
fbWY[ Wh[ ifWj_Wbbo i[fWhWj[Z \hec j^[ cWij_YWjeho
ikh\WY[i$ J^_i \WYj _i eXl_eki \hec j^[ l[ho Z[i_]d
e\ 8E? _cfbWdji$ <eh ikYY[ii\kb _di[hj_ed WdZ beWZ
jhWdic_ii_ed" _j _i _hh[b[lWdj m^[j^[h j^[ l[hj_YWb
fehj_ede\j^[_cfbWdj_i[cX[ZZ[Z_dW_heh_d\bk_Z$
?j_iWbie_hh[b[lWdjm^[j^[hXed[j_iik[_iZ[fei_j[Z
Z_h[Yjboedj^[_cfbWdjikh\WY[_dj^_iWh[W$J^_i^Wi
cWdoZ[i_hWXb[_cfb_YWj_edi0
v 7[ij^[j_Y Yedi_Z[hWj_edi Wi_Z[" j^[ ikYY[ii e\
_cfbWdjj^[hWfoZe[idejZ[f[dZedj^[fh[i[dY[
e\Wbl[ebWhXed[$
v ?d j^[ fh[i[dY[ e\ Zoi]dWj^_W" cWij_YWjeho
ikh\WY[iYWdX[_dijWbb[ZWji_j[ij^WjWh[ifWj_Wbbo
_dZ[f[dZ[dje\j^[ia[b[jWbXWi[$
7]eeZ[c[h][dY[fhe\_b[e\h[ijehWj_edied[nj[hdWb
8E? ioij[ci _i WY^_[l[Z Xo mehaWhekdZ iebkj_edi
Zk[ je j^[ icWbb Z_Wc[j[h e\ j^[ j^h[WZ[Z f_d$ <eh
j^_ih[Wied"8E?_cfbWdjh[ijehWj_edi_dj^[W[ij^[j_Y
ped[ Wh[ iec[m^Wj ^WhZ[h je h[Wb_p[ j^Wd m_j^
Yh[ijWb _cfbWdji fhel_Z[Z j^[h[ _i [dek]^ l[hj_YWb
Xed[ je fbWY[ j^[c WdZ h[gk_h[ W ]eeZ c[Wikh[
&IGÈÈ 7d[njh[c[bocej_lWj[Z
WdZm[bb#jhW_d[Zj[Wce\9D9
if[Y_Wb_iji]kWhWdj[[ih[b_WXb[
gkWb_jo_dj^[fheZkYj_ede\8E?
_cfbWdji$:kh_d]j^[fheZkYj_ed
f^Wi["Wdo[\\ehjckijX[cWZ[
_ijeb[Wl[j^[ijhkYjkh[WdZj^[
ijh[d]j^e\j^[j_jWd_kcWdZ_ji
[bWij_Yfhef[hj_[ikdWbj[h[Z
e\ Wdj_Y_fWj_ed ed j^[ Z[dj_ijÉi fWhj \eh Yehh[Yj
fei_j_ed_d]e\j^[WXkjc[dji$
Jh[Wjc[dj ikYY[ii Z[f[dZi je Wffhen_cWj[bo
.& ed fheij^[j_Y YedY[fji WdZ j^[_h [n[Ykj_ed
WdZ cW_dj[dWdY[ WdZ edbo je (& ed j^[ ikh]_YWb
fheY[Zkh[$ 7dZ _j Z[f[dZi ed h[b_WXb[" ]eeZ
Yecfb_WdY[ e\ j^[ fWj_[dji$ J^[ fWj_[dj ckij X[
_d\ehc[ZWXekjj^_iWdZckijademj^Wj_cc[Z_Wj[
beWZ Ze[i dej c[Wd j^[ _cc[Z_Wj[ [dZ e\ WYj_l[
jh[Wjc[djf^Wi[$
È
3COPEÈOFÈ4HISÈ"OOK
J^_i lebkc[ Z[iYh_X[i j^[ Wffb_YWj_ed j[Y^d_gk[i"
ikh]_YWb WffheWY^[i" fheij^[j_Y c[j^eZi WdZ
cW_dj[dWdY[ j^[hWf_[i _d Yedd[Yj_ed m_j^ 8E?
_cfbWdji$ Iec[ jof[i e\ \ehY[ jhWdic_ii_ed Wh[Wi
Wh[ [nWc_d[Z Xo <;C WdWboi_i e\ [bWij_Y X[^Wl_ekh
kdZ[h f^oi_ebe]_Y beWZ_d]$ >[Wb_d] fWjj[hdi m_j^
eh m_j^ekj beWZ_d] m_bb X[ YecfWh[Z je j^ei[ e\
iYh[m _cfbWdji XWi[Z ed Wd_cWb [nf[h_c[dji$ 8ej^
j^[ <;C h[ikbji WdZ j^[ _cfh[ii_l[ ^_ijebe]_YWb
ZWjW fh[i[dj[Z _d j^_i Xeea m_bb cWa[ _j [Wi_[h \eh
j^[h[WZ[hjeZ[l[befWXWi_YkdZ[hijWdZ_d]e\8E?
j[Y^debe]oWdZj^[Xed[h[WYj_ed_dlebl[Z$
Ej^[h Y^Wfj[hi Z[Wb m_j^ if[Y_\_Y WdWjec_YWb
i_jkWj_edi WdZ ^em j^[o Wh[ WZZh[ii[Z m_j^ 8E?
_cfbWdji$;cf^Wi_i^WiX[[dfbWY[Zed7d]b[YbWii???
WdZ??ia[b[jWbh[bWj_edi^_fi"edh[iehX[ZcWdZ_XkbWh
h_Z][i" ed YWdj_b[l[h i_jkWj_edi" WdZ ed jh[Wjc[dj
efj_edi _d j^[ feij[h_eh i[]c[dj e\ j^[ cWn_bbW$
Jh[Wjc[djYedY[fjih[bo_d]edckbj_fb[_cfbWdjiWh[
YecfWh[ZjeijhWj[]_Y_cfbWdjfbWY[c[dj$
È È %VIDENCEÈANDÈ4RUSTÈ
7d [dj_h[ Y^Wfj[h _i Z[lej[Z je j^[ j^[eh[j_YWb
XWi_i e\ _cc[Z_Wj[ beWZ_d]$ J^_i m_bb _dYbkZ[ W
Yh_j_YWbh[l_[me\j^[b_j[hWjkh[h[\[hh[ZjeXoYh[ijWb
_cfbWdjebe]_iji$
J^[ 8E? j[Y^d_gk[ _i YecfWh[Z je Yedl[dj_edWb
jh[Wjc[dj YedY[fji ki_d] Xed[ Wk]c[djWj_ed"
Xed[ ]hW\ji eh eii[eZ_ijhWYj_ed$ 9h_j_YWb WdWboi_i
h[l[Wbi j^Wj j^[ Yedl[dj_edWb ckbj_#ij[f fheY[Zkh[i
ki[Z je Wk]c[dj j^[ cWn_bbWho i_dki eh j^[ Z_ijWb
cWdZ_Xb[ Wh[ de bed][h WYY[fjWXb[ _d j^[ [hW e\
XWiWb eii[e_dj[]hWj_ed$ ?dZ[[Z" j^[o X[bed] je j^[
Yhk[bb[h Y^Wfj[hi _d j^[ ^_ijeho e\ c[Z_Y_d[ WdZ
i^ekbZX[WXWdZed[ZWigk_YaboWifeii_Xb[$J^_i_i
fWhj_YkbWhbo jhk[ e\ _b_WY Xed[ ]hW\ji \eh i_dki \beeh
Wk]c[djWj_ed$ 7]W_dij j^_i XWYa]hekdZ" j^[ b[]Wb
_cfb_YWj_edie\j^[Z_iYkii[Zjh[Wjc[djYedY[fjiWh[
YecfWh[ZXWi[ZedYkhh[djb[]_ibWj_ed_d=[hcWdo"
j^[;khef[WdKd_edWdZj^[Kd_j[ZIjWj[i$
H[f[j_j_e [ij cWj[h ijkZ_ehkc$ <WYji j^Wj Wh[
h[b[lWdj _d Z_\\[h[dj Yedd[Yj_edi Wh[ h[f[Wj[Zbo
[nfbW_d[Z _d j^_i Xeea m_j^ i^_\j_d] [cf^Wi_i
Z[f[dZ_d] ed j^[ Yedj[nj$ J^_i Wbbemi j^[ h[WZ[h
je ijWhj h[WZ_d] m^[h[l[h ^[ eh i^[ fb[Wi[i" WdZ
_j [dikh[i WdZ [bkY_ZWj[i j^[ Yedj_dk_jo e\ h[bWj[Z
Y^Wfj[hi$
È
%VIDENCEÈANDÈ4RUST
C[Z_YWbmh_j_d]ckijX[XWi[Zed[l_Z[dY[$J^_i_i
Wd _dZ_if[diWXb[ h[gk_h[c[dj X[YWki[ [l_Z[dY[ _i
j^[edbomWoe\eXjW_d_d]Y[hjW_djo$J^[i[Y[hjW_dj_[i
eXjW_d[ZXomWoe\[l_Z[dY[Wh[ceh[b_a[bojeijWdZ
j^[j[ije\j_c[ÄWjb[WijfWhjij^[h[e\ÄWdZfhel_Z[Z
j^Wjj^[gk[ij_ediWdZf[hif[Yj_l[i\hecm^_Y^j^[o
m[h[Z[h_l[ZijWdZj^[j[ije\j_c[Wim[bb$E\Yekhi["
j^_ifh[ikffei[ij^Wjj^[Wkj^ehim[h[^ed[ij_dj^[
\_hijfbWY[$
Ç8E? j[Y^debe]o _i dej XWi[Z ed iY_[dj_\_Y
[l_Z[dY[$ÇIjWj[c[djie\j^_ia_dZYWdX[^[WhZj_c[
WdZW]W_d\hecf[efb[jho_d]jeWle_Zj^[jhekXb[e\
b[Whd_d]j^[j[Y^d_gk[WdZe\iYh[[d_d]j^[b_j[hWjkh[
\ehf[hj_d[djh[fehji"m^_Y^Wh[WXkdZWdjbofh[i[dj"
WdZjeh[WZj^[c$H[\[hh_d]ikY^Yh_j_Yijej^[f_b[ie\
[n_ij_d]b_j[hWjkh[edj^[ikX`[Yjm_bbkikWbboi_b[dY[
j^[c$ CkY^ b_j[hWjkh[ ^Wi X[[d [nj[di_l[bo ijkZ_[Z
WdZ[lWbkWj[Z\ehj^_iXeea$=_l[dj^[kdm_[bZocWii
e\Z[djWbWdZc[Z_YWbb_j[hWjkh[j^Wj^WiWYYkckbWj[Z
el[hj^[Y[djkh_[i"deYbW_cjeYecfb[j[d[ii_icWZ[$
M^Wj _i ijh_a_d] _d h[jheif[Yj _i j^[ \WYj j^Wj W
ikXijWdj_Wb XWi_i e\ ademb[Z][ j^Wj _i de bed][h W
fWhje\Ykhh[djZ[djWbjhW_d_d]mWiWbh[WZoZ_iYbei[Z
Xo [Whbo Wkj^ehi m^e ^Wl[ ceh[ eh b[ii \Wbb[d _dje
eXb_l_ed$ J^[ iWc[ ademb[Z][ h[Wff[Whi _d W ]h[Wj
dkcX[he\ÆceZ[hdÇfkXb_YWj_edi"j^[edboZ_\\[h[dY[
h[Wbbo X[_d] _d j^[ mehZi ki[Z$ ?d h[jheif[Yj" j^[i[
-
[WhboWkj^ehiÄ_dYbkZ_d]Meb\\"J^_[bcWdd"=[hX[h"
=oi_" <heij" CWhj_d WdZ 8khh eh FbWdWi Ä bW_Z ekj
j^[[dj_h[WhcWc[djWh_kc\eh8E?Wbed]j_c[W]e$
>em[l[h" j^[_h lWh_eki \_dZ_d]i WdZ [nfbWdWj_edi
Wijej^[fhWYj_YWb_cfb[c[djWj_ede\j^[i[ioij[ci
^Wl[d[l[hX[[d\ehcWbboYedieb_ZWj[Z$J^[fh[i[dj
XeeamWimh_jj[dje\_bbj^_i]WfWdZje[dYekhW][j^[
h[WZ_d]e\^_ijeh_YWbWhj_Yb[iWdZXeeai$
J^_i Xeea h[\b[Yji fhWYj_YWb [nf[h_[dY[
WdZ [nWc_d[i _j W]W_dij ademd YedY[fji _d
fheij^eZedj_Yi"ikh][ho"WdZf^oi_ebe]oÄ[if[Y_Wbbo
_d Xed[ c[Y^Wd_Yi$ J^[ h[ikbj m_bb X[ j^Wj Wbb
jh[Wjc[dj c[j^eZi Z[iYh_X[Z ^[h[ ^Wl[ W iekdZ
iY_[dj_\_Y\ekdZWj_edZ[h_l[Z\hecWlWh_[joe\Z[djWb
ikX#if[Y_Wbj_[i$
Iec[ e\ j^[ Y^Wfj[hi _dYbkZ[ XWh Z_W]hWci m_j^
ijWj_ij_YWb h[ikbji WdZ el[hl_[mi m_j^ekj Z[jW_b_d]
j^[ ZWjW feeb \hec m^_Y^ j^[o m[h[ Z[h_l[Z$ J^[i[
Z_W]hWci" kdb[ii ej^[hm_i[ ijWj[Z" Wh[ Xo Z[\Wkbj
XWi[Z ed j^[ jejWb dkcX[h e\ Yedi[Ykj_l[ _cfbWdji
_di[hj[ZWjekh^eif_jWb$J^[jejWbdkcX[he\_cfbWdji
Z[jW_b[Z _d j^[i[ Z_W]hWci m_bb WbmWoi X[ XWi[Z ed
j^[bWj[ijkfZWj[e\ekhZWjWXWi[WdZcWoj^kilWho
Z[f[dZ_d]edj^[Yh[Wj_edZWj[e\W]_l[dfWiiW][$?j
]e[im_j^ekjiWo_d]j^WjYWbYkbWj_ediXWi[ZedbWh][h
iWcfb[iehbed][heXi[hlWj_edf[h_eZim_bb_dlebl[W
^_]^[hb[l[be\i_]d_\_YWdY[$
Ademb[Z][ Y^Wd][i hWf_Zbo WdZ ^Wi WbmWoi X[[d
_d W ijWj[ e\ \bkn$ J^_i _i dej W h[Y[dj Z[l[befc[dj$
J^[h[ifedi_X_b_jojea[[fWXh[Wije\Z[l[befc[dji_d
Z[djWb_cfbWdjebe]ob_[im_j^j^[h[WZ[h$7i7XhW^Wc
B_dYebd fkj _j ie Wfjbo0Æ7 feb_j_Y_Wd YWd \eeb ceij
f[efb[ ed Wbceij [l[ho _iik[ ceij e\ j^[ j_c[" Xkj
deXeZo YWd \eeb [l[hoXeZo ed [l[ho i_d]b[ _iik[
Wbbe\j^[j_c[Ç$J^_i_iWijhk[e\Wkj^ehiWi_j_ie\
feb_j_Y_WdiÄWdZ\ehj^[h[WZ[hjeYedi_Z[h$
È
4HEÈ)NTERNET
J^[?dj[hd[j^WifWl[Zj^[mWo\ehj^[Xh[Waj^hek]^
e\ 8E? j[Y^debe]o WdZ m_bb Yedj_dk[ je X[ W cW`eh
YWjWboij$ J^[h[ Wh[ jme h[Wiedi \eh j^_i$ <eh ed[
j^_d]" j^[ ?dj[hd[j ^Wi Yh[Wj[Z Wd effehjkd_jo \eh
fhWYj_j_ed[hi je [nY^Wd][ j^[_h [nf[h_[dY[i Xo
jhWdic_jj_d] f_Yjkh[i WdZ hWZ_e]hWf^i" [dWXb_d]
j^[cje`e_d\ehY[i_dWYeehZ_dWj[ZcWdd[hjemeha
ekjefj_cWbjh[Wjc[dji\ehZ_\\_YkbjYWi[i$JeZWo_j_i
feii_Xb[je[nY^Wd][l_Z[eZeYkc[djWj_ede\ikh]_YWb
fheY[Zkh[i"WdZmh_j_d]iYWdX[Z_ii[c_dWj[ZWjj^[
jekY^e\WXkjjed$?j^WiX[[diW_Zj^Wjj^ek]^ji"edY[
j^[o ^Wl[ X[[d fkXb_i^[Z ed j^[ MehbZ M_Z[ M[X"
YWdd[l[hX[[nj_d]k_i^[Z$
<eh Wdej^[h j^_d]" j^[ ?dj[hd[j ^Wi X[[d j^[
\_hij c[Z_kc j^hek]^ m^_Y^ fWj_[dji YekbZ b[Whd
WXekj j^[ c[h[ [n_ij[dY[ e\ 8E? _cfbWdji Wi W
. 9^Wfj[h'È 3TRUGGLESÈANDÈ3UCCESSES
jh[Wjc[dj efj_ed" ie j^Wj Y[hjW_d eXijhkYj_ed_iji
_d ekh fhe\[ii_ed Wh[ de bed][h WXb[ je ikffh[ii
j^[ j[Y^d_gk[ ikYY[ii\kbbo$ FWj_[dji m_bb kbj_cWj[bo
Ælej[ m_j^ j^[_h \[[jÇ Ä _$[$ j^[o m_bb mWba WmWo
\hec jh[Wjc[dj efj_edi j^Wj Wh[ Xej^ _dlWi_l[ WdZ
[nf[di_l[?i\ehj[jWb$(&&($
È
2ESULTSÈANDÈ/UTCOMESÈÈ
!PPLESÈANDÈ/RANGES j^[fefkbWh_pWj_ede\j^_ij[Y^d_gk[$
?dj^[b_j[hWjkh[edYh[ijWb_cfbWdjebe]o"_j_iYecced
fhWYj_Y[jeYWbYkbWj[ikYY[iihWj[i\eh_cfbWdji\hec
j^[_h fheXWX_b_jo e\ ikhl_lWb$ J^[ Ykhh[dj ijWj_ij_YWb
WffheWY^_ijeim[[fWbb_cfbWdjij^Wjm[h[beijX[\eh[
X[_d] beWZ[Z Xo W fheij^[j_Y ijhkYjkh[ kdZ[h j^[
YWhf[j$J^[i[beii[iWh[Z_ic_ii[ZWiÆkd\ehjkdWj[Ç"
Æ_d\[Yj_ed#h[bWj[ZÇ" Æ_Z_efWj^_YÇ eh i_cfbo Wi
Ækd[nfbW_dWXb[Ç$ J^[o d[l[h [dj[h j^[ ijWj_ij_Yi$
D[_j^[h Ze j^[ ijWj_ij_Yi WYYekdj \eh _cfbWdji j^Wj
YekbZ dej X[ _dijWbb[Z _d j^[ \_hij fbWY[" X[YWki[
j^[ WZ`klWdj fheY[Zkh[ e\ Xed[ Wk]c[djWj_ed eh
eii[eZ_ijhWYj_ed ^WZ \W_b[Z" eh \eh j^ei[ YWi[i _d
m^_Y^ Wd Wjj[cfj Wj j^[hWfo ^WZ dej X[[d cWZ[
X[YWki[ e\ lWh_eki ÆYedjhW_dZ_YWj_ediÇ Yedd[Yj[Z
m_j^Yh[ijWb_cfbWdji$?dWZZ_j_edj^ei[YWi[i^Wl[je
[dj[hj^[[gkWj_ed"m^_Y^^Wl[dejX[[djh[Wj[ZWjWbb"
X[YWki[j^[WZ`klWdjfheY[Zkh[im[h[dejYecfWj_Xb[
m_j^j^[b_\[ijob[e\j^[fWj_[dji_$[$^eki[m_l[im^e
Z_ZdejmWdjjefh[i[djj^[ci[bl[ijej^[_h^kiXWdZi
m_j^ekj j[[j^ Zkh_d] j^[ ^[Wb_d] f[h_eZ e\ j^[
Wk]c[djWj_ed1ehXki_d[ic[dm^eijWo[Zm_j^j^[_h
Z[djkh[iX[YWki[j^[oYekbZdejW\\ehZjeijWoWmWo
\hecj^[_h`eX\ehiecWdoWffe_djc[dji$
7bie" m[ ^Wl[ je Yedi_Z[h" j^Wj gk_j[ W \[m
fej[dj_Wb fWj_[dji mekbZ X[ m_bb_d] je fWo \eh Xed[
Wk]c[djWj_edieh8E?je][j\_n[Zj[[j^"Xkjj^[o
ZedejmWdjjekdZ[h]eb[d]j^oik\\[h_d]$
È
4HEÈ6ISION
M^_b[ _j _i Yb[Wh j^Wj j^[ _Z[Wb_ij_Y dej_ed e\ Wbb
fWj_[dji ^Wl_d] W b_\[bed] h_]^j je \_n[Z j[[j^ m_bb
d[l[hYec[jhk["_j_iWbieYb[Whj^Wjj^_i]eWbYekbZ
dej feii_Xbo X[ WY^_[l[Z Xo Yh[ijWb _cfbWdjebe]o
Wbed[$ J^[ lWh_eki h[Wiedi \eh j^_i ^Wl[ X[[d
c[dj_ed[Z fh[l_ekibo _d j^_i Y^Wfj[h" WdZ j^[o Wh[
]e_d] je X[ Z[cedijhWj[Z WdZ [nfbW_d[Z _d ]h[Wj[h
Z[jW_b j^hek]^ekj j^_i Xeea$ ?j _i dej edbo j^[ ^_]^
Yeiji if[Y_\_YWbbo Wh_i_d] _d Yedd[Yj_ed m_j^ j^[
_dlWi_l[ WZ`klWdj fheY[Zkh[i d[[Z[Z \eh Yh[ijWb
_cfbWdj jh[Wjc[dj j^Wj m_bb e\j[d fh[l[dj Wdo ceh[
[nj[di_l[ _cfbWdj#XWi[Z h[ijehWj_edi \hec X[_d]
h[Wb_p[Z"Xkj_j_iWbiej^WjcWdofWj_[djiYWddejX[
jh[Wj[Z Xo Yh[ijWb _cfbWdjebe]o Wbje][j^[h" \eh m[bb#
ademdfWj^ef^oi_ebe]_YWbh[Wiedi$J^_i_idejjeiWo
j^WjYh[ijWb_cfbWdjiWh[_d\[h_eh"b[jWbed[kdik_j[Z"
_d fh_dY_fb[$ HWj^[h" j^[ ^_]^bo _dlWi_l[ dWjkh[ WdZ
Yeijb_d[ii e\ j^[ d[Y[iiWho WZ`klWdj fheY[Zkh[i
Wh[ fhe^_X_j_l[ je j^[_h m_Z[ifh[WZ ki[$ J^[h[\eh["
Yh[ijWb _cfbWdji Wh[ Yb[Whbo dej W YWdZ_ZWj[ _d j^[
gk[ij \eh e\\[h_d] Z[djWb _cfbWdji ed W XheWZ iYWb[$
8E?_cfbWdjiWh[f[h\[YjboWXb[WdZh[WZoje\_bbj^_i
]Wf$ J^[ fh[i[dj Xeea ^Wi X[[d mh_jj[d je ikffehj
È
,ISTENINGÈTOÈ0ATIENTSÈ$EMANDS
FWj_[dji ^Wl[ j^[ \ebbem_d] [nf[YjWj_edi e\ _cfbWdj
jh[Wjc[dj0
v J^[o mWdj Wdo c_ii_d] j[[j^ je X[ h[fbWY[Z Wj
c_d_ckc_dlWi_l[d[ii_dWi_d]b[fheY[Zkh[1WdZ
j^[o mWdj je X[ j^hek]^ m_j^ j^_i fheXb[c edY[
WdZ\ehWbb$
v J^[omWdjj^[[dj_h[jh[Wjc[djjeX[W\\ehZWXb[$
v J^[o mWdj Wbb fWhji e\ j^[ h[ijehWj_ed je X[ m[bb
WYY[ii_Xb[ \eh Xhki^_d] WdZ \beii_d]1 W\j[h Wbb"
cWdo e\ j^[c beij j^[_h j[[j^ Zk[ je feeh ehWb
^o]_[d[$ 7do XWZ ^WX_ji ikY^ Wi icea_d] WdZ
YWh[b[iiXhki^_d]%\beii_d]i^ekbZX[WXWdZed[Z$
v J^[o cW_dbo mWdj je ^Wl[Æ\_n[Z j[[j^Ç h[ijeh[Z1
j^[oWh[dej_dj[h[ij[Z_d^Wl_d]j^[_hXed[lebkc[
_dYh[Wi[ZWdZhWh[boWjjWY^]h[Wj_cfehjWdY[jeW
dWjkhWbÆ[c[h][dY[ fhe\_b[Ç W YedY[fj el[hki[Z
_d j^[ b_j[hWjkh[" Xkj j^[o i_cfbo m_i^ je ^Wl[
j^[_h fheXb[c iebl[Z _d W Zemd#je#[Whj^ WdZ
W[ij^[j_YWbboWYY[fjWXb[cWdd[h$
?d h[Wb b_\[" j^[i[ [nf[YjWj_edi Wh[ hWh[bo c[j Xo
Yh[ijWb_cfbWdjioij[ciiYh[m_cfbWdji"Zk[jej^[
\ebbem_d]h[Wiedi0
v >[Wb_d]f[h_eZiWh[kikWbbobed]$
v ?d cWdo YWi[i" i[l[hWb fheY[Zkh[i X[Yec[
d[Y[iiWho$
v ?\Xed[lebkc[_i_dik\\_Y_[dj"WZ`klWdjfheY[Zkh[i
X[Yec[ d[Y[iiWho j^Wj Wh[ kikWbbo ceh[ _dlWi_l[
WdZ ceh[ [nf[di_l[ j^Wd j^[ _cfbWdj fheY[Zkh[
_ji[b\$
v ?dWZZ_j_edjeX[_d]l[ho[nf[di_l["j^[i[WZ`klWdj
fheY[Zkh[i YWhho ^_]^ W h_ia e\ _d\[Yj_ed eh
d[Yhei_i$
v :[if_j[j^[bWh][iYef[e\j^[hWfo"WYedi_Z[hWXb[
dkcX[he\fWj_[djiYWddejX[jh[Wj[Zm_j^Yh[ijWb
_cfbWdjiWjWbb$
v FWj_[dji jh[Wj[Z m_j^ iYh[m _cfbWdji m_bb \WY[
_dj[di_l[ehWb^o]_[d[h[gk_h[c[dji$
v Icea[hi^Wl[Wd_dYh[Wi[Zh_iae\_cfbWdjbeii$
È È ,ISTENINGÈTOÈ0ATIENTS@È$EMANDSÈ
8E? _cfbWdji Wh[ Wbie W Z[i_hWXb[ efj_ed \hec j^[
Z[dj_ijÉif[hif[Yj_l[$J^[ioij[cYWdX[[ijWXb_i^[Z
_dj^[Z[djWbe\\_Y[WjbemYeij"h[gk_h[iWcWdW][WXb[
Z[]h[[ e\ WZZ_j_edWb jhW_d_d]" _dlebl[i W icWbb
dkcX[he\fheij^[j_YYecfed[dji"WdZe\\[hiW^_]^
ikYY[iihWj[$8E?_cfbWdjiWh[Wkd_gk[boefj_c_p[Z
j^[hWf[kj_Yefj_ed$?dcWdoi_jkWj_edi"8E?ioij[ci
YWdX[ki[Z_dYed`kdYj_edm_j^Yh[ijWb_cfbWdjije
efj_cWbbojWa[WZlWdjW][e\Xej^ioij[ci$
Jh[Wjc[dj m_j^ 8E? _cfbWdji _i i_cfb[h WdZ
gk_Ya[h j^Wd Yh[ijWb _cfbWdj j^[hWfo i_dY[ de
Wk]c[djWj_ed fheY[Zkh[i Wh[ _dlebl[Z$ 8Wi[Z ed
ekh [nf[h_[dY[ m_j^ ceh[ j^Wd '"&&& fWj_[dj YWi[i
jh[Wj[Z m_j^ 8E? _cfbWdji" /+ e\ fWj_[dji YWd X[
ikYY[ii\kbbo jh[Wj[Z m_j^ \_n[Z h[ijehWj_edi _d Wd
_cc[Z_Wj[WdZZ[\_d_j_l[cWdd[h$?dj^[h[cW_d_d]
/
+" W ikYY[ii\kb ekjYec[ YWd kikWbbo X[ [dikh[Z
Xo h[fbWY_d] Wdo \W_b[Z _cfbWdji _d W i[YedZWho
fheY[Zkh[$I_jkWj_edi_dm^_Y^WikYY[ii\kbekjYec[
YWddej X[ WY^_[l[Z Wh[ l[ho hWh[ WXekj &$+ e\
fWj_[dji$ J^[i[ YWi[i ckij X[ YWh[\kbbo WdWboi[Z
WdZcWoX[jh[WjWXb[W\j[hWbbXoki_d]ceh[_dlWi_l[
j[Y^d_gk[iikY^WiXed[]hW\j_d]WiWbWijh[iehj$
7\j[hj^ehek]^ijkZoe\j^_iXeea"oek"j^[h[WZ[h"
cWo[dZkfWia_d]oekhi[b\"ÆM^o_dj^[mehbZZ_ZdÉj
m[ ijWhj Ze_d] j^_d]i b_a[ j^_i W bed] j_c[ W]e5Ç ?\
j^Wj^Wff[di"oekm_bbX[edj^[h_]^jYekhi[$Oekm_bb
ikYY[ii\kbboY_hYkcdWl_]Wj[j^[Z[di[\e]WdZij[[f
Yb_\\ie\j[d\ekdZedj^[hekj[jeZ[djWb_cfbWdjebe]o"
WdZoekm_bbdejWbbemoekhi[b\jeX[i_Z[jhWYa[ZXo
_dj[dj_edWbbo c_ib[WZ_d] X[WYedi$ =eeZ bkYa Ä WdZ
^Wl[Wfb[WiWdj`ekhd[o

#(!04%2È
(ISTORYÈASÈ$OCUMENTEDÈBYÈ0ATENTSÈÈ
ANDÈ0ATENTÈ!PPLICATIONS
?j ^Wi X[[d W bed] jhWZ_j_ed _d c[Z_Y_d[ j^Wj d[m
_Z[Wi WdZ jh[Wjc[dj YedY[fji Wh[ ^WhZbo [l[h
_dl[dj[Z_di_Z[j^[kd_l[hi_j_[i$KikWbbo"fhWYj_j_ed[hi
ÄX[YWki[j^[oh[Wbbo\WY[j^[fWj_[djiÉfheXb[ciZWo#
je#ZWoÄWh[j^[ed[ijeZ[l[befd[miebkj_edi$Dej
kdj_bbWj[hWh[j^[j[Y^d_gk[iWZefj[ZXokd_l[hi_j_[i"
WdZkikWbbo_jm_bbX[d[Y[iiWho"e\Yekhi["jefWoj^[
kd_l[hi_j_[ijeY^Wd][j^[_hmWoe\j^_da_d]"meha_d]
WdZ j[WY^_d]$ J^[ ^_ijeho e\ 8E? _cfbWdjebe]o
h[\b[Yji j^_i i_jkWj_ed" Wi YWd X[ i[[d beea_d] Wj
j^[ fWj[dj i_jkWj_ed _d j^_i \_[bZ$ FWj[dji Wffb_[Z
\eh WdZ" e\ Yekhi[" fWj[dji ]hWdj[Z Wh[ h[bWj_l[bo
eX`[Yj_l[ Yh_j[h_W je ]e Xo$ J^[o ^[bf ki `kZ][ m^e
j^[ f[efb[ m[h[ j^Wj ^Wl[ ][dk_d[bo i[j iY_[dj_\_Y
c_b[ijed[iWdZXhea[dm_j^jhWZ_j_edWbj^_da_d]_dW
YedijhkYj_l[mWo$
8o Wbb WYYekdji" j^[ \_hij [deiiWb _cfbWdj Z[i_]d
j^Wjh[b_[ZedWbWj[hWb_di[hj_edfWj^WdZYWf_jWb_p[Z
ed j^[ ijWX_b_jo e\ j^[ _dd[h WdZ ekj[h Yehj_YWb
Xed[ mWi Z[l_i[Z _d ?jWbo <$F$ IfW^d" f[hiedWb
Yecckd_YWj_ed J^[ Z_ia WdZ j^h[WZ[Z f_d m[h[
_di[hj[Zi[fWhWj[bo_dj^_iZ[i_]d"j^[bWjj[hj^hek]^
Wd[njhWl[hj_YWbZh_bb^eb[$<_dWbboXej^Yecfed[dji
m[h[ Yedd[Yj[Z m_j^ W iYh[m$ J^[ j[Y^debe]_YWb
c[Wdi \eh j^[ cWdk\WYjkh[ e\ i_d]b[#kd_j j_jWd_kc
_cfbWdji e\ WZ[gkWj[ i_p[ m[h[ dej WlW_bWXb[ Wj j^[
j_c[$
J^[ \_hij i_d]b[#kd_j _cfbWdj mWi Z[l[bef[Z WdZ
ki[Z Xo @[Wd#CWhY @kbb_[j '/-($ J^_i Z[i_]d mWi
edboWlW_bWXb[_ded[i_p[WdZe\\[h[ZdeXWiWbfbWj[
h[i_b_[dY[$ ?d \WYj" j^_i a_dZ e\ h[i_b_[dY[ mekbZ
^Wl[X[[dkdZ[i_hWXb["Yedi_Z[h_d]j^Wjj^[f_dmWi
j^h[WZ[ZWbbj^[mWojej^[XWiWbfbWj[$J^[iYef[e\
_dZ_YWj_edi\ehj^_iZ[i_]dmWib_c_j[ZjeWh[Wim^[h[
j^[ XWiWb fbWj[ h[WY^[Z Xej^ Yehj_YWb ijhkYjkh[i" ie
j^Wj _ji ki[ mWi [ii[dj_Wbbo Yed\_d[Z je j^[ Wdj[h_eh
i[]c[djie\[_j^[h`Wm$?dY_Z[djWbbo"j^[j^h[WZ[Zf_d
mWiedboWlW_bWXb[_ded[ijWdZWhZb[d]j^WdZ^WZje
X[h[ZkY[ZXoj^[ki[hWid[[Z[Z$?j_i_dj[h[ij_d]je
h[WZ @kbb_[jÉi Z[iYh_fj_ed _d j^[ fWj[dj if[Y_\_YWj_ed$
@kbb_[jYb[Whboh[Ye]d_p[ij^[Z_iWZlWdjW][ie\_cfbWdj
fbWY[c[dj m_j^ekj Yehj_YWb ikffehj0 @kbb_[j [nfbW_di
j^Wj"YedjhWhojeB_daemÉiWffheWY^if[Y_\_[Z_dK$I$
fWj[dj)"*,+"**'"j^[]_d]_lWbh[i_ijWdY[WdZj^[j_]^j
fh[iikh[\_je\j^[XbWZ[_cfbWdjm_bbieed]_l[mWoje
cWij_YWjehofh[iikh[$?dj^_imWo"j^[XbWZ[_ifh[ii[Z
 ¬ 
4DJFODF
JT
UIF
BSU
PG
DSFBUJOH
LOPXMFEHF
Z[[f[h _dje j^[ Xed[ WdZ m_bb [l[djkWbbo beZ][
h_]^j ed j^[ Yehj_YWb ijhkYjkh[$ EXl_ekibo" @kbb_[j
^WZ X[[d Ybei[bo eXi[hl_d] j^[ Yedi[gk[dY[i je X[
\WY[Zm^[d[deiiWb_cfbWdjibWYa_d]Yehj_YWbikffehj
Wh[ ceX_b_p[Z Xo j^[ fheij^[j_Y ikf[hijhkYjkh[$ >[
ijWj[Z j^Wj ^_i _dl[dj_ed mWi W_c[Z Wj Yh[Wj_d] W
h[b_WXb[jof[e\WdY^ehW][j^WjmWii_cfb[_dZ[i_]d
WdZ [Wio je _di[hj$ @kbb_[j" ^em[l[h" Z_Z dej h[Wbbo
h[Wb_p[ j^[ _cfehjWdY[ e\ X_Yehj_YWb WdY^ehW][ WdZ
j^[ feii_X_b_jo e\ j^[ _ie[bWij_Y _dYehfehWj_ed e\ W
`Wm#_cfbWdj#h[ijehWj_edioij[c$
JeikccWh_p["m^_b[j^[eh_]_dWb_cfbWdjZ[i_]d
Xo BeX[bbe mWi XWi[Z ed _di[hj_d] jme i[fWhWj[
Yecfed[dji"j^[Z[i_]dXo@kbb_[j\[Wjkh[ZWm[bZ[Z
`e_dj X[jm[[d j^[ j^h[WZ[Z f_d WdZ j^[ XWiWb fbWj[$
>_ibWj[hWb_cfbWdjmWi]hWdj[ZWK$I$fWj[dj@kbb_[j
'/-+$ Fh[ikcWXbo" j^[ edbo j^_d] j^Wj @kbb_[j ^WZ _d
c_dZ mWi je ki[ ^_i emd _Z[W Wi _d[nf[di_l[bo Wi
feii_Xb[$ >[ mWdj[Z je Wle_Z W i_jkWj_ed _d m^_Y^
iec[ed[[bi[Wffb_[Z\ehWfWj[djedj^[XWi_ie\^_i
j^ek]^jiWdZ_Z[Wi"bWj[hfh[l[dj_d]^_c\hecki_d]
^_iemd_cfbWdji$
Iec[ o[Whi bWj[h j^[ <h[dY^ Z[dj_ij :h$ 9bkd[j#
9eij['/-+Wffb_[Z\ehWfWj[djedj^[cWdk\WYjkh_d]
j[Y^d_gk[ e\ W J#i^Wf[Z i_d]b[#kd_j _cfbWdj" m^_Y^
i^em[Z iec[ e\ j^[ iWc[ [ii[dj_Wb Y^WhWYj[h_ij_Yi
Wij^[Z[i_]dZ[iYh_X[ZXo@kbb_[j_d'/-($J^[<h[dY^
fWj[dj mWi ]hWdj[Z WdZ h[cW_d[Z [\\[Yj_l[ kdj_b _ji
[nf_ho_d'//,$
J^[h_]^jie\fWj[djm[h[WYgk_h[ZXoj^[;k][d
A”^bcWddYecfWdoj^hek]^_jiikXi_Z_WhoP[hYWj^Wj
Yedj_dk[Z je cWha[j j^_i _cfbWdj Z[i_]d \eh cWdo
o[Whi$J^_i_iWbiem^[h[@kbb_[jeXjW_d[Z^_i_cfbWdji$
&IGÈ :hWm_d]\hecKIF)"/(+"./(
'( 9^Wfj[h(È (ISTORYÈASÈ$OCUMENTEDÈBYÈ0ATENTSÈANDÈ0ATENTÈ!PPLICATIONS
&IGÈ ?cfbWdjZ[i_]dXo:h$9bkd[j#9eij["<hWdY[
9bkd[j#9eij["Xoj^[mWo"mekbZ_d_j_WbboXko^_iemd
_cfbWdji_d?jWbojeWle_ZfWo_d]^_iemdb_Y[dY[\[[i$
IYehj[YY_"_djkhd"WYgk_h[Z^_iIm_ii#cWZ[_cfbWdji
l_WCedWYe$P[hYWZ_iYedj_dk[Zj^_ifheZkYj_edb_d[
Wo[WhW\j[h@kbb_[jÉiZ[Wj^_dI[fj[cX[h'/.)$7hekdZ
j^[iWc[j_c["IYehj[YY_[dj[h[Zj^[cWha[jm_j^^_i
Ykjj[hiWdZhejWj_edWbboiocc[jh_YWbZ[i_]didWc[Z
Æ:_ia_cfbWdjÇ$?jWff[Whij^Wjj^[i[Z[l[befc[dji
^[bZ ]h[Wj Wff[Wb \eh 9bkd[j#9eij[ ^_ci[b\ X[YWki[
^[ Wbbem[Z IYehj[YY_ je Yedj_dk[ fheZkY_d] WdZ
cWha[j_d]^_ifheZkYjim_j^ekjWb_Y[dY[<$F$IfW^d"
f[hiedWbYecckd_YWj_ed"(&&'$7domWo"jWa_d]ekj
fWj[djiedcWdk\WYjkh_d]fheY[ii[iedbo_dif[Y_\_Y
;khef[Wd Yekdjh_[i _i de bed][h c[Wd_d]\kb j^[i[
ZWoi$7i W cWjj[h e\ \WYj" fWj[dji ed cWdk\WYjkh_d]
j[Y^d_gk[i Wh[ b_a[bo je X[Yec[ fe_djb[ii [l[d
_\ Yed\_d[Z je ;khef[ _d j^_i [hW e\ _dYh[Wi_d]bo
]beXWbcWha[jiWdZY^[WfcWdk\WYjkh_d]i_j[i_dj^[
Yekdjh_[ie\j^[\ehc[h;Wij8beYa$
J^h[[\khj^[hfWj[djijWa[dekjXoIYehj[YY__dj^[
KI7'/.-"'/..WdZ_d;khef['/.+WZZ[ZWdej^[h
Y^Wfj[hjej^[^_ijehoe\Z_ia_cfbWdjebe]o$
?d^_iK$I$fWj[dj"IYehj[YY_Z[iYh_X[ZWd_cfbWdj
j^Wji[hl[ZWi_jiemd_di[hj_edjeeb$J^[fWj[djWbie
Yel[hiiec[Wif[Yjie\j^[bWj[hWb_di[hj_edfheY[ii$
J^[ _Z[W mWi je Z[i_]d Wd _cfbWdj ikh\WY[ j^Wj
_dYbkZ[ZYkjj[h\bkj[iWdZjeh[cel[j^[jkhX_d[W\j[h
j^[Xed[YedYWl_jo^WZX[[dYkj"j^[h[Xob[Wl_d]j^[
_cfbWdjm[bbWdY^eh[Z_di_Z[j^[Xed[$J^[jkhX_d[i
WlW_bWXb[ j^[d WdZ jeZWo ^Wl[ W Y^kYa Z_Wc[j[h
&IGÈ :hWm_d]\hecKIF*"-((",.-
e\ '$,cc" m^_Y^ mWi W b_c_j_d] \WYjeh \eh j^[
Z_Wc[j[he\j^[_cfbWdji^W\j_$[$j^[j^h[WZ[Zf_d$
9edi[gk[djbo" j^_i Z[i_]d hekj_d[bo b[Z je _cfbWdj
\hWYjkh[i$J^[ioij[cWiZ[iYh_X[Z_dj^[fWj[dj^Wi
d[l[hX[[dm_Z[bocWha[j[Z$
<_]kh[($* _bbkijhWj[i j^[ bWj[hWb _di[hj_ed fWj^1
IYehj[YY_[dl_i_ed[ZWioij[c_dm^_Y^j^[i_p[WdZ
i^Wf[e\j^[_cfbWdjX[ZZ_Zdejd[Y[iiWh_boYe_dY_Z[
m_j^j^[_cfbWdjZ[i_]d$
?j[c._d<_]$($+i^emij^Wjj^[eij[ejecofWj^mWi
bed][hj^Wdj^[_cfbWdj$J^_iWffheWY^fh[ikffei[i
j^Wj j^[ Yehj_YWb Xed[ ijhkYjkh[ _d j^[ cWdZ_Xb[ _i
WZ[gkWj[bo m_Z[$ ?j _i d[Y[iiWho je h[c[cX[h j^Wj
\kdYj_edWbWbj[hWj_ediWiieY_Wj[Zm_j^j^[h[ijehWj_l[
jh[Wjc[djeh^ehcedWbY^Wd][icWob[WZjecWii_l[
[dZeij[Wb h[iehfj_ed$ ?\ ie" j^[ Y^WdY[i Wh[ j^Wj j^[
_cfbWdjm_bbh[Y[Z[_db_d]kWbehl[ij_XkbWhZ_h[Yj_ed
_djej^[d[mbo[lebl_d]YWdY[bbekiXed[Wh[Wi$J^_i
fheXb[c ^Wi X[[d [b_c_dWj[Z _d j^[ Wiocc[jh_YWb
_cfbWdjZ[i_]di"m^_Y^Wh[Z_iYkii[ZX[bem$
J^[ K$I$ fWj[dji m[h[ ]hWdj[Z m_j^ekj fheXb[ci
Wj j^[ j_c[$ J^[ fheY[Zkh[ m[dj dej ie iceej^bo
È (ISTORYÈASÈ$OCUMENTEDÈBYÈ0ATENTSÈANDÈ0ATENTÈ!PPLICATIONSÈ ')

_d ;khef[" m^[h[ j^[ fWj[dj if[Y_\_YWj_ed ^WZ je X[

h[l_i[Z$ C[Wdm^_b[" IYehj[YY_ ^WZ X[[d Yebb[Yj_d]
[nf[h_[dY[Xoki_d]^_i_cfbWdjZ[i_]di_dfhWYj_Y["
iej^[h[mWij_c[jeWc[dZj^[eh_]_dWbfWj[djYbW_ci
je h[\b[Yj j^_i [nf[h_[dY[ Xo j^[ j_c[ j^[ ;khef[Wd
fWj[dj mWi [l[djkWbbo ]hWdj[Z$ J^[ K$I$ fWj[dji" Xo
YedjhWij"m[h[]hWdj[ZWbceijkdceZ_\_[Z$
:[if_j[ j^[i[ Z[l[befc[dji" j^[ h[iekhY[i j^Wj
m[h[\kdd[bb[Z_djej^[kd_l[hi_j_[i\ehj^[j[WY^_d]
e\ Z[djWb _cfbWdjebe]o m[h[ _dlWh_WXbo Z_ijh_Xkj[Z
_d\Wlekhe\iYh[m_cfbWdji$?dZkijhomWi[nf[Yj_d]
W\Wij[hjkhdWhekdZ_dh[l[dk[i\heciYh[m_cfbWdji
WdZ h[Wied[Z j^Wj j^[ _di[hj_ed j[Y^d_gk[i YekbZ
X[ [nfbW_d[Z ceh[ h[WZ_bo je Z[dj_iji j^Wd j^[
fheY[Zkh[\ehXbWZ[WdZZ_ia_cfbWdji$7bie"j^[h_iai
jej^[fheij^[j_Ymehai[[c[ZicWbb[h_\edboj^ei[
iYh[m _cfbWdji j^Wj m[h[ \ekdZ je X[ _djWYj W\j[h W
&IGÈ :hWm_d]\hecKIF*"-((",.-WdZKIF*".'+"/-*
^[Wb_d]f[h_eZe\)Ä,cedj^iYekbZX[\_jj[Zm_j^W
jW_beh#cWZ[ikf[hijhkYjkh[$
?d ej^[h mehZi" j^[ YedY[fj e\ _cc[Z_Wj[
beWZ_d] WiieY_Wj[Z m_j^ j^[ 8E? ioij[c [djW_b[Z
j^[ h[gk_h[c[dj j^Wj Wbb _di[hj[Z _cfbWdji ^WZ je
X[ Yb_d_YWbbo ikYY[ii\kb$ I_dY[ Wdo _cfbWdj \W_bkh[
WkjecWj_YWbbo b[WZi je beii e\ j^[ ikf[hijhkYjkh["
j^[h[ _i WbmWoi W h_ia e\ \_dWdY_Wb Yedi[gk[dY[i

&IGÈ ;dbWh][Zi[Yj_ede\<_]$($*

&IGÈ 7dej^[hZhWm_d]\hecj^ei[fheZkYj_l[o[Whii^emi
j^WjIYehj[YY_[dl_i_ed[Zj^[ki[e\icWbbh_d]iWbed]j^[i^W\j
i[hl_d] Wi \ehY[#jhWdic_jj_d] ikh\WY[i WdZ Z[fj^ _dZ_YWjehi$
J^[ _cfbWdj _ji[b\ Wbie \[Wjkh[Z h_d]i e\ j^_i jof[$ J^[
WZlWdjW][ e\ j^_i Yed\_]khWj_ed mWi j^Wj _j ]Wl[ j^[ ikh][ed &IGÈ :hWm_d]i \hec ;F & (*' /,( 8'$ J^[i[ ia[jY^[i
W l[ho WYYkhWj[ _Z[W ^em bed] j^[ _cfbWdj d[[Z[Z je X[$ Ed _bbkijhWj[ _d Z[jW_b j^[ _di[hj_ed fheY[Zkh[ ][d[hWj_d] j^[
j^[ Zemdi_Z[" _j _dlebl[Z Wd WZZ_j_edWb h_ia e\ ckYeiWb WdZ _cfbWdj X[Z$ J^[ l[hj_YWb WdZ ^eh_pedjWb Z_c[di_ed e\ j^[
Xed[_hh_jWj_ed_dj^[fh[i[dY[e\[bWij_Y_cfbWdj#h[ijehWj_ed _di[hj_ed fWj^ m[h[ eXjW_d[Z i_ckbjWd[ekibo Xo ki_d] W
ioij[ci if[Y_WbboZ[i_]d[ZYkjj[h
'* 9^Wfj[h(È (ISTORYÈASÈ$OCUMENTEDÈBYÈ0ATENTSÈANDÈ0ATENTÈ!PPLICATIONS

je j^[ Z[dj_ij$ M^_b[ 8E? m[dj j^hek]^ W f^Wi[ Ej^[h \[bbem Z[dj_iji ^Wl[ Wbie Yedjh_Xkj[Z
e\ _d[nYkiWXb[ d[]b[Yj \eh j^[i[ h[Wiedi" W \bkhho _Z[Wi je j^[ Z[l[befc[dj j^Wj [l[djkWbbo b[Z je
e\ WZ`klWdj fheY[Zkh[i \eh Xed[ Wk]c[djWj_ed% XWiWb eii[e_dj[]hWj_ed$ J^[ 8[b]_Wd Z[dj_ij HeX[hj
]hW\j_d] [c[h][Z ed j^[ iY[d[$ J^_i Z[l[befc[dj Ijh[[b '/.&" \eh _dijWdY[" mWi j^[ \_hij je Z[iYh_X[
cWo^Wl[X[[dWXb[ii_d]\ehiec[ÄfWhj_YkbWhbo\eh X[dZWXb[ bWj[hWb _cfbWdji$ Ijh[[b feijkbWj[Z j^Wj
cWn_bbe\WY_Wbikh][ediÄXkj_j^Wi_cfhel[Zd[_j^[h _cfbWdj jh[Wjc[dj ckij jho je WY^_[l[ W f[h\[Yj
j^[ WYjkWb ikYY[ii deh j^[ j^[eh[j_YWb fej[dj_Wb e\ XWbWdY[e\\ehY[i$J^_iZ[cWdZ_idejfbWki_Xb[\hec
_cfbWdjjh[Wjc[dj$ jeZWoÉi f[hif[Yj_l[1 W\j[h Wbb" j^[ Xed[ ijhkYjkh[ _d
7d [ii[dj_Wb \[Wjkh[ e\ j^_i Z[i_]d mWi j^Wj m^_Y^j^[\ehY[#jhWdic_jj_d]Wh[WiWh[[cX[ZZ[ZWh[
_cfbWdjiWdZjeebim[h[i[fWhWj[Z$IYehj[YY_ÉifWj[dj dejkd_\ehcbofhej[Yj[ZW]W_dijh[iehfj_ed"[_j^[h$
bWmo[hi Z[i[hl[ Yedi_Z[hWXb[ h[if[Yj \eh j^[ \WYj 7h[Wi + WdZ . _d <_]$($. Wh[ j^[ X[dZWXb[ bWj[hWb
j^Wj j^[o ikYY[[Z[Z" Xo h[iekhY[\kb f^hWi_d]" _d ijkXi$
_dYehfehWj_d] Wi ikXYbW_c , j^[ [nWYj effei_j[ e\ J^[ \WYj j^Wj Z_iai Wj j^[ _cfbWdj XWi[ YWd X[
j^[eh_]_dWb_Z[We\j^[fWj[djWffb_YWj_ed"ikY^j^Wj ki[Z _d W Yecfb[j[bo Z_\\[h[dj cWdd[h ^WZ X[[d
_j [iYWf[Zj^[ h[l_[m[hiÉ dej_Y[WdZ\ehc[ZfWhj e\ Z[cedijhWj[ZXo9^h_ij[di[dWi[WhboWi_d'/,+$J^[
j^[fWj[dj]hWdj[Z$ YWkZWb _di[hj_ed fWj^ e\ j^_i Z[i_]d ^Wi h[cW_d[Z
?d'//'"IYehj[YY_fkXb_i^[ZWh[jheif[Yj_l[ijkZo iec[m^Wje\WdeXijWYb[$:[dj_ijiWh[dejWYYkijec[Z
ed j^[ Yb_d_YWb ekjYec[i e\ ^_i :_ia_cfbWdj ioij[c jej^_ijof[e\ikh]_YWbWffheWY^$
IYehj[YY_[jWb$(&&'$?dj^[o[Whi'/-/Ä'/./"WjejWb <ehj^[iWc[h[Wied"j^[jhWdicWdZ_XkbWh_cfbWdj
e\+".*._cfbWdji^WZX[[d_di[hj[Z"+/&e\m^_Y^^WZ JC? Z[i_]d" Wbj^ek]^ e\\[h_d] [njh[c[bo ]eeZ
jeX[h[cel[Z$Ceije\j^[i[_cfbWdjbeii[ieYYkhh[Z h[ikbji _d j^[ jh[Wjc[dj e\ cWdZ_XkbWh h[iehfj_ed"
_dj^[f[h_eZ'/.&Ä'/.*"fh[ikcWXbo[_j^[hX[YWki[ ^Wi d[l[h X[[d jee fefkbWh Wced] Z[dj_iji$ 7
j^[ Z_ia Z_Wc[j[hi m[h[ jee icWbb eh X[YWki[ j^[
j^h[WZ[Zf_dim[h[jeei^ehj$7dej^[h\WYjehmWij^Wj
j^[eh_]_dWbZ_iaim[h[dejf[h\ehWj[ZWjWbb1j^[d[nj
][d[hWj_ed\[Wjkh[Zf[h\ehWj_edij^Wjm[h[ij_bbl[ho
icWbb$ <hWYjkh[i h[ikbj_d] \hec j^[ icWbb Z_Wc[j[h
e\ j^[ j^h[WZ[Z f_di W Yedi[gk[dY[ e\ WZ^[h_d]
je j^[ K$I$ fWj[dj if[Y_\_YWj_ed WdZ j^[ '$,cc
i^W\j Z_Wc[j[h Wbie Yedjh_Xkj[Z je iec[ \W_bkh[i$
Dejm_j^ijWdZ_d]"WYkckbWj_l[ikYY[iihWj[e\Wbceij
/& el[h W '&#o[Wh f[h_eZ mWi W h[cWhaWXb[ \[Wj"
Yedi_Z[h_d] j^Wj i_c_bWh \_]kh[i m[h[ Wbie h[fehj[Z
\eh iYh[m WdZ XbWZ[ _cfbWdji Wj j^[ j_c[$ M_j^
IYehj[YY_Éi Z[l[befc[dj e\ ijWdZWhZ_p[Z Ykjj[hi \eh
_cfbWdjX[Zi"bWj[hWb_cfbWdjebe]okbj_cWj[boX[YWc[
Wdefj_ed[l[d_dj^[^WdZie\b[iiia_b\kbikh][edi$
J^[h[\eh[IYehj[YY__ih_]^jbojeX[h[]WhZ[ZWied[
e\j^[Æ\ekdZ_d]\Wj^[hiÇe\bWj[hWb_cfbWdjebe]o$
?d^_iYecfh[^[di_l[XeeaedZ[djWb_cfbWdjebe]o"
fkXb_i^[Z _d (&&'" IYehj[YY_ bW_Z ekj W bWh][
dkcX[h e\ jh[Wjc[dj efj_edi m_j^ Z_ia _cfbWdji$
>[ YecX_d[Z Z_ia _cfbWdji m_j^ÆijhkYjkh[Ç iYh[m
_cfbWdji" cW_dbo \eh iYh[m[Z Xh_Z][i$ >_i ckbj_fb[
_cfbWdjYedY[fjXWi[Zed.Ä'*_cfbWdji_d[WY^WhY^
mWi WiieY_Wj[Z m_j^ ^k][ cWj[h_Wb h[gk_h[c[dji
WdZ [dehceki Yeiji$ ?d WZZ_j_ed" _j jkhd[Z ekj j^Wj
j^[Xed[ijhkYjkh[imekbZij_\\[dWiWh[ikbje\j^_i
WffheWY^$ 8o j^[ iWc[ jea[d" jeZWoÉi _cfbWdji Ze
dej\[Wjkh[ikh\WY[[dbWh][c[djjeWle_Z_hh_jWj_ede\
j^[ikhhekdZ_d]Xed[$7iWYedi[gk[dY["_dZ_l_ZkWb
_cfbWdjij^WjWh[[cX[ZZ[Z_d[bWij_YXed[i[]c[dji
cWojkhdekjjeX[ceX_b[m^[dXh_Z][iWh[h[cel[Z$
&IGÈ ÆF[h\[Yjbo XWbWdY[ZÇ Z_ia _cfbWdj m_j^ X[dZWXb[
J^_i jof[ e\ ceX_b_jo Ze[i dej ^Wl[ Wdo Yb_d_YWb eh bWj[hWb ijkXi j^Wj Wh[ _dj[dZ[Z je [dikh[ fh_cWho ijWX_b_jo
hWZ_e]hWf^_Y_cfb_YWj_edi$9edi_Z[h_d]j^[_cfbWdj% je bWj[hWb \ehY[i$ ?d ej^[h mehZi" fWhj e\ j^[ Z[i_]d m_bb X[
h[ijehWj_edioij[cWiWm^eb["j^[i[ceX_b[_cfbWdji beYa[Z kf _d W ikXf[h_eij[Wb fei_j_ed$ J^_i YedY[fj e\ XWiWb
ij_bbYedij_jkj[WijWXb[XWi_i\ehj^[h[ijehWj_ed$ eii[e_dj[]hWj_ed^Wiikhl_l[Zjej^_iZWo
È (ISTORYÈASÈ$OCUMENTEDÈBYÈ0ATENTSÈANDÈ0ATENTÈ!PPLICATIONSÈ '+

^WdZ\kb e\ \[bbem Z[dj_iji m[bb l[hi[Z _d ikh]_YWb\ehbeWZZ[\b[Yj_edWdZhekdZ\hWc[mehajhWdi_j_edi

j[Y^d_gk[i^Wl[ki[Zj^[i[_cfbWdjl[hoikYY[ii\kbbo
\eh Z[YWZ[i$ Dkc[heki fWj_[dji ^Wl[ j^Wda\kbbo
h[Yel[h[Zj^[_hcWij_YWjeho\kdYj_ed_dj^_imWo$
J^[JC?ioij[c^WiWbej_dYeccedm_j^jeZWoÉi
8E?ioij[c0
v J^[ _cfbWdji ^Wl[ de beWZ jhWdic_ii_ed [_j^[h
d[Wh Wh[Wi m^[h[ j^[ _cfbWdj f[d[jhWj[i j^[
ckYeiWeh_dj^[l[hj_YWb_cfbWdjfehj_ed$
v 7bbbeWZjhWdic_ii_edjWa[ifbWY[_dWh[Wij^WjWh[
iW\[\hec_d\[Yj_ed$
v BeWZjhWdic_ii_ed_ickbj_Yehj_YWb$
7dej^[h_ddelWj_l[c_dZ_d\bk[dY_d]j^[Z[l[befc[dj ÆZ_ia_cfbWdjebe]oÇÄIYehj[YY_Z_ZdejfWo[dek]^
e\ Z[djWb _cfbWdji mWi 7bX[hj Akhj_i$ J^[ Z[i_]d
^[ if[Y_\_[Z _d ^_i fWj[dj e\ '/.. mWi W_c[Z Wj
WdY^eh_d]j^[j^h[WZ[Zf_dZ[[f_di_Z[j^[Xed[je
[dZem j^[ _cfbWdj i^W\j m_j^ h[i_b_[dY[ WdZ heec
\eh \b[nkhWb cWde[klh[ m^_b[ fh[l[dj_d] _d\[Yj_edi
\hec WZlWdY_d] je j^[ beWZ#jhWdic_jj_d] _cfbWdj
i[]c[dji$7jj^Wjj_c["\[Wjkh[iikY^WihekdZijhkji
jeWle_ZbeWZf[Waim[h[h[cWhaWXb[WY^_[l[c[dji_d
ijhkYjkhWbZ[i_]d$J^[XbeeZikffbo_dj^[_di[hj_ed
Wh[WmekbZfheXWXboh[cW_dbWh][bo_djWYjm_j^j^_i
Z[i_]d$
7dej^[h dWc[ je X[ c[dj_ed[Z _d j^_i Yedj[nj
_i7b\h[Z ;Z[bcWdd" m^ei[ K$I$ fWj[dj if[Y_\_YWj_ed
'/-. Wbie _dYbkZ[Z WbX[_j Wi W c_deh fe_dj XWiWb
iebkj_edi\eh^_i_cfbWdjZ[i_]d$
AWmW^WhW'/./ijkZ_[Zj^[ki[e\Z_iYedj_dkeki
ikh\WY[iWdZfhel_Z[Zh[b[lWdjif[Y_\_YWj_edi\ehWbb
jof[ie\_cfbWdji$
?d j^[ [Whbo '/.&i Ä _$[$ _d j^[ [Whbo f^Wi[ e\

&IGÈ <hec KIF *"-,."/+,1 ia[b[j_p[Z _cfbWdji _d W XbWZ[

Z[i_]d

&IGÈ <hec KIF )"*-*"+)-$ 9^h_ij[di[dÉi _cfbWdj Z[i_]d

h[b_[Z ed W YWkZWb _di[hj_ed fWj^$ J^[ Z_ia mWi dej _di[hj[Z &IGÈ ?cfbWdjZ[i_]de\KIF*"-,."/+,_dWXWia[jYed\_]khW#
_dje Wd [deiiWb fei_j_ed Xkj mWi Yel[h[Z Xo YWkZWb Xed[ j_ed$ BWj[hWb _di[hj_ed e\ j^_i _cfbWdj _i fh[l[dj[Z Xo ijhkji
]hemj^_dZk[Yekhi[ '&,WdZ'&.
', 9^Wfj[h(È (ISTORYÈASÈ$OCUMENTEDÈBYÈ0ATENTSÈANDÈ0ATENTÈ!PPLICATIONS
&IGÈ ?cfbWdj Z[i_]d m_j^ Z_iYedj_dkeki ikh\WY[" \hec
KIF*"/,*".&'
Wjj[dj_edjej^[fheXb[ce\j^[Yecfhec_i[ZXbeeZ
ikffbo WXel[ j^[ _cfbWdji$ ?d\bWccWjeho eij[eboi_i
l[hj_YWbbo WXel[ j^[ XWiWb fbWj[ mWi W Yecced
eXi[hlWj_ed" Wi j^[ [Whbo _cfbWdj Z[i_]di m[h[
ij_bb X[jj[h ik_j[Z \eh ki[ _d j^[ Wbl[ebWh h_Z][$
9ecfb_YWj_edie\j^_ijof[m[h[YWki[ZXo_dik\\_Y_[dj
XbeeZikffboYh[ijWbbojej^[Z_ia"Zk[jej^[\WYjj^Wj
j^ei[ [Whbo Z_iai m[h[ dej f[h\ehWj[Z$ 8Wi[Z ed
Ykhh[djademb[Z]["j^[jof[e\f[h\ehWj_edif[Y_\_[Z
Xo AWmW^WhW mWi dej kf j^[ Y^Wbb[d][ [_j^[h WdZ
mekbZ^Wl[\W_b[Zje[dikh[WdWZ[gkWj[XbeeZikffbo
Yh[ijWbbojej^[XWiWbfbWj[`kijWim[bb$M^[j^[h^_i
_cfbWdjim[h[[l[hcWdk\WYjkh[Z_ikdademd$
IYehj[YY_Éi Z_ijh_Xkj_ed YecfWdo L_Yjeho D_Y["
<hWdY[ cWha[j[Z jme Z_\\[h[dj _cfbWdj ioij[ci$
J^[Æ;:Ç i[h_[i \[Wjkh[i Wd [nj[hdWb j^h[WZ _d_j_Wb
j^h[WZ0 C(&$*&1 j^[ ikXi[gk[dj l[hi_ed C(&$(+
_i ij_bb ijWj[ e\ j^[ Whj WdZ Z[b_YWj[ h_Xi Wbed] j^[
i^W\jWij^h[WZcWha[hi$7lW_bWXb[_cfbWdjZ_Wc[j[hi
m[h[ +Ä'+cc$ 7bb _cfbWdji ^Wl[ \[Wjkh[Z hekdZ
Z_iaiWdZWh[WlW_bWXb[Wii_d]b[#"ZekXb[#"jh_fb[#eh
[l[d gkWZhkfb[#Z_ia Z[i_]di$ J^[ Z_ijWdY[ X[jm[[d
_dZ_l_ZkWbZ_iai_i_dlWh_WXbo)cc$7Xekj'//&"IfW^d
&IGÈ ;Z[bcWddÉiX[dZWXb[
WZWfjWXb[_cfbWdji
fh[lW_b[Z ed IYehj[YY_ je fheZkY[ ÆWdWjec_YWbbo
i^Wf[ZÇ ckbj_#Z_ia Z[i_]di" _$[$ _cfbWdji m_j^
ckbj_fb[ Z_iai e\ Z_\\[h[dj i_p[i$ Jme e\ j^ei[ d[m
_cfbWdjjof[iÄ;::'(%.=*WdZ;::'+%/=*Ä^Wl[
i_dY[ X[[d cWha[j[Z WdZ ki[Z _d Yb_d_YWb fhWYj_Y[
m_j^ ]h[Wj ikYY[ii$ J^[o ^Wl[ Yec[ je X[ m_Z[bo
ki[Z fWhj_YkbWhbo _d cWn_bbWho h[ijehWj_edi$ ?Z[Wbbo"
j^[oWbbemgkWZh_Yehj_YWbWdY^ehW][_dj^[cWn_bbWho
i_dki"m^ei[XedoijhkYjkh[\h[gk[djbo^Wij^[i^Wf[
e\Wd_dl[hj[ZfohWc_Z$
8[jj[h kj_b_pWj_ed e\ j^[ Yehj_YWb Xed[ mWi
Wbie m^Wj j^h[[ Z[dj_iji Wj ?J? ^WZ _d c_dZ m^[d
j^[o fh[i[dj[Z Wd _cfbWdj j^Wj _dYbkZ[Z dW_bi \eh
h[j[dj_ed$ J^_i Z[i_]d Xo @”h] IY^c_Z" 9^h_ije\
>cc[hb[ dem W :[fWhjc[dj >[WZ Wj j^[ :[djWb
IY^eeb Wj Pkh_Y^ Kd_l[hi_jo WdZ D_aebWki F[j[h
BWd] Ykhh[djbo W :[fWhjc[dj >[WZ Wj j^[ :[djWb
IY^eebWj8[hdKd_l[hi_jo'//'mWiXWi_YWbboWij[f
_dj^[h_]^jZ_h[Yj_ed$
J^[ _dl[djehi Z[i[hl[ Yh[Z_j \eh h[Wb_p_d] j^Wj
_cfbWdjiikffehj[ZXobWj[hWbYehj_YWbXed[mekbZ
e\\[hWZlWdjW][i_dj^_dXed[ijhkYjkh[i$IjhWkcWdd
7=^Wid[l[h_cfb[c[dj[Zj^_iZ[i_]d$J^[oZ_Zdej
jWa[ _dje Yedi_Z[hWj_ed j^[ l_iYe#[bWij_Y fhef[hj_[i
e\ Xed[ WdZ j^[ YedY[fj e\ i[b\#jhWX[YkbWj_d] Wi
[nfbW_d[Z_d9^Wfj[h/$
J^[_dl[djehiXWh[boc_ii[Zj^[XkbbÉi[o[edo[j
Wdej^[h eYYWi_ed$ 7 XWiWb fbWj[ m_j^ Wd _dj[hdWbbo
j^h[WZ[Z Yob_dZ[h WjjWY^[Z je _j mWi Wbie if[Y_\_[Z
_d j^[ =[hcWd kj_b_jo ceZ[b Wffb_YWj_ed e\ '//*$
EXl_ekibo"j^[if_a[i_dj[dZ[Zjee\\[hWdY^ehW][_d
j^[ Xed[ YWd edbo X[ [\\[Yj_l[ _d j^[ _d_j_Wb f^Wi[$
BWj[h ed" j^[o m_bb _dl_j[ beWZ f[Wai WdZ beYWb
eij[eboi_i$
J^_i Z[i_]d mWi _d [\\[Yj Wd Æed#fbWdjÇ hWj^[h
j^Wd Wd Æ_d#fbWdjÇ$ ?d WZZ_j_ed" _j mWi _dj[dZ[Z
je ^ebZ W c[cXhWd[ j^Wj mekbZ ij_ckbWj[ Xed[
]hemj^ kdZ[hd[Wj^$ =_l[d j^[ iYWdjo XbeeZ ikffbo"
_j _i h[WiedWXb[ je Wiikc[ j^Wj W ijhkYjkh[ e\ j^_i
jof[ mekbZ hekj_d[bo b[WZ je i[l[h[ _d\[Yj_edi WdZ
[l[djkWbbojej^[beiie\j^[[dj_h[_cfbWdj#h[ijehWj_ed
È (ISTORYÈASÈ$OCUMENTEDÈBYÈ0ATENTSÈANDÈ0ATENTÈ!PPLICATIONSÈ
&IGÈ 9> ,.- ,-( 7+0 J^[ j^h[[#Z_c[di_edWb ijhkYjkh[
_d <_]$($' _i Z[i_]d[Z je WYY[fj _dYec_d] beWZi m_j^ekj
\hWYjkh_d]$ J^[ j^_d ijhkji m[h[ ^WhZbo YWfWXb[ e\ ^WdZb_d]
cWij_YWjehobeWZi_dWdWZ[gkWj[cWdd[h
&IGÈ <hec j^[ iWc[ fWj[dj Wi _d <_]$($'*$ 7d]b[Z ijhkji
mekbZfh[ikcWXbojkhdekjjeX[l[ho_dWffhefh_Wj[_dYb_d_YWb
fhWYj_Y[$ J^_i _cfbWdj Z[i_]d h[\b[Yji W c[Y^Wd_ij_Y c_dZi[j
j^Wj _i l[ho Z[jWY^[Z \hec j^[ h[Wb_j_[i e\ ^kcWd X_ebe]o$
7d _cfbWdj e\ j^_i jof[ mekbZ X[Æ[njhWj[hh_jeh_Wb_p[ZÇ \hec
j^[l[hoekji[jWdZijWdZib_jjb[Y^WdY[e\X[_d]ikYY[ii\kbbo
_dj[]hWj[Z
Yecfb[n$M^_b[j^[bWjj[hjmeZ[l[befc[djiX[Whde
Z_h[Yj h[bWj_edi^_f je XWiWb eii[e_dj[]hWj_ed" j^[o
Ze _bbkijhWj[ W if[Y_\_Y c_dZi[j j^Wj mWi fh[lWb[dj
_d W if[Y_\_Y [hW$ J^[o _bbkijhWj[ ^em W ]hekf e\
iY_[dj_\_YWbbo Yecc_jj[Z Z[dj_iji jh_[Z je meha ekj
iebkj_edi _d m^_Y^ jh[Wjc[dj fbWdd_d] mekbZ dej
X[ ]k_Z[Z Xo j^[ hkb[i e\ X_ebe]o WdZ \kdYj_ed Xkj #ONCLUSIONJ^[_Z[We\XWiWb"m_Z[#Wh[Wikffehj\eh
mekbZ[nf[Yj^kcWdX_ebe]ojeo_[bZje_jiemdi[j _cfbWdjimWijWa[dkfXocWdoZ[l[bef[hiWjiec[
e\hkb[i$ fe_dj$?dcWdoe\j^[fWj[djiWdZfWj[djWffb_YWj_edi
'-
C[Wdm^_b[" W ]eeZ WdZ fhWYj_YWb iebkj_ed mWi
Z[l[bef[Z Wbceij i_ckbjWd[ekibo _d lWh_eki Z[djWb
e\\_Y[i$ A$#>$ C”bb[h Wffb_[Z \eh W fWj[dj \eh ^_i
ZekXb[#kd_jZ[i_]d'///"m^_Y^_dYbkZ[ZWj^h[WZ[Z
f_d je X[ iYh[m[Z je j^[ XWiWb fbWj[$ J^[ fh_dY_fWb
eX`[Yj_l[ mWi je fhel_Z[ WdY^ehW][ \eh h[ijehWj_edi
Wbed]j^[cWn_bbWhoi_dki$C”bb[hÉi_Z[WjefbWY[j^[
XWiWbfbWj[_di_Z[j^[cWn_bbWhoi_dkiXkjX[bemj^[
IY^d[_Z[h_Wdc[cXhWd[mWiXh_bb_WdjWdZ\Whi_]^j[Z$
Ki_d]j^_iYedY[fj"j^[h[i_ZkWbXed[lebkc[kdZ[h
j^[ i_dki m_bb X[ fhej[Yj[Z W]W_dij _d\[Yj_ed WdZ
m_bb [l[d X[ fh[i[hl[Z _\ j^[ _cfbWdj _i beij$ J^[
_dl[djeh ijWj[Z j^Wj ^[ ^WZ X[[d b[Z Xo j^[eh[j_YWb
Yedi_Z[hWj_edi m_j^ekj [l[h ki_d] j^ei[ _cfbWdji
^_ci[b\$Iec[Wif[Yjie\j^_id[mYedY[fj^WZX[[d
ki[Zfh[l_ekibo_dj^[Yb_d_YWbmeham_j^i_d]b[#kd_j
8E?_cfbWdji$
7Xekjj^[iWc[j_c["IfW^dWffb_[Z\ehWfWj[dj
ed W ckbj_#kd_j _cfbWdj ioij[c \[Wjkh_d] iYh[m
Yedd[Yj_ediWdZWckbj_#j^h[WZ[Zf_d'///$
?^Z[WdZIfW^d^WZbW_Zj^[\ekdZWj_ed\ehXWiWb
eii[e_dj[]hWj_ed [l[d X[\eh[ j^Wj j_c[" Xo Wffbo_d]
\ehWfWj[djedj^[\_hij[bWij_Y_cfbWdjZ[i_]d"j^ki
jkhd_d]WmWo_dj^[ehoWdZfhWYj_Y[\hecj^[hWj^[h
c[Y^Wd_ij_Y j^[eho e\ Yh[ijWb _cfbWdji WdZ h_]_Z
Xed[#_cfbWdj#fheij^[j_Yiioij[ci$
J^[ XWiWb fbWj[i m[h[ Yed\_]kh[Z je cWjY^ j^[
WdWjec_YWb i^Wf[ e\ j^[ `WmXed[" WdZ j^[ Yh[ijWb
fbWj[ mWi fbWY[Z _d W ceh[ h[i_b_[dj fei_j_ed j^Wd
j^[ XWiWb fbWj[$ 8o l_hjkWbbo [b_c_dWj_d] j^[ h_ia e\
Yh[ijWb eij[eboi_i _d j^[ cWn_bbW" j^_i Z[l[befc[dj
YWdX[h[]WhZ[ZWiWc_b[ijed[_dj^[^_ijehoe\8E?$
7jj^[iWc[j_c["beWZjhWdic_ii_ed_dj^[Wh[We\j^[
Yh[ijWbfbWj[mWiYed\_d[Zjej^[fWbWjWbXed["m^_Y^
WffWh[djbo mWi ckY^ X[jj[h ik_j[Z \eh j^_i jWia _d
j[hci e\ ijhkYjkh[" h[iehfj_ed j[dZ[dYo WdZ XbeeZ
ikffboj^Wdj^[l[ij_XkbWhXed[$
8o '//." IfW^d WdZ ?^Z[ ^WZ dej Z[\_d_j_l[bo
Whh_l[ZWjj^[YedYbki_edj^WjbeWZjhWdic_ii_ed_dj^[
Wh[We\j^[j^h[WZ[Zf_dmWiWbje][j^[hkdd[Y[iiWho$
J^[h[\eh[" j^[ [Whbo _cfbWdji e\ j^[i[ i[h_[i mekbZ
ij_bb \[Wjkh[ j^[ h_X#ijob[ ikh\WY[ [dbWh][c[dj
Z[iYh_X[Z Xo 9bkd[j#9eij[$ J^ei[ Z[i_]di" _d [\\[Yj"
cWha[Zj^[jhWdi_j_ed\hecYh[ijWbje][dk_d[boXWiWb
_cfbWdji$
J^[ \[Wjkh[ e\ W ikh\WY[#[dbWh][Z i^W\j mWi
[b_c_dWj[Z edbo 'o[Wh bWj[h m^[d j^[ Im_ii fWj[dj
if[Y_\_YWj_ed 9> ,/& *', 7+ mWi ikXc_jj[Z Wi W
YehebbWhoje;F//(+&(./$.$
Ceh[ h[Y[djbo" \khj^[h _cfhel[c[dji ^Wl[ X[[d
WZZ[Zjej^[cWYhe#WdZc_Yhe#Z[i_]de\j^[beWZ#
jhWdic_jj_d]Wh[WiWdZjej^[jhWdi_j_edped[ijemWhZi
j^[ded#beWZ#jhWdic_jj_d]\hWc[mehaWh[Wi$
'. 9^Wfj[h(È (ISTORYÈASÈ$OCUMENTEDÈBYÈ0ATENTSÈANDÈ0ATENTÈ!PPLICATIONS

gkej[Z ^[h[" j^[ h[iebkj_ed e\ i_jkWj_edi _d m^_Y^ Xed[ j_iik[ Wbie \eh _cc[Z_Wj[ beWZ_d] fheY[Zkh[i$
_dik\\_Y_[dj l[hj_YWb Xed[ lebkc[ mWi WlW_bWXb[ mWi Edbo @kbb_[j '/-(" IYehj[YY_ '/.+ WdZ ?^Z[ \hec
m^Wj]Wl[h_i[jej^[lWh_eki_Z[Wi$Ej^[hZ[l[bef[hi '//. [l[h jkhd[Z j^[_h _Z[Wi _dje ikYY[ii\kbbo
m[h[ceh[_dj[h[ij[Z_dkj_b_p_d]j^[^WhZ[hYehj_YWb cWha[jWXb[WdZYb_d_YWbbofhWYj_YWbfheZkYji$

&IGÈ ?cfbWdjZ[i_]d\[Wjkh_d]Wd
_dj[hdWbboj^h[WZ[ZYob_dZ[h"Wif_a[Z
XWiWbfbWj[WdZWc[cXhWd[_dj[dZ[Z
jeij_ckbWj[Xed[]hemj^

&IGÈ C”bb[hÉiZekXb[#kd_j_cfbWdjmWiWdY^eh[Z_di_Z[j^[cWn_bbWho
i_dkiWdZ\[Wjkh[Zi[l[hWb_di[hj_edfe_dji\ehj^[j^h[WZ[Zf_d$J^[
ceh[h[Y[dj:_iajhWYaioij[cmWiceZ[bb[ZW\j[hj^_iZ[i_]d$J^[h[m[h[
deb[]WbeXijWYb[ijej^_iZ[l[befc[djX[YWki[C”bb[h^WZd[l[h\ebbem[Z
kfed^_ifWj[djWffb_YWj_ed
È (ISTORYÈASÈ$OCUMENTEDÈBYÈ0ATENTSÈANDÈ0ATENTÈ!PPLICATIONSÈ '/

&IGÈ J^[j^h[WZ[Zf_dYecfh_i[ii[l[hWbÆijeh[oiÇjem^_Y^beWZ#
jhWdic_jj_d]fbWj[ie\Z_\\[h[dji^Wf[iYWdX[WjjWY^[Z$?dYedjhWijje
j^[bWj[hZ[l[befc[dje\Z_ijhWYjeh_cfbWdji"IfW^dÉiZ[i_]d^WZWbmWoi
h[b_[Zedfh[#Ykj_di[hj_edfWj^mWoicWjY^_d]j^[Z_ia#je#Z_iaZ_ijWdY[$
:_ijhWYjeh_cfbWdjiWh[_di[hj[ZXoi[fWhWj_d]Xed[YecfWhjc[dji\eh
h[WhhWd][c[djWjWbWj[hj_c["m^_Y^_idejj^[YWi[m_j^IfW^dÉiZ[i_]d

&IGÈ ?^Z[WdZIfW^d"_dWYebbWXehWj_l[[\\ehj"Z[l[bef[Z_cfbWdjij^Wj
X[^Wl[Z[bWij_YWbbo_di_Z[j^[Xed["Wbbem_d]h[i_b_[dY[e\j^[j^h[WZ[Z
f_d$?dj^_imWo"j^[Ze]cWj^WjWbb[deiiWb_cfbWdji[]c[djid[[Z[Z
jeX[Æeii[e_dj[]hWj[ZÇ_dWijWj_YmWomWiXhea[d$J^[YedijhkYj_ede\
j^[i[_cfbWdji[dWXb[Zj^[jhWdic_ii_ede\kd[gkWbfWhjie\j^[beWZ
jeXej^XWiWbfbWj[i$J^[XWiWbfbWj[mWiZ[i_]d[ZjeX[ceh[h_]_Z
j^Wdj^[Yh[ijWbfbWj[$>[dY[WbWh][hWcekdje\j^[Y^[m_d]\ehY[mWi
jhWdic_jj[Zj^hek]^j^[bem[hfbWj[m^_b[j^[Yh[ijWbfbWj[fhel_Z[i_d_j_Wb
ijWX_b_pWj_ed$?j_id[Y[iiWhojeh[c[cX[hj^Wj_j_i_dlWh_WXboj^[XWiWb
fehj_ede\j^[_cfbWdjXeZoj^Wjm_bbjhWdic_j\ehY[_dWbb_cfbWdji_d
j^[bed]j[hc$?\Z[dj_ijiWh[i^emd<;CWdWboi[iehf^eje[bWij_Yijh[ii
_cW][ie\_cfbWdji[cX[ZZ[Z_dFb[n_]bWii_dÆiY_[dj_\_YÇijkZ_[i"j^[o
m_bbWbmWoii^embeYWbijh[iif[Wai_dj^[YebbWhh[]_ede\j^[_cfbWdj$
8kjj^[i[ijkZ_[ieh_cW][iZedejh[\b[Yjj^[jhk[i_jkWj_ed$Kdb_a[j^[
Fb[n_]bWiiceZ[b"b_l[Xed[YWdWle_Zj^[i[ijh[iif[Wai$J^[h[Wh[i[l[hWb
c[Y^Wd_iciWjmehajeWY^_[l[j^_i"ikY^WiY^Wd][i_dj^[h[bWj_l[b[l[b
e\c_d[hWb_pWj_edXoh[Z_ijh_Xkj_d]&#Wh[WiWdZ'#Wh[Wi$?\j^[ijh[iif[Wa
m[h[WYjkWbbobeYWj[Z_dj^[YebbWhh[]_ed"j^_imekbZh[ikbj_dcWii_l[
c_d[hWb_pWj_ed"WdZm[mekbZd[l[hi[[j^[YhWj[h#ijob[Xed[YebbWfi[
Y^WhWYj[h_ij_Ye\Yh[ijWb_cfbWdji
(& 9^Wfj[h(È (ISTORYÈASÈ$OCUMENTEDÈBYÈ0ATENTSÈANDÈ0ATENTÈ!PPLICATIONS
&IGÈ Ikh\WY[ [dbWh][c[dj Wbed] j^[ i^W\j _d ej^[hm_i[
h[i_b_[dj_cfbWdji$J^_iZ[i_]d^WiX[[d[if[Y_WbboikYY[ii\kb
_dh_]_Zjof[ie\_cfbWdj#h[ijehWj_edYecfb[n[i
&IGÈ J^_i Wiocc[jh_YWb 8E? _cfbWdj Z[i_]d" \_hij
Z[iYh_X[Z _d (&&&" mWi YWfWXb[ e\ Yecf[diWj_d] \eh j^[
Y[djh_\k]Wbh[iehfj_edfWjj[hde\j^[cWdZ_Xb["m^_b[j^[Xed[
YWl_j_[i\eh_di[hj_edYekbZij_bbX[fh[fWh[Zm_j^hejWj_edWbbo
iocc[jh_YWb _dijhkc[dji$ 7hhem ', _dZ_YWj[i j^[ _di[hj_ed
fWj^$ J^[ j^h[WZ[Z f_d _i beYWj[Z WmWo \hec j^[ Y[djhWb
fei_j_ed ed j^[ _cfbWdj XWi[" Xkj e\\i[j KIF ,"*&("+', 8($
J^_i Z[i_]d Wbbemi Yef_d] m_j^ j^[ Y[djh_f[jWb h[iehfj_ed e\
j^[kff[h`WmWim[bbWim_j^j^[Y[djh_\k]Wbh[iehfj_ede\j^[
Z_ijWbbem[h`Wm
&IGÈ 8E?Z[i_]dim_j^j^h[[m[XXWhi^Wl[b[iih[i_b_[dY[
j^WdZ[i_]dim_j^edbojmem[XXWhi
&IGÈ <hWc[meha ijhkYjkh[i \[Wjkh_d] \ekh m[X XWhi Wh[
[l[dceh[h_]_Z$J^[c[Y^Wd_YWbm[Wafe_djiWh[beYWj[Z_dj^[
f[h_f^[hWbWh[W$Dej[j^Wj_cfbWdjim_j^ed[hekdZb[\jWdZ
ed[igkWh[h_]^j[dZcWoeYYWi_edWbbo]_l[h_i[je_dYh[Wi[Z
eij[eboi_i m^[d j^[ kdZ[hbo_d] Xed[ ijhkYjkh[i Wj j^[ j^h[[
_di[hj_ed fe_dji Wh[ dej X_ec[Y^Wd_YWbbo iodY^hed_p[Z WdZ
Ze dej i^Wh[ j^[ iWc[ Z[]h[[ e\ c_d[hWb_pWj_ed$ J^[h[\eh[
j^[ _di[hj_ed e\ j^[i[ _cfbWdji ckij X[ ceh[ YWh[\kbbo
fbWdd[Z$J^[j^h[[fe_djiWh[beYWj[ZWjj^[Æ[Z][iÇehYehj_YWb
Æ[dZfe_djiÇ e\ j^[ _cfbWdj0 ed[ [Z][ _i beYWj[Z Wj j^[ hekdZ
i_Z["m^_b[j^[effei_j[i_Z[YedjW_dijme[Z][i
&IGÈ ;nWYj <;C ijkZ_[i h[ikbj[Z _d \hWYjkh[#fhee\
][ec[jh_YWb Yed\_]khWj_edi j^Wj ^[bf[Z je fh[l[dj dejY^
ijh[ii[i_d^_]^#beWZWh[Wi
È (ISTORYÈASÈ$OCUMENTEDÈBYÈ0ATENTSÈANDÈ0ATENTÈ!PPLICATIONSÈ ('

A B

C D

&IGÈAnD ?cfbWdjim_j^Z_iaij^WjYekbZX[cel[ZW]W_dij[WY^ej^[hW\j[h_di[hj_ed"Wbbem[Zjh[Wjc[dj[l[d_dYWi[ie\icWbb
l[hj_YWbXed[ikffbom^_bijj^[h[ijehWj_ed_i_di_jkWdZbeWZ[Z

&IGÈ Cekdj_d] j^[ j^h[WZ[Z f_d je j^[ XWiWb fbWj[ Wj Wd
Wd]b[m_bbcel[j^[Xed[_dWif[Y_\_YZ_h[Yj_ed$B[\jWdZh_]^j
3X[\eh[WdZW\j[hZ_ijhWYj_ed
&IGÈ 7 j^h[WZ[Z f_d \[Wjkh_d] jme effei_j[ j^h[WZi m_bb
c_d_c_p[ eYYbkiWb _cXWbWdY[i Zkh_d] j^[ f^Wi[ e\ [b[lWj_ed
WdZ j^ki h[ZkY[ j^[ d[[Z \eh eYYbkiWb WZ`kijc[dji$ B[\j WdZ
h_]^j3X[\eh[WdZW\j[hZ_ijhWYj_ed
(( 9^Wfj[h(È (ISTORYÈASÈ$OCUMENTEDÈBYÈ0ATENTSÈANDÈ0ATENTÈ!PPLICATIONS

&IGÈ 7j^h[WZ[Zf_d\[Wjkh_d]ed[j^h[WZedbom_bbh[ikbj
_dWceh[fhedekdY[Z[b[lWj_ede\j^[Yh[ijWbXed[i[]c[dj
j^Wd j^[ Z[i_]d i^emd _d <_]$($(/$ J^[h[ _i W ]h[Wj[h d[[Z
\eh eYYbkiWb WZ`kijc[dji$ B[\j WdZ h_]^j 3 X[\eh[ WdZ W\j[h
Z_ijhWYj_ed &IGÈ 8E?Z_ijhWYjeh\[Wjkh_d]W\ebZWXb[XWiWbZ_ia

&IGÈ JeijWX_b_p[j^[XWiWbfbWj["WdWZZ_j_edWbefj_edWbbo &IGÈ Ed[WZlWdjW][e\j^[Z[jWY^WXb[XWiWbfbWj[mWij^Wj

Z[jWY^WXb[ ijhkj YWd X[ cekdj[Z" eh W \ebZWXb[ Z[i_]d e\ j^[Xed[kj_b_p[Z\ehijWX_b_pWj_edZ_Zdej^Wl[jeX[Z_h[Yjbo
j^[ l[ij_XkbWh _cfbWdj i[]c[dji YWd X[ ki[Z Wi i^emd _d X[bem j^[ XWiWb Z_ia" Xkj ceh[ bWj[hWb Xed[ ijhkYjkh[i YekbZ
<_]$($)( X[ki[ZWim[bb

&IGÈAnC I_d]b[#kd_j8E?
Z[i_]di\[Wjkh_d]Wl[ij_XkbWh
fWhj_WbZ_iaWh[ki[Z_\j^[
l[ij_XkbWhXed[_dj^[cWn_bbWho
feij[h_ehi[]c[djbWYai_d
gkWdj_joeh_iikiY[fj_Xb[je
\hWYjkh[$7dej^[hWZlWdjW][_i
j^Wjj^[h[_ided[[Z\ehXej^
Z_iaije\kbbojhWdil[hi[j^[
cWn_bbWhoi_dki"m^_Y^_cfhel[i
ikh]_YWbfh[Y_i_ed
È (ISTORYÈASÈ$OCUMENTEDÈBYÈ0ATENTSÈANDÈ0ATENTÈ!PPLICATIONSÈ ()

&IGÈ CWYhec[Y^Wd_YWb ikh\WY[ [dbWh][c[dj Yehh[i# &IGÈAB :hWm_d] ed 8E?" <kY^i kdZ 9^_[hdo :; '&( '(
fedZ_d] je j^[ j^h[WZ e\ W iYh[m _cfbWdj Wbed] j^[ beWZ# .'+ 7'1 \_b[Z (( CWhY^ (&&( Z[l[bef[Z W Z_ijhWYjeh m_j^ W
jhWdic_jj_d]Wh[WimWi_djheZkY[Zjeh[fbWY[c_Yhec[Y^Wd_YWb YWhZWd#ijob[ WZlWdY[ c[Y^Wd_ic$ J^[ bWh][ h[Y[ii[i _d j^[
ikh\WY[ [dbWh][c[dj$ J^[ d[[Z \eh iWdZXbWij_d] Wbb j^[ XWiWbfbWj[_dZ_YWj[j^Wjj^[i[jeebiYekbZWbieX[b[\j\ehki[
beWZ#jhWdic_jj_d] Wh[Wi mWi j^ki h[dZ[h[Z eXieb[j[" m^_Y^ Wi_cfbWdji
c_d_c_p[Z j^[ ifWY[ \eh XWYj[h_Wb c_Yheh[j[dj_ed$ J^_i
_dYh[Wi[Z j^[ j^[hWf[kj_Y if[Yjhkc \eh _cfbWdji Wbed] j^[
cWn_bbWhoi_dkiWdZ\ehi_d]b[#ij[ffheY[Zkh[i_df[h_eZedjWbbo
_dlebl[ZWh[Wi

&IGÈ JhWdi#i_dki _cfbWdjWj_ed ki_d] i_d]b[#kd_j 8E?

_cfbWdjimWi\_hijc[dj_ed[Z_dKIF'&$',)$&,*$7dofheY[Zkh[i
\ehXed[Wk]c[djWj_edYekbZX[Yecfb[j[boWle_Z[Zm_j^j^_i
WffheWY^$JhWdi#i_dki_cfbWdjWj_edh[ZkY[iXej^j^[ZkhWj_ed
WdZ j^[ Yeij e\ jh[Wjc[dj$ >_fXed[ ]hW\j_d] WdZ i_c_bWh &IGÈ 7 ikXf[h_eij[Wbbo ikffehj[Z Z_ijhWYj_ed Z[l_Y[ mWi
Wk]c[djWj_l[ fheY[Zkh[i ^Wl[ X[Yec[ h[ZkdZWdj [nY[fj _d if[Y_\_[Z_d:;'//&-*(&7'=hW\[jWb$'///j^WjYecX_d[i
j^[W[ij^[j_Yped[ iec[Y^WhWYj[h_ij_Yie\Z_ijhWYjehiWdZe\8E?$J^_i_ied[e\
j^[ \[m fWj[dj Wffb_YWj_edi _d Z[djWb _cfbWdjebe]o j^Wj mWi
\_b[Z\hecm_j^_dWKd_l[hi_jo:[fWhjc[dj

&IGÈ KIF'&$',)Ä'),\_hijZ[iYh_X[ZXej^Wbj[hdWj_l[_cfbWd#
jWj_edj[Y^d_gk[im_j^ehm_j^ekj_djhW#i_dkiWk]c[djWj_ed$
Iec[ki[hiij_bbfh[\[hj^[Wk]c[djWj_l[WffheWY^$7jj^[iWc[
j_c["j^[oh[fehjiec[beii[ie\_cfbWdjiWdZe\Wk]c[djWj_ed
cWj[h_Wb_di_Z[j^[i_dki"fWhj_YkbWhbo_dj^[h[]_ede\j^[\_hij
cebWh WdZ _\ [njhWYj_ed mWi f[h\ehc[Z _d j^[ iWc[ ikh]_YWb
fheY[Zkh[$ J^[ ZhWm_d] _bbkijhWj[i j^Wj 8E? _cfbWdji YWd X[ &IGÈ J^[ 7kijh_Wd cWn_bbe\WY_Wb ikh][ed AWjp[dX[_ii[h
h[WZ_bo_di[hj[Z[l[d_di_dkiWh[Wij^Wj^Wl[X[[dWk]c[dj[Z '/./Wffb_[Z\ehWi_c_bWhfWj[dj$J^_ijof[e\fWj[djWbbem[Z
fh[l_ekibokikWbbo[bi[m^[h[ b_\j_d] j^[ i_dki c[cXhWd[ _d W jme#ijW][ fheY[Zkh[" m_j^ W
^eh_pedjWbXWi[fbWj[Yedd[Yj[Zjej^[l[hj_YWb_cfbWdjfWhj_d
Wjme#f_[Y[Z[i_]d
(* 9^Wfj[h(È (ISTORYÈASÈ$OCUMENTEDÈBYÈ0ATENTSÈANDÈ0ATENTÈ!PPLICATIONS
&IGÈ 7i^a_dWpo'//.Wffb_[Z\ehWK$I$fWj[dj_dm^_Y^
^[ fh[i[dj[Z j^[ ceZkbWh Yecfei_j_ed e\ Wd _cfbWdj$ ?d
WZZ_j_edjeceZkbWhYh[ijWb_cfbWdjZ[i_]di_dYbkZ_d]WXbWZ[
_cfbWdj m_j^ bWj[hWb Yehj_YWb ikffehj Xo WZZ_j_edWb f_di" W
bWj[hWb_cfbWdjm_j^j^[iWc[Z[i_]dmWiWbiefh[i[dj[Z
&IGÈ ;d][ba[ (&&& _i ed[ e\ j^[ \[m h[i[WhY^[hi WdZ
_dl[djehi \hec WYWZ[c_W je X[ b_ij[Z _d Yedd[Yj_ed m_j^ j^[
el[hl_[m _d j^_i Y^Wfj[h$ >[" jee" h[Ye]d_p[Z j^Wj edbo ]eeZ
Yehj_YWb ikffehj e\\[hi ik\\_Y_[dj fh_cWho ijWX_b_jo$ I_dY[ j^[
j[hcÆikXf[h_eij[Wb _cfbWdjÇ ^Wi ib_]^jbo ZkX_eki el[hjed[i
_d j^[ =[hcWd#if[Wa_d] Yekdjh_[i" ;d][ba[ Z[i_]dWj[Z ^_i
_cfbWdjWiÆikX]_d]_lWbÇ$Ded[j^[b[ii"j^[bWj[hWbj[hc_dWjehi
j^Wj YWd X[ WZWfj[Z je j^[ `WmXed[ Wh[ _d \WYj ikXf[h_eij[Wb
Wif[Yjie\j^[_cfbWdj$I_c_bWhjeX[dj8E?_cfbWdjZ_iai"j^[o
cWoX[WZWfj[Zjej^[i^Wf[e\j^[`WmXed[eh[l[diYh[m[Z
Zemd$?\ik\\_Y_[dj[bWij_YcWj[h_Wb_iki[Z"_dj[]hWj_ede\j^_i
_cfbWdj _i YedY[_lWXb[$ Ed[ mekbZ ^Wl[ je dej[" ^em[l[h"
j^Wj bWh][ _cfbWdji e\ j^_i jof[ mekbZ h[gk_h[ c[Y^Wd_YWb
iodY^hed_pWj_ede\l[hoZ_\\[h[djh[]_edie\j^[`Wm

#(!04%2È
-ORPHOLOGYÈOFÈ"/)È)MPLANTSÈÈ
ANDÈ2ELATEDÈ$ESIGNS
9^Wfj[h(fhel_Z[ZWdel[hl_[me\j^[Z_\\[h[djjof[i
e\bWj[hWb_cfbWdjiZ[l_i[Z"_djheZkY[ZWdZ[cfbeo[Z
el[h j^[ fWij )&o[Whi$ J^[ fh[i[dj Y^Wfj[h m_bb
fhel_Z[ j^[ h[WZ[h m_j^ j^[ d[Y[iiWho XWYa]hekdZ
je kdZ[hijWdZ j^[ Z_\\[h[dY[i WdZ YeccedWb_j_[i
e\ j^[i[ Z[i_]di" Wi m[bb Wi j^[_h Wffb_YWj_edi _d
Yb_d_YWb fhWYj_Y[$ JeZWo _j _i Wbceij _cfeii_Xb[ je
ZhWm W Yb[Wh b_d[ X[jm[[d ¼Z_ia½ _cfbWdji WdZ 8E?
_cfbWdji$ El[h j^[ bWij \[m o[Whi _d fWhj_YkbWh" j^[
i_c_bWh_j_[iX[jm[[dj^ei[Z[i_]di^Wl[_dYh[Wi[Z_d
lWh_ekimWoi$J^[iWc[Z[l[befc[dj^WiWbiejWa[d
fbWY[_dYh[ijWb_cfbWdjebe]o$M^_b[_cfbWdjie\j^[
:_ia_cfbWdjjof[Wh[XWiWb_cfbWdjiWdZm^_b[j^[o
jWa[ _dje WYYekdj j^[ YedY[fj e\ X_Yehj_YWb ikffehj"
j^[i[ h_]_Z :_ia_cfbWdji Ze dej _cfb[c[dj j^[
YedY[fj e\ _ie[bWij_Y_jo m_j^ j^[ Xed[ je j^[ iWc[
[nj[dje\WYjkWb8E?_cfbWdjim_j^Wia[b[jWbZ[i_]d$
È
-ORPHOLOGYÈOFÈTHEÈ4HREADEDÈ0IN
J^[j[hc¼j^h[WZ[Zf_d½Z[dej[ij^[_cfbWdji[]c[dj
Yedd[Yj_d] j^[ Z_iai je j^[ [b[c[dj h[jW_d_d]
j^[ fheij^[j_Y ikf[hijhkYjkh[$ ?j mWi _djheZkY[Z
Z[b_X[hWj[bojeZ[iYh_X[j^[\kdYj_ede\j^_il[hj_YWb
Yecfed[dj" m^_Y^ _cfb_[i j^Wj ej^[h jWiai" ikY^
Wi Z_h[Yj [deiiWb beWZ jhWdic_ii_ed" Wh[ dej fWhj
e\ _ji \kdYj_ed$ ?j _i j^[h[\eh[ _hh[b[lWdj m^[j^[h
j^[ j^h[WZ[Z f_d X[Yec[i \kbbo ¼eii[e_dj[]hWj[Z½"
m^[j^[h_jX[Yec[iedbo¼eii[eWZWfj[Z½ehm^[j^[h
_jX[Yec[i[cX[ZZ[Z_dYedd[Yj_l[j_iik[$J^[[nWYj
cWd_\[ijWj_edi e\ ikYY[ii\kb _dj[]hWj_ed cWo lWho
m_Z[bo"Wij^[h[WZ[hm_bbb[WhdbWj[h_dj^_iXeeai[[
9^Wfj[h()$
IYehj[YY_[gk_ff[Zj^[;:_cfbWdji[h_[im_j^h_X#
ijob[ Z[fj^ cWha[hi Wbed] j^[ i^W\j" m^_Y^ e\\[h[Z
ki[\kb ]k_ZWdY[ [if[Y_Wbbo \eh X[]_dd[hi" i_dY[ j^[
jWia e\ WZlWdY_d] j^[ _cfbWdj je j^[ WdWjec_YWbbo
Yehh[YjZ[fj^e\j^[XWiWbh_Z][cWoX[gk_j[Z_\\_Ykbj
_dj^[^WdZie\_d[nf[h_[dY[Zikh][edi$Edj^[ej^[h
^WdZ"Z[fj^cWha[himekbZWYjkWbboX[ceh[ki[\kb
edj^[Ykjj[hhWj^[hj^Wdedj^[_cfbWdjX[YWki["de
cWjj[h ^em m[bb j^[o Wh[ Z[i_]d[Z" j^[o _dlWh_WXbo
WZZ je j^[ h_ia e\ fbWgk[ h[j[dj_ed WdZ _d\[Yj_ed$
;l[djkWbbo"j^_iYWdiec[j_c[ih[ikbj_dYhWj[h#ijob[
 ¬ 
Xed[ YebbWfi[$ J^_i [l[djkWb_jo _i m[bb ademd je X[
WiieY_Wj[Z m_j^ l[hj_YWb beWZ jhWdic_ii_ed ikh\WY[i$
J^[h[\eh[" m^Wj cWo X[ Wd WZlWdjW][ _d j^[ [Whbo
f^Wi[e\jh[Wjc[djcWojkhdekjjeX[WZ_iWZlWdjW][
_d j^[ bed][h j[hc$ J^[i[ Yedi_Z[hWj_edi ^Wl[
fhecfj[ZkijeWXWdZedj^[ki[e\j^[i[cWha[hi$
J^[ Z_ijWdY[i e\ '$+cc X[jm[[d j^[ h_Xi ed
j^[ _cfbWdj m[h[ eh_]_dWbbo _dj[dZ[Z je Wbbem j^[
ef[hWjehWdWii[iic[dje\j^[b[d]j^e\j^[_cfbWdj
h[gk_h[Z$ 7bj^ek]^ 8E? _cfbWdji WdZ _dj[hdWb Z_ia
_cfbWdjiYec[m_j^Yecfb[j[boiceej^i^W\jikh\WY[i
jeZWo"j^[b[d]j^e\j^[j^h[WZ[Zf_d_iij_bbc[Wikh[Z
_d¼=½kd_ji0'=3'$+cc$M_j^Wd_cfbWdje\b[d]j^
=+" j^[ Z_ijWdY[ X[jm[[d j^[ Yh[ijWb Z_ia WdZ j^[
X[]_dd_d]e\j^[[nj[hdWbj^h[WZ_ij^ki-$+cc$
9edi_Z[h_d]j^Wjd_Y^[eh]Wd_iciikY^WiXWYj[h_W
eh eij[eXbWiji WdZ eij[eYoj[i m_bb fh[\[hWXbo
Yebed_p[ ikh\WY[i j^Wj \[Wjkh[ cWYhec[Y^Wd_YWb
ifWY[i" _j Z[\_d_j[bo cWa[i i[di[ je ki[ j^h[WZ[Z
f_di m_j^ W Yecfb[j[bo iceej^ ikh\WY[$ Hek]^[d[Z
ikh\WY[i_dj^[ckYeiWbf[d[jhWj_edWh[WcWo_dj^[
i^ehjj[hc[d^WdY[eii[e_dj[]hWj_ed$JWa_d]j^[bed]
f[hif[Yj_l[ ed _cfbWdj b_\[j_c[" j^_i \[Wjkh[ e\ j^[
_cfbWdjm_bb_dl_j[XWYj[h_WbWjjWYa$;deiiWb_cfbWdj
ikh\WY[iWh[`kijWib_a[bojeX[Yec[WZm[bb_d]]hekdZ
\eh c_Yheeh]Wd_ici Wi heej YWdWb_Ykb_ YWf_bbWh_[i$
Dej[ j^Wj Wdoj^_d] j^Wj X[d[\_ji eii[e_dj[]hWj_ed
m_bbWbieX[d[\_jc_Yheeh]Wd_ici"i_dY[ikh\WY[iWh[
Yecf[j_j_l[boeYYkf_[ZXoeij[eYoj[iehXoXWYj[h_W$
:[[f _di_Z[ ij[h_b[ Xed[ ijhkYjkh[i" j^[ eij[eYoj[i
m_bbkikWbbofh[lW_b$?dj^[_cc[Z_Wj[l_Y_d_jojej^[
[l[h#_d\[Yj[Z ehWb YWl_jo j^[ XWYj[h_W ^Wl[ W X[jj[h
Y^WdY[ e\ ikhl_lWb X[YWki[ j^[o Wh[ ]hem_d] ckY^
\Wij[h"WZWfjX[jj[hje^_]^bof[h\ki[ZWdZeno][d_p[Z
ie\j j_iik[ kdZ j^ki X[^Wl[ ceh[ W]]h[ii_l[bo WdZ
ikYY[ii\kb$
EdY[ j^[ _d\[Yj_ed ^Wi h[WY^[Z j^[ _cfbWdj
ikh\WY["Yebed_pWj_edm_bbh[b[djb[iibojWa[_jiYekhi[$
?j _i l_hjkWbbo _cfeii_Xb[ je Yedjheb f[h_#_cfbWdj_j_i
edhek]^ikh\WY[i$
?d WZZ_j_ed" i_d]b[#ij[f fheY[Zkh[i _d m^_Y^
[njhWYj_edWdZ_cfbWdjfbWY[c[djWh[f[h\ehc[Z_d
j^[iWc[i[ii_ed\WlekhikY^Yebed_pWj_edZk[jej^[
_dYed]hk[djikh\WY[i_dlebl[Z"_$[$j^[]WfWh[WiWh[
fh[\[hh[Zi_j[ie\hWf_ZYebed_pWj_ed$
(, 9^Wfj[h)È -ORPHOLOGYÈOFÈ"/)È)MPLANTSÈANDÈ2ELATEDÈ$ESIGNS
&IGÈ J^_i ;: '& =, _cfbWdj bWYai Xed[ Wffei_j_ed Zemd
je X[bem j^[ j^h[WZ[Z f_d$ 7j j^[ j_c[ j^[ f_Yjkh[ mWi
jWa[d" j^[ _cfbWdj ^WZ X[[d _d i_jk \eh +o[Whi$ J^[ beWZ#
jhWdic_jj_d] i[]c[dji Wh[ _d \kbb \kdYj_ed$ J^[ _cfbWdj _i
beYWj[Z _d jee ^_]^ W fei_j_ed bem = lWbk[$ FWhj_YkbWhbo Wj
j^[ Wdj[h_eh Wif[Yj" _j Wbceij \Wbbi i^ehj e\ j^[ m^_j[ b_d[ e\
cWn_ckc beWZ jhWdic_ii_ed" _dZ_YWj_d] j^Wj j^[ _cfbWdj _i
kdb_a[bo je ikhl_l[ _d j^[ bed][h j[hc$ J^_i [nWcfb[ Yb[Whbo
Z[cedijhWj[ij^[_dj[hWYj_edX[jm[[dXWYj[h_WbWjjWYaiWdZj^[
\kdYj_edWbj[dZ[dYojefh[i[hl[f[h_#_cfbWdjc_d[hWb_pWj_ed$
?dj^_iif[Y_\_YfWj_[dj"j^[YedZ_j_edi\ehXWYj[h_WbWjjWYam[h[
fWhj_YkbWhbo\WlekhWXb["Zk[jel[hofeehehWb^o]_[d["hek]^
l[hj_YWb_cfbWdjikh\WY[i"[bWij_Y_joe\j^[_cfbWdj#h[ijehWj_ed
Yecfb[n"WdZ^[Wloicea_d]
&IGÈ J^[jhWdi_j_ed\hecÆZ_ia_cfbWdjiÇje8E?_cfbWdji
mWi cWha[Z Xo W f[h_eZ _d m^_Y^ _cfbWdji m_j^ ZkWb
beWZ jhWdic_ii_ed m[h[ j^[ ijWj[ e\ j^[ Whj$ ?d j^_i Z[i_]d"
beWZ jhWdic_ii_ed mWi ikffei[Z je jWa[ fbWY[ Xej^ _d j^[
l[hj_YWb WdZ _d j^[ XWiWb _cfbWdj fWhj$ J^[i[ _cfbWdji Wh[
f[h\[Yjbo i[hl_Y[WXb[ _\ j^[ X[^Wl_ekh e\ Xej^ j^[ l[hj_YWb
WdZ j^[ ^eh_pedjWb Xed[ ijhkYjkh[i ki[Z \eh WdY^ehW][ Wh[
c[Y^Wd_YWbbo iodY^hed_p[Z m_j^ j^[ _cfbWdj ikh\WY[$ J^_i _i
cW_dboj^[YWi[_dj^[Wdj[h_ehi[]c[dje\j^[cWdZ_Xb[$J^[
h_XiWh['$+ccWfWhjWdZh[fh[i[djj^[=]hWZkWj_ed
7jj[cfji je WY^_[l[ efj_cWb _dj[]hWj_ed e\ j^[
l[hj_YWb_cfbWdji[]c[djXoYecX_d_d]cWYheiYef_Y
ij[fi WdZ c_YheiYef_Y ikh\WY[ [dbWh][c[dj Xo
iWdZXbWij_d]^Wl[b[ZjeX[jj[hYb_d_YWbh[ikbji_dj[hci
e\ _d_j_Wb ^[Wb_d]$ F[hcWd[dj eii[e_dj[]hWj_ed YWd
[l[dX[eXjW_d[ZWbed]j^[l[hj_YWb_cfbWdji[]c[dj"
fhel_Z[Zj^Wjj^[dkcX[he\_cfbWdjifbWY[Z_d[WY^
WhY^ _i WZ[gkWj[ WdZ j^Wj j^[ Z[i_]d e\ j^[ Xed[#
_cfbWdj#h[ijehWj_ed Yecfb[n _i ik\\_Y_[djbo h_]_Z$
9ekdj[hWYj_d] \ehY[i _dYbkZ[ [bWij_YWbbo _djhkZ_d]
eYYbkiWb\ehY[i"\kdYj_edWbi^[Wh_d]beWZi"kdXWbWdY[Z
[njhki_ed\ehY[i"WdZ\b[n_ede\j^[`WmWjbWh][$J^[
bWjj[h cWo Wcekdj je i[l[hWb c_bb_c[jh[i WdZ YWd
X[ h[WZ_bo c[Wikh[Z" [if[Y_Wbbo _d j^[ cWdZ_Xb[$
J^[i[ Yekdj[hWYj_d] \ehY[i b[WZ je ceX_b_jo Wj j^[
_cfbWdj#Xed[ _dj[h\WY[" j^[h[Xo `[efWhZ_p_d] j^[
Ybei[eii[e_dj[]hWj_ede\bed]j^h[WZ[Zf_di$?dj^[
fh[i[dY[ e\ ikh\WY[#[dbWh][Z j^h[WZ[Z f_di [bWij_Y
c_Yhe#cel[c[dj 7i^cWd WdZ lWd 8ki^a_ha '/.-
cWo_hh_jWj[j^[Yedd[Yj_l[j_iik[ijhkYjkh[iWdZ"Wj
j^[ iWc[ j_c[" ikffehj _deYkbWj_ed e\ j^[ XWYj[h_W
h[i_Z_d] ed j^[ hek]^[d[Z ikh\WY[i$ 7do _d\[Yj_edi
_d j^[ mWa[ e\ Xed[ Wlkbi_ed j^Wj Wh[ YWfWXb[ e\
WZlWdY_d] je j^[ Z[[f[h Xed[ i[]c[dji m_bb h[ikbj
_d YhWj[h#ijob[ eij[eboi_i$ M^_b[ YebbWfi[i e\ j^_i
jof[ Ze dej d[Y[iiWh_bo _cfW_h j^[ \kdYj_ed e\ j^[
_cfbWdj <_]$)$' Wi bed] Wi j^[ \ehY[#jhWdic_jj_d]
Z_iai dejWXbo j^[ XWiWb Z_ia h[cW_d _djWYj" j^[o
Wh[ d[l[hj^[b[ii kdZ[i_hWXb[$ Hek]^[d[Z _cfbWdj
ikh\WY[iYbei[jej^[ehWbYWl_jo_dlebl[W]h[Wj[hh_ia
e\ XWYj[h_Wb h[j[dj_ed$ Ceh[el[h" h[i_b_[dj _cfbWdj#
h[ijehWj_ed ioij[ci i[[c je h[ikbj _d c[Y^Wd_YWb
_hh_jWj_edXoceX_b_p_d]j^[ikh\WY[ie\j^[j^h[WZ[Z
f_dWdZj^[Xed[W]W_dij[WY^ej^[h$IkY^_hh_jWj_ed
_i Wbie b_a[bo je h[ZkY[ j^[ Y^WdY[i e\ h[_dj[]hWj_ed
i^ekbZj^[_cfbWdjX[Yec[ceX_b[_ji[b\$
J^[ j[dZ[dYo je h[ZkY[ j^[ dkcX[h e\ _cfbWdji
\eh Xh_Z][ h[ijehWj_edi eh_]_dWbbo Whei[ \hec Yeij
Yedi_Z[hWj_edi WdZ Yedi_Z[h_d] X_ec[Y^Wd_Yi$ ?d
WYYehZWdY[m_j^j^Wjj[dZ[dYo"j^[jhWdi_j_ed\hecj^[
\_hijZ_ia_cfbWdjijejhk[8E?Z[i_]dimWi]hWZkWbbo
cWZ[$7\j[hWbb"j^[Xh_Z][ifWdiWdZj^[WiieY_Wj[Z
fei_j_edWbY^Wd][iX[jm[[dWXkjc[dji_dYh[Wi[ZWi
j^[ dkcX[h e\ _cfbWdj[Z WXkjc[dji Z[Yh[Wi[Z$ ?d
ej^[h mehZi" j^[ ckjkWb ceX_b_jo e\ j^[ WXkjc[dji
X[YWc[ ]h[Wj[h" m^_Y^ mWi dej f[h i[ _dYedi_ij[dj
m_j^ ]eeZ ijWX_b_jo Xo XWiWb eii[e_dj[]hWj_ed$ J^[
j^h[WZ[Z f_di m[h[ ikX`[Yj[Z je W ^_]^[h Z[]h[[ e\
Z[\b[Yj_ed" m^_Y^ YWki[Z j^[ _cfbWdji je _djhkZ[
Z[[f[h _dje j^[ Xed[ WdZ ckYeiW Yh[Wj_d] \h_Yj_ed$
J^[^WhZ#j_iik[_hh_jWj_edWiieY_Wj[Zm_j^j^[_djhW#
Xedocel[c[dji_dlebl[ZWh_iae\l[hj_YWbXed[beii
Wbed] j^[ j^h[WZ[Z f_d$ M^[d 8E? _cfbWdji m_j^
W iceej^ i^W\j m[h[ _djheZkY[Z" j^[ j^h[WZ[Z f_d
m_bbh[Y[Z[_djej^[WiieY_Wj[Z^WhZ#WdZie\j#j_iik[
ijhkYjkh[im_j^ekjYWki_d]Wdodej_Y[WXb[_hh_jWj_ed
eh XWYj[h_Wb _deYkbWj_ed$ Kbj_cWj[bo" j^_i ijhkYjkhWb
Z[jW_b fh[fWh[Z j^[ ]hekdZ \eh Yecfh[^[di_l[
_cfbWdj j^[hWfo Wbed] j^[ cWn_bbWho i_dki" m^[h[
È È ,OADÈ4RANSMISSIONÈBYÈ$ISKSÈORÈ2INGSÈ
j^[j^[hWf[kj_Yif[Yjhkc^WZ^_j^[hjeX[[db_c_j[Z$
<khj^[hceh[" bWh][ Z_ijWdY[i X[jm[[d j^[ j^h[WZ[Z
f_di cWZ[ _j kdb_a[bo \eh j^[ f[h_#_cfbWdj Xed[ je
X[^Wl[ c[Y^Wd_YWbbo _d iodY^hed_pWj_ed m_j^ j^[
j^h[WZ[Z f_d$ IkY^ X[^Wl_ekh mekbZ ^Wl[ X[[d
h[gk_h[Z _\ eii[e_dj[]hWj_ed e\ l[hj_YWb _cfbWdj
i[]c[djid[[Z[ZjeX[cW_djW_d[Z$J^[\kdYj_ede\
j^[l[hj_YWb_cfbWdji[]c[dji^Wii_dY[X[[dbWh][bo
h[ZkY[Z je Yecf[diWj_d] \eh cej_edWb Z_\\[h[dY[i
X[jm[[dj^[_dj[]hWj[ZZ_iaWh[Wi"i_dY[j^[i[mekbZ
d[l[h gk_j[ X[^Wl[ iodY^hedekibo$ J^[ Xh_Z][
_ji[b\ X[YWc[ j^[ \_n[Z h[\[h[dY[ fe_dj m_j^_d j^[
cWij_YWjeho ioij[c1 ^em[l[h" kdb_a[ m_j^ Yh[ijWb
_cfbWdjiWdZj[[j^"j^[fedj_Yie\8E?#XWi[ZXh_Z][i
[if[Y_Wbbo_dijhWj[]_Yfei_j_ediWdZm_j^\[mXWiWb
fbWj[iWh[debed][hZ_h[YjboYedd[Yj[Zm_j^j^[\Wj[
e\j^[Wbl[ebWhXed[$
Je ikccWh_p[0 j^[ Z_h[Yj_ed j^Wj ^Wi [l[djkWbbo
b[Zje][dk_d[8E?ioij[cimWi_d_j_WbboZ[\_d[ZXo
IYehj[YY_Éi_cfbWdjZ[i_]di\[Wjkh_d]Z[fj^cWha[hi
WdZ ikh\WY[#[dbWh][Z i^W\ji$ J^[ b_j[hWjkh[ WdZ
j^_da_d] WiieY_Wj[Z m_j^ Yh[ijWb _cfbWdjebe]o ki[Z
je X[ ie f[hikWi_l[ j^Wj Wbb Z[i_]di \eh [deiiWb
_cfbWdj i[]c[dji mekbZ \[Wjkh[ c_Yhe# WdZ
cWYhec[Y^Wd_YWb ikh\WY[ [dbWh][c[dj \eh W bed]
j_c[$ Ceh[ h[Y[djbo" ^oXh_Z Z[i_]di m[h[ Z[l[bef[Z
_d m^_Y^ j^[ i^W\j i[]c[dji d[Wh j^[ ckYeiW m[h[
iceej^WdZj^[XWiWbi[]c[djim[h[hek]^[d[Z\eh
ikh\WY[ [dbWh][c[dj$ J^[i[ m[h[ j^[ \_hij Z[i_]di
je e\\[h jhk[ XWiWb eii[e_dj[]hWj_ed WdZ ijhWj[]_Y
WXkjc[djfei_j_ed_d]"ki_d]edbo\ekh_cfbWdjif[h
`Wm$
7i m_bb X[ Z[cedijhWj[Z [bi[m^[h[ _d j^_i Xeea"
el[h]hemj^ e\ ikXYh[ijWb _cfbWdj i[]c[dji Xo
Yedd[Yj_l[j_iik[Ze[idej_hh[l[hi_Xbofh[l[djeii[e#
WZWfjWj_ed$8oYedjhWij"ikXi[gk[djeii[eWZWfjWj_ed
eheii[e_dj[]hWj_ed_idebed][hWh[Wb_ij_Y[nf[YjWj_ed
edY[ XWYj[h_Wb _d\[Yj_ed ^Wi ifh[WZ je Wd eij[eboj_Y
Wh[W" m^_Y^ _i fh[ikcWXbo Zk[ je j^[ WiieY_Wj[Z
4RANSMITTINGÈ3URFACES
]hWdkbWj_edWhekdZj^[_cfbWdj$
M_j^j^[iceej^#i^W\j[ZZ[i_]diWlW_bWXb[jeZWo"
_cfbWdjjh[Wjc[djWbed]j^[cWn_bbWhoi_dkiYWdX[
h[WZ_bof[h\ehc[ZXofbWY_d]j^[Z_iaWdZfWhje\j^[
j^h[WZ[Z f_d _di_Z[ j^[ i_dki$ JhWdi#i_dki _cfbWdj
fbWY[c[djX[Yec[ikdWle_ZWXb[_\j^[l[hj_YWbXed[
lebkc[YWkZWbbojej^[i_dki_iicWbbWdZj^[[nf[Yj[Z
Y^Wd][i_dj^[_djhW#XedojhW`[Yjeh_[iWh[WbieicWbb$
?d j^_i i_jkWj_ed" _djhWi_dki _cfbWdjWj_ed _i W X[jj[h
X_ec[Y^Wd_YWb efj_ed$ J^[ ki[ e\ Yh[ijWb _cfbWdji
mekbZ _dlebl[ WZ`klWdj fheY[Zkh[i \eh i_dki \beeh
Wk]c[djWj_ed je \WY_b_jWj[ beWZ jhWdic_ii_ed Wbed]
j^[[dj_h[l[hj_YWbfehj_ede\j^[i[_cfbWdji$
(-
È
,OADÈ4RANSMISSIONÈBYÈ$ISKSÈORÈ2INGS
J^[Yh[ijWbWdZj^[XWiWbfbWj[e\ckbj_#Z_ia[bWij_Y
_cfbWdji ki[Z \eh XWiWbbo eii[e_dj[]hWj[Z _cfbWdj#
h[ijehWj_ed ioij[ci ^Wl[ Z_\\[h[dj \kdYj_edi$ J^[
cW_d fkhfei[ e\ j^[ Yh[ijWb fbWj[ _i je fhel_Z[
WZZ_j_edWb ijWX_b_pWj_ed e\ j^[ _cfbWdj$ J^[ Yh[ijWb
fbWj[ bei[i _ji _cfehjWdY[ edY[ j^[ XWiWb fbWj[ ^Wi
eii_\_[Z je \kbb beWZ#X[Wh_d] YWfWY_jo$ I_dY[ j^[
Yh[ijWbWdZXWiWbfbWj[ie\j^[\ehc[hÆZ_ia_cfbWdjiÇ
m[h[ [gkWbbo h[i_b_[dj W]W_dij j^[ j^h[WZ[Z f_d" Wd
[ij_cWj[Z '&Ä'+ e\ j^[i[ YWi[i ^WZ je X[ \ebbem[Z
kfXoikXi[gk[djboh[cel_d]j^[Yh[ijWbfbWj[$Kdb[ii
j^_imWiZed[ieed"j^[h[mWiWh_iae\_d\[Yj_edWdZ
eij[eboi_i WZlWdY_d] \hec Yh[ijWb Z_h[Yj_ed$ EdY[
j^[ _d\[Yj_ed mWi _cfWYj[Z _d j^[ ikXckYeiWb eh
_djhWeii[eki Wh[W" j^[h[ mWi W h_ia j^Wj _j mekbZ
[l[djkWbbo WZlWdY[ je j^[ XWiWb fbWj[" ie j^Wj j^[
[dj_h[_cfbWdjmWi[l[djkWbbobeij$
Ed[e\j^[ceijki[\kbZ[l[befc[djie\j^[fWij
\[m o[Whi ^Wi X[[d je _cfhel[ j^[ h[i_b_[dY[ e\ j^[
Yh[ijWb fbWj[ _d h[bWj_edi^_f je j^[ XWiWb Z_ia$ ?d
d[m8E?_cfbWdji"j^[m[XXWhe\j^[Yh[ijWbfbWj[_i
beYWj[Z f[hf[dZ_YkbWh je j^[ m[X XWhi e\ j^[ XWiWb
fbWj[$?dej^[hmehZi"j^_ifWhje\j^[Yh[ijWbfbWj[_i
_di[hj[ZZ_h[Yjbo_djej^[fWbWjWbXed["m[bbfhej[Yj[Z
W]W_dijh[iehfj_ed$
J^[ eij[ejeco Wh[W _d j^[ l[ij_XkbWh Xed[" Xo
YedjhWij" _i Yheii[Z edbo Xo j^[ h_d] e\ j^[ Yh[ijWb
fbWj[$J^[h_d]WYjib_a[Wj[dja[[f_d]j^[f[h_eij[kc
WmWo\hecj^[Xed["j^ki\WY_b_jWj_d]Wdofh_cWhoeh
i[YedZWhoWk]c[djWj_edfheY[Zkh[i$
È
$ISTANCEÈ"ETWEENÈ#RESTALÈÈ
ANDÈ"ASALÈ,OAD
:ekXb[%ckbj_fb[Z_ia_cfbWdji^Wl[X[[dWlW_bWXb[_d
<hWdY[ i_dY[ WhekdZ '/..$ J^[ Z_ia#je#Z_ia _dj[hlWb
ed j^[i[ _cfbWdji _i )cc$ If[Y_\_Y ZekXb[ Ykjj[hi
cWjY^_d] j^[i[ Z_ijWdY[i \eh bWj[hWb eij[ejeco Wh[
WlW_bWXb[$M[^Wl[i_dY["_dYebbWXehWj_edm_j^IfW^d"
_djheZkY[Z _cfbWdji WdZ eij[ejeco jeebi \eh +#cc
Z_ia#je#Z_ia_dj[hlWbi_dekhYb_d_Y$
J^_iceZ_\_YWj_edmWifhecfj[ZXoekheXi[hlWj_ed
j^Wj j^[ heec \eh cWde[klh[ _di_Z[ j^[ Xed[ mWi
l[hoicWbbm^[d[l[hj^[d[[Z\ehikh]_YWbh[celWbe\
Yh[ijWbfbWj[Whei[$J^_ibWYae\ifWY[_dlebl[ZW^_]^
h_iae\_djWYjXed[X[_d][d]W][Zeh"_dZ[[Z"ZWcW][Z
Xoikh]_YWb_dijhkc[dji$J^[i[cWd_fkbWj_edi_dj^[
Wh[W e\ j^[ Yh[ijWb fbWj[ ^Wl[ dem X[Yec[ [Wi_[h
m^[d[l[hj^[d[[Z\ehYehh[Yj_l[_dj[hl[dj_edWh_i[i
_dYWi[im^[h[j^[d[mbo_djheZkY[ZZ[i_]dim_j^j^[
bWh][hZ_ia#je#Z_ia_dj[hlWbim[h[ki[Z$
(. 9^Wfj[h)È -ORPHOLOGYÈOFÈ"/)È)MPLANTSÈANDÈ2ELATEDÈ$ESIGNS
&IGÈ 7Yed\_]khWj_ed_dm^_Y^Xej^Z_iai^Wl_d]j^[iWc[
j^_Yad[ii WdZ \[Wjkh_d] jme m[X XWhi [WY^ m_bb h[ikbj _d Wd
kd[gkWbZ_ijh_Xkj_ede\\kdYj_edWbbeWZi"_$[$j^[Yh[ijWbZ_ia_i
ikX`[Yj[Zje]h[Wj[h\ehY[ij^Wdj^[XWiWbZ_ia$9edi[gk[djbo"
j^[Yh[ijWbZ_iam_bbX[ceh[ikiY[fj_Xb[jeel[hbeWZeij[eboi_i"
_dm^_Y^YWi[j^[XWiWbZ_iam_bbij_bbh[cW_deii[e_dj[]hWj[Z
\eh j^[ j_c[ X[_d]$ ?d \WYj" j^[ ]h[Wj[h h_ia e\ eij[eboi_i
WhekdZj^[Yh[ijWbZ_ia_iWbieW\kdYj_ede\_ji]h[Wj[hh_]_Z_jo
YecfWh[ZjeWXWiWbZ_iae\j^[iWc[j^_Yad[ii$FkjZ_\\[h[djbo"
_j Ze[i dej [l[d jWa[ Wd kdXWbWdY[Z \ehY[ Z_ijh_Xkj_ed je
_dYh[Wi[ j^[ h_ia$ Iec[ ki[hi ^Wl[ i[l[h[Z ed[ m[X XWh e\
Yh[ijWb Z_iai fh_eh je _di[hj_ed _d ehZ[h je cWa[ j^[c ceh[
[bWij_Y
4RANSMITTINGÈ3URFACES
&IGÈ J^[Yh[ijWbZ_ia_djeZWoÉi8E?Z[i_]di_dYbkZ[iedbo
ed[m[XXWh"m^_Y^e\\[hiW]h[Wj[hZ[]h[[e\h[i_b_[dY[Wjj^[
Yh[ijWbj^WdWjj^[XWiWbZ_ia$J^[Yh[ijWbZ_ia_i_di[hj[Zm_j^
j^[ m[X XWh \WY_d] fWbWjWbbo" ikY^ j^Wj j^[ _dYec_d] \ehY[i
Wh[ ]k_Z[Z h_]^j _dje j^[ fWbWjWb Xed[" m^_Y^ _i fhej[Yj[Z
W]W_dij h[iehfj_ed$ J^_i _i _d YedjhWij je j^[ XWiWb fbWj["
m^[h[_dYec_d]\ehY[iWh[Z_ijh_Xkj[Zj^hek]^ekjj^[h_d]_d
WYYehZWdY[m_j^j^[X_ec[Y^Wd_Yie\j^[YhWd_WbXed[m^[h[
Xej^j^[l[ij_XkbWhWdZj^[Y[djhWbXed[ijhkYjkh[iWh[[gkWbbo
m[bb fhej[Yj[Z W]W_dij h[iehfj_ed$ J^[ f_Yjkh[ _bbkijhWj[i
j^[ feb_i^[Z Yh[ijWb i[]c[dji WdZ j^[ icWbb Z_Wc[j[h e\ j^[
j^h[WZ[Zf_d2(cc l[ij_XkbWhXkjj^[c[Z_WbWif[YjWdZjWa[WZlWdjW][
J^[h[ mWi o[j Wdej^[h Yedi_Z[hWj_ed j^Wj b[Z je
j^_iceZ_\_[ZZ[i_]d$<ehj^[Xed[ikhhekdZ_d]j^[
Z_iaijeX[\kdYj_edWb_dj[hcie\beWZjhWdic_ii_ed"
WdWZ[gkWj[XbeeZikffbo^WijeX[fh[i[dj$?cfbWdj
ijhkYjkh[i m_bb _cf[Z[ eh Z_ihkfj j^[ XbeeZ ikffbo$
J^_i i^ehjYec_d] X[YWc[ Yb[Wh _d j^[ '/.&i m^[d
j^[ \_hij i[h_[i e\ ÆZ_ia _cfbWdjiÇ" m^_Y^ \[Wjkh[Z
_dWZ[gkWj[bo j^_d c_Yhef[h\ehWj_edi _d j^[ XWiWb
fbWj[i YecX_d[Z m_j^ i^ehj j^h[WZ[Z f_di" m[h[
\h[gk[djbobeijX[YWki[e\feehYedZ_j_edi_dj[hci
e\XbeeZikffboWdZ_cckd[Z[\[dY[Yh[ijWbbojej^[
Z_iai$7dWZ[gkWj[XbeeZikffbo_iZ[Y_i_l[\ehbed]#
j[hc ikhl_lWb e\ 8E?" m^_Y^ if[Y_\_YWbbo Wffb_[i je
j^[Wh[We\j^[Yh[ijWbZ_iaWim[bb$;l[hi_dY[m[m[h[
WXb[je_di[hj8E?_cfbWdji\[Wjkh_d]j^[bWh][hZ_ia#
je#Z_ia _dj[hlWbi e\ +cc" m[ eXi[hl[Z j^Wj Xej^
XWiWbfbWj[i_dj[]hWj[Z[l[dbom[bb$7im_bbX[i^emd
_d 9^Wfj[h()" j^[ \ehcWj_ed e\ i[YedZWho eij[edi
WhekdZ ed[ e\ j^[ XWiWb fbWj[i Ze[i dej i[[c je
_dj[h\[h[m_j^i_c_bWh\ehcWj_ediedj^[ej^[hXWiWb
fbWj[$7bie"j^[dkjh_[djikffbo\eh[WY^XWiWbfbWj[_i
Wiikc[ZjeX[bWh][h_\j^[Z_iaiWh[beYWj[Z\khj^[h
WfWhj$ FheXb[ci m_j^ _cfbWdj#h[ijehWj_ed ioij[ci
ikffehj[Z Xo j^_i jof[ e\ _cfbWdji Wh[ [njh[c[bo
hWh[$ J^_i _i [l[d jhk[ e\ j^ei[ YWi[i _d m^_Y^ edbo
W i_d]b[ ed[ e\ j^[i[ _cfbWdji YekbZ X[ _di[hj[Z
kikWbbojeh[fbWY[Wdkff[hYWd_d[$
È
3HAPEÈOFÈ"ASALÈ,OAD
M^[d hejWj_edWbbo iocc[jh_YWb Z_iai m[h[ ki[Z _d
_cfbWdji" Ybei[ _dif[Yj_ed e\ j^ei[ Z[i_]di mekbZ
h[l[Wbj^Wjj^[om[h[edboYed]hk[djm_j^j^[Xed[
ijhkYjkh[ ed j^[ _di[hj_ed i_Z[ \WY_d] WmWo \hec
j^[ eij[ejeco fWj^mWo$ Ed j^[ l[ij_XkbWh i_Z[" j^[
Z_ia Z_Z dej \_bb j^[ [dj_h[ eij[ejeco fWj^mWo Xkj
b[\j W ]Wf _d j^[ Xed[ j^Wj mekbZ dej Ybei[ kdj_b
eii_\_YWj_ed_dj^[^[Wb_d]f^Wi[mWiYecfb[j[Z$J^[
i_jkWj_edmWiYecfekdZ[ZXoj^[\WYjj^Wjj^[Yh[ijWb
i_Z[e\j^[l[ij_XkbWhh_d]i[]c[djmWidejYel[h[Z
m_j^Xed[_\j^[eij[ejecomWif[hf[dZ_YkbWhjej^[
Xed[ ikh\WY[$ ?j mWi Wiikc[Z j^Wj j^_i c_]^j YWki[
^[Wb_d]fheXb[ci$
Je h[c[Zo j^_i i_jkWj_ed" j^[ d[nj ][d[hWj_ed
e\ Z_iai ^WZ W \bWjj[d[Z h[YjWd]kbWh Z[i_]d ed ed[
i_Z[WdZh[cW_d[ZhekdZ[Zedj^[ej^[hi_Z[$?dj^[
\_hij_cfbWdjiWlW_bWXb[m_j^j^_iZ[i_]d"j^[]h[Wj[h
Z_ijWdY[\hecj^[Z_iah_cjej^[j^h[WZ[Zf_dmWi
Yed\_d[Z je j^[ h[YjWd]kbWh Wh[W$ Ki[hi mekbZ h[\[h
je j^[i[ _cfbWdji WiÆIÇ Z[i_]di$ J^[ÆIÇ ^Wi i_dY[
X[Yec[Wd[ijWXb_i^[ZfWhje\j^[_Z[dj_\_YWj_edYeZ[
ki[Z\ehWdo8E?#_cfbWdjjof[\[Wjkh_d]Wjb[Wijed[
\bWjj[d[Z i_Z[$ ;nf[h_[dY[Z ki[hi Wbie Wffbo j^[i[
_cfbWdjim_j^j^[\bWjj[d[Zi_Z[\WY_d]dejjemWhZij^[
È È 3TRUCTURALÈ2ESILIENCEÈOFÈ)MPLANTSÈ (/

e\ j^[ Wiocc[jh_YWb fei_j_ed e\ j^[ j^h[WZ[Z f_d$

J^_iWffheWY^_iWZlWdjW][eki_\j^[l[ij_XkbWhXed[
ijhkYjkh[_iY^WhWYj[h_p[ZXo[njh[c[h[iehfj_edWdZ
j^[cW_dXkhZ[de\beWZjhWdic_ii_ed^Wii^_\j[Zje
j^[c[Z_WbXed[ijhkYjkh[$;l[d_\_j_idej_dj[dZ[Z
je fbWY[ j^[ f_d jemWhZi j^[ c[Z_Wb Wif[Yj [$]$
m_j^;:77I_cfbWdji"j^[\bWji_Z[e\j^[Z_iam_bb
WkjecWj_YWbbo\WY[jemWhZij^[fWbWjWbi_Z[m^[dj^_i
WffheWY^_iki[Z$
F[h\ehWj[Z _cfbWdji Z_iai Wh[ W YedZ_j_e i_d[
gkW ded X[YWki[ j^[ Yecckd_YWj_ed X[jm[[d j^[
WZ`e_d_d] Xed[ ijhkYjkh[i _d j^[ Yh[ijWb WdZ XWiWb
Wh[W mekbZ X[ el[hbo Z_ihkfj[Z _d j^[ fh[i[dY[
e\ Ybei[Z#ikh\WY[ Z_iai$ Kd_dj[hhkfj[Z XWi[fbWj[i
mekbZ Wbie _cf[Z[ j^[ XbeeZ ikffbo je j^[ ceh[
Yh[ijWb ijhkYjkh[i" j^[h[Xo YWki_d] [Whbo _cfbWdj
beiiWdZcWii_l[Xed[beii$BWijXkjdejb[Wij"bWh][
ded#f[h\ehWj[Z _cfbWdji mekbZ Yedjh_Xkj[ je j^[
fWj^e][d[i_ie\iWhYecWiEjj'/-&1Dej^Zkh\j'/,'$

È
3TRUCTURALÈ2ESILIENCEÈOFÈ)MPLANTS

;bWij_Y X[^Wl_ekh e\ _dZ_l_ZkWb _cfbWdji m_j^_d

j^[ iWc[ _cfbWdj#h[ijehWj_ed Yecfb[n _i Wbie Wd
_dZ_YWj_ed j^Wj j^[i[ _cfbWdji cWo dej f[h\ehc
j^[_h beWZ#X[Wh_d] \kdYj_ed Wi j^[o i^ekbZ" i_dY[
j^[h[ _i WbmWoi W Y^WdY[ _d j^_i i_jkWj_ed j^Wj j^[o
cWo o_[bZ je \kdYj_edWb beWZi Xo [bWij_Y X[dZ_d]$
J^[ beWZi mekbZ j^[d i^_\j je Wdo ej^[h _cfbWdji
m_j^_dj^[iWc[Yecfb[n"m^_Y^cWoX[ikXijWdj_Wbbo
ceh[ h_]_Z$ Iec[j_c[i j^[i[ WZZ_j_edWb beWZi cWo
X[ [nY[ii_l[$ J^_i c[Y^Wd_ic d[[Zi je X[ jWa[d
_djeYedi_Z[hWj_ed$J^[YedY[fje\ijhWj[]_Y_cfbWdj
fei_j_ed_d]_cfb_[ij^WjWb_c_j[ZdkcX[he\_cfbWdji
&IGÈÈ A >[Wl_bo ia[b[j_p[Z _cfbWdj e\ j^[ ;::I jof[$ J^[
XWiWb fbWj[ _dYbkZ[i jme m[X XWhi1 j^[ Yh[ijWb fbWj[ _dYbkZ[i
edboed[XWhWdZ_iikXijWdj_Wbboceh[h[i_b_[dj$J^[j^h[WZ[Z
f_d_icWY^_d[ZWXel[j^[Yh[ijWbfbWj[1Wbbej^[hikh\WY[iWh[
iWdZXbWij[Z$J^[[njhWehZ_dWhoh[i_b_[dY[e\j^_i_cfbWdjjof[
_iWffWh[dj1YecfWh[je<_]$)$*$ B Jh_fb[8E?_cfbWdjim_j^
icWbbZ_iaZ_Wc[j[hiWh[ckY^ceh[h_]_Zj^Wd_cfbWdjim_j^
\[m[h Z_iai WdZ bWh][h Z_Wc[j[hi$ 8E? _cfbWdjebe]_iji YWd
j^[h[\eh[Y^eei[dejedboX[jm[[d_cfbWdji_dcWdoZ_\\[h[dj
i_p[i" Xkj YWd Wbie i[b[Yj WYYehZ_d] je j^[ h[i_b_[dY[ e\ j^[
_cfbWdj

m_bbX[ikX`[Yj[ZjeikXijWdj_Wb\ehY[i$El[hbo[bWij_Y
_cfbWdjim_j^_dikY^Wioij[ccWoX[WZ_iWZlWdjW][
fWhj_YkbWhbo _d j^[ cWn_bbW$ ?d j^[ cWdZ_Xb[" Xo
YedjhWij"]h[Wj[hbWj[hWb[bWij_Y_jo_iWYjkWbboh[gk_h[Z
\eh\kbb#WhY^h[ijehWj_edi$

È
#ONFIGURATIONÈANDÈ2ELATIVEÈ$IMENSIONSÈÈ
OFÈTHEÈ)MPLANTÈ#OMPONENTS

J^[Z_Wc[j[he\j^[XWiWbZ_ia_d8E?_cfbWdjii^ekbZ
fh[\[hWXboX[WibWh][Wifeii_Xb[jec[[jfheij^[j_Y
h[gk_h[c[dji$ <hec j^[ 8E? _cfbWdjebe]_ijÉi
&IGÈ ?cfbWdj \[Wjkh_d] W m_Z[h Z_ia#je#Z_ia _dj[hlWb e\ l_[mfe_dj" _cfbWdji \[Wjkh_d] W beWZ#jhWdic_jj_d]
+cc XWiWbfbWj[e\b[iij^Wd/cc_dZ_Wc[j[hfWhj_YkbWhbo
)& 9^Wfj[h)È -ORPHOLOGYÈOFÈ"/)È)MPLANTSÈANDÈ2ELATEDÈ$ESIGNS

j^ei[ m_j^ W j^_Yad[ii e\ &$,cc eh ceh[ ckij
X[ h[]WhZ[Z Wi h_]_Z$ ?cfbWdji m_j^ W bWh][h Z_ia
Z_Wc[j[h Wh[ ceh[ [bWij_Y j^Wd _cfbWdji m_j^ W
icWbb[h#Z_Wc[j[h Z_ia e\ j^[ iWc[ j^_Yad[ii$ ;l[d
ceh[ _cfehjWdj" j^[ beWZ#jhWdic_jj_d] ikh\WY[i
e\ j^[i[ _cfbWdji Wh[ beYWj[Z \Whj^[h WmWo \hec
fej[dj_Wb _d\[Yj_ed i_j[i eh _d\[Yj_ed [djho fe_dji$
J^_i"W\j[hWbb"_ij^[kbj_cWj[Yh_j[h_ed\ehj^[bed]#
j[hcikhl_lWbe\_cfbWdji$
Fkj Z_\\[h[djbo" j^[ Z_ijWdY[ X[jm[[d j^[ beWZ#
jhWdic_jj_d]ikh\WY[iWdZj^[i_j[e\XWYj[h_WbWjjWYa
YWd X[ _dYh[Wi[Z Xo ki_d] W bWh][#Z_Wc[j[h Z_ia$
7dWbj[hdWj_l[efj_edmekbZX[jei[b[YjWd_cfbWdj
m_j^Wbed][hj^h[WZ[Zf_d$Dej[j^WjceZ_\o_d]j^[
b[d]j^ e\ j^[ j^h[WZ[Z f_d cWo Yh_j_YWbbo Wbj[h j^[
b[l[hYed\_]khWj_ed$
J^[m[XXWhiYedd[Yjj^[Z_iaijej^[j^h[WZ[Z
f_d$J^[i^Wf[WdZi_p[e\j^[i[XWhiZ[f[dZiedj^[_h
\kdYj_ede\Yedl[hj_d]\kdYj_edWbbeWZije_ie[bWij_Y
l_XhWj_ediWdZYoYb_YbeWZij^Wjj^[ikffehj_d]Xed[
YWdjeb[hWj[$
J^[ XWhi i^ekbZ X[ h[i_ijWdj je \hWYjkh[ WdZ
YWfWXb[e\\ehY[Z_ijh_Xkj_edel[hbWh][hXed[Wh[Wi
jeWle_Zeij[eboi_iXobeYWbijh[iiYedY[djhWj_edi$
?dehZ[hjei_cfb_\oj^[ijehW][e\_cfbWdjikdj_b
ki[" Z[i_]di m_j^ ceh[ j^Wd ed[ m[X XWh m[h[
Z[l[bef[Z$ J^[i[ Z[i_]di ^Wl[ X[[d ademd Wi7:I
_cfbWdji$<eh[nWcfb["Wd;:7:I'(%'-=-YekbZX[
ki[Z_djmeZ_\\[h[djmWoi0[_j^[hWiWh[]kbWh'('-#
cc _cfbWdj Xo h[cel_d] j^[ WZZ_j_edWb XWh" eh Wi
W'('+#cc_cfbWdjXoh[cel_d]j^[h_d]i[]c[dj
X[oedZ j^[ XWh$ J^[ d[Y[iiWho WZ`kijc[dji m[h[
f[h\ehc[Z _djhWef[hWj_l[bo m_j^ W jkd]ij[d YWhX_Z[
Ykjj[h$ 7dej^[h fefkbWh Z[i_]d _i j^[ ;:7:I /%'*
=+Ä=- Z[i_]d$ Dej[ j^Wj edbo ed[ m[X XWh ckij
X[ h[cel[Z je cW_djW_d j^[ _dj[]h_jo e\ j^[ h_d]
ijhkYjkh[ d[[Z[Z \eh efj_ckc beWZ Z_ijh_Xkj_ed e\
j^[Z_ia$:_ihkfj_ede\j^_iijhkYjkh[mekbZh[ikbj_d
beYWbijh[iif[WaiWbed]j^[_cfbWdj#Xed[_dj[h\WY[$
È
3URFACEÈ!REASÈOFÈ)MPLANTS
;dbWh][Z eh iceej^ ikh\WY[i _d if[Y_\_Y _cfbWdj
i[]c[dji cWo X[ Wd WZlWdjW][ eh W Z_iWZlWdjW]["
Z[f[dZ_d]edj^[Yb_d_YWbi_jkWj_ed$<ehj^WjcWjj[h"
m^Wj cWo Wff[Wh je X[ Wd WZlWdjW][ _d_j_Wbbo cWo
jkhd ekj je X[ W Z_iWZlWdjW][ _d j^[ bed] j[hc$
J^_i feii_Xb[ Yedi[gk[dY[ X[YWc[ [l_Z[dj Wj W
j_c[ m^[d j^[ ikh\WY[ e\ Yh[ijWb _cfbWdji mekbZ
Yeccedbo \[Wjkh[ JFI J_jWd_kc FbWicW IfhWo[Z
YeWj_d]$J^ei[_cfbWdjim[h[ifhWo[Zm_j^j_jWd_kc
fWhj_Yb[i Wj ^_]^ j[cf[hWjkh[i" m^_Y^ h[ikbj[Z _d
[njh[c[bohek]^ikh\WY[im_j^bWYkdW[X[jm[[dj^[
fWhj_Yb[i$ J^[i[ ikh\WY[ fhef[hj_[i e\\[h[Z [nY[bb[dj
YedZ_j_edi\ehXed[WZ^[i_edWdZfh_cWhoijWX_b_jo$
Kd\ehjkdWj[bo" j^[o \Wlekh[Z dej edbo WZ^[i_ed
e\ Xed[ Xkj Wbie XWYj[h_Wb h[j[dj_ed$ M^[d[l[h
_d\[Yj_edi YWc[ je fWii" j^[ ]hekdZ mWi fh[fWh[Z
\eh XWYj[h_W je Yebed_p[ j^[ bWYkdW[ X[jm[[d WdZ
kdZ[h j^[ JFI fWhj_Yb[i Wi Æf[hcWd[dj h[i_Z[djiÇ$
J^[h[\eh[ _j mWi e\j[d d[Y[iiWho" m^[d _d\[Yj_edi
eYYkhh[Z"jec[Y^Wd_YWbboijh_fj^[_cfbWdje\_jijef
bWo[h"_Z[WbboWbbj^[mWoZemdjej^[Xed[$'
IWdZXbWij[Zikh\WY[iWh[WbceijWihek]^WiJFI#
YeWj[Z ikh\WY[i" Xkj j^[o YWd X[ [\\[Yj_l[bo mWi^[Z
WdZ l[dj_bWj[Z" m^_Y^ _i [dehcekibo ^[bf\kb _d
[b_c_dWj_d] f[h_#_cfbWdj_j_i$ ?cfbWdj ikh\WY[i j^Wj
^Wl[ dej X[[d iWdZXbWij[Z Wh[ j^[ [Wi_[ij je Yb[Wd"
Xkj j^[o e\\[h b[ii h[j[dj_ed \eh c_YheWdY^ehW][
m_j^_dj^[Xed[j^Wd[dbWh][Zikh\WY[i$9ecfb[j[bo
iceej^ ikh\WY[i m[h[ ki[Z _d 8hd[cWha _cfbWdji
\hec '/,. kf je WhekdZ (&&&$ M^_b[ j^[i[ Z[i_]di
m[h[ Yb_d_YWbbo l[ho ikYY[ii\kb" j^[o Z_Z dej kikWbbo
Wbbemj_c[bobeWZ_d]$

'
&IGÈ ;:7I /%'+ =+ _cfbWdj$ :k[ je j^[ Wiocc[jh_YWb
beYWj_ed e\ j^[ j^h[WZ[Z f_d" WhekdZ -+ e\ _dYec_d] Wn_Wb
beWZim_bbX[jhWdic_jj[Zjej^[hekdZ[Zi[]c[dje\j^[Z_ia
h_]^j$J^[ijhW_]^ji[]c[djh_]^jm_bbedbo^Wl[jeX[Whj^[
h[cW_d_d](+e\j^[\kdYj_edWbbeWZ$J^[_cfbWdjYWdWbieX[
_di[hj[Zj^[ej^[hmWohekdZ_\j^_iZ_ijh_Xkj_ed_iYedi_Z[h[Z
_dWffhefh_Wj[
J^Wj IjhWkcWdd m[dj \hec JFI YeWj_d] je IB7 YeWj_d]
_i h[cWhaWXb[ _d ceh[ j^Wd ed[ h[if[Yj$ 7i bWj[ Wi _d
'//-" 8ki[h ^WZ i^emd _d W XheWZbo Z[i_]d[Z ijkZo j^Wj
JFI#YeWj[Z \kbb iYh[mi e\ j^[ ?J? jof[ Wh[ [njh[c[bo
h[i_ijWdj$ Ded[j^[b[ii" IjhWkcWdd WXWdZed[Z j^_i Z[i_]d
WdZijWhj[ZcWha[j_d]j^[IB7YeWj_d]"m_j^ekjWdo[gkWb
ijkZo i^em_d] j^Wj j^[ IB7 YeWj_d] _i ikf[h_eh$ ?j _i ^WhZ
je kdZ[hijWdZ m^o W fheZkYj _i WXWdZed[Z j^Wj ^WZ ^WZ
ÆiY_[dj_\_YWbbo fhel[dÇ ikYY[ii m_j^ekj \_hij Z[cedijhWj_d]
j^[ikf[h_ehgkWb_j_[ie\j^[ikYY[iiehfheZkYj$Jej^_iZWo"
cWdo ki[hi Y_j[ j^[ WXel[#dWc[Z ijkZo" W ijkZo j^Wj ^WZ
X[[d f[h\ehc[Z ki_d] Yecfb[j[bo Z_\\[h[dj _cfbWdji j^Wj
Wh[dej[l[dWlW_bWXb[edj^[cWha[jjeZWoWdZm^[h[edbo
Wi_d]b[Z[i_]d\[Wjkh[ij_bbYehh[ifedZijej^[iY_[dj_\_YWbbo
j[ij[Z_cfbWdj0j^[_djhWehWbYekfb_d]Z[i_]d_dj[hdWbYed[
WdZ_dj[hdWbeYjW]ed$=eeZcWha[j_d]Wbbemij^[i[bb_d]e\
WXhWdZd[mfheZkYjm_j^fhel[dbed]#j[hcikYY[ii
È È %LASTICÈ6ERSUSÈ3TIFFÈ)MPLANT
2ESTORATIONÈ3YSTEMSÈ )'
J^[ [nf[h_[dY[ m_j^ iYh[m _cfbWdji e\ j^[
8hd[cWhajof[^WiX[[dj^WjZ[i_]dim_j^iceej^
ikh\WY[i_dlebl[W^_]^[hhWj[e\fh[cWjkh[_cfbWdj
beiij^WdJFI#YeWj[ZZ[i_]die\j^[?J?%IjhWkcWddeh
?CPjof[$Edj^[ej^[h^WdZ"j^[bWjj[hjme_cfbWdj
jof[i ^Wl[ X[[d WiieY_Wj[Z m_j^ W Yedi_Z[hWXb[
hWj[ e\ f[h_#_cfbWdj_j_i" ]_d]_l_j_i WdZ f[h_#_cfbWdj
eij[eboi_i$BWh][#iYWb[Xed[YebbWfi[iifh[WZ_d]\hec
j^[_cfbWdjYebbWh_dWf_YWbZ_h[Yj_edm[h[Wjof_YWb
Yecfb_YWj_ede\j^[i[Z[i_]di$
7bb#iceej^ikh\WY[i_dj^[Yh[ijWbi[]c[dje\j^[
j^h[WZ[Z f_d Wh[ W ijWdZWhZ \[Wjkh[ e\ jeZWoÉi 8E?
Z[i_]di$ Ikh\WY[ [dbWh][c[dj" _\ Wdo" _i [ii[dj_Wbbo
2ESTORATIONÈ
Yed\_d[Zjej^[beWZ#jhWdic_jj_d]Z_iai"j^[m[XXWhi
WdZj^[bem[h\_\j^e\j^[j^h[WZ[Zf_d$;l[hi_dY[m[
^Wl[ki[Zj^_iYed\_]khWj_ede\iceej^WdZhek]^[d[Z
ikh\WY[i"j^[_dY_Z[dY[e\f[h_#_cfbWdj_j_i^Wi\Wbb[d
ZhWcWj_YWbbo$ M[ d[l[h [nf[Yj[Z 8hd[cWha#ijob[
beWZ jhWdic_ii_ed eh eii[e_dj[]hWj_ed je jWa[ fbWY[
Wbed] j^[ j^h[WZ[Z f_di e\ j^[i[ Z[i_]di$ 7\j[h Wbb"
8E?ioij[ci_dlebl[ded[[Z\ehWdoe\j^_i$:k[je
j^[ iceej^d[ii e\ j^[ j^h[WZ[Z f_d" j^[ _cfbWdj#
h[ijehWj_ed Yecfb[n X[Yec[i ceh[ [bWij_Y$ Ded#
Wkj^eh_p[Z _cfbWdjebe]_iji hekj_d[bo c_i_dj[hfh[j
j^_i[bWij_Y_jo"j^_da_d]j^WjikY^h[ijehWj_ediWh[_d
WfeehYedZ_j_ed$
;dbWh][Z ikh\WY[i eYYWi_edWbbo jkhd ekj je X[ W
Z_iWZlWdjW][ ed ZekXb[#Z_ia 8E? _cfbWdji m_j^ W
Z_ia#je#Z_ia_dj[hlWbe\)cc$9edi_Z[hj^Wjj^[Xkba
e\\kdYj_edWbbeWZim_bbX[]k_Z[Zjej^[XWiWbZ_iaWi
j^[Yh[ijWbZ_ia_iikX`[Yj[Zje]h[Wj[hbWj[hWb\ehY[i"
j^[h[Xobei_d]YedjWYjm_j^j^[Xed[_dWhekdZ'+
e\YWi[i$J^[[dbWh][Zikh\WY[icWoj^ki_hh_jWj[j^[
YebbW][dekiXed[i[]c[djiWdZfej[dj_Wbbo]_l[h_i[
je hWZ_e]hWf^_YWbbo cWd_\[ij eij[eboi_i Zemd j^[
heWZ$ J^_i fheY[ii _i ded#XWYj[h_Wb WdZ h[l[hi_Xb[
_d_ji[WhboijW][i$?jX[Yec[i_hh[l[hi_Xb[edbobWj[h
edY[XWYj[h_Wb_dlWi_ed^WiX[[dWbbem[ZjeeYYkhl_W
j^[j^h[WZ[Zf_dIfW^d'//($
J^[ Wffhefh_Wj[ jh[Wjc[dj e\ ikY^ eij[eboj_Y
fheY[ii[i_ijeh[cel[j^[Yh[ijWbfbWj[Wi[nf[Z_j_ekibo
Wi feii_Xb[$ ?d h[Y[dj jh_fb[#Z_ia Z[i_]di" ikh\WY[
[dbWh][c[dj^WiX[[dh[ZkY[Zjej^[jmeXWiWbh_d]i"
m^_b[j^[Yh[ijWbh_d]_ib[\jiceej^$
?dj^[<h[dY^iY^eebe\8E?"jeZWoÉiÆ:_ia_cfbWdjiÇ
m_j^_dj[hdWbj^h[WZ_d]Wh[iceej^Wbbj^[mWohekdZ
_$[$ \[Wjkh_d] de ikh\WY[ [dbWh][c[dj m^Wjie[l[h"
^Wl[X[[d[cfbeo[Zl[hoikYY[ii\kbbo$J^[gk[ij_ed
m^[j^[h j^[i[ _cfbWdji cWo X[ WZlWdjW][eki _d W
][d[hWb mWo el[h j^[ fWhj_Wbbo iWdZXbWij[Z Z[i_]di
j^Wjm[ki[_dekhemdfhWYj_Y[^WidejX[[d\ehcWbbo
_dl[ij_]Wj[Z$7jb[Wij_jmekbZWff[WhfbWki_Xb[j^WjW
iceej^Yh[ijWbfbWj[cWoc_d_c_p[_hh_jWj_edijej^[
Xedo _cfbWdj _d YWi[ j^[ fbWj[ X[Yec[i Z_ibeZ][Z
WdZ ceX_b[$ Jh[Wjc[dj e\ f[h_#_cfbWdj_j_i mekbZ"
e\ Yekhi[" Wbie X[ [Wi_[h WdZ ceh[ b_a[bo je X[
ikYY[ii\kb _\ j^[ d[[Z Wh_i[i$7i W Z_iWZlWdjW][" Wbb#
iceej^_cfbWdjie\\[hb[iifh_cWhoijWX_b_joW]W_dij
\h_Yj_ed WdZ [if[Y_Wbbo hejWj_ed" m^_Y^ c[Wdi j^Wj
ceh[ _cfbWdji ^Wl[ je X[ _di[hj[Z [if[Y_Wbbo _d
_cc[Z_Wj[#beWZfhejeYebij^WdmekbZX[d[Y[iiWho
ej^[hm_i[$
J^[h_iae\cWh]_dWbeij[eboi_im_j^;:_cfbWdji
\[Wjkh_d]Wiceej^WdZj^_di^W\j_id[]b_]_Xb[[l[d
_d fWj_[dji m_j^ feeh ehWb ^o]_[d[" Wi _cfh[ii_l[bo
[n[cfb_\_[ZXoj^[YWi[h[fehji_d9^Wfj[h.$
È
%LASTICÈ6ERSUSÈ3TIFFÈ)MPLANT
3YSTEMS
J^[ _cfbWdjebe]_ij ckij Z[Y_Z[ m^[j^[h je ki[
ceh[ [bWij_Y eh h_]_Z 8E? _cfbWdj Z[i_]di$ J^[
ceh[XWiWbfbWj[iW8E?_cfbWdj^Wi"j^[ceh[h_]_Z
_i _ji X[^Wl_ekh _d j^[ Xed[ Ä WdZ j^[ bWh][h j^[
XWi[ fbWj[i Wj W ]_l[d j^_Yad[ii" j^[ ceh[ [bWij_Y
_i _ji X[^Wl_ekh$ ?d h_]_Z Xed[ Wh[Wi" h_]_Z Z[i_]di
[$]$ jh_fb[#Z_ia _cfbWdji e\ j^[ ;::: jof[ Wh[ Wd
Wffhefh_Wj[Y^e_Y[$J^[oYWdX[ki[Z_dYed`kdYj_ed
m_j^ej^[h8E?_cfbWdjieh"_dZ[[Z"Yh[ijWb_cfbWdji
jeikffehjceh[h_]_Z_cfbWdj#h[ijehWj_edYecfb[n[i"
eh j^[o YWd X[ ki[Z Wi i_d]b[#jeej^ _cfbWdji je
h[fbWY[Wdj[h_ehj[[j^ehfh[cebWhi_dj^[cWn_bbWeh
cWdZ_Xb[$
9h[ijWb_cfbWdjebe]_ijij[dZjeZ[doj^[d[[Z\eh
_ie[bWij_Y X[^Wl_ekh e\ _cfbWdji _d i_jk$ <hec j^[
[nf[h_[dY[ ]W_d[Z m_j^ iYh[m Z[i_]di" Wdo l_i_Xb[
ceX_b_joe\j^[_cfbWdj_ikdZ[i_hWXb[$?j_ijhk[j^Wj
bWYae\fh_cWhoijWX_b_jo_ied[e\j^[cW_dh[Wiedi
\eh [Whbo _cfbWdj beii m_j^ Yh[ijWb Z[i_]di$ 9h[ijWb
_cfbWdjebe]_iji_d\[h\hecj^_ij^Wjj^[`WmXed[m_bb
]hem jemWhZi _cfbWdji \eh m^_Y^ fh_cWho ijWX_b_jo
^Wi X[[d WY^_[l[Z WdZ fhefW]Wj[ ed j^[_h ikh\WY[i
ÆlebkdjWh_boÇehÆ_dj[dj_edWbboÇ"Wi_jm[h["jefh[fWh[
j^[]hekdZ\eh\kdYj_edWbbeWZjhWdic_ii_ed$7im_bb
X[i^emd\khj^[hX[bem"ed[cW`eh_dY[dj_l[\ehXed[
h[ceZ[bb_d]Yec[i\hecij_ckbWj_ede\d[_]^Xekh_d]
eij[edi ed \ehY[#jhWdic_jj_d] jhW`[Yjeh_[i X[_d]
Z_ihkfj[Z _d j^[ fheY[ii e\ fh[fWh_d] j^[ _cfbWdj
X[Z$ J^_i c[Y^Wd_ic ^Wi X[[d Z[iYh_X[Z _d j^[
ehj^efW[Z_Y b_j[hWjkh[ \eh Z[YWZ[i$ J^[ _cfbWdj
_ji[b\ c[Z_Wj[i j^[i[ ij_ckb_ edbo je j^[ [nj[dj e\
jhWdic_jj_d] \kdYj_edWb beWZi WdZ j^[h[Xo Yh[Wj_d]
\ehY[f[Wai_dj^[[Whbof^Wi[$
9b_d_YWb Wdaobei_i e\ j[[j^ _i h_]^jbo h[]WhZ[Z Wi
W fWj^ebe]_Y YedZ_j_ed$ ?j _i j^[h[\eh[ dej [dj_h[bo
Yedi_ij[dj \eh Z[djWb _cfbWdjebe]_iji je feijkbWj[
j^[ iWc[ YedZ_j_ed Wi W jh[Wjc[dj eX`[Yj_l[ _d j^[
YWi[e\_cfbWdji$Eii[e_dj[]hWj_edWbed]j^[l[hj_YWb
Z_c[di_ed _i Wd _d^[h[dj h[gk_h[c[dj \eh Yh[ijWb
_cfbWdjii_dY[j^[obWYaWdo^eh_pedjWbYecfed[dji$
?j\ebbemij^Wjj^[i[_cfbWdjih[ZkY[j^[[bWij_Y_joe\
j^[`Wm$7Z[i_]dWj_edb_a[Æheej#i^Wf[ZÇ_cfbWdji_i
)( 9^Wfj[h)È -ORPHOLOGYÈOFÈ"/)È)MPLANTSÈANDÈ2ELATEDÈ$ESIGNS
fkh[bo\ehcWb_dc[Wd_d]WdZYWddejY^Wd][j^[\WYj
j^Wjj^[i[Z[i_]dibWYa[ii[dj_WbY^WhWYj[h_ij_Yie\W
dWjkhWb heej" [bWij_Y ikif[di_ed X[_d] ed[ e\ j^[c$
8E? _cfbWdji Wh[ [bWij_YWbbo ikif[dZ[Z X[jm[[d
Yehj_YWbXed[ijhkYjkh[i$?dj^_imWo"j^[o^Wl[ckY^
ceh[_dYeccedm_j^dWjkhWbheejiWdZj^[[bWij_Y
\[Wjkh[i [dWXb[ j^[ h[ijehWj_l[ Z[dj_ij je cekdj
bWh][h Xh_Z][i ed edbo W \[m _cfbWdji f[h `Wm$ J^[
WZlWdjW][ e\ [bWij_Y_jo _i h[ZkY[Z Wi j^[ dkcX[h
e\ _cfbWdji ikffehj_d] W h[ijehWj_ed _dYh[Wi[i$
?dYh[Wi_d]j^[dkcX[he\Z_iaiWdZj^[j^_Yad[iie\
j^[i^W\j"XWhWdZh_d]"^em[l[h"m_bbWbieh[ZkY[j^[
[bWij_Y_joe\j^[el[hWbbYecfb[n$
J^[ \_hij ][d[hWj_ed e\ Z_ia _cfbWdji Xo @kbb_[j
l_hjkWbboWbbem[Zde[bWij_Y_jom^Wjie[l[h$7bj^ek]^
j^[o m[h[ cWZ[ \hec Wd [bWij_Y jof[ e\ j_jWd_kc"
j^[om[h[`kijjeej^_YajeW\\ehZj^[h[gk_h[ZZ[]h[[
e\ _ie[bWij_Y_jo$ ;l[d j^[ h[_d\ehY[Z _dj[hdWb <h[dY^
:_ia_cfbWdji cWZ[ \hec ]hWZ[ ( j_jWd_kc m[h["
WdZ ij_bb Wh[" ik_jWXb[ edbo \eh h_]_Z ckbj_#_cfbWdj
YedY[fji$IYehj[YY_Z[cedijhWj[Zj^Wjh_]_Z_cfbWdj#
h[ijehWj_ed Yecfb[n[i YekbZ X[ [ijWXb_i^[Z l[ho
ikYY[ii\kbbo Xo _di[hj_d] W bWh][ dkcX[h e\ bWj[hWb
_cfbWdji [l[d _d YecX_dWj_ed m_j^ iYh[m _cfbWdji"
Yecfb[j[bo d[]b[Yj_d] j^[ [bWij_Y fhef[hj_[i e\
j^[ `Wm Xed[i$ Ed j^[ m^eb[" j^[ ^_ijeho e\ XWiWb
eii[e_dj[]hWj_ed el[h j^[ fWij )&o[Whi ^Wi X[[d
Y^WhWYj[h_p[ZXoWb[Whd_d]fheY[iiZh_l[dXockjkWb
_dfkj ed j^[ fWhj e\ ki[hi WdZ cWdk\WYjkh[hi$ J^[
j[njXeea Xo IYehj[YY_" C_iY^ WdZ 8[dd[h (&&'
cW_dbo i^emi h_]_Z _cfbWdj#h[ijehWj_ed ioij[ci$
J^[_h ckbj_#_cfbWdj YedY[fj" m^_b[ X[_d] W l_WXb[
ijhWj[]o _d fh_dY_fb[" Ze[i dej `kij_\o j^[ \_dWdY_Wb
[nf[di[_dcWdoi_jkWj_edi"WdZj^[bWh][dkcX[he\
_cfbWdji_di[hj[ZZe[iicWYae\Æel[hjh[Wjc[djÇ$
?d ekh [nf[h_[dY[" \ekh eh \_l[ 8E? _cfbWdji
m_bb ik\\_Y[ je [dikh[ ijWXb[ h[ijehWj_edi _d j^[
cWdZ_Xb[$ ?d j^[ cWn_bbW" W ]h[Wj[h dkcX[h e\
_cfbWdjicWoX[iW\[h"jWa_d]j^[bem[hXed[gkWb_jo
WdZ ^_]^ c[Y^Wd_YWb ijh[ii [$]$ Xo fWhW\kdYj_ed
_dje Yedi_Z[hWj_ed$ ?d gk_j[ W \[m YWi[i" W ]h[Wj[h
dkcX[h e\ Z_iai f[h _cfbWdj i^ekbZ X[ i[b[Yj[Z
Wbie$9ecX_dWj_edm_j^i[l[hWbYh[ijWb_cfbWdjicWo
X[ Wffhefh_Wj[ je [dikh[ WZ[gkWj[ ijWX_b_jo e\ j^[
ijhkYjkh[$ <khj^[hceh[" j^_i WffheWY^ Wbbemi \eh
_cc[Z_Wj[beWZ_d]_dW]h[Wj[hdkcX[he\YWi[i$J^[
YedZ_j_edi_dj^[cWn_bbWh[]WhZ_d]j^[h[bWj_edi^_f
X[jm[[d_dj[hdWbfh[iikh[WdZ[nj[hdWb_$[$Yehj_YWb
Yecfh[ii_l[%j[di_b[ ijh[ii[i Wh[ dej j^[ iWc[ Wi _d
j^[ cWdZ_Xb[$ J^[h[\eh[" j^[ _cfbWdjebe]_ij i^ekbZ
Yedi_Z[h fbWY_d] WZZ_j_edWb _cfbWdji _dij[WZ e\
ijh_Yjbo\ebbem_d]j^[\ehcWbhkb[ie\ijhWj[]_Y_cfbWdj
fei_j_ed_d]$J^_iWffb_[i[if[Y_WbbojeYWi[i_dm^_Y^
cWij_YWjeho \kdYj_ed d[[Zi je X[ h[#[ijWXb_i^[Z Wi
m[bb$7bWh][hdkcX[he\_cfbWdjiehZ_iaif[h8E?
_cfbWdj _i d[Y[iiWho _\ j^[ m_Zj^ e\ j^[ eYYbkiWb
ikh\WY[ e\ j^[ fheij^[j_Yi _i Z[i_h[Z je X[ bWh][h
WdZfhel_Z[Ykifii[[9^Wfj[h'&\ehYecc[djied
j^ei[\[Wjkh[ie\j^[ikf[hijhkYjkh[i$
È
2ETENTIONÈ3YSTEMSÈFORÈ0ROSTHETICÈ
3UPERSTRUCTURESÈ%$È6ERSUSÈ)$È4YPES
?d Yh[ijWb _cfbWdjebe]o" j^h[[ [ii[dj_Wb ioij[ci Wh[
ki[Z je Yedd[Yj ikf[hijhkYjkh[i je j^[ _di[hj[Z
_cfbWdj \_njkh[i0 Yed[ Yedd[Yj_edi" _dj[hdWb iYh[m
Yedd[Yj_edi[_j^[he\j^[Xh_Z][ehe\j^[WXkjc[dj"
WdZ Z_h[Yj eh _dZ_h[Yj Y[c[djWj_ed$ ?dj[hdWb iYh[m
&IGÈAnC J^[?:Eioij[c_i
XWi[Zedj^[C(_dj[hdWbj^h[WZi"
YecX_d[Zm_j^[nj[hdWbeYjW]edWb
Wdj_#hejWj_ed\[Wjkh[$J^[ioij[c_i
\kbboYecfWj_Xb[m_j^?J?_cfbWdji$
;:_cfbWdji\[Wjkh[Wd[nj[hdWb
C(&$(+j^h[WZ$;8jof[iWh[
cWdk\WYjkh[ZjeYedjW_dj^[XWiWb
fbWj[i"j^[j^h[WZ^ebZ[hm^_Y^
Ze[idej^ebZWj^h[WZ_dj^_i
YWi[WdZj^[WXkjc[dj_ded[
f_[Y[$J^ei[_cfbWdjiWh[Y^[Wf[h
X[YWki[_j_idejd[Y[iiWhojeXko
WXkjc[dji
È È 2ETENTIONÈ3YSTEMSÈFORÈ0ROSTHETICÈ3UPERSTRUCTURESÈ
Yedd[Yj_edi h[gk_h[ j^[ ki[ e\ Wd _dj[hdWb j^h[WZ"
m^_Y^cWo^Wl[Z_\\[h[djYed\_]khWj_ediZ[f[dZ_d]
edj^[_cfbWdjjof[$Jef[hcWd[djboh[i_ij\kdYj_edWb
beWZi"j^[j^h[WZckij^Wl[Wc_d_ckcZ_Wc[j[h$?d
fhWYj_Y["C(eh[l[dC)_dj[hdWbj^h[WZiWh[ki[Z
\ehh[b_WXb[Yedd[Yj_edi$
J^[<h[dY^?:_cfbWdjiWh[ki[Zm_j^C'$*_dj[hdWb
j^h[WZi$ J^[o Wh[ ki[Z _d YecX_dWj_ed m_j^ fkh[
]ebZ iYh[mi j^Wj fbWij_YWbbo Wbj[h j^[_h i^Wf[ _d j^[
fheY[iie\iYh[m_d]WdZWh[ikXi[gk[djboh[jW_d[ZXo
W ^_]^ Z[]h[[ e\ ijWj_Y \h_Yj_ed$ J^[ Yb_d_YWb ikYY[ii
e\j^_ijof[e\iYh[mh[j[dj_ed_iWbieZk[jej^[\WYj
j^Wj_j_ikikWbboWffb_[Z_dj^[fh[i[dY[e\dkc[heki
_cfbWdji$
;nj[hdWb 8E? _cfbWdji ^Wl[ WbmWoi ki[Z C(
[nj[hdWb j^h[WZi" h[]WhZb[ii e\ cWdk\WYjkh[h$ J^[
9Wi[IjkZo'
9Wi[IjkZo(
))
j^h[WZf_jY^[i^Wl[Z_c_d_i^[Zel[hj_c[$J^[ceij
kikWbf_jY^_idem&$(+cc$Iec[[nj[hdWb8E?Wh[
ij_bb [gk_ff[Z m_j^ W &$*&cc f_jY^ WdZ e\ Yekhi[
_cfbWdjm_j^C(&$*&j^h[WZWh[ij_bb\ekdZ_dcWdo
fWj_[dji$ J^_i ckij X[ jWa[d _dje Yedi_Z[hWj_ed
m^[d fbWY_d] d[m fheij^[j_Yi ed ebZ[h jof[i e\
Æ:_ia_cfbWdjiÇJ^[j[hcÆ[nj[hdWbÇ8E?h[\[hijej^[
[nj[hdWb_$[$cWb[j^h[WZ<_]$)$.X$
?dj[hdWb8E?_cfbWdjiWiki[Z_d<hWdY[?:#jof[
Z[i_]di WYYehZ_d] je IYehj[YY_ \[Wjkh[ Wd [nj[hdWb
^[nW]ed$ ;l[d ie" j^[ j[hcÆ_dj[hdWbÇ h[\[hi je j^[
_dj[hdWb iYh[m Yedd[Yj_ed$ J^[i[ Z[i_]dWj_edi Wh[
dej Yedi_ij[dj m_j^ j^[ j[hc_debe]o ki[Z _d Yh[ijWb
_cfbWdjebe]o$
&IGÈ I_njh_fb[#Z_ia8E?
_cfbWdjiWdZjmeZekXb[#Z_ia8E?
_cfbWdjifhel_Z[WijWXb[XWi_i\eh
Wd_cc[Z_Wj[bobeWZ[Z\kbbXh_Z][
\ehj^[kff[h`Wm$7bb8E?_cfbWdji
^Wl[X[[dfbWY[Z_cc[Z_Wj[boW\j[h
j^[h[celWbe\\ekhej^[h_cfbWdji$
J^[Xed[#_cfbWdj#h[ijehWj_ed
ioij[c_iYecfb[j[boh_]_Z1j^[h[Wh[
deh[i_b_[dj[b[c[dji$?dj^[Wh[We\
j^[kff[hh_]^jj^_hZcebWh"Wjh_fb[#
Z_ia8E?_cfbWdjmWifbWY[Z_dWd
eXb_gk[Z_h[Yj_ed"ki_d]j^[iWc[
Xed[Wh[WiWjkX[he#fj[ho]e_ZiYh[m
mekbZ
&IGÈ M^_b[j^[Wdj[h_ehjh_fb[#Z_ia8E?
_cfbWdjiWh[h_]_Zf[hi["j^[m_Z[#ifWdd_d]
Xh_Z][WdZj^[ijhWj[]_Yfei_j_ede\j^[_cfbWdji
Yh[Wj[iWd[bWij_YXed[#_cfbWdj#h[ijehWj_ed
ioij[cm^[h[j^[`WmXed[YWdZ[l[befWdZ
cel[\h[[boX[bemj^[Xh_Z][$J^[\Wj[e\j^[
Xh_Z][_idejb_da[Zjej^Wje\j^[Yh[ijWbXed[
)* 9^Wfj[h)È -ORPHOLOGYÈOFÈ"/)È)MPLANTSÈANDÈ2ELATEDÈ$ESIGNS
È
#ONCLUSION
J^[Z[i_]de\8E?_cfbWdjii^emiWYb[WhijhkYjkh[$
7ffhefh_Wj[ Z[i_]di Wh[ dem WlW_bWXb[ \eh [l[ho
YedY[_lWXb[ jWia$ J^[ \ebbem_d] Wif[Yji e\ _cfbWdj
Z[i_]d Wh[ Wd _dj[]hWb fWhj e\ j^[ 8E? jh[Wjc[dj
f^_beief^o0
v CkYeiWb [c[h][dY[ fe_dji m_j^ icWbb Z_Wc[j[hi
fh[l[dj j^[ f[d[jhWj_ed e\ fWj^e][di WdZ j^[
Z[l[befc[dj e\ f[h_#_cfbWdj_j_i \eh Z[jW_bi i[[
9^Wfj[h.$
v ;bWij_YZ[i_]d0J^[WZlWdjW][ie\j^[[bWij_YZ[i_]d
Wh[ceijdej_Y[WXb[_\edboW\[m8E?_cfbWdjiWh[
fbWY[Z_d[WY^`Wm$
v 8_Yehj_YWbikffehj0?j_iW]eeZ_Z[WjefbWY[8E?
_cfbWdjiikY^j^Wjj^[oh[WY^j^[Yehj_YWbh[]_ed
edXej^i_Z[ie\j^[`WmXed[$
v I[b[Yj_d] j^[ bed][ij feii_Xb[ j^h[WZ[Z f_d0
H[ikbji_defj_cWbWYY[ii\ehehWb^o]_[d[WdZ_d
WkjeYb[Wd_d] i[[ 9^Wfj[h. WdZ ^Wi W fei_j_l[
_d\bk[dY[ed[bWij_Yfhef[hj_[i
v J^[ Y^e_Y[ e\ Yedd[Yj_d] WXkjc[dji Wbie ^Wi Wd
_d\bk[dY[ ed j^[ [bWij_Y_jo e\ j^[ ijhkYjkh[ i[[
9^Wfj[hi*WdZ+
v Ik\\_Y_[djbo [nj[di_l[ l[hj_YWb WdZ ^eh_pedjWb
eij[ejec_[i \Wlekh ikffkhWj_ed _d j^[ [l[dj e\
fh[ef[hWj_l[ eh _djhWef[hWj_l[ _d\[Yj_ed i[[
9^Wfj[hi.WdZ()

#(!04%2È
)NSERTIONÈ4OOLSÈANDÈ)MPLANTÈ$ESIGNS
È
4OOLSÈFORÈ%XTERNALÈ4HREADÈ$ESIGNS
Je_di[hj8E?_cfbWdjiWJ#i^Wf[Zeij[ejeco^Wije
X[Ykj_djej^[Xed[$J^[_dijhkc[djiki[Z\ehj^_i
Wh[kikWbboZ[i_]d[ZjeYkj[_j^[hj^[l[hj_YWbehj^[
^eh_pedjWbfWhj$J^[h[Wh[Wbie_dijhkc[dji"^em[l[h"
j^Wj Wh[ Z[i_]d[Z je Ykj j^[ l[hj_YWb WdZ ^eh_pedjWb
fWhjii_ckbjWd[ekibo$M_j^_db_c_jij^[i[_dijhkc[dji
YWdX[h[fbWY[Z[$]$m_j^Wjkd]ij[dYWhX_Z[Ykjj[h
_\h[gk_h[Z\eh_djhWef[hWj_l[WYY[ii_X_b_jo$
&IGÈ 7 l[hj_YWb Ykjj[h _i ki[Z je fh[fWh[ j^[ Y^Wdd[b \eh
j^[ j^h[WZ[Z f_d$7j j^[ iWc[ j_c[ j^_i _dijhkc[dj fh[fWh[i
j^[ ]hekdZ \eh j^[ bWj[hWb Ykjj[hi je X[ ki[Z _d j^[ d[nj
ij[f$ J^[ l[hj_YWb Ykjj[h _bbkijhWj[Z _d j^_i \_]kh[ \[Wjkh[i <=
j[di_ed Wj '$,cc WdZ j^ki YWd X[ ki[Z m_j^ W jkhX_d[ WdZ
^_]^#if[[ZYedjhW#Wd]b[^WdZf_[Y[$J^[m_Zj^e\j^[meha_d]
ikh\WY[_iWbie'$,cc$J^[Ykjm_Zj^_ij^kiicWbb[hj^Wdj^[
m_Zj^ e\ j^[ j^h[WZ[Z f_d" m^_Y^ c[Wdi j^Wj i[l[hWb Ykjj_d]
ij[fiWh[h[gk_h[Z$CWdoki[hi\_hijWffboWdehcWbjkd]ij[d
YWhX_Z[ Ykjj[h je [nf[Z_j[ f[d[jhWj_ed e\ j^[ ^WhZ Yehj_YWb
Xed["m^_Y^_dYh[Wi[ij^[b_\[ifWde\j^[l[hj_YWbYkjj[h$Dej[
j^Wj j^[ Z_Wc[j[h e\ j^[ l[hj_YWb j^h[WZ[Z f_d _i bWh][h j^Wd
'$,cc$J^_ic[Wdij^Wjj^[ibej^WijeX[m_Z[d[Zm_j^j^[
iWc[_dijhkc[dj"m^_Y^]_l[ij^[ef[hWjehWY^WdY[jeib_]^jbo
WZ`kijj^[fei_j_ede\j^[ibejWdZj^[l[hj_YWb_cfbWdjfWhj
&IGÈ BWj[hWbYkjj[hB9"'(cc_dZ_Wc[j[h
 ¬ 
J^[bWj[hWbYkjj[h_iki[ZjeYh[Wj[j^[^eh_pedjWb
Z_c[di_ed e\ j^[ eij[ejeco$ I[l[hWb bWj[hWb Ykjj[hi
m_j^ _dYh[c[djWb Z_Wc[j[hi Wh[ ki[Z ikYY[ii_l[bo"
ijWhj_d] m_j^ -cc$ J^[ bWh][ij Ykjj[h Ykhh[djbo
WlW_bWXb[ ^Wi W Z_Wc[j[h e\ '+cc$ ?d ie\j[h j_iik[
WdZm_j^W]eeZjkhX_d[[d]_d["Ykjj[him_j^bWh][h
Z_Wc[j[h c_]^j X[ ki[Z h_]^j WmWo" ie j^Wj j^[
l[hj_YWbi_p[e\j^[^eh_pedjWbibejZe[idejX[Yec[
jeebWh][$
Jm_d Ykjj[hi Wh[ ki[Z \eh ZekXb[#Z_ia _cfbWdji$
J^[_h \kdYj_ed _i jme\ebZ0 j^[o Z[\_d[ j^[ Z_ia#je#
Z_ia Z_ijWdY[" WdZ j^[o [dikh[ j^Wj Xej^ Ykji Wh[
fWhWbb[b$Jm_dYkjj[hiWh[WlW_bWXb[_djmeZ_Wc[j[hi0
j^[ /#cc eh -#cc jof[i Z[\_d[ W Z_ia#je#Z_ia
Z_ijWdY[e\+cceh)cc"h[if[Yj_l[bo$
J^[ki[e\bWj[hWbYkjj[him_j^ekjYkjj_d]\[Wjkh[i
Wbed]j^[i^W\j^Wij^[WZlWdjW][j^Wjj^[^eh_pedjWb
eij[ejeco YWd X[ Yh[Wj[Z ceh[ if[[Z_bo$ J^_i
&IGÈ Jm_dYecX_Ykjj[h\eh
jmeZ_iai-cc_dZ_Wc[j[hj^Wj
Wh[)ccWfWhj
), 9^Wfj[h*È )NSERTIONÈ4OOLSÈANDÈ)MPLANTÈ$ESIGNS
fh[ikffei[i" ^em[l[h" j^Wj j^[ fh[Y[Z_d] l[hj_YWb
Ykj^WiX[[dfbWY[Zfhef[hboWjh_]^jWd]b[im_j^j^[
ikXi[gk[dj^eh_pedjWbbWj[hWbYkj$?\j^WjmWidejj^[
YWi["W9ecXeYkjj[h^WijeX[ki[Z_dj[hc[Z_Wj[boje
Yh[Wj[j^[h[gk_h[Zh_]^jWd]b[X[jm[[dj^[l[hj_YWb
WdZj^[^eh_pedjWbibejXo¼feij#Ykjj_d]½WZ`kij_d]
j^[ l[hj_YWb _dY_i_ed$ ;nf[h_[dY[Z _cfbWdjebe]_iji
kikWbbo ^Wl[ de fheXb[c fbWY_d] Xej^ _dY_i_edi
Yehh[YjboWjh_]^jWd]b[i$
7i W Y[hjW_d Z_iWZlWdjW][ e\ Wbb <= _dijhkc[dji"
j^[ Y^kYai cWo Ybej kf m_j^ XbeeZ _djheZkY[Z
Zkh_d]j^[fheY[Zkh["Wij^[ikh][edm_bbdejWbmWoi
X[ WXb[ je [dikh[ j^[ WXi[dY[ e\ Wdo XbeeZ ed j^[
ikh\WY[i je X[ _di[hj[Z _dje j^[ jkhX_d[ Zkh_d]
ikh][ho$ J^[h[\eh[" iec[ ki[hi fh[\[h je meha m_j^
_dijhkc[dji je X[ _di[hj[Z _dje j^[ Xbk[ YedjhW#
Wd]b[^WdZf_[Y['0'X[YWki[j^[i[^WdZf_[Y[imeha
m_j^ekj Y^kYai$ Ed[ Z_iWZlWdjW][ e\ YedjhW#Wd]b[
^WdZf_[Y[i" ^em[l[h" _i j^Wj j^[ i^W\j YWddej X[
h[ZkY[Z _d b[d]j^1 _j _i j^[h[\eh[ d[Y[iiWho je a[[f
Ykjj[him_j^Z_\\[h[dji^W\jb[d]j^i_dijeYa$
&IGÈ 9ecX_Ykjj[hA9"'&cc_dZ_Wc[j[h"m_j^Ykjj_d]
ikh\WY[i ed Xej^ j^[ Z_ia WdZ j^[ i^W\j$ J^[i[ Ykjj[hi Wh[
WlW_bWXb[m_j^Z_ia^[_]^jie\&$*cc"&$,ccWdZ&$.cc
È
%XTERNALÈ)MPLANTSÈ%$
7i W hkb[" i_d]b[#kd_j _cfbWdji Wh[ h[Wbbo m^Wj j^[
dWc[ ik]][iji" _$[$ j^[o Wh[ cWZ[ e\ W i_d]b[ _d]ej
e\ j_jWd_kc" ki_d] W ^_]^#fh[Y_i_ed WdZ ^_]^#Yeij
cWdk\WYjkh_d]j[Y^d_gk[$
J^[i[ _cfbWdji [lebl[Z \hec hejWj_edWbbo
iocc[jh_YWb Z[i_]di m_j^ ed[ eh i[l[hWb beWZ#
jhWdic_jj_d] ikh\WY[i$ J^[ i_p[ e\ j^[i[ _cfbWdji _i
]_l[dWiXWi[ikh\WY[Wh[WehhWZ_ki_dcc$J^[^[_]^j
e\j^[j^h[WZ[Zf_d_i]_l[d_d=kd_ji'=3'$+cc
WdZ_ic[Wikh[Z\hecj^[kff[hcWh]_de\j^[XWi[
Z_ia je j^[ X[]_dd_d] e\ j^[ j^h[WZ" j^ki _dYbkZ_d]
j^[i^ekbZ[hX[bemj^[j^h[WZ$
:[i_]di m_j^ W i[c_Y_hYkbWh XWi[ YWd X[ ki[Z
je fhej[Yj j^[ _cfbWdj W]W_dij hejWj_ed m_j^_d j^[
eij[ejecoibej"j^[hekdZi_Z[X[_d]_di[hj[Z_djej^[
Z[fj^e\j^[Xed[m^_b[j^[\bWji_Z[XehZ[hiedj^[
Xed[bWj[hWbbo_$[$c[Z_WbboWdZZ_ijWbboWdZjemWhZi
j^[l[ij_XkbWhWif[Yj$J^[i[Z[i_]die\\[hl[ho]eeZ
fh_cWhoijWX_b_jo$
?dcWdoYWi[i"j^[Yehj_YWbXed[ijhkYjkh[i_dj^[
cWn_bbW WdZ cWdZ_Xb[ Wh[ beYWj[Z '(Ä'*cc WfWhj$
7i hejWj_edWbbo iocc[jh_YWb Z[i_]di YWddej dej X[
h[WZ_bo_di[hj[Z_dj^_ii_jkWj_ed"_j_ih[Yecc[dZ[Z
je ki[ b[d]j^o 8E? Z[i_]di$ J^[ ceij Wffhefh_Wj[
Z[i_]d \eh j^_i fkhfei[ _i j^[ ;:7I _cfbWdj
WlW_bWXb[ Wi /'(cc" /'*cc" eh '&'*cc"
;:7:I _cfbWdji '(%'-cc" eh ;:77I _cfbWdji
'&(&cc$

&IGÈ BWj[hWb Ykjj[h '(cc _d Z_Wc[j[h \eh YedjhW#Wd]b[
^WdZf_[Y[
&IGÈAB ;:/=.kdZ;:-=.$J^[i[jme_cfbWdjjof[iWh[
[njh[c[bofefkbWh"i_dY[j^[if[Y_\_Yh[bWj_edi^_fX[jm[[dj^[
Z_iaZ_Wc[j[hWdZj^[i^W\jb[d]j^Wbbemij^[_hWffb_YWj_ed_d
W ]h[Wj dkcX[h e\ Yb_d_YWb i_jkWj_edi$ J^[i[ Z[i_]di Wh[ Wbie
[njh[c[boh[b_WXb[
È È 4OOLSÈFORÈ%XTERNALÈ4HREADÈ$ESIGNSÈ )-

&IGÈAB ;::I_cfbWdjih_]^jWh[m[bbik_j[Z\eh_di[hj_ed

&IGÈ :ekXb[#Z_ia _cfbWdji /%- =+$ J^[ =+" =- WdZ =.
l[hi_edie\j^[i[ZekXb[#Z_ia_cfbWdji/eh'&ccZ_Wc[j[h
Wj j^[ XWi[ Z_ia Wh[ Yeccedbo ki[Z je h[fbWY[ YWd_d[i _d
Xej^`Wmi
_dje ijWXb[ Xed[ ijhkYjkh[i$ ?\ j^[ l[hj_YWb Xed[ lebkc[ _i
]h[Wj[h" _j _i h[Yecc[dZ[Z je ki[ ;N::I _cfbWdji b[\j" Wi
j^[ ]h[Wj[h Z_ijWdY[ X[jm[[d j^[ beWZ#jhWdic_jj_d] ikh\WY[i
+cc m_bb fh[l[dj 8CKi \hec _dj[h\[h_d] m_j^ [WY^ ej^[h
Zkh_d]Xed[h[fW_hfheY[ii[ii[[9^Wfj[h()

&IGÈA ;:I _cfbWdji \[Wjkh[ W XWiWb fbWj[ j^Wj _i XWi_YWbbo Y_hYkbWh Xkj m_j^ W bed][h hWZ_ki jemWhZi j^[ Wd]b[Z [dZi$ J^[
_cfbWdj _i j^ki fhej[Yj[Z W]W_dij hejWj_ed _d j^[ Xed[ YWl_jo$ <khj^[hceh[" _ji bWj[hWb i[]c[dji ijWX_b_p[ j^[ _cfbWdj W]W_dij
h[cel_d] \ehY[i Xo _dYh[Wi_d] j^[ \h_Yj_ed$ ;:I /=, Wh[ ki[Z ceij Yeccedbo _d j^[ Wh[W e\ j^[ i[YedZ cebWhi _d j^[
cWdZ_Xb[$ B 7Z[i_]dm_j^jmeWZZ_j_edWb[Z][ie\\[hickY^]h[Wj[hfh_cWhoijWX_b_joWdZWd_djhWXedoWdj_#hejWj_ed\[Wjkh[
j^WdWY_hYkbWhZ[i_]dm_j^j^[iWc[XWi[Z_Wc[j[h$:[i_]dim_j^[Z][iWd\bWjXWi[#fbWj[iWh[YWbb[ZÆI#Jof[_cfbWdjiÇ$

;:77I_cfbWdji\[Wjkh[ed[hekdZ[ZWdZed[\bWj J^[ j[dZ[dYo e\ ki[hi je fbWY[ \[m[h WdZ

i_Z[" Xkj j^[o Wh[ Wbie WlW_bWXb[ m_j^ jme hekdZ[Z
i_Z[i$ CWn_ckc Z_c[di_edi Wh[ (&cc _d m_Zj^
WdZ '&cc _d ^[_]^j$ 8[YWki[ j^[ j^h[WZ[Z f_d
_dlWh_WXbo^WijeX[Y[djhWbbobeYWj[ZZkh_d]_cfbWdj
cWdk\WYjkh["j_jWd_kc_d]ejim_j^WZ_Wc[j[he\el[h
)&ccmekbZX[h[gk_h[Z$?dehZ[hje[Yedec_p[ed
j^[ Wcekdj e\ j_jWd_kc ki[Z _d j^[ cWdk\WYjkh_d]
fheY[ii"j^[j^h[WZ[Zf_dmWii^_\j[Z(cc\hecj^[
Y[djh[e\j^[Y_hYb[_dWc[Z_WbZ_h[Yj_ed"_$[$jemWhZi
j^[ Y[djh[ e\ j^[ _cfbWdj$ 7lW_bWXb[ b[d]j^i hWd][
\hec=+je=/$
\[m[h _cfbWdji _d [WY^ `Wm _i Wbie h[\b[Yj[Z _d j^[
Z[l[befc[dj e\ _cfbWdj Z[i_]di$ JeZWoÉi :_iaei
_cfbWdji" \eh _dijWdY[" Wh[ Y^WhWYj[h_p[Z Xo W Z_ia
^[_]^j e\ &$,Ä&$.cc$ J^[ cWj[h_Wbi ki[Z \eh j^_i
Z[i_]d _dYbkZ[ fkh[ j_jWd_kc ]hWZ[ ' eh ( WdZ
J_'+Ce$ <eh efj_cWb \hWYjkh[ h[i_ijWdY[" j^[ hWZ_ki
_d j^[ jhWdi_j_edWb ped[ X[jm[[d j^[ j^h[WZ[Z f_d
WdZ j^[ m[X XWh ^Wi X[[d h[_d\ehY[Z" WdZ j^[ m[X
XWh_ji[b\_iWbiej^_Ya[hWim[bb$M^_b[j^[i[\[Wjkh[i
Wbbem\eh]h[Wj[hbeWZ_d]"_j_id[l[hj^[b[ii_cfehjWdj
jea[[f_dc_dZj^WjZk[jej^[[bWij_Y_joe\j^[Xedo
_cfbWdj X[Zi" Ybei[ eii[eWZWfjWj_ed e\ Wbb _cfbWdj
ikh\WY[iYWddejX[feii_XboWjjW_d[Z_dj^[fh[i[dY[
e\W^_]^Z[]h[[e\c_d[hWb_pWj_ed$J^_Ya[h_cfbWdji
). 9^Wfj[h*È )NSERTIONÈ4OOLSÈANDÈ)MPLANTÈ$ESIGNS
&IGÈ ;:7 _cfbWdj -',cc m_j^ Y[djhWbbo beYWj[Z
j^h[WZ[Zf_d
Wh[ b[ii [bWij_Y j^Wd j^_dd[h _cfbWdji cWZ[ e\ j^[
iWc[ cWj[h_Wb$ J^_i f^[dec[ded X[Yec[i h[b[lWdj
cW_dbo m_j^ _cfbWdji jhWdil[hi_d] Xed[ ijhkYjkh[i
j^WjWh[ekje\iodY_dj[hcie\Z_ibeYWj_ed$J^_Ya[h
_cfbWdjiWh[ceh[b_a[bojeX[i[b[Yj[Zm^[dijhWj[]_Y
_cfbWdjfei_j_ed_d]_ifbWdd[Z$
È
!BUTMENTSÈANDÈ#OMPONENTSÈFORÈ%XTERNAL
4HREADÈ$ESIGNS
J^[ j^h[[ WXkjc[dj jof[i _d <_]$*$', Wh[ f[h\[Yjbo
i[hl_Y[WXb[\ehceijWffb_YWj_edi$
J^[jejWb^[_]^je\j^[i[_cfbWdjjof[i_i,$+cc
\eh JI:* WdZ '&$+cc \eh J:I+ WdZ JI://$ J^[
JI:// WXkjc[dji ^Wl[ W ceh[ _dj[hdWb%ikf[h_eh
fei_j_ed e\ j^[ _dj[hdWb j^h[WZ_d] Wi Z_ij_d]k_i^_d]
\[Wjkh["Wbbem_d]bed][h_cfbWdji^W\jijeX[WZ`kij[Z
_d W ckYeiWb Z_h[Yj_ed$ J^[ WZlWdjW][ e\ JI://
WXkjc[dji _i j^Wj j^[o e\\[h W l[ho bed] ikh\WY[ \eh
Y[c[dj_d] [l[d ed ;: _cfbWdji m^ei[ j^h[WZ _i
beYWj[Z_dWl[ho^_]^fei_j_ed$<h[gk[djbo"WXkjc[dji
ed bed] j^h[WZ[Z f_di ^Wl[ je X[ h[ZkY[Z Zemd je
j^[ j^h[WZ" m^_Y^ mekbZ Xh_d] j^[ b[d]j^ WlW_bWXb[
\ehY[c[dj_d]Zemdjej^[j^h[WZb[d]j^e\hek]^bo
)Ä+cc$:[\_Y_jie\j^_ijof[YWdX[[Wi_bo[b_c_dWj[Z
Xo ki_d] JI:// WXkjc[dji" m^_Y^ m_bb _dYh[Wi[
j^[ WlW_bWXb[ ikh\WY[ \eh Y[c[djWj_ed Xo Wdej^[h
*cc_dckYeiWbZ_h[Yj_ed$D[l[hj^[b[ii"YWh[ckij
X[ jWa[d j^Wj de Z_h[Yj YedjWYj je j^[ ckYeiW _i
[ijWXb_i^[Z" i_dY[ j^[ Wfhed#ijob[ Yel[hW][ j[dZi je
\Wlekh h[j[dj_ed e\ \eeZ h[cdWdji$ ?j _i \h[gk[djbo
W ]eeZ _Z[W je Z[Y_Z[ ed ki_d] bed][h j^h[WZ[Z
f_di Zkh_d] j^[ fheY[Zkh[ WdZ Yecf[diWj[ \eh j^[
_dYh[Wi[Zb[d]j^Xoki_d]JI://WXkjc[dji\ehj^[
fheij^[j_Y ikf[hijhkYjkh[$ ?d i_jkWj_edi m^[h[ j^[
j^h[WZ[Zf_d_ibeYWj[Z_dWibef[ZckYeiWbWh[W"j^[
JI://WXkjc[djWdZj^[ifWY[i_dj^[ikf[hijhkYjkh[
Z[i_]d[Zje^ebZj^[cYWdX[h[ZkY[ZeXb_gk[bo$
J^[ iWc[ WXkjc[dj jof[i Wh[ Wbie WlW_bWXb[ _d
m^_j[:[bh_d$J^[i[Z[i_]diWh[ceh[[bWij_Y"W\[Wjkh[
_i fh[\[hh[Z Xo cWdo 8E? ki[hi$ :7 WXkjc[dji YWd
X[ XedZ[Z m_j^ ]bWii#_edec[h Y[c[dj je eXjW_d W
i[c_#f[hcWd[djYedd[Yj_edj^Wj_iijWXb[o[jWbbemi
Z[#XedZ_d] _d W h[bWj_l[bo i_cfb[ cWdd[h _\ j^[
d[[Z Wh_i[i$ 9ecX_d[Z m_j^ Y[c[dji b_a[ FWdWl_W"
j^[ocWoX[ki[Z\ehZ[\_d_j_l[Y[c[djWj_ed$:[bh_d
WXkjc[djiWh[kdik_j[Z_\j^[8E?_ijeX[\b[n[Z\eh
Wd]kbWj_ed X[YWki[ j^[o Wh[ b_WXb[ je Xh[Wa _d j^_i
if[Y_\_Yi_jkWj_ed$?dij[WZ"_j_iX[jj[hjeki[j_jWd_kc
&IGÈA ;:7I/%'(=+$J^_i_cfbWdjZ[i_]d_i
fh[Zec_dWdjboki[Z_dZ_ijWb`Wmi[]c[dji$;:7I_cfbWdji
Wh[WbieWlW_bWXb[m_j^j^h[[m[XXWhihWZ_Wj_d]\hecj^[
j^h[WZ[Zf_d$ B ;:7I_cfbWdjiWh[WbieWlW_bWXb[m_j^
j^h[[m[XXWhi
È È 4OOLSÈFORÈ%XTERNALÈ4HREADÈ$ESIGNSÈ )/

&IGÈ ;:7I /%'* =-$ J^_i _cfbWdj jof[ YWd X[ ki[Z Wi
[_j^[h W /'&cc eh W /'*cc Z[i_]d Xo h[cel_d] ed[ eh
j^[ej^[he\j^[m[XXWhi$?j_iWbiefeii_Xb[je_dijWbbj^[XWi[
ikh\WY[e\/'&cc[deiiWbboWdZ\ebZj^[i[YedZXWhWh[Wed
j^[l[ij_XkbWhehfWbWjWbWif[YjWid[[Z[Z
&IGÈ J^_ijof[e\8E?_cfbWdj\[Wjkh[iedboed[YedjWYj
i_j[ ed [_j^[h Yehj_YWb Xed[ ijhkYjkh[1 j^[h[\eh[" edbo j^[i[
jme Wh[Wi ^Wl[ je X[ iodY^hed_p[Z ;:77 '&Ä(& =.$ J^[i[
&IGÈAB Jh_fb[#Z_ia8E?_cfbWdjiWh[WlW_bWXb[m_j^WZ_W#
c[j[h e\ -cc m_j^ WdZ m_j^ekj X[l[bb_d] [nj[hdWb j^h[WZ
l[hi_ed$ Jh_fb[#Z_ia 8E? Z[i_]di \[Wjkh_d] W bWh][h Z_ia Wj
j^[ Xejjec Ä j^ki WZWfj_d] X[jj[h je Yecced WdWjec_YWb
i_jkWj_ediÄWh[WbieWlW_bWXb[
jof[iWh[cW_dboki[Z_dj^[Wh[We\j^[cWn_bbWhoi_dki$J^[ &IGÈAB J^_i _cfbWdj Z[i_]d m_j^ W i[YedZ l[ij_XkbWh
X[l[bl_i_Xb[edj^[h_]^ji_Z[e\j^[XWiWbfbWj[m_bbY[djh[j^[ i[c_#Z_ia _i fh[Zec_dWdjbo ki[Z X[bem j^[ cWn_bbWho i_dki$
_cfbWdjZkh_d]jhWdi#i_dki_di[hj_ed_djej^[fWbWjWbibej$J^[ J^[ ZekXb[#Z_ia i[]c[dj _i _di[hj[Z l[ij_XkbWhbo1 edbo ed[
_cfbWdjYWdX[fbWY[Zm_j^j^[fhe`[Yj_d]i_Z[[_j^[hjemWhZi Z_ia jhWdil[hi[i j^[ i_dki$ J^[ XWiWb i[c_#Z_ia cWo X[
j^[ h_]^j eh jemWhZi j^[ b[\j$ Dej[ j^Wj j^[ Wcekdj e\ beWZ Wd]kbWj[Zi[[L_Z[e/
jhWdic_jj[Z je j^[ Yehj_YWb Xed[ _i _dl[hi[bo fhefehj_edWb je
j^[ i_p[ e\ j^[ XWiWb fbWj[ ed [WY^ i_Z[ e\ j^[ j^h[WZ[Z f_d$
I_dY[j^[h[Wh[jmef[d[jhWj_edbeYWj_edie\j^[Yehj_YWbXed[
ed j^[ igkWh[ i_Z[" W &#Wh[W _di_Z[ j^[ Xed[ cWo iec[j_c[i
Wd Wf_YWbbo feb_i^[Z d[Ya Wh[W e\ *cc b[d]j^ YWd
Z[l[befWhekdZed[e\j^ei[f[d[jhWj_edWh[Wii[[9^Wfj[h/
\ehZ[jW_bi X[ki[Z$
7Xkjc[dji cWZ[ e\ :[bh_d YWd Wbie X[ ki[Z _\
]h[Wj[h[bWij_Y_joe\j^[_cfbWdj#h[ijehWj_edioij[c_i
WXkjc[dji eh j^[ J7F#: jeeb iYh[m[Z edje j^[ Z[i_h[Z$J^[:7+WdZ:7//Z[i_]di\[Wjkh[j^[iWc[
j^h[WZ\ehj^_ijof[e\cWd_fkbWj_edi[[L_Z[e-$ [nj[hdWbc[Wikh[c[djiWij^[_hc[jWbb_YYekdj[hfWhji$
?\ j^[ jhWdi_j_edWb ped[i je j^[ _cfbWdj Yec[ je J^ki j^[ ki[h YWd mW_j kdj_b j^[ Y[c[djWj_ed ij[f
b_[_dWikXckYeiWbfei_j_edWdomWo"WXkjc[djim_j^ X[\eh[Z[Y_Z_d]edm^_Y^_cfbWdjjof[jeki[$:[bh_d
*& 9^Wfj[h*È )NSERTIONÈ4OOLSÈANDÈ)MPLANTÈ$ESIGNS

Wbb 8E? ioij[ci$ F_d b[d]j^i e\ =+Ä=- Wh[ ceij

&IGÈ IjWdZWhZWXkjc[djZ[i_]diJI:*"JI:+WdZJI://
Yeccedboki[Z$I^ehj[hf_db[d]j^iWh[hWh[boki[Z"
m^_b[ ]h[Wj[h b[d]j^i kf je ='' Wh[ X[Yec_d]
_dYh[Wi_d]bo fefkbWh$ J^h[WZ[Z f_di _d j^[ =/Ä=''
hWd][ ^Wl[ edbo X[[d WlW_bWXb[ _d j^[ fWij \[m
o[Whi1 ^[dY[ _j m_bb jWa[ Wdej^[h m^_b[ X[\eh[ j^[_h
j^[hWf[kj_Yki[\kbd[iiWdZiYef[e\Wffb_YWj_ediWh[
]e_d]jeX[m_Z[boh[Ye]d_p[Z$
8E? _cfbWdji YWd X[ _dijWbb[Z WdZ _cc[Z_Wj[bo
beWZ[Zh_]^jW\j[h[njhWYj_ed_dj^[iWc[i[ii_ed"Wi
j^[Yehj_YWbh_Z][ijhkYjkh[_ikikWbbom[bbfh[i[hl[Z
\ebbem_d] [njhWYj_ed$ ?j _i h[Yecc[dZ[Z je _di[hj
j^[j^h[WZ[Zf_dj^hek]^WbWj[hWbfWj^mWo_djej^[
WlW_bWXb[ Xed[ m^[d[l[h feii_Xb[$ J^_i WffheWY^
YWdX[hekj_d[boWffb_[Z_dj^[cWn_bbW"\eh_dijWdY["
m^[h[ j^[ _dj[hhWZ_YkbWh Xed[ lebkc[ _i \h[gk[djbo
WZ[gkWj[W\j[h[njhWYj_ede\j^[\_hijWdZ%ehi[YedZ
cebWh$7do_d\bWccWjehofheY[ii[ij^WjcWoij_bbX[
fh[i[dj_dj^[Xed[d[[ZjeX[YWh[\kbbo[b_c_dWj[Z$
If[Y_Wb YWh[ ckij X[ jWa[d j^Wj Wdo h[i_ZkWb
_d\bWccWj_edi Wh[ Wbbem[Z je ZhW_d e\\ WhekdZ j^[
beWZ#jhWdic_jj_d] Z_iai$ J^ki j^[ fei_j_ed e\ j^[
Z_iai"WdZ^[dY[j^[_di[hj_edfWj^"ckijX[YWh[\kbbo
fbWdd[Z je Wle_Z Wdo h[fei_j_ed_d] e\ j^[ Ä e\j[d
Z[[f[hÄWbl[ebW[$

&IGÈ 7Xkjc[dj Z[i_]di :7//" :7+ WdZ :7*$ Dej[ j^Wj

j^[i[WXkjc[djWh[dejl_i_Xb[edN#hWoi$<ehj^_ih[WiedWdZ
È
Wbie X[YWki[ j^[o Wh[ gk_j[ [bWij_Y" ed[ YWd ][j j^[ mhed] 4OOLSÈFORÈ%XTERNAL 4HREADÈ)MPLANTS
_cfh[ii_ed j^Wj j^[ Xh_Z][ _i dej Yedd[Yj[Z Xo Wd WXkjc[dj I[[<_]$*$(&"*$(*W"*$)'W#\$
WjWbb

È
#OMPATIBLEÈ#RESTALÈ)MPLANTÈ4YPESÈÈ
+/3È3YSTEMÈANDÈ3È)MPLANTS
9ecfh[ii_ed iYh[mi e\ j^[ AEI jof[ YWd X[
Yedl[d_[djbo YecX_d[Z m_j^ 8E? _cfbWdji j^Wdai
je j^[_h _Z[dj_YWb Yed\_]khWj_ed$ J^_i _i ed[ e\ j^[
h[Wiedi m^o cWdo _cfbWdjebe]_ij b_a[ je ki[ Xej^
_cfbWdj jof[i i_Z[ Xo i_Z[ \eh XWh WjjWY^c[dji _d
j^[cWdZ_Xb[i[[Wbie9^Wfj[h'/$9ecX_dWj_ede\
AEIiYh[miWdZ8E?_cfbWdji_iWbieki[\kb_dad_\[#
[Z][ZcWn_bbWhoh_Z][i$
&IGÈ 7Xkjc[djZ[i_]diJI:**WdZJI:++m_j^[bed]Wj[Z
feb_i^[Z d[Yai YecfWh[Z je j^[ i^ehj[h JI:* WdZ JI:+
Z[i_]di È
3EMI PERMANENTÈ"ONDINGÈÈ
ONÈ%$È)MPLANTS
WXkjc[dji m_bb Wbbem \eh ]h[Wj[h ceX_b_jo _d j^[
jhWdi_j_edWbped[X[jm[[dj^[j^h[WZ[Zf_dWdZj^[ J^[Z[l[befc[dje\i[c_#f[hcWd[djXedZ_d]efj_edi
WXkjc[dj$ ^WiX[[dY^WhWYj[h_p[ZXoZ_\\[h[djWffheWY^[i0
M^_b[ j^[ ikh\WY[ Wh[W e\ j^[ _cfbWdj XWi[ v 9[c[dji XWi[Z ed c[j^WYhobWj[ YecfekdZi
_]deh_d]WdohekdZ[Z[Z][i_i]_l[d_dc_bb_c[jh[i [$]$ 9[hW\_n =[djW 9[hWl[h =cX>" <hWda\khj"
[$]$'&'*cc\eh;:7I'&%'*=,"j^[b[d]j^e\j^[ =[hcWdo ^Wl[ X[[d ki[Z j^Wj Wbbem \eh Z[#
j^h[WZ[Z f_d _i YbWii_\_[Z _d ]hWZ[i '=3'$+cc$ XedZ_d] Xo j^[hcWb WYj_ed Wffb_YWj_ed e\ ^[Wj$
J^_i = YWj[]eh_pWj_ed _i ki[Z WYheii j^[ mehbZ \eh J^[ ^[Wj YWd X[ ][d[hWj[Z Xo Wffbo_d] hejWj_d]
È È 4OOLSÈFORÈ%XTERNALÈ4HREADÈ$ESIGNSÈ *'

&IGÈAB J^[JI:#I8WXkjc[djZ[i_]d_iki[Zje][j^[hm_j^WdD9dobedYWfje[ijWXb_i^Wh[l[hi_Xb[Yedd[Yj_ede\j^[

fheij^[j_YijhkYjkh[WdZ"Wjj^[iWc[j_c["Y[c[djWj_ed[$]$e\WijWX_b_p_d]XWhWjjWY^c[dj_dj^[Wh[We\j^[Yed_YWbWXkjc[dj
i[]c[dji$J^[Yb_d_YWbWffb_YWj_ed_i_bbkijhWj[Z_dX$J^[XWbbh[jW_d[h_dj[]hWj[Z_dj^_ijof[e\WXkjc[djZe[idej^Wl[jeX[
iebZ[h[Z je YWij edje j^[ XWh WjjWY^c[dj$ X I_dY[ JI: I8 WXkjc[dji ^Wl[ j^[ XWbb h[jW_d[h Wi _dj[]hWb Yecfed[dji" j^[ XWh
WjjWY^c[dj_i\WXh_YWj[Zm_j^edboed[YWij#edh_d]j^Wj_iib_ff[Zel[hj^[XWbbh[jW_d[hWdZi[Ykh[ZXoWZ^[i_l[XedZ_d]eh
Y[c[djWj_ed

v 9_hYb_f ioij[ci [$]$ IH+1 cWj[h_Wb0 J_ =hWZ[ +$
&IGÈ ?di[hj_edW_Z?JAEI_iki[ZjeiYh[mWdZj_]^j[dj^[
WXkjc[dj el[h j^[ [nj[hdWb _cfbWdj j^h[WZ$ J^[ ^[WZ e\ j^[ v :ekXb[#j^h[WZ[Z iYh[mi \WY_b_jWj[ j^[ _di[hj_ed
jeeb_iYecfWj_Xb[m_j^j^[H7J(hWjY^[jWdZej^[hjeebi[$]$
m_j^j^[?J?Ioij[c
&IGÈ JhWdi\[hYef_d]iWbbem_cfh[ii_edijeX[cWZ[[l[d
_di_jkWj_edim^[h[WdWXkjc[djWh[We\WZ[gkWj[b[d]j^_idej
WYY[ii_Xb[ \eh j^[ _cfh[ii_ed cWj[h_Wb Zk[ je feijef[hWj_l[ v I_dY[ j^[ l[hj_YWb Z_c[di_ed YWddej X[ [Wi_bo
im[bb_d]ehZ[[ffbWY[c[dje\j^[_cfbWdj$
_dijhkc[djidejWXbojkd]ij[dYWhX_Z[Ykjj[hije
j^[\hWc[mehaehj^[WXkjc[djWh[W$
J^[i[ ioij[ci ckij X[ [gk_ff[Z m_j^ fh[Y_i_ed
]heel[i [$]$ I7+1 cWj[h_Wb0 9e9hCe _d j^[
\hWc[mehaWdZm_j^if[Y_WbWXkjc[dji\[Wjkh_d]
]heel[iWim[bb$J^[Z[]h[[e\fh[Y_i_edh[gk_h[Z
_d j^[ Z[djWb bWXehWjeho _i ikXijWdj_Wbbo ^_]^[h
j^Wdm_j^Y[c[dj[Zkd_ji$?\j^[h[gk_h[ZZ[]h[[
e\ fh[Y_i_ed _i ekj e\ h[WY^ Zk[ je j^[ [nj[dj e\
ckiYkbWh `Wm \b[n_ed" fWii_l[ Y[c[djWj_ed ckij
X[ f[h\ehc[Z fWhj_YkbWhbo _d j^[ cWdZ_Xb[$
J^[ h[ijehWj_ed YWd X[ h[cel[Z Xo Z[ijheo_d]
j^[ Y_hYb_fi WdZ h[fbWY[Z Xo ikXij_jkj_d] d[m
Y_hYb_fi$ J[cfehWho Y[c[dji eh i_b_Yed[i Wh[
ki[Z WZZ_j_edWbbo je Ybei[ Wdo ]Wfi X[jm[[d j^[
WXkjc[dj WdZ j^[ ]heel[" j^ki c_d_c_p_d] XWZ
ic[bbiWdZXWYj[h_Wbh[j[dj_ed$
e\ fheij^[j_Y ijhkYjkh[i cW_dbo _d i_jkWj_edi
m^[h[ j^[ WXkjc[dji i^em l[ho Z_\\[h[dj Wn_Wb
_dYb_dWj_edi$?dj^[fh[i[dY[e\cWdZ_XkbWhh_Z][
h[iehfj_ed" \eh _dijWdY[" f[hcWd[dj Y[c[dj YWd
X[ ki[Z \eh j^[ Wdj[h_eh WXkjc[dji" m^_b[ j^[
Z_ijWb WXkjc[dji Wh[ Yedd[Yj[Z m_j^ ZekXb[#
j^h[WZ[Z iYh[mi$ J^_i iebkj_ed Y[hjW_dbo ^Wi j^[
Z_iWZlWdjW][ j^Wj j^[ ifWY[ h[gk_h[c[dji \eh
j^[ lWh_eki Yecfed[dji Wh[ ]h[Wj[h$ :ekXb[#
j^h[WZ[ZiYh[mim_bbWbieWbbemj[cfehWhoXh_Z][i
je X[ _di[hj[Z _d ikY^ W mWo j^Wj j^[o YWd X[
Yedl[d_[djbo h[cel[Z$ J^[ [nj[hdWb j^h[WZi e\
j^[ ZekXb[#j^h[WZ[Z WXkjc[dji Wh[ cWZ[ \hec
9h9eCe" ie j^Wj j^[i[ fWhji YWd X[ Yedd[Yj[Z
Z_h[Yjbojej^[Xh_Z][XofbWicWehbWi[hm[bZ_d]$
cW_djW_d[Z m^[d ZekXb[#j^h[WZ[Z iYh[mi Wh[
*( 9^Wfj[h*È )NSERTIONÈ4OOLSÈANDÈ)MPLANTÈ$ESIGNS

&IGÈ 9ecX_dWj_ed
e\AEIWdZ8E?_cfbWdji
kj_b_p_d]j^[[n_ij_d]dWj_l[
Xed[ijhkYjkh[$<ehj^[
AEIiYh[mi"j^[cWn_bbWho
h_Z][^WZjeX[^eh_pedjWbbo
[nfWdZ[Z$J^Wdaijej^[
bWh][dkcX[he\_cfbWdji"
Wj[cfehWhoXh_Z][YekbZ
d[l[hj^[b[iiX[_di[hj[Z
WdZ_cc[Z_Wj[bobeWZ[Z

&IGÈ JkX[he#fj[ho]e_Z
iYh[miWh[dehcWbbodej
_dYbkZ[Z_dj^[j[cfehWho
h[ijehWj_ed$Iec[j_c[ij^[o
YWd[l[dX[[nYbkZ[Z\hec
j^[Z[\_d_j_l[h[ijehWj_ed"
fhel_Z[Zj^WjWbbej^[h
_cfbWdjiWh[ikYY[ii\kbbo
eii[e_dj[]hWj[ZWdZj^[
Wdj[h_eh_cfbWdjiWh[
WZ[gkWj[boijWX_b_p[Z$
I[[9^Wfj[h',\ehZ[jW_bi
h[]WhZ_d]j^_iYedY[fje\
jkX[hefj[ho]e_ZiYh[mi

ki[Z" j^[ iYh[m ^Wi je X[ jkhd[Z je j^[ j^h[WZ j^h[WZ[Z f_d$ 8ej^ cWo ]_l[ h_i[ je f^ed[j_Y
e\ j^[ _cfbWdj X[\eh[ j^[ Y[c[djWj_ed e\ ej^[h fheXb[ci$
_cfbWdji WXkjc[dji _i f[h\ehc[Z$ Ej^[hm_i[" _\ v 7i _dZ_YWj[Z WXel[" Xh_Z][i j^Wj m_bb ^Wl[ je X[
Y[c[djWj_ed _i f[h\ehc[Z _d j^[ fh[i[dY[ e\ h[cel[Z _d Zk[ Yekhi[ YWd X[ Y[c[dj[Z _d W
Wdj[h_ehikffehjedbo"j^[Z_ijWbXh_Z][i[]c[dji i[c_#f[hcWd[dj cWdd[h Xo YecX_d_d] ]bWii#
cWoikZZ[dbojkhdekjjeX[_dWd_d\hW#eYYbkiWb _edec[hY[c[djiehf^eif^Wj[Y[c[djm_j^:[bh_d
fei_j_ed \ebbem_d] Y[c[djWj_ed$ ?\ ZekXb[# WXkjc[dji :7*" :7+" :7//$ J^_i WffheWY^
j^h[WZ[Z iYh[mi Wh[ ki[Z j^hek]^ekj" j^[ ^[_]^j YWd Wbie X[ WZefj[Z _d i_jkWj_edi m^[h[ heeji
YWdX[Y^[Ya[Z"WdZWdoikXi[gk[djWZ`kijc[dji j^Wj YWddej X[ fh[i[hl[Z _d j^[ bed] j[hc YWd
f[h\ehc[Z"ceh[[Wi_bo$Kd\ehjkdWj[bo"j^[ki[e\ ij_bb X[ _dYehfehWj[Z \eh _d_j_Wb ijWX_b_jo eh Xed[
ZekXb[#j^h[WZ[Z iYh[mi _d j^[ Wdj[h_eh i[]c[dj fh[i[hlWj_ededWj[cfehWhoXWi_i$7YWi[b_a[j^_i
_ikikWbbodeje\j[dWdefj_ed"i_dY[j^[oh[gk_h[ _i_bbkijhWj[Z_d<_]$*$(+WÄZ$
ckY^ ifWY[ WdZ W hWj^[h fWbWjWb beYWj_ed e\ j^[
È È )NTERNALÈ$ESIGNÈWITHÈANÈ%XTERNALÈ(EXAGONÈ)$È3YSTEM È *)

&IGÈA :ekXb[#j^h[WZ[Z iYh[m \eh Wd [nj[hdWb 8E? _cfbWdj$ IYh[m_d] _i f[h\ehc[Z m_j^ Wd >JI'$(+ ^[n[Z _dijhkc[dj"
m^_Y^Yec[i_djmeZ_\\[h[djb[d]j^ij^[\_]kh[i^emij^[i^ehjl[hi_ed$ B ?dj^[cWdZ_Xb["ZekXb[#j^h[WZ[ZiYh[miWh[W
]eeZY^e_Y[_di_jkWj_edim^[h[j^[_di[hj_edfWj^Z_\\[hiYedi_Z[hWXboX[jm[[dj^[Z_ijWb_cfbWdjiWdZj^[Wdj[h_ehWXkjc[dji
j[[j^eh_cfbWdjim^_b[j^[_cfbWdjiYWddejX[\b[n[ZZk[jej^[h[ZkY[Zl[hj_YWbZ_c[di_ed$J^[_cfehjWdjfWhjZkh_d]j^[
Y[c[djWj_ed ij[f _i j^Wj j^[ _cfbWdj j^h[WZ _i fbWY[Z Y[djhWbbo _dje j^[ _dj[hdWb j^h[WZ e\ j^[ fheij^[j_Y ikf[hijhkYjkh[$ J^[
ZekXb[#j^h[WZ[ZiYh[mYWdX[fbWY[Zi_ckbjWd[ekibom_j^j^[Y[c[djWj_edij[fehbWj[h$ C :ekXb[#j^h[WZ[ZiYh[miYWdWbieX[
fei_j_ed[ZedeYYbkiWbikh\WY[i$?dj^_iYWi["j^[h[ijehWj_edmWiY[c[dj[ZWj)*WdZiYh[m[Zjej^[8E?_cfbWdjWj),

È _di[hj_ed [Wi_[h m^[h[ jkX[hefj[ho]e_Z iYh[mi Wh[

)NTERNALÈ$ESIGNSÈWITHÈANÈ%XTERNALÈ(EXAGONÈ _dlebl[Z$
)$È3YSTEM

J^[?:i[h_[iWYYehZ_d]jeIYehj[YY_mWiZ[l[bef[Z
_d YecX_dWj_ed m_j^ ¼IjhkYjkh[½ iYh[m _cfbWdji _d
j^[l[ho[Whbof^Wi[e\iYh[m_cfbWdjZ[i_]di$
J^[o \[Wjkh[ Wd _dj[hdWb j^h[WZ C'$*" m^_Y^
_i YecX_d[Z m_j^ Wd [nj[hdWb ^[nW]ed ikhhekdZ[Z
Xo W h_d]#i^Wf[Z [dYbeikh[$ J^_i Z[i_]d _i edbo
4HREADÈ$ESIGNSÈ)$/È3YSTEM
YecfWj_Xb[m_j^j^[ijhkYjkhWbiYh[m_cfbWdjioij[c$
J^[ X_] WZlWdjW][ e\ j^_i jof[ e\ Z[i_]d _i j^Wj
j^[ [nj[hdWb eYjW]ed Ze[i dej fhejhkZ[ \hec j^[
h[ijehWj_ed ikh\WY[ e\ j^[ _cfbWdj$ J^_i Wbbemi j^[
_di[hj_ed e\ h[ijehWj_edi [l[d m^[h[ j^[ _cfbWdji
j^[ci[bl[iWh[dejfWhWbb[b$J^_i\[Wjkh[WbiecWa[i
È
)NTERNALÈ"/)È$ESIGNSÈÈ
WITHÈANÈ%XTERNALÈ/CTAGON
È
)NTERNAL
?:E _cfbWdji ^Wl[ W ckY^ ceh[ h_]_Z Z[i_]d j^Wd
;: _cfbWdji$ J^[ j^h[WZ[Z f_di ^Wl[ W Z_Wc[j[h e\
($)cc ;: '$/cc" WdZ j^[ fheij^[j_Y ijhkYjkh[
_i jof_YWbbo cekdj[Z je j^[ _cfbWdji l_W W iYh[m[Z
Yedd[Yj_ed$ J^[ ikh][ed _i j^ki \WY[Z m_j^ j^[
** 9^Wfj[h*È )NSERTIONÈ4OOLSÈANDÈ)MPLANTÈ$ESIGNS

&IGÈA J^[XWiWbi[]c[dje\j^_icWn_bbWhoXh_Z][mWih[_d\ehY[Zm_j^f_dafehY[bW_dZk[jelebkc[fheXb[ci\ebbem_d]j^[
beiie\_dY_iehi$J^[h[i_ZkWbYWd_d[im_bbcW_djW_dj^[m_Zj^WdZWdj[heZ_ijWbZ_c[di_ede\j^[h_Z][$J^[h[\eh["[njhWYj_ede\
YWd_d[ii^ekbZX[Z[bWo[ZWibed]Wifeii_Xb["m^_Y^YWdedboX[eXjW_d[Zj^hek]^i[c_#f[hcWd[djY[c[djWj_ed$ B <hedjWb
l_[me\Xh_Z][X[\eh[i[c_#f[hcWd[djY[c[djWj_ed$ C J^[jmeYWd_d[iWh[dejd[[Z[Zjeh[jW_dj^[Xh_Z]["m^_Y^_iijWX_b_p[Z
f[h\[Yjbom[bbXoj^[_di[hj[Zjh_fb[8E?_cfbWdji$Ij_bb"j^[YWd_d[iWh[WXb[jefh[i[hl[j^[WlW_bWXb[Xed[m_Zj^\ehWY[hjW_d
f[h_eZe\j_c["m^_Y^m_bbi_]d_\_YWdjbo_cfhel[j^[i_jkWj_ed_dj[hcie\lebkc[WdZW[ij^[j_Yi$<ehi[c_#f[hcWd[djY[c[djWj_ed"
fe_dj[Z:7WXkjc[djiWh[YecX_d[Zm_j^]bWii#_edec[hY[c[dj$Dej[j^Wji[c_#Z[\_d_j_l[Y[c[djWj_ediedj[[j^ki_d]J[cf
8edZ Wh[ edbo feii_Xb[ \eh W b_c_j[Z f[h_eZ e\ j_c[" i_dY[ j[[j^ j[dZ je Z[YWo kdZ[hd[Wj^ j^[i[ Y[c[dji$ D FWdehWc_Y
hWZ_e]hWf^e\j^[iWc[YWi[

WZZ_j_edWb Y^Wbb[d][ je fei_j_ed j^[ _cfbWdji _d
ikY^WmWoj^Wjj^[iYh[miWh[dejbeYWj[Z_dW\WY_Wb
fei_j_ed$?:E_cfbWdjiZe"^em[l[h"e\\[hj^[Z[\_d_j[
WZlWdjW][e\Wbbem_d]j^[fheij^[j_YijhkYjkh[jeX[
h[cel[ZWjWdoj_c[$I_dY[j^[Z_ijWdY[X[jm[[dj^[
Z_ia WdZ j^[ Ykf#i^Wf[Z ^[WZ lWh_[i Z[f[dZ_d] ed
j^[ = lWbk[" W Z[Z_YWj[Z _d_j_Wb Ykjj[h d[[Zi je X[
ki[Z\eh[WY^=lWbk[$
È
4OOLSÈFORÈ3URGERY
?j _i h[Yecc[dZ[Z je a[[f Wbb ikh]_YWb _dijhkc[dji
^WdZo_dWm[bb#ijhkYjkh[ZbWoekj$J^[YecfWhjc[dj
ed j^[ h_]^j YWd X[ ki[Z \eh _cfbWdji j^Wj m[h[
kdfWYa[ZXkjdejki[ZedWfh[l_ekieYYWi_ed$
Iec[j_c[i_j_id[Y[iiWhojei^ehj[d;:_cfbWdji
Ä \eh [nWcfb[ X[YWki[ j^[ i^ehj[h b[d]j^ d[[Z[Z
_i dej _d ijeYa Zkh_d] ikh][ho" Xkj Wbie _j cWo Wbie
jkhd ekj je X[ d[Y[iiWho bWj[h" Wj j^[ X[]_dd_d] e\
j^[ fheij^[j_Y f^Wi[ e\ jh[Wjc[dj" Wi j^[ ]_d]_lW
cWo^Wl[YedjhWYj[ZXokd[nf[Yj[Z[nj[dj"b[Wl_d]W
bed][nfei[Zikh\WY[e\j^[j^h[WZ[Zf_dl_i_Xb[$J^[
J7F#:_dijhkc[dj_iki[ZjeYh[Wj[Wd[mj^h[WZed
;:#_cfbWdji W\j[h j^[ eh_]_dWb j^h[WZ ^Wi X[[d beij
ehYkje\\$
È
)NTERNALÈ6ERSUSÈ%XTERNALÈ4HREADÈ$ESIGNS
J^[ WZlWdjW][ e\ ?: _cfbWdji _i j^Wj j^[ Z[djWb
j[Y^d_Y_Wd ^Wi de fheXb[ci m_j^ j^[ l[hj_YWb
Z_c[di_ed" Wi j^[ iYh[m Yedd[Yj_ed [nj[dZi Z[[f
_djej^[_dj[hdWbj^h[WZ"m^_b[j^[ifWY[h[gk_h[c[dj
WXel[ j^[ ckYeiW _i edbo (Ä)cc$ :[if_j[ j^_i
h[bWj_edi^_f"j^[iYh[mYedd[Yj_edi^Wl[jeX[fbWY[Z
Wjj^[]_d]_lWbb[l[bjef[hc_jWYY[ii\ehYb[Wd_d]WdZ
jeWle_ZfeYa[j\ehcWj_ed$J^[bWh][Z_Wc[j[he\j^[
Ykff[d[jhWj_d]j^[ckYeiWWbbemic_Yheeh]Wd_ici
je WZlWdY[ Z[[f[h$ <eh j^_i h[Wied" ?: WdZ ?:E
È È )NTERNALÈ6ERSUSÈ%XTERNALÈ4HREADÈ$ESIGNSÈ *+

_cfbWdji Ze dej \[Wjkh[ ikh\WY[#[dbWh][Z Ykfi eh

&IGÈ 7dej^[h efj_ed e\ Yedd[Yj_d] ikf[hijhkYjkh[i _d W
i[c_#f[hcWd[djcWdd[h_iXoj^[ki[e\Y_hYb_fi$J^[Y_hYb_f
i^emd ed j^[ b[\j _i _di[hj[Z j^hek]^ j^[ ibej i^emd ed j^[
h_]^j kdj_b _j [d]W][i j^[ ]heel[ e\ j^[ WXkjc[dj$ J^[d j^[
^WdZb[_iXhea[de\\j^[h_d]$<ehh[celWbWjWbWj[hj_c["j^[
h_d]^WijeX[Z[ijheo[Z
&IGÈ ?::/=*$J^[Yedd[Yj_edfWhji_dj[hdWbj^h[WZWdZ
^[nW]edWh[Yb[Whbol_i_Xb[
j^h[WZ[Z f_di$ 7bie" iYh[m[Z ijhkYjkh[i YWd X[
h[cel[Zceh[[Wi_boj^WdY[c[dj[ZijhkYjkh[i$
Ed j^[ ej^[h ^WdZ" ?: _cfbWdji YWddej X[ ki[Z
\eh [bWij_Y _cfbWdj#h[ijehWj_ed ioij[ci Zk[ je
j^[_h m_Z[ Ykfi WdZ ceh[ h_]_Z Z[i_]di$ I_dY[ j^[
fheij^[j_YiYh[miWh[j^_dd[hj^Wdj^[j^h[WZie\;:
ioij[ci" j^[o Wh[ ceh[ ikiY[fj_Xb[ je Xh[WaW][ WdZ
beei[d_d]$
J^[ceijZ_\\_YkbjfWhje\j^[_di[hj_edfheY[Zkh[
\eh?:_cfbWdji_ijefbWY[j^[YkfWj_jiYehh[Yjb[l[b$
M^_b[ ;: _cfbWdji Wh[ WbmWoi fbWY[Z _d ckbj_fb[i
_d W b_d]kWb eh fWbWjWb Z_h[Yj_ed je Yh[Wj[ ifWY[ \eh
W[ij^[j_Y Yedi_Z[hWj_edi" j^[ ?: _cfbWdji ckij X[
WiieY_Wj[Z m_j^ Wd ¼[c[h][dY[ fhe\_b[½" _$[$ j^[
d[m ¼jeej^½ _i Z[l[bef[Z \hec _di_Z[ j^[ ]_d]_lW
Wjj^[fei_j_ede\j^[Ykf$H[ijeh_d]W[ij^[j_Yim_j^
?: _cfbWdji _i W ceh[ Yecfb[n jWia" fWhj_YkbWhbo
m^[d j^[ ]_d]_lWb b[l[bi Wh[ l[ho Z_\\[h[dj WdZ
_d j^[ fh[i[dY[ e\ l[ij_XkbWh YebbWfi[ \ebbem_d]
f[h_eZedjWbZ_i[Wi[$9bei[Wjj[dj_edckijX[fW_Zje
j^_i Wif[Yj Zkh_d] j^[ ikh]_YWb fheY[Zkh[$ ?j i^ekbZ
X[h[c[cX[h[Zj^Wj?:WdZ?:Eioij[ciYWddejX[
ikXi[gk[djboh[ZkY[Z_db[d]j^"m^_Y^c[Wdi]h[Wj[h
YWh[ckijX[[n[hY_i[Z_dijeYa#a[[f_d]$Edj^[ej^[h
^WdZ"fheij^[j_YijhkYjkh[ied?:WdZ?:E_cfbWdji
cWo X[ kdiYh[m[Z" m^_Y^ \WY_b_jWj[i Wdo \ebbem#kf
jh[Wjc[dj W_c[Z Wj h[fbWY_d] _cfbWdji eh h[fW_h_d]
j^[fheij^[j_YijhkYjkh[$;:_cfbWdjiÄfWhj_YkbWhbo
j^[ ceh[ h[Y[dj Z[i_]di \[Wjkh_d] iceej^ i^W\ji
Äl_hjkWbbod[l[hh[ikbj_dYhWj[h#ijob[YebbWfi[e\j^[
cWh]_dWb Xed[ ijhkYjkh[" WdZ j^[o Wh[ WbmWoi m[bb
WYY[ii_Xb[ je Xhki^_d] WdZ \beii_d] Xo j^[ fWj_[dj
[l[d_\j^[fehY[bW_dh[ijehWj_ed_iY^WhWYj[h_p[ZXo
l[ij_XkbWhel[hYedjekh_d]$J^[oWbiee\\[h\WlekhWXb[
YedZ_j_edi\ehi[b\#Yb[Wd_d]$
J^_i _i Wd [ii[dj_Wb h[Wied m^o fheij^[j_Y kd_ji
Wh[ kikWbbo Yedd[Yj[Z je ;: _cfbWdji Xo mWo e\

&IGÈA ?:E/%'(=+$J^[eYjW]edWb^[WZ_iYecfWj_Xb[Xej^m_j^I#_cfbWdjiWdZ?J?#_cfbWdji$:k[jej^[Y[djh_Yfei_j_ed
e\j^[j^h[WZ[Zf_d"j^[^eh_pedjWbYkjckijX[YWhh_[Z\khj^[hj^Wjj^[jh[WZ[Zf_d_ji[b\mekbZh[gk_h["m^_Y^YWdX[WY^_[l[Z
Xo ki_d] Wd B9/# eh B9'&#jof[ Ykjj[h$ B <eh ?:E#_cfbWdji Y[c[dj_d] WXkjc[dji Wh[ WlW_bWXb[$ J^[o Wh[ iYh[m[Z _dje j^[
_dj[hdWbj^h[WZe\j^[eYjW]edWb^[WZ$J^[YhemdckijX[Y[c[dj[Zel[hj^[WXkjc[djWdZh[WY^j^[ekj[hh_d]"m^_Y^\[Wjkh[i
WZ_Wc[j[he\*$.cc
*, 9^Wfj[h*È )NSERTIONÈ4OOLSÈANDÈ)MPLANTÈ$ESIGNS
Y[c[dj_d]$ F[h_eZ_Y h[celWb e\ j^[ fheij^[j_Y
ikf[hijhkYjkh[" Wi \h[gk[djbo h[Yecc[dZ[Z m_j^
Yh[ijWbioij[ciWdZ?:_cfbWdji"X[Yec[id[Y[iiWho
b[ii \h[gk[djbo" Wi j^[ j^_d [c[h][dY[ fe_dji e\
j^[ WXkjc[dji j[dZ je ^Wl[ \WlekhWXbo ]eeZ i[b\#
Yb[Wd_d]fhef[hj_[i$
&IGÈ B9-Ykjj[h\ehYedjhW#Wd]b[^WdZf_[Y[ki[Z\eh
Ykjj_d]j^[YkfWjW=)Z_ijWdY[$<eh[WY^=#b[d]j^Wi[fWhWj[
Ykjj_d]_dijhkc[dj_id[Y[iiWho
&IGÈ <kbbo[gk_ff[Zikh]_YWbjhWo\eh
_dijhkc[dji\eh<=j[di_ed
7i c[dj_ed[Z" j^[ fheij^[j_Y iYh[m \eh ?:
_cfbWdji Yedi_iji e\ fkh[ ]ebZ WdZ _i Z[i_]d[Z
je kdZ[h]e fbWij_Y Z[\ehcWj_ed Zkh_d] iYh[m_d]"
j^ki cWn_c_p_d] j^[ ikh\WY[ Wh[W e\ j^[ iYh[m
Yedd[Yj_ed je h[_d\ehY[ h[j[dj_ed e\ j^[ fheij^[j_Y
ikf[hijhkYjkh[$ <_d[#]ebZ iYh[mi Wbie i^em ^_]^[h
\hWYjkh[ h[i_ijWdY[ X[YWki[ j^[o Wh[ ie\j i[[ \eh
\khj^[hZ[jW_bimmm$Z_ia_cfbWdj$Yec$
È È )NTERNALÈ6ERSUSÈ%XTERNALÈ4HREADÈ$ESIGNSÈ *-

&IGÈA JWf\[Wjkh_d]W^[WZj^Wj_iYecfWj_Xb[m_j^WH7J(hWjY^[jmh[dY^$
J^[jWfYWdX[ki[Z\eh0'iW\[\b[n_d]e\j^[j^h[WZ[Zf_dZkh_d]j^[fheY[Zkh[1
(Yh[Wj_d]Wd[mehbed][hj^h[WZX[\eh[ehW\j[h_cfbWdjWj_ed1)h[cel_d]Wdo
YWbYkbki"YedYh[c[djiehej^[hZ[Xh_i\hec[nj[hdWbj^h[WZi1*h[fW_h_d]j^[
[nj[hdWbj^h[WZW\j[h_dWZl[hj[djbo_di[hj_d]j^[WXkjc[djWjWdWd]b[$ BnF ?\
j^[_cfbWdjbeeai[nY[ii_l[bobed]Zkh_d]fbWY[c[djWdZ_\deej^[h_cfbWdj
_iWlW_bWXb["_jYWdX[h[ZkY[ZWdZ\_jj[Zm_j^Wd[mj^h[WZ$<ehj^_ifkhfei["
j^[XWi[e\j^[j^h[WZ^WijeX[h[cel[ZWim[bb$J^[ie\j[hj_jWd_kcWbbeoe\
j^[j^h[WZ[Zf_dm_bbX[iec[m^WjYecfh[ii[ZXoj^[^WhZ[hcWj[h_Wbe\j^[
WXkjc[dj$7Xkjc[djiedh[#jWff[Zj^h[WZii^ekbZdejX[h[cel[ZedY[j^[o
^Wl[X[[dj_]^j[d[Z"i_dY[\_hcboj_]^j[d[ZWXkjc[djiWh[b_a[boje^Wl[WijhW_d#
^WhZ[d[ZYedd[Yj_ed_dj[h\WY[$J_'+Ce#_cfbWdjiYWddejX[]_l[dWd[mj^h[WZ_d
j^_imWoX[YWki[j^[_cfbWdjcWj[h_Wb_ijeeijhed]

#(!04%2È
%QUIPMENTÈANDÈ3URGICALÈ4ECHNIQUES
È
0LANSÈANDÈ/UTCOMESÈANDÈTHEÈ#OEXISTENCEÈ
"ETWEENÈ,IVINGÈANDÈ$EADÈ/BJECTS
F[efb[j[dZjej^_da_j_ihWj^[hbe]_YWbj^Wj_dijWbb_d]
\_n[Zj[[j^_iWdWZlWdjW][$8kje\j[d[dek]^_jWbceij
i[[ci j^Wj j^[ `Wm j^Wj _i h[Y[_l_d] j^[ h[gk_i_j[
_cfbWdji X[]i je Z_\\[h$ ?j _i Wdo _cfbWdjebe]_ijÉi
Z[i_h[ \eh j^[ `WmXed[ je [dj[h _dje W ijWj[ e\
f[WY[\kb Ye[n_ij[dY[ m_j^ j^[ _cfbWdj[Z eX`[Yj$ ?d
ekh ef_d_ed" j^_i mehai X[ij _\ j^[ XWi_Y \kdYj_edi
e\j^[Xed[Wh[dej_cfW_h[Z$J^[i[XWi_Y\kdYj_edi
_dYbkZ[ j^[ cejeh \kdYj_ed j^Wj _i h[gk_h[Z \eh j^[
ikhl_lWb e\ Wdo Xed[ WdZ j^[ kd_cf[Z[Z \bem e\
dkjh_[dji"]Wi[i"WdZmWij[fheZkYji$
È
'ENERALÈ#ONSIDERATIONS
8[\eh[ j^[ _cfbWdj fheY[Zkh[ X[]_di" fW_d#
h[b_[l_d] c[Wikh[i ckij X[ jWa[d$ J^[ ikh]_YWb i_j[
_i Z_i_d\[Yj[Z m_j^ Y^beh^[n_Z_d[ Z_]bkYedWj[ eh
8[jWZ_d[$<khj^[hceh["j^[Z[dj_ijcWoY^eei[jee_b
j^[Yehd[hie\j^[cekj^"m_j^ehm_j^ekjfh[l_eki
Wffb_YWj_ede\[ei_d$
J^[_cfbWdjYWdedboX[fbWY[ZW\j[hWfWhWYh[ijWb
\bWf ^Wi X[[d h[\b[Yj[Z bed]_jkZ_dWbbo je j^[ `Wm$
7 ckYef[h_eij[Wb \bWf _i b_X[hWbbo Z_ibeZ][Z WdZ
m[bb i[Ykh[Z je Wle_Z Wdo YedjWYj m_j^ hejWj_d]
_dijhkc[dji$8Wi[ZedekhYb_d_YWb[nf[h_[dY["j^[h[
_iWZ_ij_dYjh[bWj_edi^_fX[jm[[dj^[i_p[e\j^[\kbb
j^_Yad[ii \bWf WdZ j^[ b[l[b e\ feijef[hWj_l[ fW_d$
J^[b[l[bWdZZkhWj_ede\feijef[hWj_l[fW_dYWdX[
h[ZkY[Z"^em[l[h"Xoa[[f_d]j^[fheY[Zkh[h[bWj_l[bo
i^ehjWdZb_X[hWbboZ_ibeZ]_d]ckYef[h_eij[Wbj_iik[
\eh\bWfh[\b[Yj_ed$;nf[h_[dY[Zikh][edim_bbkikWbbo
jWa[ de bed][h j^Wd WhekdZ ,&c_d \eh W Yecfb[j[
_cfbWdj fheY[Zkh[ Z[i_]d[Z je ikffehj W \kbb#WhY^
h[ijehWj_ed$ Dej[ j^Wj j^[ \bWf ckij X[ h[\b[Yj[Z \Wh
[dek]^iej^Wjj^[_dY_i_edYWddej_dj[h\[h[m_j^j^[
Z_iaWh[We\j^[fbWdd[Z8E?_cfbWdj$
?\ Wdo j[[j^ Wh[ je X[ [njhWYj[Z _d j^[ iWc[
fheY[Zkh[" j^[ _dY_i_ed _i Z[i_]d[Z ikY^ j^Wj W
YehedWb WZlWdY[c[dj \bWf YWd X[ \ehc[Z je X[
ZhWmdel[hj^[Wbl[ebki$J^[WZ`WY[djj[[j^Wh[dej
 ¬ 
Y_hYkcY_i[Z _d j^_i i_jkWj_ed$ J^_i _i fWhj_YkbWhbo
_cfehjWdj _\ Wdo h[i_ZkWb j[[j^ beYWj[Z d[nj je j^[
_cfbWdji_j[Wh[jeX[b[\j_dfbWY[$
Ekh ijhWj[]o _d f[h_eZedjWbbo _dlebl[Z Wh[Wi _i
je Y_hYkcY_i[ Wdo ]hWdkbWj_ed Wh[Wi WdZ h[cel[
j^[cWbed]m_j^j^[j[[j^$J^[X[ijmWojeZ[Wbm_j^
ckbj_#heej[Z j[[j^" kdb[ii j^[o Wh[ el[hbo ceX_b["
_i je i[fWhWj[ j^[c Wj j^[ heej b[l[b je fh[i[hl[
W cWn_ckc Wcekdj e\ Xed[$ Ed j^[ ej^[h ^WdZ"
WdoXed[ijhkYjkh[ij^Wjm_bbfh[ikcWXboX[beijje
h[iehfj_ed i^ekbZ X[ h[cel[Z h_]^j WmWo" ie j^Wj
j^[h[_idemWo\ehWdofehj_edie\j^[_cfbWdjZ_ia
je X[ _dWZl[hj[djbo _dYbkZ[Z _d j^ei[ ijhkYjkh[i$
I_dY[ cWYhejhW`[Yjeho#Zh_l[d Xed[ h[iehfj_ed _i
_d[l_jWXb[" Wdo Z_ia Wh[Wi j^Wj Yec[ je X[ beYWj[Z
_di_Z[ikY^Xed[ijhkYjkh[iWh[Y[hjW_djebei[j^[_h
[deiiWb ikffehj$ ?d ehZ[h je Yehh[Yjbo fei_j_ed j^[
_cfbWdj_dWbbj^h[[fbWd[i"j^[ikh][edckijh[cW_d
WmWh[ e\ j^[ ¼X_]½ f_Yjkh[ Zkh_d] j^[ eij[ejeco
fheY[Zkh[ hWj^[h j^Wd YedY[djhWj_d] ieb[bo ed j^[
_dijhkc[dj$ Del_Y[i _d fWhj_YkbWh j[dZ je \eYki jee
ckY^ ed j^[ _cc[Z_Wj[ Xed[ ijhkYjkh[" j^[h[Xo
bei_d] i_]^j e\ j^[ _dijhkc[dj Wn_i" j^[ h[bWj_l[
Ykjj_d] Z[fj^ WdZ j^[ [dZfe_dj e\ Ykjj_d]$ J^[
_cfbWdj Wn_i _i dehcWbbo i[b[Yj[Z m_j^ekj h[]WhZ je
j^[_dYb_dWj_ede\j^[l[ij_XkbWhXed[ijhkYjkh[$J^[
]eWb_ijei[Ykh[X_Yehj_YWbWdY^ehW][e\j^[Z_ia_d
Wfei_j_edj^Wj_iYedi_ij[djm_j^j^[WlW_bWXb[Xed[
ijhkYjkh[$
7i Wd WZZ_j_edWb h[gk_h[c[dj _d ?:E%?:EJ
_cfbWdji" j^[ iYh[m WYY[ii ^eb[i ckij dej Yec[
je X[ beYWj[Z _d Wd W[ij^[j_YWbbo h[b[lWdj fei_j_ed$
J^[i[Z[i_]diWh[j^kickY^ceh[Z_\\_Ykbjjeki[_d
j^[W[ij^[j_Yped["fWhj_YkbWhboi_dY[j^[_hj^h[WZ[Z
f_diZedejWbbemX[dZ_d]$J^[iWc[Wffb_[ije;:
_cfbWdjicWZ[e\J_'+Ce$J^[j^h[WZ[Zf_die\j^[i[
Z[i_]diYWddejX[X[dj_dj^[_djhWehWb[dl_hedc[dj
[_j^[h$
J^Wdaijej^[_hiceej^ikh\WY[Z[i_]d"j^[i^W\ji
e\8E?_cfbWdjiWh[f[h\[Yjboik_j[Zjeh[i_Z[_d\h[[
]_d]_lW$ >em[l[h" j^[ ijhWj[]o e\ \bWf fh[fWhWj_ed
i^ekbZ" m^[d[l[h feii_Xb[" b[WZ je W h[ikbj m^[h[
WjjWY^[Z ckYeiW _i fbWY[Z WhekdZ j^[ j^h[WZ[Z
f_d$
J^[ _cfbWdj X[Z _i Yh[Wj[Z j^hek]^ W bWj[hWb
WYY[ii ki_d] l[hj_YWb Ykjj[hi" ^eh_pedjWb Ykjj[hi WdZ
+& 9^Wfj[h+È %QUIPMENTÈANDÈ3URGICALÈ4ECHNIQUES

&IGÈÈA M^[dj^[^ehj_Ykbjkh_ijZ[j[hc_d[Zj^[Z[i_]de\j^_i\[dY[WdZj^[h[bWj_l[fei_j_edie\j^[\[dY[WdZj^[jh[[i"^[
YWd^WhZbo^Wl[X[[dWmWh[e\j^[[dehcekiijh[d]j^WdZj^[feii_Xb[[nj[dje\\kjkh[]hemj^$>emYekbZ^[ej^[hm_i[fbWY[
ikY^Äfheif[Yj_l[boÄcWii_l[jh[[ih_]^jd[njjeWZ[b_YWj["ia[b[jed_p[Z\[dY[5>em[l[h"Xej^j^[i[kd_ji"j^[jh[[WdZj^[\[dY["
m[h[WXb[jeW]h[[edWckjkWbboWYY[fjWXb[b[l[be\f[WY[\kbYe[n_ij[dY[WdZ_dj^_icWdd[hm[Wj^[hj^[Z[YWZ[i$ B El[hj^[
o[Whi"j^[d"j^[jh[[j^WjmWiYedZ[cd[Zje]hemWdZj^[\[dY[j^WjmWiYedZ[cd[Zjem_j^ijWdZckij^Wl[Yec[jeiec[a_dZ
e\WhhWd][c[dj$Gk_j[fheXWXbo"_j_idemceh[j^[jh[[j^Wj^ebZij^[\[dY[je][j^[hj^Wdj^[\[dY[ÉiemdiYh[mi$7YecfWhWXb[
h[ikbj e\ f[WY[\kb ifWj_Wb Ye[n_ij[dY[ X[jm[[d b_l_d] WdZ Z[WZ cWjj[h _i j^[ eX`[Yj_l[ e\ ekh [deiiWb _cfbWdjebe]_YWb meha
Äm^[j^[hm[ki[Yh[ijWbehXWiWb_cfbWdji$M_j^_dj^[YedjWYjWh[Wi"beYWj[Z_di_Z[j^[jh[["j^[\[dY[Z[j[hc_d[ij^[fei_j_edi
WdZeh_[djWj_edie\j^[cWYhejhW`[Yjeh_[i$J^Wjj^[\[dY[[l[d_\_j^WZX[[dcWZ[\hecj_jWd_kcm_j^j^[ceijc_hWYkbeki
ikh\WY[Yedij_jkj[iWdWZZ_j_edWbij_ckbki\ehj^[jh[[je]hem_iiec[j^_d]m[mekbZdejikif[Yj$8kjYbei[eXi[hlWj_ede\
j^[Z_\\[h[djfWhjie\j^[jhkda[c[h]_d]ceh[\[hl[djboehceh[m[Wabob[WZed[jeWiikc[j^Wjj^[&Ä'hkb[Ze[i^ebZ\eh
jh[[iWim[bbi[[9^Wfj[h/\ehZ[jW_bie\j^_iWif[Yj$ C J^_ijh[[mWi[gkWbboYWfWXb[e\X[Wh_d]j^[XkhZ[de\j^[o[WhiWdZ
j^[fhen_c_joe\j^[\[dY["j^_ij_c[m_j^ekjWdo_dj_cWj[Yedd[Yj_edX[jm[[dj^[jmeX[_d]d[Y[iiWho$7YecfWhWXb[h[ikbje\
f[WY[\kbifWj_WbYe[n_ij[dY[X[jm[[db_l_d]WdZZ[WZcWjj[hYWdX[j^[eX`[Yj_l[e\ekh_cfbWdjebe]_YWbmeham_j^ikXf[h_eij[Wb
_cfbWdji eh X[dj el[h l[ij_XkbWh 8E? ijhkji$ D F[WY[\kb Ye[n_ij[dY[ ckij ^Wl[ [n_ij[Z ^[h[" jee" Wj iec[ fe_dj _d j^[ fWij$
>em[l[h" Y_hYkcijWdY[i j^Wj fheXWXbo m[h[ kdh[bWj[Z je j^[ \WYj e\ Ye[n_ij[dY[ _ji[b\ ^Wl[ edbo W\\ehZ[Z j^[ b_l_d] cWjj[h W
i^ehj[hj_c[ifWdjeikhl_l[

YecX_dWj_edYkjj[hi$J^[\_hijl[hj_YWbXed[YkjYWd
X[f[h\ehc[Zm_j^Wjkd]ij[dYWhX_Z[Ykjj[hjeWle_Z
kdd[Y[iiWhom[Whe\j^[l[hj_YWbYkjj[h$
J^[ fh[fWhWj_ed _i kikWbbo f[h\ehc[Z m_j^ W
jkhX_d[kdZ[hfhe\ki[_hh_]Wj_ed$JkhX_d[ie\\[hj^[
WZlWdjW][ e\ W bem jehgk[" _$[$ j^[o m_bb [l[d ijef
hejWj_d]m^[dj^[ikh][edki[i[nY[ii_l[\ehY[$J^_i
fh[YWkj_edm_bbWle_ZXej^^[Wj#h[bWj[Z_d`kh_[ijej^[
Xed[WdZfh[cWjkh[m[Whe\j^[Ykjj_d]_dijhkc[dji$
>[bf\kb jeebi Wbie _dYbkZ[ ^_]^#if[[Z YedjhW#Wd]b[
^WdZf_[Y[i WdZ j^[ ;B9E ioij[c m_j^ ed#XeWhZ
jehgk[ Yedjheb h[Y[djbo _djheZkY[Z Xo M>$ J^[
bWjj[hioij[c_iefj_cWbboki[Z_dYed`kdYj_edm_j^W
YedjhW#Wd]b[^WdZf_[Y['0($-Wj(&"&&&eh*&"&&&hfc
m_j^ j^[ jehgk[ WZ`kij[Z je )&$ >_]^#if[[Z
YedjhW#Wd]b[ ^WdZf_[Y[i cekdj[Z je Yedl[dj_edWb
È È 'ENERALÈ#ONSIDERATIONSÈ
Z[djWb kd_ji Ze dej WbmWoi e\\[h jehgk[ WZ`kijc[dj$
J^[ Ykjj[hi cWo iec[j_c[i X[dZ _d j^[ ^WdZi e\
_d[nf[h_[dY[Z ikh][edi" Wi [l[d c_deh hejWj_edWb
_cXWbWdY[i \hec j^[ X[Wh_d] _\ j^[ _dijhkc[dj m_bb
_cc[Z_Wj[boZ[\ehcj^[Ykjj[hm^[dmeha_d]Wj^_]^
jehgk[$7\j[hWbb"j^[_dijhkc[djh[WY^[i^_]^if[[Zi
Wbceij _dijWdjbo$ J^[ if[[Z e\ hejWj_ed Wi ikY^" de
cWjj[h ^em ^_]^ _j _i" YWddej _d\b_Yj Wdom^[h[ d[Wh
j^[ZWcW][Zed[XoWd[nY[ii_l[jehgk[$
EdY[j^[l[hj_YWbWdZbWj[hWbXed[Ykji^Wl[X[[d
Yh[Wj[Z" j^[ _cfbWdj _i _di[hj[Z j^hek]^ W bWj[hWb
WYY[ii ki_d] YWh[\kbbo Zei[Z ^Wcc[h#ijob[ ijhea[i$
7i j^[ ijhkYjkhWb ^[_]^j _d j^[ XWiWb fbWj[ Wh[W
cWolWhoZ[f[dZ_d]edj^[[nWYjZ[i_]d"_jcWoX[
d[Y[iiWho je [bed]Wj[ j^[ l[hj_YWb Ykji \khj^[h je
cWjY^ j^[ Z[i_h[Z _cfbWdj Z[i_]d$ El[hbo \ehY[\kb
ijhea[i j^Wj cW_dbo ^_j j^[ j^h[WZ[Z f_d i^ekbZ X[
Wle_Z[Z Wi j^[o cWo _dZkY[ fbWij_Y Z[\ehcWj_ed
Wbed] j^[ f_d WdZ%eh j^[ m[X XWhi$ ?\ Wdo fWhji e\
j^[ _cfbWdj Wh[ ikX`[Yj[Z je fbWij_Y Z[\ehcWj_ed"
j^[i[ fWhji m_bb X[ ^WhZ[h j^Wd j^[ h[cW_d_d] ded#
Z[\ehc[ZfWhji$
?dj^_ii_jkWj_ed"Wh[Wie\f[Waijh[iiYedY[djhWj_edi
m_bbZ[l[befh_]^jd[njjej^[Z[\ehcWj_ed"YWhho_d]
Wd_dYh[Wi[Zh_iae\\hWYjkh[_\ikX`[Yj[Zjefem[h\kb
YoYb_Y beWZi$ Dej edbo cWo j^[ l[hj_YWb eij[ejeco
X[ jee dWhhem" Xkj _cfbWdj _di[hj_ed cWo Wbie X[
_cf[Z[Z _\ j^[ ^eh_pedjWb eij[ejeco _i jee icWbb$
J^[ ^[_]^j e\ j^[ ^eh_pedjWb eij[ejeco _i cW_dbo
i[b[Yj[Z _d WYYehZWdY[ m_j^ j^[ j^_Yad[ii e\ j^[
_cfbWdjZ_ia$8ed[gkWb_jo_i"^em[l[h"WbieW\WYjeh$
?dj^[feij[h_ehi[]c[dje\j^[cWn_bbW"_jcWoX[W
]eeZ_Z[WjeYh[Wj[WdkdZ[hi_p[Z_cfbWdjX[Z0iec[
ki[hib_a[je_di[hj'&#cc_cfbWdjiW\j[hki_d]W/#
ccYkjj[h\ehj^[fh[fWhWj_ed$J^_iWffheWY^e\\[hi
]eeZ fh_cWho ijWX_b_jo e\ j^[ _cfbWdj$ Dej[ j^Wj
j^[ ^eh_pedjWb eij[ejeco ckij X[ WZlWdY[Z Z[[f
[dek]^ieX_Yehj_YWbWdY^ehW][_iWY^_[l[Z$
?d j^[ cWdZ_Xb[ _j cWo X[ d[Y[iiWho je jWa[ j^[
h[l[hi[WffheWY^"dWc[boje_di[hjW/#cc_cfbWdj
W\j[h fh[fWh_d] W '&#cc _cfbWdj X[Z$ Iec[j_c[i
j^_i _i j^[ edbo mWo je _di[hj j^[ _cfbWdj m_j^ekj
_d\b_Yj_d] ZWcW][$ 7i j^[ Y[djhWb fehj_ed e\ j^[
m[X XWhi _i l[hj_YWbbo h[_d\ehY[Z YecfWh[Z je j^[
f[h_f^[hWbfehj_edWjj^[h_d]"WdWZ[gkWj[YbWcf_d]
[\\[Yj_ifh[i[djX[jm[[dm[XXWhWdZh_d]$
Iec[j_c[i j^[ Ykjj[h cWo ikZZ[dbo X[Yec[
`Wcc[Z _di_Z[ j^[ Xed[ WdZ h[i_ij X[_d] h[cel[Z$
IkY^`Wcc_d]_ifWhj_YkbWhboYecced_dj^[fheY[ii
e\[nfWdZ_d]^eh_pedjWbibeji_dj^[Z_ijWbcWdZ_Xb[
je /cc WdZ _i YWki[Z Xo fbWij_Y Z[\ehcWj_ed e\
j^[ `Wm _ji[b\" m^_Y^ _i ikX`[Yj[Z je ijhed] \b[n_ed
Zkh_d] cekj^ ef[d_d]$ @Wm ijhkYjkh[i m_bb o_[bZ
ceh[ h[WZ_bo je \b[nkhWb \ehY[i m^_b[ ^eh_pedjWb
Ykjj[hi Wh[ X[_d] ki[Z X[YWki[ j^[o ^Wl[ X[[d
m[Wa[d[Z Xo j^[ fh[l_ekibo [ijWXb_i^[Z l[hj_YWb Ykj
Wbh[WZo$J^[h[ikbjWdjfbWij_YZ[\ehcWj_edij[ci\hec
+'
c_YheYhWYai$ 8ed[ j_iik[ f[hc_ji YhWYa \ehcWj_ed
m^_b[h[i_ij_d]YhWYafhefW]Wj_ed$9ecfei_j[ii^Wh[
j^_ifhef[hjoWim[bb"m^[h[Wi]bWiiX[^Wl[ij^[ej^[h
mWohekdZXof[hc_jj_d]WY[hjW_dZ[]h[[e\\b[n_ed
XkjXh[Wa_d]Wbed]_ji[dj_h[ikh\WY[edY[j^[fe_dj
e\ de h[jkhd ^Wi X[[d h[WY^[Z" j^ki bWYa_d] j^[
ijhkYjkhWbWX_b_jojefh[l[djZemdh_]^j\W_bkh[$
J^[ [nj[dj je m^_Y^ j^[ cWdZ_Xb[ _i fbWij_YWbbo
Z[\ehc[Z Yehh[bWj[i m_j^ j^[ Z[]h[[ je m^_Y^
j^[ Wbl[ebWh Yh[ij ^Wi X[[d i[fWhWj[Z WdZ j^[
Ykj [nj[dZ[Z _d W c[Z_Wb Z_h[Yj_ed$ J^[ h[WZ[h _i
h[\[hh[Z je 9^Wfj[h''$' \eh W Z[jW_b[Z Z_iYkii_ed e\
j^[ X_ec[Y^Wd_YWb _cfb_YWj_edi e\ m[Wa[d[Z Xed[
ijhkYjkh[i _d j^[ Z_ijWb cWdZ_Xb[ \eh j^[ l[hj_YWb
Z_c[di_ed$Iec[ki[hifh[\[hje_di[hj8E?_cfbWdji
j^hek]^ W b_d]kWb WYY[ii fWhj_YkbWhbo _d j^[ b[\j
cWdZ_Xb[ _\ j^Wj Wh[W _i m[bb WYY[ii_Xb[ WdZ j^[
Yehj_YWb Xed[ lebkc[ ^Wi X[[d \ekdZ je X[ ]h[Wj[h
edj^[l[ij_XkbWhWif[Yj$
Ibej ]Wk][i YWd X[ ki[Z je WiY[hjW_d j^Wj j^[
_cfbWdjm_bbiceej^bo]b_Z[_djej^[ibej$J^[i[W_Zi
Wh[ cWZ[ e\ W j_jWd_kc Wbbeo \[Wjkh_d] W feb_i^[Z
ikh\WY[$J^[oYWdX[Yb[Wd[ZWdZh[ki[Z$;nf[h_[dY[Z
ki[hi m_bb dej dehcWbbo ki[ W ibej ]Wk][" X[YWki[
j^[h[ _i de h[Wied m^o j^[ _cfbWdj i^ekbZ dej \_j
_djej^[ibej_\j^[Ykjj[hYekbZX[WZlWdY[Ziceej^bo
WdZj^[_di[hj_edfheY[Zkh[_idejZ[bWo[Z$>em[l[h
j^[ ki[ e\ W ibej ]Wk][ cWo X[ Wffhefh_Wj[ _\ j^[
eij[ejeco mWi f[h\ehc[Z _d W i[h_ekibo h[iehX[Z
Wh[W e\ j^[ cWn_bbW eh cWdZ_Xb[ je Wle_Z Y^_ff_d]
e\j^[\hW]_b[Xed[Yel[hXo^Wl_d]jeki[[nY[ii_l[
\ehY[Zkh_d]j^[_di[hj_edfheY[Zkh[$
M^Wj[l[h j^[ YWi[ cWo X[" j^[ Z[dj_ij ^Wi je
cWa[ ikh[ j^Wj j^[ eij[ejeco [nj[dZi _dje Xej^
Yehj_YWbXed[ijhkYjkh[iWdZj^Wjj^[_cfbWdjYWdX[
iceej^boWZlWdY[Zj^hek]^j^[ibej$
Ded#h[iehXWXb[ ]hW\j_d] cWj[h_Wbi \eh j^[ Xed[
Ykji Wh[ YedjhW#_dZ_YWj[Z _d j^[ cWdZ_Xb[ X[YWki[
j^[h[ _i W h_ia j^Wj j^[ cWj[h_Wb cWo c_]hWj[ WdZ
]_l[ h_i[ je Y^hed_Y _hh_jWj_ed e\ j^[ c[djWb d[hl[$
7domWo" j^[ ijh[ii#h[bWj[Z h[][d[hWj_l[ YWfWY_jo e\
j^_i Xed[ _i ie ]eeZ j^Wj j^[ ibeji m_bb Ybei[
ifedjWd[ekibo Xo dWj_l[ Xed[ ]hemj^$ 7dej^[h
Yedl[d_[dj efj_ed _i je _djheZkY[ XbeeZ#Z[h_l[Z
Wkjebe]eki c[cXhWd[i m_j^ W YWbY_kc f^eif^Wj[
ehYWbY_kcikbf^Wj[WZZ_j_l[_djej^[ibeji:e^Wd[j
Wb$ (&&)1 8bec [j Wb$ '//.$ J^[ eij[ejeco fWj^mWoi
cWo X[ eXijhkYj[Z Xo YWbY_kc ikbf^Wj[ eh jh_#
 YWbY_kc f^eif^Wj[ femZ[h Wi ikXijhWj[ Zedehi$
Ekh _cfh[ii_ed ^Wi X[[d j^Wj YWbY_kc ikbf^Wj[ _i
W ^_]^bo [\\[Yj_l[ c[Z_Wjeh e\ ie\j j_iik[ Ybeikh[$
<khj^[hceh[" _j Wff[Whi je h[ZkY[ feijef[hWj_l[
fW_d$J^[i[\_dZ_d]iWh[ikX`[Yj_l[WdZh[cW_djeX[
Yed\_hc[Z_d\ehcWbijkZ_[i$
?d j^[ cWn_bbW" Wdo cW`eh Xed[ Z[\[Yji cWo X[
\_bb[Z m_j^ ]hW\j_d] cWj[h_Wbi J9F" >7" Wkje]hW\ji
eh Wbbe]hW\ji%n[de]hW\ji eh Yel[h[Z m_j^ FH<$ J^[
+( 9^Wfj[h+È %QUIPMENTÈANDÈ3URGICALÈ4ECHNIQUES
_cfehjWdj fWhj _i j^Wj j^[ ]hW\j_d] cWj[h_Wb YWd X[
iW\[boYbei[Z"iej^Wj_jYWddejX[Yec[_d\[Yj[Z$IkY^
i[Wb_d]YWddejfeii_XboX[WY^_[l[Z_\j^[Wk]c[djWj_ed
^Wi X[[d f[h\ehc[Z Wbed] j^[ j^h[WZ[Z f_d$ J^[
efj_ed e\ f[h\ehc_d] Wk]c[djWj_ed fheY[Zkh[i Wj
i_j[ie\[njhWYj_edj^Wjki[Zje^WhXekhf[h_eZedjWbbo
Yecfhec_i[Z j[[j^ eh" \eh j^Wj cWjj[h" fkjh_Z fhe#
Y[ii[i i^ekbZ X[ Yedi_Z[h[Z m_j^ iec[ iY[fj_Y_ic
X[YWki[j^[h[_iW^_]^h_iaj^Wjj^[]hW\j_d]cWj[h_Wb
cWo X[Yec[ _d\[Yj[Z$ ?\ ]hW\j_d] _i f[h\ehc[Z _d
j^[i[YWi[i"j^[ikffkhWj_edekji_Z[e\j^[Xed[ckij
X[ Yedi_Z[h[Z WdZ W fWj^ \eh ikffkhWj_ed ckij X[
b[\j$J^[_cfbWdjWj_edfheY[Zkh[WiikY^_i"e\Yekhi["
dej YedjhW#_dZ_YWj[Z _d j^[i[ i_jkWj_edi deh _i j^_i
fh[ef[hWj_l[ i_jkWj_ed Wd WXiebkj[ YedjhW_dZ_YWj_ed
\eh ]hW\j_d] _d YecX_dWj_ed m_j^ j^[ fbWY[c[dj e\
8E?_cfbWdji$
J^[ j^_Yad[ii e\ j^[ Xed[ Ykji Z[f[dZi ed j^[
_cfbWdj Z[i_]d$ ;:NI#jof[ i_d]b[#Z_ia _cfbWdji
\[Wjkh[ W f[h_f^[hWb Z_ia ^[_]^j e\ &$.cc" j^ki
h[gk_h_d] j^[ ki[ e\ j^_Ya[h Ykjj[hi$ J^[ \ebbem_d]
Ykjj[hiWh[WlW_bWXb[0

)

NN
)

NN
)

NN
‘

NN
¤
¤
¤ _hh_]Wj_ed m_j^ Wffhefh_Wj[ ifhWo `[j WZ`kijc[dj$
‘

NN
¤
¤
¤ ?d#l_le ijkZ_[i h[l[Wb[Z j^Wj j^[ j[cf[hWjkh[ Z[[f
‘

NN
¤
¤

‘

NN
¤


M^_b[ _j cWo X[ feii_Xb[ je ki[ Wd ×kdZ[hi_p[ZÆ
Ykjj[h _d j^[ cWn_bbW je _cfhel[ fh_cWho ijWX_b_jo"
W Ykjj[h e\ hek]^bo j^[ iWc[ Z_c[di_edi Wi j^[
_cfbWdj_ih[gk_h[Z_dj^[cWdZ_Xb[$<khj^[hceh["_j
_i h[Yecc[dZ[Z je ki[ W '&#cc Ykjj[h \eh ;:7:I
_cfbWdjim_j^WXWiWbikh\WY[Wh[We\/'*ccjeX[
_di[hj[Z_dj^[Z_ijWbi[]c[dje\j^[cWdZ_Xb[$7\j[h
Wbb" j^[ _cfbWdjebe]_ij m_bb d[l[h ikYY[[Z _d Ykjj_d]
Wf[h\[YjboijhW_]^jibej_djej^[Xed[$J^[h[\eh["j^[
_cfbWdjYWddejX[WZlWdY[Zm_j^ekj`Wcc_d]kdb[ii
j^[ibej_iib_]^jbom_Z[h_dj^[\_hijfbWY[_$[$'&cc
_dij[WZe\/cc$
È
)RRIGATION
?hh_]Wj_ed _i kikWbbo d[Y[iiWho je fhej[Yj j^[ Xed[
W]W_dijel[h^[Wj_d]$J^[\WYjj^WjikY^Yeeb_d]ckij
X[fhel_Z[ZZkh_d]Zh_bb_d]fheY[Zkh[i_idejh[Wbbo
ef[d je Z[XWj[$ 7bXh[ajiied '/.+ WdZ ;h_aiied
[j Wb$ '/.( Z[cedijhWj[Z j^Wj W j[cf[hWjkh[ e\
*-–9 cW_djW_d[Z el[h 'c_d m_bb ]_l[ h_i[ je i_]d_\#
_YWdjbo h[ZkY[Z Xed[ ]hemj^ _d j^[ l_Y_d_jo e\
hek]^[d[Z _cfbWdj ikh\WY[i$7 j[cf[hWjkh[ e\ **–9
cW_djW_d[Z \eh kf je 'c_d" Xo YedjhWij" Ze[i dej
_dZkY[Z[cedijhWXb[h[ZkYj_edi_dXed[\ehcWj_ed$
CkY^ ceh[ Yedjhel[hi_Wb _i j^[ _iik[ m^[j^[h _j _i
feii_Xb[ je [dikh[ WZ[gkWj[ Yeeb_d] Z[[f _di_Z[
j^[ eij[ejeco YWl_jo" [if[Y_Wbbo m^[d ^_]^#if[[Z
hejWj_d] _dijhkc[dji Wh[ ki[Z$ M^_b[ j^_i gk[ij_ed
^WiX[[dWZZh[ii[Z_dWdkcX[he\[nY[bb[djijkZ_[i"
j^[ Yb_d_YWb h[b[lWdY[ e\ j^[i[ \_dZ_d]i d[[Zi je
X[ h[WffhW_i[Z W]W_dij j^[ XWYa]hekdZ e\ ceZ[hd
_cfbWdjj[Y^debe]o$
IYehj[YY_ WdZ :eci '/.- Z[cedijhWj[Z j^Wj
^[Wj Ze[i dej WYYkckbWj[ _d W i_]d_\_YWdj mWo Zk[
je j^[ mWj[h#W_h [nY^Wd][ h[ikbj_d] \hec Yehh[Yj
_di_Z[j^[eij[ejecoYWl_joh_i[ijeedboWhekdZ(,Ä
(.–9 m^[d _hh_]Wj_ed _i fhel_Z[Z Wj '.–9 IYehj[YY_
'/..1IYehj[YY_[jWb$'//&$
<_]kh[i+$,Ä+$.Yb[WhboZ[cedijhWj[j^[ki[\kbd[ii
e\ ikffbo_d] Xej^ j^[ jkhX_d[ WdZ j^[ kd_l[hiWb
ioh_d][ m_j^ Wd Wffhefh_Wj[ Yeeb_d] c[Z_kc$ J^[
c_deh Wbj[hWj_edi h[gk_h[Z \eh j^_i YWd X[ cWZ[
je Wdo Z[djWb kd_j$ J^[×Yb[Wd#mWj[h ioij[ciÆ Yec#
cedbo ki[Z _d j^[ KI YWd X[ Yedd[Yj[Z je j^[
Z[b_l[ho f_f[ WdZ _dj[]hWj[Z _dje j^[ mWj[h ikffbo$
:[dj_iji m^e hekj_d[bo _di[hj _cfbWdji m_bb ieed[h
eh bWj[h ki[ W Z[Z_YWj[Z Y^W_h \eh j^[i[ fheY[Zkh[i$
J^[h[_iWYjkWbboded[[ZjeYedd[Yjj^_iY^W_hjej^[
jWfmWj[hioij[c$
&IGÈAnD J^[l[hj_YWbeij[ejecoibej_iYkj\_hij$
?jZ[\_d[ij^[Z_h[Yj_ed"j^[Z[fWhjkh[fe_djWdZ
j^[[dZfe_dje\_di[hj_ed$IkXi[gk[djbo"WdkcX[h
e\^eh_pedjWbYkjj[him_j^_dYh[c[djWbZ_Wc[j[hi
ijWhj_d]m_j^W-#ccYkjj[hWh[Wffb_[Z$?d
cWn_bbWhoijhkYjkh[iWdZedj^[ded#meha_d]
i_Z[e\j^[cWdZ_Xb["_j_i\h[gk[djbofeii_Xb[je
[ijWXb_i^Xej^j^[l[hj_YWbWdZj^[^eh_pedjWbibej
WjedY[Xoki_d]WYecX_dWj_edYkjj[h[$]$'&cc$
EdY[j^[ibeji^Wl[X[[dYecfb[j[Z"j^[_cfbWdj
YWdX[_di[hj[Z$?j_ih[Yecc[dZ[Zjeki[_cfbWdji
j^WjWh[iec[m^WjÆel[hi_p[ZÇ_dh[bWj_edjej^[
Xed[ijhkYjkh[
È È )RRIGATIONÈ
&IGÈ J^_i Z_W]hWc i^emi j^[ Yehh[Yj ^[_]^ji e\ j^[
fheij^[j_Y Yedd[Yjehi$ <eh 8E? _cfbWdji m_j^ [nj[hdWb
j^h[WZ_d];jof[i"j^[h[]_ede\j^[j^h[WZ_ifei_j_ed[ZWi\Wh
ekji_Z[j^[ckYeiWWifeii_Xb[$8oYedjhWij"ckbj_#kd_jiYh[m
_cfbWdjiWh[_di[hj[Z_djej^[Xed[ikY^j^Wjedboj^[feb_i^[Z
fWhji e\ j^[ j^h[WZ Wh[ beYWj[Z _d j^[ ckYeiWb Wh[W$ 8E?
_cfbWdjim_j^_dj[hdWbj^h[WZ_d]?:eh?:Ejof[i"b_a[iYh[m
_cfbWdji" YWd X[ ikXc[h][Z ceh[ Z[[fbo j^Wd ;: _cfbWdji$
J^[fh_Y[jeX[fW_Z"^em[l[h"_ij^[WZZ_j_edWbYb[Wd_d][\\ehj
h[gk_h[Z$M[j[dZjeZ_if[di[m_j^?:E_cfbWdji_d\Wlekhe\
;: _cfbWdji _d fWj_[dji m_j^ Z_iY[hd_Xbo feeh ehWb ^o]_[d["
_cckde#Z[\_Y_[dY_[i eh YedYec_jWdj Z_i[Wi[i j^Wj WZl[hi[bo
W\\[Yjj^[jh[Wjc[djfhe]dei_i"Wim[bbWi_dicea[hi
J^[ fhWYj_j_ed[h m_bb d[[Z je Yedi_Z[h j^[
\ebbem_d]fe_dji0
v ?i j^[ gkWb_jo e\ j^[ mWj[h \hec j^[ Z[djWb kd_j
WZ[gkWj["eh_iWif[Y_Wb_hh_]Wj_ed\bk_Zh[gk_h[Z5
?d ceij i_jkWj_edi" W jkhX_d[ WdZ dehcWb Yb[Wd
mWj[h m_bb X[ Wbb j^Wj _i h[gk_h[Z je f[h\ehc j^[
[dj_h[ikh]_YWbfheY[Zkh[$
v J^[ Z[Y_i_ed je ki[ W if[Y_Wb _hh_]Wj_ed \bk_Z
hW_i[ij^[gk[ij_edm^[j^[hj^[fheY[Zkh[YWdX[
f[h\ehc[Zm_j^j^[h[]kbWhZ[djWbkd_jehm^[j^[h
Wi[fWhWj[ikh]_YWbkd_jm_bbX[h[gk_h[Z$
v J^[Z[dj_ijckijWbiem[_]^kfj^[fheiWdZYedi
4RANSMITTINGÈ
\ehmeha_d]m_j^<=_dijhkc[djim^[j^[h_dj^[
jkhX_d[ eh j^[ ^_]^#if[[Z Wd]b[Z ^WdZf_[Y[ eh
m_j^ Wd]b[Z ^WdZf_[Y[ Yedd[Yj_edi _$[$ j^[ Xbk[
'0'^WdZf_[Y[$
v J^[ jkhX_d[i ckij \[Wjkh[ bWh][ hejeh XbWZ[i je
e\\[hj^[h[gk_h[Zfem[hb[l[b$7bie"j^[X[Wh_d]i
+)
&IGÈAnC 8E?jkX[hei_jo
_cfbWdjiWh[_djheZkY[Z
fWhWbb[bjej^[ibejWdZ
j^[djm_ij[Z_di_Z[j^[
Xed[jeWZWfjj^[c
efj_cWbbojej^[WlW_bWXb[
`WmijhkYjkh[
e\bWh][#hejehjkhX_d[iWff[WhjeX[ceh[hk]][Z"
m^_Y^gk_YabofWoie\\m_j^bWh][#Z_Wc[j[hYkjj[hi$
?d ekh fhWYj_Y[" m[ ^Wl[ Yec[ je ki[ A7LE ,+&
WdZ ,+&7 Wi ekh fh[\[hh[Z ioij[c WdZ j[dZ je
Yedikc[j^h[[hejeh^[WZi_dhek]^bo+&&_cfbWdj
fheY[Zkh[iWo[Wh$
M[ dehcWbbo ki[ ij[h_b[ H_d][h bWYjWj[ Wi W Yeeb_d]
c[Z_kc" m^_Y^ _i ijeh[Z _d j^[ h[\h_][hWjeh$ :k[ je
_jiYecfei_j_ed"H_d][hbWYjWj[_iceh[X[d_]djej^[
Xed[ j^Wd iWb_d[$7\j[h Wbb" j^[ Xed[ ^WhXekhi ^_]^
YedY[djhWj_edi e\ iWbji WdZ fhej[_di WdZ _i gk_Yabo
ZhW_d[Z e\ j^[i[ ikXijWdY[i m^[d YedjWYj m_j^
b_gk_Zi e\ bem[h eicebWh_jo eh Wbj[h[Z Yecfei_j_ed
_i[ijWXb_i^[Z$
JeikccWh_p["j^Wdaijej^[WlW_bWX_b_joe\if[Y_Wb
ikh]_YWb [gk_fc[dj WdZ j^[ efj_ed je h[jhe\_j Wbb
Yedl[dj_edWbZ[djWbkd_jim_j^Yb[Wd#mWj[hioij[ci"
m[ Wh[ jeZWo _d W fei_j_ed je YedZkYj eij[ejeco
fheY[Zkh[im_j^^_]^#if[[ZhejWj_d]_dijhkc[dji_d
WYb[WdWdZf^oi_ebe]_YWbcWdd[h?^Z[(&&($?\j^[
fheY[Zkh[_iYehh[Yjbo^WdZb[Z"j^[Xed[m_bbdejX[
ZWcW][ZX[oedZm^Wj_i_d[l_jWXb[$
Dej Wbb Xed[ Wh[Wi Wh[ [gkWbbo ikXc_ii_l[ je j^[
Ykjj_d]_dijhkc[djiki[Z\eheij[ejeco$9ecfh[ii_l[
Wh[Wi Y^[m_d] i_Z[ e\\[h j^[ ]h[Wj[ij WdZ j[di_b[
Wh[Wided#Y^[m_d]i_Z[j^[icWbb[ijh[i_ijWdY[$J^_i
^ebZijhk[\ehXej^`Wmi$8Wi[Zedj^[i[fWhWc[j[hi"
j^[ h[ikbji e\ j^[ fh[ef[hWj_l[ \kdYj_edWb WdWboi_i
YWdX[_djhWef[hWj_l[bol[h_\_[Z$
È
#ONFIGURATIONÈOFÈTHEÈ,OAD
3URFACEÈANDÈ4HREADEDÈ0IN
?d j^[ W[ij^[j_Y ped[" fWhj_YkbWhbo e\ j^[ cWn_bbW"
j^[ j^h[WZ[Z f_di i^ekbZ X[ fbWY[Z Wi \Wh fWbWjWbbo
Wi feii_Xb[" ie j^Wj j^[ j[Y^d_Y_Wd ^Wi \h[[Zec je
efj_cWbbo Z[i_]d j^[ Wdj[h_eh Z[dj_j_ed$ Je Wle_Z
+* 9^Wfj[h+È %QUIPMENTÈANDÈ3URGICALÈ4ECHNIQUES

&IGÈÈA Iec[j_c[iWYkhl[Zibej_ih[gk_h[ZjeWY^_[l[j^[Z[i_h[Z
_cfbWdjfei_j_edWdZjekj_b_p[h[cej[Xed[Wh[Wi$ B ?di[hj_ede\Wjh_fb[#
Z_ia8E?_cfbWdj_djeWYWd_d[ieYa[j$ C ?di[hj_ede\WYecfh[ii_ed
iYh[m_djej^[dWhhemh_Z][i[]c[djjej^[Wdj[h_ehe\j^[jh_fb[#Z_ia8E?
_cfbWdji$ D 8E?_cfbWdjifbWY[Z_dj^[Z_ijWbcWn_bbWhoh[]_ede\j[d
d[[ZjeX[fh[#X[dji[l[hWbj_c[i"iej^Wjj^[YkhlWjkh[e\j^[j^h[WZ[Zf_d
Yecf[diWj[i\ehj^[fWbWjWb_dYb_dWj_ede\j^[ibej$J^_im_bbWbbembWh][h#
Z_Wc[j[hZ_iaijeX[_djheZkY[Z$J^[l[ij_XkbWh\b[n_ede\j^[XWiWbfbWj[
e\\[hi]eeZWZWfjWj_edjej^[bWj[hWbmWbbe\j^[cWn_bbWhoi_dki;:7I
'&%'*=-$7fj[ho]e_ZiYh[mIJ9*$''/_iWbh[WZo_dfbWY[Z_ijWbbo

&IGÈ ;l[dm_j^j^[Ykjj[h\kbbo_di[hj[Z"[dek]^_hh_]Wj_ed &IGÈ M^[djm_dYkjj[hiWh[ki[Z"j^[_hh_]Wj_ed\bk_Zm_bb

\bk_Z_iZh_l[dj^hek]^j^[eij[ejecoibej$J^[Yeeb_d][\\[Yj dejdehcWbboh[WY^X[oedZj^[Yh[ijWbZ_ia1j^[XWiWbZ_ia^Wi
_i[l[dX[jj[hm^[dWdW[heieb_iki[Z$J^[f_Yjkh[_bbkijhWj[i jeX[_hh_]Wj[Zi[fWhWj[bo
Wj[ijeij[ejecof[h\ehc[ZedWf_]iYWfkbW
È È #ONFIGURATIONÈOFÈTHEÈ,OAD
4RANSMITTINGÈ3URFACEÈANDÈ4HREADEDÈ0INÈ ++
&IGÈ J^[XWiWbZ_iae\j^[Ykjj[h_iYeeb[ZXoWdWZZ_j_edWb
ifhWo`[jWffb_[ZbWj[hWbboj^hek]^Wkd_l[hiWbioh_d][
h[ijh_Yj_d] jed]k[ cel[c[dji" _cfbWdji i^ekbZ dej
X[fbWY[Zjej^[Wdj[h_ehe\j^[YWd_d[i$
M_j^ j^[ _cfbWdj Z[i_]di WlW_bWXb[ jeZWo" _j _i
kikWbbo dej d[Y[iiWho je fbWY[ ceh[ j^Wd \ekh _c#
fbWdji f[h `Wm$ 7Xkjc[dji Wj j^[ fei_j_edi e\ j^[
YWd_d[i WdZ i[YedZ cebWhi m_bb kikWbbo ik\\_Y[ \eh
ijhWj[]_YWbbo ikffehj[Z h[ijehWj_edi$ 7ZZ_j_edWb
_cfbWdjicWoX[_dZ_YWj[Z"^em[l[h"_dif[Y_\_Yi_jkW#
j_edi$9edi_Z[hj^[\ebbem_d]fe_dji0
v Jh_fb[#Z_ia _cfbWdji cWo iec[j_c[i X[ W ki[\kb
efj_ed_dj^[Wdj[h_ehi[]c[dje\j^[cWn_bbWZk[
jej^[_heii[efhej[Yj_l[[\\[Yj$
v ?\j^[_cc[Z_Wj[ekjYec[e\_dZ_l_ZkWb_cfbWdji_d
j[hcie\fh_cWhoijWX_b_jo_ikdY[hjW_d"WZZ_j_edWb
_cfbWdjicWo_cfhel[j^[fhe]dei_ie\j^[el[hWbb
ijhkYjkh[$
v Jh[Wjc[dj e\ i[l[h[ Zoi\kdYj_ed cWo _dlebl[ W
f^Wi[e\^_]^ckiYb[h[i_ijWdY[m^_b[j^[Y^[m_d]
\kdYj_ed_iX[_d]h[Yed\_]kh[Z$?dj^_ii_jkWj_ed"_j
cWoWYjkWbboX[d[Y[iiWhoje×iWYh_\_Y[Æ_dZ_l_ZkWb
_cfbWdjijeYh[Wj[ifWY[\ehj^[Y^[m_d]ckiYb[i$
J^_i fh[ikffei[i j^Wj WZZ_j_edWb _cfbWdji m[h[
_di[hj[Z_dj^[\_hijfbWY["ehj^[[dj_h[ijhkYjkh[
m_bbX[_d`[efWhZo$7bj[hdWj_l[bo"j^[Z[dj_ijcWo
Y^eei[jeb[Wl[Wdoh[i_ZkWbj[[j^_dfbWY[\ehj^[
ZkhWj_ed e\ j^[ ^[Wb_d] f^Wi[ WdZ [njhWYj j^[c
bWj[h X[\eh[ _di[hj_d] j^[ Z[\_d_j_l[ h[ijehWj_ed$
Iec[ ki[hi" ^em[l[h" fh[\[h je ki[ _cfbWdji
ifWh_d]bo_dj^[_d_j_Wbf^Wi[jeh[jW_dWcWn_ckc
e\ Æl_h]_dÆ Xed[ ijhkYjkh[ \eh Wdo WZZ_j_edWb
&IGÈ ?jjWa[i_djh_]k_d]bob_jjb[jei[jkfWd[h]edec_YWbbo
Yehh[Yj ef[hWjeho$ 7 if_jjeed _i dej h[gk_h[Z$ J^[ Yb[Wd#
mWj[h ioij[c _i cekdj[Z X[^_dZ j^[ _dijhkc[dj jhWo ed j^[
jhWdil[hi[Whce\j^[kd_j
_cfbWdjfheY[Zkh[iZemdj^[heWZ$J^_iijhWj[]o
cWoX[WZl_iWXb[_\j^[Xed[lebkc[_i][d[hWbbo
bem$8ej^ijhWj[]_[i^Wl[if[Y_\_YWZlWdjW][iWdZ
Z_iWZlWdjW][i$
v Iec[ki[hi_di[hj\_l[_cfbWdjif[h`Wm$?dWZZ_j_ed
je j^[ Z_ijWb _cfbWdj _d Xej^ feij[h_eh i[]c[dji"
j^[oki[WjejWbe\j^h[[Wdj[h_eh_cfbWdji"jWa_d]
WZlWdjW][e\j^[Wdj[h_ehdWiWbif_d[_dj^[cWn_bbW
WdZ j^[ ^[Wl_bo jhW`[Yjeh_Wb_p[Z WdZ c_d[hWb_p[Z
Wdj[h_ehi[]c[dje\j^[cWdZ_Xb[$
v J^[ X[ij h[ikbji _d j^[ Z_ijWb cWn_bbW ^Wl[ X[[d
eXjW_d[Zm_j^'(#cc_cfbWdji$J^[m_Zj^h[gk_h[Z
jei[Ykh[WZ[gkWj[ikffehj_iWbiee\\[h[ZXo;:7I
/%'(kdZ;:7I'&%'*$
v J^[ dkcX[h e\ _cfbWdji je X[ _di[hj[Z _d j^[
cWn_bbW Wbie Z[f[dZi ed j^[ Wffb_YWXb[ Z_ia
Z_Wc[j[hi$J^[icWbb[hj^[Z_Wc[j[hi"j^[]h[Wj[h
j^[dkcX[he\_cfbWdjiWdZ%ehZ_iaif[h_cfbWdj$
v 8ed[ [bWij_Y_jo _d j^[ cWdZ_Xb[ i^ekbZ dej X[
kdd[Y[iiWh_bo h[ZkY[Z Xo ki_d] h_]_Z _cfbWdj
Z[i_]di$ BWh][#Z_Wc[j[h _cfbWdji i^ekbZ X[
Wle_Z[Z Wj j^[ Z_ijWb WXkjc[dj fei_j_ed _d j^[
cWdZ_Xb[$ ?\ j^[o ^Wl[ je X[ ki[Z W\j[h Wbb" j^[
Z_iai i^ekbZ X[ _di[hj[Z Wj W hWj^[h Z[[f b[l[b$
<ekh _cfbWdji _d j^[ cWdZ_Xb[ m_bb dehcWbbo
ik\\_Y[WiijhWj[]_YWXkjc[dji$
v 7bb h[b[lWdj fWhWc[j[hi ikY^ Wi j^[ Z_Wc[j[h"
fei_j_edWdZj^_Yad[iie\j^[Z_iaiWim[bbWij^[
dkcX[he\_cfbWdjiWdZj^[dkcX[he\Z_iaif[h
_cfbWdjd[[ZjeX[cWjY^[Z$
+, 9^Wfj[h+È %QUIPMENTÈANDÈ3URGICALÈ4ECHNIQUES

&IGÈÈ A Jme fbWij_Y \bWiai m_bb dehcWbbo X[ ik\\_Y_[dj [l[d \eh [nj[di_l[ eij[ejeco fheY[Zkh[i$ J^[ H_d][hÉi iebkj_ed _i
Z_if[di[Zj^hek]^Wbbb_d[i"_dYbkZ_d]j^[kd_l[hiWbioh_d][$J^[_hh_]Wj_ed\bk_Zd[[ZijeX[jhWdi\[hh[Z_djej^[[cfjo\bWiai$
J^[ioij[cYWdX[\bki^[Zm_j^Y^beh^[n_Z_d[Z_]bkYedWj[iebkj_ed\ehYb[Wd_d]$ B J^_i;B9Eioij[cXoM>_$[$j^[icWbb[h
l[hi_edm_j^ed#XeWhZjehgk[Yedjheb_if[h\[Yjboi[hl_Y[WXb[\ehWbbfhWYj_YWb8E?fkhfei[i$J^[_hh_]Wj_edc[Z_kc_iikffb_[Z
Z_h[Yjbo\hecj^[ij[h_b[YedjW_d[hj^hek]^j^[]h[[d[nj[hdWbjkX[

v ?\ j^[ fWj_[dj m[Whi W Yecfb[j[ Z[djkh[ _d j^[ WdZj^[WXkjc[dj%Yhemdm_bbX[beYWj[Zik\\_Y_[djbo

effei_d] `Wm" j^[ cWij_YWjeho \ehY[i m_bb X[
h[bWj_l[bo bem$ ?j _i j^[h[\eh[ ki[\kb je a[[f j^[
dkcX[he\_cfbWdjiicWbb$
v 8Wi[Z ed W jejWb iWcfb[ e\ '"(&& Yedi[Ykj_l[
8E?_cfbWdji"j^[fheXWX_b_joe\_cfbWdjikhl_lWb
XWi[ZedZ_iaZ_Wc[j[hiYWdX[ikccWh_p[ZWi_d
JWXb[+$'0
JWXb[+$'$ H[ikbji Wh[ dej Xhea[d kf WYYehZ_d] je cWn_bbWho
l[hikicWdZ_XkbWh_cfbWdji$J^[\_dZ_d]iZedejYed\_hcj^[
ikif_Y_edj^Wj_cfbWdjbeii[i_dlebl_d]bWh][hZ_iaZ_Wc[j[hi
Æ[nj[di_ed _cfbWdjiÇ cWo X[ WiieY_Wj[Z m_j^ ikXijWdj_Wbbo
]h[Wj[hbeii[ie\Xed[lebkc[$J^[fhWYj_j_ed[h"^em[l[h"^Wi
iec[j_c[iedboXed[m_j^Wm_Zj^e\-ccWlW_bWXb[$Beii[i"
_d ekh h[jheif[Yj_l[ l_[m" e\j[d eYYkhh[Z _d YWi[i" m^[h[ _j
mekbZ^Wl[X[[dfeii_Xb[jefbWY[WbWh][h_cfbWdjiWbj^ek]^
j^_i i[[c[Z dej WZl_iWXb[ _d j^[ if[Y_\_Y i_jkWj_ed Zkh_d]
j^[ ef[hWj_ed$Dej[j^Wjj^_ijWXb[Ze[idejYecc[djedj^[
dkcX[h e\ XWi[#fbWj[i Xkj h[]WhZi edbo j^[ bWh][ij eh j^[
edboXWi[#fbWj[e\j^[_cfbWdji
%JBNFUFS
PG
UIF
CBTBM

EJTL
3BUF
PG
JNQMBOU
MPTT
cWn_c_p[Zjej^[fe_dje\X[_d]b_c_j[ZXofheij^[j_Y

BGUFS

ZFBST


CBTFE
PO
BMM
QBUJFOUT
i_jkWj_edi$J^[edbofbWY[m^[h[^_]^[h=lWbk[iYWd

NN


NN


NN


NN


NN

J^[ b[d]j^ e\ j^[ j^h[WZ[Z f_d ckij X[ i[b[Yj[Z
ikY^j^Wjj^[Yedd[Yj_edfe_djX[jm[[dj^[_cfbWdj
\Wh \hec j^[ ckYeiW$ ?d j^_i mWo" j^[ ckYeiWb
f[d[jhWj_ed fe_dj e\ j^[ _cfbWdj h[cW_di icWbb
WdZ Wj j^[ b[l[b e\ j^[ feb_i^[Z _cfbWdj i[]c[dj$
?d\[Yj_edi Wh[ j^[h[Xo Wle_Z[Z" WdZ j^[ WZlWdjW][
e\ W j^_d ckYeiWb f[d[jhWj_ed _i efj_cWbbo kj_b_p[Z$
J^[fe_djm^[h[j^[_cfbWdjc[[jij^[Yhemd^Wije
X[ f[h_eZ_YWbbo ced_jeh[Z" i_dY[ Xed[ h[ceZ[bb_d]
_ib_a[bojeYedj_dk[\ehj^[h[ije\j^[fWj_[djÈib_\[$
CkYeiWb fheb_\[hWj_ed cWo ]_l[ h_i[ je el[h]hemj^
e\j^[WXkjc[djWdZikf[hijhkYjkh[$J^_icWoXbeYa
j^[ ZhW_dW][ fWj^mWoi WdZ ikXi[gk[djbo fhecej[
h[j[dj_l[_d\bWccWj_edWjj^[_cfbWdji^W\j$JecWa[
j^_d]imehi["\bk_Zij^WjYWddejZhW_de\\j^hek]^W
Yh[ijWb fWj^mWo m_bb c_]hWj[ Z[[f[h" m^_Y^ YWhh_[i
W h_ia e\ j^[ _d\[Yj_ed ifh[WZ_d] je j^[ Xed[ WdZ
XWiWbfbWj[$J^[h[WZ[h_ih[\[hh[Zje9^Wfj[h-\ehW
Z[jW_b[ZZ_iYkii_ede\jh[Wjc[djfbWdd_d]$
7dej^[h fh_dY_fb[ e\ _cfbWdj i[b[Yj_ed _i j^Wj
j^[ b[d]j^ e\ j^[ j^h[WZ[Z f_d i^ekbZ WbmWoi X[
h[gk_h[c[djiedbo$=,eh=-Z[i_]diWh[ki[Z_dceij
X[ hekj_d[bo ki[Z _i _d j^[ Wdj[h_eh i[]c[dj e\ j^[
cWdZ_Xb[$
?\_cfbWdjbeii[iWh[[lWbkWj[ZXWi[Zed=lWbk[i
hWj^[h j^Wd Z_ia Z_Wc[j[hi" _j X[Yec[i Yb[Wh m^_Y^
= lWbk[i Wh[ fh[\[hWXb[$ J^[ ZWjW ]_l[d _d <_]i$+$''
WdZ+$'(Wh[XWi[ZedWbbijhkYjkhWbjof[iYebb[Yj_l[bo$
J^[o h[fh[i[dj W jejWb e\ ,+' 8E? _cfbWdji _d j^[
cWn_bbW*'beii[i3,$)WdZ,*+8E?_cfbWdji_d
j^[cWdZ_Xb['*beii[i3($'$
È È #ONFIGURATIONÈOFÈTHEÈ,OAD
4RANSMITTINGÈ3URFACEÈANDÈ4HREADEDÈ0INÈ +-
&IGÈ ?cfbWdji beij _d j^[ cWn_bbW WYYehZ_d] je = lWbk[i$
J^[ X[ij h[ikbji m[h[ eXjW_d[Z m_j^ =*Ä=. Z[i_]di$ J^[
_bbkijhWj[Z ZWjW h[\[h je [nj[hdWb#j^h[WZ _cfbWdji ;:" ;:I"
;:7I"[jY$ m[h[ dej YWki[Z Xo j^[ _cfbWdj ioij[c Wi ikY^$
&IGÈ ?cfbWdjibeij_dj^[cWdZ_Xb[WYYehZ_d]je=lWbk[i$
J^[ Y^Whj b[Wl[i de ZekXj j^Wj j^[ ^_]^[h = lWbk[i Wh[
WiieY_Wj[Z m_j^ W ^_]^ fheXWX_b_jo e\ _cfbWdj ikhl_lWb$ J^_i
_iZk[jej^[\b[nkhWbYecf[diWj_ede\\[h[ZXobed]j^h[WZ[Z
f_di$Kd\ehjkdWj[bo"j^_ib[d]j^YWddejX[i[b[Yj[ZWhX_jhWh_bo
Xkj_ie\j[db_c_j[ZXoWh[ZkY[Zl[hj_YWbZ_c[di_ed
7Xkjc[dji cWZ[ \hec :[bh_d :7*" +" // ^[bf
je Yef[ m_j^ j^[ \b[n_ed e\ j^[ cWdZ_Xb[$ >[dY[ _j
_i WZlWdjW][eki je [gk_f Wj b[Wij ed[ e\ j^[ Z_ijWb
_cfbWdji _d W \kbb Xh_Z][ m_j^ j^ei[ WXkjc[dji$
?\ ceh[ j^Wd jme 8E? Wh[ fbWY[Z _d W hem _d ed[
`Wm" W ^ofeceY^b_ed cWo Z[l[bef$ :7#WXkjc[dji
^[bf je [Wi[ j^[ \ehY[i ed j^[ 8E? _cfbWdj _d j^[
c_ZZb[$ J^[ iWc[ fheXb[c _i ademd \hec j[[j^0
8h_Z][i \hec j^[ )hZ el[h j^[ +j^ je j^[ -j^ jeej^
i^em j[dZ je ^Whc j^[ jeej^ _d j^[ c_ZZb[ Wbh[WZo
W\j[h iec[ o[Whi$ Iec[ 8E?#_cfbWdjebe]_iji Ze dej
ki[ Wd WXkjc[dji ed _dj[hc[Z_Wj[ [nj[hdWb 8E?$
?dij[WZj^[oki[c[j^WYhobWj[jeYedd[Yjj^[Xh_Z][
jej^[_cfbWdj$D[_j^[h:[bh_ddehc[j^WYhobWj[Wh["
^em[l[h"l_i_Xb[_dN#hWoi$
J^[\ebbem_d]YedYbki_ediYWdX[ZhWmd0
v½ J^[hWj[e\_cfbWdjbeii_i^_]^[h_dj^[cWdZ_Xb[$
M^_Y^ijhkYjkhWbZ[i_]die\\[hj^[X[ijh[ikbji_d
j^[cWdZ_Xb[h[cW_dijeX[_dl[ij_]Wj[Z$
v J^[ ^_]^[h j^[ = lWbk[i" j^[ bem[h j^[ hWj[ e\
_cfbWdj beii _d j^[ cWdZ_Xb[$ J^[ X[ij h[ikbji
Wh[eXjW_d[Zm_j^=,Ä=/Z[i_]di$>_]^=lWbk[i
e\\[hX[jj[hWZWfjWj_ede\j^[_cfbWdj#h[ijehWj_ed
ioij[cje`Wm\b[n_ed$
v = lWbk[i _d j^[ hWd][ e\ =*Ä=. WffWh[djbo e\\[h
j^[ ]h[Wj[ij iW\[jo _d j^[ cWdZ_Xb[ m_j^ =- WdZ
=+ Z[i_]di o_[bZ_d] ib_]^jbo X[jj[h WdZ feeh[h
h[ikbji"h[if[Yj_l[bo$
v½ J^[fh[i[dj[ZZWjWh[\b[Yjdejedbo_cfbWdjibeij
je_d\[Yj_edehel[hbeWZeij[eboi_iXkjWbie_cfbWdj
\hWYjkh[i$;l[djih[bWj[ZjeceX_b[ikf[hijhkYjkh[i
m[h[Wbie_dYbkZ[Z_dj^[WdWboi_i$?dej^[hmehZi"
Wdo_cfbWdjbeii[ieYYkhh_d]W\j[hikf[hijhkYjkh[i
X[YWc[ Z_ibeZ][Z \hec dWjkhWb jeej^ WXkjc[dji
Wh[ Wbie h[\b[Yj[Z _d j^[ jWXb[" [l[d j^ek]^ j^[o
;nYbkZ_d] j^[i[ YWi[i mekbZ Xh_d] j^[ hWj[ e\
_cfbWdjbeiiZemdXoWdej^[h*&$
v El[hbo bem = lWbk[i YWhho Wd _dYh[Wi[Z h_ia
e\ _d\[Yj_edi WZlWdY_d] jemWhZi j^[ XWiWb fbWj[$
El[hbo^_]^=lWbk[i"XoYedjhWij"m_bb_dYh[Wi[j^[
b[l[h \ehY[i$7bb beii[i W\\[Yj_d] =/ Z[i_]di m[h[
Zk[ je _cfbWdj \hWYjkh[ Wj ijhWj[]_Y fei_j_edi _d
j^[cWn_bbW$7\j[hceZ_\o_d]j^[XWiWbi[]c[dje\
j^[i[Z[i_]di"m[^Wl[d[l[hW]W_deXi[hl[Zj^_i
jof[e\fheXb[c$
Iec[Yb_d_YWbi_jkWj_edih[gk_h[if[Y_\_YWffheWY^[i0
v 8E? _cfbWdji Wh[ WbmWoi fei_j_ed[Z m^[h[ j^[
Xed[ lebkc[ _i efj_cWb$ J^_i Ze[i dej WbmWoi
Ye_dY_Z[ m_j^ j^[ fei_j_ed j^Wj mekbZ X[ ceij
Z[i_hWXb[\hecWfkh[bofheij^[j_YijWdZfe_dj$J^[
j^h[WZ[Z f_d ^Wi je X[ fWhWbb[b_p[Z Xo X[dZ_d]
W\j[h _di[hj_ed" eh _dZ[[Z fh_eh je _di[hj_ed _\
j^[Xed[ijhkYjkh[_il[hom[Wa$7jWdohWj["j^_i
ij[f i^ekbZ X[ f[h\ehc[Z X[\eh[ j^[ Z[\_d_j_l[
ikjkh_d]"Wij^[h[_iWbmWoiWY^WdY[j^Wjj^[Z_iai
m_bbX[ib_]^jboZ_ibeYWj[ZXocWd_fkbWj_d]j^[f_d$
?dj^WjYWi["j^[_cfbWdjYWdij_bbX[cel[ZXWYa
je _ji Yehh[Yj fei_j_ed X[\eh[ j^[ \bWf _i Ybei[Z$
J^[ WXkjc[dj YWd X[ kdiYh[m[Z je e\\[h X[jj[h
WYY[ii \eh j^[ X[dZ_d] fheY[Zkh[$ 7bj[hdWj_l[bo"
j^[ kdiYh[m[Z J7F : jeeb YWd X[ ki[Z m_j^
eh m_j^ekj j^[ ^[bf e\ W H7J( hWjY^[j mh[dY^$
?\ _Z[Wb fWhWbb[b_ic YWddej X[ [ijWXb_i^[Z" Wdo
ib_]^j Z[l_Wj_edi YWd X[ [Wi_bo el[hYec[ _d j^[
\WXh_YWj_edWdZ_di[hj_edfheY[ii$
v ?djhWehWbX[dZ_d]_idejWdefj_edm_j^_dj[hdWb#
j^h[WZ8E?Z[i_]di_$[$?:EWdZ?:$
v ?\ j^[ Xed[ lebkc[ WXel[ j^[ _d\[h_eh Wbl[ebWh
d[hl[ _d j^[ Z_ijWb cWdZ_Xb[ _i dej ik\\_Y_[dj"
j^[ beWZ#jhWdic_jj_d] Z_ia YWd Wbie X[ fbWY[Z
kdZ[h j^[ d[hl[$ J^_i _i WY^_[l[Z Xo [nfei_d]
j^[d[hl[Wjj^[fbWdd[Z_cfbWdji_j[WdZfbWY_d]
j^[ j^h[WZ[Z f_d bWj[hWbbo _d W iW\[ fei_j_ed$
J^_iijhWj[]oi^ekbZedboX[ki[ZXom[bb#l[hi[Z
+. 9^Wfj[h+È %QUIPMENTÈANDÈ3URGICALÈ4ECHNIQUES
ikh][edi m_j^ W ij[WZo ^WdZ WdZ ij[WZo d[hl[i
m^e Wh[ jhW_d[Z _d j^h[[#Z_c[di_edWb j^_da_d]
i[[L_Z[e'-$
v ?cfbWdji Wbed] j^[ cWn_bbWho Wh[ [_j^[h _di[hj[Z
W\j[hj^[Xed[^WiX[[dWk]c[dj[ZXoi_dki\beeh
[b[lWj_ed Wi Z[iYh_X[Z X[bem" eh j^[o Wh[ fbWY[Z
_di_Z[ j^[ i_dki \ebbem_d] fWhj_Wb h[celWb e\ j^[
IY^d[_Z[h_Wdc[cXhWd[$M^_Y^WffheWY^_ijWa[d
Ze[idejZ[f[dZedj^[h[i_ZkWbXed[lebkc[e\
j^[ Wbl[ebWh Yh[ij Xkj Xo j^[ h[gk_h[c[dj j^Wj W
ik\\_Y_[djbom_Z[XWiWbfbWj[YWdX[ki[Zjei[Ykh[
X_Yehj_YWbWdY^ehW][$?\j^[l[hj_YWbZ_c[di_ede\
j^[ h[i_ZkWb Xed[ ijhkYjkh[ _i icWbb" _j _i kikWbbo
fh[\[hWXb[ je jWa[ j^[ _djhW#i_dki WffheWY^ \eh
_ji X[jj[h ZhW_dW][ YedZ_j_edi _d j^[ [l[dj e\
_d\[Yj_edi$J^[h[WZ[h_ih[\[hh[Zje9^Wfj[h'.\eh
WZ[jW_b[ZZ_iYkii_ede\j^[i[WffheWY^[i$
v J^[ _djhW#i_dki _di[hj_ed j[Y^d_gk[ cWo iec[#
j_c[i b[WZ je _d\[Yj_edi e\ j^[ i_dki$ I_dY[
j^[i[ _d\[Yj_edi ckij X[ W]]h[ii_l[bo jh[Wj[Z"
fh[YWkj_edickijX[jWa[d\ehj^_i[l[djkWb_joXo
[dikh_d] j^Wj Wffhefh_Wj[ ZhW_dW][ fWj^mWoi Wh[
fh[i[dj$7doYecfb_YWj_ediWh_i_d]\hec_d\[Yj_edi
e\j^[cWn_bbWhoi_dkiWh[_dlWh_WXboZk[jefeeh
ZhW_dW][ YedZ_j_edi$ :[Yed][ijWdj dei[ Zhefi
WdZ h_di_d] m_j^ iWb_d[ i^ekbZ X[ Wffb_[Z Wi j^[
jh[Wjc[dj e\ Y^e_Y[$ ?d i_jkWj_edi ikY^ Wi j^[i["
j^[ Z[dj_ij i^ekbZ fh[\[hWXb[ YebbWXehWj[ m_j^ W
m[bb#l[hi[Zeje#h^_debWhod]ebe]_ijm^e_iWbieWd v I_d]b[#Z_ia _cfbWdji ckij X[ fbWY[Z ikY^ j^Wj
[nf[h_[dY[Zikh][ed$Jho_d]jeiebl[j^[fheXb[c
m_j^Wdj_X_ej_Yi_iYedjhW#_dZ_YWj[Z$J^_iijhWj[]o
YWd edbo e\\[h fWbb_Wj_l[ h[b_[\ Xkj XWi_YWbbo
f[hf[jkWj[i j^[ fheXb[c$ JejWb XbeYaW][ e\ j^[
i[c_bkdWh ^_Wjki cWo ]_l[ h_i[ je ikffkhWj_ed
j^hek]^ eheWdjhWb \_ijkbW[" m^_Y^ cWo \ehc Wj
h[cej[beYWj_edi\hecj^[_cfbWdji_j[$M^_b[j^[i[
\_ijkbW[ cWo Wbie \ehc Wbed] j^[ j^h[WZ[Z f_di"
j^[o Wh[ ceh[ Yeccedbo eXi[hl[Z _d feij[h_eh
beYWj_edi m_j^ de _cfbWdji _d j^[_h _cc[Z_Wj[
l_Y_d_jo$ J^[o Wh[ W dWjkhWb Yedi[gk[dY[ e\
el[hfh[iikh[ _d j^[ i_dki" m^_Y^ m_bb kikWbbo
h[iebl[ W\j[h Yecf[j[dj ;DJ jh[Wjc[dj [dWXb_d] v J^[ Z[dj_ij i^ekbZ WbmWoi ijh_l[ je i[Ykh[ W
j^[ \bk_Zi je ZhW_d e\\ Wi j^[o i^ekbZ$ ?\ ikY^
_d\[Yj_edi Wh[ dej W]]h[ii_l[bo jh[Wj[Z" j^[h[ _i
W h_ia j^Wj j^[ _d\[Yj_ed cWo ifh[WZ je j^[ beWZ#
jhWdic_jj_d] ikh\WY[ e\ j^[ _cfbWdj" [l[djkWbbo
h[ikbj_d]_dbeiie\j^[_cfbWdj$
v½ J^[ i_dki YWd Wbie X[ h[^WX_b_jWj[Z Xo jh[Wj_d]
j^[ikh\WY[#[dbWh][ZbeWZ#jhWdic_jj_d]ikh\WY[i
m_j^ ^oZhe][d f[hen_Z[ )Ä+$ 7 i[YedZWho
Wk]c[djWj_l[fheY[Zkh[YWdX[f[h\ehc[Z[_j^[h
i_ckbjWd[ekibo eh Wj W bWj[h j_c[$ 7k]c[djWj_ed
_dje j^[ ef[d" fh[l_ekibo _d\[Yj[Z i_dki _i dej
h[Yecc[dZ[Z$
v ?j _i Wbie feii_Xb[ je h_di[ j^[ [dj_h[ i_dki m_j^
^oZhe][d f[hen_Z[ )Ä+ Xo _djheZkY_d] W j^_d
YWddkbW Wbed] j^[ j^h[WZ[Z f_d$ Ed _dij_bb_d]
W icWbb Wcekdj e\ j^[ \bk_Z" W fkhkb[dj ic[bb
i^ekbZ[cWdWj[j^hek]^j^[^_Wjki$?\j^Wj_idej
j^[ YWi[" j^[ dWjkhWb ZhW_dW][ fWj^mWo cWo X[
XbeYa[Z$?dej^[hmehZi"_\j^[c[Z_YWj_ed#_dZkY[Z
el[hfh[iikh[ YWddej X[ Z_iY^Wh][Z j^hek]^ j^[
dWjkhWb fWiiW][" h_di_d] m_bb dej X[ ikYY[ii\kb"
WdZj^[h[_iWh_iaj^Wjj^[el[hfh[iikh[cWojWa[
WZ_\\[h[djhekj["j^kiifh[WZ_d]j^[fkijeWh[Wi
m^[h[_jZe[idejX[bed]$?\h_di_d]_iikYY[ii\kb"
Wbbfkim_bbX[[b_c_dWj[Z\hecj^[cWn_bbWhoi_dki
_d W cWjj[h e\ c_dkj[i$ J^[ ^[WZ e\ j^[ fWj_[dj
i^ekbZX[Xhek]^j_djeWfei_j_edm^[h[j^[\bk_Z
hkdi je][j^[h X[\eh[ j^[ ^_Wjki$ J^[ fWj_[dj m_bb
mWdj je if_j ekj j^[ h[b[Wi[Z \bk_Z i[l[hWb j_c[i$
?jm_bbX[d[Y[iiWhojel[dj_bWj[j^[ef[hWjehom[bb
W\j[hj^_ijof[e\jh[Wjc[dj$
v FheX_d]Wbed]j^[j^h[WZ[Zf_de\W8E?_cfbWdj
eh _dje j^[ \_ijkbWj[Z Wh[Wi jemWhZi j^[ _cfbWdj
_i ijh_Yjbo YedjhW_dZ_YWj[Z" j^ki Wcekdj_d] je
cWbfhWYj_Y[$ IkY^ fheX_d] ^Wi de Z_W]deij_Y eh
j^[hWf[kj_Yi_]d_\_YWdY[m^Wjie[l[hWdZ_ijejWbbo
kdd[Y[iiWho$ Ed j^[ YedjhWho" j^[i[ c[Wikh[i
hekj_d[boWZZWm^ebbod[mfWj^e][d_Yif[Yjhkc
je fh[l_ekibo kdW\\[Yj[Z Wh[Wi Xo mWo e\ Yheii#
YedjWc_dWj_ed$ Kd\ehjkdWj[bo" iec[ Yh[ijWb
_cfbWdjebe]_ijiYedj_dk[je[cfbeoj^[i[fheX_d]
j[Y^d_gk[i$ J^[ h[WZ[h _i h[\[hh[Z je 9^Wfj[h(-
\ehWZ[jW_b[ZZ_iYkii_ed$
Z_iaiWh[ik\\_Y_[djbo\WhWfWhj_\j^[l[hj_YWbXed[
ijhkYjkh[_ih[ZkY[Z$Ej^[hm_i[j^[feijef[hWj_l[
Yh[ijWbXed[Yel[hcWojkhdekjjeX[_dWZ[gkWj["
j^[h[Xofhecej_d]_d\[Yj_ediWdZd[Yhei_i$J^[h[
_i Wbie W ZWd][h j^Wj j^[ h[i_ZkWb Xed[ ijhkYjkh[
Yel[h_d]Xej^Z_iaicWoY^_fe\\ehj^Wj_d\[Yj_edi
cWoifh[WZ\heced[_cfbWdjjej^[ej^[h"m^_Y^
m_bb ieed[h eh bWj[h ]_l[ h_i[ je ceX_b_jo e\ j^[
ikf[hijhkYjkh[_ji[b\$;l[dmehi["j^_ifheY[iicWo
[l[djkWbboh[ikbj_dfWhj_Wb^ehi[i^e[Zemd\hWYjkh[
Y^WhWYj[h_p[ZXo_iebWj[ZceX_b[Xed[Wh[WiWbed]
j^[cWn_bbWhoh_Z][$
fei_j_edm^[h[Wjb[WijWicWbbfWhje\j^[_di[hj[Z
_cfbWdj fhe`[Yji bWj[hWbbo \hec j^[ `Wm$ J^_i
Yed\_]khWj_ed^Wii[l[hWbWZlWdjW][i$<_hije\Wbb"
j^[fWj_[djm_bb[nf[h_[dY[f[h_eij[WbfW_di^ekbZ
j^[ Z_ia X[ ceX_b_p[Z Xo [nY[ii_l[ beWZ_d]$ IkY^
WdWb[hj\kdYj_edYWddejX[eXjW_d[Z_\j^[[dj_h[
Z_ia ikh\WY[ _i WdY^eh[Z m_j^_d Yehj_YWb Xed[$
<khj^[hceh["j^[`Wmlebkc[_i]e_d]je_dYh[Wi[
Wij^[cWij_YWjeho\ehY[i]W_dcec[djkc_dj^[
feijef[hWj_l[ f^Wi[$ El[hbo icWbb 8E? _cfbWdji
cWo Z[iY[dZ _d j^_i fheY[ii je j^[ fe_dj e\
h[WY^_d]j^[YWdY[bbekiYeh[e\j^[Xed["j^[h[Xo
bei_d] j^[_h Yehj_YWb ikffehj$ BWijbo" _cfbWdji
Z_iYedd[Yj[Z \hec j^[ f[h_eij[Wb XbeeZ ikffbo
YWddeje\\[hefj_cWbbeWZYecf[diWj_ed$
È È #ONFIGURATIONÈOFÈTHEÈ,OAD
4RANSMITTINGÈ3URFACEÈANDÈ4HREADEDÈ0INÈ +/
v Fhe`[Yj_d]_cfbWdjWh[WicWoX[YedjhW#_dZ_YWj[Z
_d j^[ feij[h_eh i[]c[dj e\ j^[ cWn_bbW$ J^[
Z[dj_ij ^Wi je Wii[ii fh_eh je \bWf h[\b[Yj_ed
m^[j^[hehdejj^[Xkb]_d]Z_ijWbfehj_edie\j^[
cWn_bbW Wh[ Yel[h[Z Xo WjjWY^[Z ckYeiW$ ?\ j^[o
Wh["j^[iWc[Wh[WiWh[]e_d]jeX[el[h]hemdXo
Ybei[ \_jj_d] ijhkYjkh[i e\ WjjWY^[Z ]_d]_lW edY[
W]W_d W\j[h _cfbWdji ^Wl[ X[[d _di[hj[Z$ 7do
fe_dj[Zfhe`[Yj_d]Z_iai[]c[djic_]^jieed[heh
bWj[hfki^j^[_hmWoj^hek]^j^[i[ijhkYjkh[iWdZ
j^ki X[Yec[ fhed[ je _d\[Yj_ed$ 7do fhe`[Yj_d]
Z_ia i[]c[dji _d ikY^ Wh[Wi ckij j^[h[\eh[ X[
c[j_Ykbekibo Wle_Z[Z$ ?\ j^[o Wh[ _d[l_jWXb[" j^[
W\\[Yj[ZXed[ijhkYjkh[ckijX[Wk]c[dj[Zh_]^j
WmWo eh Wj W bWj[h j_c[$ 7dej^[h fej[dj_Wbbo
^[bf\kbWffheWY^mekbZX[jeYel[hj^[Z_iaim_j^
c[cXhWd[iZ[i_]d[Zjea[[fj^[ckYef[h_eij[Wb
\bWf×WjWhcÈib[d]j^Ækdj_bd[mXed[^Wi\ehc[Z
kdZ[hd[Wj^$
:kh_d]mekdZYbeikh["W^eb[_ifkdY^[Z_djej^[\bWf
_dj^[Wh[We\j^[j^h[WZ[Zf_d"Wbbem_d]j^[\bWfjeX[
ZhWmd el[h j^[ _cfbWdj" j^[h[Xo eXjW_d_d] ijWX_b_jo
W]W_dijj[di_b[\ehY[i$J^[dj^[ikjkh[_if[h\ehc[Z
ed j^[ c[Z_Wb Wif[Yj$7j _cfbWdjWj_ed i_j[i j^Wj Wh[
Yecfhec_i[Z Xo ie\j#j_iik[ _d\[Yj_ed" j^[ mekdZ
Ybeikh[ _i b[\j iec[m^Wj f[hc[WXb[ je f[hc_j W
Y[hjW_d Z[]h[[ e\ ikffkhWj_ed WdZ WkjeYb[Wd_d] e\
j^[mekdZ$
J^[ ikjkh[i Wh[ h[cel[Z Wi ieed Wi feii_Xb[$ ?\
de j[di_b[ \ehY[i Wh[ eXi[hl[Z ed j^[ mekdZi" j^[
ikjkh[i YWd X[ h[cel[Z ed j^[ \_hij feijef[hWj_l[
ZWo$?\j^[fWj_[djicea[i_dj^[feijef[hWj_l[f^Wi["
_jcWoX[d[Y[iiWhojemW_j\ehi[l[hWbZWoiX[\eh[j^[
ikjkh[iYWdX[h[cel[Z$Ekhh[Yecc[dZWj_ed_ij^Wj
fWj_[djii^ekbZdejicea[\ehWjb[Wij,m[[aiX[\eh[
0LATEÈ!REAS
WdZ )m[[ai W\j[h j^[ fheY[Zkh[" adem_d] \kbb m[bb
j^Wjj^_ih[Yecc[dZWj_ed_il_hjkWbbod[l[h^[[Z[Z$
9ecfhec_i[ZmekdZ^[Wb_d]"e\j[dWiieY_Wj[Zm_j^
bWh][foe][d_Y]hWdkbecWi"_iWYeccedeXi[hlWj_ed
Wced] icea[hi" Xkj Wbie Wced] fWj_[dji m^e ^Wl[
mehd^[Wl_bobeWZ[ZZ[djkh[iel[hcWdoo[Whieh^Wl[
X[[dikX`[Yj[Zjeckbj_fb[[njhWYj_edi$J^[W\\[Yj[Z
h[]_edi i^em W f[j[Y^_Wb Xb[[Z_d] j[dZ[dYo" m^_Y^
cWo X[ WiocfjecWj_Y eh h[Ykhh[djbo iocfjecWj_Y
WdZ _i kikWbbo dej_Y[Z Xo j^[ fWj_[dji j^[ci[bl[i"
[if[Y_Wbbo Zkh_d] Xhki^_d]$ 7d Wffhefh_Wj[ jh[Wj#
c[dj ceZWb_jo _d j^[i[ i_jkWj_edi _i je YWh[\kbbo
ijh_f j^[ ]hWdkbecWjeki Wh[W Xo ikfhWf[h_eij[Wb
[b[Yjheikh][ho" \ebbem[Z Xo [jY^_d] m_j^ ^oZhe][d
f[hen_Z[)&ehY^hec_kcjh_en_Z[$J^_ij[Y^d_gk[
je ij_ckbWj[ ^[Wb_d] _i [l[d [\\[Yj_l[ m_j^ bWh][
]hWdkbecWjeki Wh[Wi$ C_bZ [jY^_d] m_j^ >(E( )&
cWo X[ Wbb j^Wj _i h[gk_h[Z$ J^[ W\\[Yj[Z j_iik[ _i
WffWh[djbod[_j^[hh[^WX_b_jWj[Zdehh[`[Yj[Z_dj^_i
if[Y_\_Y jof[ e\ ckYeiWb h[WYj_ed$ ?d j^_i mWo" j^[
Y^hed_Y_d\[Yj_ed_dj^[\ehc[h\bWfWh[Wm_bbf[hi_ij
\eh cWdo ZWoi eh _dZ[[Z m[[ai _\ de jh[Wjc[dj _i
fhel_Z[Z$
;jY^_d] ]_l[i h_i[ je \eWc \ehcWj_ed _d j^[
W\\[Yj[Z Wh[Wi m^_b[ de h[ifedi[ _i i[[d Wbed] j^[
ded#W\\[Yj[ZckYeiWbijhkYjkh[i$
8ed[ ^[Wb_d] _d j^[ feijef[hWj_l[ f^Wi[ e\ 8E?
jh[Wjc[dj _i W YWiYWZ[#ijob[ fheY[ii j^Wj _dlWh_WXbo
kd\ebZi _d W kd_\ehc cWdd[h$ ?\ j^[ fheY[ii _i
Z_ihkfj[Z Xo Wdo _dj[h\[h_d] \WYjehi" j^[ eh_]_dWb
YedZ_j_ede\j^[j_iik[YWddebed][hX[h[ijeh[Z$J^[
^[Wb_d]fheY[iim_bbfheY[[Z_dWdWjof_YWbcWdd[h"
kikWbbo _dlebl_d] Yedd[Yj_l[ j_iik[ h[fW_h$ J^[ edbo
mWo je h[ijeh[ j^[ ijWj[ X[\eh[ j^[ ^[Wb_d] fheY[ii
mWiZ_ihkfj[Z_ijeYh[Wj[Wdej^[h_d`khoWiieY_Wj[Z
m_j^ Xb[[Z_d]$7do d[mbo \ehc[Z Yedd[Yj_l[ j_iik[
Wh[Wi^Wl[jeX[h[cel[Z"Wij^[omekbZ_d^_X_jXed[
\ehcWj_ed_dWYecf[j_j_l[cWdd[h$
È
#OMBINATIONÈWITHÈ3CREWÈ)MPLANTSÈÈ
ANDÈ"ENDINGÈOFÈ"ASE
?dYWi[j^WjdWhhemXed[Wh[WiWh[beYWj[ZX[jm[[d
[njhWYj_ed ieYa[ji" AEI#iYh[m _cfbWdji Wh[ Wd
Wbj[hdWj_l[ je 8E?$ <_]kh[i+$'* WdZ +$'+ i^em Wd
[nWcfb[\ehj^_iijhWj[]o$
?d i_jkWj_edi _d m^_Y^ j^[ h[i_ZkWb Xed[ _i
_dik\\_Y_[dj" j^[ Z[dj_ij ckij \_dZ W c[j^eZ e\
^eh_pedjWb[dbWh][c[djjeWYYecceZWj[j^[_cfbWdj$

&IGÈAB ?d\bWc[ZckYeiWbijhkYjkh[iWh[ij_bbl_i_Xb[Wij^[\hWc[meha_ijh_[Z_d$J^[oWh[[jY^[Zm_j^>(E()&$8oj^[

j_c[j^[Xh_Z][_i_di[hj[Z"j^[_d\bWccWj_ed^WibWh][boh[iebl[Z$Ej^[hm_i["j^[[jY^_d]ij[fmekbZ^Wl[X[[dh[f[Wj[Z"ehj^[
j_iik[mekbZ^Wl[h[cel[ZXo[b[Yjheikh][ho
,& 9^Wfj[h+È %QUIPMENTÈANDÈ3URGICALÈ4ECHNIQUES

&IGÈ
7Zc_d_ij[h_d]
J[hhWYehjh_b#IWbX[je
j^[ikh\WY[Wh[We\
AEI#iYh[m_cfbWdji
_iWdefj_ed$J^_i
\WjjoYh[Wc[d^WdY[i
j^[iYh[m_d]#_d
fheY[Zkh[

&IGÈ 7\j[h \kbb _di[hj_ed e\ j^[ _cfbWdj" j^[ Z_ia fhe#
`[Yj_d]edj^[l[ij_XkbWhWif[Yj_iX[dj$J^ei[WZWfj[Z_cfbWdj
ikh\WY[iYWdX[WZZ_j_edWbbojh[Wj[ZXoi[YedZWhoWk]c[djWj_ed
Wj W bWj[h j_c[$ J^[ X[dZ_d] Wbj[hi j^[ \ehY[ Z_ijh_Xkj_ed
_di_Z[j^[h_d]"h[dZ[h_d]j^[_cfbWdjceh[h_]_Z$J^[h_iae\
_cfbWdj\hWYjkh[YWdX[h[ZkY[ZXoki_d]Z[i_]dim_j^i[l[hWb
m[X XWhi ;:7:I \eh j^_i cWd_fkbWj_ed m^[d[l[h feii_Xb[
J^[ XWh d[Wh j^[ i^W\j _i WdY^eh[Z _d j^[ l[ij_XkbWh Yehj_YWb
Xed[ m^_b[ j^[ X[dj i[]c[dj e\\[hi ijWX_b_jo W]W_dij bWj[hWb
\ehY[i$ 7bj[hdWj_l[bo" _\ j^[ Z[dj_ij Y^eei[i dej je X[dZ j^[
fhe`[Yj_d] fWhji" j^[ Xed[ Wh[Wi Yel[h[Z Xo j^[ f[h_eij[kc
_d W j[dj#ijob[ \Wi^_ed YWd Wbie X[ ikX`[Yj[Z je W fh_cWho eh
i[YedZWhoWk]c[djWj_edfheY[Zkh[$9edjWYje\j^[l[ij_XkbWh
Z_iai[]c[djijej^[Yehj_YWbXed[i^ekbZX[h[#[ijWXb_i^[Z\eh
j^[ h_d] ijhkYjkh[ je h[Yel[h _ji i^eYa#WXiehX_d] fhef[hj_[i
l[ij_XkbWhijhkjicWoX[X[djWbie_djej^[Z_h[Yj_ede\j^[jef
e\j^[Yh[ij0i[[L_Z[ei-WdZ''\ehZ[jW_bi

&IGÈ AEI iYh[m _cfbWdji Wh[ [gk_ff[Z m_j^ j^[ iWc[

^[WZ#jof[j^Wj_iWlW_bWXb[\eh8E?#_cfbWdjiWbieJI:*$J^_i
cWa[i_j[Wio\ehj^[Z[dj_ijj[Y^d_Y_WdWdZj^[ikh][ed"i_dY[
Wbb jeebi WdZ j^[ WdWbe]i Wh[ j^[ iWc[$ Iec[ jof[i e\ AEI#
iYh[m_cfbWdjiWh[[gk_ff[Zm_j^WX[dZWXb[WXkjc[dj#^[WZ

J^[ceijeXl_ekiWffheWY^_ijeWZWfjj^[_cfbWdj"
m^_Y^ i^ekbZ X[ Wi bWh][ Wi feii_Xb[" je j^[ Xed[
ijhkYjkh[ Xo l[ij_XkbWh eh" b[ii \h[gk[djbo" fWbWjWb
X[dZ_d]$ Je Wle_Z ZWcW]_d] j^[ WlW_bWXb[ Xed[
ijhkYjkh[i"_j_ih[Yecc[dZ[ZjeikX`[Yjj^[_cfbWdj
je ib_]^j fh[#X[dZ_d] Wj j^[ Z[i_h[Z beYWj_ed X[\eh[
_di[hj_d]_j$?dl[ho\hW]_b[Xed[iWbbe\j^[X[dZ_d]
ckijX[Zed[X[\eh[_di[hj_edj^[_cfbWdjWjWbb$
Kdb[ii j^[ _di[hj_ed fWj^ e\ j^[ _cfbWdj _i
f[hf[dZ_YkbWh je j^[ fbWdd[Z _di[hj_ed fWj^ e\ j^[
ikf[hijhkYjkh["j^[j^h[WZ[Zf_d^WijeX[ikX`[Yj[Z
&IGÈ Ed h[l_i_j_d] j^[ i_j[ W\j[h WhekdZ ,cedj^i" j^[
je ib_]^j fh[#X[dZ_d] Wi m[bb$ 7\j[h j^[ _cfbWdj X[dj_cfbWdji[]c[dj^WidejX[[del[h]hemdXoXed[o[j"
^Wi X[[d \kbbo _di[hj[Z WdZ X_Yehj_YWb WdY^ehW][ m^_b[ j^[ l[hj_YWb ibej ^Wi d_Y[bo ^[Wb[Z kf$ 7 i[YedZWho
eXjW_d[Z" j^[ fhe`[Yj_d] fWhj YWd X[ WZWfj[Z je j^[ Wk]c[djWj_ed fheY[Zkh[ mekbZ X[ feii_Xb[ Xkj _i dej
po]ecWj_YeWbl[ebWhYh[ij$ _cc[Z_Wj[bo_dZ_YWj[Z
È È )NTRAOPERATIVEÈ"LEEDINGÈ
È
)NTRAOPERATIVEÈ"LEEDING
M^_b[j^[h[_iWbmWoiWh_iaj^WjWdol[ii[bid[Whj^[
ikh]_YWb i_j[ cWo ][j _d`kh[Z Zkh_d] j^[ fheY[Zkh["
j^_ih_ia_ifWhj_YkbWhbo^_]^_di_jkWj_edie\h[ZkY[Z
Xed[ lebkc[$ ?d j^_i i[Yj_ed" m[ i^Wbb Z_iYkii j^[
lWh_ekiWdWjec_YWbijhkYjkh[ij^Wjfei[Wh_iaZkh_d]
ikh][ho"WdZm[i^Wbbi[[^emYecfb_YWj_edih[bWj[Z
jeXb[[Z_d]YWdX[Wle_Z[ZWdZjh[Wj[Z$
v½ FWbWjWbWhj[ho
J^[h_iae\l[ii[biX[_d]_d`kh[Z_i[if[Y_Wbbo^_]^
_d j^[ fh[i[dY[ e\ l[hj_YWbbo h[iehX[Z Xed[$ Ed[
mWo e\ WffheWY^_d] j^[ Wh[W _i Xo dej Z[\b[Yj_d]
W \bWf ed j^[ fWbWjWb i_Z[$ J^_i _i feii_Xb[" _\
h[b_WXb[9Jf_Yjkh[iWh[Wj^WdZWdZ]_l[[dek]^
_d\ehcWj_ed WXekj j^[ d[Y[iiWho m_Zj^ e\ j^[
Xed[$ 7do Xb[[Z_d] h[WYj_edi YWd X[ Z[Wbj m_j^
[Wi_bo_\j^[fWbWjWb\bWf_idej\kbboZ_ibeZ][Z$J^[
bWj[hWb Ykj ckij X[ f[h\ehc[Z YWh[\kbbo" ie j^Wj
Wdo _d`kh_[i je j^_i l[ii[b _dYh[Wi[Z Xb[[Z_d] v CWdZ_XkbWhWhj[ho
Wh[_cc[Z_Wj[bodej_Y[Z$Edj^[ej^[h^WdZ"ikY^
_d`khoZ[cedijhWj[iX[oedZZekXjj^WjX_Yehj_YWb
WdY^ehW][^WiX[[dh[WY^[Z$
M^[dXb[[Z_d]\hecj^[fWbWjWbWhj[ho_idej_Y[Z"
j^[Ykjj_d]fheY[Zkh[\ehj^[^eh_pedjWbeij[ejeco
^WijeX[ijeff[Z_cc[Z_Wj[bo$J^[_cfbWdjYWdX[
_di[hj[Zh_]^jWmWo$J^_im_bbijefj^[Xb[[Z_d]_d
j^[lWijcW`eh_joe\YWi[iWij^[[cfjoeij[ejeco
ibej _i \_bb[Z$ 7do h[i_ZkWb Xb[[Z_d] m_bb X[ Z[Wbj
m_j^ Xo j^[ fheY[ii e\ mekdZ Ybeikh[$ ?d j^ei[
hWh[YWi[im^[h[Yecfb[j[^W[ceijWi_iYWddejX[
WY^_[l[Z" Wd Wb]_dWj[ _cfh[ii_ed YWd X[ jWa[d je
\WXh_YWj[ W Zh[ii_d] fbWj[ [$]$ \hec W Z[[f#ZhWm
fbWj["m^_Y^i^ekbZX[bWh][[dek]^jeh[WY^j^[
h[\b[Yj_ed \ebZ" _i iYh[m[Z je j^[ _cfbWdji m_j^
j^[^[bfe\j^[WXkjc[djiWdZb_d[Zm_j^jWcfed
imWXi _\ d[Y[iiWho$ J^_i fheY[Zkh[ m_bb h[b_WXbo
ijefj^[Xb[[Z_d]$8b[[Z_d]Wj_dZ_l_ZkWbikh]_YWb
i_j[i YWd X[ ijeff[Z m_j^ beYWb Zh[ii_d] fbWj[i
\WXh_YWj[Z \hec fbWij_Y \e_b ki_d]" \eh _dijWdY["
j^[ij[h_b[fWYaW][e\j^[:_iaei_cfbWdjiehj^[
ikjkh[ cWj[h_Wb" je X[ iYh[m[Z je j^[ _cfbWdj
m_j^j^[WXkjc[dj$J^[Z[dj_ijcWoY^eei[jeki[
WJI://#jof[WXkjc[djjeefj_c_p[j^[fh[iikh[
[n[hj[Zedj^[ie\j#j_iik[ijhkYjkh[$
7do Xb[[Z_d] _dje j^[ cWn_bbWho i_dki YWddej X[
ijeff[ZWjj^[iekhY[$M[^Wl[d[l[h[nf[h_[dY[Z
Wdo YWi[i e\ Xb[[Z_d] j^hek]^ j^[ i[c_bkdWh
^_Wjki _dje j^[ f^Whodn eh \hec j^[ dei[ _d ekh
fhWYj_Y[$ HWj^[h" j^[ XbeeZ _di_Z[ j^[ cWn_bbWho v <WY_WbWhj[ho
i_dkimekbZWbmWoiYeW]kbWj[m_j^_dWi^ehjj_c["
j^kieXijhkYj_d]j^[dWjkhWbfWiiW][i$
J^[ i[YedZ WffheWY^ je Wle_Z Xb[[Z_d] _i Xo
Z[\[Yj_d]j^[fWbWjWbckYeiWb\bWfWdZceX_b_p_d]
j^[ l[ii[bi$ J^_i mWo j^[o YWd X[ iWl[Z \hec
,'
ZWcW][$Dej[j^WjZ[\b[Yj_ede\W\bWfm_bbWbmWoi
[d^WdY[h[ceZ[bb_d]e\j^[[nfei[ZXed[Wh[W$
v ?dY_iWbWhj[ho
J^_i l[ii[b _i Wbceij _dlWh_WXbo _d`kh[Z m^[d
_cfbWdji ^Wl[ X[[d fbWY[Z _d j^[ Wh[W e\ j^[
Wdj[h_eh dWiWb if_d[$7i W ][d[hWb hkb[" X_Yehj_YWb
WdY^ehW][ e\ 8E? _cfbWdji YWd edbo X[ h[Wb_p[Z
_d j^_i Wh[W m^[d j^[ Yehj_YWb Xed[ ijhkYjkh[ ed
j^[ fWbWjWb Wif[Yj X[oedZ j^[ Whj[ho _i h[WY^[Z$
I_dY[ j^_i l[ii[b _i kikWbbo hWj^[h icWbb WdZ
_ji _dj[hdWb fh[iikh[ bem" j^[ Xb[[Z_d] YWd X[
[\\[Yj_l[bo ijeff[Z Xo i_cfb[ ikjkh_d]$ 7domWo
_j _i \eh W[ij^[j_YWb h[Wiedi _d cWdo YWi[i dej
h[Yecc[dZ[Z je fbWY[ _cfbWdji X[jm[[d j^[
kff[h YWd_d[i$ ?d hWh[ YWi[i fWj_[dji h[fehj
f[hi_ij[dj fW_d W\j[h j^[ fbWY[c[dj e\ _cfbWdji
d[Wh eh _d j^[ _dY_iWb YWdWb$$ J^_i fW_d i[[ci je
ij[c\hecWd_cceX_b_iWj_ede\j^[Xed[iWjj^[
ikjkh[i WdZ dej \hec j^[ YWdWb eh j^[ d[hl[i$
H[celWb e\ j^[ _cfbWdj _i ed feii_Xb[ jh[Wjc[dj
e\j^_ijof[e\fW_d$
M^[d_cfbWdjiWh[fbWY[Z`kijWXel[j^[cWdZ_XkbWh
YWdWb" j^[h[ _i WbmWoi W Y^WdY[ j^Wj j^[ YWdWb _i
_dlWZ[Z Xo j^[ Ykjj_d] _dijhkc[dji$ ?d`kh_[i je
j^[d[hl[Wh[hWh[_dj^_iYedd[Yj_edX[YWki[j^[
d[hl[Æfhej[YjiÇ_ji[b\gk_j[ikYY[ii\kbbo"Wibed]_j
_i dej WdW[ij^[i_p[Z Xo W cWdZ_Xb[ XbeYa$ CkY^
ceh[ Yecced Wh[ Xb[[Z_d] h[WYj_edi YWki[Z Xo
fW_db[ii_d`kh_[ijej^[cWdZ_XkbWhWhj[hom_j^
_ji _cfb_YWj_edi \eh j^[ \khj^[h ^WdZb_d] e\ j^[
ikh]_YWb fheY[Zkh[$ I_dY[ j^[ eij[ejeco _i dej
dehcWbbo Yecfb[j[Z Xo j^[ j_c[ e\ Xb[[Z_d]" j^[
gk[ij_ed m^[j^[h j^[ _cfbWdj fheY[Zkh[ i^ekbZ
X[Yedj_dk[ZWjj^Wjif[Y_\_Yi_j[ckijX[YWh[\kbbo
h[Yedi_Z[h[Z$ 7\j[h Wbb" 8E? _cfbWdji fbWY[Z Wj W
i_j[ m^[h[ j^[ Xed[ cWdZ_XkbWh YWdWb ^Wi X[[d
ef[d[ZcWo]_l[h_i[jej^[hcWbi[di_j_l_jo_dj^Wj
Wh[WZemdj^[heWZ"WiWdof^oi_YWblWh_Wj_edim_bb
X[jhWdic_jj[Zj^hek]^j^[_cfbWdji^W\jh_]^jje
cWdZ_XkbWhd[hl[_\j^[YWdWb_idej[dYbei[ZXo
Xed[$
J^[ Z[dj_ij i^ekbZ j^[h[\eh[ WbmWoi Yedi_Z[h j^[
efj_ede\Yh[Wj_d]Wd[meij[ejeco"j^kifbWY_d]
j^[_cfbWdj\khj^[hZ_ijWbboehc[i_Wbbo"edX[_d]
\WY[Z m_j^ Xb[[Z_d] \hec j^[ cWdZ_XkbWh Whj[ho$
J^[ Xb[[Z_d] Wi ikY^ YWd X[ [Wi_bo ijeff[Z Xo
`kijYbei_d]j^[eij[ejecoibej$?diec[fWj_[dji"
j^[ cWdZ_XkbWh Whj[ho WdZ d[hl[ fWii Wbed] _d
i[fWhWj[ YWdWbi" m^_Y^ YWddej X[ Z_W]deij_YWbbo
_Z[dj_\_[ZIWdY^_i[jWb$(&&)$
?d`kh_[i je j^[ \WY_Wb Whj[ho Wh[ W fWhj_YkbWhbo
kdfb[WiWdj a_dZ e\ Yecfb_YWj_ed$ ?d[nf[h_[dY[Z
ikh][edi m_bb _d_j_Wbbo \W_b je kdZ[hijWdZ ^em
j^_i YekbZ ^Wff[d$ ?\ [nj[di_l[ \bWf h[\b[Yj_ed _i
f[h\ehc[Z _d i_jkWj_edi e\ ^[Wlo cWdZ_XkbWh
,( 9^Wfj[h+È %QUIPMENTÈANDÈ3URGICALÈ4ECHNIQUES
h[iehfj_ed" j^[d j^[ \bWf m_bb h[cW_d kdZ[h
Yedi_Z[hWXb[ j[di_b[ ijh[ii Zk[ je j^[ h[jhWYj_d]
\ehY[[n[hj[ZXoj^[c[djWbd[hl[$?\j^[Wii_ijWdj
ehikh][edbei[iYedjhebe\j^[fhej[Yj_l[ifWjkbW
Zkh_d] j^[ eij[ejeco" j^[ Ykjj[h cWo [dj[h j^[
l[ij_XkbWh Y^[[a Wh[W m^[h[ _j cWo _dlWZ[ j^[
\WY_Wb Whj[ho e\ _ji WiieY_Wj[Z l[_d \hec _di_Z[$
8ej^ jof[i e\ _d`kho m_bb ]_l[ h_i[ je fhe\ki[
Xb[[Z_d]Wj^_]^fh[iikh[$
J^[ _cc[Z_Wj[bo h[gk_h[Z jh[Wjc[dj _d j^[i[
i_jkWj_edi_ijeYecfh[iij^[W\\[Yj[Zl[ii[bW]W_dij
j^[ XehZ[h e\ j^[ cWdZ_Xb[$ J^[ Yecfh[ii_ed
^Wi je X[ cW_djW_d[Z \eh Wj b[Wij (&c_d$ ?\ j^[
Xb[[Z_d] _i ij_bb dej ijeff[Z Xo j^_i" j^[ \bWf
ckijX[ikjkh[Zm_j^ekjkdd[Y[iiWhoZ[bWoi$J^[
Yecfh[ii_l[ \ehY[ ckij dej X[ h[b[Wi[Z X[\eh[
j^[ikjkh[_iYecfb[j[Z$?\j^_iZe[idejiebl[j^[
fheXb[c[_j^[h"j^[l[ii[bd[[ZijeX[l_i_j[ZWdZ
b_]Wj[Z j^hek]^ Wd [njhWehWb WYY[ii W\j[h X[_d]
ef[d[Z kf _\ d[Y[iiWho$ J^[ fWj_[dj i^ekbZ X[
ced_jeh[Z\ehiec[j_c[ikXi[gk[djbo$
v IkXcWdZ_XkbWhWhj[h_Wbfb[nki
F[d[jhWj_d] j^[ b_d]kWb Yehj_YWb Xed[ ijhkYjkh[
m^_b[ Wffbo_d] j^[ Ykjj[h \eh Wd _dj[h\ehWc_dWb
_cfbWdj fheY[Zkh[ YWhh_[i j^[ h_ia e\ _d`kh_d]
ikXcWdZ_XkbWhl[ii[bi$7iWcWjj[he\\WYj"i[l[hWb
fWj_[djiWh[edh[YehZ_dj^[b_j[hWjkh[edYh[ijWb
_cfbWdjebe]oWi^Wl_d]Z_[ZW\j[hikY^_dY_Z[dji
M[_Xh_Y^ (&&($ M^Wj cWa[i j^_i i_jkWj_ed ie
fheXb[cWj_Y _i j^Wj de Xed[ ijhkYjkh[ _i fh[i[dj
W]W_dij m^_Y^ j^[ l[ii[b YWd X[ Yecfh[ii[Z
\eh ^W[ceijWi_i$ B_]Wj_d] ed[ ikffbo_d] l[ii[b
_i kikWbbo dej feii_Xb[$ ;l[d _\ Xej^ ikffbo_d]
l[ii[bi Wh[ b_]Wj[Z" ^em[l[h" j^[ i_jkWj_ed ij_bb
h[cW_di b_\[#j^h[Wj[d_d] X[YWki[ Yecfh[ii_ed e\
j^_iWh[W_iZ_\\_Ykbj$J^[ikXcWdZ_XkbWhlWiYkbWh
fb[nkim_bba[[fXb[[Z_d]_dj[hdWbboW\j[hikjkh_d]"
j^ki Z_ifbWY_d] j^[ ie\j#j_iik[ ijhkYjkh[i" ie
j^Wj j^[ jed]k[ WdZ \beeh e\ j^[ cekj^ cWo X[
[b[lWj[ZZhWcWj_YWbbojej^[fe_dje\eXijhkYj_d]
j^[W_hmWoi$?j_id[Y[iiWhojeced_jehj^[fWj_[dj
edWd_dfWj_[djXWi_iW\j[h_dY_Z[djie\j^_ijof[$
?djhWef[hWj_l[bo"j^[Z[dj_ijYWd[ijWXb_i^XomWoe\
Z_\\[h[dj_WbZ_W]dei_ij^Wjj^[iekhY[e\Xb[[Z_d]_i
h[Wbbo_dj^[ikXcWdZ_XkbWhfb[nki"i_dY[fhe\ki[
Xb[[Z_d] cWo Wbie [cWdWj[ \hec j^[ cWdZ_Xb[
_ji[b\L_Z[e)$8b[[Z_d]\hecj^[ikXcWdZ_XkbWh
fb[nkiYWdWjb[WijX[ijeff[Z_dj^[eij[ejecoWh[W
Xo Yecfh[ii_d] j^[ b_d]kWb ie\j#j_iik[ ijhkYjkh[i
W]W_dij j^[ cWdZ_XkbWh Xed[" j^[h[Xo Z_ihkfj_d]
j^[l[ij_XkbWhXbeeZijh[Wc\hecj^[_cfbWdji_j[$
8b[[Z_d]\hecj^[cWdZ_Xb[_ji[b\"XoYedjhWij"m_bb
dejh[ifedZjeYecfh[ii_d]j^[b_d]kWbie\j#j_iik[
ijhkYjkh[iWjj^[ikif[Yj[Zi_j[e\f[h\ehWj_edi[[
L_Z[e ( \eh Z[jW_bi ed Z_ij_d]k_i^_d] j^[ iekhY[
e\Xb[[Z_d]_dj^_iWh[W$M^Wj_ib[iim[bb#ademd
_i j^Wj ed[ eh jme icWbb[h Whj[h_[i kikWbbo [dj[h
j^[cWdZ_Xb[\hecj^[b_d]kWbi_Z[$J^[i[Whj[h_[i
cWo X[ 'Ä'$.cc _d Z_Wc[j[h WdZ eYYWi_edWbbo
YWki[ cWii_l[ ^W[cehh^W][i Bkij_] [j Wb$ (&&)"
m^_Y^"^em[l[h"kikWbbogk_YaboikXi_Z[edY[j^[
_cfbWdj _i fbWY[Z WdZ j^[ ckYef[h_eij[Wb \bWf _i
ikjkh[ZYbei[Z$
=eeZfbWdd_d]e\j^[eij[ejecoXo9J_cW]_d]YWd
X[ ^[bf\kb je Wle_Z Whj[h_Wb Xb[[Z_d] fWhj_YkbWhbo _d
j^[ ^WdZi e\ del_Y[i$ J^[ ie\j#j_iik[ ijhkYjkh[i _d
j^[ cWdZ_Xb[ YWd Wbie X[ fhej[Yj[Z m_j^ W ifWjkbW
eh hWifWjeho W\j[h b_d]kWb \bWf h[\b[Yj_ed$ ?\ \bWf
h[\b[Yj_ed_idejYedi_Z[h[ZWffhefh_Wj["j^[Wii_ijWdj
\ekhj^ gkWZhWdj eh Z[dj_ij j^_hZ gkWZhWdj YWd
ki[ W \_d][h je WiY[hjW_d Xo ÆYekdj[h#fWbfWj_edÇ
m^[d j^[ ie\j j_iik[ _i h[WY^[Z ed jhWdil[hi_d] j^[
YedjhWbWj[hWbYehj_YWbXed[ijhkYjkh[$
:[dj_ijim^eWh[`kijijWhj_d]ekj_d8E?j^[hWfo
WdZ m^ei[ ikh]_YWb [nf[h_[dY[ cWo ij_bb X[ b_c_j[Z
cWoX[W\hW_Ze\ZWcW]_d]iec[e\j^[bWh][hXbeeZ
l[ii[biWjj^[ikh]_YWbi_j[$J^_i\[WhYWd]eie\WhWi
je h[ikbj _d 8E? _cfbWdji dej X[_d] _di[hj[Z m^[h[
j^[oi^ekbZ\hecWX_ec[Y^Wd_YWbfe_dje\l_[m"eh
dej _d W Yehh[Yj X_Yehj_YWb fei_j_ed$ >em[l[h" j^_i
Ze[i dej ^[bf j^[ fWj_[dj$ ;nf[h_[dY[Z ef[hWjehi
Wh[d[l[hW\hW_Ze\XbeeZl[ii[biehd[hl[i1j^[om_bb
ef[hWj[ YWh[\kbbo WdZ Y_hYkcif[Yjbo WdZ fbWY[ j^[
_cfbWdj m^[h[ j^[o m_bb \kdYj_ed X[ij$ J^[ YWki[
e\ Wdo ^W[cehh^W][i j^Wj cWo eYYkh m_bb ^Wl[ je
X[ [nWc_d[Z WdZ j^[ d[Y[iiWho c[Wikh[i jWa[d je
Yedjhebj^[c$
?d i_jkWj_edi e\ i[l[h[ f[h_eZedjWb ZWcW][" j^[
ie\j#j_iik[ijhkYjkh[icWoX[c[bbem[Zjej^[fe_dj
e\ Wbbem_d] Z_\\ki[ Xb[[Z_d] [l[d _\ YeW]kbWj_ed
_i edbo c_bZbo _cfW_h[Z$ J^[ Z[dj_ij i^ekbZ \_hij
Wjj[cfj je [ijWXb_i^ W bWh][ YedjWYj Wh[W e\ j^[
mekdZ cWh]_di Xo ikjkh_d] j^[ i_j[ WhekdZ W m_Z[
cWh]_d e\ ^[Wbj^o j_iik[$ ?\ j^_i \_hij Wjj[cfj _i dej
ikYY[ii\kb"WdoWZZ_j_edWbikjkh[iWh[kikWbboki[b[ii$
7YjkWbbo"j^[omekbZX[ceh[^Whc\kbj^WdX[d[\_Y_Wb
Xo jhWkcWj_p_d] j^[ j_iik[ [l[d ceh[ WdZ Yh[Wj_d]
WZZ_j_edWb ^eb[i$ 7Yj_l[ YeW]kbWj_ed _i dej kikWbbo
^[bf\kb[_j^[hXkjYWhh_[ij^[h_iae\fhefW]Wj_d]j^[
_d`khojei[]c[djim^[h[j^[bkc[de\j^[W\\[Yj[Z
l[ii[bi_ibWh][h$Fh[iikh[jWcfedWZ[Wffb_[Zjej^[
Xedo XWi[ \hec Wd [njhWehWb Z_h[Yj_ed e\\[h X[jj[h
Y^WdY[ie\ikYY[ii"dejWXbo_\j^[Xb[[Z_d]_ibeYWj[Z
l[ij_XkbWhbo je j^[ Xed[$ =eeZ h[ikbji ^Wl[ X[[d
eXjW_d[Z" \eh _dijWdY[" m_j^ ceZ_\_[Z ehj^eZedj_Y
Z[l_Y[iikY^Wi^[WZ][WhiehY^_dYWfi$J^[ikffehj
Wh[Wie\j^[i[Z[l_Y[iYWdX[[nfWdZ[Zm_j^WYhob_Y
h[i_d je _dYbkZ[ j^[ W\\[Yj[Z Wh[Wi" j^[d ikffehj[Z
W]W_dijj^[d[YaeheYY_fkj$
È È -EDICATIONÈ ,)

.OTE
'$ ?djWYj YeW]kbWj_ed _i W cWdZWjeho h[gk_h[#
c[dj \eh Wbb fheY[Zkh[i _dlebl_d] 8E?
_cfbWdji$
($ ?j_id[Y[iiWhojefWoWjj[dj_edjej^[XbeeZ
l[ii[biWdZd[hl[iZkh_d]Wdef[hWj_ed$?j_i
ZWd][heki"^em[l[h"jeX[W\hW_Ze\j^[c$

M^[d[l[h fhe\ki[ Xb[[Z_d] eYYkhi" j^[ Z[dj_ij ^Wi

je h[Wiikh[ j^Wj j^[ fWj_[dj _i dej ed Wdo jof[ e\
Wdj_YeW]kbWdj Zhk]i$ 7 ]h[Wj cWdo fWj_[dji m^e
^Wl[jWa[d7if_h_d9WhZ_eel[hcWdoo[Whim_bbdej
[l[d h[Wb_p[ j^Wj j^_i jof[ e\ c[Z_YWj_ed cWo X[
h[b[lWdj _d Yedd[Yj_ed m_j^ Z[djWb _cfbWdj j^[hWfo$
Iec[ ][d[hWb fhWYj_j_ed[hi ijhed]bo X[b_[l[ _d
Wdj_YeW]kbWj_edj^[hWfoWdZfh[iYh_X[j^ei[Zhk]ije
j^[_hfWj_[djiedWb_\[bed]XWi_i$M^_b[j^[gk[ij_ed
\eh ^em bed] W fWj_[dj ^Wi X[[d ed Wdj_YeW]kbWdj
Zhk]i _i _dlWh_WXbo Wdim[h[Z _d Z[jW_b" j^[ i[YedZ
gk[ij_ed\eh^emckY^bed][hj^_ij^[hWfo_i]e_d]
jeX[Yedj_dk[Zm_bbkikWbboZhWmWXbWdaijWh[$
J^[ Zh[ii_d] i^ekbZ X[ b[\j _d fbWY[ de bed][h
j^Wd _i d[Y[iiWho 'Ä(ZWoi Wj j^[ ceij ie j^Wj
ikffkhWj_ed \hec j^[ ikh]_YWb i_j[ WdZ \bWf Wh[W
_i dej kdZkbo _cf[Z[Z$ J^[ fh[iikh[ [n[hj[Z Xo
j^[ Zh[ii_d] YWd X[ _dYh[Wi[Z Xo ki_d] W JI://
WXkjc[dj eh Xo \ebZ_d] j^[ fbWij_Y bWo[h i[l[hWb
j_c[i$ ?d j^[ cWn_bbW" j^[ Z[dj_ij cWo Wbj[hdWj_l[bo &IGÈAnC 7 beYWb Zh[ii_d] fbWj[ YWd X[ cWZ[ \hec j^[
Y^eei[jeWffbobWXehWjeho#cWZ[Zh[ii_d]iYel[h_d] fbWij_YmhWff_d]e\j^[:_iaei_cfbWdjWdZWffb_[Zje][j^[h
m_j^j^[WXkjc[djXo[ijWXb_i^_d]j^[iYh[mYedd[Yj_ed$7\j[h
i[l[hWb_cfbWdji$ Wd Wffhefh_Wj[ f_[Y[ e\ fbWij_Y ^Wi X[[d Ykj ekj WdZ \ebZ[Z
edY["W^eb[_iYkj_djeXej^bWo[hij^hek]^m^_Y^j^[oYWdX[
ib_ff[Zel[hj^[j^h[WZ[Zf_dWdZi[Ykh[Zm_j^j^[WXkjc[dj$
È
-EDICATION

7dj_X_ej_Y jh[Wjc[dj _i Yeccedbo h[Yecc[dZ[Z
_d Z[djWb _cfbWdjebe]o Wbj^ek]^ W h[Wb X[d[\_j ^Wi
d[l[hX[[d[ijWXb_i^[Z$<ehj^_ih[Wied"m[edboki[
Wdj_X_ej_Yi m^[d if[Y_\_Y c[Z_YWb h[Wiedi Wh]k[ _d
\Wlekh e\ ikY^ Yel[hW][" kikWbbo W\j[h Yedikbj_d]
j^[ ][d[hWb fhWYj_j_ed[h" m^e cWo [l[d Y^eei[ je
Z[\_d[ j^[ jof[ e\ Wdj_X_ej_Y je X[ ki[Z$ Dkc[heki
h[Yecc[dZWj_edi\ehWdj_X_ej_Yjh[Wjc[dj^Wl[X[[d
fhel_Z[Z _d j^[ b_j[hWjkh[$ ?d ekh emd fhWYj_Y[" m[
^Wl[ f[h\ehc[Z WhekdZ ("&&& _cfbWdj fheY[Zkh[i
m_j^ekj Wdj_X_ej_Y Yel[hW][$ M[ ^Wl[ dej eXi[hl[Z
Wdo Z_iWZlWdjW][i$ Feijef[hWj_l[ im[bb_d] YWd X[
Wle_Z[ZXoikXYkjWd[ekibo_d`[Yj[ZYehj_Yeij[he_Zi$
J^[_cfbWdjfheY[Zkh[WiikY^YWdX[f[h\ehc[Z
kdZ[h ][d[hWb WdW[ij^[i_W" i[ZWj_ed" d_jheki en_Z[
WdWb][i_W eh beYWb WdW[ij^[i_W$ M[ ^Wl[ \ekdZ j^Wj
_j _i ][d[hWbbo i_cfb[ij je ki[ beYWb WdW[ij^[i_W"
m^_Y^Wbbemij^[fWj_[djjeWYj_l[boa[[f^_icekj^
ef[d WdZ Yedjheb j^[ cel[c[dji e\ ^_i jed]k[$
FWj_[dji kdZ[h i[ZWj_ed eh d_jheki en_Z[ WdWb][i_W
Wh[ceh[b_a[bojeimWbbemeX`[YjiikY^WiiYh[mieh
Xed[ \hW]c[dji j^Wd ded#i[ZWj[Z fWj_[dji$ =[d[hWb
WdW[ij^[i_W" Xo YecfWh_ied" e\\[hi j^[ WZlWdjW][
j^Wj j^[ f^Whodn _i ijeff[Z kf ie j^Wj j^[ fWj_[dji
YWddej feii_Xbo imWbbem Wdo eX`[Yji$ <khj^[hceh["
j^[XbeeZfh[iikh[YWdX[][djboWdZiW\[boh[ZkY[Z
kdZ[h][d[hWbWdW[ij^[i_W"m^_Y^YWdX[X[d[\_Y_Wb_d
[nj[di_l[ fheY[Zkh[i$ Ed j^[ Zemdi_Z[" _d\hWd[hlWb
_cfbWdj fbWY[c[dj m_bb _dlebl[ ceh[ [nj[di_l[
[nfeikh[ e\ j^[ cWdZ_XkbWh d[hl[ _\ f[h\ehc[Z
kdZ[h ][d[hWb WdW[ij^[i_W" j^[h[Xo m[Wa[d_d]
h[iehX[Zh_Z][ijhkYjkh[i[l[d\khj^[h$
Ed[ijhWj[]oj^Wjm[\[[b^WiX[[dl[hoki[\kb_d
Wbbekhikh]_YWbfheY[Zkh[i_ijeWffboeno][d)b%c_d
Yedj_dkekiboj^hek]^WdWiWbfheX[$J^_ifh[YWkj_ed
m_bba[[fXbeeZeno][dYedY[djhWj_ediijWXb[[l[d_d
Yh_j_YWbi_jkWj_edi"m^_Y^Ze[iW]h[WjZ[Wbjeh[ZkY[
j^[fWj_[djÉiijh[iib[l[b$
,* 9^Wfj[h+È %QUIPMENTÈANDÈ3URGICALÈ4ECHNIQUES

Fhef^obWYj_Y Wffb_YWj_ed e\ c_bZ d_jheki en_Z[

WdWb][i_W _i W ki[\kb fh[YWkj_ed _d fWj_[dji m_j^ W
^_ijeho e\ ^[Whj Z_i[Wi[$ J^[ hWj_edWb[ \eh j^_i _i
gk_j[ i_cfbo je Wbb[l_Wj[ Wdo fW_d\kb i[diWj_edi"
j^[h[Xo[b_c_dWj_d]j^[feii_X_b_joe\i^eYa#_dZkY[Z
WYkj[iocfjeci$CeZ[hdd_jhekien_Z[ioij[cie\\[h
Z_]_jWb ced_jeh_d] e\ j^[ ]Wi c_njkh[ WdZ WYekij_Y
i_]dWbim^[ded[e\j^[]Wi[i_iki[Zkf$
Iec[ ki[hi h[Yecc[dZ jh[Wj_d] j^[ fWj_[dj je
WXkdZWdj Wcekdji e\ mWhc j[W WdZ Z[njhei[ je
ijh[d]j^[d^_iel[hWbbYedij_jkj_ed\ehj^[fheY[Zkh[$
?j_iYedi_ij[djm_j^ekhemdeXi[hlWj_edij^Wjiec[
fWj_[djiWh[ieiYWh[ZXoj^[fheif[Yje\kdZ[h]e_d]
ehWbikh][hoj^Wjj^[oZedej[WjehZh_daX[\eh[j^[
fheY[Zkh["j^kiYec_d]jej^[e\\_Y[_bb#fh[fWh[Z$M[
j^[h[\eh[ WZl_i[ ekh fWj_[dji je [Wj WdZ Zh_da ÆWi
kikWbÇkdb[iiZ[[fi[ZWj_edeh][d[hWbWdW[ij^[i_W
_ifbWdd[Ziej^Wjj^[_hdehcWbZ_khdWbfWjj[hdiWh[
dejkfi[jZkh_d]j^[jh[Wjc[dj$7Zc_d_ij[h_d]mWhc
mWj[h Zkh_d] j^[ ef[hWj_ed [l[ho (&Ä)&c_d ^[bfi
&IGÈ J^[ CWjh_n ioij[c YWd X[ WZZ_j_edWbbo \_jj[Z m_j^
j^[fWj_[djiWkjedec_Yd[hl[ioij[cWdZj^[cWjh_n Wd eno][d Z[cWdZ lWbl[ je [\\[Yj_l[bo Z[Wb m_j^ [c[h][dYo
je ijWo _d XWbWdY[$ J^[ iWc[" Xo j^[ mWo" Wbie ^[bfi i_jkWj_edi$ Jme \bWiai e\ eno][d WdZ d_jheki en_Z[ [WY^ m_bb
ki ZeYjehi Zkh_d] b[d]j^o ikh]_YWb _dj[hl[dj_edi$ [dikh[j^Wjj^[ikffbo_id[l[h_dj[hhkfj[Z
Ie Xej^ fWj_[dj WdZ j^[ ZeYjeh i^ekbZ jWa[ W i^ehj
Xh[WaWdZh[\_bbj^[_hb_gk_Zh[i[hle_h$
?d j^[ feijef[hWj_l[ Yekhi[" j^[ fWj_[dji Wh[
jh[Wj[Zm_j^WdWb][i_Yi$:[f[dZ_d]edWd_dZ_l_ZkWbÉi
fW_d i[di_j_l_jo" FedijWd c[\[dWc_Y WY_Z eh ceh[
[\\[Yj_l[ Zhk]i ikY^ Wi BWcWb_d[ Wh[ ki[Z$ Ceij
fWj_[djim_bbX[\h[[e\fW_dedj^[\_hijfeijef[hWj_l[
ZWo$Feijef[hWj_l[fW_dm_bbX[bem[h_\j^[fheY[Zkh[
mWif[h\ehc[Zim_\jboWdZm_j^b_X[hWb\bWfh[\b[Yj_ed$
:[dje^[n_Z_d[ ]bkYedWj[ _i h[Yecc[dZ[Z \eh Wdj_#
_d\[Yj_ed fhef^obWn_i \hec j^[ \_hij feijef[hWj_l[
ZWo$
Ped[i e\ cW`eh im[bb_d] YWd X[ gk_Yabo h[iebl[Z
Xobocf^Wj_YZhW_dW][_dj^[^WdZie\Wm[bb#l[hi[Z
Z[dj_ijehZ[djWbWii_ijWdj$J^[_cfehjWdjfWhj_ije

&IGÈ J^_i 9H?J?97H; ioij[c _i ki[Z je ced_jeh

YWhZ_elWiYkbWh \kdYj_ed$ Eno][d iWjkhWj_ed WdZ ^[Whj hWj[
Wh[ki[\kbfWhWc[j[hi\ehhekj_d[Z[djWbfheY[Zkh[i$J^[;9=
\kdYj_ed_idejh[gk_h[Z

ZhW_d j^[ ZhW_dW][ h[]_edi _d j^[ bem[h d[Ya Wh[W

\_hijX[\eh[WZZh[ii_d]j^[im[bb_d]_dj^[Y^[[aWh[W$
7jejWbe\j^h[[eh\ekhZW_boi[ii_edie\'+c_dm_bb
^[bfjegk_Yabo[b_c_dWj[j^[im[bb_d]iWdZ"WXel[Wbb"
jeh[ZkY[j^[eXijhkYj_l[fh[iikh[$FWj_[djim^eWh[
ikiY[fj_Xb[jeim[bb_d]iYWdX[jh[Wj[ZXobocf^Wj_Y
ZhW_dW][[l[dfeijef[hWj_l[bo$
?\ i_ba ikjkh[i Wh[ ki[Z [$]$ )$&" j^[o i^ekbZ X[
h[cel[Zedj^[i[YedZfeijef[hWj_l[ZWoWjj^[bWj[ij$
7i de j[di_b[ \ehY[i m_bb WYj ed j^[ ckYef[h_eij[Wb
&IGÈ CWjhnD(Ec_n[hioij[cm_j^ki[h#\h_[dZboYedjheb \bWf_\j^[\bWfmWiZhWmdel[hj^[j^h[WZ[Zf_die\
WdZZ_ifbWofWd[b j^[_cfbWdj"j^[ikjkh[iYWdX[h[cel[Zedj^[\_hij
È È )NJURYÈTOÈ!DJACENTÈ4EETHÈ ,+

&IGÈAnF J^[ceijZ_ijWb8E?_cfbWdj_dj^[cWn_bbWi^ekbZWbmWoiX[fWbWjWbbo_dYb_d[ZX[YWki[j^[i[b[Yj[ZZ_iaZ_Wc[j[h
i^ekbZX[Wim_Z[Wifeii_Xb[W"X$J^[j^h[WZ[Zf_dm_bbdebed][h_dj[h\[h[m_j^j^[jed]k[edY[_j^WiX[[dX[djjeeXjW_d
fWhWbb[b_ic m_j^ j^[ h[i_ZkWb j[[j^$ J^[h[ _i ij_bb [dek]^ ifWY[ je fei_j_ed j^[ ikf[hijhkYjkh[ d[nj je j^[ j^h[WZ[Z f_d$ J^[
_cfbWdj jof[ i^ekbZ X[ i[b[Yj[Z ikY^ j^Wj j^[ Y[djh[ e\ ]hWl_jo e\ j^[ fheij^[j_Y meha m_bb X[ beYWj[Z WXel[ j^[ ikffehj_d]
febo]ede\j^[_cfbWdjiXWi[fbWj[["\$E\j[d_j_idejfeii_Xb[jeYel[hj^[Yedd[Yj_edX[jm[[d_cfbWdjWdZh[ijehWj_edm_j^
Y[hWc_Yi$7ZZ_d]Y[hWc_YimekbZYWki[\khj^[h_dYh[Wi[_dj^[i_p[e\j^[Xh_Z]["j^ki_dj[h\[h_d]m_j^j^[\kdYj_edWbfWj^mWoi
e\j^[jed]k[

feijef[hWj_l[ ZWo$ Iodj^[j_Y ikjkh[ cWj[h_Wbi Wh[ Wh[fh[i[dj$E\Yekhi["j^[h_d]Z_ia_ibeYWj[ZX[bem

h[Yecc[dZ[Z _\ j^[ ikjkh[i Wh[ je X[ b[\j _d fbWY[
bed][hj^Wdj^Wj[$]$X[YWki[j^[cWn_bbWhoi_dkimWi
ef[d[Z Zkh_d] j^[ fheY[Zkh[$ H[iehXWXb[ ikjkh[
cWj[h_Wb _i dej Wffhefh_Wj[ X[YWki[ j^[ h[iehfj_ed
mekbZ]_l[h_i[je_d\bWccWj_ed$
È
)MPLANTÈ0OSITIONINGÈÈ
FORÈ0ROSTHETICÈ4REATMENT
8[YWki[ ^eh_pedjWbbo h[ZkY[Z Xed[ lebkc[ _i
fh[i[dj eh m_bb X[ fh[i[dj W\j[h j[[j^ ^Wl[ X[[d
[njhWYj[Z" j^[h[ i^ekbZ X[ de fheXb[c fbWY_d] j^[
ikf[hijhkYjkh[X[\eh[j^[h_Z][$J^[icWbbZ_Wc[j[h
e\j^[j^h[WZ[Zf_d_ied[e\j^[]h[Wj[ijWZlWdjW][i
e\ [nj[hdWb#j^h[WZ 8E? _cfbWdj Z[i_]di$ J^Wdai
je _ji j^_dd[ii" j^[ j^h[WZ[Z f_d YWd X[ _di[hj[Z
_dje j^[ Xed[ \khj^[h fWbWjWbbo%b_d]kWbbo j^Wd j^[
fh[l_eki fei_j_ed e\ j^[ Z[djWb heeji$ <_]kh[+$((W
_bbkijhWj[i W fWhj_Wb Yhemd _d j^[ cWn_bbW \eh m^_Y^
j^[ j^h[WZ[Z f_d ^WZ je X[ fbWY[Z \Wh jemWhZi j^[
fWbWj[$ <khj^[hceh[" _j ^WZ je X[ fWbWjWbbo _dYb_d[Z$
J^[lWijcW`eh_joe\fWj_[dji^Wl[defheXb[cm_j^
j^_i _cfbWdj fei_j_ed _\ de hek]^ eh i^Whf ikh\WY[i
j^[ Whj_\_Y_Wb Yhemd Wj (- W\j[h Wbb je [dikh[ j^[
ijhkYjkhWb _dj[]h_jo e\ j^[ Xh_Z][ Xkj _i de bed][h
l_i_Xb[\ebbem_d]\bWfYbeikh[$
È
)NJURYÈTOÈ!DJACENTÈ4EETH
?d ekh meha m_j^ 8E? _cfbWdji" m[ eYYWi_edWbbo
^WZ j^[ XWZ bkYa e\ _d\b_Yj_d] ZWcW][ je WZ`WY[dj
dWjkhWb heeji$ J^_i jof[ e\ c_i^Wf YWddej X[ hkb[Z
ekjm_j^Y[hjW_djo[l[d_dj^[^WdZie\Y_hYkcif[Yj
ki[hi m_j^ m[bb#jhW_d[Z [o[i$ >em[l[h" m[ Z_Z dej
eXi[hl[WdocW`ehfeijef[hWj_l[fheXb[ci_dWdoe\
j^[i[ YWi[i$7 dkcX[h e\ ^_ijebe]_YWb j[iji \W_b[Z je
[ijWXb_i^ Wdo kdZ[i_hWXb[ Yedi[gk[dY[i _d ceij e\
j^[i[ i_jkWj_edi" fWhj_YkbWhbo m^[d j^[ heej Z[dj_d
hWj^[h j^Wd j^[ fkbf mWi W\\[Yj[Z$ J^[ h[WZ[h _i
h[\[hh[Z je 9^Wfj[h() \eh W Z[jW_b[Z Z_iYkii_ed
e\ j^[i[ j[iji$ 7do _d`kh_[i je j[[j^ Xo j^[ 8E?
eij[ejeco fheY[Zkh[ Wbbemi j^[ ikhhekdZ_d] Xed[
ijhkYjkh[je]hem_djej^[Yh[Wj[Z]WfWdZj^ki_dje
j^[ jeej^$ FheXb[ci Wh[ b_a[bo je Wh_i[ _\ ikY^ j[[j^
d[[ZjeX[[njhWYj[ZZemdj^[heWZ$
,, 9^Wfj[h+È %QUIPMENTÈANDÈ3URGICALÈ4ECHNIQUES
&IGÈ ?j_if[h\[Yjbofeii_Xb[jefbWY[i[l[hWb8E?_cfbWdji
i_Z[ Xo i_Z[ m_j^ j^[ Z_iai el[hbWff_d]$ J^_i ijhWj[]o d[[Zi
fhWYj_Y[" ^em[l[h" X[YWki[ j^[ l[hj_YWb _cfbWdj Yecfed[dji
YWddej X[ _di[hj[Z _d W fWhWbb[b cWdd[h _d `Wm Wh[Wi m_j^
Z_\\[h[dj l[hj_YWb eh_[djWj_edi$ J^_i Wbie ^Wi _cfb_YWj_edi \eh
j^[ ^eh_pedjWb _cfbWdj i[]c[dji$ ?\ j^[ l[hj_YWb Z_l[h][dY[
_i jee fhedekdY[Z" ^eh_pedjWb YedjWYj X[jm[[d j^[ Z_iai _i
ceh[ b_a[bo$ 8[YWki[ j^[ Z_iai e\ hekdZ[Z _cfbWdj Z[i_]di
;:" ;::" ;::: Wh[ m_Z[ij _d j^[ Y[djh[ e\ j^[ `Wm" j^[
i[gk[dY[_dm^_Y^j^[_cfbWdjiWh[_di[hj[Z_iWbieWh[b[lWdj
\WYjeh$ ?j _i h[Yecc[dZ[Z je f[h\ehc Wbb eij[ejec_[i X[\eh[
Wdo_cfbWdjiWh[_di[hj[Z$Dej[j^Wjj^[Xed[#eh_[dj_d][\\[Yj
e\ j^[ cWij_YWjeho \ehY[ cWo el[hbWf eh X[ YWdY[bb[Z m^[d
_cfbWdji Wh[ fei_j_ed[Z Ybei[bo i_Z[ Xo i_Z[$ J^[ h_ia e\
^Whc\kb el[hbWff_d] j[dZi je X[ icWbb" ^em[l[h" _d Yehj_YWb
Xed[ijhkYjkh[ij^WjWh[ikX`[Yj[Zje^[WlocWYhejhW`[Yjeh_Wb
ijh[ii[i
&IGÈ I_jkWj_edWjj^[+#o[Wh\ebbem#kf$J^[Z_iae\j^[8E?
_cfbWdjWj*,_ifWhj_WbbobeYWj[Z_dj^[Z_ijWbheeji[]c[dje\
jeej^*+
È
)NTRAOPERATIVEÈ6ISION
M^[d[l[h _cfbWdji Wh[ beij" j^[h[ Wh[ kikWbbo
i[l[hWb h[Wiedi _dlebl[Z$ 8Wi[Z ed W jejWb e\ '",('
Yedi[Ykj_l[ _cfbWdji fbWY[Z _d ekh fhWYj_Y[" m[
WZZh[ii[Zj^[gk[ij_ed^emj^[b[\jWdZh_]^ji_Z[i
e\j^[iakbbYecfWh[Z_dj[hcie\_cfbWdjZkhWX_b_jo$
J^[ ikhfh_i_d] h[ikbj mWi j^Wj j^[ hWj[ e\ _cfbWdj
beiimWiikXijWdj_Wbbo^_]^[hedj^[b[\ji_Z["_$[$ed
j^[i_Z[\WY_d]WmWo\hecj^[Z[dj_ij$?d\WYj"d[Whbo
jm_Y[WicWdo_cfbWdjim[h[beij_dj^[i[YedZWdZ
j^_hZ gkWZhWdji j^Wd ed j^[ h_]^j i_Z[$ ?j i[[ci
feii_Xb[ j^Wj j^[ ikh]_YWb fheY[Zkh[ cWo X[ b[ii
ikYY[ii\kb ed j^[ b[\j Zk[ je b_c_j[Z l_i_ed e\ j^[
ikh]_YWbi_j[$7dej^[hfeii_Xb[YWki[cWoX[j^Wjj^[
Z[dj_ij ijWhji ekj meha_d] ed j^[ h_]^j WdZ cWo X[
ib_]^jbo\Wj_]k[ZXoj^[j_c[h[WY^[ij^[b[\ji_Z[$M[
Zej^_da"^em[l[h"j^Wjj^[\_hij[nfbWdWj_ed_iceh[
fbWki_Xb[$Fh[ikcWXbo"j^[Z[dj_ij^Wi]h[Wj[hjhekXb[
WY^_[l_d]j^[fheij^[j_Yjh[Wjc[djeX`[Yj_l[ieded[
if[Y_\_Y i_Z[ X[YWki[ j^[ _djhWehWb \_[bZ e\ l_i_ed _i
dej X_bWj[hWbbo [gkWb$ M[ Wjj[cfj je a[[f j^[ jejWb
dkcX[h e\ _cfbWdji bWh][ [dek]^ ie j^Wj c_deh
&IGÈÈA HWj[e\_cfbWdjbeiiedj^[b[\ji_Z[0,$)+'e\.'-
_cfbWdji$ B HWj[e\_cfbWdjbeiiedj^[h_]^ji_Z[0*$*)+
e\.&*_cfbWdji
È È !NALYSINGÈTHEÈ#AUSESÈOFÈ)MPLANTÈ,OSSÈ
[hhehi_dj^[fheij^[j_YmehaWh[ekjm[_]^[ZXoj^[
el[hWbb ioij[c$7j Wdo hWj[" _j Wff[Whi j^Wj ckY^ e\
j^[ ekjYec[ Z[f[dZi dej ie ckY^ ed j^[ _cfbWdj
ioij[c Xkj ed j^[ gkWb_jo e\ j^[ f^oi_Y_WdÉi meha
WdZj^[fWj_[djÉiYecfb_WdY[$7iWd[nfbWdWjehodej["
j^[ AWfbWd#C[_[h Ykhl[i _bbkijhWj[Z _d <_]$+$(+W"X
[n^_X_j ceh[ fhedekdY[Z ij[fi \eh [Whbo j^Wd bWj[
_cfbWdjbeii[i$
È
!NALYSINGÈTHEÈ#AUSESÈOFÈ)MPLANTÈ,OSS
7d WdWboi_i e\ j^[ YWki[i m^o j^[ 8E? _cfbWdji
fh[i[dj[Z WXel[ m[h[ beij o_[bZi j^[ \ebbem_d]
h[ikbj0
9Wki[ '0 :[\_Y_[dj fbWdd_d]$ J^_i YWj[]eho
Yecfh_i[ijh[Wjc[djim^[h[0
v½ 7d _dik\\_Y_[dj dkcX[h e\ _cfbWdji mWi fbWY[Z
]_l[d j^[ ^_ijeho e\ j^[ beYWb Xed[ ikffbo" j^[
cWij_YWjeho fWjj[hd eh j^[ i_jkWj_ed _d j^[
effei_d]`Wm$
v½ J^[h_]_Z_joe\j^[_cfbWdjih[bWj_l[je[WY^ej^[h
WdZjej^[`WmmWiY^ei[d_dYehh[Yjbo$
v J^[_cfbWdji_dijeYaWh[dejj^[h_]^jed[iehjee
\[m1 j^[ [n_ij_d] _cfbWdji Ze dej WYjkWbbo Wbbem
_di[hj_d]j^[Z_iai_dj^[XWiWbXed[Wh[Wi$
v J[[j^ kdZ[h Xh_Z][i fbWdd[Z je _dYbkZ[ dWjkhWb
WXkjc[dji bWj[h jkhd ekj dej je X[ ik\\_Y_[djbo
ijWXb[$ >em[l[h" _\ jeej^ ceX_b_jo eYYkhi" j^[h[
_i W h_ia e\ ikXi[gk[dj ZWcW][" m_j^ el[hbeWZ
eij[eboi_i eh 8E? _cfbWdj \hWYjkh[ W feii_Xb[
Yedi[gk[dY[$ FWhj_YkbWhbo Yh_j_YWb [lWbkWj_ed _i
h[gk_h[Z \eh [dZeZedj_YWbbo jh[Wj[Z WXkjc[dji
m_j^ehm_j^ekj[dZeZedj_Yfeiji$
,-
9Wki[(0:[\_Y_[dY_[iZkh_d]ikh]_YWb_dj[hl[dj_ed$
J^_iYWj[]ehoYecfh_i[ijh[Wjc[djim^[h[0
v 8_Yehj_YWbWdY^ehW][mWidejWY^_[l[Z$
v ?cfbWdji m[h[ dej fbWY[Z Wj j^[ ijhWj[]_Y fei_#
j_edi$
v J^[=lWbk[i[b[Yj[Z_ijeeicWbb$
v J^[XWiWbfbWj[_di[hj[Z_ijeeicWbb$
v ?cfh[ii_ed cWj[h_Wb mWi fh[ii[Z _dje j^[ \h[i^
mekdZ$ :e dej ki[ j^_d#\bem_d] i_b_Yed[i
_cc[Z_Wj[bo W\j[h ikh][ho1 fh[\[hWXbo ki[
_hh[l[hi_Xb[ ^oZheYebbe_Zi eh i_b_Yed[ fkjjo
cWj[h_Wbi$
9Wki[)0Fheij^eZedj_YfheXb[ci
v ?di[hj_ede\h[ijehWj_edij^WjWh[kdZ[hijh[iieh
j[di_edÄj^_icWoikXi[gk[djboh[ikbj_d_cfbWdj
\hWYjkh[iehel[hbeWZeij[eboi_i$
v ?dYehh[YjWZ`kijc[dje\cWij_YWjeho\kdYj_ed$
v FWj_[dj _di_ij_d] ed Z[jh_c[djWb cWij_YWjeho
\kdYj_edWb^WX_ji$
v½ ?dik\\_Y_[dj WZ`kijc[dj%Xk_bZkf e\ eYYbkiWb
ikh\WY[i _d h[ifedi[ je h[Wb_]dc[dji _d Xed[
jhW`[Yjeh_[iehh[bWj_l[i^_\ji_dj^[fei_j_ede\j^[
h[ijehWj_ed$
v ?dijWbbWj_ed e\ cWij_YWjeho ikh\WY[i e\ kd[gkWb
b[d]j^edYedjhWbWj[hWbi_Z[i$
Ioij[c#h[bWj[Z YWki[i e\ _cfbWdj beii0 M_j^ Yh[ijWb
_cfbWdji" ibem" Xkj f[hi_ij[dj Xed[ beii Wbed] j^[
l[hj_YWbWif[Yje\j^[_cfbWdjie#YWbb[ZY^hed_Yf[h_#
_cfbWdj_j_i_ied[e\j^[fh_cWhoh[Wiedi\eh_cfbWdj
beii$ De ikY^ ioij[c#h[bWj[Z YWki[i e\ _cfbWdj beii
m[h[\ekdZ\eh8E?_cfbWdji[l[h$
  ¬ 
#(!04%2È

$IAGNOSTICS

È
)NTRODUCTION
J^[fkhfei[e\Z_W]dei_i_ije[nfbeh[WdeX`[Yj_l[
W]W_dij j^[ XWYa]hekdZ e\ W ijhWj[]_Y jWia$ ?d
WYYehZWdY[m_j^j^_iÆc_b_jWhoÇZ[\_d_j_ed"j^[Z[dj_ij
m_bbdejYedi_Z[hWbbj^[\WYjehij^WjcWoYedY[_lWXbo
X[h[b[lWdjjej^[jh[Wjc[dj"Xkjedboj^ei[j^Wjm_bb
^[bf ^_c je WY^_[l[ j^[ jh[Wjc[dj eX`[Yj_l[$ 8o j^[
iWc[ jea[d" j^[ \WYj j^Wj W jh[Wjc[dj eX`[Yj_l[ YWd
X[WY^_[l[Z_idej[dek]^"Xkjj^[Z[dj_ijm_bbedbo
Yedi_Z[h j^ei[ eX`[Yj_l[i j^Wj m_bb WYjkWbbo X[d[\_j
j^[fWj_[dj$
v ?\ j[[j^ Wh[ dej _dYbkZ[Z" m^Wj c[Wikh[i YWd X[
jWa[d je [dikh[ j^[_h fei_j_edWb ijWX_b_jo [$]$
eYYbki_ed"ifb_dj_d]"_dYbki_ed_dWXh_Z][5
v ?dm^_Y^Xed[Wh[Wii^ekbZj^[8E?_cfbWdjiX[
WdY^eh[Z5J^[fhe]dei_i_dXej^`Wmi_i[if[Y_Wbbo
]eeZ _d j^[ YWd_d[ WdZ i[YedZ cebWh fei_j_edi$
M^_b[j^[Wdj[h_ehi[]c[djie\\[h]eeZYedZ_j_edi
\ehWdY^ehW][Wim[bb"_cfbWdji_dj^[i[Wh[WicWo
i[l[h[boh[ijh_Yjj^[\h[[Zece\fheij^[j_YZ[i_]d$
J^[ fei_j_edi e\ j^[ fh[cebWhi WdZ \_hij cebWhi
Wh[h[bWj_l[bokdijWXb[_dXej^`Wmi$
v M^Wj _i j^[ Ykhh[dj \kdYj_edWb ijWj[ e\ j^[
cWij_YWjehoioij[c5

È
È
4HEÈ3TRATEGICÈ4ASK
/RTHOPANTOMOGRAPHS
J^[ gk_dj[ii[dj_Wb jh[Wjc[dj eX`[Yj_l[ m_bb X[ je
h[ijeh[WXWbWdY[ZWdZ[\\_Y_[djcWij_YWjeho\kdYj_ed$ Ekhh[Yecc[dZWj_ed_iWbmWoijeeXjW_dWfWdehWc_Y
J^_i eX`[Yj_l[ YWd edbo X[ WY^_[l[Z j^hek]^ \_n[Z hWZ_e]hWf^ fh_eh je Wdo a_dZ e\ cW`eh h[ijehWj_l[
cWij_YWjeho ikh\WY[i$ 8E? _cfbWdji Wh[ ckY^ ceh[ jh[Wjc[dj$ 8Wi[Z ed j^[i[ _cW][i" j^[ Z[dj_ij YWd
ik_jWXb[ j^Wd Yh[ijWb _cfbWdji \eh j^_i fkhfei[ [lWbkWj[ j^[ l[hj_YWb Xed[ ijhkYjkh[ WlW_bWXb[ Wj j^[
X[YWki[ j^[ Xed[ ijhkYjkh[ h[gk_h[Z je _di[hj j^[i[ i[b[Yj[Z b[l[b e\ j^[ fbWdd[Z _cfbWdjWj_ed i_j[ WdZ
Z[i_]di_il_hjkWbboWbmWoifh[i[dj$ [njhWYj W m[Wbj^ e\ _d\ehcWj_ed ed j^[ \ebbem_d]
J^[ h[gk_h[c[dji _d j[hci e\ fh[ef[hWj_l[ \kdYj_edWbWif[Yji0
Z_W]dei_i m_bb Z[f[dZ ed j^[ Yecfb[n_jo e\ j^[ v :_ijWdY[i \hec Wdo [dZWd][h[Z d[_]^Xekh_d]
_dZ_l_ZkWb YWi[ WdZ j^[ [nf[h_[dY[ e\ j^[ ikh][ed$ ijhkYjkh[i$
?\ j^[ WlW_bWXb[ Xed[ lebkc[ _i ifWhi[" _j m_bb X[ v :_\\[h[dj_Wbi_p[e\YedZob[i_dZ_YWj_d]Wfh[\[hh[Z
Z_\\_YkbjjefbWdj^[ikh]_YWbfheY[Zkh[_dWZ[jW_b[Z Y^[m_d]i_Z[WdZ\kdYj_edWb_cXWbWdY[ii[[Wbie
cWdd[h$ >em[l[h" i_dY[ j^[h[ _i de d[[Z \eh j^[ 9^Wfj[hi'&WdZ'-$
[c[h][dY[ fe_dji e\ 8E? _cfbWdji je Ye_dY_Z[ m_j^ v :_\\[h[dj_Wb c_d[hWb_pWj_ed e\ Yehj_YWb ijhkYjkh[i
j^[ beYWj_ed e\ j^[ h[ijeh[Z Yhemdi" j^[ Z[dj_ij _i _dZ_YWj[ikd_bWj[hWb\kdYj_ed1
WbmWoi _d W fei_j_ed je kj_b_p[ j^[ WlW_bWXb[ Xed[ v :_\\[h[dj_Wbb[d]j^e\^eh_pedjWbXhWdY^[i_dZ_YWj[i
ijhkYjkh[m_j^ekjcWa_d]WdocW`ehYedY[ii_edije Wbed]^_ijehoe\kd_bWj[hWbY^[m_d]1
j^[fheij^[j_Yh[gk_h[c[dji$J^[ikh]_YWbfheY[Zkh[
_i]h[Wjbo\WY_b_jWj[ZXoj^_i$ J^[ fWdehWc_Y _cW][ m_bb dehcWbbo e\\[h [dek]^
_d\ehcWj_ed \eh cWdZ_XkbWh h[ijehWj_edi$ ?d j^[
cWn_bbW" WZZ_j_edWb jece]hWci cWo X[ ki[\kb je
È
h[\_d[ j^[ Z_W]dei_i eh [l[d je ced_jeh j^[ Yekhi[
%XPLORINGÈTHEÈ4REATMENTÈ/BJECTIVE
e\j^[hWfo$
J^[ Yb_d_YWb [nWc_dWj_ed d[[Zi je WZZh[ii j^[ :[djWb\_bcicWoX[ki[\kbje_Z[dj_\oWdofheXb[ci
\ebbem_d]_cfehjWdjgk[ij_edi0 ed _dZ_l_ZkWb j[[j^ eh _cfbWdji$ J^[o Wbie ^[bf je
v½ 7h[ j^[h[ Wdo j[[j^ m^ei[ fhe]dei_i _i ]eeZ Z[j[Yj Wdo f[hi_ij[dj _djhWXedo _d\bWccWj_edi WdZ
[dek]^ j^Wj j^[o YWd X[ Yed\_Z[djbo _dYbkZ[Z _d j^[_hfheZkYjiWim[bbWih[i_ZkWbheejijhkYjkh[i$
j^[h[ijehWj_ed5M^Wjjof[e\h[ijehWj_l[ijhkYjkh[
i^ekbZX[ki[Z5
-& 9^Wfj[h,È $IAGNOSTICS

È
0ANORAMICÈ2ADIOGRAPHÈOFÈTHEÈ3KULL

7del[hl_[me\j^[YhWd_WbijhkYjkh[icWoX[ki[\kb
_d i_jkWj_ed m^[h[ j^[ \kdYj_edWb WdZ iocc[jh_YWb
h[bWj_edi e\ j^[ iakbb Wh[ dej [dj_h[bo Yb[Wh$ J^[
Z[jW_biYedjW_d[Z_dj^[i[_cW][iWh[Wbie_cfehjWdj
_\ j^[ eYYbkiWb h[bWj_edi WdZ j^[ l[hj_YWb Z_c[di_ed
d[[ZjeX[h[WZ`kij[Z$J^[YhWd_WbijhkYjkh[iYWdX[
l_[m[Z Xo eXjW_d_d] fWdehWc_Y \hedjWb WdZ bWj[hWb
hWZ_e]hWf^ie\j^[iakbb$
J^[ \hedjWb fWdehWc_Y hWZ_e]hWf^ fhel_Z[i W
]eeZel[hl_[me\j^[YhWd_Wbiocc[jho_dj^[\hedjWb
fbWd[$ 8o [lWbkWj_d] j^[ ckiYb[ WjjWY^c[dj Wh[Wi"
&IGÈ :_\\[h[djbofhedekdY[ZWjjWY^c[djie\j^[cWii[j[h
YedYbki_ediYWdWbieX[ZhWmdWXekjj^[Z_ijh_Xkj_ed ckiYb[ _dZ_YWj[ W bed] ^_ijeho e\ kd_bWj[hWb \kdYj_ed WdZ
e\Y^[m_d]\ehY[i$ Wiocc[jh_YWbia[b[jWbh[bWj_edi

È
,ATERALÈ4ELERADIOGRAPHS

J^[ bWj[hWb j[b[hWZ_e]hWf^ e\\[hi _d\ehcWj_ed ed

j^[ jhk[ ia[b[jWb X_j[ h[bWj_edi$ ?\ Wd _dYh[Wi[ e\ j^[
l[hj_YWb Z_c[di_ed _i fbWdd[Z" _j YWd X[ ki[Z je
i_ckbWj[ j^[ [\\[Yji ed j^[ el[hWbb YhWd_Wb ijhkYjkh[
WdZ je [lWbkWj[ j^[ Y^[m_d] b[l[b$ J^_i jof[ e\
_cW][^[bfij^[Z[dj_ijjei[b[YjWffhefh_Wj[_cfbWdj
fei_j_ediWdZ_cfbWdjZ[i_]di=#lWbk[ifWhj_YkbWhbo
_d i_jkWj_edi m^[h[ j^[ ifWY[ WlW_bWXb[ _d j^[ Z_ijWb
i[]c[dji_ib_c_j[Z$

È
0ALPATORYÈ%XAMINATION

7ij^[ie\j#j_iik[ijhkYjkh[ie\j^[cWdZ_Xb[YWdX[
h[WZ_bo cWd_fkbWj[Z" j^[ YedZ_j_edi \eh fWbfWj_d]
j^[ Xedo ijhkYjkh[ Wh[ l[ho \WlekhWXb[$ ?j _i WbmWoi
d[Y[iiWho je fWbfWj[ j^[ m_Zj^ e\ j^[ `WmXed[ _d
j^[Wh[We\j^[cobe^oe_Zb_d[fh_ehje_di[hj_d]Wdo
_cfbWdji _d j^[ Z_ijWb cWdZ_Xb[$ 7bie" j^[ Z[dj_ij
d[[Zije[nfbeh[j^[Z_h[Yj_ede\j^[kdZ[hbo_d]Xed[$
J^[Xed[ijhkYjkh[WhekdZj^[Z_ijWbWjjWY^c[dje\
j^[ cobe^oe_Z ckiYb[ m_j^ _ji c[Z_Wbbo jWf[h_d] &IGÈ BWj[hWbj[b[hWZ_e]hWf^ii^ekbZX[eXjW_d[ZX[\eh[WdZ
i^Wf[ _i m[bb lWiYkbWh_p[Z WdZ cW_djW_d[Z ijWXb[ W\j[h_cfbWdjj^[hWfojeY^[Yaj^[eh_[djWj_ede\j^[Xh_Z][_d
Xo ckiYkbWh ij_ckbWj_ed" j^[h[Xo e\\[h_d] _Z[Wb h[bWj_ed je j^[ h[b[lWdj fbWd[i$ ?d WZZ_j_ed" j^[ Z[dj_ij cWo
mWdjjeWffboYedjhWijc[Z_kc[$]$XWh_kcibkhho"m^_Y^_d
YedZ_j_edijeWYYecceZWj[j^[b_d]kWbZ_iai[]c[dj j^_i[nWcfb[_iki[Zjel_ikWb_p[j^[\WY_Wbfhe\_b[
e\ j^[ Z_ijWb 8E? _cfbWdj$ 8_Yehj_YWb WdY^ehW][ YWd
WbieX[h[WZ_boeXjW_d[Z_dj^_iWh[WX[YWki[j^[Xed[
[nj[dZi\khj^[hbWj[hWbboWXel[WdZX[bemj^[jWh][j ?d j^[ Wdj[h_eh i[]c[dj e\ j^[ cWdZ_Xb[" f_ji e\
Wh[W" ie j^Wj fheXb[ci Wh[ kdb_a[bo je eYYkh [l[d _\ lWho_d]i_p[ickijX[[nf[Yj[Z"iec[e\m^_Y^cWo
j^[_cfbWdj_idej_di[hj[ZZ[[f[dek]^$J^_i_iedbo YedjW_d kdfb[WiWdjbo bWh][ l[ii[bi e\ j^[ Whj[h_Wb
jhk[_\j^[_cfbWdj_ii[Wj[Z_dik\\_Y_[djbo\WhZ_ijWbbo WdWijecei_i$ ?j _i j^[h[\eh[ WbmWoi d[Y[iiWho je
WdZ_ijhkbofei_j_ed[Z_dehX[bemj^[j[hc_dWj_ed fWbfWj[ j^_i Wh[W j^ehek]^bo" kdb[ii _j _i fbWdd[Z
b_d[e\j^[m^_j[b_d[$ je Z_ibeZ][ j^[ ckYeiW ed j^[ b_d]kWb i_Z[ e\ j^[
È È &UNCTIONALÈ$IAGNOSISÈANDÈ2ESTORATIVEÈ!LTERNATIVESÈ
cWdZ_Xb[Zkh_d]j^[fheY[Zkh[WdZfhej[Yjj^[ie\j#
j_iik[ijhkYjkh[im_j^WhWifWjeho$
J^[ YedZ_j_edi \eh fWbfWjeho [nWc_dWj_ed Wh[
ckY^b[ii\WlekhWXb[_dj^[cWn_bbWm^[h[j^[fWbWjWb
ie\j#j_iik[ijhkYjkh[iWh[j^_YaWdZ^WhZ$J^[fWbWjWb
Whj[ho"m^_Y^j[dZijeX[YedY[Wb[ZX[bemW^Wb\#ef[d
XedoYWdWb"_il_hjkWbbod[l[hfWbfWXb[$M^[d[l[hj^[
i_jkWj_ed_ikdYb[Wh"j^[edbomWoje[nfbeh[j^[Xed[
ijhkYjkh[i _i Xo Z_ibeZ]_d] W \bWf$ J^[ _cfbWdj i_j[
\eh j^[ jkX[hefj[ho]e_Z iYh[m YWddej X[ l_[m[Z
[_j^[hedWZ[djWb\_bcehedWdEF=$J^[edbomWo
je [nfbeh[ j^_i Wh[W" i^ekbZ j^[ d[[Z Wh_i[" _i Xo
jece]hWf^o$
È
&UNCTIONALÈ$IAGNOSISÈÈ
ANDÈ2ESTORATIVEÈ!LTERNATIVES
J^[\_hijfWhWc[j[hjeX[[ijWXb_i^[Z_im^[j^[hj^[
c_Zb_d[ie\Xej^`WmiYe_dY_Z[$J^[bWX_Wb\h[dkcm_bb
kikWbboik\\_Y[Wih[\[h[dY[fe_dj$?jcWoX[d[Y[iiWho
jeZ_ih[]WhZj^_ifWhWc[j[h_\Wdoj[[j^Wh[c_ii_d]
kd_bWj[hWbbo Zk[ je W][d[i_i eh [njhWYj_ed X[YWki[
Wdo c_Zb_d[ i^_\ji WiieY_Wj[Z m_j^ j^[i[ i_jkWj_edi
YWddej WdZ ckij dej X[ Yehh[Yj[Z Xo fheij^[j_Y
c[Wdi$J^[iWc[Wffb_[i_\j^[EF=h[l[Wbij^Wjj^[
^eh_pedjWbXhWdY^e\j^[cWdZ_Xb[_idej[gkWbbobed]
edXej^i_Z[ie\j^[`Wm$
:[l_Wj_edi_dj^[ef[d_d]WdZYbei_d]cel[c[dji
e\ j^[ cekj^ Wh[ j^[ cW_d Z_W]deij_Y Yh_j[h_ed
_dZ_YWj_d]j^[fh[i[dY[e\\kdYj_edWbfheXb[ci$J^_i
ijWj[c[dj _i jhk[ h[]WhZb[ii e\ m^[j^[h eh dej j^[
Zoi\kdYj_ed _i iocfjecWj_Y eh WiocfjecWj_Y$ FW_d
_iijh_YjboYed\_d[Zjej^[meha_d]i_Z[$
;bed]Wj_ed e\ j[[j^ YWd X[ eXi[hl[Z ed j^[
ded#meha_d] i_Z[ m^[h[ j^[ _djhki_l[ [\\[Yj e\
j^[ cWij_YWjeho \kdYj_ed _i b[ii cWha[Z$ I_dY[ j^[
Wdj[h_ehi[]c[dj_$[$YWd_d[jeYWd_d[e\j^[cWn_bbW
_iWbmWoiWYj_lWj[ZWiWm^eb["_j_icW_dboj^[Y[djhWb
WdZ bWj[hWb _dY_iehi e\ j^[ ded#meha_d] i_Z[ j^Wj
X[Yec[ [bed]Wj[Z$ Feij[h_eh j[[j^" Xo YedjhWij" m_bb
CORRECTABLEÈ$YSFUNCTIONS
WbmWoi X[Yec[ [bed]Wj[Z Yebb[Yj_l[bo$ J^[ eYYbkiWb
fbWd[ m_bb Z[l_Wj[ \hec j^[ ^eh_pedjWb b_d[ _d j^[i[
YWi[i" jWa_d] W YhWd_Wb Yekhi[ ed j^[ meha_d] i_Z[
WdZWYWkZWbYekhi[edj^[ded#meha_d]i_Z[$<hec
W\hedjWbf[hif[Yj_l["j^_ijof[e\eYYbkiWbfbWd[m_bb
Yec[WYheiiWiWdeXb_gk[b_d[Wbj^ek]^_j_ih[WbboW
m_dZ_d]b_d[i[[9^Wfj[h'&\ehZ[jW_bi$
BWj[hWb_pWj_ede\j^[Z[dj_j_edYWdWbieX[eXi[hl[Z
edj^[meha_d]i_Z["Zk[jej^[\WYjj^Wjj^[_djhki_l[
\ehY[iWh[kd_bWj[hWbboijhed][h$J^_iZ[l[befc[djcWo
YWki[fheij^[j_YfheXb[ci"i_dY[j^[\ehc[hmeha_d]
i_Z[m_bbX[el[hbobWj[hWbh[bWj_l[jej^[cWdZ_XkbWh
j[[j^ W\j[h j^[ c_Zb_d[ ^Wi X[[d WZ`kij[Z m_j^ W
l_[m je h[#[ijWXb_i^_d] W f^oi_ebe]_YWb \kdYj_ed$ ?d
Z_\\_Ykbji_jkWj_edi"WYehh[YjboWZ`kij[Zc_Zb_d[cWo
-'
[l[d ]_l[ h_i[ je bWj[hWb ded#eYYbki_ed$ Fej[dj_Wb
jh[Wjc[dj Wbj[hdWj_l[i mekbZ _dYbkZ[ m_Z[ Xh_Z][
[b[c[dji"c[Z_Wb_pWj_ede\j^[Xh_Z][h[bWj_l[jej^[
Xed["ehehj^eZedj_Yfh[#jh[Wjc[dj$H[WZ`kij_d]j^[
c_Zb_d[m_bbWbmWoih[ikbj_dWkd_bWj[hWb_dYh[Wi[e\
j^[l[hj_YWbZ_c[di_ed_\j[[j^Wh[ij_bbfh[i[dj_dj^[
cWn_bbW$ J^[ c_d_ckc h[gk_h[c[dj m_j^ h[]WhZ je
j^[ l[hj_YWb Z_c[di_ed _i Z[\_d[Z Xo j^[ [bed]Wj[Z
i_Z[ _$[$ j^[ \ehc[h ded#meha_d] i_Z[$ ?d ceij e\
j^[i[i_jkWj_edi"d[mbWj[hejhki_ed\WY[jim_bbd[[Zje
X[[ijWXb_i^[Zm_j^WXhWi_l[_dijhkc[dji$
Kd_bWj[hWb [njhWYj_edi ed j^[ ded#meha_d] i_Z[
m_bb _dlWh_WXbo ]_l[ h_i[ je j_bj_d] e\ j^[ cebWhi
Z_ijWbjej^[[njhWYj_edieYa[j"m_j^j^[Z_ijWbYkifi
]W_d_d]ceh[l[hj_YWbifWY[$J^[fh[cWjkh[YedjWYji
h[ikbj_d] \hec j^_i Z[l[befc[dj cWo YWki[ j^[
cWdZ_Xb[ je X[Yec[ Z[Y[djhWb_p[Z _d Wbb ifWj_Wb
Z_h[Yj_edi" j^ki Yh[Wj_d] beYa[Z X_j[ i_jkWj_ed$ J^[
j[[j^ ed j^[ meha_d] i_Z[ Wh[" Xo YedjhWij" ceh[
b_a[bo je kdZ[h]e XeZ_bo cel[c[dji _d W bWj[hWb
Z_h[Yj_ed_$[$jhWdibWj_edcel[c[dji$
J^[ YedZobWh Wd]b[ _i bWh][ ed j^[ meha_d] i_Z[
X[YWki[j^[cel[c[djijWa_d]fbWY[_dj^_iWh[WWh[
Yed\_d[ZjehejWj_ed$J^[Wd]b[edj^[ded#meha_d]
i_Z["XoYedjhWij"_il[ho\bWjX[YWki[j^[jhWdibWj_ed
cel[c[dji Zec_dWj_d] j^_i Wh[W Yekdj[hWYj j^[
Z[l[befc[dje\Wij[[fjkX[hYb[$
J^_i i_jkWj_ed h[ikbji _d Z_\\[h[dj 7<CF Wd]b[i
ed Xej^ i_Z[i e\ j^[ `Wm$ J^[ Wd]b[ _i WbmWoi bWh][h
edj^[ded#meha_d]i_Z[Zk[jej^[[bed]Wj_edWdZ
c[Z_Wb_pWj_ed e\ j[[j^$ J^[ [\\ehj h[gk_h[Z je Y^[m
edj^_ii_Z[X[Yec[i[l[d]h[Wj[h"WdZj^[j[dZ[dYo
je h[jW_d j^[ kd_bWj[hWb Y^[m_d] fWjj[hd _i \khj^[h
h[_d\ehY[Z$
7][#h[bWj[Z Z_Wij[cWi cWo \ehc j^hek]^
f[h_eZedjWbbo_dZkY[Zfhejhki_edWdZ[bed]Wj_ed_d
WZZ_j_edjef^oi_ebe]_YWbWXhWi_ed"m^_Y^m_bbYWki[
j^[j[[j^jeX[Yec[dWhhem[h[l[d_dj^[WXi[dY[e\
f[h_eZedjWbfheXb[ci$
È
.ON
7do jh[Wjc[dj fbWdi _dlebl_d] j^[ ki[ e\ 8E?
_cfbWdji i^ekbZ X[ h[Yedi_Z[h[Z _\ W XWbWdY[Z
\kdYj_ed WffWh[djbo YWddej X[ h[ijeh[Z Xo Wdo
c[Wdi$ Feii_Xb[ h[Wiedi _dYbkZ[ [\\[h[dj eh W\\[h[dj
d[hl[ Zoi\kdYj_ed" fWhWboi_i e\ ckiYb[i [$]$ W\j[h
feboeco[b_j_i"ehZ_ii[Yj_ede\ckiYb[i%`Wmi[]c[dji$
7bb j^[i[ \WYjehi YWd Yh[Wj[ i_jkWj_edi _d m^_Y^ W
XWbWdY[ZcWij_YWjeho\kdYj_ed_i[_j^[hekje\h[WY^
ehYWddejX[fhef[hboYedjhebb[Z$H[ijehWj_l[j^[hWfo
XWi[Z ed ijhWj[]_YWbbo fei_j_ed[Z 8E? _cfbWdji _i
dej _dZ_YWj[Z _d j^[i[ YWi[i$ ?dij[WZ" Wd Wjj[cfj
i^ekbZ X[ cWZ[ je cWn_c_p[ Xej^ j^[ dkcX[h e\
_di[hj[Z _cfbWdji WdZ j^[ dkcX[h e\ Z_iai f[h
_cfbWdj" j^ki Yh[Wj_d] W i_jkWj_ed _d m^_Y^ j^[
-( 9^Wfj[h,È $IAGNOSTICS
ikcjejWbe\j^[i[YedjWYjikh\WY[im_bbij_bbWbbemW
\WlekhWXb[\ehY[Z_ijh_Xkj_ed[l[d_dj^[fh[i[dY[e\
_dWffhefh_Wj[beWZ_d]fWjj[hdij^WjmekbZej^[hm_i[
]_l[ h_i[ je eij[eboi_i WhekdZ _dZ_l_ZkWb Z_iai WdZ
beii e\ _dZ_l_ZkWb _cfbWdji Zk[ je _iebWj_ed#h[bWj[Z
el[hbeWZ_d]$ ?j _i ij_bb feii_Xb[ je ki[ j^_i ckbj_#
_cfbWdj ijhWj[]o m_j^ _cc[Z_Wj[ beWZ_d]$ J^[
bWh][h dkcX[h e\ _cfbWdji WdZ beWZ#jhWdic_jj_d]
ikh\WY[i m_bb _dYh[Wi[ j^[ Z_h[Yj Xed[#fh[i[hl_d]
[\\[Yje\j^[_cfbWdjikh\WY[ih[bWj_l[jej^[[\\[Yje\
cWYhejhW`[Yjeh_[i$
8E?#XWi[Z jh[Wjc[dj m_j^ ijhWj[]_Y _cfbWdj
fei_j_ed_d]edbo_iYedjhW#_dZ_YWj[Z_dj^[fh[i[dY[
e\ f[hcWd[dj Zoi\kdYj_ed$ 9edi_Z[h j^Wj W h[ij_d]
eii[eki ioij[c cWo X[ fh[i[dj Wj j^[ ekji[j e\
j^[hWfo _d m^_Y^ j^[ fh[ef[hWj_l[ jhW`[Yjeh_Wb Xed[
eh_[djWj_ed cWo de bed][h X[ m^ebbo _d b_d[ m_j^
j^[ \kdYj_edWb fWjj[hd$ 7do _dYh[Wi[ e\ j^[ 8CK
\h[gk[dYo WdZ Whj_\_Y_Wb ij_ckbWj_ed e\ h[ceZ[bb_d]
_d j^_i i_jkWj_ed Wi jh_]][h[Z Xo Wd _cfbWdjWj_ed
fheY[Zkh[ mekbZ WXhkfjbo _dZkY[ h[eh_[djWj_ed e\
j^[ Xed[ ijhkYjkh[i" fWhj_YkbWhbo _\ j^[ cWij_YWjeho
\kdYj_ed _i dej X_bWj[hWbbo XWbWdY[Z" m^_Y^ ]_l[
h_i[ je ikXijWdj_Wb cehf^ebe]_YWb Wbj[hWj_edi$ ?d
cWij_YWjehoioij[cij^WjWh[dejX_bWj[hWbboXWbWdY[Z"
_j_iYedi_Z[hWXbo^WhZ[hjej[bb_dWZlWdY[m^_Y^Xed[
Wh[Wim_bbh[cW_dijWXb[WdZik\\_Y_[djboc_d[hWb_p[Z
el[hj^[o[Whi$
J^[fWj_[dji^ekbZX[_d\ehc[Z"j^Wjj^[jh[Wjc[dj
ekjYec[ _i b[ii fh[Z_YjWXb[ _d j^[ fh[i[dY[ e\
f[hcWd[dj Zoi\kdYj_edi$ J^[i[ fWj_[dji" ^em[l[h"
^Wl[Wijhed]Z[i_h[je]W_d_cfbWdjj^[hWfo"X[YWki[
j^[_h_cfW_h[ZehWb\kdYj_ed_iWjh[c[dZekifheXb[c
\eh j^[c$ I_dY[ W[ij^[j_Y ikh][ho WdZ [if[Y_Wbbo
h[ZkYj_ed e\ j^[ cWii[j[h ckiYb[ Wh[ X[Yec_d]
ceh[ fefkbWh jeZWo" m[ ckij jWa[ j^[ feii_X_b_jo
_dje Yedi_Z[hWj_ed j^Wj fWj_[dji ^Wl[ ^WZ fWhji e\
j^[_hY^[m_d]ckiYb[ih[cel[Z$J^_im_bbW\\[Yj8E?
_cfbWdjjh[Wjc[dj_diec[h[if[Yji0
:k[ je i[l[h[ Y^Wd][i _d j^[ cWij_YWjeho \ehY[i"
i[l[h[ h[ceZ[bb_d] cWo jWa[ fbWY[ X[YWki[ j^[
[gk_b_Xh_kc X[jm[[d \ehY[i WdZ Xed[ cWii mWi
Y^Wd][Z$ J^[ gk[ij_ed e\ m^[j^[h j^[ Z[]h[[ e\
feijef[hWj_l[c_d[hWb_pWj_ede\j^[Xed[cWjh_nm_bb
[l[h h[WY^ fh[ef[hWj_l[ lWbk[i ckij Wbie X[ hW_i[Z$
J^_igk[ij_ed_iZ_h[Yjboh[bWj[Zjej^[ijWX_b_joe\j^[
YedjWYji_jkWj_edWdZj^[ijWX_b_joe\j^[cWij_YWjeho
fbWd[$
J^[ Y^[m_d] \ehY[i m_bb dej X[ j^[ iWc[ ed
Xej^ i_Z[i X[YWki[ j^[ ckiYb[i m_bb kikWbbo dej X[
h[cel[ZWXiebkj[boiocc[jh_YWbbo$7bie\ehY[l[Yjehi
m_bb^Wl[Y^Wd][Z$<ehj^_ih[WiedfWj_[djim_j^j^_i
fh[efe[hWj_l[ijWjkii^ekbZX[Yedi_Z[h[ZWi^Wl_d]
W^_ZZ[dded#Yehh[YjWXb[Zoi\kdYj_ed$
IjhWj[]_Y_cfbWdjfbWY[c[dj_idejh[Yecc[dZ[Z
_dj^[i[YWi[iWdZj^[fWj_[djickijX[_d\ehc[Zj^Wj
j^[ Z_ii[Yj_ed e\ Y^[m_d] ckiYb[i cWo Yecfb_YWj[
_cfbWdjjh[Wjc[dj$
È
3TORAGEÈ2EQUIREMENTS
:[dj_iji m^e hWh[bo ki[ _cfbWdji" eh m^e Wh[ `kij
X[]_dd_d]jeki[j^[c"j[dZjeWYgk_h[Wbbd[Y[iiWho
_dijhkc[dji m^_b[ \W_b_d] je a[[f W m[bb#Wiiehj[Z
i[b[Yj_ede\_cfbWdji_dijeYa$J^_ia_dZe\WffheWY^
_iYb[Whbodejh[Yecc[dZ[Zm_j^8E?_cfbWdji$<eh
ed[j^_d]"_j_iZ_\\_YkbjjeWYgk_h[j^[Yehh[Yj_cfbWdj
jof[i\ehWif[Y_\_YfWj_[djm_j^ekj^Wl_d][nf[di_l[
9J iYWdi f[h\ehc[Z X[\eh[^WdZ$ <eh Wdej^[h"
j^[ Z[dj_ij m_bb dej X[ WXb[ je e\\[h _cfbWdjWj_ed
fheY[Zkh[i_cc[Z_Wj[bo[$]$W\j[h[njhWYj_d]j[[j^
kdb[ii^[a[[fiWjb[WijWicWbbi[b[Yj_ede\_cfbWdji
_dijeYa$J^_i_iYb[WhbodejWd_Z[Wbi_jkWj_edX[YWki[
j^[i[ i_d]b[#ij[f fheY[Zkh[i Wh[ l[ho \WlekhWXb[
Xej^ \eh Yb_d_YWb WdZ fioY^ebe]_YWb h[Wiedi$ J^[
[njhWYj_ed ieYa[j m_bb Wbbem [\\[Yj_l[ ikffkhWj_ed
\hecj^[_cfbWdji_j["WdZj^[fWj_[djm_bbX[ifWh[Z
j^[ \hkijhWj_ed e\ jeej^ beii _\ j^[ Z[ijhkYj_l[ ij[f
e\ jeej^ [njhWYj_ed _i _cc[Z_Wj[bo \ebbem[Z Xo j^[
YedijhkYj_l[ ij[f e\ _di[hj_d]" _\ dej W d[m jeej^"
j^[dWjb[Wijj^[XWi_i\ehW\_n[Zh[ijehWj_ed$
7i W c_d_ckc h[gk_h[c[dj" j^[ Z[dj_ij i^ekbZ
WbmWoi ^Wl[ =+Ä=- _cfbWdji m_j^ Z_Wc[j[hi e\ /Ä
'(cc ^WdZo$ Jh_fb[#Z_ia =)Ä=- _cfbWdji m_j^
eh m_j^ekj W \_n[Z ^[WZ Wi m[bb Wi ;:77I '&%(&
WdZ ;:7:I '(%'- Z[i_]di Wh[ \h[gk[djbo YWbb[Z \eh
Wi m[bb$ 7bie" 8E? ki[hi b_a[ je WZZ_j_edWbbo _di[hj
;:I - WdZ / =. _cfbWdji \eh X[jj[h ijWX_b_pWj_ed
Wi Wd efj_edWb \_\j^ _cfbWdj je ikffehj Yecfb[j[#
WhY^ h[ijehWj_edi$ ;:7I WdZ ;:7:I e\\[h ]h[Wj
\b[n_X_b_jo_dm_Zj^X[YWki[j^[oYWdX[X[dj"ehj^[o
YWdX[_di[hj[ZjhWdil[hi[boehZ_W]edWbbo$J^[;:7I
/%'*=-Z[i_]d_iY[hjW_dboj^[ceijYeccedboki[Z
i_d]b[#Z_ia_cfbWdjWjfh[i[dj"Wbed]m_j^hekdZ[Zeh
Wd]kbWhZ[i_]dim_j^WZ_Wc[j[he\'(cc$
M^[d ZekXb[#Z_ia _cfbWdji Wh[ Yedi_Z[h[Z
Wffhefh_Wj[" j^[o i^ekbZ X[ i[b[Yj[Z _d ikY^ W mWo
j^Wj j^[ XWiWb Z_ia _i Wi bWh][ Wi feii_Xb[$ 8WiWb
Z_Wc[j[hie\Wjb[Wij'(ccYWdX[Yeccedboki[Z
_d j^[ cWn_bbW" m^_b[ Z_Wc[j[hi e\ / eh '&cc Wh[
kikWbboWffhefh_Wj[_dj^[cWdZ_Xb[$M[Zedejki[
Wdo ckbj_#Z_ia _cfbWdji Z_ijWbbo e\ j^[ cWdZ_XkbWh
d[hl[iej^Wjj^[_cfbWdj#h[ijehWj_edijhkYjkh[Ze[i
dejX[Yec[kdZkboh_]_Z$
8E? _cfbWdji Wh[ [njh[c[bo \b[n_Xb[ j^Wdai je
j^[efj_ede\ki_d]eXb_gk[_di[hj_edfWj^mWoi$?j_i
j^[h[\eh[dejd[Y[iiWhojef[h\ehcWYecfh[^[di_l[
Z_W]deij_Ymeha#kfWih[gk_h[Z\ehYh[ijWb_cfbWdji
_dcWdoi_jkWj_edi$
È È $IAGNOSISÈOFÈ3PEECHÈANDÈ(EARINGÈ&UNCTIONÈ
È
3YSTEMICÈ(EALTHÈ$IAGNOSIS
J^[ioij[c_YZ_W]deij_Yh[gk_h[c[dji\ehh[ijehWj_l[
jh[Wjc[dji XWi[Z ed 8E? _cfbWdji Wh[ [ii[dj_Wbbo
j^[ iWc[ Wi _d Yh[ijWb _cfbWdjebe]o$ M[ ki[ j^[
\ebbem_d] ijWdZWhZ_p[Z gk[ij_eddW_h[" je X[ \_bb[Z
_d Xo j^[ ][d[hWb fhWYj_j_ed[h" je b[Whd ceh[ WXekj
ekh fWj_[djiÉ c[Z_YWb ^_ijeh_[i$ ?d iec[ i_jkWj_edi
_j cWo X[ d[Y[iiWho je ][j _d jekY^ Z_h[Yjbo je
[dgk_h[ WXekj j^[ fh[i[dY[ e\ Wbb[h]_[i WdZ j^[ ki[
e\ Wdo Wdj_YeW]kbWdj Zhk]i" Wdj_X_ej_Yi eh ej^[h
c[Z_YWj_edi$
J^[ _iik[ e\ YedjhW_dZ_YWj_edi je Z[djWb _cfbWdj
j^[hWfo^WiX[[dZ_iYkii[Z\ehZ[YWZ[i$Iec[e\j^[i[
Z_iYkii_edi cWo ^Wl[ X[[d fhecfj[Z Xo Wjj[cfji
je XbWc[ if[Y_\_Y _cfbWdj beii[i ed j^[ fWj_[dji
j^[ci[bl[i hWj^[h j^Wd je j^[ _cfbWdjebe]_iji eh
h[ijehWj_l[ Z[dj_iji$ JeZWo" ceh[ WdZ ceh[ [nf[hji
W]h[[ j^Wj W ]h[Wj cWdo e\ j^[ \WYjehi j^Wj ki[Z
je X[ h[]WhZ[Z Wi WXiebkj[ YedjhW#_dZ_YWj_edi je
_cfbWdjjh[Wjc[djZedejh[WbboW\\[Yjj^[jh[Wjc[dj
ekjYec[WdZbed]#j[hcijWX_b_joe\_cfbWdji$Edj^[
YedjhWho0
v M[^Wl[ikYY[ii\kbbojh[Wj[ZfWj_[djim_j^Z_WX[j[i
c[bb_jki">?Lehb_l[hZ_i[Wi[el[hWbbj^[i[o[Whi$
8E?_cfbWdji^Wl[Wbieo_[bZ[Z[nY[bb[djh[ikbji_d
icea[hi$M[^Wl[Wbiejh[Wj[ZcWdofWj_[djim^e
gk_j icea_d] \eh ]eeZ je fhej[Yj j^[_h _cfbWdj#
ikffehj[ZXh_Z][i$
v 7bj^ek]^j^_ieXi[hlWj_edh[cW_dijeX[l[h_\_[Z
_d\ehcWbijkZ_[i"j^[fhe]dei_ie\8E?_cfbWdji
Ze[i dej i[[c je Z_\\[h _d Wdo mWo X[jm[[d
icea[hiWdZded#icea[hiedY[ie\j#j_iik[^[Wb_d]
^WiX[[dYecfb[j[Z$
v FWj_[dji m_j^ m[bb#Yedjhebb[Z Z_WX[j[i c[bb_jki
j[dZjeX[]eeZYWdZ_ZWj[i\eh_cfbWdjjh[Wjc[dj
X[YWki[e\j^[_h]h[Wj[h^[Wbj^WmWh[d[ii$
v J^[ h_ia e\ Yecfb_YWj_edi j[dZi je X[ ^_]^[h _d
fWj_[djim_j^Wh[bWj_l[bokdYh_j_YWbWdZd[]b_][dj
Wjj_jkZ[ jemWhZi b_\[ X[YWki[ j^[o Wh[ b[ii b_a[bo
je Yecfbo m_j^ j^[ jh[Wjc[dj h[gk_h[c[dji j^Wd
Wh[ fWj_[dji m_j^ YedYec_jWdj Z_i[Wi[i i[[
9^Wfj[h(,"i[Yj_ed*$
v 7do h_ia \WYjehi ^Wl[ je X[ Z_iYkii[Z m_j^ Wbb
\hWdad[ii$7\j[hWbb"j^[kbj_cWj[Z[Y_i_edm^[j^[h
ehdej_cfbWdjj^[hWfoi^ekbZX[f[h\ehc[Zckij
X[jWa[ddejXoj^[Z[dj_ijXkjXoj^[fWj_[dj$
v M[ ^Wl[ Z[l[bef[Z W Yh_j_YWb Wjj_jkZ[ jemWhZi
fWj_[djim_j^WikXijWdj_WbZh_da_d]^WX_j"Wbj^ek]^
j^[ ki[ e\ WbYe^eb _i [njh[c[bo m_Z[ifh[WZ j^[i[
ZWoi$ J^[ iWc[ h[i[hlWj_edi Wffbo je icea[hi"
e\ Yekhi[" i_dY[ Wdo e\ j^[i[ ^WX_ji Wh[ ][d[hWbbo
_dZ_YWj_l[e\i[b\#d[]b_][djX[^Wl_ekh$
-)
Iec[ YedYec_jWdj Z_i[Wi[i m_bb W\\[Yj dej ie ckY^
j^[ h[ijehWj_l[ WdZ cW_dj[dWdY[ f^Wi[i e\ 8E?
j^[hWfoWij^[_cfbWdjWj_edfheY[Zkh[_ji[b\$7Xiebkj[
YedjhW_dZ_YWj_edi mekbZ _dYbkZ[ Y^[cej^[hWfo"
_cckdeikffh[ii_l[ j^[hWfo" b[kYefe[d_W" WdZ
cWb_]dWdj ^W[cWjefe_[j_Y Z_i[Wi[i$ De YbW_c je
Yecfb[j[d[ii _i X[_d] cWZ[ ^[h[$ ?d fWj_[dji m^e
^Wl[ ikhl_l[Z Wdo e\ j^[i[ h[bWj[Z Z_i[Wi[i" j^[
efj_ed e\ _di[hj_d] 8E? _cfbWdji W\j[h Wbb d[[Zi
je X[ Z_iYkii[Z m_j^ j^[ jh[Wj_d] f^oi_Y_Wdi m_j^
h[]WhZjej^[_dZ_l_ZkWbÉiY_hYkcijWdY[i"fheXWX_b_jo
e\ h[Ykhh[dj Z_i[Wi[ WdZ b_\[ [nf[YjWdYo$ ?\ _cfbWdj
j^[hWfo_iYedi_Z[h[ZWffhefh_Wj[_dfWj_[djim_j^W
b_c_j[Z b_\[ [nf[YjWdYo" 8E?#XWi[Z WffheWY^[i m_j^
_cc[Z_Wj[ beWZ_d] Wh[ Y[hjW_dbo ceh[ Wffhefh_Wj[
j^Wd Wdo Yh[ijWb _cfbWdjebe]_YWb fhejeYebi" m^_Y^
m_bbdehcWbbo_dlebl[fhebed][Z^[Wb_d]f[h_eZi$
7dej^[h _iik[ j^Wj d[[Zi je X[ Yedi_Z[h[Z l[ho
YWh[\kbbo _i m^[j^[h j^[ _cfbWdj fheY[Zkh[ i^ekbZ
X[ f[h\ehc[Z kdZ[h ][d[hWb WdW[ij^[i_W" i[ZWj_ed"
d_jheki en_Z[ WdWb][i_W eh beYWb WdW[ij^[i_W$
9edj_dkeki Wffb_YWj_ed e\ eno][d [$]$ )b%c_d
j^hek]^WdWiWbfheX[_iijhed]boh[Yecc[dZ[Z_d
fWj_[djim_j^_cfW_h[Zh[if_hWjeho\kdYj_ed$
È
3TRUCTURALÈ(ISTORYÈOFÈTHEÈ)MPLANTÈ3ITE
J^[ beYWb ^_ijeho e\ j^[ _cfbWdj i_j[" _dYbkZ_d] j^[
i[b\#jhWX[YkbWj_d]Xed[fhef[hj_[i"ckijX[YWh[\kbbo
[nfbeh[Zi[[9^Wfj[h/"i[Yj_ed'$,$J^[jhW`[Yjeh_Wb
eh_[djWj_ede\j^[Yehj_YWbXed[ijhkYjkh[im_bbh[cW_d
kdW\\[Yj[Z Xo Wdo j[[j^ [njhWYj[Z eh Wdo Yh[ijWb
_cfbWdjibeiji^ehjboX[\eh[j^[8E?fheY[Zkh[$?\Wdo
8E?_cfbWdjim[h[beij"^em[l[h"j^[h[_iWY^WdY[e\
&#Wh[Wi^Wl_d]\ehc[Zj^WjWh[dej]e_d]jeX[ijWXb[
WdY^ehW][ fe_dji \eh _cc[Z_Wj[bo beWZ[Z _cfbWdji
i[[ <_]$/$,$ ?d j^_i i_jkWj_ed" _j _i h[Yecc[dZ[Z
Wbbem j^[ _cfbWdji je ^[Wb m_j^ekj beWZ_d] \eh W
f[h_eZe\,m[[ai$7bj[hdWj_l[bo"_j_iWbiefeii_Xb[je
_di[hj j^[ d[m 8E? _cfbWdj Wj W Z_\\[h[dj i_j[ eh je
h[_di[hjWZ[i_]dm_j^W]h[Wj[hdkcX[he\Z_iaij^Wd
j^[fh[l_eki_cfbWdj$
È
$IAGNOSISÈOFÈ3PEECHÈANDÈ(EARINGÈ&UNCTION
M^[d[l[h [nj[di_l[ h[ijehWj_edi Wh[ fbWdd[Z" Wd
kd[gk_leYWb Z_W]dei_i i^ekbZ X[ eXjW_d[Z fh_eh
je j^[ l[ho \_hij jh[Wjc[dj ij[fi ^em j^[ fWj_[djÉi
if[[Y^ \kdYj_ed ^Wi Z[l[bef[Z el[h j^[ o[Whi WdZ
jem^Wj[nj[djj^[^[Wh_d]\kdYj_ed_i_djWYjWim[bb$
Dej[ j^Wj cWdo fWj_[dji m_bb YbWc j^Wj j^[o ^Wl[
de fheXb[ci m_j^ ^[Wh_d] _d ][d[hWb$ D[l[hj^[b[ii"
cWdo ebZ[h fWj_[dji m_bb X[ WXb[ je ^[Wh [dek]^
-* 9^Wfj[h,È $IAGNOSTICS

QB[jj[h^[WZe\Z[djWbe\\_Y[S

FWj_[djdWc[0

:Wj[0

:[Wh:h$

M[Wh[fbWdd_d]%Yedi_Z[h_d]Z[djWbjh[Wjc[djki_d][deiiWb_cfbWdji\ehj^[WXel[fWj_[dj$?dehZ[h
jeX[WXb[jefhe]deij_YWj[j^[jh[Wjc[djekjYec[WdZjejWa[Wdoif[Y_Wbc[Wikh[ij^Wjd[[ZjeX[
jWa[dX[\eh[ikh][ho"m[d[[ZjeademW\[m\WYjiWXekjoekhfWj_[dji$M[mekbZj^[h[\eh[b_a[jeWia
oekjeWdim[hj^[\ebbem_d]gk[ij_edi%f[h\ehcj^[\ebbem_d][nWc_dWj_edi0

Fb[Wi[Y_hYb[WiWffhefh_Wj[WdZ[bWXehWj[m^[h[d[[Z[Z

%PFT
UIF
QBUJFOU
TVGGFS
GSPN
BOZ
OPODPNQFOTBUFE
EJTPSEFST
PG
IBFNBUPQPJFTJT
PS
UIF
FOEPDSJOBM
TZTUFN
:FT
/P
%PFT
UIF
QBUJFOU
TVGGFS
GSPN
BOZ
DBSEJPWBTDVMBS
EJTFBTF
UIBU
JT
SFTJTUBOU
UP
UIFSBQZ
:FT
/P
%PFT
UIF
QBUJFOU
TVGGFS
GSPN
BOZ
NBMJHOBODJFT
XJUI
B
OFHBUJWF
PS
JOGBVTU
QSPHOPTJT
:FT
/P
%PFT
UIF
QBUJFOU
TVGGFS
GSPN
BOZ
SIFVNBUPJE
EJTFBTF
:FT
/P
*T
UIF
QBUJFOU
QFSNBOFOUMZ
JNNVOPDPNQSPNJTFE
)*7
JNNVOPTVQQSFTTJPO

:FT
/P
%PFT
UIF
QBUJFOU
TVGGFS
GSPN
BOZ
QTZDIPQBUIPMPHJDBM
EJTPSEFST
UIBU
BGGFDU
IJT
PS
IFS
QFSTPOBMJUZ
:FT
/P
%PFT
UIF
QBUJFOU
TVGGFS
GSPN
BOZ
PUIFS
HFOFSBM
EJTFBTFT
PS
GPDBM
JOGFDUJPOT
:FT
/P
%PFT
UIF
QBUJFOU
IBWF
BOZ
BMMFSHJFT
:FT
/P
%PFT
UIF
QBUJFOU
TVGGFS
GSPN
BOZ
TVCTUJUVUBCMF
EJTPSEFST
:FT
/P
%PFT
UIF
QBUJFOU
TVGGFS
GSPN
BOZ
EJTFBTFT
PG
UIF
CPOFT
PS
CPOF
NFUBCPMJTN
:FT
/P
%PFT
UIF
QBUJFOU
IBWF
B
IJTUPSZ
PG
EJTPSEFST
PG
UIF
VQQFS
OBTBM
USBDU
FTQFDJBMMZ
UIF
OBTBM
TJOVTFT
:FT
/P

9ecc[dji0

:Wj[0 F^oi_Y_WdÉii_]dWjkh[WdZe\\_Y[i[Wb0

?\j^[h[Wh[Wdofe_djij^Wjc[h_jehh[gk_h[Z_iYkii_ed"fb[Wi[Zedej^[i_jWj[jeYWbbc[$

8[ijh[]WhZi"
QI_]dWjkh[e\_cfbWdjebe]_ijS

\eh [l[hoZWo fkhfei[i" Xkj j^[_h ^[Wh_d] m_bb dej j^[_hf^ed[j_Yf[h\ehcWdY[l_Wj^[h[]kbWhWkZ_jeho

X[ [gkWbbo ]eeZ Wj Wbb \h[gk[dY_[i$ <eh j^[c" I#"
<#" J># WdZ I>#iekdZi m_bb e\j[d X[ _d j^[ ded#
WkZ_Xb[ \h[gk[dYo h[]_ed" m^_Y^ _i m^o j^[o cWo
^Wl[ Z_\\_Ykbj_[i Yedjhebb_d] j^[i[ iekdZi Ä iekdZi
j^WjWh[e\fWhj_YkbWh_cfehjWdY[\ehYb[Whif[[Y^$
Edbo W fWj_[dj m^e ^[Whi m[bb _i _d W fei_j_ed
je meha WYj_l[bo ed Wdo f^ed[j_Y fheXb[ci j^Wj
m_bb _d[l_jWXbo Wh_i[ _d Wdo [nj[di_l[ h[ijehWj_l[
jh[Wjc[dj$ 7 ]h[Wj cWdo fWj_[dji Ze dej [l[d
dej_Y[ j^Wj j^[_h if[[Y^ _i _cfW_h[Z X[YWki[ j^[o
YWddej ^[Wh j^[ci[bl[i fhef[hbo$ ?dij[WZ" j^[o Wh[
Yedj_dkekibo h[c_dZ[Z Xo ej^[hi j^Wj j^[o ^Wl[
W fheXb[c$ ;l[d be]efW[Z_Y j^[hWfo m_bb \W_b _d
fWj_[dji kdWXb[ je ^[Wh j^[ci[bl[i$ EdY[ W]W_d"
j^[i[ fWj_[dji Ze dej ^Wl[ W fheXb[c if[Wa_d]" Xkj
j^[o Wh[ WZced_i^[Z Xo ekji_Z[hi je Y^Wd][ j^[_h
X[^Wl_ekh m_j^ekj [l[h ^Wl_d] W Y^WdY[ je Yedjheb
\[[ZXWYac[Y^Wd_ici$
?d fWj_[dji m_j^ ]eeZ ^[Wh_d] YWfWY_jo" Wdo
f^ed[j_YfheXb[ci_dZkY[ZXoh[ijehWj_l[jh[Wjc[dj
YWd X[ [nf[Yj[Z je h[iebl[ _d W cWjj[h e\ m[[ai
eh cedj^i$ :kh_d] j^Wj f[h_eZ" j^[ f^ed[j_Y
f[h\ehcWdY[ m_bb X[ X[jj[h _d j^[ cehd_d]i j^Wd
_d j^[ [l[d_d]i$ J^[ fWj_[dj i^ekbZ X[ _d\ehc[Z e\
j^[i[Z[l[befc[djiX[\eh[j^[jh[Wjc[dj_iijWhj[Z$
J^[Y_hYWZ_WdlWh_WX_b_joe\f^ed[j_Yf[h\ehcWdY[
Yec[i \hec j^[ \WYj j^Wj j^[ fWj_[dj ^Wi je cWa[
W YediY_eki [\\ehj je Yedjheb if[[Y^ kdj_b d[m
[d]hWci ^Wl[ \ehc[Z j^Wj m_bb jWa[ YWh[ e\ j^_i
jWia Xo kdYediY_eki cejeh h[ifedi[i$7i YediY_eki
Yedjheb _i ckY^ ceh[ [n^Wkij_d] j^Wd [d]hWc#
Zh_l[d Yedjheb" j^[ h_i_d] b[l[b e\ \Wj_]k[ jemWhZi
j^[ [dZ e\ j^[ ZWo m_bb Wbbem j^[ ebZ [d]hWci je
h[]W_dYedjheb$J^[i[Wh[dejefj_c_p[Z\ehj^[d[m
È È $IAGNOSISÈOFÈ3PEECHÈANDÈ(EARINGÈ&UNCTIONÈ
_djhWehWb i_jkWj_ed" j^[h[Xo YWki_d] j^[ f^ed[j_Y
f[h\ehcWdY[jeZ[j[h_ehWj[$
Ceh[el[h"cWdofWj_[dji^Wl[W^WhZj_c[jhWYa_d]
Zemd j^[ iekhY[ e\ j^[_h f^ed[j_Y fheXb[c$ M^_b[
j^[o m_bb WbmWoi j[dZ je _cfb_YWj[ j^[ b[d]j^ eh
fei_j_ede\j^[_hWdj[h_ehj[[j^"j^[i[fWhWc[j[him_bb
dejd[Y[iiWh_boX[j^[jhk[YWki[$?dekh[nf[h_[dY["
[nY[ii_l[bo c[Z_Wbbo fei_j_ed[Z fh[cebWhi WdZ
cebWhi Wh[ `kij Wi Yeccedbo _dlebl[Z _d j^[
YWkiWj_ed e\ f^ed[j_Y fheXb[ci$ J^[i[ j[[j^ m_bb
Z[\b[Yj j^[ jed]k[ Zkh_d] _ji \ehmWhZ cel[c[dji
kikWbbo _d W l[hj_YWb Z_h[Yj_ed" m^_Y^ cWo [_j^[h
YWki[f^ed[j_YfheXb[ci"ehj^[fWj_[djcWolW]k[bo
YecfbW_de\Z_iYec\ehjm_j^ekjX[_d]WXb[jef_dj^[
iocfjecZemd$?j_iXodec[WdiW]_l[dj^Wjj^[i[
fheXb[ci YWd X[ [b_c_dWj[Z Xo cel_d] j^[ Z[djWb
WhY^[i je j^[_h fh[ef[hWj_l[ beYWj_edi m^[d j^[
-+
Z[djkh[i m[h[ ij_bb _d fbWY[$ 7\j[h Wbb" j^[ fheXb[ci
WiieY_Wj[Z m_j^ j^[ jed]k[ WdZ ej^[h ie\j#j_iik[
ijhkYjkh[i cWo X[ fkh[bo Zk[ je j^[ ikXijWdj_Wb
Y^Wd][i _d cWij_YWjeho \kdYj_ed i_dY[ j^[ j_c[ j^[
Z[djkh[ mWi mehd$ <eh [nWcfb[" j^[ cWdZ_Xb[ cWo
h[bWfi[\Wh_djeh[ijfei_j_ededY[_jieYYbkiWb^[_]^j
mWih[#[ijWXb_i^[ZWdZWdWdj[h_ehY^[m_d]fWjj[hd
^Wi X[[d WXWdZed[Z" j^[h[Xo Yh[Wj_d] W i_jkWj_ed
j^Wj j^[ fWj_[dj m_bb _d_j_Wbbo [nf[h_[dY[ Wi b_c_j_d]
jej^[ie\j#j_iik[ijhkYjkh[idejWXboj^[jed]k[WdZ
\beehe\j^[cekj^$J^[YedZ_j_edi\ehWdoa_dZe\
h[ijehWj_l[ j^[hWfo _d m^_Y^ j^[ ifWj_Wb h[bWj_edi e\
j^[ jed]k[ WdZ ej^[h ie\j#j_iik[ ijhkYjkh[i d[[Zi
je X[ ceZ_\_[Z" Wh[ fWhj_YkbWhbo kd\WlekhWXb[ _d
fWj_[dji [n^_X_j_d] fh[ef[hWj_l[bo Wd Wdj[h_eh
Y^[m_d] fWjj[hd YecX_d[Z m_j^ Wd WZlWdY[Z eh
Z[l_Wj[Zfei_j_ede\j^[cWdZ_Xb[$
  ¬ 
#(!04%2È

4REATMENTÈ0LANNING
4
*IEF
BOE
5
.BJFS

J^Wdaijej^[j[Y^d_gk[e\XWiWbeii[e_dj[]hWj_ed"m[ ]eeZ_Z[W$J^[kd_bWj[hWbjeej^beiicWo"\eh_dijWdY["
Wh[jeZWo_dWfei_j_edjejh[Wj/+e\Yecfb[j[boeh ^Wl[X[[dYWki[ZXo[nY[ii_l[beWZ_d]h[bWj[ZjeWd
fWhj_Wbbo[Z[djkbekifWj_[djim_j^\_n[Zh[ijehWj_edi$ kdXWbWdY[Z \kdYj_edWb fWjj[hd$ >em[l[h" kd_bWj[hWb
J^_i]eWbYWdedboX[WY^_[l[Z_\WdkcX[he\hkb[i Y^[m_d] m_bb dej h[iebl[ ifedjWd[ekibo _\ ceij e\
Wh[ eXi[hl[Z m_j^ h[]WhZ je m^[h[ j^[ _cfbWdji j^[ ej^[h cWij_YWjeho ikh\WY[i _d j^[ cWdZ_Xb[ Wh[
i^ekbZ X[ fbWY[Z WdZ m^[d WdZ ^em j^[o i^ekbZ cWbfei_j_ed[Z eh _\ Wd kdiocc[jh_YWb7<CF Wd]b[
X[ YecX_d[Z m_j^ h[i_ZkWb j[[j^$ Ceij _cfehjWdjbo" _i fh[i[dj X[YWki[ j^[ h[i_ZkWb Ykifi ][d[hWj[ Wd
j^[ _cfbWdjebe]_ij ckij kdZ[hijWdZ j^[ \kdYj_edWb kd\WlekhWXb[ ]k_ZWdY[$ J^[h[ mWi W j_c[ m^[d m[
h[gk_h[c[djie\j^[jh[Wjc[djWdZf[h\ehceYYbkiWb m[h[ _dYb_d[Z je eXb_][ m_j^ h[gk[iji je f[h\ehc
WZ`kijc[dji_dWj_c[bocWdd[h$ ikY^beYWbjh[Wjc[dj$JeZWoekhfh[\[hh[ZWffheWY^
J^[h[ Wh[ Ykhh[djbo jme Z_ij_dYj f^_beief^_[i e\ _ijeh[WZ`kijj^[cWij_YWjeho\kdYj_edWjbWh][WdZje
^em 8E? _cfbWdji i^ekbZ X[ Wffb_[Z$ M^_b[ j^[o Z[Yb_d[jh[Wjc[dj_\WdkdZ[hijWdZ_d]_idejh[WY^[Z$
Wh[ Xej^ Yb_d_YWbbo ikYY[ii\kb" j^[o Ze ^Wl[ j^[_h H[WZ`kijc[djh[gk_h[i[Whbo_cfbWdjfheY[Zkh[i\eh
if[Y_\_YWZlWdjW][iWdZZ_iWZlWdjW][i$J^[jh[Wjc[dj _ji\_n[Z\ekdZWj_ed$
f^_beief^oWZleYWj[ZXo?^Z[">WWiWdZIfW^dh[b_[i Jh[Wjc[dj Z[Y_i_edi _d \Wlekh e\ ijhWj[]_YWbbo
ed edbo \ekh _cfbWdji f[h `Wm" _di[hj[Z Wj ijhWj[]_Y fbWY[Z _cfbWdji je ikffehj W Yecfb[j[ \_n[Z Xh_Z][
fei_j_edi$ J^_i WffheWY^ Ze[i dej _cf[Z[ \b[n_ed YWdX[cWZ[ceh[h[WZ_bo_\j^[\ebbem_d]YedZ_j_edi
e\j^[Xed[ijhkYjkh[iX[jm[[dj^[_cfbWdji$?dj^_i Wh[c[j0
mWo"WXed[#_cfbWdjh[ijehWj_edm_j^WZWfj[Z\b[n_ed v J^[ia[b[jWbc_Zb_d[ie\j^[cWn_bbWWdZcWdZ_Xb[
_iYh[Wj[Z$ Ye_dY_Z[Yb_d_YWb[nWc_dWj_edWdZ%ehEF=$
J^[ ej^[h jh[Wjc[dj f^_beief^o" WZleYWj[Z Xo v J^[ Yb_d_YWbbo eXi[hl[Z7<CF Wd]b[i Wh[ i_c_bWh
IYehj[YY_" >[kYacWdd WdZ CW_[h" W_ci je Yh[Wj[ edjeej^#]k_Z[ZbWj[hWbcel[c[djjej^[b[\jWdZ
W h_]_Z _cfbWdj#h[ijehWj_ed ioij[c Xo _di[hj_d] W h_]^j$
cWn_ckcdkcX[he\_cfbWdji$7ij^[i[ioij[ciWh[ v J^[ fWj^ Yel[h[Z Zkh_d] bWj[hWb cel[c[dji _i
ceh[h_]_Zj^Wdj^[Xed[_ji[b\"j^[\ehY[#jhWdic_jj_d] WXekjj^[iWc[_dXej^Z_h[Yj_edi$
ikh\WY[i YWddej X[Yec[ i[Wcb[iibo _dj[]hWj[Z _d v J^[cekj^ef[dim_j^WijhW_]^jcel[c[dj$
j^[_h[dj_h[joWjW^_]^Z[]h[[e\c_d[hWb_pWj_ed$
?\ j^[h[ Wh[ Wdo \kdYj_edWb eXijWYb[i je WY^_[l_d] W
XWbWdY[Zi_jkWj_ed"j^[_cfbWdjebe]_ijckijYedi_Z[h
È _di[hj_d] W ]h[Wj[h dkcX[h e\ _cfbWdji ki_d]
3COPEÈOFÈ4HERAPY ckbj_#Z_iaZ[i_]di"j^kiWXWdZed_d]j^[YedY[fje\
ijhWj[]_Yfei_j_ed_d]$
IjhWj[]_Y _cfbWdj fei_j_ed_d] _i j^[ b[Wij jhWkcWj_Y 9^Wfj[h'& m_bb _dYbkZ[ W Z[jW_b[Z Z_iYkii_ed e\
WffheWY^YedY[_lWXb["WdZ_jefj_cWbbofh[i[hl[ij^[ \kdYj_edWbWif[YjiWdZj^[_h_cfWYjedj^[hWfoWdZ
\b[nkhWbfhef[hj_[ie\j^[`Wm$?jicW_di^ehjYec_d] Xed[cW_dj[dWdY[$
_i j^Wj W h[b_WXb[ Yed\_]khWj_ed e\ \ehY[i YWd edbo
X[ eXjW_d[Z _\ j^[ XWi[b_d[ i_jkWj_ed _i Yehh[Yjbo
WdWboi[Z WdZ _\ j^[ ekjYec[ _i Ybei[bo ced_jeh[Z È
el[h j^[ \ebbem_d] '(Ä(*cedj^i" kdj_b j^[ f^Wi[ .UMBERÈOFÈ)MPLANTSÈÈ
e\ Xed[ ^[Wb_d]" h[c_d[hWb_pWj_ed WdZ \kdYj_edWb FORÈ#OMPLETEÈ"RIDGES
efj_c_pWj_ed_iYecfb[j[Z$
?cfbWdjebe]_iji Yeccedbo i[[ fWj_[dji m^e Wh[ C_d_c_p_d]j^[dkcX[he\_cfbWdjiXoijhWj[]_Yfei_#
WmWh[ j^Wj j^[o ^Wl[ W fheXb[c m_j^ W fWhj_Wb j_ed_d]_iWl[hoikYY[ii\kbWffheWY^"XkjcWn_c_p_d]
Z[djkh[ WdZ m^e mWdj jh[Wjc[dj je X[ Yed\_d[Z je j^[ dkcX[h e\ _cfbWdji ^Wi _ji WZlWdjW][i jee$ 7
j^Wj if[Y_\_Y Wh[W$ ?d j^_i i_jkWj_ed" _j m_bb \_hij X[ Z[jW_b[ZZ_iYkii_ede\j^[fheiWdZYedi\ebbemi$
d[Y[iiWhojeWii[iim^[j^[hikY^beYWbjh[Wjc[dj_iW
-. 9^Wfj[h-È 4REATMENTÈ0LANNING
È
-AXILLARYÈ2ESTORATIONS
J^[ fei_j_edi e\ j^[ YWd_d[i WdZ i[YedZ cebWhi
Wh[ ki[Z Wi ijhWj[]_Y _cfbWdj beYWj_edi Xej^ _d j^[
cWdZ_Xb[ WdZ _d j^[ cWn_bbW$ ?d ekh [nf[h_[dY["
_\ _cfbWdji e\ WZ[gkWj[ i_p[ WdZ ijWX_b_jo YWd X[
_di[hj[Z Wj j^[i[ i_j[i" j^[h[ m_bb kikWbbo X[ de
d[[Z \eh Wdo WZZ_j_edWb _cfbWdji$ ?d \WYj" edbo ed[
WZZ_j_edWb _cfbWdj fbWY[Z _d j^[ dWiWb if_d[ Wh[W
cWo Yh[Wj[ W ^ofeceY^b_ed i_jkWj_ed" cWa_d] j^[
fheij^[j_Y ijhkYjkh[ j_bj WhekdZ j^Wj fe_dj$ 8h_Z][i
j^Wj Wh[ ikffehj[Z Xo _cfbWdji edbo WbmWoi YWhho W
h_iae\Wiocc[jh_YWb_djhki_ed_\WZ_\\[h[djdkcX[h
e\_cfbWdjiehbeWZ#jhWdic_jj_d]Z_iaim[h[_di[hj[Z
edXej^i_Z[ie\j^[`Wm$J^[YWd_d[fei_j_edkikWbbo
e\\[hi [dek]^ ifWY[ je _di[hj W i_d]b[#Z_ia _cfbWdj
m_j^ W ^_]^ = lWbk[ WdZ W Z_ia Z_Wc[j[h e\ Wj
b[Wij /cc$ 7bj[hdWj_l[bo" jh_fb[#Z_ia _cfbWdji m_j^
W Z_Wc[j[h e\ -cc" eh m_j^ W bWh][h Z_Wc[j[h Wj
j^[XWiWbZ_ia"Wh[Wdefj_edWim[bb$?\WikXijWdj_Wb
Xed[lebkc[_iWlW_bWXb["ZekXb[#Z_ia_cfbWdjim_j^
WcWn_ckcZ_ia#je#Z_ia_dj[hlWbYWdX[ki[Z$J^[i[
Z[i_]diWh[jeZWoWlW_bWXb[m_j^WXWiWbZ_iaZ_Wc[j[h
e\'("'*eh'+cc$
;:7I_cfbWdjim_j^WXWiWbikh\WY[Wh[We\/'("
/'* eh '&'*cc YWd dehcWbbo X[ ki[Z \eh j^[
Z_ijWbWXkjc[djWjj^[fei_j_ede\j^[i[YedZcebWh$
7ZZ_j_edWbki[e\Wfj[ho]e_ZiYh[mYWd[d^WdY[j^[
ijWX_b_joe\j^[_cfbWdj#h[ijehWj_edioij[c$
?\ WZ[gkWj[ ikffehj \eh j^[ Xh_Z][ YWddej X[
Yh[Wj[Z Wj j^[ YWd_d[ fei_j_edi" j^[ Z[dj_ij i^ekbZ
Yedi_Z[h[ijWXb_i^_d]Wd_cfbWdj#h[ijehWj_edioij[c
XWi[ZedWbWh][dkcX[he\_cfbWdjickbj_#_cfbWdj
YedY[fj$J^_ij[Y^d_gk[^WiX[[dki[Z\ehcWdoo[Whi
Xo _cfbWdjebe]_iji b_a[ B_daem" =hW\[bcWdd" 8Wk[h"
8h_dacWdd" >[_dh_Y^ eh IYehj[YY_$ ?j Wbie _dlebl[i
j^[ ki[ e\ dkc[heki Z_\\[h[dj _cfbWdj Z[i_]di
Z_Wc[j[hi" b[d]j^i WdZ h[gk_h[i Yecfh[^[di_l[
jhW_d_d] _d _cfbWdjebe]o WdZ W m[bb Wiiehj[Z ijeYa
e\ _cfbWdji _d j^[ e\\_Y[$ ?d WZZ_j_ed" _j h[gk_h[i
&IGÈÈ A CWn_bbWho h[ijehWj_ed ikffehj[Z Xo ijhWj[]_YWbbo fei_j_ed[Z WXkjc[dji$ B ?d cWdo YWi[i" Wbb _j jWa[i je eXjW_d
ijhWj[]_YWXkjc[dji\ehZkhWXb[cWn_bbWhoh[ijehWj_edi_ijeYecX_d[Wi_d]b[8E?_cfbWdjm_j^h[i_ZkWbdWjkhWbj[[j^
[nY[bb[djj^h[[#Z_c[di_edWbj^_da_d]$Ckbj_#_cfbWdj
jh[Wjc[dji Wh[ [nf[di_l[ WdZ j_c[#Yedikc_d]" Xkj
j^[oe\\[hWl[ho]eeZfhe]dei_i$
J^[Z[]h[[e\h[iehfj_edWdZXed[gkWb_jolWh_[i
m_Z[bo _d j^[ cWn_bbW$ ?d i_jkWj_edi m^[h[ Xed[
YedZ_j_edi ^Wl[ h[cW_d[Z ijWXb[ el[h Wd [nj[dZ[Z
f[h_eZ e\ j_c[" _j _i iec[j_c[i feii_Xb[ je _Z[dj_\o
\kdYj_ed#h[bWj[ZfWjj[hdi$KikWbbo"j^[Xed[ijhkYjkh[
_idWhhemXkjh[bWj_l[bo^_]^_dj^[Wdj[h_ehi[]c[dj"
\bWj_dj^[ikXWdjhWbfehj_ede\j^[feij[h_ehi[]c[dj"
WdZedY[W]W_dhWj^[hlebkc_dekiWim[bbWiie\j_d
j^[ jkX[hei_jo Wh[W$ J^[ ckiYb[ WjjWY^c[dj Wh[Wi
e\ j^[ bWj[hWb fj[ho]e_Z ckiYb[ Wh[ kikWbbo m[bb
c_d[hWb_p[Z$ J^[i[ Z_\\[h[dY[i h[gk_h[ j^[ ki[ e\ W
m_Z[hWd][e\_cfbWdjjof[ijejWa[WZlWdjW][e\j^[
dWj_l[ ckbj_Yehj_YWb Xed[ ijhkYjkh[i m^_b[ Wle_Z_d]
Wdo ceh[ [nj[di_l[ ]hW\j_d] eh Wk]c[djWj_ed
fheY[Zkh[i$ 7domWo" _j mekbZ dej X[ feii_Xb[ je
eXjW_dWdWZ[gkWj[fh_cWhoijWX_b_joe\j^[_cfbWdj
XWi[Z ed jhWdifbWdj[Z eh Wk]c[dj[Z Xed[" i_dY[
j^[i[ ijhkYjkh[i YWddej feii_Xbo c_d[hWb_p[
je j^[ h[gk_h[Z [nj[dj _d ikY^ W i^ehj j_c[$ J^[
Yecf[diWj_ed j^Wj ikh\WY[ [\\[Yji YWd fhel_Z[ \eh
c_ii_d]cWYhejhW`[Yjeh_[i_il[hob_c_j[Z$Dej[Wbie
j^Wjikh]_YWbbojh[Wj[ZWh[Wih[cW_dkdZ[hc_d[hWb_p[Z
\ehWbed]j_c[$
M[ikif[Yjj^WjWbbYkhh[djboademdikh\WY[jof[i
Wh[ hWj^[h i_c_bWh _d gkWb_jo" m_j^ j^[ [nY[fj_ed
e\ j^h[[#Z_c[di_edWb cWjh_n ikh\WY[i" m^_Y^ Wbbem
f[h\ki_ed e\ j^[ Xed[ \hec jme i_Z[i Eii[efeh[
_cfbWdji$7\j[hWbb"j^[cW_dZ_iWZlWdjW][e\[deiiWb
ikh\WY[i_ij^[_cfW_h[ZXbeeZikffboWdZZhW_dW][$
7YYehZ_d]jeC_iY^WdZ@kZo"j^[Wdj[h_ehcWn_bbW
i^ekbZ X[ [gk_ff[Z m_j^ Wi cWdo fh_cWh_bo ijWXb[
_cfbWdji Wi feii_Xb[ je Yecf[diWj[ \eh j^[ _d_j_Wb
m[Wad[iie\j^[Z_ijWbi[]c[dji$?j_i_hh[b[lWdjm^_Y^
_cfbWdj Z[i_]di Wh[ YecX_d[Z je WY^_[l[ j^[ ]eWb$
M^WjcWjj[hi_ij^Wjj^[Xed[lebkc[_i_d][d_ekibo
WdZ WZ[gkWj[bo kj_b_p[Z$ 7do h[i_ZkWb j[[j^ _d j^[
Wdj[h_ehi[]c[djYWdX[^[bf\kbWim[bb$
È È .UMBERÈOFÈ)MPLANTSÈFORÈ#OMPLETEÈ"RIDGESÈ
&IGÈ CWn_bbWhoh[ijehWj_edikffehj[ZXockbj_fb[_cfbWdji$
J^[ Z_ijWb WXkjc[dji Yedi_ij e\ jkX[hei_jo WdZ fj[ho]e_Z
iYh[mi"m^_b[8E?_cfbWdjim[h[ki[Z_dj^[Wdj[h_ehi[]c[dj
_dWYYehZWdY[m_j^j^[WlW_bWXb[Xed[m_Zj^$J^[8E?_cfbWdj
Wj ') mWi l[ij_XkbWhbo \ebZ[Z WdZ WZWfj[Z je j^[ l[ij_XkbWh
ikh\WY[e\j^[cWn_bbW
&IGÈ 9Wd_d[i YWd e\\[h l[ho ]eeZ ikffehj$ J^[o YWd X[
ki[ZWbed[eh_dYecX_dWj_edm_j^j^[\_hijfh[cebWh
&IGÈAnC J^[i[iY^[cWj_YZhWm_d]i_bbkijhWj[j^[Yehh[Yj_cfbWdjfei_j_edi\ehijhWj[]_Y_cfbWdjfbWY[c[dj_dj^[cWdZ_Xb[
-/
?d i_jkWj_edi e\ WZlWdY[Z h[iehfj_ed" _j _i de
bed][h feii_Xb[ je Z_\\[h[dj_Wj[ X[jm[[d XWiWb WdZ
Yh[ijWb_cfbWdjWj_ed$J^[_cfehjWdjfWhj_ijekj_b_p[
j^[Yehj_YWbXed[$
È
-ANDIBULARÈ2ESTORATIONS
I_dY[j^[cWdZ_Xb[cWoX[ikX`[Yjje^[Wlojehi_ed"
W ckbj_#_cfbWdj ijhWj[]o mekbZ el[hbo h[ZkY[ j^[
[bWij_Y_joe\j^WjXed[$<ehj^_ih[Wied"m[][d[hWbbo
ki[\ekhjei_n_cfbWdji"m_j^ed[Z_ijWb_cfbWdjed
[WY^i_Z[edbo$IjWXb[YWd_d[iYWdX[ki[Z_dij[WZe\
Wd_cfbWdj$
JeZWom[j[dZjeki[de8E?_cfbWdjim_j^ceh[
j^Wded[Z_ia_dj^[Z_ijWbcWdZ_Xb[WdZfh[\[hjefkj
de_cfbWdjiWjj^[fh[cebWhfei_j_edije[dikh[j^Wj
j^[ [bWij_Y_jo e\ j^[ cWdZ_Xb[ _i dej el[hbo h[ZkY[Z
WdZj^Wjde^_]^fe_dj_iYh[Wj[Z_dj^[c_ZZb[e\j^[
^eh_pedjWbfWhje\j^_iXed[$Jh_fb[#WdZZekXb[#Z_ia
8E? _cfbWdji YWd X[ ki[Z je ]eeZ [\\[Yj Wbed] j^[
Wdj[h_ehXbeYae\j^[cWdZ_Xb[$
?d j^[ cWn_bbW" 8E? _cfbWdji cWo X[ YecX_d[Z
m_j^dWjkhWbWXkjc[dji_dl_hjkWbboWdoYecX_dWj_ed"
Wibed]Wij^[j[[j^Wh[ijWXb[[dek]^jee\\[hbed]#
j[hc h[i_ijWdY[ je j^[ \ehY[i WYj_d] ed _j$ M^[d
Yedi_Z[h_d] W jeej^ Wi fWhj e\ W bWh][h Xh_Z][" _j
i^ekbZX[Yedi_Z[h[Zj^Wjel[hWbbcWij_YWjeho\ehY[i
m_bb_dYh[Wi[$
.& 9^Wfj[h-È 4REATMENTÈ0LANNING
È
7HICHÈ*AWÈ3HOULDÈBEÈ2ESTOREDÈ&IRST ?\ W Yecfb[j[ Z[djkh[ _i fh[i[dj _d j^[ cWn_bbW"
9edY[hd_d] j^[ _iik[ m^_Y^ `Wm i^ekbZ X[ h[ijeh[Z
\_hij" m[ ^Wl[ Z[l[bef[Z j^[ \ebbem_d] WffheWY^ _d
ekh Yb_d_Y0 _\ j^[hWf[kj_Y ceZ_\_YWj_edi Wh[ d[[Z[Z
_dXej^`Wmi"j^[cWdZ_Xb[i^ekbZX[jh[Wj[Z\_hij_\
feii_Xb[$J^[h[Wh[i[l[hWbh[Wiedi0
v 9ecfb[j[Z[djkh[iWh[dejh[jW_d[Zd[WhboWim[bb
_d j^[ cWdZ_Xb[ Wi _d j^[ cWn_bbW$ J^[h[\eh[" j^[
d[[Zjefhel_Z[h[b_[\_i]h[Wj[h_dj^[cWdZ_Xb[$
v ?d cWdo YWi[i" WZZ_j_edWb _cfbWdj jh[Wjc[dj _d
j^[cWn_bbWjkhdiekjjeX[h[ZkdZWdjedY[W\_n[Z
h[ijehWj_ed^WiX[[d_di[hj[Z_dj^[cWdZ_Xb[$
v J^[ cehf^ebe]_YWb Y^Wd][i _d j^[ cWdZ_Xb[ Wh[
e\j[d ikXijWdj_Wb" fWhj_YkbWhbo _d j^[ mWa[ e\
WZ`kijc[dji f[h\ehc[Z je h[#[ijWXb_i^ W dehcWb
cWij_YWjeho fWjj[hd$ I_ckbjWd[eki fbWY[c[dj e\
_cfbWdji _d j^[ cWn_bbW WdZ cWdZ_Xb[ YWhh_[i
W ^_]^ h_ia e\ el[hbeWZ_d] j^[ d[mbo _di[hj[Z
_cfbWdji _d j^[ cWn_bbW$ H[bWj_l[ [b[lWj_ed e\ j^[
Z_ijWb_cfbWdji_i[if[Y_Wbbob_WXb[je_d\b_YjZWcW][
je cWn_bbW$ 9edZ_j_edi Wh[ ceh[ \WlekhWXb[ edY[
j^[\kdYj_edWbWZWfjWj_edW\j[h_cfbWdjfbWY[c[dj
_dj^[cWdZ_Xb[^Wl[X[[dbWh][boYecfb[j[Z$
I_c_bWh h[ikbji m[h[ h[fehj[Z Xo B_dZgk_ij WdZ
9Whbiied '/.(" m^e eXi[hl[Z j^Wj j^[ WX_b_jo je
[Wj[_]^jekje\j[djof[ie\\eeZij^Wjj^[fWj_[dji
^WZfh[l_ekiboX[[dkdWXb[je[WjmWih[ijeh[ZW\j[h
_di[hj_d] W cWdZ_XkbWh h[ijehWj_ed ikffehj[Z Xo
[deiiWb_cfbWdji$9^[m_d]\kdYj_edmWii_]d_\_YWdjbo
_cfhel[Z edY[ j^[i[ h[ijehWj_edi m[h[ _d fbWY[$ ?d
fWj_[djiedWb_c_j[ZXkZ][j"WYeij#X[d[\_jWdWboi_i
m_bbj^[h[\eh[Z[\_d_j[boWh]k[_d\Wlekhe\fhel_Z_d]
Wd _cfbWdj#XWi[Z iebkj_ed _d j^[ cWdZ_Xb[ hWj^[h
j^Wdj^[cWn_bbW$J^_iijhWj[]om_bbX[[\\[Yj_l[_dj^[
cW`eh_joe\fWj_[djiWdZm_bbe\j[dh[dZ[hWZZ_j_edWb
jh[Wjc[dj e\ j^[ cWn_bbW h[ZkdZWdj$ 7YYehZ_d] je
B_dZgk_ij WdZ 9Whbiied" _cfbWdj jh[Wjc[dj e\ j^[
cWn_bbW _i edbo d[Y[iiWho _d if[Y_\_Y YWi[i$ M[ \[[b
j^Wj j^_i l_[m d[[Zi je X[ fkj _dje f[hif[Yj_l[" Wi
Yedi_Z[hWXb[ fhe]h[ii ^Wi X[[d cWZ[ m_j^ _cfbWdj
jh[Wjc[dj_dj^[cWn_bbWi_dY['/.($M_j^jeZWoÉi8E?
j[Y^debe]o" _cfbWdj#ikffehj[Z \_n[Z h[ijehWj_edi
^Wl[X[Yec[`kijWiW\\ehZWXb["ikYY[ii\kbWdZi_cfb[
je h[Wb_p[ _d j^[ cWn_bbW Wi j^[o ^Wl[ X[[d _d j^[
cWdZ_Xb[WbbWbed]$
Jh[Wj_d] j^[ cWdZ_Xb[ \_hij cWa[i i[di[ \hec W
\kdYj_edWb l_[mfe_dj Wi m[bb$ JWbb]h[d [j Wb$ '/.,
Z[cedijhWj[Z j^Wj j^[ Y^Wd][i _d cWij_YWjeho
\kdYj_ed Xhek]^j WXekj Xo _di[hj_d] _cc[Z_Wj[
Z[djkh[i _d j^[ cWdZ_Xb[ YWd X[ h[ZkY[Z _\ W \_n[Z
Z[dj_j_ed_iWjb[WijfWhj_Wbbofh[i[dj_dj^[cWdZ_Xb[$
J^_i YedYbki_ed _i gk_j[ fbWki_Xb[" Yedi_Z[h_d] j^Wj
X[jj[hckiYb[eh_[djWj_ed_iWY^_[l[ZZkh_d]Y^[m_d]
_\h[b_WXbofei_j_ed[Zj[[j^Wh[fh[i[dj_dWjb[Wijed[
`Wm$
j^[d[Y[iiWho[b[lWj_ede\j^[eYYbkiWbfbWd[jemWhZi
9Wcf[hÉifbWd[YWdX[f[h\ehc[Zceh[h[WZ_boj^Wd
_dj^[fh[i[dY[e\W\_n[Zh[ijehWj_edehe\[bed]Wj[Z
dWjkhWb j[[j^$ ?d if_j[ e\ j^Wj" j^[ eYYbkiWb fbWd[
i^ekbZ WbmWoi X[ [gkWb_p[Z _\ d[Y[iiWho$ Jho_d]
je iWl[ ced[o ed j^_i Wif[Yj e\ jh[Wjc[dj m_bb X[
Yekdj[hfheZkYj_l[_dj^[bed]j[hc$
Ed[ Wbie ^Wi je a[[f _d c_dZ j^[ \WYj j^Wj j^[
j[[j^ _d j^[ cWdZ_Xb[ e\j[d h[i_ij _cXWbWdY[Z
i_jkWj_edi X[jj[h j^Wd j^[ j[[j^ _d j^[ cWn_bbW$ ?\
_d j^[ cWn_bbW bWh][ Xh_Z][i Wh[ fh[i[dj" j^_i m_bb
iec[j_c[ib[WZjeWi_jkWj_edm^[h[WfWj_[dj\WY[i
W Yecfb[j[ Xh[WaZemd e\ j^[ cWn_bbWho h[ijehWj_ed
WdZ Z[dj_j_ed m_j^ j^[ h[Wied \eh j^[ XhWaZemd
X[_d]beYWj[Z_dj^[ijhed][h"XkjkdXWbWdY[ZWdZ%eh
kd\WlekhWXbo Z[i_]d[Z fheij^[j_Yi _d j^[ bem[h `Wm$
M[ ijhed]bo h[Yecc[dZ _d j^[i[ YWi[i WbmWoi je
jh[Wj j^[ bem[h `Wm \_hij eh i_ckbjWd[ekibo" X[YWki[
_j _i ZWd][heki je h[bo ed j^[ fWj_[djÉi m_bb_d]d[ii
h[Wbbo je jh[Wj j^[ cWdZ_Xb[ W\j[h j^[ fheXb[ci _d
j^[W[ij^[j_YWbboje^_c%^[hceh[_cfehjWdjkff[h
`Wm$ M[ ^Wl[ i[[d iWZ YWi[i m^[h[ j^[ fWj_[dji
\eh]ej WXekj j^[ W]h[[c[dj WXekj jh[Wjc[dj _d j^[
cWdZ_Xb[" lWd_i^[Z \hec j^[ iY[d[ [l[d c_ii_d]
h[]kbWhY^[Ya#kfi_dehZ[hdejjeX[h[c_dZ[ZWXekj
j^[ W]h[[c[dj" WdZ h[jkhd[Z bWj[h m_j^ fheXb[ci
W]W_d_dj^[kff[h`Wm$
È
7HENÈ3HOULDÈTHEÈ)MPLANTSÈBEÈ,OADED
EXl_ekibo" j^[h[ _i de mWo \eh _cfbWdji je h[cW_d
Yecfb[j[boÆded#beWZ[ZÇedY[j^[oWh[beYWj[Zm_j^_d
j^[Xed[$J^[Wffhefh_Wj[fe_dje\j_c[Wjm^_Y^Wbb
eh fWhj e\ j^[ Y^[m_d] \ehY[ i^ekbZ X[ jhWdic_jj[Z
j^hek]^ Wbb eh iec[ e\ j^[ 8E? _cfbWdji edje j^[
Yehj_YWbXed[m_bbZ[f[dZedj^[YedZ_j_edifh[i[dj
Zkh_d]ikh][ho"j^[dkcX[he\_cfbWdji_di[hj[Z"WdZ
j^[][d[hWbY_hYkcijWdY[ikdZ[hm^_Y^cWij_YWj_ed
jWa[ifbWY[$I_dY[j^[YhWd_WbXed[_if[hcWd[djbo_dW
ijWj[e\jehi_ed"j^[h[YWdX[deikY^j^_d]WiWÆded#
beWZ[ZÇijWj[e\_cfbWdji$M[j^[h[\eh[cW_djW_dj^Wj
_j_iceh[i[di_Xb[jeZ[\_d[j^[jof[WdZZ_h[Yj_ede\
beWZ_d]l_WWfheij^[j_Yikf[hijhkYjkh[j^Wdjeb[Wl[
j^[Xed[m_j^ekjj^_im[bb#Zei[Zij_ckbki$
FWhje\j^_ihWj_edWb[_ije_di[hjj^[ikf[hijhkYjkh[
m^_b[[nY[bb[djfh_cWhoijWX_b_jo_ifh[i[dj$<ebbem_d]
j^_ibe]_Y"fheij^[j_YbeWZ_d]i^ekbZjWa[fbWY[m_j^_d
j^[.Ä'(ZWoij^[ieed[h"j^[X[jj[h$:k[YWh[ckij
X[[n[hY_i[Z_dZ[Y_Z_d]edj^_iijhWj[]o"m^_Y^cWo
X[YedjhW_dZ_YWj[Z_dif[Y_\_YYWi[i_$[$_dikh]_YWbbo
fh[#jh[Wj[ZWh[Wi$J^[ej^[hWbj[hdWj_l[mekbZX[je
beWZj^[_cfbWdjiW\j[h,Ä.m[[aim^[dj^[f^Wi[e\
È È 'ENERALÈ"IOMECHANICALÈ#ONSIDERATIONSÈINÈ4REATMENTÈ0LANNINGÈ
Xed[ ^[Wb_d] WdZ Xed[ h[fW_h ^Wi X[[d Yecfb[j[Z$
J^[ _cfbWdjebe]_ij cWo mWdj je i[b[Yj W Z_\\[h[dj
j_c[ _\ dkc[heki WXkjc[dji Wh[ fh[i[dj" fhel_Z[Z
j^Wj j^[ ikf[hijhkYjkh[ YWd j^[d X[ _di[hj[Z _d
W j[di_ed#\h[[ cWdd[h$ IkY^ h[#iY^[Zkb_d] _i b[ii
WZl_iWXb[_dj^[cWn_bbWj^Wd_dj^[cWdZ_Xb[m_j^_ji
Yedi_Z[hWXb[cWYhejhW`[Yjeh_Wbijh[ii[i$
8ej^`WmikdZ[h]e[nj[di_l[Xed[h[ceZ[bb_d]$?\
WbWh][dkcX[he\beWZ#jhWdic_jj_d]Z_iai^Wl[X[[d
_di[hj[Z" _j _i kdb_a[bo j^Wj _dZ_l_ZkWb _cfbWdji Wh[
beWZ[Zjej^[fe_dje\Yh[Wj_d]Z[b[j[h_ekieij[eboj_Y
fheY[ii[i$ Ed j^[ Zemdi_Z[" b_jjb[ Xed[ m_bb h[cW_d
\eh W i[YedZ jh[Wjc[dj Wjj[cfj _\ _cfbWdji X[Yec[
kdijWXb[X[YWki[e\ej^[h\WYjehi$
;ii[dj_Wbbo" m[ WbmWoi Wjj[cfj je _di[hj Wi cWdo
_cfbWdji WdZ beWZ#jhWdic_jj_d] ikh\WY[i _d j^[
ikh]_YWb f^Wi[ e\ jh[Wjc[dj Wi Wh[ d[Y[iiWho je
h[Wb_p[ _cc[Z_Wj[ beWZ_d]$ ?d \_hij _cfbWdjWj_ed
fheY[Zkh[i" j^[ ]eWb e\ _cc[Z_Wj[ beWZ_d] YWd X[
WY^_[l[ZWbceij_dlWh_WXbo$7j[cfehWhoh[ijehWj_ed
_i_di[hj[Z_dj^[cWn_bbW\eh(Ä'(cedj^i"m^_b[j^[
cWdZ_Xb[ YWd kikWbbo X[ jh[Wj[Z m_j^ W Z[\_d_j_l[
h[ijehWj_ed h_]^j WmWo$ J[cfehWho h[ijehWj_edi cWo
d[[Z je X[ h[fbWY[Z eh WZ`kij[Z _di_Z[ eh ekji_Z[
j^[cekj^i[l[hWbj_c[i"fWhj_YkbWhbo_dj^[cWn_bbW"
Wi \kdYj_edWb WdZ cehf^ebe]_YWb Wbj[hWj_edi Wh[
Z[l[bef_d] el[h j^[ Yekhi[ e\ jh[Wjc[dj WdZ%eh
[nj[di_l[ Y^[m_d]#h[bWj[Z WZ`kijc[dji ^Wl[ je X[
f[h\ehc[Z$ Ed eYYWi_ed" _j cWo X[ d[Y[iiWho je
Yecf[diWj[ \eh ifedjWd[eki h[fei_j_ed_d] e\ j^[
JC@i$IkY^h[fei_j_ed_d]cWoedboeYYkhW\j[hm[[ai
eh _dZ[[Z cedj^i WdZ cWo fheY[[Z _d W ij[fm_i[
\Wi^_ed"h[\b[Yj_d]j^[ij[f#Xo#ij[fh[b[Wi[e\ifWij_Y
YedjhWYj_edie\j^[bWj[hWbfj[ho]e_ZckiYb[$?dj^ei[
YWi[i" j^[ cWij_YWjeho ikh\WY[i ckij X[ h[Z[i_]d[Z
i[l[hWbj_c[i"WbiejWa_d]_djeYedi_Z[hWj_edj^Wjj^[
ij[[fd[iie\j^[Ykifickij\_jj^[W][e\j^[fWj_[dj$
7doZ[bWoi_dh[WZ`kijc[djcWojh_]][hWkd_bWj[hWb
ehWdj[h_ehY^[m_d]fWjj[hd$
È
'ENERALÈ"IOMECHANICALÈ#ONSIDERATIONSÈÈ
INÈ4REATMENTÈ0LANNING
8E? _cfbWdji Wh[ Z[i_]d[Z je h[fbWY[ dWjkhWb j[[j^
WdZ Wiikc[ j^[_h \kdYj_ed e\ jhWdic_jj_d] j^[
_dYec_d] cWij_YWjeho beWZi _dje j^[ Xed[$ J^[o
Yedi_ij e\ ed[ eh i[l[hWb beWZ#jhWdic_jj_d] Z_iai
Wbieh[\[hh[ZjeWiXWiWbfbWj[iehh_d]i"Wj^h[WZ[Z
f_d dej Z[i_]d[Z \eh beWZ jhWdic_ii_ed" WdZ m[X
XWhi Yedd[Yj_d] j^[ Z_iai je j^[ j^h[WZ[Z f_d$
J^[ Z_iai Wh[ WlW_bWXb[ _d Z_\\[h[dj i^Wf[i W_c[Z
Wj efj_cWbbo WZWfj_d] j^[ _dj[]hWj[Z _cfbWdji je
Z_\\[h[djXed[Yed\_]khWj_edi$9ehh[YjY^e_Y[e\j^[
Z_c[di_edi e\ j^[ 8E? _cfbWdj _i h[gk_h[Z X[YWki[
8E? _cfbWdji" kdb_a[ iYh[m Z[i_]di" WbmWoi kj_b_p[
.'
j^[ WlW_bWXb[ dWj_l[ Xed[ ijhkYjkh[ je WdY^eh j^[
_cfbWdj#h[ijehWj_ed ioij[ci$ J^[ Xed[ WlW_bWXb[ Wj
j^[X[]_dd_d]e\j^[j^[hWfo_iYedi_Z[h[ZjeX[j^[
X[ijXed[e\j^[fWj_[dj"X[YWki[_j_iWiikc[ZjeX[
_d j^[ Wh[Wi e\ cW_d jhW`[Yjeh_[i kdZ[h \kdYj_edWb
YedZ_j_edi$
9ehj_YWbbo WdY^eh[Z XWiWb fbWj[i Wh[ Wd _dj[]hWb
Yecfed[dj e\ 8E? _cfbWdji Z[i_]d[Z je ]k_Z[ j^[
cWij_YWjeho\ehY[i_djej^[[deiiWbifWY[$:[f[dZ_d]
ed j^[ _dZ_YWj_ed" ed[ eh i[l[hWb Z_iai f[h _cfbWdj
cWo X[ h[gk_h[Z" Wbed] m_j^ j^h[WZ[Z f_di j^Wj Wh[
h[bWj_l[bo h_]_Z eh [bWij_Y$ J^[ [deiiWb ikh\WY[i e\
j^[ _cfbWdj cWo X[ [_j^[h hek]^[d[Z eh iceej^"
Z[f[dZ_d] ed j^[ jWia j^[o Wh[ Z[i_]d[Z je \kb\_b
Xej^ _d j^[ [Whbo jh[Wjc[dj f^Wi[ WdZ _d j^[ bed]
j[hc$
?dekh[nf[h_[dY["Z_iaim_j^WZ_Wc[j[he\b[iij^Wd
/ccm_bbWbmWoiYedij_jkj[h[bWj_l[boh_]_Zfe_djie\
beWZ jhWdic_ii_ed$ Ijh_Yjbo if[Wa_d]" j^[i[ Z[i_]di
Ze dej Wbbem _cfbWdj#h[ijehWj_ed ioij[ci j^Wj jhkbo
Yed\ehc je j^[ fh_dY_fb[ e\ XWiWb eii[e_dj[]hWj_ed$
7j b[Wij" j^[ [bWij_Y_jo e\ j^[i[ ioij[ci m_bb X[
Yedi_Z[hWXbo h[ZkY[Z$ J^_i Yb_d_YWbbo kdZ[i_hWXb[
bWYae\[bWij_Y_jo_iW]]hWlWj[ZXoi^ehjj^h[WZ[Zf_di
WdZZ_iaij^WjWh[icWbb_dZ_Wc[j[hXkjj^_Ya$
?d WZZ_j_ed" j^[ c[Y^Wd_YWb fhef[hj_[i e\ j^[
_cfbWdj cWj[h_Wb Wh[ Wd _cfehjWdj \WYjeh Wi m[bb$
8E? _cfbWdji Wh[ kikWbbo cWZ[ e\ =hWZ[ ' 7IJC
< ,-" =hWZ[ ( eh =hWZ[ ) j_jWd_kc Wi f[h j^Wj
7IJC ijWdZWhZ$ Iec[ Z[i_]di Wh[ Wbie WlW_bWXb[ Wi
Wd [njh[c[bo ijhed] j_jWd_kc#ceboXZ[dkc Wbbeo
J_'+Ce$J^_iWbbeoYecX_d[ij^[[bWij_Y_joe\=hWZ[
'j_jWd_kcm_j^Wb[l[be\ijh[d]j^j^WjYWdej^[hm_i[
edbo X[ WjjW_d[Z m_j^ =hWZ[ * j_jWd_kc$ Bed]#j[hc
eXi[hlWj_edi m_j^ j^_i d[m cWj[h_Wb Wh[ dej o[j
WlW_bWXb[$M[Ykhh[djboki[j^_icWj[h_Wb_dijhkYjkh[i
j^Wj^Wl[jeh[i_ij]h[Wjb[l[h\ehY[i$J^_i_i\h[gk[djbo
j^[ YWi[ m^[d cWii_l[ ia[b[jWb Z_iYh[fWdY_[i e\
cWn_bbWho c_Yhe]dWj^_W eh cWdZ_XkbWh fhe]dWj^_W
^Wl[jeX[el[hYec[$
J^[ fkhfei[ e\ j^_i Xeea _i je Z[iYh_X[ ^em
_cfbWdj#h[ijehWj_edioij[ciYWdX[_dj[]hWj[Zceh[
ehb[ii_ie[bWij_YWbbo_djej^[l_iYe[bWij_Y[dl_hedc[dj
e\j^[^kcWd`Wm$8ed[gkWb_joWiZ[\_d[ZXoC_iY^
?Ä?L edbo Z[iYh_X[i j^[ fh[i[dj YedZ_j_ed e\
j^[ Xed[" m^_Y^ _i eXl_ekibo feeh _d [Z[djkbeki
i_jkWj_ediWij^[Xed[_idejjhW_d[Z$J^[h[\eh["j^_i
YbWii_\_YWj_ed_ibWh][bo_hh[b[lWdj\ehWdWjec_ijiWdZ
8E? _cfbWdjebe]_iji Wb_a[$ C[Wikh_d] >ekdi\_[bZ
kd_ji _i" _d [\\[Yj" jejWbbo ki[b[ii _\ m[ Yedi_Z[h j^Wj
j^[c[Wikh[ZfWhWc[j[him_bbY^Wd][_dijWdjboedY[
_cfbWdji^Wl[X[[d_di[hj[Z$
J^[ edbo _dj[h[ij_d] Wif[Yj _i ^em j^[ Xed[
c[Y^Wd_ici h[ifedi_Xb[ \eh h[Ye]d_p_d]" iYWdd_d]"
h[`[Yj_d]eh[dYbei_d]j^[_cfbWdjYWdX[efj_cWbbo
kj_b_p[Z$J^[i[c[Y^Wd_iciWh[ceh[b_a[bojeX[^Wl[
WYYehZ_d]jefbWd_\Wd_djWYjXbeeZikffbo_iWlW_bWXb[
.( 9^Wfj[h-È 4REATMENTÈ0LANNING
WdZ _\ eij[e][d_Y ij[c Y[bbi Wh[ fh[i[dj _d bWh][
dkcX[hi[l[dWjj^[ekji[je\_cfbWdjjh[Wjc[dj$
J^[h[ Wh[ Wbie i_jkWj_edi _d m^_Y^ ceh[ h_]_Z
Z[i_]di [$]$ jh_fb[#Z_ia _cfbWdji e\ j^[ Æ;:::Ç
jof[ Wh[ Wd Wffhefh_Wj[ Y^e_Y[$ J^[o YWd X[ ki[Z
_d Yed`kdYj_ed m_j^ ej^[h 8E? eh" _dZ[[Z" Yh[ijWb
_cfbWdji je ikffehj ceh[ h_]_Z _cfbWdj#h[ijehWj_ed
Yecfb[n[i" eh j^[o YWd X[ ki[Z Wi i_d]b[#jeej^
_cfbWdjijeh[fbWY[Wdj[h_ehj[[j^ehfh[cebWhi_dj^[
cWn_bbWehcWdZ_Xb[$8WhWjjWY^c[djiYWdX[ki[Zje
]eeZ[\\[Yjedjh_fb[#Z_ia_cfbWdjiWim[bb$
7bj^ek]^j^[YedY[fje\_ie[bWij_YWdY^ehW][e\
Z[djWb_cfbWdjih[Wff[Whii[l[hWbj_c[i_dj^[^_ijeho
e\ekhfhe\[ii_ed8h[c[[jWb$'//)"j^[YedY[fjmWi
\kbbo h[Wb_p[Z edbo ed W \[m eYYWi_edi$ ?djhWceX_b[
[b[c[dji m[h[ Z[l[bef[Z WdZ _djheZkY[Z Xo ?CP
_d j^[ [Whbo ZWoi e\ ceZ[hd Yh[ijWb _cfbWdjebe]o"
XWi[Zedj^[h[Wb_pWj_edj^Wjj^[^kcWdXeZomWiW
l_iYe[bWij_Y ioij[c WdZ i^ekbZ dej X[ jh[Wj[Z m_j^
h_]_Z _cfbWdji Yedd[Yj[Z Xo h_]_Z ifb_dj_d]$ Ej^[h
cWdk\WYjkh[hi Z_Z dej \ebbem ik_j" ^em[l[h" WdZ
jeZWoj^[YedY[fj_ih[]WhZ[ZWieXieb[j[$M[Wh[jebZ
j^Wj j^[ cWha[jÆZ_Z dej WYY[fjÇ j^[i[ Z[i_]di WdZ
j^Wj j^[o Wh[ ebZ#\Wi^_ed[Z$ Ceh[ fheXWXbo" ej^[h
fheZkYjim[h[ikffehj[ZXo^[Wl_[hWZl[hj_i_d]WdZ
YWc[_dW^[WZ"Z[if_j[j^[\WYjj^Wjj^[?CPYedY[fj
WiikY^mWiX_ec[Y^Wd_YWbbo\bWmb[ii$ j^[ bed]#j[hc ikhl_lWb e\ j^[ _cfbWdj 8hWdZj
M_j^ Yh[ijWb _cfbWdji" ceX_b[ _dYehfehWj_ed e\
j^[ _cfbWdj XeZo _i" W\j[h Wbb" jWdjWcekdj je \_Xhe#
eii[e_dj[]hWj_ed" m^_Y^ m_bb gk_Yabo ]_l[ h_i[ je
_cfbWdjbeiiedY[j^[\_XhekiWh[W][ji_d\[Yj[Z$J^_i
fheXb[cZe[idej[n_ijm_j^8E?_cfbWdji$
9h[ijWb _cfbWdjebe]_iji _d\[h \hec j^_i j^Wj j^[
`WmXed[ m_bb ]hem jemWhZi _cfbWdji \eh m^_Y^
fh_cWho ijWX_b_jo ^Wi X[[d WY^_[l[Z ÆlebkdjWh_boÇ
WdZÆZ[b_X[hWj[boÇ"Wi_jm[h["jefh[fWh[j^[]hekdZ
\eh \kdYj_edWb beWZ jhWdic_ii_ed$ 7i m_bb X[ i^emd
\khj^[h X[bem" W ikXijWdj_Wbbo ]h[Wj[h _dY[dj_l[
\eh Xed[ h[ceZ[bb_d] Yec[i \hec ij_ckbWj_ed e\
d[_]^Xekh_d] eij[edi m^[d \ehY[ jhWdic_jj_d]
jhW`[Yjeh_[iWh[Z_ihkfj[Z_dj^[fheY[iie\fh[fWh_d]
j^[ _cfbWdj X[Z$ J^_i c[Y^Wd_ic ^Wi X[[d m[bb
ademd Wbie _d ehj^efW[Z_Y ikh][ho$ J^[ _cfbWdj
_ji[b\c[Z_Wj[iij_ckb_edbojeWl[hoicWbb[nj[dj_d
j^[Z_h[YjYedjWYjWh[W$
J^[ \ehY[i WYj_d] ed j^[ lWh_eki Xed[i e\ j^[
iakbb lWho m_Z[bo _d Z_\\[h[dj YhWd_Wb Wh[Wi$ J^[i[
Xed[i Wh[ j^[h[\eh[ [bWij_Y WdZ i^em l[ho Z_\\[h[dj
Z[]h[[i e\ c_d[hWb_pWj_ed Z[f[dZ_d] ed j^[_h [nWYj
beYWj_ed$ J^[i[ eXi[hlWj_edi Wh[ ceij WffWh[dj _d
j^[Wdj[h_ehcWdZ_Xb[$7h[WiY^WhWYj[h_p[ZXobem[h
c_d[hWb_pWj_ed WdZ ^_]^[h [bWij_Y_jo m_bb h[ifedZ
je \b[nkhWb \ehY[i Xo ceh[ [nj[di_l[ Z[\ehcWj_ed$
?djheZkY_d] bWh][ bed] _cfbWdj XeZ_[i _d Wh[Wi e\
j^_i jof[ YWd ]_l[ h_i[ je Wdo ed[ e\ j^[ \ebbem_d]
iY[dWh_ei0
v J^[ [bWij_Y_jo e\ j^[ ikhhekdZ_d] Xed[ cWo
Z[Yh[Wi[jecWjY^j^[[bWij_Y_joe\j^[_cfbWdj$?d
j^WjYWi["ej^[hped[ie\^_]^[bWij_Y_jom_bb\ehc
_dj^Wj`Wm_dij[WZ$
v J^[^_]^[bWij_Y_jocWoh[cW_d_djWYj"XkjedboW
icWbb f[hY[djW][ e\ j^[ [deiiWb ikh\WY[ X[Yec[i
eii[e_dj[]hWj[Z$
v J^[ ^_]^ [bWij_Y_jo cWo h[cW_d _djWYj" WdZ W
^_]^ f[hY[djW][ e\ j^[ [deiiWb ikh\WY[ X[Yec[i
eii[e_dj[]hWj[Z"Xkjj^[Xed[_ikdZ[hc_d[hWb_p[Z"
iej^Wjj^[lWh_ekiXed[bWo[hiWh[\h[[boceX_b[$
J^[ j[hc Æ[njhWj[hh_jeh_Wb_pWj_edÇ e\ j^[ _cfbWdji
^Wi X[[d fhefei[Z X[YWki[ eii[e_dj[]hWj_ed mWi
h[]WhZ[Z Wi W Z[b_c_j_d] h[WYj_ed Ä W fheY[ii e\
ÆYoij_\_YWj_edÇ"Wi_jm[h[$7d_cfbWdjj^kiX[Yec[i
[njhWj[hh_jeh_Wb_p[Z Wi Yehj_YWb Xed[ \ehci _d j^[
_dj[h\WY[Wh[W"kbj_cWj[boh[ZkY_d]j^[XbeeZikffbo
WdZ[nj[hc_dWj_d]Wdoeij[eYoj[id[Whj^[_cfbWdj$
J^_i h[WYj_ed _i Wbie Zk[ je W Z_ihkfj[Z eno][d
WdZ ikXijhWj[ ikffbo" m^_Y^ [l[djkWbbo YWki[i j^[
eij[eYoj[id[Whj^[_cfbWdjjeX[Yec[foYdej_YWdZ
j^kij^h[Wj[d[ZXo[nj_dYj_ed$
?dYh[ijWb_cfbWdjebe]o"_j^WiX[[dfeijkbWj[Zj^Wj
j^[ikh\WY[WlW_bWXb[\eheii[e_dj[]hWj_edi^ekbZX[
WibWh][Wifeii_Xb[:=PCA":=?"(&&'jeefj_c_p[
'//,$ J^_i Z[cWdZ b[Z je j^[ _djheZkYj_ed e\ bed]
_cfbWdji"\ebbem[ZXobWh][#Z_Wc[j[h_cfbWdji$J^[i[
Z[l[befc[dji _]deh[Z" ^em[l[h" j^Wj j^[ ckYeiWb
f[d[jhWj_ed fe_dj e\ bWh][#Z_Wc[j[h _cfbWdji _i
Yedi_Z[hWXbo bWh][h" j^ki e\\[h_d] ceh[ ifWY[ \eh
_d\[Yj_ed$ J^[ fhe]dei_i e\ i^ehj _cfbWdji m_j^
hek]^[d[Z ikh\WY[i _i i[h_ekibo cWhh[Z Xo j^[ \WYj
j^WjXWYj[h_WbbeWZih_i[[nfed[dj_Wbbom_j^_dYh[Wi_d]
_cfbWdjZ_Wc[j[hiAdWki(&&&1C”bb[h#>[hpe]WdZ
B_dZeh\ '//,$ J^[ _djhWeii[eki XbeeZ ikffbo _i
fh[ikcWXbo]h[Wjboh[ZkY[Z"m^_Y^cWo[l[dfhecej[
j^[ Z[l[befc[dj e\ iWhYecWi Zemd j^[ heWZ$ Iec[
e\j^[feijkbWj[ie\Yh[ijWb_cfbWdjebe]oWh[_dZ[[Z
gk[ij_edWXb[$ 7i W YWi[ _d fe_dj" j^[ fhe]dei_i e\
_cfbWdji Yel[h[Z m_j^ W feheki YeWj_d] Wbbem_d]
f[h\ki_edkdj_bZ[[fkdZ[hj^[ikh\WY[Eii[efeh[
X[Yec[i feeh[h m_j^ _dYh[Wi_d] _cfbWdj b[d]j^i
X[YWki[j^[f[h\ki_edioij[cbei[i_ji\kdYj_edWb_jo
_dbed][hZ[i_]di$
Bed][h _cfbWdji fbWY[Z _d Wh[Wi e\ \b[n_ed Wh[
XekdZjejhWdil[hi[lWh_eki[deiiWbbWo[hij^Wjm_bb
Y^Wd][j^[_hh[bWj_l[fei_j_ediZkh_d]dehcWbY^[m_d]
\kdYj_ed$J^[i[cel[c[djiWh[ceh[WffWh[dj_dj^[
cWdZ_Xb[" Xkj j^[o Wh[ i_]d_\_YWdj _d j^[ cWn_bbW Wi
m[bb$?dYedjhWijjej^[if[Y_Wbbofh[fWh[Zia[b[j_p[Z
iakbbiki[Z\ehWdWjec_YWbijkZ_[i"b_l[YhWd_WbXed[i
Wh[ Y^WhWYj[h_p[Z Xo h[bWj_l[ ceX_b_jo WdZ ^_]^
^oZheijWj_Y fh[iikh[i$ ?d WZZ_j_ed" j^[o Wh[ W\\[Yj[Z
Xo j^[ h^oj^c_YWb cel[c[dji e\ j^[ YhWd_eiWYhWb"
h[if_hWjeho WdZ cWij_YWjeho ioij[ci$ DejWXbo Xo
È È 'ENERALÈ"IOMECHANICALÈ#ONSIDERATIONSÈINÈ4REATMENTÈ0LANNINGÈ
j^[ WYj_l[ cel[c[dji e\ cWij_YWj_ed WdZ \WY_Wb
[nfh[ii_ed" j^[ Xed[i Wh[ YedijWdjbo a[fj _d W ijWj[
e\ ckjkWb \bkn WdZ _djhWXedo jehi_ed$ Dej[ j^Wj j^[
_djhWeij[edWb\beme\dkjh_[dji_i[d^WdY[ZXoXed[
jehi_ed$
J^[ ikYY[ii\kb ekjYec[i e\ ib_]^jbo Yed_YWb
ded#j^h[WZ[Z _cfbWdji m_j^ W if^[h_YWb ikh\WY[
Eii[efeh[ Z[cedijhWj[ j^Wj j^[ iWc[ Z[]h[[ e\
WdY^ehW][ YWd Wbie X[ eXjW_d[Z m_j^ l[ho i^ehj
Z[i_]di$ J^[i[ _cfbWdji ij_ckbWj[ c_d[hWb_pWj_ed
_d W hWZ_e]hWf^_YWbbo Z[cedijhWXb[ cWdd[h WdZ
Wh[ YWfWXb[" WYYehZ_d] je j^[_h ki[hi" e\ ikffehj_d]
fheij^[j_Y h[ijehWj_edi m^_b[ _dlebl_d] hWj^[h
Z_ijehj[Z Yhemd#_cfbWdj hWj_ei$ EXl_ekibo" j^[i[
_cfbWdji YWddej X[ ifb_dj[Z i_dY[ j^[ j[di_edi
Z[l[bef_d] j^hek]^ j^[ fheij^[j_Y ijhkYjkh[ mekbZ
[l[djkWbbo h[ikbj _d Xed[ Wlkbi_ed W\j[h Wbb$ J^[
\_hij fe_dj je Yedi_Z[h m_j^ j^[i[ _cfbWdji _i j^Wj
j^[o i^ekbZ X[ _di[hj[Z el[h j^[_h [dj_h[ b[d]j^
_djeWXed[bWo[he\kd_\ehcX[^Wl_ekh$7iWh[ikbj"
j^[ b[l[b e\ \kdYj_edWb cel[c[dji _di_Z[ j^[ Xedo
_cfbWdj X[Z m_bb X[ h[bWj_l[bo bem$ ?d ej^[h mehZi"
j^[i[ _cfbWdji m_bb h[cW_d kdW\\[Yj[Z Xo Wdo beYWb
eh Yecfh[^[di_l[ cel[c[dji e\ j^[ YhWd_Wb Xed[i
Ä fhel_Z[Z" e\ Yekhi[" j^Wj j^[o Wh[ dej ki[Z je
ikffehj bWh][#ifWd Xh_Z][i$ J^[ i[YedZ fe_dj je
Yedi_Z[h _i j^[ _d][d_eki ikh\WY[ ijhkYjkh[ e\ j^[i[
_cfbWdji" m^_Y^ _d_j_Wbbo fh[l[dji j^[ Xed[ \hec
]hem_d] jee Z[[fbo kdZ[h j^[ ikh\WY[$ J^[ [cfjo
ifWY[ `kij X[bem j^[ ikh\WY[ h[fh[i[dji W Yed\bk[dj
ioij[ce\YWdWbij^Wj[dWXb[idkjh_[djijeX[ikffb_[Z
Xo mWo e\ c_YheY_hYkbWj_ed l[ho ckY^ Wi j^[o Wh[
ikffb_[Z dWjkhWbbo j^hek]^ eij[edi$ ?d ej^[h mehZi"
j^[ikh\WY[edm^_Y^j^[Xed[bWo[hm_bbX[\ehc_d]
X[Whi ]h[Wj[h h[i[cXbWdY[ je W j^h[[#Z_c[di_edWb
c_Yhej_jh[ fbWj[ j^Wd je W Z[WZ _cfbWdj ikh\WY[$
J^_i [nWcfb[ edY[ W]W_d Z[cedijhWj[i j^Wj [l[d
c_dkj[YedjWYjikh\WY[im_bbkbj_cWj[boX[ik\\_Y_[dj
jeWZ[gkWj[bo]k_Z[cWij_YWjehobeWZi_djej^[Xed[$
7iWfh[h[gk_i_j["^em[l[h"j^[ikh\WY[YedjWYjckij
X[ beYWj[Z _d Wd Wh[W j^Wj _i m[bb ikffb_[Z m_j^
dkjh_[dji$ M_j^ Yehj_YWbbo WdY^eh[Z 8E? _cfbWdji"
j^[i[dkjh_[djicWoX[Z[h_l[Z\hecj^[f[h_eij[kc
eh \hec j^[ _dj[h_eh e\ j^[ `Wm Xed[$ M_j^ Yh[ijWb
_cfbWdji"_j_iiec[j_c[ifeii_Xb[jeWY^_[l[j^_i]eWb
j^hek]^_d][d_ekiboijhkYjkh[Zikh\WY[iWdZYWh[\kbbo
i[b[Yj[Z_cfbWdji_j[i$<hecj^[fe_djij^Wj^Wl[`kij
X[[dZ_iYkii[Z"_jX[Yec[iYb[Whm^oj^[c_d_ckc
b[d]j^i WdZ ikh\WY[i j^Wj ^Wl[ X[[dÆiY_[dj_\_YWbboÇ
feijkbWj[Z\ehYh[ijWb_cfbWdjiedboWffbojeif[Y_\_Y
_cfbWdj Z[i_]di$ ?d ej^[h mehZi" j^[o edbo Wffbo
je _cfbWdji m_j^ ikh\WY[ Y^WhWYj[h_ij_Yi j^Wj Wh[
Yedl[dj_edWbehZedejb[dZj^[ci[bl[ijeX_ebe]_YWb
_dj[]hWj_edX[YWki[j^[oYWddejX[f[h\ki[Zm[bb_d
ed[mWoehWdej^[h$
7jj^_ife_dj"WXh_[\Z_iYkii_ede\m^Wj^WiYec[je
X[ademdWiÆheej#\ehc_cfbWdjiÇcWoX[ki[\kb$J^_i
.)
j[hcik]][ijij^Wjj^[i[Z[i_]di_c_jWj[dWjkh["Wi_j
m[h["XoX[_d]Yed\_]kh[ZWdZX[^Wl_d]b_a[dWjkhWb
j[[j^$J^_il_[m_]deh[i"^em[l[h"j^Wjj^ei[_cfbWdji
Wh[ jejWbbo _cceX_b[ _di_Z[ j^[ `Wm$ ?d ej^[h mehZi"
j^[o Wh[ l_hjkWbbo _d W ijWj[ e\ Wdaobei_i$7daobei_i
e\dWjkhWbj[[j^_ikdZ_ifkj[ZboWfWj^ebe]_YWbijWj[
h[gk_h_d] jh[Wjc[dj kdb[ii j^[ jeej^ edbo X[Yec[i
Wdaobei[Z _d _ji Yb_d_YWb Z[i_hWXb[ [dZ fei_j_ed$
9h[ijWb _cfbWdjebe]_iji jho Z[if[hWj[bo je [ijWXb_i^
j^_i fWj^ebe]_YWb ijWj[ Wi W jh[Wjc[dj eX`[Yj_l[$
J^[ dedi[di_YWb j[hc e\ Æ\kdYj_edWb Wdaobei_iÇ
ki[Z _d j^_i Yedd[Yj_ed _i WYjkWbbo W f[hl[hi_ed
e\ j^[ kdZ[hbo_d] YedY[fj$ Eii[e_dj[]hWj_ed Wbed]
j^[ l[hj_YWb Z_c[di_ed _i" e\ Yekhi[" Wd _d^[h[dj
h[gk_h[c[dj \eh Yh[ijWb _cfbWdji i_dY[ j^[o bWYa
Wdo ^eh_pedjWb Yecfed[dji$ J^[h[\eh[" `Wm Wh[W _d
m^_Y^ j^[i[ _cfbWdji Wh[ beYWj[Z _i h[ZkY[Z$ J^[
bed][hj^[_cfbWdj"j^[]h[Wj[hj^[beiie\[bWij_Y_jo$
7 Z[i_]dWj_ed b_a[ Æheej#\ehcÇ _cfbWdji _i fkh[bo
\ehcWb _d c[Wd_d] WdZ YWddej Y^Wd][ j^[ \WYj j^Wj
j^[i[Z[i_]dibWYa[ii[dj_WbY^WhWYj[h_ij_Yie\dWjkhWb
heeji ikY^ Wi [bWij_Y ikif[di_ed eh \kdYj_edWbbo
ikffehj[ZWZWfjWj_ede\f[h\ki_ed$8E?_cfbWdji"Xo
YedjhWij" Wh[ [bWij_YWbbo ikif[dZ[Z X[jm[[d Yehj_YWb
Xed[ ijhkYjkh[i$ ?d j^_i mWo" j^[ l_iYe[bWij_Y_jo WdZ
\b[n_X_b_jo e\ j^[ `Wm Wh[W Wh[ WZ[gkWj[bo fh[i[hl[Z$
?dWZZ_j_ed"j^[Yedd[Yj_l[j_iik[Wbed]j^[l[hj_YWb
_cfbWdjWn_iZe[idej_dj[h\[h[m_j^\bemf[h\ki_ed$
7ffWh[djbo j^[h[ _i W d[[Z \eh j^_i f[h\ki_ed je X[
_djWYj" m^_Y^ _i m^o eii[e_dj[]hWj_ed jWa[i ckY^
bed][h ed j^[i[ _cfbWdj ikh\WY[i j^Wd ed j^[ XWiWb
Z_iai[]c[dji$
J^[ \_hij ][d[hWj_ed e\ Z_ia _cfbWdji Xo @kbb_[j
Wbbem[Zl_hjkWbbode[bWij_Y_jom^Wjie[l[h$7bj^ek]^
j^[o m[h[ cWZ[ \hec [bWij_Y =hWZ[ ' j_jWd_kc"
j^[o m[h[ `kij jee j^_Ya je W\\ehZ j^[ h[gk_h[Z
Z[]h[[e\_ie[bWij_Y_jo$;l[dj^[:_ia_cfbWdjZ[i_]di
cWZ[ Xo IYehj[YY_ \hec =hWZ[ ( j_jWd_kc m[h[
WdZ Yedj_dk[ je X[ edbo ik_jWXb[ \eh 8E?#XWi[Z
_cfbWdj#h[ijehWj_ed ioij[ci _\ j^[ Z_ia Z_Wc[j[h
mWi WZ[gkWj[$ J^[ h[Wied _i eXl_eki0 ed j^[ ed[
^WdZ" icWbb Z[i_]di Wh[ dej YWfWXb[ e\ h[WY^_d]
j^[Yehj_YWbXed[ijhkYjkh[i_dWbbi_jkWj_edi1edj^[
ej^[h ^WdZ" ^_]^[h ]hWZ[i e\ fkh[ j_jWd_kc Wh[ dej
YWfWXb[ e\ ][d[hWj_d] j^[ ijWj[ e\ d[Wh _ie[bWij_Y_jo
h[gk_h[Z je eXjW_d WZ[gkWj[ eii[e_dj[]hWj_ed e\
j^[ beWZ#jhWdic_jj_d] ikh\WY[i$ >Wl_d] iW_Z j^Wj"
_cfbWdjbeii[iWh[[njh[c[bohWh[fh[Y_i[bom_j^-=.
;:"-=+;::eh-=-;:::Z[i_]di"Zk[jej^[\WYj
j^Wjj^[oWh[kikWbbo_di[hj[Z_d^_]^boc_d[hWb_p[Z
Xed[ Wh[Wi m^[h[ [bWij_Y_jo _i dej W jef fh_eh_jo
Yedi_Z[hWj_ed$ IYehj[YY_ Z[cedijhWj[Z _d ^_i Xeea
j^Wj h_]_Z _cfbWdj#h[ijehWj_ed Yecfb[n[i YekbZ X[
[ijWXb_i^[Z l[ho ikYY[ii\kbbo Xo _di[hj_d] W bWh][
dkcX[he\h_]_ZboZ[i_]d[Z_cfbWdji_dYecX_dWj_ed
m_j^iYh[m_cfbWdji$
.* 9^Wfj[h-È 4REATMENTÈ0LANNING
JeZWoÉi :_iaei#jof[ _cfbWdji e\\[h W XWbWdY[Z
YecX_dWj_ed e\ i^Wf[" j^_Yad[ii WdZ i_p[$ J^[_h
Z[l[befc[djmWiXWi[Zedj^[_dfkje\[nf[h_[dY[Z
ki[hi" ]_l_d] h_i[ je W Z[i_]d j^Wj _i efj_c_p[Z \eh
j^[ [nf[Yj[Z \kdYj_edWb beWZi WdZ j^[ ceX_b_jo
e\ j^[ ^kcWd iakbb m^_b[ [dikh_d] j^Wj WZ[gkWj[
eii[e_dj[]hWj_ede\j^[XWiWbfbWj[i_iWY^_[l[ZWjWbb
j_c[i$
È
#EMENTINGÈ6ERSUSÈ3CREWING
J^[h[ _i de i_cfb[ Wdim[h je j^[ gk[ij_ed m^[j^[h
ikf[hijhkYjkh[i i^ekbZ X[ Y[c[dj[Z eh iYh[m[Z
je _cfbWdji$ 7 fh[\[hh[Z WffheWY^ e\ Yh[ijWb
_cfbWdjebe]o fWhj_YkbWhbo _d j^[ cWn_bbW _i je
iYh[m W XWh WjjWY^c[dj je j^[ _cfbWdji WdZ ki[ W
Yel[hZ[djkh[ Wi fheij^[j_Y ikf[hijhkYjkh[$ J^[i[
ioij[ci" _j _i Wh]k[Z" Wh[ X[jj[h WYY[ii_Xb[ \eh i[b\#
f[h\ehc[ZehWb^o]_[d[$J^[[nf[h_[dY[e\j^ekiWdZi
e\fWj_[djijh[Wj[Zm_j^8E?_cfbWdjii^emij^Wjj^_i
YbW_c_ikd\ekdZ[Z$J^[jhkj^_ij^Wj\_n[Zfheij^[j_Y
iebkj_edi j^Wj Wh[ Xej^ W[ij^[j_Y WdZ WYY[ii_Xb[
YWd X[ fhel_Z[Z [l[d _d j^[ ceij kd\WlekhWXb[ e\
i_jkWj_edi$ ?d ekh l_[m" j^[ fh[Z_b[Yj_ed e\ Yh[ijWb
_cfbWdjebe]_iji \eh iYh[m[Z XWh WjjWY^c[dji h[Wbbo
^Wi je Ze m_j^ j^[ ^_]^ hWj[ e\ _cfbWdj beii m_j^
j^[i[ Z[i_]di$ J^[ jhk[ h[Wied _i j^Wj j^[i[ beii[i
YWd X[ ÆWZc_d_ijhWj[ZÇ X[jj[h kdZ[h iYh[m[Z XWh
WjjWY^c[dj j^Wd kdZ[h Y[c[dj[Z Xh_Z][i" j^[h[Xo
Wle_Z_d]j^[\_dWdY_Wbh_ia_$[$j^[bWXehWjehoYeiji
e\^Wl_d]jeh[fbWY[j^[ikf[hijhkYjkh[[l[hoj_c[Wd
_cfbWdj_ibeij$IYh[mYedd[Yj_edie\\[h_d]Wfh[Y_i[
\_jWh[ckY^ceh[Z_\\_Ykbjjeh[Wb_p[j^WdY[c[dj[Z
Yedd[Yj_edi" fWhj_YkbWhbo _d i_jkWj_edi m^[h[ j^[
Xed[ cehf^ebe]o ^Wi Y^Wd][Z el[h j^[ Yekhi[ e\
jh[Wjc[dj WdZ _\ YedZ_j_edi _d j^[ jho#_d f^Wi[ Wh[
de bed][h j^[ iWc[ Wi _d j^[ f^Wi[ e\ _cfh[ii_ed#
jWa_d]$
Iec[ ki[hi fh[\[h je h[cel[ j^[ fheij^[j_Y
ikf[hijhkYjkh[ Wj h[]kbWh _dj[hlWbi$ J^_i dWjkhWbbo
h[gk_h[i j^[ ki[ e\ W iYh[m Yedd[Yj_ed$ 9[c[dj[Z
Xh_Z][iWh[dejWdefj_ed_dj^WjYWi[$
Ed[ e\ j^[ h[Wiedi m^o iYh[m Yedd[Yj_edi Wh[
ceh[Yedl[d_[djjeki[edh_]_Z_cfbWdjijof[i?:E"
?:EJeh?:_iX[YWki[iYh[m#h[jW_d[ZXh_Z][iYWddej
Z[l[bef fh[#beWZi Wbed] j^[_h XWiWb Yecfed[dji$
Ed j^[ ej^[h ^WdZ" _dj[hdWb#j^h[WZ ioij[ci Wh[
WiieY_Wj[Zm_j^bWh][_cfbWdj^[WZie\WZ[gkWj[mWbb
j^_Yad[ii" m^_Y^ [djW_bi bWh][h ckYeiWb f[d[jhWj_ed
fe_dji"j^[h[Xo_dYh[Wi_d]j^[h_iae\_d\[Yj_edi$
Ej^[hki[hiZedejm_i^jeh[cel[j^[Xh_Z][i[l[h
W]W_d$ J^[h[\eh[" j^[o ^Wl[ de eYYWi_ed je [cXWha
edj^[j[Y^d_YWbboZ[cWdZ_d]jWiae\[ijWXb_i^_d]W
iYh[mYedd[Yj_ed$7\j[hWbb"j^[j_c[WdZced[o]e_d]
_djej^[\WXh_YWj_ede\WiYh[m#h[jW_d[ZXh_Z][mekbZ
ik\\_Y[je\WXh_YWj[jmei_cfb[Xh_Z][i\heciYhWjY^$
7domWo"Wd[mXh_Z][[l[dWi_cfb[8heiWcb[#jof[
Xh_Z][ _i e\j[d j^[ X[jj[h iebkj_ed _d j^[ [l[dj e\
Yecfb_YWj_edi$ M[ j^[h[\eh[ ki[ Y[c[dj[Z Xh_Z][i
_dij[WZe\iYh[m#h[jW_d[ZXh_Z][im^[d[l[hfeii_Xb[
WdZWZl_i[ekhfWj_[djijeif[dZb[iiced[oeded[
if[Y_\_Y h[ijehWj_ed Xkj je ^Wl[ d[m h[ijehWj_edi
\WXh_YWj[Z\hecj_c[jej_c[_dij[WZ$7iWcWjj[he\
\WYj"d[mh[ijehWj_edim_bbX[d[[Z[ZWkjecWj_YWbboWi
j^[ebZed[iWh[h[ZkY[Zel[hj_c[Xoj^[d[Y[iiWho
eYYbkiWbWZ`kijc[dji$
?d ekh fhWYj_Y[" ;:#jof[ _cfbWdji ^Wl[ o_[bZ[Z
j^[X[ijh[ikbji$J^_ifh[ikcWXbo^WijeZem_j^j^[_h
^_]^h[i_ijWdY[je_d\[Yj_edi"m^_Y^m[Wjjh_Xkj[jej^[
j^_dfeb_i^[Zikh\WY[iWjj^[b[l[bm^[h[j^[_cfbWdj
f[d[jhWj[i j^[ ckYeiW$ J^[ iYh[m Yedd[Yj_ed YWd
l_hjkWbboWbmWoiX[[ijWXb_i^[Zekji_Z[e\j^[ckYeiW$
?d j^_i mWo" j^[ Yedd[Yj_edi Wh[ m[bb WYY[ii_Xb[ WdZ
i[b\#ZhW_d_d]$
Je ikccWh_p[" [l[ho WffheWY^ ^Wi if[Y_\_Y
WZlWdjW][i WdZ Z_iWZlWdjW][i$ 7 fWdWY[W Ze[i dej
[n_ij$H[]WhZ_d]j^[gk[ij_edkdZ[hZ_iYkii_ed^[h["
j^[kd_l[hi_j_[ih[f[Wj[Zboim_jY^[Zi_Z[i[l[ho\[m
o[Whi$ ?j _i iW\[ je Wiikc[ j^Wj j^[i[ Y^Wd][i e\
^[Whj m[h[ fhecfj[Z dej ie ckY^ Xo \_hij#^WdZ
Z[b_X[hWj_edi WdZ [nf[h_[dY[ Wi Xo Z[f[dZ[dY[ ed
j^_hZ#fWhjo\kdZ_d]Wjj^[^WdZie\if[Y_\_Y_cfbWdj
cWdk\WYjkh[hi$
È
2EDUCINGÈ&UNCTIONALÈANDÈ0ARAFUNCTIONALÈ
,OADSÈBYÈ0ROSTHETICÈ4REATMENT
7Z`kij_d] j^[ fei_j_ed e\ j^[ cWij_YWjeho ikh\WY[i
YWd Yh[Wj[ W i_jkWj_ed j^Wj ^[bfi je h[ZkY[ j^[
cWij_YWjeho\ehY[iXobeWZ_d]j^[JC@ijhkYjkh[i$
J^[Yedi[gk[dY[ie\]h[WjcWij_YWjeho\ehY[iWh[
WbieWffWh[dj_dfWj_[djim[Wh_d]Z[djkh[i$C[hY_[h
WdZBW\edjWdj'/-/eXi[hl[Zceh[WZlWdY[ZYWi[i
e\ h_Z][ h[iehfj_ed _d fWj_[dji Y^WhWYj[h_p[Z Xo
icWbb bem[h \WY[i WdZ ^eh_pedjWb eh_[djWj_ed e\
j^[ cWdZ_Xb[ _$[$ icWbb ]ed_ed Wd]b[$ J^[o Wbie
c[dj_ed[Zj^Wjj^[WjjWY^c[djie\j^[`Wm#[b[lWj_d]
ckiYb[i m[h[ beYWj[Z ceh[ Wdj[h_ehbo _d j^ei[
fWj_[dji$ ?d j^[ fWj_[dji m^e i^em[Z W h[bWj_l[bo
ef[d X_j[" j^[ bWij \kdYj_edWb cebWhi m[h[ beYWj[Z
iec[m^Wj ceh[ Wdj[h_ehbo je j^[ \hedj cWh]_d
e\ j^[ Y^[m_d] ckiYb[i fWhj_Y_fWj_d] _d Ybei_d]
cel[c[dji$Fh[ikcWXbo"j^[ehX_YkbWh_ieh_ickiYb[
_iceh[ijhed]bo_dlebl[Z_dY^[m_d]#h[bWj[ZYbei_d]
cel[c[dji_dj^ei[fWj_[dji$
JWa_d]WZlWdjW][e\j^[]eeZ_dj[]hWj_l[YWfWY_jo
e\ j^[ Z_ijWb cWdZ_Xb[" m[ _dlWh_WXbo fbWY[ 8E?
_cfbWdji_d_jij[hc_dWbi[]c[djehkdZ[hj^[b_d[W
eXb_gkW m^_j[ b_d[ _d j^[ EF=$ J^[ [dZfe_dj e\
fheij^[j_Y \kdYj_ed _i Wj j^[ fei_j_ed e\ j^[ \_hij
È È 2EDUCINGÈ&UNCTIONALÈ,OADSÈBYÈ$RUGÈ4REATMENTÈ .+

È
2EDUCINGÈ&UNCTIONALÈ,OADSÈÈ
BYÈ$RUGÈ4REATMENT

J^[Y^[m_d]\ehY[d[[ZijeX[h[ZkY[Z_dj^[[Whbo
feijef[hWj_l[f^Wi[jefh[i[hl[_d_j_WbXed[YedjWYj
Wi Xed[ ijhkYjkh[i Wh[ X[_d] h[fW_h[Z$ M[ _dijhkYj
ekh fWj_[dji je Yed\_d[ j^[_h Z_[j je ie\j \eeZi j^Wj
A B
Wh[dejY^[m[ZWjWbbehYWdX[Y^eff[Zj^hek]^_d
W i_d]b[ X_j[$ D[l[hj^[b[ii" j^[h[ Wh[ WbmWoi iec[
&IGÈAB J^[ fei_j_edWb h[bWj_edi^_fi X[jm[[d j^[ Z[djWb
WhY^[i WdZ ckiYb[i cWo lWho$ J^[ i_jkWj_ed ed j^[ h_]^j _i
Y^WhWYj[h_p[Z Xo W icWbb ]ed_ed Wd]b[ WdZ W Z_ijWb fei_j_ed
e\ j^[ cWij_YWjeho ikh\WY[i$ J^[ JC@ _i fhej[Yj[Z \hec ^_]^
Y^[m_d]beWZi[n[hj[ZXoj^[Z[djWbWhY^[i"m^_Y^_im^oj^[h[
_ided[]Wj_l[\[[ZXWYaed[nY[ii_l[\ehY[i$J^_i_dYh[Wi[ij^[
h_iae\fWhW\kdYj_ed$Edj^[b[\ji_Z["XoYedjhWij"j^[l[hj_YWb
ckiYb[ \ehY[i Wh[ dej XbeYa[Z Xo j^[ Z[dj_j_ed WdZ \kbbo
_cfWYj j^[ `e_dj Wh[W$ J^[ cWii[j[h ckiYb[ ^Wi Wd Wdj[h_eh
WdZWfeij[h_ehfWhj"WdZWdom[Wad[iie\ed[e\j^[i[fWhji
cWob[WZjeZ_\\[h[dY[i_dbeWZfhefW]Wj_edjej^[`e_djZkh_d]
cWij_YWj_ed WdZ fWhW\kdYj_edWb WYj_l_j_[i ceZ_\_[Z \hec
C[hY_[hWdZBW\edjWdj'/-/ WXb[jeZh_l[WYWh\ehj^[ZkhWj_ede\jh[Wjc[dj$
&IGÈ M^_b[ j^[ Z_ijWb fei_j_edi m[h[ i[b[Yj[Z \eh j^[
8E? _cfbWdji X[YWki[ e\ j^[_h X_ec[Y^Wd_YWb ijWX_b_jo" de
cWij_YWjeho ikh\WY[i Wh[ h[gk_h[Z Z_ijWbbo je j^[ \_hij cebWh$
J^[ fedj_Yi Wh[ Z[i_]d[Z m_j^ W ckYeiWb Yb[WhWdY[" ie j^Wj
j^[oYWddej_dj[h\[h[m_j^j^[Yh[ijWb]hemj^e\j^[cWdZ_Xb[
cebWh$?dj^_imWo"m[Whj_\_Y_WbboYh[Wj[Wi_jkWj_edb_a[
j^[ed[_bbkijhWj[Zedj^[b[\ji_Z[e\<_]$-$,$?dj^[
feijef[hWj_l[h[ceZ[bb_d]f^Wi["j^[cehf^ebe]oe\
j^[ cWdZ_Xb[ Y^Wd][i Xo X[dZ_d] ib_]^jbo kfmWhZi
jemWhZij^[YWkZWbWif[Yj$J^_i]_l[ih_i[jefh[cWjkh[
YedjWYji_dj^[Z_ijWbfeij[h_ehi[]c[djj^Wj^Wl[je
X[ f[h_eZ_YWbbo WZ`kij[Z$ ?\ j^[i[ WZ`kijc[dji Wh[
f[h\ehc[Z bWj[ eh dej Wj Wbb" j^[ _cfbWdji _d j^[
cWdZ_Xb[eh_dj^[effei_d]`WmcWoX[W\\[Yj[ZXo
el[hbeWZeij[eboi_i$
fWj_[djim^eZedej]hWifj^[c[Wd_d]e\ÆYWh[\kbÇ
WdZ\W_bjekdZ[hijWdZj^[_cfb_YWj_edie\WZWfjWj_ed
beii[i$ FWj_[dji m_j^ fWhW\kdYj_edi m^e Wh[ WmWh[
e\ j^[_h fheXb[c WdZ Wh[ \ekdZ Xo j^[ Z[dj_ij je
f[h\ehc [nY[ii_l[ X_j_d] cel[c[dji Wi m[bb YWd
X[ fhef^obWYj_YWbbo jh[Wj[Z m_j^ Zhk]i j^Wj h[ZkY[
cWij_YWjeho\ehY[i$
Ed[ efj_ed mekbZ X[ je h[ZkY[ j^[ WYj_l_jo
e\ j^[ [dj_h[ eh]Wd_ic Xo c[Z_YWj_edi b_a[ ehWb
c[fheXWcWj[$ Dej[ j^Wj j^[i[ fWj_[dji m_bb dej X[
?j ^Wi j^[h[\eh[ X[Yec[ _dYh[Wi_d]bo fefkbWh
je ki[ Zhk]i m_j^ beYWb WYj_l_jo ikY^ Wi Xejkb_dkc
jen_dIecc[hWdZIWjjb[h(&&'1lWdB_dZ[hd(&&&$
H[ikbjiXWi[Zedh[bWj_l[bobWh][fWj_[djiWcfb[iWh[
dem Wbie WlW_bWXb[ \eh j^[ jh[Wjc[dj e\ Xhkn_ic Xo
_d\_bjhWj_ed e\ j^[ feij[h_eh j[cfehWb_i ckiYb[ WdZ%
ehj^[cWii[j[hckiYb[9^_a^Wd_[jWb$(&&'$
J^[\ebbem_d]ZeiW][if[Y_\_YWj_edi\ehXejkb_dkc
jen_d Wh[ XWi[Z ed j^[ Yecc[hY_Wbbo WlW_bWXb[
fh[fWhWj_edi :oifehj eh 8ejen$ J^[i[ fheZkYji
Wh[ fWYaW][Z Wi W Zho ikXijWdY[ XekdZ je ^kcWd
WbXkc_d j^Wj _i h[Yedij_jkj[Z Xo j^[ ki[h m_j^ W
ieZ_kcY^beh_Z[_d`[Yj_ed&$/jeo_[bZWiebkj_ed$
J^[ fheZkYj ^Wi je X[ ijeh[Z _d W Yeeb fbWY[ WdZ
jhWdifehj[Z_dWh[\h_][hWj[ZijWj[$EdY[h[Yedij_jkj[Z"
:oifehj ^Wi je X[ ki[Z m_j^_d j^[ iWc[ ZWo$ Ed[
fWYaW][YedjW_di+&&kd_jie\j^[ZhofheZkYj"m^_Y^
m_bbik\\_Y[jejh[WjkfjejmefWj_[dji$
Je c_d_c_p[ Yeiji" _j cWo X[ ki[\kb je iY^[Zkb[
jh[Wjc[dji ikY^ j^Wj j^[ fWYaW][ YWd X[ i^Wh[Z
X[jm[[djmefWj_[dji$J^[fh[fWhWj_edckijdejX[
i^Wa[d Zkh_d] h[Yedij_jkj_ed je Wle_Z _dWYj_lWj_d]
j^[WYj_l[_d]h[Z_[dj"m^_Y^_idejjeeijWXb[$
:oifehj XbeYai Y^eb_d[h]_Y jhWdic_ii_ed Wbed]
j^[ cejeh [dZfbWj[ Xo _d^_X_j_d] j^[ h[b[Wi[ e\
WY[jobY^eb_d[$?d_j_Wbbo"j^[ceZ[e\WYj_ed_iZ_h[Yj[Z
Wj X_dZ_d] j^[ [njhWY[bbkbWh h[Y[fjehi _d W if[Y_\_Y
WdZ iWjkhWXb[ cWdd[h$ IkXi[gk[djbo j^[ jen_d _i
_dj[hdWb_p[Z$J^[d[hl[[dZ_d]ie\j^[cejeh[dZfbWj[
m_bb de bed][h h[ifedZ je d[khWb _cfkbi[i" WdZ j^[
Y^[cejhWdic_jj[h _i dej h[b[Wi[Z$ Fh[ikcWXbo" j^[
ijhkYjkh[i e\ j^[ cejeh [dZfbWj[ Wh[ Z_i_dj[]hWj[Z
XoY^[c_YWbWYj_ededY[j^[jen_d^WiWZlWdY[Z_dje
j^[Y[bb$
., 9^Wfj[h-È 4REATMENTÈ0LANNING
?cfkbi[jhWdic_ii_ed_ih[ijeh[ZWid[hl[[dZ_d]i
WdZ cejeh [dZfbWj[i Wh[ X[_d] h[#[ijWXb_i^[Z _d
j^[ f^Wi[ e\ h[][d[hWj_ed" m^_Y^ m_bb ijWhj WhekdZ
.m[[aiW\j[hj^[jen_dmWiWZc_d_ijhWj[Z$M^_b[j^[
d[mbo \ehc[Z ijhkYjkh[i Wh[ WdWjec_YWbbo Z_\\[h[dj
\hec j^[ fh[l_eki ed[i" j^[o Wh[ d[l[hj^[b[ii \kbbo
\kdYj_edWb$ ?j _i dej h[Yecc[dZ[Z je ki[ i[l[hWb
Wffb_YWj_edi _d i[h_[i" Wi j^[ Yedi[gk[dY[i e\ j^_i
WffheWY^^Wl[dejX[[d_dl[ij_]Wj[Z$
È
$OSAGE
7Zei[e\Wffhen_cWj[bo+&&kd_jimekbZj^[eh[j_YWbbo
ik\\_Y[jeWffh[Y_WXboXbeYaj^[cWii[j[hehj[cfehWb_i
ckiYb[$7del[hbobemZei[m_bbh[ZkY[j^[ZkhWj_ed
e\ WYj_ed X[YWki[ Wdo h[i_ZkWb ckiYb[ cel[c[dji
WiieY_Wj[Z m_j^ ikXjejWb _dWYj_lWj_ed m_bb ij_ckbWj[
j^[ XbeeZ ikffbo je j^[ fe_dj e\ \bki^_d] j^[ WYj_l[
_d]h[Z_[djWmWo$J^[h[\eh["j^[Zei[b[l[bf[hckiYb[
i^ekbZX[_dj^[hWd][e\'&&Ä(+&$J^[fh[fWhWj_ed
i^ekbZX[_d`[Yj[ZWjjmei[fWhWj[i_j[i"fh[\[hWXboWj
j^[`WmWd]b[WdZj^[WZ`WY[djfWhjiWdj[h_ehjej^[
cWii[j[hckiYb[$
?\ j^[ cWii[j[h ckiYb[ _i XbeYa[Z edbo" j^[
fWj_[dj m_bb Wjj[cfj je h[ijeh[ ^_i eh ^[h dehcWb
cWij_YWjeho \ehY[ Xo Xeeij_d] j^[ WYj_l_jo e\ j^[
j[cfehWb_i ckiYb[$ J^ki j^[ edbo mWo je [dikh[
j^Wj j^[ cWij_YWjeho \ehY[i Wh[ iW\[bo h[ZkY[Z _i Xo
_dWYj_lWj_d] Xej^ ckiYb[i _d W X_bWj[hWb cWdd[h$
CkiYb[ _dWYj_lWj_ed m_bb X[]_d m_j^_d 'Ä)ZWoi e\
_d`[Yj_ed WdZ bWij \eh (m[[ai kf je +cedj^i Wj W
c[Wd ZkhWj_ed e\ (cedj^i$ J^[ [\\[Yj _i Xk_bZ_d]
kf ]hWZkWbbo$ ?j X[]_di d[Wh j^[ _d`[Yj_ed i_j[ WdZ
m_bbj^[difh[WZj^hek]^ekjj^[ckiYb[_dWcWjj[h
e\(Ä)ZWoi$
Jh[Wj_d]j^[j[cfehWb_iWdZcWii[j[hckiYb[ied
Xej^i_Z[ie\j^[`Wmm_bbjWa[WhekdZ*&&Ä.&&kd_ji$
M^_b[ j^_i Zei[ b[l[b _i \Wh X[bem j^[ b[j^Wb hWd][
e\ )/"(&&Ä-."*&&kd_ji _d ^kcWdi" j^_i hWd][ h[\[hi
je j^[ ioij[c_Y jen_Y_jo$7do beYWb Wffb_YWj_edi j^Wj
h[WY^ j^[ coeYWhZ_kc" \eh _dijWdY[" mekbZ X[ b_\[#
j^h[Wj[d_d][l[dWjj^[hWf[kj_YZei[i$J^[Zhk]^Wi
jeX[jhWdifehj[Z_dWh[\h_][hWj[ZijWj[WdZYWh[\kbbo
ijeh[Z$
J^[iebkj_ed_i_d`[Yj[Z_djhWckiYkbWhbo"fh[\[hWXbo
j^hek]^ Wd [njhWehWb WYY[ii$ J^[ \ehY[ f[Wai e\ j^[
ckiYb[Wh[fh[\[hh[Zi_j[ie\Wffb_YWj_ed$J^[oYWdX[
beYWj[ZXolebkdjWhockiYb[\b[n_d]$
È
!DVERSEÈ%FFECTS
?\j^[cWii[j[hckiYb[_i_dWYj_lWj[Zedbo"j^[cWd#
Z_Xb[ m_bb WZlWdY[ je j^[ fe_dj e\ ][d[hWj_d]
[nY[ii_l[bo ijhed] Wdj[h_eh YedjWYji$ Ej^[h Y^[m_d]
ckiYb[i" dejWXbo j^[ bWj[hWb fj[ho]e_Z ckiYb[" cWo
h[ifedZ je j^_i m_j^ Z_\\ki[ fW_d h[WYj_edi$ 7do
imWbbem_d]#h[bWj[Z iocfjeci Wh[ kikWbbo Zk[ je
ikX`[Yj_l[ Y^Wd][i _d h[\b[n c[Y^Wd_ici" fhel_Z[Z
j^Wjj^[_d`[Yj_edmWiYehh[Yjbof[h\ehc[Z$IWb_lWj_ed
cWo Wbie X[ ikX`[Yj_l[bo _dYh[Wi[Z$ 7dj[h_eh
h[beYWj_ede\j^[cWdZ_Xb[d[[ZijeX[ced_jeh[ZWdZ
WYYecfWd_[ZXoeYYbkiWbWZ`kijc[dji_\d[Y[iiWho$
Ej^[h WZl[hi[ [\\[Yji _dYbkZ[ fWhWboi_i e\
d[_]^Xekh_d] ckiYb[i" m^_Y^ _i kikWbbo h[l[hi_Xb[$
;c[h][dYol[dj_bWj_edi^ekbZX[WlW_bWXb[edi^ehj
dej_Y[" i_dY[ h[if_hWjeho ckiYb[i cWo Wbie X[Yec[
_dlebl[Z_\j^[_d`[Yj_ed_idejfhef[hbo[n[Ykj[Z$7d
Wdj_Zej[_idejWlW_bWXb[$
7i j^[ cWdZ_Xb[ cWo kdZ[h]e Wdj[h_eh h[fei_#
j_ed_d] ed bei_d] j^[ XWbWdY_d] ikffehj fhel_Z[Z
Xo j^[ cWii[j[h ckiYb[" j[cfehWho h[ijehWj_edi
_di[hj[Z_dj^_if^Wi[^Wl[jeX[WZ`kij[Z_dWj_c[bo
cWdd[h je Wle_Z [nY[ii_l[ beWZ_d] Xo fheij^[j_Y eh
cWij_YWjeho\ehY[i$
M[ ^Wl[ eXi[hl[Z cWdo YWi[i _d m^_Y^ j^[
cWdZ_Xb[ kdZ[hm[dj i_]d_\_YWdj h[beYWj_ed W\j[h
_d`[Yj_ede\:oifehj$?dekhl_[m"j^_if^[dec[ded
_iZk[jeWfheY[iie\h[bWnWj_edehh[eh_[djWj_ede\
j^[ [dj_h[ cWij_YWjeho WffWhWjki _d m^_Y^ ckiYb[i
ifWici Wh[ h[iebl[Z j^Wj ^Wl[ WbmWoi X[[d fh[i[dj
Xkj h[cW_d[Z kdZ[j[Yj[Z WdZ d[l[h h[iebl[Z
ifedjWd[ekibo$
È
)NDICATIONSÈANDÈ2ATIONALE
È
0ROPHYLACTICÈ!DMINISTRATION
=[d[hWbbo if[Wa_d]" Wdo d[mbo _dijWbb[Z beWZ#
jhWdic_jj_d] ikh\WY[i _d Xed[#_cfbWdj _dj[h\WY[i
i^ekbZ X[ fhej[Yj[Z W]W_dij i^[Wh_d] \ehY[i WdZ
Z[b[j[h_ekiel[hbeWZikdj_bWdWZ[gkWj[beWZ#h[i_ijWdj
_dj[]hWj_ede\j^[[deiiWbj_jWd_kcikh\WY[i^WiX[[d
h[WY^[Z$
J^[ \eYki e\ beYWb ckiYb[ XbeYaWZ[ _d Z[djWb
_cfbWdjebe]o _i ed i_jkWj_edi m^[h[ [nj[di_l[
Ybkij[hie\Y^[m_d]ckiYb[iYWdX[h[WZ_bo_Z[dj_\_[Z
Xol_ikWb[nWc_dWj_edehfWbfWj_ed$Jh[Wjc[dj_iWbie
_dZ_YWj[Z_dfWj_[djim^eh[fehj^Wl_d]Wh[YehZe\
deYjkhdWbckiYb[WYj_l_joWdZm^e[n^_X_jWZlWdY[Z
Z[djkh[#h[bWj[Z fh[iikh[ Wjhef^_[i$ J^[i[ fWj_[dji
Wh[ kdWXb[ je Yedjheb j^[_h cWij_YWjeho \ehY[i _d
W lebkdjWho cWdd[h WdZ Wff[Wh je X[ h[bWj_l[bo
jeb[hWdjeh"\ehj^WjcWjj[h"_dZeb[djm_j^h[if[Yjje
ehWbiocfjeci[$]$fh[iikh[ieh[i$
<khj^[hceh[" jh[Wjc[dj m_j^ Xejkb_dkc jen_d
_i Wbie _dZ_YWj[Z _d fWj_[dji m^e [l_Z[djbo ^Wl[ W
feehÆi[di[ e\ Z_h[Yj_edÇ Wi \Wh Wi ehWb \kdYj_ed _i
YedY[hd[Z$J^[i[fWj_[djij[dZjeZ[l[bef[nY[ii_l[
^WX_jkWb\ehY[i_dWm_Z[lWh_[joe\Y^[m_d]Wh[Wij^Wj
Wh[dejZ_h[YjboWiieY_Wj[Zm_j^cWij_YWj_ed_ji[b\Xkj
È È 2EDUCINGÈ&UNCTIONALÈ,OADSÈBYÈ$RUGÈ4REATMENTÈ
Wh[ jh_]][h[Z _d Wd _dlebkdjWho WdZ kdYedjhebb[Z
cWdd[h$ ?d ekh [nf[h_[dY[" j^[i[ c[Y^Wd_ici Wh[
ceij b_a[bo WiieY_Wj[Z m_j^ fioY^ebe]_YWb \WYjehi$
8ej^ [njhel[hj[Z WdZ _d^_X_j[Z f[hiedWb_jo
ijhkYjkh[iYekbZX[W\\[Yj[Z$FWj_[djim_j^[YY[djh_Y
fWhW\kdYj_edi" m^_Y^ \h[gk[djbo ]e kdZ[j[Yj[Z _d
fhWYj_Y["Wh[h[dZ[h[ZkdWXb[jeki[j^[\kbb\ehY[e\
j^[_hckiYb[iWim[bb$
7ZlWdY[Zh_Z][h[iehfj_ed_dlebl_d]fWfohWY[eki
j^_d Xed[ mWbbi" dejWXbo _d j^[ cWn_bbW" _i Wdej^[h
i_jkWj_ed m^[h[ j^[ Y^[m_d] \ehY[i cWo d[[Z je X[
h[ZkY[Z$
:kh_d]ib[[fj^[cWdZ_XkbWhfei_j_edZ_\\[hi\hec
j^[ fei_j_ed Zkh_d] j^[ ZWo$ CkiYkbWh ZodWc_Yi
Zkh_d] ib[[f Wh[ kd_gk[ je j^Wj Zkh_d] lebkdjWho
Yb[dY^_d]WdZ[n[hjW]h[Wj[hc[Y^Wd_YWbbeWZedj^[
XWbWdY_d]i_Z[j[cfehe#cWdZ_XkbWh`e_djC_dW]_[j
Wb$'/..$J^[h[\eh[\ehY[i[n[hj[Zedj^[f[h_#_cfbWdj
Xed[YWddejX[Yedjhebb[ZXoj^[fWj_[djZkh_d]j^[
d_]^j Wi j^[o YWd Zkh_d] ZWoj_c[$ J^_i _i Wdej^[h
h[Wied m^o _d YWi[i m_j^ W Yecfhec_i[Z Xed[
ikffbo[if[Y_Wbbo_dj^[kff[h`Wmj^[Wffb_YWj_ed
e\Xejkb_dkcjen_dckijX[Yedi_Z[h[Z$
FWj_[dji m^e fh[ikcWXbo Z[l[bef ]h[Wj \ehY[i
ed Ybei_d] j^[_h `Wmi YWd Wbie X[ _Z[dj_\_[Z Xo
h[cej[ hWZ_e]hWf^i$ Cbb[h '/,, h[fehj[Z
j^Wj j^[ WYj_l_jo e\ j^[ cWii[j[h WdZ j[cfehWb_i
ckiYb[i lWh_[i Z[f[dZ_d] ed j^[ _dYb_dWj_ed e\ j^[
cWdZ_Xb[" Y^WhWYj[h_p[Z Xo _dYh[Wi_d] Wcfb_jkZ[
_d Wd Wdj[heikf[h_eh Z_h[Yj_ed Wi j^[ cWdZ_Xb[
hejWj[i$ J^[ ]ed_ed Wd]b[ _i icWbb _d j^[i[ YWi[i$
<_dZ_d]i je j^[ [\\[Yj j^Wj j^[ cWii[j[h ckiYb[ _i
ceijWYj_l[_d_dZ_l_ZkWbim_j^WicWbb]ed_edWd]b[
m[h[ Wbie h[fehj[Z Xo M_jj '/,)$ ?d][hlWbb WdZ
J^_bWdZ[h '/-* eXi[hl[Z W Z_ij_dYj h[bWj_edi^_f
X[jm[[d \WY_Wb cehf^ebe]o ed j^[ ed[ ^WdZ WdZ
ckiYb[WYj_l_joZkh_d]Y^[m_d]Wim[bbWicWn_ckc
_dj[hYkif_ZWj_ed ed j^[ ej^[h$ :kh_d] \kdYj_ed" j^[
Wcfb_jkZ[ie\j^[cWii[j[hWdZj[cfehWb_ickiYb[i
m[h[ ^_]^[h m^[d j^[ `Wm XWi[i m[h[ fWhWbb[b Xkj
Wbiem^[dj^[cWdZ_XkbWheYYbkiWbb_d[WdZj^[=e#
=d b_d[ m[h[ fWhWbb[b$ Ijhed] Y^[m_d] \ehY[i m[h[
WiieY_Wj[Z m_j^ icWbbd[ii e\ j^[ bem[h \WY[i WdZ
f[hf[dZ_YkbWh `Wm Wd]b[i$ IWiiekd_ '/,/ h[fehj[Z
j^WjckiYb[\ehY[im[h[j^h[[je\ekhj_c[iijhed][h
_d fWj_[dji m_j^ W icWbb l[hj_YWb Z_c[di_ed j^Wd _d
fWj_[djim_j^Wh[bWj_l[boef[dX_j[$
7do j[[j^ beYWj[Z X[jm[[d j^[ ckiYb[ [dZi
YWd eXl_ekibo h[ZkY[ j^[ \ehY[i je X[ WXiehX[Z
Xo j^[ JC@i$ B_c A^[d] (&&& Z[cedijhWj[Z _d
j^_iYedd[Yj_edj^WjY^[m_d]\ehY[i_dYh[Wi[Zm^[d
j^[ JC@ Wh[W mWi WdW[ij^[j_p[Z Wj j^[ j_c[ e\
c[Wikh[c[dj$
?d i_jkWj_edi m^[h[ i[l[hWb e\ j^[ WXel[#
c[dj_ed[Z \WYjehi Wh[ i_ckbjWd[ekibo fh[i[dj" j^[
ki[e\Xejkb_dkcjen_di^ekbZX[Yedi_Z[h[ZWbbj^[
ceh["[if[Y_Wbbo_\ijhWj[]_YWXkjc[djiWh[fbWdd[Z$
.-
J^[fhef^obWYj_Yki[e\Xejkb_dkcjen_d_iY[hjW_dbo
_dZ_YWj[Z _d fWj_[dji m_j^ i[l[h[ eij[efehei_i m^e
Wh[jh[Wj[Zm_j^cWn_bbWho_cfbWdji$
È
4HERAPEUTICÈ!PPLICATIONÈOFÈ"OTULINUMÈ4OXIN
;l[d8E?_cfbWdjij^Wj^Wl[X[[d\_hcbo_dj[]hWj[Z
\ehcWdoo[WhicWoikZZ[dboX[Yec[ceX_b[$J^[i[
i_jkWj_edi Wh[ kikWbbo YWki[Z Xo Wbj[hWj_edi Wj j^[
cWij_YWjeho ikh\WY[i$ M[ ^Wl[ hekj_d[bo eXi[hl[Z
YWi[i_dm^_Y^cW`ehWh[Wie\cWij_YWj_edm[h[beij_d
j^[effei_d]`Wme\jejWb8E?#XWi[ZXh_Z][i$Kdb[ii
j^[i[ cWij_YWjeho ikh\WY[i Wh[ h[fbWY[Z _d W j_c[bo
cWdd[h" W kd_bWj[hWb Y^[m_d] fWjj[hd m_bb Z[l[bef
WdZ]_l[h_i[je_cfbWdjceX_b_jo$J^[h[Wiedi\ehj^_i
Wh[Wi\ebbemi0
v J^[fheY[iie\Yecfh[^[di_l[h[ceZ[bb_d]b[WZ_d]
je j^[ Z[l[befc[dj e\ d[m beWZ#jhWdic_jj_d]
jhW`[Yjeh_[im_bbf[hi[Yecfhec_i[j^[ijWX_b_joe\
j^[_cfbWdji$
v Kd_bWj[hWbY^[m_d]_ib_WXb[je[nY[ii_l[bobeWZj^[
_cfbWdjiedj^Wji_Z[e\j^[`Wm$
?cfbWdji j^Wj m[h[ m[bb _dj[]hWj[Z j^[ \_hij j_c[
WhekdZ ^Wl[ W ]eeZ Y^WdY[ e\ h[Yel[h_d] j^[_h
ijWX_b_jo Wi bed] Wi j^[ Z[YWbY_\_[Z cWjh_n _d j^[
]hWdkbWj_edj_iik[^WidejX[[dh[ceZ[bb[ZWdZj^[
i_jkWj_ed_idej[nWY[hXWj[ZXoWdo_d\[Yj_ediWbed]
j^[beWZ#jhWdic_jj_d]ikh\WY[i$
J^[ jh[Wjc[dj h[gk_h[c[dj _d j^[i[ i_jkWj_edi _i
je [b_c_dWj[ j^[ YWki[ e\ [nY[ii_l[ beWZ_d] m_j^ekj
Z[bWo$ Ed[ mWo e\ WY^_[l_d] j^_i cWo X[ je _di[hj
WZZ_j_edWb _cfbWdji _d j^[ effei_d] `Wm WdZ" e\
Yekhi["_dj^[W\\[Yj[Z`Wm_\d[Y[iiWho$7domWo"j^[
jh[Wjc[dj ckij X[ W_c[Z Wj h[ijeh_d] W XWbWdY[Z
Y^[m_d] \kdYj_ed$ 7j j^[ iWc[ j_c[" j^[ Y^[m_d]
\ehY[i Wh[ h[ZkY[Z Xo WZc_d_ijhWj_ed e\ Xejkb_dkc
jen_d$J^[Y^WdY[ie\h[_dj[]hWj_edWh[ikXijWdj_Wbbo
_cfhel[ZXoj^_ifh[YWkj_ed$M[^Wl[eXi[hl[ZYWi[i
_dm^_Y^^_]^boceX_b[Xh_Z][iijWX_b_p[Z_dWcWjj[h
e\m[[aiW\j[hf[h\ehc_d]j^[i[jmec[Wikh[i$
?dekhl_[m"j^[ki[e\_dj[hY[fjehi_idejWl_WXb[
Wbj[hdWj_l[ je j^[ jh[Wjc[dj Z[iYh_X[Z WXel[$ 7\j[h
Wbb" j^[i[ Z[l_Y[i h[bo ed ckiYb[#][d[hWj[Z ij_ckb_
\eYki[ZedWicWbbdkcX[he\j[[j^j^WjWh[Z[i_]d[Z
je h[ZkY[ j^[ Y^[m_d] \ehY[i Xo _dZkY_d] fW_d$
?cfbWdjiZedej^Wl[fhefh_eh[Y[fjehi$
Ifb_dj j^[hWf_[i" J;DI Z[l_Y[i WdZ ikY^b_a[ Wh[
dej ^[bf\kb [_j^[h$ 7bb j^[i[ Wbj[hdWj_l[ WffheWY^[i
Wh[kdWXb[jeZ[b_l[hj^[h[gk_h[Z[\\[Yj"m^_Y^_ije
h[b_[l[j^[_cfbWdj#Xed[_dj[h\WY[ie\Wdo[nY[ii_l[
\ehY[i m^Wjie[l[h \eh W Z[\_d[Z f[h_eZ e\ j_c[
Wffhen_cWj[bo(cedj^i$
Ed[cWoX[j[cfj[ZjeWh]k[j^Wjjh[Wjc[djm_j^
Xejkb_dkc jen_d ckij X[ [gkWbbo Z[b[j[h_eki i_dY[
j^[Y^[m_d]\ehY[im_bbh[jkhdjej^[_hebZb[l[biW\j[h
jh[Wjc[dj$J^_iWh]kc[djc_ii[ij^[fe_dj$7\j[hWbb"
.. 9^Wfj[h-È 4REATMENTÈ0LANNING
Wd _dYh[Wi[ _d cWij_YWjeho beWZ _i Wffhefh_Wj[ WdZ
_dZ[[Z d[Y[iiWho edY[ j^[ _cfbWdj#Xed[ _dj[h\WY[
^Wi Yedieb_ZWj[Z je j^[ fe_dj e\ e\\[h_d] WZ[gkWj[
ikffehj _d ehZ[h je _cfhel[ Xed[ gkWb_jo _d j^[
_dj[h\WY[Wh[W$
Dej[j^Wjj^[ckiYb[im_bbi^ehj[dWij^[_hWYj_l_jo
_dYh[Wi[i m_j^ j^[ h[Yel[ho e\ Y^[m_d] \ehY[i edY[
j^[jen_d_idebed][h[\\[Yj_l[$J^[h[\eh["j^[Z_ijWb
fehj_edie\j^[fheij^[j_Yikf[hijhkYjkh["m^_Y^^Wi
^ece][dekibo i[jjb[Z _d j^[ _djhWehWb ifWY[ Zkh_d]
^[Wb_d]" d[[Z je X[ [nj[di_l[bo h[ZkY[Z je Wle_Z
[nY[ii_l[beWZ_d]$
È
%XTRACTIONÈ6ERSUSÈ0RESERVATIONÈÈ
OFÈ.ATURALÈ4OOTHÈ3TRUCTURES
H[ijehWj_l[ Z[dj_iji Wh[ hekj_d[bo \WY[Z m_j^ j^[
gk[ij_ed e\ m^[j^[h if[Y_\_Y j[[j^ i^ekbZ X[
[njhWYj[Z eh fh[i[hl[Z$ J^[ efj_ed e\ fh[i[hl_d]
j[[j^ WbmWoi mWhhWdji iec[ iY[fj_Y_ic$ M[ i^ekbZ
WbmWoi h[c[cX[h _d j^_i Yedj[nj m^Wj ekh fWj_[dji
WYjkWbbo[nf[Yj\hecfheij^[j_Yjh[Wjc[dj$
9edi_Z[hj^[\ebbem_d]fe_dji0
v I[h_ekibo Yecfhec_i[Z j[[j^ i^ekbZ dej X[
_dYbkZ[Z _d j^[ fheij^[j_Y ijhkYjkh[ kdb[ii j^[h[
Wh[]eeZh[WiedijeZeie$If[Y_\_YWbbo"j^[Z[dj_ij
cWo Y^eei[ je _dYbkZ[ Wdo h[i_ZkWb j[[j^ _d
j^[ j[cfehWho h[ijehWj_ed je WXiehX j^[ \ehY[i
Z[l[bef_d] _d j^[ [Whbo f^Wi[ e\ jh[Wjc[dj m^_b[
j^[ cWij_YWjeho fWjj[hd _i X[_d] [nj[di_l[bo
h[Yed\_]kh[Z$ IkXi[gk[djbo" j^[i[ j[[j^ YWd ij_bb
X[ [njhWYj[Z eh h[fbWY[Z Xo _cfbWdji \eh j^[
Z[\_d_j_l[h[ijehWj_ed$
v H[ijehWj_edij^WjWh[ikffehj[ZXo_cfbWdjiedbo
m^_b[XehZ[h_d]edh[i_ZkWbj[[j^m^ei[fhe]dei_i
_i kdY[hjW_d WbmWoi YWhho j^[ h_ia e\ _dYkhh_d]
ikXijWdj_WbYecfb_YWj_edi_\j^ei[j[[j^Wh[ieed[h
eh bWj[h beij WdZ d[[Z je X[ h[fbWY[Z W\j[h Wbb$
?j _i j^[h[\eh[ X[jj[h je Yedi_Z[h [njhWYj_d] Wdo
ikY^ WZ`WY[dj j[[j^ h_]^j WmWo WdZ _dYehfehWj[
j^[i[ beYWj_edi _dje j^[ h[ijehWj_ed _d j^[ \_hij
fbWY[$ J^_i ijhWj[]o ^Wi X[[d i^emd je X[ ceh[
[Yedec_YWb_dj^[bed]hkd$
v J^[i_cfb[ijiebkj_ed_dcWdoYWdj_b[l[hi_jkWj_edi
_ije_dYehfehWj[Wdj[h_ehj[[j^$7im_bbX[i^emd
_d9^Wfj[h'("_dYbki_ede\YWd_d[ih[ikbji_dl[ho
ZkhWXb[ h[ijehWj_edi$ Jeej^#ikffehj[Z Xh_Z][i
[nj[dZ_d] \hec W Z_ijWb je Wd Wdj[h_eh WXkjc[dj
Wh[Wm[bb#[ijWXb_i^[ZYedl[dj_edWbfheij^eZedj_Y
j[Y^d_gk[$ J^[h[ _i de h[Wied je ki[ W Z_\\[h[dj
WffheWY^\eh_cfbWdj#ikffehj[ZXh_Z][i$
v 8[\eh[ h[fbWY_d] W \_hij cebWh _d j^[ cWdZ_Xb["
ed[ i^ekbZ YWh[\kbbo Wii[ii ^em j^_i WffheWY^
YecfWh[i je W Yedl[dj_edWb jeej^#ikffehj[Z
Xh_Z][m_j^j^[i[YedZcebWhWiWXkjc[dj$M^_b[
m[^Wl[iYWhY[boeXi[hl[ZWdoYecfb_YWj_edim_j^
Jof[ )Y WdZ Jof[ * ijhkYjkh[i" _j _i d[l[hj^[b[ii
mehj^ dej_d] j^Wj j^[ fei_j_ed e\ j^[ \_hij cebWh
m_bb hWh[bo e\\[h W jhkbo ijhWj[]_Y fei_j_ed \eh
_cfbWdjfbWY[c[djm_j^h[if[YjjeWd[Z[djkbeki
cWdZ_Xb[$ J^[h[\eh[" _\ j^[ i[YedZ cebWh
_i [nf[Yj[Z je bWij \eh Wdej^[h +Ä'&o[Whi" m[
mekbZ WbmWoi fh[\[h W Yh[ijWb _cfbWdj iebkj_ed
eh W Yedl[dj_edWb jeej^#ikffehj[Z Xh_Z][ je W
8E?#XWi[Z iebkj_ed$ 7bj[hdWj_l[bo" _\ j^[ i[YedZ
cebWh^WiWfeeh[hfhe]dei_ij^Wdj^Wj"m[mekbZ
h[fbWY[ _j m_j^ W 8E? _cfbWdj [_j^[h Wbed[ eh _d
YecX_dWj_edm_j^WjkX[hefj[ho]e_ZiYh[m$
v½ Heej YWdWb j[[j^ i^ekbZ X[ _dYehfehWj[Z Wi
WXkjc[dji edbo _\ j^[ heej YWdWb \_bb_d] mWi
ikYY[ii\kbWdZ_\j^[Yhemde\\[hi[dek]^h[j[dj_ed
W\j[h_djheZkY_d]WYWijZem[bYeh[_\d[Y[iiWho$
È
4EMPORARYÈ2ESTORATIONS
:[f[dZ_d] ed j^[ j^[hWf[kj_Y iYef[ WdZ j^[
jh[Wjc[dj iY^[Zkb[" j^[ _cfbWdji cWo ^Wl[ je X[
\_jj[Z m_j^ W j[cfehWho Xh_Z][ _d ehZ[h je h[ijeh[
j^[ fWj_[djÉi Y^[m_d] WX_b_jo" Xkj Wbie je j[ij j^[
eYYbkiWb b[l[b" j^[ eYYbkiWb h[bWj_edi^_fi WdZ j^[
cWij_YWjeho\kdYj_ed$?dej^[hmehZi"j^[j[cfehWho
h[ijehWj_ed_iWl[ho_cfehjWdj[b[c[dje\j^[el[hWbb
jh[Wjc[djfbWd$J^[f^Wi[e\fhel_i_edWb_pWj_edcWo
bWijX[jm[[d(WdZ/cedj^i"_diec[fWj_[dji_jcWo
jWa[ ceh[ j^Wd W o[Wh$ 7domWo" j^[ [nWYj ZkhWj_ed
_i dej W cW`eh YedY[hd Wi j^[ fWj_[dj _i d[l[h b[\j
m_j^ekj\_n[Zj[[j^$?dj^[fh[i[dY[e\[nY[ii_l[]Wf
\ehcWj_edkdZ[hj^[fedj_Yi"j^[Z[dj_ijcWoY^eei[
je _di[hj W j[cfehWho [f_j^[i_i eh je ikXij_jkj[ W
i[YedZj[cfehWhoXh_Z][$
È
3COPEÈOFÈ2ESTORATIVEÈ4REATMENT
?\j^[eYYbkiWbjWXb[_idej[gkWbbobed]edXej^i_Z[i
e\ j^[ `Wm" j^[ fWj_[dj m_bb ieed[h eh bWj[h Z[l[bef
Wfh[\[hh[ZY^[m_d]i_Z[$J^_im_bbdehcWbboX[j^[
i_Z[ m^[h[ j^[ eYYbkiWb jWXb[ [nj[dZi \Whj^[h _dje
j^[ Z_ijWb `Wm i[]c[dj$ J^_i i_jkWj_ed cWo ]_l[ h_i[
je _cfbWdj \hWYjkh[ eh je kdZ[i_hWXb[ Wiocc[jh_[i
e\ j^[ `Wm _d j[hci e\ i^Wf[ WdZ c_d[hWb_pWj_ed$
?d j^_i fheY[ii" i_j[i j^Wj mekbZ dehcWbbo b[dZ
j^[ci[bl[i je _cfbWdjWj_ed cWo X[Yec[ kdijWXb[
WdZl_Y[l[hiW$;ijWXb_i^_d]\kdYj_edWbiocc[jho_i
W cWjj[h e\ jef fh_eh_jo _\ W h[b_WXb[ jh[Wjc[dj fbWd
_i je X[ [ijWXb_i^[Z$ J^_i ]eWb cWo X[ Z_\\_Ykbj eh
[l[d_cfeii_Xb[jeWY^_[l[_dh[ijehWj_l[jh[Wjc[dji
m^[h[fWhjie\j^[dWjkhWbj[[j^^Wl[jeX[b[\j_dWd
kd\WlekhWXb[YedZ_j_ed$
È È 4HEÈ3IGNIFICANCEÈOFÈ4HIRDÈ-OLARSÈ
;l[d _\ iocc[jh_YWb h[bWj_edi^_fi ^Wl[ X[[d
[ijWXb_i^[Z"j^_ii_jkWj_ed_ikdb_a[bojeh[cW_dijWXb[$
HWj^[h" j^[ YhWd_Wb Xed[i m_bb kdZ[h]e Yedj_dkeki
cehf^ebe]_YWb Y^Wd][i$ 7i fWhj e\ j^_i fheY[ii"
j^[ fei_j_ed e\ j^[ cWij_YWjeho ikh\WY[i m_bb X[
Yedj_dkekibo Wbj[h[Z Wi m[bb$ IkXjhWYj_l[ WdZ%eh
WZZ_j_l[ eYYbkiWb WZ`kijc[dji Wh[ d[[Z[Z je h[\b[Yj
j^[i[ Y^Wd][i$ ?\ j^[o Wh[ dej f[h\ehc[Z _d j_c["
j^[ Xed[#_cfbWdj#h[ijehWj_ed ioij[c m_bb j[dZ je
bWfi[_djekd_bWj[hWb\kdYj_edWbfWjj[hdim_j^i[h_eki
Yedi[gk[dY[i \eh j^[ fh[i[hlWj_ed e\ j^[ ioij[c Wj
bWh][$
<eh j^[ _cfbWdjebe]_ij" j^[i[ fe_dji Wh[ _d i^Whf
YedjhWij je j^[ f^_beief^o e\ eii[e_dj[]hWj_ed$ ?j
_i d[l[hj^[b[ii W \Wbi[ fh[c_i[ je j^_da e\ _cfbWdj#
h[ijehWj_ed ioij[ci" de cWjj[h ^em m[bb j^[o Wh[
eii[e_dj[]hWj[Z" Wi X[_d] _cceX_b[ _d j^[ Yedj[nj
e\ j^[ iakbb" Yedi_Z[h_d] j^Wj j^[ YhWd_Wb Xed[i
Wh[ j^[ci[bl[i ikX`[Yj je Z[\ehcWj_ed WdZ ceX_b[
h[bWj_l[ je [WY^ ej^[h$ ?cfbWdji" Xo YedjhWij" Ze
dej feii[ii j^[ WX_b_jo e\ dWjkhWb j[[j^ je WZWfj
Xo [bed]Wj_ed$ Ed j^[ ej^[h ^WdZ" Y^Wd][i e\ j^[
^eh_pedjWb Xed[ b[l[b YWd \h[gk[djbo X[ _Z[dj_\_[Z
Wi h[bWj_l[ [bed]Wj_ed X[i_Z[i XWYj[h_Wb _d\bk[dY[i"
m^_Y^ ^Wl[ W ]h[Wj _cfWYj fWhj_YkbWhbo _d Yh[ijWb
_cfbWdji$?j_ij^[h[\eh[d[Y[iiWhojekdZ[hijWdZj^[
X_ec[Y^Wd_Yie\j^[el[hWbbioij[cWdZje[ijWXb_i^
h[\[h[dY[ fe_dji j^Wj ]e X[oedZ j^[ _cc[Z_Wj[
l_Y_d_jo e\ j^[ _di[hj[Z _cfbWdji$ J^_iÆX_] f_Yjkh[Ç
YWddejX[YWfjkh[ZXoicWbb#iYWb[_cW][i$
J^[ iYef[ e\ h[ijehWj_l[ jh[Wjc[dj _i Z[\_d[Z Xo
j^[ jh[Wjc[dj eX`[Yj_l[" m^_Y^ _i je [ijWXb_i^ Wd
WZ[gkWj["ijWXb[WdZiocc[jh_YWbY^[m_d]\kdYj_ed$
È
4HEÈ3IGNIFICANCEÈOFÈ4HIRDÈ-OLARS
7iW][d[hWbhkb["j^[kff[hj^_hZcebWhiWh[h[cel[Z
X[\eh[ 8E? jh[Wjc[dj$ ?d hWh[ YWi[i" _\ j^[ fei_j_ed
WdZ heej h[bWj_edi^_fi Wh[ \WlekhWXb[" j^[o YWd X[
_dYehfehWj[ZWiZ_ijWbWXkjc[dji$I_jkWj_edi_dm^_Y^
Wj^_hZcebWhYWdX[b[\jÆWi_iÇWh[[njh[c[bohWh[$
7do m_iZec j[[j^ _d j^[ cWdZ_Xb[ j^Wj ^Wl[ de
YedjhWbWj[hWb Yekdj[hfWhj i^ekbZ X[ h[cel[Z Wi
m[bb" [l[d _\ j^[o Ze dej fWhj_Y_fWj[ _d cWij_YWj_ed
WdZ Ze dej i[[c je _dlebl[ Wdo fheXb[ci ed j^[
\WY[ e\ _j$ J^[ \WYj _i j^Wj j^_hZ cebWhi m_bb ieed[h
eh bWj[h Wbj[h j^[ cWij_YWjeho fbWd[1 _\ j^[o Wh[
fh[i[dj kd_bWj[hWbbo" j^[o Wh[ Yedi[gk[djbo b_WXb[
je _dZkY[ X_Wi[Z Y^[m_d] fWjj[hdi IWje '/.-$ M[
Ze dej ikif[Yj j^Wj j^_hZ cebWhi [n[hj WdoÆ\ehY[iÇ
ed j^[ Wdj[h_eh j[[j^ f[h i[$ J^[_h fh[i[dY[ Ze[i
Z[\b[Yj j^[ cWYhejhW`[Yjeh_[i e\ j^[ `Wm$ J^[ h[ikbji
_d W fhebed][Z f^Wi[ e\ h[ceZ[bb_d] YecfWh[Z je
i_jkWj_edi m^[h[ [hkfj_ed#h[bWj[Z h[ceZ[bb_d] _i
Yecfb[j[ZW\j[hj^[i[YedZcebWh^Wi[hkfj[Z$J^_i
./
&IGÈ J^[ Z[Y_i_ed je jWa[ ekj )hZ cebWhi _i iec[j_c[i
Z_\\_Ykbj je cWa[" i_dY[ j^[_h h[celWb jh_]][hi [nj[di_l[
h[ceZ[bb_d] WdZ bWh][ Z[\[Yji Wh[ \ekdZ W\j[h [njhWYj_ed$
?d j^[ YWi[ i^emd ^[h[" \khj^[h [hkfj_ed e\ '. ^WZ je X[
[nf[Yj[Z"m^_Y^WbieYWki[Zh[ceZ[bb_d]j^Wjb[ZjeWbeiie\
_dj[]hWj_ed e\ j^[ 8E? _cfbWdj _d H[]_ed ',$ J^[ h[cW_d_d]
jeej^ Wbie fhel_Z[Z W Yedi_Z[hWXb[ XWYj[h_Wb feeb" WdZ )hZ
cebWhiXbeYaj^[h[iehfj_ed#h[i_ijWdjWh[We\j^[jkX[hei_jo$?j
_ih[Yecc[dZ[Z[_j^[hjeki[j^[)hZcebWhWiWXkjc[djehje
[njhWYj_jWifWhje\j^[j^[hWfo$
fhebed][Zh[ceZ[bb_d]m_bb[nj[dZ_djeWf^Wi[e\b_\[
m^[dj^[^ehcedWbi_jkWj_ed_idebed][hZ_h[Yj[ZWj
Xk_bZ_d]kfXed[lebkc[$;d^WdY[Zh[ceZ[bb_d]_d
j^_if^Wi[e\b_\[m_bbj^[h[\eh["edXWbWdY["YWki[j^[
Xed[ lebkc[ je Z[Yh[Wi[ _d WXiebkj[ j[hci$ <hec
j^[ Z[dj_ijÉi f[hif[Yj_l[" j^[ j[[j^ Wh[ X[Yec_d]
_dYh[Wi_d]boYhemZ[Z$
Ç9hemZ_d]Ç c[Wdi j^Wj j^[ ifWY[ h[gk_h[c[dji
\eh j^[ Yb_d_YWb Yhemdi ekji_Z[ e\ j^[ Xed[ Wh[ Wj
lWh_WdY[ m_j^ j^[ Xed[ lebkc[ ikhhekdZ_d] j^[
heeji$
7YYehZ_d] je jeZWoÉi W[ij^[j_Y [nf[YjWj_edi" j^[
Yhemdi e\ j^[ Wdj[h_eh Z[dj_j_ed i^ekbZ _Z[Wbbo
beea b_a[ f[Whbi WhhWd][Z Wbed] W d[YabWY[$ IkY^
Wd WhhWd][c[dj _i edbo feii_Xb[ m_j^ iocc[jh_YWb
WdZ ifWY[#eYYkfo_d] heeji$ <eh j^_i fkhfei[" Xed[
lebkc[_id[[Z[Z_dj^[ded#ikffehj_l[Wh[WX[jm[[d
j^[ heeji" [l[d j^ek]^ j^_i Xed[ _i _hh[b[lWdj \eh
j^[ ijhkYjkhWb _dj[]h_jo e\ j^[ `Wm$ J^[ i[YedZWho
eij[edi[dYbei[j^[l[ij_XkbWhWdZb_d]kWbWif[Yjie\
j^[heejib_a[X[bji$J^[i[X[bji^Wl[jeX[dWhhem[Z
je iWl[ Xed[ \eh j^[ hekdZ[Z jeej^ ijhkYjkh[i
_d j^[ Wdj[h_eh i[]c[dj$ J^_i fheY[ii Xh_d]i j^[
heeji Ybei[h je [WY^ ej^[h WdZ ]_l[i h_i[ je j^[
\Wdd[Z#ekj WhhWd][c[dj e\ j^[ Wdj[h_eh Yhemdi$
J^_i Z[l[befc[dj cWo X[ Whh[ij[Z _\ j^[ Wdj[h_eh
j[[j^ Wh[ h[jW_d[Z Xo ehj^eZedj_Y jh[Wjc[dj el[h
cWdoo[Whikdj_bj^[f^Wi[e\]hemj^"[hkfj_edWdZ
WiieY_Wj[Z h[ceZ[bb_d] ^Wi X[[d Yecfb[j[Z$ ?\ Wdo
j^_hZcebWhi^Wl[dejX[[dh[cel[Z"j^_iij[WZoijWj[
m_bbdejX[h[WY^[Z\ehcWdoo[WhijeYec[$:[bWo[Z
h[celWb W\j[h j^[ W][ hWd][ e\ '(Ä'*o[Whi ^Wi jme
Z_iWZlWdjW][i0
v =hemj^#h[bWj[Zh[ceZ[bb_d]m_bbbWijbed][h$
v 8oj^_ij_c["ifWY[^WiWbh[WZoX[[deYYkf_[ZXo
/& 9^Wfj[h-È 4REATMENTÈ0LANNING

j^[ j^_hZ cebWhi" WdZ h[iehfj_ed e\ j^[ Wdj[h_eh fbWd[ m_bb dej Z[iY[dZ \Wh [dek]^ je Yh[Wj[ j^[
hWcki m_j^ h[bWj_l[ [bed]Wj_ed e\ j^[ ^eh_pedjWb d[Y[iiWhoifWY[Wjj^[i[ZehiWbi_j[i$
XhWdY^^WijWa[dfbWY[Wim[bb$ v I_jkWj_edi m^[h[ cWdZ_XkbWh j^_hZ cebWhi Wh[
h[cel[ZWdZh[fbWY[Zm_j^_cfbWdjiW\j[h^Wl_d]
8kjm^oZe[ij^[[hkfj_ede\j^_hZcebWhi^Wl[ikY^ X[[d_dfbWY[\ehcWdoo[Whim_bbkikWbboh[ikbj_d
\Wh#h[WY^_d]_cfb_YWj_edi5J^_igk[ij_edYWdedboX[ Wh[bWj_l[[b[lWj_ede\j^[Yh[ijWbXed[b[l[b_dj^[
WZZh[ii[Z\eh[WY^`Wmi[fWhWj[bo$ W\\[Yj[ZWh[WX[YWki[j^[Wh[We\j^[cWdZ_XkbWh
v J^[ cWdZ_XkbWh j^_hZ cebWhi [hkfj _d Wh[Wi j^Wj Wd]b[ YWd edbo Z[l[bef _ji X_ec[Y^Wd_YWbbo
Wh[YhkY_Wbbo_cfehjWdj\ehj^[ijWX_b_joe\j^[`Wm$ efj_cWb cWYhejhW`[Yjeh_Wb eh_[djWj_ed W\j[h j^[
Jeej^ [hkfj_ed _i fh[Y[Z[Z Xo eij[eboi_i _d j^[ jeej^^WiX[[dh[cel[Z$M^_b[j^ei[cebWhiWh[
Yhemd h[]_ed$ ;dpoc[i m_bb WZZ_j_edWbbo ie\j[d fh[i[dj"j^[om_bba[[fj^[Wbl[ebWhYh[ijbemZk[
j^[Xed[ijhkYjkh[m^[h[[hkfj_ed_ijejWa[fbWY[$ je j^[ Y^[m_d] \ehY[i _dlebl[Z$ CWn_bbWho j^_hZ
?\j^[Xed[j^hek]^m^_Y^j^[j^_hZcebWh[hkfji cebWhi j^Wj Wh[ _cfWYj[Z eh fWhj_Wbbo _cfWYj[Z
_i W beWZ#X[Wh_d] ijhkYjkh[" m^_Y^ _i j^[ YWi[ _d Ze dej b[WZ je j^_i [\\[Yj X[YWki[ j^[o Wh[ Wj j^[
j^[cWdZ_Xb["j^_iijhkYjkh[d[[ZijeX[h[fbWY[Z c[hYo e\ j^[ cWYhejhW`[Yjeh_[i _d j^[ WXi[dY[
_cc[Z_Wj[bo$ J^_i d[m Xed[ \ehcWj_ed kikWbbo e\ Wdo cWij_YWjeho ij_ckb_ W\j[h j^[_h heeji ^Wl[
eYYkhil[ij_XkbWhbojej^[Yhemd_$[$l[ij_XkbWhbo Z[l[bef[Z$?j_idejWbmWoi[Wiojefh[Z_Yjm^[j^[h
je j^[ Wh[W m^[h[ j^[ heej m_bb X[ beYWj[Z W\j[h ehdejj^[hWckim_bbkdZ[h]eWdj[h_ehh[beYWj_ed
[hkfj_ed^WiX[[dYecfb[j[Z$:[f[dZ_d]edj^[ W\j[h cWdZ_XkbWh j^_hZ cebWhi ^Wl[ [hkfj[Z$ 7i
beYWj_ede\j^[cWYhejhW`[Yjeh_[i"j^[j^_hZcebWh W cWjj[h e\ \WYj" fheXb[ci \eh _cfbWdj jh[Wjc[dj
cWo[hkfj_dj^[Y[djh[e\j^[h_Z][eh_dWbWj[hWb _d j^Wj h[]_ed Wh[ iec[j_c[i YWki[Z Xo Wdj[h_eh
fei_j_ed$?doekd]fWj_[djim^eh[gk_h[i_]d_\_YWdj [nfWdi_ede\j^[ie\j#j_iik[ijhkYjkh[iWbed[$
Yehj_YWbXed[ijhkYjkh[iX[YWki[e\^_]^Y^[m_d] v Ehj^eZedj_iji\h[gk[djboWh]k[j^Wjj^_hZcebWhi
\ehY[i" j^[ cWYhejhW`[Yjeh_Wbbo eh_[dj[Z Yehj_YWb i^ekbZX[[njhWYj[ZX[YWki[j^[o_dZkY[YhemZ_d]
Xed[ijhkYjkh[_dj^[Wh[We\j^[`WmWd]b[m_bbX[ _d j^[ Wdj[h_eh i[]c[dj$ M^_b[ m[ Ze dej W]h[[
Z[\b[Yj[Z _d W ceh[ b_d]kWb Z_h[Yj_ed _\ j^[ j^_hZ m_j^ j^_i [nfbWdWj_ed f[h i[" m[ Ze i[[ W YWkiWb
cebWh Ze[i dej [hkfj Z_h[Yjbo \hec j^[ h_Z][" h[bWj_edi^_f W\j[h Wbb" _d j^Wj j^[ fhebed][Z
j^[h[Xo ]_l_d] h_i[ je j^[ m[bb#ademd b_d]kWb h[ceZ[bb_d]_dj^[Wh[We\j^[j^_hZcebWh_dZkY[i
fhe`[Yj_ediWbed]j^[Z_ijWbh_Z][$?dWZZ_j_ed"j^_hZ h[ceZ[bb_d] _d j^[ Wdj[h_eh i[]c[dj Wi m[bb"
cebWh[hkfj_edm_bbWbie_d\bk[dY[j^[l[ij_XkbWh j^[h[Xoh[ZkY_d]_jilebkc[$
l[hiki b_d]kWb cWYhejhW`[Yjeh_[i e\ j^[ \_hij WdZ
i[YedZcebWhi$ 7im_j^_cfbWdji"j^[Xed[#fh[i[hl_d][\\[Yje\heeji
v J^[Z[djkbeki^eh_pedjWbXhWdY^e\j^[cWdZ_Xb[ j^WjWh[ikX`[Yj[Zjec[Y^Wd_YWb\ehY[iedbo[nj[dZi
h[cW_di bWh][bo kdY^Wd][Z Zkh_d] ]hemj^ el[h ib_]^jbo X[oedZ j^[ bWc_dW Yh_XheiW Wj X[ij$ M[
cWdoo[Whi"m^_b[j^[hWcki]hemi_dWYhWd_WbWdZ i^ekbZWbieYedi_Z[hj^Wjj^[effehjkd_jojefh[i[hl[
Z_ijWbZ_h[Yj_ed$J^[Wdj[h_ehi[]c[dje\j^[hWcki j[[j^ _d j^[ bed] j[hc [l[d _d ebZ[h fWj_[dji _i
Ze[idejkdZ[h]eh[iehfj_edkdj_bj^[i[YedZWdZ [ii[dj_WbboWdWY^_[l[c[dje\ceZ[hdZ[dj_ijho$<hec
j^_hZcebWhi[hkfj$?dZ[[Z"j^[omekbZdejX[WXb[ WX_ec[Y^Wd_YWbl_[mfe_dj"WYecfb[j[Z[dj_j_edYWd
je[hkfjej^[hm_i[$J^[^eh_pedjWbXhWdY^e\j^[ edbo X[ fh[i[hl[Z \eh W b_\[j_c[ Wj j^[ [nf[di[ e\
cWdZ_Xb[ _i ijh[jY^[Z _d j^_i fheY[ii$ M^[j^[h [njh[c[bo ijhW_d_d] j^[ Xed[ lebkc[$ ?\ j^[ \_hij
WZ[gkWj[ h[iehfj_ed \hec Wd Wdj[h_eh Z_h[Yj_ed cebWhi m[h[ W\\[Yj[Z Xo YWh_[i eh ^WZ je Z[Wb m_j^
_ifeii_Xb[Z[f[dZiedj^[ijh[d]j^WdZZ_h[Yj_ed ik\\_Y_[djbo WXhWi_l[ \eeZi [Whbo _d b_\[" j^[h[ mekbZ
e\ j^[ ckiYb[ ijhkYjkh[i$ J^[ cWii[j[h ckiYb[i dehcWbbo X[ [dek]^ ifWY[ \eh j^[ j^_hZ cebWhi
_d fWhj_YkbWh YWd X[ WjjWY^[Z _d ikY^ W mWo j^Wj je [hkfj m_j^ de d[[Z \eh j^[ cWij_YWjeho b[l[b je
WZ[gkWj[h[iehfj_edYWddejjWa[fbWY[X[YWki[j^[ Z[iY[dZ$ 9edi_Z[h_d] j^[ [\\ehji W_c[Z Wj jeej^
c_d[hWb_pWj_edj[dZ[dYoe\j^[Wdj[h_ehWiY[dZ_d] fh[i[hlWj_ed WdZ je c[[j W[ij^[j_Y [nf[YjWj_edi" _j
hWcki_iceh[fem[h\kbj^Wdj^[j[dZ[dYoe\j^[ _ikikWbbo`kij_\_[Zje[njhWYjWdoj^_hZcebWhih_]^j
j^_hZcebWhjeYh[Wj[eij[eboi_i$J^_im_bb]_l[h_i[ WmWo$
jei_jkWj_edie\fWhj_Wbh[j[dj_ed$ ?dekh[nf[h_[dY["j^_hZcebWhii^ekbZkikWbboX[
v ?d j^[ cWn_bbW" 9Wcf[hÉi fbWd[ ^Wi je Z[iY[dZ [njhWYj[Z _d Yedd[Yj_ed m_j^ 8E? jh[Wjc[dj kdb[ii
\eh j^_hZ cebWhi je [hkfj igk[[p_d]#ekj [\\[Yj j^[o YWd X[ _dYehfehWj[Z _dje j^[ h[ijehWj_ed je
X[YWki[ j^[h[ _i dej [dek]^ ifWY[ \eh Wbb j^h[[ ]eeZ[\\[Yj$J^[beYWj_ede\Z_ibeYWj[Zj^_hZcebWhi
cebWhi Wi bed] Wi j^[ cWn_bbW ^Wi W Z_ijeYhWd_Wb _dj^[cWn_bbWkikWbboYe_dY_Z[im_j^j^[i_j[j^Wj_i
eh_[djWj_ed$ J^[ [hkfj_ed WdZ ]hemj^ j[dZ[dYo h[gk_h[Z\ehijhWj[]_Y_cfbWdjfei_j_ed_d]$?\h[celWb
_i Yekdj[hWYj[Z Xo Y^[m_d] \ehY[i$ J^_hZ cebWhi e\ j^[ j^_hZ cebWh _i WiieY_Wj[Z m_j^ l[ij_XkbWh
YWddej [hkfj _d j^[ cWn_bbW _\ l[ho fem[h\kb Yehj_YWb Xed[ beii" W jme#ijW][ ikh]_YWb fheY[Zkh[
Y^[m_d]\ehY[iWh[fh[i[djX[YWki[j^[cWij_YWjeho ckijX[Yedi_Z[h[Z$
È È 4HEÈ3IGNIFICANCEÈOFÈ4HIRDÈ-OLARSÈ /'

A B

&IGÈAnC J^[j^_hZcebWhmWi_d_j_Wbboki[ZWiWZ_ijWb
WXkjc[dj\ehWXh_Z][j^WjmWiWdj[h_ehboikffehj[ZXoW
8E?_cfbWdj$<ebbem_d][njhWYj_ede\j^[jeej^X[YWki[
e\[dZeZedj_YfheXb[ci"WXh_Z][ikffehj[ZXojme8E?
_cfbWdjimWi_di[hj[Z$7\j[hiec[j_c["j^[Z_ijWb8E?"
m^_Y^^WZX[[d_di[hj[ZWjj^[i_j[e\j^[Z_ijWbheeje\j^[
j^_hZcebWh"^WZjeX[]_l[dkfX[YWki[j^[ckYeiWa[fj
el[h]hem_d]j^[j^h[WZ[Zf_d$Edh[ZkY_d]j^[j^h[WZ[Zf_d"
Wd[m8E?_cfbWdjmWi_di[hj[ZWj)-$;l[djkWbbo"j^[Wh[W
X[jm[[dj^[Y[djhWbWdZj^[Z_ijWb_cfbWdjh[]W_d[Zl[hj_YWb
C Xed[lebkc[Y_hYb["Z[cedijhWj_d]j^WjWdj[h_ehhWcki
h[iehfj_ed_iWh[l[hi_Xb[fheY[ii

&IGÈ M^_b[j^[cWYhejhW`[Yjeh_[ie\j^[cWdZ_Xb[[nj[dZl[ij_XkbWhbo\hec
j^[WiY[dZ_d]hWckifWijj^[j[[j^"j^[j[[j^Wh[\ehY[ZjemWhZij^[b_d]kWb
Wif[Yj$J^[jed]k[fhel_Z[ij^[d[Y[iiWhoYekdj[h\ehY[$8[jm[[dj^[YWd_d[i"
j^[ijWj_YWbboikffehj_l[cWYhejhW`[Yjeh_[ifheY[[Zedj^[b_d]kWbehl[ij_XkbWh
Wif[Yje\j^[j[[j^Wjj^[heejb[l[b$<ebbem_d][njhWYj_ede\j^[j[[j^"j^[o
_dlWh_WXbocel[jemWhZij^[b_d]kWbWif[Yj$J^[d[Y[iiWhoYekdj[h\ehY[\eh
j^[fei_j_ede\j[[j^_dj^[Z[djkbekiWdj[h_ehi[]c[dje\j^[cWdZ_Xb[_i
fhel_Z[ZXoj^[ehX_YkbWh_ieh_ickiYb[$J^[YWd_d[_ibeYWj[ZWjj^[Y[djh[e\
j^[jhW`[Yjeh_[i$:_ijWbbojej^[YWd_d["j^[cWYhejhW`[Yjeh_[iWh[_dYh[Wi_d]bo
eh_[djWj[Zl[ij_XkbWhbojej^[j[[j^$J^[oYheiij^_ib_d[_dj^[heejWh[We\j^[
fh[cebWhi
/( 9^Wfj[h-È 4REATMENTÈ0LANNING

A B

C D

E F

&IGÈAnG H[^WX_b_jWj_ede\j^[
cWn_bbWWdZcWdZ_Xb[_dWi_d]b[#
ij[ffheY[Zkh[$J^[ijhWj[]_YWbbo
_cfehjWdjj[[j^()WdZ(-YekbZ
X[b[\j_dfbWY["iej^Wjedbojme
ijhWj[]_Y_cfbWdji^WZjeX[
fbWY[Z_dj^[cWn_bbW$Jof_YWb
G YWdj_b[l[hi_jkWj_edim[h[jh[Wj[Z
_dj^[cWdZ_Xb[
È È &INALÈ#OMMENTSÈ /)

J^[ fheij^[j_Y Z[i_]d i^ekbZ jWa[ _dje Yed# XoYh[ijWb_cfbWdjebe]_iji"m_bbfh[l[djWX_bWj[hWbbo

i_Z[hWj_ed j^Wj m^_b[ Xed[ h[iehfj_ed _i Y[djh_\k]Wb XWbWdY[ZcWij_YWj_edfWjj[hd$
_d j^[ cWdZ_Xb[" j^[ cWYhejhW`[Yjeh_[i m_bb h[beYWj[ +$ J^[ Z[i_]d fh_dY_fb[i \eh j^[ eYYbkiWb ikh\WY[i
Y[djh_f[jWbbo_dWc[Z_WbZ_h[Yj_ed$ WdZ fbWd[i _d 8E?#XWi[Z h[ijehWj_ed Wh[ WYjkWbbo
ceh[ _d b_d[ m_j^ Yecfb[j[ Z[djkh[i j^Wd m_j^
jeej^#ikffehj[Z\_n[Zh[ijehWj_edi$
È ,$ 7doj[[j^_dj^[effei_d]`WmckijX[WZ[gkWj[bo
3UMMARY ikffehj[Z ed Wd _dZ_l_ZkWb XWi_i$ 7do j[[j^
fhejhkZ_d] \hec j^[ eYYbkiWb fbWd[ d[[Z je X[
J^[ fWj^ jemWhZ \_n[Z h[ijehWj_edi ckij WbmWoi X[ h[ZkY[Z$
XWi[ZedWYehh[YjeYYbkiWbfbWd[$ -$ ?dj^[fh[i[dY[e\Zoi\kdYj_edi"_j_ih[Yecc[dZ[Z
'$ 7 iehj e\ XWbWdY[Z cWij_YWjeho \kdYj_ed _i ceh[ je fhel_Z[ W \_n[Z h[ijehWj_ed \eh j^[ cWdZ_Xb[
[Wi_boWY^_[lWXb[jefhel_Z[_\WYecfb[j[Z[djkh[ m^_b[ f[h\ehc_d] XWbWdY_d] jh[Wjc[dj _d j^[
_ifh[i[dj_ded[`Wm"m^_b[j^[ej^[h`WmkikWbbo cWn_bbWÄki_d]Wj[cfehWhoYecfb[j[kff[hZ[d#
j^[ cWdZ_Xb[" m^[h[ WYY[fjWXb[ h[j[dj_ed e\ jkh[ _\ d[Y[iiWho$ J^_i Z#jekh cWo X[ gk_j[ e\j[d
W Yecfb[j[ Z[djkh[ _i ckY^ ceh[ Z_\\_Ykbj je d[Y[iiWho \eh \_dWdY_Wb h[Wiedi$ ?d ][d[hWb _j _i
WY^_[l[ _i jh[Wj[Z m_j^ Wd _cfbWdj#ikffehj[Z WbmWoiX[jj[hjefhel_Z[\kbbo\_n[Zkff[hWdZbem[h
\_n[Zh[ijehWj_edj^WjcWoehcWodej_dYbkZ[Wdo WhY^[iWdZj^_i_i"m^Wji^ekbZX[h[Yecc[dZ[Z
dWjkhWb WXkjc[dji$ ?\ j^[ effei_d] `Wm YedjW_di je j^[ fWj_[dj$ Edbo m_j^ \_n[Z j[[j^ f[hcWd[dj
W \_n[Z h[ijehWj_ed" c[Wikh[i ckij X[ jWa[d je XWbWdY[YWdX[[ijWXb_i^[Z$
\WY_b_jWj[[gk_b_XhWj_ed\ebbem_d]8E?j^[hWfo$
($ ;if[Y_Wbbo _d j^[ [Whbo f^Wi[i e\ jh[Wjc[dj" Wbb
YedjWYji i^ekbZ X[ beYWj[Z m_j^_d j^[ ikffehj È
febo]edcWha[ZXoj^[]h[Wj[ijY_hYkc\[h[dY[e\ &INALÈ#OMMENTS
j^[XWi[fbWj[ie\j^[Z_iai$J^_ih[gk_h[c[djckij
X[Xehd[_dc_dZm^[dZ[i_]d_d]j^[h[ijehWj_ed$ 7fWhj\hecm^Wj^WiX[[diW_Z_dj^_iY^Wfj[h"j^[h[
J^[ j[Y^d_Y_Wd m_bb h[gk_h[ Yb[Wh _dijhkYj_edi Wi _iWbieWYWi[W]W_dijim_jY^_d]fWj_[djiZ_h[Yjbo\hec
je j^[ i_p[ e\ j^[ Xh_Z][ Wi m[bb Wi j^[ jof[ WdZ \_n[Z jeej^#ikffehj[Z je \_n[Z _cfbWdj#ikffehj[Z
beYWj_ede\j^[Ykifi_dlebl[Z$J^[i[_dijhkYj_edi h[ijehWj_edi$?jjWa[iiec[fWj_[djij^[[nf[h_[dY[e\
YWdX[Z[h_l[Z\hecj^[i_p[e\j^[Z_iaiedj^[ed[ m[Wh_d]WZ[djkh[jeWffh[Y_Wj[j^[^_]^Yec\ehje\
^WdZ WdZ j^[_h ifWj_Wb eh_[djWj_ed ed j^[ ej^[h$ \_n[Z j[[j^$ ?\ j^[ Yedj_dk_jo e\ \_n[Z h[ijehWj_edi _i
J^_iZe[idejWffbojej^[Wdj[h_ehh[]_ed"m^[h[ d[l[h Xhea[d" j^ei[ fWj_[dji cWo d[l[h adem m^Wj
j^[ h[ijehWj_ed m_bb X[ Z[i_]d[Z _d WYYehZWdY[ b_\[ mekbZ X[ b_a[ m_j^ekj \_n[Z j[[j^$ J^_i bWYa e\
m_j^\kdYj_edWbWdZW[ij^[j_Yh[gk_h[c[dji$ Wffh[Y_Wj_ed cWo h[ZkY[ j^[ fWj_[djÉi Yecfb_WdY[
)$ 7ijhkYjkh[ZeYYbkiWbh[b_[\_ih[gk_h[Zje\WY_b_jWj[ WdZ m_bb_d]d[ii je \kb\_b ^_i eh ^[h emd YedjhWYjkWb
j^[Yhki^_d]e\\eeZ$ eXb_]Wj_edi_dj^[bed]j[hc$?dj^_imWo"Wd_dj[hlWb_d
*$ J^[ eYYbkiWb ikh\WY[i ckij X[ WZ[gkWj[bo m_Z[$ m^_Y^j^[fWj_[dj^Wijem[WhWh[celWXb[h[ijehWj_ed
IcWbbWdZdWhhemikh\WY[i"WiYedi_Z[h[ZZ[i_hWXb[ cWo[l[dX[WZlWdjW][eki$
  ¬ 
#(!04%2È

!SPECTSÈOFÈ"/)È4REATMENTÈÈ
INÈ0ERIODONTALLYÈ)NVOLVEDÈ#ASES
4
*IEF
7
-FLPWJD
BOE
;
"MFLTJD

È c[jWXeb_p[Xed[j_iik[Z_h[Yjbo$Ijh_Yjboif[Wa_d]"
)NTRODUCTIONÈANDÈ$EFINITION Xed[ _i j^[ bWij j^_d] j^Wj XWYj[h_W mekbZ [Wj
lebkdjWh_bo0 8ed[ ckij \_hij X[ Yedl[hj[Z je ie\j
J^_iY^Wfj[hZ_iYkii[ilWh_eki8E?jh[Wjc[djefj_edi j_iik[h[gk_h_d]WcWii_l[Wcekdje\h_di_d]m_j^
_dfWj_[djim_j^f[h_eZedjWbbo_dlebl[ZZ[dj_j_edi$ XbeeZ_dehZ[hjeh[cel[j^[^_]^YedY[djhWj_ed
7i^WiX[[di^emdWdZm_bbX[i^emdXodkc[h# e\ _edi1 edbo j^[d YWd _j X[ _dlWZ[Z Xo XWYj[h_W
eki [nWcfb[i _d j^_i Xeea" f[h_eZedjWb Z_i[Wi[ WdZc[jWXeb_p[ZXoj^[c$
WiieY_Wj[Z m_j^ [nY[ii_l[ ie\j#j_iik[ ]hemj^ _i W v 8o YedjhWij m_j^ Yh[ijWb _cfbWdji" de [njhW#
Z_ifbWY[c[dj fheY[ii j^Wj YWd X[ jhWY[Z XWYa je j[hh_jeh_Wb_p_d] h[ifedi[ _i i[[d _d j^[ Wh[W e\
Y^Wd][i _d j^[ Z_h[Yj_ed WdZ fh[iikh[ e\ j^[ XbeeZ j^[j^h[WZ[Zf_de\8E?_cfbWdji"WdZdeYehj_YWb
\bem Wj j^[ _dj[h\WY[ X[jm[[d j^[ Xed[ WdZ j^[ Xed[m_bb\ehcWhekdZj^_i_cfbWdjfWhj_d_j_Wbbo$
ie\j j_iik[i$ ?j _i j^_i Wif[Yj Ä hWj^[h j^Wd j^[ J^_ic[Wdij^Wjj^[\bemjeWdZ\hecj^[jhWdi_j_ed
XWYj[h_ebe]_YWb Wif[Yji Ä j^Wj ckij X[ i[[d Wi j^[ ped[ X[jm[[d j^[ f[h_eij[Wb j_iik[ WdZ j^[ Xed[
ceij iWb_[dj ed[ m^[d h[WZ_d] j^_i Y^Wfj[h Wi m[bb _i j^[ iWc[ Wi _d j^ei[ Wh[Wi e\ j^[ `Wm m^[h[
Wi m^[d jh[Wj_d] f[h_eZedjWbbo _dlebl[Z Z[dj_j_edi$ de _cfbWdj mWi fei_j_ed[Z" _$[$ j^[ \WYj j^Wj Wd
8ed[ ckij cW_djW_d W ^_]^ b[l[b e\ c_d[hWb_pWj_ed _cfbWdj_ifh[i[dj^Wide_d\bk[dY[_dj^_icWjj[h$
WdZ j^[h[\eh[ Ze[i dej jeb[hWj[ Wdo ijh[Wc_d] eh J^_i Wbie [nfbW_di m^o j^[ ie\j#j_iik[ h[]_edi
YWf_bbWho XbeeZ f[h\ki_ed WdZ de ^_]^ XbeeZ \bem WhekdZ8E?_cfbWdjikikWbboi^emWXiebkj[bode
fh[iikh[$?\j^[i[ZeeYYkh"j^[¼Xedo½fhef[hj_[ie\ _dYb_dWj_edjeZ[l[beff[h__cfbWdj_j_i$
j^[Xed[j_iik[Z_iWff[Wh"WdZ_j_ih[fbWY[ZXoj_iik[
e\ lWh_eki jof[i j^Wj YWd ikccWh_bo X[ Z[i_]dWj[Z J^[ Ækdf^oi_ebe]_YWbÇ \hec j^[ XWYj[h_Wb fe_dj
Wiie\jj_iik[i$ e\ l_[m YedY[djhWj_ed e\ _edi _d j^[ ikXijhWj[
Ed j^[ ej^[h ^WdZ" Xed[ cWo Wbie X[ beij _\ _ji ÆXed[Ç" h[gk_h[i _djhWehWb XWYj[h_W je kdZ[h]e W
_dj[hdWb f[h\ki_ed _i bem[h j^Wd j^[ [njhWeii[eki i_]d_\_YWdj c[jWcehf^ei_i Ä YecfWhWXb[ _d iYef[
lWiYkbWhfh[iikh[0 je W jhWdi_j_ed \hec W iWbjmWj[h \_i^ je W \h[i^mWj[h
v ;nY[ii_l[c_d[hWb_pWj_ede\"[$]$j^[m^_j[b_d["j^[ \_i^Ä`kij_dehZ[hjef^oi_YWbboWffheWY^j^[Xed["
b_d[WeXb_gkW"_dj^[cWdZ_Xb[fkjij^[Wbl[ebWhfWhj jeiWodej^_d]e\c[jWXeb_p_d]_j$?jcWoX[j^[YWi[
e\j^[Xed[_dWfh[YWh_ekidkjh_c[djWbfei_j_ed j^Wj j^[ ]hekf f[h_eZedjWbbo fWj^e][d_Y XWYj[h_W
YecfWh[Z je j^[ ie\j j_iik[i i[[ 9^Wfj[h'& \eh _i \ekdZ _d Z[[f feYa[ji [nWYjbo X[YWki[ j^[o YWd
Z[jW_bi$ YedZ_j_edWbboWZ`kijje_dYh[Wi[Z_edYedY[djhWj_edi
v ?\ j^[ cWij_YWjeho \ehY[i Wh[ jee bem m^_Y^ d[Wh j^[ Xed[ YecfWhWXb[ je [hoj^heYoj[i _d j^[
c[Wdi0 _dik\\_Y_[dj Z_h[Yj ij_ckbWj_ed e\ j^[ \ehcWj_l[f^Wi[$
Xed[ikhhekdZ_d]j^[j[[j^l_Wj^[f[h_eZedj_kc 9h[ijWb _cfbWdjebe]_iji" dej ikhfh_i_d]bo" ^Wl[
WdZ _dik\\_Y_[dj \b[n_ed%WYj_l_jo e\ j^[ `Wm Wi W ijhed] Wl[hi_ed W]W_dij _cfbWdji _d f[h_eZedjWb
W m^eb[" j^[ YWf_bbWho \bem e\ dkjh_[dji je j^[ _dlebl[Z j_iik[1 j^[_h [nf[h_[dY[ ^Wi i^emd j^[c
Xed[_i_dWZ[gkWj[boikffehj[Z"h[ikbj_d]_dded# j^Wj j^[ beii hWj[ _i Yedi_Z[hWXb[ W\j[h _cfbWdjWj_ed
_d\bWccWjehoWjhef^oe\j^[Xed[$ _d _d\[Yj[Z h[]_edi$ 8E? _cfbWdjebe]_iji [nf[h_[dY[
v ?d YWi[i m_j^ Wdj[h_eh Y^[m_d] fWjj[hdi" W ^_]^ j^[ [nWYj effei_j[0 ikYY[ii\kb 8E? _cfbWdjWj_ed
Z[]h[[ e\ c_d[hWb_pWj_ed e\ j^[ Z_ijWb cWdZ_Xb[ _i feii_Xb[ [l[d _d Wh[Wi e\ i[l[h[ f[h_eZedjWb
_i YWki[Z [nWYjbo Xo j^Wj Y^[m_d] fWjj[hd" m^_Y^ _dlebl[c[dj" _d ed[ jh[Wjc[dj ij[f WdZ l[ho
_i m^o m[ YWd YbWii_\o j^[ [dik_d] f[h_eZedj_j_i d[Wjbo" Wi bed] Wi Y[hjW_d \kdZWc[djWb fh_dY_fb[i
Wi ijh_Yjbo \kdYj_edWb _d eh_]_d" [l[d j^ek]^" e\ Wh[ eXi[hl[Z$ J^[ i_j[i WhekdZ 8E? _cfbWdji Wh[
Yekhi[" XWYj[h_Wb _dlebl[c[dj Wff[Whi Wi j^[ [njh[c[bo h[i_ijWdj je XWYj[h_Wb WjjWYai$ J^ki 8E?
Z_i[Wi[fhe]h[ii[i$ YWd X[ _di[hj[Z _cc[Z_Wj[bo W\j[h [njhWYj_edi _d
v 7im[YWdi[[[WY^j_c[Wia[b[jed_i\ekdZ_dj^[ f[h_eZedjWbbo_dlebl[ZWh[Wi$J^[Xed[WhekdZ8E?
]hekdZ" j^[ XWYj[h_W j^[ci[bl[i Wh[ dej WXb[ je _cfbWdji kikWbbo Wbbemi _dj[]hWj_ed e\ j^[ _cfbWdj
/, 9^Wfj[h.È !SPECTSÈOFÈ"/)È4REATMENTÈINÈ0ERIODONTALLYÈ)NVOLVEDÈ#ASES

4ABLEÈ :_\\[h[dY[i_dZ[i_]dWdZYb_d_YWbWZlWdjW][ie\8E?_cfbWdji

$SFTUBM
JNQMBOUT
#0*
JNQMBOUT
$MJOJDBM
BEWBOUBHFT

5ISFBEFE
QJO
4VSGBDFFOMBSHFE
.BDIJOFE
TVSGBDF
#0*
JNQMBOUT
BSF
MFTT

WFSUJDBM
BTQFDU
PG

m
.BDSPEFTJHO
UISFBE

JOGFDUJPOQSPOF
UIF
JNQMBOU
m
&UDIJOHTBOECMBTUJOH


-PBE
USBOTNJTTJPO
7FSUJDBM
DMPTF
UP
PS
GBS

#BTBM
GBS
GSPN
UIF
NPVUI
-PBE
USBOTNJTTJPO
BSFB


GSPN
UIF
NPVUI
EFQFOEJOH


JO
JOGFDUJPOQSPUFDUFE
SFHJPOT

PO
UIF
EFTJHO

4USVDUVSF
PG
UIF

1PMF
OFBS
UIF
DPSF
#SPBE
MBUFSBM
TVQQPSU

MPBECFBSJOH
BSFBT

-PBE
USBOTNJTTJPO

-PBE
USBOTNJTTJPO
BSFBT

-PBE
USBOTNJTTJPO
BSFBT

#0*
JNQMBOUT
BSF
MFTT

WT
JOGFDUJPO
SPVHIMZ
DPJODJEF
XJUI

BSF
SFNPWFE
GSPN
JOGFDUJPO
JOGFDUJPOQSPOF

JOGFDUJPO
FOUSZ
QBUIT
FOUSZ
QBUIT


/VUSJFOU
BOE
PYZHFO
TVQQMZ
&OPTTBM
TVQQMZ
PG
OVUSJFOUT

1FSJPTUFBM
TVQQMZ

0WFSMPBE
TJUVBUJPOT
DBO
CF


BOE
USBOTQPSU
TQFFE

PG
OVUSJFOUT
DBO
CF
SFHVMBUFE
DBVHIU
BOE
SFQBJSFE
CZ


BSF
MJNJUFE
XJUIJO
XJEF
NBSHJOT
JODSFBTJOH
UIF
OVUSJFOU
TVQQMZ

.VDPTBM
FNFSHFODF
QPJOU
4IPVME
CF
MPDBUFE
JO

.BZ
CF
MPDBUFE
JO
FJUIFS

.VDI
GSFFEPN
JO
QPTJUJPOJOH

BUUBDIFE
NVDPTB
JG
UIF

BUUBDIFE
PS
VOBUUBDIFE

#0*
JNQMBOUT
XPVOET
NBZ

WFSUJDBM
BTQFDU
IBT
B

NVDPTB
CF
DMPTFE
XJUI
XJEFMZ


SPVHI
UFYUVSF

NPCJMJ[FE
GMBQT
BGUFS




FYUSBDUJPOT

4ZODISPOJ[BUJPO
PG
CPOF

3FTUPSBUJPO
JT
TZODISPOJ[FE

3FTUPSBUJPO
JT
TZODISPOJ[FE
5IF
GBUF
PG
UIF
BMWFPMBS

BOE
TVQFSTUSVDUVSF
XJUI
DSFTUBMBMWFPMBS
BTQFDU



PG
UIF
CPOF
EVF
UP



SJHJE
DPOOFDUJPO











JOUFSGBDFT
DPNQFOTBUF



XJUI
CBTBM
BTQFDU
PG
UIF


CPOF
JT
PG
OP
DPOTFRVFODF
CPOF
EVF
UP
SJHJE
DPOOFDUJPO
GPS
UIF
QSFTFSWBUJPO
PG
#0*


JNQMBOUT
MBSHF
CSJEHFT

TZODISPOJ[F
CBTBM
CPOF
BSFBT

IPSJ[POUBM
BOE
WFSUJDBM
#0*

BTQFDUT

GPS
BOZ
MBDL
PG
TZODISPOJDJUZ

3FDBMM
SFRVJSFNFOUT
'SFRVFOU
-FTT
GSFRVFOU
UIBO
GPS

-PX
DPTU
UP
QBUJFOUT
EVSJOH

OBUVSBM
UFFUI
UIF
NBJOUFOBODF
QIBTF



USFBUNFOU
TVDDFTT
OPU
WFSZ



EFQFOEFOU
PO
IZHJFOF

/JDPUJOF
BCVTF
*OGMVFODFT
UIF
JNQMBOUT

*OGMVFODFT
POMZ
UIF
JOJUJBM

4NPLJOH
JT
OP
DPOUSB

DIBODF
PG
TVSWJWBM
TPGUUJTTVF
IFBMJOH
QSPDFTT
JOEJDBUJPO
JU
POMZ
DPOTUJUVUFT




B
SJTL
EVSJOH
JOJUJBM




XPVOE
IFBMJOH

*NQMBOU
WPMVNF
4DSFX
¤
NN

NN
&%4
(

NN
#FUUFS
CMPPE
TVQQMZ
UP

UIF
JNQMBOU
TJEF




#FUUFS
QBTTBHF
GSPN
CMPPE




UISPVHI
UIF
JNQMBOU
TJUF
7PMVNF
PG
CBDUFSJB
BOE

%JBNFUFS
7PMVNF
%JBNFUFS
7PMVNF
5IJO
QFOFUSBUJPO
BSFBT
TIPX
EFCSJT
JO
B

NN
QPDLFU

NN


NN

NN




NN
MFTT
EFCSJT
BOE
TJHOJGJDBOUMZ
BTTVNJOH
UIF
MBZFS
JT


NN




NN

MFTT
CBDUFSJBM
BUUBDL
TVSGBDF


NN
UIJDL



-FTT
CBDUFSJBSFMBUFE
DIBOHFT



PG
CMPPE
GMPX
JO
EJSFDUJPO




BOE
RVBOUJUZ





"CVUNFOU
EJBNFUFS
m
NN
m
NN
*OGFDUJPO
SFQFMMFE




iPO
BMM
TJEFTu
È È )NTRODUCTIONÈANDÈ$EFINITIONÈ
[l[d j^ek]^ _d\[Yj_edi cWo X[ fh[i[dj W\j[h j^[
[njhWYj_ediehWiWh[ikbje\f[h_eZedjWb_dlebl[c[dj$
M^oj^_iZ_\\[h[dY[5
M[X[b_[l[j^[h[WiedjeX[j^[_cfbWdjZ[i_]dWdZ
j^[ dWjkh[ e\ j^[ _di[hj_ed fheY[ii$ JWXb[.$' i^emi
j^[ Z_\\[h[dY[i X[jm[[d Yh[ijWb WdZ 8E? _cfbWdj
jof[iWdZj^[Yb_d_YWbWZlWdjW][ie\j^[bWjj[h$
?ji^ekbZX[dej[Zj^Wjj^[Z_\\[h[dY[iWh[i^emd
WdZ eh]Wd_p[Z ^[h[ _d j[hci e\ ][d[hWb fh_dY_fb[i$
9[hjW_djof[ie\Yh[ijWb_cfbWdjiZedejgk_j[\_jj^[
fWjj[hd$LWh_ekijhWdi_j_edWbjof[i[n_ij0
v J^[ X_Yehj_YWb iYh[m EhWbjhed_Yi m_j^ _ji l[ho
m_Z[ j^h[WZ YecX_d[Z m_j^ iceej^ l[hj_YWb
_cfbWdj ikh\WY[i _i ed[ e\ j^[i[ [nY[fj_edi$ J^_i
_cfbWdj _i ijh_Yjbo XWiWbbo eii[e_dj[]hWj[Z [l[d
j^ek]^_j_i_di[hj[Z\hecYh[ijWbbo$
v J^[ ie#YWbb[Z feheki#YeWj[Z _cfbWdji ikY^
Wi Eii[efeh[ Wh[ Wdej^[h e\ j^ei[ [nY[fj_edi$
M_j^ j^[_h bWh][ f[h\ki_ed Wh[Wi beYWj[Z Ybei[
je j^[ _cfbWdji" j^[o e\\[h W j^h[[#Z_c[di_edWb
dkjh_[dj cWjh_n je j^[ Yehj_YWb Xed[$ 8o YedjhWij
m_j^ Yedl[dj_edWb iYh[m _cfbWdji" j^[ _cfbWdji
YWd X[ i^ehj WdZ ij_bb W\\ehZ \_hc WdZ ijWXb[
WdY^ehW][$7Z_iWZlWdjW][e\j^_ijof[e\_cfbWdj
_i j^Wj j^[o Wh[ [njh[c[bo fhed[ je _d\[Yj_ed
Zkh_d] j^[ ^[Wb_d] f^Wi[" i_dY[ j^[ f[h\ki_ed
Wh[Wi"m^_Y^Wh[beYWj[Z_dj^[Z[fj^e\j^[j^h[[#
Z_c[di_edWb ijhkYjkh[" Wh[ hWf_Zbo Yebed_p[Z
WdZ e\\[h W \WlekhWXb[ [dl_hedc[dj \eh XWYj[h_Wb
]hemj^$EdY[Yebed_p[Z"j^[i[Wh[WiWh[fhWYj_YWbbo
_cfeii_Xb[ je iWd_j_p[$ EdY[ _dj[]hWj[Z" ed j^[
ej^[h ^WdZ" Eii[efeh[ _cfbWdji Wh[ [njh[c[bo
ZkhWXb[$ Bed][h _cfbWdji m_j^ j^[ iWc[ jof[ e\
ikh\WY[Wh[b[iiik_jWXb["i_dY[j^[f[h\ki_edfWj^i"
h[WY^_d] \hec XWiWbbo je Yh[ijWbbo" X[Yec[ jee
bed]WdZ_cf[d[jhWXb["kbj_cWj[bo[b_c_dWj_d]j^[
WZlWdjW][ij^[i[_cfbWdjiej^[hm_i[e\\[h$
v 9h[ijWb _cfbWdji m_j^ W Yed_YWb Z[i_]d Wh[
Wdej^[h f[Ykb_Wh jof[0 9ecfh[ii_ed iYh[mi
m_j^ W fhedekdY[Z Yed_YWb i^Wf[ Ze dej e\\[h
A B
/-
[dek]^ YedjWYj Wh[W \eh Z[[f [deiiWb beWZ
jhWdic_ii_ed$ I_dY[ j^[ eii[e_dj[]hWj[Z _cfbWdj
ikh\WY[_dYh[Wi[ijemWhZj^[Yh[ijWbWif[Yj"Z_h[Yj
_dj[hWYj_ed X[jm[[d j^_i ikh\WY[ WdZ j^[ Yehj_YWb
Xed[ m_bb Wbie _dYh[Wi[ _d gkWdj_jWj_l[ h[bWj_l[
j[hci$9ecfWh[ZjeYob_dZh_YWbiYh[mi"WicWbb[h
f[hY[djW][ e\ j^[ beWZ _i jhWdic_jj[Z _d j^[
XWiWb fWhj e\ j^[ Xed[ WdZ W ]h[Wj[h f[hY[djW][
_d j^[ Yh[ijWb fWhj m_j^ j^[i[ _cfbWdji$ J^_i
Wif[Yj fheXWXbo ^[bfi j^[i[ _cfbWdji fhecej[
Xed[ fh[i[hlWj_ed$ I_dY[ h[c_d[hWb_pWj_ed j[dZi
je X[ ceh[ fhedekdY[Z _d j^[ Yh[ijWb Wh[W" j^[i[
_cfbWdjiWh[ceh[h[i_ijWdjje_d\[Yj_edj^WdWh[
Yob_dZh_YWbiYh[mi$
J^[h[ _i W Yedi_Z[hWXb[ Z_\\[h[dY[ X[jm[[d j^_i
fheY[Zkh[ WdZ [ijWXb_i^[Z _Z[Wi YedY[hd_d] j^[
ikYY[ii_ede\f[h_eZedjWbj^[hWfoWdZfheij^eZedj_Y
j^[hWfo$M^Wj_ijhk[e\j[[j^_ikikWbbodejlWb_Z\eh
Yecfb[j[Z[djkh[iikffehj[ZXo8E?_cfbWdji$
I_dY[ 8E? _cfbWdji f[hc_j _cc[Z_Wj[ _di[hj_ed
e\ \_n[Z h[ijehWj_edi j^hek]^ekj j^[ jh[Wj[Z h[]_ed"
_j _i dej d[Y[iiWho je f[h\ehc f[h_eZedjWb j^[hWfo
X[\eh[ j^[ [njhWYj_ed e\ j[[j^ WdZ j^[ _di[hj_ed e\
_cfbWdji$ J^_i c[Wdi j^Wj j^[ [nY[bb[dj beYWb XbeeZ
ikffbo e\ j^[ _djhWehWb ie\j j_iik[i YWd X[ ki[Z je
WZlWdjW][$ J^_i c[Wdi j^Wj j^[ Y^WdY[i e\ [\\[Yj_l[
feijef[hWj_l[_d\[Yj_edYedjhebWh[]h[Wjbo[d^WdY[Z$
M_j^ Yh[ijWb _cfbWdji" j^[ _cfbWdj _ji[b\ XbeYai j^[
ceij [\\[Yj_l[ fWj^ e\ h[celWb \eh _djhWef[hWj_l[bo
_djheZkY[Z _d\bWccWjeho fheY[ii[i WdZ j^[_h
h[i_Zk[" m^_b[ 8E? _cfbWdji WbmWoi Wbbem [\\_Y_[dj
ikffkhWj_edj^hek]^j^[_di[hj_edibeji$
7iWhkb["bed]#j[hcfhel_i_edWbh[ijehWj_edim_bb
X[ _di[hj[Z \ebbem_d] 8E? j^[hWfo" [if[Y_Wbbo _d j^[
cWn_bbW$7do]_d]_lWbi^h_daW][ehXed[h[ceZ[bb_d]
j^WjZe[ieYYkhm_bbX[e\defhWYj_YWbYedi[gk[dY[$
7[ij^[j_Yi Wh[ h[ijeh[Z edY[ j^[ ie\j j_iik[i ^Wl[
^[Wb[ZÄj^Wj_i"WjWj_c[m^[dj^[ckYeiWbi_jkWj_ed
m_bb^Wl[ijWX_b_p[Z$

&IGÈAB J^_i*&#o[Wh#ebZfWj_[djmWifh_cWh_bo_dj[h[ij[Z_dWceh[X[Wkj_\kbcWn_bbWhoic_b[$>[hcWdZ_XkbWhj[[j^m[h[

XWh[bol_i_Xb[m^[di^[ef[d[Z^[hcekj^dehcWbbo$<ehj^_ih[WiedWdZfheXWXboWbie\eh\_dWdY_Wbh[Wiedij^[cWn_bbWmWi
jeX[i[b[Yj_l[bojh[Wj[Z$J^[cWdZ_XkbWhj[[j^m[h[i_cfboYb[Wd[Zm^_Y^^Widebed]#j[hc[\\[Yj$Ed[o[Whfeijef[hWj_l[bo"
j^[ cWdZ_XkbWh i_jkWj_ed mWi `kij Wi Z[iebWj[ Wi X[\eh[ jh[Wjc[dj$ J^[ [njh[c[ Xk_bZ#kf e\ YedYh[c[dji m_j^ [nj[di_l[
XWYj[h_WbfbWgk[Z_Zdej_d\bk[dY[j^[fei_j_l[^[Wb_d]fheY[iie\j^[_cfbWdji"m^ei[j^h[WZ[Zf_diZ_Zdeji^emWdofbWgk[
ehYWbYkbki
/. 9^Wfj[h.È !SPECTSÈOFÈ"/)È4REATMENTÈINÈ0ERIODONTALLYÈ)NVOLVEDÈ#ASES

A B

C D

&IGÈAnG 9ecfb[j[_cfbWdj
WdZfheij^eZedj_Yjh[Wjc[dj
_dXej^`Wmi$ A 9b_d_YWb
i_jkWj_edWjXWi[b_d[$8[YWki[
E e\j^[^_]^Z[]h[[e\ceX_b_jo
_dj^[cWn_bbW"j^_i`WmmWi
jh[Wj[Z\_hij$ B :kh_d]j^[\_hij
i[ii_ed"Wbbh[cW_d_d]cWn_bbWho
j[[j^m[h[[njhWYj[Z"WdZ\ekh
ijhWj[]_YWbbofei_j_ed[Z8E?
_cfbWdjim[h[_di[hj[Z$J^[
_cfbWdjim[h[_cc[Z_Wj[bo
beWZ[Zm_j^W\_n[Zj[cfehWho
Xh_Z][$ C 7\j[hckYeiWb
^[Wb_d]"XkjX[\eh[_di[hj_d]j^[
Z[\_d_j_l[ikf[hijhkYjkh[$ D 9
b_d_YWbWff[WhWdY[*o[WhiW\j[h
jh[Wjc[dj$:kh_d]j^_ij_c["j^[
cWdZ_Xb[^WZX[[dh[^WX_b_jWj[Z
Wim[bb$ E Fh[ef[hWj_l[
EF=$ F Iec[_cfbWdjim[h[
fbWY[Z_di_Z[j^[Wbl[ebWhieYa[ji"
ej^[hiX[jm[[dj^[c$ G <ekh
G
o[Whifeijef[hWj_l[bo$M[bb#^[Wb[Z
Xed[WdZijWXb[_cfbWdji
È È )MMEDIATELYÈ,OADEDÈ"/)ÈATÈ0ERIODONTALLYÈ)NVOLVEDÈ3ITESÈ //

Zkh_d] j^[ eXi[hlWj_ed f[h_eZ (&&'Ä(&&( m[h[

È _dYbkZ[Z_dj^[ijkZo$
)MMEDIATELYÈ,OADEDÈ"/)ÈÈ J^[Z[Y_i_edje_dYbkZ[j^[_cfbWdji_djej^[ijkZo
ATÈ0ERIODONTALLYÈ)NVOLVEDÈ3ITES mWi cWZ[ XWi[Z ed Yb_d_YWb eXi[hlWj_ed$ J^[ j[[j^
WdZ f[h_eZedjWb j_iik[i Wj Wbb i_j[i m[h[ [nWc_d[Z
7fh[b_c_dWhoijkZomWicWZ[e\fWj_[djim_j^kfje ^_ijebe]_YWbbo je Z[j[hc_d[ j^[ [nWYj Z[]h[[ e\
(*cedj^ie\\ebbem#kf$ f[h_eZedjWb_dlebl[c[dj$'
7jejWbe\+,8E?_cfbWdjim[h[fbWY[Z\ebbem_d]
j^[[njhWYj_ede\(*cebWhi"*fh[cebWhi"'*YWd_d[i
È
WdZ'_dY_ieh$I_d]b[#Z_iaehZekXb[#Z_iaceZ[bim[h[
)NTRODUCTION
ki[Z" jWa_d] _dje WYYekdj j^[ WlW_bWXb[ l[hj_YWb WdZ
^eh_pedjWb Xed[ lebkc[$ 8_Yehj_YWb eh ckbj_Yehj_YWb
?d h[ifedi[ je _dYh[Wi_d] fWj_[dj Z[cWdZ el[h j^[ ikffehjmWiWY^_[l[Z_dWbbYWi[i$
bWij Z[YWZ[" j^[ \eYki e\ _cfbWdj jh[Wjc[dj ^Wi
i^_\j[Z jemWhZ _cc[Z_Wj[ beWZ_d] e\ cWn_bbWho eh
È
cWdZ_XkbWh_cfbWdji$
3URGICALÈ0ROCEDURE
?d_j_Wb Yb_d_YWb ijkZ_[i ed _cc[Z_Wj[bo beWZ[Z
_cfbWdji ^Wl[ Z[cedijhWj[Z lWh_WXb[ Z[]h[[i e\ Fh[c[Z_YWj_ed Yedi_ij[Z e\ Wcen_Y_bb_d (]
ikYY[ii\eh\kbb#WhY^h[^WX_b_jWj_edIY^d_jcWdd[jWb$ WZc_d_ij[h[Z (^ X[\eh[ ikh][ho$ 7 h[]_edWb WdZ
'//-$?d][d[hWb"j^[ifb_dj_d]e\i[l[hWb_cfbWdjiXo beYWb WdW[ij^[j_Y NobeYW_d[ mWi WZc_d_ij[h[Z$ 7
c[Wdie\j^[ikf[hijhkYjkh[h[ikbji_dWd_cfhel[Z Yh[ijWb_dY_i_edmWicWZ[jeWYY[iij^[Wbl[ebWhXed[$
fhe]dei_i\ehj^[_cfbWdjiWdZX[jj[hikhl_lWbe\j^[ 7hekdZ j^[ f[h_eZedjWbbo _dlebl[Z j[[j^" Wbb ie\j
ikf[hijhkYjkh[_ji[b\$Ej^[hijkZ_[ij^Wj^Wl[\eYki[Z j_iik[im[h[h[cel[ZWdZfbWY[Z_dW\ehcWbZ[^oZ[
ed_cc[Z_Wj[beWZ_d]e\i_d]b[#jeej^_cfbWdji_dj^[ iebkj_ed \eh ikXi[gk[dj _dl[ij_]Wj_ed$ J^[ _cfbWdj
W[ij^[j_Yped[^Wl[i^emd]h[Wj[hikYY[ii$>em[l[h" i_j[im[h[fh[fWh[Z\ebbem_d]ijWdZWhZ8E?fhejeYeb"
_cc[Z_Wj[ beWZ_d] i[[ci je `[efWhZ_p[ j^[ ikYY[ii ki_d]h[]kbWh^_]^#if[[ZYkjj_d]XkhiWdZ_hh_]Wj_ed
hWj[e\Yh[ijWb_cfbWdjjh[Wjc[dj$ m_j^ ij[h_b[ H_d][h iebkj_ed H_#BWY" 8$ 8hWkd"
J^[ ikYY[ii hWj[ e\ Yh[ijWb _cfbWdji i[[ci je X[ C[bikd][d" =[hcWdo$ 8ed[ lebkc[" Z[di_jo WdZ
^_]^[hm_j^fbWY[c[dj_d_d\[Yj_ed#\h[[Xed[j_iik[$ j^[ f[h_c[j[h e\ j^[ Z[djWb WhY^ Z[j[hc_d[Z j^[
7bie" j^[ b[l[b e\ XWYj[h_Wb YedjWc_dWj_ed _d j^[ dkcX[h e\ _cfbWdji Wffhefh_Wj[ \eh WY^_[l_d] j^[
ikhhekdZ_d]ie\jj_iik[ii^ekbZX[WibemWifeii_Xb[$ fheij^eZedj_YeX`[Yj_l[$J^[\bWfim[h[j^[dikjkh[Z
?d ZW_bo fhWYj_Y[ j^_i c[Wdi j^Wj" Wj f[h_eZedjWbbo m_j^ I_p[ )$& i_ba ikjkh[i _d j^[_h YehedWb fei_j_ed$
_dlebl[Zi_j[i"[njhWYj_edm_bb^Wl[jejWa[fbWY[bed] 7\j[h ikh][ho" j^[ fWj_[dji m[h[ _dijhkYj[Z je h_di[
X[\eh[ Yh[ijWb _cfbWdji YWd X[ _di[hj[Z$ <ebbem_d] m_j^ Y^beh^[n_Z_d[ jm_Y[ W ZWo \eh '+ZWoi" ijWhj_d]
jeej^ [njhWYj_ed j^[ fWj_[dj m_bb d[[Z je WYY[fj ed j^[ \_hij feijef[hWj_l[ ZWo" WdZ j^[d je ki[ Wd
W ^[Wb_d] f[h_eZ e\ Yedi_Z[hWXb[ ZkhWj_ed" e\j[d kbjhW#ie\jjeej^Xhki^\ehWdej^[h'+ZWoi$7dWb][i_Yi
^Wl_d]jem[Whh[celWXb[Z[djkh[iZkh_d]j^_ij_c[$ m[h[WZc_d_ij[h[ZedZ[cWdZ$

È
/BJECTIVES
J^[ fkhfei[ e\ j^[ ijkZo h[fehj[Z ^[h[ mWi je
[lWbkWj[ j^[ ikhl_lWb hWj[ e\ 8E? _cfbWdji _di[hj[Z
_cc[Z_Wj[bo W\j[h [njhWYj_ed e\ f[h_eZedjWbbo
_dlebl[Zj[[j^Z_h[Yjbo_djej^[[njhWYj_edieYa[j$
È
-ATERIALSÈANDÈ-ETHODS
J^_hjo#ed[ fWj_[dji m_j^ i[l[h[ je WZlWdY[Z f[h_e#
Zedj_j_iWdZWc[WdW][e\,*$-¦.$+(o[WhifWhj_Y_fWj[Z
_dj^_iijkZo$7bbfWj_[dji^WZX[[d_d\ehc[Ze\j^[
dWjkh[e\j^[_cf[dZ_d]fheY[Zkh[WdZ^WZi_]d[Z
Wd_d\ehc[ZYedi[dj\ehc$J^[fhejeYebe\j^[ijkZo
Yedi_ij[Z e\ _cc[Z_Wj[bo beWZ_d] j^[ 8E? _cfbWdji
W\j[h [njhWYj_ed e\ j^[ f[h_eZedjWbbo _dlebl[Z j[[j^$
7bb _cfbWdji fbWY[Z Wj f[h_eZedjWbbo _dlebl[Z i_j[i
È
0ROSTHETICÈ0ROTOCOL
7d _cfh[ii_ed mWi jWa[d ki_d] W jhWdifWh[dj ef[d
_cfh[ii_edjhWo"WdZj^[fWj_[djÉiX_j[mWih[YehZ[Z$
J[cfehWhoh[i_dXh_Z][im[h[_di[hj[Z_cc[Z_Wj[bo
W\j[h ikh][ho eh m_j^_d *.^ e\ j^[ ef[hWj_ed WdZ
ced_jeh[Z h[]kbWhbo$ J^[ Wl[hW][ j_c[ X[jm[[d j^[
_di[hj_ede\j^[8E?_cfbWdjWdZj^[_di[hj_ede\j^[
Z[\_d_j_l[ikf[hijhkYjkh[mWi-ZWoi$Ed[mekbZ^Wl[
jeYedi_Z[h"^em[l[h"j^Wjj^[j[cfehWhoh[ijehWj_ed
^WZWbh[WZoWbbem[Z\kbbcWij_YWjeho\kdYj_ed$
' 7bb ^_ijebe]_YWb [nWc_dWj_edi m[h[ f[h\ehc[Z Wj j^[
FWj^ebe]_[#?dij_jkj\”hX_efj_iY^[:_W]deij_a"Fhe\[iiehC$
CWa[a"Pkh_Y^"Im_jp[hbWdZ$
'&& 9^Wfj[h.È !SPECTSÈOFÈ"/)È4REATMENTÈINÈ0ERIODONTALLYÈ)NVOLVEDÈ#ASES

4ABLEÈ H[]_ede\8E?_cfbWdjfbWY[c[dj_dj^[kff[hWdZ
È
j^[bem[h`Wm
&OLLOW 5P
3FHJPO
PG
FYUSBDUJPO
/VNCFS
PG


5PUBM
J^[ Wl[hW][ \ebbem#kf f[h_eZ mWi ,cedj^i hWd][
#0*
JNQMBOUT
*Ä(*cedj^i$ :_W]deij_Y hWZ_e]hWf^i m[h[ jWa[d
WjXWi[b_d[WdZWj,"'(WdZ(*cedj^i$J^[_d\bk[dY[ 



e\ j^[ \ebbem_d] fWhWc[j[hi ed _cfbWdj ikYY[ii eh 



\W_bkh[ mWi [lWbkWj[Z0 ][dZ[h" WhY^" icea_d] WdZ 



i[l[h_joe\Yecfb_YWj_ediW\j[hikh][ho<_]i$.$)Ä.$." 



JWXb[.$($ 











È 



2ESULTS 







J^_hjo#ed[ fWj_[dji m_j^ i[l[h[ je WZlWdY[Z 



f[h_eZedjWb Z_i[Wi[ fWhj_Y_fWj[Z _d j^_i ijkZo$ J^[ 



ijkZo fefkbWj_ed Yedi_iji e\ '* mec[d WdZ '- 







c[d m_j^ W c[Wd W][ e\ ,*$-¦.$+(o[Whi$ J^_hjo# 



d_d[ f[h Y[dj e\ j^[ fWj_[dji h[fehj icea_d] Wd 



Wl[hW][ e\ ')$. Y_]Wh[jj[i f[h ZWo$ FWj_[dji h[Y[_l[Z

&IGÈ >_ijebe]_YWbh[ikbji
&IGÈ :_ijh_Xkj_ede\j^[fWj_[djiXo][dZ[h

&IGÈ L_jWbli$ded#l_jWbj[[j^

&IGÈ :_ijh_Xkj_ede\i_d]b[#8E?WdZZekXb[#8E?_cfbWdji

&IGÈ F[h_eZ e\ \ebbem#kf WdZ \kdYj_ed e\ j^[ 8E?

&IGÈ Icea_d]^WX_ji _cfbWdji
È È 3UMMARYÈ
&IGÈ ?\8E?_cfbWdjiWh[_di[hj[Zd[njjej^[Wbl[ebWhmWbb"
j^_i mWbb i^ekbZ h[jW_d W c_d_ckc j^_Yad[ii 7 e\ l[hj_YWb
Xed[ j^Wj YWd X[ ikffb_[Z m_j^ dkjh_[dji \hec W Y[djhWb
Z_h[Yj_ed$ ?\ j^_i _i dej eXi[hl[Z" j^[h[ _i W ZWd][h e\ Xed[
d[Yhei_i_dj^[Yh[ijWbWif[Yje\j^[i[fjkcj^kifheZkY[Z
&IGÈ ?j_idejWfheXb[cjefbWY[fWhjie\j^[Z_ia_di_Z[
j^[ ieYa[j WdZ je fbWY[ j^[ j^h[WZ[Z f_d Wj W Z_ijWdY[ 7
\hec j^[ ieYa[j mWbb$ I_dY[ j^[ h_d] Z_ia _i f[h\ehWj[Z" j^[
feii_X_b_jo e\ Yecckd_YWj_ed m_j^ j^[ Yh[ijWb Wif[Yj e\ j^[
Xed[m_j^_jif[Z_Yb[edj^[_di[hj_edi_Z[ij_bb[n_iji
&IGÈ ?\ j^[ _cfbWdj _i fbWY[Z Z_h[Yjbo _dje j^[ ieYa[j"
j^[ XWiWb fWhj e\ j^[ ieYa[j ckij X[ ef[d[Z m_j^ W Ykjj_d]
_dijhkc[dj _d ehZ[h je [dikh[ WZ[gkWj[ ikffkhWj_ed _d j^[
Wbl[ebWhWh[W$?\j^[_cfbWdjm[h[fbWY[ZWdo^_]^[h"_d\[Yj_edi
WdZ]hWdkbWj_edfheY[ii[iYekbZf[hi_ijX[jm[[dj^[Z_iaWdZ
j^[Xejjece\j^[Wbl[ebWhieYa[j$J^_ifbWY[c[dj_ij^[h[\eh[
Z[\_d_j_l[bomhed]$>em[l[h"_j_ifeii_Xb[jeb[Wl[jmee\j^h[[
eh ed[ e\ jme XWiWb fbWj[i _di_Z[ j^[ ieYa[j" Wi bed] Wi ed[
XWiWbfbWj[_ifei_j_ed[ZX[bemj^[\beehe\j^[ieYa[j
&IGÈ J^_i ZhWm_d] i^emi j^[ Yehh[Yj fbWY[c[dj e\ j^[
XWiWb XWi[#fbWj[ X[bem j^[ XehZ[h e\ j^[ ieYa[j e\ j^[
[njhWYj[Zjeej^
'&'
&IGÈ M^WjmWiiW_Z\eh<_]$.$''WdZ<_]$.$'(WbieWffb_[i
jej^[cWn_bbW$?j_idejh[Yecc[dZ[Zjeb[Wl[j^[Y[_b_d]e\
j^[ieYa[j_djWYjWii^emd^[h[$?j_ie\j[d^[h[j^Wj_d\[Yj_ed
WdZ]hWdkbWj_edWYYkckbWj[iel[hj^[o[Whi$;l[dWia[b[jj[Z
XWiWb fbWj[ mekbZ b[WZ je Wd kdmWdj[Z h[j[dj_ed [\\[Yj$ <eh
ceh[ _d\ehcWj_ed ed j^[ Yehh[Yj fei_j_ed_d] e\ _cfbWdji _d
j^[feij[h_ehcWn_bbW"fb[Wi[h[\[hje9^Wfj[h'.
W jejWb +, 8E? _cfbWdji _di[hj[Z _d j^[ [njhWYj_ed
ieYa[ji e\ j^[ f[h_eZedjWbbo _dlebl[Z j[[j^$ J^_hjo#
i_n 8E? _cfbWdji m[h[ fbWY[Z _d j^[ cWn_bbW1 (&
8E? _cfbWdji m[h[ fbWY[Z _d j^[ cWdZ_Xb[$ 7bb
YWi[i m[h[ beWZ[Z m_j^ fhel_i_edWb h[ijehWj_edi
_cc[Z_Wj[boW\j[hikh][ho$J^[Wl[hW][j_c[X[jm[[d
_di[hj_ed e\ j^[ 8E? _cfbWdji WdZ j^[ _di[hj_ed e\
j^[ ikf[hijhkYjkh[ mWi -ZWoi$ De _cfbWdj ceX_b_jo
eh f[h_#_cfbWdj hWZ_ebkY[dY_[i m[h[ eXi[hl[Z Wj
j^[ h[YWbb Wffe_djc[dji$ J^[ YkckbWj_l[ _cfbWdj
ikhl_lWb hWj[ mWi '&& Wj kf je (*cedj^i$ :kh_d]
j^[ iWc[ f[h_eZ" m[ _di[hj[Z *& 8E? _cfbWdji _d
W ]hekf e\ bed]#j[hc [Z[djkbeki fWj_[dji m_j^
Wjhef^_[Z `WmXed[i$ Jme e\ j^[ _cfbWdji + ^WZ
je X[ h[cel[Z X[YWki[ e\ fh_cWho _d\[Yj_ed$ ?j YWd
X[ YedYbkZ[Z \hec j^_i YecfWh_ied j^Wj W h[b_WXb[
WdZ ijhed] XbeeZ ikffbo _i ceh[ _cfehjWdj \eh j^[
Yb_d_YWbikYY[iie\8E?_cfbWdjij^Wdj^[fh[i[dY[eh
WXi[dY[e\XWYj[h_W$
È
/PTIMALÈ0OSITIONÈOFÈ"/)È)MPLANTSÈÈ
INÈTHEÈ6ICINITYÈOFÈ%XTRACTIONÈ3OCKETS
I[[<_].$/#.$')"',$-
È
0ECULIARITIESÈ#ONCERNINGÈ)MPLANTSÈ
INÈ0ERIODONTALLYÈ)NVOLVEDÈ4ISSUE
?cfbWdjWj_ed _d f[h_eZedjWbbo _dlebl[Z h[]_edi ^Wi
WZlWdjW][i WdZ Z_iWZlWdjW][i el[h _cfbWdjWj_ed _d
[Z[djkbekih[]_edie\bed]ijWdZ_d]0
È
3UMMARY
8E? _cfbWdji Wh[ iW\[ j^[hWf[kj_Y WZ`kdYji _d
Z[djWb _cfbWdjebe]o if[Y_\_YWbbo _d f[h_eZedjWbbo
_dlebl[Z Wh[Wi$ J^[ _di[hj_ed fheY[ii Yh[Wj[i
'&( 9^Wfj[h.È !SPECTSÈOFÈ"/)È4REATMENTÈINÈ0ERIODONTALLYÈ)NVOLVEDÈ#ASES

4ABLEÈ J^[WZlWdjW][ie\_cfbWdji_df[h_eZedjWbbo_dlebl[ZWh[WiWh[XWbWdY[ZXoZ_iWZlWdjW][ij^WjckijX[Yedi_Z[h[Z
m^[dZhW\j_d]Wjh[Wjc[djfbWd

%JTBEWBOUBHF
"EWBOUBHF

4PGUUJTTVF
JOGFDUJPO

/P
TUFSJMJUZ
BU
UIF
JNQMBOU
TJUF
(PPE
JOUSBCPOZ
CMPPE
TVQQMZ

CFGPSF
PQFSBUJPO

(PPE
TPGUUJTTVF
CMPPE
TVQQMZ

5JTTVF
IFBMJOH
-BSHF
SFNPEFMMJOH
BSFBT
FYQFDUFE

'BTU
BOE
FGGJDJFOU
CPOZ
BOE
TPGUUJTTVF

QSJNBSZ
TUBCJMJUZ
NBZ
CF
MPTU

IFBMJOH
FYQFDUFE

.BTUJDBUPSZ
GVODUJPO
/FXBMUFSFE
DIFXJOH
GVODUJPOQBUUFSOT


NVTU
CF
CVJMU
VQ

.BTUJDBUPSZ
GPSDFT
4USPOHFS
BGUFS
SFDPOTUSVDUJPO

-PX
GPSDFT
JO
JOJUJBM
IFBMJOH
QIBTF

FOEBOHFSFE
FRVJMJCSJVN


BOE
TIPSUFOJOH
PG
NVTDMFT

0TTFPJOUFHSBUJPO
*OJUJBMMZ
QPSPVT
CPOF
XJUI
MJUUMF
TUSFOHUI
'BTU
SFNPEFMMJOH
BOE
NPEFMMJOH

m_Z[ ikffkhWj_ed ibeji j^Wj W\\ehZ ZhW_dW][ \eh
j^[ fheZkYji e\ _djhWef[hWj_l[ WdZ fh[ef[hWj_l[
_d\[Yj_ed$ J^[ ibeji Wbie fh[l[dj b_gk_Z ijWi_i _di_Z[
j^[Xed[$J^[[nY[bb[djYb_d_YWbh[ikbjiYekbZWbieX[
i^emd_dWd_cWb[nf[h_c[djii[[9^Wfj[h()$
J^[ib[dZ[h[c[h][dY[fhe\_b[cWa[i\eh[nY[bb[dj
i[b\#Yb[Wdi_d] fhef[hj_[i" m^_Y^ c[Wdi j^Wj [l[d
fWj_[dji m_j^ h[ZkY[Z ehWb ^o]_[d[ YWd h[Y[_l[ 8E?
_cfbWdji$J^_i_ijhk[Xej^e\oekd][hfWj_[djim_j^
^WX_jkWbbo XWZ ehWb ^o]_[d[ WdZ e\ ebZ[h fWj_[dji
m^ei[ehWb^o]_[d[YWfWX_b_j_[iWh[h[ZkY[ZX[YWki[
e\j^[_hW][$

#(!04%2È
&OUR
$IMENSIONALÈ#ONSIDERATIONSÈÈ
OFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS
È
0ROPERTIESÈOFÈ"ONEÈ4ISSUEÈÈ
INÈTHEÈ/RALÈ%NVIRONMENT
È
#ORTICALÈ"ONE
?d j^_i Y^Wfj[h" m[ i^Wbb [nfbW_d Xed[ fhef[hj_[i
XWi[Z ed W dkcX[h e\ YedY[fji" [WY^ _bbkc_dWj_d]
ed[ if[Y_\_Y Wif[Yj e\ j^[ eii[eki b_\[ YoYb[$ 7bb e\
j^[i[YedY[fjiWh[Wffb_YWXb[Wjj^[iWc[j_c["WdZ
j^[o Wh[ _dZ[[Z h[b[lWdj \eh ekh _cfbWdjebe]_YWb
meha$
9edl[dj_edWb j^_da_d] _d Yh[ijWb _cfbWdjebe]o
_i \eYki[Z ed fbWY_d] Wd _cfbWdj ×Yehh[YjboÆ \hec
W jme# eh j^h[[#Z_c[di_edWb l_[mfe_dj WdZ" edY[
j^_i ^Wi X[[d WY^_[l[Z" ed WZZ_d] j^[ fheij^[j_Y
ikf[hijhkYjkh[ _d _ji Yehh[Yj fei_j_ed _d j^[ ehWb
YWl_jo$ ?d h[Y[dj o[Whi" j^h[[#Z_c[di_edWb fbWdd_d]
j[Y^d_gk[i ^Wl[ X[[d _dYh[Wi_d]bo ki[Z \eh j^_i
fkhfei[" Wbj^ek]^ j^[ Yh[ijWb _cfbWdji ki[Z Wh[
[ii[dj_Wbbojme#Z_c[di_edWb$
?\ j^[ _dj[h\WY[i e\ Xej^ fei_j_edi Ze dej
Ye_dY_Z[" j^[ Xedo WdY^eh_d] fe_dji Wh[ h[beYWj[Z
XoWk]c[djWj_l[c[Wikh[ije×cWa[Æj^[cYe_dY_Z[$
7YYehZ_d]jej^_if^_beief^o"_cfbWdjim_bbX[fbWY[Z
Wj i_j[i j^Wj Wh[ Yedi_Z[h[Z Wffhefh_Wj[ \hec W
fheij^[j_Y l_[mfe_dj" [l[d j^ek]^ j^ei[ i_j[i cWo
X[ Y^WhWYj[h_p[Z Xo Xed[ beii$M^Wj _i h[]WhZ[Z Wi
×Wffhefh_Wj[Æ_i"_dY_Z[djWbbo"kbj_cWj[boZ[j[hc_d[Z
XWi[Z ed W[ij^[j_Y hWj^[h j^Wd X_ec[Y^Wd_YWb
Yedi_Z[hWj_edi$
J^[\WYjj^Wjj^[\_hijjmeZ_c[di_ediWh[l_[m[Z
edbo m_j^ h[if[Yj je j^[ Xed[ beYWj[Z Wj j^[ i_j[ e\
_cfbWdjWj_ed _i Yedi_ij[dj m_j^ j^[ fh[i[dj ijWj[
e\ j^_da_d] _d Z[djWb _cfbWdjebe]o$ J^[ gk[ij_ed
m^[j^[h j^[ _cfbWdjWj_ed i_j[ YWd X[ [nf[Yj[Z je
^WhXekh W ik\\_Y_[dj Xed[ lebkc[ _d j^[ bed] j[hc
f[h i[ Ä _$[$ [l[d _\ de _cfbWdj eh ej^[h jh[Wjc[dj
mWif[h\ehc[ZÄ_iceijbo_hh[b[lWdjjeYedl[dj_edWb
j^_da_d]$?j_iYeccedboWiikc[Zj^Wjj^[_cfbWdj#
ikhhekdZ_d] Xed[ _i ik\\_Y_[djbo ij_ckbWj[Z" WdZ
j^kifh[i[hl[Z"XoWd×eii[efhej[Yj_l[Æ[\\[Yje\j^[
_cfbWdj$ ?d j^_i l_[m" Wdo YhWj[h#ijob[ YebbWfi[i Wh[
Wd×kdWle_ZWXb[h[ikbje\XWYj[h_WbWYj_edÆ$J^[oWh[
jhWZ_j_edWbbo dej Wjjh_Xkj[Z je cWij_YWj_ed#h[bWj[Z
 ¬ 
5FFUI
BOE
JNQMBOUT
BSF
OVUTIFMMT


JO
UIF
XBWFT
PG
UIF
FWPMWJOH
CPOF
Xed[ h[ceZ[bb_d]" Z_iki[ Wjhef^o" eh YecX_dWj_edi
e\j^ei[\WYjehi$
J^[ceij_cfehjWdjZ[j[hc_dWdj\ehWikYY[ii\kb
bed]#j[hcekjYec[_i"^em[l[h"j^[Yedi_Z[hWj_ede\
j^[j_c[\WYjeh_d^[h[djjeXedoj_iik[i$J^_i×\ekhj^
Z_c[di_edÆ m_bb Z[j[hc_d[ m^[j^[h ijWXb[ Xed[
YedZ_j_edim_bbX[fh[i[djWjj^[i_j[e\_cfbWdjWj_ed
kdZ[h bed]#j[hc beWZ_d] WdZ \kdYj_edWb fWjj[hdi$
J_c[ _i Yh_j_YWb" i_dY[ j^[ ^[Wb_d] WdZ h[ceZ[bb_d]
fheY[ii[i _di_Z[ j^[ Xed[ cWo jkhd ekj je X[
_d\bk[dY[Z Xo \WYjehi j^Wj j^[ _cfbWdjebe]_ij mekbZ
dej j^_da e\ h_]^j WmWo$ M[ m_bb j^[h[\eh[ beea Wj
iec[\WYjiWdZZ[l[befc[djiYbei[boYedd[Yj[Zm_j^
[l[hoZWo_cfbWdjmeha$
È
"ONEÈ(EALINGÈ2EMODELLING
B[jki\_hijZ[\_d[W\[mj[hci0Fh_cWhoeij[edijhWl[b
j^hek]^mel[dehfb[n_\ehcXed[WdZYh[Wj["WiWd
Wdim[h je c[Y^Wd_YWb ijh[ii j^[ \_hij bed]_jkZ_dWb
YWl_j_[i$ I[YedZWho eij[edi Wh[ jkdd[bb_d] j^hek]^
&IGÈ 8ed[ckbj_#Y[bbkbWhkd_ji8CKiYedi_ije\eij[YbWiji
WdZ eij[eXbWiji m^_Y^ Wh[ YecX_d_d] j^[_h WYj_l_j_[i je
W Ykjj_d] Yed[ j^Wj Æ[WjiÇ Xed[ W^[WZ e\ j^[ eij[ed WdZ
Z[fei_jedi Xed[ _di_Z[ j^[ d[mbo \ehc[Z YWl_jo$ J^[ ped[
X[jm[[d Ykjj_d] WdZ Z[fei_j_ed _i YWbb[Z h[l[hiWb ped[$ J^[
jkdd[bb_d]jWa[ifbWY[WjWffhen$*&ªcWZWo$Ed^_ijebe]_YWb
i[Yj_edi8CKicWoX[i[[d_d\hecj^[i_Z[Wi_dj^[bem[h
f_Yjkh[ eh j^[o cWo X[ Ykj Wi i^emd _d j^[ kff[h j^h[[
i[Yj_edi$ D[mbo Z[fei_j[Z Xed[ YWd X[ bWX[bb[Z m_j^ i[l[hWb
ijW_di" kikWbbo m_j^ j[jhWYoYb_d[$ J^_i ikXijWdY[ Z[fei_ji _d
^_]^ YedY[djhWj_ed _d d[mbo c_d[hWb_p[Z Xed[" j^ki j[bb_d]
kim^_Y^eij[ediehm^_Y^Wh[Wie\mel[dXed[Wh[d[mWdZ
h[\_bb_d] Wj j^[ j_c[ e\ bWX[bb_d] YecfWh[ <_]i$()$)(W" ()$))$
:hWm_d]\hecCWhj_d[jWb$'//.
'&* 9^Wfj[h/È &OUR
$IMENSIONALÈ#ONSIDERATIONSÈOFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS
Xed["m^_Y^^WiX[[deh]Wd_p[ZXofh_cWhoeij[edi$
>[dY[i[YedZWhoeij[edi×[WjÆfh_cWhoeij[edi"m^_b[
fh_cWho eij[edi h[ceZ[b mel[d Xed[" fb[n_\ehc
Xed[ eh Wdo ej^[h ceZ[bb[Z Xed[ cWj[h_Wbi$ ?djWYj
fh_cWhoeij[ediWh[edbo\ekdZ_doekd]_dZ_l_ZkWbi$
J^[ebZ[hj^[_dZ_l_ZkWb][ji"j^[Z[di[hj^[Z[di[h
Wh[ i[YedZWho eij[edi fWYa[Z$ 8ed[ _d`kho b[WZi je
h[ceZ[bb_d]"j^kiYh[Wj_d]cWdoi[YedZWhoeij[edi$
H[]WhZb[iie\j^[jof[e\[WhboXed[^[Wb_d]Wjj^[
_cfbWdji_j["eij[edWbXed[m_bb^Wl[\ehc[Z_dZk[
Yekhi[WdZm_bb_dYh[Wi_d]bocWjkh[WdZc_d[hWb_p[$
J^[b_\[YoYb[e\eij[ediYel[hij^[\ebbem_d]ijW][i0
v 7Yj_lWj_ed f^Wi[$ Fh[Ykhieh Y[bbi Z[l[bef _dje
Z_\\[h[dj_Wj[Z Y[bbi cW_dbo eij[eYbWiji m_j^_d
WhekdZ)ZWoi$
v H[iehfj_edf^Wi[$D[mbo\ehc[Zeij[eYbWiji]_l[
h_i[jeXed[h[iehfj_edWjWif[[Ze\*&ªc%ZWo$7
ÆYkjj_d] Yed[Ç e\ Y[bbi º)&&(&&ªc _d b[d]j^%
m_Zj^ _i WZlWdY_d] j^hek]^ j^[ Xed[ ijhkYjkh["
b[Wl_d] X[^_dZ W ded#c_d[hWb_p[Z jkdd[b \_bb[Z
m_j^ \bk_Z$ J^[ Xed[ _i X[Yec_d] _dYh[Wi_d]bo
feheki _d j^[ fheY[ii$ J^_i _dYh[Wi[ _d fehei_jo
_i WiieY_Wj[Z m_j^ ^_]^[h [bWij_Y_jo WdZ bem
c[Y^Wd_YWb\hWYjkh[h[i_ijWdY[$
v H[l[hiWbf^Wi[$M_j^_di[l[hWbZWoi"j^[eij[eYbWiji
]_l[ mWo je eij[eXbWiji Wi j^[ fh_c[ iekhY[ e\
WYj_l_jo" m^_Y^ ]_l[i h_i[ je W Yob_dZh_YWb ifWY[
[c[h]_d] X[jm[[d j^[ j_f e\ j^[ ÆYkjj_d] Yed[Ç
WdZj^[ÆjW_bÇ$J^[b[d]j^e\j^_iifWY[Z[f[dZied
j^[Z[bWo\hecXed[h[iehfj_edjeXed[\ehcWj_ed$
?d \_d_i^[Z i[YedZWho eij[edi" j^[ Y[c[dj b_d[
Ye_dY_Z[i m_j^ j^[ beYWj_ed \ehc_d] j^[ Xed[
ikh\WY[Zkh_d]j^_ih[l[hiWbf^Wi[$J^[ZkhWj_ede\
j^_ih[l[hiWbf^Wi[_d^kcWdi_iWhekdZ)&ZWoi$
v F^Wi[ e\ d[m Xed[ \ehcWj_ed$ Eij[eXbWiji \_hij
Wff[Wh _d j^[ f[h_f^[ho e\ j^[ jkdd[b" m^[h[
j^[o ijWhj \ehc_d] YedY[djh_Y cWjh_n bWc[bbW[$
J^_i _dlebl[i W Z_Wc[j[h beii e\ WXekj '$(ªc%
ZWo$ 7 Y[djhWb ^Wl[h_Wd YWdWb d[[Zi je h[cW_d"
i_dY[ j^[ eij[eXbWiji d[[Z je X[ dekh_i^[Z$ ?d
^kcWdi"j^[i[^Wl[h_WdYWdWbih[WY^WZ_Wc[j[he\
WhekdZ*&Ä+&ªcXoj^[[dZe\j^[\_bb_d]f^Wi[$
7ZZ_j_edWb Ybeikh[ e\ j^[ YWdWbi _i dej fbWdd[Z$
J^[ ZkhWj_ed e\ j^_i f^Wi[ e\ Xed[ \ehcWj_ed _i
WhekdZ)cedj^i$
v C_d[hWb_pWj_ed f^Wi[$ 7\j[h ded#c_d[hWb_p[Z
cWjh_nÆeij[e_ZÇ^WiX[[dZ[fei_j[Z"W]hWZkWb
fheY[ii e\ c_d[hWb_pWj_ed _i ijWhj[Z$ J^[h[ _i W
Z[bWoe\WhekdZ'&ZWoiX[jm[[dj^[[dZe\cWjh_n
\ehcWj_ed WdZ j^[ X[]_dd_d] e\ c_d[hWb_pWj_ed$
J^[Æfh_cWhoc_d[hWb_pWj_edÇeYYkhh_d]m_j^_dj^[
\_hij\[mZWoiW\j[hj^[fheY[ii^WiX[[d_d_j_Wj[Z
WYYekdji \eh WhekdZ ,& e\ Wbb c_d[hWb_pWj_ed$
J^[i[YedZWhoc_d[hWb_pWj_edf^Wi["m^_Y^]_l[i
j^[ Xed[ _ji Z[\_d_j_l[ ^WhZd[ii" m_bb j^[d jWa[
Wdej^[h ,Ä'(cedj^i" Z[f[dZ_d] ed j^[ beYWb
\kdYj_edWbh[gk_h[c[dji$
v :ehcWdj f^Wi[$ 7\j[h j^[ jkdd[bb_d] WdZ \_bb_d]
fheY[ii[i^Wl[X[[dYecfb[j[Z"WZehcWdjf^Wi[
[dik[i _d m^_Y^ j^[ eij[eXbWiji m_bb Z[l[bef
[_j^[h _dje eij[eYoj[i eh _dje j^[ Y[bbi b_d_d]
j^[ ^Wl[h_Wd YWdWb$ ?d j^_i f^Wi[" j^[ Y[bbi jWa[
kf j^[_h c[Y^Wd_YWb" c[jWXeb_Y WdZ ^ec[eijWj_Y
\kdYj_ed$
J^_i YWiYWZ[ e\ fheY[ii[i m_bb WbmWoi Z[l[bef _d W
kd_\ehc cWdd[h _\ dej^_d] _dj[h\[h[i m_j^ j^[c$
J^[ j[hc 8CK Xed[ cehf^ebe]_YWb kd_j Wi ki[Z
^[h[_dW\j[h_iYeccedboki[Zjeh[\[hjej^_iÆYkjj_d]
Yed[Ç$8CKYel[hij^[m^eb[fheY[iiekjb_d[ZWXel[
_d_jiY[bbkbWhWdZifWj_Wb[dj_h[joÄ_$[$j^[WYj_l_joe\
eij[eYbWiji Wi m[bb Wi j^[ Z[fei_j_ed e\ cWjh_n WdZ
j^[fheY[iie\c_d[hWb_pWj_ed$
EdY[m[^Wl[kdZ[hijeeZj^_iYWiYWZ[e\fheY[ii[i"
_j X[Yec[i l[ho ^WhZ je [nfbW_d j^[ Æc_hWYkbekiÇ
FHF fbWj[b[j#h_Y^ fbWicW jh[Wjc[dj" m^_Y^ _i
ikffei[Z je o_[bZ X[d[\_ji _d W cWjj[h e\ ZWoi$
Ceij e\ j^[ fhef[hj_[i Yeccedbo WiYh_X[Z je FHF
j^[hWfo jeZWo YWddej feii_Xbo [n_ij Wi ijWj[Z$ J^[
cWha[j_d]YbW_cicWZ[\ehFHFÄm^_Y^^Wl[X[[d
^_]^bo [\\[Yj_l[ WdZ Wh[ ikffehj[Z Xo cWdo Z[djWb
iY^eebi Ä _i kd\ekdZ[Z \hec W iY_[dj_\_Y l_[mfe_dj$
?d \WYj" _j _i W j[bb_d] [nWcfb[ e\ ^em _dWZ[gkWj[bo
jhW_d[Z][d[hWbfhWYj_j_ed[hiWdZ"_dZ[[Z"dkc[heki
if[Y_Wb_p[Z f[h_eZedjebe]_iji WdZ _cfbWdjebe]_iji"
Wh[ Zkf[Z Xo _dZkijho _dje WYgk_h_d]Æd[m Ybej^[i
\eh j^[ [cf[hehÇ$ ?\ \eh de ej^[h h[Wied" FHF
YWddejX[Yec[[\\[Yj_l[Zk[jefbWj[b[jW]]h[]Wj_ed$
<khj^[hceh["WibWj[hY^Wfj[hie\j^_iXeeam_bbi^em"
j^[h[YWdX[de]h[Wj[h_dY[dj_l[\ehXed[\ehcWj_ed
WdZ cW_dj[dWdY[ j^Wd Yedj_dkeki \kdYj_ed$ FHF
Y[hjW_dbo_idejWikXij_jkj[\ehj^_i[_j^[h$
M^WjZe[icWa[i[di["^em[l[h"_ije\_bb[njhWY#
j_ed ieYa[ji m_j^ Xed[#]hW\j_d] cWj[h_Wbi ikY^ Wi
8_e Eii eh jh_YWbY_kc f^eif^Wj[ Ä _dZ[[Z" [l[d
_d[nf[di_l[YWbY_kcikbf^Wj[ehjh_ÄYWbY_kcf^ei#
f^Wj[ \hec j^[ f^WhcWYo cWo Ze$ 7\j[h Wbb" j^[i[
[njhWd[eki cWj[h_Wbi m_bb fh[l[dj h[eh_[djWj_ed _$[$
ijhW_]^j[d_d]e\j^[eij[ediikhhekdZ_d]j^[[njhWY#
j_edieYa[jb_a[WX[bjXoj^[_hi^[[hf^oi_YWbXWhh_[h
\kdYj_ed_dj^[_d_j_Wbf^Wi[e\Xed[^[Wb_d]"m^_Y^
mekbZ ej^[hm_i[ YWki[ j^[ Wbl[ebWh ieYa[j mWbbi je
YebbWfi[$?j_i_hh[b[lWdjm^[j^[hj^[\_bb_d]cWj[h_Wb_i
]e_d]jeX[h[iehX[ZZemdj^[heWZ"Wij^[eij[edWb
ioij[c m_bb X[ XWYa _d W ijWj[ e\ [gk_b_Xh_kc _d
j^[ bWj[h ijW][i e\ ^[Wb_d] fWhj_YkbWhbo _d WZkbji"
ie j^Wj j^[ cehf^ebe]_YWb Y^Wd][i e\ j^[ Yehj_YWb
Xed[ i[]c[dji Wh[ de bed][h Wi fhedekdY[Z Wi
fh[l_ekibo$
7ceh[_cfehjWdj_iik[\ehj^[ikYY[ii\kbekjYec[
e\ _cfbWdj fbWY[c[dji YedY[hdi j^[ Z_h[Yj_ed _d
m^_Y^j^[8CKiWh[cel_d]j^hek]^j^[Xed[$
8CKi YWd ijWhj WdZ [dZ Wj Wdo Yehj_YWb Xed[
ikh\WY[ f[h_eij[kc" [dZeij[kc" ^Wl[h_Wd YWdWbi
È È 0ROPERTIESÈOFÈ"ONEÈ4ISSUEÈINÈTHEÈORALÈ%NVIRONMENTÈ '&+

j^Wj _i dej Yel[h[Z Xo YWhj_bW][ eh [nYbkZ[Z \hec
h[ceZ[bbWj_ed\ehej^[hh[Wiedi[$]$eij[e_Z$J^[o
kikWbbo cel[ j^hek]^ j^[ Xed[ _d bed]_jkZ_dWb
Z_h[Yj_ed"m_j^ekjX[_d]W\\[Yj[ZXoWdofh_cWhoeh
i[YedZWhoeij[edij^WjcWo[n_ijXoj^Wjj_c[$8CKi
Wh[ YWfWXb[ e\ Z[l[bef_d] _dje i[fWhWj[ fhed]i _d
Yecfb[j[bo Z_\\[h[dj Z_h[Yj_edi$ ?j _i Wiikc[Z j^Wj
j^[ Z_h[Yj_ed kbj_cWj[bo Z[f[dZi ed j^[ Z[]h[[ e\
c[Y^Wd_YWb ijh[ii[i WdZ ed j^[ Xed[ ijhkYjkh[$
Dej[j^Wjj^[l[ho\ehcWj_ede\8CKim_bbWbj[hj^[
ijh[ii Z_ijh_Xkj_ed _di_Z[ j^[ beYWb Xed[ Wi ijWXb[
c_d[hWb_p[ZWh[WiWh[X[_d]Z_iiebl[Z$J^[h[\eh["de
Yb[Whb_d[YWdX[ZhWmdX[jm[[dj^[YWki[WdZ[\\[Yj
e\8CKWYj_l_jom_j^h[]WhZje_jiZ_h[Yj_edWdZj^[
Z_ijWdY[Yel[h[Z$8CKYWdYWjY^kfWdoikXijWdY[i
_di_Z[ j^[ Xed[ Zkh_d] j^[_h jhWl[b$ J^[o m_bb j^[d
kdbeWZj^[ckdZ[hj^[f[h_eij[kc"m^_Y^i[hl[iWi
W[nY^Wd][fbWd[$Iec[ikXijWdY[i"b_a[c[jWben_Z[i"
cWojhWl[bm_j^j^[8CKiekje\j^[Xed[Xkjj^[o
m_bbdejX[WXb[jefWiij^[XWhh_[he\j^[f[h_eij[kc
_dje j^[ XbeeZ$ ?dij[WZ" j^[o m_bb h[cW_d b_a[ W
jWjjeeedj^[_di_Z[e\j^[f[h_eij[kc"m^_Y^YekbZ
j^[d Wbj[h j^[ f[hc[WX_b_jo e\ j^[ f[h_eij[kc \eh
ej^[h ikXijWdY[i$ A[[f j^_i _d c_dZ" m^[d h[WZ_d]
9^Wfj[h/$,$
M^[j^[hj^[\_bb_d]e\jkdd[bi_iWYYecfb_i^[ZXo
ed[][d[hWj_edehi[l[hWb][d[hWj_edie\eij[eXbWiji
_i kdY[hjW_d$7j Wdo hWj[" j^[ \_bb_d] f^Wi[ Ze[i dej
fheY[[Z _d W kd_\ehc cWdd[h Xkj _dYbkZ[i Z[bWoi
Zkh_d] m^_Y^ j^[ eij[eXbWiji cWo [_j^[h h[cW_d Wj
h[ijehcWoi[fWhWj[$
Eij[ediWh[ikffboYWdWbim_j^Wl[hobWh][ikh\WY[$
?d ded#lWiYkbWh_p[Z Xed[ Wh[Wi" j^[o jWa[ YWh[ e\
dkjh_[dj[nY^Wd][XomWoe\Z_\\ki_ed$;bWij_YXed[
ijhkYjkh[i fhecej[ j^[ _djhWeij[edWb Yedl[oWdY[
e\ dkjh_[dji Xo cel[c[dj#h[bWj[Z Z[\ehcWj_ed$
J^_i X[d[\_Y_Wb [\\[Yj _i WXi[dj _d ceh[ h_]_Z Xed[
ijhkYjkh[i1 j^[h[\eh[" j^[ eij[edi _d bed] jkXkbWh
Xed[i ^Wl[ W bWh][h bkc[d j^Wd j^[ eij[edi _d j^[
h_XijeYecf[diWj[\ehj^[bWYae\Z[\ehcWj_ed$
M_j^ h[if[Yj je 8E? _cfbWdji WdZ _cfbWdji
_d ][d[hWb" j^_i c[Wdi j^Wj Z[\_d_j_l[ ÆijWXb[Ç
_dYehfehWj_ed e\ _cfbWdji _dje j^[ \kdYj_edWb
fheY[ii[i _di_Z[ j^[ ehWb YWl_jo YWd X[ [nf[Yj[Z
W\j[h ' eh (o[Whi Wj j^[ [Whb_[ij$7\j[h j^Wj j_c[" j^[
Yecfb_YWj_ed hWj[ m_bb Z[Yh[Wi[" Wi Xej^ j^[ Xed[
jhW`[Yjeh_[i WdZ j^[ cWij_YWjeho \kdYj_ed m_bb ^Wl[
WffheWY^[ZWijWXb[kff[hb_c_j$7jhk[ij[WZoijWj[
_i dej WjjW_dWXb[" ^em[l[h" \eh jme h[Wiedi$ <_hijbo"
j^[ h[i_ZkWb \kdYj_edWb ij_ckbki _i jee icWbb dej[
Wbie j^Wj bed] jkXkbWh Xed[i Wh[ d[l[h Yecfb[j[bo
ijhW_]^j \eh j^_i jhWdi\ehcWj_ed je X[ el[hYec[$
I[YedZbo" Wdo jhW`[Yjeh_Wb WZWfjWj_ed m_bb ]_l[ h_i[
je ckiYkbWh WZ`kijc[dji WdZ l_Y[ l[hiW" m^_Y^ m_bb
a[[f Wdo ioij[ci e\ j^_i jof[ ÆeiY_bbWj_d]Ç ed W
ikXefj_cWb b[l[b$ JhW`[Yjeh_Wb WZWfjWj_ed _i WbmWoi
W Yedi[gk[dY[ e\ fWij \kdYj_edWb ijh[ii[i" WdZ Wdo
\kdYj_edWb ijh[ii[i eYYkhh_d] Wj fh[i[dj m_bb X[
h[\b[Yj[Z _d Xed[ cehf^ebe]o m_j^ W bed] Z[bWo
_dlebl[Z$
È
7HYÈ$OESÈ"-5È!CTIVATIONÈ/CCUR
8CKiYWdX[WYj_lWj[Zj^hek]^lWh_ekiij_ckb_0
v 8CKi cWo X[ WYj_lWj[Z je h[fW_h Wdo YhWYai
WdZ c_YheYhWYai _di_Z[ j^[ Xed[ j^Wj ^Wl[ X[[d
YWki[Z Xo [nY[ii_l[ beWZi Ceh_ WdZ 8khh '//)1
8khh [j Wb$ '/.+$7j \_hij" j^[ h[fW_h meha m_bb X[
Yed\_d[Z je j^[ i_j[ e\ _d_j_Wb _d`kho$ >em[l[h"
i_dY[ j^[ h[fW_h c[Y^Wd_ic _dlebl[i W ]h[Wj[h
Z[]h[[e\fehei_jo"m^_Y^m_bbWbj[hj^[j[di_ede\
j^[Xed[WiWm^eb["i_jkWj_edicWoWh_i[_dm^_Y^
j^[fehekiped[fhefW]Wj[iel[hWbWh][Wh[W$8ed[
ZWcW][WdZjhWkcWm_bb_d_j_Wj[WZZ_j_edWbh[fW_h
c[Y^Wd_ici X[oedZ j^[ f^oi_ebe]_YWb hekj_d[$

A B

&IGÈÈ A ?di[hj_ed e\ j^h[[ Yh[ijWb _cfbWdji h[fbWY_d] j[[j^ ''" (' WdZ ((" \ebbem[Z Xo _cc[Z_Wj[ beWZ_d] m_j^ j^h[[ i_d]b[
Yhemdi$ B <ekh cedj^i bWj[h" j^[ eii[e_dj[]hWj[Z _cfbWdj h[fbWY_d] jeej^ '' ^Wi ijWhj[Z je c_]hWj[ _d W bWj[hWb l[ij_XkbWh
Z_h[Yj_ed$J^[l[ij_XkbWhYehj_YWbXed[mWih[ceZ[bb[Z7ja_died[jWb$'/--"m_j^j^[h[ikbjj^Wjj^[_cfbWdj#ikffehj[ZYhemd
^WikdZ[h]ed[h[eh_[djWj_edZk[jej^[[gk_b_Xh_kce\\ehY[iX[jm[[dj^[jed]k[WdZkff[hb_f$M[^Wl[eXi[hl[Zj^[iWc[
Z[l[befc[dje\Xed[W\j[h_cc[Z_Wj[beWZ_d]e\i_d]b[#jeej^8E?_cfbWdji$?cc[Z_Wj[bobeWZ[Zi_d]b[#jeej^h[ijehWj_ediki_d]
8E?_cfbWdjic_]^jh[gk_h[el[hd_]^jifb_dj_d]Zkh_d]j^[h[ceZ[bb_d]f[h_eZe\j^[l[ij_XkbWhYehj_YWbmWbb"m^_Y^_i[nf[Yj[Z
X[jm[[dj^[)hZWdZ,j^cedj^ifeijef[hWj_l[bo
'&, 9^Wfj[h/È &OUR
$IMENSIONALÈ#ONSIDERATIONSÈOFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS
J^[ h[fW_h[Z Xed[ i^emi W icWbb[h Z[di_jo e\
i[YedZWho eij[edi Wj W ^_]^[h dkcX[h e\ 8CK
WYj_lWj_edi$ ?d ej^[h mehZi" j^[ Xed[ _i b_j[hWbbo
Æh[`kl[dWj[ZÇ _d j^[ fheY[ii e\ h[ceZ[bb_d] Ä W
fheY[ii j^Wj cWo ifh[WZ je [nj[dZ[Z Xed[ Wh[Wi
7ja_died[jWb$'/--$
v½ :_iki[ m_bb ]_l[ h_i[ je W ^_]^[h Z[]h[[ e\
fehei_jo Wi m[bb$ 7\j[h Wbb" 8CKi Wh[ \ehc[Z
Wj W Y[hjW_d \h[gk[dYo _d Wd W][#Z[f[dZ[dj
cWdd[h$?dj^[[l[dje\Z_iki["j^[jkdd[biWh[dej
h[\_bb[Z gk_Yabo" WdZ Xed[ fehei_jo m_bb _dYh[Wi["
m^_Y^ m_bb [l[djkWbbo YWki[ j^[ el[hWbb Z[]h[[
e\ c_d[hWb_pWj_ed je Z[Yh[Wi[$ Kdb_a[ _d Xed[
jhWkcW"^em[l[h"m^[h[j^[h[ceZ[bb_d]h[cW_di
bWh][bo Yed\_d[Z je j^[ YhWYa Wh[W" Z_iki[#h[bWj[Z
fehei_jo _dlWh_WXbo YWki[i j^[ Xed[ ijhkYjkh[ je
h[ceZ[b_dWkd_\ehccWdd[h$
v :_ih[]WhZ_d] jhWkcW WdZ Z_iki[ Wi YWkiWj_l[
\WYjehi" 8CK WYj_lWj_ed _i dehcWbbo Wd W][#
Z[f[dZ[djf^[dec[dedYedjhebb[ZXo^ehced[i$
7Yj_lWj_ed\h[gk[dY_[iWh[]_l[d_d8CKWYj_lWj[Z
f[hcc(WdZo[Wh$J^[oWh[^_]^[ij_dY^_bZ^eeZ
kf je ,&8CK%cc(%o[Wh WdZ bem[ij _d ebZ W][
Zemd je 'Ä(8CK%cc(%o[Wh$ 8CK WYj_lWj_ed
\h[gk[dY_[i_dh_XXed[i^Wl[X[[di^emdjeZhef
jej^[_h\_hijlWbb[oWjW][)+"\ebbem[ZXoWib_]^j
h[Yel[ho kdj_b j^[o Zhef edY[ W]W_d bWj[h _d b_\[$
J^[Ykhl[h[i[cXb[iWZWcf[ZeiY_bbWj_edfWjj[hd
<_]$/$*$
7dej^[hb[iiedj^Wj<_]$/$*^ebZi\ehekhmeha_ij^Wj
Wdo_cfbWdjjh[Wjc[dje\fWj_[djifWijj^[W][e\)+
m_bb X[ f[h\ehc[Z ed W h[bWj_l[bo _dWYj_l[" h[ij_d]
eij[edWbioij[cY^WhWYj[h_p[ZXoWl[hobemZ[]h[[
e\ h[ceZ[bb_d] f[h i[$ J^[ h[ceZ[bb_d] jh_]][h[Z
Xo j^[ _cfbWdj fheY[Zkh[ m_bb j^[d \_hij _dZkY[
h[ceZ[bb_d]e\j^[ikh]_YWbi_j["Xkjj^[fheY[ii[im_bb J^[\ebbem_d]YedYbki_ediYWdX[ZhWmd0
[nj[dZj^hek]^ekjj^[[dj_h[`Wmi[]c[dji$J^[cW_d v Ijh[d]j^[d_d]e\j^[cWij_YWjeho\ehY[m_bbYWki[
\WYjehiZ[j[hc_d_d]j^[Z_h[Yj_ede\j^_ih[ceZ[bb_d]
Wh[\ehY[#h[bWj[Z[\\[YjiXocWYhejhW`[Yjeh_[iWdZ_d
j^[ _dj[h\WY[ Wh[W" Xkj Wbie ^ehcedWb _d\bk[dY[i Wi
\WhWij^[Z_h[Yj_edWdZ[nj[dje\Xed[h[ceZ[bb_d]
&IGÈ H[ceZ[bb_d]_dh[ifedi[jeZodWc_YbeWZ_d]HkX_d
'/.*$<ekhbeWZ_d]YoYb[if[hZWoYfZm[h[ik\\_Y_[djjea[[f
j^[Xed[cWiiYedijWdj_dj^_i[nf[h_c[dj
&IGÈ 8CK
WYj_lWj_edfbejj[Z
W]W_dijW][
8khh[jWb$'//.
Wh[ YedY[hd[Z$ ?cfbWdj jh[Wjc[dji f[h\ehc[Z ed
fWj_[djikdZ[h(+o[Whi"XoYedjhWij"Wh[dejb_a[boje
jh_]][h W bej e\ WZZ_j_edWb h[ceZ[bb_d]" ie j^Wj j^[
[\\[Yji ed cWYhejhW`[Yjeh_[i m_bb X[ icWbb[h Wi m[bb
i[[WbieCWhnWdZ=Wh]'//.$H[Y[djbofh[ef[hWj[Z
i_j[i" ^em[l[h" i^em W ^_]^[h 8CK WYj_lWj_ed hWj[
Zk[ je ed]e_d] h[ceZ[bb_d]$ J^[ fbWY[c[dj e\ 8E?
_cfbWdji_dj^[i[Wh[Wi_iij_bbfeii_Xb["Xkj_cc[Z_Wj[
beWZ_d]cWodejX[WZl_iWXb[$
>_ijebe]_YWb ijkZ_[i Wh[ Wd _cfehjWdj [b[c[dj e\
_cfbWdjebe]_YWbh[i[WhY^$7dej^[hdejWXb[_cfb_YWj_ed
e\ <_]$/$* _i j^Wj j^[ _cfbWdjebe]_YWb ZWjW eXjW_d[Z
_d Wd_cWb [nf[h_c[dji YWddej X[ h[WZ_bo jhWdibWj[Z
je ^kcWdi" i_dY[ j^[o Wh[ kikWbbo f[h\ehc[Z ed
oekd] WZkbj Wd_cWbi _$[$ i^ehjbo W\j[h ]hemj^ ^Wi
X[[d Yecfb[j[Z$ J^ei[ oekd] Wd_cWbi Wh[ j^ki _d
Wdej^[hÆf^Wi[ e\ Xed[ b_\[Ç" Yehh[ifedZ_d] je j^[
b[\jceij i[]c[dj e\ ekh ]hWf^" m^_b[ ekh Z[djWb
_cfbWdj fWj_[dji j[dZ je X[ fWij *&" j^ki i^em_d]
W icWbb Z[]h[[ e\ ifedjWd[eki 8CK WYj_l_jo1 j^[_h
eij[edWbioij[ciWh[ceh[ehb[iiWjh[ij$
Wdo YhWYai WdZ c_YheYhWYai _d j^[ Xed[ WhekdZ
beWZ#jhWdic_jj_d]Z_iaWh[Wije_dYh[Wi[WdZ]_l[
h_i[jeW]h[Wj[hZ[]h[[e\fehei_joWiieY_Wj[Zm_j^
_dYh[Wi[Z ceX_b_jo e\ j^[ _cfbWdj$ J^_i Ze[i dej
d[Y[iiWh_bo c[Wd" ^em[l[h" j^Wj Z_h[Yj YedjWYj Wj
j^[ _cfbWdj#Xed[ _dj[h\WY[ _i beij$ Fehei_j_[i YWd
WYYkckbWj[jeWfe_djm^[h[f[h\ki_ed_di_Z[j^[
h[fW_h Wh[W _i ie ijhed] j^Wj j^[ Z[]h[[ h[gk_h[Z
e\c_d[hWb_pWj_edYWddejX[cW_djW_d[Z0m[YWbb
j^_i ijWj[Æel[hbeWZ eij[eboi_iÇ$ ?j _i W h[l[hi_Xb[
i_jkWj_ed" Wi bed] Wi de _d\[Yj_edi W\\[Yji j^[i[
Wh[Wi" ceZ_\_[i j^[ fhef[hj_[i e\ j^[ j_iik[ WdZ
_dZkY[i]hWdkbWj_ed$
v M[Wa[d_d] e\ j^[ cWij_YWjeho \ehY[ cWo ]_l[
h_i[ je ][d[hWb_p[Z h[ceZ[bb_d] e\ j^[ `WmXed["
m^_Y^ m_bb Wbie X[ WYYecfWd_[Z Xo W Z[Yh[Wi[
_d Xed[ c_d[hWb_pWj_ed$ Ceh[el[h" Wdo kdbeWZ[Z
_cfbWdji e\\[h_d] de \kdYj_edWb ij_ckbWj_ed e\
j^[ ikhhekdZ_d] Xed[ ijhkYjkh[ m_bb m[Wa[d j^[
È È 0ROPERTIESÈOFÈ"ONEÈ4ISSUEÈINÈTHEÈORALÈ%NVIRONMENTÈ '&-

Xed[hWj^[hj^Wdijh[d]j^[d_j$J^[h[Xo"Wdo\ehY[# `e_dj$ Edbo \_Xheki YWhj_bW][ _i \b[n_Xb[ [dek]^

jhWdic_jj_d] jhW`[Yjeh_[i Wh[ b_a[bo je Y_hYkcl[dj je WZWfj WYYehZ_d]bo$ J^_i WZWfjWj_ed Wbie
j^[i[_cfbWdji_dj^[_hZ[l[befc[djWbiei[[j^[ [nfbW_di m^o kd_bWj[hWb Y^[m_d] fWjj[hdi ]_l[
Z_iYkii_ed e\ &Ä' fhef[hj_[i Wj j^[ [dZ e\ j^_i h_i[ je hWZ_e]hWf^_YWbbo cWd_\[ij Wbj[hWj_edi e\
Y^Wfj[h$ j^[JC@i$I_]d_\_YWdj\bWjj[d_d]e\j^[`e_djim_bb"
v 7do _cfbWdji j^Wj Ze dej fWhj_Y_fWj[ _d cWij_# _d _ji jkhd" _dYh[Wi[ j^[ _cfehjWdY[ e\ ckiYkbWh
YWj_ed cWo dej X[ WXb[ je ij_ckbWj[ j^[ Xed[ Wj ]k_ZWdY[$ J^[ hWc_\_YWj_edi e\ j^_i i^ehj ekjb_d[
j^[ _dj[h\WY[ _d Wd WZ[gkWj[ cWdd[h$ KdbeWZ[Z Wh[Z_iYkii[Z_d9^Wfj[h'&$
_cfbWdji Wh[ j^ki ceh[ b_a[bo je X[ beij" m^_Y^ v 8[_d]WhhWd][Z_dWibWdj[Zfei_j_edjej^[iW]_jjWb
cWo jWa[ o[Whi$ ?d j^Wj YWi[" j^[ Z[c_d[hWb_p_d] fbWd[" j^[ JC@i Wh[ Z[i_]d[Z d[_j^[h \eh fkh[bo
[\\[Yje\XWYj[h_W_dj^[YebbWhWh[W]W_dij^[kff[h bWj[hWb deh \eh Wdj[h_eh hejWj_edWb cel[c[dji$
^WdZ WdZ m_bb [l[djkWbbo ]_l[ h_i[ je ikXWYkj[ HWj^[h" j^_i jof[ e\ `e_dj [nY[bi _d bWj[heWdj[h_eh
Y^hed_Y eij[eco[b_j_i WiieY_Wj[Z m_j^ W cWii_l[ Z_ibeYWj_ed" h[ikbj_d] _d W ]h_dZ_d] cel[c[dj
Z[Yh[Wi[_dc_d[hWb_pWj_ed$ j^Wj_iefj_c_p[Z\ehY^[m_d]$J^_iWkjecWj_YWbbo
_dlebl[iWbed]Whj_YkbWhfWj^mWoedj^[XWbWdY_d]
i_Z[" m^[h[Wi j^[ YedZob[ ed j^[ meha_d] i_Z[
È
f[h\ehcim^Wj_iX[jj[hZ[iYh_X[ZWiWhejWj_edWb
)NTERACTIONSÈ"ETWEENÈ*OINTSÈANDÈ"ONEÈ#HANGES
cel[c[dj$J^[i[\kdYj_edWbWYYecfb_i^c[djiWh[
>oWb_d[ YWhj_bW][ YWd X[ d[_j^[h c_d[hWb_p[Z deh ekji_Z[j^[iYef[e\^oWb_d[`e_dji$
fheY[ii[ZXoeij[eXbWiji1j^[okdZ[h]edeceZ[bb_d]
ehh[ceZ[bb_d]m^Wjie[l[h$8oYedjhWij"h[ceZ[bb_d]
È
Ze[i jWa[ fbWY[ _d \_Xheki YWhj_bW][" ikY^ Wi j^[
(ORMONALÈANDÈ-ECHANICALÈ)NFLUENCESÈÈ
YWhj_bW][Yel[h_d]j^[JC@i$
$URINGÈ'ROWTHÈANDÈ!GING
J^_iZ_\\[h[dY[Wff[Whibe]_YWb_\m[Yedi_Z[hj^[
\ebbem_d]\WYji0 J^[ W][ e\ Xed[ iWcfb[i e\ ademd jefe]hWf^_YWb
v Kdb_a[ Wdo ej^[h `e_dj _d j^[ ^kcWd XeZo" j^[ eh_]_d[$]$\hecj_X_WbXed[YWdX[WYYkhWj[boZ[j[h#
JC@i Wh[ jme `e_dji ed Xej^ [dZi e\ j^[ iWc[ c_d[ZXWi[Zedj^[dkcX[he\i[YedZWhoeij[edi_d
Xed[Whj_YkbWj_d]m_j^j^[iWc[effei_d]Xed[3 Wdo ]_l[d Yheii#i[Yj_ed$ Ed j^_i XWi_i" j^[ W][ e\ W
j^[Whj_YkbWh\eiiW[e\Xej^j[cfehWbXed[i\ehj^[ fWj_[djYWdX[f_dfe_dj[Zje¦+Ä-o[Whi>Wjjd[hWdZ
fkhfei[e\j^_iZ_iYkii_ed$ <heij '/,)$ J^ki j^[ dkcX[h e\ i[YedZWho eij[edi
v 7j j^[ iWc[ j_c[" Xej^ `Wmi Wh[ Yedj_dkekibo ]hWZkWbbo h_i[i j^hek]^ekj b_\[1 el[h j^[ o[Whi" j^[o
ikX`[Yj[Z je cehf^ebe]_YWb Y^Wd][i Xo j^[ X[Yec[ _dYh[Wi_d]bo el[hbWff[Z WdZ YedZ[di[Z
Z[dj_j_ed Ä _$[$ j^[ \ehcWj_ed" ]hemj^" [hkfj_ed" A[hb[o'/,+$J^[bed]jkXkbWhXed[i^Wl[Wj[dZ[dYo
ki[WdZbeiie\j[[j^$ jeÆijhW_]^j[dekjÇ_dWYYehZWdY[m_j^j^[_h\kdYj_ed
v J^[i[ Y^Wd][i Wh[ ie [nj[di_l[ j^Wj j^[o mekbZ el[h j_c[$'7doed[ m^e ^Wi ^WZ Wd effehjkd_jo je
Z_i[d]W][ j^[ ^_]^#fh[Y_i_ed \_j e\ j^[ ^oWb_d[ ced_jeh WdWjec_YWb Z[l[befc[dji _d j^[ \_hij o[Whi
e\b_\[cWo^Wl[dej[Zj^Wjj^[j^_]^im_bbijhW_]^j[d
ekj Wbb e\ W ikZZ[d edY[ j^[ Y^_bZ _i X[]_dd_d] je
mWba$?dj^_ii_jkWj_ed"j^[ijhed]\b[n_ed_idejbed][h
WYY[fjWXb[ \hec W c[Y^Wd_YWb l_[mfe_dj" Xkj j^_i
fheXb[c_iiebl[ZWcWp_d]bo\Wij_dWYYehZWdY[m_j^
<heijÉi \b[nkhWb d[kjhWb_pWj_ed j^[eho <DJ$ J^[
YhkY_Wbc[Y^Wd_ic_if[h_eij[WbceZ[bb_d]Wbed]j^[
YedYWl[Xed[i[]c[dji$
?df^Wi[ie\ikXijWdj_Wb]hemj^"j^[hWj[e\Xed[
h[ceZ[bb_d] _i ]h[Wj[h _d Y^_bZh[d j^Wd _d WZkbji"
m^_Y^ _i dWjkhWbbo Zk[ je j^[ ^ehcedWb i_jkWj_ed$
:k[ je j^[ \Wij if[[Z e\ ]hemj^ _d WZeb[iY[dji"
j^[ Z[]h[[ e\ c_d[hWb_pWj_ed cWo iec[j_c[i bW]
X[^_dZ$ J^[ \ehcWj_ed e\ fb[n_\ehc Xed[ Wi W

&IGÈ KdbeWZ[Z iYh[m _cfbWdji \[Wjkh_d] de ikh\WY[

[dbWh][c[dj .o[Whi W\j[h _di[hj_ed$ J^ei[ _cfbWdji YekbZ
X[ [Wi_bo h[cel[Z Xo `kij Æf_Ya_d] j^[c kfÇ$ J^[o m[h[
Y^WhWYj[h_p[Z Xo Y^hed_Y _d\bWccWj_ed W\j[h ^Wl_d] X[[d
h[f[Wj[Zbo Yel[h[Z Xo ckYeiW$ J^[ cWYhejhW`[Yjeh_[i Wle_Z
j^[i[_cfbWdjiWYYehZ_d]jej^[&Ä'hkb["WideXed[#fh[i[hl_d]
ij_ckbki_ifh[i[djWjj^[[deiiWb_cfbWdjikh\WY[
' >em[l[h" j^[o d[l[h WjjW_d Wd WXiebkj[bo ijhW_]^j \ehc"
i_dY[ j^[ bWij X_j e\ ijhW_]^j[d_d] h[gk_h[i W c[Y^Wd_YWb
ij_ckbki j^Wj _i WXi[dj$ J^[ bem[h j^[ h[i_ZkWb YkhlWjkh["
j^[ bem[h j^[ ijh[ii \WY_b_jWj_d] j^[ h[i_ZkWb ijhW_]^j[d_d]
[\\ehj" j^Wj _i" j^[ Y^Wd][ _d YedYWl_jo WYYehZ_d] je <heijÉi
<DJj^[eho$
'&. 9^Wfj[h/È &OUR
$IMENSIONALÈ#ONSIDERATIONSÈOFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS
j[cfehWhoYehiW][_ied[e\j^[fh[YWkj_edij^Wjj^[
b_l[ Xed[ cWo jWa[ W]W_dij \hWYjkh[ Wi j^[ ijh[ii[i
Wh[ Yedj_dkekibo Y^Wd]_d] Xej^ _d Z[]h[[ WdZ _d
Z_h[Yj_ed$ 8[YWki[ j^[ WYj_l_jo _i kikWbbo Z[Yh[Wi[Z
_d WZkbji Wi m[bb" j^[ \h[gk[dYo e\ 8CK WYj_lWj_ed
Zhefi gk_Yabo$7ffWh[djbo" j^_i h[ikbji _d W i^ehjW][
e\ WYj_lWj_ed m^_Y^ _i j^[d Yekdj[hWYj[Z Xo W d[m
h_i[_d\h[gk[dYo$
È
Z[djWb heeji WdZ j^[ f[h_eZedjWb b_]Wc[dj Ä m^[h[
]h[WjWcekdjie\XbeeZWh[d[[Z[ZedWYedj_dkeki
XWi_i je cW_djW_d j^[ beYWb _cckd[ ioij[c WdZ
dekh_i^ j^[ j_iik[i Ä WdZ _i ZhW_d[Z j^hek]^ j^[
ikXf[h_eij[Wb j_iik[$ 7\j[h j^[ bWij jeej^ ^Wi X[[d
[njhWYj[Z"j^[Xed[m_bbYbei[_dWZ[\_d_j_l[cWdd[h"
WdZj^[_dj[h_ehe\j^[cWdZ_Xb[X[Yec[iYed][ij[Z$
J^[ bWij h[cW_d_d] ZhW_dW][ fWj^mWo j^hek]^ j^[
c[djWbWhj[ho_iel[hbodWhhem$;l[dm^_b[j[[j^Wh[
ij_bb fh[i[dj" j^[ _dYh[Wi[ _d c_d[hWb_pWj_ed _d j^[
cWdZ_Xb[ m_bb i_]d_\_YWdjbo hW_i[ j^[ h[i_ijWdY[ je
$ISUSEÈ!TROPHYÈ"LOODÈ3UPPLYÈÈ
ANDÈ0ERIODONTALÈ0ROBLEMS
9edjhWho je W m_Z[ifh[WZ c_iYedY[fj_ed" `WmXed[i
i^em h[iehfj_ed dej X[YWki[ j^[o Wh[ ikX`[Yj[Z
je Z[djkh[ fh[iikh[" Xkj X[YWki[ j^[o ik\\[h
\hec kdZ[hdekh_i^c[dj YecX_d[Z m_j^ W bWYa e\
ZhW_dW][$(Fh[iikh["WiWhkb["Yh[Wj[iXed[$
J^[ eXi[hlWj_ed j^Wj j^[ l[hj_YWb Xed[ lebkc[
fWhj_YkbWhbo _d j^[ feij[h_eh i[]c[dj e\ j^[
cWdZ_Xb[ hWf_Zbo Z[Yh[Wi[i W\j[h _di[hj_ed e\ W
Z[djkh[ 8bWjj[h\[_d WdZ FWod[ '/.+ ^Wi fhecfj[Z
[nfbWdWj_edi je j^[ [\\[Yj j^Wj j^[ Xed[ _iÆfki^[Z
WmWoÇ$ J^_i dej_ed e\ W Z[djkh[#h[bWj[Z fh[iikh[
Wjhef^oYedj_dk[ijeX[jWk]^jWjZ[djWbiY^eebiWdZ
_i\_hcbofbWdj[Z_dZ[dj_ijiÉ^[WZi"Z[if_j[j^[m[bb#
ademd \WYj j^Wj j^[h[ _i de h[bWj_edi^_f X[jm[[d
j^[ ikh\WY[ Wh[W e\ j^[ Z[djkh[ XWi[ WdZ j^[ [nj[dj
e\ Wjhef^o" Wbj^ek]^ ikY^ W h[bWj_edi^_f mekbZ X[
be]_YWb_\j^[fh[iikh[f[hikh\WY[kd_jm[h[Wh[b[lWdj
\WYjehIk[dW]W[jWb$'//-$
9edi[gk[djbo"j^[h[ZkYj_ed_dXed[lebkc[_idej
Zk[jej^[Y^[m_d]fh[iikh[XkjjeWYecX_dWj_ede\
_dZ_l_ZkWb \WYjehi ikY^ Wi bWYa e\ _djhWXedo XbeeZ
ikffbo_dj^[WXi[dY[e\WZhW_dW][fWj^mWo\hecj^[
Yh[ijWbckYeiW"m^_Y^W\\[Yjif[h_eij[Wbh[][d[hWj_ed$
IkXi[gk[djbo" j^[ cWdZ_XkbWh Whj[ho m_bb X[ ceh[
ikiY[fj_Xb[j^Wdceijej^[hWhj[h_[ijeiYb[hei_iWdZ
fWhj_Wb Ybeikh[ 8hWZb[o '/-+$ J^_i _i fWhj_YkbWhbo
jhk[W\j[hj^[j[[j^^Wl[X[[d[njhWYj[Z$J^_iWhj[ho_i
WhekdZ'+o[WhiW^[WZe\j^[cW`ehYWhej_ZWhj[ho_d
j[hcie\_jiZ[]h[[e\iYb[hei_i$J^[h[\eh["j^[Y[djhWb
XbeeZ ikffbo je j^[ cWdZ_Xb[ m_bb X[ i_]d_\_YWdjbo
h[ZkY[Z fWhj_YkbWhbo _d i_jkWj_edi e\ WZlWdY[Z
h[iehfj_edC[hY_[hWdZL_d[j'/.)$<ebbem_d]jeej^
beii"j^[Xed[#ij_ckbWj_d]\kdYj_edWbed]j^[Z[djWb
heeji _i ]ed[" ie j^Wj j^[ Wbl[ebWh `Wm Wh[Wi m_bb
i_cfbo ikYYkcX je Z_iki[ Wjhef^o$ J^[ h[Wied m^o
j^[XbeeZikffbojej^[cWdZ_Xb[_i]h[Wjboh[ZkY[Z
_i j^Wj de ceh[ ZhW_dW][ fWj^mWoi Wh[ fh[i[dj
\ebbem_d] jeej^ beii$ M^_b[ j[[j^ Wh[ fh[i[dj" j^[
XbeeZijh[Wc je j^[ cWdZ_Xb[ _i Z_ijh_Xkj[Z je j^[
( ?\Xed[h[Wbbom[h[ jeh[iehXkdZ[hfh[iikh["j^[Xed[i _d
ekh\[[jmekbZ^Wl[jeX[i^h_da_d]ÄfWhj_YkbWhboj^[^[[b
Xed[ F[efb[ mekbZ X[ Xko_d] icWbb[h i^e[i WdZ i^ehj[h
jheki[hiedWh[]kbWhXWi_i$
_djhWlWiWb fh[iikh[ e\ j^[ cWdZ_XkbWh Whj[ho _d j^[
*j^Z[YWZ[e\b_\["iej^Wjj^[Z_h[Yj_ede\j^[XbeeZ
ikffbo cWo YedY[_lWXbo X[ h[l[hi[Z" j^ki ]e_d]
\hec j^[ f[h_f^[ho je j^[ Y[djh[" _d iec[ f[efb[$
?d^[Wl_boh[iehX[ZcWdZ_Xb[i_$[$_dj^[h[cW_d_d]
XWiWbi[]c[dji_j_iademdWdomWoj^Wjj^[Xkbae\
j^[XbeeZikffbo_i]k_Z[Z\hecj^[f[h_f^[hWbped[
j^hek]^ j^[ f[h_eij[kc$ ?d ej^[h mehZi" W dkcX[h
e\fe_djiYWdX[cWZ[jeikffehjj^[dej_edj^Wjj^[
fWjj[hde\XbeeZikffboY^Wd][i_dj^[mWa[e\Xed[
beiiWbed]j^[Wbl[ebWhYh[ij$J^[cW_dfkhfei[e\j^[
[nj[di_l[ _djhWXedo XbeeZ ikffbo" m^_Y^ _i m_j^ekj
fWhWbb[b _d j^[ ^kcWd ia[b[jed" _i je dekh_i^ j^[
j[[j^WdZje\_]^jWdo_d\[Yj_ediWiieY_Wj[Zm_j^j^[_h
fh[i[dY[$ Ej^[hm_i[" j^[ cWdZ_XkbWh Whj[ho mekbZ
^Wl[ je Yecckd_YWj[ m_j^ j^[ ÆcWdZ_XkbWh l[_dÇ
W\j[hj^[j[hc_dWbXhWdY^[iWdZYWf_bbWh_[iYedjW_d[Z
_dj^[j[[j^WdZf[h_eZedj_kc^Wl[X[[dbeij$
7]W_dijj^[XWYa]hekdZekjb_d[ZWXel["ed[e\j^[
[ii[dj_WbfheXb[cim_j^Yh[ijWb_cfbWdji_dh[iehX[Z
h_Z][i Wff[Whi je X[ j^Wj j^[ _dj[h_eh XbeeZ ikffbo
d[[Z[Z je e\\[h _cckd[ Z[\[dY[ WdZ [deiiWb \ehY[
jhWdic_ii_ed^WiX[[dWbceijehYecfb[j[boZhW_d[Z
Xo j^[ j_c[ e\ _cfbWdj fbWY[c[dj$ 8E? _cfbWdji"
Xo YedjhWij" cW_dbo h[gk_h[ j^[ f[h_eij[Wb XbeeZ
ikffbo WdZ ZhW_dW][ je X[ _dj[]hWj[Z WdZ \eh \ehY[
jhWdic_ii_edjeX[ikffehj[Z$J^_iXbeeZikffbom_bb
X[WlW_bWXb[[gkWbbom[bbWjWdoW]["[l[d_di_jkWj_edi
e\ WZlWdY[Z h_Z][ h[iehfj_ed$ Ceh[ _cfehjWdjbo"
_j YWd X[ h[]kbWj[Z ckY^ X[jj[h WdZ \Wij[h j^Wd
j^[ _djhWXedo XbeeZ ikffbo e\ j^[ cWn_bbW WdZ
cWdZ_Xb[$
7do h[celWXb[ h[ijehWj_edi _di[hj[Z _d j^[
feij[h_eh i[]c[dj m_bb _d\bk[dY[ `Wm cel[c[dji
Xo i_]d_\_YWdjbo h[ZkY_d] j^[ l[hj_YWb hWd][ e\
cWij_YWjeho cel[c[dji WdZ h[ZkY_d] j^[ bWj[hWb
[nYkhi_edi_dWcWjj[he\edboWhekdZ(o[WhiJWbb]h[d
[j Wb$ '/./$ J^[i[ \kdYj_edWb Wbj[hWj_edi m_bb ]_l[
h_i[ je j^[ gkWb_jWj_l[ Y^Wd][i _d `Wm cehf^ebe]o
Yeccedbo eXi[hl[Z _d fWj_[dji m[Wh_d] Z[djkh[i$
I_c_bWh h[ikbji Wh[ i[[d m^[d j^[ eYYbkiWb jWXb[ ed
\_n[Zh[ijehWj_edi_iicWbb$
9edl[hi[bo" j^[ iWc[ \kdYj_edWb Wbj[hWj_edi
YWd ]_l[ h_i[ je W ]W_d _d Xed[ lebkc[ W\j[h 8E?
jh[Wjc[dj$ J^[ h[WZ[h _i h[\[hh[Z je 9^Wfj[h/$) \eh
Wd[n^Wkij_l[Z_iYkii_ede\j^_ic[Y^Wd_ic$
È È 0ROPERTIESÈOFÈ"ONEÈ4ISSUEÈINÈTHEÈORALÈ%NVIRONMENTÈ
;l_Z[dY[ \eh j^[ [n_ij[dY[ e\ W h[bWj_edi^_f
X[jm[[d ZhW_dW][ YedZ_j_edi WdZ Xed[ lebkc[ ^Wi
X[[dfhel_Z[ZXoOW\\[[jWb$'//*"m^ekd_bWj[hWbbo
ceX_b_p[Z ckYef[h_eij[Wb \bWfi _d j^[ cWdZ_Xb[i
e\ hWji" m^_Y^ m[h[ j^[d _cc[Z_Wj[bo h[fei_j_ed[Z
m_j^ekj ikjkh_d] W\j[h edbo )&i$ J^[ `Wmi m[h[
^_ijebe]_YWbbo \ebbem[Z kf Xo YecfWh_d] Xej^ i_Z[i
W\j[h )" -" '&" (' WdZ '(&ZWoi$ CWii_l[ h[iehfj_ed e\
j^[ Wbl[ebWh WdZ [dZeij[Wb Xed[ mWi fh[i[dj W\j[h
edbo '&ZWoi$ J^[ _cfh[ii_l[ f_Yjkh[i _d j^Wj h[fehj
Yb[Whbo i^em ^em ckY^ _dj[hdWb ZWcW][ YWd X[
YWki[Z Xo [nj[hdWb \bWf \ehcWj_ed _\ de ZhW_d_d]
eij[ejeco_ib[\jW\j[hYbei_d]j^[\bWf$8_bWj[hWb_$[$
b_d]kWb WdZ l[ij_XkbWh \bWfi h[ikbj[Z _d W ]h[Wj[h
Z[]h[[ e\ h[iehfj_ed j^Wd kd_bWj[hWb \bWfi" Wi j^[
XbeeZijh[Wc_iYkje\\Wbje][j^[h$7\j[h'(&ZWoi"j^[
Wbl[ebWh h_Z][i m[h[ bWh][bo h[ijeh[Z$ ?j \ebbemi j^Wj
j^_i Wjhef^o e\ _dj[hdWb Xed[ ijhkYjkh[i _i Zk[ je
_dik\\_Y_[dj ZhW_dW][" m^_Y^ _d jkhd m_bb YWki[ j^[
_dYec_d]XbeeZikffbojeX[h[ZkY[ZWim[bb"j^[h[Xo
YWki_d]kdZ[hdkjh_j_ed$J^[ef[dibeji\ebbem_d]j^[
_di[hj_ede\8E?_cfbWdjiWh[fh[ikcWXboYWfWXb[e\
fh[l[dj_d]j^_iijWi_i$
È
!SPECTSÈOFÈ0ERIODONTALÈ$ISEASE
:kh_d] j^[ Z[l[befc[dj e\ f[h_eZedj_j_i" j^[
el[hfh[iikh[ ][d[hWj[Z Xo j^[ [nj[hdWb f[h_eZedjWb
j_iik[Wff[WhijeeXijhkYjZhW_dW][\hecj^[_dj[h_eh
e\j^[Xed["m^_Y^[l[djkWbbob[WZijeWZ[b[j[h_eki
ijWj[ e\ ijWi_i$ MWd] [j Wb$ (&&) i^em[Z j^Wj j^[
Wl[hW][ _dj[hij_j_Wb fh[iikh[ m_bb X[ [b[lWj[Z _d
i_jkWj_edie\l[dekiijWi_iWdZj^kicWo_d\bk[dY[Wj
b[Wijj^[\ehcWj_ede\f[h_eij[WbXed[$
?d WZZ_j_ed je Z_h[Yjbo _d\bk[dY_d] XWYj[h_Wb
Ykbjkh[i" Z[djWb kbjhWied_Y j^[hWfo WffWh[djbo ^Wi W
c[Y^Wd_YWb[\\[Yjedj^_iijWi_iWdZ^[bfijeh[ijeh[
h[]kbWh\bemYedZ_j_edifWhj_YkbWhbo_dj^ei[h[]_edi
j^Wj Wh[ dej ikX`[Yj je j^[ h^oj^c_YWb XbeeZijh[Wc
Ä _$[$ _d j^[ eij[edWb ijhkYjkh[i m^[h[ j^[ _dj[hdWb
\beme\dkjh_[djiWdZmWij[fheZkYjiWh[Yedl[o[ZXo
YWf_bbWhoWYj_edWdZc[Y^Wd_YWbZ[\ehcWj_ede\j^[
Xed[$$J^[h[Wiedm^of[h_#_cfbWdj_j_ij^[hWfoe\j[d
\W_bicWoX[j^Wjj^[hek]^ikh\WY[iWh[h[#fefkbWj[Z
Xoc_Yheeh]Wd_iciWbh[WZoZkh_d]j^[^[Wb_d]f^Wi[
j^Wj m_bb _cc[Z_Wj[bo [d^WdY[ j^[ XbeeZ ikffbo
WdZY[bbkbWh]hWdkbWj_ed"j^[h[Xo_cf[Z_d]ZhW_dW][$
9ecfh[ii_ediYh[mi\[Wjkh_d]m_Z[m_dZ_d]ic_]^j
j^[h[\eh[X[b[iiikiY[fj_Xb[jef[h_#_cfbWdj_j_ij^Wd
ieb_Z iYh[m _cfbWdji" Wi j^[ \bWdai e\ j^[ m_dZ_d]i
m_bbZ_h[Yjj^[_djhWXedoXbeeZijh[WcWmWo\hecj^[
_cfbWdj$ Ceh[el[h" eii[e_dj[]hWj_ed _i iodedoceki
m_j^ l[hj_YWb Yehj_YWb_pWj_ed _d Yh[ijWb _cfbWdj
Z[i_]di$ >em[l[h" i_dY[ Yehj_YWb Xed[ ijhkYjkh[i
Z[Y[b[hWj[j^[\beme\XbeeZWdZdkjh_[dji"f[h_eij[Wb
dekh_i^c[djWdZf[h_eij[WbZhW_dW][Wh[_cfehjWdj"
'&/
Xkj j^[o Wh[ WkjecWj_YWbbo Z_ihkfj[Z W\j[h ikh]_YWb
jh[Wjc[dj e\ f[h_eZedj_j_i m_j^ \bWfi$ 7hekdZ
_cfbWdji"j^[jhWdifehje\dkjh_[dji_i]h[Wjbo_cf[Z[Z
Xo j^[ _cfbWdj _ji[b\" j^[ XbeYaW][ Z[f[dZ_d] ed
j^[_hZ_Wc[j[hWdZb[d]j^$I^ehj_cfbWdji\[Wjkh_d]
ikh\WY[ij^WjWbbem_dj[hdWbf[h\ki_ed[$]$Eii[efeh[
_cfbWdji ^Wl[ X[[d ikYY[ii\kbbo [cfbeo[Z Xej^ _d
Z[djWb _cfbWdjebe]o WdZ _d ehj^efW[Z_Y ikh][ho$
J^[i[ Z[i_]di el[hYec[ j^[ fheXb[c e\ dkjh_[dj
Yedl[oWdY[ Xo ^Wl_d] W f[hc[WXb[ ikh\WY[$ J^[
bed][h j^[i[ _cfbWdji" j^[ b[ii b_a[bo j^[o m_bb ikh#
l_l[" i_dY[ j^[ f[h\ki_ed [\\[Yj _i h[ZkY[Z m_j^
_dYh[Wi_d]b[d]j^"WdZc_d[hWb_pWj_ed_dj^[_dj[h\WY[
Wh[W _i h[ZkY[Z Wi m[bb Wi Xed[ Wh[Wi e\ Z_\\[h[dj
cWYhejhW`[Yjeh_Wb eh_[djWj_ed Wh[ Yheii[Z Xo j^[
_cfbWdj$
7i ieed Wi fbWgk[#_dZkY[Z ]_d]_l_j_i h[ikbji _d
W im[bb_d] e\ j^[ ]kci" j^[h[ _i W h_ia j^Wj j^[ \bem
e\ XbeeZ \hec j^[ f[h_eZedjWb f[h\ki_ed ifWY[ _i
^Wbj[ZehWjb[Wij_cf[Z[Z$?\j^_i^Wff[di"WdZ_\j^[
f[h\ki_ed e\ j^[ Xed[ _i Yecfhec_i[Z Wi W h[ikbj"
]_d]_l_j_i m_bb jkhd f[h_eZedj_j_i" WYYecfWd_[Z
Xo W Xed[ h[WYj_ed Wjhef^o YWki[Z Xo h[ZkY[Z
f[h\ki_ed$ 7j j^[ iWc[ j_c[" j^[ beYWb f> Y^Wd][i"
WdZ_cckdebe]_YWbYecf[j[dY[_iZ[Yh[Wi[Z$
<eh j^[ h[Wiedi ijWj[Z WXel[" m[ h[]WhZ _j Wi Wd
ef[d gk[ij_ed m^[j^[h XWYj[h_W Wh[ h[Wbbo YWki#
Wbbo _dlebl[Z _d j^[ fhe]h[ii_ed e\ f[h_eZedj_j_i
_d j^[ mWo m[ Wh[ jWk]^j je j^_da$ N_c[d[p [j
Wb$ (&&& i^em[Z j^Wj j^[ XWYj[h_Wb Yecfei_j_ed
eXi[hl[Z _d f[h_eZedjWb feYa[ji _i Wbie fh[i[dj _d
j^[ ikfhW]_d]_lWb fbWgk[ e\ fWj_[dji m_j^ ^[Wbj^o
f[h_eZedj_kc$ 7\j[h Wbb" _j mekbZ X[ YedY[_lWXb[
j^Wj j^ei[ effehjkd_ij_Y c_Yheeh]Wd_ici cWo
X[ WjjhWYj[Z Xo j^[ Z[]hWZWj_ed fheZkYji e\ j^[
_dYh[Wi_d]bokdZ[hdekh_i^[Zf[h_eZedjWbfeYa[jWdZ
cWo WZlWdY[ Z[[f[h \eh Z_\\[h[dj h[Wiedi Wj W bWj[h
j_c[$ ?d ej^[h mehZi" j^[ ijWi_i j^Wj m_bb [l[djkWbbo
]_l[ h_i[ je Xed[ h[iehfj_ed cWo X[ YWki[Z Xo W
]_d]_l_j_i#h[bWj[Zfh[iikh[h[l[hiWb_dj^[f[h_f^[hWb
f[h_eZedjWbl[ii[bi$8omWoe\WdWbe]o"deeXi[hl[h
mekbZWiikc[j^Wjj^[lkbjkh[ii_jj_d]edWZ[WZ]dk
_dj^[7\h_YWdiWlWddW^^Wl[WYjkWbboa_bb[Zj^[]dk$
9khh[dj f[h_eZedjebe]_YWb j^_da_d] Ze[i" ^em[l[h"
Wiikc[ j^Wj j^[ Xed[ _i WYjkWbbo WjjWYa[Z eh Xo j^[
XWYj[h_W$ Dem" m^_b[ j^[h[ _i de ZekXj j^Wj XWYj[h_W
m_bb\WY_b_jWj[j^[fhe]h[ii_ede\f[h_eZedjWbZ_i[Wi["
j^[h[Wh[dkc[heki_dZ_YWj_ediWh]k_d]W]W_dijj^[_h
YWkiWbheb[_dXed[h[iehfj_ed$
?j_im[bbademdj^Wjj^[WdY^ehW][e\\kdYj_edWb
j[[j^ _d j^[_h Xedo X[Z _i _dYh[Wi_d]bo beij Wi
f[h_eZedjWb Z_i[Wi[ fhe]h[ii[i$ 7i W Yedi[gk[dY["
c_YheY_hYkbWj_ed_ih[ZkY[Z$Be]_delWWdZAh[Y^_dW
'//. i^em[Z j^Wj c_YheY_hYkbWj_ed \ebbem_d] j^[
edi[j e\ cWij_YWjeho \kdYj_ed Wi Wii[ii[Z m_j^
Y^[m_d] ]kc _dYh[Wi[Z Xo -& _d j^[ WXi[dY[ e\
f[h_eZedjWbZ_i[Wi[$?dceZ[hWj[Z_i[Wi["j^[_dYh[Wi[
''& 9^Wfj[h/È &OUR
$IMENSIONALÈ#ONSIDERATIONSÈOFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS
mWi '/Ä)'$ ?d YWi[i e\ i[l[h[ Z[[f f[h_eZedj_j_i"
^em[l[h" j^[ i_jkWj_ed mWi h[l[hi[Z" _$[$ Y_hYkbWj_ed
mekbZ[l[dZ[Yh[Wi[Xo,Be]_delWWdZAh[Y^_dW
'//.$J^[Wkj^ehiWjjh_Xkj[Zj^_i\_dZ_d]jeY^Wd][i
_d lWiYkbWh c_Yhe#WhY^_j[Yjkh[ _dlebl_d]" Wced]
ej^[h j^_d]i" W h[l[hi[Z fh[iikh[ h[bWj_edi^_f _d
j^[f[h_eZedjWbl[ii[bi$?dj^_ii_jkWj_ed"j^[Yh[ijWb
i[]c[djie\j^[f[h_eZedj_kcWh[ikffb_[Z\hecj^[
f[h_eij[kc WdZ ckYeiW" m^_b[ j^[ XWiWb i[]c[dji
Yedj_dk[ je X[ ikffb_[Z \hec j^[ [deiiWb ifWY[$
KdZ[hdehcWbfh[iikh[YedZ_j_edi"j^[[deiiWbXbeeZ
ikffbo mekbZ ZhW_d je j^[ f[h_eij[kc WdZ ckYeiW"
Xkj _d j^[ if[Y_\_Y i_jkWj_ed e\ WYkj[ _d\[Yj_ed"
ZhW_dW][ _i eXijhkYj[Z Xo j^[ _dj[hdWb fh[iikh[
_dYh[Wi[ _d j^[ Yh[ijWb f[h_eZedj_kc$ J^[h[\eh["
f[h_eZedj_j_i _i [ii[dj_Wbbo W Z_i[Wi[ _d m^_Y^ j^[
Xed[ _i Z[fb[j[Z e\ dkjh_[dji Wi j^[ XbeeZ \bem _i
kdZ[hc_d[Z Xo XbeYa_d] j^[ ZhW_dW][$ J^[ lebkc[
e\ j^[ kdZ[hdekh_i^[Z Xed[ ijhkYjkh[i _i h[ZkY[Z
WdZ _j m_bb X[ h[fbWY[Z Xo ie\j#j_iik[ ijhkYjkh[i$
J^[i[j_iik[iWh[ikiY[fj_Xb[je_d\bWccWj_edYWki[Z
Xoj^[dkc[hekiZ[]hWZWj_edfheZkYjie\j^[Xed[
_d][d[hWb[dpoc[i"[jY$WdZj^[eij[eboi_i#h[bWj[Z
^_]^ _ed b[l[bi _d fWhj_YkbWh$ J^[ d[mbo \ehc[Z
f[h_eZedjWbj_iik[ijhkYjkh[iWjj^[Z[fb[j[ZWbl[ebWh
Yh[ijWh["_dj^[_hjkhd"dejfWhj_YkbWhbom[bbik_j[Zje
h[iehX j^[i[ cWii_l[ _ed YedY[djhWj_edi WdZ Xed[
Z[]hWZWj_ed fheZkYji$ ?d ehZ[h je [dikh[ ZhW_dW][
e\j^[i[fheZkYji"j^[XbeeZY_hYkbWj_edj^hek]^j^[
Yh[ijWb f[h_eZedj_kc d[[Zi je X[ _dYh[Wi[Z" m^_Y^
X[Yec[iYb_d_YWbbocWd_\[ijWiW^[_]^j[d[ZXb[[Z_d]
j[dZ[dYo$
Iec[ _dZ_YWj_edi je j^_i [\\[Yj Wh[ ademd je
Wbb Z[dj_iji$ M^[d[l[h j[[j^ ikhhekdZ[Z Xo
bWh][ ]hWdkbecWjeki h[]_edi Wh[ [njhWYj[Z" j^[
]hWdkbecWjekij_iik[m_bbXb[[Z^[Wl_bo$J^[Xb[[Z_d]
m_bbijefgk_YaboedY[j^[]hWdkbecWj_iik[^WiX[[d
h[cel[Z$ J^ki j^[ Xb[[Z_d] eh_]_dWj[i dej _d j^[
Xed[Xkj_dj^[ie\jj_iik[$J^[Xed[\h[gk[djboi^emi
bWh][ Yh_Xh_\ehc ef[d_d]i _d j^[ YedjWYj Wh[W m_j^
j^[]hWdkbecWm_j^ekjXb[[Z_d]\hecj^[i[ef[d_d]i
m^[dj^_ij_iik[_ih[cel[Z$J^[iWc[[\\[YjYWdX[
eXi[hl[ZWjY^_bZX_hj^m^[h[kj[h_d[^W[cehh^W][_i
ijeff[Zgk_YaboW\j[hj^[fbWY[djW^WiX[[dZ_ibeZ][Z1
_\j^[i[fWhWj_ed"^em[l[h"\W_bieh_i_dYecfb[j["j^[
^W[cehh^W][ cWo f[hi_ij je j^[ fe_dj e\ X[Yec_d]
b_\[#j^h[Wj[d_d]$ 8b[[Z_d] \hec j^[ fbWY[djW _ji[b\
_i d[]b_]_Xb[ X[YWki[ j^[ bkc[d e\ j^[ XbeeZijh[Wc
\hec j^[ d[mXehd eh]Wd_ic _i jee icWbb" m^_Y^ _i
i_c_bWhjej^[XbeeZikffboi_jkWj_ed_dj^[`WmXed[1
j^[ fh[iikh[ _i j^ki jee bem WdZ" ceh[ _cfehjWdjbo"
YWddej X[ h[]kbWj[Z kfmWhZ$ ?d fbWY[djW" i[fWhWj[
XbeeZijh[Wci Wh[ [nY^Wd][Z Wj j^[ _dj[h\WY[$ @Wm
]hWdkbecWi"XoYecfWh_ied"XWi_YWbboij[c\heced[
i_d]b[XbeeZijh[Wc"Xkjj^[fh[iikh[h[bWj_edi^_fi_d
j^[ Wh[W e\ j^[ j[hc_dWb XhWdY^[i Wh[ ikY^ j^Wj j^[
fh[iikh[Yec_d]\hecj^[ie\jj_iik[fh[lW_bi$J^_i_i
j^[YWki[e\j^[fhe]h[ii_l[Z[l[befc[djkd\ebZ_d]
jemWhZij^[Xed["Xkjeh_]_dWj_d]Wjj^[ie\jj_iik[i$
J^[WdY_[djm_iZece\Xed[ikh][edi"¼=eZfhej[Yj
ki \hec j^[ ie\j j_iik[i½" [nfh[ii[i j^[ h[Ye]d_j_ed
j^Wj j^[ Xed[ _ji[b\ _i W h[b_WXb[ fWhjd[h e\ ekh
_cfbWdjebe]_YWbmeha"Xkjj^Wjj^[Z[l[befc[djWdZ
j^[^[Wb_d]fheY[iie\j^[ie\jj_iik[iWh[e\j[dYWki[
\eh YedY[hd$ J^_i _i [gkWbbo jhk[ _d f[h_eZedjebe]o"
m^[h[ j^[ Z_ifbWY[c[dj e\ j^[ ^WhZ j_iik[i Xo j^[
fheb_\[hWj_d] ie\j j_iik[i _i j^[ l[ho [ii[dY[ e\ j^[
Z_i[Wi[$8ed["WiWhkb["jeb[hWj[ib[iidkjh_j_edWdZW
bWYae\eno][dX[jj[hj^WdjeeckY^e\Xej^$
J^[ Xed[ _i dehcWbbo kdWXb[" \eh WdWjec_YWb
h[Wiedi" je Y^Wd][ _ji _dj[hdWb XbeeZ ikffbo$ M[
ZekXjj^WjXed[j^Wj_iWim[bb#f[h\ki[ZWiie\jj_iik[
YekbZ h[cW_d ^_]^bo c_d[hWb_p[Z WdZ j^Wj _j mekbZ
h[cW_d W ikXijWdY[ m^_Y^ mekbZ X[ h[Ye]d_p[Z Wi
¼Xed[½WjWbb$?ji[[cib_a[boj^Wjel[hbeWZeij[eboi_i
WjZ_iafbWj[ieYYkhiZk[je^_]^f[h\ki_ed_d_j_Wj[Z
Xo j^[ ^[Wb_d] fheY[ii W\j[h dkc[heki YhWYai ^Wl[
eYYkhh[Z _d j^[ iWc[ h[]_ed e\ j^[ Yehj_YWb Xed[$
7d WYYkckbWj_ed e\ fehei_j_[i Zk[ je fhedekdY[Z
h[ceZ[bb_d]cWoWbieYedjh_Xkj[jej^[Z[l[befc[dj
e\Yehj_YWbZ[\[Yjie\j^_ijof[$
Gk_j[ W \[m gk[ij_edi h[cW_d ef[d WXekj j^[
dWjkh[e\Xed[Wjj^[dWdeiYWb[$?j_iYb[Whj^Wjj^[
ceb[YkbWh ijhkYjkh[ e\ Xed[ _i h[ifedi_Xb[ \eh j^[
ijh[d]j^e\j^[\_dWbfheZkYjBWdZ_i'//+1>kW`_Wd[j
Wb$(&&)$J^_icWo_cfbo"^em[l[h"j^Wjj^[m_Z[boki[Z
[d]_d[[h_d] YedY[fj e\ ijh[ii YedY[djhWj_ed Wj \bWm
beYWj_edicWodejX[Wffb_YWXb[Wjj^[b[l[be\j^ei[
dWdefWhj_Yb[ie\m^_Y^Xed[Yedi_iji$J^[h[ikbjie\
j^[_dl[ij_]Wj_ediWdZ_Z[Wie\<heijfh[i[djbo\ehc
Wik\\_Y_[djXWi_i\ehj^[_cfbWdjebe]_ijÉimeham_j^_d
j^[`WmXed[i$
È
2OLEÈOFÈ$IRECTÈ"ONEÈ3TIMULATIONÈÈ
INÈ#RESTALÈ)MPLANTS
<hec jeZWoÉi lWdjW][ fe_dj" _j _i ZekXj\kb j^Wj
l[hj_YWbbo eii[e_dj[]hWj[Z _cfbWdj ikh\WY[i YWd
ij_ckbWj[ j^[ Xed[ ik\\_Y_[djbo je [dikh[ j^Wj j^[
Xed[lebkc[_icW_djW_d[Z$7jb[Wij_dj^[YebbWhWh[W"
j^[\ehY[ij^WjmekbZYWki[j^[Xed[jeh[c_d[hWb_p[
m_bb e\j[d X[ m[Wa[h j^Wd j^[ \ehY[i fhecej_d]
Z[c_d[hWb_pWj_edWiWYedi[gk[dY[e\XWYj[h_WbWjjWYa$
J^_i fheY[ii ]_l[i h_i[ je j^[ YhWj[h#ijob[ YebbWfi[i
i[[d m_j^ Yh[ijWb _cfbWdji$ ?d ehZ[h je fh[l[dj
XWYj[h_Wbh[j[dj_ed"iec[Yh[ijWb_cfbWdjjof[iYec[
m_j^ W ^oXh_Z Z[i_]d _d m^_Y^ j^[ Yh[ijWb i[]c[dji
Ze dej \[Wjkh[ ikh\WY[ [dbWh][c[dj$ J^[i[ Z[i_]di
^Wl[cW_dboX[[dki[Z\eh_cfbWdjim_j^l[hoicWbb
j^h[WZi WdZ m_j^ekj ^eh_pedjWb beWZ#jhWdic_jj_d]
ikh\WY[i$ <hec j^[ \WYj j^Wj j^[i[ iceej^ ikh\WY[i
Wh[dejYWfWXb[e\jhWdic_jj_d]beWZi"_j\ebbemij^Wj
[l[d _cfbWdji \[Wjkh_d] l[hj_YWb beWZ#jhWdic_jj_d]
È È 0ROPERTIESÈOFÈ"ONEÈ4ISSUEÈINÈTHEÈORALÈ%NVIRONMENTÈ
ikh\WY[i d[[Z je kdZ[h]e XWiWb eii[e_dj[]hWj_ed _\
j^[o Wh[ je ikhl_l[ _d Wd [dl_hedc[dj b_a[ j^[ `Wm
Y^WhWYj[h_p[ZXo^_]^XWYj[h_WbbeWZi$
7bj^ek]^ [b[Yjh_Y fej[dj_Wbi Wh[ ademd je X[
YWfWXb[e\_d\bk[dY_d]j^[c[Y^Wd_icWdZZ_h[Yj_ed
e\ Xed[ ^[Wb_d]" _j ^Wi dej X[[d Z[cedijhWj[Z j^Wj
[b[YjhecW]d[j_Y \_[bZi Wffb_[Z Z_h[Yjbo ed j_jWd_kc
_cfbWdjiYWdfhecej[¼^[Wb_d]½e\j^[f[h_#_cfbWdj
Xed[ijhkYjkh[i8kppW[jWb$(&&)$
È
'''
m_j^ ekh c[Y^Wd_ij_Y j^_da_d] WdZ cWj^[cWj_YWb
ioij[ci ikY^ Wi <;C ceZ[bi" i_dY[ Wbb j^[i[
WffheWY^[i\W_bjeWYYekdj\ehj^[\kppoX[^Wl_ekhe\
b_l[Xed[$C[Y^Wd_YWbj[ij_d]e\Xed[fhef[hj_[im_bb
f[hi[_dZkY[Xed[h[ceZ[bb_d]"j^[h[XoYWki_d]j^[
c[Y^Wd_YWbfhef[hj_[ijeY^Wd][$
È
#LINICALÈ!PPLICATION
J^[ ^_]^ Yb_d_YWb h[b[lWdY[ e\ j^[ &Ä' fhef[hjo
X[Yec[iYb[Wh_\m[Yedi_Z[hj^[\ebbem_d]fe_dji0
v M^[d j^[ _cfbWdj _i _di[hj[Z _dje j^[ Xed[" j^[
&ORCEÈ$EFORMATIONÈ0RESSUREÈANDÈ&LOW
7i8CKiWh[\ehc[Z"j^[Xed[X[Yec[iceh[feheki
WdZj^kib[iih[i_ijWdj$J^[Z[]h[[e\c_d[hWb_pWj_ed
_d h[ceZ[bb[Z Xed[ _i (&Ä)+ bem[h j^Wd _d \kbbo
c_d[hWb_p[Z fh_cWho Xed[ ijhkYjkh[i$ J^[ beii _d
j[di_b[ ijh[d]j^ _i ]h[Wj[h j^Wd j^[ beii _d i^[Wh
ijh[d]j^$M^[dj^[[bWij_YhWd][_i[nY[[Z[Z"fbWij_Y
Z[\ehcWj_edm_bbeYYkh[l[d_deij[edWbXed["WdZ_j
m_bbeYYkh[Whb_[h_dh[ceZ[bb[ZWh[Wi$J^[WjjW_dWXb[
b[l[be\fbWij_YZ[\ehcWj_ed_i^_]^[ij_\j^[Z_h[Yj_ed
e\ j^[ _dYec_d] beWZ _i fWhWbb[b je j^[ eij[edi$ ?\
Wd [gk_lWb[dj beWZ c[[ji j^[ eij[edi Wn_Wbbo" j^[
WjjW_dWXb[b[l[be\fbWij_YZ[\ehcWj_ed_iicWbb[h$
Eij[edWbf[h\ki_ed_iYWki[ZXoj^[fh[iikh[WdZ
\h[gk[dYo e\ XbeeZ Y_hYkbWj_ed '&cc >] Wj (>p
WdZckiYb[YedjhWYj_ed)&cc>]Wj'>p1j^[ceij
_cfehjWdj Wif[Yj" ^em[l[h" _i c[Y^Wd_YWb beWZ_d]
'&&c_YheijW_d Wj '>p$ 9Wf_bbWho \ehY[i fbWo W
heb[ Wi m[bb MWd] [j Wb$ '///$ F[hc[WX_b_jo WYheii
Y[c[dj b_d[i _i" ^em[l[h" _hh[b[lWdj$ 7d _dYh[Wi[ e\
ijh[ii YoYb[i f[h j_c[ kd_j m_bb" ^em[l[h" h[ikbj _d W
ceh[ fhedekdY[Z \bk_Z fh[iikh[ ]hWZ_[dj d[Wh j^[
eij[edWbYWdWbi$
È
4HEÈnÈ0ROPERTYÈANDÈTHEÈ3ELF
4RABECULATIONÈ
-ODELÈnÈ-ICROMODELLING
8ed[ _i W cWj[h_Wb j^Wj _i YWfWXb[ e\ Z[l[bef_d] W
jhWX[YkbWhijhkYjkh[Xo_ji[b\$8ed[_iWbieYWfWXb[e\
Y^Wd]_d] j^[ Z_ijh_Xkj_ed e\ j^[ beWZ jhWdic_ii_ed
jWia X[jm[[d Z_\\[h[dj Wh[Wi _di_Z[ j^[ Xed[ eh
m_j^_d j^[ Yehj_YWb Xed[ Ckbb[dZ[h [j Wb$ '//*$ 7
^ofej^[j_YWb f[h\[Yjbo ^ece][d[eki _iejhef_Y Xed[
XbeYa mekbZ X[Yec[ _dYh[Wi_d]bo Wd_iejhef_Y ed
X[_d]ikX`[Yj[Zje\kdYj_edWbbeWZ_d]$?dj^_ifheY[ii"
_jmekbZZ[l[befXej^Wh[Wie\^[_]^j[d[ZWdZWh[Wi
e\h[ZkY[Zc_d[hWb_pWj_ed$J^_iX[^Wl_ekh_iademd
Wi j^[ ¼&Ä' fhef[hjo½$ J^_i X[^Wl_ekh _i WYjkWbbo
gk_j[WcWp_d]"Wij^[YedjWYjWh[Wie\j^[jhWX[YkbW["
_\\ehfkh[bocWj^[cWj_YWbYedi_Z[hWj_edi"Wh[WbmWoi
b_a[bojeX[WiieY_Wj[Zm_j^f[Waijh[ii[iWdZ^[dY[
m_j^ eij[eboj_Y j[dZ[dY_[i$ J^_i [\\[Yj" m^_Y^ _i
ademd Wi ¼Y^[Ya[hXeWhZ_d]½" Yb[Whbo _dZ_YWj[i j^Wj
m[Wh[kdWXb[jeYWfjkh[j^[jhk[Yhkne\j^[cWjj[h
cWYhejhW`[Yjeh_[i_dj^[ibejWh[WWh[_dj[hhkfj[Z$
?dj^[^[Wb_d]f^Wi["j^[i_jkWj_edcWoWh_i[j^Wj
j^[Xed[Wh[Wid[Whj^[Z_iaWh[c_d[hWb_p[ZX[jj[h
j^Wdj^[_cc[Z_Wj[Wh[We\_di[hj_edZk[jei[b\#
jhWX[YkbWj_ede\j^[Yehj_YWbXed[$?dej^[hmehZi"
j^[ _cc[Z_Wj[ Wh[W e\ _di[hj_ed X[Yec[i j^[ &#
Wh[W"m^_b[Wh[Wi_dj^[[nj[dZ[Zl_Y_d_joX[Yec[
'#Wh[Wi$ J^[ h_ia j^Wj j^_i i_jkWj_ed cWo Wh_i[
_i icWbb[h _d j^[ cWdZ_Xb[ j^Wd _d j^[ cWn_bbW$
J^[ ijh[ii#h[bWj[Z c_d[hWb_pWj_ed fh[iikh[ _d j^[
cWdZ_Xb[_i^_]^[hWjijhWj[]_Y_cfbWdjfei_j_edi$
v M^[d[l[h W bWh][ dkcX[h e\ _cfbWdji Wh[
_di[hj[Z _d j^[ cWn_bbW fWhj_YkbWhbo jh_fb[#Z_ia
ehZekXb[#Z_ia8E?_cfbWdji_dYed`kdYj_edm_j^
bed]iYh[mi"j^[l[ij_XkbWhcWYhejhW`[Yjeh_[iWh[
bWh][boZ[ijheo[Z"WdZW^[Wb_d]fheY[ii[dik[ij^Wj
_ikdZ[\_d[Z_dj[hcie\jhW`[Yjehoeh_[djWj_edWdZ
_dm^_Y^j^[[\\[Yjie\j^[_cfbWdjikh\WY[fh[lW_b$
8_ec[Y^Wd_YWbbo" j^[ i_jkWj_ed YWd X[ YecfWh[Z
je j^[ ]hW\j_d] e\ bWh][ Xed[ XbeYai [$]$ \hec
j^[iakbb$8ed[]hW\jie\j^_ijof[Wh[dejikX`[Yj
je Wdo Z[\_d[Z \kdYj_ed Zkh_d] ^[Wb_d] [_j^[h$
J^[h[\eh[" _cfbWdji je X[ beWZ[Z Wj W bWj[h j_c[
YWd XWi_YWbbo X[ _di[hj[Z h_]^j WmWo _d j^[ iWc[
i[ii_ed$ >em[l[h" jh[Wjc[dj m_j^ 8E? _cfbWdji
e\\[hi ]h[Wj[h WZlWdjW][i YecfWh[Z je ]hW\j_d]
X[YWki[ j^[i[ _cfbWdji Wh[ _di[hj[Z _dje dWj_l[
l_jWb Xed[ j^Wj m_bb h[Yel[h _ji cWYhejhW`[Yjeh_Wb
fhef[hj_[i\Wij[h$
v J^[Wd_iejhef_Yfhef[hj_[ie\Xed[Wh[cWii_l[bo
Y^Wd][Zehd[kjhWb_p[ZXo_di[hj_d]8E?_cfbWdji
_d bWh][ dkcX[hi" ie j^Wj j^[ Xed[ X[Yec[i
l_hjkWbbo_iejhef_Y$M^[dj^[Wd_iejhef_Yfhef[hj_[i
Wh[ bWj[h h[Yel[h[Z" iec[ fehj_edi e\ j^[ 8E?
Z_iai eh [l[d j^[ _cfbWdji j^[ci[bl[i Yec[ je
X[ beYWj[Z _d '#Wh[Wi" m^_b[ ej^[h fWhji m_bb X[
beYWj[Z _d &#Wh[Wi$ J^_i m_bb" e\ Yekhi[" _d\bk[dY[
j^[ Yb_d_YWb ceX_b_jo e\ _dZ_l_ZkWb _cfbWdji$ 7i
\kdYj_edWb Wbj[hWj_edi Yedl[hj_d] '#Wh[Wi je &#
Wh[Wi WdZ l_Y[ l[hiW Wh[ WbmWoi feii_Xb[ el[h
j^[ o[Whi" _cfbWdj ceX_b_jo Ze[i dej Y^Wd][ j^[
fheXWX_b_joe\_cfbWdjikhl_lWb_dWdoi_]d_\_YWdj
cWdd[h$ J^[h[\eh[" _j jWa[i W bej e\ [nf[h_[dY[
je Wffh[Y_Wj[ m^[j^[h W 8E? _cfbWdj i^ekbZ X[
h[cel[Z$
''( 9^Wfj[h/È &OUR
$IMENSIONALÈ#ONSIDERATIONSÈOFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS

v 7iWZZ_j_edWb_cfbWdjiWh[fbWY[Zd[njjeib_]^jbo v ?\ 8E? _cfbWdji Wh[ _di[hj[Z _cc[Z_Wj[bo W\j[h

ceX_b[ W_b_d] 8E? _cfbWdji" j^[ d[mbo \ehc_d]
cWYhejhW`[Yjeh_[iWh[Z[ijheo[ZedY[W]W_d"m^_Y^
m_bb dehcWbbo h[ikbj _d Xej^ XWiWb Z_iai X[_d]
_dj[]hWj[Z$7do ]hWdkbWj_ed j_iik[ j^Wj cWo ^Wl[
\ehc[Z dWjkhWbbo ^Wi je X[ h[cel[Z \hec j^[
ceX_b[ Z_ia$ 8ed[ ]hW\j_d] cWj[h_Wb YWd Wbie
X[ WZZ[Z" fhel_Z[Z j^Wj j^[ ibej Wh[W Ze[i dej
Yecckd_YWj[ m_j^ j^[ ehWb YWl_jo$ J^[ bed][h
h[ceZ[bb_d] f^Wi[ e\ j^[ Xed[ ]hW\j_d] cWj[h_Wb
cWo" Wj b[Wij _d j^[eho" YWki[ j^[ Wh[W je X[ edY[ h[ZkYj_ed _i dej h[gk_h[Z \eh W[ij^[j_YWb h[Wiedi"
W]W_djhW`[Yjeh_WbboZ[cWhYWj[ZWiW&#Wh[W$
v J^[ &Ä' YedY[fj _i Wbie h[\b[Yj[Z _d _cfbWdj
Z[i_]di$ 9b_d_YWb h[ikbji ^WZ i^emd j^Wj ZekXb[#
Z_ia 8E? _cfbWdji m_j^ W Z_ia#je#Z_ia Z_ijWdY[
e\ )cc j[dZ[Z je ]_l[ h_i[ je Xed[ beii ed j^[
Yh[ijWb fbWj[ _d '&Ä(+ e\ Wbb YWi[i$ J^_i [\\[Yj
cWo^Wl[X[[dZk[jej^[\WYjj^Wjj^[jmefbWj[i
_dj[h\[h[Z m_j^ Xed[ ^[Wb_d] Wi j^[o Z[\_d[Z j^[
Z_h[Yj_ed e\ j^[ jhW`[Yjeh_[i$ <eh [nWcfb[" Xej^
fbWj[i cWo ^Wl[ ][d[hWj[Z el[hbo WZ`WY[dj '#
Wh[Wi$ J^[i[ fheXb[ci m[h[ de bed][h eXi[hl[Z
m^[d j^[ Z_ia#je#Z_ia Z_ijWdY[ mWi _dYh[Wi[Z
\hec)ccje+ccehm^[djmeZ_iaie\Z_\\[h[dj
h[i_b_[dY[m[h[ki[Zj^[Yh[ijWbZ_ia^Wi\[Wjkh[Z
edboed[m[XXWh[l[hi_dY[$
[njhWYj_ed" Y^WdY[i Wh[ j^Wj j^[ [dj_h[ Xed[ Wh[W
m_bb X[ h[ceZ[bb[Z Yecfb[j[bo WYYehZ_d] je d[m
cWYhejhW`[Yjeh_WbYh_j[h_W"iej^WjZ_h[Yj_dj[h\WY[
YedjWYj m_bb fh[lW_b _d j^[ [Whbo feijef[hWj_l[
f^Wi[$ J^_i m_bb fhecej[ _cfbWdj ^[Wb_d]$ ?j
_i _cfehjWdj" ^em[l[h" je h[ZkY[ fhejhkZ_d]
Wbl[ebWhmWbbi\hecl[ij_XkbWhZ_h[Yj_edi_dY[j^[
ieYa[jim_bbdejX[h[\_bb[Zm_j^Xed[jej^[iWc[
m_Zj^ j^Wd m^[d j^[ jeej^ mWi ij_bb fh[i[dj$ ?\
c[cXhWd[i cWo X[ Yedi_Z[h[Z Wi WZZ_j_edWb
jh[Wjc[dj efj_ed$ I[YedZWho Wk]c[djWj_ed _i
Wbie W ]eeZ jh[Wjc[dj Wbj[hdWj_l[$ J^[ j^h[WZ[Z
f_di ^Wl[ je X[ WZlWdY[Z \Wh _dje j^[ fWbWjWb
dWj_l[ Xed[" jWa_d] j^[ Wiocc[jh_YWb i^Wf[ e\
j^[ Wbl[ebWh Xed[ _dje Yedi_Z[hWj_ed$ 7 d[]Wj_l[
[\\[Yj ed j^[ fh[i[hlWj_ed e\ [gkWb cWij_YWj_ed
YWdX[[nf[Yj[Z\heckd_bWj[hWb[njhWYj_edi"Wij^[
cWij_YWjeho \ehY[i WdZ d[m Z_ijh_Xkj_ed e\
&# WdZ '#Wh[Wi m_bb iec[j_c[i _djhkZ[ ed j^[
_cfbWdj[Z i_Z[" Xkj ijWo_d] Yb[Wh e\ j^[ b[l[b
e\ j^[ YedjhWbWj[hWb i_Z[$ J^[h[\eh[" j^[i[ YWi[i
ckijX[WZ[gkWj[boWdZf[h_eZ_YWbbo\ebbem[Zkf$
Jh[Wjc[dj YedY[fji XWi[Z ed ckbj_fb[ _cfbWdji
d[[ZjeX[Yedi_Z[h[ZWim[bb$

A B

C D

&IGÈAnD J^[i[Z_W]hWcii^emWijh_Yjbo^eh_pedjWbjhW`[Yjeh_WbXed[i[]c[dj_djem^_Y^W8E?_cfbWdj_i_di[hj[ZA$M_j^_d
j^[\hWc[mehae\Xed[Z[\[Yj^[Wb_d]"j^[eh_[djWj_ede\j^WjfWhje\j^[Xed[Y^Wd][iB$J^_ic[Wdij^Wjj^[8E?_cfbWdjcWo
j[cfehWh_bo\_dZ_ji[b\_dWh[ceZ[bb_d]Wh[W&#Wh[WWdZX[Yec[ceX_b[AnC$>em[l[h"Wibed]Wij^[8E?_cfbWdjmWi_di[hj[Z
_djeWh[]_ede\j^[Xed[j^Wjm_bbh[cW_dijWXb[_dj^[bed]j[hc"j^[Xed[Wh[WibeYWj[ZWhekdZj^[XWiWbfbWj[m_bbh[c_d[hWb_p[
WdZkd_j[je\ehcWd[mcWYhejhW`[Yjeho"WdZj^[_cfbWdjm_bbijWX_b_p[D$J^[Xh_Z][ckija[[fWbb[nj[hdWb\ehY[iYedijWdj
WdZm_j^_dWYY[fjWXb[Z_c[di_edi$?dj[hdWbijhkYjkhWbY^Wd][i_dj^[`WmXed[m_bbdejWbmWoih[ikbj_dY^Wd][i_di^Wf[j^WjWh[
[Wi_boZ_iY[hd_Xb[\hecekji_Z[
È ÈÈ &ORMÈ&OLLOWSÈ&UNCTIONÈ '')

v½ ?\ceX_b[Z_iaWh[WiWh[eXi[hl[Zfh_cWh_bo_dj^[
l[ij_XkbWhWif[Yje\j^[Z_ijWbcWn_bbW"WZZ_j_edWb
l[ij_XkbWh beWZ jhWdic_ii_ed Wh[Wi YWd X[ WZZ[Z
m_j^j^[^[bfe\Yb_fii[[<_]$($)*$J^_iWffheWY^
jWa[iWZlWdjW][e\d[WhXo'#Wh[Wie\j^[Xed[WdZ
[dWXb[i d[m Xed[ \ehcWj_ed je jWa[ fbWY[ \hec
j^[i_j[e\Xb[[Z_d]0
J^[\ebbem_d]\WYjii^ekbZX[dej[Z_dj^_iYedj[nj0
7h[Wi Y^WhWYj[h_p[Z Xo bem[h c_d[hWb_pWj_ed YWd
Wbie^Wl[j^[_heh_]_d_die#YWbb[Z¼WY_Zh[]_edi½[$]$
_dj^[Wf_YWbh[]_ede\[dZeZedj_YWbbojh[Wj[Zj[[j^$
j^[Xed[^[Wb_d]fheY[iiWdZj^[h[Z_ijh_Xkj_ede\j^[
&#Wh[Wi WdZ '#Wh[Wi YWd X[ ij[[h[Z _d j^[ Z_h[Yj_ed
e\ W dehcWb Z_ijh_Xkj_ed$ 8_bWj[hWbbo _cXWbWdY[Z
cWij_YWj_ed" Xo YedjhWij" m_bb h[ikbj _d Wd Wjof_YWb
Z_ijh_Xkj_ede\c_d[hWb_pWj_edped[i$
È
&ORMÈ&OLLOWSÈ&UNCTION
8JMM
;VSJDI
TUPQ
BU
UIJT
USBJO
"MCFSU
&JOTUFJO

J^[i[ Xed[ Wh[Wi Wh[ kdWXb[ je jhWdic_j Wdo beWZi$

?d j^[_h fbWY[" ej^[h Xed[ Wh[Wi cWjkh[ je \ehc '#
Wh[Wi"m^_b[o[jej^[hiZ[l[bef_dje&#Wh[Wi$<hecW
X_ec[Y^Wd_YWbfe_dje\l_[m"j^[d"_jZe[idejcWa[
WZ_\\[h[dY[_\W&#ped[Z[l[befiX[YWki[e\[nY[ii_l[
\b[n_ed_$[$fhedekdY[Zh[ceZ[bb_d]ehX[YWki[e\
^of[hWY_Z_\_YWj_edehY^Wd][i_dlWiYkbWh_pWj_ed$
J^[Z[l[befc[dje\&#Wh[WicWoY^Wd][j^[beWZ
jhWdic_ii_ed fWj^i WYheii j^[ [dj_h[ `Wm" [l[d je
j^[ fe_dj m^[h[ j^[ ikhl_lWb e\ _cfbWdji cWo X[ Wj
ijWa[$ ?\ _cfbWdji _d '#Wh[Wi ikZZ[dbo [dZ kf _d &#
Wh[Wi" j^[_h ijWX_b_jo ckij ik\\[h$ J^_i _d jkhd cWo
^Wl[ d[]Wj_l[ Yedi[gk[dY[i \eh j^[ ijWX_b_jo e\ j^[
[dj_h[ ikf[hijhkYjkh[ WdZ _dZ[[Z feii_Xbo [l[d j^[
effei_d]`Wm$Jeiec[[nj[dj"j^[Z_ijh_Xkj_ede\&#
Wh[WiWdZ'#Wh[WiYWdX[Z_W]dei[Zfh[ef[hWj_l[boXo
hWZ_e]hWf^_Y[nWc_dWj_ed$>em[l[h"j^[fh[ef[hWj_l[
Z_ijh_Xkj_ed e\ j^[i[ Wh[Wi m_bb X[ Y^Wd][Z Xo j^[
eij[ejeco e\ j^[ _cfbWdjWj_ed fheY[ii" m_j^ j^[
c[jWXeb_Y i_jkWj_ed e\ j^[ Xed[ Y^Wd]_d] Wi m[bb
ikffkhWj_ed%ZhW_dW]["i[[9^Wfj[h.$
?\ j^[ cWij_YWjeho \kdYj_ed _i [gk_b_XhWj[Z ieed
W\j[h_cfbWdjWj_ed"\eh[nWcfb[Xo_cc[Z_Wj[beWZ_d]"
J^_i Y^Wfj[h m_bb Y[hjW_dbo X[ j^[ ceij _dj[h[ij_d]
fWhj e\ j^[ Xeea \eh j^[ ademb[Z][WXb[ h[WZ[h" Wi
j^[ Z[djWb b_j[hWjkh[ Ze[i dej YedjW_d W ]h[Wj cWdo
iodefj_Y Z_iYkii_edi e\ j^[ \WYji ^[h[_d Z[iYh_X[Z$
J^[ YedYbki_edi ZhWmd \hec j^[i[ eXi[hlWj_edi"
_\ Wffb_[Z _d W Yedi_ij[dj cWdd[h" mekbZ _cfWYj
kfed j^[ [dj_h[ \_[bZ e\ Z[dj_ijho WdZ mekbZ YWbb
_dje gk[ij_ed cWdo Wif[Yji e\ m^Wj m[ ^Wl[ Yec[
je h[]WhZ Wi X[ij fhWYj_Y[ _d ekh [l[hoZWo Yb_d_YWb
meha _dje gk[ij_ed$ J^[ Yecf_bWj_ed e\ _dZ_l_ZkWb
\WYjehi_dj^[c_ZZb[e\j^[Y^Wfj[hm_bbfhel_Z[j^[
h[WZ[h m_j^ ceh[ \eeZ \eh j^ek]^j Xkj m_bb jWa[ W
]h[WjWcekdje\Yb_d_YWbf[hY[fj_l[d[iiWdZj[Y^d_YWb
Z[nj[h_jo je X[ _cfb[c[dj[Z$ J^[ gkejWj_ed WXel[
Y^WhWYj[h_p[i j^[ j^[eho e\ h[bWj_l_jo$ M_j^ h[]WhZ
je j^[ cehf^ebe]_YWb Y^Wd][i YWki[Z Xo Z[djWb
_cfbWdjebe]oWdZikXi[gk[djfheij^[j_Yi"m[c_]^j
mWdj je ki[ W Z_\\[h[dj mehZ_d]0 M^[h[ _i j^[ h[Wb
h[\[h[dY[fe_djm_j^_dj^[`WmXed[i5
CWo j^[ gkejWj_ed WXel[ i^Whf[d j^[ h[WZ[hÈi
WmWh[d[iie\j^[Yedi[gk[dY[ie\WXiebkj[h[bWj_l_jo
WdZ e\ j^[ Wbb#[cXhWY_d] _dj[hZ[f[dZ[dY[ e\ Wbb

A B C
&IGÈAnC 7dej^[h Wif[Yj e\ j^[ i[b\#jhWX[YkbWj_ed ceZ[b e\ j^[ Xed[ _i eXi[hl[Z _\ cWij_YWjeho beWZi Wh[ Wffb_[Z l_W
Wiocc[jh_YWb8E?_cfbWdji1Wi^emij^[i_jkWj_edm_j^WXWbWdY[ZbeWZ0j^[j^_Yad[iie\j^[Yehj_YWbj_iik[ih[cW_dikdY^Wd][Z
_dj^[bed]j[hcXej^edj^[b[\jWdZh_]^ji_Z[i$7iocc[jh_YWb8E?_cfbWdji_dYh[Wi[j^[beWZedj^[i_Z[edm^_Y^j^[Z_ia_i
i^ehj[h"Yh[Wj_d]ceh[Xed["[l[dWbbem_d]j^[i_Z[j^Wj_ib[ii^[Wl_bobeWZ[Z^[h[0h_]^ji_Z[jeZ[l[bef_djeWd&#Wh[W$J^_i
i_jkWj_ed_ie\j[d\ekdZ_dj^[cWn_bbW_dj^[h[]_edie\j^[i[YedZfh[cebWhehj^[\_hijcebWh
''* 9^Wfj[h/È &OUR
$IMENSIONALÈ#ONSIDERATIONSÈOFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS
Y^Wd][i_d`Wmim_j^_djWYjZ[dj_j_ediWdZ_d`WmXed[i
m_j^ _cfbWdj#ikffehj[Z h[ijehWj_edi$ :k[ je j^[
]hWZkWb Z[l[befc[dj e\ cehf^ebe]_YWb Y^Wd][i"
Z[dj_iji WdZ fWj_[dji Wh[ e\j[d dej WmWh[ e\ j^[_h
[nj[di_l[_cfb_YWj_edi$7iWh[ikbj"j^[i[Y^Wd][iWh[
dej\ebbem[Zkffhef[hbo"WdZj^[oWh[kj_b_p[ZckY^
jeehWh[bo\ehj^[hWf[kj_Yfkhfei[i$
EkhZW_bomeham_j^8E?^WijWk]^jkije\eYkiekh
Wjj[dj_ed fh_cWh_bo ed cWij_YWjeho \kdYj_ed" i_dY[
j^[heb[e\cWij_YWj_ed_ickY^ceh[_cfehjWdjj^Wd
j^[ YedY[fj e\ ijWj_Y eYYbki_ed$ J^[ Z_\\[h[dY[i e\
8E?YecfWh[ZjeYedl[dj_edWbfheij^[j_YWffheWY^[i
h[bo_d] ed dWjkhWb j[[j^ WdZ Yh[ijWb _cfbWdji Wh[
ikXijWdj_Wb$<eh[nWcfb["j^[ki[\kbd[iie\h[ZkY_d]
j^[m_Zj^e\_cfbWdj#ikffehj[Zj[[j^^Wid[l[hX[[d
Z[cedijhWj[Z" Wbj^ek]^ j^[ Z[cWdZ ^Wi \h[gk[djbo
X[[dhW_i[ZC[h_Yia[#Ij[hd(&&&$
?di_jkWj_edim^[h[m[bb#WdY^eh[Zj[[j^m_j^bed]
heejiehbed]Yh[ijWb_cfbWdjiWh[WlW_bWXb[_dWZ[gkWj[
dkcX[hi"j^[fe_djiZ_iYkii[Z_dj^_iY^Wfj[hc_]^j
i[[c dej Wbb j^Wj _cfehjWdj$ 7\j[h Wbb" bed]#bWij_d]
ijhkYjkh[i _$[$ ijhkYjkh[i bWij_d] ekj j^[ mWhhWdjo
f[h_eZ YWd X[ Xk_bj ed \ekdZWj_edi b_a[ j^_i [l[d
m^[dWdocWij_YWjehoYedi_Z[hWj_ediWh[Yecfb[j[bo
_]deh[Z$D[l[hj^[b[ii"WdoiYh[m\hWYjkh[i"fehY[bW_d
Y^_ff_d]"f[h_eZedjWbjeej^ceX_b_joWdZ%eh_cfbWdji
beijm_bb_dZ_YWj[j^Wj\ehY[iWh[fh[i[djj^WjWh[dej
jeb[hWj[Z m[bb eh j^Wj X_ec[Y^Wd_YWb Z[l[befc[dji
Zedeji[[cjekd\ebZWYYehZ_d]jefbWd$
7domWo" j^[ 8E? _cfbWdjebe]_ij hWh[bo ][ji je
mehakdZ[hikY^\WlekhWXb[YedZ_j_ediXkj_ikikWbbo
\WY[ZXoWZlWdY[Zl[hj_YWbh_Z][h[iehfj_edWbbem_d]
edbo [njh[c[bo icWbb \ehY[#jhWdic_jj_d] Wh[Wi je
X[ _di[hj[Z _dje j^[ Xed[$ J^[h[\eh[" Wdo [nY[ii_l[
fheij^[j_YbeWZ_d]d[[ZijeX[Wle_Z[Zeh[b_c_dWj[Z$
Ed j^[ ej^[h ^WdZ" 8E? _cfbWdji m_bb Wbbem iec[
\h[[Zecm_j^h[]WhZjej^[b[d]j^WdZdWjkh[e\j^[
Y^[m_d]ikh\WY[i$
?dWZZ_j_ed"j^[[\\[Yjie\j^[cWij_YWjeho\kdYj_ed
edXed[cehf^ebe]od[[ZjeX[Yedi_Z[h[ZWim[bb$
J^[\ebbem_d]b_ijfhel_Z[iiec[\eeZ\ehj^ek]^j0
v @Wm Wh[Wi j^Wj Wh[ dej f[h i[ ij_ckbWj[Z Xo j^[
beWZ#jhWdic_jj_d]Z_iaiWh[d[l[hj^[b[iiikX`[Yj[Z
je \kdYj_edWb beWZ_d]$ ?d j^[ fh[i[dY[ e\ [gkWb
ckiYb[ \kdYj_ed ed Xej^ i_Z[i e\ j^[ `Wm" Wdo
cehf^ebe]_YWbZ_\\[h[dY[iWh[ibembo[l[d[Zekj$
7i W fh[h[gk_i_j[" j^[ fheij^[j_Y h[ijehWj_ed ^Wi
je[dikh[WX_bWj[hWbbokd_\ehc\kdYj_edY^[m_d]
\kdYj_ed"dkcX[he\Y^[m_d]ikh\WY[i"b[d]j^WdZ
fei_j_ed e\ Y^[m_d] ikh\WY[i" ckiYb[ \kdYj_ed
WdZ" Xo _cfb_YWj_ed" ckiYb[ ijh[d]j^$ ?d ehZ[h
je cW_djW_d j^_i XWbWdY[Z \kdYj_ed" eYYbkiWb
WZ`kijc[dji ^Wl[ je X[ f[h\ehc[Z ed W h[]kbWh
XWi_i$
v J^[ h_]_Z Xh_Z][ m_bb X[Yec[ fWhj e\ j^[ ioij[c
_ji[b\ WdZ WYj_l[bo Y^Wd][ _ji cehf^ebe]_YWb
ikhhekdZ_d]$?\"\eh[nWcfb["Yecfb[j[Xh_Z][iWh[
_di[hj[Z_dje`Wmij^WjWh[l[hoZ_ii_c_bWh_di^Wf["
WfheY[iie\cehf^ebe]_YWbWii_c_bWj_edm_bbjWa[
fbWY[$ :kh_d] j^_i fheY[ii" j^[ eii[e_dj[]hWj[Z
_cfbWdji Wh[ ikX`[Yj[Z je Yedi_Z[hWXb[ ijh[ii$
FWj_[dji j^[ci[bl[i c_]^j dej dej_Y[ j^_i ijh[ii
Wi"[$]$ikXWYkj[×fW_dÆ$Iec[fWj_[djim_bbdej_Y[
j^[ j[di_ed Wi ieed Wi j^[ Xh_Z][ _i j[cfehWh_bo
h[cel[Z$
v Fh_cWhoh[ij_jkj_ed_dj^[^[Wb_d]f^Wi[\ebbem_d]
_cfbWdj fbWY[c[dj" dejWXbo _d j^[ cWdZ_Xb[" _i
WY^_[l[ZXoZ[fei_j_ede\f[h_eij[WbXed[edj^[
ed[ ^WdZ" WdZ Xo \ehcWj_ed e\ mel[d Xed[ _d
j^[ eij[ejeco ibeji ed j^[ ej^[h$ IkXi[gk[djbo"
j^[ eij[edWb X[bj _i h[Xk_bj Xo 8CK jkdd[bb_d]
WYheiij^[`Wm"m^_Y^demkdZ[h]e[iWfheY[iie\
j^ehek]^h[ceZ[bb_d]$?dYh[Wi_d]Y^[m_d]\ehY[i
WdZ Y^Wd]_d] cWij_YWjeho fWjj[hdi m_bb Wbie
fhecfj j^[ `Wm je Y^Wd][ _ji cehf^ebe]o$ J^[
fWj_[djih[fehji_c_bWhijh[ii[iWifWj_[djim[Wh_d]
\h[i^boh[WZ`kij[Z\_n[Zehj^eZedj_YWffb_WdY[i$
v 7h[Wi j^Wj ^WZ X[[d h[ZkY[Z _d h[ifedi[ je j^[
_di[hj_ed e\ Z[djkh[i Wh[ WXb[ je Z[l[bef _d Wbb
Z_h[Yj_ediZ[\_d[ZXoj^[ceZ_\_[Z\kdYj_ed$J^ki
j^[oYWdWbieZ[l[befjemWhZij^[eYYbkiWbWif[Yj
i[[ 9^Wfj[h/$) \eh W ceh[ Z[jW_b[Z Z_iYkii_ed"
fhel_Z[Z j^Wj j^[ ij_ckbki _i dej fh[#[cfj[Z
Xo ijhed][h ij_ckb_ Yec_d] \hec j^[ fheij^[j_Y
ikf[hijhkYjkh[ eh _cfbWdji$ 7i W YWi[ _d fe_dj"
[nfWdi_ed Wffei_j_ed%ceZ[bbWj_ed e\ j^[ Xed[
_dYh[ijWbZ_h[Yj_ed"m^_Y^mekbZX[feii_Xb[\hec
W \kdYj_edWb ijWdZfe_dj" _i j^mWhj[Z Xo Y^hed_Y
f[h_#_cfbWdj_j_i_dj^[fh[i[dY[e\bWh][#Z_Wc[j[h
Yh[ijWb _cfbWdji" Xkj Wbie Xo j^[ el[hbo Z[[f WdZ
Y^hed_YWbbo_d\[Yj[ZjhWdi_j_edped[iX[jm[[dj^[
WXkjc[djiWdZj^ei[_cfbWdji$J^_i_idejj^[YWi[
m_j^8E?_cfbWdji"Wim[i^Wbbb[Whd_dj^[i[Yj_ed
ed^_ijebe]o$
v FWhj_YkbWh Wjj[dj_ed ckij j^[h[\eh[ X[ Z[lej[Z
je YWi[i _d m^_Y^ j^[ beWZ#jhWdic_jj_d] ikh\WY[i
e\ 8E? _cfbWdji Yec[ je X[ beYWj[Z _d Xed[
&IGÈ Fh[ef[hWj_l[ Yb_d_YWb i_jkWj_ed$ J^[ cWn_bbWho _i
h[ijeh[Z m_j^ W Yecfb[j[ Z[djkh[1 W Yheii#X_j[ ^Wi X[[d
WZ`kij[Zedj^[h_]^j$DWjkhWbZ[dj_j_ed_dj^[h_]^jcWdZ_Xb["
fWhj_WbZ[djkh[_dj^[b[\jcWdZ_Xb[ikffehj[ZXoWYbWifed
j^[c[i_WbWdZXof[h_eZedj_kcedj^[Z_ijWb[dZ
È È &ORMÈ&OLLOWSÈ&UNCTIONÈ ''+

A B

&IGÈÈA J^[feijef[hWj_l[i_jkWj_ed_iY^WhWYj[h_p[ZXoYedi_Z[hWXb[l[hj_YWbZ_\\[h[dY[im_j^_dj^[cWdZ_Xb[$?\j^[h[i_ZkWb
dWjkhWbjeej^_ifh[i[hl[Z"_jm_bbX[_cfeii_Xb[jeXWbWdY[j^[lebkc[Xoh[ZkY_d]j^[h_]^ji_Z["Wij^_imekbZYWki[j^[jeej^
je_djhkZ[$7YYehZ_d]bo"j^[lebkc[e\j^[b[\jhWcki^WijeX[_dYh[Wi[Z$ B 7jj^[fWj_[djÉih[gk[ij"jeej^*)mWib[\j_dfbWY[
\ehj^[fh_cWho\_n[Zh[ijehWj_ed$J^[Xh_Z][_dYbkZ[iWYWij\hWc[mehaWdZ_iYel[h[Zm_j^fehY[bW_d$Dej[j^[c_Zb_d[i^_\j"
m^_Y^_iWbh[WZoh[\b[Yj[Z_dj^[Xed[ijhkYjkh[$<eh\kdYj_edWbh[Wiedi"j^[Wh[W**Ä*,^WZkdZ[h]ed[ikXijWdj_Wbh[iehfj_ed
m_j^_d W i^ehj j_c[" ]_l_d] j^[ Xedo ikhhekdZ_d]i e\ j^[ heeji e\ jeej^ *) W fhec_d[dj Wff[WhWdY[$ J^[ jeej^ ^Wi W l[ho
[nfei[Zfei_j_ed$ C J^[Yehj_YWbXed[edj^[l[ij_XkbWhWif[Yje\jeej^*)_i[njh[c[boj^_dd[ZekjWdZfWhj_Wbbo\[d[ijhWj[Z$
D[l[hj^[b[ii"j^_ijeej^mWia[fjkdj_bj^[d[m[gk_b_Xh_kc_dj^[cWij_YWj_edmWi\ekdZ

&IGÈ Jeej^*)mWi[l[djkWbboh[fbWY[Zm_j^Wdej^[h8E?
_cfbWdj fh_eh je _di[hj_d] j^[ i[YedZ Xh_Z][ X[YWki[ _j mWi
b_a[bo je ikYYkcX je h[iehfj_ed ieed[h eh bWj[h Z[if_j[ j^[
Yedi_Z[hWXb[ij_ckbkiYec_d]\hecj^[f[h_eZedjWbb_]Wc[dj$ &IGÈ 8Wi[b_d[ EF=$ ;njh[c[ h[iehfj_ed ed j^[ b[\j1 j^[
Dej[ j^Wj j^[ Z_ijWb fedj_Yi ckij X[ beYWj[Z m[bb WXel[ j^[ h_]^jhWcki_i"_\Wdoj^_d]"^of[hjhef^_Y
ckYeiW" i_dY[ j^[ cWdZ_Xb[ _i ]e_d] je ]hem _d W Yh[ijWb
Z_h[Yj_ed"m^_Y^cWoh[ikbj_dfh[iikh[ifejiehb[l[h\ehY[i

Wh[Wi j^Wj m_bb kdZ[h]e h[bWj_l[ c_]hWj_ed _d j^[ e\\[h_d]l[hj_YWbYecf[diWj_edYec[_djefbWoWi

feijef[hWj_l[Yekhi[$:k[jej^[_heii[e_dj[]hWj_ed" m[bb"ikY^Wi[bed]Wj_ede\j^[cWdZ_XkbWhhWcki
j^[ _cfbWdji j^[ci[bl[i m_bb cel[ Wbed] m_j^ ehh[beYWj_ede\j^[WiieY_Wj[ZJC@$
j^[ Xed[$ M_j^ h[]WhZ je j^[ h[bWj_l[ l[hj_YWb v 8ed[ cehf^ebe]o Y^Wd][i Wi cWij_YWjeho \ehY[i
_dYh[Wi[ehc_]hWj_ede\j^[Yh[ijWbYehj_YWbXed[ Wh[ X[_d] h[ijeh[Z je j^[_h \kbb fej[dj_Wb$ J^[i[
_d j^[ Z_ijWb cWdZ_Xb[" j^_i c[Wdi j^Wj [nY[ii_l[ Y^Wd][i m_bb Z[f[dZ ed j^[ fWj_[djÈi W][ WdZ
fheij^[j_Y beWZ_d] cWo eYYkh _d j^_i Wh[W$ 7\j[h c[jWXeb_ic$ 7do Y^Wd][i _d Xed[ i^Wf[ WdZ
Wbb"fh[cWjkh[YedjWYjiWh[b_a[boje[c[h][Wij^[ \kdYj_ed" eh _d Xed[ \kdYj_ed Wbed[" _i \ebbem[Z
_cfbWdji c_]hWj[ kfmWhZi kdb[ii ej^[h \WYjehi Xo if[Y_\_Y Z[\_d[Z Y^Wd][i _d _dj[hdWb Xed[
'', 9^Wfj[h/È &OUR $IMENSIONALÈ#ONSIDERATIONSÈOFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS

&IGÈ EF= eXjW_d[Z W\j[h _di[hj_ed e\ j^[ i[YedZ

cWdZ_XkbWh Xh_Z][ WdZ h[ijehWj_ed e\ j^[ cWn_bbW$ J^[
fheY[ii e\ ckjkWb `Wm lebkc[ Yecf[diWj_ed YWd dem X[
WYYkhWj[boced_jeh[ZWdZd[[ZijeX[\WY_b_jWj[ZXof[h_eZ_Y
eYYbkiWb WZ`kijc[dji m_j^ WXhWi_l[ _dijhkc[dji [$]$ _d j^[
j^_hZ gkWZhWdj$ J^[ \_n[Z h[\[h[dY[ fe_dj e\ j^[i[ _cfbWdj#
h[ijehWj_ed ioij[ci _i j^[ eYYbkiWb fbWd[$ IfedjWd[eki
h[YedijhkYj_ed e\ j^[ l[hj_YWb Xed[ lebkc[ cWo jWa[ fbWY[
[_j^[h WXel[ j^[ Z_iai" eh j^[ _cfbWdj ^Wi je cel[ kfmWhZi
je][j^[h m_j^ j^[ ikhhekdZ_d] Xed[" m^_Y^ _i edbo feii_Xb[ &IGÈ 9hWd_WbF7YWbYkbWj[Zedj^[XWi_ie\j^[9JW\j[h
_\ Wd WZ[gkWj[ eYYbkiWb Yb[WhWdY[ _i [ijWXb_i^[Z Xo WXhWi_l[ jh[Wjc[dj$ Dej[ j^Wj edbo c_d_cWb h[i_ZkWb Xed[ _i fh[i[dj
_dijhkc[dji$ J^[ _cfbWdj Wj )) YWddej eii[e_dj[]hWj[ _d W _d j^[ cWn_bbW$ J^ei[ Xed[ Wh[Wi Wh[ h[i_ijWdj je \khj^[h
Z[\_d_j_l[ cWdd[h kdZ[h j^[i[ YedZ_j_edi$ ?j _i Yedj_dkekibo h[iehfj_ed X[YWki[ W cWYhe#jhW`[Yjeh_Wb Z[cWdZ \eh beWZ
kdZ[hijh[ii"m^_Y^_idej_Y[ZXoj^[fWj_[dj jhWdic_ii_edfh[l[djij^[_hh[iehfj_ed

&IGÈ J^[fedj_Yid[[ZjeX[f[h_eZ_YWbboh[ZkY[Z\hecW
XWiWbZ_h[Yj_ed

&IGÈ BWj[hWb j[b[hWZ_e]hWf^ W\j[h jh[Wjc[dj$ FWhj e\ j^[

Z[dj_j_ed _i dej WhhWd][Z WXel[ j^[ eii[e_dj[]hWj[Z ikffehj
Wh[Wi"m^_Y^h[gk_h[iYWh[\kbXWbWdY_d]

WhY^_j[Yjkh[ WdZ Xo [gkWbbo Z[\_d[Z i[YedZWho

&IGÈ 9J el[hl_[m el[h j^[ jhWdi#i_dki 8E? _cfbWdji _d
j^[feij[h_ehcWn_bbW
Y^Wd][i_d[nj[hdWbi^Wf[$7bbe\j^_i_i]el[hd[Z
Xo cWj^[cWj_YWb bWmi Meb\\ './($ M^_b[ j^[h[
_ideZekXjj^Wjj^_iijWj[c[dj_ijhk["_jh[cW_di
Yed\_d[Zjej^[Y^Wd][i]e_d]ed_di_Z[j^[Xed[$
J^[ h[ijehWj_l[ Z[dj_ij _i \WY[Z m_j^ W bed][h
Y^W_d e\ Yedi[gk[dY[i$ J^[ Y^Wd][Z Xed[ i^Wf[
_ib_a[bojeX[\ebbem[ZXoY^Wd][i_dj^[i^Wf[e\
È È &ORMÈ&OLLOWSÈ&UNCTIONÈ ''-

C D

&IGÈAnD 9ecfWh[Zjej^[XWi[b_d[f_Yjkh[eXjW_d[Z,o[Whifh[l_ekibo<_]i$/$''Ä/$')"j^[lebkc[e\j^[cWdZ_Xb[Wff[Whi
m[bbXWbWdY[Z"cW_dboWiWh[ikbje\Wk]c[djWj_ede\j^[b[\jhWcki$J^[_cfbWdji_dj^[b[\ji_Z[e\j^[`WmWh[Y^WhWYj[h_p[ZXo
Yh[ijWbXed[beii_$[$YebbWfi[[nj[dZ_d]jej^[Wh[Wj^WjYedij_jkj[ij^[WXiebkj[^eh_pedjWbb_d[e\j^_iXed[$7m^_j[Yh[ijWb
b_d[e\Yehj_YWbXed[^Wi\ehc[Zedj^[h_]^j1Wc_d[hWb_pWj_edped[[nYbkZ_d]j^[h[i_ZkWbh_Z][YWdX[eXi[hl[Zedj^[b[\j$
:[if_j[ÆYehh[YjÇ_ieYh[ijWb_di[hj_ed"Xed[beii^WieYYkhh[Z_dj^ei[Wh[Wim^[h[j^[Xed[cWiiWdZj^[b[l[be\j^[Yh[ij^Wl[
[l[d[ZekjZk[je\kdYj_edWb_d\bk[dY[i$>[dY[j^[_cfbWdjiedj^[h_]^jWh[Y^WhWYj[h_p[ZXofhe]h[ii_l[ÆXed[beiiÇ$):k[je
j^[h[bWj_l[kfmWhZc_]hWj_ede\j^[h_]^jhWckikdZ[hj^[iWc[fheij^[j_Yh[ijehWj_ed"j^[ceh[fb_WXb[Xed[ijhkYjkh[_dj^[
feij[h_ehi[]c[dje\j^[cWn_bbW^WiX[[d\ehY[Zjeh[]h[ii\hecYWkZWbZ_h[Yj_ed$ÆnÇ_dZ_YWj[ij^[Wh[We\beYWb_p[Zh[]h[ii_ed
WiWZ[djkh[#c[Z_Wj[ZWdim[hjeXed[Xk_bZkf_dj^[cWdZ_Xb["m^_b[j^[o[bbemb_d[cWhaij^[b[l[bWdZZ_h[Yj_ede\j^[cW_d
beWZ#jhWdic_jj_d]b_d[m_j^_dj^[jkXkbWhXed[$ A I_jkWj_edW\j[ho[Whie\m[Wh_d]WYbWif#ikffehj[Zkd_bWj[hWbfWhj_WbZ[djkh[$
J^[Xed[_dj^[Wh[We\j^[fh[cebWhi^WiX[[dfh[i[hl[Zj^WdaijebeWZjhWdic_ii_edj^hek]^j^[j[[j^$ B I_jkWj_edW\j[h
jeej^ [njhWYj_ed WdZ _di[hj_ed e\ i_n [deiiWb _cfbWdji je ikffehj W Xh_Z][ ikffehj[Z Xo _cfbWdji edbo$ J^[ i[YedZ _cfbWdj
\hecj^[b[\j_i\_jj[Zm_j^W^[Wb_d]YWf$7bb_cfbWdjim[h[_di[hj[ZWjj^[iWc[ÆYehh[YjÇYh[ijWbb[l[b$ C 7jj^[+#o[Wh\ebbem#
kf$ D M^Wjh[i[cXb[iWYhWj[h#jof[Xed[YebbWfi[Wj)*WdZ)+_ih[WbboZk[jeWfheY[iie\cehf^ebe]_YWbefj_c_pWj_ede\j^[
[dj_h[cWdZ_Xb[

JC@ ijhkYjkh[ WdZ _d ckiYb[ \kdYj_ed Y^[m_d]
ckiYb[i" d[Ya ckiYb[i" m^_Y^ m_bb edY[ W]W_d
_d\bk[dY[i^Wf[e\j^[Xed[$
v H[WYj_l[ c_]hWj_ed e\ j^[ JC@i _i \h[gk[djbo
eXi[hl[Zedboi[l[hWbcedj^iW\j[h8E?#ikffehj[Z
Yecfb[j[ h[ijehWj_edi m[h[ _dijWbb[Z$ E\ Yekhi["
ed[ c_]^j Yedj[dZ Wj j^_i fe_dj j^Wj j^[ Z[dj_ij
i_cfbocWo^Wl[X[[dkdWXb[jefhef[hboh[]_ij[h
j^[ eYYbki_ed$ 8Wi[Z ed ekh eXi[hlWj_edi" _j _i
)
8Wi[Z ed j^[ ijWdZWhZi ki[Z _d Yh[ijWb _cfbWdjebe]o" j^_i
YWi[_iY^WhWYj[h_p[ZXoXed[beiie\ceh[j^Wded[#j^_hZe\
j^[_cfbWdjb[d]j^_ded[#j^_hZe\Wbb_cfbWdji,o[WhiW\j[h
_cfbWdjWj_ed$ =e_d] Xo j^[i[ Yh_j[h_W" j^[ _cfbWdj ioij[c
mekbZ dej c[[j j^[ ijWdZWhZi e\ iY_[dj_\_Y Z[dj_ijho$ 7bie
i[[7bXh[ajied[jWb$'/.,$
ceh[ fbWki_Xb[ j^Wj j^[ JC@ ijhkYjkh[i cWo X[
Z[Yecfh[ii[ZWij^[`WmXed[_iX[_d]h[ceZ[bb[Z"
dejWXbo_d_jil[hj_YWbZ_c[di_ed$J^[Z_iaYWdj^ki
Y^Wd][ _ji fei_j_ed" WdZ j^[ cWij_YWjeho ioij[c
m_j^ _ji [l[h#fh[i[dj j[dZ[dYo e\ i[b\#^[Wb_d]
WYjkWbbo][jiWY^WdY[je[nfbe_jj^_ifej[dj_Wb$7j
Wdo hWj[" j^[ j[Y^d_gk[ e\ XWiWb eii[e_dj[]hWj_ed
e\\[hi kdfh[Y[Z[dj[Z feii_X_b_j_[i e\ \kdYj_edWb
j^[hWfo Xo Wbbem_d] beWZ jhWdic_ii_ed i_j[i
je X[ h[ijeh[Z _d j^[ Z_ijWb `Wm Wh[Wi" m^_Y^
Wh[ WdWjec_YWbbo Z[i_]d[Z je YWhho j^[ cW_d
XkhZ[de\cWij_YWj_ed$J^_ijof[e\j^[hWfo_idej
Yed\_d[Z je _d\bk[dY_d] ckiYkbWh ijhkYjkh[i Xkj
if[Y_\_YWbbo e\\[hi Wd effehjkd_jo \eh [nj[di_l[
Xed[h[ceZ[bb_d]"\ehXed[lebkc[Yecf[diWj_ed"
WdZ\eh_d\bk[dY_d]j^[X_ec[Y^Wd_YWbi_jkWj_ed_d
Wf^oi_ebe]_YWbcWdd[h$
''. 9^Wfj[h/È &OUR
$IMENSIONALÈ#ONSIDERATIONSÈOFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS
v 7i m[ i^Wbb b[Whd _d j^[ i[Yj_ed ed ^_ijebe]o"
cehf^ebe]o _i Wbie _d\bk[dY[Z Xo j^[ eij[ejeco
ibeji$ 8ed[ ibeji _di[hj[Z _dje Yedl[n Xed[
Wh[Wi m_bb h[_d\ehY[ j^[ Yedl[n_jo Wi j^[ Xed["
m^_Y^ _i Yedj_dkekibo a[fj kdZ[h j[di_ed Xo j^[
Y^[m_d]ckiYb[i"m_bb[bWij_YWbboo_[bZjej^[ibej$
IkXi[gk[djbo"j^[eh_]_dWbXed[cehf^ebe]om_bb
X[h[ijeh[ZXomWoe\ceZ[bb_d]Wij^[eij[ejeco
ibeji Wh[ X[_d] h[fW_h[Z$ I_dY[ h[ceZ[bb_d]
m_bb Wbie X[ ]e_d] ed _d WZZ_j_ed je ceZ[bb_d]"
c_d[hWb_pWj_ed _d j^[ W\\[Yj[Z `Wm Wh[Wi m_bb
Z[Yh[Wi[ Wj bWh][$ 7\j[h Wbb" j^[ jkdd[b#\ehc_d]
8CKm_bbWbie[nj[dZjem[bb#eii_\_[ZWh[Wi"j^[h[Xo
h[ZkY_d]j^[_heij[edWbZ[di_jo$?\[dj_h[`WmiWh[
jh[Wj[Zm_j^WbWh][dkcX[he\8E?_cfbWdji"j^[
el[hWbbc_d[hWb_pWj_edYWdX[[nf[Yj[ZjeY^Wd][
ZhWcWj_YWbbo$ Fh[ikcWXbo" j^[i[ [\\[Yji Wh[ ceh[
fhedekdY[Z_dj^[cWdZ_Xb[j^Wd_dj^[cWn_bbW$
v J^ki m[ Wh[ \WY[Z m_j^ W hWj^[h Yecfb[n ioij[c
e\ h[]kbWjeho c[Y^Wd_ici j^Wj Wh[ ]el[hd[Z
Xo j^[ bWmi e\ Xed[ \ehcWj_ed Xkj Wbie Xo j^[
d[khef^oi_ebe]_YWb h[]kbWjeho c[Y^Wd_ici e\
ckiYb[\kdYj_ed$8ej^c[Y^Wd_iciWh[dejf[hi[
Z_h[Yj[ZWjWYYecfb_i^_d]j^[Yb_d_YWbboZ[i_hWXb[
^[Wb_d]fheY[ii"Xkjj^[oiec[j_c[ih[gk_h[^[Wlo
Z[djWbWZ`kijc[djijeX[cWZ[$
v ?d j[hci e\ _ji Xedo WhY^_j[Yjkh[" j^[ cWdZ_Xb[
YWdX[YecfWh[ZjeWhWY^_j_Ybed]jkXkbWhXed[$
v J^[ c[Y^Wd_YWb fhef[hj_[i e\ Xed[ Wh[ cW_dbo W
\kdYj_ede\fehei_jo"Z[]h[[e\c_d[hWb_pWj_ed"WdZ
eh_[djWj_ed e\ YebbW][deki \_Xh[i$ Cehf^ebe]_YWb
Y^Wd][i h[ikbji \hec ckiYb[ \ehY[i WdZ j^[_h
[\\[Yjed_dZ_l_ZkWbWh[Wi$
v <hec jeZWoÉi ijWdZfe_dj" j^[ YedY[fj e\ Xed[
jhWdi\ehcWj_ed Wi eh_]_dWbbo Z[\_d[Z Xo Meb\\
_dYbkZ[ij^[\ebbem_d][b[c[dji0
Ä Efj_c_p_d]ijh[d]j^\ehm[_]^j
Ä 7hhWd]_d] jhWX[YkbW[ _d WYYehZWdY[ m_j^ j^[
cW_dj^hkije\\ehY[i
Ä 7kjeh[]kbWj_ed e\ Xed[ ijhkYjkh[i Xo Y[bbi
h[WYj_d]jec[Y^Wd_YWbijh[ii
v J^[ Xed[ _d_j_Wbbo h[Xk_bj _d l[hj_YWb Z_h[Yj_ed _i




Y^WhWYj[h_p[ZXofehei_j_[ij^WjWh[l_i_Xb[jej^[
dWa[Z[o["Wjb[Wij_dj^[ikf[h\_Y_WbWh[W"_dZ_YWj_d]
j^Wj Z_\\[h[dj b[l[bi e\ ij_ckbWj_ed ^Wi jWa[d
fbWY[ Wj Z_\\[h[dj i_j[i$ 8ed[ \ehcWj_ed _i beYWbbo
[nY[ii_l[$ Fh_dY_fWb \ehY[ Z_h[Yj_edi Wh[ \ehc[Z
Xo h[ceZ[bb_d] edbo bWj[h$ J^_i h[ceZ[bb_d] YWd
edbo Yec[ je fWii _\ j^[ d[mbo \ehc[Z Wh[Wi Wh[
c[Y^Wd_YWbbo Y^Wbb[d][Z" _$[$ _\ j^[o Wh[ fkj _dje




ÆYb_d_YWbi[hl_Y[Ç$
v 8oeXi[hl_d]j^[ijh[d]j^[d_d][\\[Yje\_dYbkZ_d]
eh [nYbkZ_d] if[Y_\_Y [deiiWb 8E? _cfbWdji" _j
X[Yec[i Yb[Wh j^Wj Æeii[e_dj[]hWj_edÇ h[Wbbo
c[WdiÆeii[eWZWfjWj_edÇ$J^[Xed[^WiZ_\\[h[dj
c[Y^Wd_ici e\ WZWfjWj_ed Wj _ji Z_ifeiWb$ <eh
ed[ j^_d]" j^[ Z_ijWdY[ X[jm[[d j^[ c_d[hWb_p[Z
cWjh_nWdZj^[j_jWd_kcikh\WY[YWdY^Wd][$J^[
c_d[hWb_p[ZcWjh_nYWdWYjb_a[WÆic[WhbWo[hÇje
el[hYec[ [nY[ii_l[ Z_\\[h[dY[i _d [bWij_Y_jo$ Ed
j^[ej^[h^WdZ"_j_iYedY[_lWXb[j^Wjj^[Z[]h[[e\
Xed[c_d[hWb_pWj_ed_dj^[_cc[Z_Wj[eh[nj[dZ[Z
l_Y_d_joe\j^[_cfbWdjcWoX[a[fjbemWim[bb[$]$
Xo ijhed] Yedj_dkeki h[ceZ[bb_d]$ 7j Wdo hWj["
Yedi_Z[hWXb[Z_\\[h[dY[i_d[bWij_Y_joWh[feii_Xb["
WdZ j^[ Z[]h[[ e\ Xed[ c_d[hWb_pWj_ed YWd lWho
Yedi_Z[hWXb[ Z[f[dZ_d] ed j^[ h[gk_h[c[dji
fh[i[dj$
v ?j _i h[WiedWXb[ je Wiikc[ j^Wj j^[ Z[]h[[ e\
c_d[hWb_pWj_ed _d Xed[ ijhkYjkh[i kdZ[h]e_d]
i[l[hWb ikh]_YWb fheY[Zkh[i m_bb Y^Wd][ Wj bWh][$
J^_i Y^Wd][ _d beYWb c_d[hWb_pWj_ed m_bb" _d _ji
jkhd"Y^Wd][j^[el[hWbb[bWij_Y_joe\j^[`Wm$
v ?j _i Wbie h[WiedWXb[ je Wiikc[ j^Wj [WY^ `Wm
i[]c[dj^Wi_jiemdfh[ef[hWj_l[XWi[b_d[[bWij_Y_jo
Wi W Yedi[gk[dY[ e\ YkckbWj_l[ c[Y^Wd_YWb"
_d\bWccWjeho" ^ehcedWb WdZ ][d[j_Y _d\bk[dY[i$
J^_i XWi[b_d[ [bWij_Y_jo cWo i^em Yedi_Z[hWXb[
_djhW_dZ_l_ZkWbZ_\\[h[dY[i$
H[cWhaWXbo"j^[\hWYjkh[h[i_ijWdY[e\Yehj_YWbXed[
_ih[ZkY[ZXo.&WdZ_ji[bWij_Y_joceZkb[_dYh[Wi[Z
Xo)&&_\j^[c_d[hWb_pWj_edYedj[djh_i[i\hec+/
je.,m%m_$[$Xo+&$J^[i[Y^Wd][iWh[YWki[Z
fkh[boXo\kdYj_ed"WdZj^[oWh[Wbieb_a[bojeeYYkh
_dj^[l_Y_d_joe\[deiiWb_cfbWdji"Z[f[dZ_d]edj^[
fheij^[j_YbeWZ$?dj^[WXi[dY[e\Wdoej^[h\WYjehi"
ikY^Wi_d\bWccWj_edi"j^[oWh[WbmWoih[l[hi_Xb[$
J^[ ceb[YkbWh ijhkYjkh[ WdZ eh]Wd_pWj_ed e\
YhoijWbi _di_Z[ j^[ cWjh_n Wh[ YhkY_Wb Z[j[hc_dWdji
e\ Xed[ ijh[d]j^ h[]WhZb[ii e\ j^[ \kdYj_edWb jWiai
je X[ \kb\_bb[Z BWdZ_i '//+$ J^[ Z[fei_j_ed e\ W
m[bb#ijhkYjkh[Z cWjh_n fh[fWh[i j^[ ]hekdZ \eh W
4ABLEÈ C[Y^Wd_YWbfhef[hj_[ie\Xed[9khh[o'/.'
7BSJBCMF
&ML
BOUMFST
$PX
GFNVS
8IBMF
CVMMB
'SBDUVSF


SFTJTUBODF
+N
'MFYVSBM




TUSFOHUI
.1B
&MBTUJDJUZ




NPEVMF
(1B
%FOTJUZ
HNM
"DPVTUJD




JNQFEBODF



LH
NT
.JOFSBM




DPOUFOU
XU

È È &ORMÈ&OLLOWSÈ&UNCTIONÈ
m[bb#ijhkYjkh[Zc_d[hWb_pWj_edfheY[ii$M_j^h[]WhZ
je8E?ioij[ci"j^_ic[Wdij^WjWdo_cfbWdjceX_b_jo
j^Wj _dj[h\[h[i m_j^ cWjh_n \ehcWj_ed _d j^_i f^Wi[
cWo h[ikbj _d WXdehcWb cWjh_n YedZ_j_edi" j^ki
b[WZ_d] je j^[ \ehcWj_ed e\ c[Y^Wd_YWbbo _d\[h_eh
Xed[ ijhkYjkh[i$ >[dY[ beWZ_d] _d m[Wa Xed[i
m_j^ b_jjb[ fh_cWho \_nWj_ed WdZ b_jjb[ Xed[ \bem
i^ekbZ dej jWa[ fbWY[ X[jm[[d ZWo '( WdZ ZWo *&
feijef[hWj_l[bo$
7d efj_c_p[Z fheY[ii cWjh_n \ehcWj_ed ^Wi Wd
_cfehjWdj _d\bk[dY[ ed j^[ fheXWX_b_jo e\ ikhl_lWb
e\ j^[ _cfbWdj Wbie _d j^[ bed] j[hc$ 9b_d_YWbbo"
[l[d kd\WlekhWXb[ XWi[b_d[ YedZ_j_edi" h[ikbj_d]
_d _d\[h_eh cWjh_n \ehcWj_ed" m_bb ij_bb X[ WXb[ je
Wbbem h[]kbWh _d_j_Wb beWZ_d] e\ j^[ _cfbWdj$
?d\[h_eh cWjh_n \ehcWj_ed cWo Wbie X[ Yehh[Yj[Z"
m_j^_d Y[hjW_d b_c_ji" Xo eii[eWZWfjWj_ed WdZ ]Wf
`kcf_d]$?j_iWbiefeii_Xb[j^WjWd_cfbWdjj^WjmWi
ÆZ_iWZlWdjW][ZÇ \hec j^[ ijWhj YWd \kdYj_ed m[bb
_d j^[ \_hij ikf[hijhkYjkh[ _di[hj[Z" \eh cWdo o[Whi$
>em[l[h" _j cWo l[ho m[bb dej ikhl_l[ W Y^Wd][ e\
beWZ h[ikbj_d] \hec W d[m" i[YedZ ikf[hijhkYjkh[$
J^[ ikf[hijhkYjkh[ ki[Z cWo h[cW_d ijWXb[ W\j[h
jhWkcWj_pWj_edWYY_Z[dji"f^oi_YWb\_]^jiZkh_d]j^[
[Whboc_d[hWb_pWj_edf^Wi[$?\j^[Xh_Z][_iY^Wd][ZWj
WbWj[hfe_dj"j^ek]^"j^[ÆYehh_ZehÇ\ehYecf[diWj_ed
j^Wj j^[ Xed[ YWd e\\[h m_bb e\j[d X[ b[\j" WdZ j^[
f[h_#_cfbWdj Xed[ ikXijWdY[ m_bb hWf_Zbo [n^_X_j
l_eb[djeij[eboi_i$J^_i_ied[e\j^[h[Wiedim^oj^[
_d_j_Wbi[hl_Y[fhel_Z[hi^ekbZX[j^[ed[jeZ[Y_Z[
ed j^[ \kjkh[ jh[Wjc[dj Yekhi[ _d fheXb[c YWi[i$
7do ikXi[gk[dj jh[Wjc[dj fhel_Z[h cWo dej adem
j^[ Y_hYkcijWdY[i fh[lW_b_d] _d j^[ \_hij jh[Wjc[dj
YWi[ WdZ cWo dej ^Wl[ j^[ X[ij ]h_f ed feii_Xb[
\khj^[hhekj[ie\jh[Wjc[dj$?\_cfbWdjim^ei[cWjh_n
\ehcWj_edmWifh[l_ekiboYecfhec_i[ZWh[_dYbkZ[Z
_d ikXi[gk[dj ikf[hijhkYjkh[i" j^[ [dik_d] beii e\
j^[_h beWZ#jhWdic_jj_d] \kdYj_ed cWo m[bb h[dZ[h
j^[ [dj_h[ d[m h[ijehWj_ed kdkiWXb[$ Edbo ^[%i^[
ademij^[\kbb^_ijehoe\j^[_cfbWdjWdZj^[i_j[$I[[
9^Wfj[h(-\ehceh[Yecc[dji$
?dj^[Z[djWbb_j[hWjkh["_j^WiX[[dfeijkbWj[Zj^Wj
j^[Wdj[h_ehi[]c[dje\j^[cWdZ_Xb[_iieh[i_ijWdj
X[YWki[_jYedjW_diiecWdockiYb[WjjWY^c[dji$Ed
Ybei[h_dif[Yj_ed"j^[dkcX[he\ckiYb[iWjjWY^c[dji
_i dej ie ]h[Wj W\j[h Wbb$ J^[h[\eh[" j^[h[ ckij X[
ej^[hh[Wiedi\ehj^_iijWX_b_jo$
?d ^_i [Whbo ijkZo e\ Xed[ jhWdi\ehcWj_ed"
Meb\\ Wbh[WZo fhel_Z[Z _cfh[ii_l[ _bbkijhWj_edi e\
hWY^_j_Y bed] jkXkbWh Xed[i" m^_Y^ Z[iYh_X[i j^[
[ii[dj_Wb dWjkh[ e\ j^[ cWdZ_Xb[$ J^[ YkhlWjkh[
e\ j^[ cWdZ_Xb[ _i W \kdYj_edWb Y^WhWYj[h_ij_Y$ J^[
Z_\\[h[dY[ijeÆjhWZ_j_edWbÇh_Ya[jiWh[Zk[jej^[\WYj
j^Wj j^[ cWdZ_Xb[ _i Z[\ehc[Z Xo j^[ ]hemj^ WdZ
fhejhkZ_d]\ehY[e\j^[jed]k[edj^[ed[^WdZ"WdZ
Xojeej^]hemj^edj^[ej^[h$EdY[j^[ej^[hckiYb[#
h[bWj[Z\ehY[i_dj^[ehWbYWl_joWh[\WYjeh[Z_dWim[bb"
''/
&IGÈ :ekXb[8E?_cfbWdj_dWZe]ÉicWdZ_Xb["*cedj^i
W\j[h _cfbWdj fbWY[c[dj$ J[jhWYoYb_d[ bWX[bb_d] h[l[Wbi j^Wj
j^[ \ehcWj_ed e\ 8CKi Wj j^[ XWiWb fbWj[ _i ijhed][h j^Wd
WhekdZj^[Yh[ijWbXWiWbfbWj[$El[hbeWZ_dbeWZ#jhWdic_jj_d]
Wh[Wie\j^[Z_iam_bb_dl[hjj^[\bemX[YWki[j^[Z[cWdZ\eh
dkjh_[dji_i]h[Wj[hj^Wdm^Wjj^[Xed[_ji[b\YWde\\[h$?dj^[
[l[dj j^Wj j^[ el[hbeWZ _i dej WZZh[ii[Z fheij^eZedj_YWbbo"
j^[ [nY[ii XbeeZ ikffbo h[bWj_l[ je m^Wj _i d[[Z[Z \eh Xed[
lebkc[fh[i[hlWj_edm_bbf[hi_ij"WdZj^[^_]^Z[]h[[e\Xed[
c_d[hWb_pWj_ed_ih[ZkY[ZX[YWki[_jYWddejX[a[fjkfkdZ[h
^_]^#\bem YedZ_j_edi$ J^_i m_bb ikXi[gk[djbo Z[ijWX_b_p[ j^[
_cfbWdj
j^[i[fheY[ii[iWh[XekdZjeh[ikbj_dWdj[h_ehXed[
WcWiic[dj$?dej^[hmehZi"j^[Xed[YedY[djhWj_ed
_idejYWki[ZXoj^[ckiYb[WjjWY^c[dji_dj^WjWh[W
Xkj Xo j^[ i^[[h cehf^ebe]o e\ j^[ jkXkbWh Xed["
m^_Y^ _i [nfei[Z je \b[nkhWb ijh[ii[i Xo j^[ bWj[hWb
fj[ho]e_ZckiYb[iZkh_d]cekj^ef[d_d]$
J^[fei_j_edc_]hWj_ede\j^[[n_jfe_dje\j^[
c[djWb d[hl[ YWd kbj_cWj[bo Wbie X[ [nfbW_d[Z _d
j^[i[j[hci$?dcWdofWj_[dji"j^_ife_djcel[iWmWo
\hec j^[ Wdj[h_eh Yehj_YWb Xed[ Wh[W jemWhZi j^[
Z_ijWb Wif[Yj j^hek]^ j^[ fh[cebWhi Wi j^[ l[hj_YWb
Z_c[di_ed _dYh[Wi[i" [l[djkWbbo h[ikbj_d] _d j^[
Y^WhWYj[h_ij_YÆbeefÇ_dj^[hWZ_e]hWf^$
8[\eh[ j^[ im_jY^ je j^[ f[hcWd[dj Z[dj_j_ed _i
Yecfb[j[Z" j^[ cWdZ_XkbWh d[hl[ YWdWb _i beYWj[Z
hWj^[h Z[[f Wj j^[ bem[h XehZ[h e\ j^[ cWdZ_Xb[$
J^[ beef _i dej l_i_Xb[ _d Y^_bZh[d$ Edbo m^[d j^[
f[hcWd[dj j[[j^ [hkfj m_bb j^[ YWdWb ]hem el[h
lWho_d]Z_ijWdY[i_dYh[ijWbZ_h[Yj_ed$J^[beefm_bb
\ehc _\ Z_ijWb c_]hWj_ed e\ Wdj[h_eh j[[j^ WdZ Xed[
lebkc[i jWa[i fbWY[ Zk[ je \kdYj_edWb _dY[dj_l[i
Zkh_d] l[hj_YWb ]hemj^ e\ j^[ cWdZ_Xb[$ J^_i cWo
^Wff[d" \eh [nWcfb[" _d YbWii#??%( fWj_[dji m_j^
[bed]Wj[Z \hedji eh _d fWj_[dji m_j^ Yecf[diWj[Z
YbWii ??? h[bWj_edi^_fi$ J^[ hWZ_e]hWf^_Y i^Wf[ e\
j^[ cWdZ_XkbWh d[hl[ j^[h[\eh[ e\\[hi _d\ehcWj_ed
ed[WY^_dZ_l_ZkWbÉiZ[l[befc[dj"_dZ_YWj_d]]hemj^
f[WaiWdZWbbem_d]YedYbki_edijeX[ZhWmdWijej^[
YWki[WdZZ[l[befc[dje\Wiocc[jh_[i$
;l[d j[Y^d_YWbbo ÆYehh[YjÇ WXki[i Xo c[Wdi e\
fWhj_WbZ[djkh[iYWdi_]d_\_YWdjboWbj[hj^[cWij_YWjeho
fWjj[hd WdZ cehf^ebe]o e\ j^[ `Wm$ CWdZ_XkbWh
\ehcWdZ\kdYj_edkbj_cWj[bo^Wl[jeX[_da[[f_d]
'(& 9^Wfj[h/È &OUR
$IMENSIONALÈ#ONSIDERATIONSÈOFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS
&IGÈ JhWdi\ehcWj_ede\hWY^_j_Ybed]jkXkbWhXed[i\hec
Meb\\'./(
m_j^ j^[ 8E? ioij[c$ ?\ j^[h[ Wh[ ]h[Wj \kdYj_edWb
Z_\\[h[dY[iX[jm[[dj^[fh[ef[hWj_l[i_jkWj_edm_j^ v ?d j^[ XWi[b_d[ i_jkWj_ed <_]$/$((" j^[ fWhj_Wb
W fWhj_Wb Z[djkh[ WdZ j^[ fbWdd[Z 8E?#ikffehj[Z
h[ijehWj_ed"j^[heWZjeikYY[iicWoX[[dYkcX[h[Z
XoYecfb_YWj_ediikY^Wi_cfbWdjbeii"eij[eboi_iWdZ
\hWYjkh[$
J^[i[ Wbj[hWj_edi h[gk_h[ Yecfb[j[ h[ceZ[bb_d]
e\j^[[dj_h[cWdZ_Xb[WdZ"_dWZZ_j_ed"ceZ[bb_d]_d
Yh[ijWb Z_h[Yj_ed$ J^[ beWZ#jhWdic_jj_d] jhW`[Yjeh_[i
m[h[ h[Xk_bj \hec iYhWjY^$ ?j _i \W_h je iWo j^Wj m^Wj _dfbWY[m_j^Z_ijWbXWbbh[jW_d[hi"WdZijWX_b_p[ZXo
m[ i[[ _i" X_ec[Y^Wd_YWbbo if[Wa_d]" W Yecfb[j[bo
Æd[mÇ eh ÆZ_\\[h[djÇ cWdZ_Xb[$ ?d h[jheif[Yj" _j _i
^WhZboikhfh_i_d]j^Wjj^_iekjYec[i^ekbZ^Wl[X[[d
fh[Y[Z[ZXoh[Ykhh[dj[f_ieZ[ie\el[hbeWZeij[eboi_i
WdZ_cfbWdj\hWYjkh[i$?dYbkZ_d]WYWi[b_a[j^_i_dje
j^[8E?ikhl_lWbijWj_ij_YikdYecc[dj[ZmekbZdej
Ze`kij_Y[je_jiif[Y_\_YdWjkh[$M^WjcWjj[hiWjj^[
[dZe\j^[ZWo_ij^[Yb_d_YWbekjYec["m^_Y^^em[l[h
mekbZ ^Wl[ X[[d kdWjjW_dWXb[ m_j^ekj j^[ fWj_[djÉi
[n[cfbWhoWjj_jkZ[WdZYebbWXehWj_ed$
J^[ijhkYjkhWbWbj[hWj_edieXi[hl[Z_dj^_ifWj_[dj
mekbZX[_dYedY[_lWXb[_dj^[WXi[dY[e\WY^Wd][Z
cWij_YWj_edfWjj[hdD[k\[bZ'/+.$
&IGÈ JhWdi\ehcWj_ede\hWY^_j_Ybed]jkXkbWhXed[i\hec
Meb\\'./(
J^[i[Wh[j^[Z_\\[h[dY[i_dZ[jW_b0
Z[djkh[ \ehY[Z j^[ Z_ijWb fWhj e\ j^[ cWdZ_Xb[
_d YWkZWb Z_h[Yj_ed" j^[h[Xo ][d[hWj_d]
kdZ[hc_d[hWb_p[ZYh[ijWbWh[Wi$?dehZ[hjeh[i_ij
j^[cWij_YWjeho\ehY[iW\j[hWbb"^[Wl_boc_d[hWb_p[Z
Wh[WiWh[\ehc[ZWjj^[bem[hcWdZ_XkbWhXehZ[h
fhej[Yj_d] j^[ cWdZ_Xb[ W]W_dij \hWYjkh[$ J^[
Wdj[h_ehh[ijehWj_edi_dcWdZ_Xb[Wh[ifb_dj[Z"a[fj
W Yedj_dkeki WjjWY^c[dj$ J^[ cWdZ_Xb[ mekbZ
d[[Z je ]W_d Yh[ijWb lebkc[ _d j^_i i_jkWj_ed Xkj
_i fh[l[dj[Z \hec Ze_d] ie Xo j^[ cWij_YWjeho
fh[iikh[$ Edbo j^[ ikffehj e\ j^[ Wdj[h_eh j[[j^
W]W_dijj^[l[ij_XkbWhYehj_YWbXed[e\j^[Wdj[h_eh
cWdZ_XkbWh i[]c[dj fh[l[dji j^ei[ j[[j^ \hec
o_[bZ_d] je j^[ Z_ijWb b[l[h \ehY[ ekjh_]^j$ 7i W
h[ikbje\jeej^ceX_b_jo"j^[Yh[ijWbWdj[h_ehWh[We\
j^[cWdZ_Xb[_ihWj^[hie\j$J^[i[Z[iebWj[XWi[b_d[
YedZ_j_edi m[h[ XWi_YWbbo _Wjhe][d_Y _d dWjkh[$
J^[o mekbZ ^Wl[ X[[d kdWjjW_dWXb[ m_j^ekj j^[
[njh[c[bo c_i]k_Z[Z j^[hWf[kj_Y WffheWY^ e\
Wdj[h_ehifb_dj_d]YecX_d[Zm_j^XWbbh[jW_d[hiWdZ
È È &ORMÈ&OLLOWSÈ&UNCTIONÈ '('

WdWjjWY^c[dj$Edj^[Zemd^_bbiYWb["j^_ifWj_[dj
hWdai l[ho bem _dZ[[Z$ 8_eY^[c_YWbbo if[Wa_d]"
j^_i_iWl[hoYecfb[nYWi[$J^[hWZ_e]hWf^i^emi
WjkXkbWhXed[ijhkYjkh[\ehXej^Z_ijWbh[]_edie\
j^[cWdZ_Xb[$
v 7jj^[[dZe\j^[hWfo"j^[m^_j[b_d[edj^[b[\j_i
X[]_dd_d] je \ehc$ C[Wdm^_b[" j^[ fhedekdY[Z
ped[ e\ eii_\_YWj_ed Wj j^[ bem[h hWcki _i
i_]d_\_YWdjbo h[ZkY[Z$ J^[ Z_ijWb _cfbWdji ed j^[
b[\jWdZh_]^jWh[_dWd_d\hWd[hlWbWdZikfhWd[hlWb
beYWj_ed" h[if[Yj_l[bo$ J^[ eii_\_YWj_ed fheY[ii
WhekdZ j^[ Z_ijWb _cfbWdj ed j^[ h_]^j _i dej
jee WZlWdY[Z Wj j^_i fe_dj" _dZ_YWj_d] j^Wj ceh[
[nj[di_l[h[ceZ[bb_d]_i]e_d]ed$Fh[ikcWXbo"_j
mekbZ ^Wl[ X[[d X[jj[h je h[_di[hj j^[ b[\j Z_ijWb
_cfbWdjjeWd_d\hWd[hlWbfei_j_edWim[bb$?dXej^
Z_ijWb h[]_edi e\ j^[ cWdZ_Xb[" j^[ hWZ_e]hWf^
i^emiWbceijYecfb[j[Z_iiebkj_ede\j^[jkXkbWh

A B

C D

&IGÈA J^[fh[ef[hWj_l[i_jkWj_ed_iY^WhWYj[h_p[ZXocWii_l[h[iehfj_ede\j^[Z_ijWbcWdZ_Xb[m_j^Wj^_dYehj_YWbXed[
lebkc[ Wbed] j^[ Z_ijWb h_Z][$ J^[ fWj_[dj m[Whi Wd Wdj[h_ehbo h[jW_d[Z fWhj_Wb Z[djkh[ WdZ i^emi fem[h\kb Y^[m_d] \ehY[i
edYb_d_YWb[nWc_dWj_ed$J^[XWiWb[Z][e\j^[cWdZ_Xb[_i[njh[c[bocWii_l[WdZ[nj[dZii[Wcb[iiboXWYajej^[Wh[We\j^[
cWdZ_XkbWhWd]b[$J^[Y^[m_d]fWjj[hd_iXWbWdY[Z"Wicehf^ebe]_YWbZ_\\[h[dY[iX[jm[[dj^[h_]^jWdZb[\ji_Z[ie\j^[`Wm
Wh[ dej fh[i[dj$ B IkYY[ii\kb ekjYec[ \ebbem_d] ckbj_fb[ _cfbWdjWj_ed fheY[Zkh[i WdZ iec[ _cfbWdj \hWYjkh[i$ J^[ XWiWb
ped[e\eii_\_YWj_ed^WiYecfb[j[boZ_iiebl[Z$Edj^[h_]^ji_Z["j^[m^_j[b_d[^Wi[c[h][Z$J^[Z_ijWb_cfbWdjedj^[b[\j_i
beYWj[Z_dWh[bWj_l[boWdj[h_ehfei_j_edX[YWki[j^[d[hl[fh[l[dj[Z_jifbWY[c[djWjWceh[Z_ijWbbeYWj_ed$<ehj^[fh_cWho
h[ijehWj_ed" _d\hWd[hlWb fbWY[c[dj mWi h[gk_h[Z$ J^[ l[hj_YWb j^_Yad[ii e\ j^[ cWdZ_Xb[ _dYh[Wi[Z$ <eh ,cedj^i" j^[ fWj_[dj
meh[Wd_cfbWdj#ikffehj[ZXh_Z][h[jW_d[Z_dj^[Wdj[h_ehi[]c[djm_j^Wh[ZkY[ZcWij_YWjehojWXb[$8oj^[j_c[j^_if_Yjkh[
mWieXjW_d[Z"j^[jkXkbWhijhkYjkh[e\j^[Z_ijWbcWdZ_Xb[ij_bbl_i_Xb[_d<_]$/$((^WZX[[dfWhj_WbboZ_iiebl[ZXo[deiiWbbeWZ
jhWdic_ii_ed$7iWh[ikbj"j^[Wd_iejhef_Yfhef[hj_[iWdZ[bWij_Y_joe\j^[Xed[^WZY^Wd][ZWim[bb$ C :k[jej^[WZlWdY[Z
h_Z][h[iehfj_ed"j^[jhWdi_j_edWh[WiX[jm[[dj^[h[ijehWj_edWdZj^[_cfbWdjiYWdedbojWa[j^[\ehce\j[Y^d_YWbWXkjc[dji$
7\j[hWbb"j^[effei_d]`Wm_iYecfb[j[bo_djWYjm_j^dWjkhWbj[[j^"WdZj^[b[l[be\j^[cWdZ_XkbWhZ[djWbWhY^i^ekbZX[ikY^j^Wj
dehcWb\kdYj_ed_i[dikh[Z$ D J^_if_Yjkh[Z[cedijhWj[ij^[Z_\\[h[djmWoi_dm^_Y^j^[_cfbWdji_d\bk[dY[Xed[cehf^ebe]o$
M^_b[j^[8E?_cfbWdji[Wi_bof[hc_j\kdYj_edWbWZWfjWj_ede\j^[Xed[cehf^ebe]o"j^[jmeYh[ijWb_cfbWdji\ehY[Wd_dYh[Wi[Z
f[h_#_cfbWdjXed[b[l[bj^Wj_iWffWh[djboÆmhed]Ç\hecWX_ec[Y^Wd_YWbfe_dje\l_[m$J^_iXed[b[l[bYekbZdejf[hi_ijkdZ[h
fh[lW_b_d]\kdYj_edWbYedZ_j_edi$J^[cWdZ_XkbWhWjhef^o_iWh[ikbje\j^[Z[j[h_ehWj[Z[deiiWblWiYkbWh_pWj_ed\ebbem_d]jeej^
beii$J^[gk[ij_ede\m^[j^[hj^[_di[hj_edibeji\ehj^[8E?_cfbWdjc_]^j_dj[hY[fj%ZhW_dj^[\beme\dkjh_[djijej^[Wdj[h_eh
i[]c[dje\j^[cWdZ_Xb[mekbZY[hjW_dboX[Wd_dj[h[ij_d]ed[je\ebbemkfed$D[l[hj^[b[ii"j^[lWiYkbWh_pWj_ede\ÄWdZj^ki
j^[ikffboe\dkjh_[djijeÄj^[h[i_ZkWbXed[WhekdZj^[iYh[m_cfbWdjiZe[idejWff[WhjeeXWZ$J^[_d\beme\dkjh_[dji_dje
WdZj^[ekj\beme\mWij[cWj[h_Wbiekje\j^[Xed["_$[$j^hek]^j^[ckYeiWehj^[f[h_eij[Wbj_iik[i"i[[cijeX[ik\\_Y_[djje
cW_djW_dj^_iWcekdje\Xed[Wb_l[$J^[dkjh_j_edWbi_jkWj_ede\j^[Yh[ijWbf[h_#_cfbWdjXed[_ii_c_bWhjej^[Xedoi^[Wj^e\
Z[djWbheeji_dj^[i_dki$J^[iYh[m_cfbWdjii[[cjecW_djW_dXed[_dWh[Wim^[h[_j_i\hecW\kdYj_edWbfe_dje\l_[mdej
d[[Z[Z$Ieed[hehbWj[h\kdYj_edm_bbjWa[Whkb[el[heii[e_dj[]hWj_edWdZj^_icWoX[ed[e\j^[h[Wiedim^oiYh[mZ[i_]di
j[dZjei^emW]hWZkWbbeiie\l[hj_YWbXed[
'(( 9^Wfj[h/È &OUR $IMENSIONALÈ#ONSIDERATIONSÈOFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS

Xed[ ijhkYjkh[ Wi W h[ikbj e\ j^[ d[mbo Yh[Wj[Z v ?\ikY^j[[j^i^emWd[nY[ii_l[j[dZ[dYojecel[

[deiiWbbeWZjhWdic_ii_edfWjj[hd$ Wi jhW`[Yjeh_Wb eh_[djWj_ed e\ j^[ `Wm _i X[_d]
[ijWXb_i^[ZWdZ_\j^[i[cel[c[djijWa[WZ_\\[h[dj
J^[h[\eh[" j^[ _iik[ e\ _dZ_l_ZkWb _cfbWdj h_ia Z_h[Yj_ed j^Wd j^[ _cfbWdji _dlebl[Z" j^[d j^[
_i WiieY_Wj[Z dej ie ckY^ m_j^ W feeh XWi[b_d[ _cfbWdji cWo X[ ikX`[Yj[Z je ^[Wlo fh[b_c_dWho
i_jkWj_ed _d j[hci eh WlW_bWXb[ Xed[ lebkc[ Wi ijh[ii[i"j^kiX[_d]Wjh_iae\\hWYjkh_d]$?dYWi[i
m_j^ j^[ \kdYj_edWb ceZ_\_YWj_ed WdZ j^[ gk[ij_ed ikY^Wij^[i["ceh[_cfbWdji^Wl[jeX[fbWY[Z$
^em [nj[di_l[bo j^[ Wh[W e\ j^[ \ehY[#jhWdic_jj_d] v ?dekh[nf[h_[dY["j^[i[j[dZ[dY_[iWh[\h[gk[djbo
_dj[h\WY[_i]e_d]jeX[h[ceZ[bb[Z$M^_b[[bWij_Y_jo [dYekdj[h[Z m_j^ cWn_bbWho ioij[ci _dlebl_d]
e\ j^[ Xedo ijhkYjkh[i _i f[h i[ W f^oi_ebe]_YWb j[[j^)WdZ*WdZ+eded[i_Z[m^_b[j^[ej^[h
fhef[hjo e\ j^[ `Wmi" [nW]][hWj[Z eh _dWZ[gkWj[ i_Z[_dYbkZ[iWi_d]b[ijhWj[]_Y8E?_cfbWdj_dj^[
[bWij_Y_joWh[i_]die\[nY[ii_l[beWZ_d]eh\kdYj_edWb YWd_d[ Wh[W$ ?d j^[ fh[i[dY[ e\ edbo ed[ YWd_d[
_d\[h_eh_jo"h[if[Yj_l[bo@kd]'/+($ m_j^ekj _fi_bWj[hWb fh[cebWhi" j^[ h[i_ijWdY[ e\
I_jkWj_edi Y^WhWYj[h_p[Z Xo ckbj_fb[ W][d[i_i e\ j^[ YWd_d[ je cWn_bbWho h[ceZ[bb_d] j[dZ[dY_[i
j[[j^e\\[h_d\ehcWj_ededj^[dWjkh[e\cWdZ_XkbWh i[[ci je X[ b[ii m_Z[bo Z_ijh_Xkj[Z" ie j^Wj j^[
]hemj^ _d j^[ WXi[dY[ e\ Wdo el[hbWff_d] X[jm[[d YWd_d[_idejikX`[Yj[ZjeWd[nY[ii_l[c_]hWj_ed
j[[j^WdZXed[ijhkYjkh[i$Ceije\j^[XbeeZikffbo j[dZ[dYo$ J^[ iWc[ _i jhk[ _\ j^[ fh[cebWhi eh
_dj^[XWiWb`Wmi[]c[djYec[i\hecj^[f[h_eij[kc" Wdo Wdj[h_eh j[[j^ WhekdZ _dZ_l_ZkWb YWd_d[i Wh[
m^_b[j^[Yh[ijWbXbeeZikffbo_iZ[j[hc_d[ZXoj^[ [njhWYj[ZWdZh[fbWY[Zm_j^_cfbWdji_dWi_d]b[#
cWdZ_XkbWh Whj[ho$ J^_i ijhed][h XbeeZ ikffbo _i ij[f fheY[Zkh[$ J^[ Xed[ h[ceZ[bb_d] m_bb X[
d[Y[iiWho X[YWki[ e\ j^[ ^_]^ c[jWXeb_Y WYj_l_jo ie [nj[di_l[ _d j^_i i_jkWj_ed j^Wj [l[d W icWbb
j^Wj_i]e_d]jejWa[fbWY[Wij[[j^^Wl[jeX[\ehc[Z dkcX[he\8E?_cfbWdjim_bbdejX[ikX`[Yj[Zje
WdZcWij_YWjeho\ehY[id[[ZjeX[jhWdic_jj[Z_di_Z[ fh[b_c_dWhoijh[ii[i$
j^[Xed[$:k[jej^[feeh[hc[jWXeb_Yi_jkWj_ed"j^[ v B_a[m_i[" j^[ fhe]dei_i e\ W i_d]b[ ijhWj[]_YWbbo
bem[hcWh]_de\j^[cWdZ_Xb[m_bbWbmWoiX[WXb[je fbWY[Z 8E? _cfbWdj m_bb X[ _cfhel[Z Xo ijWXb[
]hemb[iigk_YaboWdZ[nj[di_l[bo"m^_Y^_ij^[cW_d Z_ijWb WXkjc[dji fbWY[Z Z_W]edWbbo W]W_dij j^[
h[Wied"X[i_Z[i\kdYj_edWbWif[Yji"\ehj^[h[beYWj_ed h[i_ZkWbZ[dj_j_ed$
e\ Wbl[ebWh h_Z][ WdZ j^[ `Wm XWi[$ Heej YkhlWjkh[
Yec[i je fWii Wi j^[ heej j_fi ]hem _dje `Wm Wh[Wi ?\Wjh[Wjc[djfheY[Zkh[\W_bi"j^_i\W_bkh[m_bbe\j[d
m^ei[]hemj^j[dZ[dYohkdiYekdj[hjej^[Wbl[ebWh i^[Z iec[ b_]^j ed j^[ b_c_ji e\ \kdYj_ed WdZ j^[
h_Z][eh_i_dik\\_Y_[djWjj^[j_c[e\heej]hemj^$ h[Wiedi \eh \kdYj_ed eh \W_bkh[$ J^[ \ebbem_d] YWi[
<khj^[hb[iiedijeX[ZhWmd\hec9Wi[IjkZo+0 ]_l[i ki Wd _Z[W e\ j^[ [nj[dj WdZ beYWj_ed e\
v½ J[[j^Wh[a[fj_dj^[iWc[fbWY[Xoj^[f[h_eZedjWb cWdZ_XkbWh Z[\ehc_j_[i _d fWj_[dji m_j^ kd_bWj[hWb
b_]Wc[dj" eh j^[o cel[ j^hek]^ j^[ Xed[ Xo Y^[m_d]fWjj[hdi$
h[ceZ[bb_d]$ J^[i[ cel[c[dji Wh[ f[h\ehc[Z Beea_d]Wjj^[i[jmeYWi[i_dYedj[nj"m[YWdZhWm
_d j^[ WXi[dY[ e\ Wdo WZZ_j_edWb Z_h[Yj eYYbkiWb j^[\ebbem_d]YedYbki_edi0
ehcWij_YWjeho\ehY[i$J^[Xed[b[l[bWjj^[Yh[ij v J^[Z_\\[h[dY[_db[d]j^X[jm[[dj^[jme^eh_pedjWb
j[dZije`e_d_dW^[Wbj^of[h_eZedjWbi_jkWj_ed XhWdY^[ie\j^[cWdZ_Xb[m_bbXWbWdY[Z#ekjedY[
j^[F:BWh[WWjWh_]^jWd]b[<_]$/$()Z$ j^[cWij_YWjeho\kdYj_ed^WiX[[d[gk_b_XhWj[Z$
v ?\ jhk[ Wbl[ebWh Xed[ _i c_ii_d] WdZ j^[ Yh[ij v ?\"Zkh_d]j^_if^Wi["\_n[Zh[ijehWj_ediikffehj[Z
e\ j^[ `WmXed[ Ye_dY_Z[i m_j^ j^[ Yh[ijWb Xo dWjkhWb j[[j^ WdZ%eh 8E? _cfbWdji Wh[ mehd"
cWYhejhW`[Yjeh_[i" j[[j^ YWddej [bed]Wj[ [l[d _\ j^[ Xed[ i[]c[dj YedjW_d_d] j^[ 8E? _cfbWdji
j^[_hWdjW]ed_ij_iWXi[dj$?dWijWXb[f[h_eZedjWb cWo X[ Z_ibeYWj[Z$ J^_i cWo Yh[Wj[ j[di_ed
i_jkWj_ed"_j_idejfeii_Xb[jeh[l[hi[j^[_dYbki_ed j^Wj cWo eYYWi_edWbbo X[Yec[ ie ijhed] j^Wj
e\ j^[ Xed[ Wh[Wi WhekdZ j^[ jeej^ _d j^[ j^[ _cfbWdj _ji[b\ \W_bi$ ?dijWbb_d] h_]_Z Xh_Z][i
cWYhejhW`[Yjeh_[i WdZ je b[j j^[ jeej^ [bed]Wj[ ikffehj[ZXocWdo8E?_cfbWdjiWdZa[fjijh_Yjbo
Wbed] m_j^ _ji F:B$ 8kj Wi 9Wi[ IjkZo * i^emi" WfWhj\hecdWjkhWbj[[j^Wff[WhijeX[Wi[di_Xb[
j^_i \WY_b_jo Wff[Whi je X[ b_c_j[Z m_j^ Yh[ijWb Wbj[hdWj_l[YedijhkYj_edjof[(^1i[[9^Wfj[h'($
_cfbWdji1 i_dY[ _j _i dej d[Y[iiWho je cW_djW_d J^[ [deiiWb _cfbWdj ikh\WY[i i^ekbZ X[ iceej^
j^[ f[h\ki_ed ijhkYjkh[i _d j^[ Xed[ d[Wh j^[ _dehZ[hdejjefh[l[djj^[Xed[ikXijWdY[\hec
_cfbWdj" j^[i[ _cfbWdji YWd [bed]Wj[ Wbed] m_j^ Zh_\j_d] WdZ je \WY_b_jWj[ W YedijWdjbo h[d[m_d]
j^[_dj[h\WY_WbXed[$ \ehce\eii[eWZWfjWj_edm_j^ifWj_WbWZWfjWj_ed$
v J[[j^ Wh[ ikX`[Yj[Z je j^[i[ \ehY[i [l[d m^[d v J^[Y^Wd][i_db[d]j^_dj^[^eh_pedjWbXhWdY^[i
_dYehfehWj[Z _d _cfbWdj#h[ijehWj_ed ioij[ci$ e\ j^[ cWdZ_Xb[ fh[ikcWXbo jWa[ fbWY[ _d j^[
Eij[ejec_[i \eh 8E? _cfbWdji cWo ]_l[ h_i[ je Wh[W e\ \b[n_ed WhekdZ j^[ i[YedZ fh[cebWh WdZ
ikXijWdj_Wb h[ceZ[bb_d] fheY[ii[i" Wi j^[o m_bb \_hijcebWhWdZWh[YWki[ZXoj^[Xed[ikXijWdY[
e\j[dZ_ihkfj[ii[dj_WbjhW`[Yjeh_[i$ Zh_\j_d]WfWhj_dj^_iWh[W$J^_ifheY[iifheXWXbo
È È &ORMÈ&OLLOWSÈ&UNCTIONÈ '()

A B

C E

&IGÈÈA EF=e\W\[cWb[fWj_[djWj'*o[WhiWdZ''cedj^i$Dej[j^Wjj^[Z[dj_j_ed_dj^[cWdZ_Xb[i^emi^WhZboWdo]Wfi$
9ecfWh[j^_ijeÆ9Wi[IjkZo-Çe\j^_iY^Wfj[hWdZ<_]$()$*,$ B EF=Wj'+o[WhiWdZ'cedj^$Dej[j^Wj]WfiWh[dem[c[h]_d]
edj^[h_]^ji_Z[$7fWj_[dje\j^[iWc[W][m_j^_djWYjfh[cebWhiWdZi[YedZcebWhimekbZi^emdeceh[]WfiWjj^_ife_dj$
7dj[h_eh]hemj^e\j^[cWdZ_Xb[jeeafbWY[j^hek]^j^[XWiWb`Wmi[]c[dj1fWhje\j^[Wbl[ebWhh_Z][b_da[Zjej^_iijhkYjkh[
ijWoiX[^_dZjemWhZij^[Z_ijWbWif[Yj$J^[beef_ij^[h[\eh[l[hofhedekdY[Z$9edi[gk[djbo"j^[\_hijbem[hcebWhWdZj^[YWd_d[
edj^[h_]^ji^emWh[l[hi[ZYkhlWjkh[Y^WhWYj[h_ij_Y"m^_Y^_idehcWbboedboi[[dm_j^fh[cebWhi"h[ikbj_d]\hecj^[]hemj^#
h[bWj[ZZ_ijWbi^_\je\j^[Wbl[ebWhXed[i[]c[djZkh_d]Wdj[h_ehY^_d]hemj^$J^[Wiocc[jh_YZ[l[befc[dj_iYWki[ZXoY^[m_d]
fWjj[hd"m^_Y^^Wicel[Zkd_bWj[hWbbojej^[b[\ji_Z[$J^[b[\jcWdZ_XkbWhXehZ[hi^emiceh[c_d[hWb_pWj_ed1j^[c_Zb_d[^Wi
i^_\j[Zjej^[b[\j$JeikccWh_p["j^[Wbl[ebWhh_Z][WdZj^[XWiWb`WmXed[i[]c[djf[h\ehcckjkWbi^_\ji$J^[i[i^_\ji^Wl[
W i^Wf_d] [\\[Yj ed j^[ j[[j^ YedjW_d[Z _d j^[ `Wm WdZ j^[ d[hl[ YWdWb$ 8WiWb `Wm ]hemj^ _i ceh[ fhedekdY[Z j^Wd Wbl[ebWh
]hemj^$?dj^_imWo"j^[fhec_d[dY[e\j^[Y^_d_i][d[hWj[ZWjWj_c[m^[dj^[cWn_bbWhoWdj[h_ehi[]c[dj^WiYecfb[j[Z_ji
Wdj[h_eh]hemj^WdZa[[fij^[cWdZ_XkbWhWdj[h_ehi[]c[djXWYaWim[bb$J^[X_bWj[hWbboj^_dZ_ijWbYehj_YWbXed[Wjj^[bem[h
cWdZ_XkbWhXehZ[h_dZ_YWj[ij^Wjj^[fh[iikh["WdZ^[dY[j^[Y^[m_d]beWZ"_dj^[i[Wh[Wi_iicWbb$ C BWj[hWbj[b[hWZ_e]hWf^
Wj'(o[WhiWdZ'cedj^$J^[cebWhiWh[m_j^ekjYedjWYj$?dj^_ii_jkWj_ed"_jmWiWjj[cfj[ZjeWY^_[l[cebWheYYbki_edm_j^j^[
^[bfe\[bWij_Yijecel[j^[cebWhijemWhZi[WY^ej^[h$J^_iWjj[cfjmWiikYY[ii\kbWj\_hij$J^[fWj_[djikXi[gk[djboh[fehj[Z
j^Wji^[^WZijWhj[ZjeZ[l[beffeij[h_ehY^[m_d]$7\j[hWi^ehjm^_b["i^[^WZ[nf[h_[dY[ZfW_dWdZceX_b_jo_dj^[Wdj[h_eh
i[]c[djWdZj^[dh[l[hj[Zje^[hfh[l_ekiWdj[h_ehY^[m_d]fWjj[hdWi_dYbWii??h[bWj_edi$J^[cebWhij^[dWbceij_dijWdjbo
ijWhj[Zjecel[WmWo\hec[WY^ej^[h"XWYa_dje_d\hWeYYbkiWbfei_j_ed$J^_iX[^Wl_ekhXoj^[cebWhi_ikd[nf[Yj[ZYedi_Z[h_d]
j^[fh[Y[fje\iY_[dj_\_YZ[dj_ijhoj^WjWbbj[[j^^Wl[Wj[dZ[dYoje[hkfjedWb_\[bed]XWi_i$J^_ifWj_[djÉij[[j^"X[_d][cX[ZZ[Z
_d\WlekhWXb[YedZ_j_edie\_djWYjf[h_eZedjWbijhkYjkh[iWdZeij[edWb\ehY[jhWdic_ii_ed"i^em[Zde_dYb_dWj_edm^Wjie[l[h
je[hkfj\khj^[hjemWhZij^[eYYbkiWbfbWd[$J^[Z_ijWbXed[lebkc[iWh[_dik\\_Y_[djjeWbbemj^[cebWhije[ijWXb_i^YedjWYj$?d
Wh[Wim_j^Wi_d]b[jeej^edbo"deWbl[ebWhXed[Z[l[befi$ DÈE ?\j^[f[h_eZedjWbj_iik[iWh[^[Wbj^o"j[[j^m_bbj[dZjefei_j_ed
j^[ci[bl[iWjh_]^jWd]b[ie\j^[ikhhekdZ_d]Xed[D$?\j^[Yh[ijWbXed[b[l[bWdZj^[cWYhejhW`[Yjeh_[iYe_dY_Z["[hkfj_ed
h[gk_h[ij^[\ehcWj_ede\d[mcWYhejhW`[Yjeh_[iE
'(* 9^Wfj[h/È &OUR $IMENSIONALÈ#ONSIDERATIONSÈOFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS

A B

&IGÈAnC =h[Wjbo[bed]Wj[Zfeij[h_ehj[[j^_dj^[\_hijgkWZhWdje\j^_i
*+#o[Wh#ebZ\[cWb[fWj_[djWh[WdeXijWYb[jej^[hWfo$7iWdWbj[hdWj_l[
je[njhWYj_ed"i^ehj[d_d]j^[j[[j^WdZjh[Wj_d]j^[c[dZeZedj_YWbbomWi
Yedi_Z[h[Z$8kj[l[die"j^[h[ikbjmekbZ^Wl[X[[dWdW[ij^[j_YYecfhec_i[$
?jmWij^[h[\eh[Z[Y_Z[Zje[njhWYjj^[feij[h_ehj[[j^_dj^[\_hijgkWZhWdj$
J^[^[_]^je\j^[Wbl[ebWhh_Z][mWiieed]h[Wjboh[ZkY[ZWiWh[ikbj$J^[
C 8E?_cfbWdj^WZjeh[Y[_l[jhWdi#i_dkifbWY[c[dj_dehZ[hje[dikh[_ji
beYWj_edekji_Z[j^[h[iehfj_edWh[W

jWa[i fbWY[ j^hek]^ekj b_\[" ceh[ eh b[ii m_j^ekj fbWY_d]j^[_cfbWdji_dped[im^_Y^m[[nf[Yjje

X[_d]dej_Y[Z0_jYWdWbieX[l_ikWb_p[ZXobeea_d]
Wj j^[ Ykhl_d] Y^WhWYj[h_ij_Yi e\ j^[ cWdZ_XkbWh
fh[cebWhi YecfWh[Z je j^[ cWdZ_XkbWh cebWhi$
8ej^]hekfie\j[[j^j^kiYedijWdjbo]hemjemWhZi
[WY^ej^[h_dehZ[hjee\\i[jj^[f[hcWd[djXed[
Zh_\jj^[oWh[ikX`[Yj[Zje$J^[eYYbkiWbh[b_[\_ie\
]h[Wj_cfehjWdY[\ehj^[Z[\_d_j_l[fei_j_ediWdZ
eh_[djWj_edi e\ j^[i[ j[[j^$ Ekh \_dZ_d]i Wh[ dej
Yedi_ij[djm_j^j^[[nfbWdWj_edie\7ja_died[jWb$
'/--$
v ?\ j^[ cWdZ_XkbWh Wdj[h_eh j[[j^ \ebbem j^[
fh[cebWhi ed j^[_h Z_ijWb fWj^ Wi W h[ikbj e\
ie\j#j_iik[Wh[WikdZ[hj[di_edWdZW^of[hWYj_l[
ehX_YkbWh_i eh_i ckiYb[ WdZ j^[ ifWY[ j^Wj
X[Yec[i WlW_bWXb[ _i \_bb[Z \hec Wdj[h_ehbo" j^_i
m_bbh[ikbj_dWijhed]"fhedekdY[ZY^_d$
È
#ONCLUSIONS
?dj^[YWi[ijkZ_[ifh[i[dj[ZWXel["iec[Wif[Yjie\
Xed[h[WYj_edm[h[Z_iYkii[Zj^WjWh[_cfehjWdj\eh
8E?jh[Wjc[djWdZYWdX[ikccWh_p[ZWi\ebbemi0
v 9^Wd][i_dl[hj_YWbZ_c[di_edm_bbWbj[hdejedbo
j^[ \ehY[ h[bWj_edi X[jm[[d j^[ `Wmi" Xkj _d j^[
bed] j[hc j^[o m_bb Wbie Wbj[h j^[ WhY^_j[YjkhWb
ijhkYjkh[ e\ j^[ \WY_Wb iakbb$ J^[ fheXWX_b_jo
e\ _cfbWdj ikhl_lWb YWd X[ _cfhel[Z ieb[bo Xo
X[fh[i[djh[]WhZb[iie\Wdoej^[h_d\bk[dY[$
v Ed j^[ ej^[h ^WdZ" _j Wff[Whi j^Wj _cfbWdji cWo
\W_b [l[d _d ÆiW\[Ç fei_j_edi _\ Wd _dWffhefh_Wj[
l[hj_YWb Z_c[di_ed mWi i[b[Yj[Z" i_dY[ j^[ d[mbo
[ijWXb_i^[Z cWij_YWj_ed fWjj[hd cWo _dlebl[ W
Y^Wd][Z" iec[j_c[i kdZ[i_hWXb[ Z_ijh_Xkj_ed e\
j[di_edWdZfh[iikh[Wh[Wi$
v J^[XWiWbfWhje\j^[`Wmim_bbc_d[hWb_p[ieed[h
j^Wdj^[Wbl[ebWhi_Z["WiXed[]hemj^WdZjeej^
[hkfj_ed m_bb Yedj_dkekibo _d_j_Wj[ d[m 8CKi
_di_Z[j^[Wbl[ebWhh_Z][$J^[i[8CKim_bbfh[l[dj
eii_\_YWj_ed kdj_b W XWbWdY[Z jeej^ fei_j_ed WdZ
`Wm\kdYj_ed^WiX[[dWjjW_d[Z$
v H[ceZ[bb_d]_ijh_]][h[ZedY[W]W_dXojeej^beii
WdZ_cfbWdjWj_edfheY[Zkh[i$
v 8beeZ ikffbo je j^[ Wbl[ebWh Xed[ Z[j[h_ehWj[i
_dYh[Wi_d]bo Wi eii_\_YWj_ed fheY[ii[i jWa[ fbWY[
W\j[h]hemj^^WiX[[dYecfb[j[Z$
v M^_b[ j[[j^ Wh[ fh[i[dj" efj_cWb jhW`[Yjeh_Wb
eh_[djWj_ed e\ j^[ Xed[ YWddej X[ [ijWXb_i^[Z$
<ebbem_d] jeej^ beii" j^[ l[ij_XkbWh jhW`[Yjeh_[i _d
Xej^ `Wmi cel[ jemWhZi j^[ c[Z_Wb Wif[Yj$ 8ed[
h[iehfj_ed m_bb \ebbem W Y[djh_\k]Wb fWjj[hd _d j^[
cWdZ_Xb[" Wbj^ek]^ j^[ cWYhejhW`[Yjeh_[i cel[
c[Z_Wbbo$ J^[ cWn_bbW kdZ[h]e[i W Y[djh_f[jWb
h[iehfj_ededbo$
È È &ORMÈ&OLLOWSÈ&UNCTIONÈ '(+

D E

&IGÈÈ A Fh[ef[hWj_l[bo" j^[ fWj_[dj fh[i[dj[Z m_j^ fhedekdY[Z cWdZ_XkbWh Wjhef^o$ J^[ jme cWn_bbWho j[[j^ ^WZ ij_bb
f[hc_jj[ZY^[m_d]\ehcWdoo[Whi"Xkjedboedj^[b[\ji_Z[$7iWh[ikbj"j^[cWdZ_XkbWhc_Zb_d[^WZZh_\j[ZcWii_l[bojej^[b[\j$
J^[h_]^j^eh_pedjWbXhWdY^e\j^[cWdZ_Xb[mWiijh[jY^[Z_dj^_ifheY[ii$ B :_iYh[fWdY_[ie\j^_icW]d_jkZ[eXl_ekiboh[gk_h[
ieckY^h[ceZ[bb_d]_dXej^`Wmij^Wjj^[jmeZ_ijWb8E?_cfbWdjiYekbZdejfh[i[hl[j^[_heii[e_dj[]hWj[ZijWj[$D[l[hj^[b[ii"
j^_i\_hijh[ijehWj_ed^WZh[cW_d[Z_d\kdYj_ed\eh+o[Whi$8oYedjhWijm_j^j^[i_jkWj_ed_d<_]$/$(*Z"["eii[e_dj[]hWj_ede\j^[
Z_ijWb8E?_cfbWdjimWiY[hjW_dbodejj^[efj_ckcWbj^ek]^dejWXi[djYecfb[j[bo"WdZj^[fWj_[djÉiehWb^o]_[d[^WX_jim[h[
[njh[c[bokdiWj_i\WYjeho$<ehj^[i[h[Wiedi"bWh][hWh[Wie\c_d[hWb_pWj_edZ[\_Y_[dY_[iYekbZX[Yec[[ijWXb_i^[Z"m_j^j^[Xh_Z][
kbj_cWj[boX[_d]ikffehj[ZceijboXoj^[Wdj[h_eh_cfbWdji$ C 8E?j^[hWfoWdZYedYkhh[dj[gk_b_XhWj_ede\j^[cWij_YWjeho
\kdYj_ed^WZj^[h[ikbjj^Wjj^[c_Zb_d[YekbZdemX[h[fei_j_ed[ZikY^j^Wjj^[b[\j^eh_pedjWbXhWdY^e\j^[cWdZ_Xb[YekbZ
_dYh[Wi[ikXijWdj_Wbbo_db[d]j^WdZj^[Z_\\[h[dY[_d^[_]^jX[jm[[dj^[jmeXhWdY^[ib[l[bb[Z$J^[j[di_edij^_iYh[Wj[Zm[h[
W]W_d _dYecfWj_Xb[ m_j^ eii[e_dj[]hWj_ed e\ j^[ 8E? _cfbWdj _d j^[ h[]_ed e\ jeej^ )-$ J^[ _cfbWdj mWi h[cel[Z" WdZ j^[
Xh_Z][mWib[\jikffehj[ZXo\ekh8E?_cfbWdji$M[Wiikc[j^WjW\j[h'eh(o[Whi"Wd[m_cfbWdjYekbZX[iW\[bo_dj[]hWj[Z_d
j^[iWc[h[]_edWdZYedd[Yj[Zjej^[Xh_Z][$Dej[j^[cWii_l[cehf^ebe]_YWbY^Wd][iX[jm[[dj^[XWi[b_d[i_jkWj_edWdZj^[
hWZ_e]hWf^jWa[dW\j[h-o[Whie\m[Wh_d]\_n[Zh[ijehWj_edi"m_j^_dYh[Wi_d]bo[gk_b_XhWj[ZcWij_YWjeho\kdYj_ed$?jmWidejkdj_b
cWdoo[Whi^WZfWii[ZWdZj^[jmecWn_bbWhofh[cebWhi^WZX[[d[njhWYj[Zj^Wjj^_icWij_YWjeho\kdYj_edYekbZX[WZ`kij[Z
fhef[hbo$ 9ecfb[j[bo [Z[djkbeki `Wm gkWZhWdji m_j^ W \[m YedjhWbWj[hWb j[[j^ YWd X[ j^[ h[Wied \eh kd_bWj[hWb cWij_YWj_ed
fWjj[hdi$ D Jmefeij[h_ehi[]c[djim[h[_di[hj[Z\_hij_dj^_ifWj_[dj$8[YWki[j^[fedj_Yi^WZdejX[[dh[ZkY[Zedj^[XWiWb
i_Z[e\j^[Xh_Z]["j^[_cfbWdjXWhi\hWYjkh[Z$9edjhWhojeekhdehcWbkiW]["j^[beWZ#jhWdic_jj_d]Z_iae\j^[b[\j8E?_cfbWdj
mWidejh[cel[Z1_dij[WZ"Wd[mZ_iamWi_di[hj[ZZ_h[YjboX[bemj^[ebZZ_ia$?jmWifeii_Xb[jeh[#ki[j^[\_hijXh_Z][WiW
j[cfehWhoh[ijehWj_ed$J^_ih[ikbj[Z_dWhWdZech[bWj_l[fei_j_edWbh[eh_[djWj_ed_di_Z[j^[Xed[$7\[mcedj^ibWj[h"j^[b[\j
_cfbWdj \hWYjkh[Z W]W_d$ J^[ j^_hZ Z_ia mWi W]W_d _di[hj[Z X[bem j^[ i[YedZ ed[$ E J^[ fWdehWc_Y el[hl_[m hWZ_e]hWf^
jWa[dWjWbWj[heYYWi_edYb[Whboi^emiWd_dYh[Wi_d]Z_ijWb_pWj_ede\j^[Z_iaib[\j_dfbWY[_dj^[j^_hZgkWZhWdjWij^[Z_iaim[h[
Zh_\j_d]WdZY^Wd]_d]beYWj_edWbed]m_j^j^[Xed[ikXijWdY[
'(, 9^Wfj[h/È &OUR
$IMENSIONALÈ#ONSIDERATIONSÈOFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS
v ?d j^[ fh[i[dY[ e\ W kd_bWj[hWb Y^[m_d] fWjj[hd"
j[di_b[ \ehY[i m_bb X[ WYj_d] ed j^[ Yh[ijWb `Wm
i[]c[dje\j^[ded#meha_d]i_Z[$H[bWj_l[bWYae\
l[hj_YWbeYYbkiWbij_ckbWj_edm_bbYWki[^eh_pedjWb
jhW`[Yjeh_[ie\j^[jhWX[YkbWhjof[je\ehcm_j^_d
j^[XeZoe\j^[`Wm$
v J^[[nj[dje\j^[[njhki_ede\cWn_bbWhofeij[h_eh
j[[j^YWdX[Yedi_Z[hWXb[$Kdb[iiWYYecfWd_[ZXo
f[h_eZedjWb Z[ijhkYj_ed" j^[ j[[j^ m_bbÆjWa[ j^[
Xed[Wbed]Ç$?\ikY^[bed]Wj[Zj[[j^Wh[h[cel[Z"
j^_i m_bb h[ikbj _d W l[ho \Wij _dlebkj_ed e\ j^[
Wbl[ebWhXed["m^_Y^m_bbX[h[ZkY[Zjej^[i_p[_j
mekbZ^Wl[^WZ^WZj^[jeej^dejX[[d[njhkZ[Z$
J^[ YWkZWb Yehj_YWb Xed[ e\ j^[ cWn_bbWho i_dki
b_c_jij^[_dlebkj_edWhoj[dZ[dYo$
?d WZZ_j_ed je c[Y^Wd_YWb \WYjehi" ^ehced[i fbWo
W l_jWb heb[ _d Xed[ ][d[hWj_ed WdZ ]hemj^#h[bWj[Z
Xed[ h[ceZ[bb_d] Wi m[bb$ ?cfbWdj fWj_[dji Ze dej
X[bed] je Wd W][ ]hekf m^[h[ ]hemj^ [\\[Yji fbWo
Wheb["Xkjj^[oj[dZjeX[W\\b_Yj[Z"jeiec[Z[]h[["
Xo ][d[hWb_p[Z W][ _dlebkj_ed WdZ Z_iki[ Wjhef^o
W\\[Yj_d] j^[ [dj_h[ XeZo$ <ebbem_d] jeej^ beii" j^[
Xed[ j^Wj j^[ j[[j^ ^Wl[ ÆXhek]^j Wbed]Ç _d j^[
]hemj^ f^Wi[ m_bb kdZ[h]e _dlebkj_ed$ J[cfehWho
]hemj^ f[Wai cWo [l[d eYYkh _d ebZ W][ \ebbem_d]
jhWkcW je j^[ Xed[ Wi c[Z_Wjehi Wh[ h[b[Wi[Z _d
bWh][Wcekdjij^WjWh[YWfWXb[e\_dZkY_d]d[mXed[
]hemj^dejedboWjj^[_cc[Z_Wj[i_j[e\j^[jhWkcW
Xkj _d ceh[ h[cej[ Wh[Wi Wi m[bb 8WX [j Wb$ '/.+1
8Wa[h'/(($
È
)MPACTÈOFÈ#OMPRESSIONÈANDÈ4ENSIONÈÈ
ONÈTHEÈ6ERTICALÈ"ONEÈ,EVEL
È
)NTRODUCTION
@kZ]_d] \hec _ji WhY^_j[Yjkh[" j^[ cWdZ_Xb[ _i
[ii[dj_Wbbo W bed] jkXkbWh Xed[ 7i^cWd WdZ lWd
8ki^a_ha '/.-$ J^[ Y^_d _i Wd Wh[W e\ cWn_ckc
\b[n_ed_dm^_Y^jhW`[Yjeh_[i\hecXej^i_Z[iel[hbWf
je \ehc W ijhkYjkh[ e\ ^_]^ Z[di_jo$ 8[_d] W ÆiW\[
^Wl[dÇ \eh WdY^ehW][" j^[ Y^_d _i W fh[\[hh[Z i_j[
\eh _cfbWdj fbWY[c[dj$ J^[ i^Wf[ e\ j^[ cWdZ_Xb[
_i Z[h_l[Z \hec W dkcX[h e\ \WYjehi$ 9hkY_Wb
Z[j[hc_dWdji _dYbkZ[ ckiYb[ \kdYj_ed _$[$ Y^[m_d]
WdZc_c_YckiYb[iWim[bbWij^[dkcX[h"i_p[WdZ
fei_j_ed e\ j[[j^$ 7\j[h j[[j^ ^Wl[ X[[d [njhWYj[Z"
j^[h[bWj[ZXed[ijhkYjkh[e\j^[Wbl[ebWhh_Z][m_bb
kdZ[h]eZ_iki[Wjhef^o"_$[$j^[l[hj_YWbXed[lebkc[
m_bbX[h[ZkY[Z_dWYb_d_YWbbocWd_\[ijcWdd[h$J^[
fh[i[dY[ e\ Wdo h[ijehWj_edi j^Wj Wh[ _dik\\_Y_[djbo
ikffehj[Z Xo h[i_ZkWb j[[j^ eh [deiiWb WdY^ehW][
cWo WYY[b[hWj[ j^_i fheY[ii e\ Xed[ h[iehfj_ed
D^h_ [j Wb$ '/.-1 @kd] '/+/" j^[h[Xo _d\bk[dY_d]
j^[ l[hj_YWb Z_c[di_ed e\ eYYbki_ed WdZ ^[dY[ j^[
l[hj_YWbZ_c[di_ede\j^[\WY[WjbWh][Ic_j^'/-+$
L[ho ckY^ b_a[ j^[ mWo m[ Z_\\[h[dj_Wj[ X[jm[[d
beWZ#X[Wh_d] WdZ ded#beWZ#X[Wh_d] ijhkYjkh[i _d
Xk_bZ_d]i" m[ YWd cWa[ j^[ iWc[ Z_ij_dYj_ed _d j^[
`Wmi$ J^[ÆbeWZ#X[Wh_d]Ç ijhkYjkh[i e\ j^[ `Wmi Wh[
j^ei[Wh[Wij^Wjfeii[iiWjhW`[Yjeh_Wbeh_[djWj_edWi
Wh[ikbje\cWij_YWjeho\kdYj_edWdZWh[Z[i_]d[Zje
fh[l[djc[Y^Wd_YWb\W_bkh[e\j^[`WmWjbWh][$J^[i[
ijhkYjkh[iWh[ijWXb[jeh[iehfj_ed$8ed[Wh[Wim^ei[
fh_dY_fWb jWia _i je WYYecceZWj[ j^[ Z[djWb heeji
^Wl[ de beWZ#X[Wh_d] \kdYj_ed$ J^[ Z_ij_dYj_ed _i
dej WbmWoi Yb[Wh" ^em[l[h$ <eh [nWcfb[" j^[ XWiWb
heeji[]c[djie\bem[hi[YedZcebWhiWh[\h[gk[djbo
beYWj[Z_dbeWZ#X[Wh_d]`Wmi[]c[dji"m^_Y^_i]eeZ
\ehXed[fh[i[hlWj_edWdZj^ki\ehj^[fh[i[hlWj_ed
e\ j[[j^" fhel_Z[Z j^Wj Wffhefh_Wj[ \kdYj_edWb
fWjj[hdiWh[fh[i[dj$
J^[h[ ^Wl[ X[[d l[ho ifehWZ_Y _dZ_YWj_edi _d
j^[ b_j[hWjkh[ j^Wj 8E?#XWi[Z h[ijehWj_edi Wh[ dej
edbo WXb[ je Whh[ij j^[ Xed[ beii Xhek]^j WXekj Xo
f[h_eZedjWb Z_i[Wi[ Xkj Wbie je ][d[hWj[ d[m Xed[
j_iik[IYehj[YY_[jWb$(&&'$<ebbem#kf[nWc_dWj_edi
e\ _cfbWdj#h[ijehWj_ed ioij[ci _d ^[Wl_bo h[iehX[Z
Wh[Wie\j^[Z_ijWbcWdZ_Xb[^Wl[iec[j_c[ih[l[Wb[Z
Yedi_Z[hWXb[ d[m Xed[ \ehcWj_ed X[bem WdZ WXel[
j^[ beWZ#jhWdic_jj_d] Z_iai e\ 8E? _cfbWdji$ Bed]#
j[hc ikYY[ii YWd edbo X[ WY^_[l[Z _\ j^[ jh[Wjc[dj
YedY[fjZkboYedi_Z[hij^[\kdYj_edWbh[gk_h[c[dji$
M[ ^Wl[ fh[l_ekibo Z[cedijhWj[Z j^Wj j^[ Xed[
lebkc[ _d h[iehX[Z Z_ijWb cWdZ_Xb[i m_bb hekj_d[bo
_dYh[Wi[ W\j[h beYWb _dijWbbWj_ed WdZ beWZ_d] e\
_cfbWdji ?^Z[ (&&)$ ?d \ebbem#kf [nWc_dWj_edi e\
'(& fWj_[dji" m[ eXi[hl[Z Xed[ ]W_di _d j^[ hWd][
e\&$'Ä+$*ccWXel[WdZe\kfje*$)ccX[bemj^[
XWiWb Z_ia$ J^[ Z_ijWdY[ e\ 8E? _cfbWdji \hec j^[
ikh\WY[e\j^[Wbl[ebWhYh[ijWdZj^[bem[hXehZ[he\
j^[cWdZ_Xb[j[dZije_dYh[Wi[$?ded[[njh[c[YWi["
Wd _dYh[Wi[ _d l[hj_YWb Xed[ Z_c[di_ed e\ ,$(cc
mWic[Wikh[Z$
?dYh[Wi[i _d Xed[ lebkc[ m[h[ [if[Y_Wbbo
fhedekdY[Z _d j^ei[ Wh[Wi m^[h[ h[celWXb[
_dj[]kc[dj#ikffehj[Z h[ijehWj_edi ^WZ X[[d mehd$
J^[o m[h[ ]h[Wj[h ij_bb _d fedj_Y h[]_edi m^[h[ de
_cfbWdjim[h[fh[i[dj$
?d kd_bWj[hWb fWjj[hdi e\ `Wm cel[c[dj" l[hj_YWb
Z[l[befc[dje\Xed[_ih[ZkY[Zedj^[meha_d]i_Z[
WdZ [d^WdY[Z _d j^[ Wh[W e\ j^[ (dZ fh[cebWh WdZ
'ijcebWhe\j^[ded#meha_d]i_Z[$J^_im_bbb[WZjeW
Z[\ehcWj_ede\j^[`WmXed[WdZjeWdWbj[hWj_ede\
j^[h[bWj_edi^_fX[jm[[dj^[fheij^[j_YWbmehaf_[Y[
WdZ j^[ Yh[ij e\ j^[ Xed[$ J^_i _i Zk[ je j^[ \WYj
j^Wjj^[Wbl[ebWhYh[ijikh\WY[e\j^[meha_d]i_Z[_i
ikX`[Yj[Z je Yecfh[ii_l[ \ehY[i" m^[h[Wi j^[ ded#
meha_d]i_Z[_iZec_dWj[ZXoj[di_b[\ehY[i$
È ÈÈ )MPACTÈOFÈ#OMPRESSIONÈANDÈ4ENSIONÈONÈTHEÈ6ERTICALÈ"ONEÈ,EVELÈ
È
"ACKGROUNDÈ#ONSIDERATIONSÈ2EGARDINGÈÈ
6ERTICALÈ"ONEÈ'ROWTH
J^[l[hj_YWbYecfed[dje\jeZWoÉi8E?_cfbWdji_$[$
j^[j^h[WZ[Zf_d_iiceej^$J^[ikh\WY[e\j^[XWiWb
fbWj[i"^em[l[h"cWoX[hek]^[d[ZXoiWdZXbWij_d]je
cWn_c_p[j^[WlW_bWXb[ikh\WY[^oXh_ZZ[i_]d$J^[
cWij_YWjeho beWZ _i jhWdic_jj[Z [nYbki_l[bo j^hek]^
j^[i[ XWiWb fbWj[i$ J^[ ki[ e\ Yh[ijWb _cfbWdji ^Wi
X[[d Z[iYh_X[Z je X[ WiieY_Wj[Z m_j^ Yedj_dkeki
l[hj_YWb Xed[ beii IY^b_[f^Wa[ WdZ D[kaWc (&&&
7bie"j^[i[_cfbWdjij[dZjei_da_djej^[cWdZ_Xb[
kdb[iij^[oWh[ikffehj[Z[$]$b_d]kWbboXoYehj_YWb
Xed[$J^_i_ifWhj_YkbWhbojhk[e\XbWZ[_cfbWdji$De
f[hj_d[dj h[ikbji ^Wl[ o[j X[[d fkXb_i^[Z \eh 8E?
_cfbWdji$
JmefWj_[dji_dm^eccWdZ_XkbWh_cfbWdjim[h[
fbWY[Z iocc[jh_YWbbo ed j^[ b[\j WdZ h_]^j i_Z[i
h[l[Wb[ZfWjj[hdie\Xed[]hemj^j^Wjm[h[[ii[dj_Wbbo
kd_bWj[hWb$Ikhfh_i_d]bo"j^[fh[\[hh[Zi_Z[iYe_dY_Z[Z
m_j^j^[i_Z[im^[h[j^[l[hj_YWbZ_c[di_ed^WZX[[d
]h[Wj[h [l[d X[\eh[ _cfbWdjWj_ed$ J^[ Wffei_j_ed
fWjj[hd _d j^[i[ fWj_[dji mWi j^[ [nWYj effei_j[ e\
j^[fWjj[hdi[[d_dWbbej^[hfWj_[djiijkZ_[Z$
J^[h[ikbjiedYb_d_YWb[nWc_dWj_edYed\_hc[Zj^[
\_dZ_d] eXjW_d[Z Xo _dj[hl_[m WdZ eXi[hlWj_ed j^Wj
j^ei[cWij_YWjehofWjj[hdim[h[fkh[bokd_bWj[hWb_d
dWjkh["WiJC@\kdYj_edjej^[YedjhWbWj[hWbi_Z[mWi
WbceijYecfb[j[boeXijhkYj[Z$L[hj_YWbXed[]W_dmWi
eXi[hl[ZcW_dboedj^[ded#meha_d]i_Z[$
J^_i jof[ e\ Wffei_j_ed X[^Wl_ekh ^WZ X[[d
Z[iYh_X[Z fh[l_ekibo Xo >obWdZ[h '/-/$ ?j mWi
Wjjh_Xkj[Z je j^[ \WYj j^Wj Yecfh[ii_l[ \ehY[i
Z[l[bef[Z ed j^[ ded#meha_d] i_Z[ e\ j^[ bem[h
cWdZ_XkbWh cWh]_d Zkh_d] cWij_YWj_ed m^[h[Wi
j[di_b[\ehY[im[h[fh[Zec_dWdj_dj^[kff[hfehj_ed
e\j^[Wbl[ebWhh_Z][$J^[h[ikbjij^Wj>obWdZ[h^WZ
eXjW_d[Z_dceda[oim[h[bWj[hYed\_hc[Z_d]h[Wj[h
Z[jW_b _d ijkZ_[i ed ^kcWdi f[h\ehc[Z Xo Aeh_ej^
WdZ >WddWc '//* WdZ :[Y^em WdZ >obWdZ[h
(&&&$
Je Yecf[diWj[ \eh ]h[Wj[h Y^[m_d] \ehY[i" j^[
`Wm cWo ]hem dej edbo l[hj_YWbbo Xkj Wbie bWj[hWbbo
eh c[Z_Wbbo$M^_b[ j^[i[ Z_c[di_edWb Y^Wd][i m[h[
ekji_Z[ j^[ iYef[ e\ j^_i if[Y_\_Y ijkZo" j^[o d[[Z
jeX[jWa[d_djeYedi_Z[hWj_edXoi[b[Yj_d]_cfbWdji
e\ WZ[gkWj[ m_Zj^$ J^[ j[Y^d_gk[ e\ b[Wl_d] fWhji
e\ j^[ XWi[ fbWj[ ekji_Z[ Xed[ _i b_c_j[Z je Wh[Wi
m^[h[j^[XkYYWbie\j#j_iik[ijhkYjkh[iWh[dejel[hbo
j^_dehYedi_ije\j^_dWjjWY^[Z]_d]_lW"i_dY[j^ei[
j_iik[ jof[i cWo YWki[ ckYeiWb f[d[jhWj_ed e\ j^[
fhe`[Yj_d] _cfbWdj$ J^_i WffheWY^ _i Wbie ki[\kb \eh
[WhboZ[j[Yj_ede\el[hbeWZeij[eboi_iÄ_$[$edY[j^[
_cfbWdj_iib_]^jboceX_b_p[Z"j^[fWj_[djm_bbdej_Y[
c_bZfW_dZkh_d]eYYbki_edWdZ"m^_Y^m_bb]_l[j^[c
Wdeffehjkd_jojeYedjWYjj^[_cfbWdjebe]_ij_dZk[
'(-
Yekhi[$J^_ijof[e\ded#XWYj[h_WbceX_b_jo_ikikWbbo
h[l[hi_Xb[" fWhj_YkbWhbo _d Wh[Wi e\ X_ec[Y^Wd_YWb
ijh[ii WdZ _\ jh[Wj[Z _d W Yecf[j[dj WdZ j_c[bo
cWdd[h$
B_a[m_i["Xed[_iYWfWXb[e\WZWfj_d]je\kdYj_edWb
Wbj[hWj_ediXoY^Wd]_d]_jiZ[]h[[e\c_d[hWb_pWj_ed$
H[i[WhY^ _d Yh[ijWb _cfbWdjebe]o _i ieb[bo \eYki[Z
ed WY^_[l_d]Æeii[e_dj[]hWj_edÇ" m^_b[ _]deh_d] j^[
\WYj j^Wj cW`eh ieb_Z XeZ_[i ikY^ Wi bed] _cfbWdji
eh[nj[di_l[_cfbWdj#h[ijehWj_edioij[ci_dj[]hWj[Z
_djeXed[i[]c[djij^WjWh[ikX`[YjjedWjkhWb\b[n_ed
WdZm^ei[\b[nkhWbX[^Wl_ekh_iZ_\\[h[dj\hecj^Wj
e\Xed[m_bb[_j^[hdejX[eii[e_dj[]hWj[Zel[hj^[_h
[dj_h[ ikh\WY[ eh m_bb _dlebl[ Z_\\[h[dj Z[]h[[i e\
Xed[c_d[hWb_pWj_edWbed]j^[_dj[h\WY[$
I_dY[ j^[ ^kcWd XeZo bWYai jhk[ h[\[h[dY[
fe_dji" eh_[djWj_ed _d bed]_jkZ_dWb c[Wikh[c[dji
_i Z_\\_Ykbj$ ;deiiWbbo WdY^eh[Z eii[e_dj[]hWj[Z
8E? _cfbWdji YWd Y^Wd][ j^[_h fei_j_ed h[bWj_l[
je j^[ hWZ_e]hWf^_YWbbo l_i_Xb[ XekdZWh_[i e\
j^[ `Wm Wi j^[ Xed[ cehf^ebe]o Y^Wd][i Zk[ je
\kdYj_edWb _d\bk[dY[i$ 8WiWb fbWj[i _di[hj[Z _d j^[
Z_ijWbcWdZ_Xb[j[dZjec_]hWj[kfmWhZi_dWYhWd_Wb
Z_h[Yj_edh[bWj_l[jej^[bem[h[Z][e\j^[cWdZ_Xb[$
J^_i kfmWhZ c_]hWj_ed _i j^[eh[j_YWbbo effei[Z je
j^[ Y^[m_d] \ehY[" m^ei[ j[dZ[dYo _i je fki^ j^[
Z_ia jemWhZi j^[ YWkZWb Wif[Yj$ ?j Wff[Whi j^Wj j^[
ij[WZo \ehY[ e\ jhW`[Yjeh_Wb h[ceZ[bb_d] _i ijhed][h
j^Wdj^[f[h_eZ_Y_d\bk[dY[e\cWij_YWj_ed$?dijWbb_d]
\ehY[#jhWdic_jj_d]ikh\WY[i_dj^[[deiiWbifWY[WdZ
_cceX_b_p_d]j^[ch[bWj_l[je[WY^ej^[hXofheij^[j_Y
c[Wdim_bbYh[Wj[h[bWj_l[h[\[h[dY[fe_dji"
Ed j^[ ed[ ^WdZ" j^[ cWij_YWj_ed ikh\WY[i ]k_Z[
j^[ckiYb[i1edj^[ej^[h^WdZ"j^[ckiYb[\kdYj_ed
j^ki ceZ_\_[Z ^Wi Wd [\\[Yj ed j^[ jhW`[Yjeh_Wb
WhY^_j[Yjkh[e\j^[Xed[ijhkYjkh[WdZ_cfbWdjX[Z$
J^[Xed[ckijj^[h[\eh[X[]_l[dWdeffehjkd_jo
jeY^Wd][_jicehf^ebe]o_dehZ[hjeWZWfjWdZjeh[#
eh_[dj_jijhW`[Yjeho$J^[]hemj^j[dZ[dY_[i_dYh[ijWb
Z_h[Yj_ed ckij dej X[ j^mWhj[Z Xo j^[ fh[i[dY[
e\ fedj_Yi$ ?d ekh [nf[h_[dY[" YedjWYj X[jm[[d
fedj_YiWdZckYeiWcWo]hWZkWbbo]_l[h_i[jefW_d
\h[gk[djbo Wj W ikXYediY_eki b[l[b WdZ Wle_ZWdY[
fWjj[hdi$ J^_i cWo fh[l[dj kd_\ehc cWij_YWj_ed"
j^ki`[efWhZ_p_d]j^[_dj[]hWj_ede\_cfbWdji"eh]_l[
h_i[je[nY[ii_l[beWZ_d]$
?dWZZ_j_ed"YedjWYjX[jm[[dfedj_YiWdZckYeiW
m_bb a[[f j^[ Xedo ijhkYjkh[ e\ j^[ `Wmi \hec
Z[l[bef_d] j^[_h ceij \WlekhWXb[ X_ec[Y^Wd_YWb
i^Wf[$J^_i"jee"cWoYWki[fheXb[ci_dj^[_cfbWdj
X[Z$ <eh [nWcfb[" ]hemj^ cWo eYYkh _d Z_h[Yj_edi
ej^[h j^Wd j^[ X_ec[Y^Wd_YWbbo \WlekhWXb[ Yh[ijWb
Z_h[Yj_ed[$]$_dm_Zj^$?dj^[mehij#YWi[iY[dWh_e"
j^[beWZ#jhWdic_jj_d]ikh\WY[icWobei[j^[_hYehj_YWb
YedjWYj$ I_dY[ cehf^ebe]_YWb Y^Wd][i e\ j^_i jof[
YWd d[l[h X[ [nYbkZ[Z m_j^ Y[hjW_djo" 8E? _cfbWdji
i^ekbZ WbmWoi X[ _di[hj[Z ikY^ j^Wj j^[o j[dZ je
'(. 9^Wfj[h/È &OUR
$IMENSIONALÈ#ONSIDERATIONSÈOFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS
fhe`[Yj \hec j^[ Yehj_YWb Xed[ hWj^[h j^Wd X[_d]
beYWj[Z_dWZ[[f[hfei_j_ed$
?dWZlWdY[ZZ_ijWbh_Z][h[iehfj_ed"m^[h[[dek]^
Xed[ lebkc[ _i fh[i[dj _d j^[ Wdj[h_eh i[]c[dji je
WdY^eh W \_n[Z h[ijehWj_ed" _j cWo X[ WZl_iWXb[ dej
je _di[hj j^[ Z[\_d_j_l[ h[ijehWj_ed h_]^j WmWo Xkj
je WZefj W mW_j#WdZ#i[[ ijhWj[]o \ebbem_d] Z_ijWb
_cfbWdjfbWY[c[djkdj_bj^[kfmWhZc_]hWj_ede\j^[
_cfbWdjWiieY_Wj[Zm_j^l[hj_YWbXed[\ehcWj_ed^Wi
X[[d Yecfb[j[Z$ 8ed[ Wffei_j_ed c_]^j X[ ]h[Wj[h
_\ de cWij_YWjeho \ehY[i Wh[ fh[i[dj je Yekdj[hWYj
_j$ <khj^[hceh[" j^_i mekbZ j^[eh[j_YWbbo h[ZkY[ j^[
d[[Z\ehikXjhWYj_l[WZ`kijc[djijej^[h[ijehWj_ed$
?\ j^[ b_d]kWb Wif[Yj e\ j^[ h[i_ZkWb h_Z][ _i
l[ho ^_]^ Xkj dWhhem" j^[ j^h[WZ[Z f_d YWd X[
fbWY[Z bWj[hWbbo je j^[ h_Z][$ J^_i m_bb Yh[Wj[ WXekj
j^[ iWc[ ifWj_Wb h[bWj_edi^_f Wi _\ j^[ h_Z][ m[h[
ijh_Yjbo]hem_d]_dWYhWd_WbZ_h[Yj_edW\j[h_cfbWdj
fbWY[c[dj$ ?d j^[i[ i_jkWj_edi" ekh WffheWY^ _i je
Z_ihkfj j^[ jhW`[Yjeh_[i e\ j^[ h[i_ZkWb h_Z][ \hec
j^[ Wbl[ebWh Yh[ij Zemd je j^[ XWiWb cWdZ_XkbWh
i[]c[dj Xo c[Wdi e\ W l[hj_YWb eij[ejeco Yh[Wj[Z
m_j^Wjkd]ij[dYWhX_Z[Ykjj[hc[i_Wbjej^[_cfbWdj
i_j[$ J^_i _dYh[Wi[i j^[ \kdYj_edWb ijh[ii ed j^[
_cfbWdj eij[ejeco" m^_Y^" _d ekh [nf[h_[dY[" m_bb
WYY[b[hWj[^[Wb_d]WdZj^[h[Xo_cfhel[j^[Y^WdY[i
e\ ikYY[ii\kb _dj[]hWj_ed e\ j^[ _cfbWdj$ ?\ j^_i
eij[ejeco _i dej f[h\ehc[Z" j^[ h_ia e\ _dj[]hWj_ed
fheXb[ci _i ^_]^[h X[YWki[ j^[ Xed[ m_bb bWYa j^[
\kdYj_edWbij_ckbkijeYbei[j^[bWj[hWbeij[ejeco$
<kdYj_edWbbo _dZkY[Z Xk_bZ#kfi e\ l[hj_YWb Xed[
cWii _d j^[ cWdZ_Xb[ ^Wl[ Wbie X[[d Z_iYkii[Z _d
Yedd[Yj_ed m_j^ jhWdicWdZ_XkbWh _cfbWdji JC?
8eia[h [j Wb$ '//'$ J^_i jof[ e\ Xk_bZ#kf Wff[Whi
jeZ[f[dZedj^[fh[i[dY[e\]h[Wj[hY^[m_d]\ehY[i
WYj_d] ed j^[ Xed[ \hec [deiiWb Z_h[Yj_ed Wi W
h[ikbj e\ h[ijeh[Z \kdYj_ed WdZ ed j^[ WXi[dY[ e\
_d\[Yj_ed#h[bWj[ZXed[YebbWfi[im^[h[j^[_cfbWdji
f[d[jhWj[ j^[ ckYeiW$ J^[h[\eh[" j^[ jhWdickYeiWb
l[hj_YWb_cfbWdjikh\WY[ickijdejfWhj_Y_fWj[_dbeWZ
jhWdic_ii_ed1Wbie"j^[o^Wl[jeX[feb_i^[Zje^_]^
]beii$J^ki"m^_b[JC?WdZ8E?_cfbWdjih[boedj^[
iWc[fh_dY_fb[\ehbeWZjhWdic_ii_ed"j^[^WdZb_d]e\
8E?_cfbWdji_ii_cfb[h$
<ehi[l[hWbh[Wiedi"fWj_[djim^e^Wl[fh[l_ekibo
mehd W Z[djkh[ m_bb X[d[\_j ceh[ \hec d[m Xed[
\ehcWj_edj^WdfWj_[djim^e^WZdejfh[l_ekibomehd
W h[ijehWj_ed _d j^[ [Z[djkbeki Wh[W$ <eh ed[ j^_d]"
j^[ _d_j_Wb i_jkWj_ed _i b[ii \WlekhWXb[ Wi j^[ Z_iki[
Wjhef^o e\ j^[ [Z[djkbeki h_Z][ _i YecfekdZ[Z Xo
Z[djkh[#_dZkY[Zh[iehfj_ed$7ffWh[djbo"j^[Wjhef^o
_ifWhj_Wbboh[l[hi_Xb[$Ceh[el[h"Y^[m_d]\ehY[im_bb
Z[Yh[Wi[_dfWj_[djim[Wh_d]Z[djkh[iWiWh[ikbje\
Wle_Z_d] fh[iikh[#h[bWj[Z fW_d$ J^[ Y^[m_d] \ehY[i
YWd j^[h[\eh[ X[ [nf[Yj[Z je _dYh[Wi[ W\j[h W \_n[Z
h[ijehWj_ed ^Wi X[[d _di[hj[Z$ EdY[ j^[ Z[djkh[ _i
de bed][h mehd" j^[ Yecfh[ii_l[ \ehY[i WYj_d] ed
j^[ ckYeiW" j^ki ]_l_d] h_i[ je Y^hed_Y _iY^[c_W e\
j^[ Yh[ijWb ckYef[h_eij[kc" Wh[ h[ZkY[Z C[hY_[h
WdZ L_d[j '/.)$ J^[ XbeeZ ikffbo j^hek]^ j^[
Y[djhWb cWdZ_XkbWh Whj[ho _i h[ZkY[Z _d WZlWdY[Z
cWdZ_XkbWhh[iehfj_ed8hWZb[o'/-+$
7ja_died [j Wb$ '/-- Z[cedijhWj[Z Z_\\[h[dj
h[]_edWb Xed[ Z[di_j_[i _d f_]i" Ze]i WdZ ^kcWdi
\ebbem_d] jeej^ [njhWYj_ed$ 8ed[ Z[di_jo _d Wh[Wi
[nY[[Z_d]j^[Wbl[eb_mekbZWbieY^Wd][_dWi[YedZ
f^Wi[e\h[ceZ[bb_d]$?dj^[_d_j_Wbf^Wi["j^[Z[di_jo
mekbZZ[Yh[Wi[Zk[jeW]h[Wj[hZ[]h[[e\fehei_jo$J^[
jkdd[bb_d]i[YedZWhoeij[edi8CKimekbZ_dZkY[
Xed[h[ceZ[bb_d][l[d_dj^[Wh[WiikhhekdZ_d]j^[
Wbl[eb_$7\j[h_d_j_Wb^[Wb_d]"h[iehfj_edmWieXi[hl[Z
_dj^[Wh[We\j^[[njhWYj_edieYa[j$H[iehfj_edmWi
Z[bWo[Z_\Yh[ijWb_cfbWdji^WZX[[d_di[hj[Z_dj^[
Wh[We\j^[Wbl[ebki"WdZXed[Z[di_jomWi\ekdZje
X[_dYh[Wi[Z1_d\WYj"Xed[Z[di_jomekbZiec[j_c[i
[l[d h_i[ WXel[ j^[ XWi[b_d[ b[l[b$ D_d[ cedj^i
W\j[h _cfbWdjWj_ed" h[iehfj_ed fheY[ii[i WZl[hi[bo
W\\[Yj_d]j^[fh[i[hlWj_ede\Wbl[ebWhXed[m[h[i[[d
_d j^[ _cfbWdj Wh[W$ Ed XWbWdY[" j^[ [nf[h_c[dji
f[h\ehc[Z Xo 7ja_died [j Wb$ o_[bZ[Z de [l_Z[dY[
e\ Wdo Y^Wd][i ed j^[ b_d]kWb i_Z[ e\ j^[ cWdZ_Xb[
\ebbem_d] _di[hj_ed e\ Yh[ijWb _cfbWdji" m^_Y^ _i _d
a[[f_d] m_j^ ekh emd \_dZ_d]i eXjW_d[Z fh[l_ekibo
m_j^^[Wb[ZXkjkdbeWZ[ZZ[djWb_cfbWdji_dZe]i$
8ej^jeej^[njhWYj_edWdZj^[_di[hj_ede\c[jWb
_cfbWdji m_bb ij_ckbWj[ Xed[ h[ceZ[bb_d]$ Jeej^
[njhWYj_ed ]_l[i h_i[ je Z_iki[ Wjhef^o" m^_Y^ j^[
_cfbWdjWj_edfheY[Zkh[_iZ[i_]d[ZjeWle_Z$
<ebbem_d] j^[ [njhWYj_ed e\ cWdZ_XkbWh cebWhi"
j^[ beWZ#jhWdic_jj_d] b_d[ e\ j^[ cWdZ_Xb[" kikWbbo
beYWj[ZWbed]j^[l[ij_XkbWhWif[Yj"cWojhWl[bjej^[
b_d]kWbWif[YjWdZjWa[WYhWd_WbhWj^[hj^WdbWj[hWb
eh_[djWj_ed$J^ki"_dfWj_[djim_j^_djWYjZ[dj_j_edi"
j^[cebWhifh[l[djj^[\ehY[#jhWdic_jj_d]b_d[\hec
[ijWXb_i^_d] _ji _Z[Wb Z_ijec[i_Wb eh_[djWj_ed$ ?d
fWj_[dji m_j^ Z[[f cWdZ_XkbWh f[h_eZedj_j_i" j^[
\ehY[#jhWdic_jj_d] b_d[i X[Yec[ Z_ibeYWj[Z Z[if_j[
j^[ fh[i[dY[ e\ j[[j^" m^_Y^ m_bb kbj_cWj[bo YWki[
j^ei[j[[j^jeX[beij$
Ded[j^[b[ii" j^[ fh_dY_fWb \ehY[#jhWdic_jj_d]
ijhkYjkh[ e\ j^[ cWdZ_XkbWh Xed[ m_bb ij_bb h[cW_d
kdY^Wd][Z_\fh[cebWhiWh[[njhWYj[Zehh[fbWY[ZXo
_cfbWdji7ja_died[jWb$'/--$
J^[h[ Wh[ dkc[heki _dZ_YWj_edi _d j^[ b_j[hWjkh[
j^WjbeWZ#h[bWj[Zijh[ii_dj^[cWdZ_Xb[[$]$XockiYb[
WjjWY^c[djiWdZej^[h\kdYj_edWbc[Y^Wd_icim_bb
_d\bk[dY[Xed[]hemj^$=hemj^_ih[ZkY[Z_\ckiYb[i
Wh[ h[cel[Z Ceeh[ '/-)$ 8o h[cel_d] j^[c
kd_bWj[hWbbo"j^[Z_h[Yj_ede\]hemj^YWdX[ceZ_\_[Z
IY^kcWa[h WdZ :eabWZWb '/,.$ Jeej^ [hkfj_ed
WdZ j^[ i^[[h fh[i[dY[ e\ j[[j^ m_bb _d\bk[dY[ Xed[
h[ceZ[bb_d] WdZ" ^[dY[" Xed[ ijhkYjkh[ P[d]e [j
Wb$'/-)$
È È )MPACTÈOFÈ#OMPRESSIONÈANDÈ4ENSIONÈONÈTHEÈ6ERTICALÈ"ONEÈ,EVELÈ
?j ^Wi X[[d ademd \eh W bed] j_c[ j^Wj Xed[
\hWYjkh[i^[Wb_d]_dWYkhl[Zfei_j_edm_bbijhW_]^j[d
ekj el[h j^[ o[Whi @Wdi[d '/(&1 8Wii[j '/,+$ <heij
'/,* feijkbWj[Z j^Wj j^[ Xed[ h[WYj_ed Ze[i dej
fh_cWh_boh[ikbj\hecYecfh[ii_l[WdZj[di_b[\ehY[i
Xkj \hec j^[ j[dZ[dYo e\ j^[ \ehY[ WYj_d] ed j^[
Xed[jeY^Wd][_jiYkhlWjkh[$?d^_ij^[ehoe\\b[nkhWb
d[kjhWb_pWj_ed" ^[ ikccWh_p[Z j^Wj _dYh[Wi_d]
YedYWl_jo ]_l[i h_i[ je Xed[ Wffei_j_ed" m^[h[Wi
_dYh[Wi_d] Yedl[n_jo ]_l[i h_i[ je Xed[ h[iehfj_ed$
J^_i cWo X[ ed[ h[Wied \eh j^[ i^Whf _dYh[Wi[ e\
l[hj_YWbXed[lebkc[eXi[hl[Z_dj^[Z_ijWbcWdZ_Xb[
W\j[h h[fbWY_d] Z[djkh[i$ J^[ YkhlWjkh[ _i j^ki
h[ZkY[Z$
È
#LINICALÈ!PPLICATION
J^[[nf[h_[dY[m_j^8E?#XWi[Z_cfbWdj#h[ijehWj_ed
ioij[ci kdZ[hiYeh[i j^[ [njhWehZ_dWho _cfehjWdY[
e\ W Yecf[j[dj \ebbem#kf fhejeYeb$ FWhj_YkbWhbo _d
j^[ \_hij (o[Whi \ebbem_d] ikh][ho eh fheij^[j_Y
jh[Wjc[dj _d_j_Wb jh[Wjc[dj eh h[#jh[Wjc[dj" j^[
h[bWj_l[ c_]hWj_ed e\ j^[ XWiWb Z_ia cWo ]_l[ h_i[
je i_]d_\_YWdj fh[cWjkh[ YedjWYji$ <eh j^_i h[Wied"
ikXjhWYj_l[eYYbkiWbWZ`kijc[djid[[ZjeX[YedZkYj[Z
f[h_eZ_YWbbo WdZ _d W j_c[bo cWdd[h$ J^[ [nj[dj
e\ j^_i h[gk_h[c[dj _i ]h[Wj[h j^Wd Z[dj_iji m^e
Wh[ _d[nf[h_[dY[Z m^[d _j Yec[i je 8E? _cfbWdji
mekbZ dehcWbbo Yedi_Z[h je X[ d[Y[iiWho XWi[Z
ed j^[_h [nf[h_[dY[ m_j^ dWjkhWb j[[j^ eh Yh[ijWb
_cfbWdji$ ?j _i \h[gk[djbo d[Y[iiWho" \eh [nWcfb[" je
[nj[dZikXjhWYj_l[WZ`kijc[djiZemd_djej^[c[jWb
\hWc[meha$?dfWj_[djim_j^eYYbkiWbZ[\ehc_j_[i"_j_i
kikWbbod[Y[iiWhojeh[Xk_bZWbbcWij_YWjehoikh\WY[i
i[l[hWb j_c[i Wi \kdYj_edWb XbeYai Wh[ _dYh[Wi_d]bo
X[_d] h[iebl[Z el[h j^[ Yekhi[ e\ jh[Wjc[dj$ M[
ki[ XedZ[Z Yecfei_j[ \eh j^_i fkhfei[" i_dY[ j^_i
cWj[h_WbYWdX[h[WZ_boWZZ[ZjefehY[bW_dikh\WY[i$
<khj^[h _dl[ij_]Wj_edi Wh[ d[[Z[Z je [nWc_d[
cehf^ebe]_YWb Y^Wd][i e\ j^[ cWn_bbWho Xed[ Wi
W h[ikbj e\ _dYh[Wi_d] \kdYj_edWb ij_ckb_$ 9b_d_YWb
[nf[h_[dY[ ^Wi i^emd j^Wj fedj_Yi _d j^[ cWn_bbW
m_bbhekj_d[boYWbb\ehXWiWbWZ`kijc[djWim[bb$B[l[h
\ehY[i fki^_d] j^[ fedj_Yi W]W_dij j^[ ckYeiW WdZ
h_Z][ cWo YWki[ _cfbWdj beii$ ?d ekh [nf[h_[dY["
j^[ i_jkWj_ed _i iec[m^Wj Z_\\[h[dj _d j^[ cWn_bbW$
J^[ cWYhejhW`[Yjeh_[i _d j^[ Z_ijWb cWn_bbW j[dZ je
eh_[dj j^[ci[bl[i jemWhZi j^[ jWh][j fe_dji e\ j^[
Z_ijWb ckiYb[i$ J^[h[\eh[" j^[ Z_ijWb 8E? Z_iai Wh[
ceh[b_a[bojebei[j^[_hl[hj_YWbZ_c[di_edWdZi_da
_dje j^[ Xed[ _d W YWkZWb Z_h[Yj_ed$ J^[ h[ikbjWdj
fh[cWjkh[ YedjWYji _d j^[ Wdj[h_eh i[]c[dj e\ j^[
cWn_bbWcWo]_l[h_i[jekdZ[i_hWXb[[njhki_l[\ehY[i
WYj_d]edj^[feij[h_eh8E?_cfbWdji$
?\j^[cWij_YWjehoikh\WY[i\ebbem_d]cWdZ_XkbWh
_cfbWdj fbWY[c[dj Wh[ dej WZ`kij[Z _d Zk[ Yekhi["
'(/
j^[ cWdZ_Xb[ m_bb ik\\[h ZWcW][ _\ W ijWXb[ dWjkhWb
Z[dj_j_ed _i fh[i[dj _d j^[ cWn_bbW$ 8o YedjhWij"
_\ 8E?#XWi[Z _cfbWdj#h[ijehWj_ed ioij[ci _d j^[
cWn_bbW Wh[ WiieY_Wj[Z m_j^ feeh Xed[ gkWb_jo WdZ
gkWdj_jo"ZWcW][m_bbceh[b_a[boX[_d\b_Yj[Z_dj^[
cWn_bbW_dj^[\ehce\el[hbeWZeij[eboi_ieh_cfbWdj
\hWYjkh[i$
?dfWj_[djim_j^f[h_eZedjWbZ_i[Wi[m^eeh_]_dWbbo
fh[i[dj[Zm_j^ceX_b[j[[j^"8E?_cfbWdjjh[Wjc[dj
j[dZijeh[ikbj_dYedj_dkekibo_dYh[Wi_d]cWij_YWjeho
\ehY[i" h[Yed\_]khWj_ed e\ j^[ eYYbkiWb fbWd[" WdZ
[nj[di_l[Xed[h[ceZ[bb_d]$?dekh[nf[h_[dY["j^[i[
fWj_[djij^[h[\eh[h[gk_h[[if[Y_WbboYbei[ced_jeh_d]
WdZ[l[dceh[eYYbkiWbWZ`kijc[djij^WdkikWb$
Ed[ e\ j^[ fWj_[dji m_j^ Yedi_ij[djbo Z_ii_c_bWh
Y^[m_d] fWjj[hdi cW_djW_d[Z ^[h ijh_Yjbo kd_bWj[hWb
Y^[m_d]fWjj[hd\ehWffhen_cWj[bo(o[Whi\ebbem_d]
jh[Wjc[dj$7bie"j^[edi[je\l[hj_YWbXed[]W_dedj^[
h[iehX[Zi_Z[e\j^[`WmmWiYedi_Z[hWXboZ[bWo[Z_d
j^_ifWj_[dj$?d\WYj"j^[fheY[iie\l[hj_YWbXed[]W_d
mWi dej _d_j_Wj[Z kdj_b W XWbWdY[Z Y^[m_d] fWjj[hd
^WZ X[[d WjjW_d[Z" ik]][ij_d] j^Wj j^[ Y^Wd][i _d
Xed[ijhkYjkh[m[h[dejedboZk[jefeijef[hWj_l[
ceZ[bb_d]#h[bWj[ZikXf[h_eij[Wb_dYh[Wi[i_dl[hj_YWb
Xed[lebkc[$
?d[njh[c[YWi[ie\Z_ijWbcWdZ_XkbWhh[iehfj_ed"
_j cWo X[ ki[\kb je jWa[ WZlWdjW][ e\ \kdYj_edWbbo
_dZkY[Z d[m Xed[ \ehcWj_ed Xo [cfbeo_d] W jme#
ij[f _cfbWdjWj_ed j[Y^d_gk[ <_]i$/$(-" /$(.$ 7\j[h
Wbb"W8E?_cfbWdjWjj^[fei_j_ede\j^[i[YedZcebWh
YWddejX[_di[hj[Zkdb[iiWc_d_ckcl[hj_YWbXed[
lebkc[ e\ WhekdZ (cc _i WlW_bWXb[$ ?d j^Wj YWi[" W
ceh[Z_ijWbfei_j_edWbed]j^[WiY[dZ_d]hWckiYWd
X[i[b[Yj[Z$Ed[i^ekbZYedi_Z[hj^Wj_cfbWdji_dj^_i
fei_j_edcWodejX[WYY[fjWXb[_dj^[bed]hkd"Xej^
X[YWki[ j^[o YWddej X[ WYY[ii[Z m_j^ ehWb ^o]_[d[
_dijhkc[dji WdZ X[YWki[ j^[ Xed[ WdZ ie\j j_iik[i
j[dZjeel[h]hemj^[_cfbWdji_j[$J^[iWc[_ijhk[
e\j^[ie\j#j_iik[ijhkYjkh[ie\j^[bWj[hWbY^[[aWh[W
Wij^[ocel[_dWdj[h_ehZ_h[Yj_ed$J^[fWj_[djd[[Zi
je X[ _d\ehc[Z e\ j^[i[ [l[djkWb_j_[i$ :[if_j[ Wdo
Y^hed_Y_d\bWccWj_edWh_i_d]\hecikY^el[h]hemj^"
j^[bed]Xh_Z][ifWdX[jm[[dj^[YWd_d[Wh[WWdZj^[
Z_ijWb _cfbWdj m_bb ieed h[l[Wb WXkdZWdj ]hemj^ e\
l[hj_YWbXed[lebkc["j^[h[Xo[dWXb_d]Wi[YedZWho
fheY[Zkh[je_di[hjj^[_cfbWdjWj_jiceijZ[i_hWXb[
i_j[$ J^[ ebZ Xh_Z][ WdZ j^[ d[m _cfbWdj Wh[ X[ij
Yedd[Yj[Z Xo Wd el[hXh_Z][$ J^[ fbWj[ e\ j^[ \_hij
_cfbWdjYWdX[[_j^[hh[cel[Zehb[\j_dfbWY[_dj^[
i[YedZfheY[Zkh[$M[][d[hWbbofh[\[hjeb[Wl[_j_d
fbWY[" j^[h[Xo a[[f_d] j^[ Yehj_YWb Xed[ ijhkYjkh[i
bWh][bo kdY^Wd][Z WdZ c_d_c_p_d] j^[ [nj[dj e\
Xed[h[ceZ[bb_d]$
?j _i iec[j_c[i Z_\\_Ykbj je Yedl_dY[ fWj_[dji
j^Wj WXhWi_l[ XWiWb WZ`kijc[dji e\ j^[ fedj_Yi Wh[
h[Wbbod[Y[iiWho"i_dY[Wd_cfh[ii_ede\kdd[Y[iiWho
ZWcW][jej^[Xh_Z][cWoX[Yh[Wj[Z$J^[fWj_[dj^Wi
')& 9^Wfj[h/È &OUR
$IMENSIONALÈ#ONSIDERATIONSÈOFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS
jeX[_d\ehc[Ze\j^_id[Y[ii_jo_dWi[di_j_l[cWdd[h"
iej^Wjj^[h[gk_h[Zjh[Wjc[djYWdX[f[h\ehc[ZWdZ
Wh]kc[dji Wh[ Wle_Z[Z$7bie" j^[ j^h[WZ[Z f_d cWo
iec[j_c[ijkhdekjjeei^ehj_di_jkWj_edie\cWii_l[
l[hj_YWbXed[]hemj^"iej^Wjj^[WXkjc[dj_dj[h\WY[
h[Ykhh[djboi_dai_djeWikXckYeiWbfei_j_ed$?dj^_i
i_jkWj_ed"j^[_cfbWdjebe]_ijcWo\_hijWjj[cfjjeki[
JI:++ehJI:**WXkjc[dji_dij[WZ$?\j^[Z_b[ccW
_i ij_bb dej iebl[Z" ed[ c_]^j Yedi_Z[h h[ZkY_d] j^[
Xed[[nj[di_l[bol_WWYh[ijWbWffheWY^$
È
3UMMARY
J^[i^Wf[e\j^[cWdZ_XkbWhh_Z][cWoY^Wd][W\j[h
8E?_cfbWdjim[h[_di[hj[Z"_dlebl_d]l[hj_YWbXed[
]W_d Xej^ X[bem WdZ WXel[ j^[ beWZ#jhWdic_jj_d]
XWiWb fbWj[$ J^[ Xed[ ][d[hWj[Z WXel[ j^[ XWiWb
fbWj[ Yec[i je X[ beYWj[Z ed j^[ b_d]kWb i_Z[ e\
j^[ [Z[djkbeki cWdZ_Xb[ _d WYYehZWdY[ m_j^ j^[
fh_dY_fWb jhW`[Yjeh_[i$ J^ki \ehcWj_ed e\ d[m Xed[
cW_dbojWa[ifbWY[b_d]kWbbojej^[j^h[WZ[Zf_d$
J^[[njhWXed[lebkc[hekj_d[bo\ehc[ZX[bemj^[
XWiWbfbWj[_iYWfWXb[e\hW_i_d]j^[_cfbWdjWdZj^[
fheij^[j_YijhkYjkh[h[bWj_l[jej^[eYYbkiWbfbWd[$?j
_ij^[h[\eh[d[Y[iiWhojef[h\ehcikXjhWYj_l[eYYbkiWb
WZ`kijc[djedj^[XWiWbikh\WY[ie\j^[fedj_YiWdZ
j^[eYYbkiWbikh\WY[iWjh[]kbWhi^ehj_dj[hlWbi\ehWj
b[Wij(o[Whi\ebbem_d]_cfbWdjWj_ed$:[Yecfh[ii_ed
e\j^[JC@[$]$m^[dj^[Z[djkh[_idebed][hki[Z
eh W h[bWj_l[ [bed]Wj_ed e\ j^[ cWdZ_XkbWh hWcki
cWo YedY[_lWXbo eYYkh Wi W Yekdj[hfWhj je j^[
kfmWhZc_]hWj_ede\j^[fheij^[j_YijhkYjkh[$
I_dY[l[hj_YWbXed[Wffei_j_ed_iWbiejeX[[nf[Yj[Z
_dj^[Wh[WiX[jm[[dj^[_cfbWdji"j^[fedj_Yii^ekbZ
WbmWoiX[_dj[]hWj[Zm_j^iec[Yb[WhWdY[$?\YedjWYj
m_j^j^[Yh[ijWbckYeiW_i[ijWXb_i^[ZWij^[Xh_Z][
_imehd"j^[fedj_Yid[[ZjeX[h[ZkY[Zl_WWYWkZWb
WffheWY^"Wij^[[dZfe_dje\l[hj_YWbXed[]hemj^_i
dejademd$
IjkZ_[i f[h\ehc[Z ed ^kcWdi WdZ Wd_cWbi
^Wl[ Yedi_ij[djbo Z[cedijhWj[Z j^Wj l[hj_YWb
Xed[ \ehcWj_ed Ze[i _dZ[[Z jWa[ fbWY[$ 7d_cWb
[nf[h_c[dji ^Wl[ WZZ_j_edWbbo i^emd j^Wj b_d]kWb
Xed[Wffei_j_edWbiejWa[ifbWY["feii_XboWiWh[ikbj
e\ eij[ejeco#h[bWj[Z fbWij_Y h[ceZ[bb_d] e\ j^[
cWdZ_XkbWh h_Z][ \eh YkhlWjkh[ WdZ Xed[ lebkc[
Yecf[diWj_ed$
I_dY[ ceZ_\_YWj_edi je j^[ h[ijehWj_ed ckij X[
[nf[Yj[Z W\j[h Wdo Y^Wd][i _d Y^[m_d] \kdYj_ed"
j^[i[ Y^Wd][i m_bb Wbie _dlebl[ cehf^ebe]_YWb
WZWfjWj_edi e\ j^[ Xed[$ J^_i" _d jkhd" cWo ^Wl[
Yedi[gk[dY[i \eh j^[ fei_j_ed WdZ beWZ_d] e\ 8E?
_cfbWdji$ 8E?#XWi[Z _cfbWdj#h[ijehWj_ed ioij[ci
m_bb ijWX_b_p[ m_j^_d 'Ä)o[Whi$ J^[ jof[ WdZ [nj[dj
e\ cehf^ebe]_YWb Y^Wd][i Zkh_d] j^_i f[h_eZ m_bb
Z[f[dZedj^[Z_\\[h[dY[X[jm[[dfh[ef[hWj_l[WdZ
feijef[hWj_l[\kdYj_edWdZedm^[j^[hWh[celWXb[
h[ijehWj_ed^WZX[[dmehdfh[l_ekibo$
I_dY[j^[kd_\ehcki[e\j^[fheij^[j_YijhkYjkh[
_$[$" W ijWXb[ iocc[jh_YWb Y^[m_d] \kdYj_ed
_d\bk[dY[i Xed[ \ehcWj_ed" _j _i h[WiedWXb[ je
Wiikc[ j^Wj fheij^[j_Y ceZ_\_YWj_edi f[h\ehc[Z
ed _cfbWdji j^Wj ^Wl[ Wbh[WZo ^[Wb[Z m_bb ^Wl[ \Wh#
h[WY^_d]Yedi[gk[dY[i_dj[hcie\Xed[cehf^ebe]o$
J^[h[\eh[" fWj_[dji _d m^ec W d[m h[ijehWj_ed mWi
fbWY[Zed[n_ij_d]_cfbWdjid[[ZjeX[\ebbem[Zkf
Ybei[bo Xo W Yecf[j[dj _cfbWdjebe]_ij \eh Wdej^[h
(o[Whi$
=[d[hWbbo if[Wa_d]" W j^h[WZ[Z f_d e\ cWn_ckc
b[d]j^i^ekbZX[i[b[Yj[Z\eh8E?_cfbWdji"XWi[Zed
j^[ _dj[heYYbkiWb Z_c[di_edi$ J^_i m_bb fh[l[dj j^[
h[ijehWj_ed#Xed[ eh h[ijehWj_ed#ckYeiW _dj[h\WY[
\hec X[_d] el[h]hemd Xo Xed[ eh ckYeiW [l[d _\
l[hj_YWbXed[Wffei_j_ed_i[nj[di_l[$
?\j^[l[hj_YWbXed[lebkc[Wjj^[i_j[e\j^[i[YedZ
cebWh _i _dWZ[gkWj[" Wd Wbj[hdWj_l[ c[j^eZ YWd X[
WZefj[Z _d m^_Y^ Wd _cfbWdj _i \_hij fbWY[Z _d j^[
bem[h i[]c[dj e\ j^[ WiY[dZ_d] hWcki" \ebbem[Z Xo
_di[hj_d]W\_n[Zh[ijehWj_edjeij_ckbWj[\kdYj_edWb
Xed[ Wffei_j_ed$ J^[ Z_ijWb _cfbWdj YWd bWj[h X[
h[fbWY[Zm_j^Wceh[Wdj[h_eh8E?_cfbWdj$J^[beWZ#
jhWdic_jj_d]Z_iae\j^[\_hij_cfbWdj_idehcWbbob[\j
_dfbWY[m_j^j^_iijhWj[]o$
8Wi[Zed8E?_cfbWdji"\_n[Zh[ijehWj_ediYWd[l[d
X[_di[hj[Z_di_jkWj_edie\[njh[c[h_Z][h[iehfj_ed$
>em[l[h" j^[ ikh]_YWb WdZ fheij^[j_Y c[Wikh[i
h[gk_h[Z\ehj^_ifkhfei[m_bb_dj[h\[h[ikXijWdj_Wbbo
m_j^j^[X_ec[Y^Wd_Yie\j^[cWij_YWjehoWffWhWjki$
:k[ je j^[ [nj[di_l[ cehf^ebe]_YWb Y^Wd][i _d j^[
`WmXed[" WZ`kijc[dji je j^[ fheij^[j_Y h[ijehWj_ed
d[[ZjeX[cWZ[edWh[]kbWhXWi_i$
?cfbWdj#h[ijehWj_ed ioij[ci XWi[Z ed 8E?
_cfbWdji fh[ikcWXbo Z_\\[h \hec j^ei[ XWi[Z ed
Yh[ijWb _cfbWdji m_j^ h[]WhZ je j^[ dWjkh[ WdZ
[nj[di_l[d[ii e\ j^[ \ebbem#kf fhejeYeb 8[iY^
'///$ =eeZ fWj_[dj Yecfb_WdY[ _i _dZ_if[diWXb[ _\
WijWXb[ekjYec[_ijeX[WY^_[l[Z$J^[dWc[¼XWiWb
eii[e_dj[]hWj_ed½ fheY[Zkh[ _i i[b\#[nfbWdWjeho
W]W_dijj^[XWYa]hekdZfh[i[dj[Z_dj^_iY^Wfj[h$J^[
j[Y^d_gk[e\¼eii[eZ_ijhWYj_ed½W_c[ZWj_dYh[Wi_d]
j^[l[hj_YWbXed[lebkc[_idej_dZ_YWj[Z_dj^[Z_ijWb
cWdZ_Xb[X[YWki[j^[h[gk_h[ZXed[lebkc[m_bbX[
[ijWXb_i^[Z ifedjWd[ekibo W\j[h 8E? _cfbWdji ^Wl[
X[[dfkj_djefheij^[j_Yi[hl_Y[_dWdWZ[gkWj[WdZ
iocc[jh_YWbcWdd[h$
È È (ORMONALÈ)NFLUENCESÈANDÈ$RUGÈ4REATMENTÈ
&IGÈ :ekXb[#Z_ia 8E? _cfbWdj m_j^ W Yhemd XbeYa
h[ijehWj_ed$ J^[ ebZ Yehj_YWb Xed[ b_d[ _i Yb[Whbo l_i_Xb[$
B_d]kWbbo" j^[h[ _i d[m \ehcWj_ed e\ mel[d Xed[$ J^[
Yedd[Yj_l[ j_iik[ _d j^[ i^W\j Wh[W [nj[dZi X[bem j^[ Yhemd"
WdZ j^[h[ _i de [f_j^[b_Wb ]hemj^ _d W YWkZWb Z_h[Yj_ed$ J^[
ie\j#j_iik[ ijhkYjkh[i WhekdZ 8E? _cfbWdji Ze dej i[[c
je ^Wl[ W bWo[h[Z ijhkYjkh[ X_ebe]_YWb m_Zj^ b_a[ j^[ ed[
Z[iYh_X[Zm_j^Yh[ijWb_cfbWdji$J^[_cfbWdj^WiX[[djh[Wj[Z
Xoi^ej#f[[d_d]\ehWiceej^kd_\ehcikh\WY[
&IGÈ Ekjb_d[e\Xed[h[ceZ[bb_d]WhekdZW8E?_cfbWdj
_d j^[ Z_ijWb cWdZ_Xb[$ B[\j ?d_j_Wb i^Wf[ e\ j^[ h[iehX[Z
cWdZ_Xb[1 Y[djh[ i_jkWj_ed Wj '(cedj^i W\j[h 8E? _di[hj_ed1
h_]^j i_jkWj_ed Wj (*cedj^i$ ;WY^ _dj[hhkfj[Z b_d[ _dZ_YWj[i
j^[i^Wf[e\j^[WZ`WY[djZhWm_d]jej^[b[\j
&IGÈ I_jkWj_edW\j[h_di[hj_ede\j^[Æ\_hijÇ_cfbWdjWj).$
J^[l[hj_YWbh[bWj_ediWh[ikY^j^WjWd_cfbWdjm_j^W^_]^[h
= lWbk[ YekbZ dej X[ i[b[Yj[Z$ J^[ J#ibej e\ j^[ eh_]_dWb
_cfbWdjWj_ed Wjj[cfj Wj )- _i ij_bb l_i_Xb[$ J^Wj Wjj[cfj ^WZ
\W_b[Z X[YWki[ j^[ cWdZ_XkbWh YWdWb mWi beYWj[Z jee \Wh
Yh[ijWbbo$?d\hWd[hlWb_cfbWdjWj_ed\W_b[ZX[YWki[e\j^[el[hbo
bWj[hWbfei_j_ede\j^[YWdWb
')'
&IGÈ J^[ iWc[ fWj_[dj ('cedj^i bWj[h$ J^[ i[YedZ
_cfbWdj ^WZ X[[d _di[hj[Z '+cedj^i W\j[h j^[ \_hij ed[$
J^[ \_hij Xh_Z][ mWi Yedd[Yj[Z m_j^ j^[ d[m _cfbWdj l_W Wd
el[hXh_Z][$ J^[ j^h[WZ[Z f_d e\ j^[ \_hij _cfbWdj Wj (. mWi
h[cel[Z1 j^[ fbWj[ mWi b[\j _d fbWY[$ L[hj_YWb h[ZkYj_ed e\
j^[ d[mbo \ehc[Z Xed[ _i dej W ki[\kb efj_ed _d j^[i[ YWi[i
X[YWki[j^[Xed[mekbZX[]hem_d]XWYaW]W_d
&IGÈ ?j_idejh[Yecc[dZ[Zjeb_d[j^[Xh_Z][m_j^Wm_Z[
XWi[ e\ c[jWb" i_dY[ _j mekbZ X[ l[ho Z_\\_Ykbj je h[ZkY[ WdZ
h[feb_i^j^_icWj[h_Wbm^[dl[hj_YWbXed[]hemj^eYYkhi_\j^[
d[[ZWh_i[i$B_a[m_i["j^[h[_i^WhZboWdoifWY[b[\jjeWYY[ii
j^[XWi[m_j^ehWb^o]_[d[_dijhkc[dji
È
(ORMONALÈ)NFLUENCESÈANDÈ$RUGÈ4REATMENT
È
%FFECTSÈOFÈ(ORMONALÈ$EFICITS
Eij[efehei_ie\\[hiWY^WdY[jeijkZoj^[dWjkh[WdZ
[nj[dje\^ehcedWb_d\bk[dY[iedXed[X[^Wl_ekh_dW
XehZ[hb_d[i_jkWj_ed$J^[Xed[#cWhhemifWY[im_j^_d
j^[Xed[[nfWdZ_dj^_iZ_i[Wi["_$[$Xed[h[iehfj_ed
jWa[ifbWY[\hecj^[_di_Z[$J^[jhWX[YkbWhijhkYjkh[i
Wh[ m[Wa[d[Z$ ?\ Xed[ _i \kdYj_edWbbo _dZkY[Z je
_dYh[Wi[ _ji lebkc[" j^[ Wffei_j_ed fheY[ii[i m_bb
jWa[ fbWY[ ed j^[ ekji_Z[ e\ j^[ Xed[$ J^[ W\\[Yj[Z
Xed[ijhkYjkh[im_bbX[Yec[j^_Ya[h$8ed[jhW_d_d]_i
j^[edboki[\kbbed]#j[hcjh[Wjc[dj\eheij[efehei_i"
Wbj^ek]^ Zhk]i j^Wj m_bb _dYh[Wi[ j^[ Z[]h[[ e\
c_d[hWb_pWj_ed [$]$ <eiWcWn cWo X[ d[[Z[Z Wi
m[bbiej^Wj[n[hY_i[m_j^ekj_dYkhh_d]Xed[\hWYjkh[
X[Yec[ifeii_Xb[_dj^[\_hijfbWY[$
')( 9^Wfj[h/È &OUR
$IMENSIONALÈ#ONSIDERATIONSÈOFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS

&IGÈAnC ;l[d j^ek]^ j^[ ceZ[bb[Z Xed[ eh j^[ i[[c_d]bo c_ii_d] Xed[ WXel[ j^[ Z_ia _i de bed][h fh[i[dj" _cfbWdj
ikhl_lWb_iij_bbdej_d`[efWhZo$7Yh[ijWb_cfbWdjmekbZ^Wl[X[[dbeijXoj^_ij_c[_$[$/o[WhiW\j[hj^[_cfbWdjfheY[Zkh[Zk[
je_jibWYae\XWiWbWdY^ehW][$M^[j^[hj^[Xed[ijhkYjkh[beYWj[ZYh[ijWbbojej^[Z_ia_ifh[i[hl[Zm_bb[ii[dj_WbboZ[f[dZed
cWij_YWjeho\kdYj_ed"fh[\[hh[Zmeha_d]i_Z["cWij_YWjeho\ehY[iWdZÄb[ii_cfehjWdjboÄedehWb^o]_[d["beYWb_cckd[ijWjki
WdZj^[ikh\WY[ijhkYjkh[e\j^[j^h[WZ[Zf_d$9h[ijWbXed[beiimWi\Wlekh[ZXoj^[ikh\WY[ijhkYjkh[e\j^_iebZ[h_cfbWdj$?\W
kd_bWj[hWbY^[m_d]fWjj[hd_ifh[i[djj^_iif[Y_\_YfWj_[dj^WZWfh[\[h[dY[\ehj^[b[\ji_Z["j[di_b[jhW`[Yjeh_[im_bb_dYh[Wi_d]bo
\ehcedj^[kff[hcWh]_de\j^[ded#Y^[m_d]"m^_Y^Wh[b[iih[i_ijWdjjeh[iehfj_edj^Wdj^[Yecfh[ii[ZXed[ijhkYjkh[ied
j^[kff[hcWh]_de\j^[meha_d]i_Z[$J^[XWYj[h_WbWjjWYaWZ_ia_cfbWdjm_j^Wikh\WY[#[dbWh][Zl[hj_YWb_cfbWdj[b[c[djmWi
ki[Z^Wimedekjel[hj^[Xed[Éi]hemj^j[dZ[dY_[i1Wbie"j^_ifWj_[djc_]^j^Wl[^WZWbWj[hWbbokdXWbWdY[ZY^[m_d]fWjj[hd
fhecej_d]j^[h[iehfj_ede\Xed[edj^[h_]^ji_]^je\j^[cWdZ_Xb[

&IGÈAnC 8ed[ h[][d[hWj_ed \ebbem_d] [njhWYj_ed e\ jeej^ *- WdZ

_cfbWdj fbWY[c[dj _d j^[ iWc[ i[ii_ed m_j^ _cc[Z_Wj[ beWZ_d]$L[hj_YWb
Xed[]hemj^mWiWbieZk[jej^[\WYjj^Wjj^[fh[\[hh[Zb[\jmeha_d]i_Z[
C mWi cW_djW_d[Z$ J^[ hWZ_e]hWf^i _d X WdZ Y m[h[ eXjW_d[Z *m[[ai WdZ
-cedj^iW\j[hj^[fheY[Zkh["h[if[Yj_l[bo
È È (ORMONALÈ)NFLUENCESÈANDÈ$RUGÈ4REATMENTÈ '))

&IGÈÈA I_jkWj_ed)o[WhiW\j[h_cfbWdjWj_ed$J^[_d_j_Wbbol_i_Xb[j^h[WZ[Zf_d_idemYel[h[Zm_j^Xed[$Edboj^[WXkjc[dj
[c[h][i l_i_Xbo \hec j^[ Xed[$ J^[ jhWdi_j_edWb ped[ X[jm[[d WXkjc[dj WdZ j^h[WZ[Z f_d _i fefkbWj[Z Xo XWYj[h_W" m^_Y^
fh[l[djj^[Xed[\hec]hem_d]\khj^[h$ B B_d]kWbl_[m$B_d]kWbbojej^[fedj_Y"j^[h[_i[dek]^ifWY[\eh\kdYj_edWbbo_dZkY[Z
l[hj_YWbXed[]hemj^

&IGÈ J^[ fedj_Yi e\ j^_i Xh_Z][ Wh[ [nj[dZ[Z YWkZWbbo

ckY^ jee \Wh$ 9edjWYj m_j^ j^[ ckYeiW m_bb X[ [ijWXb_i^[Z
ieed$ EdY[ j^_i b_d[ ^Wi X[[d Yheii[Z" j^[ Xh_Z][ m_bb [_j^[h &IGÈ L[hj_YWb Xed[ ]hemj^ cWo ]_l[ h_i[ je [nj[di_l[
X[Z_ibeZ][Z\heced[e\j^[WXkjc[dji"ehj^[WXkjc[dj_$[$ fh[iikh[ieh[iX[bemfedj_Yi
j^[ h[i_ZkWb jeej^ ijhkYjkh[ eh _cfbWdj m_bb \hWYjkh[$ EdY[
j^[ \kdYj_edWb YedjWYj je j^[ Xed[ ^Wi X[[d [ijWXb_i^[Z" j^[
_dY[dj_l[\ehXed[]hemj^m_bbX[[l[d]h[Wj[h$J^_icWo]_l[
h_i[jefheXb[cil[hoieedkdb[iiikX`[Yj_l[WZ`kijc[djiWh[
cWZ[edWYedj_dkekiXWi_i

M^[di[hkcYWbY_kcb[l[biWh[\Wbb_d]"fWhWj^ohe_Z
^ehced[_ih[b[Wi[Zj^Wjm_bbij_ckbWj[eij[eYbWijije
_dZkY[Xed[beii"iej^WjYWbY_kc_ih[b[Wi[Z_djej^[
Y_hYkbWj_d] XbeeZ$ 8o j^[ iWc[ jea[d" YWbY_jed_d _i
h[b[Wi[Z m^[d YWbY_kc b[l[bi Wh[ ^_]^" ie j^Wj j^[
fheY[ii _i h[l[hi[Z$ ?d ej^[h mehZi" eij[efehei_i
Z[l[befi m^[d j^[ [gk_b_Xh_kc i^_\ji _d \Wlekh e\
h[iehfj_ed$JeZWoj^[[gk_b_Xh_kcYWdX[_d\bk[dY[Z
Xo Zhk] jh[Wjc[dj$ :hk]i ikY^ Wi <eiWcWn m_bb
_cfhel[YWbY_kcZ[fei_j_edXoWZ`kij_d]j^[YWbY_kc
XWbWdY[$
?d ehZ[h je fh[i[hl[ j^[ c[Y^Wd_YWb ij_\\d[ii
e\ j^[ Xed[ Z[if_j[ j^[ lebkc[ beii YWki[Z Xo
eij[efehei_i" j^[ Z[]h[[ e\ c_d[hWb_pWj_ed e\ j^[
h[cW_d_d] Yehj_YWb Xed[ _i _dYh[Wi[Z$ J^_i [nfbW_di
j^[ Xh_jjb[d[ii WdZ j^[ Yecc_dkj[Z \hWYjkh[i
eXi[hl[Zm_j^eij[efehej_YXed[$?jZe[idej[nfbW_d"
\eh _dijWdY[" j^[ feeh ^[Wb_d] j[dZ[dYo _d \[cehWb
^[WZ\hWYjkh[i$M^_b[j^[i[^ehcedWb_d\bk[dY[iZe
^Wl[WikijW_d[Zbed]#j[hc[\\[Yj"j^[o^Wl[de[\\[Yj
ed WYkj[ Xed[ jhWkcW" Wi j^[ YWiYWZ[#ijob[ h[fW_h
c[Y^Wd_ici Wh[ jh_]][h[Z WdZ cW_djW_d[Z ceijbo
Xo beYWb \WYjehi$ J^[ feeh ^[Wb_d] _d eij[efehej_Y
\hWYjkh[i ^Wi b[ii m_j^ ^ehced[i je Ze j^Wd m_j^
j^[ bem Xed[ lebkc[ WdZ j^[ c_d_cWb el[hbWf WdZ
YedjWYj ikh\WY[ e\ j^[ Xedo [dZi e\ j^[ \hWYjkh[
[$]$ \[cehWb ^[WZ" m^_b[ j^[ h[i_ZkWb Yehj_YWb
Xed[ijhkYjkh[_iY^WhWYj[h_p[ZXoW^_]^Z[]h[[e\
c_d[hWb_pWj_edWdZWm[WaXbeeZikffbo$?d\[cehWb
^[WZ \hWYjkh[i" j^[ fheXb[c _i YecfekdZ[Z Xo j^[
h[bWj_l[bo ]h[Wj fhef[di_jo e\ j^[ \hWYjkh[ [dZi je
X[Yec[ Z_ibeYWj[Z W]W_dij [WY^ ej^[h$ J^[h[\eh["
')* 9^Wfj[h/È &OUR
$IMENSIONALÈ#ONSIDERATIONSÈOFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS
j^[ fh[\[hh[Z c[j^eZ jeZWo _i je _dYehfehWj[ W ^_f
[dZefheij^[i_i hWj^[h j^Wd _cceX_b_p_d] j^[ \[ckh
WdZj^[h[ije\j^[m^eb[XeZo$J^[bWjj[hWffheWY^"
m^_Y^ ki[Z je X[ ijWj[ e\ j^[ Whj \eh W bed] j_c["
mekbZb[Wl[j^[[dj_h[eh]Wd_ic_cceX_b_p[Z\ehjee
bed]" j^[h[Xo fhecej_d] ][d[hWb_p[Z eij[efehei_i
[l[d\khj^[h$
J^[d[mbo\ehc[ZXed[_dj^[Z[\[YjWh[Wi^emi
W icWbb[h Z[di_jo e\ i[YedZWho eij[edi m^_b[ j^[
dkcX[h e\ 8CK WYj_lWj_edi _i ^_]^[h$ ?d ej^[h
mehZi" j^[ jhWkcWj_p[Z Xed[ X[Yec[i ¼oekd][h½
WdZceh[[bWij_Y$7iWdkdZ[i_hWXb[Yedi[gk[dY[e\
j^_ih[`kl[dWj_ed"^em[l[h"j^[[bWij_Y_joZ_\\[h[dj_Wb
X[jm[[d j^[ fh[[n_ij_d] eij[efehej_Y Xed[ 8khh [j
Wb$ '//- WdZ j^[ [bWij_Y d[m Xed[ _i ie ]h[Wj j^Wj
j^[ ^[Wb_d] fhe]h[ii m_bb kd\ebZ l[ho ibk]]_i^bo$
<h[gk[djbo" _j jWa[i i[l[hWb ceh[ \hWYjkh[i _d j^[
iWc[Wh[WjeXh_d]WXekj[neijei_i#ijob[eii_\_YWj_ed
WdZWXkdZWdjXed[\ehcWj_ed$
È
&RACTURESÈ!FTERÈ)MPLANTÈ4HERAPY
FWj_[djim_j^^ehcedWbZ[\_Y_[dY_[i_dXed[ijh[d]j^
^Wl[ W ]h[Wj[h h_ia e\ `Wm \hWYjkh[i Zk[ je YhWYa
fhefW]Wj_ed ed _cc[Z_Wj[ beWZ_d]$ J^[i[ `Wm
\hWYjkh[ieYYkhfh[Zec_dWdjbo_dj^[cWdZ_Xb[$F[h_#
_cfbWdj \hWYjkh[i m_j^ Yh[ijWb _cfbWdji m_bb WbmWoi
d[Y[ii_jWj[ [nfbWdjWj_ed$ 7\j[h Wbb" ikY^ \hWYjkh[i
m_bb _dlWh_WXbo eYYkh Wbed] j^[ l[hj_YWb _cfbWdj
Wn_im^ei[ikh\WY[_ic_Yhec[Y^Wd_YWbbohek]^[d[Z"
j^[h[Xofhecej_d]_d\[Yj_ed"_dWZZ_j_edjej^[\WYj
j^Wj Yh[ijWb _cfbWdji ^Wl[ de WZZ_j_edWb ijWX_b_p_d]
Yecfed[djiikY^WiZ_iaiWdZh_d]i$?d`Wm\hWYjkh[i
d[Wh 8E? _cfbWdji" j^[ if[Yjhkc e\ Wffb_YWXb[
jh[Wjc[djefj_edi_iXheWZ[h$
FWj_[dji m_j^ fhedekdY[Z eij[efehei_i Wh[ b_WXb[
je_dYkhifedjWd[eki\hWYjkh[i"dejWXbo_dj^[Z_ijWb
i[]c[dji e\ j^[ cWdZ_Xb[$ J^[i[ \hWYjkh[i eYYkh
kikWbbo iocc[jh_YWb$ J^Wj _i je iWo" W\j[h j^[ \_hij
i_Z[ ^Wi \hWYjkh[Z" j^[ YedjhWbWj[hWb i_Z[ m_bb ieed
\ebbemik_j$
J^[ \WYj j^Wj j^[i[ \hWYjkh[i edbo eYYkh W\j[h
WXekj ,m[[ai _i Zk[ je j^[ _dYh[Wi[Z fehei_jo _d
j^_if^Wi[e\Xed[h[ceZ[bb_d]_dZkY[ZXoY^Wd][i
WdZ _cfhel[c[dji _d \kdYj_ed$ Jhkbo ijWXb[ Wh[Wi
X[Yec[_dYh[Wi_d]boicWbb[h"iej^Wjj^[ijh[ii[im_bb
kbj_cWj[bo_dYh[Wi[jej^[fe_dje\\hWYjkh[$M_j^8E?
_cfbWdji" j^[ beWZ#jhWdic_jj_d] _cfbWdj i[]c[dji
Wh[Wbh[WZom[bb_dj[]hWj[Zm^[d`Wm\hWYjkh[eYYkhi
Wbed] j^[ j^h[WZ[Z f_d _$[$ j^[ ceij Z[X_b_jWj[Z
`Wm Wh[W _d j^[ _d_j_Wb f^Wi[ e\ h[ceZ[bb_d]$
J^Wdai je j^_i _dj[]hWj_ed" WZZ_j_edWb j^[hWfo _i
kikWbbo kdd[Y[iiWho" fhel_Z[Z j^Wj j^[ fheij^[j_Y
ikf[hijhkYjkh[_iWbh[WZo_dfbWY[jei[hl[WiWifb_dj$
?d ekh l_[m" j^[ _cfehjWdY[ e\ _cc[Z_Wj[ beWZ_d]
_deij[efehei_ifWj_[djiYWddejX[el[hijWj[Z$?dj^[
hWh[[l[dje\8E?#h[bWj[ZXed[\hWYjkh[i"j^[\hWYjkh[
m_bb WbmWoi eYYkh l[hj_YWbbo Wbed] j^[ j^h[WZ[Z f_d
X[YWki[ j^_i _i j^[ m[Wa[ij Wh[W$ Eii_\_YWj_ed _d j^[
Z_iaWh[Wi_i"XoYedjhWij"WbmWoi_djWYj[l[dj^ek]^
j^[^ehcedWbi_jkWj_edcWoX[kd\WlekhWXb[$
J^[j[dZ[dYoe\j^[Yh[ijWbXed[je]hemjemWhZi
l[hj_YWbbo YWd X[ eXi[hl[Z _d Wd [n[cfbWho cWdd[h
W\j[h^ehced[#h[bWj[Z\hWYjkh[i_dj^[Z_ijWbcWdZ_Xb[$
8ed[ceZ[bb_d]WdZh[ceZ[bb_d]_iijhed]boij_ckbWj[Z
Xoj^_ijof[e\\hWYjkh["WdZcehf^ebe]_YWbY^Wd][i
m_bb Z[l[bef \Wij[h j^Wd _d j^[ WXi[dY[ e\ \hWYjkh[$
J^[h[\eh["j^[Xh_Z][i^Wl[jeX[f[h_eZ_YWbboh[ZkY[Z
Wbed] j^[ XWiWb Wif[Yj$ <hWYjkh[i _d j^[ Wh[W e\
fh[cebWhi [$]$ _d ijhkYjkh[i m_j^ Wdj[h_eh ikffehj
edbo kikWbbo h[cW_d kd_bWj[hWb$ CeZ_\_YWj_edi e\
j^[ b_d]kWb YkhlWjkh[ e\ j^[ cWdZ_Xb[ Wh[ j^[h[\eh[
b_a[bo$ ?\ j^[ \hWYjkh[ _i \ebbem[Z Xo [nj[di_l[ Xed[
Wffei_j_ed" j^[ fh[cebWh _cfbWdji cWo bei[ j^[_h
b_d]kWb Yehj_YWb WdY^ehW][$ J^[i[ YWi[i ^Wl[ je X[
Ybei[bo ced_jeh[Z" WdZ j^[ W\\[Yj[Z _cfbWdji cWo
d[[ZjeX[h[fbWY[Zm_j^bWh][hed[i_dj[hcie\Z_ia
Z_Wc[j[h$J^[Xh_Z][YWddehcWbboX[h[ki[Z$
<hWYjkh[i _d j^[ cWn_bbW Wh[ h[bWj_l[bo hWh[
m_j^ 8E? _cfbWdji$ Ed[ YWi[ j^Wj eYYkhh[Z _d ekh
fhWYj_Y[ mWi WffWh[djbo Zk[ je j^[ ki[ e\ W ifh_d]
WYY[b[hWjeh9hemd9b_Yajeh[cel[j^[Xh_Z][$J^_i
\hWYjkh[ [dYecfWii[Z j^[ [dj_h[ Wbl[ebWh h_Z][ _d
j^[Z_ijWbcWn_bbWWbed]m_j^j^[_dj[]hWj[Z_cfbWdj$
IkXi[gk[djbo" j^[ Y^[m_d] \ehY[i b[Z je W ib_]^j
Wdj[h_ehZ_ibeYWj_ede\j^[Xh_Z]["WdZj^[\hWYjkh[Z
Xed[ i[]c[dj hejWj[Z Xo WhekdZ (& Z[]h[[i _d W
l[ij_XkbWh Z_h[Yj_ed$ M[ m[h[ dej WXb[ je l[h_\o
m^[j^[h j^[ Z_ijWb Xed[ XbeYa ib_Z WmWo _d Wd
eXb_gk[bo bWj[hWb Z_h[Yj_ed Wbed] j^[ ijWXb[ Wdj[h_eh
i[]c[dj e\ j^[ cWn_bbW eh m^[j^[h j^[ hejWj_ed
mWiZk[jej^[Yedj_dk[Zfh[i[dY[e\WZ_ijec[Z_Wb
WjjWY^c[dj[$]$_dj^[Wh[We\j^[Y^[m_d]ckiYb[i$
<khj^[h jh[Wjc[dj Yedi_ij[Z _d fbWY_d] WZZ_j_edWb
Wdj[h_eh _cfbWdji$ 7\j[h j^Wj" Wbb ijhkYjkh[i _$[$ Wbb
_cfbWdji" j^[ d[m Xh_Z][" WdZ j^[ \hWYjkh[Z Xed[
Wh[WijWX_b_p[Z$
Eij[efehej_Y`Wm\hWYjkh[iW\j[h_di[hj_ede\8E?
_cfbWdjiYWddejkikWbboX[l[h_\_[ZXohWZ_e]hWf^o"
Wi j^[h[ _i ^WhZbo Wdo ifWY[ b[\j \eh Z_ibeYWj_ed Zk[
je j^[ Yecc_dkj[Z dWjkh[ e\ j^[ \hWYjkh[ WdZ j^[
_cfbWdjebe]_YWbifb_dj_d]$7bie"j^[\hWYjkh[[dZim_bb
_dj[hbeYa _cc[Z_Wj[bo$ M^_b[ W i_d]b[ 8E? _cfbWdj
YWd f[h i[ fhel_Z[ [\\[Yj_l[ ifb_dj_d]" j^_i [\\[Yj _i
[l[dceh[fhedekdY[Zm^[dj^[Xh_Z][_i_dfbWY[$
Ceh[_cfehjWdjbo"j^[Xh_Z][m_bbfh[fWh[j^[]hekdZ
\eh dehcWb `Wm \kdYj_ed je X[ h[#[ijWXb_i^[Z$ J^[
fWj_[dj i^ekbZ ij_Ya m_j^ ie\j \eeZ el[h (Ä*m[[ai$
7dj_X_ej_YYel[hW][_ikdd[Y[iiWho_dekh[nf[h_[dY[$
J^[fhedekdY[ZceZ[bb_d]cWo]_l[h_i[jeijhW_di"
Z_ij[di_ediWdZh[ZZ[d_d]Wjj^[\hWYjkh[i_j[$J^[i[
iocfjeci Wh[ dej je X[ Yed\ki[Z m_j^ j^ei[ e\
XWYj[h_Wb_d\bWccWj_ed$
È È (ORMONALÈ)NFLUENCESÈANDÈ$RUGÈ4REATMENTÈ
?d j^[ [l[dj e\ _djhWef[hWj_l[ `Wm \hWYjkh[" j^[
Z[dj_ijcWoY^eei[jeb[Wl[j^[_cfbWdj_dfbWY[WdZ
ki[c_d_#fbWj[i\ehifb_dj_d]$J^[_iik[e\_cc[Z_Wj[
beWZ_d]d[[ZijeX[YWh[\kbboh[Yedi_Z[h[Z$?\WYY[f#
jWXb[ cWij_YWjeho \kdYj_ed YWd X[ WjjW_d[Z" _j _i
Y[hjW_dbofh[\[hWXb[je_dYehfehWj[Wc[jWb#h[_d\ehY[Z
Xh_Z][WiieedWifeii_Xb[\eh[\\[Yj_l[ifb_dj_d]$
8ed[ Yel[hi el[h _cfbWdji YWd X[ b[\j _d fbWY[
ed\hWYjkh_d]Xkjd[[ZjeX[_cceX_b_p[Z[$]$m_j^
eij[eiodj^[i_iiYh[mi$
?d j^[ mWa[ e\ `Wm \hWYjkh[i" Wdo WiieY_Wj[Z
_cfbWdjicWo\hWYjkh[jee"Wij^[f[h_f^[hWbikh\WY[i
e\j^[_dj[]hWj[ZZ_iaim_bbcel[h[bWj_l[je[WY^ej^[h"
je][j^[hm_j^j^[ikhhekdZ_d]Xed[ijhkYjkh[i$J^_i
m_bb Yh[Wj[ j[di_edi _di_Z[ j^[ _cfbWdj \_njkh[ j^Wj
Ä [_j^[h Xo j^[ci[bl[i eh _d Yed`kdYj_ed m_j^ j^[
cWij_YWjeho\ehY[iÄcWo[nY[[Zj^[hWd][e\[bWij_Y
h[l[hi_Xb[Z[\ehcWj_ede\j^[_cfbWdj$I_dY[_cfbWdj
i[]c[dji j^Wj ^Wl[ kdZ[h]ed[ fbWij_Y Z[\ehcWj_ed
Wh[ ceh[ h_]_Z b[ii [bWij_Y j^Wd ded#Z[\ehc[Z
i[]c[dji"j^[oWh[b[iih[i_ijWdjjelWh_WXb[\b[nkhWb
beWZ_d]$ J^[ h[WZ[h _i h[\[hh[Z je 9^Wfj[h(' \eh W
ceh[Z[jW_b[ZZ_iYkii_ed$
A B
C j^[iYh[mcWofhecej[_d\[Yj_edWdZm_bbWbie_d^_X_jj^[
')+
È
&RACTURESÈANDÈ/STEOMYELITIS
9h[ijWb _cfbWdji ^Wl[ bWh][ ckYeiWb [c[h][dY[
fe_dji WdZ hek]^ ikh\WY[i$ J^_i YecX_dWj_ed m_bb
fhecej[ _d\[Yj_edi$ Kdb_a[ dWjkhWb j[[j^" _cfbWdji
^Wl[ de jhWdi_j_edWb Wh[Wi Yedi_ij_d] e\ ie\j j_iik[
[$]$f[h_eZedjWbb_]Wc[dji"iej^WjWdoZ[[f_d\[Y#
j_edi m_bb gk_Yabo ]_l[ h_i[ je eij[eco[b_j_i$ <eh
\hWYjkh[i e\ j^[ [dj_h[ cWdZ_Xb[ je eYYkh" ^em[l[h"
WZZ_j_edWb \WYjehi ckij Yec[ _dje fbWo" ikY^ Wi
^ehcedWb Z[\_Y_[dY_[i WdZ bem XbeeZ ikffbo je j^[
W\\[Yj[Z Xed[ Wh[W" YecX_d[Z m_j^ ^_]^ beWZi WdZ%
eh ^[Wlo h[ceZ[bb_d]$ ?\ _cfbWdji WdZ fheij^[j_Y
ikf[hijhkYjkh[i Wh[ _di[hj[Z _d i_jkWj_edi e\ WZ#
lWdY[Z h_Z][ h[iehfj_ed" j^[h[ _i WbmWoi W Y^WdY[
j^Wj \kdYj_edWbbo _dZkY[Z cehf^ebe]_YWb Y^Wd][i
m_bb ]_l[ h_i[ je [nj[di_l[ h[ceZ[bb_d] e\ j^[ [dj_h[
`Wm$ ?j ckij X[ Xehd[ _d c_dZ j^Wj j^_i c[Y^Wd_ic
cWoX[Wbbj^Wj_ih[gk_h[ZjeYWki[eij[eco[b_j_i_d
j^[fh[i[dY[e\XWYj[h_Wb_dlWi_ed$?dekh[nf[h_[dY["
fheXb[ci e\ j^_i jof[ Wh[ dej Wd _iik[ m_j^ 8E?
_cfbWdji"]_l[dj^[icWbbZ_Wc[j[he\j^[_hckYeiWb
[c[h][dY[ fe_dj WdZ j^[_h iceej^ ikh\WY[ e\\[h_d]
kd\WlekhWXb[ YedZ_j_edi \eh XWYj[h_Wb h[j[dj_ed$ M[
ckijWZZj^Wjekh[nf[h_[dY[_ibWh][boYed\_d[Zje
[nj[hdWb#j^h[WZ8E?Z[i_]dim_j^WZ_Wc[j[he\b[ii
j^Wd(ccWjj^[_hckYeiWb[c[h][dY[fe_dj$
&IGÈAnC :kh_d]j^[_di[hj_ede\jme8E?_cfbWdji_d
j^[Z_ijWbcWdZ_Xb["j^[Yh[ijWbXed[b_ZY^_ff[Ze\\$8ej^
XWiWbfbWj[iX[YWc[[nfei[Z$?cc[Z_Wj[boj^[Xed[b_ZmWi
iYh[m[ZXWYa_djefbWY[WdZj^[_cfbWdjim[h[beWZ[Z$7\j[h
,cedj^ij^[iYh[mmWijWa[dekj"X[YWki[_j^WZYh[Wj[ZW
ib_]^jfWhW[ij^[i_We\j^[cWdZ_XkbWhd[hl[$Dej[j^Wjj^[
Yh[ijWbXed[i[]c[djjkhd[Z_djeW&#h[]_edi[[9^Wfj[h/
\ehZ[jW_bi[l[dW\j[hiYh[mh[celWb$<_nWj_d]Y^_ff[Z#e\\
Xed[i[]c[dji_iWdefj_ed"Xkjj^[h[Wh[jmeZ_iWZlWdjW][i0
\kdYj_edWbij_ckbWj_ede\j^[\_nWj[ZXed[$
'), 9^Wfj[h/È &OUR
$IMENSIONALÈ#ONSIDERATIONSÈOFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS

È
0SYCHOSOCIALÈ!SPECTS
?j_i_cfehjWdjjeh[Wb_p[j^WjZ_i[Wi[ie\ikffehj_d]
j_iik[Wh[WcW`eh_iik[_dc[Z_Y_d[$Eij[efehei_i_i
jeZWoj^[ceijYeccedXed[Z_i[Wi[_d_dZkijh_Wb_p[Z
Yekdjh_[i$ Fh[l[dj_l[ c[Wikh[i je Wl[hj ZWcW][ je
j^[ ikffehj_d] Xed[ ijhkYjkh[i" _dYbkZ_d] f^oi_YWb
[n[hY_i[jeXk_bZkfWdZijh[d]j^[dj^[ckiYb[i"^Wl[
X[Yec[m_Z[boWYY[fj[Z$
J^[ ^kcWd `Wmi Wh[ Yedj_dkekibo ikX`[Yj[Z je
]h[WjbeWZi"Wbceijh[]WhZb[iie\^emm[bbj^[ckiYb[i
Wh[ jhW_d[Z$ ;l[d W cel[c[dj ikY^ Wi m_Z[ cekj^
ef[d_d] _i WiieY_Wj[Z m_j^ cWii_l[ jehi_ed Xej^ _d
j^[cWn_bbWWdZ_dj^[cWdZ_Xb[$
FWj_[dji m_j^ eij[efehei_i d[[Z je [nfbeh[
m^Wj beWZi j^[o YWd jeb[hWj[ \hec W c[Y^Wd_YWb
ijWdZfe_dj WdZ ijh_a[ W XWbWdY[ X[jm[[d ijh[ii WdZ
h[ij$ >Wl_d] _dYkhh[Z ckbj_fb[ Xed[ \hWYjkh[i _d
j^[ fWij" j^[i[ fWj_[dji ^Wl[ kikWbbo Z[l[bef[Z W
Z[[f[hkdZ[hijWdZ_d]e\j^[_hZ_i[Wi[WdZWh[ceh[
h[Y[fj_l[ je Yedi[hlWj_l[ jh[Wjc[dj j[Y^d_gk[i _d
j^[ W\j[hcWj^ e\ \hWYjkh[i$ 8E?#XWi[Z iebkj_edi
e\\[h Yedi_Z[hWXb[ WZlWdjW][i el[h Yh[ijWb _cfbWdji
_d j^_i i_jkWj_ed$ <eh fWj_[dji m_j^ eij[efehei_i"
Xed[ \hWYjkh[i Wh[ W Yecced WdZ \Wc_b_Wh [l[dj$
J^[h[\eh[" j^[ [l[djkWb_jo e\ `Wm \hWYjkh[i _d j^[
mWa[e\_cfbWdjfheY[Zkh[i_iWbieW¼dehcWb½j^_d]
je [nf[Yj \eh j^[c$ J^[ Z[dj_ij YWd j^[h[\eh[ [Wi_bo
WZefj j^[ mW_j#WdZ#i[[ ijhWj[]o WdZ Yedi[hlWj_l[
jh[Wjc[dj Z_iYkii[Z WXel[$ ?d WZlWdY[Z h_Z][
h[iehfj_ed" j^[ Z[dj_ij _i ceh[ b_a[bo je i[b[Yj W
Yedi[hlWj_l[ WffheWY^ WdomWo 8WhX[h (&&'" ]_l[d
j^[ h[ZkY[Z XbeeZ ikffbo WdZ j^[ ^_]^ h_ia e\
_d\[Yj_ed_dj^_ii_jkWj_ed$J^[h_iae\eij[eco[b_j_i
_ii_]d_\_YWdjbo]h[Wj[h_\j^[\hWYjkh[_i[nfei[Z\eh
jh[Wjc[dj$M[d[[Zjeh[c[cX[hj^Wjj^[\kdYj_edWb
j_iik[YedZ_j_ediWbed]j^[feb_i^[Zl[hj_YWbikh\WY[
e\j^[j^h[WZ[Zf_dm_bb^Wl[ijWX_b_p[ZXoj^_ij_c[
jej^[fe_dje\cWjY^_d]j^[f^oi_ebe]_YWbijWj[e\W
Ybei[ZckYeiWbijhkYjkh[$
È
#ONCLUSION
Eij[efehej_Y \hWYjkh[i e\ j^[ `Wmi W\j[h fbWY[c[dj
e\8E?cWoX[WYedi[gk[dY[e\Wfei_j_l[\[[ZXWYa
X[jm[[d ZWcW][ WYYkckbWj_ed WdZ j^[ _dYh[Wi[Z
h[ceZ[bb_d] ifWY[ WiieY_Wj[Z m_j^ j^[ h[fW_h$
>[dY[\hWYjkh[ikikWbboeYYkh,m[[aiW\j[h_cfbWdj
fbWY[c[dj$ J^[ Xed[ WhekdZ j^[ beWZ#jhWdic_jj_d]
XWi[ fbWj[i _i Wj j^_i ijW][ e\ ^[Wb_d] Wbh[WZo m[bb
WjjWY^[Z je j^[ XWi[ fbWj[ WdZ ^Wi ^[Wb[Z _d_j_Wbbo$
J^[ \hWYjkh[ kikWbbo eYYkhi _d j^[ h[]_ed X[bem
j^[ jh[WZ[Z f_d$ Jh[Wjc[dj e\ j^_i [l[dj i^ekbZ
X[ W Yedi[hlWj_l[ ed[ WdZ fWj_[dji m_j^ ademd
eij[efehej_YZ_i[Wi[i^ekbZX[jh[Wj[Z_d_cc[Z_Wj[
beWZ$J^_imWoj^[ijWX_b_p_d]Xh_Z][_i_dijWbb[Zm[bb
X[\eh[j^[[nf[Yj[Z\hWYjkh[jWa[ifbWY[$
?cfhel_d]j^[gkWb_joe\Xed[j^hek]^c[Z_YWj_ed
m_j^ X_f^eif^edWj[i [$]$ <eiWcWn _i Wd efj_ed
_d YWi[ j^Wj eij[efehej_Y j[dZ[dY_[i Wh[ ademd
fh[ef[hWj_l[bo$

&IGÈ 7ffhen_cWj[bo ,m[[ai \ebbem_d] _di[hj_ed e\ W \_n[Z Xh_Z][ ed \_l[ 8E? _cfbWdji" j^[ cWdZ_Xb[ \hWYjkh[Z _d W
fWhWc[Z_WdZ_h[Yj_edWhekdZj^[Wh[We\jeej^))"Wjj^[fe_djjem^_Y^j^[j^h[WZ[Zf_de\j^[ZekXb[#Z_ia8E?_cfbWdjmekbZ
[nj[dZ$I_dY[j^[Xh_Z][^WZWbh[WZoX[[d_di[hj[Z"de_cc[Z_Wj[j^[hWf[kj_YWYj_edmWih[gk_h[Z$:kh_d]j^[^[Wb_d]fheY[ii
fbWij_Y Z[\ehcWj_ed e\ j^[ cWdZ_Xb[ eYYkhh[Z" m_j^ Wffei_j_edWb h[ceZ[bb_d] Wi W Yedi[gk[dY[$ J^_i Y^Wd][Z j^[ YkhlWjkh[
WhekdZ **" WdZ j^[ 8E? _cfbWdj -=. ;: eh_]_dWbbo _di[hj[Z ^[h[ beij _ji YedjWYj m_j^ j^[ b_d]kWb Yehj_YWb Xed[ WdZ X[YWc[
_dijWXb[$?jmWi[nY^Wd][Z\ehWm_Z[h/=.;:_cfbWdj$J^[Xh_Z][Z_Zdej^Wl[jeX[h[fbWY[Z
È È -ACROSCOPICÈ&UNCTIONALÈ!NATOMYÈ
È
-ACROSCOPICÈ&UNCTIONALÈ!NATOMY
-PPLJOH
BU
B
CPOF
JT
MPPLJOH
JOUP
UIF
QBTU
È
)NTRODUCTION
M^_b[j^[_d\bk[dY[e\\kdYj_eded\ehc"Wih[bWj_d]
2ELATEDÈ#HANGESÈINÈ*AWÈ-ORPHOLOGY
je Xed[ ijhkYjkh[i" ^Wi X[[d m_Z[bo Z_iYkii[Z _d
j^[ iY_[dj_\_Y Yecckd_jo" j^[i[ c[Y^Wd_ici Wh[
bWh][bo_]deh[Z_dYb_d_YWbZ[djWbfhWYj_Y[$Ieb_ZXWi_Y
h[i[WhY^ _i _d i^ehj ikffbo jeZWo" Wi j^_hZ#fWhjo
\kdZ_d]e\iY_[dj_\_Y_dl[ij_]Wj_edi^Wikd\ehjkdWj[bo
X[Yec[ Wbb jee Yecced$ ?d WZZ_j_ed" Wd_cWbi \eh
[nf[h_c[djWbijkZ_[iWh[debed][hh[WZ_boWlW_bWXb[$
I_dY[ j^[h[ _i iYWhY[bo Wdo h[jkhd ed j^[ j_c[ WdZ
ced[o]e_d]_djeXWi_Yh[i[WhY^"ijkZ_[ie\j^_ijof[
m_bbedboX[f[h\ehc[Z_\cWii_l[f[hiedWb_dj[h[iji
Wh[_dlebl[Z$BkYa_bo"m[Wh[_dWfei_j_edjeZhWmed
W h[bWj_l[bo ieb_Z XWi[ e\ iY_[dj_\_Y ZWjW Yebb[Yj[Z _d
j^[i[YedZ^Wb\e\j^[jm[dj_[j^Y[djkho$
Dkc[heki[nf[h_c[djWbijkZ_[i^Wl[Z[cedijhWj[Z
j^Wj Xed[ ]hemj^ _d j^[ `Wm _i _d\bk[dY[Z Xo beWZ#
h[bWj[Z ijh[ii[i [$]$ Xo ckiYb[ WjjWY^c[dji WdZ
ej^[h\kdYj_edWbc[Y^Wd_ici$=hemj^_ih[ZkY[Z_\
ckiYb[iWh[h[cel[ZCeeh['/-)$8oh[cel_d]j^[c
kd_bWj[hWbbo"j^[Z_h[Yj_ede\]hemj^YWdX[ceZ_\_[Z
IY^kcWa[h WdZ :eabWZWb '/,.$ Jeej^ [hkfj_ed
WdZ j^[ i^[[h fh[i[dY[ e\ j[[j^ m_bb _d\bk[dY[ Xed[
h[ceZ[bb_d]WdZ^[dY[Xed[ijhkYjkh[P[d]e[jWb$
'/-)$
MWi^Xkhd '/*- eXi[hl[Z lWh_eki jof[i e\
ia[b[jWb Wiocc[jh_[i W\j[h fWhj_Wb h[celWb e\ j^[
po]ecWj_Y WhY^ m_j^ekj ZWcW][ je j^[ cWii[j[h
ckiYb[ _d '#ZWo#ebZ _d hWji$ I_c_bWh Wbj[hWj_edi ed
h[cel_d] j^[ cWii[j[h ckiYb[ m[h[ eXjW_d[Z Xo
>ehem_jp WdZ I^Wf_he '/++$ DWdZW [j Wb$ '/,.
_dl[ij_]Wj[Z j^[ [\\[Yj e\ h[beYWj_d] j^[ Z_ijWb
WjjWY^c[dje\j^[cWii[j[hckiYb[_d'$+#cedj^#ebZ
j[hh_[hied`Wmcehf^ebe]oW\j[hWdej^[h-$+cedj^i$
J^[ cehf^ebe]_YWb Z_\\[h[dY[i h[bWj_l[ je j^[
YedjhWbWj[hWbdehcWbi_Z[jkhd[ZekjjeX[l[hoicWbb$
J^_i\_dZ_d]cWoX[Zk[jelWh_eki\WYjehi$<ehed[
j^_d]" j^[ h[beYWj[Z Y^[m_d] ckiYb[i ^WZ X[Yec[
Yedi_Z[hWXbo icWbb[h WdZ j^ki m[Wa[h$ ?d if_j[ e\
j^Wj"c_Zb_d[i^_\jijemWhZij^[jh[Wj[Zi_Z[m[h[i[[d
j^Wjeh_]_dWj[ZWhekdZj^[fh[cebWhi$J^[i[h[ikbji
YWddejX[Z_h[YjbojhWdibWj[Zje^kcWdi"WiZe]i^Wl[
W ijh_Yjbo l[hj_YWb Y^[m_d] fWjj[hd$ J^[_h YedZob[
\kdYj_ed_iYed\_d[Zjefkh[^_d][Wn_icel[c[dji1
_d\WYj"j^[_hl[hojeej^cehf^ebe]o_iZ[i_]d[Z\eh
l[hj_YWbY^eff_d]cel[c[djiedbo$D[l[hj^[b[ii"j^[
bem[hcWh]_de\j^[cWdZ_Xb[\[Wjkh[iWdWdj[]ed_Wb
dejY^" ikY^ Wi j^[ ed[ j^Wj _i iec[j_c[i Yb[Whbo
l_i_Xb[ _d EF=i e\ ^kcWd cWdZ_Xb[i Wi m[bb$ ?j
')-
Wff[Whi j^Wj j^[ Wdj[h_eh cWh]_d e\ j^[ cWii[j[h
ckiYb[ _i ceh[ WYj_l[ _d j^[i[ _dZ_l_ZkWbi j^Wd
j^[ Z_ijWb ckiYb[ fehj_ed$ 7\j[h Wbb" Xej^ ckiYb[
i[]c[dji Wh[ i[fWhWj[ WdWjec_YWb WdZ \kdYj_edWb
[dj_j_[i ;iY^b[h '/+($ =[d[hWbbo if[Wa_d]" Xed[
]hemj^_ib_a[bojeZ[Y[b[hWj[W\j[hckiYb[i^Wl[X[[d
i[fWhWj[Z7l_i'/,'$
È
!GE
EdY[]hemj^^WiX[[dYecfb[j[ZWdZj^[cWdZ_Xb[
^Wi h[WY^[Z _ji cWn_ckc i_p[" kikWbbo W fheY[ii e\
h[iehfj_ed WdZ h[ceZ[bb_d] _i ]hWZkWbbo _d_j_Wj[Z$
:kh_d] j^_i f^Wi[" j^[ fehei_j_[i _di_Z[ j^[
Xed[ WYgk_h[ Wd kd[l[d Z_ijh_Xkj_ed" WdZ Xed[
cehf^ebe]o Z[l[befi jemWhZi j^[ i^Wf[ m[ YWd
i[[ _d ebZ [Z[djkbeki fWj_[dji$ J^_i W][_d] fheY[ii
kd\ebZi _d j^[ iWc[ cWdd[h h[]WhZb[ii e\ m^[j^[h
j[[j^ Wh[ fh[i[dj eh WXi[dj" Wi j^[ Z_ijh_Xkj_ed e\
fehei_j_[i _i [gkWb _d Xej^ YWi[i 7ja_died WdZ
MeeZ^[WZ'/,.$8ed[h[iehfj_ed_iWbmWoiijhed][h
XkYYWbbo j^Wd c[Z_Wbbo$ Kf je WhekdZ )+o[Whi e\
W]["j^[fehei_joe\j^[cWdZ_Xb[h[cW_diYedijWdj$
7\j[h j^Wj" _j a[[fi Z[Yh[Wi_d] \eh WhekdZ '&o[Whi
WdZ j^[d _dYh[Wi[i W]W_d bWj[h _d b_\[ CWdied WdZ
BkYWi '/,($ J^[ ^_]^[h Xed[ Z[di_jo X[jm[[d
j^[ W][i )& WdZ *& c_]^j Wbie ^Wl[ je Ze m_j^
j^[ ^_]^[h fh[lWb[dY[ e\ f[h_eZedj_j_i _d j^_i W][
]hekf$ I_dY[ b[ii fehei_jo _i WiieY_Wj[Z m_j^ b[ii
f[h\ki_ed WdZ ^_]^[h c_d[hWb_pWj_ed" j^[ ijhkYjkhWb
Z[\[dY[ ijWjki e\ j^[ `Wm c_]^j X[ Wbj[h[Z$ M^_b[
ZWjW e\ j^_i jof[ Wh[ dej WlW_bWXb[ \eh j^[ cWn_bbW"
j^[j[cfehWbh[bWj_edi^_fi_dj^[cWdZ_Xb[Wh[ceh[
eh b[ii _d a[[f_d] m_j^ j^[ hWj[ e\ 8CK \ehcWj_ed
<_]$/$*$ ?j _i j^[h[\eh[ h[WiedWXb[ je Wiikc[ j^Wj
YedZ_j_edi Wh[ i_c_bWh _d j^[ cWn_bbW$ :[djkbeki
`WmiZedejh[l[WbZhefi_dj^[8CKYkhl[Wii^Whf
Wi j^[ ed[ _d <_]$/$*" fh[ikcWXbo X[YWki[ j^[ `Wmi
Wh[ Yedj_dkekibo h[ceZ[bb[Z kf je WhekdZ j^[ )&
eh*&o[Whie\W][Zk[jeYedj_dk_d]jeej^[hkfj_ed
WdZ Y^Wd]_d] \kdYj_edWb h[gk_h[c[dji$ I_dY[ Wdo
[njhWYj_edWdZ_cfbWdjWj_edfheY[Zkh[im_bb_dZkY[
d[m h[ceZ[bb_d]" _j _i Wbceij _cfeii_Xb[ je ZhWm
Wdo ijWj_ij_YWbbo i_]d_\_YWdj YedYbki_edi WXekj j^[
fehei_joe\`Wmi$Ikhfh_i_d]bo"j^[h[_idei[n#if[Y_\_Y
Z_\\[h[dY[_dfehei_jo$ledMem[hdWdZIjebjp['/-.
\W_b[Zje[ijWXb_i^WdoZ_\\[h[dY[iX[jm[[dcWb[WdZ
\[cWb[ lebkdj[[hi XWi[Z ed h[bWj_l[ Xed[ lebkc["
jhWX[YkbWh ijhkYjkh[i WdZ 8CK WYj_l_jo$ J^[o Wbie
\ekdZ j^Wj fehei_j_[i _d j^[ cWdZ_Xb[i e\ WZkbji
_dYh[Wi[Z _d Wd W][#Z[f[dZ[dj cWdd[h$ J^[ W][
e\ Wd _dZ_l_ZkWb YWd X[ [ij_cWj[Z gk_j[ [nWYjbo Xo
[lWbkWj_ed j^[ Z[di_jo e\ i[YedZWho eij[edi e\ j^[
bed] Xed[i [$]$ j^[ \[ckh$ J^_i j[ij m_bb dej ]_l[
h[fheZkY_Xb[ h[ikbji _d j^[ `Wm Xed[i i_dY[ j^[i[
Xed[i Wh[ ikX`[Yji je jee cWdo ded#ijh[ii h[bWj[Z
'). 9^Wfj[h/È &OUR
$IMENSIONALÈ#ONSIDERATIONSÈOFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS

_d\bk[dY[ij^hek]^ekjj^[f^Wi[Zkh_d]m^_Y^j[[j^ _dYh[Wi[ _d Wd Wdj[h_eh Z_h[Yj_ed _i YWki[Z Xo j^[
Wh[fh[i[dj"beijWdZh[fbWY[Z$ c[i_e#Z_ijWb _dYb_dWj_ed e\ j^[ Ykifi e\ j^[ j[[j^
Jeej^beiim_bb]h[Wjbo_d\bk[dY[Xed[cehf^ebe]o" _d Xej^ `Wmi$7i W h[ikbj" j^[ Wdj[h_eh dWiWb if_d[ _i
Wi j^[ Xed[ ijhkYjkh[ _cc[Z_Wj[bo ikhhekdZ_d] j^[ Yh[Wj[Z Xo W ikhfbki e\ Xed[ m^_Y^ _i cel[Z Wbed]
jeej^ m_bb kdZ[h]e beYWb h[iehfj_ed$ J^[ Y^Wd][Z Wdj[h_ehbo ed Xej^ i_Z[i e\ j^[ cWn_bbW WdZ f_b[i
kj_b_pWj_ed fWjj[hd e\ j^[ W\\[Yj[Z `Wm i[]c[dj m_bb kf Wf_YWbbo WdZ X[jm[[d j^[ heeji e\ j^[ cWn_bbWho
[nj[di_l[bo Wbj[h j^[ cehf^ebe]o e\ j^[ [dj_h[ `Wm$ Y[djhWb_dY_iehiI[_f[b'/+.$J^[h[_iWd_dYh[Wi[_d
J^[ cWij_YWjeho \ehY[i Wh[ dej WbmWoi h[ZkY[Z ijhW_d_dj^[Wbl[ebWhWhY^WdZWhekdZj^[h_ce\j^[
_cc[Z_Wj[bo" Xkj j^[o YWd _dYh[Wi[ beYWbbo je dWiWbYWl_jo=heii[jWb$(&&'$
Yecf[diWj[ \eh j^[ jeej^ beii" eh beii e\ XWbWdY[ Ej^[h W][#h[bWj[Z Wbj[hWj_edi _d cWn_bbWho
>obWdZ[h'/-/$ cehf^ebe]o m_bb X[ Z_iYkii[Z _d Yedd[Yj_ed m_j^
_cfbWdjj^[hWfoWbed]j^[cWn_bbWhoi_dki$
È
-AXILLARYÈ-ORPHOLOGY È
4HEÈ0ROBLEMÈOFÈ3YMMETRYÈÈ
?d _dZ_l_ZkWbi m_j^ dehcWb Y^[m_d] \kdYj_ed"
7HICHÈ7ASÈ&IRSTÈ4HEÈ(ENÈORÈTHEÈ%GG
j^[ fh[iikh[ e\ j^[ cWdZ_Xb[ [n[hji Wd eXb_gk[bo
WZlWdY_d] \ehY[ ed j^[ j[[j^$ J^[ Yehj_YWb Xed[ 7i[nfbW_d[Zfh[l_ekibo_d9^Wfj[h/$)"Xej^i_Z[ie\
ed j^[ l[ij_XkbWh Wif[Yj e\ j^[ cWn_bbW WXiehXi j^[ cWdZ_Xb[ ^Wl[ W j[dZ[dYo je b[l[b ekj _d j[hci
j^[i[\ehY[ib_a[Wd[j$J^_ifheY[iiij_ckbWj[iXed[ e\ Xed[ lebkc[$ J^_i j[dZ[dYo _i fh[ikcWXbo Zk[
]hemj^$7ij^[Xed[_i_dYh[Wi_d]boYecfh[ii[Z_dW je j^[ iocc[jh_YWb Wb_]dc[dj e\ ckiYb[i WdZ j^[
c[Z_WbWdj[h_ehZ_h[Yj_ed"j^[bWh][Xed[XbeYae\j^[ iocc[jh_YWb_dd[hlWj_ede\j^[i[ckiYb[i$
dWiWbif_d[_i\ehc[Z$ 7iocc[jh_YWb Xed[ YedZ_j_edi Wh[ eXi[hl[Z
J^_ifheY[ii_i]hWf^_YWbbo_bbkijhWj[ZXoj^[\_dZ_d] cW_dbo _d j^[ cWdZ_Xb[" m^[h[ c_Zb_d[ i^_\ji jWa[
j^Wj[njhWYj_ede\j^[cWn_bbWhoYWd_d[WdZYecfb[j[ fbWY[ W\j[h kd_bWj[hWb Y^[m_d] fWjj[hdi ^Wl[ X[[d
i[fWhWj_ede\j^[cWn_bbW_dWl[ij_Xkbe#ehWbZ_h[Yj_ed fh[i[dj el[h [nj[dZ[Z f[h_eZi e\ j_c[$ CWa_ [j Wb$
m_bb]_l[h_i[jej^[\ehcWj_ede\WjkX[hei_joc[i_Wbbo (&&'f[h\ehc[ZWl[ho_d\ehcWj_l[ijkZoXWi[Zed
WdZl[ij_XkbWhbojej^[cWn_bbWho\_hijfh[cebWh$=_l[d )( lebkdj[[hi W][0 .Ä)&o[Whi m_j^ Wiocc[jh_YWb
j^[ if[[Z e\ d[m Xed[ \ehcWj_ed" edbo fb[n_\ehc cWdZ_Xb[iZ[l_Wj_d]Xo)ccehceh[$J^[oeXi[hl[Z
Xed[YWdZ[l[bef$7ij^[eij[ejecoWh[W_i^[Wb_d]" j^Wj f[Wa c_d[hWb_pWj_ed mWi ^_]^[h WdZ Y^[m_d]
fWhj e\ j^[ fb[n_\ehc Xed[ _i h[iehX[Z m^_b[ fWhj ckiYb[i m[h[ bWh][h ed j^[ i^ehj[h i_Z[i e\ j^ei[
e\ j^[ jkX[hei_jo m_bb ¼jhWl[b½ \Whj^[h jemWhZi j^[ cWdZ_Xb[i$ J^[ Wkj^ehi Z_Z dej Z_iYkii j^[ YWki[
c[Z_Wb Wif[Yj WdZ m_bb [l[djkWbbo c[h][ m_j^ j^[ e\j^[i[Wiocc[jh_[i"WdZj^[oZ_ZdejXh[WaZemd
Xed[_dj^[Wh[We\j^[bWj[hWb_dY_ieh$J^_ii_jkWj_ed j^[[nWYji_j[ie\f[Wac_d[hWb_pWj_ed$Ikhfh_i_d]bo"W
]_l[i Wd _cfh[ii_l[ Z[cedijhWj_ed e\ ^em bWh][ fh[\[hh[ZY^[m_d]i_Z[mWidejeXi[hl[Z_dj^_i]hekf
Xed[lebkc[iWh[h[beYWj[Z$M^_b[j^[\ehY[iWYj_d] e\ fWj_[dji$ F[h^Wfi j^_i _iik[ mWi dej WZZh[ii[Z
edi_d]b[#heejj[[j^ikY^Wifh[cebWhiWh[l_hjkWbbo if[Y_\_YWbbo [dek]^$ ?j _i Wbie YedY[_lWXb[ j^Wj j^[
WbmWoi [YY[djh_Y _d dWjkh[" cebWhi Wh[ ceh[ e\j[d \ehY[i[n[hj[ZXoj^[ckiYb[im_bbWYgk_h[WX_bWj[hWb
W\\[Yj[Z Xo Y[djh_Y \ehY[i j^Wj Ze dej d[Y[iiWh_bo [gk_b_Xh_kc _d j^_i W][ ]hekf edY[ j^[ Wiocc[jho
\Wlekh c[i_Wb_pWj_ed$ ?d WZZ_j_ed" cWn_bbWho cebWhi _i\kbboZ[l[bef[Z$J^_i\_dZ_d]"_dWi[di["Yed\b_Yji
m_bb j[dZ je hejWj[ WhekdZ j^[_h fWbWjWb heej hWj^[h m_j^j^[Yb_d_YWbeXi[hlWj_edj^Wj[WhboZ[l[befc[dj
j^Wd WYjkWbbo c_]hWj[ _d W c[i_Wb Z_h[Yj_ed$ J^[ e\kd_bWj[hWbY^[m_d]fWjj[hdi[$]$Zk[jefW_d\kbeh
bem[h fh[cebWhi Wh[ ceh[ b_a[bo je cel[ Z_ijWbbo c_ii_d] Z[Y_Zkeki j[[j^ ed j^[ YedjhWbWj[hWb i_Z[
Zk[jej^[_heXb_gk[ikh\WY[YedjWYj1_j_iWbie\ehj^_i m_bb jh_]][h W ib_]^j [njhki_ed m_j^ hejWj_ed e\ j^[
h[Wied j^Wj j^[o kikWbbo i^em Wd _dl[hi[ YkhlWjkh[ kff[h \_hij cebWh ed j^[ ded#Y^[m_d] i_Z[" j^[h[Xo
Y^WhWYj[h_ij_Y$J^[kff[hfh[cebWhiZedej^Wl[j^_i Yh[Wj_d]Wkd_bWj[hWbYbWii#??j[dZ[dYo$?\i_jkWj_edie\
Y^WhWYj[h_ij_YX[YWki[j^[o[lebl[Z\hecWkd_\ehc j^_ijof[Wh[b[\jYecfb[j[bokdjh[Wj[Z_$[$dej[l[d
Xed[cWii$J^[bem[hfh[cebWhi"XoYedjhWij"[lebl[ Xo WYj_l[ im_jY^_d] e\ j^[ Y^[m_d] i_Z[ eh eYYbkiWb
m_j^j^[XeZoe\j^[heej_dj^[Wbl[ebWhXed[WdZj^[ WZ`kijc[dj e\ j^[ Z[Y_Zkeki j[[j^" j^[ W\\[Yj[Z
j_fe\j^[heej_dj^[XWiWbXed[$ i_Z[ m_bb X[ W\\b_Yj[Z m_j^ YhemZ_d] WdZ Yheii#X_j[
J^[ jhW`[Yjeh_Wb ijhkYjkh[i e\ j^[ cWn_bbW Wh[ j[dZ[dY_[i" \ebbem[Z Xo W c_Zb_d[ i^_\j jemWhZi
_d\bk[dY[Z Xo jme cW`eh ckiYb[ Z_h[Yj_edi0 J^[ j^[ Y^[m_d] i_Z[$ J^[ fh[Y_i[ c[Y^Wd_ici Wj meha
bWj[hWbfj[ho]e_ZckiYb[fkbbij^[cWn_bbW_dWiW]_jjWb X[Yec[eXiYkh[ZedY[j^[Y^[m_d]i_Z[^Wii^_\j[Z
Z_h[Yj_ed$ J^[ cWii[j[h" j[cfehWb_i WdZ c[Z_Wb i[l[hWb j_c[i WdZ j^[ YWki[#[\\[Yj h[bWj_edi^_fi
fj[ho]e_ZckiYb[iWYjl[hj_YWbboWdZj[dZje_dYh[Wi[ Wh[ de bed][h Yb[Wh$ J^[ kd_bWj[hWb 9bWii ?? jeej^
Xed[ lebkc[ _d j^[ Wdj[h_eh fWhj e\ j^[ cWn_bbW _\ h[bWj_edi^_fm_bbj^[dedY[W]W_dW\\[Yjj^[Y^[m_d]
j[[j^jhWdic_jj^[i[\ehY[ijej^[Xed[$8ed[lebkc[ fWjj[hd$
È È -ICROSCOPICÈ!NATOMYÈANDÈ.UTRIENTÈ3UPPLYÈ
È
3UMMARYÈ,OOKINGÈINTOÈTHEÈ0AST
J^[\ekhj^Z_c[di_edÄ_$[$j^[j_c[\WYjehÄ_dlebl[i
Yedj_dkeki h[ceZ[bb_d] WdZ ^[dY[ Yedj_dkeki
cehf^ebe]_YWb Y^Wd][i _d Xed[ ijhkYjkh[i$ 7do
_d\[Yj_edi"f[h_eZedjWbfheXb[ciWdZ%eh[njhWYj_edi
^Wl[ Wd WZZ_j_edWb _cfWYj$ <kdYj_ed _i W Z[Y_i_l[
_d\bk[dY[ ed j^[ \ehcWj_ed" cW_dj[dWdY[ WdZ
h[iehfj_ed e\ Xed[$ ?cfbWdj[Z Xed[ i[]c[dji
j^Wj m_bb fh[ikcWXbo Yec[ je X[ h[iehX[Z Wh[Wi
Wi W h[ikbj e\ fh[[n_ij_d] eh _dZkY[Z \kdYj_edWb
YedZ_j_edim_bbbei[j^[_hikffehj_d]fhef[hj_[iWdZ
X[Yec[ ikiY[fj_Xb[ je _d\[Yj_ed l[ho ieed$ J^ki
m[Wa[d[Z"j^[oYWddebed][h\kb\_bj^[_hjWiae\beWZ
jhWdic_ii_ed$ >_ijebe]_Y Xed[ i[Yj_edi fhel_Z[ ki
m_j^ W cWf e\ h[ceZ[bb_d] Z_h[Yj_ed$ 7bb e\ j^[i[
8CKi m[h[ fh[Y[Z[Z" WdZ _d [\\[Yj jh_]][h[Z" Xo
c[Y^Wd_YWbij_ckb_$M[YWdi[[WYj_l[Y[bb\ehcWj_edi
edj^[i[i[Yj_edi"WdZm[YWdi[[j^Wjj^[[l[djiXo
m^_Y^W]_l[dWYj_l_jomWijh_]][h[ZeYYkhh[Ziec[
j_c[W]e$?j_i_cfeii_Xb[jeh[jheif[Yj_l[bo_Z[dj_\o
j^[ jh_]][h \eh if[Y_\_Y 8CK \ehcWj_edi WdZ" Wj
j^[ iWc[ j_c[" _Z[dj_\o j^[_h \kjkh[ Z_h[Yj_ed WdZ
[dZfe_dji$J^[h[Wied_i"j^Wjj^[_dl[ij_]Wj_ed_ji[b\
mekbZX[Wd_dlWi_l[fheY[Zkh["m^_Y^mekbZY^Wd][
j^[jkdd[bb_d]e\j^[8CKikdZ[h_dl[ij_]Wj_ed$7\j[h
Wbb" 8CK \ehcWj_edi Yedjh_Xkj[ je j^[ kdY[hjW_djo
j^[ci[bl[i i_c_bWh je >[_i[dX[h]Éi kdY[hjW_djo
fh_dY_fb[ Xo _dZkY_d] Y^Wd][i _d j^[ ij_\\d[ii WdZ
Wd_iejhef_Y fhef[hj_[i e\ j^[ W\\[Yj[Z Xed[ edY[
j^[o ^Wl[ X[[d jh_]][h[Z$ ?d j^_i mWo" j^[ eXi[hl[Z
8CKcWo[_j^[h_dZkY[\khj^[h8CKWYj_lWj_edi"eh
_jcWo_dZkY[_jiemdj[hc_dWj_ed$M^_Y^[l[djm_bb
eYYkhZ[f[dZi"Wced]ej^[hj^_d]i"edj^[ij_\\d[ii
_dj^[W\\[Yj[ZXed[i[]c[dj"edj^[\kdYj_edWbbeWZ
fh[i[djZkh_d]8CK\ehcWj_ed"WdZedj^[^ehcedWb
i_jkWj_ede\j^[Xed[WjbWh][$
8omWoe\WdWbe]o"j^[h[WZ[hcWomWdjjeYedi_Z[h
ekh l_ikWb _cW][ e\ \WhWmWo ijWhi$ M^[d j^[ b_]^j
\hec j^[i[ ijWhi [l[djkWbbo Whh_l[i ed ;Whj^" m^Wj
m[f[hY[_l[m_j^ekh[o[iWYjkWbboh[\b[Yjij^[h[Wb_jo
e\WZ_ijWdjfWij$Kbj_cWj[bo"m[YWdedbo[l[hYWjY^
W ]b_cfi[ e\ j^[ fWij$ J^[ iWc[ _i jhk[ m^[d m[
beea Wj W Xed[$7\j[h Wbb" m^Wj m[ ][j je i[[ _i edbo
j^[ cehf^ebe]_YWb Yedi[gk[dY[i e\ j^[ ][d[j_YWbbo
_dZkY[Z" ^ehcedWbbo c[Z_Wj[Z WdZ \kdYj_edWbbo
Z_h[Yj[Z]hemj^e\WXed[ijhkYjkh["\ebbem[ZXoj^[
f^Wi[e\\kdYj_edWbki[m_j^Wbb_ji[nj[hdWb_d\bk[dY[i"
Zemdjej^[f^Wi[e\Z_iki[Wjhef^o$FWhj_YkbWhbo_d
j^[ `Wm Wh[W" _j _i \h[gk[djbo feii_Xb[ je h[WZ j^[
Wffhen_cWj[ j[cfehWb i[gk[dY[ e\ j^[ \kdYj_edWb
Y^Wd][i WdZ Z_ijkhXWdY[ _d j^[ cWij_YWj_ed ioij[c
edfWdehWc_YhWZ_e]hWf^ie\fWhj_WbboehYecfb[j[bo
[Z[djkbeki fWj_[dji$ J^[ h[WZ[h _i h[\[hh[Z je
9^Wfj[h'&\ehWZ[jW_b[ZZ_iYkii_ed$
')/
È
-ICROSCOPICÈ!NATOMYÈANDÈ.UTRIENTÈ3UPPLY
È
7HYÈANDÈ(OWÈi!LLÈ4HINGSÈ!REÈINÈ&LUXw
J^[`WmiWh[ikffb_[Zm_j^dkjh_[djiWdZXbeeZ\hec
Z_\\[h[djiekhY[i$J^[XWiWbfehj_ede\j^[cWdZ_Xb[
_iX[b_[l[ZjeX[f[h\ki[Z\hecj^[f[h_eij[kc"m^_b[
j^[ Wbl[ebWh fehj_ed WdZ j^[ j[[j^" m^_Y^ h[gk_h[
Yedi_Z[hWXbo ceh[ XbeeZ" Wh[ ikffb_[Z Z_h[Yjbo Xo
j^[cWdZ_XkbWhWhj[ho$J^_iWhj[ho_iWdedje][d[j_Y
d[Y[ii_jo$ ?d _ji WXi[dY[" j^[ j[[j^ WdZ f[h_eZedjWb
ijhkYjkh[iYekbZdejX[WZ[gkWj[bodekh_i^[Z"i_dY[
j^[ Xed[ lebkc[ _i jee cWii_l[ _d h[bWj_ed je j^[
\[[Z_d] fhef[hj_[i e\ XbeeZ Z_\\ki_ed edbo IWaW [j
Wb$(&&($
?j_idejYecfb[j[bokdZ[hijeeZ^emj^[eij[edWb
ijhkYjkh[i Wh[ ikffb_[Z m_j^ dkjh_[dji WdZ m^Wj
YedZ_j_edi Wh[ fh[i[dj _di_Z[ j^[ eij[edi$ J^[
\ebbem_d] fWhW]hWf^i fhel_Z[ W Xh_[\ h[l_[m e\ j^[
b_j[hWjkh[edj^_i_iik[$
F[jhel [j Wb$ '/./ _dl[ij_]Wj[Z _djhW#eij[edWb
fej[dj_WbiWdZfhefei[ZW<;CceZ[bZ[cedijhWj_d]
j^[ [\\[Yji e\ lWh_WXb[ beWZ_d] ed \bem YedZ_j_edi
_di_Z[ j^[ eij[edi$ 7d _cfehjWdj \WYjeh \eh \bem
f[hi_ij[dY[_ij^[Z_Wc[j[he\j^[eij[edi"m^_Y^lWh_[i
beYWbboF\[_\\[h'//.$H_Xeij[edi"\eh_dijWdY["^Wl[
W icWbb[h Z_Wc[j[h _djhW_dZ_l_ZkWbbo j^Wd \[cehWb
eij[edi$ J^[ \bem h[i_ijWdY[ _d \[cehWb eij[edi _i
j^[h[\eh[ icWbb[h" ie j^Wj f[h\ki_ed _i WZ[gkWj[bo
ikffehj[ZZ[if_j[j^[\WYjj^Wjj^[\[ckh_iikX`[Yj[Z
jeWicWbb[hZ[]h[[e\\kdYj_edWb[bWij_YZ[\ehcWj_ed
j^Wdj^[h_Xi$J^[h_XiWh[Yedi_Z[hWXboZ_ibeYWj[ZXo
h[if_hWj_ed1 j^[i[ \kdYj_edWb cel[c[dji" m^_Y^ Wh[
WXi[dj_dj^[\[ckh"ikffehjj^[\beme\dkjh_[dji$?j
i[[cij^Wjj^WjXed[jh_[i^WhZjea[[fWdo\bknm_j^_d
ijh_YjboZ[\_d[Zb_c_jiWdZj^Wjbem[hf[h\ki_edZe[i
b[ii^Whcj^Wd[nW]][hWj[Zf[h\ki_ed$Edj^[ej^[h
^WdZ" bem[h[Z ekj\bem \hec j^[ Xed[ _i ^Whc\kb _d
WdoYWi[$
J^[ ^[Whj#Zh_l[d h^oj^c_YWb fhefkbi_ed e\
XbeeZ j^hek]^ j^[ l[ii[bi _i dej W h[b[lWdj \WYjeh
_d Wh[Wi Wi f[h_f^[hWb Wi Xed[ F[jhel WdZ FebbWYa
(&&)$ Be]_delW [j Wb$ '//. Z[cedijhWj[Z j^Wj
_dYh[Wi[ZY^[m_d]WYj_l_joZ_Zdeji_]d_\_YWdjboWbj[h
j^[ f[h_eZedjWb XbeeZ ikffbo _d fWj_[dji m_j^ekj
f[h_eZedjWb Z_i[Wi[ Xkj Z_Z ^Wl[ W dejWXb[ [\\[Yj
_d j^[ fh[i[dY[ e\ f[h_eZedj_j_i$ M_j^_d '&c_d e\
cWij_YWj_edf[h\ehc[ZedY^[m_d]]kci"j^[XbeeZ
\bem _dYh[Wi[Z Xo ))$ J^[ fkbiWj_ed e\ j^[ XbeeZ
\bem_dj^[h^oj^ce\j^[^[WhjX[WjYWdX[eXi[hl[Z
\eh j^[ f[h_eZedjWb b_]Wc[dj ]Wf" Xkj _j YWddej X[
eXi[hl[Z_di_Z[j^[Yehj_YWbXed[$
J^[WYj_l_joe\eij[eYbWiji_iXekdZje_dYh[Wi[j^[
eicej_Y fh[iikh[ _di_Z[ j^[ 8CKi _d W i_]d_\_YWdj
'*& 9^Wfj[h/È &OUR
$IMENSIONALÈ#ONSIDERATIONSÈOFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS
cWdd[h$ 7\j[h Wbb" j^[ dkcX[h e\ fWhj_Yb[i WdZ
ceb[Ykb[i h_i[i i^Whfbo m^_b[ j^[ Wcekdj e\ b_gk_Z
YWddej _dYh[Wi[" WdZ iWbji Wh[ dej ZhW_d[Z [_j^[h$
Fh[ikcWXbo"j^[eicej_Yfh[iikh[_di_Z[j^[eij[edi
_i ed[ e\ j^[ h[Wiedi \eh j^[_h fheb_\[hWj_ed WdZ
cel[c[dj _di_Z[ j^[ Xed[$ JWl[i (&&( YedYbkZ[Z
j^Wjj^[Z_\\_Ykbjoe\Ykbj_lWj_d]XbeeZY[bbicWo^Wl[
jeZem_j^j^[ki[e\c[Z_Wm^ei[_edYedY[djhWj_ed
cWjY^[i j^[ ed[ eXi[hl[Z _d Y_hYkbWj_d] XbeeZ$
J^[i[ YedZ_j_edi Wh[ dej fh[i[dj Wj j^[ dWjkhWb
i_j[ e\ ^W[cWjefe_[i_i$ JWl[i Wbie i^em[Z j^Wj _ed
YedY[djhWj_ediZekXb[Zm_j^_dj^[\_hijm[[ae\j^[
eij[edWbb_\[YoYb["\ebbem[ZXoWicWbb[h_dYh[Wi[_dj^[
d[nj(m[[ai$7\j[h)m[[ai"_edYedY[djhWj_edim[h[
'&X[bemj^[ÆdehcWbÇb[l[b$J^_if[h_eZe\)m[[ai
_i Yedi_ij[dj m_j^ j^[ ZkhWj_ed e\ [hoj^hefe_[i_i$
J^[h[\eh["ej^[hYkbjkh[ioij[cie\\[h_d]ZodWc_Y\bem
YedZ_j_ediWh[d[[Z[Zjei_ckbWj[^W[cWjefe_[i_i_d
Wh[Wb_ij_YcWdd[h$8ejY^m[o[jWb$(&&)WdZ=ec[i
[j Wb$ (&&) Z[cedijhWj[Z j^Wj Xed[ ]hemj^ mWi
ckY^ ceh[ [\\[Yj_l[ _\ j^h[[#Z_c[di_edWb cWjh_Y[i
m[h[ ki[Z \eh Ykbjkh[ j^Wj Wbbem[Z \bem f[h\ki_ed
\hec Xej^ i_Z[i j^Wd ed \bWj ikXijhWj[i Wbbem_d]
dekh_i^c[dj \hec ed[ i_Z[ edbo$7hekdZ j^[ icWbb
XWiWbfbWj[ie\8E?"f[h\[YjikffkhWj_edWdZdkjh_[dj
ikffbo Wh[ ]kWhWdj[[Z$ 9[c[djeXbWiji" jee" Wh[
ceh[ [\\[Yj_l[bo Ykbj_lWj[Z ed j^h[[#Z_c[di_edWb
ikXijhWj[iB_c(&&&$?j_im[bb[ijWXb_i^[Zj^Wjj^[
dkYb[_ e\ eij[eYoj[i X[Yec[ foadej_Y d[Wh ded#
f[h\ehWj[Z _cfbWdj ikh\WY[i$ IfWj_Wb h[bWj_edi^_fi
e\ j^_i jof[ Ze dej Wffbo je 8E? _cfbWdji" i_dY[
j^[_h ia[b[j_p[Z Z[i_]d Ze[i dej i[h_ekibo W\\[Yj
j^[ gkWb_jo e\ \bem f[h\ki_ed$ ;\\[Yj_l[ dkjh_[dj
ikffbocWoX[ed[e\j^[h[Wiedim^o[\\[Yj_l[beWZ
jhWdic_ii_ed jWa[i fbWY[ _d 8E? _cfbWdji Z[if_j[
j^[ Yedi_Z[hWXbo icWbb[h _cfbWdj#Xed[ _dj[h\WY[
YecfWh[Z je Yh[ijWb Z[i_]di$ 7 YecX_dWj_ed e\
jme \WYjehi c_]^j [nfbW_d j^_i f^[dec[ded$ <eh
&IGÈ L[ii[bi\hecj^[F:BWh[
Z_h[YjboYedd[Yj[Zjel[ii[bi\hecj^[
ehWbckYeiW$8beeZYWd\bem_d[_j^[h
Z_h[Yj_ed"Z[f[dZ_d]edj^[h[bWj_l[
fh[iikh[X[jm[[dj^[ikffboWh[Wi
ed[ j^_d]" W icWbb[h _cfbWdj#Xed[ _dj[h\WY[ c_]^j
[dWXb[WfheY[iie\_dj[hdWb\bemf[h\ki_edd[Whj^[
_cfbWdj" j^[h[Xo _cfhel_d] j^[ dkjh_[dj ikffbo je
j^[ ikhhekdZ_d] Xed[ ijhkYjkh[ WdZ [d^WdY_d] j^[
Z[]h[[e\c_d[hWb_pWj_ed$<ehWdej^[hj^_d]"WicWbb[h
_dj[h\WY[m_bb[d^WdY[beWZjhWdic_ii_edjej^[Xed["
j^[h[Xo[nf[Z_j_d]WdZikffehj_d]j^[cWjkhWj_ede\
j^[i[Wh[WiWibed]Wideel[hbeWZWff[Whi$=_WlWh[i_
[jWb$(&&)Z[cedijhWj[Zj^Wjj^[YedjWYjWh[WWjj^[
_cfbWdj#Xed[ _dj[h\WY[ mWi bWh][h m_j^ 9WF#YeWj[Z
WdZ j_jWd_kc fbWicW ifhWo[Z ikh\WY[i$7j j^[ iWc[
j_c[" W ^_]^[h Z[]h[[ e\ Xed[ c_d[hWb_pWj_ed d[Wh
j^[_cfbWdjYekbZedboX[eXjW_d[Z_dYh[ijWb_cfbWdj
jof[im_j^[jY^[ZehcWY^_d[Zikh\WY[i$
;nj[di_l[ Z_iYkii_edi Wh[ kdZ[h mWo ed m^[j^[h
8E?_cfbWdjicWoc_c_Yj^[fkbiWj_ede\j^[dWjkhWb
jeej^_di_Z[j^[Wbl[ebWhieYa[j"m^_Y^Wh[WiieY_Wj[Z
m_j^WikYj_ed#fh[iikh[[\\[Yj\ehZ[jW_biWXekjj^_i
_Z[W h[\[h je mmm$cWjh_n#Y[dj[h$Z[$ J^_i mekbZ
[dikh[ j^[ fh[i[dY[ e\ c_YheY_hYkbWj_ed \eh j^[
[dj_h[b_\[e\j^[_cfbWdj$Ceh[el[h"j^[f[h\ehWj_edi
_d j^[ Z_ia [dWXb[ XbeeZ l[ii[bi je ]hem j^hek]^
j^[ _cfbWdj$ 7\j[h Wbb" j^[ fkcf [\\[Yj _dZkY[Z
Xo j^[ Wbl[eb_ j^Wj ][d[hWj[i l[deki ZhW_dW][ _i
de bed][h fh[i[dj edY[ j[[j^ ^Wl[ X[[d [njhWYj[Z$
J^_i m_bb kbj_cWj[bo _dZkY[ Xed[ h[iehfj_ed$ J^[
ikffbo l[ii[bi [$]$ j^[ cWdZ_XkbWh Whj[ho m_bb
cW_djW_d j^[ h[gk_i_j[ el[hfh[iikh[ Wi bed] Wi j^[o
Wh[ dej X[]_dd_d] je jkhd iYb[hej_Y$ IkffkhWj_ed
ibejiYh[Wj[ZXoj^[eij[ejecofhel_Z[WdWZ[gkWj[
ZhW_dW][fWj^mWo$;l[dj^ek]^j^[i[ibejim_bbYbei[
bWj[h" _d j^[ Xed[#^[Wb_d] f^Wi[" j^[ [bWij_Y l[hj_YWb
[nYkhi_edi e\ j^[ 8E? _cfbWdji YWd X[ [nf[Yj[Z je
h[cW_d\ehb_\[$
J^[ cWdZ_Xb[ WdZ cWn_bbW i^em W bej e\ Whj[h_Wb
WdWijecei[i$?j_i_dj^[dWjkh[e\WdWijecei[ij^Wj
XbeeZ cWo \bem _d Xej^ Z_h[Yj_edi" Wi bed] Wi de
lWbl[i Wh[ fh[i[dj$ J^[ XbeeZ fh[iikh[ m_j^_d j^[
È È -ICROSCOPICÈ!NATOMYÈANDÈ.UTRIENTÈ3UPPLYÈ
f[h_f^[hWb f[h_eZedjWb l[ii[bi YWd X[Yec[ jee bem
YecfWh[Z je j^[ ckYeiWb XbeeZ fh[iikh[" m^_Y^
cWoXbeYaeh_d^_X_jj^[ekj\beme\XbeeZ\hecj^[i[
Xed[i$ 9edijWdj bWYa e\ ekj\bem m_bb _d jkhd b[WZ
je f[hcWd[djbo h[ZkY[Z _d\bem" YWki_d] fh[cWjkh[
iYb[hej_Y Z[][d[hWj_ed e\ j^[ cWdZ_XkbWh Whj[ho$
IjWi_i h[ZkY[i j^[ dekh_i^c[dj e\ j^[ `WmXed[ Wj
Xej^ [dZi$ J^_i ikffehji Wbie j^[ Z[l[befc[dj e\
f[h_eZedjWbZ_i[Wi[0J^[kdf^oi_ebe]_YWbbo_dYh[Wi[Z
\bem e\ XbeeZ jemWhZi j^[ Xed[ \hec j^[ ckYeiW
WdZ j^[ _dYh[Wi[ _d XbeeZ fh[iikh[ Xej^ WZl[hi[bo
W\\[Yj j^[ WX_b_jo e\ j^[ f[h_eij[kc je WXiehX mWij[
ikXijWdY[i Yec_d] _d \hec eij[edi WdZ _dje j^[
ikXf[h_eij[Wb ]Wf$ ?dij[WZ" j^[ f[h_eij[Wb j_iik[i
ijWhj [lWfehWj_d] b_gk_Z" m^_Y^ j^[d \ehci fWhj
e\ j^[ Yb_d_YWbbo l_i_Xb[ [nkZWj[" WdZ ^Whc_d] j^[
WZ`WY[dj Xed[ Xo [nY[ii eno][dWj_ed$ 7 h[l[hiWb
e\ j^[ Z_h[Yj_ed e\ j^[ XbeeZ \bem jemWhZi j^[
Xed[" YecX_d[Z m_j^ XWYj[h_Wb WjjWYa" Wbie b[WZi je
]hWdkbWj_ed e\ j^[ ie\j j_iik[i" WYYecfWd_[Z Xo W
beii e\ h[iehfj_l[ fhef[hj_[i$ J^[ Y[bbi d[nj je j^[
Xed[debed][h^Wl[j^[h[iehfj_l[fhef[hj_[ie\j^[
\ehc[hf[h_eij[kc$
J^[ Yecfb[n i_jkWj_ed" m_j^ \WYjehi b_a[
_dj[hij_j_Wb%_djhWeij[edWb \bem" cWii jhWdifehj"
fh[i[hlWj_ed e\ eij[eYoj[ dkjh_c[dj" WdZ j^[
h[]kbWj_ed e\ h[ceZ[bb_d] WYj_l_jo WdZ j^[ Z[fei_j
e\ Xed[ mWij[ ekj\bem Wh[ Wbb _dj[hYedd[Yj[Z JWc_
[j Wb$ (&&($ 9khh[dj h[i[WhY^ _dje Xed[ f^oi_ebe]o
WdZ eij[ebe]o ^Wi o_[bZ[Z _cfehjWdj ZWjW ed j^[
XWi_Y fhef[hj_[i e\ Xed[" m^_Y^ ^Wl[ X[[d kj_b_p[Z
_dj^[Yb_d_YWbWffb_YWj_edWdZZ[l[befc[dje\XWiWb
eii[e_dj[]hWj_ed \eh W bed] j_c[ m_j^ekj X[_d]
WmWh[e\j^[f^oi_ebe]_YWbXWYa]hekdZA_³h'//*$
M[ kdZ[hijWdZ j^Wj f[h_eij[Wb j_iik[ ^Wi j^[ iWc[
\kdYj_ed Wi bkd] j_iik[0 _d j^[ bkd]i" bWh][ ikh\WY[i
Wh[d[Y[iiWho\ehj^[[nY^Wd][e\]Wi[i"WdZ_jZe[i
dej cWa[ Wdo Z_\\[h[dY[ je m^Wj fWhj e\ j^[ bkd]
ikh\WY[ j^[ ]Wi _i Z_h[Yj[Z$ I_dY[ j^[ [dZfe_dj e\
i[YedZWhoeij[ediYWdX[Wdom^[h[edj^[f[h_eij[Wb
ikh\WY[e\j^[Xed[i"j^[mWij[[nf[bb[Z\hecj^ei[
Wf[hjkh[i ckij X[ WXiehX[Z Wj Wdo fe_dj$ KdZ[h
j^[i[ YedZ_j_edi" _j mekbZ dej cWa[ i[di[ \eh j^[
XeZojeYedd[Yj[l[hoeij[edjeWZhW_d_d]l[_d0j^[
ecd_fej[dj f[h_eij[Wb WXiehfj_ed \e_b e\\[h X[jj[h
i[hl_Y[$
È
#LINICALÈ#ONSIDERATIONS
Ekh fh[\[hh[Z Yeeb_d] c[Z_kc \eh j^[ eij[ejeco
fheY[Zkh[ _i h_d][h bWYjWj[$ M[ ikif[Yj j^Wj j^_i
c[Z_kc ZhW_di j^[ Xed[ b[ii WdZ c_d_c_p[i j^[
h[ikbjWdjZhef_deicej_Yfh[iikh[$J^[ki[e\\Wjjo
iebkj_edi je c_d_c_p[ ikh][ho#h[bWj[Z jhWkcW Wbie
^Wi W bed]#ijWdZ_d] jhWZ_j_ed _d ehWb Xed[ ikh][ho$
Ed[ fh[fWhWj_ed ^Wi X[[d h[\[hh[Z je Wi fehj_e
'*'
&IGÈ Eh_]_dWb _cfbWdj Z[i_]d b[\j WdZ _djhWef[hWj_l[bo
efj_c_p[Z Z[i_]d h_]^j" h[cel[Z W\j[h ''o[Whi _d \kdYj_ed$
J^Wdai je j^[ [dbWh][Z f[h\ki_ed ^eb[i" j^[ _cfbWdj X[YWc[
ceh[ [bWij_Y WdZ X[jj[h _dj[]hWj[Z _dje j^[ l_iYe[bWij_Y
[dl_hedc[dj$ 8beeZ \bem je j^[ Xed[ Wh[Wi Yh[ijWbbo e\ j^[
XWiWbfbWj[mWi_cfhel[ZXoj^_iicWbbY^Wd][_dZ[i_]d
cW]_YW1_j_dYbkZ[iYeZb_l[he_bWiYWhh_[h"c[fWYhob
WdZ[k][deb$Iec[ki[hifh[\[hjeWZZWdWdj_X_ej_Y
ikY^WiJ[hhWYehjh_bDjej^[fh[fWhWj_ed$
I_dY[ j^[ f[h_f^[hWb i[]c[dj e\ j^[ Wbl[ebWh
Yh[ij _i Wiikc[Z je X[ ikffb_[Z \hec W Y[djhWb
Z_h[Yj_ed" j^[ _cfbWdj Z_ia cWo fei[ Wd eXijWYb[
je [\\[Yj_l[ f[h\ki_ed$ J^[ _d_j_Wbbo hekdZ ÆZ_ia
_cfbWdjiÇ _djheZkY[Z WhekdZ '/.) m[h[ [gk_ff[Z
m_j^l[hoicWbbXeh[ij^WjmekbZdej[dikh[WZ[gkWj[
f[h\ki_ed$?dWZZ_j_ed"j^[ikh\WY[#[dbWh][Zi^W\jie\
j^ei[ Z[i_]di mekbZ fhecej[ _d\[Yj_edi WZlWdY_d]
\hec j^[ Yh[ij$ Ki[hi mekbZ j^[h[\eh[ ceZ_\o j^[
_cfbWdj Zkh_d] j^[ fheY[Zkh[ Xo Yedd[Yj_d] jme
hekdZXeh[^eb[ied[WY^i_Z[je\ehca_Zd[o#i^Wf[Z
[bed]Wj[Z^eb[i$
9edi_Z[hWbiej^Wjj^[_cfbWdj#h[ijehWj_edioij[c
^Wi je ijWo _d Wd [bWij_Y kd_ed m_j^ j^[ l_iYe[bWij_Y
Xed[ ijhkYjkh[i$ J^[h[\eh[" [dek]^ ifWY[ _di_Z[
j^[Xed[_id[[Z[Z\ehXedoZ[\ehcWj_edi$IjhWj[]_Y
_cfbWdj fbWY[c[dj mekbZ j^[h[\eh[ i[[c je X[ j^[
c[j^eZe\Y^e_Y[$J^_i_ied[e\j^[h[Wiedim^om[
jhojeWle_Zi_dkiWk]c[djWj_ed"Wij^[i[fheY[Zkh[i
m_bb_dYh[Wi[j^[Wcekdje\[njhWd[ekicWj[h_WbWdZ
_cf[Z[Wdo[bWij_YZ[\ehcWj_edie\j^[_cfbWdjWdZ
Xed[_dWdkd\eh[i[[WXb[cWdd[h$;l[d_di_jkWj_edi
e\WZlWdY[Zh_Z][h[iehfj_ed"j^[h[_iWbmWoi[dek]^
dWjkhWbXed[jefbWY[W8E?_cfbWdj$?dm[_]^_d]j^[
fhei WdZ Yedi e\ Wk]c[djWj_ed" ed[ i^ekbZ WbmWoi
Yedi_Z[hj^Wjj^[WlW_bWXb[Xed[ijhkYjkh[_ifh[Y_i[bo
j^[ Xed[ ijhkYjkh[ j^Wj ^Wi ikhl_l[Z W]W_dij Wbb j^[
eZZi$J^[h[\eh["j^[WlW_bWXb[Xed[_iWbiej^[ÆX[ijÇ
'*( 9^Wfj[h/È &OUR
$IMENSIONALÈ#ONSIDERATIONSÈOFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS
Xed[$ ?j _i Xej^ efj_cWbbo beYWj[Z WdZ WZ[gkWj[bo
dekh_i^[Z$Ed[i^ekbZWbieYedi_Z[hj^Wjj^[XbeeZ
ikffbojej^[cWn_bbW_ib_c_j[Z"WiedboicWbbWhj[h_[i
ikffbo j^_i Wh[W$ <khj^[hceh[" j^ei[ Whj[h_[i Wh[
Yedd[Yj[Z j^hek]^ j^h[[ WdWijecei[i _d\hWehX_jWb"
Wbl[ebWh ikf[h_eh feij[h_eh WdZ Wbl[ebWh ikf[h_eh
_d\[h_ehWhj[h_[i"m^_Y^c[Wdij^WjWd_dj[hhkfj_ed
e\ed[e\j^[Whj[h_[im_bbkikWbbodejb[WZjeWh[fW_h
e\j^[W\\[Yj[Zl[ii[bXkjjeh[][d[hWj_edj^hek]^W
d[mYWf_bbWhofb[nkiIebWh[jWb$'///$
8ed[h[iehfj_edcWoX[WYedi[gk[dY[e\el[h#eh
kdZ[hdkjh_j_ed$?di_jkWj_edie\[njh[c[h[iehfj_ed"
_djhWXedo XbeeZ ikffbo _i de bed][h YhkY_Wb \eh j^[
Xed[$ J^[ Xed[ lebkc[ j^Wj m_bb X[ WlW_bWXb[ _d
j^[ bed] j[hc _i cW_dbo Z[j[hc_d[Z Xo j^[ b[l[b e\
dkjh_j_ed fhel_Z[Z Xo j^[ f[h_eij[kc$ <kdYj_edWb
kj_b_pWj_ed m_bb Z[j[hc_d[ j^[ eh_[djWj_ed" hWj^[h
j^Wd j^[ lebkc[" e\ Xed[ cehf^ebe]o$ ?d YWi[ j^Wj
kdZ[hdkjh_j_ed_idej\ebbem[ZXoWh[ZkYj_ede\Xed[
cWii" \Wjjo Z[][d[hWj_ed cWo eYYkh$ ?j _i ][d[hWbbo
X[b_[l[Z j^Wj j^_i YedZ_j_ed ijWhji m_j^ [f_ieZ[i e\
Xed[#Y[bb _iY^[c_W \ebbem[Z Xo ijhkYjkhWb Y^Wd][i
_d_deh]Wd_Y[b[c[dji=b_cY^[hWdZA[dpehW'/-/1
<_YWj'/.+ j^Wj XbeeZ YWddej X[ ik\\_Y_[djbo eXjW_d[Z \eh j^[
M^_b[ j^[ 8E?#ikffehj[Z h[ijehWj_ed _i X[_d]
mehd"ed[ckij[nf[Yjj^[Xed[lebkc[je_dYh[Wi[
Wi W h[ikbj e\ \kdYj_edWb beWZi$ J^_i cWo h[ikbj _d
j^[fedj_YWh[WYec_d]_djeZ_h[YjWdZj_]^jYedjWYj
m_j^j^[ckYeiWWdZj^Wjj^[gkWdj_joWdZZ_h[Yj_ed
e\ j^[ XbeeZ \bem _i Y^Wd][Z Xo j^[ Æf[hcWd[dj
fh[iikh[ ifejÇ$ ?\ j^[ 8E? beWZ#jhWdic_jj_d] h[]_ed
mWi fei_j_ed[Z Ybei[ je j^[ fedj_Y iec[j^_d] j^Wj
cWo ^Wff[d [Wi_bo m_j^ fedj_Yi m_j^ [$]$ l[ij_XkbWh
el[h^Wd]i" j^[ f[h_#_cfbWdj Xed[ cWo [n^_X_j
i[YedZWho Wjhef^o$ J^[ Xed[" m^_Y^ ^WZ X[[d
]hem_d] Zk[ je j^[ [n_ij_d] \kdYj_edWb beWZ" m_bb
^Wl[ _ji emd XbeeZ ikffbo WdZ ZhW_dW][ Ykj e\\ Xo
j^[fedj_Yh[]_ed$?j_id[Y[iiWhojeY^[Yaj^[fedj_Y
h[]_ediedWh[]kbWhXWi_iWdZjef[h\ehcikXjhWYj_l[
Yehh[Yj_edi Wi d[[Z[Z$ I[[ 9^Wfj[h/$- \eh ceh[
Z[jW_bi$
7do c_ii_d] j[[j^ _d j^[ bem[h Wdj[h_eh i[]c[dj
YWd X[ [Wi_bo h[fbWY[Z m_j^ _cfbWdj#ikffehj[Z
h[ijehWj_edi$ J^[ Wdj[h_eh i[]c[dj e\ j^[ cWdZ_Xb[
_il[hoijWXb["iej^Wj_cfbWdjiYWdWbmWoiX[h[b_WXbo
WdY^eh[Z _d j^_i Wh[W$ J^[ \ebbem_d] YWi[ h[fehj
_bbkijhWj[iWYWi[_dm^_Y^j[[j^*(Ä)(m[h[h[fbWY[Z
m_j^ jme _cfbWdji" m^_Y^ m[h[ ki[Z je ikffehj W
Xh_Z][[nj[dZ_d]el[h\ekhj[[j^$78E?_cfbWdjmWi
_di[hj[Z ed j^[ h_]^j" W Yecfh[ii_ed iYh[m ed j^[
b[\j$J^[hWZ_e]hWf^eXjW_d[ZWjj^[(#o[Wh\ebbem#kf
h[l[Wb[Z Z_ij_dYj Z_\\[h[dY[i X[jm[[d j^[ _cfbWdji
h[]WhZ_d] j^[_h [\\[Yj ed j^[ Xed[$ 9edi_Z[h j^Wj
j^[ XbeeZ ikffbo Yec_d] \hec j^[ _di_Z[ e\ j^[
cWdZ_Xb[ _i Z[h_l[Z \hec j^[ cWdZ_XkbWh Whj[ho$
?dj^[fh[i[dY[e\W8E?_cfbWdj"Wdofeij#ikh]_YWb
fh[iikh[Xk_bZ_d]kf_di_Z[j^[cWdZ_Xb[YWdWbmWoi
X[ ZhW_d[Z$ I_jkWj_edi e\ el[hfh[iikh[ j^Wj m_bb
ikXi[gk[djbo ZWcW][ j^[ ifed]_eki WdZ Yehj_YWb
ijhkYjkh[i Wh[ j^[h[Xo Wle_Z[Z$ >em[l[h" j^_i Wbie
c[Wdi j^Wj _d iec[ ifWj_Wb i_jkWj_edi j^[ XbeeZ
ikffbo\ehj^[Yh[ijWb_cfbWdjicWoX[ZhW_d[ZWmWo
j^hek]^ j^[ eij[ejeco ibej$ ?d j^[ YWi[ _bbkijhWj[Z"
j^[ iYh[m _cfbWdj _i eXl_ekibo WZ[gkWj[bo ikffb_[Z
\hec j^[ b[\j i_Z[$ Fh[iikh[ ZhW_dW][ j^hek]^ j^[
h_]^j i_Z[" m^[h[ j^[ 8E? _cfbWdj mWi fbWY[Z" _i
[_j^[h Yb_d_YWbbo kd_cfehjWdj" eh j^[h[ _i [dek]^
XbeeZikffbo\hecj^[b[\ji_Z[jeYel[hj^[beii[ied
j^[h_]^ji_Z[$
?\ Xej^ _cfbWdji m[h[ _di[hj[Z ed j^[ iWc[ i_Z[
[$]$ j^[ iYh[m _cfbWdj Wj *' WdZ j^[ 8E? _cfbWdj
Wj *(" j^[ iYh[m mekbZ ^WhZbo X[ ikffb_[Z m_j^
ik\\_Y_[dj Wcekdji e\ XbeeZ \hec j^[ YedjhWbWj[hWb
b[\j i_Z[$ ?d j^Wj YWi[" j^[ fei_j_ed e\ j^[ 8E?
_cfbWdji mekbZ X[ hWj^[h Z[b[j[h_eki \eh j^[ iYh[m
_cfbWdj"Wij^[Z_ijWbXbeeZikffbomekbZX[ZhW_d[Z
e\\j^hek]^j^[ikffkhWj_edibeje\j^[8E?_cfbWdj
m_j^ekj[l[hh[WY^_d]*'$J^_ii_jkWj_edcWoh[ikbj_d
kdZ[hdkjh_j_ede\i_j[*'$F[h_#_cfbWdj_j_iikffehj[Z
XofeehehWb^o]_[d[cWoZ[l[befXoj^[i^[[h\WYj
Xed[\ehbWYae\_djhWXedoikffbo$M[^Wl[eXi[hl[Z
YWi[i ikY^ Wi j^[i[ _d ekh fhWYj_Y[$ ?d j^[ cWn_bbW"
j^[XbeeZikffbo_iceh[Z_\\ki["WdZYehh[ifedZ_d]
fheXb[ci^Wl[dejX[[deXi[hl[Z$
È
(OLISTICÈ#ONSIDERATIONSÈONÈ)MPLANTÈ4HERAPYÈÈ
INÈ&IELDSÈOFÈ$ISTURBANCE
LWh_eki ^ofej^[i[i \hec j^[ h[Wbc e\ _dj[]hWj_l[
c[Z_Y_d[Äe\j[d\_nWj[Zedj^[cWj[h_WbiÄ^Wl[YWij
WZkX_ekib_]^jedZ[djWb_cfbWdjebe]o$
J^_ih[ikbj[Z_dkd`kij_\_[ZbemWYY[fjWdY[b[l[bi
e\]eeZXed[ikh][hom_j^ikXi[gk[dj_cfbWdjWj_ed
m_j^_dj^[^eb_ij_Yc[Z_YWbYecckd_jo"m^_Y^hWd][i
\hecdWjkhWb^[Wb[hiWdZY^_hefhWYjehijeWbj[hdWj_l[
j^[hWf_iji _dYbkZ_d] ^eb_ij_YWbbo jhW_d[Z WYWZ[c_Y
f^oi_Y_Wdi$ ?j ^Wi X[[d ademd i_dY[ j^[ '/+&i j^Wj
\_[bZi e\ Z_ijkhXWdY[ m_j^_d j^[ Xed[ YWd YWki[
fheXb[ci Wj Wdo fe_dj m_j^_d j^[ XeZo$ <_[bZi e\
Z_ijkhXWdY[m[h[WbieWiieY_Wj[Zm_j^_cfbWdji"m_j^
dWjkhefWj^o dej Ykhh[djbo Z_\\[h[dj_Wj_d] X[jm[[d
j^[ Z_\\[h[dj jof[i e\ _cfbWdji$ ?d j^_i mWo" Yh[ijWb
p_hYed_W_cfbWdjiWh[Ykhh[djbokdZ[hZ_iYkii_edWi
Wd Wbj[hdWj_l[ je j_jWd_kc _cfbWdji" Wbj^ek]^ j^[o
^Wl[j^[iWc[ijhkYjkhWbZ_iWZlWdjW][i\ehj^[Xed[
c[jWXeb_ic$
:oi\kdYj_ediWdZfW_djof_YWbboeYYkhWiWh[ikbj
e\\_[bZie\Z_ijkhXWdY[beYWj[Zm_j^_dj^[`WmXed[$
J^[^_]^_dY_Z[dY[e\\_[bZie\Z_ijkhXWdY[_dj^[`Wm
h[]_ed_ii_cfboj^[fh[i[dY[e\WdZbWj[hZWcW][je
j[[j^ÄZWcW][_dYbkZ_d]YWh_[i"heejYWdWbjh[Wjc[dji"
Y^hed_Y _d\bWccWj_ed" c_d_ckc feii_X_b_j_[i e\
È È -ICROSCOPICÈ!NATOMYÈANDÈ.UTRIENTÈ3UPPLYÈ
C 9h[ijWb_cfbWdji_dj^[i[Wh[WiWdZj^[feijef[hWj_l[
&IGÈAnC 8h_Z][WYheii*(Ä)(ikffehj[ZXoed[8E?_cfbWdj
WdZed[Yecfh[ii_ediYh[m$J^[Xed[beYWj[ZYh[ijWbbojej^[
Z_ia _i c[Y^Wd_YWbbo _dWYj_l[ WdZ j^ki kdZ[hc_d[hWb_p[Z$
9ehj_YWb Xed[ ^Wi \ehc[Z WhekdZ j^[ [deiiWb fehj_ed e\
j^[ iYh[m _cfbWdj$ J^[ Yh[ijWb h[]_ed _i c_d[hWb_p[Z ceh[
ijhed]bo
'*)
&IGÈ ?\ 8E? _cfbWdji Wh[ fbWY[Z X[jm[[d j[[j^" i_c_bWh
c_d[hWb_pWj_edfWjj[hdi[c[h][$J^[ceh[ijhed]boc_d[hWb_p[Z
Yehj_YWb Xed[ e\ j^[ Wbl[ebWh ieYa[j YWd X[ i[[d WhekdZ
j^[ j[[j^$ 9h[ijWbbo e\ j^[ Z_ia" j^[ Xed[ _i c[Y^Wd_YWbbo
_dWYj_l[WdZj^[h[\eh[hWj^[hb[iiijhed]boc_d[hWb_p[Z$Ceh[
fhedekdY[Z c_d[hWb_pWj_ed WhekdZ j^[ j^h[WZ[Z f_d _i edbo
i[[dm_j^[Whb_[hZ_ia_cfbWdjiWi_dj^_ihWZ_e]hWf^+o[Whi
feijef[hWj_l[boj^WjjhWdic_jcWij_YWjeho\ehY[iXej^Wjj^[
j^h[WZ[Z f_d WdZ Wj j^[ Z_ia$ J^_i jof[ e\ 8E? _cfbWdj" Zk[
je ^_]^[h cWj[h_Wb ijh[d]j^ WdZ ijhed][h Z[i_]d" Wbbemi b[ii
_dj[hXedoeiY_bbWj_edj^Wd_cfbWdjicWZ[\hecfkh[j_jWd_kc
_dYh[Wi_d] j^[ _djhWeii[eki XbeeZ ikffbo$ De ej^[h
Xed[ ^Wi ie cWdo [djho ]Wj[i \eh Z_ijkhXWdY[i$ 7i
i^emd WXel[" Wd WZl[hi[ ZhW_dW][ i_jkWj_ed \hec
j^[ Xed[ _i m^[h[ j^[ fheXb[c _i WYjkWbbo beYWj[Z"
dej ie ckY^ j^[ _djhWeii[eki XbeeZ ikffbo$Æ7Y_ZÇ
Z[YWbY_\_YWj_ed ped[i m_j^ b_jjb[ c[jWXeb_Y WYj_l_jo
Wh[ Yedi_Z[h[Z W fWhj_YkbWhbo i[h_eki XkhZ[d je
j^[ ^kcWd eh]Wd_ic Wi W m^eb[$ J^[i[ Wh[Wi Wh[
l[ho ijWXb[ WdZ e\j[d [n^_X_j \Wjjo Z[][d[hWj_ed$
Ybeikh[e\j^[Xedoikh]_YWbmekdZm_j^j^[_cfbWdj
_ji[b\ \khj^[h Yecfhec_i[ j^[ c[jWXeb_Y i_jkWj_ed"
fh[i[hl_d] eh [l[d fhecej_d] j^[ Y^WhWYj[h e\ j^_i
Wh[WWiW\_[bZe\Z_ijkhXWdY[$
H[bWj_d] iec[ f[h_f^[hWb ZWcW][ je W c[h_Z_Wd
WdZWiieY_Wj_d]_jm_j^W`Wmh[]_edm^[h[WYh[ijWb
'** 9^Wfj[h/È &OUR
$IMENSIONALÈ#ONSIDERATIONSÈOFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS
_cfbWdj_ibeYWj[Zc[WdiYed\ki_d]YWki[WdZ[\\[Yj$
E\j[dj^[cWj[h_Wbj_jWd_kc"j_jWd_kcen_Z[m_bbX[
^[bZ h[ifedi_Xb[ \eh Wdo ZWcW][$ ?d \WYj" ^em[l[h"
j^[ fheXb[c _i ^WhZbo m_j^ j^[ cWj[h_Wb1 hWj^[h" j^[
c[jWXeb_ice\j^[Yh[ijWb_cfbWdjh[]_edikhhekdZ_d]
j^[ Yh[ijWb _cfbWdj _i b[ii \WlekhWXb[ j^Wd X[\eh[
_cfbWdjWj_ed"ehWjb[Wij[gkWbboXWZ$J^[eij[ejeco
f[h\ehc[Z \eh j^[ fbWY[c[dj e\ Yh[ijWb _cfbWdji
kikWbboZ_[idejf[hc_jXed[h[][d[hWj_ed$Be]_YWbbo"
j^[d" [nj[di_l[ Xed[ jh[f^_dWj_ed WYYehZ_d] je
IY^hZ[h mekbZ WbmWoi ^Wl[ je X[ f[h\ehc[Z _d
Yedd[Yj_ed m_j^ Yh[ijWb _cfbWdji _d ehZ[h je Yh[Wj[
j^[d[Y[iiWhof[h_eij[WbZhW_dW][$
7\j[h fbWY[c[dj e\ 8E? _cfbWdji" Xo YedjhWij"
W Yecfb[j[bo Z_\\[h[dj WdZ ckY^ c_h[ \WlekhWXb[
i_jkWj_ed fh[lW_bi j^Wj fhecej[i Wd _cfhel[Z
c[jWXeb_ice\j^[Xed[$J^[eij[ejecoibejif[hc_j
kd_d^_X_j[Z[nY^Wd][WdZZhW_dW]["c[Wd_d]j^WjW
XWbWdY[Zc[jWXeb_icYWdgk_YaboX[Yec[[ijWXb_i^[Z
_dj^[f[h_#_cfbWdjXed[$J^[bWj[hWbcel[c[djie\
j^[ [bWij_Y jof[i e\ 8E? _cfbWdji YWki[ WZZ_j_edWb
c[Y^Wd_YWb ZhW_dW][$ J^[ eij[ejeco ibej Ze[i dej
Ybei[kdj_bj^[\bemi_jkWj_edf[hc_ji$L[hj_YWbfWhji
e\ j^[ _cfbWdji Ze dej ^Wl[ je X[ eii[e_dj[]hWj[Z"
XkjYWdl_XhWj[Wjl[hoicWbbWcfb_jkZ[ij^hek]^ekj
j^[_h b_\[j_c[$ J^[h[ _i W j^[eho j^Wj j^_i ][d[hWj[i
f_[pe[b[Yjh_Y Yedjheb _cfkbi[i j^Wj ij_ckbWj[ Xed[
]hemj^$ <hec W ^eb_ij_Y fe_dj e\ l_[m" h[][d[hWj_ed
e\ j^[ Xed[ \kdYj_ed m_bb h[ikbj" l_W j^[ c[h_Z_Wd
h[bWj_edi^_f" _d ^[Wb_d] _cfkbi[i j^hek]^ekj j^[
[dj_h[XeZo"WiZ[iYh_X[Z"[$]$Xo>kd[a['/./$
<eh iec[ o[Whi dem _j ^Wi X[[d feii_Xb[ je jWa[
Yecfkj[h#Wii_ij[Z c[Wikh[c[dji e\ j^[ c[h_Z_Wd
\kdYj_edil_Wj^[h[i_ijWdY[e\j^[ia_dWj(*[dZfe_dji
ed j^[ [njh[c_j_[i i[[ mmm$c[Zfh[l[dj$Yec \eh
Z[jW_bi$M[f[h\ehc[ZYecfWhWj_l[fh[ef[hWj_l[WdZ
feijef[hWj_l[ c[Wikh[c[dji _d ekh Yb_d_Y$M[ m[h[
WXb[jei^emj^Wj"Zkh_d]Yehh[Yjikh]_YWbjh[Wjc[dj
e\ \_[bZi e\ Z_ijkhXWdY[ WdZ YedYkhh[dj _di[hj_ed
e\8E?_cfbWdji_dj^ei[l[ho\_[bZie\Z_ijkhXWdY["
j^[ c[h_Z_Wd ioij[c _i _d\bk[dY[Z \WlekhWXbo$ J^[
\ebbem_d]]hWf^i[n[cfb_\oiec[e\j^ei[YWi[i$
M_j^ j^[ ^[bf e\ 8?E _cfbWdji _j _i feii_Xb[
je h[ijeh[ j^[ Z[dj_j_ed ed W \_n[Z XWi_i _d Wbb
Xed[ i_jkWj_edi$ J^_i [Wi[i j^[ Z[dj_iji Z[Y_i_ed je
[njhWYjj^ei[j[[j^m^_Y^Wh[ikif[Yj[Zje_cfW_hj^[
c[jWXeb_Y i_jkWj_ed WdZ ^Whc j^[ XeZo Wi W m^eb[$
JeZWofWj_[djim_j^j^_ia_dZe\fheXb[cWh[dejb[\j
WiehWbYh_ffb[i\ehj^[h[ije\j^[_hb_\[$
È
3IMULTANEOUSÈ-INERALIZATIONÈÈ
ANDÈ2EMODELLINGÈ4ENDENCIES
'
,SBTT
BOE
4
*IEF
?dZ[f[dZ[djbojh_]][h[ZXed[jhWdi\ehcWj_edij_ckb_
WdZj^[Z_ijh_Xkj_ede\jWiaim_j^_dj^[Yehj_YWbXed[
cWo WYj i_ckbjWd[ekibo WdZ ]W_d _cfehjWdY[ \eh
Xed[lebkc[WdZ\kdYj_edWbZ_ijh_Xkj_edÄ[if[Y_Wbbo
m_j^ijhWj[]_YWbbofbWY[Z8E?_cfbWdji%WXkjc[dji0
J^[Æ[nfWdi_edÇe\j^[cWn_bbWhoi_dkiYedj_dk[i
j^hek]^ekjWb_\[j_c[WdZZe[idej[dZW\j[hj^[j[[j^
^Wl[X[[d[njhWYj[Z$?\h[ijehWj_ediikffehj[ZXo8E?
_cfbWdjiWh[_di[hj[Zj^Wj^Wl[WZ_ijWbWXkjc[dj_d
j^[ceh[c[Z_Wbh[]_ede\j^[cWn_bbWhoi_dki"j^[o
m_bbX[beYWj[Z_dWh[]_edj^Wj[nfWdZiYWkZWbbo_d
j^[ Z_h[Yj_ed e\ j^[ h[ijehWj_ed" fej[dj_Wbbo jWa_d]
j^[Yh[ijWbYehj_YWbXed[m_j^_j_dWYWkZWbZ_h[Yj_ed$
Eded[^WdZ"j^_icWob[WZjej^[fedj_YiYedjWYj_d]
j^[ ckYeiW1 ed j^[ ej^[h ^WdZ" _j m_bb b[WZ je
fh[cWjkh[ YedjWYji _\ Z_ijWb _cfbWdji m[h[ fbWY[Z
_d j^_i h[]_ed$ Fh[cWjkh[ YedjWYji _d j^_i Wh[W cWo
Wbie X[ YWki[Z Xo j^[ WXi[dY[ e\ Z_ijWb ikffehj \eh
j^[cWdZ_Xb[$?\dWjkhWbcWn_bbWhoi[YedZcebWhiWh[
ij_bbfh[i[djZ_ijWbboe\j^[_cfbWdj#ikffehj[ZXh_Z]["
j^[i[j[[j^cWoX[Yec[cel[YhWd_Wbbo\ebbem_d]j^[
cehf^ebe]_YWb Y^Wd][i e\ j^[ Xed[" W]W_d h[ikbj_d]
_d fh[cWjkh[ YedjWYji ed j^[ Z_ijWb _cfbWdj Xehd[
Xh_Z][ikh\WY[$
H^oj^c_YWb \kdYj_edWb beWZi W\\[Yj_d] j^[
kdZ[hbo_d] Xed[ m_bb \khj^[h _dYh[Wi[ j^[
c_d[hWb_pWj_edj[dZ[dYo0m[Wh[Z[Wb_d]m_j^Wi[b\#
Wcfb_\o_d] Yedjheb beef$ M[ j^[h[\eh[ h[Yecc[dZ
\h[gk[dj [nWc_dWj_ed e\ j^[ [nj[dj e\ ckYeiWb
YedjWYj WdZ h[ZkYj_ed Wj h[]kbWh _dj[hlWbi$ ?\ j^_i
h[Yecc[dZWj_ed _i dej \ebbem[Z" j^[ Xed[ _d j^_i
h[]_ed m_bb X[Yec[ [l[h ceh[ ijhed]bo c_d[hWb_p[Z
WdZ]hemXolebkc[$
J^_icWoh[ikbj_dWdkcX[he\Z_\\[h[dj[\\[Yji$
v ?\ &#Wh[Wi _d j^[ Wbl[ebWh h[]_ed e\ j^[ cWn_bbW
jeej^ *Ä, c_d[hWb_p[" j^_i m_bb Y^Wd][ j^[
Z_ijh_Xkj_ed e\ &#Wh[Wi WdZ '#Wh[Wi el[h j^[ bed]
j[hcXomWoe\i[b\#jhWX[YkbWj_ed07h[WiX[d[Wj^
j^[ fedj_Y cWo Wiikc[ cWYhejhW`[Yjeh_Wb jWiai
cWjkh_d] _dje '#Wh[Wi" m_j^ ej^[h h[]_edi _d
jkhd bei_d] _d ijhkYjkhWb _cfehjWdY[ Z[]hWZ_d]
_dje &#Wh[Wi WdZ fej[dj_Wbbo X[_d] h[iehX[Z$ ?j
_i fWhj_YkbWhbo j^ei[ Wh[Wi _d j^[ Z_ijWb cWn_bbW
j^Wj Wh[ beYWj[Z Wj W Z_ijWdY[ \hec j^[ fedj_Yi
j^WjcWobei[j^[_hijWj_YWbboikffehj_l[\kdYj_ed
WdZ X[Yec[ Wjhef^_[Z <_]$/$)$ 8E? _cfbWdji
_dj[]hWj[Z _d ikY^ Wd Wh[W cWo X[ Z[ijWX_b_p[Z$
J^_icWoW\\[YjWh[Wieh_cfbWdjijej^[Z_ijWbeh
c[i_Wbe\j^[d[mbo\ehc[Z'#Wh[W$
È È 3IMULTANEOUSÈ-INERALIZATIONÈANDÈ2EMODELLINGÈ4ENDENCIESÈ '*+

&IGÈAnC <ebbem_d]Wijh_YjZ[djWb_dZ_YWj_ed"
[dZeZedj_YWbbojh[Wj[Zj[[j^m[h[h[cel[Z
\hecj^[cWn_bbWWdZcWdZ_Xb[e\W,,#o[Wh#ebZ
fWj_[dj"WdZWjejWbe\[_]^j8E?_cfbWdjim[h[
_di[hj[Z$J^[[d[h]oXWbWdY[i^em[ZWfei_j_l[
Z[l[befc[dj$ A Fh[ef[hWj_l[c[Wikh[c[dj$
B Feijef[hWj_l[c[Wikh[c[dj$ C 8WbWdY[Z
ijWjkib_d[h[ZW\j[hikh][ho

C
'*, 9^Wfj[h/È &OUR $IMENSIONALÈ#ONSIDERATIONSÈOFÈ"ONEÈ-ORPHOLOGYÈANDÈ-ECHANICS

v ?\" ed jef e\ j^Wj" Wd Wdj[h_eh Y^[m_d] fWjj[hd _i
fh[i[dj" Wd [njhkZ_d] [\\[Yj m_bb X[ [n[hj[Z ed
Z_ijWb_cfbWdjij^WjcWomehaiod[h]_ij_YWbbom_j^
j^[h[ceZ[bb_d]fheY[iiWdZm_j^j^[h[Wb_]dc[dj
e\ j^[ cWn_bbWho cWYhejhW`[Yjeh_[i" YkckbWj_l[bo
_dYh[Wi_d] j^[ h_ia e\ _cfbWdj beii$ 7Z`kijc[dji
ckijj^[h[\eh[X[f[h\ehc[Z_dWj_c[bocWdd[h$
v ?\j^[Xed[X[bemj^[fedj_Y[nfWdZijeeckY^"_ji
XbeeZikffboWdZÄ[l[dceh[Äj^[\beme\XbeeZ
\hecj^[Wh[WcWoX[_cfW_h[ZWim[bb$J^[\bem
e\ XbeeZ \hec j^[ Wh[W _i _cfW_h[Z \_hij" X[YWki[
j^[fh[iikh[_dj^[l[dekiWif[Yje\j^[YWf_bbWho
ioij[cm_j^_dj^[Xed[_ibem[hWdZWdoXbeeZ
ikffbo je j^_i h[]_ed mekbZ X[ Yedj_d][dj ed
&IGÈAB 7+*#o[Wh#ebZfWj_[djm_j^W
X_bWj[hWbYWdj_b[l[hi_jkWj_edi[[9^Wfj[h'(
mWi_di[hj[Zm_j^j^h[[8E?_cfbWdji"jmeed
j^[b[\jWdZed[edj^[h_]^j$J^[c[Wikh[c[dji
m[h[jWa[dm_j^j^[Fhe]deiC[h_Z_WdZ_W]deij_Y
ioij[c$mmm$c[Zfh[l[dj$Z[$ A Fh[ef[hWj_l[
h[bWj_edim_j^i_]d_\_YWdjZ_\\[h[dY[i_dia_d
h[i_ijWdY[Wj(*c[h_Z_Wd#h[bWj[Zc[Wikh_d]
fe_dji$ B H[bWj_ediW\j[hjh[Wjc[dje\j^h[[
\_[bZie\Z_ijkhXWdY[Xo_di[hj_d]8E?_cfbWdji
W h[l[hiWb _d \bem Z_h[Yj_ed$ H[l[hi_d] j^[ \bem
Z_h[Yj_ed_cfb_[iWd_dYh[Wi[_dXed[eno][dWj_ed
_dj^[Yehj_YWbh[]_ed"dWjkhWbboWiieY_Wj[Zm_j^W
h[ZkYj_ed_dXed[lebkc[=ebZ^WX[h'/+.$7do
c[Y^Wd_YWb_hh_jWj_edj^Wjh[ikbji_dj^[\ehcWj_ed
e\ ]hWdkbWj_ed j_iik[ m_bb ^Wl[ j^[ iWc[ [\\[Yj$
=hWdkbWj_ed j_iik[ m_bb h[fbWY[ f[h_eij[Wb j_iik[
m_j^ekj Wiikc_d] j^[ \kdYj_ed e\ j^[ bWjj[h$
?dYh[Wi[Z c_d[hWb_pWj_ed e\ j^[ Xed[ j_iik[ _i
fhecej[Z Xo bem eno][d j[di_ed 8h_]^jed [j Wb$
'/-'$ 7d _dYh[Wi[ _d j^[ XbeeZ ikffbo em_d] je
W h[l[hiWb _d \bem Z_h[Yj_ed _dYbkZ_d] j^[ Wh[W
e\]hWdkbWj_edj_iik[m_bbj^kij[dZjeh[ikbj_dW
Z[Yh[Wi[_dXed[lebkc[$
È È 3IMULTANEOUSÈ-INERALIZATIONÈANDÈ2EMODELLINGÈ4ENDENCIESÈ
&IGÈ ?\j^[ceijZ_ijWb8E?_cfbWdj_ifbWY[ZWdj[h_ehje
j^[cWn_bbWhoi_dki"j^[[nfWdi_ede\j^[i_dkiYWdX[[nf[Yj[Z
je Yedj_dk[$ J^_i m_bb b[WZ je Z[iY[dj e\ j^[ Xh_Z][meha
WdZ [Whbo YedjWYji _d j^[ Wh[W e\ j^[ bWij fedj_Yi$ J^_i
Z[l[befc[dj ^Wi je X[ ced_jeh[Z WdZ \h[gk[dj WZ`kijc[dji
cWoX[d[Y[iiWhoi[[L_Z[ei(+"(-
&IGÈ B[\jZ_ijWbcWn_bbW$J^[ZekXb[#Z_ia8E?_cfbWdj^Wi
cedefeb_p[Z j^[ jWia e\ beWZ jhWdic_ii_ed _d j^_i Wh[W WdZ
_ibeYWj[Z_dW\kdYj_edWb'#Wh[W$J^[Xed[WhekdZj^[Z_iae\
j^[i_d]b[#Z_ia8E?_cfbWdj_ikdZ[hc_d[hWb_p[Z$J^_i_cfbWdj
_idembeYWj[Z_dW&#Wh[W"[l[dj^ek]^j^[_cfbWdjfei_j_ed
mekbZ f[hc_j cWjkhWj_ed je W '#Wh[W$ J^[ h[c_d[hWb_pWj_ed
jh[dZ e\ j^[ Z_ijWb _cfbWdj _i l[ho bem" m^_Y^ _i m^o Wj
b[Wij j^[ j^h[WZ[Z f_d ek]^j je X[ h[cel[Z Wi ieed Wi Wdo
_d\bWccWjeho h[WYj_edi Wi h[ikbj e\ j^[ Z[c_d[hWb_pWj_ed e\
Xed[Wh[i[[d_dj^_iWh[W
v Ej^[h \WYjehi Wbie fbWo W heb[ _d Z[j[hc_d_d]
m^[j^[h Xed[ j_iik[ _i WYjkWbbo beij eh Yh[Wj[Z0
?d j^[ Yh[ijWb Wif[Yj e\ j^[ Z_ijWb cWdZ_Xb[" j^[
Xed[ \ehcWj_ed fheY[ii cWo X[ ie ijhed] j^Wj
l[hj_YWb Xed[ ]hemj^ m_bb fki^ Xh_Z][i e\\ j^[_h
_cfbWdj WXkjc[dji eh i_cfbo Xh[Wa j^[ 8E?
_cfbWdji$7i_c_bWhZ[l[befc[dj_ideji[[dl[ho
'*-
\h[gk[djbo _d j^[ Z_ijWb cWn_bbW$ >[h[" W jh[dZ
jemWhZl[hj_YWbXed[beiiZk[jecWYhejhW`[Yjeh_Wb
Xed[ h[ceZ[bb_d] WdZ ijWX_b_pWj_ed e\ j^[ XWiWb
Xed[fh[Zec_dWj[i_dj^[Wbl[ebWhh[]_ed$
v El[hWbb"j^[&Ä'ijhkYjkh[_iceh[lWh_WXb[_dj^[
cWn_bbWj^Wd_dj^[cWdZ_Xb[$
v ?d YWi[ j^Wj edbo ed[ i_Z[ e\ j^[ cWn_bbW _i
[gk_ff[Z m_j^ 8E? _cfbWdji" j^[ Y^Wd][i _d
Xed[cehf^ebe]om_bbZ_\\[hX[jm[[dXej^i_Z[i"
Yh[Wj_d]el[hbeWZkikWbboedj^[i_Z[m_j^dWjkhWb
j[[j^$
Fh[iikh[ ed j^[ Xed[ _d j^[ Wh[W e\ j^[ fedj_Y YWd
j^ki h[ikbj _d Wd _dYh[Wi[ _d Xed[ lebkc[" m^_b[
h^oj^c_YWb fh[iikh[ ed j^[ ckYeiW m_bb h[ikbj _d
Wd _dYh[Wi[ _d j^[ XbeeZ ikffbo WdZ j^[h[\eh[ _d
W beii e\ Xed[ lebkc[$ 8ej^ fheY[ii[i YWd eYYkh
YedYkhh[djbo$ J^_i _i ed[ e\ j^[ h[Wiedi m^o _j _i W
]eeZ _Z[W \eh 8E? _cfbWdjebe]_iji je fbWY[ \ehY[#
jhWdic_jj_d]Wh[Wi_dXWiWbXed[h[]_edi"WmWo\hec
j^[ h[ijehWj_ed$ J^[i[ XWiWb Xed[ h[]_edi Wh[ ceh[
h[i_ijWdjjeh[iehfj_edWdZfhej[Yj[Z\hecj^[Z_h[Yj
[\\[Yji e\ fh[iikh[ \hec j^[ fedj_Yi$ ?\ j^_i jof[
e\ fbWY[c[dj _i dej feii_Xb[" \h[gk[dj h[YWbbi WdZ
Yehh[Yj_edi Wh[ h[gk_h[Z kdj_b ijWXb[ YedZ_j_edi Wh[
h[WY^[Z$
Ed[efj_ed\ehjh[Wj_d]kdijWXb[_cfbWdj#fheij^[j_Y
ioij[ci _i je WZZ 8E? _cfbWdji WdZ je b[Wl[ j^[
kdijWXb[_cfbWdji_dfbWY[$J^[hWj_edWb[X[^_dZj^_i
fheY[Zkh[_ij^Wj'#Wh[WiYWdX[[nf[Yj[Zje\ehc_d
j^[ l_Y_d_jo e\ _dijWXb[ _cfbWdji j^[ Xed[ d[Wh j^[
XWiWbfbWj[ih[fh[i[dj_d]&#Wh[Wi"Wij^[i[Wh[Wia[[f
Z[l[bef_d]Zk[je\kdYj_edWbh[gk_h[c[dji$7\j[hj^[
_di[hj_ede\j^[WZZ_j_edWb8E?_cfbWdj"j^['#Wh[W_d
m^_Y^_jmWi_di[hj[Zm_bbbei[_jibeWZ#jhWdic_jj_d]
\kdYj_edi"m^_Y^j[dZije_cfhel[j^[Y^WdY[e\j^[
Xed[ Wh[W d[Wh j^[ XWiWb fbWj[ e\ j^[ kdijWXb[ 8E?
_cfbWdjcWjkh_d]WdZjkhd_d]_djeW'#Wh[WW]W_d$7i
Wbed]#j[hch[ikbj"Xej^_cfbWdjim_bbX[_dj[]hWj[Z
Wj W Yedi_Z[hWXb[ Z[]h[[ e\ c_d[hWb_pWj_ed WdZ m_bb
i^Wh[j^[jWiae\[dZeii[eki#beWZjhWdic_ii_ed$J^_i
jh[Wjc[dj efj_ed [n_iji Wi bed] Wi j^[ Xed[#cWjh_n
Wh[Wi_dgk[ij_edWh[dej[nf[Yj[Zjei^emWbj[hWj_edi
WiWh[ikbje\_d\[Yj_ed$'#Wh[WiWh[kikWbbo[nf[Yj[Z
eh i[[d ed j^[ fWdjece]hWf^ je h[i_Z[ ceh[
Z[[fbom_j^_dj^[XWiWbXed[Wh[Wi1j^[XWiWbfbWj[i
e\ j^[ ebZ _cfbWdj WdZ j^[ d[m _cfbWdj i^ekbZ X[
gk_j[Ybei[je[WY^ej^[h$?\j^[Z_ijWdY[X[jm[[dj^[
XWiWbfbWj[i_ijeebWh]["j^_ijh[Wjc[djWffheWY^cWo
dejX[ikYY[ii\kbX[YWki[de_dj[hWYj_edX[jm[[dj^[
Xed[Wh[WicWoeYYkh$
  ¬ 
#(!04%2È

&UNCTIONALÈ#ONSIDERATIONSÈÈ
ASÈTHEÈ'UIDINGÈ4REATMENTÈ0RINCIPLE

È
,ONG
4ERMÈ&UNCTIONÈ2EQUIRESÈÈ
0ERSISTENTÈ"ALANCE
M^_b[ _j _i [Wi_bo feii_Xb[ \eh jh[[i je WZWfj je
j^[ ^Whi^ h[Wb_j_[i e\ b_\[" \eh [nWcfb[ Xo ]hem_d]
Z_W]edWbbo" \ebbem_d] j^[ fh[lW_b_d] m_dZi" j^[
^kcWd XeZo _i WXb[ je WY^_[l[ i_c_bWh \[Wji edbo Wj
jh[c[dZekiYeij_dj[hcie\[d[h]o$8oYedjhWijm_j^
j^[Yedj_dkekiia[b[jede\jh[[i"j^[Xedoia[b[jede\
j^[ ^kcWd XeZo Yedi_iji e\ i[fWhWj[ i[]c[dji j^Wj
Wh[ ifh[WZ m_Z[ ef[d Xo WdZ X[jm[[d j^[ ckiYb[i$
7ibWdj[Zfeijkh[ehWiocc[jh_YWb\kdYj_edh[gk_h[i
Wd[njhWWcekdje\[d[h]o"i_dY[j^[Y[djh[e\]hWl_jo
e\j^[XeZo[Wi_boj^h[Wj[dijemWdZ[he\\j^[^kcWd
XeZoÉi h[bWj_l[bo icWbb XWi[ Wh[W$ Je Wle_Z j^_i WdZ
je XWbWdY[ j^[ XeZo" XeZo cWii ckij X[ h[beYWj[Z"
h[ikbj_d]_dbeYWbel[hbeWZ$
J^[h[]_ede\j^[iakbbWdZj^[d[YaYWdX[ki[Z
WiYekdj[hXWbWdY_d]cWiiWdZcel[ZWmWo\hecj^[
Y[djh[e\]hWl_jo$>em[l[h"j^[oYWdWbieX[j^[l[ho
YWki[ e\ feijkhWb _cXWbWdY[i WdZ e\ Yecf[diWjeho
[\\[Yjiedj^[[njh[c_j_[iehj^[jehie$
9ekdj[hWYj_d] feijkhWb _cXWbWdY[i eh Zoi\kdY#
j_edi _d ed[ h[]_ed eh ed[ ckiYb[ kikWbbo h[gk_h[i

A B

&IGÈÈ A <h[[bo Z[l[bef_d] W ]_l[d fej[dj_Wb" kd_cf[Z[Z WdZ kdeXijhkYj[Z Xo [nj[hdWb \ehY[i" m^_b[ h[Y[_l_d] ik\\_Y_[dj"
Yedj_dkekidkjh_j_ed_dm[bb#YWbYkbWj[ZZei[iÄj^_i_ij^[eX`[Yj_l[e\Wdob_\[\ehc$M^Wj_ijhk[e\bWh][fbWdji_i[gkWbbojhk[e\
j^[b_\[e\Wdoi_d]b[Y[bb"WdZe\WdoXed[WiWm^eb["WdZe\Wdo_dZ_l_ZkWbXed[Y[bb$7bWYae\dkjh_[djiWdZj^[Z_ifbWY[c[djXo
Yecf[j_j_l[]hemj^e\_dZ_][dekiWim[bbWi[ne][dekieh]Wd_iciYWdYWki[j^[Xed[ÉiY^WdY[e\ikhl_lWbjeZ[j[h_ehWj[$Jeekh
[o[i"j^_ijh[[Wff[WhijeX[l[hj_YWb"Wbj^ek]^j^[jh[[jhkda_iWYjkWbbodejeh_[dj[ZWjW/&–Wd]b[jej^[]hekdZ$ B J^[[\\[Yji
e\Wiocc[jh_YWbckiYb[fem[hWh[i_c_bWhÄjeijWom_j^_dj^[iWc[c[jWf^ehÄjej^ei[e\Wijhed][Whj^gkWa[j^WjY^Wd][i
j^[eh_[djWj_ede\eX`[Yjih[bWj_l[jej^[]hekdZ$;nj[hdWbf^oi_YWb\WYjehicWoYWki[\_hcboWdY^eh[Zjh[[ije]hem_dWibWdj[Z
Z_h[Yj_ed$J^[YWki[e\Wiocc[jh_[i_d^kcWdi_ikikWbbobeYWj[Z_di_Z[j^[W\\[Yj[Zeh]Wd_ic_ji[b\WdZ_jcWoX[Z[\_d_j_l[bo
\eh]ejj[d$E\j[dbed]\eh]ejj[dik\\[h_d]ih[cW_df[hi_ij[dj_di_d]b[ckiYb[iYedjhWYj_edij^hek]^ekjb_\[
'+& 9^Wfj[h'&È &UNCTIONALÈ#ONSIDERATIONSÈASÈTHEÈ'UIDINGÈ4REATMENTÈ0RINCIPLE
[nY[ii_l[WYj_l_joeh[n[hj_ededj^[fWhje\dkc[heki
ckiYb[i" WdZ j^_i _i j^[ h[Wied \eh j^[ Yedi_Z[hWXb[
[d[h]oZ[\_Y_j$
?dWYjkWbh[Wb_jo"j^[icWbbi^_\jX[jm[[d<_]$'&$'W
WdZ<_]$'&$'Xh[gk_h[i[njh[c[bohWf_ZWdZWZ[gkWj[
WZWfjWj_ed"j^[[nj[dje\m^_Y^_iWbmWoiZ_\\_Ykbjje
f[hY[_l[0 M_j^ jh[[i" j^[ XWbWdY_d] cWii _i ^_ZZ[d
kdZ[h]hekdZ$?dj^[^kcWdXeZo"WdoWiocc[jh_[i
j^Wj [n_ij cWo X[ YedY[Wb[Z \hec i_]^j Xo j^[ ie\j
j_iik[i$
È )NTRODUCTION
J^[ Y^[m_d] \kdYj_ed YWd edbo X[ \kbbo h[ijeh[Z
_\ WZ`kijc[dji Wh[ cWZ[ je eXjW_d W XWbWdY[Z
cWij_YWj_ed fWjj[hd$ JhWZ_j_edWbbo" _j ^Wi X[[d
Wjj[cfj[Z je WY^_[l[ j^_i ]eWb Xo ehj^eZedj_Y"
Yedi[hlWj_l[ WdZ fheij^[j_Y c[Wdi$ JeZWo j^[
if[Yjhkc Wbie _dYbkZ[i _cfbWdjebe]_YWb efj_edi$
M[ X[b_[l[ j^Wj gk[ij_edi h[bWj_d] je cWij_YWjeho
\kdYj_edm_bbZ[\_d[j^[\kjkh[e\Z[djWb_cfbWdjebe]o
WdZe\Z[dj_ijhoWjbWh][$9khh[djf[h_eZedjebe]_YWb"
ehj^eZedj_Y WdZ fheij^[j_Y YedY[fji d[[Z je X[
j^ehek]^bo h[l_[m[Z WdZ ceZ_\_[Z XWi[Z ed j^[
h[Wb_pWj_edj^WjWdoj[[j^Wim[bbWif[h_eZedjWbWdZ
Xed[ ijhkYjkh[i YWd edbo X[ fh[i[hl[Z _d W bWij_d]
cWdd[h _\ Wbb [ii[dj_Wb \kdYj_edWb h[gk_h[c[dji Wh[
iWj_i\_[Z$J^[i[h[gk_h[c[djim_bbX[Z_iYkii[Z_dj^[
fh[i[djY^Wfj[h$
;Whbo _dj[hl[dj_ed _i W fh_c[ fh[h[gk_i_j[ \eh
[\\[Yj_l[ \kdYj_edWb h[^WX_b_jWj_ed$ 7bb if[Y_Wb_iji
_dlebl[Z_dj^[jh[Wjc[djckijh[if[Yjj^[el[hh_Z_d]
_cfehjWdY[ e\ j^[ \kdYj_edWb jh[Wjc[dj eX`[Yj_l[$
J^[iY_[dj_\_Y\ekdZWj_edi\ehj^[jh[Wjc[djhWj_edWb[
Z[iYh_X[Z _d j^_i Y^Wfj[h Wh[ [Wio je kdZ[hijWdZ
FbWdWi '//($ ?d j^_i Y^Wfj[h" j^[ h[WZ[h m_bb b[Whd
m^o j^[ h[ijehWj_l[ Z[dj_ij ckij W_c je WY^_[l[ W
ijWXb[ cWij_YWjeho \kdYj_ed" m^Wj ^[ ckij Ze je
fh[i[hl[ _j" WdZ m^o ^[ i^ekbZ cWa[ j^[ d[Y[iiWho
WZ`kijc[dji[l[d_di_jkWj_edim^[h[j^[jh[Wjc[dj
h[gk_h[c[djijeWY^_[l[j^_i]eWbWh[[nj[di_l[$
FWj_[dji i[[a_d] Z[djWb jh[Wjc[dji Wh[ kikWbbo
X[jj[hWmWh[j^Wdj^[Z[dj_ijm^Wjjof[e\fheXb[c
j^[o WYjkWbbo ^Wl[$ >em[l[h" i_dY[ j^[o YWd d[_j^[h
Z[iYh_X[ deh Z[cedijhWj[ j^[ fheXb[c" j^[o j[dZ
je Z[\[h je j^[ Z[dj_ijÉi `kZ][c[dj$ J^[ \WYj j^Wj
j^[ j^ek]^ji e\ jeZWoÉi Z[dj_iji Wh[ _dehZ_dWj[bo
Y[djh[Z ed j[Y^d_YWb j[hci Ze[i dej ^[bf je Xh_Z][
j^_i Yecckd_YWj_ed ]Wf [_j^[h$ F[efb[ m^e mWba
m_j^ W b_cf YWd Yecckd_YWj[ j^[_h fheXb[c X[jj[h
Xej^ X[YWki[ j^[o YWd eXi[hl[ j^[ci[bl[i X[jj[h
WdZ X[YWki[ j^[ fheXb[c _i Wbie l_i_Xb[ je ej^[hi$
Kd_bWj[hWb Y^[m_d] fWjj[hdi Wh[ dej kikWbbo l_i_Xb[
jeekji_Z[hi"WdZj^[oYWddejX[Yehh[Yj[ZWibed]Wi
j^[fWj^mWoi\ehX_bWj[hWbboXWbWdY[Zcel[c[djiWh[
XbeYa[Z Xo ckiYb[i WdZ%eh ^WhZ#j_iik[ ijhkYjkh[i$
Iec[j_c[i ed[ YWddej ^[bf ][jj_d] j^[ _cfh[ii_ed
j^Wj Wbb XWi_Y ademb[Z][ j^Wj W ijkZ[dj dWjkhWbbo
feii[ii[i ed [dj[h_d] W Z[djWb iY^eeb _i [\\[Yj_l[bo
Xkh_[ZkdZ[hW\beeZe\ademb[Z][Xoj^[j_c[^[eh
i^[ [l[djkWbbo ]hWZkWj[i$ ?d W i[di[" del_Y[i ^Wl[ W
X[jj[h_djk_j_l[ademb[Z][e\^emÆY^[m_d]Çmehai$
?dj^[fh[i[djY^Wfj[h"m[YWdedbo[nfbW_dj^[a[o
\[Wjkh[i e\ j^[ j^[hWf[kj_Y ijhWj[]o WdZ Z_iYkii j^[
XWi_YYedi_Z[hWj_edi_dlebl[Z$FhWYj_Y[WdZ[nf[h_[dY[
Wi m[bb Wi Wd kdYecfhec_i_d] jh[Wjc[dj ijhWj[]o
Wh[ j^[ gk_dj[ii[dj_Wb h[gk_h[c[dji \eh ikYY[ii\kb
ekjYec[i$M[ki[ZjeWffboj^[c_d_cWbj^[hWf[kj_Y
iebkj_edijWk]^jWjj^[kd_l[hi_j_[iWdZ_cfei[ZXo
^[Wbj^_dikhWdY[fhel_Z[hiekhi[bl[i\ehcWdoo[Whi$
M[ j^[h[\eh[ ^WZ Wcfb[ effehjkd_jo je i[[ m^Wj
Z_iWZlWdjW][ij^[o_dlebl[_dj^[c[Z_kcWdZbed]
j[hc$ JeZWo m[ Z[Yb_d[ Wdo jh[Wjc[dj h[gk[iji j^Wj
Wh[dejW_c[ZWj[ijWXb_i^_d]WXWbWdY[ZcWij_YWjeho
\kdYj_ed$ Ikhfh_i_d]bo" j^[ Yedl[dj_edWb ijhWj[]o e\
e\\[h_d]h[ijehWj_l[jh[Wjc[dj_dWf_[Y[c[WbcWdd[h
m_j^ekj Wd el[hWbb YedY[fj \eh j^[ cWij_YWjeho
WffWhWjkiWjbWh][^WiX[[dki[Zj^hek]^ekj^_ijeho$
8Wi[Z ed j^_i ijhWj[]o" j^[ fWj_[dj _i b[\j m_j^ekj W
XWbWdY[Z cWij_YWjeho \kdYj_ed kdj_b ^[ eh i^[ ^Wi
\_dWbbo h[WY^[Z j^[ fe_dj m^[h[ W Yecfb[j[ Z[djkh[
_i _di[hj[Z$ J^_i _i j^[ \_hij j_c[ m^[d W XWbWdY[Z
cWij_YWjeho \kdYj_ed _i WYjkWbbo [ijWXb_i^[Z" _\ edbo
je [dikh[ j^Wj j^[ Z[djkh[ _i WYY[fjWXbo h[jW_d[Z$
M_j^j^[^[bfe\8E?_cfbWdji"m[Wh[jeZWoWXb[je
_cfb[c[dj\_n[Z[deiiWbikffehj_dWj_c[bo"h[b_WXb[
WdZ Yecfh[^[di_l[ cWdd[h$ J^[o [dWXb[ ki je
_dj[hl[d[_dWdof^Wi[e\j^[]hWZkWbbofhe]h[ii_d]
YebbWfi[ e\ cWij_YWjeho \kdYj_ed m_j^ekj h[]WhZ je
j^[Wcekdje\l[hj_YWbXed[WlW_bWXb[$
CWij_YWj_ed j^[hWfo _i j^[ edbo h[b_WXb[ mWo je
fh[i[hl[Xed[XoWZ[gkWj[\kdYj_ed$
8E? _cfbWdji e\\[h WXiebkj[ \h[[Zec _d j^[
ifWj_Wbfei_j_ed_d]e\ikf[hijhkYjkh[i"j^[h[Xo
]_l_d]kiWdeffehjkd_jojeZ[\_d[j^[fei_j_ed
WdZ eh_[djWj_ed e\ cWij_YWjeho ikh\WY[i ieb[bo
Xo \kdYj_edWb Yedi_Z[hWj_edi$ J^[ jh[Wjc[dj
eX`[Yj_l[ _i je Yh[Wj[ W bWj[hWbbo eh_[dj[Z
cWij_YWjeho\kdYj_edj^Wj_iXWbWdY[ZedXej^
i_Z[ie\j^[`Wm$
È
$ECOMPENSATIONÈÈ
OFÈTHEÈ-ASTICATORYÈ!PPARATUS
?j _i WbmWoi d[Y[iiWho je WdWboi[ j^[ W[j_ebe]o e\
Z_i[Wi[i eh Zoi\kdYj_edi X[\eh[ Wdo Yedi_Z[hWj_edi
h[bWj[Zjej^[jh[Wjc[djWiikY^YWdX[cWZ[$7m_Z[
È È $ECOMPENSATIONÈOFÈTHEÈ-ASTICATORYÈ!PPARATUSÈ '+'

lWh_[jo e\ fWhWc[j[hi Ä _dYbkZ_d] j^[ i_p[ e\ j[[j^" h[]kbWj[ZXoj^[\ebbem_d]\WYjehi0

j^[ i_p[ WdZ fei_j_ed Wi m[bb Wi j^[ \ekdZWj_edi '$ CkiYb[#h[bWj[Z\WYjehi
WdZ ikif[di_edi e\ j^[ XWiWb `Wm i[]c[dji" j^[ 7$CkiYb[if_dZb[c[Y^Wd_ici_dckiYb[iWjjWY^[Z
eYYbkiWbfbWd["j^[gkWb_joWdZb[d]j^e\j^[Y^[m_d] jej^[cWdZ_Xb[
ckiYb[i" XeZo feijkh[ WdZ c_c_Y ckiYb[i Ä Wh[ 8$ Ij_ckb_Yec_d]\hec=eb]_ÉiYehfkiYb[i_dj^[
_dj[hjm_d[Z_dWX_ef^oi_YWbYedj_dkkcj^Wjh[cW_di ckiYb[iWjjWY^[Zjej^[cWdZ_Xb[
je X[ _dl[ij_]Wj[Z _d Z[jW_b$ J^[i[ fWhWc[j[hi 9$ 7\\[h[dj ij_ckb_ Yec_d] \hec j^[ d[Ya
Yec[ _d Yekdjb[ii Yed\_]khWj_edi$ ?d j^_i mWo" j^[ ckiYb[i
\kdYj_edWb if[Yjhkc e\ ^kcWd Z[l[befc[dj ^Wi :$FW_d_dj^[ckiYb[iWjjWY^[Zjej^[cWdZ_Xb[
je X[ [njh[c[bo XheWZ je WbbemÆi[h_Wb fheZkYj_edÇ ($ JC@#h[bWj[Z\WYjehi
e\ \kdYj_edWb _dZ_l_ZkWbi [l[d kdZ[h j^[ ceij 7$Ij_ckb_Yec_d]\hecc[Y^Wdeh[Y[fjehi_dj^[
WZl[hi[e\YedZ_j_ediWdZj^[ceij_dWffhefh_Wj[e\ Whj_YkbWhYWfikb[
Yed\_]khWj_edi$?d[d]_d[[h_d]j[hci"ed[YekbZiWo 8$ 7\\[h[dj ij_ckb_ Yec_d] \hec WYY[iieho
j^Wjj^[fheZkYj_ed#h[bWj[ZWdZijhkYjkhWbjeb[hWdY[ b_]Wc[dji
b_c_ji Wh[ ki[Z je j^[ \kbb[ij [nj[dj feii_Xb[$ J^[i[ 9$ FW_deh_]_dWj_d]\hec`e_djijhkYjkh[i
fheY[ii[i Wh[ Zh_l[d Xo ]hemj^ WdZ \kdYj_ed$ EdY[ )$ EhWb" \WY_Wb WdZ f[h_ehWb ie\j#j_iik[ i[diWj_edi
j^[ [dZfe_dj e\ ]hemj^ ^Wi X[[d h[WY^[Z" j^[ edbo fW_d"ij_\\d[ii"c[Y^Wd_YWbi[diWj_ediWdZj^[hcWb
\ehY[ j^Wj Yedj_dk[i je _d\bk[dY[ cehf^ebe]o _d ij_ckb_
YedijhkYj_l[ cWdd[h _i j^[ \ehY[ e\ \kdYj_ed$ ?d *$ Jeej^#h[bWj[Z\WYjehi
WZZ_j_ed"Z[][d[hWj_l[WdZ^ehcedWb_d\bk[dY[iWh[ 7$Jeej^WY^[iWdZf[h_eZedjWbfW_d
]hWZkWbboYec_d]jej^[\eh[Wim[bb$ 8$ Ij_ckb_Yec_d]\hecj^[f[h_eZedjWbb_]Wc[dj
EdY[ j^[ [dZfe_dj e\ ]hemj^ ^Wi X[[d h[WY^[Z" +$ F^Whodn#h[bWj[Z \WYjehi0 FW_d" ^ofeceX_b_jo"
\kdYj_edWbbo l_WXb[ h[ikbji m_bb X[ fh[i[dj [l[d _d`kh_[i"j^[hcWbij_ckb_
j^ek]^ j^[ Z[fWhjkh[ fe_dji cWo ^Wl[ X[[d
[njh[c[bo Z_\\[h[dj eh kd\WlekhWXb[$ >em[l[h" dej Fh[cWjkh[ YedjWYji WiieY_Wj[Z m_j^ j_bj[Z WdZ%eh
Wbbe\j^[i[h[ikbjiWh[ijWXb[$Iec[e\j^[cWh[Æ`kij [bed]Wj[Zj[[j^cWo]hWZkWbbo]_l[h_i[jeZ[l_Wj_edi
WXekjÇ XWbWdY[Z hWj^[h j^Wd Æm[bbÇ XWbWdY[Z$ J^[ j^WjY^Wd][j^[fei_j_ede\j^[cWdZ_Xb[h[bWj_l[je
Y^WdY[i j^Wj j^[i[ h[ikbji YWd h[cW_d ijWXb[ \eh W j^[j[[j^_dj^[cWn_bbW"YWki_d]j^[Y^[m_d]WYj_l_jo
b_\[j_c[Wh[ib_c$J^[f^Wi[e\]hemj^_i\ebbem[ZXo Wi m[bb Wi j^[ WYj_l_jo e\ Y^[m_d] ckiYb[i je i^_\j
Wf^Wi[e\Z[Yecf[diWj_edj^Wjm_bbbWij\ehj^[h[ij jemWhZi ej^[h `Wm h[]_edi m_j^ekj YWki_d] WYkj[
e\j^[fWj_[djÉib_\[WdZ_ijh_]][h[ZXoWiocc[jh_YWb fW_d$
\kdYj_edÄj^Wj_ijeiWo"Xoj^[\WYjj^Wj[b[c[djie\ Ceij Z[djkh[#h[bWj[Z fh[iikh[ ieh[i" Xkj
j^[ ia[b[jWb ioij[c Wh[ kj_b_p[Z _d W ded#XWbWdY[Z Wbie f[h_eZedjWbbo _dZkY[Z jeej^ ceX_b_jo WdZ
cWdd[h$ Z[ijhkYj_ed" m_bb cWii_l[bo h[]kbWj[ j^[ cWij_YWjeho
J^[ cW_d \WYjehi h[ifedi_Xb[ \eh j^[ fhe]h[ii_l[ \ehY[ ZemdmWhZ" iec[j^_d] j^Wj _i kbj_cWj[bo Wbie
Z[Yecf[diWj_ed e\ j^[ cWij_YWjeho ioij[c jWdjWcekdjjefW_dWle_ZWdY[$
Wh[ _bbkijhWj[Z _d j^[ \ebbem_d] ikXi[Yj_edi$ J^[
_cfehjWdjfWhj\ehj^[ZW_boh[gk_h[c[djie\Z_W]dei_i
È
WdZ jh[Wjc[dj _d j^[ Z[djWb e\\_Y[ _i je _Z[dj_\o
5NILATERALÈ#HEWINGÈANDÈ3IDEÈ3WITCHING
j^[ j[cfehWb i[gk[dY[ WdZ h[bWj_l[ _cfehjWdY[
e\ j^[i[ lWh_eki \WYjehi _d [WY^ fWj_[djÉi ]hWZkWb 7do[Z[djkbekiifWY[i"j_bj[Zj[[j^WdZ%ehfh[cWjkh[
Z[Yecf[diWj_ed e\ j^[ cWij_YWjeho \kdYj_ed$ M[ YedjWYji m_bb h[ZkY[ j^[ [\\_Y_[dYo e\ Y^[m_d]"
Wh[ jWba_d] WXekj j^[ _cfWYj e\ `e_dji" ckiYb[i W ]h[Wj[h [\\ehj _i h[gk_h[Z je WY^_[l[ j^[ iWc[
WdZ cWij_YWjeho ikh\WY[i" Xkj m[ Wh[ Wbie jWba_d] Y^[m_d]h[ikbjiedj^[W\\[Yj[Zi_Z[Wiedj^[_djWYj
i_Z[$ J^[ XhW_d m_bb gk_Yabo h[]_ij[h j^_i _cXWbWdY[
WXekj j^[ Æibej^ \WYjehÇ Wi W XWi_Y fh_dY_fb[ e\ Wbb
^kcWd [n_ij[dY[$M_j^ h[]WhZ je ekh jef_Y Wj ^WdZ" WdZim_jY^j^[Y^[m_d]beWZjej^[_djWYji_Z[$J^[
j^_i c[Wdi j^Wj Wd _dZ_l_ZkWb m_bb WbmWoi fh[\[h j[[j^ e\ j^[ ikffehj ped[ ed j^[ meha_d] i_Z[ Wh[
j^[Æ[Wi_[hÇ Y^[m_d] i_Z[" [l[d j^ek]^ W lebkdjWho hWj^[hfhed[je_djhki_ed"m^[h[Wij^[YedjhWbWj[hWb
[\\ehjjeki[j^[i_Z[m^[h[Y^[m_d]_i^WhZ[hmekbZ j[[j^ Wh[ ceh[ b_a[bo je ^of[h[hkfj el[h j_c[
WYjkWbboX[j^[][djb[ijjh[Wjc[dj_cW]_dWXb[$ Zk[ je j^[ icWbb[h _djhki_l[ [\\[Yj e\ j^[ Y^[m_d]
ckiYb[i ed j^[ ded#meha_d] i_Z[$ 7j j^[ iWc[
j_c[" j^[ j[[j^ ed j^[ meha_d] i_Z[ e\ j^[ cWn_bbW
È
m_bb c_]hWj[ iec[m^Wj _d W Y[djh_\k]Wb Z_h[Yj_ed"
!VOIDANCEÈ0ATTERNS
m^_b[ j^[ YedjhWbWj[hWb j[[j^ Wh[ ceh[ b_a[bo je
H[\b[n_l[ Wle_ZWdY[ e\ fW_d ^Wi j^[ ]h[Wj[ij [\\[Yj kdZ[h]ec[Z_Wb_pWj_ed$J^_ifheY[ii_iYb_d_YWbboWdZ
ed\kdYj_edWdZ"Xo_cfb_YWj_ed"ed\ehc$7YYehZ_d] hWZ_e]hWf^_YWbbo [l_Z[dj Wi W c_Zb_d[ i^_\j jemWhZi
je AWmWckhW '/-*" cWij_YWjeho cel[c[dji Wh[ j^[meha_d]i_Z[$7ij^[\kdYj_edWbcWij_YWjehoWd]b[
'+( 9^Wfj[h'&È &UNCTIONALÈ#ONSIDERATIONSÈASÈTHEÈ'UIDINGÈ4REATMENTÈ0RINCIPLE

&IGÈÈA 8Wi[b_d[i_jkWj_edm_j^Wb_]d[Zc_Zb_d[iWdZiocc[jh_YWb7<CFWd]b[i$<ehcW_djW_d_d][gkWbcWij_YWj_ededXej^
i_Z[ie\j^[`Wm"_j_idejh[Wbbo_cfehjWdjje^Wl[icWbb[hehbWh][h7<CFWd]b[i$?j_iedbo_cfehjWdjj^Wjj^[Wd]b[i^emij^[
iWc[lWbk[edXej^i_Z[i$ B ?dj^[[l[djj^Wjed[i_Z[Z[l[befiekjjeX[Yec[j^[fh[\[hh[ZY^[m_d]i_Z[^[h[h_]^ji_Z[
e\f_Yjkh["j^[c_Zb_d[i^_\jijej^[meha_d]i_Z[$J[[j^edj^_ii_Z[Wh[_djhkZ[ZWdZ\bWh[ZbWj[hWb"m^_b[j^[Z[dj_j_ededj^[
ded#Y^[m_d]#i_Z[Wh[[bed]Wj_d]WdZcel[c[Z_Wbbo]h[[dWhhemi$J^[eYYbkiWbfbWd[Z[iY[dZi"WdZj^[7<CFWd]b[_dYh[Wi[i
edj^[ded#meha_d]i_Z[$ C ?dehZ[hjeYehh[Yjj^_i"cWj[h_WbckijX[WZZ[Zjej^[Yhemdiedj^[meha_d]i_Z[$7jj^[iWc[
j_c[]h_dZ_d]e\c[Z_Wb_p[ZYkifiedj^[ded#meha_d]i_Z[_if[h\ehc[Z$J^_imWoj^[X_j[_iX[_d]b_\j[ZÆkd_bWj[hWbboÇedj^[
meha_d]i_Z[$ D Jof_YWbYb_d_YWbi_jkWj_edW\j[hWkd_bWj[hWbY^[m_d]fWjj[hd^WiX[[dfh[i[dj\ehcWdoo[Whi$J[[j^('WdZ((
m[h[_djhkZ[ZXoj^[cWij_YWjeho\ehY[m^_b[j[[j^''WdZ'(X[YWc[[bed]Wj[Z$ E ?dj^[WXi[dY[e\]_d]_lWbh[Y[ii_ed"eh_\j^[
Z[djWbd[YaiWh[Yel[h[ZXoWd[f_j^[i_iWi_dj^_i\_]kh["j^[jhk[h[bWj_edi^_fiWh[WYjkWbbodejjeeeXl_eki$:[dj_ijiWh[ki[Z
jeWdel[hbodWhhem\_[bZe\l_i_ed$:[l_Wj_edie\j^[cWij_YWjehofbWd[Wh[ceh[eXl_ekim^[dl_[m[Z\hecWZ_ijWdY[

e\ FbWdWi 7<CF" Wd]b[i \edYj_edd[bi cWij_YWje_h[i \bWjbWj[hWbY^[m_d]cel[c[dji_dj^[\_hijfbWY[$

Z[ FbWdWi ed j^[ ded#meha_d] i_Z[ Y^Wd][i Wi W
h[ikbje\c[i_Wb_p[ZWdZ[bed]Wj[Zj[[j^"j^[Y^[m_d]
fWjj[hd X[Yec[i kd_bWj[hWb \eh ]eeZ$ J^[ ]h[Wj[h
j^[ X_bWj[hWb Z_iYh[fWdYo _d j[hci e\ 7<CF Wd]b[i"
j^[ ceh[ fhedekdY[Z j^[ kd_bWj[hWb fWjj[hd$ J^[
fWj_[dj m_bb _dYh[Wi_d]bo ^Wl[ jhekXb[ Y^[m_d] ed
j^[ded#meha_d]i_Z[Wij^[[nj[dje\cekj^ef[d_d]
h[gk_h[Zedj^Wji_Z[jeZeiem_bb_dYh[Wi[ij[WZ_bo$
?dj[h[ij_d]bo"j^[Y^[m_d]i_Z[_idejZ[\_d[ZXoj^[
WXiebkj[lWbk[e\j^[7<CFWd]b[XkjXoj^[h[bWj_l[
Z_\\[h[dY[X[jm[[dXej^Wd]b[i$FWj_[djim_j^Z[[f#
X_j[ h[bWj_edi cWo j^ki h[l[Wb W bWh][ 7<CF Wd]b[
X[YWki[ j^[_h eYYbkiWb h[bWj_edi Ze dej f[hc_j Wdo
:[l[befc[djiikY^Wij^[i[YWdX[h[WZ_bol[h_\_[Z
_dj^[EF=_\j^[oedboWh[fh[i[djbed][dek]^$Dej
edboZe[ij^[c_Zb_d[i^_\jX[Yec[[l_Z[dj"Xkjj^[
YedZob[ieXjW_dZ_\\[h[dji^Wf[iZk[jej^[beWZ_d]
_cXWbWdY[$J^[YedZob[iedj^[meha_d]i_Z[m_bbX[
bWh][WdZhekdZ[Z"m^_b[j^ei[edj^[ded#meha_d]
i_Z[ m_bb X[ \bWjj[d[Z jemWhZi j^[ Wdj[h_eh$ Ceh[
_cfehjWdjbo"j^[bed]Z_ijWdY[j^[o^Wl[jeYel[hWi
j^[oWZlWdY[\ehmWhZm_bbcWa[j^[cicWbb[hedj^[
m^eb[$ J^[ Whj_YkbWh [c_d[dY[ m_bb X[Yec[ \bWjj[h
Wim[bb$
?\j^[Wbj[hdWj_l[Y^[m_d]i_Z[_ic_ii_d]Wbh[WZo
WdZ j^[ Y^[m_d] WX_b_jo ed j^[ fh[\[hh[Z i_Z[ _i
È È $ECOMPENSATIONÈOFÈTHEÈ-ASTICATORYÈ!PPARATUSÈ '+)

beij _dje j^[ XWh]W_d" j^[ fWj_[dj m_bb gk_Yabo i[[a

bed][hf[h_eZio_[bZj^[iWc[[\\[YjWiZ_ii[Yj[Zeh
_cfbWdj jh[Wjc[dj$ ?d j^_i i_jkWj_ed" cWdo fWj_[dji
fWhWboi[Z ckiYb[i$ CWbfei_j_ed[Z j[[j^ m_bb XbeYa
h[fehjj^Wjj^[beiie\ed[if[Y_\_Yjeej^^Wib[\jj^[_h
h[]kbWh cel[c[dji WdZ ]_l[ h_i[ je YhWcfi eh
Y^[m_d]WX_b_joi[h_ekibo_cfW_h[Z$J^[_hZ[dj_iji"ed Wjhef^o e\ ckiYb[i$ >Wl_d] X[[d fh[i[dj \eh W bed]
j^[ej^[h^WdZ"m_bbe\j[d\_dZ_j^WhZjekdZ[hijWdZ j_c["j^[i[fheXb[cim_bbf[hi_ij[l[dW\j[hj^[YWki[
eh Zemdh_]^j _bbe]_YWb m^o ed[ if[Y_\_Y jeej^ ^Wi X[[d h[cel[Z [$]$ W\j[h jeej^ beii$ H[ijh_Yj[Z
i^ekbZ ^Wl[ ^WZ ikY^ \Wh#h[WY^_d] Yedi[gk[dY[i Y^[m_d]cel[c[djicWoeYYkhWjWdoj_c[WdZ^Wl[
m^[dckbj_fb[j[[j^Wh[c_ii_d]$J^[Z[dj_iji^ekbZ jeX[jh[Wj[Zm_j^ekjZ[bWo$
Yedi_Z[h ^_ci[b\ mWhd[Z Xo ikY^ ijWj[c[dji$ 7\j[h J^[Z_W]dei_i_ii_cfb[0
Wbb"Wdoa_dZe\Z[djWbjh[Wjc[dji^ekbZWbmWoiW_c v Ed X[_d] Wia[Z je f[h\ehc Y^[m_d] cel[c[dji
je [ijWXb_i^ W Yecfb[j[ i[j e\ cWij_YWjeho ikh\WY[i m_j^j^[ehWbYWl_jo[cfjo"j^[fWj_[djm_bbh[l[Wb
j^Wj _dj[hWYj [gkWbbo m[bb j^hek]^ekj$ J^[ fWj_[dj ed[e\j^[\ebbem_d]cel[c[djfWjj[hdi0
i^ekbZX[WZl_i[Zje^Wl[j^[h[ijehWj_l[jh[Wjc[dj Ä Fkh[Y^eff_d]cel[c[dji
f[h\ehc[ZYecfh[^[di_l[bohWj^[hj^Wdkd_bWj[hWbbo$ Ä 7ZlWdY_d] cel[c[dji Wdj[h_eh Y^[m_d]
J^_i _i j^[ edbo mWo je jh[Wj j^[ kd_bWj[hWb fWjj[hd fWjj[hd
m_j^ W h[bWj_l[bo ]eeZ Y^WdY[ e\ ikYY[ii" j^[h[Xo Ä Kd_bWj[hWbbWj[hWbcel[c[dji
]h[Wjbo[d^WdY_d]Xej^j^[bed][l_joe\j^[_cfbWdji Ä 8_bWj[hWbboXWbWdY[Z]h_dZ_d]cel[c[dji
WdZ j^[ ekjYec[ e\ j^[ h[ijehWj_l[ jh[Wjc[dj Wj Fkh[Y^eff_d]cel[c[djiWdZWZlWdY_d]cel[#
bWh][$?dYh[ijWb_cfbWdjebe]o"Wj[hc_dWb_cfbWdj_d c[dji Wh[ cW_dbo eXi[hl[Z _d i_jkWj_edi e\ Z[[f
j^[\_hijfh[cebWhfei_j_ed_iiec[j_c[iWZZ[ZZk[ X_j[%l[hj_YWb el[hX_j[ _$[$ _d YWi[i e\ fh_cWho
je j^[ ^[Wlo Z[f[dZ[dY[ e\ j^[i[ Z[i_]di ed j^[ JC@ Zoi\kdYj_ed$ Kd_bWj[hWb bWj[hWb cel[c[dji
l[hj_YWb j^_Yad[ii e\ j^[ WlW_bWXb[ Xed[ ijhkYjkh[$ Wh[eXi[hl[Z_dj^[fh[i[dY[e\Z_iYh[fWdj7<CF
Iec[ Wkj^ehi [l[d h[Yecc[dZ fbWY_d] Wdo Wd]b[i$ 8_bWj[hWbbo XWbWdY[Z ]h_dZ_d] cel[c[dji
_cfbWdj#ikffehj[Z Yhemdi ib_]^jbo X[bem j^[ b[l[b Wh[ edbo eXi[hl[Z m^[d j^[ 7<CF Wd]b[i Wh[
e\ eYYbki_ed$M^_b[ m[ i^Wbb _]deh[ \eh j^[ fkhfei[ WXekj[gkWb$
e\ j^_i Z_iYkii_ed m^[j^[h jh[Wjc[dji e\ j^_i jof[ Fh[YWkj_edi ckij X[ jWa[d je fh[l[dj h[ijh_Yj[Z
cWa[ Wdo i[di[ Wj Wbb" j^[o Wh[ Yb[Whbo kdd[Y[iiWhoY^[m_d]cel[c[dji_dj^[jh[Wjc[djf^Wi[$
WdZ _dZ[[Z Yekdj[hfheZkYj_l[ m_j^ 8E? _cfbWdji$ v M^[d j^[ Z[dj_ij _di[hji j^[ fheij^[j_Y ikf[h#
7\j[hWbb"_j_il_hjkWbboWbmWoifeii_Xb[jefbWY[j^[i[ ijhkYjkh[" ^[ eh i^[ ckij beea X[oedZ eYYbkiWb
Z[i_]di _d j^[ jkX[hei_jo Wh[W je eXjW_d j[Y^d_YWb fWhWc[j[hiXkj[dikh[j^WjWkd_\ehccWij_YWj_ed
WXkjc[dji _d j^[i[ fei_j_edi" ie j^Wj W \kdYj_edWb fWjj[hd _i m_j^_d h[WY^ \eh j^[ fWj_[dj$ :k[ je
eYYbkiWbjWXb[YWdX[[ijWXb_i^[Zj^Wj[nj[dZih_]^jje f[h_f^[hWbboehY[djhWbbo_dZkY[Zf[hi_ij[djckiYb[
j^[fei_j_ede\j^[\_hijcebWh$?dj^_imWo"_j_iWbmWoi Zoi\kdYj_edi"fWj_[djm_j^fh[#[n_ij_d]\kdYj_edWb
feii_Xb[ je [ijWXb_i^ W kd_\ehc cWij_YWj_ed fWjj[hd Z_iehZ[hi Wh[ hWh[bo WXb[ je f[h\ehc X_bWj[hWb
Y^WhWYj[h_p[ZXocWij_YWjehoikh\WY[ie\[gkWbb[d]j^ ]h_dZ_d]cel[c[djih_]^jWmWoW\j[h"[l[d_\ÆWbbÇ
WdZm_Zj^edXej^i_Z[ie\j^[`Wm$J^[Z[l[befc[dj _dj[h\[h[dY[i^Wl[X[[d[b_c_dWj[ZWdZj^[7<CF
e\Wfh[\[hh[ZY^[m_d]i_Z[YWddejX[Wle_Z[Z_\j^[ Wd]b[i efj_cWbbo WZ`kij[Z$ J^[i[ fWj_[dji d[[Z
7F<C_ijeeZ_\\[h[djel[hWf[h_eZe\j_c[$Edj^[ je kdZ[h]e f[h_eZ_Y jh[Wjc[dj i[ii_edi je h[bWn
ej^[h^WdZ"WXi[dY[e\Z_ijWbXWbWdY[eded[i_Z[m_bb j^[_h ckiYb[i WdZ fhWYj_i[ Wffhefh_Wj[ Y^[m_d]
Wbiejh_]][hj^[Z[l[befc[dje\Wfh[\[hh[ZY^[m_d] cel[c[dji kdZ[h f^oi_ej^[hWfo ]k_ZWdY[$
i_Z[ [l[d _d YWi[i m_j^ iocc[jh_YWb 7<CF Wd]b[i$ M[ \ekdZ j^Wj W f[h_eZ e\ )Ä*m[[ai X[jm[[d
M[b[Whd\hecj^_ij^Wj]Wfi_dj^[WhY^[iWh[e\j[d WZ`kijc[dj i[ii_edi _i X[jj[h j^Wd Wffbo_d]
b[iiZ[j[hc_d_d]\ehj^[Z[j[h_ehWj_ede\j^[Y^[m_d] Y^Wd][i Wj i^ehj[h _dj[hlWbi$ J^[ ckiYb[i d[[Z
fWjj[hd j^Wd Z_\\[h[dY[i _d 7<CF Wd]b[i m_j^ j^_i j_c[ je [ijWXb_i^ W d[m fh[#\_dWb XWbWdY["
ikXi[gk[dj l[hj_YWb Z_\\[h[dY[i X[jm[[d j^[ i_Z[i WhhWd][\ehik\\_Y_[djXbeeZikffboWdZZhW_dW][
WdZZ_\\[h[dY[i_dj^[i_jkWj_ede\Z_ijWbXWbWdY[$?d WdZXk_bZkf\ehY[i$
\WYjWfh[\[hh[ZY^[m_d]i_Z[m_bb_djhkZ[j^[j[[j^_d F^oi_ej^[hWf_ijib_a[jef[h\ehcj^[_hjh[Wjc[dji
Xej^WhY^[ie\j^_ii_Z[WdZb[WZje[bed]Wj_ededj^[ Wj i^ehj _dj[hlWbi [_j^[h ZW_bo eh [l[ho ej^[h
effei_j[i_j[$J^_iWbed[fh[l[djiXWbWdY[m^[dj^[ ZWo" fh[ikcWXbo je efj_c_p[ j^[_h iY^[Zkb[i$
_dZ_l_ZkWbjh_[ijeki[j^[ded#Y^[m_d]i_Z[Zkh_d] M[ Ze dej j^_da j^Wj j^[i[ i^ehj _dj[hlWbi Wh[
cWij_YWj_ed$ Wffhefh_Wj[ m^[d j^[ eX`[Yj_l[ _i je ijWX_b_p[
j^[ cWij_YWjeho fWjj[hd$ ?d ekh [nf[h_[dY[" _j
_i X[jj[h je f[h\ehc f^oi_ej^[hWf[kj_Y i[ii_edi
È
edY[ W m[[a" m_j^ Y^W_hi_Z[ ikXjhWYj_l[%WZZ_j_l[
2ESTRICTEDÈ-OVEMENT
WZ`kijc[djiW\j[h[l[hoj^h[[je\ekhi[ii_edi$J^[
FheXb[ci h[bWj[Z je cWij_YWj_ed cWo X[ YWki[Z Xo ckiYb[i WiieY_Wj[Z m_j^ i[h_ekibo Zoi\kdYj_edWb
h[ijh_Yj[Z cel[c[dji$ CkiYb[ fWhji kdki[Z el[h Z[dj_j_edi i_cfbo d[[Z ceh[ j_c[ je WZWfj WdZ
'+* 9^Wfj[h'&È &UNCTIONALÈ#ONSIDERATIONSÈASÈTHEÈ'UIDINGÈ4REATMENTÈ0RINCIPLE
jeh[Yel[hWZ[i_hWXb[b[l[be\cWij_YWjeho\ehY[i$
F^oi_ej^[hWf[kj_Y i[ii_edi f[h\ehc[Z Wj i^ehj[h
PHYSIOLOGICALÈ(YPOMOBILITYÈ$UEÈÈ
_dj[hlWbihW_i[j^[el[hWbbYeijim_j^ekjWY^_[l_d]
j^[_heX`[Yj_l[iceh[[\\[Yj_l[boeh[l[d\Wij[h$
v Ceh[ _d\ehcWj_ed ed fei_j_ed#h[bWj[Z fheXb[ci
YWd X[ eXjW_d[Z Xo eXi[hl_d] j^[ Ybei_d]
cel[c[dje\j^[`Wmi$?\j^_icel[c[djfheY[[Zi
iceej^bo m_j^ekj _dlebl_d] c_Zb_d[ Z[l_Wj_ed"
j^[d j^[ c_Zb_d[ _i fh[ikcWXbo Yehh[Yj$ 7
jm_jY^_d] cel[c[dj" Xo YedjhWij" _dZ_YWj[i j^Wj
j^[ ^WX_jkWb eYYbki_ed _i Wj lWh_WdY[ m_j^ j^[
h[jhWbWdZ^eh_pedjWbJC@fei_j_edi$J^[i[ckiYb[
jm_jY^[i _dZ_YWj[ j^[ fh[i[dY[ e\ Wd WXdehcWb
_dj[hYkif_ZWj_ed fWjj[hd$ M^_b[ WdWjec_YWb
bWdZcWhai Wh[ Wbie _d\ehcWj_l[" j^[o Wh[ dej
Wbje][j^[h h[b_WXb[" Yedi_Z[h_d] j^Wj Wbb YhWd_Wb
ijhkYjkh[iWh[ceX_b[h[bWj_l[jej^[Y[djh[e\j^[
iakbb$8ej^j^[bWX_Wb\h[dkbkcWdZj^[b_d[e\j^[
c[Z_WdhWf^W[cWoY^Wd][h[bWj_l[jej^[Y[djh_Y
fei_j_ede\j^[cWdZ_Xb[$
v ?\ j^[ Xed[ lebkc[ _d j^[ cWn_bbW _i icWbb WdZ
Wiocc[jh_YWb" eh _\ j^[ Yed\_]khWj_ed e\ 8E?
_cfbWdji _i Wiocc[jh_YWb" j^[d j^[ _cfbWdj#
h[ijehWj_ed m_bb dej X[ kd_\ehcbo ijWXb[ W]W_dij
j^[YhWd_Wbboeh_[dj[ZY^[m_d]fh[iikh[$J^[iWc[
_ijhk[_\j^[Y^[m_d]\ehY[iWh[dejXWbWdY[Zed
Xej^ i_Z[i e\ j^[ `Wm Wj j^[ ijWhj e\ jh[Wjc[dj$
<hec W Yb_d_YWb l_[mfe_dj" j^[ h[ikbjWdj _cfbWdj#
h[ijehWj_ed ioij[ci m_bb X[ Wiocc[jh_YWbbo
_djhkZ[Z edY[ j^[o Wh[ eii[e_dj[]hWj[Z$ J^_i
cWo gk_Yabo ]_l[ h_i[ je W ibWdj[Z cWij_YWjeho
fbWd[ WdZ Z_iYh[fWdj 7<CF Wd]b[i m_j^ Wbb j^[
\kdYj_edWb Yedi[gk[dY[i Z[iYh_X[Z \eh j^_i jof[
e\i_jkWj_ed$
v EdY[j^[j[[j^^Wl[[hkfj[Z"j^[_hWhhWd][c[djm_bb
X[Z[\_d[ZXoeYYbkiWbWdZcWij_YWjehofWhWc[j[hi
Zkh_d] dehcWb f^oi_ebe]_YWb Z[l[befc[dj$ ?d
j^_i fheY[ii" j^[ Xedo cWYhejhW`[Yjeh_[i Wh[
h[Yed\_]kh[Z _d ikY^ W mWo j^Wj jeej^ fei_j_ed
h[cW_di h[bWj_l[bo ijWXb[$ ?d j^[ fh[i[dY[ e\
[nY[ii_l[ ckiYb[ \ehY[i" j^[ j[[j^ fWhj_Y_fWj_d]
_d cWij_YWj_ed cWo Y^Wd][ j^[_h fei_j_ed ikY^
j^Wj j^[ Xedo cWYhejhW`[Yjeh_[i jWa[ el[h \hec
j^[eYYbkiWbijhkYjkh[Wij^[cW_dZ[j[hc_dWdj$?d
j^[i[i_jkWj_edi"_dZ_l_ZkWbj[[j^m_bbY^Wd][j^[_h
fei_j_ed WdZ WYgk_h[ ded#f^oi_ebe]_YWb YedjWYj
fei_j_edi eh bei[ YedjWYj m_j^ j^[_h WdjW]ed_iji$
J^_ifheY[iicWoeYYkhWjWdoW][$?dcWdoYWi[i"
j^[[d^WdY[ZckiYb[jed[_iZk[jefioY^ebe]_YWb
j[di_edi$ >of[hjed_W e\ j^[ _dj[hdWb Y^[m_d]
ckiYb[i YWddej X[ l_ikWbbo Z[j[Yj[Z$ J^[ h[WZ[h
_ih[\[hh[Zje9^Wfj[h'-\ehWZ[jW_b[ZZ_iYkii_ed
e\YhWd_ecWdZ_XkbWhiodZhec[i_dfWj_[djim_j^
fioY^ebe]_YWbZ_iehZ[hi9^Wfj[h'-$
È
.ON
TOÈ,ACKÈOFÈ!BRASION
7XhWi_ede\Z[Y_Zkekij[[j^_idejedboÆdehcWbÇXkj
_i W fh[h[gk_i_j[ \eh dehcWb Yehh[Yj Z[l[befc[dj$
Ed j^[ ed[ ^WdZ" j^[ \eeZi WlW_bWXb[ jeZWo cWo
dej X[ WXhWi_l[ [dek]^ eh cWo dej ij_ckbWj[ j^[
Y^[m_d] WYj_l_jo ik\\_Y_[djbo je Yh[Wj[ WXhWi_ed$ Ed
j^[ej^[h^WdZ"jeZWoiY^_bZh[dcWobWYaj^[f^oi_YWb
WYj_l_joWdZ][d[hWbjhW_d_d]h[gk_h[ZjeXk_bZkfj^[
d[Y[iiWhockiYb[ijh[d]j^_dj^[\_hijfbWY[$?dif_j[
e\ j^Wj" f[efb[ ]hem jWbb[h j^Wd _d \ehc[h j_c[i Wi
W h[ikbj e\ Yedj_dkeki \eeZ ikffbo WdZ \WlekhWXb[
^ehcedWbYedZ_j_edi"m^_Y^ckbj_fb_[ij^[fej[dj_Wb
ZWcW][ _d\b_Yj[Z Xo b[l[h \ehY[i _d j^[ [l[dj e\
cWb\kdYj_ed$
7iocc[jh_YWb WXhWi_ed e\ Z[Y_Zkeki j[[j^ _i
ik]][ij_l[e\kd_bWj[hWb\kdYj_ed$J^_ii_jkWj_edYWd
X[ [Wi_bo h[c[Z_[Z Xo eYYbkiWb WZ`kijc[dj j^[hWfo"
m^_Y^_idehcWbboijWhj[Zedj^[YWd_d[i$7ZZ_j_edWb
ij[fi m_bb X[ h[gk_h[Z _\ j^[ WZ`kijc[dj j^[hWfo
\W_bije[ijWXb_i^W^Whced_p[ZcWij_YWjeho\kdYj_ed
Y^WhWYj[h_p[Z Xo W ik\\_Y_[djbo bWj[hWb cel[c[dj
fWjj[hd$ ?d j^_i mWo" j^[ fkhfei[ e\ cWij_YWj_ed
j^[hWfo _i je b_X[hWj[ j^[ cel[c[dj fej[dj_Wb j^Wj
_iXWi_YWbbofh[i[djXkj_ieXijhkYj[ZXo^WhZ#j_iik[
ijhkYjkh[i$ FW_d\kb Y^Wd][i \hec Z[Y_Zkeki je
f[hcWd[djj[[j^Wh[WfWhj_YkbWhboYeccedYWki[e\
f[hi_ij[dj Zoi\kdYj_edi WdZ h[ijh_Yj[Z cel[c[dji$
J^[i[ fheXb[ci Z[l[bef \Wij[h j^Wd _d WZkbji Wi
j^[ fheY[ii[i e\ Xed[ h[ceZ[bb_d] Wh[ fWhj_YkbWhbo
[nj[di_l[ _d j^_i f^Wi[$ EYYbkiWb WZ`kijc[dji m_bb
^[bfje_d_j_Wj[ifedjWd[eki^[Wb_d]$
?\ cehf^ebe]_YWb Z_iYh[fWdY_[i Wh[ fh[i[dj Wi W
h[ikbje\Z[bWo[Zj^[hWfo"jh[Wjc[djm_j^ehj^eZedj_Y
Z[l_Y[i X[Yec[i d[Y[iiWho$ Jh[Wjc[dj ckij X[
[nfWdZ[Z _\ j^[ Xed[ m_Zj^ _i _dWZ[gkWj[ m^[d
j^[ \_hij cebWhi [hkfj$ Kd_bWj[hWb Y^[m_d] fWjj[hdi
_d j^[ [Whbo jhWdi_j_edWb f^Wi[ \hec Z[Y_Zkeki je
f[hcWd[dj j[[j^ m_bb gk_Yabo ]_l[ h_i[ je _dYehh[Yj
jeej^fei_j_edij^Wjm_bbdebed][hh[iebl[ifedjWd[#
ekibo$ <eh _dijWdY[" W kd_bWj[hWb Y^[m_d] fWjj[hd
WiieY_Wj[Zm_j^c_deh[bed]Wj_ede\j^[\_hijcebWh
WdZ ib_]^j Wdj[h_eh c_]hWj_ed m_bb gk_Yabo Yh[Wj[
kd_bWj[hWb 9bWii ?? h[bWj_edi j^Wj m_bb f[hi_ij \eh[l[h
_\b[\jkdjh[Wj[Z$
?dekh[nf[h_[dY["j^[Z[Y_ZkekiYWd_d[ifei[j^[
]h[Wj[ij eXijWYb[ je bWj[hejhki_ed _d j^[ Z[Y_Zkeki
Z[dj_j_ed$ 9^_bZh[d e\ Wbb W][i m_bb _dijWdjbo im_jY^
\hec Y^eff_d] cel[c[dji je W bWj[hWbbo eh_[dj[Z
Y^[m_d]fWjj[hdedY[j^[Ykifie\j^[i[YWd_d[iWh[
h[ZkY[Z$J^[Z[dj_ijcWomWdjjejhoj^_iWffheWY^
WdZ" edY[ Yedl_dY[Z e\ _ji ki[\kbd[ii" _dYbkZ[ _j
Wi W hekj_d[ fhef^obWYj_Y c[Wikh[ _dje ^_i eh ^[h
j^[hWf[kj_Yif[Yjhkc$9^_bZh[dj[dZjem[bYec[j^[
ekjYec[e\j^_ic[Wikh[ckY^ceh[ifedjWd[ekibo
È È #LINICALÈ$IAGNOSTICSÈ '++

4ABLEÈÈ Jof_YWb W][#if[Y_\_Y Z_ijh_Xkj_edi e\ WXhWi_ed" bWj[hWb Yecfed[dji" m^_Y^ Wh[ _dj[hc[Z_Wj[ _d
7<CF Wd]b[i WdZ jeej^ YedjWYji$ ?\ ded#WXhWZ[Z Ykifi Wh[ i[l[h_jo X[jm[[d f^oi_ebe]_Y ]h_dZ_d] cel[c[dj
fh[i[dj \eh jee bed]" j^[ 7<CF Wd]b[ m_bb h[cW_d jee ]h[Wj$
WdZWdj[h_ehY^[m_d]fWjj[hdi$
JeZWoÉi \eeZi Wh[ jee ie\j je _dZkY[ WZ[gkWj[ WXhWi_ed$
8hkn_ic Ze[i dej dehcWbbo WXhWZ[ j^[ j[[j^ _d W X_bWj[hWbbo FWj^ebe]_YWb fheY[ii[i Wh[ Wbie _dZ_YWj[Z Xo
XWbWdY[ZcWdd[hFbWdWi'//( Z_ijWbbo [bed]Wj[Z j[[j^ _d j^[ feij[h_eh i[]c[dj
e\ j^[ cWdZ_Xb[ WdZ ibWdj[Z cWij_YWjeho fbWd[i
"HF
ZFBST

"CSBTJPO
"'.1
%JBTUFNB _dlebl_d] kd_bWj[hWb [b[lWj_ed e\ ed[ cWdZ_XkbWh
YWd_d[$

m

m
?d j^[ lWij cW`eh_jo e\ YWi[i" fW_d\kb iocfjeci



EFHSFFT
 Wh[_d_j_Wbboedbofh[i[djedj^[meha_d]i_Z[$J^[o
Wh[ kikWbbo YWki[Z Xo ifWiceZ_Y YedjhWYj_ed WdZ

m

m ^ofen_W e\ j^[ bWj[hWb fj[ho]e_Z ckiYb[" m^_Y^ _i
kdZ[hf[h\ki[ZX[YWki[_jYWddebed][hX[[nj[dZ[Z$



m ?dWZlWdY[ZYWi[i"j^[iocfjecicWoifh[WZjej^[
d[YackiYb[i"cW_dboW\\[Yj_d]j^[meha_d]i_Z[edY[



m
W]W_d$



 J^[h[ _i W Z_h[Yj h[bWj_edi^_f X[jm[[d Ykif
_dYb_dWj_ediWdZY^[m_d]WX_b_jo$Kd_bWj[hWbY^[m_d]



EFHSFFT

j^WdWZkbji"Wbj^ek]^j^[[\\[Yj_iXWi_YWbboj^[iWc[
_d Xej^ W][ ]hekfi$7ffWh[djbo" iec[ WZkbji ^Wl[ W
^WhZj_c[WYY[fj_d]kd_cfW_h[Zcel[c[djiX[YWki[
j^[ h[ijh_Yj[Z ckiYb[ \kdYj_ed _i _d]hW_d[Z ckY^
ceh[Z[[fboj^Wd_dY^_bZh[dic_dZi$
È
#LINICALÈ$IAGNOSTICS
L_ikWb WdWboi_i e\ j^[ ]h_dZ_d] cel[c[dj m_bb
fhel_Z[ W gk_Ya el[hl_[m e\ j^[ h[gk_h[Z iYef[ e\
Z_W]dei_i$ 9ecfb[n [b[Yjhed_Y c[Wikh[c[dji m_bb
edbo YWfjkh[ j^[ Ykhh[dj ijWjki e\ ckiYb[#_dZkY[Z
fheXb[ci" j^[h[Xo e\\[h_d] de h[b[lWdj _d\ehcWj_ed
\ehj^[jof[e\j^[hWfoj^Wjm_bbX[Z_iYkii[ZX[bem$
HWj^[h" j^[ cekj^ i^ekbZ X[ ibembo ef[d[Z WdZ
Ybei[Z Xo j^[ fWj_[dj$ ?\ j^[i[ cel[c[dji Ze dej
_dlebl[ Wdo Z[l_Wj_edi" j^[ cWij_YWjeho \kdYj_ed _i
fh[ikcWXbodehcWb$
7i m[ ^Wl[ c[dj_ed[Z X[\eh[" WdWjec_YWb bWdZ#
cWhai ikY^ Wi j^[ c[Z_Wd hWf^W[ b_d[ eh j^[ bWX_Wb
\hW[dkc cWo X[ _d\ehcWj_l[" Xkj j^[o cWo Wbie X[
Z[Y[fj_l[$ Ehj^eZedj_Y fh[#jh[Wjc[dj eh kd_bWj[hWb
[njhWYj_edim_bbb[Wl[j^[`Wmf[hcWd[djboZ[\ehc[Z"
m^_Y^_iWbiejhk[_di_jkWj_edie\fhebed][Zkd_bWj[hWb
[Z[djkb_icWbiei[[9^Wfj[h(("9Wi[IjkZo'$
J^[ fh[i[dY[ e\ Wdo Zoi\kdYj_edi YWd X[ hkb[Z
ekjm_j^]h[WjY[hjW_djo_\j^[[nYkhi_l[cel[c[dji
e\ j^[ cWdZ_Xb[ Wh[ bWh][bo _Z[dj_YWb jemWhZi Xej^
i_Z[i"Wbie_dlebl_d][gkWb7<CFWd]b[i$7bbWdj[h_eh
Y^[m_d] fWjj[hdi Wh[ fWj^ebe]_YWb _d dWjkh[$ J^[
iWc[ _i jhk[ e\ Wdo Y^eff_d] fWjj[hdi m_j^ \[m
fWjj[hdi Wh[ WiieY_Wj[Z m_j^ kd_bWj[hWb WXhWi_ed"
_djhki_ede\j^[feij[h_ehj[[j^edj^[meha_d]i_Z["
WdZ [bed]Wj_ed e\ j^[ feij[h_eh j[[j^ ed j^[ ded#
meha_d] i_Z[$ ?d j^[ fh[i[dY[ e\ Wdj[h_eh Y^[m_d]
fWjj[hdi" j^[ Wdj[h_eh j[[j^ X[Yec[ [bed]Wj[Z _d
j^[ cWn_bbW WdZ _d j^[ cWdZ_Xb[$ 8ej^ `Wmi Ze dej
i^em j^[ iWc[ fWjj[hd e\ [njhki_ed WdZ _djhki_ed$
J^[cWdZ_Xb[_icWZ[kfe\jmeZ_ij_dYj\kdYj_edWb
XbeYaie\[gkWbi_p[j^WjWh[i[fWhWj[ZXoj^[c[Z_Wd
fbWd[$ J^[ cWn_bbW" Xo YedjhWij" _i ikXZ_l_Z[Z _dje
j^h[[\kdYj_edWbXbeYaiÄ_$[$ed[Wdj[h_ehXbeYaWdZ
jmefeij[h_ehXbeYai$?dej^[hmehZi"WdocWij_YWjeho
WYj_l_jo m_bb WbmWoi _dlebl[ ed[ e\ j^[i[ XbeYai _d
_ji [dj_h[jo$ J^[h[\eh[" i_jkWj_edi cWo Wh_i[ _d j^[
cWn_bbWm^[h[j^[Wdj[h_ehj[[j^edj^[meha_d]i_Z[
Wh[ _djhkZ[Z m^_b[ j^ei[ ed j^[ ded#meha_d] i_Z[
X[Yec[[bed]Wj[Z$I_dY[j^[Wdj[h_ehY^[m_d]fWjj[hd
m_bbij_ckbWj[cel[c[djie\Wbbj[[j^Wbed]j^[iWc[
\kdYj_edWb XbeYa" Wbb j[[j^ Wbed] j^[ XbeYa mekbZ
dehcWbbo X[Yec[ [bed]Wj[Z" m^_Y^ _i fh[l[dj[Z _d
W kd_bWj[hWb cWdd[h Xo j^[ beYWb _djhki_l[ \ehY[i
fh[i[djedj^[Y^[m_d]i_Z[$
?\ j^[ [\\[Yji e\ [bed]Wj_ed WdZ _djhki_ed \W_b
je YWdY[b [WY^ ej^[h el[h Wd [nj[dZ[Z f[h_eZ e\
j_c[" j^[ cWij_YWjeho fbWd[ X[Yec[i ibWdj[Z$ J^[
cWn_bbWho fh[cebWhi ed j^[ meha_d] i_Z[ Wh[ j^[
\_hij j[[j^ je X[ _djhkZ[Z$ 7j j^[ iWc[ j_c[" j^[
WdjW]ed_ij_Y fh[cebWhi WdZ j^[ WZ`e_d_d] YWd_d[i
_d j^[ cWdZ_Xb[ X[Yec[ [bed]Wj[Z$ EdY[ j^[ fe_dj
e\ de h[jkhd _i h[WY^[Z" j^[ cWij_YWjeho fbWd[ m_bb
h[cW_d f[hcWd[djbo ibWdj[Z" WdZ j^[ _dZ_l_ZkWb _i
kdWXb[ je h[]W_d [gk_b_Xh_kc m_j^ekj fhe\[ii_edWb
^[bf$ J^[ cWij_YWjeho \kdYj_ed X[Yec[i kd_bWj[hWb
hWj^[hgk_Yabo$7iWh[ikbj"j^[j[[j^edj^[meha_d]
i_Z[ Wh[ bWj[hWb_p[Z WdZ j^[ Z[djWb WhY^ _i [dbWh][Z$
J^[ cWn_bbWho j[[j^ ed j^[ ded#meha_d] i_Z[" Xo
YedjhWij" Wh[ c[Z_Wb_p[Z WdZ X[Yec[ [bed]Wj[Z$
;WhbocWd_\[ijWj_edijof_YWbbo_dYbkZ[YhemZ_d]WdZ
hejWj_ed WhekdZ j^[ bWj[hWb _dY_iehi$L[ho e\j[d" j^[
'+, 9^Wfj[h'&È &UNCTIONALÈ#ONSIDERATIONSÈASÈTHEÈ'UIDINGÈ4REATMENTÈ0RINCIPLE

cehf^ebe]_YWbWZWfjWX_b_joe\j^[JC@_i[njh[c[bo
]eeZ$ J^[ Whj_YkbWh [c_d[dY[ e\j[d _dj[h\[h[i m_j^
j^[[nj[di_ede\j^[bWj[hWbfj[ho]e_ZckiYb[$

È
2ELAXINGÈ*OINTSÈANDÈ-USCLES

7dj[h_eh `_]i Wh[ W l[ho iW\[ WdZ ki[\kb jeeb \eh

Z_W]deij_YWdZj^[hWf[kj_Yfkhfei[i$J^[oWbbemj^[
JC@i je h[bWn je iec[ [nj[dj$ >Wl_d] iW_Z j^Wj" j^[
Y^[m_d]ckiYb[iWh[\h[gk[djbokdWXb[jeh[bWn_dW
cWjj[he\^ekhiW\j[h^Wl_d]X[[d]h[Wjbo^of[hjed_Y
A
\eh cWdo o[Whi" Xkj j^_i fheY[ii cWo jWa[ i[l[hWb
m[[aieh_dZ[[Zcedj^i$J^[_djhWehWbjh[Wjc[dj_i
gk_Yabo Yecfb[j[Z$ J^[ Wdj[h_eh `_] m_bb [\\[Yj_l[bo
h[ijeh[ W ceh[ Y[djhWb fei_j_ed$ IkXi[gk[djbo" W
Z_ijWb Xk_bZ#kf m_j^ i_b_Yed[ eh WYhob_Y h[i_d YWd X[
f[h\ehc[Z je WZ`kij j^[ X_ec[Y^Wd_YWb Y[djh[ WdZ
Xh_d] j^[ ckiYb[i _dje \eYki$ J^_i WffheWY^ m_bb
dehcWbbo h[ijeh[ W ijhW_]^j fWj^ e\ cekj^ ef[d_d]$
Ed j^[ Zemdi_Z[" j^_iÆgk_Ya \_nÇ m_bb ^WhZbo Wbbem
j^[ cWij_YWjeho fbWd[ je X[ Yehh[Yj[Z Wj j^[ iWc[
j_c[$
CWn_bbWho fh[cebWhi WdZ cebWhi j^Wj Wh[ hejWj[Z
WdZ%eh [bed]Wj[Z cWo Wbie Yedij_jkj[ kd_bWj[hWb
eXijWYb[i je \kdYj_ed WdZ ^Wl[ je X[ eYYbkiWbbo
ikffehj[Zeh[njhWYj[Zm^[d_dZekXj<_]$'&$-$
B

&IGÈAB 8ej^ feij[h_eh i[]c[dji e\ W Yecfb[j[ Z[djkh[$

7 Ykhl[ e\ If[[ _i l_i_Xb[ ed ed[ i_Z[ WdZ h[l[hi[Z ed j^[ È
ej^[hi_Z[ 0ERIODONTALÈ#ONSEQUENCESÈOFÈ&UNCTION

9khh[dj h[i[WhY^ _d f[h_eZedjebe]o j[dZi je \eYki

Ykhl[ e\ If[[ X[Yec[i h[l[hi[Z ed ed[ i_Z[ WdZ edjmeWh[Wi0
[d^WdY[Zedj^[ej^[hi_Z[e\j^[`Wm$ v <ehcWj_ed e\ d[m Xed[ Wj i_j[i m^[h[ j^[ dWj_l[
Xed[ijhkYjkh[iYekbZdejX[cW_djW_d[Z$
v ;b_c_dWj_d]XWYj[h_W"m^_Y^Wh[^[bZjeX[j^[ieb[
È YWki[e\f[h_eZedjWbZ_i[Wi[WdZXed[beii$
8
2AYÈ$IAGNOSTICS
B[ii Wjj[dj_ed _i Z[lej[Z je `Wm \kdYj_ed Wj bWh][
J^[ fWdehWc_Y hWZ_e]hWf^ e\\[hi _cfehjWdj WdZjej^[f[h_eZedjWbYedi[gk[dY[ie\\kdYj_ed$?d
_d\ehcWj_ed Xej^ ed j^[ Ykhh[dj _djhWehWb i_jkWj_ed ekhl_[m"j^[YWkiWbh[bWj_edi^_fi_dj^_iYedd[Yj_ed
WdZ ed Wdo fWij [l[dji _d j[hci e\ i_Z[ im_jY^_d]" Wh[ hekj_d[bo Yed\ki[Z$ J^[ Zoi\kdYj_edi i^ekbZ
c_]hWj_ede\j^[cWdZ_Xb[WdZc_Zb_d[fheXb[ci$ X[ h[]WhZ[Z Wi j^[ fh_cWho YWkiWb \WYjeh WdZ Wdo
I_Z[ im_jY^_d] cWo ^Wff[d edY[ W]W_d W\j[h Wdo XWYj[h_Wb fheXb[ci Wi W \ebbem#kf [\\[Yj$ M^_b[
j[[j^ ed j^[ meha_d] i_Z[ ^Wl[ X[[d beij eh j^[ Z_W]deij_Y WdZ j^[hWf[kj_Y WffheWY^[i j^Wj Wh[
ded#meha_d] i_Z[ ^Wi X[[d h[ijeh[Z" m^_Y^ m_bb ieb[bo \eYki[Z ed j^[ XWYj[h_Wb beWZ cWo ikYY[[Z
ieed[h eh bWj[h X[ h[\b[Yj[Z _d j^[ i^Wf[ e\ j^[ _d Yedjhebb_d] WYkj[ f[h_eZedjWb fheXb[ci" j^[o Wh[
YedZob[i$7dj[h_ehbo\bWjj[d[ZYedZob[iedXej^i_Z[i kdWXb[ je ijef Z_i[Wi[ fhe]h[ii_ed eh h[ijeh[ Wdo
e\j^[`Wm_dZ_YWj[j^Wjj^[Y^[m_d]i_Z[^WiY^Wd][Z c_ii_d]Xed[ijhkYjkh[i_dWbWij_d]cWdd[h$7jhkbo
i[l[hWbj_c[i_dj^[fWj_[dji^_ijeho$ ikijW_dWXb[ ekjYec[ YWd edbo X[ WY^_[l[Z edY[ j^[
J^[j[hcÆ^_d][Wn_iÇWiki[ZWjZ[djWbiY^eebi_iW \kdYj_edWbh[gk_h[c[djiWh[c[j$
c_idec[hj^Wjc_ii[ij^[fe_djYecfb[j[bo$J^[JC@ ?d ekh [nf[h_[dY[" _j _i eYYWi_edWbbo ik\\_Y_[dj je
_i ]k_Z[Z WdZ a[fj _d fbWY[ Xo ckiYb[i [nYbki_l[bo$ h[^WX_b_jWj[ j^[ `Wm j^Wj _i ceh[ i[l[h[bo W\\[Yj[Z
Eii[eki XehZ[h ijhkYjkh[i iYWhY[bo fWhj_Y_fWj[ Xo jeej^ beii WdZ f[h_eZedjWb Z_i[Wi[ X[YWki[ j^[
_d ÆYedZobWh ]k_ZWdY[Ç Wj Wbb$ ?d WZZ_j_ed" j^[ effei_d] `Wm m_bb j^[d jWa[ YWh[ e\ _ji[b\$ J^_i
È È 0ERIODONTALÈ#ONSEQUENCESÈOFÈ&UNCTIONÈ
fh[ikffei[ij^Wjj^[eYYbkiWbi_jkWj_edX[jm[[dj^[
jme `Wmi _i _djWYj WdZ Wbbemi W ik\\_Y_[dj Z[]h[[ e\
beWZ jhWdic_ii_ed je j^[ f[h_eZedjWb ijhkYjkh[i$
?j _i j^[h[\eh[ h[Yecc[dZ[Z je Ybei[ Wdo c_ii_d]
ifWY[i" [l[d _\ edbo _d W j[cfehWho cWdd[h$ J^_i
WffheWY^ cWo iec[j_c[i Wle_Z \khj^[h [njhWYj_edi
_d j^[ effei_d] `Wm$ F[h_eZedjWb h[^WX_b_jWj_ed"
_Z[Wb eYYbkiWb beWZ_d]" ]eeZ ehWb ^o]_[d[ WdZ Wd
Wffhefh_Wj[Y^[m_d]\ehY[m_bbikffehjj^[_d^[h[dj
fem[hie\ifedjWd[eki^[Wb_d]$
È
-USCLEÈ0OWERÈANDÈ#HEWINGÈ0ATTERN
8ej^ j^[ fh[i[dY[ e\ ijhed] ij_ckb_ \hec j^[
f[h_eZedj_kc WdZ j^[ Z[l[befc[dj e\ fh[\[hh[Z
Y^[m_d] i_Z[i Wi ikY^ ^Wl[ Wd _cfWYj ed j^[ b[l[b
WdZgkWb_joe\ckiYb[WYj_l_jo$?dj^_imWo"j^[ckiYb[
fem[h cW_dbo e\ j^[ cWii[j[h WdZ j[cfehWb_i
ckiYb[i m_bb Z[Yh[Wi[ Wi f[h_eZedjWb Z[ijhkYj_ed
fhe]h[ii[i_dj^[fh[i[dY[e\Wd_djWYjikffehjped[$
J^_i _i j^[ edbo mWo jeej^ beii _i Wle_Z[Z \eh o[Whi
'+-
&IGÈ J^[YedZob[i_dj^_i
cWdZ_Xb[e\W*&#o[Wh#ebZ
mecWdWh[WXekjj^[iWc[i_p[
WdZi_c_bWhbohekdZ[ZedXej^
i_Z[ie\j^[`Wm$I_Z[im_jY^_d]
^WidejeYYkhh[Z[l[dj^ek]^
j^[kff[hb[\jm_iZecjeej^
_iij_bb_cfWYj[Z$Ikhfh_i_d]bo"
kd_bWj[hWb[njhWYj_ede\Wdkff[h
fh[cebWh^WiW\\[Yj[Zd[_j^[h
j^[cWij_YWjeho\kdYj_eddehj^[
cehf^ebe]oe\j^[JC@_dj^_i
i_jkWj_ed
&IGÈ J^_i*&#o[Wh#ebZ
mecWdh[l[WbiZ_ij_dYji_]die\
kd_bWj[hWbY^[m_d]$J^[YedZob[
edj^[h_]^j_iikXijWdj_WbbobWh][h
j^Wdj^[YedZob[edj^[b[\j"
_dZ_YWj_d]j^Wjkd_bWj[hWbY^[m_d]
edj^[h_]^ji_Z[ckij^Wl[X[[d
fh[i[djel[hcWdoo[Whi$I_dY[
Xej^YedZob[iWh[Wdj[h_ehbo
\b[n[Z"j^[ockij^Wl[cel[Z
h[jhWbbo_dWdej^[hf^Wi[
[l[dj^ek]^j^[W\\[Yj[Zj[[j^cWoX[]h[WjboceX_b[$
Bem[h_d]j^[Wcekdje\j^[cWij_YWjeho\ehY[im_bb
h[ikbj_dWbWYae\ZhW_dW][j^hek]^j^[f[h_eZedjWb
j_iik[i$J^ei[j_iik[im_bbj^[dX[m_Z[d[Zje[dWXb[
ik\\_Y_[dj ekj\bem$ J^_i m_Z[d_d] _i YecX_d[Z m_j^
Wd_dYh[Wi[_dceX_b_jo$
J^[ _cfehjWdj heb[ e\ Y^[m_d] fem[h h[]kbWj_ed
_i[if[Y_WbboWffWh[dj_dfWj_[djim_j^ia[b[jWb9bWii
?? h[bWj_edi$ ?d \kbb#Xbemd YWi[i e\ j^_i fWj^ebe]o"
Wdj[h_ehYedjWYjiWh[c_ii_d]$J^[cWij_YWjeho\ehY[
m_bb X[ h[ZkY[Z je Wle_Z fW_d edbo m^[d j^[ j[[j^
Ykj _dje j^[ fWbWjWb ckYeiW$ J^[ Y^[m_d] fem[h
m_bb _dYh[Wi[ X[YWki[ j^[ ^_]^bo h[]kbWj_d] [\\[Yj
e\ j^[ eXb_gk[ ikh\WY[ YedjWYji ed j^[ Wdj[h_eh
j[[j^ _i c_ii_d]" m^_Y^ m_bb ]_l[ h_i[ je \khj^[h
_djhki_ed e\ j^[ feij[h_eh j[[j^ m^_b[ j^[ Wdj[h_eh
j[[j^ X[Yec[ i_ckbjWd[ekibo [bed]Wj[Z$ J^_i m_bb
W]]hWlWj[ j^[ Z[[f X_j[ [l[d \khj^[h$ <khj^[hceh["
fWj_[djim_j^WZ[[fX_j[^Wl[jeef[dj^[_hcekj^i
m_Z[h je _djheZkY[ j^[ iWc[ Wcekdj e\ \eeZ j^Wd
fWj_[dji m_j^ dehcWb h[bWj_edi$ J^[ cWdZ_Xb[ _i
j^ki \b[n[Z \khj^[h" j^[ Z[]h[[ e\ c_d[hWb_pWj_ed
'+. 9^Wfj[h'&È &UNCTIONALÈ#ONSIDERATIONSÈASÈTHEÈ'UIDINGÈ4REATMENTÈ0RINCIPLE

B C

&IGÈAnC J^[ meha_d] i_Z[ _i dej edbo [l_Z[dj \hec j^[ YedZob[ Xkj Wbie \hec j^[ YWdY[bbeki Xed[ ijhkYjkh[i _d j^[
^eh_pedjWbXhWdY^e\j^[cWdZ_Xb[$ B H[bWj_l[bo^eh_pedjWbb_d[i_dj^[Wh[We\j^[i[YedZcebWh$ A 8oYedjhWij"WcWii_l[
Yh[ijWbXed[ijhkYjkh[Wj)-m_j^ekjWdo^eh_pedjWbb_d[i$ C J^[iWc[YWi[,cedj^iW\j[hj^[\kdYj_edWbeXijWYb[^WiX[[d
h[cel[Z$J^[^eh_pedjWbb_d[iZ_ijWbboje*-Wh[dem]h[Wjboh[ZkY[Z"WdZj^[Yh[ijWb`WmWh[W_iceh[^[Wl_boc_d[hWb_p[Zj^Wd
Wjj^[ijWhje\j^[j^[hWfo$ A J^_iYedZobWhijhkYjkh[_ijof_YWbboWiieY_Wj[Zm_j^kd_bWj[hWbY^[m_d]edj^[b[\ji_Z[$J^[h_]^j
YedZob[ded#meha_d]i_Z[_i\bWjj[d[Z$J^[Y^[m_d]fheXb[cmWiZk[jej^[el[hbobed]l[ij_XkbWhYkifWj'*"m^_Y^fh[l[dj[Z
bWj[hejhki_edjemWhZij^[h_]^ji_Z[$J^[h[\eh["j^[cWij_YWjeho\kdYj_edcel[Zjej^[b[\ji_Z[$J^[_cfb_YWj[ZYkifcWodej
^Wl[X[[d[nY[ii_l[bobed]\hecj^[ekji[j$J^[iWc[\kdYj_edWbekjYec[mekbZh[ikbj\hecbWYae\fWbWjWbikffehje\j^[Yhemd
eh\hecc[Z_Wbc_]hWj_ede\j^[bem[hfh[cebWh"jedWc[edbojme[nWcfb[i

_d j^[ Wh[W e\ \b[n_ed _i \kdYj_edWbbo h[ZkY[Z" WdZ
fhen_cWb YedjWYji e\ j^[ feij[h_eh j[[j^ Zkh_d]
cekj^ ef[d_d] Wh[ h[ZkY[Z$ J^[ h[ZkY[Z fhen_cWb
YedjWYji m_bb fhecej[ f[h_eZedjWb Z[ijhkYj_ed"
j^[h[Xo WYY[b[hWj_d] \khj^[h _djhki_ed [l[d _\ j^[
ckiYb[ fem[h cWo h[cW_d YedijWdj @[hdX[h] [j Wb$
'/.)1=ekbZWdZF_Yjed'/,,$J^[Z[l[befc[djj^ki
f[hf[jkWj[i _ji[b\ X[YWki[ j^[ Z_ijWb Y^[m_d] Wh[Wi
Wh[ kj_b_p[Z b[ii j^Wd j^[ Wdj[h_eh Wh[Wi$ H[_d\ehY[Z
XedoijhkYjkh[i^Wl[jeX[Xk_bj_dj^[Wh[We\j^[`Wm
Wd]b[$M[^Wl[eXi[hl[Zj^Wjj^[m^_j[b_d[il_i_Xb[Wj
j^[Wdj[h_ehWd]b[e\j^[cWdZ_Xb[edj^[fWdehWc_Y
N#hWoi b_d[W eXb_gkW X[Yec[ ceh[ fhedekdY[Z
WdZYWkZWb_p[Z$J^_i_iWbe]_YWbh[WYj_ede\j^[Xed[
je j^[ cWij_YWjeho \ehY[i WYj_d] j^hek]^ j^[ bed]
b[l[h Yh[Wj[Z Xo Wdj[h_eh Y^[m_d] fWjj[hdi$ CebWh
Y^[m_d]fWjj[hdicWo[n^_X_jj^[iWc[\ehY[i"Xkjj^[
b[l[hW][ i_jkWj_ed _i ceh[ WZlWdjW][eki YecfWh[Z
je Wd Wdj[h_eh Y^[m_d] fWjj[hd$ J^[ [deiiWb XbeeZ
ikffbo Yh[ijWbbo je j^[ ^[Wl_bo c_d[hWb_p[Z Wh[W _d
j^[feij[h_ehi[]c[dj_ij^[h[XoYecfhec_i[Z"j^ki
h[ijh_Yj_d] j^[ f[h_eZedjWb Z[\[dY[ fej[dj_Wb$ J^_i
m_bbieed[hehbWj[hfhecej[f[h_eZedjWbZ_i[Wi[ed
Wbbjeej^ikh\WY[ijej^[Yh[ijWbe\j^[m^_j[b_d[$J^[
m^_j[ b_d[ YWd ÆYWjY^Ç Ä Z[f[dZ_d] ed j^[ ifWj_Wb
i_jkWj_edÄbWh][fWhjie\j^[heejie\j^[cWdZ_XkbWh
i[YedZcebWhi"Xkj^WhZbo[l[hj^[heejie\j^[\_hij
cebWhi eh j^[ i[YedZ fh[cebWhi$ I[YedZ cebWhi _d
j^[i[YWi[ij^_i^Wl[W]eeZY^WdY[e\ikhl_lWb[l[d
_\ j^[o YWhho m_Z[#ifWd Xh_Z][i" m^_b[ \_hij cebWhi
Ze dej$ J^[o j[dZ je ][j beij [Whbo WdZ h[i_ij Wbb
Wjj[cfjiWjf[h_eZedjWbjh[Wjc[dj$J^[Z[l[befc[dj
e\ j^[ m^_j[ b_d[ WdZ j^[ gk[ij_ed Wi je m^_Y^ fWhj
e\ j^[ heej _iÆYWk]^jÇ Xo _j m_bb Z[Y_Z[ j^[ \Wj[ e\
È È /CCLUSIONÈ6ERSUSÈ-ASTICATIONÈ
j^[jeej^Wim[bbWij^[\Wj[e\j^[8E?_cfbWdj$8E?
_cfbWdji ckij j^[h[\eh[ X[ fbWY[Z X[bem j^[ m^_j[
b_d[ehWjj^[fbWY[m^[h[_jhkdiekj"eh_dj^[Wh[W
m^[h[ ed[ mekbZ [nf[Yj j^[ b_d[ je X[ eh Z[l[bef
m_j^ ^_]^[h cWij_YWjeho \ehY[i fh[i[dj$ J^[ m^_j[
b_d[_iYh[Wj[ZXo^_]^boc_d[hWb_p[Zl[ij_XkbWhXed[
i^em_d] l[ho b_jjb[ h[ceZ[bb_d]$ 7do 8E? _cfbWdj
fbWY[Zj^[h[m_bbkikWbboWkjecWj_YWbbojekY^"edj^[
b_d]kWbWif[Yje\j^[cWdZ_Xb["j^[h[]_edm^[h[j^[
cobe^oe_ZckiYb[_iWjjWY^[Z1j^_iWh[W"jee"_igk_j[
h[i_ijWdjjeh[iehfj_ed$
FWj_[dji m[Wh_d] jeej^#ikffehj[Z \_n[Z Xh_Z][i
Z[l[bef ^_]^[h cWij_YWjeho \ehY[i j^Wd fWj_[dji
m_j^ dWjkhWb j[[j^ AhW\j '/,($ Fh[ikcWXbo" j^[
f[h_eZedjWb h[Y[fjehi fhel_Z[ _dWYYkhWj[ WdZ
h[ZkY[Z\[[ZXWYa_dj^[i[fWj_[dji$
J^[ Ybei_d] cel[c[dj e\ j^[ `Wm _i dej edbo W
\kdYj_ed e\ h[bWj_l[ ckiYb[ fem[h Xkj Wbie e\ j^[
i[gk[dY[ e\ ckiYb[ WYj_l_jo$ J^[ _dl[ij_]Wjeh YWd
[lWbkWj[ j^[ ckiYb[ jed[ YecfWh[Z je ^_i emd
ckiYb[ WYj_l_jo WdZ Z[cedijhWj[ j^[ Z_\\[h[dY[ je
j^[ fWj_[dj$ J^[ ckiYb[i ed j^[ i_Z[ m^[h[ j^[
fh[cWjkh[ YedjWYji Wh[ fh[i[dj m_bb YedjhWYj \_hij"
m^_b[ j^[ h[WYj_ed e\ j^[ YedjhWbWj[hWb ckiYb[i _i
ib_]^jboZ[bWo[ZXkjj^[djWa[ibed][hjeh[iebl[$
È
/CCLUSIONÈ6ERSUSÈ-ASTICATION
J^[ Z[djWb b_j[hWjkh[ _i h_\[ m_j^ fhefeiWbi \eh
eYYbkiWb WdZ cWij_YWjeho jh[Wjc[dj YedY[fji$ Iec[
WffheWY^[i WdZ iec[ WZl_Y[i Wh[ YecfWj_Xb[ m_j^
ej^[hi"m^_b[ej^[hiWh[ckjkWbbo[nYbki_l[$
M[i^Wbb\_hijZ_iYkiim^Wj^Wff[dim^[dDWjkh[
jWa[i _ji Yekhi[ m_j^ekj _dj[hl[dj_ed Xo Z[dj_iji$
IYW_\[ WdZ >ebj '/,/ _dl[ij_]Wj[Z j^[ Z_ijh_Xkj_ed
e\ eYYbkiWb WdZ \kdYj_edWb fWjj[hdi _d W jejWb e\
'(&& WZkbj fWj_[dji$ E\ j^[i[ fWj_[dji" /*& -.$)
fh[i[dj[Z m_j^7d]b[ 9bWii ?" ()& '/ m_j^7d]b[
9bWii??"WdZ)&($+m_j^7d]b[9bWii???h[bWj_edi$
9Wd_d[]k_ZWdY[mWiX_bWj[hWbbo_djWYj_d,*&fWj_[dji
+-WdZkd_bWj[hWbbo_djWYj_d'.*fWj_[dji',$)$
Fkh[ fhejhki_ed mWi WiieY_Wj[Z m_j^ de YWd_d[
]k_ZWdY[ _d //$* e\ fWj_[dji$ J^[ YWd_d[i e\ /'
e\fWj_[dji[n^_X_j[ZY[djh_YYedjWYji$?j_id[Y[iiWho
je a[[f _d c_dZ j^Wj j^[i[ \_]kh[i cWo lWho m_Z[bo
Z[f[dZ_d] ed j^[ fefkbWj_ed _dl[ij_]Wj[Z X[YWki[
9bWii???h[bWj_ediWh[ademdje_dlebl[^_]^[dZ[c_Y
fh[lWb[dY[i$
8hea[d Zemd Xo 7d]b[ YbWii[i" YWd_d[ ]k_ZWdY[
mWifh[i[djX_bWj[hWbbo_d+-WdZkd_bWj[hWbbo_d',
e\ 7d]b[ 9bWii ? fWj_[dji$ M^_b[ j^[i[ f[hY[djW][i
m[h[ [l[d ^_]^[h Wced] j^[ 9bWii ?? fWj_[dji ,-
X_bWj[hWb" '- kd_bWj[hWb" j^[o m[h[ Yedi_Z[hWXbo
bem[h Wced] j^[ 9bWii ??? fWj_[dji ') X_bWj[hWb"
(& kd_bWj[hWb$ 7][ ]hekfi m[h[ dej Z_iYkii[Z _d
'+/
j^WjijkZo$
Kd_bWj[hWbehX_bWj[hWbYWd_d[]k_ZWdY[_ifh[i[dj
_d-&e\fWj_[djiWjW][(+Xkjedbo_d*&WjW][*+$
J^_iZ_\\[h[dY[h[ikbji\hecWXhWi_ede\j^[YWd_d[i
WdZ [bed]Wj_ed e\ j^[ fh[cebWhi WdZ cebWhi$ J^[
ebZ[h j^[ fWj_[dj ]hekf eXi[hl[Z" j^[ ^_]^[h j^[
fh[lWb[dY[e\]hekf\kdYj_edWdZWXhWi_ed$
Dkc[heki h[YedijhkYj_l[ YedY[fji Ze dej jWa[
j^_i _dje WYYekdj$ ?j _i ij_bb Yecced fhWYj_Y[ Wj
Z[djWb iY^eebi je mWn kf j^h[[#fe_dj YedjWYji" WdZ
jhW_d[[ie\Z[djWbj[Y^debe]oWh[ij_bbjWk]^jjemeha
jemWhZifhedekdY[Zoekj^\kbYkifi$J^[FebpÉiYkifi
_djheZkY[Z_dj^['/.&im[h[XWi[Zedj^[h[Wb_pWj_ed
j^Wj j^_i jof[ e\ eYYbki_ed _i kdik_jWXb[ \eh ebZ[h
fWj_[dji$J^[i[Z[i_]dicWZ[_jfeii_Xb[jeYecX_d[
\h[[Zec _d Y[djh_Y m_j^ Ykifi j^Wj m[h[ W[ij^[j_Y
\hec j^[ Z[dj_ijÉi f[hif[Yj_l[$ FebpÉi Ykifi Wh[ dej
h[Wbbo Ykifi$ ?d [\\[Yj" j^[o Wh[ hWj^[h b[l[b eYYbkiWb
ikh\WY[i m_j^ Wd W[ij^[j_YWbbo Z[i_]d[Z ikh\WY[
fWjj[hd$<hecW\kdYj_edWbl_[mfe_dj"j^[i[ikh\WY[i
Yedij_jkj[WdWXhWZ[ZZ[dj_j_ed"Wbbem_d]j^[Z[djWb
j[Y^d_Y_Wdehj^[Z[dj_ijjeWY^_[l[YWd_d[]k_ZWdY[
eh]hekf\kdYj_edWid[[Z[Z$?dZW_boZ[djWbfhWYj_Y["
j^[eX`[Yj_l[e\WY^_[l_d]Wjh_]][h#\h[[cWij_YWjeho
\kdYj_ed YWd X[ WY^_[l[Z ceh[ [Wi_bo WdZ iW\[bo Xo
Z[i_]d_d]eYYbkiWbijefi8[ohed'/,/$
?d j^[ \_dWb WdWboi_i" Xej^ YedY[fji cWo meha
f[h\[Yjbo m[bb X[YWki[ _j _i h[Wbbo kf je j^[ fWj_[dj
je Z[Y_Z[ ^em j^[ eYYbki_ed _i je X[ kj_b_p[Z WdZ
m^[j^[h _j m_bb X[ ki[Z eh WXki[Z$ 8ej^ jof[i e\
eYYbki_edWh[YecfWj_Xb[m_j^]eeZehWb^[Wbj^"WdZ
Xej^ cWo _dlebl[ fheXb[ci _\ j^[ fWj_[dj" m^[j^[h
YediY_ekibo eh kdYediY_ekibo" efji \eh Zoi\kdYj_ed
CY7ZWc8bWa['/-,$M^Wj[l[hj^[YWi[cWoX["j^[
_dj[hbeYa_d]e\Ykifi^WijeX[h[ZkY[Zeh[b_c_dWj[Z
el[h j^[ Yekhi[ e\ b_\[$ J^_i YWddej kikWbbo X[
WY^_[l[Z m_j^ WXhWi_l[ _dijhkc[dji X[YWki[ j^[
&IGÈ J^_i hejWj[Z WdZ [bed]Wj[Z i[YedZ cebWh _d j^[
cWn_bbW Ze[i dej Wbbem f^oi_ebe]_YWb bWj[hejhki_ed WdZ
fh[l[dji j^[ Xed[ ijhkYjkh[ WhekdZ j^[ l[ij_XkbWh heeji e\
j^[ cebWhi \hec X[_d] \kdYj_edWbbo kj_b_p[Z$ J^[ h[ikbjWdj
beYWb Z_iki[ Wjhef^o kikWbbo ][ji Z_W]dei[Z Wi Æ_Z_efWj^_Y
f[h_eZedj_j_iÇ" m^_Y^ Ze[i dej h[\b[Yj j^[ jhk[ YWki[$ J^[
l[ij_XkbWhYkifie\j^[cebWhiWh[dejikX`[Yj[ZjeWdoa_dZe\
\kdYj_ed_dj^_ii_jkWj_ed
',& 9^Wfj[h'&È &UNCTIONALÈ#ONSIDERATIONSÈASÈTHEÈ'UIDINGÈ4REATMENTÈ0RINCIPLE
Z[[f[d_d]X_j[m_bb_dl_j[Wdj[h_ehY^[m_d]fWjj[hdi$
7domWo" eYYbkiWb YedjWYji Wh[ ^WhZbo [l[h
[ijWXb_i^[Z Zkh_d] Y^[m_d]$ EhZ[hbo h^oj^c_YWb
cel[c[dji"m^_Y^m_bbX[Z_iYkii[Z_dZ[jW_bX[bem"
Wh[ ckY^ ceh[ _cfehjWdj \eh cWij_YWj_ed j^Wd
ehZ[hbo eYYbkiWb h[bWj_edi$ ;lWbkWj_d] W fheij^[j_Y
h[YedijhkYj_ed XWi[Z ed eYYbki_ed _i b_a[ j[ij_d]
XeejiXo`kijijWdZ_d]_dj^[c$8eejij^WjWh[ÆcWZ[
\eh mWba_d]Ç YWd edbo X[ eXjW_d[Z Xo _dYbkZ_d] j^[
fWhWc[j[hie\cWij_YWj_edWim[bb$
CWij_YWj_ed YedY[fji Wh[ cW_dbo h[Wb_p[Z _d
j^[\ehce\h[celWXb[Yecfb[j[Z[djkh[i"Xkj
j^[o Ze fbWo W l_jWb heb[ _d 8E?#ikffehj[Z
h[ijehWj_edi$ Fheij^[j_Y h[ijehWj_edi j^Wj Wh[
XWi[Zedj^[i[YedY[fjiWh[WbmWoifh[\[hWXb[$
J^[o kikWbbo h[gk_h[ [nj[di_l[ h[ijehWj_edi
_d j^[ effei_d] `Wm Wi m[bb" [l[d j^ek]^ j^[
fWj_[djcWoi[[ded[[Z\ehj^_i$
È
.EUROMUSCULARÈ#ONTROLÈINÈ)MPLANTÈ0ATIENTS
?d fWj_[dji m_j^ dWjkhWb Z[dj_j_edi" j^[ f[h_eZedjWb
d[hl[[dZ_d]i^Wl[ckY^b[iie\WYedjheb\kdYj_ed
j^Wdj^[if_dZb[iWdZj[dZedie\j^[Y^[m_d]ckiYb[i$
J^[ JC@ _i" e\ Yekhi[" W Yecfb[n fhefh_eY[fj_l[
eh]Wd Wi m[bb$ J^[i[ `e_dji Wff[Wh je ^Wl[ W ckY^
]h[Wj[h \h[[Zec e\ f^oi_ebe]_YWb cel[c[dj j^Wd"
\eh _dijWdY[" j^[ `e_dji e\ j^[ Whci WdZ b[]i$ ?d
WZZ_j_ed" j^[ b_\[bed] cehf^ebe]_YWb WZWfjWX_b_jo
e\ j^[i[ \_Xheki `e_dji _i kd_gk[ Wced] j^[ ^oWb_d[
`e_dji e\ j^[ ^kcWd XeZo$ J^[ fej[dj_Wb e\ Xedo
Wffei_j_edi Z[Yh[Wi[i m_j^ j^[ m_Z[d_d] e\ j^[
JC@`e_djifWY[[if[Y_Wbbo_dfWj_[djim_j^Wdj[h_eh
Y^[m_d] fWjj[hdi X[YWki[ bem[h Z_h[Yj eh _dZ_h[Yj
jhWdic_ii_ede\\ehY[ijej^_iWh[We\j^[Xed[eYYkhi
m^_b[ j^[ `e_dji fei_j_ed X[Yec[i ceh[ lWh_WXb[
>_[biY^[h'/,'$
J^[ i_jkWj_ed YedY[hd_d] d[khedWb Yedjheb _i
iec[m^Wj Z_\\[h[dj _d j^[ fh[i[dY[ e\ _cfbWdj#
ikffehj[Zh[ijehWj_ediX[YWki[j^[h[_ide\[[ZXWYa
\hec j^[ f[h_eZedj_kc" m^_Y^ mekbZ dehcWbbo
fWhj_Y_fWj[ _d j^[ Yedjheb c[Y^Wd_ic$ 7 i_c_bWh
jof[e\h[\b[nYWdX[_dZkY[Zl_Wf[h_eij[WbfW_d_d
i_jkWj_edi m^[h[ j^[ Z_iai e\ 8E? _cfbWdji fhe`[Yj
bWj[hWbbo \hec j^[ Yehj_YWb Xed[ cWh]_d$ ?d j^[
fh[i[dY[ e\ [nY[ii_l[ \kdYj_edWb eh fWhW\kdYj_edWb
beWZi ed 8E? _cfbWdji" j^[ Xed[ WhhekdZ beWZ#
jhWdic_jj_d] Z_iai m_bb \_hij h[WYj Xo Z[l[bef_d]
h[l[hi_Xb[ kdZ[hc_d[hWb_p[Z ped[i$ EdY[ j^[ Z_ia
X[Yec[iib_]^jboceX_b["f[h_eij[WbfW_dm_bbZ[l[bef
j^Wj cWo f[h i[ h[]kbWj[ j^[ cWij_YWjeho \ehY[i
ZemdmWhZ"j^[h[Xo_dZkY_d]h[c_d[hWb_pWj_ede\j^[
beWZ#jhWdic_jj_d]_cfbWdj_dj[h\WY[$
J^[ WXel[ fheY[ii YWd edbo X[ Z_h[Yj[Z jemWhZi
Yb_d_YWbboikYY[ii\kb^[Wb_d]Wibed]Wij^[eij[eboj_Y
Xed[Wh[WZe[idejX[Yec[ikf[h_d\[Yj[Z$M^[j^[h
ikY^ikf[h_d\[Yj_edeYYkhim_bbZ[f[dZdejedboed
j^[XWYj[h_WbbeWZWdZj^[ehWb^o]_[d[ijWjkiXkjWbie
ed j^[ b[d]j^ e\ j^[ j^h[WZ[Z f_d" _$[$ j^[ Z_ijWdY[
X[jm[[d beWZ jhWdic_ii_ed Wh[Wi WdZ j^[ ckYeiWb
f[d[jhWj_ed$
8[i_Z[i hWh[ fW_d \hec ceX_b[ XWiWb fbWj[i" de
ej^[h Z_h[Yj fW_d i_]dWbi eh _d\ehcWj_ed ij[cc_d]
\hecj^[_cfbWdjih[WY^j^[XhW_d$?d\ehcWj_ed\hec
j^[ ckiYb[i WdZ `e_dji fh[lW_b$ J^_i _i ed[ e\ j^[
cW_d h[Wiedi m^o fWj_[dji m_j^ _cfbWdj#ikffehj[Z
h[ijehWj_edi WZWfj hWj^[h gk_Yabo je Y^Wd][i _d j^[
\kdYj_ed fWj^ j^Wj mWi Yh[Wj[Z Xo fheij^eZedj_Y
c[Wdi$
È
2EFLEXESÈANDÈ%NGRAMS
J^[ cel[c[dji e\ j^[ cWdZ_Xb[ Wh[ Yedjhebb[Z l_W
j^[ eYYbkiWb YedjWYji _d j[hci e\ ^[_]^j WdZ l_W
j^[ cWij_YWjeho ikh\WY[i _d j[hci e\ Z_h[Yj_ed$ J^[
Wffb_YWXb[ hWd][ e\ cel[c[dji YWd X[ h[jh_[l[Z
\hec j^[ ÆcW_d c[cehoÇ e\ j^[ d[kheckiYkbWh
ioij[c" m^_Y^ _i Yedj_dkekibo kfZWj[Z$ ImWbbem_d]"
XoYedjhWij"\ebbemiWh[\b[nfWjj[hdj^Wj_i[nYbki_l[bo
_d[hj _d dWjkh[" j^ki X[_d] WÆ^WhZmWh[#Yedjhebb[ZÇ
\kdYj_edWb_jo" Wi _j m[h[$ CWij_YWj_ed Wh_i[i \hec Wd
WYgk_h[Z WdZ h[WZ_bo WZWfjWXb[ fWjj[hd e\ ckiYb[
YebbWXehWj_ed" m^_Y^ YWd edbo jWa[ h[Yekhi[ je Wd
kdZ[b[jWXb[ XWYakf _\ Z[l_Wj_edi \hec dehcWb
\kdYj_edeYYkh$J^_iXWYakf_ibeWZ[Z_djej^[cW_d
c[cehom^[dj^[ioij[c_iÆh[Xeej[ZÇXo[b_c_dWj_d]
\kdYj_edWb eXijWYb[i$ J^[ beWZ_d] e\ iocc[jh_YWb
[d]hWci_i\WY_b_jWj[ZXoWd[l[h#fh[i[dj_dYb_dWj_ed
jeh[#hkdebZ[d]hWci$
J^[ckiYb[i^Wl[j^[jWiae\[ijWXb_i^_d]j^[ceij
fb[WiWdj YedjWYj h[bWj_edi X[jm[[d j^[ cWn_bbW WdZ
cWdZ_Xb[Ä_\feii_Xb[XoWle_Z_d]WdoXWZYedjWYji
WdZfW_d\kbi[diWj_edi$?dj^_imWo"WdoÆX_j[Çj^Wj_i
[ijWXb_i^[ZXojeej^ehfheij^[j_YYedjWYj_iWbeYa[Z
X_j[" WdZ Wdo ÆX_j[ jWa_d]Ç X[Yec[i W \ehY[Z ÆX_j[
Z[b_l[hoÇ_dfheij^[j_YYedj[nji$
7le_ZWdY[e\fW_dWdZWjof_YWbcel[c[djfWjj[hdi
YWd ]_l[ h_i[ je i_jkWj_edi m^[h[ _dj[h\[h[dY[i Wh[
dej W\\[Yj[Z Xo _dYehh[Yj beWZ_d] j^[ci[bl[i Xkj
_d\b_Yj ZWcW][ ed i[[c_d]bo kdh[bWj[Z j[[j^$ J^_i
c[Y^Wd_ic _i dej WbmWoi eXl_eki$ J^[ \WYj j^Wj W
Y^W_d ^Wi Xhea[d Wj _ji m[Wa[ij b_da Ze[i dej j[bb
ki Wj m^_Y^ b_da j^[ [nY[ii_l[ \ehY[ j^Wj YWki[Z j^[
Xh[WaW][eYYkhh[Z$
H[\b[n[i Wh[ kdY^Wd][WXb[" Xkj [d]hWci YWd X[
h[b[]Wj[Z\hecj^[cW_dc[cehoXod[mboWYgk_h[Z
È È )MPLANTÈ4REATMENTÈASÈ&IRST
,INEÈ4HERAPYÈOFÈ-ASTICATIONÈ ','
cel[c[dj fWjj[hdi$ If[[Y^ _i Zh_l[d Xo jof_YWb
[d]hWci$ M^[d[l[h 8E?#XWi[Z \_n[Z h[ijehWj_edi
Wh[h[Wb_p[Z_di_jkWj_ediY^WhWYj[h_p[ZXoWZlWdY[Z
Xed[h[iehfj_ed"j^[i[fWj_[djicWo^Wl[Wl[ho^WhZ
j_c[WZWfj_d]j^[_hif[[Y^^WX_ji$J^[i_jkWj_edm_bb
_cfhel[ Xo ZW_bo [n[hY_i[$ FWj_[dji m_bb h[bWfi[ _dje
ebZ [d]hWci m^[d j^[o Wh[ ib[[fo" m^_Y^ _i m^o
f^ed[j_Yf[h\ehcWdY[j[dZijeh[WY^_jibem[ijb[l[b
_dj^[W\j[hdeedehbWj[h_dj^[[l[d_d]WdZZkh_d]
j^[d_]^j$
,INEÈ4HERAPYÈÈ
È
2ECONSTRUCTINGÈTHEÈ#HEWINGÈ&UNCTION
M^_b[j^[h[Wh[Z_\\[h[djmWoij^[X_bWj[hWbboXWbWdY[Z
cWij_YWj_ed fWjj[hd cWo YebbWfi[" Wbb ijhWj[]_[i
je h[ijeh[ \kdYj_ed Wh[ Z_h[Yj[Z Wj [ijWXb_i^_d]
W Yehh[Yj cWij_YWjeho fbWd[ WdZ \kdYj_edWbbo
eh_[dj[Z cWij_YWjeho ikh\WY[i$ 7i X_j[ h[]_ijhWj_ed
_d j^[ ^WX_jkWb fei_j_ed _i [nY[[Z_d]bo _dWYYkhWj["
fWhj_YkbWhbo m^[d j^[ ckiYb[ \ehY[i Wh[ h[ZkY[Z"
h[ijehWj_edi Wh[ \WXh_YWj[Z WdZ j^[ _dj[hcWn_bbWho
h[bWj_ediZ[\_d[ZXWi[Zedj^[ceijZehiWbh[bWj_edi^_f
feii_Xb[8[ohed'/,/$IkXi[gk[djbo"j^[cWij_YWjeho
\kdYj_ed fWj^i ^Wl[ je X[ WZ`kij[Z _djhWehWbbo m_j^
WXhWi_l[ _dijhkc[dji eh Xo Xk_bZ_d] kf ^WhZ j_iik[$
M^Wj m[ [nf[Yj \hec j^[ Z[djWb bWXehWjeho _i W
fh[b_c_dWho Xh_Z][" m^_Y^ m_bb j^[d X[ [nj[di_l[bo
WZ`kij[Z _d j^[ fWj_[djÉi cekj^$ M^[j^[h Wdej^[h
]bWp_d] ij[f _i f[h\ehc[Z edY[ j^[i[ WZ`kijc[dji
^Wl[X[[df[h\ehc[Z^WijeX[Z[Y_Z[ZedWYWi[#Xo#
YWi[XWi_i$7dod[[Z\ehWXhWi_l[WZ`kijc[djiZkh_d]
j^[ f^Wi[ e\ ]hWZkWb ckiYb[ h[bWnWj_ed YWddej X[
Z[Wbj m_j^ Xo ]bWp_d] X[YWki[ j^[ fehY[bW_d Xk_bZ#
kf m_bb jeb[hWj[ Wdej^[h lWYkkc \_h_d] W\j[h ^Wl_d]
X[[d _d i_jk \eh Wd [nj[dZ[Z f[h_eZ e\ j_c[$ ?\ j^Wj
_ij^[YWi["Wd[mXh_Z][_i\WXh_YWj[Z"ehj^[[n_ij_d]
\hWc[mehah[#l[d[[h[Z"_\Yedi_Z[h[Zd[Y[iiWho\hec
Wd W[ij^[j_Y l_[mfe_dj$ J[cfehWho h[ijehWj_edi ed
8E?#_cfbWdjid[[ZjeX[l[hoij_\\$J^_ih[gk_h[c[dj
YWdX[c[jXoki_d]j^_YabWo[hie\h[i_dehWc[jWb
\hWc[meha$BWh][#ifWdXh_Z][iikffehj[ZXoWicWbb
dkcX[h e\ WXkjc[dji i^ekbZ WbmWoi X[ Y[c[dj[Z
m_j^ ijhed] Y[c[dji eh WYhob_Y h[i_d je Yecf[diWj[
\ehWdoh[cel_d]b[l[h\ehY[i$F[h_eZie\j[cfehWho
Y[c[djWj_ed[$]$m^_b[j^[effei_j[`Wm_iWmW_j_d]
X[h[YedijhkYj_edi^ekbZX[a[[fi^ehj$
?j_iiec[j_c[iYecfb[j[bo_cfeii_Xb[jeh[YehZW
jhkboh[jhWbfei_j_ede\j^[JC@i"fWhj_YkbWhbo_\j^[o
^Wl[ X[[d ]h[Wjbo Z_ibeYWj[Z \eh cWdo o[Whi$ J^[i[
i_jkWj_edi cWo X[ Zk[ je f[hcWd[djbo ^of[hjed_Y
Y^[m_d] ckiYb[i dejWXbo j^[ bWj[hWb fj[ho]e_Z
ckiYb[" eh j^[o cWo X[ Zk[ je `Wcc_d] e\ j^[
Whj_YkbWh ifWY[ Xo Yedd[Yj_l[ j_iik[ ijhkYjkh[i j^Wj
YWddej X[ _cc[Z_Wj[bo h[fei_j_ed[Z$ IkXijWdj_Wb
hWZ_e]hWf^_YZ_iYh[fWdY_[i_dj^[h[bWj_l[fei_j_edie\
j^[JC@iWh[_dZ_YWj_l[e\j^_ijof[e\Yecfb_YWj_ed$
9edd[Yj_l[ j_iik[ ijhkYjkh[i _d j^[ Whj_YkbWh ifWY[
YWd X[ Z[Wbj m_j^ Xo WZ`kij_d] j^[ W\\[Yj[Z i_Z[ je
W ib_]^jbo _d\hWeYYbkiWb b[l[b$ ?d ekh fhWYj_Y[" m[
^Wl[ hekj_d[bo X[[d WXb[ je h[#[ijWXb_i^ efj_cWb
JC@ fei_j_ed_d] _d j^_i mWo m_j^_d W \[m cedj^i
iec[j_c[iWYYecfWd_[ZXof^oi_ej^[hWfo$
È
)MPLANTÈ4REATMENTÈASÈ&IRST
OFÈ-ASTICATION
Iec[dW_l[Æ[nf[hjiÇWffe_dj[ZXoj^[Yekhji"WdZ[l[d
iec[h[fh[i[djWj_l[ie\WYWZ[c_W"a[[fh[f[Wj_d]j^[
\W_ho#jWb[j^Wjj^[l[hj_YWbWdZiW]_jjWbh[bWj_ediYWd
\_hijX[h[ijeh[ZXoWh[celWXb[h[ijehWj_ed"\ebbem[Z
Xo jhWdi\[hh_d] j^[ h[ikbji je W \_n[Z h[ijehWj_ed
Zemdj^[heWZ$J^_idej_ed_iWXikhZ"_\\ehdeej^[h
h[Wied j^Wj h[celWXb[ h[ijehWj_edi YWddej feii_Xbo
h[ijeh[WÆdehcWbÇckiYb[\kdYj_ed_dj^[\_hijfbWY[$
J^[ h[WZ[h cWo mWdj je Yedi_Z[h j^[ \ebbem_d]
c[jWf^eh0?cW]_d[j^[h[_iiec[]hWl[b_di_Z[oekh
h_]^ji^e[$Demj^Wjoekadem_j"[l[hoj^_d]_i\_d["
ie fb[Wi[ ijef b_cf_d] h_]^j dem$ M[ Wh[ ]e_d] je
h[cel[j^[]hWl[bd[njm[[a$
7bie dej[ j^Wj W Z[djkh[ YWddej X[ h[WiedWXbo
h[jW_d[Z [l[d _d i_jkWj_edi e\ ceZ[hWj[ Xed[
h[iehfj_ed"m^_Y^_ifbW_d\hecj^[l[ho\WYjWbbj^[
ckiYb[i _dlebl[Z Y^[m_d] ckiYb[i" c_c_Y ckiYb[i
WdZ jed]k[ m_bb if[Y_\_YWbbo \eYki ed j^[ jWia e\
imWbbem_d] \eeZ m_j^ekj imWbbem_d] j^[ Z[djkh[$
9ecfb[j[ Z[djkh[i j[dZ je X[ WiieY_Wj[Z m_j^
Y^eff_d]cel[c[djiX[YWki[WdobWj[hWbcel[c[dji
Wh[fWhj_YkbWhboZ[jh_c[djWbjeh[j[dj_ed$
H[ijeh_d]j^[cWij_YWjeho\kdYj_edm_j^j^[^[bf
e\_cc[Z_Wj[bobeWZ[Z8E?#XWi[Zh[ijehWj_edi_idej
fh_cWh_bo WZlWdjW][eki X[YWki[ _j e\\[hi W Ægk_Ya
\_nÇiebkj_ed$;ijWXb_i^_d]WXWbWdY[ZY^[m_d]WX_b_jo
m_j^\_n[Zj[[j^_iWd_cfehjWdj]eWbj^Wji^ekbZX[
WY^_[l[Z Wi ieed Wi feii_Xb[$ ?d \WYj" j^[ fWj_[dji
j^[ci[bl[ij[dZjeh[Wb_p[j^_i_cfehjWdY[$?dcWdo
YWi[i"j^[\_hijij[fjemWhZiWY^_[l_d]j^_i]eWb_ije
fhWYj_i[WYehh[YjcWij_YWjehofWjj[hd$
J^[d[nj]eWbijeX[WY^_[l[Z_dj^[bed][hj[hc
Wh[ je [dikh[ j^Wj j^[ _cfbWdji X[Yec[ WdY^eh[Z
_d W bWij_d] cWdd[h" j^Wj j^[ Xed[ ijhkYjkh[i h[WY^
cWjkh_jo" WdZ j^Wj j^[ cWij_YWjeho \kdYj_ed" m^_Y^
^WZX[[d]hWZkWbbobeijel[hj^[o[Whi"m_bbX[\kbbo
h[ijeh[Z$ ?d cWdo YWi[i" j^_i h[eh]Wd_pWj_ed e\ beij
\kdYj_ediedj^[XWi_ie\ia[b[jWbXed[ijhkYjkh[im_bb
h[gk_h[WZZ_j_edWbij[fi$<eh_dijWdY["_jcWoX[Yec[
d[Y[iiWho je _di[hj Yecfb[c[djWho eh WZZ_j_edWb
fheij^[j_Y h[ijehWj_edi eh je h[fbWY[ Wdo _cfbWdji
j^Wj Wh[ de bed][h WXb[ je \kb\_b j^[_h jWia e\ beWZ
jhWdic_ii_ed$
',( 9^Wfj[h'&È &UNCTIONALÈ#ONSIDERATIONSÈASÈTHEÈ'UIDINGÈ4REATMENTÈ0RINCIPLE
J^_i Yecfh[^[di_l[ h[eh]Wd_pWj_ed e\ j^[
cWij_YWjeho \kdYj_ed YWd edbo X[ WY^_[l[Z _d W
dkcX[h e\ ikYY[ii_l[ ij[fi Ä i_c_bWh je ikYY[ii_l[
bWo[hi e\ fW_dj" m^[h[ [WY^ i_d]b[ bWo[h i^ekbZ X[
Wbbem[ZjeZhoiej^Wj_jYWdfhef[hboieb_Z_\oX[\eh[
j^[d[njbWo[h_iWffb_[Z$?dj^[lWijcW`eh_joe\YWi[i"
j^[ \_hij ij[f ckij X[ je _di[hj W \_n[Z h[ijehWj_ed
Wi j^[ Z[fWhjkh[ fe_dj \eh Wbb \khj^[h ij[fi e\ j^[
fheij^[j_Yjh[Wjc[dj$Iec[j_c[i_jcWoX[ki[\kbje
_cfhel[ eh h[d[m j^[ [n_ij_d] Z[djkh[ X[\eh[ Wdo
_cfbWdjiWh[_di[hj[Z"Xkjj^[i[YWi[iWh[l[hohWh[$
:[djkh[iZedejWbbemj^[Xk_bZ_d]ckiYb[fem[h"
WdZ j^[o Wh[ kdWXb[ je Yh[Wj[ ik_jWXb[ \kdYj_edWb
YedZ_j_edi \eh j^[ ikXi[gk[dj \_n[Z h[ijehWj_ed$7bb
j^[oYWdWY^_[l[_ijei_ckbWj[j^[l[hj_YWbZ_c[di_ed"
m^_Y^ _i W j^[eh[j_YWb Yedi_Z[hWj_ed X[YWki[ j^[
b_c_jWj_edi _cfei[Z Xo bWYa e\ h[j[dj_ed YWddej X[
el[hYec[_dfhWYj_Y[$
Je Wle_Z fheXb[ci m_j^ fWj_[dj Yecfb_WdY[" _j
ckij X[ h[f[Wj[Zbo fe_dj[Z ekj je j^[ fWj_[dj j^Wj
_cc[Z_Wj[ beWZ_d] e\ _cfbWdji Ze[i dej c[Wd j^[
_cc[Z_Wj[[dZe\j^[jh[Wjc[dj$J^[effei_j[_ijhk[0
j^[ WYj_l[ f^Wi[ e\ \kdYj_edWb jh[Wjc[dj YWd edbo
ijWhjW\j[hj^[fbWY[c[dje\j^[\_n[Zh[ijehWj_edi$
È
2ATIONALEÈOFÈ#REATINGÈAÈ"ALANCEDÈ&UNCTION
M_j^_cfbWdj#h[ijehWj_edioij[cij^WjWh[ikffehj[Z
Xo dkc[heki _cfbWdji" _j _i Z_\\_Ykbj je Z[j[hc_d[
j^[ \ehY[i WYj_d] ed _dZ_l_ZkWb _cfbWdji$ J^_i jWia
_i gk_j[ [Wio" Xo YedjhWij" m_j^ ioij[ci j^Wj Wh[
XWi[ZedijhWj[]_Y_cfbWdjfei_j_ed_d]$8Wi[Zedekh
ademb[Z][ e\ `Wm \b[n_ed" cWij_YWjeho \kdYj_ed" j^[
Z_h[Yj_edi e\ ckiYb[#_dZkY[Z \ehY[i WYj_d] ed j^[
YhWd_WbXed["WdZj^[[gk_b_Xh_kce\\ehY[iWYj_d]ed
8E?_cfbWdji"j^[h[bWj_edi^_fi_bbkijhWj[Z_d<_]$'&$-
^Wl[jeX[jWa[d_djeYedi_Z[hWj_edWiWc_d_ckc
h[gk_h[c[dj$
FWj_[dji i^ekbZ d[l[h X[ _dijhkYj[Z je ÆWle_ZÇ
if[Y_\_Y i_j[i m^[h[ _cfbWdji ^Wl[ X[Yec[ ib_]^jbo
ceX_b[ eh Wh[ fW_d\kb$ 7fWhj \hec j^[ \WYj j^Wj
j^_i Wle_ZWdY[ ijhWj[]o _i kdb_a[bo je X[ ikYY[ii\kb
WdomWo" kd_bWj[hWb Wle_ZWdY[ fWjj[hdi m_bb ^Wl[
j^[ iWc[ kdZ[i_hWXb[ Yedi[gk[dY[i Wi ^WX_jkWb
kd_bWj[hWb Y^[m_d] fWjj[hdi0 j^[ ded#meha_d] i_Z[
Z[l[befi fkbb jhW`[Yjeh_[i Wbed] j^[ Yh[ij e\ j^[
cWdZ_Xb[" j^[h[Xo h[ZkY_d] j^[ j[dZ[dYo jemWhZi
c_d[hWb_pWj_ed" m^_Y^ mekbZ WYjkWbbo Z[ijWX_b_p[
j^[ W\\[Yj[Z _cfbWdji \khj^[h$ ?d j^[ cWn_bbW" j^[
[dj_h[Wle_Z[ZXed[h[]_edm_bbX[_dYh[Wi_d]bob[ii
c_d[hWb_p[Z" WdZ j^[ _cfbWdji ceX_b_p[Z Wi m[bb$ ?d
j^[kff[h`Wm"j^_im_bbceh[h[WZ_boh[ikbj_dfW_de\W
f[h_eij[Wbeh_]_dj^Wd_dj^[cWdZ_Xb[$8E?_cfbWdji
h[gk_h[WZ[gkWj[beWZ_d]jeX[efj_cWbbo_dj[]hWj[Z$
J^[ Z[l[befc[dj e\ fkbb Wh[Wi WdZ c[Y^Wd_YWbbo
&IGÈ IY^[cWj_Yl_[me\j^[\ehY[iWYj_d]ed8E?_cfbWdji
_d W \kbb bem[h Xh_Z][$ Dej[ j^Wj WZZ_d] \khj^[h _cfbWdji Wj
ijhWj[]_Y fei_j_edi cWo Yh[Wj[ ^ofeceY^b_edi" m^_Y^ WZZ
\khj^[h \ehY[i je j^[ ijhWj[]_Y _cfbWdji$ '" 'W L[hj_YWb WdZ
bWj[hWbY^[m_d]\ehY[i_dj^[fh[i[dY[e\X_bWj[hWbboXWbWdY[Z
beWZ_d]$ (" (W L[hj_YWb [njhki_ed \ehY[i _d j^[ fh[i[dY[ e\
YedjhWbWj[hWb beWZ_d]$ J^[ _cfbWdji _d j^[ Wdj[h_eh i[]c[dji
YWd_d\bk[dY[j^[Z_h[Yj_ede\j^[YWkZWbboeh_[dj[Zkd_bWj[hWb
ded#XWbWdY[ZbeWZ_d]e\_cfbWdj)-jej^[fe_dje\Yh[Wj_d]
Wd [njhkZ_d] \ehY[$ ) :_ibeYWj_ed e\ Xed[ ijhkYjkh[i _d j^[
_cfbWdj Wh[W Xo kd_bWj[hWb Y^[m_d] ed j^[ b[\j i_Z[$ J[di_b[
\ehY[i _d j^[ kff[h fehj_ed e\ j^[ cWdZ_Xb[$ * @Wm \b[n_ed
_dZkY[Z Xo dehcWb cekj^ ef[d_d]$ J^[ Y[djh[ e\ \b[n_ed
_i lWh_WXb[$ ?ji fh[Y_i[ beYWj_ed _i Z[j[hc_d[Z Xo j^[ mWo _d
m^_Y^ j^[ Y^[m_d] \ehY[ Z[l[befi" Xo j^[ i[gk[dY[ e\ Wdo
[njhWYj_edi" WdZ Xo j^[ jof[ e\ j^[ fheij^[j_Y h[ijehWj_ed$ +
9ecfh[ii_l[ \ehY[ Yekdj[h_d] j^[ \ehY[ Z[iYh_X[Z _d _j[c )
Zkh_d] kd_bWj[hWb Y^[m_d]$ , J[di_b[ \ehY[i jhWdic_jj[Z \hec
WdZ je ej^[h `Wm i[]c[dji j^hek]^ j^[ ikf[hijhkYjkh[$ -
:_ibeYWj_d] \ehY[i e\ ckiYkbWh eh_]_d m_j^ [\\[Yji _di_Z[ j^[
`Wmj^Wji^_\jj^[_cfbWdjX[ZiW]W_dij[WY^ej^[hWiWh[ikbj
e\\kdYj_ed
m[Wa[hkdbeWZ[Zeh_dWZ[gkWj[bobeWZ[ZXed[Wh[Wi
ckij X[ Wle_Z[Z Wj Wbb Yeiji$ 7do ^_]^bo ceX_b[
_cfbWdjii^ekbZX[Z[jWY^[Z\hecj^[ikf[hijhkYjkh[
i[[ 9^Wfj[h(, eh [nY^Wd][Z$ Je ikccWh_p[" _j _i
WXiebkj[bo YedjhW_dZ_YWj[Z je _dijhkYj fWj_[dji je
Wle_ZfW_d\kbWh[WiehjeY^[mkd_bWj[hWbbo$7doikY^
Wjj[cfji mekbZ \khj^[h Z[X_b_jWj[ j^[ Wbh[WZo m[Wa
Xed[Wh[WWdZWh[b_WXb[jeh[ikbj_d[nY[ii_l[beWZ_d]
e\j^[meha_d]i_Z[$Edj^[effei_j[i_Z["m^_Y^j^[
fWj_[djmWdjijeiWl[\hecbeWZ"Yh[ijWbj[Wh_d]\ehY[i
m_bb h[ZkY[ j^[ c_d[hWb_pWj_ed e\ j^[ Xed[ cWjh_n"
b[WZ_d] je WdZ _dYh[Wi_d] ceX_b_jo e\ j^[ _cfbWdji$
M^_b[_jmekbZX[feii_Xb[jeWle_Zki_d]WdZbeWZ_d]
WXhea[db[]"j^_ied[#i_Z[Zd[ii_idejfeii_Xb[_dj^[
`WmiX[YWki[ÆXej^i_Z[iÇWh[_dijWbb[Zedj^[iWc[
Xed[$ Kd_bWj[hWb ki[ m_bb Wbj[h j^[ Z_ijh_Xkj_ed e\ '#
WdZ&#Wh[Wi_dWdkdZ[i_h[ZcWdd[h$
<eh W X[jj[h el[hl_[m" b[j ki Xh_[\bo h[YWf_jkbWj[
j^[Yedi[Ykj_l[ijW][ie\dehcWbcWij_YWj_ed$
?\j^[Z[dj_ijfhecfjiWfWj_[djjecWhaYedjWYjied
eYYbkiWbfWf[h"j^[fWj_[djm_bbf[h\ehccel[c[dji
j^Wj ^[ eh i^[ Ze[i dej dehcWbbo f[h\ehc m^_b[
Y^[m_d]"dWc[boWbWj[hWbcel[c[dje\j^[cWdZ_Xb[
\hec j^[ Y[djh_Y fei_j_ed i_Z[mWoi$ J^[ [nWYj
effei_j[ _i j^[ YWi[ Zkh_d] j^[ dehcWb cWij_YWjeho
WYj<_]$'&$/0
È È -ASTICATIONÈ4HERAPYÈ!LLOWSÈ%FFECTIVEÈ"ONEÈ-ANAGEMENTÈ
v J^[ cWdZ_Xb[ _i [b[lWj[Z \hec bWj[hWbbo
ÆYbeikh[Ç$
v½ J^[j[[j^jekY^_dWd[YY[djh_Yfei_j_edWdZ]b_Z[
jemWhZ j^[ Y[djh_Y fei_j_ed m^_b[ YedjWYj_d] j^[
\eeZ Xebki ÆYoYb[#_dÇ1 j^_i _i Wbie YWbb[Z j^[
Æ[dj[hf^Wi[Ç$L[hobWh][\ehY[iWh[[n[hj[Zedj^[
h[ijehWj_ed_dj^_if^Wi[$
v J^[ Y[djh_Y fei_j_ed _i edbo cW_djW_d[Z \eh W
\hWYj_ede\Wi[YedZ$<ehY[ie\Z_\\[h[djcW]d_jkZ[
cWoeYYkhZkh_d]j^_if^Wi[$J^[h[_ib_jjb[YedjWYj
X[jm[[dj^[j[[j^Wjj^_ife_dj$
vJ^_i_i\ebbem[ZXoj^[ijWhje\j^[ÆYoYb[#ekjÇf^Wi[
_d m^_Y^ j^[ j[[j^" m^_b[ j^[o Wh[ ij_bb Y^[m_d]
WdZYhki^_d]\eeZ"Wh[Wbh[WZocel_d]WfWhj\hec
[WY^ej^[hW]W_d$?dj^_if^Wi["j^[Y^[m_d]\ehY[i
Wh[bemWij^[ef[d_d]e\j^[cekj^_i_cc_d[dj$
v ?d j^[ ef[d_d] f^Wi[" j^[h[ _i de bed][h Wdo
YedjWYj X[jm[[d j^[ j[[j^$ J^[ cWdZ_Xb[ cel[i
_d W l[ij_XkbWh Z_h[Yj_ed je h[#[dj[h j^[ Ybeikh[
f^Wi[$
v J^[ ]h[Wj[ij cWij_YWjeho \ehY[i eYYkh _d j^[
[dj[h f^Wi[$ J^_i _i m^o _j _i ie _cfehjWdj j^Wj
X_bWj[hWb ikffehj XWbWdY_d] _i fh[i[dj _d j^_i
f^Wi[1_\dej"j^[ded#XWbWdY[Zeffei_d]i_Z[m_bb
X[ ikX`[Yj je Yedi_Z[hWXb[ [njhki_ed \ehY[i" WdZ
fem[h\kbcWij_YWj_ed_i_cf[Z[ZXoj^[j_bj_d]e\
j^[cWdZ_Xb[i[[<_]$'&$."Whhemi("(W :kh_d] imWbbem_d]" j^[ jed]k[ [n[hji \ehcWj_l[
v ?\ [gk_b_XhWj_ed e\ j^[ \ehY[i Wj ( WdZ (W _i dej
feii_Xb[ Xo fheij^eZedj_Y c[Wdi" i[]c[dj[Z
Xh_Z][i m_j^ cWdo 8E? _cfbWdji WdZ Yh[ijWb
_cfbWdj jof[i i^ekbZ kikWbbo X[ fh[\[hh[Z je
Y_hYkbWhh[ijehWj_edi$
v I_dY[ j^[ Y[djh_Y fei_j_ed WhekdZ m^_Y^ ckY^
e\ j^[ YedY[fjkWb kd_l[hi[ e\ fheij^eZedj_Yi
jhWZ_j_edWbboh[lebl[i_iedboWY^_[l[Z\ehWl[ho
i^ehj f[h_eZ e\ j_c[" _j ^WhZbo fbWoi Wdo heb[ _d
WYjkWb h[Wb_jo Ä be]_YWbbo [dek]^$ M^_b[ _j Ze[i
Z[j[hc_d[eYYbkiWb^[_]^j"_j^WhZbo^WiWdo[\\[Yj
edYehh[Yjeh_dYehh[Yj\kdYj_ed$
v J^[ cWij_YWjeho \kdYj_ed YWd edbo X[ [lWbkWj[Z
_\ j^[ eYYbkiWb fWf[h _i ik\\_Y_[djbo j^_Ya \eh W
h[Wb_ij_Y Y^[m_d] i_jkWj_ed je X[ i_ckbWj[Z$ J^[
ki[e\Wj^_d\e_bI^_cijeYaWdZi_c_bWhfheZkYji
Ze[idejo_[bZj^[iWc[]eeZh[ikbj\ehZ_W]dei_i
WdZj^[hWfo$
8o YedjhWij m_j^ j^[ cWij_YWjeho \kdYj_ed" j^[
imWbbem_d]\kdYj_ed_iYedjhebb[ZXoh[\b[n[iWdZ_i
dejkikWbboWc[dWXb[jeYediY_eki_d\bk[dY[i$:kh_d]
imWbbem_d]"ecd_bWj[hWbjeej^YedjWYjii^ekbZeYYkh"
WdZ j^[ YedjWYj _d\ehcWj_ed i^ekbZ dej Z[l_Wj[
eh dej Z[l_Wj[ i_]d_\_YWdjbo \hec j^[ _d\ehcWj_ed
]_l[dZkh_d]cWij_YWj_ed$J^[jeej^YedjWYjiZkh_d]
imWbbem_d] cWa[ W cW`eh Yedjh_Xkj_ed jemWhZ
ZhW_d_d]j^[f[h_eZedjWbj_iik[i"_$[$:hkccÉiYedjheb
cel[c[djiWh[dejedboj^[h[\ehYedjhebXkjWbie"je
Wdej_dYedi_Z[hWXb[[nj[dj"\ehZhW_dW][$
',)
&IGÈ J^[feij[h_ehj[[j^_dj^[[dj[hf^Wi[$J^[cWdZ_Xb[
^Wii^_\j[ZbWj[hWbbo$M_j^_dj^[ikXi[gk[djcWij_YWjehoYoYb["
j^[ l[ij_XkbWh Ykif e\ j^[ cWdZ_XkbWh jeej^ m_bb \_hij ]b_Z[
Wbed] j^[ YkifWb _dYb_d[i e\ j^[ cWn_bbWho jeej^ m_j^ _ji
l[ij_XkbWh\WY[j$7i_jZe[iie"j^[X_j[Ybei[i$J^[_dYb_dWj_ede\
j^[i[jmeYkifWbibef[ickijh[bWj[Yehh[Yjbojej^[_dYb_dWj_ed
e\j^[l[ij_XkbWhibef[e\j^[b_d]kWbYkife\j^[cWdZ_XkbWh
cebWhWdZj^[Yehh[ifedZ_d]Ykifie\j^[cWdZ_XkbWhcebWh
edj^[YedjhWbWj[hWbi_Z[$Ded[e\j^[i[]k_Z_d]fbWd[ii^ekbZ
Wdim[h \eh ]k_ZWdY[ Xo _ji[b\ _$[$ m_j^ekj Wdo YedjhWbWj[hWb
]k_ZWdY[_dj^[YoYb[#_df^Wi[
ij_ckb_ ed j^[ fWbWj[ WdZ ed j^[ bWj[hWb Wif[Yji e\
j^[ cebWhi" m^_b[ j^[ fh[iikh[ e\ j^[ b_fi a[[fi j^[
Wdj[h_ehj[[j^_db_d[$M^[dh[ijeh_d]Wd[Z[djkbeki
cWn_bbW"Wi_jkWj_edcWoeYYkh_dm^_Y^j^[\kdYj_edWb
h[gk_h[c[dji de bed][h Ye_dY_Z[ m_j^ j^[ fWj_[djÉi
W[ij^[j_Y[nf[YjWj_edi$J^[h[Wiedm_bb\h[gk[djboX[
j^Wjj^[ikffehje\j^[ie\jj_iik[iXoj^[Xed[WdZ
j^[ ij_ckbWj_ed" fei_j_ed" beYWj_ed WdZ _dYb_dWj_ed
e\j^[c_c[j_YckiYb[idebed][hYehh[ifedZjej^[
i_jkWj_edm^[dj^[fWj_[djij_bb^WZWbbehceije\^_i
eh ^[h j[[j^$ ?d YWi[i ikY^ Wi j^[i[" W Yecfhec_i[
ckij X[ \ekdZ$ J^_i _i j^[ ZecW_d e\ [f_j^[j_Y
j^[hWfo" i_dY[ [f_j^[i[i Wbbem fbWY_d] j^[ j[[j^ Wj W
\kdYj_edWbbo\WlekhWXb[fei_j_ed[l[d_\j^[[n_ij_d]
^WhZ WdZ ie\j j_iik[i Wh[ dej beYWj[Z \WlekhWXbo"
ikYY[ii\kbbo Yehh[Yj_d] Wdo W[ij^[j_Y Z[\_Y_[dY_[i Wj
WbWj[hfe_dj$
È
-ASTICATIONÈ4HERAPYÈ!LLOWSÈÈ
%FFECTIVEÈ"ONEÈ-ANAGEMENT
8ed[ ijhkYjkh[i m_bb edbo X[ fh[i[hl[Z _\ j^[o Wh[
ik\\_Y_[djbo beWZ[Z" WYj_lWj[Z" \[Z WdZ ZhW_d[Z$
H[ijehWj_l[jh[Wjc[djXWi[Zed8E?_cfbWdjim_bbo_[bZ
ikYY[ii\kbekjYec[i[l[d_d[njh[c[boh[iehX[Z`Wm
ijhkYjkh[i$<ehj^_ifkhfei["Wiocc[jh_YWbXWbWdY[Z
WdZ\ehY[\kbY^[m_d]\kdYj_ed^WijeX[[ijWXb_i^[Z
WdZcW_djW_d[Z$J^[h[\eh["j^[cWij_YWjeho\kdYj_ed
',* 9^Wfj[h'&È &UNCTIONALÈ#ONSIDERATIONSÈASÈTHEÈ'UIDINGÈ4REATMENTÈ0RINCIPLE
^Wi je X[ f[h_eZ_YWbbo h[WZ`kij[Z Xo ikXjhWYj_l[ eh
WZZ_j_l[c[Wdi$
9edl[dj_edWb h[ijehWj_edi Ä m^[j^[h \_n[Z eh
h[celWXb[ Ä Wh[ WbmWoi W_c[Z Wj [dikh_d] Wd
WYY[fjWXb[ cWij_YWjeho \kdYj_ed WdZ Wj cWn_c_p_d]
j^[b_\[[nf[YjWdYoe\\kdYj_edWbj[[j^$Iec["Xkjdej
kikWbbo ckY^" Wjj[dj_ed ][ji Z[lej[Z je fh[i[hl_d]
j^[ Xed[ ijhkYjkh[i ikhhekdZ_d] j^[ j[[j^$ J^[
Y^WdY[i e\ _d\bk[dY_d] j^[i[ Xed[ ijhkYjkh[i Xo
fheij^[j_Y c[Wdi Wh[ X_]][h j^Wd m[ Wh[ ki[Z je
j^_da$
J^[ i_jkWj_ed X[Yec[i gk_Yabo eXl_eki m_j^
8E? _cfbWdji0 J^[ Y^[m_d] \ehY[i Wh[ jhWdic_jj[Z
j^hek]^ j^[ ikf[hijhkYjkh[ Z[[f _dje j^[ XWiWb
`WmXed[ m^[h[ j^[ eii[e_dj[]hWj[Z _cfbWdj ikh\WY[
Z_h[Yjbo ij_ckbWj[i j^[ Xed[ WdZ l_XhWj[i _j$ J^[
cWij_YWjehoikh\WY[i^Wl[WceZkbWj_d][\\[Yjed`Wm
cel[c[djiWdZj^[h[\eh["Xo_cfb_YWj_ed"edckiYb[
\kdYj_edm_j^_dj^[cWij_YWjehoioij[c$7ij^[\ehY[
_cfkbi[i Wh[ Yh[Wj[Z Xo ckiYb[i WdZ jhWdic_jj[Z
_dje j^[ Xed[ l_W j^[ h[ijehWj_ed" j^[ Xed[ m_bb
kdZ[h]e cehf^ebe]_YWb Y^Wd][i _d h[ifedi[ je Wdo
Z_c[di_edWb eh Z_h[Yj_edWb Y^Wd][i _d cWij_YWjeho
Z_h[Yj_ed$ :k[ je _ji j[cfehWb Z_c[di_ed" j^_i
cehf^ebe]_YWb h[YedijhkYj_ed _i h[\[hh[Z je Wi j^[
Æ\ekhj^Z_c[di_ede\_cfbWdjebe]oÇ_dj^_iXeea$
8E? _cfbWdji YWd _dZkY[ l[hj_YWb Xed[ ]hemj^ _\
h[gk_h[Z?^Z[(&&)"fhel_Z[ZdeYecfed[djie\j^[
_cfbWdj#h[ijehWj_edYecfb[ndejWXboj^h[WZ[Zf_di"
fedj_Yieh_d\[Yj_edi_dj[h\[h[m_j^j^[fheY[ii$
CkiYb[\kdYj_ed_iYedjhebb[ZXoj^[XhW_d"Xkjj^[
XhW_dYWdedbocWa[j^[ehWbckiYb[imehaedfWj^i
j^Wj Wh[ fh[#Z[j[hc_d[Z Xo j^[ Z[djWb h[ijehWj_edi$
7doej^[hcel[c[djimekbZ\Wbb_djej^[YWj[]eh_[i
e\fWhW\kdYj_ed"\WY_Wb[nfh[ii_edi"[jY$
9h[ijWb _cfbWdjebe]_iji ^Wl[ WbmWoi feijkbWj[Z
_d\hWeYYbki_ed m^[h[ feii_Xb[ WdZ dWhhem
cWij_YWjeho ikh\WY[i Wi jh[Wjc[dj eX`[Yj_l[i$ M[
Y^Wbb[d][ j^_i WffheWY^" X[YWki[ _ji h[ikbji Wh[
_dYecfWj_Xb[ m_j^ j^[ h[gk_h[c[dj e\ bWj[hWbbo
eh_[dj[Z Y^[m_d] fWjj[hdi" m^_Y^ Wh[ j^[ edbo mWo
je [dikh[ j^Wj Wd WZ[gkWj[ ij_ckbki _i fh[i[dj \eh
Xed[ fh[i[hlWj_ed WdZ%eh \kdYj_edWbbo _dZkY[Z j^[
\ehcWj_ed e\ d[m Xed[$ BWj[hWb cel[c[dji Yh[Wj[
i^[Wh\ehY[ij^WjWbbemj^[Xed[ie\j^[`Wmijeh[]W_d
WdWZ[gkWj[cehf^ebe]_YWbi^Wf[$
>_[biY^[h '/,' fe_dj[Z ekj j^Wj j^[ cel[c[dj
e\ j^[ cWdZ_Xb[ _i _d de mWo ]k_Z[Z Xo Xed[
ijhkYjkh[i Xkj _i Z[j[hc_d[Z [nYbki_l[bo Xo ckiYb[
\ehY[iWdZckiYb[jed[$?j_i_dYkcX[djedj^[8E?
_cfbWdjebe]_ij je h[Wb_]d j^[i[ \ehY[i WdZ je cWa[
j^[ceije\j^[_hWX_b_joje_dZkY[j^[\ehcWj_ede\
d[mXed[$
È
#ONCLUSION
?\ j^[ [Z[djkbeki ifWY[i Wh[ dWhhem WdZ bed]"
\_hc heeji Wh[ WlW_bWXb[ \eh h[jW_d_d] j^[ Z[djkh["
Wi _i j^[ YWi[ _d cWdo oekd][h fWj_[dji" cWdo
Yh[Wj_l[ fheij^eZedj_Y Z[i_]di YWd X[ jWa[d _dje
Yedi_Z[hWj_ed$ 7bceij Wbb e\ j^[c m_bb Wbbem j^[
h[ijehWj_ed je h[cW_d \kdYj_edWb \eh W dkcX[h e\
o[Whi$?\j^[Xed[ikffbo_ih[ZkY[Z"^em[l[h"_jm_bb
X[ d[Y[iiWho je ki[ W h[ijehWj_l[ j[Y^d_gk[ j^Wj _i
YecfWj_Xb[m_j^j^[cWij_YWjehoioij[cWiWm^eb[$
?dekh[nf[h_[dY["j^[\ebbem_d]eX`[Yj_l[iWffbo_d
j^[YWi[e\h[ijehWj_ediikffehj[Z8E?_cfbWdji0
v =eeZ cWij_YWjeho XWbWdY[ WYYecfWd_[Z Xo W
Z[]h[[e\WXhWi_edYecc[dikhWj[m_j^W][WdZXo
ik\\_Y_[djbo[nj[di_l[eYYbkiWbikh\WY[i$
v BWj[hWb cWij_YWjeho fWjj[hdi m_j^ [gk_bWj[hWb
7<CFWd]b[ii^ekbZX[][d[hWj[Z$
v J^[eYYbkiWbfbWd[ckijdejX[jeeZ[[fZ_ijWbbo$
v J^[ Ykhl[ e\ If[[ ckij X[ WZWfj[Z je j^[
eYYbki_ed$
v J^[l[hj_YWbZ_c[di_edckijX[ik\\_Y_[dj$
v J^[iWc[dkcX[he\Y^[m_d]kd_ji"fh[\[hWXboe\
[gkWbm_Zj^"i^ekbZX[fh[i[dj_dXej^gkWZhWdji
e\j^[`Wm$
v 7bb YedjWYj f^Wi[i e\ j^[ cWij_YWjeho \kdYj_ed
ckij X[ fh[i[dj _d j^[ h[b_[\ e\ j^[ eYYbkiWb
ikh\WY[iWdZYWh[\kbboWZ`kij[Z$

#(!04%2È
0ROSTHETICÈ4REATMENTÈ#ONSIDERATIONS
È
0ROSTHETICÈ4REATMENTÈ3TEPS
8E?_cfbWdjiWh[ki[ZWbceij[nYbki_l[bojeikffehj
\_n[Z fheij^[j_Y h[ijehWj_edi$ EYYWi_edWbbo" j^[o
Wh[ Wbie ki[Z \eh XWh WjjWY^c[dji$ 8E? _cfbWdji
YecX_d[ m[bb m_j^ dWjkhWb WXkjc[dji WdZ ej^[h
[deiiWb _cfbWdj Z[i_]di$ J^[ \kdZWc[djWb gk[ij_ed
_i m^[j^[h W h_]_Z eh Wd [bWij_Y _cfbWdj#h[ijehWj_ed
ioij[c i^ekbZ X[ [ijWXb_i^[Z$ >em j^[i[ ioij[ci
Z_\\[h WdZ m^Wj _cfb_YWj_edi j^[o ^Wl[ _d j[hci e\
ijhkYjkhWb _dj[]h_jo m_bb X[ Z_iYkii[Z bWj[h _d j^_i
Y^Wfj[h$
FWhj_YkbWhbo _d YWi[i m^[h[ _cfbWdj fbWY[c[dj"
jeej^[njhWYj_edeh\bWfh[\b[Yj_edmWif[h\ehc[Z_d
j^[W[ij^[j_Yped["j^[fWj_[djii^ekbZm[WhWbed]#
j[hcj[cfehWhoXh_Z][X[\eh[j^[Z[\_d_j_l[Xh_Z][_i
_di[hj[Z$ J^_i j[cfehWho Xh_Z][ i^ekbZ X[ _di[hj[Z
m_j^ekjkdd[Y[iiWhoZ[bWoijeWle_Z_dj[h\[h_d]m_j^
j^[fWj_[djÉi[Wj_d]^WX_ji"m^_Y^mekbZ^[bfd[_j^[h
j^[^[Wb_d]fheY[iidehj^[][d[hWb^[Wbj^YedZ_j_ed
[if[Y_Wbboe\ebZ[hfWj_[dji$?j_ih[Yecc[dZ[Zjeki[
W c[jWb \hWc[meha \eh j^[i[ bed]#j[hc j[cfehWho
Xh_Z][i$
?\ \kbb#WhY^ _cfbWdj jh[Wjc[dj _i fbWdd[Z _d
fWj_[dji m^e Wbh[WZo m[Wh W Yecfb[j[ Z[djkh[" j^[
Z[dj_ijcWomWdjjeh[Z[i_]dj^[Z[djkh[_ji[b\_djeW
\_n[Zj[cfehWhoXh_Z][XoYedi_Z[hWXboh[ZkY_d]j^[
XWi[WdZ\_jj_d]j^[Z[djWbWhY^el[hj^[WXkjc[dji$
J^[ \hWc[meha _di_Z[ j^[ j[cfehWho Xh_Z][
_cfhel[ij^[fh_cWhoijWX_b_joe\j^[_cfbWdjiW]W_dij
[WY^ej^[hWdZ_ih[Yecc[dZ[ZfWhj_YkbWhbo_\bWh][
ifWdi ^Wl[ je X[ Xh_Z][Z X[jm[[d j^[ _cfbWdji$
M^_b[ j^[ Z[Y_i_ed m^[j^[h j^[ j[cfehWho Xh_Z][
i^ekbZ X[ l[d[[h[Z m_j^ Y[hWc_Yi eh WYhob_Y h[i_d
_i XWi_YWbbo b[\j je j^[ ki[hÉi Z_iYh[j_ed" j^[ ki[ e\
Y[hWc_Yi_i][d[hWbbofh[\[hWXb[$DemWZWoi"Y[hWc_Y
l[d[[hi YWd X[ \WXh_YWj[Z Wbceij Wi gk_Yabo Wi
h[i_d l[d[[hi$ Ceh[el[h" j^[o Wh[ [Wi_[h je Yb[Wd
WdZ Wh[ b[ii ikiY[fj_Xb[ je fbWgk[ WYYkckbWj_ed$
=eeZ h[ikbji ^Wl[ X[[d eXjW_d[Z m_j^ iodj^[j_Y
Y[hWc_Yi_d][d[hWbWdZm_j^IodifWh_dfWhj_YkbWh$
J^_i fheZkYj b[dZi _ji[b\ efj_cWbbo je ikXjhWYj_l[
WZ`kijc[djiWjWbemh_iae\Y^_ff_d]$J^[if[Yjhkc
e\cWj[h_Wbi\ehj^[c[jWb\hWc[meha_iij_bbb_c_j[Z
 ¬ 
Xo Yeij WdZ m[_]^j Yedi_Z[hWj_edi$ ?d \WYj" 9e9hCe
WbbeoiWdZf[h^Wfij_jWd_kcYedj_dk[jeX[j^[edbo
fhWYj_YWbY^e_Y[$8h_Z][icWZ[e\p_hYed_kcWh[dej
Wdefj_edWjj^_ife_dj"Wij^[oZedejWbbemieYa[ji
jeX[Ykjj^WjWh[icWbb[dek]^jeWYYecceZWj[j^[
[njh[c[boib_c8E?WXkjc[dji$
Heej YWdWb j[[j^ Wh[ dej kd_\ehcbo ^WdZb[Z _d
Yb_d_YWb fhWYj_Y[$ M^_b[ oekd][h Z[dj_iji j[dZ je
^Wl[ Yedi_Z[hWXb[ jhkij _d XedZ_d] fheY[Zkh[i"
[nf[h_[dY[Z Z[dj_iji j[dZ je fh[\[h Y[c[dj[Z feiji
\ehj^[h[YedijhkYj_ede\heejYWdWbj[[j^DWkcWdd
WdZBWd][(&&)$?dekh[nf[h_[dY["j^[X[ijijWX_b_jo
_i eXjW_d[Z Xo YWij feiji m_j^ bed] _djhW#YWdWb
\h_Yj_edWh[Wi$?j_iWbmWoih[Yecc[dZ[Z"^em[l[h"je
i[h_ekiboYedi_Z[hj^[efj_ede\[njhWYj_d]WdoikY^
j[[j^WdZh[fbWY_d]j^[cXo_cfbWdjih_]^jWmWo$
J^[ _cfh[ii_edi \eh j^[ Xh_Z][i i^ekbZ X[ jWa[d
m_j^ Yedl[dj_edWb i_b_Yed[i" febo[j^[h eh Wb]_dWj[
cWj[h_Wbi$?\Wfh[Y_i[_cfh[ii_edd[[ZijeX[jWa[d
h_]^j W\j[h j^[ _cfbWdjWj_ed fheY[Zkh[" YWh[ ckij
X[ jWa[d j^Wj j^[ \h[i^ ikjkh[i Wh[ dej f[d[jhWj[Z
Xo j^[ _cfh[ii_ed cWj[h_Wb$ J^[ Z[dj_ij ckij
[nYbki_l[boh[boed^_]^#l_iYei_jocWj[h_Wbi_dj^[i[
i_jkWj_ediWdZcWa[ikh[jeWffboj^[cedbojej^[
Wffhefh_Wj[ ikh\WY[i$ J^[ _dY_i_ed fWj^mWo ki[Z
_d j^[ _cfbWdjWj_ed fheY[Zkh[ _i Wbie h[b[lWdj _d
j^_i Yedd[Yj_ed$ ?\ j^[ _cfh[ii_ed _i je X[ jWa[d
_cc[Z_Wj[bo W\j[h j^[ fheY[Zkh[" j^[d Wdo dWjkhWb
WXkjc[dji i^ekbZ X[ [nYbkZ[Z \hec j^[ _dY_i_ed$
J^[ ki[ e\ Wd Wb]_dWj[ _cfh[ii_ed cWj[h_Wb mekbZ
X[Wl_WXb[Wbj[hdWj_l[_\WbbWXkjc[djiWh[_cfbWdji
eh _\ Wdo dWjkhWb WXkjc[dji ^Wl[ X[[d fh[fWh[Z _d
Wd _ie]_d]_lWb cWdd[h$ E\ Yekhi[" j^[ fekh_d] ij[f
^WijeX[f[h\ehc[Zm_j^ekjZ[bWo_dj^_ii_jkWj_ed$
<khj^[hceh[" j[Y^d_gk[i ^Wl[ X[[d Z[iYh_X[Z _d
m^_Y^ _cfh[ii_ed#jWa_d] WdZ X_j[ h[]_ijhWj_ed Wh[
f[h\ehc[Zi_ckbjWd[ekibom_j^WdeYYbkiWbh_cjhWo$
J^_i WffheWY^ e\\[hi j^[ WZlWdjW][ j^Wj Wdo ib_]^j
cWbfei_j_ed_d]e\j^[Wdj[h_eh_cfbWdjiehWXkjc[dji
YWdX[Z[j[Yj[ZWdZYehh[Yj[Z_dWj_c[bocWdd[h$
?cfh[ii_ed#jWa_d]m_j^X_j[h[]_ijhWj_edjhWoim_bb
WbmWoi _dYbkZ[ Wd WZ[gkWj[bo bWh][ ^eb[ WhekdZ j^[
_cfbWdji$ ?d ej^[h mehZi" j^[ _cfh[ii_ed cWj[h_Wb
YWd X[ Wffb_[Z j^hek]^ j^[i[ ^eb[i W\j[h j^[ jhWo
^WiX[[d_di[hj[Z"m^_Y^h[ZkY[ij^[h_iae\i_b_Yed[
cWj[h_Wb X[_d] fki^[Z _dje j^[ ikjkh[i$ 7dej^[h
',, 9^Wfj[h''È 0ROSTHETICÈ4REATMENTÈ#ONSIDERATIONS
efj_ed_ijeki[Wb]_dWj[edj^[XWi[e\j^[jhWom^_b[
ki_d] i_b_Yed[ ed j^[ WXkjc[dj fWhj \eh j^[ WYjkWb
_cfh[ii_ed#jWa_d]$
7b]_dWj[ _i W f[h\[Yjbo i[hl_Y[WXb[ _cfh[ii_ed
cWj[h_Wb_d_jiemdh_]^j\ehWdoh[ijehWj_edij^WjWh[
ikffehj[ZXo8E?_cfbWdjiedbo$
È
!BUTMENTÈ3ELECTION
?j _i ][d[hWbbo h[Yecc[dZ[Z je ki[ Y[c[dj[Z
ikf[hijhkYjkh[i ed [nj[hdWb#j^h[WZ 8E? _cfbWdji$
?j _i j^[h[\eh[ Yb[Wh j^Wj j^[ bed][ij WXkjc[dji
feii_Xb[^Wl[jeX[i[b[Yj[Z\ehcWn_ckch[j[dj_ed$
<khj^[hceh["_j_iWbmWoiX[jj[hjeki[j^_Ya[hWXkj#
c[djiWdZh[ZkY[j^[cj^Wdje_di[hji^ehj[hj^_dd[h
WXkjc[dji$ BWh][#ifWd ikf[hijhkYjkh[i i^ekbZ
j^[h[\eh[dejX[XWi[ZedJI:*#jof[WXkjc[dji$J^[
X[ij Y^e_Y[ _d j^_i i_jkWj_ed mekbZ X[ je ki[ JI:+#
jof[WXkjc[dji"j^[^[_]^j#WZ`kij_d]JI://Z[i_]d"
ehj^[[bed]Wj_d]JI:++Z[i_]d\[Wjkh_d]Wfeb_i^[Z
i^W\j$ J^hek]^ j^[ ki[ e\ :[bh_d WXkjc[dji" fWhj
e\ j^[ [bWij_Y Z[\ehcWj_ed _d j^[ [bWij_Y `Wm YWd X[
h[beYWj[Zjej^[_dj[h\WY[Wh[WX[jm[[dj^[j^h[WZ[Z
f_d WdZ j^[ WXkjc[dj$ M^[j^[h :[bh_d WXkjc[dji
YWd X[Yec[ f[hcWd[djbo WdY^eh[Z _d j^[ fh[i[dY[
e\^_]^ijh[ii[iWYj_d]edj^[\_d[j^h[WZih[cW_dije
X[[ijWXb_i^[Zj^hek]^Yb_d_YWbijkZ_[i$
J^[[bed]Wj_d]JI:**%JI:++_cfbWdjWXkjc[dji
Wh[WiieY_Wj[Zm_j^ikXijWdj_Wbbo^_]^[hb[l[h\ehY[i
WYj_d] ed j^[ Z_iai$ J^[ Z[dj_ij ckij j^[h[\eh[
cWa[ ikh[ j^Wj Wdo Xh_Z][i Wh[ i[Wj[Z ed j^[i[
WXkjc[djieh"\ehj^WjcWjj[h"edWdo_cfbWdjim_j^
^_]^=#lWbk[i_dWdWXiebkj[boj[di_ed#\h[[cWdd[h$
7do \h_Yj_ed" Wi dehcWbbo fh[i[dj ed dWjkhWb jeej^
WXkjc[dji"i^ekbZX[Wle_Z[Z$
FbWij_Y WdWbe]k[i Wh[ WlW_bWXb[ \eh Wbb WXkjc[dj
jof[i0
"CVUNFOU
*NQMBOU
"CVUNFOU

$BTUJOH

"OBMPHVF
"OBMPHVF

54%

54%

%"
*"


*"
%5*
*"
1"
54%

54%

%"
*"


*"
%5*
*"
1"
54%

%"
*"

*"
1" v J^[ c[jWb i^ekbZ[h _i el[hYedjekh[Z ed
?j _i Wbie feii_Xb[" ^em[l[h" je ki[ eh_]_dWb WXkj#
c[dji WdZ _cfbWdj WdWbe]k[i _d j^[ bWXehWjeho$
J^[ bWjj[h WffheWY^ _i h[Yecc[dZ[Z if[Y_\_YWbbo _\
j^[ WXkjc[dji Wh[ je X[ i[b[Yj[Z Xo j^[ j[Y^d_Y_Wd
i[[ I[Yj$''$(" _d m^_Y^ YWi[ j^[ bed][ij feii_Xb[
WXkjc[dj _i ki[Z \eh _cfh[ii_ed#jWa_d]$ J^[
WXkjc[dj _i j^[d h[cel[Z" iYh[m[Z W]W_dij Wd
WdWbe]k[ WdZ [cX[ZZ[Z _d fbWij[h$ 7\j[h i[b[Yj_d]
WdZ cekdj_d] Wd Wffhefh_Wj[ WdWbe]k[" j^[ Z[dj_ij
YWd\WXh_YWj[j^[h[ijehWj_l[mehaedj^_iceZ[b$J^[
j[Y^d_Y_Wd i^ekbZ _dlWh_WXbo ki[ Wd ?7// _cfbWdj
WdWbe]k[_dj^_iWffheWY^"iej^Wjj^[WXkjc[djYWd
WbmWoiX[im_jY^[ZjeWJI://Z[i_]d_\Yedi_Z[h[Z
Wffhefh_Wj[$
È
#OLLABORATIONÈWITHÈTHEÈ,ABORATORY
EdY[ j^[ \hWc[meha ^Wi X[[d \WXh_YWj[Z" _j _i jh_[Z
_d$ BWh][#ifWd Xh_Z][i cWZ[ \hec 9e9hCe YWd
^WhZbo [l[h X[ YWij \hec W i_d]b[ mehaf_[Y[ Zk[ je
j^[ijhkYjkhWbZ[\ehcWj_ediWiieY_Wj[Zm_j^YWij_d]$
J^[mehaf_[Y[iWh[[_j^[hi[fWhWj[ZW\j[hceZ[bb_d]"
eh j^[o Wh[ i[fWhWj[bo ceZ[bb[Z _d j^[ \_hij fbWY[$
?\ j^[ ceZ[b _i Yedi_Z[h[Z jhkijmehj^o" j^[d j^[
mehaf_[Y[iYWdX[Wii[cXb[Zh_]^j_dj^[bWXehWjeho$
Ej^[hm_i["j^[oWh[i[fWhWj[bo_di[hj[ZWdZXedZ[Z
je][j^[h _d j^[ fWj_[djÉi cekj^ m_j^ W \Wij#Ykh_d]
WYhob_Y h[i_d [$]$ FWjj[hd H[i_d$ =h[Wj YWh[ ckij
X[ [n[hY_i[Z _d Wii[cXb_d] j^[ mehaf_[Y[i ed j^[
iebZ[h[Z ceZ[b _d ehZ[h je Wle_Z Yehhei_l[ bWo[hi$
B[ii[nf[di_l[Wbj[hdWj_l[ijebWi[hiebZ[h_d]mekbZ
_dYbkZ[ c_YhefbWicW iebZ[h_d] eh [l[d bWh][h J?9
ioij[ci" m^_Y^ Ze dej h[gk_h[ j^[ ki[ e\ W iebZ[h$
M^_b[c_YhefbWicWioij[ciWh[ceh[[nf[di_l[j^Wd
J?9 ioij[ci" j^[o _dYbkZ[ j^[ efj_ed e\ ikXi[gk[dj
Æh[ceZ[bb_d]ÇXoWZZ_j_ede\c[jWb$
J^[ Z[\_d_j_l[ X_j[ h[]_ijhWj_ed YWd kikWbbo X[
f[h\ehc[Z i_ckbjWd[ekibo m_j^ j^[ \hWc[meha
jho#_d$ ?\ j^[ feijef[hWj_l[ ckYeiWb im[bb_d] ^Wi
Wbh[WZo h[iebl[Z Xo j^Wj j_c[" Wd el[h#_cfh[ii_ed
m_j^ Wb]_dWj[ eh i_b_Yed[ i^ekbZ X[ jWa[d m_j^ j^[
Z[\_d_j_l[bojh_[Z#_d\hWc[meha_dfbWY[$J^[h[bWj_edi
X[jm[[dj^[Xh_Z][WdZj^[ckYeiWm_bbX[Z_ifbWo[Z
X[jj[h_dj^[h[ikbj_d]ceZ[b$;Whbo]Wf\ehcWj_ed_i
Wle_Z[Z" WdZ j^[ Xh_Z][i j^ki \WXh_YWj[Z m_bb [Wi_bo
h[cW_dkiWXb[_dj^[c[Z_kcWdZbed]j[hc$
?cfbWdji ^Wl[ X[[d i[b[Yj[Z Yehh[Yjbo _\ j^[
j^h[WZ[Z i^W\j fehj_ed Yec[i je X[ beYWj[Z Wj b[Wij
'cc WXel[ j^[ ckYeiW" ikY^ j^Wj j^[ jhWdi_j_edWb
ped[ X[jm[[d \_njkh[ WdZ WXkjc[dj _i WYY[ii_Xb[
m_j^ehWb^o]_[d[_dijhkc[dji$J^_ih[gk_h[c[dj^Wi
_cfb_YWj_edi\ehj^[meha_dj^[Z[djWbbWXehWjeho0
j^[ l[ij_XkbWh Wif[Yj e\ j^[ W[ij^[j_Y ped[$ 7
fkdYj_\ehc YedjWYj e\ j^[ c[jWb%Y[hWc_Yi m_j^
j^[ ckYeiW _i [ijWXb_i^[Z$ 7j j^[ iWc[ j_c["
j^[ ifWY[ X[jm[[d j^[ j^h[WZ[Z f_d WdZ j^[
l[ij_XkbWh Wfhed ckij X[ WYY[ii_Xb[ \eh Xhki^_d]
WdZ\beii_d]$
v J^[ ped[ m^[h[ j^[ WXkjc[dj c[[ji j^[ Xh_Z][
\hWc[meha _i m_j^_d j^[ hWd][ e\ Xhki^_d] WdZ
\beii_d]$ J^[h[\eh[" j^[ fh[Y_i[ \_j e\ j^[ Xh_Z][
_i ckY^ b[ii e\ W h[gk_h[c[dj j^Wd m_j^ iYh[m
_cfbWdji eh dWjkhWb j[[j^$ 7bie" j^[ ]Wf X[jm[[d
j^[ WXkjc[dj WdZ j^[ Xh_Z][ YWd X[ h[b_WXbo
È È 0ROSTHETICÈ4REATMENTÈ3TEPSÈ
Ybei[Z_dWf[hcWd[djcWdd[hm_j^j^[Y[c[dji
WlW_bWXb[ jeZWo$ J^[ `eX e\ j^[ Z[djWb j[Y^d_Y_Wd
_i ]h[Wjbo \WY_b_jWj[Z Xo j^[i[ WZlWdjW][i" m^_Y^
Wh[ fWhj_YkbWhbo h[b[lWdj _d j^[ cWdZ_Xb[$ 7\j[h
Wbb" f[h\[Yj Yed]hk[dY[ X[jm[[d j^[ WXkjc[dji
WdZ j^[ \hWc[meha _i l_hjkWbbo kdWjjW_dWXb[ _d
Yecfb[j[cWdZ_XkbWhXh_Z][i"]_l[dj^[\b[n_ede\
j^[ `Wm Xed[$7do i^Whf fhe`[Yj_d] Wh[Wi YWd X[
[Wi_boYehh[Yj[Z"hekdZ[ZWdZfeb_i^[Z$
:kh_d] j^[ Y[hWc_Y jho#_d" \kdYj_edWb Wif[Yji Wh[
[lWbkWj[ZWim[bbWij^[i^WZ[WdZi^Wf[e\j^[Xh_Z][$
<khj^[hceh[" WXhWi_l[ _dijhkc[dji YWd X[ b_X[hWbbo
ki[Z_dj^_ii[ii_ed"m^_Y^jWa[ifbWY[X[\eh[j^[bWij
\_h_d] ij[f _i f[h\ehc[Z$M^_b[ icWbb[hÆi[]c[djWbÇ
Xh_Z][iYWde\j[dX[\_d_i^[Z_dj^[bWXehWjehom_j^
ded[[Z\ehWc[jWbjho#_d"j^[Z[cWdZiedj^[X_j[
h[]_ijhWj_ed Wh[ ]h[Wj[h _d j^_i i_jkWj_ed$ 7\j[h Wbb"
W XWbWdY[Z ckiYb[ WYj_l_jo m_bb dej X[ h[ijeh[Z Wdo
j_c[ieed\ebbem_d]j^[_cfbWdjfheY[Zkh[_\fWhj_Wb
[Z[djkb_ic mWi fh[i[dj \eh Wd [nj[dZ[Z f[h_eZ
e\ j_c[" m^_Y^ _i fWhj_YkbWhbo jhk[ e\ YWdj_b[l[h
i_jkWj_edi$ J^[h[\eh[" [l[d j^ek]^ j^[h[ cWo X[ de
[l_Z[dji_]die\coeWhj^hefWj^o"j^[X_j[YWddejX[
h[b_WXboh[]_ij[h[Z_dj^[feijef[hWj_l[f^Wi[$
J[cfehWho Y[c[dji i^ekbZ X[ Wle_Z[Z ed YWi[i
m_j^ ijhWj[]_Y _cfbWdj fei_j_ed_d] _\ feii_Xb[$7\j[h
Wbb"fWj_[djim^e^Wl[]hemdki[ZjeceX_b[Z[djkh[i
el[h j^[ o[Whi YWddej X[ [nf[Yj[Z je YecfbW_d
WXekj" eh [l[d dej_Y[" Wdo Z[XedZ_d] e\ _dZ_l_ZkWb
WXkjc[dji$?\Z[XedZ_d]eYYkhiedi[l[hWbWXkjc[dji"
j^[ h[cW_d_d] XedZ[Z WXkjc[dji m_bb X[ ikX`[Yj[Z
je _dYh[Wi_d]bo [nY[ii_l[ beWZi" m^_Y^ cWo ]_l[
h_i[ je _d_j_Wbbo ded#XWYj[h_Wb WdZ j^ki h[l[hi_Xb[
eij[eboi_i eh \hWYjkh[i$ ?d fWj_[dji m_j^ ]eeZ
Yecfb_WdY[" 8E? h[ijehWj_edi YWd Wbie X[ Y[c[dj[Z
j[cfehWh_bo el[h W bed][h f[h_eZ" [if[Y_Wbbo _\ j^[
dkcX[h e\ WXkjc[dji _i bWh][ WdZ j^[ cWij_YWj_ed
_i XWbWdY[Z$ J^_i fh[ikffei[i j^Wj _j _i [dikh[Z
j^Wj fWj_[dji m_bb Wff[Wh Wj j^[ Z[djWb e\\_Y[ [l[d
X[jm[[d iY^[Zkb[Z h[YWbbi _d j^[ [l[dj j^Wj j^[
j[cfehWh_bo Y[c[dj[Z h[ijehWj_ed i^ekbZ beei[d$
?dYWi[j^Wjj^[fbWd[e\X_j[_idej_Z[Wbe\XWbWdY[
_i c_ii_d]" [l[d Z[\_d_j_l[bo Y[c[dj[Z h[ijehWj_edi
m_bb beei[d h[]kbWhbo eh j^[ f[h_cfbWdj Xed[ m_bb
i^em i_]di e\ eij[eboi_i eh j^[ _cfbWdj m_bb Xh[Wa$
H[\[hje9^Wfj[h'&\ehZ[jW_biWXekj[ijWXb_i^_d]j^[
d[Y[iiWho[gk_b_Xh_kce\\ehY[i$
7bbademdZ[\_d_j_l[Y[c[djiYWdX[ki[Z$7\j[hj^[
Y[c[dj_d]ij[f^WiX[[dYecfb[j[Z"j^[cWij_YWjeho
\kdYj_edd[[ZijeX[Y^[Ya[Z$EYYbkiWbYedi_Z[hWj_edi
Wh[ b[ii _cfehjWdj" [nY[fj j^Wj WdjW]ed_iji ckij
X[ a[fj _d j^[_h fei_j_edi$ 7\j[h Wbb" j^[ jh[Wjc[dj
eX`[Yj_l[ _i je e\\[h \kdYj_edWb _dYehfehWj_ed e\
j^[ _cfbWdj#h[ijehWj_ed ioij[c$ J^[ cWij_YWjeho
\kdYj_ed _i j^[ cW_d Wif[Yj e\ j^_i ]eWb$ 7i \Wh Wi
eYYbkiWb fWhWc[j[hi Wh[ YedY[hd[Z" _j _i kikWbbo
',-
ik\\_Y_[djje[ijWXb_i^WicWbbdkcX[he\X_bWj[hWbWdZ
i_ckbjWd[ekiYedjWYjfe_dji"if[Y_\_YWbbo_dj^[Wh[W
e\j^[fWbWjWbYkifi$
;nj[di_l[ijhkYjkh[i^Wl[jeX[\ebbem[ZkfYbei[bo
_d WYYehZWdY[ m_j^ j^[ [n_ij_d] ckiYb[ i_jkWj_ed"
[if[Y_Wbbo _d j^[ fh[i[dY[ e\ coeWhj^hefWj^o WdZ
WXdehcWbeYYbkiWbh[bWj_edi^_fi$J^[\_hij\ebbem#kf
l_i_j_iiY^[Zkb[Zm_j^_dj^[\_hijjmeje\ekhm[[ai$
?\[nj[di_l[cWij_YWjehoWdZeYYbkiWbYehh[Yj_ediWh[
h[gk_h[Z Wj j^_i fe_dj" W i_c_bWh _dj[hlWb _i i[b[Yj[Z
kdj_bj^[d[njl_i_j$?\j^[X_j[i_jkWj_ed^WiWffh[Y_WXbo
h[bWn[Z WdZ cel[Z jemWhZi Y[djh_Y h[bWj_edi" j^[
fWj_[dj i^ekbZ Yec[ XWYa W\j[h WhekdZ )cedj^i$
?\ j^[ fei_j_edWb WdZ \kdYj_edWb h[bWj_edi^_fi ^Wl[
ijWX_b_p[Z Xo j^Wj j_c[" j^[ \ebbem#kf fhejeYeb YWd
X[ im_jY^[Z je ,#cedj^ _dj[hlWbi$ HWZ_e]hWf^i Wh[
eXjW_d[Z i[c_WddkWbbo _d j^[ \_hij jme o[Whi$ 7\j[h
j^Wj"hWZ_e]hWf^_Y[nWc_dWj_edim_bbedboX[h[gk_h[Z
_\ WdZ m^[d fheXb[ci eYYkh$ ?\ j^[ h[ijehWj_ed Wbie
_dYbkZ[i h[i_ZkWb jeej^ ijhkYjkh[i Wbed]i_Z[ j^[
8E?_cfbWdji"hWZ_e]hWf^im_bbe\Yekhi[^Wl[jeX[
eXjW_d[Zf[h_eZ_YWbboedWbed]#j[hcXWi_i$
?d j^[ fh[i[dY[ e\ WZlWdY[Z h_Z][ h[iehfj_ed eh
h[bWj_l[ cWbfei_j_ed_d] e\ j^[ `Wmi" _j _i Yeccedbo
eXi[hl[Z j^Wj j^[ fei_j_edi e\ j^[ _cfbWdji Wh[
Wj lWh_WdY[ m_j^ j^[ ikXi[gk[dj fei_j_ed e\ j^[
fheij^[j_Y j[[j^$ J^_i f^[dec[ded _i Zk[ je j^[
Y[djh_f[jWbWdZY[djh_\k]Wbh[iehfj_edfWjj[hdie\j^[
cWn_bbWWdZcWdZ_Xb["h[if[Yj_l[bo$?dej^[hmehZi"j^[
j^h[WZ[Zf_di_dj^[cWdZ_Xb[m_bbWbmWoiX[beYWj[Z
_d W ib_]^jbo ceh[ l[ij_XkbWh fei_j_ed j^Wd Z[i_h[Z"
m^_b[ j^ei[ _d j^[ cWn_bbW m_bb X[ Y^WhWYj[h_p[Z Xo
Wd el[hbo fWbWjWb fei_j_ed$ Ej^[h Yed\_]khWj_edi Wh[
dWjkhWbboWbiefeii_Xb[_\if[Y_\_Yi_jkWj_edi_dj[hci
e\h[bWj_l[`Wmm_Zj^ieheYYbkiWbh[bWj_ediWh[fh[i[dj$
<_hije\Wbb"WdW]h[[c[djckijX[h[WY^[Zm_j^j^[
j[Y^d_Y_Wd m^[j^[h j^[ fheij^[j_Y ijhkYjkh[ i^ekbZ
X[ Y^WhWYj[h_p[Z Xo dehcWb eh YheiiX_j[ eYYbkiWb
h[bWj_edi$8ej^WffheWY^[iWh[l_WXb["fhel_Z[Zj^Wj
j^[ Xkba e\ j^[ h[ijehWj_ed m_bb X[ beYWj[Z el[h j^[
ikffehj_d] febo]ed e\ j^[ beWZ#jhWdic_jj_d] 8E?
ikh\WY[i$ 9bei[ YebbWXehWj_ed m_j^ j^[ bWXehWjeho _i
Wi_d[gkWded_dj^_ii_jkWj_ed"i_dY[j^[j[Y^d_Y_Wd
Ze[idejademj^[fei_j_ede\j^[XWiWbfbWj[i$J^[
]h[Wj[h j^[ Z_ijWdY[ e\ j^[ Y^[m_d] ikh\WY[i \hec
j^[ikffehj_d]febo]ed"j^[]h[Wj[hj^[dkcX[hWdZ
bWh][hj^[i_p[e\j^[Z_iaijeX[_di[hj[Z$
È
4YPESÈOFÈ/VERLOAD
:k[ je j^[_h ^[Wl_bo \eYki[Z beWZ#jhWdic_jj_d]
ikh\WY[i" 8E? _cfbWdji Wh[ ceh[ ikiY[fj_Xb[ je
el[hbeWZ_d] _d j^[ [Whbo feijef[hWj_l[ f^Wi[$ M[
Z_ij_d]k_i^ X[jm[[d \ekh jof[i e\ fheij^[j_Y el[h#
beWZ_d]" m^_Y^ m_bb X[ Z_iYkii[Z _d j^[ \ebbem_d]
fWhW]hWf^i$
',. 9^Wfj[h''È 0ROSTHETICÈ4REATMENTÈ#ONSIDERATIONS
È
0RIMARYÈ/VERLOAD
7i_jkWj_ed_dm^_Y^j^[fheij^[j_YijhkYjkh[i^emi
[Whbo YedjWYji Wj ed[ eh i[l[hWb _cfbWdj i_j[i cWo
X[ Z[\_d[Z Wi fh_cWho el[hbeWZ$ J^[i[ i_jkWj_edi
Wh[WZZh[ii[ZXoYWh[\kbboh[ZkY_d]j^[W\\[Yj[Z`Wm
i[]c[djim_j^WXhWi_l[_dijhkc[dji$
È È
3ECONDARYÈ/VERLOAD
7 i_jkWj_ed _d m^_Y^ j^[ ifWj_Wb fei_j_ed e\ j^[
cWdZ_Xb[Y^Wd][iWiWh[ikbje\Wbj[h[ZckiYb[\kdY#
j_ed cWo X[ Z[\_d[Z Wi i[YedZWho el[hbeWZ$ J^[i[
i_jkWj_edi kikWbbo eYYkh m_j^_d j^[ \_hij cedj^i
W\j[h _di[hj_d] W h[ijehWj_ed$ I[YedZWho el[hbeWZ
i_jkWj_edi Z[l[bef dWjkhWbbo m^_b[ j^[ cWij_YWjeho
\kdYj_ed _i kdZ[h]e_d] WZWfj_l[ fheY[ii[i$ J^[o
Wh[WZZh[ii[Z_dj^[iWc[mWoWifh_cWhoel[hbeWZ
i_jkWj_edi Xo h[ZkY_d] j^[ W\\[Yj[Z i[]c[dji eh
Xo hW_i_d] ej^[h i[]c[dji$ J^[o Wh[ dej W h[ikbj e\
_dYehh[Yj jh[Wjc[dj Xkj e\ ckiYkbWh h[WYj_edi$ J^[
Yb_d_Y_Wdi^ekbZ_d\ehcj^[fWj_[dje\j^_i[l[djkWb_jo
_dWZlWdY[ieWijeWle_Zc_ikdZ[hijWdZ_d]i$
I[YedZWho el[hbeWZ i_jkWj_edi Wh[ YWki[Z Xo
i^ehj#j[hc _dj[hWYj_edi X[jm[[d Y^[m_d] ckiYb[i
WdZ j^[_h d[khedWb Yedjheb$ J^[o YWd Wbie Z[l[bef
WiWh[ikbje\Y^Wd][i_dj^[`Wmcehf^ebe]o"m^_Y^
_i W h[ifedi[ je Wbj[h[Z \kdYj_edWb fWjj[hdi WdZ j^[
i_jkWj_ede\dekh_i^c[djWdZZhW_dW][e\j^[Xed[$
I[YedZWhoel[hbeWZh[gk_h[i\h[gk[djWZWfjWj_edie\
j^[ eYYbkiWb fbWj\ehc" Xo \Wh ceh[ j^Wd ed[ mekbZ
[nf[Yj \hec j^[ [nf[h_[dY[ e\ meha ed dWjkhWb
WXkjc[dji$
È
4ERTIARYÈ/VERLOAD
7i W h[ikbj e\ ed]e_d] bed]#j[hc \kdYj_edWb WZWf#
jWj_edi m^_b[ [d]hWci ]el[hd_d] j^[ Yedjheb e\
j^[ cWij_YWjeho WdZ feijkhWb ckiYb[i Wh[ X[_d]
h[Z[\_d[Z" j^[ X_cWn_bbWho fei_j_edWb h[bWj_edi cWo
kdZ[h]eikXijWdj_WbY^Wd][ij^Wjh[gk_h[Yehh[Yj_ed
[l[do[WhiW\j[h_di[hj_ed$7i\WhWi_cfbWdj#ikffehj[Z
h[ijehWj_edi Wh[ YedY[hd[Z" j^[i[ i_jkWj_edi cWo
X[ Z[iYh_X[Z Wi j[hj_Who el[hbeWZ i_jkWj_edi$ J^[o
Wh[ Yehh[Yj[Z Xo h[ZkY_d] j^[ W\\[Yj[Z Wh[Wi eh" _\
d[Y[iiWho" Xo h[fbWY_d] j^[ [dj_h[ h[ijehWj_ed$ J^_i
mehij#YWi[iY[dWh_ecWoYec[jefWii_\h[]kbWhZ[djWb
h[bWj_ediWdZWdehcWbcWij_YWjeho\kdYj_edYWddej
X[h[[ijWXb_i^[ZXoi_cfb[WXhWi_l[WZ`kijc[djieh_\
j^[l[hj_YWbZ_c[di_ed^WiX[[d[nY[ii_l[boh[ZkY[Z
Xodkc[hekiWZ`kijc[dji$
EdY[ W]W_d" j^_i jof[ e\ i_jkWj_ed _i dej Zk[
je jh[Wjc[dj [hhehi Xkj _i YWki[Z Xo bed]#j[hc
dehcWb_pWj_ede\j^[cWij_YWjeho\kdYj_edWim[bbWi
W][#h[bWj[ZWbj[hWj_edi_d`Wmcehf^ebe]o$
J^[ [nj[dj WdZ j^[ Yedi[gk[dY[i e\ i[YedZWho
WdZ j[hj_Who el[hbeWZ i_jkWj_edi" Wi m[bb Wi j^[
j_c[\hWc[i_dlebl[Z"m[h[dej\kbboWffh[Y_Wj[ZWdZ
WdWboi[Z X[\eh[ Z[djWb _cfbWdjebe]o mWi _dYbkZ[Z
_d j^[ j^[hWf[kj_Y if[Yjhkc 8eea [j Wb$ '//($
Bed]#j_c[ ki[hi e\ 8E? _cfbWdji ^Wl[ b[Whd[Z ^em
je Z[Wb m_j^ j^_i jof[ e\ fheXb[ci$ Del_Y[i" ed
j^[ ej^[h ^WdZ" ckij fWo Ybei[ Wjj[dj_ed je j^[
if[Y_\_Y Y_hYkcijWdY[i je Wle_Z jh[Wjc[dj \W_bkh[$
JC@i Wh[ hekj_d[bo eXi[hl[Z je cel[ kf je +Yc
WdZ iec[j_c[i Wi ckY^ Wi 'Yc Wi \kdYj_edWb
WXdehcWb_j_[i h[iebl[$ FWj_[dji m_j^ ia[b[jWb 9bWii
?? h[bWj_edi WdZ ]h[Wjbo Wbj[h[Z JC@ cehf^ebe]o
jof_YWbbo [n^_X_j ]h[Wj[h fei_j_edWb lWh_WX_b_jo$ I_dY[
8E? _cfbWdji Wh[ j^[ edbo efj_ed \eh fWj_[dji m_j^
WZlWdY[Z`Wmh[iehfj_edjeh[Y[_l[W\_n[Zh[ijehWj_ed
_dWi_d]b[fheY[Zkh["j^[[nf[h_[dY[e\Yedl[dj_edWb
h[ijehWj_l[fheY[Zkh[iYWddejX[h[WZ_bojhWdi\[hh[Z
je j^[ 8E? YedY[fj" WdZ _j Y[hjW_dbo YWddej X[
jhWdi\[hh[Z m_j^ekj gkWb_\_YWj_edi$ M[ Yedj_dk[
je X[ \WY[Z m_j^ j^[ fheXb[c j^Wj cWdo ded#
Wkj^eh_p[Z[nf[hjiWh[kdWmWh[e\ehkdZ[h[ij_cWj[
j^[ Yedi[gk[dY[i e\ j^[i[ WZWfjWj_ed fheY[ii[i"
ie j^Wj j^[_h \ehcWb ef_d_edi Wh[ e\j[d cWhh[Z Xo
kd\ehjkdWj[c_i`kZ][c[dji$
D[l[hj^[b[ii" j^[i[ jhW_di e\ j^ek]^j Wh[ X[_d]
_dYh[Wi_d]bo fkhik[Z Xo Yh[ijWb _cfbWdjebe]_iji
Wi m[bb$ ?dj[h[ij_d]bo" [l[d j^[ Kd_l[hi_jo e\ 8[hd"
Im_jp[hbWdZ" i[[ci je ^Wl[ WXWdZed[Z j^[ WXiebkj[
YedY[fj e\ ÆX_j[ h[]_ijhWj_edÇ _d \Wlekh e\ ÆX_j[
j[ij_d]ÇC[h_Yi[#Ij[hd(&&($
?iik[iYedY[hd_d]j^[h[]_ijhWj_ede\`e_djfei_j_ed
Wh[X[oedZj^[iYef[e\j^_iYecckd_YWj_ed$;njh[c[
`Wm h[iehfj_ed _i l_hjkWbbo WbmWoi WYYecfWd_[Z Xo
fW_d\kb eh WiocfjecWj_Y coeWhj^hefWj^o$ <WY[Xem
h[]_ijhWj_ed _i j^[h[\eh[ W gk[ij_edWXb[ c[Wikh[
9WhbiiedWdZCW]dkiied(&&&Wi_jih[ikbjmekbZ
`kij h[\b[Yj W fWj^ebe]_YWb i_jkWj_ed$ J^[h[ _i W h_ia
j^Wj j^_i fWj^ebe]_YWb i_jkWj_ed _i f[hf[jkWj[Z Xo
jhWdi\[hh_d]j^[i[\WY[XemZWjWjej^[d[mh[ijehWj_ed
m_j^ekj][jj_d]jej^[Xejjece\j^[fheXb[c$I_dY[
W iocc[jh_YWb fheij^[j_Y ekjYec[ _i Wd [ii[dj_Wb
jh[Wjc[dj eX`[Yj_l[" ej^[h j[Y^d_gk[i _dYbkZ_d] W
fbWd[h[YehZ^Wl[fhel[ZjeX[Wki[\kbWbj[hdWj_l[je
WhX_jhWhoh[]_ijhWj_edIY^jjb'//-$J^[>?F#cekdj
ioij[cZ[l[bef[Z\ehj^_ifkhfei[^Wij^[WZlWdjW][
j^Wjj^[>?FfbWd[Z[j[hc_d[Z_dj^[ceZ[bYWdX[
Y^[Ya[ZXoWfbWd[h[YehZm_j^j^[^[bfe\j^[>[WZ
B_d[i c[Wikh_d] Z[l_Y[$ I_dY[ j^[ ceZ[b _i WbmWoi
cekdj[Z _d j^[ Whj_YkbWjeh fWhWbb[b je j^[ eYYbkiWb
fbWd["_j_i[Wi_[h\ehj^[Z[djWbj[Y^d_Y_Wdje\WXh_YWj[
W^eh_pedjWbboYehh[Yjh[ijehWj_ed"m^_Y^"_djkhd"m_bb
[nf[Z_j[ j^[ WZWfjWj_ed e\ cWij_YWjeho \kdYj_ed$
?d ekh l_[m" j^[ >?F j[Y^d_gk[ [dWXb[i efj_cWb
^eh_pedjWb WZ`kijc[dj e\ j^[ cWij_YWjeho fbWd[$ ?ji
ki[hi m_bb _cc[Z_Wj[bo dej_Y[ Wdo [bed]Wj_edi _d
j^[ cWn_bbW" WdZ j^[o YWd [Wi_bo l[h_\o j^[ WXiebkj[
È È 0ROSTHETICÈ4REATMENTÈ3TEPSÈ ',/

^eh_pedjWb fbWd[ _d W h[b_WXb[ cWdd[h$ ;l[d j^_i
j[Y^d_gk[ YWddej" ^em[l[h" Y^Wd][ j^[ \WYj j^Wj
[nj[di_l[ ikXjhWYj_l[ WZ`kijc[dji eh YedjhWbWj[hWb
Yhemd_d]e\j[[j^m_bbX[d[Y[iiWho_dj^[fh[i[dY[
e\ ]h[Wjbo Z_l[h][dj 7<CF Wd]b[i ed Xej^ i_Z[i e\
j^[ `Wm$ <khj^[hceh[ m[ WbmWoi ^Wl[ je Yedi_Z[h
j^[l[hj_YWbWdZ^eh_pedjWbXed[b[l[bWhekdZj[[j^"
WhekdZ _cfbWdji WdZ X[jm[[d j[[j^" _cfbWdji WdZ
[l[d _d [Z[djkbeki i[Yj_edi e\ j^[ `Wm Wi ^_]^bo
kdijWXb[ WdZ WZWfj_d] je \kdYj_ed$ J^[ `e_dji i^em
WbWh][hWd][e\WZWfjWj_edjecWdoe\j^[Y^Wd][i"
WdZ j^ki Yecf[diWjeho [bed]Wj_edi" j^[ Xk_bZkf e\
d[m jhW`[Yjeh_[i" W][# WdZ [njhWYj_ed#h[bWj[Z Xed[
beii" Y^Wd][i _d Y^[m_d] \ehY[ WdZ cehf^ebe]_YWb
Y^Wd][i" m^_Y^ Wh[ \ebbem[Z Xo Y^Wd][i _d j^[
Y^[m_d]fWjj[hd$;l[dWÆYehh[YjÇY[djh_Yh[]_ijhWj_ed
_i XekdZ je Y^Wd][ Yedi_Z[hWXbo el[h j_c[" m^_Y^
m_bb b[WZ je el[hbeWZ ed j[[j^ WdZ _cfbWdji$ ?d
ekh [nf[h_[dY[ j^[ Y^Wd][i Wh[ ]h[Wj[h _d YWi[i
m^[h[ j^[ X_j[ _i dej XWbWdY[Z eh YedijhkYj_edi Wh[
kdiocc[jh_YWb$
h[cel_d] j^[ Z_ia X[YWki[ j^[h[ _i W h_ia j^Wj j^[
eij[eboj_Y Wh[W cWo X[Yec[ _d\[Yj[Z WdZ j^Wj j^_i
_d\[Yj_edcWo[l[difh[WZjej^[XWiWbZ_ia$7ibed]
Wij^[_d\[Yj_edh[cW_diYed\_d[Zjej^[Yh[ijWbZ_ia"
j^[_cfbWdjWiikY^YWdX[fh[i[hl[Z$
<_]kh[''$'_bbkijhWj[i^em8E?_cfbWdjimeha$J^_i
if[Y_\_Y_cfbWdjmWi_di[hj[Z_djej^[Yh[ijWbfWhje\
j^[Wbl[ebki_cc[Z_Wj[boed[njhWYj_d]jeej^*,$?d
ej^[hmehZi"j^[j^h[WZ[Zf_dmWid[l[hikhhekdZ[Z
Xo Xed[$M^_b[ j^[ h[cW_d_d] ifWY[ e\ j^[ Wbl[ebki
mWi\_bb[Zm_j^d[mbo\ehc[ZXed[Zk[je\kdYj_edWb
ij_ckbWj_ed" j^[ Wh[W e\ j^[ j^h[WZ[Z f_d h[cW_d[Z
ded#eii_\_[Z$J^[f_Yjkh[mWijWa[d+o[WhiW\j[hj^[
_cfbWdj^WZX[[d_di[hj[ZWdZ_cc[Z_Wj[bobeWZ[Z$
<_]kh[''$( i^emi W i_c_bWh YWi[ _d m^_Y^ j^[
_cfbWdj mWi" ^em[l[h" _di[hj[Z Yedi_Z[hWXbo ceh[
Z[[fbo$

È
)ATROGENICÈ4ERTIARYÈ/VERLOAD
J^[i[ i_jkWj_edi _dYbkZ[ _bb#WZl_i[Z eYYbkiWb
WZ`kijc[dji" kikWbbo cWZ[ Xo ej^[h Z[dj_iji m^e
Wh[ dej ik\\_Y_[djbo WmWh[ e\ j^[ fheXb[ci _dlebl[Z"
W\j[h eii_\_YWj_ed e\ j^[ XWiWb fbWj[i ^Wi X[[d
Yecfb[j[Z$?dYedjhWijjej^[h[]kbWhi[YedZWhoWdZ
j[hj_Whoel[hbeWZi_jkWj_edi"m^_Y^[lebl[]hWZkWbbo"
_Wjhe][d_Yj[hj_Whoel[hbeWZi_jkWj_edieYYkhWXhkfjbo
WdZ_dlebl[Wd[l[d^_]^[hh_iae\_cfbWdj\hWYjkh[$
7\j[h Wbb" j^[h[ _i dej [dek]^ j_c[ b[\j \eh j^[ m[bb#
eii_\_[Z8?E_cfbWdjjeh[WYjjej^[fheXb[cXomWo
e\el[hbeWZeij[eboi_i$ &IGÈ I_jkWj_ed_cc[Z_Wj[boX[\eh[jeej^*,mWi[njhWYj[Z
?Wjhe][d_Yel[hbeWZi_jkWj_edi"Wij^[dWc[_cfb_[i" WdZ h[fbWY[Z m_j^ Wd _cfbWdj _d j^[ iWc[ i[ii_ed ki_d]
_cc[Z_Wj[beWZ_d]
Wh[jeX[XbWc[Zed_dYehh[YjZ[djWbjh[Wjc[dj$?j_i
edbo \W_h je WZZ" ^em[l[h" j^Wj fWj_[dji m^e m[Wh
_cfbWdj#ikffehj[Zh[ijehWj_edi_dXej^`Wmim_bbdej
X[WXb[jedej_Y[WdZh[fehjWdofh[cWjkh[YedjWYji
Wih[WZ_boWifWj_[djim_j^dWjkhWbZ[dj_j_edi$
?d fWj_[dji m^e h[Y[_l[Z W \_hij 8E? h[ijehWj_ed
_d ed[ `Wm" \ebbem[Z Xo W i[YedZ 8E? h[ijehWj_ed
_d j^[ effei_j[ `Wm Wj W bWj[h j_c[" j^[ `Wm j^Wj
mWi jh[Wj[Z \_hij cWo X[ ikX`[Yj[Z je _Wjhe][d_Y
j[hj_Who el[hbeWZ_d] m^_b[ j^[ `Wm j^Wj mWi jh[Wj[Z
i[YedZcWoX[W\\[Yj[ZXoh[]kbWhjof[ie\fh_cWho"
i[YedZWho eh j[hj_Who el[hbeWZ$ 9Wi[i ikY^ Wi j^[i[
h[gk_h[ c[j_Ykbeki \ebbem#kf [nWc_dWj_edi WdZ
\kdYj_edWb WZ`kijc[dji Xo WZZ_j_l[ WdZ ikXjhWYj_l[
c[Wdi$
?dY_Z[djWbbo" eij[eboj_Y f^[dec[dW cWo h[cW_d
Yed\_d[Zje_dZ_l_ZkWbZ_iaie\Wd_cfbWdjeh_dZ[[Z
jeif[Y_\_Yfehj_edie\WZ_ia$M_j^j^[ebZZekXb[#Z_ia
_cfbWdjij^Wjij_bb\[Wjkh[ZWZ_ia#je#Z_iaZ_ijWdY[e\ &IGÈ I_jkWj_ed Wj j^[ ,#cedj^ \ebbem#kf$ J^[ [njhWYj_ed
)cc"j^[Yh[ijWbZ_iaki[ZjeX[ceh[ikiY[fj_Xb[je Wh[W ^Wi bWh][bo h[][d[hWj[Z$ 7 iceej^#i^W\j[Z ;:I '& ='&
eij[eboi_i$?dj^_ii_jkWj_ed"j^[Z[dj_ijckijYedi_Z[h _cfbWdjmWiki[Z
'-& 9^Wfj[h''È 0ROSTHETICÈ4REATMENTÈ#ONSIDERATIONS
J^[Yb_d_YWbZ[l[befc[dji_dj^[i[[nWcfb[iWjj[ij
je j^[ \WYj j^Wj W Yb[Wh#Ykj b_d[ X[jm[[d j^[ _d_j_Wb
jh[Wjc[djWdZj^[cW_dj[dWdY[f^Wi[YWddejWbmWoi
X[ ZhWmd$ J^_i [l[djkWb_jo ckij X[ fe_dj[Z ekj je
j^[ fWj_[dj je Wle_Z c_ikdZ[hijWdZ_d]i m^[d ^[
eh i^[ _i Y^Wh][Z \eh WZZ_j_edWb Z[djWb jh[Wjc[dji
j^Wj cWo X[Yec[ d[Y[iiWho W\j[h j^[ Yeij Y[_b_d]
\eh j^[ _d_j_Wb jh[Wjc[dj ^Wi X[[d h[WY^[Z$ ?d iec[
fWj_[dji" dejWXbo _d j^ei[ m_j^ coeWhj^hefWj^_[i" _j
_iZemdh_]^j_cfeii_Xb[jeZhWmWb_d[X[jm[[dj^[
_d_j_Wb jh[Wjc[dj WdZ j^[ cW_dj[dWdY[ f^Wi[$ 7\j[h
Wbb"coeWhj^hefWj^_[iWh[Y^hed_YZ_i[Wi[ij^WjcWo
h[gk_h[b_\[bed]j^[hWfo$
J^[ lWij cW`eh_jo e\ fWj_[dji" ^em[l[h" m_bb X[
WXb[je[d`eoWhWj^[hijWXb[WdZfW_d#\h[[YedZ_j_ed
j^Wdaijej^[h[Yel[hoe\Wf^oi_ebe]_YWbcWij_YWjeho
\kdYj_edm_j^_dW\[mcedj^i$
È
0ROSTHETICÈ'UIDELINES
J^[ eYYbkiWb h[bWj_edi m_bb e\j[d Z_\\[h i_]d_\_YWdjbo
\hec j^[ fh[ef[hWj_l[ i_jkWj_ed edY[ W Yecfb[j[
Xh_Z][ ^Wi X[[d _di[hj[Z$ ;if[Y_Wbbo _\ j^[ Y^[m_d]
ckiYb[im[h[^of[hjed_YWdZZoi\kdYj_edWb\ehcWdo
o[Whi"j^[h[ijehWj_l[mehaYWddejX[Yecfb[j[Z_dW
i_d]b[ij[fXkjh[gk_h[iW]hWZkWbWffheWY^$8[YWki[
defWhWc[j[he\j^[cWij_YWjeho\kdYj_edm_bbh[cW_d
kdY^Wd][ZXo\kbb#WhY^Xh_Z][i"j^[Z[dj_ijd[[Zije
f[h\ehc ikXjhWYj_l[ eh WZZ_j_l[ WZ`kijc[dji ed W
h[]kbWh XWi_i$ ?d ceij YWi[i" j^[ Z[fWhjkh[ fe_dj
\eh jh[Wjc[dj _i Wd Wbceij Ykifb[ii Z[djkh[ eh Wd
_dWZ[gkWj[h[i_ZkWbZ[dj_j_ed$J^[Ykif_dYb_dWj_edi
Wi m[bb Wi j^[ fei_j_ed WdZ dkcX[h e\ cWij_YWjeho
kd_ji Wh[ _d[l_jWXb[ Y^Wd][Z Xo j^[ h[ijehWj_l[
jh[Wjc[dj$?j_ij^[h[\eh[be]_YWbj^WjckiYb[\kdYj_ed
8[bi[hWdZ>WddWc'/.+WdZXed[cehf^ebe]om_bb
Y^Wd][Wim[bb$J^[bWjj[hm_bbY^Wd][ceh[ibemboXkj
j^[h[ikbjim_bbX[ceh[bWij_d]$7docehf^ebe]_YWb
Y^Wd][i m_bb" _d jkhd" [djW_b \kdYj_edWb Y^Wd][i"
m^_Y^ m_bb edY[ W]W_d h[gk_h[ WZ`kijc[dji ed j^[
cWij_YWjehoikh\WY[ijeX[cWZ[$M^_b[[WY^e\j^[i[
YWkiWbbo h[bWj[Z ikYY[ii_l[ Y^Wd][i cWo X[ c_deh
_\ de Yecfb_YWj_d] \WYjehi Wh[ fh[i[dj" Wbb h[b[lWdj
fWhWc[j[hi ^Wl[ je X[ \ebbem[Z kf Ybei[bo$ J^[h[
Wh["^em[l[h"WdkcX[he\[ii[dj_WbeX`[Yj_l[im^_Y^
i^ekbZ X[ WY^_[l[Z Wi [\\[Yj_l[bo Wi feii_Xb[ Xo j^[
fheij^[j_Yjh[Wjc[dj$J^[i[eX`[Yj_l[iWh[Z_iYkii[Z
X[bem$?dYecfb_YWj[ZYWi[i"jmeo[Whiehceh[cWo
fWiikdj_bj^[cWij_YWjehoioij[c^WiÆi[jjb[ZÇjej^[
fe_dj m^[h[ i_]d_\_YWdj WZ`kijc[dji Wh[ de bed][h
h[gk_h[Z$ ?\ j^[ fWj_[dj Ze[i dej Yecfbo m_j^ j^[
jh[Wjc[dj h[gk_h[c[dji eh _i kdh[b_WXb[" _j cWo X[
Z_\\_Ykbj eh _cfeii_Xb[ je WY^_[l[ j^[ fheij^[j_Y
jh[Wjc[djeX`[Yj_l[i$
È
4REATMENTÈ/BJECTIVES
'$ J^[ Ykif _dYb_dWj_ed i^ekbZ h[ikbj _d W dehcWb
eYYbkiWb Ykhl[ j^Wj _i _d a[[f_d] m_j^ j^[ W][#
if[Y_\_Yb[l[be\WXhWi_ed$
J^[ iW]_jjWb eYYbkiWb Ykhl[ _i XWi[Z ed j^[ \WY_Wb
fbWd[i9Wcf[hÉifbWd["`WmXWi["IWjeÉifbWd[$
($ J^[ fei_j_ed e\ j^[ Xh_Z][ i^ekbZ X[ [lWbkWj[Z
h[bWj_l[jej^[ie\j#j_iik[ijhkYjkh[ih_]^j\hecj^[
ekji[j"_$[$m^[dj^[\hWc[meha_ijh_[Z_d$J^Wdai
je 8E? j[Y^debe]o" \_n[Z h[ijehWj_edi Wh[ dej
fh[l[dj[Z Xo WZlWdY[Z h_Z][ h[iehfj_ed$ M^_b[
Yedl[dj_edWbWffheWY^[ijeYecfb[j[h[ijehWj_edi
ckij X[ XWi[Z ed h[j[dj_ed Wi W b_c_j_d] \WYjeh"
j^_i Wif[Yj _i dej h[b[lWdj m_j^ 8E? _cfbWdji$
J^[h[\eh[" j^[h[ _i ]h[Wj[h \h[[Zec je c[[j
W[ij^[j_Y WdZ f^ed[j_Y d[[Zi" Wbj^ek]^ j^[h[ Wh[
b_c_jWj_edijej^_iWim[bb$
7dj[hefeij[h_ehjed]k[cel[c[djii^ekbZdejX[
h[ijh_Yj[Z$CWdofWj_[djiYWddejh[b_WXbof_dZemd
j^[dWjkh[e\ikY^h[ijh_Yj_edi$J^[oe\j[dh[fehj
^Wl_d]fheXb[cim_j^j^[b[d]j^WdZfei_j_ede\
j^[ Wdj[h_eh j[[j^ Wbj^ek]^ j^[ fheXb[c _i h[Wbbo
_dj^[Z_ijWbi[]c[dj$?jcWoX[Z_\\_Ykbjjeh[ZkY[
jed]k[ cel[c[dji XWYa je j^[_h eh_]_dWb hWd][
m_j^WXh_Z][W\j[hj^[jed]k[^WZ]hemdki[Zje
Wd_dYh[Wi[ZhWd][\ebbem_d]jeej^beii$
)$ 9^[[aYedjWYjcWoWbieX[WfheXb[c$M[Wh_d]W
cWn_bbWhoZ[djkh[\ehcWdoo[Whim_bb_dYh[Wi[j^[
ie\j#j_iik[ lebkc[ _d j^[ Y^[[a Wh[W$7i W h[ikbj"
j^[i[fWj_[djij[dZjeWXiehXj^[[nY[ii_l[j_iik[
X[jm[[d j^[ d[mbo h[ijeh[Z j[[j^$ ?j _i j^[h[\eh[
&IGÈ JhWdil[hiWb
Ykif_dYb_dWj_edi_d
j^[cWn_bbW\hecjeej^
*jefjejeej^.
XejjecJ^_[bcWdd
'/).
È È 0ROSTHETICÈ4REATMENTÈ3TEPSÈ '-'

^[bf\kbjeZ[i_]dYkifie\Yedi_Z[hWXb[b[d]j^je '/+/ikhfh_i_d]boeXi[hl[Zj^Wjj^[Y^[m_d]\ehY[
fh[l[djigk[[p_d]e\j^_ij_iik[$9Wh[i^ekbZWbie Z_Z dej _dYh[Wi[ WdZ Z[Yh[Wi[ _d WYYehZWdY[ m_j^
X[jWa[djeWle_Z[dZ#je#[dZeYYbkiWbh[bWj_edi_d 8eeiÉi ^of[hXeb_Y Ykhl[ Xkj j^Wj j^[ Ykhl[ i^Wf[i
j^[ feij[h_eh i[]c[dj$ 9edi_Z[h j^Wj Wd efj_cWb lWh_[Z m_Z[bo _d W i[[c_d]bo WhX_jhWho cWdd[h$
h[bWj_edi^_f X[jm[[d j^[ l[hj_YWb Z_c[di_ed WdZ J^_i cWo X[ Zk[ je j^[ \WYj j^Wj" Z[f[dZ_d] e\ j^[
j^[ ie\j#j_iik[ ijhkYjkh[i YWddej X[ [ijWXb_i^[Z ][ec[jh_YWb Yed\_]khWj_ed" dej Wbb Y^[m_d] ckiYb[i
Wbed] h[iehX[Z h_Z][i$ ?j _i j^[h[\eh[ WbmWoi Wh[WXb[jefWhj_Y_fWj[kd_\ehcbo_dYbei_d]cel[c[dj
d[Y[iiWhojemehaekjWYecfhec_i[Ä_\d[Y[iiWho" WjWbbWd]b[ie\cekj^ef[d_d]X[YWki[iec[ckiYb[
Xojh_WbWdZ[hheh$EdY[WdWZ[gkWj[XkYYWbYedjWYj i[]c[dji m_bb edbo fki^ j^[ JC@ _dje j^[ \eiiW
_i[ijWXb_i^[Z"j^[\h[[Zece\jed]k[cel[c[dji m_j^ekj Ybei_d] j^[ `Wm$ B_c (&&& Z[cedijhWj[Z
i^ekbZX[WZ[gkWj[Wim[bb$ ]h[Wj[h Y^[m_d] \ehY[i _\ j^[ fW_d [nf[h_[dY[Z _d
j^_ii_jkWj_edmWi[b_c_dWj[ZXobeYWbWdW[ij^[i_W$?d
:k[jej^[Y[djh_\k]Wbl[hikiY[djh_f[jWbh[iehfj_ed ej^[hmehZi"j^[Y^[m_d]\ehY[iWh[h[ZkY[ZXofW_d
fWjj[hdi e\ j^[ cWdZ_Xb[ WdZ cWn_bbW" h[if[Yj_l[bo" _dj^[\_hijfbWY[$
[l[d ceZ[hWj[bo h[iehX[Z h_Z][i m_bb fh[l[dj j^[
h[ijeh[Z j[[j^ \hec cW_djW_d_d] W Z_h[Yj Y[djh_Y J^[ \ebbem_d] eXi[hlWj_edi m[h[ Wbh[WZo fkXb_i^[Z
fei_j_edel[hj^[_cfbWdjWXkjc[djii[[I[Yj$''$($ XoIm[hZbem'/,*0
v J^[ l[hj_YWb Z_c[di_ed m_bb Z[Yh[Wi[ m_j^_d
j^[ \_hij ,cedj^i e\ \_hij _di[hj_d] W Yecfb[j[
È
Z[djkh[$ J^_i Z[Yh[Wi[ _i ceh[ fhedekdY[Z _d
4HEÈ6ERTICALÈ$IMENSION
fWj_[dji m[Wh_d] jme Yecfb[j[ Z[djkh[i j^Wd _d
J^[ ki[ e\ 8E? _cfbWdji ef[di W m^ebbo d[m fWj_[djim[Wh_d]fWhj_WbZ[djkh[i$
WffheWY^ je j^[ _iik[ e\ l[hj_YWb Z_c[di_ed$ 7\j[h v J^[Wbj[h[Zl[hj_YWbZ_c[di_ede\eYYbki_ed_iWbie
Wbb" j^[i[ _cfbWdj YWd X[ _di[hj[Z h[]WhZb[ii e\ h[\b[Yj[Z _d j^[ X_j[ b[l[b" WdZ j^[ _dj[heYYbkiWb
beYWb h_Z][ YedZ_j_edi WdZ h[]WhZb[ii e\ m^[h[ j^[ Z_ijWdY[ m_bb WZWfj je j^[ Z_\\[h[dj l[hj_YWb
ikf[hijhkYjkh[_ijeX[beYWj[Z$J^[h[\eh["j^[ifWj_Wb Z_c[di_edi$
Yed\_]khWj_edWdZcWij_YWjehoY^WhWYj[h_ij_Yie\j^[ v J^[ fei_j_ed e\ j^[ cWdZ_Xb[ cWo Y^Wd][ Wbed]
ikf[hijhkYjkh[ YWd X[ i[b[Yj[Z Wj m_bb$ M^_b[ j^_i m_j^_jim[_]^j$
\h[[Zec_iWYhkY_WbWZlWdjW][el[hYh[ijWb_cfbWdji" v EdY[WYecfb[j[Z[djkh[_i_dfbWY["j^[X_j[b[l[b
ki_d]_j_dWh[WiedWXb[cWdd[h_idejWd[WiojWia$ ^WijeX[f[h_eZ_YWbboWZ`kij[Z%h[ijeh[Z$
7bb e\ j^[ WlW_bWXb[ b_j[hWjkh[ ed j^[ ikX`[Yj mWi
mh_jj[d m_j^ b_c_jWj_edi _d c_dZ j^Wj Ze dej Wffbo >WhZjcWdd [j Wb$ '/./ Z[cedijhWj[Z j^Wj j^[
je 8E?#XWi[Z \_n[Z h[ijehWj_edi$ J^[ el[hh_Z_d] Y^[m_d]\ehY[_ii_]d_\_YWdjboZ[Yh[Wi[Zceh[ieed
YedY[hd m_j^ Yecfb[j[ cWdZ_XkbWh Z[djkh[i _i ie\jj^Wded^WhZ\eeZiW\j[hj^[l[hj_YWbZ_c[di_ed
j^[_h h[j[dj_ed$ J^[_h ekjYec[ Z[f[dZi [dj_h[bo ed ^WiX[[d_dYh[Wi[Z$
m^[j^[h j^[o Wh[ Yehh[Yjbo fei_j_ed[Z WXel[ j^[ ?dWijkZoXo9Whbiied'/--"fWj_[djim_j^dWjkhWb
h_Z][ _d W XWbWdY[Z cWdd[h m^_b[ Wle_Z_d] b[l[h Z[dj_j_edi mekbZ jeb[hWj[ _dYh[Wi[i e\ j^[ l[hj_YWb
\ehY[i$ J^[ Z[i_]d e\ jeej^#ikffehj[Z h[ijehWj_edi Z_c[di_eddej[nY[[Z_d]*cc$?d\WYj"j^[Wdj[h_eh
_i Wbie b_c_j[Z Xo j^[ h[gk_h[c[dj j^Wj de b[l[h fehj_ede\j^[j[cfehWb_ickiYb[mekbZ[l[dX[Yec[
\ehY[i i^ekbZ WYj ed j^[ heeji$ 9ecfb[j[ Z[djkh[i b[iiWYj_l[_dj^_ii_jkWj_ed$
ckij dej ^Wl[ W ikXijWdj_Wb l[hj_YWb Z_c[di_ed" Wi 7bb h[b[lWdj ijkZ_[i ^Wl[ Z[cedijhWj[Z j^Wj \WY#
j^[ h[ikbjWdj b[l[h \ehY[i mekbZ h[dZ[h j^[ fWj_[dj jehi ikY^ Wi Wjjh_j_ed" jeej^ beii WdZ h[ijehWj_l[
_dYWfWXb[ e\ Y^[m_d]$ 7bie" ikY^ Z[djkh[i mekbZ j^[hWfo m_bb _dlWh_WXbo Y^Wd][ j^[ h[ij fei_j_ed e\
_cc[Z_Wj[bo Yh[Wj[ fh[iikh[ ieh[i Zk[ je j^[ ]h[Wj j^[ cWdZ_Xb[ JWbb]h[d '/+-$ Ed j^[ ej^[h ^WdZ"
\ehY[iWYj_d]edj^[ckYeiW$ j^[l[hj_YWbZ_c[di_ed_iWbieceZ_\_[ZXockiYkbWh
M^_b[ de Z[dj_ij mekbZ Z[do j^Wj _j _i hWj^[h \Wj_]k[" eh _dZ[[Z Xo W Y^Wd][Z ^[WZ feijkh[$ ?j _i
_cfehjWdjjeZ[\_d[j^[ÆYehh[YjÇl[hj_YWbZ_c[di_ed" j^[h[\eh[ h[WiedWXb[ je YedYbkZ[ j^Wj j^[ l[hj_YWb
j^[ Yb_d_YWb j[Y^d_gk[i Wffb_[Z \eh j^_i fkhfei[ Z_c[di_ed_ijeeWZWfjWXb[jemWhhWdjWdoZe]cWj_Y
Yedj_dk[ je X[ fkh[bo [cf_h_YWb _d dWjkh[$ Iec[ e\ h[Yecc[dZWj_edi$ 7do Z[cWdZi j^Wj j^[ l[hj_YWb
j^[i[j[Y^d_gk[ih[boedl_ikWbYecfWhjc[djWb_pWj_ed Z_c[di_edd[[ZijeX[¼ijh_Yjbofh[i[hl[Z½el[hj^[
e\ j^[ \WY[ WdZ Wh[ j^ki" _d [\\[Yj" ]k_Z[Z Xo Yekhi[e\fheij^[j_Yjh[Wjc[djWh[dejikXijWdj_Wj[Z
W[ij^[j_YWbhWj^[hj^Wd\kdYj_edWbfWhWc[j[hi$M^_b[ _d fhWYj_Y[$ @kZ]_d] \hec j^[ Yb_d_YWb [nf[h_[dY["
i[l[hWb c[j^eZi W_c[Z Wj [ijWXb_i^_d] j^[ l[hj_YWb Y^Wd][i _d j^[ l[hj_YWb Z_c[di_ed Wh[ jeb[hWj[Z
Z_c[di_ed XWi[Z ed j^[ Y^[m_d] \ehY[ ^Wl[ X[[d m_j^ekj fheXb[ci 9Whbiied '/--$ J^[i[ Y^Wd][i
Z_iYkii[Zl[hoWYj_l[bo\ehiec[j_c[Ijeh[o'/,(" ckij dej X[ ¼[nY[ii_l[½" ^em[l[h" _d j^[ i[di[ e\
j^[o ^Wl[ dej o_[bZ[Z Wdo Yedi_ij[dj h[ikbji B_c ¼[nY[[Z_d]½ j^[ WZWfj_l[ YWfWY_jo e\ j^[ ijecWje#
(&&&18ekY^[h[jWb$'/+/$<eh_dijWdY["8ekY^[h[jWb$ ]dWj^_Yioij[cWjj^[j_c[e\jh[Wjc[djIc_j^'/-+$
'-( 9^Wfj[h''È 0ROSTHETICÈ4REATMENTÈ#ONSIDERATIONS

È e\ c_ii_d] Wdj[h_eh YedjWYji" j^[h[Xo fhecej_d]

!NTERIORÈ!LTERATIONS Wdj[h_eh]k_ZWdY[$
($ M^_b[j^[cWdZ_Xb[h[ifedZiibembo"j^[[\\[Yj_iW
7]h[WjcWdo_dl[ij_]Wjehi^Wl[Z[iYh_X[Zj^[[\\[Yji bWij_d]ed[X[YWki[j^[h[ceZ[bb_d]jWa[ifbWY[_d
e\ Z_ijWb l[hj_YWb Wbj[hWj_edi ed j^[ Y^[m_d] ckiYb[ j^[XWiWbXed[i[]c[dj"m^_Y^_i[njh[c[boYecfWYj
m^_b[el[hbeea_d]j^[[\\[Yjiedj^[c_c_YckiYb[i$ WdZ ikffb_[Z Wbceij [nYbki_l[bo Xo f[h_eij[Wb
J^[ ehX_YkbWh_i eh_i ckiYb[" \eh _dijWdY[" m^_Y^ _i Z_\\ki_edhWj^[hj^Wd\hecj^[cWdZ_XkbWhWhj[ho$
j^[ bWh][ij cekj^#Ybei_d] ckiYb[" _i ceh[ ijhed]bo 7bbj^[i[\WYjehiYedjh_Xkj[jej^[ibemXkjbWij_d]
_dlebl[Z _d j^[ feijkh[ e\ j^[ cekj^ j^Wd j^[ dWjkh[e\WdoWZWfj_l[fheY[ii[ikd\ebZ_d]_dj^Wj
Y^[m_d] ckiYb[i 7hijWZ '/,+$ ?d ej^[h mehZi" j^[ Wh[W$
ieY_Wbbocej_lWj[Zj[dZ[dYoe\f[efb[jeYbei[j^[_h
cekj^ ^Wi ]h[Wj[h _cfb_YWj_edi \eh j^[ feijkh[ e\ J^[^_]^h_iae\Z_ijWbel[hbeWZ_d]Wh]k[i_d\Wlekh
j^[ cWdZ_Xb[ j^Wd Wdo Z_ijWb ckiYb[ WYj_l_jo$ Ed[ e\WZZ_j_edWbbo_di[hj_d]fj[ho]e_ZiYh[mim^[d[l[h
i^ekbZj^[h[\eh[WbmWoiYedi_Z[hfh_ehje_dYh[Wi_d] feii_Xb[$J^[i[ikffb[c[djWb_cfbWdjim_bb_cfhel[
j^[ l[hj_YWb Z_c[di_ed j^Wj fWj_[dji i^em_d] W j^[ Z_ijWb ikffehj m^_b[ j^[ 8E? _cfbWdji beYWj[Z
ijhed] j[dZ[dYo je Ybei[ j^[_h cekj^ m_bb WYj_l[bo X[\eh[ j^[c m_bb i_ckbjWd[ekibo WXiehX [njhki_l[
Z[l[bef ckiYb[ WYj_l_j_[i Z_h[Yj[Z W]W_dij j^[ d[m \ehY[i$
l[hj_YWb Z_c[di_ed$ ?dj[h[ij_d]bo" iec[ fWj_[dji
m^ei[ l[hj_YWb Z_c[di_ed ^Wi X[[d _dYh[Wi[Z Xo
È
c[Wdie\Wd_cfbWdj#ikffehj[Z\_n[Zh[ijehWj_edm_bb
!ESTHETICÈ#ONSIDERATIONS
h[fehjdeYjkhdWbZhod[iie\j^[cekj^WiWZ[bWo[Z
iocfjec$ Ekh _dj[hfh[jWj_ed _i j^Wj j^[i[ fWj_[dji :[dj_iji^Wl[WbmWoi[lWbkWj[Zj^[^[_]^jh[bWj_edi^_f
_d_j_Wbbo Wjj[cfj[Z je ¼WYj_l[bo½ Ybei[ j^[_h cekj^i X[jm[[d j^[ bem[h WdZ c_ZZb[ j^_hZi e\ j^[ \WY[
m^_b[Wib[[fXkjWXWdZed[Zj^[i[Wjj[cfjiWjiec[ Y^_d fe_dj je Xejjec e\ dei[" Yehd[h e\ cekj^ je
fe_dj"fh[ikcWXboZkh_d]Z[[fib[[f$J^[iocfjec fkf_bWiWdW[ij^[j_Yh[\[h[dY[fe_dj\ehj^[_hmeha
cWo h[iebl[ edY[ j^[ l[hj_YWb Z_c[di_ed _i W]W_d C_iY^(&&&$
h[ZkY[ZXocehf^ebe]_YWbY^Wd][ie\j^[cWdZ_Xb[ J^[=ebZ[dHkb[hIW\_Z[djI7"=bWdZ"Im_jp[hbWdZ
WdZ j^[ jeej^ fei_j_ed _djhki_ed" hejWj_ed WhekdZ _iWi_cfb[Xkjki[\kbW_Zje[lWbkWj[j^[bem[hj^_hZ
j^[j[hc_dWbcebWhWi^ofeceY^b_ed$ e\ j^[ \WY[ WdZ j^[ h[bWj_edi^_f X[jm[[d [o[ m_Zj^
M^_b[ j^[ [nWYj _dj[hh[bWj_edi^_fi WmW_j \khj^[h WdZj^[Z_ijWdY[X[jm[[dj^[\_hijfh[cebWhi$
_dl[ij_]Wj_ed" _j mekbZ Y[hjW_dbo X[ mhed] je <WY[i j^Wj Wh[ Y^WhWYj[h_p[Z Xo W h[YjWd]kbWh
YedYbkZ[j^Wj[l[hoj^_d]j^WjWff[Whi`kij_\_[Z\hec i^Wf[ j[dZ_d] jemWhZi fWhWbb[b `Wm XWi[i WdZ W
Wd W[ij^[j_Y l_[mfe_dj WdZ Ze[i dej kdZkbo hW_i[ fWhWbb[b Y^[m_d] fbWd[ ed j^[ ed[ ^WdZ" WdZ Xo W
j^[ ckiYb[ jed[ _d j^[ Z_ijWb `Wm i[]c[dj ckij bWh][ Z_ijWb ^[_]^j j[dZ_d] jemWhZi fhe]dWj^_Y `Wm
f[h\ehY[X[YecfWj_Xb[m_j^j^[ckiYb[i_jkWj_ed_d XWi[ h[bWj_edi ed j^[ ej^[h" Wh[ kikWbbo WiieY_Wj[Z
j^[Wdj[h_eh`Wmi[]c[dj$Dej[j^Wj8E?_cfbWdji_d
j^[ h[iehX[Z cWdZ_Xb[ m_bb WYj_l[bo m[Wa[d j^[ `Wm
i[]c[dj_dm^_Y^j^[oWh[beYWj[Zkdj_bj^[fheY[ii
e\ Z[\[Yj h[fW_h WdZ h[c_d[hWb_pWj_ed _i _d_j_Wj[Z$
?d j^_i f^Wi[ e\ Z[X_b_jWj_ed" j^[ Xed[ cehf^ebe]o
_i fWhj_YkbWhbo ikiY[fj_Xb[ je j^[ i^Wf_d] \ehY[i
e\ j^[ ckiYb[i$ ?dYh[Wi_d] j^[ l[hj_YWb Z_c[di_ed
_d j^_i i_jkWj_ed m_bb fh[#beWZ j^[ ehX_YkbWh_i eh_i
ckiYb[" j^[h[Xo \Wlekh_d] j^[ Wdj[h_eh Yecfed[dj
e\ j^[ _dYh[Wi[Z l[hj_YWb Z_c[di_ed Xo Wbj[h_d] j^[
YkhlWjkh[e\j^[^eh_pedjWbXhWdY^e\j^[cWdZ_Xb[$
J^_i i_jkWj_ed cWo ]_l[ h_i[ je [nY[ii_l[ Wdj[h_eh
YedjWYji" m^_Y^ m_bb ^Wl[ Wd _dehZ_dWj[bo [njhkZ_d]
[\\[YjWdo_cfbWdjiehj[[j^_dj^[feij[h_ehi[]c[dj
e\ j^[ cWn_bbW$ F[h_eZ_Y WZ`kijc[dji Wh[ j^[h[\eh[
d[Y[iiWho" ie j^Wj de ZWcW][ _i _d\b_Yj[Z _d j^[
cWn_bbW$9edi_Z[hj^[\ebbem_d]jmefe_dji0

'$ ;l[dc_dkj[Y^Wd][i_dj^[Wd]kbWhcehf^ebe]o
e\ j^[ Z_ijWb cWdZ_Xb[ cWo h[ikbj _d ikXijWdj_Wb
Wdj[h_ehYedjWYji$FbWij_YZ[\ehcWj_ed_dj^[Z_ijWb &IGÈ J^[ =ebZ[d Hkb[h _dZ_YWj[i j^[ fej[dj_Wb b[d]j^ e\
cWdZ_Xb[cWogk_Yabo]_l[h_i[jej^[h[ijehWj_ed j^[Wdj[h_ehj[[j^
È È 0ROSTHETICÈ4REATMENTÈ3TEPSÈ
m_j^ ij[[f JC@ fWj^ Wd]b[i$ 9edl[hi[bo" i_jkWj_edi
e\ h[jhe]dWj^_W Wh[ ][d[hWbbo WiieY_Wj[Z m_j^ icWbb
JC@fWj^Wd]b[i"WbemZ_ijWb^[_]^je\j^[\WY["WdZW
jh_Wd]kbWhi^Wf[e\j^[\WY[Wil_[m[Z\hecWbWj[hWb
f[hif[Yj_l[$J^[h[Wh[deZ_\\[h[dY[iX[jm[[dWZkbji
WdZY^_bZh[d_dj^_ih[if[Yj?d][hlWbbWdZJ^_bWdZ[h
'/-*$
J^[eh_[djWj_ede\j^[bWj[hWbfj[ho]e_ZckiYb[_i
b_da[Zjej^[Wdj[h_eh^[_]^je\j^[\WY[Wim[bb$?\j^[
ckiYb[\ebbemiWZ_ijeYhWd_Wb#je#Wdj[heYWkZWbhekj["
j^[dj^[^[_]^je\j^[Wdj[h_eh\WY[m_bbX[[dbWh][Z
Wi m[bb$ J^[ ^[_]^j e\ j^[ Wdj[h_eh \WY[ Ze[i dej"
^em[l[h" Yehh[bWj[ m_j^ j^[ eh_[djWj_ed e\ j^[ `Wm#
[b[lWj_d]ckiYb[iIfhedi[d[jWb$'//-$
È
)NSERTIONÈOFÈTHEÈ2ESTORATION
?di[hj_d] j^[ h[ijehWj_ed _d W j[di_ed#\h[[ cWdd[h
_i e\ kjceij _cfehjWdY[" [if[Y_Wbbo _\ edbo \[m 8E?
_cfbWdji ^Wl[ X[[d fbWY[Z _d [WY^ `Wm$ Ej^[hm_i[
j^[_cfbWdjim_bbdejX[WXb[jem_j^ijWdZj^[b[l[h
\ehY[iWdZijh[ii[iWiieY_Wj[Zm_j^j^_i][ec[jh_YWb
i[j#kf _d W bWij_d] cWdd[h$ ?d[nf[h_[dY[Z ki[hi
_d fWhj_YkbWh j[dZ je ^Wl[ W ^WhZ j_c[ l[h_\o_d]
m^[j^[h j^[ Xh_Z][ _i h[Wbbo i[Wj[Z _d W j[di_ed#
\h[[cWdd[h$J^[Z[dj_iji^WijecWa[ikh[j^Wjj^[
Xh_Z][_idejkdZ[hj[di_ededj^[_cfbWdjiedY[j^[
[dZfe_dj e\ _di[hj_ed ^Wi X[[d h[WY^[Z" [if[Y_Wbbo
_\ _d_j_Wb fh[iikh[ ^WZ je X[ Wffb_[Z X[YWki[ e\
Z_l[h][dj WXkjc[dji$ ?j _i j^[h[\eh[ ^[bf\kb je b[Wl[
W ]Wf X[jm[[d j^[ Yhemd WdZ j^[ WXkjc[dj" m^_Y^
_i j^[d \_bb[Z m_j^ Y[c[dj eh W Yecfei_j[ XedZ_d]
W][dj$?dj^_ih[if[Yj"j^[_di[hj_edh[gk_h[c[dji\eh
8E?#XWi[ZY[c[dj[Zh[ijehWj_ediZ_\\[hYedi_Z[hWXbo
\hec j^ei[ _d jeej^#ikffehj[Z h[ijehWj_edi m^[h[
]WfiWh[dejkikWbbofbWdd[ZZ[b_X[hWj[bo$M_j^8E?
_cfbWdji" ^em[l[h" Wdo \h_Yj_ed#XWi[Z h[j[dj_ed eh
j[di_ed_ikdZ[i_hWXb[WdZZWd][heki$
J^[ h[gk_h[c[dj e\ j[di_ed#\h[[ i[Wj_d] _i [l[d
ceh[ _cfehjWdj _d i[YedZWho _di[hj_ed fheY[Zkh[i"
i_dY[j^[i[Wh[ceh[b_a[bojeh[ikbj_d_cfbWdj\hWYjkh[
j^Wd_deij[eboi_i_dj^[[l[dje\Yecfb_YWj_edi$7\j[h
Wbb"j^[_cfbWdj_ifh[#beWZ[ZXoj^[ikf[hijhkYjkh["
m^_Y^ cWo Yh[Wj[ W i_jkWj_ed m^[h[ j^[ ikXi[gk[dj
cWij_YWjeho \ehY[i eh \b[nkhWb `Wm cel[c[dji
m_bb [nY[[Z j^[ hWd][ e\ [bWij_Y Z_ibeYWj_ed$ J^[
\hWc[mehae\j^[j[cfehWhoXh_Z][i^ekbZX[h[ki[Z
m^[d[l[hfeii_Xb[$
8Wi[ZedWijh[iiWcfb_jkZ[e\).&D%c(j^[Xbk[
b_d[ _dZ_YWj[i WhekdZ '&, je '&- YoYb[i je \W_bkh[
W fh[#beWZ e\ WhekdZ *&D%cc( m_bb ZhWcWj_YWbbo
h[ZkY[ j^[ dkcX[h e\ YoYb[i je \W_bkh[ je WhekdZ
'&+$ 8E? _cfbWdji m_bb \hWYjkh[ ieed kdZ[h YoYb_Y
beWZ_d] Xo dehcWb Y^[m_d] \ehY[i _\ j^[o Wh[ fh[#
beWZ[Z Xo j^[ ikf[hijhkYjkh[$ ?d j^_i YWi[ j^[ \ehY[
e\ fh[beWZ_d] WZZi je j^[ Y^[m_d] \ehY[$ <W_bkh[ e\
'-)
A
B
&IGÈÈ A 9oYb_Y X[dZ_d] ijh[d]j^ e\ j_jWd_kc$ B BeWZ#
Z[\ehcWj_edZ_W]hWc
j^[_cfbWdjeYYkhiWjbem[h\ehY[iehW\j[h\[m[hbeWZ
YoYb[ih[if[Yj_l[bo$
Fh[#beWZ_d] e\ _cfbWdji cWo eYYkh h_]^j WmWo
m^[d j^[ fheij^[j_Y ikf[hijhkYjkh[ _i _di[hj[Z
fh_cWho fh[#beWZ_d] eh bWj[h Xo \kdYj_edWbbo
_dZkY[Z cel[c[dji e\ _cfbWdj#ikhhekdZ_d] Xed[
ijhkYjkh[i i[YedZWho fh[#beWZ_d]$ J^[ X[^Wl_ekh
e\ 8E? _cfbWdji [if[Y_Wbbo m_j^ ^_]^ = lWbk[i
_d j^_i h[if[Yj Z_\\[hi Yedi_Z[hWXbo \hec j^Wj e\
Yh[ijWb _cfbWdji$ J^[ bWjj[h Wh[ kdb_a[bo je Wbbem
fheij^[j_Y ikf[hijhkYjkh[i je X[ _di[hj[Z m^[d _d
W fh[#beWZ[Z ijWj[" WdZ j^[o m_bb iYWhY[bo kdZ[h]e
[bWij_Y Z[\ehcWj_ed Xo YoYb_Y beWZ_d]$ 8o YedjhWij"
j^[j^h[WZ[Zf_diWdZm[XXWhie\8E?_cfbWdjiWh[
Z[\ehc[Z gk_j[ h[WZ_bo" ie j^Wj j^[ ikf[hijhkYjkh[i
YWd X[ _di[hj[Z [l[d m^[d j^[ _cfbWdji Wh[ _d W
fh[#beWZ[ZijWj[$J^[ZWcW][_dj^_ii_jkWj_ed_idej
_d\b_Yj[Zedj^[Xed[Xkjedj^[_cfbWdjij^[ci[bl[i"
m^_Y^ _i WYjkWbbo h[Wiikh_d] X[YWki[ W \hWYjkh[Z
8E? _cfbWdj _i ceh[ [Wi_bo h[fbWY[Z j^Wd W Z_ia
ikhhekdZ[ZXoeij[eboi_i$
JeikccWh_p["_jjWa[iiec[[nf[h_[dY[jeY[c[dj
bWh][#ifWdXh_Z][ije8E?_cfbWdji_dWj[di_ed#\h[[
cWdd[h$ <khj^[hceh[" ;: ioij[ci _dlebl[ Z_\\[h[dj
h[gk_h[c[dji j^Wd kikWb h[]WhZ_d] j^[ fh[Y_i_ed
e\ \_j Wj j^[ Yhemd#WXkjc[dj _dj[h\WY[$ I_dY[ j^[
jhWdi_j_edWb ped[ m_bb dehcWbbo X[ beYWj[Z WXel[
j^[ ckYeiW WdomWo" j^[h[ _i de mWo \eh h[j[dj_l[
_d\bWccWj_edi je Z[l[bef [l[d _\ c_deh jhWdi_j_edi
h[cW_d$
J^[ Y[c[djWj_ed ij[f YWd X[ f[h\ehc[Z" \eh
_dijWdY[" m_j^ ]bWii#_edec[h Y[c[dji eh WYhob_Y
'-* 9^Wfj[h''È 0ROSTHETICÈ4REATMENTÈ#ONSIDERATIONS

h[i_di9WhbiiedWdZCW]dkiied(&&&$7Yhob_Yh[i_di v J[cfehWho Xh_Z][i cWZ[ \hec WYhob_Y h[i_d YWd

e\\[hj^[WZlWdjW][e\fhebed][Zi[jj_d]j_c[iceh[ X[XedZ[Zm_j^Wbem#l_iYei_joi[b\#feboc[h_p_d]
j^Wd '&c_d" j^ki ]_l_d] j^[ Z[dj_ij ceh[ j_c[ je bkj_d] h[i_d$ ?\ j^_i ijhWj[]o _i ki[Z" j^[ Z[dj_ij
WZ`kij j^[ Xh_Z][ je W Yehh[Yj fei_j_ed WdZ" ceij i^ekbZ Ykj ]heel[i _dje j^[ WXkjc[dji je e\\[h
_cfehjWdjbo"j[di_ed#\h[[fei_j_ed$Edj^[Zemdi_Z[" cWYhec[Y^Wd_YWbWdY^ehW][$
WicWbbZhW_dW][^eb[^WijeX[Yh[Wj[Zedj^[b_d]kWb" v½ Bed]#j[hcfhel_i_edWbXh_Z][icWZ[\hecWYhob_Y
fWbWjWb eh [l[d eYYbkiWb ikh\WY[ e\ j^[ Yhemd XWi[ h[i_dYWdX[Yedd[Yj[Zm_j^h[]kbWh]bWii#_edec[h
X[YWki[ j^[ edbo mWo \eh WYhob_Y Y[c[dji je ZhW_d eh h[i_d Y[c[dji X[YWki[ j^[o m_bb X[ h[cel[Z
e\\ _i kfmWhZi j^hek]^ j^[ Yhemd$ J^[ j[Y^d_Y_Wd Xo Yecfb[j[ eh fWhj_Wb i[fWhWj_ed WdomWo$ Dej["
m_bb edbo Yh[Wj[ j^_i ZhW_dW][ ^eb[ _cc[Z_Wj[bo ^em[l[h"j^WjXh_Z][im_j^c[jWbWXkjc[djieYa[ji
X[\eh[Y[c[djWj_ed"_$[$W\j[hj^[h[ijehWj_ed^WiX[[d YWddejX[h[cel[Zkdb[iiJ[cf8edZm[Wa[d[Z
Z[\_d_j_l[boYecfb[j[Z$ f^eif^Wj[ Y[c[dj mWi ki[Z$ Ed j^[ ej^[h ^WdZ"
Ekh feb_Yo _i je ehZ[h j^[ Z_ijWb j[Y^d_YWb ikY^ c[jWb \hWc[mehai cWo ijWX_b_p[ j^[ Xh_Z][
WXkjc[dji m_j^ Wd ef[d jef \hec j^[ bWXehWjeho" l[hom[bbW]W_diji^[Wh_d]\ehY[i_dj^[WXkjc[dj#
m^_Y^ _i W Yedl[d_[dj mWo je l[h_\o m^[d j^[ [dZ Xh_Z][_dj[h\WY[$
fei_j_ede\j^[Xh_Z][_ih[WY^[Z$J^_ifWhWc[j[h_i v De cWjj[h m^_Y^ Y[c[djWj_ed j[Y^d_gk[ _i ki[Z"
[if[Y_Wbbo _cfehjWdj m^[d j^[ Y[c[djWj_ed ij[f _i _j _i [ii[dj_Wb j^Wj j^[ j[cfehWho h[ijehWj_ed _i
f[h\ehc[ZX[\eh[j^[ckYeiWbim[bb_d]^Wih[iebl[Z$ \WXh_YWj[Z\hecWi_d]b[ieb_Zmehaf_[Y[_dehZ[h
7\j[hj^[Y[c[djWj_edij[f"j^[Z[dj_ijcWoY^eei[je jeijWX_b_p[j^[8E?_cfbWdji$
eXjW_dWdej^[hEF=jeZ[j[YjWdoh[i_ZkWbZ[Xh_i$

È
4EMPORARYÈ#ONNECTIONS
?j_iWhekj_d[fheY[Zkh[_dh[ijehWj_l[Z[dj_ijhoje\_hij
Yedd[YjbWh][#ifWdXh_Z][i_dWj[cfehWhocWdd[h"
ie j^Wj j^[o YWd X[ h[cel[Z \eh Wdo ceZ_\_YWj_edi
WdZWZ`kijc[djiX[\eh[j^[Z[\_d_j_l[_di[hj_ed$J^_i
_iik[ YWd X[ _]deh[Z _d iYh[m#h[jW_d[Z h[ijehWj_edi
ikY^ Wi Xh_Z][i ikffehj[Z Xo ?:%?:E%?:E:%?:EJ
_cfbWdji$
;: ioij[ci Wh[ dej m[bb ik_j[Z \eh j^_i efj_ed
kdb[ii_dj^ei[YWi[im^[h[j^[fheij^[j_Y[b[c[dji
Wh[Yedd[Yj[Zm_j^ZekXb[#j^h[WZiYh[mi$J[cfehWho
Y[c[djWj_ed e\ bWh][#ifWd Xh_Z][i je ijhWj[]_YWbbo
fei_j_ed[Z _cfbWdji m_bb kikWbbo \W_b" i_dY[ j^[ ^_]^
ijh[ii[i WdZ [njhkZ_d] \ehY[i X[jm[[d j^[ _cfbWdji
Wh[b_WXb[je_dZkY[Z[XedZ_d]$
8E?#XWi[Zh[ijehWj_edii^ekbZj^[h[\eh[WbmWoiX[
Yedd[Yj[Zm_j^Z[\_d_j_l[Y[c[dji$I[l[hWbijhWj[]_[i
YWdX[[cfbeo[Zjeh[cel[j^[cW\j[hWbb_\j^[d[[Z
Wh_i[i0
v J^[ XedZ_d] ijh[d]j^ e\ ]bWii#_edec[h eh
f^eif^Wj[ Y[c[dj ed :[bh_d WXkjc[dji _i ikY^ &IGÈ J^[XeZoe\j^_ifeehboZ[i_]d[Zj[cfehWhoXh_Z][
j^Wjj^[Xh_Z][YWdij_bbX[h[cel[Zc[Y^Wd_YWbbo _i el[hbo m[Wa1 j^[ c[jWb \hWc[meha _i ckY^ jee i^ehj WdZ
m_j^ceZ[hWj[\ehY[$ \hW]_b[

&IGÈAnD IYh[m#h[jW_d[Zj[cfehWhoXh_Z][_dj^[cWdZ_Xb[ikffehj[ZXo?:_cfbWdji$=eeZWYY[ii_X_b_jo\ehehWb^o]_[d[
_dijhkc[djiWdZj^[cWii_l[Z[i_]de\j^[ijhkYjkh[
È È ,ABORATORYÈ0ROCEDURESÈ
?\ j^[ Z[dj_ij Y^eei[i je ki[ j[cfehWho Y[c[dj
W\j[h Wbb" ^[ i^ekbZ Wj b[Wij Yedi_Z[h [ijWXb_i^_d]
de iYh[m Yedd[Yj_ed m_j^ Wdo iYh[m _cfbWdji [$]$
jkX[hefj[ho]e_ZiYh[mi_dYbkZ[Z_dj^[Xh_Z][ifWd$
7\j[h Wbb" ikY^ iYh[m Yedd[Yj_edi mekbZ c[Wd j^Wj
j^[ [dj_h[ Xh_Z][ mekbZ ^_d][ ed edbo ed[ eh jme
iYh[m _cfbWdji _\ j^[ j[cfehWho Y[c[dj Yec[i e\\"
m^_Y^ YWhh_[i j^[ h_ia j^Wj j^[i[ _cfbWdji X[Yec[
ceX_b[" fWhj_YkbWhbo _\ h[c_d[hWb_pWj_ed _i dej o[j
Yecfb[j[$ EdY[ W Xh_Z][ Yedd[Yj[Z m_j^ j[cfehWho
Y[c[dj ^Wi X[Yec[ ceX_b[" j^[ Y^WdY[i Wh[ j^Wj
_j m_bb X[Yec[ ceX_b[ edY[ W]W_d _\ j^[ j[cfehWho
Y[c[djWj_ed _i h[f[Wj[Z$ ?j _i WXiebkj[bo cWdZWjeho
_dj^WjYWi[j^Wjj^[Xh_Z][_idejX[h[Yedd[Yj[Zje
WdoiYh[m_cfbWdji_dYbkZ[Z_dj^[ioij[cX[\eh[W
Z[\_d_j_l[%WZ[gkWj[Yedd[Yj_ede\j^[el[hWbbioij[c
_i[ijWXb_i^[Z$
7 fh[\[hh[Z WffheWY^ _d ekh fhWYj_Y[ _i je
ki[ j[cfehWho c[jWb h[ijehWj_edi m_j^ WYhob_Y eh
Y[hWc_Yl[d[[h_d]edWicWbbdkcX[he\ijhWj[]_YWbbo
fei_j_ed[Z _cfbWdji m_j^_d W \[m ZWoi e\ j^[
_cfbWdjWj_ed fheY[Zkh[$ 7bb WXhWi_l[ WZ`kijc[dji
Wh[ ikXi[gk[djbo f[h\ehc[Z ed j^_i j[cfehWho
Xh_Z]["m^_Y^_i[l[djkWbboh[fbWY[ZW\j[hWhekdZ(Ä
/cedj^i$7bb#h[i_dj[cfehWhoXh_Z][im_j^dec[jWb
Yecfed[dj YWd X[ ki[Z _\ ikffehj[Z Xo W ]h[Wj[h
dkcX[h e\ _cfbWdji$ 7]W_d" j^[ Yedd[Yj_ed i^ekbZ
_dlWh_WXboX[[ijWXb_i^[Zm_j^Z[\_d_j_l[Y[c[dj$
&IGÈ J[cfehWhoXh_Z][Yedd[Yj[Zm_j^Z[\_d_j_l[Y[c[dj
W\j[h,cedj^ie\Yb_d_YWbi[hl_Y[$Demj^WjijWXb[ded#_hh_jWj_l[
ckYeiWbh[bWj_ediWh[fh[i[dj"j^[Z[\_d_j_l[h[ijehWj_edYWdX[
\WXh_YWj[Z$7bj[hdWj_l[bo" _\ j^[ fWj_[dj Ze[i dej m_i^ je ^Wl[
j^[Xh_Z][h[fbWY[Z"Wd[f_j^[i_iYWdX[_di[hj[ZjeYel[hj^[
VENEERINGÈOFÈ"RIDGEÈ&RAMEWORKS
]WfiWdZjeWZ`kijj^[Yhemdb[d]j^i_dWYYehZWdY[m_j^j^[
fWj_[djÉiW[ij^[j_Yfh[\[h[dY[i
'-+
È
,ABORATORYÈ0ROCEDURES
/B[JS
;FDJSJ
È
,ABORATORYÈ%QUIPMENTÈFORÈ%$È)MPLANTS
J^[ WXkjc[dji Z[iYh_X[Z _d 9^Wfj[h* YWd X[ ki[Z
je]eeZ[\\[YjZ_h[Yjboedj^[ceZ[b$J^[WXkjc[dji
Wh[kdiYh[m[Z\hecj^[_cfbWdjWdZiYh[m[ZW]W_dij
Wd ?7// eh ?7 :J? _cfbWdj WdWbe]k[$ J^_i [dj_jo
_i h[fei_j_ed[Z _dje j^[ _cfh[ii_ed" m^_Y^ _i j^[d
fekh[Z$
?\ dkc[heki _cfbWdji m_j^ m_Z[bo Z_l[h]_d]
_di[hj_ed fWj^i Wh[ _dlebl[Z" _j _i h[Yecc[dZ[Z je
\WXh_YWj[ W iWm#Ykj ceZ[b \eh [Wi_[h h[celWb e\ j^[
mehaf_[Y[ _d mWn \hec j^[ ceZ[b WdZ ikXi[gk[dj
h[fei_j_ed_d]j^[c[jWb\hWc[meha$
?\?7//_cfbWdjWdWbe]k[iWh[ki[Z"j^[j[Y^d_Y_Wd
m_bbij_bbX[WXb[jeY^Wd][j^[WXkjc[djjof[\ehj^[
Z[\_d_j_l[ h[ijehWj_ed W\j[h Yedikbj_d] j^[ Z[dj_ij$ ?\
j^_i efj_ed _i Yedi_Z[h[Z kdd[Y[iiWho" j^[ [Wio#je#
ki[fbWij_YWdWbe]k[iYWdX[ki[Z_dij[WZ$J^[bWh][h
]h[oWXkjc[djWdWbe]k[iWh[ki[Z\ehJI:+"JI://
WdZJI:++WXkjc[dji"j^[h[ZWdWbe]k[iWh[ki[Z\eh
j^[JI:*WdZJI:**WXkjc[dji$
?7// _cfbWdj WdWbe]k[i ki[Z _d YecX_dWj_ed
m_j^ kdiYh[mWXb[ WXkjc[dji e\\[h j^[ \ebbem_d]
WZlWdjW][i0
v J^[j[Y^d_Y_WdYWdikXij_jkj[Z_\\[h[djWXkjc[dj
Z[i_]di$
v J^[WXkjc[djiYWdX[h[ZkY[Z_d^[_]^jh_]^jed
j^[ ceZ[b$ J^[o YWddej X[ Z_W]edWbbo h[ZkY[Z
X[YWki[ j^[ ;: ioij[c e\\[hi de Wdj_#hejWj_edWb
fhej[Yj_ed$
v ?dZ_l_ZkWb WXkjc[dji YWd X[ ec_jj[Z _d j^[
bWXehWjeho f^Wi[ ie j^Wj j^[ Xh_Z][ YWd X[
h[fei_j_ed[Zceh[h[WZ_boedjej^[ceZ[b$
v J^[\_je\j^[YhemdiYWdX[Z_h[Yjbol[h_\_[Z$
v J^[ Xh_Z][ YWd X[ Z[i_]d[Z Wi W iYh[m#h[jW_d[Z
h[ijehWj_edXWi[ZedZekXb[#j^h[WZiYh[mi$
FbWij_Y WdWbe]k[i Wh[ W ]eeZ Y^e_Y[ _\ j^[ _cfbWdji
Wh[fWhWbb[bWdZ_\j^[h[_ideZekXjm^_Y^WXkjc[dj
jof[ m_bb X[ ki[Z$ J^[o Wh[ _d[nf[di_l[ Xkj dej
h[kiWXb[$
È
2E
J^[ c[jWb \hWc[mehai e\ j[cfehWho h[ijehWj_edi
Wh[ Yeccedbo h[ki[Z _d j^[ ikXi[gk[dj Z[\_d_j_l[
h[ijehWj_edi$ Je j^_i [dZ" W YWij \hWc[meha _i
\WXh_YWj[Z" l[d[[h[Z m_j^ WYhob_Y h[i_d Wi gk_Yabo
Wi feii_Xb[" WdZ Y[c[dj[Z edje j^[ WXkjc[dji _d W
'-, 9^Wfj[h''È 0ROSTHETICÈ4REATMENTÈ#ONSIDERATIONS
A
B
C
&IGÈAnC J^[ fei_j_ed e\ j^[ JI:* WXkjc[dj Y[djh[
Wff[Whi ib_]^jbo jee ^_]^ ed j^[ ceZ[b$ 7\j[h j^[ WXkjc[dj
^Wi X[[d h[cel[Z" j^[ _cfbWdj WdWbe]k[ h[cW_di _d j^[
ceZ[b m_j^ j^[ [nj[hdWb j^h[WZ [nfei[Z$ J^[ _cfbWdj b[d]j^
_iWZ`kij[Zm_j^j^[^[bfe\WJI://WXkjc[dj$J^[WXkjc[dj
i^emd _d j^_i [nWcfb[ ij_bb d[[Zi je X[ h[ZkY[Z \hec j^[
XWiWbWif[YjjeWle_ZckYeiWbYedjWYjWdZ[nY[ii_l[h[j[dj_ed$
7bb WdWbe]k[i ed j^[ ceZ[b Yec[ m_j^ i[fWhWj[ Z_[i$ J^ki
[WY^ Z_[ YWd X[ i[fWhWj[bo h[cel[Z" WdZ j^[ Xh_Z][ YWd X[
h[fei_j_ed[Zm[bbedj^[ceZ[b[l[d_dc[jWb$?dj^[fWj_[djÉi
cekj^" Wdo ikY^ c_deh Z[\_Y_ji _d fWhWbb[b_ic m_bb dej YWki[
fheXb[ciWdomWoZk[jej^[[bWij_YX[^Wl_ekhe\j^[_cfbWdji
h[l[hi_Xb[ cWdd[h$ J^[ XedZ_d] ijh[d]j^ d[[Zi je
X[Y^[Ya[Zf[h_eZ_YWbbo_dj^[Z[djWbe\\_Y["Xkjj^[
fWj_[djckijWbieX[_dijhkYj[ZjeZeie^_ci[b\$
J^[Xh_Z][\hWc[meha_iXedZ[Zm_j^f^eif^Wj[
Y[c[dj eh ijhed] j[cfehWho Y[c[dj" ie j^Wj _j YWd
X[ h[cel[Z _d W ded#Z[ijhkYj_l[ cWdd[h Wj j^[
[dZe\j^[fhel_i_edWb_pWj_edf[h_eZ$J^[d_jYWdX[
h[fbWY[Z"_\d[Y[iiWho"XoWi_cfb[WYhob_Yh[ijehWj_ed
m_j^ h[ZkY[Z cWij_YWjeho ikh\WY[i" m^_Y^ m_bb ^Wl[
jebWij\ehW\[mZWoiedbo$C[Wdm^_b["j^[\hWc[meha
YWdX[ijh_ff[Ze\j^[WYhob_Yh[i_dWdZh[#l[d[[h[Z
m_j^WY[hWc_YXk_bZ#kf$
8[\eh[ j^[ j[cfehWho Xh_Z][ _i h[cel[Z" Wd
Wb]_dWj[ _cfh[ii_ed _i jWa[d$ J^[ h[cel[Z Xh_Z][
_i j^[d h[fei_j_ed[Z _dje j^[ _cfh[ii_ed WdZ \_jj[Z
m_j^ bWXehWjeho WdWbe]k[i fh[\[hWXbo m_j^ j^[
fbWij_Yed[i$IkXi[gk[djboj^[_cfh[ii_ed_ifekh[Z$
J^_i m_bb h[ikbj _d W Z_ij_dYj_l[ h[fh[i[djWj_ed e\
j^[ ckYeiWb jefe]hWf^o h[bWj_l[ je j^[ \hWc[meha"
XWi[Z ed m^_Y^ j^[ Y[hWc_Y l[d[[h YWd X[ WZWfj[Z
X[Wkj_\kbbojej^[ie\j#j_iik[ijhkYjkh[i$9Wh[ckijX[
jWa[dj^WjWbbh[b[lWdjijhkYjkh[iWh[m[bbWYY[ii_Xb[
\ehehWb^o]_[d[_dijhkc[dji$
J^[ cW_d fkhfei[ e\ h[ki_d] j^[ \hWc[meha _i
dej je ijh[Wcb_d[ j^[ meha\bem Xkj je jhWdi\[h j^[
j[di_edWb h[bWj_edi X[jm[[d j^[ _cfbWdji \hec j^[
j[cfehWho Xh_Z][ je j^[ Z[\_d_j_l[ Xh_Z][$ ?d ej^[h
mehZi"j^[Z[\_d_j_l[Xh_Z][m_j^_ji_Z[dj_YWb\_jm_bb
dej_cfei[Wdoijh[ii[iedj^[\kbbo_dj[]hWj[Z8E?
_cfbWdji$
È
#ONNECTINGÈTHEÈ"RIDGE
J^[ j^h[WZ[Z Xh_Z][ Yecfed[dji \eh j^[ ZekXb[#
j^h[WZ iYh[m Wh[ m[bZ[Z eh bWi[h#m[bZ[Z je j^[
\_d_i^[Z\hWc[meha$
È
!ESTHETICSÈ6ERSUSÈ!CCESSIBILITY
I[[<_]''$''
È
&ABRICATINGÈ&IXEDÈ"RIDGES
?j_ihWh[bofeii_Xb[jefekhbWh][ded#fh[Y_ekiWbbeo
\hWc[mehai m_j^ W ^_]^ c[jWb Yedj[dj \hec ed[
f_[Y[m_j^ekj_dZkY_d]]h[Wjijh[ii[i$?\ijh[ii[iWh[
dej_Y[Zm^[dj^[\hWc[meha_ih[fei_j_ed[Zedj^[
ceZ[b"j^[Xh_Z][YWdX[i[fWhWj[ZWdZh[#Wii[cXb[Z
ed j^[ ceZ[b _d W j[cfehWho cWdd[h m_j^ fWjj[hd
h[i_d X[\eh[ j^[ jho#_d f^Wi[$ J^_i m_bb _dYh[Wi[ j^[
Y^WdY[ie\eXjW_d_d]W\_jj_d]Xh_Z][Wjj^[\_hijjho#
_d"[l[dj^ek]^j^[c[jWbYedd[Yj_edim_bb^Wl[jeX[
h[#[ijWXb_i^[ZbWj[h$
È
h"ROSAMLEvÈ"RIDGES
J^[h[Wh[i[l[hWb]eeZh[Wiedije[Yedec_p[edj^[
bWXehWjehomeha]e_d]_djeXh_Z][\WXh_YWj_ed$
È È ,ABORATORYÈ0ROCEDURESÈ
A &IGÈ J^_i mecWd h[gk[ij[Z j^Wj j^[ i[YedZ cebWh
B
&IGÈÈ A J^[ ZekXb[#j^h[WZ iYh[m m_j^ _ji ib[[l[ cWZ[
\hec 9e9hCe _i fbWY[Z ed j^[ ceZ[b$ J^[ Yecfed[dji Wh[
m[bZ[Z Z_h[Yjbo ed j^[ ceZ[b$ B L_ikWbbo Wff[Wb_d] m[bZ[Z
Yedd[Yj_edX[jm[[dj^[Xh_Z][WdZj^[[nj[hdWbib[[l[
v B[ii [nf[di_l[ _cfbWdjebe]_YWb i[hl_Y[i YWd X[
W\\ehZ[ZXoceh[fWj_[dji$
v J^[X_j[h[bWj_ediYWdX[Yecfh[^[di_l[boj[ij[Z$
;nj[di_l[ ikXjhWYj_l[ WdZ WZZ_j_l[ WZ`kijc[dji
YWdX[f[h\ehc[Z\WijWdZ_d[nf[di_l[bo$
v KdijWXb[ _cfbWdji Ze dej ^Wl[ je X[ h[cel[Z
_cc[Z_Wj[boXkjYWdX[beWZ[Zm_j^Wd_d[nf[di_l[
h[ijehWj_ed$ J^_i ijhWj[]o m_bb e\j[d iWl[ j^[
'--
i^ekbZX[l[d[[h[ZWim[bb$7Yb[Wd_d]jkdd[bmWiYh[Wj[Zje
e\\[hWYY[ii\ehXhki^_d]WdZ\beii_d]
i_jkWj_ed" i_dY[ Yehh[Yj beWZ_d] ^Wi W mWo e\
_cfhel_d] j^[ ijWX_b_jo" ie j^Wj j^[ _cfbWdj YWd
X[ fh[i[hl[Z W\j[h Wbb$ ?\ _d[nf[di_l[ fheij^[j_Y
iebkj_edi Wh[ dej WlW_bWXb[" jho_d] je fh[i[hl[
W_b_d] _cfbWdji m_bb YWhho ]h[Wj[h \_dWdY_Wb h_iai
\ehj^[Z[dj_iji$J^[i[h_iaim_bbcWa[j^[cceh[
_dYb_d[Z je h[cel[ _cfbWdji" m^_Y^ m_bb h[dZ[h
_cfbWdj j^[hWfo Wj bWh][ kdd[Y[iiWh_bo _dlWi_l[$
Dej[ j^Wj j^[ bWXehWjeho Yeij \eh Wd _d[nf[di_l[
Yecfb[j[ Xh_Z][ m^_Y^ m[ ^Wl[ X[[d YWbb_d]
Æ8heiWcb[Ç Xh_Z][i [l[h i_dY[ m[ \_hij _di[hj[Z W
h[ijehWj_ede\j^_ijof[jeWfWj_[djm_j^j^[dWc[
8heiWcb[ _i dej ckY^ ^_]^[h j^Wd j^[ Yeij e\ W
i_d]b[_cfbWdj$
M[ ^Wl[ ced_jeh[Z dkc[heki fWj_[dji m[Wh_d]
j^[i[i_cfb[Xh_Z][iel[h[nj[dZ[Zf[h_eZie\j_c[
m_j^ekjeXi[hl_d]Wdoh[b[lWdjfheXb[ci$Dej[j^Wj
edbo iec[ e\ j^[ f_da WYhob_Y h[i_di Wh[ Wkj^eh_p[Z
9bWii??Wic[Z_YWbZ[l_Y[i\ehf[hcWd[dj_djhWehWb
ki[$ Iec[ cWdk\WYjkh[hi cWo YbWii_\o j^[ h[i_di
ki[ZWi9bWii?c[Z_YWbZ[l_Y[iX[YWki[WdoZ[djkh[i
cWZ[\hecj^[cm_bbX[jWa[dekjedWZW_boXWi_i$
'-. 9^Wfj[h''È 0ROSTHETICÈ4REATMENTÈ#ONSIDERATIONS

A E

B F

C G

D H
È È ,ABORATORYÈ0ROCEDURESÈ '-/

I J

&IGÈÈ A I[l[h[ Zoi]dWj^_W m_j^ h[jhkZ[Z cWn_bbW$ 7 jejWb e\ \ekh 8E? _cfbWdji WdZ ed[ IJ9 _cfbWdj m[h[ ijhWj[]_YWbbo
_di[hj[Z$ B <hWc[meha ceZ[b h[l[Wb_d] j^[ Z_c[di_edWb h[bWj_edi$ C J^[ Xh_Z][ _i Y[c[dj[Z je j^[ 8E? _cfbWdji WdZ
iYh[m[Zjej^[IJ9_cfbWdj$ D 8h_Z][W\j[hj^[jho#_d$J^[Xh_Z][Yecfed[djim[h[fh[#cekdj[Zedj^[ceZ[b$:kh_d]j^[
jho#_d"j^[X_j[mWih[]_ij[h[Zm_j^i_b_Yed[H[bWj_ed:$ E J^[_dZ_l_ZkWbYecfed[djie\j^[9e9hCeXh_Z][Wh[_cceX_b_p[Z
WdZ Yedd[Yj[Z Xo fbWicW m[bZ_d]$ F J^[ eh_]_dWb cWj[h_Wb YWd X[ ki[Z je \_bb j^[ ]Wfi$ J^[ iWc[ cWj[h_Wb YWd Wbie X[
ki[Z\ehWdoXk_bZ#kfj^WjcWoX[h[gk_h[Z$ G 7i[YedZc[jWbjho#_d_if[h\ehc[Zjel[h_\oj^[m[bZ_d]h[ikbjWdZ\ehX_j[
h[]_ijhWj_ed$ H :[dj_dXk_bZ#kf$ I <_d_i^[ZXh_Z][\[Wjkh_d]efj_cWbboZ[i_]d[ZcWij_YWjehoikh\WY[iWdZW]_d]_lWbcWia
cWZ[e\f_daY[hWc_Yi$ J IkYY[ii\kb_bbki_ede\dWjkhWbehWbh[bWj_edi

A C

B D

&IGÈAnD Æ8heiWcb[Ç#Xh_Z][i_dYbkZ[Wc[jWb\hWc[meham_j^bWh][h[j[dj_l[^eb[i"m^_Y^_iYel[h[Zm_j^f_daefWgk[WdZ
\_jj[Zm_j^WZ[dj_j_edcWZ[e\WYhob_Yh[i_dehY[hWc_Y$J^[Yedd[Yj_edX[jm[[dj^[\hWc[mehaWdZj^[Z[djkh[_i[ijWXb_i^[Z
m_j^f_daWYhob_Yh[i_d$7m[bb#l[hi[ZZ[djWbj[Y^d_Y_WdjWa[ib[iij^Wd*^je\WXh_YWj[ikY^WXh_Z]["m^_Y^[\\[Yj_l[boiWl[i
bWXehWjehoYeiji
'.& 9^Wfj[h''È 0ROSTHETICÈ4REATMENTÈ#ONSIDERATIONS

È
-ETALÈ#OREÈANDÈ6ENEERING
I[[<_]''$',#''$'.

&IGÈ J^[i[ Xh_Z][i YWd X[ h[WZ_bo _di[hj[Z [l[d _d

^[Wl_boh[iehX[ZcWdZ_Xb[i$?\j^[Z_ijWb_cfbWdjim[h[fbWY[Z
_dj^[Wh[We\j^[WiY[dZ_d]hWcki"j^[ieYa[ji\ehj^[Z_ijWb
WXkjc[djicWoX[beYWj[ZWXel[j^[Y^[m_d]b[l[b$J^[\_hij
cebWhe\j^[cWn_bbWhoZ[djkh[^WijeX[h[ZkY[Z_dj^WjYWi[

&IGÈ JI://WXkjc[djii^ekbZdejX[ki[Zjeel[hYec[
bWh][l[hj_YWbZ_iYh[fWdY_[i_di_jkWj_edie\[njh[c[h[iehfj_ed$
J^[Z[dj_iji^ekbZdejWjj[cfjjeYel[hWdo]WfiYh[Wj[ZXo
WZ[gkWj[bo i[b[Yj[Z l[ho bed] j^h[WZ[Z f_di _d j^_i mWo$
?d [nf[h_[dY[" fWj_[dji ^Wl[ de fheXb[c m_j^ j^[i[ ij_bj#b_a[
Xh_Z][ ijhkYjkh[i Wi bed] Wi j^[o h[cW_d _dl_i_Xb[ \hec j^[
ekji_Z[$Edj^[YedjhWho"j^[oj[dZjeX[^WffoWXekjj^[ki[h#
\h_[dZboWYY[ii\ehXhki^_d]WdZ\beii_d] B

&IGÈÈ A J^_i cWn_bbWho Xh_Z][ _i ikffehj[Z Xo dWjkhWb

j[[j^ WdZ 8E? _cfbWdji$ B J^[ iWc[ Xh_Z][ m_j^ j^[
_cfbWdj#ikffehj[ZYhemd''hejWj[ZXo/&Z[]h[[i$J^[Yhemd
mWi el[hYedjekh[Z jemWhZi j^[ l[ij_XkbWh Wif[Yj$ J^Wdai je
j^[beYWj_ede\j^[j^_dc[jWbYeh["WdW[ij^[j_YWbboZ[i_hWXb[
ceZ[bbWj_ed mWi WY^_[l[Z$ Ib_]^j ]_d]_lWb fheb_\[hWj_ed ed
j^[ fWbWjWb Wif[Yj ^WZ ]_l[d h_i[ je ZhW_dW][ fheXb[ci WdZ
c_bZh[ZZ[d_d]e\j^[]_d]_lW$?dj[h[ij_d]bo"fbWgk[h[j[dj_ed
mWi eXi[hl[Z _d j^[ fWbWjWb Wh[W" m^_Y^ mWi WYjkWbbo m[bb
WYY[ii_Xb[\ehehWb^o]_[d[_dijhkc[dji"hWj^[hj^WdX[bemj^[
l[ij_XkbWhboel[hYedjekh[ZY[hWc_Yi^ekbZ[h
È È ,ABORATORYÈ0ROCEDURESÈ '.'

È
2ESINÈ6ERSUSÈ#ERAMICÈ6ENEERING
J^[Z[dj_ijckijki[^_iemdZ_iYh[j_ed_di[b[Yj_d]
j^[jof[e\cWj[h_Wb\ehl[d[[h_d]$8ej^WYhob_Yh[i_di
WdZ Y[hWc_Yi ^Wl[ j^[_h ijh[d]j^i WdZ m[Wad[ii[i$
Ekh emd feb_Yo _i je ki[ W iodj^[j_Y Y[hWc_Y
IodifWh j^Wj Xb[dZi m[bb ded#deXb[ c[jWbi \eh
\hWc[mehai [l[d _\ bWh][ Xh_Z][ ifWdi Wh[ _dlebl[Z
[$]$9e9hCeWbbeoi$J^_icWj[h_Wb_idejikiY[fj_Xb[
je ijh[ii#h[bWj[Z YhWYa \ehcWj_ed" WdZ _j b[dZi _ji[b\
l[hom[bbje_djhWehWbWZ`kijc[djiWdZfeb_i^_d]$?d
ekh [nf[h_[dY[" [nj[di_l[ ikXjhWYj_l[ WZ`kijc[dji
A
Wh[ ckY^ ceh[ Z_\\_Ykbj ed dWjkhWb Y[hWc_Yi [$]$
L_jW$

&IGÈAB M^_b[ j^[ l[ij_XkbWh ikh\WY[i Wh[ fhec_d[djbo

ceZ[bb[Z d[Wh j^[ Yh[ij je efj_cWbbo ikffehj j^[ ie\j#j_iik[
ijhkYjkh[i"Y[hWc_YickijX[Wffb_[ZifWh_d]boedj^[fWbWjWb
i_Z[je\WY_b_jWj[ehWb^o]_[d[$;WY^j^h[WZ[Zf_d^Wije\[Wjkh[
Wjb[Wijed[Wh[Wj^Wj_idejYecfb[j[boYel[h[ZXoie\jj_iik[
_dehZ[hjeWbbemZhW_dW][Wbed]j^[_cfbWdj

&IGÈ ?d j^_i YWi[" j^[ h[gk_h[Z el[hYedjekh_d] mWi

dej f[h\ehc[Z" m^_Y^ o_[bZi Wd kdWYY[fjWXb[ h[ikbj _d j^[
W[ij^[j_Y ped[ kdb[ii Wd [f_j^[i_i _i _di[hj[Z Wi m[bb$ J^[
iWc[Z[i_]dmekbZ"XoYedjhWij"X[WZlWdjW][eki\ehWdoZ_ijWb
WXkjc[djiekji_Z[e\j^[W[ij^[j_Yped[X[YWki[ehWb^o]_[d[
_i]h[Wjbo\WY_b_jWj[ZXoj^_ijof[e\Yed\_]khWj_ed
  ¬ 
#(!04%2È

2EPLACINGÈ-OLARSÈINÈ"OTHÈ*AWS

_cfbWdj$ J^_i j_c[" ^em[l[h" j^[o m[h[ ki[Z _d

È YecX_dWj_edm_j^dWjkhWbWdj[h_ehWXkjc[dji$
)NTRODUCTION J^[h[ _i de i_cfb[ Wdim[h je j^[ gk[ij_ed Wi je
m^_Y^ e\ j^[ jme WffheWY^[i i^ekbZ X[ fh[\[hh[Z$
Jme[ii[dj_Wbjh[Wjc[djWbj[hdWj_l[iWh[WlW_bWXb[\eh 7 ijWj_ij_YWb h[l_[m i^emi j^Wj Xej^ Wh[ YWfWXb[ e\
Z[Wb_d] m_j^ YWdj_b[l[h i_jkWj_edi _d j^[ feij[h_eh Z[b_l[h_d] ikYY[ii\kb ekjYec[i <_]i$'($/" '($'&$ ?d
i[]c[dj0 i_jkWj_edi m^[h[ j^[ Xed[ Yed\_]khWj_ed Ze[i dej
v IjhkYjkh[i j^Wj Wh[ ikffehj[Z Xo _cfbWdji edbo f[hc_j Wd _cfbWdj#ikffehj[Z fWhj_Wb h[ijehWj_ed
_dYbkZ_d]i_d]b[#jeej^_cfbWdji$ je X[ _di[hj[Z WdZ _cc[Z_Wj[bo beWZ[Z" _j cWo X[
v 8h_Z][ijhkYjkh[iikffehj[ZXoXej^_cfbWdjiWdZ i_cfb[hjejWa[h[Yekhi[jedWjkhWbj[[j^$I_jkWj_edi
dWjkhWbj[[j^$ e\j^_ijof[Wh[[dYekdj[h[ZXej^_dj^[cWn_bbWWdZ
_dj^[cWdZ_Xb[$

È
3CORTECCISÈ-ULTI IMPLANTÈ#ONCEPT È
,ONG 4ERMÈ/UTCOMEÈOFÈ6ARIOUSÈ4REATMENTÈ
I[[<_]'($'#'($+")$/"'*$) -ODALITIESÈINÈTHEÈ0OSTERIORÈ3EGMENT

?dj^_ii[Yj_ed"m[h[fehjj^[ZWjWe\Wh[jheif[Yj_l[
È ijkZoXWi[ZedekhfWj_[djiYel[h_d]WdeXi[hlWj_ed
"/)È)MPLANTSÈ#OMBINEDÈWITHÈ.ATURALÈ4EETHÈ f[h_eZ e\ -o[Whi$ M_j^_d j^_i f[h_eZ m[ _di[hj[Z
ANDÈ#RESTALÈ)MPLANTS W jejWb e\ (.+ fheij^[j_Y ijhkYjkh[i ikffehj[Z Xo
)+, feij[h_eh 8E? _cfbWdji$ M^[h[ Wffhefh_Wj["
<_]kh[i'($,Ä'($. W]W_d _bbkijhWj[ j^[ YecX_d[Z ki[ dWjkhWb WXkjc[dji m[h[ Wbie _dYbkZ[Z$ E\ j^[i[ (.+
e\ed[jkX[hefj[ho]e_ZiYh[m_cfbWdjWdZed[8E? ijhkYjkh[i"().$'^WZjeX[h[fW_h[Zehh[fbWY[Z

&IGÈ J^_i fWdehWc_Y hWZ_e]hWf^ _bbkijhWj[i W YWi[ _d m^_Y^ Xej^ j[Y^d_gk[i ^Wl[ X[[d Wffb_[Z _d W i_d]b[ fWj_[dj$ J^[
cWn_bbW mWi h[ijeh[Z m_j^ Wd _cfbWdj#h[ijehWj_ed Yecfb[n ikffehj[Z Xo j^h[[ 8E? _cfbWdji WdZ ed[ Yecfh[ii_ed iYh[m
9edijhkYj_ed Jof[ (^$ J^[ Xh_Z][ _d j^[ feij[h_eh i[]c[dj e\ j^[ cWdZ_Xb[ _i ikffehj[Z Xo edbo ed[ ijhWj[]_Y _cfbWdj
YecX_d[Zm_j^dWjkhWbjeej^WXkjc[dji9edijhkYj_edJof['[1i[[I[Yj$'($*$'\ehWZ[\_d_j_ede\YedijhkYj_edjof[i
'.* 9^Wfj[h'(È 2EPLACINGÈ-OLARSÈINÈ"OTHÈ*AWS

&IGÈ ?djhWef[hWj_l[ l_[m$ ;deiiWb WdY^ehW][ e\
ed[ feij[h_eh i[]c[dj m_j^ekj XWbWdY_d] ikffehj je j^[
YedjhWbWj[hWb i_Z[ _i [dikh[Z Xo jme Yecfh[ii_ed iYh[mi
X[\eh[ j^[ i_dki" ed[ 8E? _cfbWdj kdZ[h j^[ i_dki" WdZ ed[
jkX[hefj[ho]e_Z iYh[m b[d]j^0 '/cc$ IYehj[YY_ fh[i[dj[Z
j^_ijof[e\h[ijehWj_edWi^_ickbj_#_cfbWdjYedY[fjWbbem_d]
_cc[Z_Wj[beWZ_d]
&IGÈ Fheij^[j_Y ikf[hijhkYjkh[ X[\eh[ _di[hj_ed$ J^[
j^h[[Wdj[h_ehYhemdim[h[Y[c[dj[Z$J^[j[Y^d_YWbWXkjc[dj
_d fei_j_ed '. mWi iYh[m[Z \hec Wd eXb_gk[ bWj[heWdj[h_eh
Z_h[Yj_ed_dWYYehZWdY[m_j^j^[Z_ijec[Z_Wb_di[hj_edfWj^
e\j^[jkX[hei_jo_cfbWdj$
?d ekh [nf[h_[dY[" ^Wl_d] h[ijehWj_edi ikffehj[Z [nYbki_l[bo
Xo_cfbWdji_iWYedY[fjj^Wjmehail[hom[bb$>em[l[h"m^[d
ki_d] 8E? _cfbWdji dej i[Ykh[Z W]W_dij hejWj_ed" ikY^ Wi
;: jof[i" Wj b[Wij j^h[[ _cfbWdji m_bb ^Wl[ je X[ fhel_Z[Z je
fh[l[dj hejWj_ed e\ j^[ Xh_Z][$ ?: _cfbWdji" m^_b[ fhej[Yj[Z
W]W_dijhejWj_edf[hi["cWoX[ikX`[YjjehejWj_eded[WhekdZ
j^[ ej^[h _\ j^[o Wh[ beWZ[Z _cc[Z_Wj[bo$ J^_i _i m^o ckbj_#
Z_ia 8E? _cfbWdji i^ekbZ X[ fh[\[hh[Z _d j^[i[ i_jkWj_edi
m^[h[l[h\[Wi_Xb[$7jWdohWj["jof[(^YedijhkYj_ediWh[l[ho
ikYY[ii\kbYb_d_YWbbo"WdZj^[oYWdX[beWZ[Z_cc[Z_Wj[bo_\j^[
Yehh[ifedZ_d]_dZ_YWj_ed[n_iji

m_j^_dj^[eXi[hlWj_edf[h_eZ$J^_iikXijWdj_Wbd[[Z
\eh i[YedZWho fheY[Zkh[i mWi YWki[Z dej ie ckY^
Xo j^[ _cfbWdji Wi Xo j^[ dWjkhWb WXkjc[dji ki[Z
_dj^_ii[h_[i$;dZeZedj_YWbbojh[Wj[Zj[[j^m[h[j^[
Yecced[ij iekhY[ e\ Yecfb_YWj_edi$ Ed j^[ ej^[h
^WdZ"ijh_Yjbo_cfbWdj#ikffehj[Zfeij[h_ehijhkYjkh[i
&IGÈ EYYbkiWbl_[m_bbkijhWj_d]j^[ifWj_Wbh[bWj_edi^_fi
beWZ[Z _cc[Z_Wj[bo ed l[hj_YWbbo h[ZkY[Z Xed[ Wh[
Wd efj_ed edbo _\ W ik\\_Y_[dj dkcX[h e\ _cfbWdji
YWd X[ _di[hj[Z$ M_j^ ceZ[hd 8E? Z[i_]di" j^[
hWd][ e\ _dZ_YWj_edi \eh fkh[bo _cfbWdj#ikffehj[Z
cWn_bbWhoijhkYjkh[i^WiXheWZ[d[Z"[if[Y_Wbbom^[d
jkX[hefj[ho]e_ZiYh[miWh[Wbie_dYbkZ[Z$
?d ekh Yb_d_Y" m[ h[\ki[ je _di[hj h[celWXb[
h[ijehWj_edi Wi W cWjj[h e\ fh_dY_fb[" [nY[fj _d
fWj_[djim^eWh[dej[b_]_Xb[\eh_cfbWdjj^[hWfo\eh
ioij[c_Yh[Wiedi$J^_i_i^emm[`kij_\oekhfeb_Yo0
v :[djkh[iW\\[Yjj^[h[i_ZkWbZ[dj_j_edXoikX`[Yj_d]
j^[cje[nY[ii_l[kdYedjhebb[ZbeWZi$
v J^[oWbieW\\[Yjj^[ijhkYjkh[iXom^_Y^j^[oWh[
ikffehj[Z" _$[$ j^[o WYY[b[hWj[ WdZ h[_d\ehY[ j^[
fheY[iie\h_Z][h[iehfj_ed$
v =_l[d j^[ h[i_b_[dY[ e\ f[h_eZedjWbbo ikffehj[Z
&IGÈ 9bei[#kfi[Yj_ede\fWdehWc_YhWZ_e]hWf^i^em_d]
Z[djkh[i" j^[ JC@ ijhkYjkh[i Wh[ b[\j m_j^ekj
j^[iWc[YWi[Wi_d<_]$'($( WZ[gkWj[ikffehj$
v J^[d[[Z\ehckiYkbWhijWX_b_pWj_ede\j^[Z[djkh[
WZl[hi[boW\\[Yjij^[Y^[m_d]\kdYj_ed$
v :_\\[h[dj_Wb h[i_b_[dY[ e\ cWij_YWjeho kd_ji cWo
]_l[h_i[jebef#i_Z[ZY^[m_d]fWjj[hdi$
È È ,ONG 4ERMÈ/UTCOMEÈOFÈ6ARIOUSÈ4REATMENTÈ-ODALITIESÈINÈTHEÈ0OSTERIORÈ3EGMENTÈ '.+

?j_ifh[Y_i[boj^[cWij_YWjeho\kdYj_edj^WjZ[dj_iji
ckij W_c je h[ijeh[ _d Wdo a_dZ e\ h[ijehWj_l[
[dZ[Wlekh$ J[Y^d_gk[i ikY^ Wi Xed[ Wk]c[djWj_ed
eh Z_ijhWYj_ed" ^em[l[h" m_bb Yedi_Z[hWXbo W\\[Yj j^[
cWij_YWjeho\kdYj_edXoh[gk_h_d]ckbj_fb[ikh]_YWb
fheY[Zkh[i WdZ jWa_d] Yedi_Z[hWXb[ j_c[$ J^[
cWij_YWjeho fWjj[hd m_bb WbmWoi j[dZ je Z[j[h_ehWj[
Wi W h[ikbj e\ Wle_ZWdY[ c[Y^Wd_ici" YedZ_j_edi
e\ bed]#j[hc Zoi\kdYj_ed WdZ Z_iki[ Wjhef^o e\
Y^[m_d]ckiYb[iFbWdWi'/.($

&IGÈ FWdehWc_Y hWZ_e]hWf^ e\ j^[ b[\j cWn_bbW X[\eh[
[njhWYj_ede\jeej^(-
È
0ATIENTS
M[ijWhj[Zekh_dZ_YWj_ed#XWi[Zh[jheif[Yj_l[ijkZo
Xo h[l_[m_d] kd_bWj[hWb WdZ X_bWj[hWb YWdj_b[l[h
i_jkWj_edi$ 7bb Yedi[Ykj_l[ _cfbWdji j^Wj m[h[ ikX#
i[gk[djbo _dYbkZ[Z _d fheij^[j_Y ijhkYjkh[i m[h[
h[l_[m[Z$7YbWii_\_YWj_ede\j^[h[ijehWj_l[ijhkYjkh[i
_dYbkZ[Z _d j^[ ijkZo _i fhel_Z[Z _d JWXb[i'($' WdZ
'($($

4ABLEÈ Jof[ ' ijhkYjkh[i0 ed[ feij[h_eh _cfbWdj" Z_ijWb

_cfbWdji"YWdj_b[l[hi_jkWj_edWjfh[i[djWj_ed

5ZQF
B
m*

5ZQF
C
m*

5ZQF
D
mm*

5ZQF
E
mmm*
&IGÈ FWdehWc_Y hWZ_e]hWf^ W\j[h [njhWYj_ed e\ jeej^ (-
WdZ_di[hj_ede\ed['/#ccjkX[hei_jo_cfbWdjWim[bbWied[ 5ZQF
F
mm*
8E?_cfbWdj_dj^[Wdj[h_eh[njhWYj_edWh[W
5ZQF
G
m*

5ZQF
H
m*

4ABLEÈ Jof[ ( ijhkYjkh[i0 jme feij[h_eh _cfbWdji" Z_ijWb

_cfbWdji"YWdj_b[l[hi_jkWj_edWjfh[i[djWj_ed

5ZQF
B
mm*m*

5ZQF
C
m*m*

5ZQF
D
mm*m*

5ZQF
E
mmm*m*

5ZQF
F
mm*m*

&IGÈ I_jkWj_ed W\j[h (*cedj^i$ Dej[ j^Wj j^[ jkX[hei_jo 5ZQF
G
m*m*
_cfbWdji[[cije^Wl[Y^Wd][Z_jifei_j_edl_[m_d]Wd]b[5
W]W_dijj^[i_dkiijhkYjkh[i$J^[Z_ijWdY[\hecj^[8E?jej^[ 5ZQF
H
m*m*
i_dkiWbieWff[Whije^Wl[Y^Wd][Z$J^[Wbl[ebWhifWY[e\j^[
[njhWYj[Z jeej^ ^Wi \_bb[Z iec[m^Wj \hec j^[ Z_ijWb" Xkj dej 5ZQF
I
*
m*m*
DPNQMFUFMZ
JNQMBOUTVQQPSUFE

\hecj^[c[i_Wb"Wif[Yj
'., 9^Wfj[h'(È 2EPLACINGÈ-OLARSÈINÈ"OTHÈ*AWS
J^[fWj_[dji_dj^_iiWcfb[m[h[(/Ä.)o[WhiebZ$
J^[ c[Wd W][ e\ fWj_[dji jh[Wj[Z m_j^ Jof[ ' eh
Jof[(ijhkYjkh[imWi+-$,eh++$,o[Whi"h[if[Yj_l[bo$
Jof[ ' ijhkYjkh[i _dYbkZ[Z /) _cfbWdji *($- _d
cWb[ fWj_[dji WdZ '(+ _cfbWdji +-$) _d \[cWb[
fWj_[dji$ Jof[ ( ijhkYjkh[i _dYbkZ[Z +, _cfbWdji
*'$. _d cWb[ fWj_[dji WdZ -. _cfbWdji +.$(
_d \[cWb[ fWj_[dji$ ?dYbki_ed e\ dWjkhWb WXkjc[dji
mWi h[ijh_Yj[Z0 j^[o m[h[ h[gk_h[Z je [n^_X_j de
cW`eh YWh_eki b[i_edi m^Wjie[l[h WdZ c_d_ckc"
_\ Wdo" ceX_b_jo$ Iec[ e\ j^[ jh[Wjc[dji f[h\ehc[Z
Wh[_bbkijhWj[Z_dj^_iY^Wfj[h$J^[gk[ij_edm^[j^[h
jeXWYYe ki[ _i W fhe]deij_Y \WYjeh \eh j^[ ekjYec[
e\8E?_cfbWdji_iceej"i_dY[ded[e\j^[_cfbWdji
_di[hj[Z Wced] Wdo e\ j^[ icea[hi m[h[ beij$ :k[
jej^[feeh[hXed[gkWb_jo_dicea[hi"j^_iikXi[je\
fWj_[dji mWi Y^WhWYj[h_p[Z Xo W ]h[Wj[h dkcX[h e\
cWn_bbWhoj^WdcWdZ_XkbWhJof[(ijhkYjkh[i$
7jejWbe\*'fWj_[djim[h[WXb[je][jh_Ze\j^[_h
fWhj_WbZ[djkh[iWiWh[ikbje\_cfbWdjjh[Wjc[dj$7bb
ej^[hfWj_[dji[_j^[h[n^_X_j[Zkdh[ijeh[Z[Z[djkbeki
Wh[Wi eh kdZ[hm[dj W i_d]b[#ij[f _cfbWdjWj_ed fhe#
Y[Zkh[j^Wj_dYbkZ[Zj^[[njhWYj_ede\j[[j^$
È
)NDICATIONS
8E?_cfbWdjim[h[_dlWh_WXboki[ZjeYh[Wj[[deiiWb
WdY^ehW][fe_dji_dWbbi_jkWj_edim^[h[j^[WlW_bWXb[
Xed[ lebkc[ mWi b_c_j[Z$ J^[o m[h[ ki[Z [_j^[h
Wbed[ eh _d YecX_dWj_ed m_j^ dWjkhWb WXkjc[dji
WdZ%ehYh[ijWb_cfbWdji$
7bb [Z[djkbeki i_jkWj_edi _d j^[ Wh[W e\ j^[ \_hij
WdZi[YedZcebWhi"m_j^ehm_j^ekjWdoWZZ_j_edWbbo
c_ii_d] j[[j^ _d j^[ feij[h_eh i[]c[dj" m[h[
Yedi_Z[h[Z Wd _dZ_YWj_ed \eh 8E? _cfbWdji$ J^[
Z[b_c_j_d] c[i_Wb j[[j^ m[h[ _dYehfehWj[Z _d j^[
ijhkYjkh[ _\ j^[o c[j j^[ Yh_j[h_W ekjb_d[Z WXel[$ ?\
j^[om[h[kdkiWXb[Xoj^[i[ijWdZWhZi"j^[ijhkYjkh[
mWifbWdd[ZjeX[ikffehj[ZXo8E?_cfbWdjiWbed[
eh_dYecX_dWj_edm_j^iYh[m_cfbWdji$?\_cc[Z_Wj[
beWZ_d] mWi fbWdd[Z" Yecfh[ii_ed iYh[mi m[h[
fh[\[hh[ZWiikffb[c[djWhoWdY^ehW][fe_dji\ehj^[
Xh_Z][ijhkYjkh[i$
È
4REATMENTÈ3CHEDULEÈANDÈ3ELECTIONÈÈ
OFÈ)MPLANTÈ$ESIGNS
7bb h[ijehWj_edi m[h[ f[h\ehc[Z m_j^ _cc[Z_Wj[
beWZ_d]$ ?d fhWYj_Y[" j^[ fheij^[j_Y ikf[hijhkYjkh[
mWifbWY[Zm_j^_d'(ZWoie\_di[hj_d]j^[_cfbWdji$
?d YWi[i m^[h[ j^_i ijhkYjkh[ mWi Z[i_]d[Z Wi W
j[cfehWho h[ijehWj_ed" j^[ Z[\_d_j_l[ Y[hWce#c[jWb
Xh_Z][ mWi _di[hj[Z de ieed[h j^Wd ,m[[ai bWj[h$
IkY^ j[cfehWh_[i m[h[ cW_dbo ki[Z W\j[h i_d]b[#
ij[f [njhWYj_ed%_cfbWdjWj_ed fheY[Zkh[i m^[h[ j^[
l[hj_YWbWdZiW]_jjWbckYeiWbijhkYjkh[im[h[[nf[Yj[Z
je h[Y[Z[ _d Wd W[ij^[j_YWbbo h[b[lWdj cWdd[h WdZ
[nj[di_l[h[ceZ[bb_d]e\j^[h_Z][mWib_a[bojeeYYkh$
7dodWjkhWbj[[j^jeX[_dYehfehWj[Z_dj^[ijhkYjkh[
m[h[fh[fWh[Z_cc[Z_Wj[boX[\eh[_cfbWdjWj_edWdZ
\_jj[Zm_j^Wj[cfehWhoh[ijehWj_ed$
8E? _cfbWdj Z[i_]di m[h[ i[b[Yj[Z XWi[Z ed j^[
h[gk_h[c[dj j^Wj j^[o e\\[h[Z X_Yehj_YWb WdY^ehW][
_d j^[ c[Z_Wb WdZ bWj[hWb Xed[ ijhkYjkh[i WdZ j^Wj
j^[j^h[WZ[Zf_di^ekbZX[beYWj[ZWjWiW\[Z_ijWdY[
\hec j^[ ckYeiWb ijhkYjkh[i$ J^[ feb_i^[Z kff[h
i[]c[dje\j^[j^h[WZ[Zf_d^WZjeX[WYY[ii_Xb[\eh
Xhki^_d] WdZ \beii_d]$ J^h[WZ[Z f_di e\ cWn_ckc
b[d]j^" Z[f[dZ_d] ed j^[ WdWjec_YWb i_jkWj_edi"
m[h[i[b[Yj[Zje[dikh[j^Wjj^[_cfbWdj#h[ijehWj_ed
ioij[cmekbZX[ik\\_Y_[djbo[bWij_Y$
Ej^[h _cfbWdj fWhWc[j[hi _dYbkZ[Z W Z_ia Z_W#
c[j[he\/Ä'+ccWdZW]hWZ[e\X[jm[[d=*WdZ=.
Z[f[dZ_d]edj^[WlW_bWXb[^eh_pedjWbXed[lebkc[$
È
)MPLANTATIONÈ0ROCEDURE
7bb _cfbWdj i_j[i m[h[ [nfei[Z Xo h[\b[Yj_d] W
ckYef[h_eij[Wb\bWf\hecYh[ijWbWdZbWj[hWbZ_h[Yj_ed
iej^WjWbbh[b[lWdjijhkYjkh[iYekbZX[m[bbl_ikWb_p[Z$
J^[_dY_i_edmWiZ[i_]d[Z_dikY^WmWoj^Wjj^[\bWf
YekbZX[f[h\ehWj[ZWdZfkbb[Zel[hj^[j^h[WZ[Zf_d
edY[j^[fheY[Zkh[mWi\_d_i^[Z$
9Wh[ mWi jWa[d je [dikh[ j^Wj j^[ ^eh_pedjWb
Xed[lebkc[mWiefj_cWbbokj_b_p[Z_dj^[_di[hj_ed
fheY[Zkh[$Efj_cWbWdY^ehW][jWa[ifh[Y[Z[dY[el[h
Wdofheij^[j_YYedi_Z[hWj_ediWjj^_ife_dj$
<eh cWdZ_XkbWh h[ijehWj_edi" Wd Wjj[cfj mWi
cWZ[ je fei_j_ed j^[ j^h[WZ[Z f_d Wi \Wh c[Z_Wbbo
Wi feii_Xb[ je effei[ j^[ fheY[ii e\ Y[djh_\k]Wb
h[iehfj_ed$ <khj^[hceh[" j^[ beWZ#jhWdic_jj_d]
_cfbWdj i[]c[dji m[h[ fbWY[Z Wj j^[ b[l[b e\ j^[
m^_j[b_d[m^[d[l[hfeii_Xb[jejWa[WZlWdjW][e\j^[
ijh[ii#h[bWj[Z]h[Wj[hj[dZ[dYoe\Xed[h[][d[hWj_ed
_d j^Wj Wh[W$ J^[ m_Zj^ e\ j^[ cWdZ_XkbWh h_Z][ _i
kikWbboX[jj[hfh[i[hl[ZWjj^_ib[l[b"m^_Y^Yecfh_i[i
jhkbo XWiWb Xed[" j^Wd _d W ceh[ ikf[h_eh fei_j_ed$
7bb 8E? _cfbWdji m[h[ _di[hj[Z ikY^ j^Wj j^[ beWZ#
jhWdic_jj_d] Z_iai m[h[ ib_]^jbo iWb_[dj" Wj b[Wij ed
j^[l[ij_XkbWhi_Z[$
<_]kh[i'($,Ä'($/ _bbkijhWj[ j^[ ikh]_YWb WffheWY^
je Yh[Wj_d] W Yed]hk[dj _cfbWdj X[Z$ <_]kh['($'&
i^emi j^[ eii[e_dj[]hWj[Z _cfbWdj Wj j^[ '(#cedj^
\ebbem#kf$
J^[_cfbWdji_j[iki[Z\ehcWn_bbWhoh[ijehWj_edi
_dYbkZ[Z j^[ fei_j_ed e\ j^[ i[YedZ cebWhi Wi m[bb
Wi j^[ Wh[W e\ j^[ po]ecWj_YeWbl[ebWh Yh[ij$ 8ej^
h[]_edi Wh[" ckY^ b_a[ j^[ YWd_d[ \eiiW" Yedi_Z[h[Z
je X[ fem[h\kb ¼cWij_YWj_ed f_bbWhi½ m[bb ik_j[Z \eh
beWZjhWdic_ii_edledB”Z_d]^Wki[dWdZFecWheb_
È È ,ONG
4ERMÈ/UTCOMEÈOFÈ6ARIOUSÈ4REATMENTÈ-ODALITIESÈINÈTHEÈ0OSTERIORÈ3EGMENTÈ
'/.,$Iec[j_c[i"^em[l[h"Xej^WdWjec_YijhkYjkh[i
Wh[ jee \Wh WfWhj je X[ Xh_Z][Z Xo W i_d]b[ _cfbWdj$
7bie"j^[WdWjec_Yi_jkWj_ed_dj^[Wh[We\j^[po]e#
cWj_YeWbl[ebWh Yh[ij cWo X[ ikY^ j^Wj j^[ lebkc[
e\j^[l[ij_XkbWhYehj_YWbXed[_ikd\WlekhWXboj^_d$
?d [_j^[h YWi[" m[ Yed\_d[Z ekh gk[ij \eh X_Yehj_YWb
WdY^ehW][jej^[Wh[We\j^[i[YedZcebWhWdZki[ZW
bWj[hWb_di[hj_edfWj^\ehWbbe\j^[i[_cfbWdji"m_j^ekj
X[_d]WXb[jeWdY^ehj^[c\hecWdeXb_gk[Wdj[h_eh
Z_h[Yj_ed_dm^Wjki[ZjeX[j^[po]ecWj_YeWbl[ebWh
Yh[ij$ 7i Wd WZZ_j_edWb c[Wikh[ _d j^[i[ YWi[i" j^[
l[ij_XkbWh _cfbWdj i[]c[dj mWi WZWfj[Z _d YhWd_Wb
Z_h[Yj_edjej^[[nj[hdWbi_dkimWbb$
J^[ Wh[W e\ j^[ fh[cebWhi mWi dej ki[Z \eh
_cfbWdjim^[d[l[hfeii_Xb[$:[f[dZ_d]edfheij^[j_Y
h[gk_h[c[dji" j^[ [YY[djh_Y j^h[WZ[Z f_di m[h[
fbWY[Z _d W ceh[ fWbWjWb eh l[ij_XkbWh fei_j_ed Xo
i[b[Yj_d] j^[ Yehh[ifedZ_d] _di[hj_ed fWj^ e\ j^[
_cfbWdj$ ?\ j^[ ikh]_YWb j[Y^d_gk[ _i WZ[gkWj[ WdZ
j^[ Xed[ ijhkYjkh[i Wh[ m[bb [nfei[Z" j^[h[ _i de
d[[Z\eh[nj[di_l[hWZ_e]hWf^_Yjh[Wjc[djfbWdd_d]$
J[cfbWj[i WdZ Zh_bb_d] W_Z[i Wh[ ^WhZbo ki[\kb m_j^
8E? _cfbWdji$ J^[ 8E? _cfbWdjebe]_ij m_bb WbmWoi
^Wl[WicWbbi[b[Yj_ede\Wffb_YWXb[_cfbWdji^WdZo$
?d j^[ Z_ijWb cWdZ_Xb[" j^[ lebkc[ e\ j^[ l[ij_#
XkbWhYehj_YWbijhkYjkh[mWidehcWbboik\\_Y_[djWdZ
mWi kj_b_p[Z WYYehZ_d]bo$ Ed j^[ b_d]kWb i_Z[" _j
mWi Wjj[cfj[Z je h[WY^ j^[ Wh[W e\ j^[ cobe^oe_Z
b_d[" m^_Y^ _i fhej[Yj[Z W]W_dij h[iehfj_ed Xo
j^[ beYWb ckiYb[ WjjWY^c[dj$ J^[ WdWjeco e\ j^[
c[Z_Wb cWdZ_Xb[ YWd X[ h[WZ_bo [nfbeh[Z Zkh_d]
j^[ fheY[Zkh[ Xo fWbfWj_ed$ Je Wle_Z _d\b_Yj_d] Wdo
ZWcW][ je j^[ WdWjec_Y ijhkYjkh[i _d j^Wj h[]_ed"
YWh[ i^ekbZ X[ jWa[d j^Wj j^[ ikXcWdZ_XkbWh \eiiW
_idejf[h\ehWj[Z$B_a[_dj^[cWn_bbW"j^[Wh[We\j^[
cWdZ_XkbWhfh[cebWhimWidejki[Z\eh_cfbWdji$
J^[ beWZ#jhWdic_jj_d] _cfbWdj Z_iai m[h[
_di[hj[Z_d`WmWh[Wim^[h[j^[Yehj_YWbXed[YekbZ
X[ [nf[Yj[Z je fhel_Z[ j^[ d[Y[iiWho ikffehj
j^hek]^ekj j^[ cehf^ebe]_YWb Y^Wd][i WiieY_Wj[Z
m_j^ _dlebkj_ed Wjhef^o WdZ \kdYj_edWb WZWfjWj_ed
_d j^[ feijef[hWj_l[ Yekhi[$ 7domWo" j^[ [nj[dj
WdZ Z_h[Yj_ed e\ Xed[ h[ceZ[bb_d] _d j^[ `Wm _i
Z[j[hc_d[Z dej ie ckY^ Xo j^[ cWij_YWjeho beWZi
jhWdic_jj[Z Xo j^[ _cfbWdj Z_ia Wi Xo j^[ \b[nkhWb
\ehY[i j^Wj Z[l[bef \hec f^oi_ebe]_YWb cel[c[dji$
J^[ceijWffhefh_Wj[_cfbWdji_j[iWh[_dj^[XWiWb
Xed[ i[]c[dji" Wi j^[i[ Wh[ YWfWXb[ e\ [dikh_d]
h[b_WXb[ikffehj\eh_cfbWdji_dWbWij_d]cWdd[h$J^[
bed]#j[hcikYY[iie\_cfbWdjj^[hWfoj^ki^_d][ied
j^[i[b[Yj_ede\Wffhefh_Wj[_cfbWdji_j[i$
F[h_ef[hWj_l[ jh[Wjc[dj m_j^ Wdj_X_ej_Yi mWi
dej hekj_d[bo WZc_d_ij[h[Z" i_dY[ W X[d[\_j e\ ikY^
fhef^obWn_i _d hekj_d[ _cfbWdj fheY[Zkh[i _$[$ Wd
[\\[Yjedj^[ikYY[iihWj[^WidejX[[dZ[cedijhWj[Z
=odj^[hWdZCWhX'//.$7dj_X_ej_Yim[h[j^[h[\eh[
edbo WZc_d_ij[h[Z je fWj_[dji m^e h[gk_h[Z
'.-
_djhWef[hWj_l[ Yel[hW][ X[YWki[ e\ W YedYec_jWdj
Z_i[Wi[[$]$[dZeYWhZ_j_i$
J^[ hWj[ e\ fh_cWho _cfbWdj beii beii[i [l[d
X[\eh[ eh _cc[Z_Wj[bo W\j[h _cc[Z_Wj[ beWZ_d]
mWi l[ho bem _d j^_i i[h_[i$ M[ Wjjh_Xkj[ j^_i ]eeZ
ikYY[ii" Wced] ej^[h h[Wiedi" je j^[ \WYj j^Wj j^[
h[bWj_l[bo m_Z[ J#i^Wf[Z eij[ejec_[i m[h[ ij_bb
ef[d _d j^[ [Whbo feijef[hWj_l[ f^Wi[" Wbbem_d]
Wdo Yedi[gk[dY[i e\ h[i_ZkWb eij_j_i eh Yheii#
YedjWc_dWj_edm_j^c_Yheeh]Wd_icijeX[[b_c_dWj[Z
Xo mWo e\ ikffkhWj_ed$ J^[ iWc[ fh_dY_fb[ _i Wbie
Wffb_[Z_dXed[jh[f^_dWj_edWYYehZ_d]jeIY^hZ[h
WdZ_dj^[jh[Wjc[dje\eij[eco[b_j_i$?j_ij^[iWc[
fh_dY_fb[ j^Wj Wbbemi ki je _di[hj _cfbWdji [l[d _d
f[h_eZedjWbbo_dlebl[ZWh[Wi$
C[\[dWc_YWY_ZWjWcWn_ckcZeiW][e\*+&&c]%
ZWo mWi WZc_d_ij[h[Z \eh WdWb][i_W$ ?d WZZ_j_ed"
fWj_[dji m[h[ WZl_i[Z je ki[ W &$( cekj^mWi^
iebkj_ed e\ Y^beh^[n_Z_d[ ]bkYedWj[ i[l[hWb j_c[i
ZW_bo" ijWhj_d] ed j^[ i[YedZ feijef[hWj_l[ ZWo$
J^[ ikjkh[i m[h[ h[cel[Z ed j^[ \_hij eh i[YedZ
feijef[hWj_l[ ZWo X[YWki[ j^[ ckYef[h_eij[Wb \bWf
mWih[jW_d[ZXoj^[j^h[WZ[Zf_de\j^[_cfbWdj$
È
0ROSTHETICÈ2ESTORATION
7bb j^[ _cfbWdji h[fehj[Z _d j^_i ijkZo m[h[ \_jj[Z
m_j^ \_n[Z Y[hWce#c[jWb Xh_Z][i$ ;l[d j^ek]^ j^[
_di[hj_ed i_j[i _$[$ j^[ [c[h][dY[ fe_dji e\ j^[
j^h[WZ[Z f_di m[h[ kikWbbo beYWj[Z _d j^[ Wh[W e\
j^[ i[YedZ cebWhi \eh efj_cWb Xed[ kj_b_pWj_ed" j^[
WYjkWb fehY[bW_d h[ijehWj_edi \eh cWij_YWj_ed m[h[
dej _dijWbb[Z X[oedZ j^[ \_hij cebWh$ J^_i WffheWY^
f[hc_jiefj_cWbWYY[ii\ehehWb#^o]_[d[_dijhkc[dji
_dj^[_cfbWdjWh[WWdZfh[l[dji[nY[ii_l[beWZ_d]_d
j^[Z_ijWbi[]c[dj"m^_Y^mekbZX[b_a[bojeeYYkhWi
j^[JC@i^_\ji_dWYhWd_eZ_ijWbZ_h[Yj_ed_dh[ifedi[
jej^[]hem_d]cWij_YWjeho\ehY[i$
7bb _cfbWdji m[h[ [nfei[Z je \kbb fheij^[j_Y
beWZ_d]$ 7do i^_\ji e\ j^[ WiieY_Wj[Z YedZob[i j^Wj
eYYkhh[Z Wi j^[ cWij_YWjeho \kdYj_ed h[Yel[h[Z
8eea [j Wb$ '//( WdZ cWij_YWjeho \ehY[i _dYh[Wi[Z
>WhWbZied WdZ 9Whbiied '/-- m[h[ YWh[\kbbo
h[WZ`kij[ZWiWhekj_d[c[Wikh[$
È
3TATISTICALÈ!NALYSISÈANDÈ2ESULTS
7bb _cfbWdji _d j^_i ijkZo m[h[ Wii[ii[Z \eh j^[_h
fheXWX_b_jo e\ ikhl_lWb Xo AWfbWd C[_[h ijWj_ij_Yi$
J^[ ZWjW m[h[ \_hij [lWbkWj[Z i[fWhWj[bo \eh Jof[
' WdZ Jof[ ( ijhkYjkh[i1 ikXi[gk[djbo" j^[ lWh_eki
ikXjof[i_dXej^]hekfim[h[Wbie[lWbkWj[Z$
7 lWbk[ e\ '$& mWi Wii_]d[Z je j^[ cWn_ckc
fheXWX_b_jo e\ ikhl_lWb" _dZ_YWj_d] j^Wj de _cfbWdj
mWibeij$;WY^ij[f_dj^[]hWf^i_]d_\_[ied[_cfbWdj
'.. 9^Wfj[h'(È 2EPLACINGÈ-OLARSÈINÈ"OTHÈ*AWS
beij$ L_[m[Z _d j^_i mWo" _cfbWdji beij _d j^[ i^ehj
j[hcm[h[h[\b[Yj[Z_dceh[fhedekdY[Zij[fij^Wd
_cfbWdji beij _d j^[ bed][h j[hc$ J^ki j^[ lWbk[i
Wbed] j^[ o#Wn_i Ze dej _dZ_YWj[ j^[ f[hY[djW][ e\
_cfbWdjibeij$
:_W]dei_i e\ W ikYY[ii\kb ekjYec[ Wj j^[ \ebbem#
kf[nWc_dWj_edmWiXWi[Zedj^[\ebbem_d]Yh_j[h_W0
v ?djWYjcWij_YWjeho\kdYj_ede\_cfbWdj
v De hWZ_e]hWf^_Y [l_Z[dY[ e\ eij[eboi_i d[Wh j^[
XWiWb Z_ia Zk[ je _d\bWccWjeho fheY[ii[i eh
[nY[ii_l[beWZ_d]
v DefW_dehed]e_d]fWj^ebe]_YfheY[ii[i
?cfbWdji dej c[[j_d] Wbb e\ j^[i[ Yh_j[h_W [dj[h[Z
j^[ ijWj_ij_YWb WdWboi_i" kdb[ii j^[ fheXb[c YekbZ
X[ h[iebl[Z" Wi _cfbWdj \W_bkh[i$ F[h_ej[ij lWbk[i Wi
Z[j[hc_d[Z\ehYh[ijWb_cfbWdjiWh[dejh[b[lWdjZk[
jej^[_d^[h[dj[bWij_Y_joe\8E?_cfbWdji$J^[h[Wh[
de [l_Z[dj iY_[dj_\_Y ZWjW \eh 8E? _cfbWdji \eh j^_i
j[nj"WdZ_dfWhj_YkbWhdeYecfWhWj_l[ZWjW$
Ed[ eX`[Yj_l[ e\ j^_i ijkZo mWi je _dl[ij_]Wj[
^em cWdo _cfbWdji Wh[ h[Wbbo d[[Z[Z \eh \_n[Z
h[ijehWj_edi_dj^[feij[h_ehi[]c[djie\j^[cWn_bbW
WdZ cWdZ_Xb[$ Je j^_i [dZ" m[ Z_\\[h[dj_Wj[Z W]W_d
X[jm[[dJof['WdZJof[(ijhkYjkh[iY^WhWYj[h_p[Z
Xo ed[ eh jme _cfbWdji _d j^[ feij[h_eh i[]c[dj"
h[if[Yj_l[bo$ J^[ lWh_eki ikX]hekfi m[h[ bWX[bb[Z
ÆWÇ j^hek]^ÆnÇ$ M^[j^[h j^[ c[i_Wb WXkjc[dj mWi
W h[i_ZkWb jeej^ ijhkYjkh[ eh Wd _cfbWdj mWi dej
Yedi_Z[h[Z_dj^_iWdWboi_i$7bbYedi[Ykj_l[_cfbWdji
j^Wjm[h[_di[hj[Z_dj^[o[Whi'//+Ä(&&)jeikffehj
Jof['ehJof[(fheij^[j_Yh[ijehWj_edim[h[_dYbkZ[Z
_dj^[WdWboi_i$
8Wi[Z ed Jof[ ' ijhkYjkh[i" ) ekj e\ ('. '$)-
_cfbWdjim[h[beij<_]$'($/$;WY^e\j^[ijhkYjkhWb
ikXjof[i'W"'Y"'\mWiW\\[Yj[ZXoed[e\j^[i[_cfbWdj
beii[i$ 8Wi[Z ed j^[ ZWo i[b[Yj[Z \eh WdWboi_i" j^[
h[]kbWh \ebbem#kf f[h_eZ e\ '(cedj^i ^WZ [bWfi[Z
_d '- e\ j^[i[ _cfbWdji" _dZ_YWj_d] j^Wj j^[ fWj_[djiÉ
Yecfb_WdY[m_j^j^[\ebbem#kfiY^[Zkb[mWi][d[hWbbo
]eeZ$ ?\ '.cedj^i ^WZ X[[d i[b[Yj[Z Wi j^[ Ykj#e\\
b_c_j" edbo \ekh _cfbWdji mekbZ ^Wl[ \Wbb[d ekji_Z[
j^[h[]kbWh\ebbem#kff[h_eZ$JmefWj_[djim_j^Jof[
'ijhkYjkh[i"ikffehj[ZXoWjejWbe\j^h[[_cfbWdji"
m[h[beijje\ebbem#kfX[YWki[j^[o^WZZ_[Z$
EXl_ekibo" j^[ beij _cfbWdji ^WZ je X[ h[fbWY[Z"
Wbed]m_j^j^[fheij^[j_Yikf[hijhkYjkh["_dWi[YedZ
fheY[Zkh[$7bb j^h[[ _cfbWdji beij ^WZ X[[d beYWj[Z
_dj^[cWdZ_Xb[$
8Wi[Z ed Jof[ ( ijhkYjkh[i" ( ekj e\ ')* '$*/
_cfbWdjim[h[beij<_]$'($'&$Ed[beiimWiWiieY_Wj[Z
m_j^ W IkXjof[ (X ijhkYjkh[ c[i_Wb _cfbWdj"
j^[ ej^[h ed[ m_j^ W IkXjof[ ([ ijhkYjkh[ Z_ijWb
_cfbWdj$?dXej^YWi[i"j^[fheij^[j_YijhkYjkh[mWi
ij_bbWZ[gkWj[boikffehj[ZXoj^[h[cW_d_d]_cfbWdj"
iej^Wjd[_j^[hXh_Z][^WZjeX[h[fbWY[Z$;l[djie\
j^_i jof[ Wh[ dej jee fheXb[cWj_Y" d[_j^[h \eh j^[
Z[djWbj[Wcdeh\ehj^[fWj_[dj"i_dY[8E?_cfbWdji
YWdX[dehcWbboh[cel[Z\hecX[bemj^[fheij^[j_Y
ikf[hijhkYjkh[ eh jWa[d ekj e\ \kdYj_ed _d W hWj^[h
^Wiib[#\h[[cWdd[h$
7bb_cfbWdjbeii[ieXi[hl[Z_dj^_iijkZoeYYkhh[Z
_dj^[cWdZ_Xb[$
?d WZZ_j_ed je j^[ WXel[#c[dj_ed[Z _cfbWdj
beii[i _d Xej^ ]hekfi" \ekh _cfbWdji ^WZ X[[d beij
X[\eh[ j^[o YekbZ X[ fkj _d \kdYj_ed$ J^[ jebb j^ki
h_i[i Xo Wdej^[h '$'$ M[ ^Wl[ je Z[iYh_X[ j^[i[
YWi[ie\_cc[Z_Wj[_cfbWdjbeiiedWi[fWhWj[XWi_i
X[YWki[ j^[o YWddej X[ WiieY_Wj[Z m_j^ W if[Y_\_Y
jof[e\fheij^[j_YijhkYjkh[$?dekhl_[m"j^[oYWdX[
Wjjh_Xkj[Zjej^[\ebbem_d]\WYjehi0
v ?dWZ[gkWj[Xed[lWiYkbWh_pWj_ed_dj^[fh[i[dY[e\
WZlWdY[ZcWdZ_XkbWhh_Z][h[iehfj_ed"YecX_d[Z
m_j^Wikh]_YWb_dY_i_edj^Wj\Wbbii^ehje\[dikh_d]
j^[ fh[i[hlWj_ed e\ l[ii[bi WdZ fhef[h Ybeikh[
e\ j^[ ikh]_YWb i_j[$ J^[i[ _cfbWdji ^Wl[ je X[
h[cel[Zm_j^ekjZ[bWojeWl[hjcW`ehZWcW][Xo
h[iehfj_ede\j^[Xed[Yel[h$
v Iec[m^Wj _dWZ[gkWj[ h[i_ZkWb Xed[ lebkc[
Yh[ijWbbojej^[Z_ia
v Kd\WlekhWXb[ifWj_WbZhW_dW][YedZ_j_edi"cW_dbo
Zk[jefeijef[hWj_l[im[bb_d]
Ekh eXi[hlWj_edi ik]][ij j^Wj j^[ _cfbWdji beii[i
eYYkhh_d] m_j^ j^[ fheij^[j_Y ikf[hijhkYjkh[i _d
fbWY[ m[h[ YWki[Z Xo Wdo ed[ eh i[l[hWb e\ j^[
\ebbem_d]\WYjehi0
J^[ YWki[ \eh j^[ _cfbWdji beij kdZ[h Jof[ '
ijhkYjkh[i YekbZ X[ jhWYa[Z Zemd je fh_cWho el[h#
beWZZk[jeWZ[\[Yj_l[l[hj_YWbZ_c[di_ede\eYYbki_ed
cWn_bbWhoYecfb[j[Z[djkh[$
Ed[ YWi[ _cfbWdj beii kdZ[h W Jof[ ( ijhkYjkh[
mWiZk[jej^[\WYjj^Wjj^_iZ_ijWb_cfbWdj^WZX[[d
_di[hj[ZWXel[j^[b_d[WeXb_gkW"_$[$_dWdWh[Wj^Wj
_i dej fhej[Yj[Z W]W_dij h[iehfj_ed$ 7i W h[ikbj" j^[
_cfbWdj [l[djkWbbo \[bb l_Yj_c je j^[ _dWZ[gkWj[
h[c_d[hWb_pWj_edj[dZ[dYoe\j^[ikhhekdZ_d]Xed[
ijhkYjkh[W\j[h*o[Whi_d\kdYj_ed$J^[ej^[h_cfbWdj
jeej^)+mWibeij_dWfWj_[djm_j^fhedekdY[Z7d]b[
YbWii??h[bWj_ediY^WhWYj[h_p[ZXo[njh[c[Z[[f#X_j[
cWbeYYbki_ed$J^_iWh[WmWiW^ofeceY^b_edh[bWj_l[
jej^[Xh_Z]["m^_Y^mekbZ_dYh[Wi[j^[beWZWYj_d]
ed j^[ _cfbWdj Z_ia [l[d _d i_cfb[ cekj^ ef[d_d]
_$[$[l[dm_j^ekjj^[Z[[fX_j[$I_dY[j^[fh[cebWh
Wh[Wi^emiWicWbbj[dZ[dYojec_d[hWb_p[Zk[jej^[
YkhlWjkh[ e\ j^[ `Wm" _j Wff[Whi j^Wj eij[eboi_i Zk[
je [nY[ii_l[ _$[$ _d h[bWj_l[ j[hci cWij_YWjeho WdZ
\b[nkhWb\ehY[i]W_d[Zj^[kff[h^WdZ$
E\ j^[ (.+ fheij^[j_Y ijhkYjkh[i h[l_[m[Z _d j^_i
ijkZo"().$'^WZjeX[h[fW_h[Zehh[fbWY[Zm_j^_d
j^[eXi[hlWj_edf[h_eZ$J^[Jof['XijhkYjkh[i"m^_Y^
[nj[dZ[Z\hecYWd_d[ijei[YedZcebWhi"m[h[\h[[e\
fheij^[j_Y Yecfb_YWj_edi Z[if_j[ j^[ Yedi_Z[hWXb[
Xh_Z][ifWdi_dlebl[Z$Ceh[fheXb[cWj_Ym[h[j^ei[
È È ,ONG
4ERMÈ/UTCOMEÈOFÈ6ARIOUSÈ4REATMENTÈ-ODALITIESÈINÈTHEÈ0OSTERIORÈ3EGMENTÈ
ijhkYjkh[ij^Wjm[h[ikffehj[ZXo\_hijfh[cebWhiWi
ieb[c[i_WbWXkjc[djjof['\$Ceh[j^Wd^Wb\e\j^[
Xh_Z][i_dj^_iYWj[]eho^WZjeX[h[fbWY[Z$?dWbbe\
j^[i[YWi[i"j^[YWd_d[mWi_dYehfehWj[Z_dj^[d[m
ijhkYjkh[$ 9ecfb_YWj_edi eYYkhh[Z ceij \h[gk[djbo
m_j^ heej YWdWb j[[j^" [if[Y_Wbbo _\ j^[o ^WZ dej
X[[djh[Wj[Zm_j^YWijfeij#WdZ#Yeh[i$J^ei[Xh_Z][i
\h[gk[djboX[YWc[ceX_b[WdZ^WZjeX[h[WjjWY^[Z$
BWijbo" _j _i d[Y[iiWho je fe_dj ekj j^Wj ekh
ijWj_ij_YWbWdWboi_iWYYekdji\ehWbb_cfbWdjij^Wjm[h[
_di[hj[Z_dj^[\_hijfbWY["m^_Y^_i_dYedjhWijjej^[
ijWj_ij_YWb^WX_jifh[i[dj[ZXoYh[ijWb_cfbWdjebe]_iji$
?dej^[hmehZi"m[^Wl[dej[d]W][Z_dj^[^WX_je\
Z_ic_ii_d]_cfbWdjibeijX[\eh[X[_d]fkj_d\kdYj_ed
WiÆ_Z_efWj^_Y[Whbobeii[iÇ"j^[h[Xo[nYbkZ_d]j^[c
\hecWdWboi_i$M[^Wl[Y^ei[djeZeXej^WiWcWjj[h
e\fh_dY_fb[WdZX[YWki[j^[WffheWY^e\_cc[Z_Wj[
beWZ_d]h[gk_h[Zkije$
È
$ISCUSSION
J^[beWZ#jhWdic_jj_d]ikh\WY[ie\8E?_cfbWdjiWh[
[njh[c[bo icWbb" ie j^Wj j^[_h X_Yehj_YWb WdY^ehW][
i^ekbZX[h[]WhZ[ZWiWc_d_ckch[gk_h[c[dj$?dj^_i
h[]WhZ"8E?Z[i_]dihkdYekdj[hjej^[ÆiY_[dj_\_YWbbo
[ijWXb_i^[ZÇl_[mj^WjbeWZjhWdic_ii_edXo_cfbWdji
h[gk_h[ickY^bWh][hikh\WY[i$J^_iYedl[dj_edWbl_[m
cWoX[XWi[Zedj^[\WYjj^Wjj^[beWZ#jhWdic_jj_d]
ikh\WY[i e\ Yh[ijWb _cfbWdji _d j^[ [deiiWb ifWY[
WbmWoiYec[jeX[beYWj[Z_dYWdY[bbekiXed[m^[h[
j^[ _djhWYehj_YWb XbeeZ ikffbo _i b_c_j[Z" m^_Y^ _i
f[h\ehY[ W b_c_j_d] \WYjeh \eh j^[ cWn_ckc beWZ#
X[Wh_d]YWfWY_joe\j^[Xed[$?dWZZ_j_ed"YWdY[bbeki
Xed[e\\[hiWicWbb[hZ[]h[[e\fh_cWhoijWX_b_joj^Wd
Yehj_YWb Xed[$ J^[ h[iehfj_ed j[dZ[dYo e\ Yehj_YWb
Xed[ WiieY_Wj[Z m_j^ ed]e_d] h[fW_h c[Y^Wd_ici
Ze[ideji[[cjeW\\[Yjj^[ijWX_b_joe\8E?_cfbWdji_d
Wi_]d_\_YWdjmWokdj_bj^[Xed[_i[l[djkWbboh[Xk_bj$
J^[ c[j^eZ e\ XWiWb eii[e_dj[]hWj_ed Wi Wffb_[Z
_d ekh fhWYj_Y[ e\\[hi i_]d_\_YWdj WZlWdjW][i el[h
Yedl[dj_edWbj[Y^d_gk[ie\fh[#_cfbWdjebe]_YWbXed[
Wk]c[djWj_ed je jh[Wj cWn_bbWho WdZ cWdZ_XkbWh
h_Z][ h[iehfj_ed$ 7Z`klWdj jh[Wjc[dj ceZWb_j_[i e\
j^_ijof[_dYbkZ[Wkjebe]ekiYWdY[bbekiXed[]hW\ji"
edbWo eij[efbWijo" _dj[hfei_j_ed eij[efbWijo" l_ieh
eij[ejeco" WbbefbWij_Y edbWoi eh eii[eZ_ijhWYj_ed$
Ceij e\ j^[i[ WffheWY^[i Wh[ XWi[Z ed ckbj_#ij[f
_dlWi_l[ikh]_YWbfhejeYebi$J^[o_]deh[j^[\WYjj^Wj
fWj_[djim^e^Wl[beijj^[_hfeij[h_ehj[[j^fh_cWh_bo
mWdjje^Wl[\_n[Zj[[j^h[ijeh[Z1Wi\ehj^[YedZ_j_ed
e\ j^[ Xed[" j^[o YekbZ dej YWh[ b[ii$ ?d ekh l_[m"
Xed[ Wk]c[djWj_ed fheY[Zkh[i Wh[ Wd kdd[Y[iiWho
mehaWhekdZ je WY^_[l[ W hWj^[h ijhW_]^j\ehmWhZ
jh[Wjc[dj eX`[Yj_l[" Wi WXkjc[dji _di[hj[Z _d j^[
[deiiWbifWY[Wh[f[h\[YjboWZ[gkWj[jeikffehj\_n[Z
'./
h[ijehWj_edi$ J^[ h[Wb jh[Wjc[dj eX`[Yj_l[ _i j^ki
WjjW_dWXb[ Xo kj_b_p_d] j^[ [n_ij_d] Xed[ ijhkYjkh["
hWj^[h j^Wd ÆYkijec_p_d]Ç j^[ fWj_[dj je \_j j^[
_cfbWdjebe]_ijÉid[[Zi$
CkY^ ^Wi X[[d iW_Z _d h[Y[dj o[Whi WXekj j^[
j[Y^d_gk[ e\ eii[eZ_ijhWYj_ed je cWn_c_p[ j^[
l[hj_YWb Xed[ lebkc[ \eh Yh[ijWb _cfbWdji >_ZZ_d]
[j Wb$ '///1 C_bb[i_#IY^eX[b [j Wb$ (&&&$ M^_b[
eii[eZ_ijhWYj_ed _i de ZekXj W l_WXb[ efj_ed" _j _i
ij_bb W ckbj_#ij[f ikh]_YWb WffheWY^ WdZ" Wi ikY^"
_dlebl[ickbj_fb[ikh]_YWbh_iai$J^[h[_ideh[Wiedje
\WlekhWckbj_#ij[ffheY[Zkh[_\j^[iWc[jh[Wjc[dj
eX`[Yj_l[ YWd X[ WY^_[l[Z `kij Wi m[bb m_j^ 8E?
_cfbWdji _d W i_d]b[#ijW][ fheY[Zkh[$ 7j j^[ l[ho
b[Wij"_jmekbZX[_cf[hWj_l[je[nfh[iibo_d\ehcWbb
fWj_[djiWXekjjekdZ[h]eckbj_#ij[ffheY[Zkh[ij^Wj
Wd Wbj[hdWj_l[ fheY[Zkh[ j^Wj _i i_c_bWhbo ikYY[ii\kb
Xkj YWd X[ f[h\ehc[Z _d W i_d]b[ i[ii_ed" ie j^Wj
j^[ YkckbWj_l[ h_ia e\ ikh][ho _i icWbb[h" mekbZ X[
WlW_bWXb[Wim[bb8eZ[dXkh]'/.)1Ikf[h_eh9ekhje\
9[bb[ '/.+$ 8Wi[Z ed o[Whi e\ [nf[h_[dY[" ^em[l[h"
j^[Wkj^ehiWh[Yed\_Z[djj^WjdefWj_[djim^e^Wl[
X[[deX`[Yj_l[boWdZYecfh[^[di_l[bo_d\ehc[Zm_bb
[l[hefj\eheii[eZ_ijhWYj_edieb[bo\ehj^[fkhfei[
e\]W_d_d]l[hj_YWbXed[lebkc[_dWd_dl_i_Xb[Wh[W$
I^ehjYh[ijWb_cfbWdjim_j^bWh][Z_Wc[j[himekbZ
i[[cjeX[Wdej^[hefj_edXkj^Wl[dejo_[bZ[Z]eeZ
h[ikbji_dYb_d_YWbfhWYj_Y[;Ya[hj[jWb$(&&'1AdWki
[jWb$(&&&$DejedboZej^[oel[hboh[ZkY[j^[XbeeZ
ikffbojej^[h_Z]["Xkjj^[_hbWh][dec_dWbZ_Wc[j[h
_d j^[ YebbWh Wh[W Wbie e\\[hi fb[djo e\ ifWY[ \eh
XWYj[h_Wbh[j[dj_ed$
J^[ efj_ed e\ _dj[]hWj_d] _cfbWdj#h[ijehWj_ed
ijhkYjkh[iXWi[Zedj_jWd_kcZ[i_]di_dWd_ie[bWij_Y
cWdd[h^WiX[[d_dl[ij_]Wj[ZXodkc[hekiWkj^ehi$
<ehYh[ijWb_cfbWdji"_jmWih_]^jboZ_ic_ii[ZZk[je
j^[l[hoZ_\\[h[dj[bWij_YX[^Wl_ekhYecfWh[ZjeXed[
Iebj[ipWdZI_[][b['/.*$CWj[h_WbiikY^Wi]hWZ[(Ä
*j_jWd_kc"b[jWbed[J_*7b*L"Wh[Z_ifhefehj_edWj[bo
ceh[ h_]_Z j^Wd YWdY[bbeki eh [l[d Yehj_YWb Xed[
8eia[hWdZCWhX'//'$M^WjYWdX[Zed[_ijecWa[
_cfbWdji o_[bZ je _dYec_d] beWZi Xo Z[b_X[hWj[bo
WZZ_d][bWij_YYecfed[djijej^[_hZ[i_]d<_]i$'($''"
'($'($?\Z[\_d_j_l[ikXi_Z[dY[e\j^[Yb_d_YWb_cfbWdj
Yhemd YWd X[ WjjW_d[Z" beWZ_d] e\ j^[ _cfbWdj m_bb
X[_d\bk[dY[Z_dWX[d[\_Y_WbmWo"jej^[fe_djm^[h[
W f^oi_ebe]_YWb ceX_b_jo Yehh[ifedZ_d] je j^Wj e\
dWjkhWbj[[j^_ih[WY^[ZH_Y^j[h'/.,$
GkWdj_jWj_l[b_c_jWj_edijej^[feii_Xb[Z[]h[[e\
h[i_b_[dY[edboWh_i[_\Wdkdb_c_j[ZdkcX[he\[bWij_Y
Z_ibeYWj_edi _i h[gk_h[Z$ J^[h[\eh[" j^[ Z_c[di_edi
e\ 8E? _cfbWdji ckij X[ ikY^ j^Wj j^[ Z_ibeYWj_ed
eYYkhh_d] _d fhWYj_Y[ m_bb WbmWoi h[cW_d m_j^_d
j^[ bem[h ^Wb\ e\ j^[ b_d[Wh i[]c[dj e\ j^[ M^b[h
Ykhl[$I_dY[cWij_YWjeho\ehY[iWdZ_dZ_YWj_edicWo
Y^Wd][" _j _i l[ho _cfehjWdj je Z[Wb m_j^ j^[ _iik[
'/& 9^Wfj[h'(È 2EPLACINGÈ-OLARSÈINÈ"OTHÈ*AWS
e\8E?_cfbWdjZ[i_]dedj^[XWi_ie\bWh][hfWj_[dj
iWcfb[i$
:k[jej^[ijhkYjkhWbfhef[hj_[ie\8E?_cfbWdji
\_jj[Z m_j^ fheij^[j_Y ikf[hijhkYjkh[i" j^[o Wh[
YWfWXb[e\WXiehX_d]cWij_YWjehoWdZ\b[nkhWb\ehY[i
m_j^ de m[Wa[d_d] e\ eii[e_dj[]hWj_ed" fhel_Z[Z
j^WjWdWffhefh_Wj[_cfbWdjjof[_ii[b[Yj[Z$<b[nkhWb
\ehY[i Wh[ ceh[ YedZkY_l[ je d[m Xed[ \ehcWj_ed
j^Wd Yecfh[ii_l[ \ehY[i <heij '/,*1 Meb\\ './($
J^_i Wffb_[i Xej^ je [nj[hdWb Yehj_YWb Xed[ WdZ" _\
_dlebl[Z_dbeWZjhWdic_ii_ed"jeYWdY[bbekiXed[$
?j ^Wi X[[d feijkbWj[Z j^Wj _cfbWdji" _d ehZ[h
je fhej[Yj j^[ Xed[ WdZ [dikh[ ijWX_b_jo _d j^[
bed]j[hc"^Wl[jeZ_ijh_Xkj[_dYec_d]beWZi[l[dbo
el[h j^[ [dj_h[ [deiiWb Wh[W$ @eei [j Wb$ (&&&
YedYbkZ[Z \hec <;C ijkZ_[i j^Wj Z_ia _cfbWdji
i^em[Z de eii[efhej[Yj_l[ [\\[Yj$ J^_i YedYbki_ed
_i dej ikffehj[Z Xo ekh [nf[h_[dY[$ <_]kh['($*
Yb[Whbo Z[cedijhWj[i j^Wj j^[ effei_j[ _i jhk[$ J^[
_bbkijhWj[Z\_dZ_d]mWieXjW_d[Z_dWZe]ÉicWdZ_Xb[
m_j^ ed[ _cc[Z_Wj[bo beWZ[Z 8E? _cfbWdj$ 7d
Wh[W e\ '$+cc Y^WhWYj[h_p[Z Xo ijhed] eij[edWb
h[ceZ[bb_d]_iWffWh[djWbed]j^[beWZ#jhWdic_jj_d]
Z_iai Wj cWij_YWjeho beWZi j^Wj Wh[ ij_bb jeb[hWj[Z
Xo j^[ Xed[$ J^_i WYj_l_jo e\ i[YedZWho eij[edi
h[\b[Yji j^[ f^oi_ebe]_YWb c[Y^Wd_ic Yecf[diWj_d]
\eh cWij_YWjeho beWZi" m^_Y^ fh[Y_i[bo Ze[i dej
jWa[ fbWY[ Wbed] j^[ l[hj_YWb _cfbWdj Wn_i Xkj Z[[f
_di_Z[ j^[ Yehj_YWb Xed[ _dj[h\WY[$ <khj^[hceh[" j^[
\WYj j^Wj h[ceZ[bb_d] YWd X[ eXi[hl[Z Xej^ WXel[
WdZ X[bem j^[ Z_iai j[bbi ki j^Wj j^[ d[[Z \eh
Yecf[diWj_ed _i dej Yed\_d[Z je cWij_YWjeho beWZi
_d Wd Wf_YWb Z_h[Yj_ed Xkj Wbie _dYbkZ[i [njhki_ed
\ehY[i" m^_Y^ Wh[ W Yedi_Z[hWXb[ \WYjeh fWhj_YkbWhbo
_dXh_Z][ijhkYjkh[i$?Z[Wbbo"Xej^jof[ie\\ehY[iWh[
]k_Z[Zf[hf[dZ_YkbWhboWdZWn_Wbbo_djej^[Yehj_YWb
Xed[ijhkYjkh[$8oYedjhWij"beWZjhWdic_ii_edWbed]
j^[ j^h[WZ[Z f_d WdZ j^[ l[hj_YWb Z_c[di_ed e\ j^[
beWZ#jhWdic_jj_d] h_d] _i" e\ Yekhi[" b[ii e\ W \WYjeh
_d8E?Z[i_]di$
J^[h[_io[jWdej^[h\WY[jjej^[_iik[e\[bWij_Y_jo$
M^_b[Wkj^ehi_dj^[b_j[hWjkh[^Wl[hekj_d[boYbW_c[Z
j^Wj [deiiWb _cfbWdji i^ekbZ X[ ¼eii[e_dj[]hWj[Z½
Wbed] j^[ l[hj_YWb beWZ#jhWdic_jj_d] ikh\WY[i" j^_i
YedY[fj _]deh[i j^[ Z[]h[[ e\ c_d[hWb_pWj_ed e\ j^[
beYWbXed[cWjh_nWdZ_ij^[h[\eh[kdik_j[ZjeZ[\_d[
j^[ YedZ_j_ed d[Y[iiWho \eh ikYY[ii\kb _dj[]hWj_ed$
J^[j[hc¼eii[e_dj[]hWj_ed½_iWbieZ[Y[fj_l[_dj^Wj
j^[ Z_h[Yj YedjWYj Z[l[bef_d] Wj j^[ _cfbWdj#Xed[
_dj[h\WY[_i"_d[\\[Yj"ed[e\¼Ybei[eii[eWZWfjWj_ed½
IY^”fXWY^ [j Wb$ '//*$ J^[ [nf[h_[dY[ m_j^ 8E?
_cfbWdji _d ZW_bo fhWYj_Y[ i^emi j^Wj j^[ Z[]h[[ e\
c_d[hWb_pWj_ed WhekdZ j^[ beWZ#jhWdic_jj_d] Z_iai
YWdY^Wd]["m_j^_db_c_ji"m^_b[j^[¼eii[e_dj[]hWj_ed½
ij_bb h[cW_di _djWYj$ J^[ h[Wiedi \eh Z[Yh[Wi_d]
c_d[hWb_pWj_ed _dYbkZ[ [bWij_Y `Wm Z[\ehcWj_ed WdZ
fheij^[j_Y beWZi j^Wj cWo [l[djkWbbo Ykbc_dWj[ _d
el[hbeWZ eij[eboi_i$ J^_i fheY[ii YWd X[ jh[Wj[Z Xo
Yehh[Yj_d]j^[fheij^[j_YbeWZWdZm_bbX[h[l[hi_Xb[\eh
Wibed]Wij^[Xed[cWjh_n^Wih[cW_d[ZkdY^Wd][Z
CWhj_d WdZ 8khh '/./ WdZ j^[ beWZ#jhWdic_jj_d]
ikh\WY[i^WidejX[Yec[_d\[Yj[Z$
?j _i \W_h je c[dj_ed j^Wj ed[ if[Y_\_Y jof[ e\
ijhkYjkh[jkhd[ZekjjeX[fheXb[cWj_Y_dekhijkZo"
Wbj^ek]^ j^_i mWi Wd _dY_Z[djWb \_dZ_d] X[YWki[
j^[ ijhkYjkh[i _d gk[ij_ed m[h[ dej Yel[h[Z Xo j^[
_dYbki_ed Yh_j[h_W$ M[ Wh[ jWba_d] WXekj cWn_bbWho
¼j^h[[#gkWhj[h Xh_Z][i½ [nj[dZ_d] \hec ed[ YWd_d[
j^hek]^ W 8E? _cfbWdj h[fbWY_d] j^[ YedjhWbWj[hWb
YWd_d[jeWdej^[h8E?_cfbWdj_dj^[Z_ijWbi[]c[dj$
J^[i[ijhkYjkh[i^WZj^[^_]^[ijhWj[e\Yecfb_YWj_edi"
kikWbbo Zk[ je \hWYjkh[ e\ j^[ YWd_d[ _cfbWdji$
J^[o m[h[ dej _dYbkZ[Z _d j^[ ijWj_ij_Yi X[YWki[
j^[oZ_Zdejh[fh[i[dj¼YWdj_b[l[h½i_jkWj_edi_dj^[
kikWbi[di[e\j^[mehZ$8oYecfWh_ied"Wbj[hdWj_l[
ijhkYjkh[ij^Wjm[h[ikffehj[ZXoj^h[[ehceh[8E?
_cfbWdji_dj^[iWc[gkWZhWdjim_j^ekjYheii_d]j^[
c_Zb_d[ m[h[ d[l[h WiieY_Wj[Z m_j^ Yecfb_YWj_edi
Zkh_d] j^[ eXi[hlWj_ed f[h_eZ$ Ed j^[ ej^[h ^WdZ"
_j_iWbie\W_hjec[dj_edj^WjWbbj^[i[_cfbWdjbeii[i
kdZ[h ¼j^h[[#gkWhj[h Xh_Z][i½ eYYkhh[Z _d fWj_[dji
m^e^WZX[[dYecfb[j[bo[Z[djkbeki_dj^[W\\[Yj[Z
gkWZhWdji" m^_Y^ ik]][iji j^Wj j^[_h cWij_YWj_ed
fWjj[hdi ckij ^Wl[ X[[d Y^WhWYj[h_p[Z Xo cWii_l[
kd_bWj[hWbel[hbeWZ_d]$
J^[ijWj_ij_YWbYecfb_YWj_edhWj[_ickY^icWbb[h
m^[d j^[ iWc[ _cfbWdj jof[i Wh[ _dj[]hWj[Z _d
ej^[hijhkYjkh[ib_a["\eh[nWcfb["Yecfb[j[Xh_Z][i$
Feijef[hWj_l[ cW_dj[dWdY[ h[gk_h[c[dji Wh[ edY[
W]W_d ^_]^[h m_j^ Xh_Z][i ikffehj[Z Xo edbo jme
8E? _cfbWdji m_j^ de dWjkhWb WXkjc[dji _dlebl[Z"
Wi j^[i[ h[ijehWj_l[ Z[i_]di Ze dej h[WZ_bo f[hc_j
ikf[hijhkYjkh[ijeX[cekdj[Z_dikY^WmWoj^Wjj^[
h[ijehWj_ed _i fhej[Yj[Z W]W_dij hejWj_ed$ 8h_Z][i e\
j^_ijof[\h[gk[djboX[YWc[ceX_b[edj^[_cfbWdji$
J^[edbomWojeWle_Zj^_ifheXb[c_ije_dYehfehWj[
Wj b[Wij ed[ WZZ_j_edWb WXkjc[dj 8E? _cfbWdj"
iYh[m _cfbWdj eh h[i_ZkWb jeej^ _dje j^[ ijhkYjkh[$
JkX[hei_jo _cfbWdji _d j^[ cWn_bbW Wh[ ed[ eXl_eki
iebkj_ed$
8h_Z][i j^Wj ^WZ X[Yec[ ceX_b[ ed j^[ c[i_Wb
WXkjc[dj WdZ ^WZ je X[ h[cel[Z \eh h[fW_h m[h[
e\j[d ^WhZ je Z_ibeZ][ \hec j^[ Y[c[dj[Z _dj[h\WY[
m_j^ j^[ Z_ijWb _cfbWdj$M[ ^Wl[ j^[h[\eh[ Y^Wd][Z
ekh WffheWY^ WdZ jeZWo b[Wl[ j^[ Z_ijWb _cfbWdji
kdl[d[[h[Z <_]$'($.$ ?d j^_i mWo" j^[ ded#
deXb[ Wbbeo \hWc[meha YWd X[ h[WZ_bo i[fWhWj[Z
_d l[hj_YWb Z_h[Yj_ed WdZ" W\j[h fbWicW m[bZ_d] e\
j^[ ibej" h[_djheZkY[Z _d j^[ iWc[ i[ii_ed m_j^ekj
_dj[h\[h_d] m_j^ j^[ fehY[bW_d Xk_bZ#kf$ J^_i
WffheWY^ _i fh[\[hWXb[ je h[cel_d] Xh_Z][i m_j^
ifh_d]WYY[b[hWjehi9hemd9b_Ya"Wij^_ij[Y^d_gk[
YWhh_[i W h_ia j^Wj j^[ m[X XWh cWo \hWYjkh[ eh
kdZ[h]e fbWij_Y Z[\ehcWj_ed" m^_Y^ mekbZ Y^Wd][
È È #ONCLUSIONSÈ
j^[[bWij_YX[^Wl_ekhe\j^[_cfbWdjcWj[h_Wb_dj^[
Z[\ehc[ZWh[W$
M[ ikif[Yj j^Wj Ybei[ eii[eWZWfjWj_ed YWddej
X[ fh[i[dj ed Wbb beWZ#jhWdic_jj_d] ikh\WY[i m^[d
_cfbWdj#h[ijehWj_ed ijhkYjkh[i Wh[ ikffehj[Z Xo W
ikXijWdj_WbdkcX[he\_cfbWdjiWdZZ_iai$7\j[hWbb"
j^[i^Wf[e\j^[WiieY_Wj[ZXed[ijhkYjkh[iY^Wd][i
Yedj_dkekiboZk[jecoe\kdYj_edWbfheY[ii[i"m^_Y^
_idejYedi_ij[djm_j^j^[dej_ede\i_ckbjWd[ekiYbei[
eii[eWZWfjWj_ed e\ ckbj_fb[ _cfbWdji$ ?di[hj_d] W
icWbbdkcX[he\8E?_cfbWdji"XoYedjhWij"m_bbWbbem
Yecfb[j[ eii[e_dj[]hWj_ed e\ Wbb beWZ#jhWdic_jj_d]
ikh\WY[i _d XWiWb Xed[ ijhkYjkh[i" fhel_Z[Z j^[
_ie[bWij_Y_cfbWdj#h[ijehWj_edijhkYjkh[iWh[Yehh[Yjbo
fbWdd[Z$<[m_cfbWdjim_bbdejh[ZkY[j^[[bWij_Y_jo
e\j^[`Wm$
I_jkWj_edi e\ WZlWdY[Z Xed[ h[iehfj_ed _d
j^[ cWdZ_Xb[ Wh[ fWhj_YkbWhbo Z[cWdZ_d] ed j^[
ikh][edÉi ia_bbi$ J^[ Y^Wbb[d][ _i dej ie ckY^ _d
Yh[Wj_d]j^[eij[ejecoWi_dj^[bWj[hWb\bWfh[\b[Yj_ed
d[[Z[Z je [nfei[ j^[ c[djWb d[hl[$ I_dY[ j^[
ckYef[h_eij[Wb\bWf_iWjjWY^[Z_dj^[Wdj[h_ehh[]_ed
e\ j^[ c[djWb d[hl[" _j cWo X[Yec[ d[Y[iiWho je
ib_]^jboceX_b_p[j^[d[hl["m^_Y^^WiX[[dW]h[Wj[h
fheXb[c _d Yb_d_YWb fhWYj_Y[ j^Wd Z_h[Yj ZWcW][ je
j^[ d[hl[ Xo j^[ _cfbWdj eh eij[ejeco _dijhkc[dj$
J^_i cWd_fkbWj_ed cWo h[ikbj _d W jhWdi_[dj beii e\
i[di_j_l_jo" m^_Y^" _d ekh [nf[h_[dY[" m_bb h[iebl[
m_j^_d)Ä,cedj^iWjj^[bWj[ij$J^_ijof[e\c_i^Wf
^Wi eYYkhh[Z [nYbki_l[bo _d YWi[i m^[h[ j^[ jejWb
l[hj_YWb Xed[ lebkc[ _d j^[ Z_ijWb _cfbWdjWj_ed
i_j[ _dYbkZ_d] j^[ c[djWb d[hl[ mWi Yb[Whbo X[bem
'&cc$ Ij_bb" j^[ Z[]h[[ e\ _dlWi_l[d[ii h[gk_h[Z
je WYYecfb_i^ W \_n[Z h[ijehWj_ed _d j^_i cWdd[h
_i Yedi_Z[hWXbo icWbb[h j^Wd m_j^ Wdo Wbj[hdWj_l[
fheY[Zkh[im[ademe\$;l[dfWj_[djim_j^WZlWdY[Z
h_Z][h[iehfj_edYWddehcWbboX[jh[Wj[Z_dWi_d]b[
fheY[Zkh[edWdekjfWj_[djXWi_i$
?d ikccWho" ekh h[jheif[Yj_l[ ijkZo e\ )+,
_cfbWdji fbWY[Z el[h W f[h_eZ e\ -o[Whi _dZ_YWj[i
j^Wj \_n[Z Xh_Z][i \eh YWdj_b[l[h i_jkWj_edi _d j^[
feij[h_eh i[]c[dj Wh[ WZ[gkWj[bo ikffehj[Z Xo W
i_d]b[ Z_ijWb 8E? _cfbWdj _\ j^[ c[i_Wb WdY^ehW][
fe_dj_iWbieijWXb[$8h_Z][iXk_bjed\_hijfh[cebWhi
Wi c[i_Wb WXkjc[dj" ^em[l[h" jkhd[Z ekj ^Wl[ Wd
kd\WlekhWXb[ fhe]dei_i$ JeZWo m[ mekbZ WbmWoi
_dYehfehWj[ j^[ YWd_d[ _d j^_i i_jkWj_ed _\ W fkh[bo
_cfbWdj#ikffehj[Z ijhkYjkh[ _i dej Wd efj_ed$ Heej
YWdWb j[[j^ ki[Z \eh WXkjc[dji i^ekbZ WbmWoi X[
\_bb[Z m_j^ YWij feij#WdZ#Yeh[i je Wle_Z Z[XedZ_d]
e\ j^[ ijhkYjkh[$ J^[ efj_ed e\ fhef^obWYj_YWbbo
h[cel_d]WdoheejYWdWbj[[j^m_j^_dj^[Xh_Z][ifWd
ckijX[Yedi_Z[h[ZWim[bb$
Iebkj_edi XWi[Z ed jme _cfbWdji \eh cWn_bbWho
h[ijehWj_edi cWo X[ WZlWdjW][eki _d j^[ fh[i[dY[
e\ feeh Xed[ gkWb_jo _\ j^[ fkhfei[ _i je [dWXb[
'/'
_cc[Z_Wj[ beWZ_d] Xo _dYh[Wi_d] j^[ dkcX[h e\
WXkjc[dji$
Iec[j_c[i j^[ Xed[ WlW_bWXb[ _d j^[ feij[h_eh
i[]c[dje\j^[cWn_bbW_iie_dWZ[gkWj[WdZfeehbo
jhW_d[Z j^Wj i_d]b[#Z_ia 8E? _cfbWdji je ikffehj
_cc[Z_Wj[bo beWZ[Z ikf[hijhkYjkh[i cWo ]_l[ h_i[
je Yecfb_YWj_edi$ 7 YecX_dWj_ed e\ \WYjehi Yec[i
_djefbWo0
v½ J^[ _cfbWdj fheY[Zkh[ _i \ebbem[Z Xo Wd _d_j_Wb
f^Wi[ e\ Xed[ beii Zk[ je j^[ fh[lWb[dj WYj_l_jo
e\ eij[eYbWiji" ]_l_d] h_i[ je Yb_d_YWbbo cWd_\[ij
ceX_b_joe\j^[_cfbWdj#h[ijehWj_edijhkYjkh[[l[d
m^_b[j^[^[Wb_d]fheY[ii_i]e_d]_jidehcWbYekhi[$
J^[ eYYbki_ed ^Wi je X[ f[h_eZ_YWbbo WZ`kij[Z _d
j^_i f^Wi[$ <khj^[hceh[" j^[ cWij_YWj_ed fWjj[hd
^Wi je X[ Y^[Ya[Z" WdZ j^[ fWj_[dji j^[ci[bl[i
^Wl[jecWa[WdWYj_l[[\\ehjjeh[ZkY[cWij_YWjeho
\ehY[i$
v L_hjkWbbo Wbb fWj_[dji _d d[[Z e\ _cfbWdj
jh[Wjc[dj h[l[Wb ceh[ eh b[ii i[l[h[ \ehci e\
coeWhj^efWj^_[i"m^_Y^m_bbZ[l[befWjj^[bWj[ij
W\j[h jeej^ beii ^Wi eYYkhh[Z$ J^_i fheY[ii m_bb
Y^Wd][ j^[ cWij_YWj_ed fWjj[hd Wi j[[j^ X[Yec[
[bed]Wj[ZWdZ%ehj_bj[Z$H[eh_[djWj_ede\ckiYb[i
cWoWbiefbWoWheb[$L[ho]hWZkWbbo"j^[Y^Wd][Z
cel[c[dj fWjj[hd m_bb ]_l[ h_i[ je Wbj[hWj_edi
_d ia[b[jWb cehf^ebe]o Wi W h[ikbj e\ dehcWb
WZWfjWj_edWbc[Y^Wd_ici$M^_b[j^[ceij[l_Z[dj
Y^Wd][im_bbdWjkhWbboeYYkh_dj^[JC@i"Z[dj_iji
Wh[ ^WhZbo ki[Z je [lWbkWj_d] j^[_h i^Wf[ WdZ
fei_j_ed _d j^[ hWZ_e]hWf^i m_j^ j^[ _dZ_l_ZkWb
^_ijehoe\j^[cWij_YWjehoWffWhWjki_dc_dZ$7i
j^[ l[hj_YWb Z_c[di_ed" j^[ cWij_YWjeho ikh\WY[i
WdZ j^[ iocc[jho e\ j^[ iakbb Wh[ h[ijeh[Z
WdZ Wbb ckiYb[i h[bWj[Z je j^[ YhWd_kc m_bb X[
[nj[di_l[boh[Yed\_]kh[Z$J^_ifheY[iiedY[W]W_d
_dlebl[i cehf^ebe]_YWb Y^Wd][i" m^_Y^ _d jkhd
m_bb_d\bk[dY[j^[ifWj_Wbfei_j_ede\j^[fheij^[j_Y
ijhkYjkh[$J^[i[Y^Wd][im_bbWbieh[gk_h[f[h_eZ_Y
WZ`kijc[dji$
v ?d ekh [nf[h_[dY[" feijef[hWj_l[ ]W_di _d cWij_#
YWjeho fej[dj_Wb Wh[ if[Y_\_YWbbo WiieY_Wj[Z m_j^
j^[[c[h][dY[e\fh[cWjkh[YedjWYji_dj^[Z_ijWb
i[]c[dj$?j_i[ii[dj_Wbj^Wjj^[i[fh[cWjkh[Yed#
jWYji Wh[ f[h_eZ_YWbbo h[ZkY[Z je Wle_Z [nY[ii_l[
beWZ_d] e\ j^[ Xed[ ijhkYjkh[i WhekdZ j^[ XWiWb
Z_iai$
È
#ONCLUSIONS
J^[j[Y^d_gk[e\XWiWbeii[e_dj[]hWj_ed_iWd[\\[Yj_l[
jeeb"_\Wffb_[ZYehh[Yjbo"jeh[ijeh[feij[h_ehi[]c[dji
W\j[hjeej^beii^WieYYkhh[Z$?j_ifWhj_YkbWhboki[\kb
_\ j^[ WlW_bWXb[ Xed[ lebkc[ _i icWbb$ Ed[ 8E?
_cfbWdj _di[hj[Z _d j^[ feij[h_eh i[]c[dj Wi Z_ijWb
'/( 9^Wfj[h'(È 2EPLACINGÈ-OLARSÈINÈ"OTHÈ*AWS

WXkjc[dj _i [dek]^ je ikffehj \_n[Z h[ijehWj_edi$

?d ekh h[jheif[Yj_l[ ijkZo" WhekdZ jm_Y[ Wi cWdo È
_cfbWdji m[h[ beij kdZ[h ijhkYjkh[i ikffehj[Z Xo 3TATISTICALÈ$IAGRAMSÈÈ
jme8E?_cfbWdjij^WdkdZ[hYecfWhWXb[ijhkYjkh[i ANDÈ2EPRESENTATIVEÈ0HOTOGRAPHS
ikffehj[Z Xo edbo ed[ _cfbWdj$ J^Wdai je j^[_h
Z[i_]d" 8E? _cfbWdji YWd X[ _cc[Z_Wj[bo beWZ[Z
h[]WhZb[iie\Xed[gkWb_jo_\WdWffhefh_Wj[_di[hj_ed
j[Y^d_gk[ _i ki[Z WdZ efj_cWb eYYbkiWb YedZ_j_edi
Wh[ fh[i[dj$ 8WiWb eii[e_dj[]hWj_ed YecX_d[i bem
_dlWi_l[d[ii m_j^ W ^_]^ ikYY[ii hWj[ WdZ e\\[hi
if[[Zo h[^WX_b_jWj_ed e\ YWdj_b[l[h i_jkWj_edi$ 8WiWb
eii[e_dj[]hWj_edckijX[h[]WhZ[ZWij^[jh[Wjc[dj
e\Y^e_Y[_dj^[i[i_jkWj_edi_\fWj_[djYebbWXehWj_ed
_i ]eeZ" fWhj_YkbWhbo _d YWi[i m^[h[ j^[ WlW_bWXb[
Xed[ijhkYjkh[_il[hj_YWbboh[ZkY[Z$
J^[ cW_d WZlWdjW][i e\ 8E? el[h Yedl[dj_edWb
j[Y^d_gk[iWh[0
'$ ?Z[Wb kj_b_pWj_ed e\ l_jWb WdZ \kdYj_edWb dWj_l[
Xed[ijhkYjkh[i
($ ?cc[Z_Wj[beWZ_d]
)$ I_d]b[#ij[ffheY[Zkh[
*$ Ded[[Z\ehWZ`klWdjXed[]hW\j_d]
+$ ;Wioh[fW_hW\j[h_cfbWdjbeii
,$ De_cfbWdj#h[bWj[ZXed[beii
-$ L[hobemjejWbcehX_Z_jo
.$ D[]b_]_Xb[_d\[Yj_edhWj[ &IGÈ El[hl_[me\_cfbWdjikhl_lWb_dJof['ijhkYjkh[i

J^[ jh[Wjc[dj e\ YWdj_b[l[h i_jkWj_edi ki_d] 8E? _i

WiW\[_dZ_YWj_edm^[h[j^[Z[dj_ij^WiYedi_Z[hWXb[
Yedjheb$ J^[i[ YWi[i e\\[h X[]_dd[hi Wd [nY[bb[dj
effehjkd_joje]W_diec[h[Wb#b_\[[nf[h_[dY[Ädej
b[WijX[YWki[j^[cWij_YWjehoYecfed[djifbWoWb[ii
_cfehjWdjheb[_dkd_bWj[hWbYWdj_b[l[hi_jkWj_edij^Wd
m^[dh[ijeh_d]WYecfb[j[`Wm$EYYbkiWbWZ`kijc[dj
WdZcW_dj[dWdY[Wh[YecfWhWj_l[boijhW_]^j\ehmWhZ$
?d ekh [nf[h_[dY[" j^[ cW_d h_ia _d YWdj_b[l[h
i_jkWj_ed W\\[Yji j^[ WXkjc[dji j^Wj c_]^j X[Yec[
kdijWXb[$ :kh_d] \kdYj_ed" l[hj_YWb Xed[ ]hemj^
cWofei[W^WpWhZjejh[Wjc[djikYY[ii$9Wh[\kbWdZ
j_c[bo \ebbem#kf YWh[ _i [ii[dj_Wb \eh W iWj_i\WYjeho
jh[Wjc[djekjYec[$

&IGÈ El[hl_[me\_cfbWdjikhl_lWb_dJof[(ijhkYjkh[i
È È 3TATISTICALÈ$IAGRAMSÈANDÈ2EPRESENTATIVEÈ0HOTOGRAPHSÈ '/)

&IGÈ IkXjof['[ijhkYjkh[
Wjj^[,#cedj^\ebbem#kf$J^[
;:7I_cfbWdj_im[bb_dj[]hWj[Z"
WdZj^[l[hj_YWbXed[ijhkYjkh[
WhekdZj^[_cfbWdj^WiXk_bjkf
fkh[boXo\kdYj_edWbij_ckbWj_ed

&IGÈ IkXjof['[ijhkYjkh[Wj
j^[)#o[Wh\ebbem#kfikffehj[ZXo
j^h[[8E?_cfbWdji
'/* 9^Wfj[h'(È 2EPLACINGÈ-OLARSÈINÈ"OTHÈ*AWS

&IGÈ IkXjof['XijhkYjkh[i
Wjj^[)#o[Wh\ebbem#kf$8ej^
Xh_Z][i"m^_Y^h[fbWY[ZWd
kdZ[i_hWXb[ceZ[b#YWijZ[djkh["
Wh[ikffehj[ZXoed[;:7I
_cfbWdjWdZed[h[i_ZkWb
YWd_d[WXkjc[dj$J^[fWj_[dj
Wbh[WZomeh[WcWn_bbWho
Yecfb[j[Z[djkh[Wjj^[j_c[e\
fh[i[djWj_ed

&IGÈ IkXjof[(XijhkYjkh[$
?cfbWdjijeh[fbWY[\_hijcebWhi
_dj^[feij[h_ehcWn_bbWWh[e\j[d
kdd[Y[iiWho$J^_ifWj_[dj^WZ
fh[l_ekibomehdWcWn_bbWho
fWhj_WbZ[djkh[
È È 3TATISTICALÈ$IAGRAMSÈANDÈ2EPRESENTATIVEÈ0HOTOGRAPHSÈ '/+

&IGÈ Ded#l[d[[h[Z Z_ijWb WXkjc[dji Wh[ W ki[\kb

fh[YWkj_edWbbem_d]j^[ijhkYjkh[jeX[h[cel[Zceh[[Wi_bo
i^ekbZ j^[ d[[Z Wh_i[$ :k[ je j^[ Y[djh_\k]Wb h[iehfj_ed A
j[dZ[dYo e\ j^[ cWdZ_Xb[" j^[i[ _cfbWdji kikWbbo [dZ kf _d
W hWj^[h bWj[hWb fei_j_ed j^Wj mekbZ dej b[Wl[ [dek]^ ifWY[
\ehWfehY[bW_dl[d[[hWdo^em$J^[iWc[Wffb_[ijej^[Z_ijWb
cWn_bbW" m^[h[ j^[ j^h[WZ[Z f_d _i b_a[bo je f[d[jhWj[ j^[
ckYeiW_dWfWbWjWbfei_j_ed

&IGÈÈ A J^_i YWi[ i^emi W Y[hWc_Y#l[d[[h[Z i[YedZ

cebWh m_j^ ef[d WjjWY^c[dj$ B ?d j^_i YWi[" edbo j^[ \_hij
cebWhmWih[fbWY[ZXoed[8E?WdZWXbeYae\Yhemdi

&IGÈ C[jWb ikh\WY[i Wh[ ceh[ ik_jWXb[ j^Wd Y[hWc_Y

&IGÈAB J^[ Xh_Z][ i^emd ^[h[ Yedd[Yji j[[j^ ') WdZ
'*m_j^W8E?_cfbWdjWj',$J^[_cfbWdj_i_di[hj[Zh[bWj_l[bo
Z[[fbo _dje j^[ Xed[$ J^_i _i W ]eeZ _Z[W \hec Wd W[ij^[j_Y
fe_dje\l_[m"Xkj_jWbieh[gk_h[ic[j_YkbekiehWb^o]_[d[
l[d[[hi m^[d _j Yec[i je ]_l_d] fWj_[dji W l_ikWb _dZ_YWj_ed
e\j^[ikYY[iie\j^[_hehWb^o]_[d[[\\ehji$CeijfWj_[djim_bb
dejc_dZj^[icWbbWcekdje\l_i_Xb[c[jWb$D[l[hj^[b[ii"j^_i
W[ij^[j_YWif[Yji^ekbZX[Z_iYkii[ZX[\eh[^WdZ$?\j^[i[YedZ
cebWh_ijeX[l[d[[h[Z"eYYbkiWbYedjWYjiedj^_ijeej^i^ekbZ
X[ Wle_Z[Z$ J^[ j^h[WZ[Z f_di m_bb dej WbmWoi X[ beYWj[Z
m_j^_d j^[ FekdZ Wh[W" o[j j^[ cebWhi ^Wl[ je X[ Yehh[Yjbo
fei_j_ed[Zm_j^_d_jiYed\_d[ije[dWXb[]eeZcWij_YWj_ed
'/, 9^Wfj[h'(È 2EPLACINGÈ-OLARSÈINÈ"OTHÈ*AWS

&IGÈ ?\l[hj_YWbifWY[f[hc_ji"Z_ijWbWXkjc[djiYWdWbie
X[l[d[[h[Z_dY[hWc_Yi$:_ijWbYWdj_b[l[h[Zfedj_YiWh[dej
h[Yecc[dZ[Z$J^[XWi[e\j^[fedj_YckijdejYedjWYjj^[
ehWbckYeiW

A B C

&IGÈAnC J^[i[]hWf^_Y_cW][ii^emj^[Z_\\[h[djjof[ie\\ehY[Z_ijh_Xkj_ed_dZ_\\[h[djYWdj_b[l[h[Zi_jkWj_edi$ A J^[

YWd_d[ WdZ j^[ \_hij cebWh je][j^[h e\\[h ieb_Z ikffehj$ <b[n_ed _i \eh j^[ ceij fWhj WXiehX[Z Xo j^[ Z_ijWb _cfbWdj$ B ?\"
^em[l[h"edboj^[\_hijfh[cebWhYedjh_Xkj[ijeWdj[h_ehikffehj"j^[8E?_cfbWdjm_bbkikWbboX[b[ii\b[n_Xb["m_j^j^[h[ikbj
j^Wj[njhkZ_d]\ehY[iWff[WhWdZkbj_cWj[boh[ikbj_dfh[cWjkh[YedjWYjim_j^j^[cWn_bbWhoZ[dj_j_ed$J^[jeej^cWogk_Yabo
X[Yec[ceX_b[WdZkbj_cWj[bo][jbeij$Jof['\YedijhkYj_edii^ekbZj^kiX[Yedi_Z[h[Zedbo_\j^[\_hijfh[cebWh^WiWbed]
heejWdZ^WidejX[[d[dZeZedj_YWbbojh[Wj[Z$?dj^[i[YWi[i"^em[l[h"j^[h[_iWbceijedboieckY^Xed[WlW_bWXb[Z_ijWbboe\j^[
\_hijfh[cebWhj^WjWdWbj[hdWj_l[Jof[(^YedijhkYj_ededj^h[[_cfbWdjiYWdX[ki[Z$J^_i_ij^[Wbj[hdWj_l[m[mekbZfh[\[h
jeZWo$ C 7bj^ek]^j^[heejikh\WY[_dj^[i[YedZfh[cebWh_iWffhen_cWj[boj^[iWc[i_p["j^[b[l[hW][_iceh[\WlekhWXb[m_j^
Wh_]_ZZ_ijWb8E?_cfbWdjX[YWki[j^[beWZ_iceh[[l[dboZ_ijh_Xkj[ZX[jm[[dj^[WXkjc[djWdZj^[_cfbWdjWdZj^[YWdj_b[l[h
\ehY[iWh[icWbb[h_dCYecfWh[ZjeB$J^[lWh_WdjiAWdZBWh[Yb_d_YWbboceh[ikYY[ii\kbj^Wdj^[ed[i^emd_dB
  ¬ 
#(!04%2È

!NTERIORÈ-ASTICATORYÈ0ATTERNSÈÈ
ANDÈ#LASSÈ))È3KELETALÈ2ELATIONS

WffhW_iWb _i f[h\ehc[Z Xo c[Wikh_d] j^[ Z_ijWdY[

È
$EFININGÈTHEÈ0ATIENTÈ'ROUP
J^_i Y^Wfj[h Z[Wbi m_j^ fWj_[dji [n^_X_j_d] _dj[h#
cWn_bbWhoh[bWj_edi^_fij^WjYWdX[Z[\_d[ZWiZ_ije#
eYbki_ed Xo ehj^eZedj_Y Yh_j[h_W$ J^[i[ YWi[i Wh[
kikWbbo WiieY_Wj[Z m_j^ W bWh][ 7D8 Wd]b[ WdZ Wd
_dj[hYkif_ZWj_ed _d m^_Y^ Xej^ j^[ YWd_d[ WdZ j^[
\_hijcebWh_dj^[cWdZ_Xb[Wh[beYWj[Zjee\WhZ_ijWbbo
_d h[bWj_ed je j^[_h cWn_bbWho WdjW]ed_iji$ 8ej^ \eh
ehj^eZedj_Y WdZ \eh _cfbWdjebe]_YWb fkhfei[i" _j _i
_cfehjWdjjebeeadejedboWjj^[7D8Wd]b[XkjWbie
Wjj^[¼M_jiWffhW_iWb½_dj^[i[YWi[i$J^[7D8Wd]b[
_ij^[Wd]b[X[jm[[dfe_dji7"8"WdZDdWi_ed_d
j^[ j[b[hWZ_e]hWf^$ J^[ 7D8 Wd]b[ _i bWh][ _\ j^[
cWdZ_XkbWhfe_dj_ibeYWj[Z\WhX[^_dZj^[cWn_bbWho
fe_dj"_dZ_YWj_d]j^[fh[i[dY[e\W9bWii??`WmXWi[
h[bWj_edi^_f$>em[l[h"j^[7D8Wd]b[Ze[ideji^[Z
b_]^jedj^[h[bWj_l[fei_j_ede\j^[`Wmi0j^_i_im^[h[
j^[M_jiWffhW_iWbYec[i_d$
J^[h[Wh[eYYbkiWbi_jkWj_edij^Wjm_bbij_bbWffhen#
_cWj[bo gkWb_\o Wi W 9bWii ? h[bWj_edi^_f Z[if_j[ j^[
fh[i[dY[ e\ ^[Wl_bo d[]Wj_l[ 7D8 Wd]b[i Ä _\ j^[
cWij_YWjehoYecfb[n_$[$j^[j[[j^m_j^j^[_hWbl[ebWh
Xed[ ijhkYjkh[i _i hejWj[Z _d Wd Wdj[he_d\[h_eh
Z_h[Yj_ed h[bWj_l[ je j^[ YhWd_Wb XWi[$ J^[ M_ji
X[jm[[d fe_dji 7 WdZ 8" m_j^ j^[ f[hf[dZ_YkbWh
b_d[ X[jm[[d j^[i[ fe_dji X[_d] fhe`[Yj[Z je j^[
cWij_YWjehofbWd[$J^[i_jkWj_edYWdedboX[YbWii_\_[Z
WiWjhk[YbWii??h[bWj_edi^_f_\j^[Z_ijWdY[c[Wikh[Z
_dj^[M_jiWffhW_iWb_ibWh][Wim[bb$J^[i[YWi[iWh[
Y^WhWYj[h_p[Z Xo bWh][ Z_iYh[fWdY_[i j^Wj Wh[ l[ho
Z_\\_YkbjjecWdW][Xoehj^eZedj_Yc[Wdi$M^[j^[h
WdZ je m^Wj [nj[dj j^[ hejWj_ed e\ j^[ cWij_YWjeho
Yecfb[n YWd WdZ i^ekbZ X[ kj_b_p[Z je _cfhel[
Z_W]deij_Y[nWc_dWj_ediWdZjh[Wjc[djij[fiW_c[Z
Wj [ijWXb_i^_d] _cfbWdj#ikffehj[Z h[ijehWj_edi
ijhkYjkh[ih[cW_dijeX[_dl[ij_]Wj[Z$8oYedjhWijm_j^
j^[ iebkj_edi fhel_Z[Z _d Yh[ijWb _cfbWdjebe]o" 8E?
_cfbWdjiWdZj^[h[ijehWj_ediikffehj[ZXoj^[cYWd
X[Z[i_]d[ZikY^j^Wjj^[oYWdYecf[diWj["jeWbWh][
[nj[dj" \eh kd\WlekhWXb[ ia[b[jWb h[bWj_edi$ ?d ej^[h
mehZi0J^[cWij_YWjehofbWd[YWdX[hejWj[Zm_j^ekj
ceZ_\o_d]j^[ia[b[jWbYed\_]khWj_ed$7dohejWj_ede\
j^[ cWij_YWjeho Yecfb[n m_bb _dlebl[ h[eh_[djWj_ed
e\j^[cWij_YWjeho\kdYj_ed"m^_Y^m_bbdehcWbboX[
WiieY_Wj[Zm_j^bed]#j[hccehf^ebe]_YWbY^Wd][ije
j^[`WmXed[$
Ia[b[jWb h[bWj_edi^_fi Wh[ dej WbmWoi Yedi_ij[djbo
YbWii_\_[Z$>kc[h_djW[jWb$'//-Z[cedijhWj[Zj^Wj
j^[l_ikWbYbWii_\_YWj_edif[h\ehc[ZXoehj^eZedj_iji
Wced]*/-<_dd_i^XeoiW][Z*Ä(&o[Whim[h[edbo

4ABLEÈ L_ikWbYbWii_\_YWj_edif[h\ehc[ZXoehj^eZedj_ijiWced]*/-<_dd_i^XeoiW][Z*Ä(&o[Whi>kc[h_djW[jWb$'//-

"/#




$MBTT
***






$MBTT
*






$MBTT
**







$MBTT
**


$MBTT
*


$MBTT
***


8JUT

"/#




$MBTT
***






$MBTT
*






$MBTT
**







$MBTT
**


$MBTT
*


$MBTT
***


7JTVBM

8JUT




$MBTT
***






$MBTT
*






$MBTT
**







$MBTT
**


$MBTT
*


$MBTT
***


7JTVBM
'/. 9^Wfj[h')È !NTERIORÈ-ASTICATORYÈ0ATTERNSÈANDÈ#LASSÈ))È3KELETALÈ2ELATIONS

hek]^bo Yedi_ij[dj m_j^ j^[ c[Wikh[Z 7D8 Wd]b[i ikccWh_p[Z Wi Æfh_cWho Whj_YkbWj_ed fheXb[ciÇ
WdZM_jiWffhW_iWbi$ J^_[bcWdd '/).$ J^[ cWij_YWjeho fWjj[hd fbWoi W
M^_b[_j_i\h[gk[djbo_cfeii_Xb[jeWii_]doekd] cW`ehheb[_dj^[W[j_ebe]oe\j^[i[YedZ_j_edi$I_dY[
j^[cWij_YWjehofWjj[hd_idejl_i_Xb[[nj[hdWbbo"j^[
fWj_[djijeWif[Y_\_Y7d]b[YbWii"j^[ia[b[jWbh[bWj_edi
_dZ_l_ZkWb_ib[\jm_j^ekjWdoieY_Wb\[[ZXWYa$J^[h[
m_bbW]]hWlWj[bWj[h_db_\["m^_Y^_ifWhj_YkbWhbojhk[
e\ 9bWii ?? fWj_[dji$ FWj_[dji m_j^ W fhedekdY[ZWh[ de [nj[hdWb eh _dj[hdWb Yedjheb c[Y^Wd_ici
j^Wj mekbZ ^[bf ^_c eh ^[h je cW_djW_d eh h[Yel[h
Z_ijeYbki_ed m_bb Z[l[bef Yb_d_YWb \[Wjkh[i j^Wj YWd
X[ [Wi_bo _Z[dj_\_[Z" WdZ" ceh[ _cfehjWdjbo" j^[oW XWbWdY[Z cWij_YWjeho \kdYj_ed$ Ceh[el[h"
m_bbZ[l[befWdkd[gk_leYWb\kdYj_edWbfWjj[hd$J^[ cWij_YWjeho_cXWbWdY[i^Wl[WmWoe\Z[j[h_ehWj_d]
hWj^[h j^Wd _cfhel_d]$ Kd[gkWb kj_b_pWj_ed m_bb
fe_dji hW_i[Z _d j^_i Y^Wfj[h Wh[ fh_cWh_bo XWi[Z
ed ekh [nf[h_[dY[ m_j^ jof_YWb 9bWii ?? fWj_[djih[_d\ehY[ j^[ fhef[di_jo \eh Wiocc[jho WdZ l_Y[
m^e [_j^[h Wbh[WZo fh[i[dj[Z m_j^ Y^WhWYj[h_ij_Y l[hiWi[[9^Wfj[h'&\ehZ[jW_bi$
\kdYj_edWb fWjj[hdi X[\eh[ jh[Wjc[dj eh _d m^ec 7dj[h_eh cWij_YWjeho fWjj[hdi _d j^[ WXi[dY[ e\
ikY^W\kdYj_edWbfWjj[hdj[dZ[ZjeX[Yec[cWd_\[ij bWj[hWb]h_dZ_d]cel[c[dji^Wl[WmWoe\Z[\b[Yj_d]
WiWh[ikbje\ekhjh[Wjc[dj$ j^[cWdZ_Xb[_dWiW]_jjWbZ_h[Yj_ed"m_j^Yecfh[ii_l[
7d]b[ Z_ij_d]k_i^[Z X[jm[[d jme ikXYWj[]eh_[i WdZ j[di_b[ ped[i Zec_dWj_d] _d j^[ YWkZWb WdZ
Yh[ijWbfehj_edie\j^[feij[h_ehi[]c[dj"h[if[Yj_l[bo$
e\ 9bWii ?? h[bWj_edi$ 9bWii ?? Z_l_i_ed ' ??%' _i
>obWdZ[h Z[cedijhWj[Z j^Wj Wdj[h_eh cWij_YWjeho
Y^WhWYj[h_p[Z Xo W fe_dj[Z cWdZ_XkbWh \hedj1 9bWii
fWjj[hdiZec_dWj[ZXoY^eff_d]cel[c[dji]_l[h_i[
?? Z_l_i_ed ( ??%( _i Y^WhWYj[h_p[Z Xo Yel[h#X_j[
WdZZ[[f#X_j[h[bWj_edi$8ej^jof[ie\cWbeYYbki_ed jeWbWh][l[hj_YWbZ_c[di_ede\j^[Z_ijWbcWdZ_Xb["
m^_Y^ _i WYjkWbbo ki[b[ii" Yedi_Z[h_d] j^Wj ceij e\
i^Wh[ j^[ \[Wjkh[ e\ h[bWj_l[ cWdZ_XkbWh h[jhki_ed"
j^[Y^[m_d]jWa[ifbWY[_dj^[Wdj[h_ehi[]c[dj$J^_i
WdZ Xej^ Wh[ Yedi_Z[h[Z je X[ ia[b[jWb _d dWjkh[$
Ceij fWj_[dji m_j^ cWdZ_XkbWh h[jhki_ed m_bb Yed\_]khWj_ed ]h[Wjbo fhecej[i jeej^ beii _d 9bWii
Z[l[bef W ijh_Yjbo Wdj[h_eh cWij_YWjeho fWjj[hd$ ??fWj_[dji"m^_Y^m_bbX[Z_iYkii[Z_dj^[\ebbem_d]
fWhW]hWf^i"ijWhj_d]m_j^j^[cWdZ_Xb[0
FWhj_YkbWhbo W\j[h j^[ ikffehj_d] Wdj[h_eh YedjWYji
^Wl[X[[dbeij"j^[l[hj_YWbcWij_YWjeho\ehY[i_dj^[ v :[[f#X_j[ WdZ Yel[h#X_j[ i_jkWj_edi _dlebl[
Wdj[h_ehi[]c[djYWddebed][hX[Yedjhebb[Z_dWd ikXijWdj_Wbbo bed][h cel[c[dj fWj^i \eh cekj^
WZ[gkWj[cWdd[h"iej^Wjj^[feij[h_ehi[]c[djiWh[ ef[d_d] j^Wd h[]kbWh el[hX_j[ i_jkWj_edi$ J^[
_dYh[Wi_d]bo ikX`[Yj[Z je kdYedjhebb[Z cWij_YWjeho cekj^ ef[d_d] \ehY[i Wh[ ]h[Wj[h" WdZ j^[
beWZi$ J^_i i_jkWj_ed _i kikWbbo WiieY_Wj[Z m_j^ YedjWYj fe_dji Wh[ h[bWn[Z Zkh_d] YWkZWb \b[n_ed
_dWZ[gkWj[ bWj[hWb Y^[m_d]" fWhj_YkbWhbo W\j[h j^[ e\ j^[ cWdZ_Xb[$ J^[i[ Yecfed[dji \Wlekh j^[
X_j[ ^Wi Z[[f[d[Z" W Yedi_Z[hWXb[ Wdj[h_eh el[hX_j[ Z[l[befc[dje\f[h_eZedj_j_i$
^WiZ[l[bef[Z"WdZWdobWj[hejhki_l[cel[c[djiWh[ v :k[ je j^[ [nY[ii_l[bo Wdj[h_eh \eYki e\ beWZ_d]
Z[\_d_j_l[bofh[l[dj[ZXo[bed]Wj[ZYWd_d[i$FWj_[dji Zkh_d][Wj_d]"ceh[cWii_l[jhW`[Yjeh_[i^Wl[jeX[
m_j^WdWhhemcWn_bbWhoXWi[WdZfe_dj[Z\hedjcWo Z[l[bef[Z\hecj^[`WmWd]b[jemWhZij^[Wdj[h_eh
ikXi[gk[djbo Z[l[bef W \kdYj_edWbbo ef[d X_j[ eh i[]c[dj$8_ec[Y^Wd_YWbbo_Z[WbcWYhejhW`[Yjeh_[i
[dZ#je#[dZ eYYbki_ed" [if[Y_Wbbo _\ j^[ cWn_bbW bW]iYWddej X[ [ijWXb_i^[Z Zk[ je j^[ bWh][ Yh[ijWb
X[^_dZ_dj[hcie\]hemj^\ebbem_d]Wdo[njhWYj_edi m_Zj^e\j^[j[[j^$J^[]h[Wj[hj^[j[dZ[dYoe\j^[
\ehehj^eZedj_Yh[Wiedi$ cWdZ_Xb[jeX[Yec[Z[\b[Yj[ZXoWdj[h_ehbeWZ_d]"
7do h[ijehWj_l[ jh[Wjc[dj ijhWj[]_[i XWi[Z ed j^[]h[Wj[hj^[j[dZ[dYoe\j^[m^_j[b_d[jeX[Yec[
8E? _cfbWdji m_bb X[ bWh][bo _Z[dj_YWb [l[d _d YWkZWb_p[Z$7Z[[fb_d[e\beWZjhWdic_ii_edm_bb
X[ WiieY_Wj[Z m_j^ dWhhem[h i[]c[dji e\ j^[
j^[ fh[i[dY[ e\ Z_\\[h[dj ia[b[jWb i_jkWj_edi$ ?j _i
_hh[b[lWdj" \eh [nWcfb[" m^[j^[h j^[ cWbeYYbki_ed _dj[h\[h_d]heeji"j^ki]h[Wjbo\WY_b_jWj_d]Wd_Z[Wb
_i YWki[Z Xo W h[jhkZ[Z Xkj ej^[hm_i[ fhef[hbo eh_[djWj_ed e\ j^[ cWYhejhW`[Yjeh_[i$ ?d j^_i mWo"
Z[l[bef[ZcWdZ_Xb["ehXocWdZ_XkbWhc_Yhe]dWj^_W" j^[beYWbXed[Z[di_jo^Wije_dYh[Wi[Wij^[edbo
ehXoWdoYecX_dWj_ede\Xej^YedZ_j_edi$M[^Wl[ mWojeYecf[diWj[\ehj^[\ehY[i_dWd[Yedec_YWb
hWh[bo eXi[hl[Z Wdj[h_eh cWij_YWjeho fWjj[hdi _d cWdd[h_\j^[Xed[lebkc[h[cW_diYedijWdj$
YWi[i e\ cWn_bbWho cWYhe]dWj^_W Y^WhWYj[h_p[Z Xo v 7iWh[ikbj"j^[Z[]h[[e\Xed[c_d[hWb_pWj_edm_bb
bWh][ID7Wd]b[i"Wibed]Wij^[ikffehjped[im[h[ _dYh[Wi[ WhekdZ j^[ XWiWb ikh\WY[i WdZ Z[Yh[Wi[
ij_bbfh[i[dj$ WhekdZ j^[ Yh[ijWb ikh\WY[i$ ?d ej^[h mehZi" j^[
XWiWb_dj[]hWj_ede\j[[j^_ih[_d\ehY[Z$
v J^[ Yh[ijWb Xed[ m_bb X[Yec[ c[Y^Wd_YWbbo b[ii
È h[i_ijWdj Z[if_j[ j^[ bWh][ h[bWj_l[ ikh\WY[ e\ j^[
$EVELOPMENTÈOFÈTHEÈ-ASTICATORYÈ0ATTERN heeji$ J^[ j[hc ÆWbl[ebWh Xed[Ç _i kbj_cWj[bo
dej Wffb_YWXb[ X[YWki[ \kdYj_edWb ij_ckb_ cWo
:[[f Wdj[h_eh el[hX_j[i Wh[ fh_cWho WdecWb_[i$ Yedl[hjiec[ped[ie\j^_iijhkYjkh[jeijWj_YWbbo
J^[ cel[c[dj h[bWj_edi _d j^[i[ fWj_[dji YWd X[ ikffehj_d]Xed[Wh[Wi$
È È $EVELOPMENTÈOFÈTHEÈ-ASTICATORYÈ0ATTERNÈ '//

v J^[ beYWbbo _dWYj_lWj[Z Xed[ m_bb ^Wl[ W icWbb[h ckiYb[Wh[Yb[Whbol_i_Xb[edj^[YhWd_WbhWZ_e]hWf^

h[c_d[hWb_pWj_ed j[dZ[dYo WdZ \[m[h Z[\[dY[i WdZEF=$
je XWYj[h_Wb WjjWYai" m^_Y^ m_bb \khj^[h fhecej[ ?\ j^[ h[i_ZkWb h_Z][ _i ^_]^ WdZ dWhhem ed ed[
j^[Z[l[befc[dje\f[h_eZedj_j_iWdZfej[dj_Wbbo i_Z[ e\ j^[ cWdZ_Xb[ Xkj l[hj_YWbbo h[iehX[Z ed j^[
ikXi[gk[djf[h_#_cfbWdj_j_i$ ej^[h i_Z[" j^[ fWj_[djÉi Z[djWb ^_ijeho m_bb kikWbbo
v ?\ik_jWXb[YedZ_j_edi\ehWdj[h_ehcWij_YWj_edWh[ h[l[Wb [nj[dZ[Z f[h_eZi e\ kd_bWj[hWb cWij_YWjeho
fh[i[dj" j^[o m_bb X[ ki[Z$ J^[ ehX_YkbWh_i eh_i beWZi" m^_Y^ cWo YWki[ fheXb[ci _d WZ`kij_d] j^[
ckiYb[ m_bb X[ ]W_d_d] j^[ kff[h ^WdZ h[bWj_l[ cWij_YWjeho \kdYj_ed$ 9ehh[ifedZ_d] Wbj[hWj_edi e\
je j^[ Z_ijWb cWij_YWjeho ckiYb[i$ J^[ cWdZ_Xb[" j^[JC@m_bbX[eXi[hlWXb[_dj^_ii_jkWj_edWim[bb$
m^_Y^ dehcWbboÆZWdY[iÇ X[jm[[d j^[ Z_ijWb WdZ <ehWfWj_[djjem[WhWfeehboh[jW_d[ZZ[djkh[_d
Wdj[h_eh ckiYb[i" m_bb Z[l[bef W ijhed] j[dZ[dYo j^[ fh[i[dY[ e\ h[i_ZkWb Wdj[h_eh j[[j^ WdZ e\ Xed[
je WZlWdY[ \ehmWhZ$ J^_i cel[c[dj fWjj[hd YWd beiijWa[iYedi_Z[hWXb[i[b\#Yedj[cfjWdZik\\[hWdY[$
Wbie X[ eXi[hl[Z _d fWj_[dji m^e Ze dej h[l[Wb J^[i[ fWj_[dji m_bb ]hWZkWbbo bei[ j^[ WX_b_jo je
9bWii ?? h[bWj_edi Xkj ^Wl[ kdZ[h]ed[ \kdYj_edWb h[b_WXboWZ`kijj^[_hJC@iWdZjeYehh[Yjbo`kZ][j^[
h[eh_[djWj_ed W\j[h jeej^ beii eh m[Wh W Z[djkh[ \ehY[Wim[bbWij^[kd_\ehc_joWdZiocc[jhoe\j^[_h
WdZ [nf[h_[dY[ j^_i \kdYj_edWb fWjj[hd je X[ j^[ cWij_YWjeho \kdYj_ed$ Kdb_a[ _d 9bWii ??? fWj_[dji"
ceijYedl[d_[djed[$ j^[j[hcÆ^_d][Wn_iÇ_iYb[WhboWc_idec[h_dj^[i[
fWj_[dji" Wi j^[ hWd][ e\ cej_ed e\ Xej^ JC@i _i
M^[j^[hehdejWfWhj_WbZ[djkh[_ifh[i[dj"j^[Z_ijWb Yedi_Z[hWXb[WdZZec_dWj[ZXockiYb[i$
fehj_edj^[cWdZ_XkbWhh_Z]["m^ei[l[hj_YWblebkc[
m_bbkikWbbo^Wl[X[[dh[ZkY[ZXof[h_eZedjWbZWcW]["
YWd\bWjj[d\khj^[hZk[jeh[iehfj_edehX[h[ZkY[Zje
WdWhhemc[Z_Wbad_\[#[Z][ijhkYjkh[$8ej^iY[dWh_ei
cWo[c[h][edY[j^[cWij_YWjehoWYj_l_jo^WiX[[d
h[beYWj[Z je j^[ Wdj[h_eh i[]c[dj" h[]WhZb[ii e\
m^[j^[hj^[fWj_[djm[WhiWZ[djkh[$J^[dWhhemWdZ
^_]^c[Z_Wbh[i_ZkWbh_Z][m_bbX[h[WY^[ZW\j[hj^[
fWhj_WbZ[djkh[^WiX[[dh[b_d[Zehh[\WXh_YWj[Zjme
ehj^h[[j_c[iWdZm_bbijWX_b_p[j^[Z[djkh[bWj[hWbbo"
fWhj_YkbWhbo _\ feij[h_eh cWij_YWjeho fWjj[hdi Wh[
ij_bb fh[i[dj WdZ j^[ l[hj_YWb Xed[ ijhkYjkh[ _i ij_bb
cW_djW_d[ZXobWj[hWbfh[iikh[h[bWj[Zjej^[Z[djkh[$
J^[WXi[dY[e\j[di_b[jhW`[Yjeh_[iedj^[Yh[ijWbXed[
e\j^[meha_d]i_Z[m_bb]_l[h_i[je\bWjh[iehfj_ed$
J^[ cWdZ_XkbWh hWcki m_bb h[l[Wb m^[j^[h j^[
cWij_YWjeho \ehY[i Wj meha Wh[ ijhed] eh m[Wa$ 7
cWha[Zbo h[YjWd]kbWh `Wm Wd]b[ =& icWbb kikWbbo &IGÈ EdY[ j^[ bWij j[[j^ _d j^[ ikffehj ped[ ^Wl[ X[[d
_dZ_YWj[ij^[fh[i[dY[e\hWj^[hfem[h\kbcWij_YWjeho beij"Wjof_YWbfWjj[hdikY^Wij^_im_bb[c[h][l[hogk_Yabo0j^[
\ehY[i$ J^[i[ fWj_[dji Wh[ ikiY[fj_Xb[ je Yb[dY^_d] h[i_ZkWbZ[dj_j_ed_iWdY^eh[Z_dWd[bed]Wj[ZXed[i[]c[dj
WdZ Xhkn_d]" WdZ j^[ WjjWY^c[dji e\ j^[ cWii[j[h ))Ä*)WiieY_Wj[Zm_j^fhedekdY[ZZ_ijWbXed[h[iehfj_ed

&IGÈ HWZ_e]hWf^e\j^[
iWc[fWj_[dj$J^_ii_jkWj_ed_i
X[ijZ[iYh_X[ZXoÆYecX_dWj_ed
iodZhec[ÇehÆA[bboÉiiodZhec[Ç$
J^[icWbbd[iie\j^[Z_ijWbYh[ijWb
m^_j[b_d[e\Yehj_YWbXed[_iW
fhe]deij_YWbbo\WlekhWXb[\WYjeh$
Dej[j^[cWii_l[YWkZWbb_d[e\
Yehj_YWbXed[YecfWh[Zjej^[
h[bWj_l[bohWZ_ebkY[djXeZoe\j^[
cWdZ_Xb[
(&& 9^Wfj[h')È !NTERIORÈ-ASTICATORYÈ0ATTERNSÈANDÈ#LASSÈ))È3KELETALÈ2ELATIONS
È
#ORRECTINGÈ#LASSÈ))È2ELATIONSÈÈ
BYÈ0ROSTHETICÈ4REATMENT
7 Z[Y_i_ed ckij X[ h[WY^[Z _d j^[ fbWdd_d] f^Wi[
m^[j^[hj^[\h[[Zece\fheij^[j_YZ[i_]dWiieY_Wj[Z
m_j^ 8E? _cfbWdjebe]o YWd WdZ i^ekbZ X[ ki[Z je
[ijWXb_i^h[]kbWh9bWii?eYYbkiWbh[bWj_edi$
J^[ edbo mWo je WY^_[l[ ikY^ Yehh[Yj_ed e\ j^[
eYYbkiWbh[bWj_ediXofheij^[j_Yc[Wdi_iXoWYecfb[j[
Xh_Z][ _d j^[ cWdZ_Xb[$ J^[ \WYj j^Wj j^[ cWdZ_Xb[
^Wi W Y[djh_\k]Wb h[iehfj_ed fWjj[hd _i YedZkY_l[
_d j^_i Yedd[Yj_ed" Wi j^[ Wdj[h_eh XWiWb Xed[ m_bb
^Wl[WZlWdY[ZjeWh[bWj_l[boWdj[h_ehfei_j_edm^_b[
j^[ feij[h_eh Z_c[di_ed e\ j^[ cWdZ_Xb[ m_bb ^Wl[
_dYh[Wi[Z_dm_Zj^Xoj^[j_c[e\jh[Wjc[dj$
7iXWi_Yh[gk_h[c[dji\ehj^_ijof[e\jh[Wjc[dj"
de_cfbWdjickijX[fbWY[Z_dj^[Wdj[h_ehi[]c[dj
))Ä*)" WdZ j^[ ie\j#j_iik[ i_jkWj_ed ckij X[ ikY^
Wi je Wbbem Wd Wdj[h_eh beYWj_ed e\ j^[ fbWdd[Z
fheij^[j_Y ijhkYjkh[$ ?di[hj_d] Wdo _cfbWdji _d j^[
Wdj[h_ehi[]c[dj*(Ä)(_dj^[WXi[dY[e\ik\\_Y_[dj
h_Z][ h[iehfj_ed cWo Yecfb_YWj[ j^[ Wjj[cfj je
Yehh[Yjj^[eYYbkiWbh[bWj_ediXofheij^[j_Yc[Wdije
j^[ fe_dj e\ jh[Wjc[dj \W_bkh[" i_dY[ j^[ h[ijehWj_ed
m_bb X[ Z[\b[Yj[Z Z_ijWbbo Xo j^[ WXkjc[dji _d j^[
XWiWb Wh[W$ ?d j^Wj beYWj_ed" j^[o m_bb _dj[h\[h[ m_j^
jed]k[ cel[c[dji" WdZ WYY[ii \eh ehWb ^o]_[d[
_dijhkc[djicWoX[_cf[Z[ZWim[bb$
J^[ kf^ebij[h_d] [\\[Yj e\ j^[ WZlWdY[Z Xh_Z][
ed j^[ ie\j#j_iik[ ijhkYjkh[i e\ j^[ bem[h b_f Wh[W
m_bb _d\bk[dY[ j^[ fWjj[hd e\ b_f Ybeikh[ WdZ j^[
fWj_[djÉi\WY_Wb[nfh[ii_edWjbWh][$J^[i[Y^Wd][iWh[
][d[hWbbo m[bb WYY[fj[Z$ ?d \WYj j^[o Wh[ Yedi_Z[h[Z
Z[i_hWXb[" i_dY[ j^[o h[l[hi[ Wdo W][#h[bWj[Z ie\j#
j_iik[h[Y[ii_edWdZmh_dab[i$
Fh[iikh[ ieh[i Wh[ iec[j_c[i eXi[hl[Z Wbed]
fedj_Yi *(Ä)(" fWhj_YkbWhbo _\ j^[ l[hj_YWb h[bWj_ed
^Wi X[[d Yedi_Z[hWXbo Wbj[h[Z m^_Y^ _i e\j[d
d[Y[iiWho je WZ`kij j^[ cWij_YWjeho fbWd[ _d j^[
fh[i[dY[ e\ YWkZWbbo Z_ibeYWj[Z Z_ijWb h_Z][i" m^_b[
j^[ ehX_YkbWh_i eh_i WdZ c[djWb ckiYb[i Wh[ l[ho
fem[h\kb$?dj^_ii_jkWj_ed"j^[W\\[Yj[Zfedj_Yid[[Z
je X[ WZ`kij[Z d[Wh j^[ h_Z][$ ?\ j^[i[ WZ`kijc[dji
Wh[dejjeb[hWj[Z"_jcWoX[Yec[d[Y[iiWhojeh[fbWY[
j^[Xh_Z][edY[W]W_d$
J^[WZlWdjW][ie\Yehh[Yj_d]j^[eYYbkiWbh[bWj_edi
Xofheij^[j_Yc[WdiWh[eXl_eki$J^[WhY^[ie\Xej^
Xh_Z][iX[Yec[Yed]hk[dj"WdZWXWbWdY[ZeYYbki_ed
j^Wj_iikffehj[ZedWbbi_Z[iYWdX[WZ`kij[Zceh[
[Wi_bo$DWjkhWbbo"j^[cWij_YWjehockiYb[im_bbdejX[
YeehZ_dWj[Z fhef[hbo WdZ j^[ cWij_YWjeho fWjj[hd
m_bb dej o[j ^Wl[ WZWfj[Z je j^_i jof[ e\ eYYbki_ed
h_]^jW\j[hj^[h[ijehWj_ed_i_di[hj[Z$M^_b[fWj_[dji
m_j^ cWha[Z 9bWii ?? h[bWj_edi [n^_X_j Wd Wdj[h_eh
cWij_YWjehofWjj[hd"j^ei[m_j^9bWii?h[bWj_edim_bb
&IGÈ ?\j^[Xed[lebkc[_dj^[cWdZ_Xb[_ih[ZkY[Z"j^[
Yh[ije\j^[_dj[h\ehWc_dWbXed[m_bbcel[jemWhZij^[Y[djh[
e\j^[^[WZ$J^[lebkc[e\j^[jed]k[_idejW\\[Yj[Z\hecj^_i
Y^Wd][ WdZ j^_i _i m^o j^[ fWj_[dji e\j[d Wia j^[ h[ijeh_d]
Z[dj_ij je WZlWdY[ j^[ bem[h Wdj[h_eh j[[j^ je j^[ \ehc[h
fei_j_ed$?dj^_iWZlWdY[Zfei_j_edj^[j[[j^Wh[dejfhej[Yj[Z
Xo Xed[ W]W_dij ceX_b[ ie\j j_iik[i WdZ fh[iikh[ ifeji cWo
Z[l[bef_dj^[Wh[We\j^[fedj_Yi$H[jhkZ_d]j^[bem[hfWhjie\
j^[fedj_YiehWjhWdifbWdjWj_ede\WjjWY^[ZckYeiWWh[]eeZ
jh[Wjc[djefj_edi
f[h\ehc bWj[hWb ]h_dZ_d] cWij_YWjeho cel[c[dji
Y^WhWYj[h_p[ZXoYWd_d[]k_ZWdY[eh]hekf\kdYj_ed$
;l[d9bWii??fWj_[djim_bbgk_Yabo]hemWYYkijec[Z
jej^[d[mi_jkWj_ededY[eYYbkiWbdehcWbh[bWj_edi
^Wl[ X[[d h[ijeh[Z" fh[ikcWXbo X[YWki[ f[hj_d[dj
[d]hWci \hec Y^_bZ^eeZ Wh[ ij_bb fh[i[dj WdZ edbo
jWa[ W b_jjb[ [n[hY_i[ je X[ [\\[Yj_l[bo h[jh_[l[Z$ ?\
j^[i[WZWfjWj_ediZedejfheY[[ZWiiceej^boWij^[o
i^ekbZ"j^_i_ikikWbboZk[jec_Zb_d[h[WZ`kijc[dji
WiieY_Wj[Z m_j^ kd_bWj[hWbbo XbeYa[Z \kdYj_ed WdZ
h[fei_j_ed_d]fheXb[cie\j^[JC@i$J^[Z[dj_ijckij
j^[h[\eh[ WbmWoi jho je WZ`kij j^[ c_Zb_d[ Yehh[Yjbo$
C_Zb_d[Z_W]dei_iYWdX[Z_\\_Ykbj_dfWj_[djim_j^W
bed]^_ijehoe\Zoi\kdYj_ediehkd_bWj[hWbjeej^beii
eh[njhWYj_edm_j^ehm_j^ekjehj^eZedj_Yj^[hWfo$
M^[d[l[hZ[dj_j_edij^WjWh[^[Wl_boZ[][d[hWj[Z
_d ijhkYjkh[ _d ifWj_Wb WdZ \kdYj_edWb j[hci Wh[ je
X[ h[^WX_b_jWj[Z W\j[h j^[ ikffehj ped[ ^Wi X[[d
beij" _j _i kikWbbo d[Y[iiWho je _dj[hl[d[ _d Xej^
`Wmii_ckbjWd[ekibo_\WdW[ij^[j_YWbbofb[Wi_d]WdZ
\kdYj_edWbbo ijWXb[ ekjYec[ _i je X[ h[WY^[Z$ ?d
WYjkWbfhWYj_Y["^em[l[h"j^_id[[Z_ie\j[dZ_\\_Ykbjje
[nfbW_d$CWdofWj_[djim_bbh[\ki[jekdZ[hijWdZm^o
j^[effei_d]`Wm"m^_Y^_ih[bWj_l[bo_djWYj"i^ekbZX[
h[ijeh[ZWim[bb$Iec[fWj_[djim_bb[l[dX[h[bkYjWdj
je ^Wl[ j^[ h[cW_d_d] Y^[m_d] i_Z[ h[ijeh[Z" Wi
j^[o Wh[ W\hW_Z j^Wj j^_i c_]^j b[Wl[ j^[c m_j^ de
Y^[m_d] WX_b_jo m^Wjie[l[h$ ?d iec[ YWi[i m^[h[
m[ ijWhj[Z j^[ h[ijehWj_ed _d ed[ `Wm" j^[ fWj_[dj
h[\ki[ZjeYedj_dk[h[ijehWj_l[meha_dj^[effei_j[
`Wm" Wbj^ek]^ j^_i mekbZ ^Wl[ X[[d d[Y[iiWho WdZ
Wbj^ek]^_j^WZX[[dfbWdd[Z\hecj^[X[]_dd_d]je
Zeie$FWj_[djicWo\_dZj^[ci[bl[iYec\ehjWXb[W\j[h
È È 6ERTICALÈ$IMENSIONÈ
h[Y[_l_d]ed[`Wmh[ijeh[Z"Xkjj^[o^Wl[de_Z[We\
j^[ fheXb[ci j^Wj m_bb eYYkh _\ j^[ i[YedZ ij[f _i
b[\j ekj$ <h[gk[djbo j^[o m_bb i[[a mhed] WZl_Y[
[bi[m^[h[ m^[h[ j^[o ][j j^[_h c_ikdZ[hijWdZ_d]i
Yed\_hc[Z$ J^[ 8E? _cfbWdjebe]_ij m_bb X[ h_]^j je
h[\ki[ h[ifedi_X_b_jo \eh \khj^[h Z[l[befc[dji _\
j^[ fWj_[dj ijefi j^[ h[ijehWj_ed ^Wb\ mWo" _$[$ W\j[h
h[ijeh_d] edbo ed[ `Wm m^[d fheXb[ci Wh[ fh[i[dj
_dXej^`Wmi"dejWbbem_d]j^[Yh[Wj_ede\WXWbWdY[Z
WdZX_bWj[hWbfWjj[hde\Y^[m_d]$
8h_Z][i ikffehj[Z Xo 8E? _cfbWdji" ijhWj[]_YWbbo
fbWY[Z" YWd X[ fei_j_ed[Z Wbceij Wj m_bb" [l[d _\
j^[ WlW_bWXb[ Xed[ lebkc[ _i icWbb Ä \eh Wi bed] Wi
j^[ cWij_YWjeho \kdYj_ed _i XWbWdY[Z" Xkj j^Wj _i
j^[ fh_cWho YedZ_j_ed WdomWo$ Kd\ehjkdWj[bo" j^[
h[Wb_pWj_ed j^Wj h[ijehWj_l[ jh[Wjc[dj i^ekbZ W_c Wj
h[ijeh_d]j^[cWij_YWjeho\kdYj_ed_dWYecfh[^[di_l[
cWdd[h_ideji^Wh[ZXoj^[^[Wbj^_dikh[hi$?dj^[_h
l_[m"jh[Wjc[djii^ekbZX[f[h\ehc[Z[Yedec_YWbbo
WdZ m_j^ekj [nY[[Z_d] j^[ b_c_ji e\ _cc[Z_Wj[
d[[Z$
J^[WffheWY^e\h[ijeh_d]Xej^`Wmii_ckbjWd[ekibo
m_bb Wbbem efj_c_pWj_ed e\ j^[ eYYbkiWb h[bWj_edi je
X[ WffheWY^[Z \hec Xej^ i_Z[i" Wj b[Wij m_j^_d j^[
b_c_ji e\ j^[ ie\j#j_iik[ ijhkYjkh[i fWhj_YkbWhbo e\
j^[cWn_bbW$
È
-AINTAININGÈ/CCLUSALÈ#LASSÈ))È2ELATIONSÈ
$URINGÈ0ROSTHETICÈ4REATMENT
?d fh_dY_fb[" e\ Yekhi[" _j _i Wbie feii_Xb[ je h[jW_d
j^[ [n_ij_d] eYYbkiWb h[bWj_edi$ ?d \WYj" j^[h[ m_bb X[
deej^[hY^e_Y[XkjjecW_djW_dj^[h[bWj_edi_\j^[h[
Wh[ Wdo h[i_ZkWb Wdj[h_eh j[[j^ WdZ%eh YWd_d[i _d
j^[ cWdZ_Xb[ j^Wj i^ekbZ X[ fh[i[hl[Z" i_dY[ j^[i[
j[[j^ m_bb Z[\_d[ j^[ fei_j_ed e\ j^[ Xh_Z][$ ?j _i
hWh[bofeii_Xb[jeki[j^[YWd_d[iWi\_hijfh[cebWhi"
Wi j^_i WffheWY^ mekbZ ]_l[ h_i[ je [njh[c[ b[l[h
(&'
\ehY[_dj^[Wdj[h_ehi[]c[dj$?dj^_ii_jkWj_ed"_j_i
h[Yecc[dZ[Zjea[[fj^[XWbWdY[kdZ[h[njh[c[bo
j_]^j Yedjheb WdZ je c_d_c_p[ j^[ el[hX_j[$ 9b_d_YWb
ijkZ_[iWh[d[[Z[ZjeWZZh[iij^[gk[ij_edm^[j^[h
8E? _cfbWdji m_j^ j^_Ya[h WdZ bWh][h Z_iai YWd X[
ki[Zje]eeZ[\\[Yj_dj^_ii_jkWj_ed$7\j[hWbb"j^_Ya[h
Z_iai Wh[ f[h\ehY[ b[ii [bWij_Y" WdZ bWh][#Z_Wc[j[h
Z_iaid[[Zceh[ifWY[jeX[_di[hj[Z$?dj^[Wdj[h_eh
cWdZ_Xb["^em[l[h"j^_iWffheWY^c_]^jjkhdekjje
X[ f[h\[Yjbo i[hl_Y[WXb[" Yedi_Z[h_d] j^Wj j^[ _dj[h#
\ehWc_dWbXed[_ib[ii[bWij_YWdomWo$
J^[i[ i_jkWj_edi YWd X[ jh[Wj[Z m_j^ kd_bWj[hWb
Xh_Z][i_\Wjb[Wijj^[YWd_d[iWh[WlW_bWXb[WdZZedej
i^em ceX_b_jo i[[ 9^Wfj[h'($ ?d WZZ_j_ed" ed[ eh
jme8E?_cfbWdjiWh[_di[hj[ZWjj^[fei_j_ede\j^[
Z_ijWbheeje\j^[\_hijcebWhiehX[^_dZj^Wjfei_j_ed$
7iocc[jh_YWb[bed]Wj[ZZ[i_]dii^ekbZX[ki[Zj^Wj
Wh[ Yed]hk[dj m_j^ j^[ m_Zj^ e\ j^[ Yehj_YWb Xed[
ijhkYjkh[ WdZ Wh[ fhej[Yj[Z W]W_dij hejWj_ed _di_Z[
j^[eij[ejecoibej$J^[i[Z[i_]dim_bbWbbemh[b_WXb[
_cc[Z_Wj[beWZ_d]$=eeZh[ikbji^Wl[X[[deXjW_d[Z
fWhj_YkbWhbo m_j^ ;:7I /%'(" /%'+" .%'* WdZ '&%'*
Z[i_]diWjWb[d]j^e\=,Ä=/$
È
6ERTICALÈ$IMENSION
?\ j^[ l[hj_YWb Z_c[di_ed _i _dYh[Wi[Z je j^[
fe_dj e\ h[ZkY_d] j^[ Z[[f Wdj[h_eh el[hX_j[ WdZ
[b_c_dWj_d] Wdo Z_h[Yj Wdj[h_eh YedjWYji" j^[d j^[
cWij_YWjeho fWjj[hd m_bb [l[djkWbbo Y^Wd][ \hec
Wdj[h_ehcel[c[djije9bWii?jof[bWj[hWb]h_dZ_d]
cel[c[djiehWjb[WijjeWY^eff_d]fWjj[hdm_j^ekj
Wdj[h_eh eh_[djWj_ed$ J^_i i^_\j m_bb jWa[ fbWY[
h[\b[n_l[bo_dceijfWj_[dji"m^_b[_jcWojWa[m[[ai
ehcedj^i_dej^[hi$<h[gk[djbo"j^[Y^Wd]_d]ckiYb[
\kdYj_ed_iWYYecfWd_[ZXojhWdi_jehoJC@Yb_Ya_d]"
Xkjj^_im_bbhWh[bof[hi_ij$?dekh_dj[hfh[jWj_ed"j^_i
f^[dec[ded _dZ_YWj[i j^Wj j^[ l[hj_YWb Z_c[di_ed
&IGÈ EF=e\j^[YWi[
_bbkijhWj[Z_d<_]i$')$'WdZ')$(
j^h[[o[WhiW\j[h_cfbWdjWj_ed
WdZh[ijehWj_l[jh[Wjc[dj$J^[
\_\j^_cfbWdj_dj^[c_ZZb[
Z[\_d[ij^[iW]_jjWbfei_j_ede\
j^[fheij^[j_Yi
(&( 9^Wfj[h')È !NTERIORÈ-ASTICATORYÈ0ATTERNSÈANDÈ#LASSÈ))È3KELETALÈ2ELATIONS

&IGÈÈA BWj[hWbj[b[hWZ_e]hWf^jWa[d)o[WhiW\j[hjh[Wjc[dj$J^[_dYb_dWj_ede\j^[cWij_YWjehofbWd[YWki[ij^[cWdZ_Xb[je
WZlWdY[eXb_gk[boWdZikYY[[Zi_dYekdj[hWYj_d]j^[cWha[Z9bWii??i_jkWj_ed$J^[cWij_YWjehofbWd[^WidejX[[dY^Wd][ZXkj
_iij_bbfWhWbb[bjej^[cWn_bbWhoXWi[$J^[cWn_bbWhoZ[djkh[mWidejceZ_\_[Z[_j^[hX[YWki[j^[fWj_[dj\[Wh[Zj^Wj^[c_]^jdej
X[WXb[jeWZWfjjeWd[mi_jkWj_ed$J^[^eh_pedjWbWd]b[_dZ_YWj[ij^[WXiebkj[^eh_pedjWbYhWd_Wbb_d[_d^WX_jkWbijhW_]^j#beea
fei_j_ed$J^[jmeWd]b[ie\j^[bem[h`WmWh[dejYed]hk[dj$J^[Wd]b[edj^[h_]^j_i[b[lWj[ZWdZhekdZ[Z\hecX[bem"m^_b[
j^[Wd]b[edj^[h_]^j^WiWceh[Wd]kbWhfhe\_b[$Ceh[cehf^ebe]_YWbY^Wd][i_dj^[cWdZ_Xb[Wh[kdb_a[bojeeYYkhW\j[hj^_i
jh[Wjc[dj"i_dY[j^[eYYbkiWbh[bWj_edi^Wl[dejX[[dWbj[h[Z$J^[Z_ijWbibef[e\j^[cWij_YWjehofbWd[Wff[Whiel[hboij[[f_dj^[
hWZ_e]hWf^$J^_i_ibWh][boWd_bbki_ed"^em[l[h"i_dY[j^[i[YedZcebWh_ic_ii_d]"WdZj^[jhk[hekdZ_d]e\j^[Ykhl[e\If[[
mekbZedboX[l_i_Xb[_dj^WjWh[W$M^WjcWjj[hi_ij^[WXi[dY[e\Wdoa_dZe\Wdj[h_ehcWij_YWjehofWjj[hd"iec[j^_d]j^Wj^Wi
X[[dWY^_[l[ZXo_djheZkY_d]WbWh][Yb[WhWdY[X[jm[[dj^[bem[hWdZkff[hWdj[h_ehj[[j^"WiWffWh[dj\hecj^[hWZ_ebe]_YWbbo
l_ikWb_p[Zkff[hb_f$ B ?\j^[eYYbkiWbfbWd[_iZ_ijWbbo_dYb_d[Z"j^[dfhejhki_l[cel[c[djim_bbh[ZkY[j^[l[hj_YWbZ_c[di_ed"
m^_Y^_iceh[WYY[fjWXb[\ehj^[ckiYb[i$<khj^[hZ_ijWb_pWj_ede\j^[cWdZ_Xb[_ifh[l[dj[ZXoj^[\WYjj^Wjj^_imekbZh[gk_h[
Wd_dYh[Wi[_dl[hj_YWbZ_c[di_ed$Edj^[ej^[h^WdZ"j^[Z[l[befc[dje\WdWdj[h_ehY^[m_d]fWjj[hd^WijeX[Wle_Z[Z$?j_i
j^[h[\eh[d[Y[iiWhojef[h_eZ_YWbboced_jehj^[i_jkWj_edWdZjef[h\ehcWXhWi_l[WZ`kijc[djim^[d[l[hh[gk_h[Z$?dj[hbeYa_d]
YkifiXbeYaWdj[h_eh]b_Z_d]"XkjcWodejX[WZ[gkWj[WjWbbfWj_[djW][iFbWdWi'//(

YWd X[ _dYh[Wi[Z [l[d \khj^[h" fWhj_YkbWhbo _d j^[
Z_ijWb i[]c[dj$ 7domWo" _dYh[Wi_d] j^[ l[hj_YWb
Z_c[di_ed cWa[i X[jj[h i[di[ \hec W j^[hWf[kj_Y
ijWdZfe_dj j^Wd Z[Yh[Wi_d] _j$7i_Z[ \hec j^Wj" j^_i
c[Wikh[ _i ikhfh_i_d]bo m[bb jeb[hWj[Z Xo Z[[f#X_j[
fWj_[dji m^e ^Wl[ h[Yel[h[Z ijWXb[ [deiiWb ikffehj
\ehcWij_YWj_edj^WdaijeWd[mbo_dijWbb[ZXh_Z][$?d
\WYj"j^[oj[dZjeX[gk_j[^Wffom_j^j^[_dYh[Wi[Z
l[hj_YWbZ_c[di_ed$
I_dY[j^[d[kheckiYkbWh[d]hWci\ehj^[bWj[he#
jhki_l[ cel[c[dji" m^[j^[h ]k_Z[Z eh kd]k_Z[Z"
^Wl[ o[j je X[ Z[l[bef[Z eh h[Z_iYel[h[Z Wj j^[
j_c[ j^[ _dYh[Wi[ _d l[hj_YWb Z_c[di_ed ^Wi X[[d
\_dWb_p[Z"j^[eYYbkiWbikh\WY[i_dlebl[Z_d]k_ZWdY[
YWddej X[ WZ`kij[Z Z[\_d_j_l[bo h_]^j WmWo$ J^[i[
WZ`kijc[dji Wh[ cWZ[ ]hWZkWbbo Wi j^[ cWij_YWjeho
fWjj[hd _i X[_d] h[Yed\_]kh[Z el[h j^[ \ebbem_d]
m[[ai eh cedj^i$ Dej[ j^Wj j^[ h[gk_h[c[dji _d
j[hcie\WXhWi_l[WZ`kijc[djiWh[gk_j[Z_\\[h[dj\eh
Wfeij[h_ehj^Wd\ehWdWdj[h_ehcWij_YWjehofWjj[hd$
J^[WZ`kijc[djijeX[cWZ[Wh[kikWbboYedi_Z[hWXb[$
?d cWdo YWi[i" j^[o m_bb h[gk_h[ W i[YedZ Xh_Z][ je
X[ _di[hj[Z _d Wj b[Wij ed[ `Wm$ <eh j^_i h[Wied" m[
fh[\[h je ki[ Wd _d[nf[di_l[ h[i_d Xh_Z][ m_j^ W
c[jWbYeh[Wi\_hiji[c_#f[hcWd[djh[ijehWj_ed$J^[
fWj_[dji i^ekbZ X[ Yedi_ij[djbo [dYekhW][Z je ki[
j^[feij[h_ehi[]c[dji\ehY^[m_d]"WdZWdoeYYbkiWb
ikh\WY[i i^ekbZ X[ WZ`kij[Z j^Wj m_bb _dj[h\[h[ m_j^
È È $IRECTÈANDÈ)NDIRECTÈ#ONSEQUENCESÈOFÈ4REATMENTÈ
&IGÈ Jh[Wjc[djh[ikbjWii^emdXoj^_ihWZ_e]hWf^e\j^[
iakbb$J^[WXiebkj[^eh_pedjWbb_d[m^_j[b_d[ed\eh[^[WZ_i
_d]eeZW]h[[c[djm_j^j^[^eh_pedjWbehX_jWbWdZcWij_YWjeho
b_d[i$J^[Z[]h[[e\c_d[hWb_pWj_edi[[cijeX[^_]^[hWjj^[
h_]^j`WmWd]b[
(&)
j^_i jof[ e\ cel[c[dji$ Kd_bWj[hWb XbeYaWZ[ e\ ed[
JC@ _i \h[gk[djbo \ekdZ WdZ _i kikWbbo YWki[Z Xo W
h[l[hi[ZM_bied Ykhl[ ed ed[ i_Z[ Ä Xo c[Z_Wb_p[Z
YWd_d[iedj^[_fi_bWj[hWbi_Z[WdZel[hbo^_]^b_d]kWb
Ykifiedj^[YedjhWbWj[hWbi_Z[\ehceh[Z[jW_bii[[
9^Wfj[h'&WdZj^[l_Z[eWd_cWj_edi$
È
$IRECTÈANDÈ)NDIRECTÈ#ONSEQUENCESÈÈ
OFÈ4REATMENT
J^[ cWij_YWjeho \kdYj_ed m_bb dehcWbbo im_jY^ je
bWj[hWb cel[c[dji hWj^[h gk_Yabo edY[ Wdj[h_eh
Y^[m_d] cel[c[dji Wh[ de bed][h feii_Xb[ j^Wdai
je j^[ _dYh[Wi[Z l[hj_YWb Z_c[di_ed$ 7do Yecfb[j[
Z[djkh[i _d j^[ cWn_bbW m_bb de bed][h X[ fhed[
je j_bj_d] [l[d W\j[h j^[ \_hij jh[Wjc[dj ij[f ^Wi
X[[d Yecfb[j[Z$ J^_i m_bb e\j[d h[dZ[h W i[YedZ
h[ijehWj_l[jh[Wjc[dj_dj^[cWn_bbWkdd[Y[iiWho"ie
j^Wjj^[_cfbWdjj^[hWfocWoh[cW_dYed\_d[Zjej^[
cWdZ_Xb[$
J^[cWij_YWjeho\kdYj_ed_ikdb_a[bojeim_jY^je
bWj[hWbcel[c[dji_\j^[efj_ede\f[h\ehc_d]Wdj[h_eh
Y^eff_d]cel[c[dji_idej[b_c_dWj[Z$<W_bkh[jeZe
iem_bbj^ki`[efWhZ_p[j^[_cfbWdjebe]_YWbekjYec[
_d j^[ cWn_bbW" Wi j^[ Wdj[h_eh _cfbWdji Wh[ dej
_di[hj[Z Z_h[Yjbo X[bem j^[ Wdj[h_eh j[[j^ Xkj ceh[
Z_ijWbbo$ ;if[Y_Wbbo _\ _cfbWdji m[h[ edbo fbWY[Z _d
ijhWj[]_YbeYWj_edi_dj^[cWn_bbW"Z[l[befc[djickij
X[ mWjY^[Z Ybei[bo" Wi [nY[ii_l[ Wdj[h_eh YedjWYji
m_bb YWki[ Wdo 8E? _cfbWdji _d j^[ YWd_d[ fei_j_ed
&IGÈ AWjedW'/./
Z[cedijhWj[Zj^Wjj^[
\ehY[iWYj_d]edj^[JC@@
WdZWdj[h_ehj[[j^Wh[Ye#
Z[j[hc_d[ZXoj^[Wd]kbWj_ed
7e\j^[Wdj[h_ehi[]c[dj
WdZj^[kff[hZ_c[di_ede\
eYYbki_edYXkjdejXoj^[
bem[hZ_c[di_ede\eYYbki_ed
Z$7YYehZ_d]bo"j^[l[hj_YWb
Z_c[di_edYWdX[_dYh[Wi[Z
el[hWbWh][ikh\WY[m_j^ekj
Y^Wd]_d]j^[[ii[dj_Wb\ehY[
Z_ijh_Xkj_ed$7do[bed]Wj[Z
j[[j^_dj^[feij[h_ehcWn_bbW
cWod[[ZjeX[h[ZkY[Z
WZZ_j_edWbbojeWle_ZW
^Wd]_d]cWij_YWjehofbWd[
(&* 9^Wfj[h')È !NTERIORÈ-ASTICATORYÈ0ATTERNSÈANDÈ#LASSÈ))È3KELETALÈ2ELATIONS

je WYj Wi W ^ofeceY^b_ed" ie j^Wj j^[ Z_ijWb 8E?
_cfbWdji Wh[ ikX`[Yj[Z je [njhki_l[ \ehY[i Zkh_d]
Ybei_d]cel[c[dji$?dj^[mehij#YWi[iY[dWh_e"j^[i[
_cfbWdjim_bbX[Yec[ceX_b[WdZd[[ZjeX[h[fbWY[Z$
?\ cWdo _cfbWdji m[h[ _di[hj[Z" j^_i h_ia X[Yec[i
icWbb[h$ D[l[hj^[b[ii" Wd Wdj[h_eh cWij_YWjeho
fWjj[hdWbmWoi_cfb_[ih[bWj_l[]h[Wj[hWYj_l_joe\j^[
bWj[hWb fj[ho]e_Z ckiYb[" m^_Y^ ij_ckbWj[i W ceh[
fhedekdY[Z jhW`[Yjeh_Wb Wb_]dc[dj e\ j^[ h[i_ZkWb
Xed[cWii_dj^[Z_ijWbcWn_bbW$
J^[ iWc[ j^_d] cWo ^Wff[d _\ j^[ d[Y[iiWho
WZ`kijc[dji ]hWZkWbbo Z[[f[d j^[ X_j[ je j^[ fe_dj
m^[h[ Wdj[h_eh YedjWYji Wh[ h[#[ijWXb_i^[Z$ ?d j^Wj
YWi[" j^[ WZ`kijc[dji cWZ[ je j^[ cWij_YWjeho
ikh\WY[i i^ekbZ dej X[ ikXjhWYj_l[ Xkj WZZ_j_l[ _d
dWjkh[$<ehceh[Z[jW_bii[[9^Wfj[h(,$ h[ijehWj_ed$ Ifb_dj_d] j^[ Wdj[h_eh _dY_iWbi m_j^ j^[
?\ W Yecfb[j[ cWn_bbWho Xh_Z][ ikffehj[Z Xo
ijhWj[]_YWbbo fbWY[Z 8E? _cfbWdj _i fbWdd[Z _d j^[
fh[i[dY[ e\ W kd_bWj[hWb bWj[hWb cWij_YWjeho fWjj[hd
WiieY_Wj[Z m_j^ Z[b_YWj[ Xed[ ijhkYjkh[i" j^[h[ _i W
h_ia j^Wj j^[ h[ijehWj_ed cWo kd_bWj[hWbbo _djhkZ[
_d W YhWd_Wb Z_h[Yj_ed [l[d j^ek]^ j^[ _cfbWdji Wh[
eii[e_dj[]hWj[Z$J^[eii[e_dj[]hWj[ZWdY^ehW][m_bb
dej X[ beij _d j^_i i_jkWj_ed Wi bed] Wi j^[ \ehY[i
h[cW_dm_j^_djeb[hWXb[b_c_ji$?dj^_ii_jkWj_ed"_j_i
d[Y[iiWhojeh[Xk_bZj^[cWij_YWjehoikh\WY[iedj^[
W\\[Yj[Zi_Z[WdZjeh[WZ`kijj^[c_Zb_d[kd_bWj[hWb
_dYh[Wi[e\j^[l[hj_YWbZ_c[di_ed$
J^[ Y^Wd]_d] fWjj[hd e\ cWij_YWj_ed m_bb Wbie
Y^Wd][ j^[ beWZ Z_ijh_Xkj_ed ed j^[ `WmXed[ _ji[b\"
j^[h[Xo_dZkY_d]Y^Wd][i_dXed[cehf^ebe]oj^Wj
m_bb"_djkhd"Yh[Wj[Wd[[Z\ehYedj_dkekiWZ`kijc[dji
e\j^[cWij_YWjehoikh\WY[i$
J^[ j[dZ[dYo e\ j^[ cWdZ_XkbWh Wdj[h_eh j[[j^
je [bed]Wj[ cWo f[hi_ij h[]WhZb[ii e\ m^[j^[h j^[
cWij_YWjeho \kdYj_ed ^Wi X[[d h[WZ`kij[Z$ 7\j[h
Wbb" j^[ h[bWj_l[ h[jhki_ed e\ j^[ cWdZ_Xb[ YWddej
X[ Yehh[Yj[Z Xo fheij^[j_Y c[Wdi _\ h[i_ZkWb j[[j^
Wh[ ij_bb fh[i[dj$ <eh j^_i h[Wied" j^[h[ _i WbmWoi W
h_iaj^Wjj^[Wdj[h_ehi[]c[djm_bbX[Yec[[b[lWj[Z
edY[ W]W_d W\j[h j^[ cWn_bbW ^Wi X[[d h[ijeh[Z$ ?\
\kdYj_edWbYedjWYjiWh[h[#[ijWXb_i^[Z_dj^_imWo"j^[
fWj_[djm_bbgk_Yaboh[bWfi[_djeWcWij_YWjehofWjj[hd
Y^WhWYj[h_p[ZXoWdj[h_ehY^eff_d]cel[c[dji"m_j^
cWo edY[ W]W_d _d\b_Yj ZWcW][ ed j^[ cWn_bbWho
YWd_d[i_iW]eeZjh[Wjc[djefj_edjefh[l[djj^_i$
È
#ONCLUSION
J^[ \_hij efj_ed je ikffehj j^[ Z[l[befc[dj e\
bWj[hWb cWij_YWjeho fWjj[hdi _i Xo Xk_bZ_d] kf j^[
cWdZ_XkbWhZ[djkh[jeWfe_djm^[h[Wdj[h_ehY^[m_d]
_idebed][hfeii_Xb[$>em[l[h"j^[kd\WlekhWXb[\ehY[
Z_ijh_Xkj_edX[jm[[dikY^Z[djkh[iWdZj^[`WmcWo
]_l[ h_i[ je ikXijWdj_Wb kdZ[i_hWXb[ Y^Wd][i _d `Wm
cehf^ebe]o$M[j^[h[\eh[fh[\[hjejh[Wjj^[cWdZ_Xb[
Xo_cfbWdjebe]_YWbc[Wdi_dWj_c[bocWdd[h$

&IGÈ J^[X_j[if[YjhkcWiieY_Wj[Zm_j^j^_ih[ijehWj_edm_bb_d[l_jWXbob[WZjeWdWdj[h_ehcWij_YWjehofWjj[hd$I_dY[j^[
feij[h_ehi[]c[djibWYaWdoikffehjped[im^Wjie[l[h"j^[fWj_[dj^WideY^e_Y[Xkjjeki[j^[Wdj[h_ehi[]c[dji\ehY^[m_d]$
J^[X[ijiebkj_ed\ehj^[fheXb[c_ije[njhWYjjeej^*-WdZ_di[hjWYecfb[j[Xh_Z][_dj^[cWdZ_Xb[ikffehj[ZXoed[8E?
_cfbWdj_d[WY^Z_ijWbi[]c[dj$>em[l[h"j^[h[ijehWj_l[mehackijX[[nj[dZ[Zjej^[effei_d]`WmWim[bb$7\j[hWbb"Wdkd[gkWb
dkcX[he\Y^[m_d]kd_jiedXej^i_Z[ie\j^[cWn_bbWmekbZ]_l[h_i[jeWkd_bWj[hWbbWj[hWbcWij_YWjehofWjj[hdedY[j^[Wdj[h_eh
fWjj[hd^WiX[[d[b_c_dWj[Z$M[mekbZ_di[hjWZZ_j_edWb8E?_cfbWdji_dj^[Z_ijWbi[]c[dj"YecX_d[Zm_j^jkX[hefj[ho]e_Z
iYh[mi"WdZh[fbWY[jeej^(-m_j^Wd_cfbWdjWim[bb
È È #ONCLUSIONÈ
A cWoh[ikbj_d[WhboYedjWYjiWdZ
J^[cWij_YWjeho\kdYj_ed_iY^Wd][Z\hecWdj[h_eh
Y^eff_d]cel[c[djijeWbWj[hWbboeh_[dj[Z]h_dZ_d]
cel[c[dji$ J^_i _dlebl[i [nj[di_l[ Y^Wd][ e\ j^[
d[kheckiYkbWhYedjhebWdZ_i\ebbem[ZXoY^Wd][i_d
Xed[cehf^ebe]o$7dj[h_ehcWij_YWjehofWjj[hdiWh[
fh[lWb[djWced]fWj_[djim_j^cWd_\[ijia[b[jWb9bWii
??h[bWj_ediWdZ[bed]Wj[ZWdj[h_ehj[[j^_d[_j^[h`Wm$
?d ekh l_[m" j^[ cW_d jh[Wjc[dj eX`[Yj_l[ _d j^[i[
i_jkWj_edi_ijeeXjW_dWbWj[hWbcWij_YWjehofWjj[hd$
7d Wdj[h_eh cWij_YWjeho fWjj[hd _i W fWj^ebe]_YWb
YedZ_j_edj^Wjh[gk_h[ijh[Wjc[dj_d_ji[b\$EdY[j^[
Wdj[h_eh YedjWYji ^Wl[ X[[d h[iebl[Z Xo _dYh[Wi_d]
(&+
&IGÈAnC ;njh[c[bo[bed]Wj[Z
bem[h\hedjj[[j^ckijX[
[njhWYj[Z_\j^[Wdj[h_ehfWjj[hd
e\Y^[m_d]YWddejX[fh[l[dj[Z
Xoej^[hc[Wdi$?dj^_ifWj_[dj"W
l[ho^Whced_Yheme\j[[j^mWi
_di[hj[Zed\ekh8E?_cfbWdji
f[h`Wm$J^[Y^[m_d]fWjj[hdmWi
Y^Wd][ZjeWbWj[hWbZ_h[Yj_ed$
Dej[j^Wjj^[jmeWhY^[ie\j^[
Xh_Z][i[[cjeX[d[Wh[hje[WY^
ej^[h_dj^[fWj_[djÉih_]^ji_Z[
_dX$J^_icWo_dZ_YWj[j^Wjed[
ehXej^`e_dji^Wl[Y^Wd][Z
j^[_hfei_j_edWdZ\kdYj_ed$J^_i
el[hbeWZe\j^[f[h_#_cfbWdjXed[
j_iik[_dj^[Z_ijWbcWn_bbW
j^[ l[hj_YWb Z_c[di_ed" j^[ Wdj[h_eh j[[j^ e\ j^[
cWdZ_Xb[YWdX[ifb_dj[Zm_j^WYecfei_j[cWj[h_Wb
je fh[l[dj j^[_h [bed]Wj_ed$ ?dYh[Wi_d] j^[ l[hj_YWb
Z_c[di_edXWi[Zedj^[cWn_bbWhoj[[j^_i][d[hWbbo
dej W l_WXb[ Wbj[hdWj_l[$ ?\ j^[ l[hj_YWb Z_c[di_ed _i
_dYh[Wi[ZXoceZ_\o_d]j^[cWdZ_XkbWhh[ijehWj_ed"
_j_ikikWbbod[Y[iiWhojel[hj_YWbboh[ZkY[j^[Z_ijWb
fWhji e\ j^[ cWn_bbWho h[ijehWj_edi _d ehZ[h je
WZ`kijj^[cWij_YWjehofbWd[je9Wcf[hÉifbWd[$J^[
i_jkWj_edd[[ZijeX[YWh[\kbboced_jeh[Zje[dikh[
j^Wjj^[bWj[hWbcWij_YWjehofWjj[hd_icW_djW_d[Z$7
h[bWfi[ _d j[hci e\ Wdj[h_eh YedjWYji X[Yec_d] j^[
(&, 9^Wfj[h')È !NTERIORÈ-ASTICATORYÈ0ATTERNSÈANDÈ#LASSÈ))È3KELETALÈ2ELATIONS
Zec_dWj_d] \WYjeh _d cWij_YWj_ed edY[ W]W_d mekbZ
]h[Wjbo`[efWhZ_p[j^[ekjYec[e\_cfbWdjjh[Wjc[dj
WdZckijj^[h[\eh[X[fh[l[dj[Z$
H[beYWj_d]j^[cWij_YWjehofWjj[hd^Wibed]#j[hc
[\\[Yji ed Xed[ cehf^ebe]o$ J^[h[\eh[" j^[ d[mbo
_di[hj[Z h[ijehWj_ed m_bb d[[Z je X[ ikXijWdj_Wbbo
WZ`kij[Z el[h j_c[$ ?j cWo [l[d X[Yec[ d[Y[iiWho
je\WXh_YWj[Wi[YedZh[ijehWj_ededY[j^[\kdYj_edWb
WdZcehf^ebe]_YWbY^Wd][iWh[Yecfb[j[Z$
J^[ \_hij efj_ed je ikffehj j^[ Z[l[befc[dj e\
bWj[hWb cWij_YWjeho fWjj[hdi _i Xo Xk_bZ_d] kf j^[
Z_ijWbcWdZ_XkbWhZ[djkh[jeWfe_djm^[h[Wdj[h_eh
Y^[m_d] _i de bed][h feii_Xb[$ M[ h[Yecc[dZ
jh[Wj_d] j^[ cWdZ_Xb[ \_hij i[[ 9^Wfj[h-$ J^[
ceij [\\[Yj_l[ Z_ijh_Xkj_ed e\ cWij_YWjeho beWZi
_i beWZ_d] e\ j^[ cWn_bbWho \kbb WhY^$ J^[ ceij
kd\WlekhWXb[ijhW_dYedY[djhWj_edieYYkhedbeWZ_d]
_dj^[Wdj[h_ehh[]_ededbo=heii(&&'$

#(!04%2È
"/)È4REATMENTÈINÈTHEÈ0RESENCEÈÈ
OFÈ#LASSÈ)))È3KELETALÈ2ELATIONS
4
*IEF
BOE
7
,POTUBOUJOPWJD
È
'ENERALÈ#ONSIDERATIONS
M[Wh[e\j[d\WY[Zm_j^fWj_[djii^em_d]WdoehWbb
e\j^[\ebbem_d]iocfjeci0
v 9bWii ??? ia[b[jWb h[bWj_edi Y^WhWYj[h_p[Z Xo
cWn_bbWho c_Yhe]dWj^_W" jhk[ cWdZ_XkbWh fhe]#
dWj^_ic"ehXej^\WYjehiYecX_d[Z
v ;Z[djkb_ic_ded[e\Xej^`Wmi
v IW]_jjWb h[iehfj_ed e\ j^[ cWn_bbWho h_Z][ Wi W
h[ikbje\[Whbo[Z[djkb_ic
Ceij e\ j^[i[ fWj_[dji m_bb \_hij fh[i[dj Wj j^[
_cfbWdjebe]_ijÉi e\\_Y[ m^[d j^[o Wh[ fWij *&o[Whi
e\ W][$ J^[_h ia[b[jWb WXdehcWb_j_[i Wh[ kikWbbo Zk[
je j^[ \WYj j^Wj de WZ[gkWj[ ehj^eZedj_Y WdZ%eh
ikh]_YWbjh[Wjc[djmWif[h\ehc[ZZkh_d]Y^_bZ^eeZ
WdZ WZeb[iY[dY[$ Iec[ YWi[i cWo Wbie Yedij_jkj[
h[bWfi[i W\j[h Yehh[Yj_l[ jh[Wjc[dj ^WZ Wbh[WZo
X[[d f[h\ehc[Z$ ?d Wbb j^[i[ fWj_[dji" Wdo fh[l_eki
h[ijehWj_l[jh[Wjc[djim[h[kikWbbof[h\ehc[ZXWi[Z
edj^[fh[#[n_ij_d]fei_j_ede\j^[Z[djWbWhY^[i$M[
iec[j_c[i][jjei[[h[celWXb[cWn_bbWhoZ[djkh[i
_dm^_Y^j^[h[ijehWj_l[Z[dj_ijWffWh[djboWjj[cfj[Z
je h[Yj_\o j^[ i_jkWj_ed j^hek]^ Wd [nW]][hWj[Z
fei_j_ed_d]e\j[[j^$J^_iW[ij^[j_YWZlWdjW][Yec[i"
^em[l[h" Wj j^[ fh_Y[ e\ Wd kd\WlekhWXb[ beWZ WdZ
b[l[h i_jkWj_ed _d j^[ feij[h_eh i[]c[dj" m^_Y^ _i
b_a[bojejh_]][hehfhefW]Wj[Z[ijhkYj_l[f[h_eZedjWb
Z[l[befc[dji$ M^[d j^[ dWjkhWb Z[dj_j_ed _d j^[
cWn_bbW_i[l[djkWbbobeij"j^[ijhkYjkhWbh[bWj_edi^_fi
m_bb X[ ikY^ j^Wj W Z[djkh[ m_j^ Wd Wffhefh_Wj[
h[j[dj_l[ijh[d]j^YWddebed][hX[h[Wb_p[Z$
Im_ii ^[Wbj^ _dikhWdY[ fhel_Z[hi Wh[ h[gk_h[Z
kdZ[h bWm je Yel[h [nf[di[i \eh fWj_[dji m_j^ W
d[]Wj_l[ 7D8 WiieY_Wj[Z m_j^ Wd [dZ#je#[dZ eh
YheiiX_j[ i_jkWj_ed _d j^[ Wdj[h_eh i[]c[dj ed W
b_\[bed] XWi_i$2\d4Im_ii <[Z[hWb ?dikhWdY[ 9ekhj
hkb_d] ZWj[Z / :[Y[cX[h (&&($2%\d4 J^_i fe_dj
_i m[bb jWa[d" X[YWki[ j^[i[ fWj_[dji Wh[ dej je
XbWc[ \eh j^[_h Z[l[befc[djWb `Wm WdecWb_[i WdZ
m_bb h[cW_d kdZ[hfh_l_b[][Z _d j[hci e\ h[ijehWj_l[
ekjYec[ij^hek]^ekjb_\[$
 ¬ 
7do ikXi[gk[dj jeej^ beii Xhek]^j WXekj Xo
_dWZ[gkWj[beWZ_d]WdZcWij_YWjeho_cXWbWdY[im_bb
WbieX[Wjjh_XkjWXb[jej^[ia[b[jWbZoi]dWj^_W$
È
#ONVENTIONALÈ3URGICALÈ!PPROACHES
Edbo W c_deh_jo e\ fWj_[dji m^e mekbZ WYjkWbbo
h[gk_h[ jh[Wjc[dj \eh cWdZ_XkbWh fhe]dWj^_ic m_bb
WYY[fjjekdZ[h]eYehh[Yj_l[ikh][ho$JeZWo"^em[l[h"
j^[i[ fheY[Zkh[i Wh[ de bed][h j^[ jh[Wjc[dj e\
\_hij Y^e_Y[ WdomWo" ]_l[d j^[ c_d_cWbbo _dlWi_l[
Wbj[hdWj_l[efj_ediXWi[ZedXWiWbeii[e_dj[]hWj_ed"
m^_Y^ `kij Ze dej _dlebl[ j^[ h_iai e\ ehj^e]dWj^_Y
ikh][hoM[bbaWcf(&&&$CWdofWj_[djim_bbhWj^[h
jeb[hWj[[njh[c[bokd\WlekhWXb[cWij_YWjehoh[bWj_edi
je j^[ fe_dj e\ X[_d] kdWXb[ je Y^[m Wbje][j^[h
j^Wd WYY[fj je kdZ[h]e ehj^e]dWj^_Y ikh][ho$ J^_i
kdm_bb_d]d[ii ^Wi je Ze m_j^ eYYkfWj_edWb WdZ
\Wc_b_Wb h[Wiedi" Xkj Wbie m_j^ j^[ h_iai e\ ikh][ho$
J^[ h_ia e\ _d\b_Yj_d] ZWcW][ je j^[ cWdZ_XkbWh
d[hl[ _d j^[ fheY[ii e\ i[fWhWj_d] j^[ cWdZ_Xb[ _i
ikXijWdj_Wb" fWhj_YkbWhbo _d WZkbji$ AeXb_d WdZ H[_b
'/-* eXi[hl[Z fWhW[ij^[j_Y iocfjeci _d '/$+
e\ j^ei[ fWj_[dji m^e ^WZ kdZ[h]ed[ iW]_jjWb#ifb_j
eij[ejec_[i WYYehZ_d] je EXm[][i[h WdZ :Wb Fedj$
J^[i[iocfjeci^WZjeX[YbWii_\_[ZWif[hcWd[dj"
i_dY[ j^[o \W_b[Z je h[iebl[ el[h Wd eXi[hlWj_ed
f[h_eZ e\ )Ä.o[Whi$7YYehZ_d] je CWY_djei^ '/.'"
j^_i ^_]^[h _dY_Z[dY[ e\ bWij_d] fWhW[ij^[i_W _i
eXi[hl[Z[if[Y_Wbbo_dfWj_[djiel[h*&o[Whie\W]["
_$[$ fh[Y_i[bo _d j^[ W][ ]hekf ceij b_a[bo je i[[a
_cfbWdjebe]_YWbjh[Wjc[dj$7bj^ek]^j^[Wkj^ehiY_j[Z
h[fehj[Z j^Wj ded[ e\ j^[ fWj_[dji m[h[ Z_iiWj_i\_[Z
m_j^j^[jh[Wjc[djekjYec[Z[if_j[j^[i_Z[[\\[Yji"
_j _i d[l[hj^[b[ii Z_\\_Ykbj je Yedl[o j^[i[ \_dZ_d]i
_d j^[ Yedj[nj e\ j^[ fWj_[dj _d\ehcWj_ed i[ii_ed$ ?j
_iWbieZ_\\_YkbjjeZ[\[dZikY^ekjYec[iW]W_dijj^[
XWYa]hekdZe\ademdi_Z[[\\[Yji_dWd[dl_hedc[dj
j^Wj _i ][d[hWbbo YedZkY_l[ je b[]Wb WYj_ed$ ?d j^_i
mWo"j^[m^eb[_iik[_dlebl[ic[Z_YWbWdZ[j^_YWb"Xkj
Wbieb[]Wb"Yedi_Z[hWj_edi$
7dej^[h cW`eh _iik[ _i j^[ h[bWfi[ hWj[ W\j[h
ikh]_YWbYehh[Yj_ede\j^[_dj[hcWn_bbWhoh[bWj_edi$J^[
\_dZ_d]ij^Wj^Wl[X[[dh[fehj[Z_dj^_iYedd[Yj_ed
(&. 9^Wfj[h'*È "/)È4REATMENTÈINÈTHEÈ0RESENCEÈOFÈ#LASSÈ)))È3KELETALÈ2ELATIONS
Wh[_dYedYbki_l["fh[ikcWXboX[YWki[j^[i[l[h_joe\
Wh[bWfi[lWh_[im_j^j^[i[l[h_joe\j^[fh[ef[hWj_l[
Zoi]dWj^_W$ @Wjkfehd '/.' h[fehj[Z j^Wj Wbj^ek]^
j^[ _dY_Z[dY[ e\ hWZ_e]hWf^_YWbbo Z[cedijhWXb[
h[bWfi[i _i ckY^ ^_]^[h j^Wd _i ][d[hWbbo Wiikc[Z"
j^[Yb_d_YWbh[ikbjiWced]j^[i[YWi[iWh[d[l[hj^[b[ii
WYY[fjWXb[$ AeXb_d WdZ H[_b '/-* ced_jeh[Z j^[
feijef[hWj_l[Yekhi[ie\'&'fWj_[djim^e^WZX[[d
jh[Wj[Z \eh cWdZ_XkbWh fhe]dWj^_ic$ 7YYehZ_d] je
j^[_h ZWjW" h[bWfi[i mekbZ cW_dbo X[ YWki[Z Xo
jed]k[\kdYj_edWdZckiYkbWh_cXWbWdY[i$J^[cW_d
ikYY[ii Yh_j[h_ed ki[Z _d j^Wj ijkZo mWi j^[ Z[]h[[
e\ Xed[ Wffei_j_ed$ P_ii[h '/--" m^e ced_jeh[Z
*(+ fWj_[dji jh[Wj[Z Xo ehj^e]dWj^_Y ikh][ho" \ekdZ
j^Wjh[bWfi[im[h[cW_dboWiieY_Wj[Zm_j^ef[dX_j[
i_jkWj_edi$J^_iWkj^ehZ_ZdejeXi[hl[WdoYecfb[j[
h[bWfi[i$
JC@ fheXb[ci Wh[ Wdej^[h feii_Xb[ Yedi[gk[dY[
e\ _dlWi_l[ ikh]_YWb fheY[Zkh[i ikY^ Wi iW]_jjWb
i[fWhWj_ed WdZ `Wm h[fei_j_ed_d] B_[Xb WdZ ;m[hi
'/.&$Ed[feii_Xb[Wbj[hdWj_l[j^Wj^WiX[[dik]][ij[Z
_dj^_iYedd[Yj_ed_i^ehi[i^e[Zemd\hWYjkh[m_j^eh
m_j^ekjWd_dj[hfei[Z]hW\j"m^_Y^_i"^em[l[h"edbo
f[h\ehc[Z Xo W j_do c_deh_jo e\ ikh][edi _d j^[
b[]Wbbo fhej[Yj[Z [dl_hedc[dj e\ j^[ kd_l[hi_j_[i$
<eh j^[ fkhfei[ e\ j^_i Z_iYkii_ed" _j i^ekbZ X[
fe_dj[Zekjj^Wjj^_iik]][ij[ZWbj[hdWj_l[_iWYjkWbbo
WcWn_cWbbo_dlWi_l[jh[Wjc[djceZWb_jo_ji[b\;m[hi
'//.$7YYehZ_d] je <_iY^[h#8hWdZ_[i '/.+" WhekdZ
)& e\ ikh]_YWb fheY[Zkh[i W_c[Z Wj Yehh[Yj_d]
cWdZ_XkbWh fhe]dWj^_ic Wh[ dej f[h\ehc[Z kdj_b
j^[fWj_[dji^Wl[beijj^[_hY^[m_d]WX_b_joWbje][j^[h
WdZWh[debed][hWXb[jem[WhWZ[djkh[$
7l[ho_cfehjWdj\WYjeh_dZ[Y_Z_d]edWdoa_dZ
e\ jh[Wjc[dj _d WZkbji _i ^em bed] j^[ fWj_[dj m_bb
X[ kdWXb[ je meha$ ?d ebZ[h fWj_[dji" j^[ ZkhWj_ed
e\ jh[Wjc[dj ckij X[ Yedi_Z[h[Z W]W_dij [WY^
_dZ_l_ZkWbÉib_\[[nf[YjWdYo$
?d Yh[ijWb _cfbWdjebe]o" fWj_[dji m_j^ [njh[c[
l[hj_YWbXed[beii"_\Yedi_Z[h[Z[b_]_Xb[\eh_cfbWdj
jh[Wjc[dj Wj Wbb" Wh[ jh[Wj[Z Wbceij [nYbki_l[bo m_j^
h[celWXb[ h[ijehWj_edi$ 7\j[h Wbb" Yh[ijWb _cfbWdji
YWd edbo X[ _di[hj[Z _d j^[ Wdj[h_eh i[]c[dj _\
l[hj_YWb Xed[ _i fh[i[dj _d ikXijWdj_Wb Wcekdji$
Ceh[el[h"j^[Z[dj_ij^WijeYedi_Z[h_dYh[Wi_d]j^[
l[hj_YWbh[bWj_ed_dehZ[hjeYehh[Yjj^[7D8IfW^d
'//-"m^_Y^dWhhemij^[if[Yjhkce\_dZ_YWj_edi\eh
Yh[ijWb_cfbWdji\khj^[h$
È
!LTERNATIVEÈ4REATMENTÈWITHÈ"/)È)MPLANTS
J^[ YedY[fj e\ jh[Wj_d] fWj_[dji m_j^ [njh[c[
ia[b[jWb Z_iYh[fWdY_[i m_j^ 8E?#XWi[Z h[ijehWj_edi
jWa[iWZlWdjW][e\j^[ifWj_Wb_dZ[f[dZ[dY[e\\[h[Z
Xo 8E? _cfbWdj Z[i_]di X[jm[[d j^[ i_j[ e\ beWZ
jhWdic_ii_ed WdZ j^[ i_j[ m^[h[ j^[ j^h[WZ[Z f_d
[c[h][i \hec j^[ ckYeiW ?^Z[ '///$ BWh][ Z_ijWb
_cfbWdjiYWdX[fbWY[Zje[dikh[j^[_dj[]h_joe\j^[
fheij^[j_Yh[ijehWj_edm_j^ekjj^[d[[ZjefbWY[Wdo
_cfbWdji_dj^[Wdj[h_ehi[]c[djm^Wjie[l[h$
?dWii[ii_d]m^[j^[hj^[jh[Wjc[dji^ekbZYedi_ij
_d W fkh[bo _cfbWdjebe]_YWb iebkj_ed eh m^[j^[h
j^[ _cfbWdj jh[Wjc[dj i^ekbZ X[ YecX_d[Z m_j^ W
ikh]_YWbfheY[Zkh["ed[ckijYedi_Z[hj^Wjj^[hWj^[h
dWhhem Xed[ ijhkYjkh[i _d j^[ cWn_bbW m_bb ^WhZbo
f[hc_jWdocW`ehh[beYWj_edm_j^ekjWZZ_j_edWbXed[
]hW\j_d]$ ?\ j^[ cWn_bbW _i jee icWbb eh h[jhkZ[Z"
h[beYWj_d] j^[ cWdZ_Xb[ XWYamWhZi _i dej _dZ_YWj[Z
WdomWoX[YWki[e\j^[ie\j#j_iik[ijhkYjkh[i_dlebl[Z$
?d j^[i[ i_jkWj_edi" m[ fh[\[h je h[ijeh[ j^[ cWn_bbW
XWi[Zed8E?_cfbWdji$
?d i_jkWj_edi m^[h[ j^[ cWdZ_Xb[ _i el[hbo bWh][
eh fhejhkZ[Z" j^[ jh[Wjc[dj e\ \_hij Y^e_Y[ m_bb X[
je h[fei_j_ed j^[ cWdZ_Xb[ XWYamWhZi \eh W[ij^[j_Y
h[Wiedi$Ikh]_YWbh[fei_j_ed_d]m_bb_dlebl[W]h[Wj[h
h_ia e\ h[bWfi[ _d j^[i[ i_jkWj_edi Wi j^[ ie\j#j_iik[
ijhkYjkh[i" m^_Y^ m_bb [nfWdZ _d Wd Wjj[cfj je
h[Yel[hj^[_heh_]_dWbifWY["cWoj^kiYWki[j^[Xed[
ijhkYjkh[ijeh[#WZlWdY[$
?d iec[ i_jkWj_edi W d[]Wj_l[ el[h`[j e\ ceh[
j^Wd)Ä*YccWoij_bbYedij_jkj[Wh[bWj_l[_dZ_YWj_ed
\eh WZ`klWdj ehj^e]dWj^_Y ikh][ho" [if[Y_Wbbo _\ j^[
fbWdd_d] f^Wi[ h[l[Wbi j^Wj W Yehh[Yjbo Wb_]d[Z
eYYbkiWbjWXb[Yehh[ifedZ_d]jej^[m_Zj^e\Wjb[Wij
j^h[[ fh[cebWhi YWddej X[ h[Wb_p[Z Xo fheij^[j_Y
c[Wdi$ Ehj^e]dWj^_Y ikh][ho m_j^ eh m_j^ekj 8E?
_cfbWdjjh[Wjc[djcWoWbieX[Yedi_Z[h[Z_\Wh[]kbWh
el[hX_j["ehWjb[WijWd[dZ#je#[dZi_jkWj_ed"Wff[Whi
ekje\h[WY^$
?dfWj_[djii^em_d][njh[c[Z_iYh[fWdY_[i"_jcWo
X[d[Y[iiWhoje[ijWXb_i^ceZ[biWdZeXjW_dh[cej[
hWZ_e]hWf^i \eh WdWboi_i" m^_b[ ceh[ ceZ[hWj[
YWi[i YWd X[ WffheWY^[Z Xo i_cfbo [dikh_d] j^Wj
Wd WZ[gkWj[ ^eh_pedjWb Xed[ ijhkYjkh[ _i WlW_bWXb[$
?cfbWdjikikWbbockijdejX[fbWY[Z_dj^[Wdj[h_eh
i[]c[dj\eh\_n[Zh[ijehWj_edi$Fh_ehje\bWfh[\b[Yj_ed"
j^[ckYeiWbf[d[jhWj_edi_j[\ehj^[j^h[WZ[Zf_d_i
cWha[Z m_j^ W jkd]ij[d YWhX_Z[ Ykjj[h$ J^[ Z[dj_ij
cWo Wbie m_i^ je ki[ W ikh]_YWb j[cfbWj[ eXjW_d[Z
\hecWmWn#kf\eh]k_ZWdY[$
J^[ iWc[ ikh]_YWb WffheWY^ _i ki[Z Wi \eh Wdo
a_dZ e\ 8E? _cfbWdjWj_ed fheY[Zkh[$ B_a[m_i[" j^[
efj_edi e\ _cc[Z_Wj[ eh Z[bWo[Z beWZ_d] YWd X[
i[b[Yj[Z _d j^[ iWc[ mWo Wi _d ej^[h fWj_[dji$ ?\
_cc[Z_Wj[ beWZ_d] _i ki[Z" Wdo YedjWYji ekji_Z[ e\
j^[ ikffehj_d] febo]ed i^ekbZ Wj \_hij X[ Wle_Z[Z$
If[Y_\_YWbbo" Wdo Wdj[h_eh YedjWYji eh Z[[f Wdj[h_eh
el[hX_j[ i_jkWj_edi d[[Z je X[ c_d_c_p[Z _d j^[
\_hij *Ä,cedj^i" WdZ j^[ fWj_[dji Wh[ _dijhkYj[Z je
WYj_l[boWle_Zj^[i[YedjWYjiZkh_d]\eeZ_djWa[$
?\i_]d_\_YWdjlebkc[Z[\_Y_jiWh[fh[i[djj^WjWh[
WZ[gkWj[bo Yel[h[Z Xo j^[ b_fi" _j _i X[jj[h je ki[
È È #ONCLUSIONÈ
_dYehfehWj[ f_da Y[hWc_Y i[]c[dji _dje j^[ Xh_Z][
\hec j^[ l[ho ekji[j$ ?d Wbb ej^[h YWi[i" j^[ Z[dj_ij
m_bb^Wl[je\_dZWl_WXb[Yecfhec_i[X[jm[[djeej^
b[d]j^" Wn_Wb _dYb_dWj_ed WdZ ie\j#j_iik[ ikffehj$
;nY[ii_l[kf^ebij[h_d]e\j^[kff[hb_f_ikikWbbodej
jeb[hWj[ZWdZcWo]_l[h_i[jefh[iikh[ieh[i$
È
#ONCLUSION
8E? _cfbWdji e\\[h W \Wij WdZ [\\[Yj_l[ XWi_i \eh
h[ijehWj_l[jh[Wjc[dj[l[d_dfWj_[djim_j^i_]d_\_YWdj
iW]_jjWb Z_iYh[fWdY_[i$ H[fei_j_ed_d] e\ j^[ `Wmi _i
dehcWbbodejh[gk_h[Z$
9Wi[IjkZo'
J^[ fWj_[dj m^ei[ YWi[ _i _bbkijhWj[Z _d <_]i$'*$'Ä
'*$* ^WZ eh_]_dWbbo X[[d h[\[hh[Z je W cWn_bbe\WY_Wb
ikh][ed m^e ik]][ij[Z jh[Wj_d] ^[h fhe]dWj^_ic
Xo iW]_jjWb i[fWhWj_ed e\ j^[ cWdZ_Xb[ WYYehZ_d]
je EXm[][i[h :Wb Fedj WdZ W cWn_bbWho Yecfb[j[
Z[djkh[$ 7 fWbWj[#\h[[ Z[djkh[ Z[i_]d mekbZ ^Wl[
X[[d l_WXb[ \eh Wi bed] Wi h[i_ZkWb j[[j^ m[h[ ij_bb
fh[i[dj" fhel_Z[Z j^Wj j^[ WZZ_j_edWb Yeiji \eh j^[
j[b[iYef[i"m^ei[c[Z_kc#j[hcfhe]dei_imWifeeh
[nY[fjedjeej^')"mekbZ^Wl[X[[dYel[h[ZXoj^[
_dikhWdY[ fhel_Z[h$ J^[ fWj_[dj h[\ki[Z je kdZ[h]e
j^[ ik]][ij[Z jh[Wjc[dj cW_dbo X[YWki[ e\ j^[ h_ia
jej^[d[hl[WdZj^[bed]ZkhWj_ede\j^[hWfo$8[_d]
W ^eki[m_\[ m_j^ Y^_bZh[d" W Yecfb[n jh[Wjc[dj e\
j^_ijof[mWiekje\j^[gk[ij_ed"dejb[WijX[YWki[
e\j^[lWh_ekiWdZ][e]hWf^_YWbboZ_ijWdjjh[Wjc[dj
beYWj_edi_dlebl[Z$
7d Wjj[cfj mWi cWZ[ je fh[lW_b ed j^[ ^[Wbj^
_dikh[h je Yel[h j^[ [nf[di[i \eh 8E? _cfbWdj
jh[Wjc[dj$ ?j X[YWc[ gk_Yabo [l_Z[dj" ^em[l[h" j^Wj
j^[ _dikhWdY[ YecfWdo mWi WXekj je ki[ _ji [Z][
Wi j^[ \_dWdY_Wbbo ceh[ fej[dj fWhjo WdZ mekbZ
Z[\[dZ _ji feb_Yo e\ ded#fWoc[dj Xo [d]W]_d] _d
o[Whi e\ b[]Wb Z_ifkj[i hWj^[h j^Wd WYYecceZWj_d]
j^[ fWj_[djÉi YbW_c$ J^[h[\eh[" j^[ fWj_[dj" m^e ^WZ
Yecfb[j[bobeij^[hWX_b_jojeY^[m"Z[Y_Z[ZjeYel[h
j^[jh[Wjc[djYeiji^[hi[b\WdZi[[ah[_cXkhi[c[dj
bWj[h$ ?d Wbb[d kdi X[aWddj[d <bb[d mkhZ[d Z_[
AhWda[dl[hi_Y^[h[hifj[ij[di^Y^ijh_Y^j[hb_Y^pkh
8[pW^bkd]Z[h8E?#J^[hWf_[l[hf\b_Y^j[j$
J^[ kff[h h_]^j YWd_d[ mWi [dZeZedj_YWbbo
jh[Wj[Z1 Wbb ej^[h j[[j^ m[h[ [njhWYj[Z$ ?d b_d[ m_j^
j^[ WlW_bWXb[ Xed[ lebkc[" W jejWb e\ [_]^j 8E?
_cfbWdjiWdZed[Yecfh[ii_ediYh[mm[h[_di[hj[Z$
Ed j^[ j^_hZ feijef[hWj_l[ ZWo" W j[cfehWho Xh_Z][
cWZ[ \hec WYhob_Y h[i_d fh[\[hWXbo m_j^ W YWij[Z
c[jWbYeh[YekbZX[_di[hj[ZWi\_hij#b_d[h[ijehWj_l[
j^[hWfo$
J^[eYYbkiWbh[bWj_edim[h[f[h_eZ_YWbboh[l_[m[Z$
Kdb_a[ _d 9bWii ?%?? fWj_[dji" j^[ _dj[hcWn_bbWho
(&/
h[bWj_ediYWdX[h[WZ_boZ[\_d[Z_dj^[lWijcW`eh_jo
fWj_[djim_j^9bWii???fhe]dWj^_ic"i_dY[j^[JC@i
Wh[ f[h\[Yjbo ijWXb[ _d j^_i i_jkWj_ed$ J^[ h[cej[
hWZ_e]hWf^ eXjW_d[Z _d j^[ feijef[hWj_l[ f^Wi[
h[l[Wb[ZWib_]^jboh[jhkZ[Zfei_j_ede\j^[cWdZ_Xb["
_dZ_YWj_d]j^[fh[i[dY[e\Wc_bZbobeYa[ZX_j[$
I_nm[[aibWj[h"j^[j[cfehWhoXh_Z][mWih[fbWY[Z
m_j^ j^[ Z[\_d_j_l[ F<C Xh_Z][$ J^_i _dj[hlWb mWi
edbo h[gk_h[Z je l[h_\o j^[ ekjYec[ e\ heej YWdWb
jh[Wjc[dj$ 7 Z[\_d_j_l[ h[ijehWj_ed ikffehj[Z Xo
_cfbWdjiedbomekbZ^Wl[X[[d_di[hj[ZckY^ceh[
fhecfjbo_dj^_ii_jkWj_ed$
7i_Z[ \hec j^[ \WYj j^Wj Yedl[dj_edWb jh[Wjc[dj
ceZWb_j_[i mekbZ ^WhZbo ^Wl[ e\\[h[Z W i_c_bWh
ekjYec[" ed[ ckij Wbie \WYjeh _d j^[ [nj[dZ[Z
f[h_eZi e\ j_c[ _d m^_Y^ j^[ fWj_[dj mekbZ ^Wl[
X[[d kdWXb[ je meha WdZ b[\j m_j^ekj Wdo a_dZ e\
h[ijehWj_ed$
Jh[Wj[Zm_j^8E?_cfbWdji"j^_iif[Y_\_YfWj_[djmWi
b[\jm_j^ekjWh[ijehWj_ed\ehWjejWbe\)ZWoi"WdZi^[
mWikdWXb[jemeha\ehed[i_d]b[ZWo$J^[Wl[hW][
jh[Wjc[djiY[dWh_e_dekhfhWYj_Y[mekbZX[j^Wjj^[
Z[\_d_j_l[ c[jWbbe#Y[hWc_Y Xh_Z][ fWhj_YkbWhbo _d
j^[cWdZ_Xb[_i_di[hj[ZW\j[h-ZWoi"ehW\j[h''ZWoi
Wjj^[bWj[ij$
FWj_[djim^eWh[_djekY^m_j^Yb_[djiedj^[`eX
Wh[ h[Yecc[dZ[Z je jWa[ jme m[[ai e\\$ ;l[d XWZ
YWi[ie\im[bb_d]WdZ\WY_WbZ_iYebekhWj_edm_bb^Wl[
h[iebl[ZXoj^Wjj_c[$
EdY[ W]W_d" j^[i[ h[ikbji Wh[ i_]d_\_YWdjbo X[jj[h
j^Wd j^ei[ eXjW_d[Z m_j^ Yedl[dj_edWb jh[Wjc[dj
ijhWj[]_[i$ 8_[hcWdd WdZ IY^[jjb[h '/-* h[fehj[Z
j^Wj fWj_[dji jh[Wj[Z Xo cWdZ_XkbWh eij[ejec_[i
m[h[kdWXb[jefkhik[j^[_heYYkfWj_ed\ehWjejWbe\
''m[[ai" m^_Y^ _dYbkZ[Z j^[ f^Wi[ e\ ehj^eZedj_Y
fh[#jh[Wjc[dj$ ?j _i \W_h je WZZ" ^em[l[h" j^Wj j^[i[
jh[Wjc[dj j_c[i YWd X[ h[ZkY[Z Xo [dikh_d] j^Wj
j^[ iYh[m Yedd[Yj_edi [ijWXb_i^[Z W\j[h eij[ejeco
Wh[ijWXb[$M^_b[Ykhh[djZ_ijhWYj_edfheY[Zkh[im_bb
Wbie _dlebl[ b[ii ×WXi[dj[[_icÆ" j^[o Ze h[gk_h[ W
Yekfb[e\cWii_l[ikh]_YWb_dj[hl[dj_ediWdZ_cfei[
WikXijWdj_Wbbo^_]^[hb[l[be\el[hWbbZ_iYec\ehjed
j^[fWj_[djiBWpWh[jWb$'///$
9Wi[IjkZo(
7 +*#o[Wh#ebZ fWj_[dj fh[i[dj[Z m_j^ W Y_hYkbWh
YheiiX_j[ i_jkWj_ed" Wd 7D8 e\ Ä)Z[]h[[i" h[i_ZkWb
j[[j^_dj^[cWn_bbW"WdZWdWbceijYecfb[j[Z[dj_j_ed
_dj^[cWdZ_Xb[$Jh[Wjc[djmWifhel_Z[ZXoi_cfbo
_di[hj_d]jme8E?_cfbWdjiWiZ_ijWbWifeii_Xb[_dje
j^[Z_ijWbcWn_bbWjeikffehjWY_hYkbWhXh_Z][$J^[i[
_cfbWdji m_bb h[i_ij j^[ YWdj_b[l[h \ehY[i Yh[Wj[Z Xo
j^[Wdj[h_ehZ[dj_j_ed$
J^[_d_j_WbYheiiX_j[mWiYed\_d[ZjeWbeYa[ZX_j[
i_jkWj_ed$M^_b[j^[fWj_[djmWiWXb[je[ijWXb_i^[Z][#
je#[Z][h[bWj_edi_dj^[Wdj[h_ehi[]c[dj"^[mWidej
WXb[ je f[h\ehc h[]kbWh Y^[m_d] _d j^_i fei_j_ed"
('& 9^Wfj[h'*È "/)È4REATMENTÈINÈTHEÈ0RESENCEÈOFÈ#LASSÈ)))È3KELETALÈ2ELATIONS

A B

&IGÈAB J[b[hWZ_e]hWf^WdZEF=e\j^[fh[ef[hWj_l[i_jkWj_ed$7bbj[[j^_dj^[cWn_bbW[nY[fj\ehjeej^')m[h[[njhWYj[Z$

7bb cWn_bbWho cebWhi [n^_X_j jkdd[bb_d] Z[\[Yji$ ;njhWYj_ed e\ jeej^ *, _i _dZ_YWj[Z Wi m[bb$ Ikh]_YWb fh[#jh[Wjc[dj Xo Wd
ehj^eZedj_ijmWidejYedi_Z[h[Zki[\kb$J^[7D8mWiWXekjÄ*Z[]h[[i$J^[ia[b[jWbYedi[gk[dY[ie\fhe]dWj^_icZedejf[h
i[YWki[WdofheXb[ci

A B

&IGÈAB J^[Wdj[h_ehj[[j^_dj^[cWn_bbWm[h[[njhWYj[ZWdZh[fbWY[ZXoWÆYehh[Yj_l[ÇY[hWce#c[jWbZ[djkh[\ehW[ij^[j_Y

h[Wiedi$J^_iZ[djkh[mWiWYjkWbboj^[iekhY[e\j^[f[h_eZedjWbfheXb[ciZ_W]dei[ZX[\eh[_cfbWdjjh[Wjc[dj
È È #ONCLUSIONÈ (''

&IGÈ 7jejWbe\i[l[d8E?_cfbWdjiWdZed[Yecfh[ii_ediYh[mm[h[_di[hj[Z$Jeej^')mWiWbie_dYbkZ[Z_dj^[h[ijehWj_ed$
J^_i EF= mWi jWa[d +o[Whi W\j[h j^[ cWn_bbW ^WZ X[[d h[ijeh[Z$ J^[ Xed[ ijhkYjkh[i WhekdZ j^[ beWZ#jhWdic_jj_d] ikh\WY[i
Zedejh[l[WbWdoZ[\_Y_ji_dj[hcie\^[Wb_d]$DeYh[ijWbXed[_iWffWh[dj$J^[jh[Wjc[djYedY[fj_dj^_ifWj_[djmWiXWi[Zed
ckbj_fb[hWj^[hj^WdijhWj[]_Y_cfbWdjfbWY[c[dj$?dj^[c[Wdj_c["j^[cWdZ_Xb[mWih[ijeh[ZWim[bb

&IGÈ 9b_d_YWbi_jkWj_edW\j[h,o[Whi

ie j^Wj j^[ cWdZ_Xb[ mWi _d[l_jWXbo Z[\b[Yj[Z _d Wd

Wdj[h_ehZ_h[Yj_ed$?jmWij^[h[\eh[ikif[Yj[Zj^Wjj^[
fWj_[dj mekbZ Z[l[bef W dehcWb Y^[m_d] \kdYj_ed
W\j[h _dYh[Wi_d] j^[ l[hj_YWb h[bWj_ed Xo WhekdZ
'&cc$ J^_i Wiikcfj_ed jkhd[Z ekj je X[ Yehh[Yj$
I[l[hWbYhemdh[ijehWj_edi_dj^[feij[h_ehi[]c[dj
e\ j^[ cWdZ_Xb[ ^WZ je X[ _di[hj[Z WZZ_j_edWbbo je
B
Yecf[diWj[\ehj^[Wbj[h[Zl[hj_YWbh[bWj_ed$

;l[d_\j^[cWn_bbW_iijhed]boh[jhkZ[Z"WdWjj[cfj &IGÈAB ?djhWehWb l_[m e\ j^[ h[i_ZkWb Z[dj_j_ed _d j^[
i^ekbZX[cWZ[je[ijWXb_i^Yehh[Yjh[bWj_ediX[jm[[d cWn_bbW$Jeej^((mWiYed][d_jWbboc_ii_d]$M^_b[j^[fWj_[dj
j^[ YWd_d[i WdZ je _di[hj j^[ cWn_bbWho Wdj[h_eh mWiWXb[je[ijWXb_i^Wd[dZ#je#[dZeYYbki_ed"^WX_jkWbY^[m_d]
_cfbWdjiWjj^[YWd_d[fei_j_ed$ mWiedbofeii_Xb[_dWYheiiX_j[Yed\_]khWj_ed
('( 9^Wfj[h'*È "/)È4REATMENTÈINÈTHEÈ0RESENCEÈOFÈ#LASSÈ)))È3KELETALÈ2ELATIONS

&IGÈ I_jkWj_edW\j[h_di[hj_ede\W\_n[ZXh_Z][

&IGÈAB Fh[#

WdZfeijef[hWj_l[
j[b[hWZ_e]hWf^i$J^[
7D8h[cW_did[]Wj_l[
W\j[hjh[Wjc[dj$J^_i
ekjYec["m^_Y^_i
XWi[Zededbojme8E?
_cfbWdji"YekbZX[
h[Wb_p[Z_dWcWjj[he\
ZWoi
È È #ONCLUSIONÈ (')

A B

C D

&IGÈAB 9b_d_YWb l_[mi X[\eh[ WdZ W\j[h jh[Wjc[dj m_j^ W \_n[Z Xh_Z][ ikffehj[Z Xo 8E? _cfbWdji$ J^[ _d_j_Wb el[h`[j
Wcekdj[Zjehek]^bo*Yc$J^kij^[Xh_Z][mWiZ[i_]d[Zdejedbojeh[fbWY[j^[j[[j^XkjWbiejeYecf[diWj[\ehj^[cWn_bbWho
Z_iYh[fWdYoWdZjh[Wjj^[i[l[h[cWij_YWjehoZoi\kdYj_ed$ C 7dj[h_ehbojej^[YWd_d[i"deXed[mWiWlW_bWXb[jeWdY^ehWdo
_cfbWdji$7domWo"_jmekbZdejX[ki[\kbjefbWY[Wdo8E?_cfbWdji_dj^[Wdj[h_ehi[]c[dj"Wi_cfbWdji_dj^[i[fei_j_edicWo
]h[WjboYecfb_YWj[j^[`eXe\j^[Z[djWbj[Y^d_Y_Wd$7domWoWZZ_j_edWb_cfbWdjiX[jm[[dj^[YWd_d[h[]_edWh[dejh[gk_h[Z\eh
beWZjhWdic_ii_edfkhfei[i$ D J^_ifWdehWc_YhWZ_e]hWf^Ze[iYedl[oWd_cfh[ii_ede\[njh[c[l[hj_YWbZ_iYh[fWdY_[i"Xkj
_jZe[idejfhel_Z[Wdo_d\ehcWj_ededj^[_hiW]_jjWbZ_c[di_ed$J^[f_Yjkh[ii^em_d]j^[\WXh_YWj_edij[fi\ehj^[cWn_bbWho
Xh_Z][Wh[fh_dj[ZWdZZ_iYkii[Z_d9^Wfj[h''$($J^[Yecfh[ii_ediYh[m_dj^[kff[h`Wm_d^_X_jij^[el[hWbb[bWij_Y_joe\j^[
Xed[#_cfbWdj#fheij^[j_Yioij[c1_jcWoX[d[Y[iiWhojeh[cel[ehZ[jWY^_jbWj[hed$J^_i_cfbWdjmWi_di[hj[Zedboje[d^WdY[
fh_cWhoijWX_b_jo$

&IGÈAB I_dY[de

_cfbWdji^Wl[jeX[
_di[hj[Z_dj^[Wdj[h_eh
i[]c[dj"j^[h[_ide
d[[Z\eh\bWfh[\b[Yj_ed
_dj^_iWh[W

A
('* 9^Wfj[h'*È "/)È4REATMENTÈINÈTHEÈ0RESENCEÈOFÈ#LASSÈ)))È3KELETALÈ2ELATIONS

A
E

B
&IGÈA ?d j^_i YWi[" j^[ cWn_bbW ^WZ X[[d [Z[djkbeki
\eh ceh[ j^Wd '&o[Whi WdZ j^[ fWj_[dj YekbZ dej jeb[hWj[
j^[ Z[djkh[$ J^[ bem[h Z[dj_j_ed bWYa[Z Wdo \kdYj_edWb
ij_ckbWj_ed" m^_Y^ b[Z je i[l[h[ f[h_eZedjWb Z[ijhkYj_ed$
Edbo j^h[[ j[[j^ i[[c[Z je X[ mehj^ fh[i[hl_d]$ B I_n
ZWoi feijef[hWj_l[bo j^[ c[jWb \hWc[ \eh j^[ kff[h Xh_Z][
mWijh_[Z_d$?dj^[c[Wdj_c["j^[h[cW_d_d]bem[hj[[j^^WZ
h[Y[_l[Z W YWij feij$ C 7bj^ek]^ ;:7I#jof[ 8E? _cfbWdji
m[h[_di[hj[ZY[djhWbbo_djej^[cWdZ_Xb["j^[fei_j_ede\j^[
j^h[WZ[Zf_di_igk_j[bWj[hWb$J^_iZe[idejYh[Wj[h[ijehWj_l[
fheXb[ci$J^[el[hWbbjh[Wjc[djj_c[\ehj^_iYWi[mWi)m[[ai"
Zkh_d] m^_Y^ i_n Wffe_djc[dji m[h[ cWZ[$ J^[d W i[h_[i e\
eYYbkiWb WZ`kijc[dj i[ii_edi je [ijWXb_i^ \kdYj_edWb XWbWdY[
mWi h[gk_h[Z$ De Wdj[h_eh YedjWYji m[h[ Wbbem[Z Wj \_hij$
C ?djhki_ede\j^[Z_ijWb8E?_cfbWdjmWii[[dbWj[h"m^_Y^b[Z
je W Ybeikh[ e\ j^[ _d_j_Wbbo fheij^eZedj_Y Æef[d X_j[Ç i[[
9^Wfj[h(,$' \eh Z[jW_bi$ 8ej^ Xh_Z][i Wh[ i^emd Wj j^[ \_dWb
jho#_d$ 7dj[h_eh YedjWYji Wh[ dej [ijWXb_i^[Z Wj j^_i fe_dj
je Wle_Z \ehY[ _cXWbWdY[i m_j^_d j^[ febo]ed Yh[Wj[Z Xo
j^[ \ekh _cfbWdji _d j^[ cWn_bbW$ J^[ ZekXb[ j^h[WZ iYh[mi
Wh[ dej o[j _di[hj[Z$ D 9J _cW][ i^em_d] j^[ Yehh[Yjbo
fbWY[Z8E?_cfbWdjiWdZj^[fei_j_ede\j^[jkX[hefj[ho]e_Z
iYh[m h[bWj_l[ je 8E? _cfbWdj$ E J^[ fhedekdY[Z iW]_jjWb
Z_iYh[fWdYo WffWh[dj \hec j^_i bWj[hWb j[b[hWZ_e]hWf^ mWi
Yehh[Yj[Z[nYbki_l[boXo_cfbWdj#XWi[Zh[ijehWj_l[jh[Wjc[dj$
Edbo j^[ Wdj[h_eh dWiWb if_d[ fhe`[Yji ekj e\ j^[ ej^[hm_i[
h[jhkZ[ZXed[ijhkYjkh[iYecfWh[<_]$'*$'&Z$ F 7bj^ek]^
j^[ i_jkWj_ed _d <_]$'*$'&Z cWo beea Wi j^ek]^ j^[ 8E?
_cfbWdjim[h[_di[hj[Z_dWd[nY[ii_l[bobWj[hWbfei_j_ed"j^_i
EF= e\ j^[ iakbb i^emi j^Wj Xej^ _cfbWdji m[h[ _di[hj[Z
Y[djh_YWbbo je j^[ `Wm WdZ j^Wj efj_cWb X_Yehj_YWb WdY^ehW][
^WiX[[dWY^_[l[Z_dXej^YWi[i$J^[bWj[hWbZ_c[di_ed_iWbie
W\\[Yj[Z_dfhedekdY[ZYWi[ie\Zoi]dWj^_WXkjYWdX[[Wi_bo
Yehh[Yj[Zm_j^8E?_cfbWdji$;c[h][dY[fhe\_b[i_dj^[Z_ijWb
D
i[]c[djm[h[Yedi_Z[h[Zkdd[Y[iiWho_dj^_iYWi[

#(!04%2È
4REATINGÈTHEÈ!TROPHIEDÈ-ANDIBLE
È
)NTRODUCTION
?j _i ijWdZWhZ fheY[Zkh[ _d Yh[ijWb _cfbWdjebe]o
jeZWoje_di[hjiYh[mim_j^Wc_d_ckcb[d]j^e\'&Ä
')cc _d j^[ Wdj[h_eh cWdZ_XkbWh h[]_ed" fhel_Z[Z
j^[h[_i[dek]^l[hj_YWbXed[^[_]^j$:[f[dZ_d]ed
^em cWdo iYh[m _cfbWdji j^[h[ kbj_cWj[bo _i heec
\eh" j^[ fWj_[dji cWo h[Y[_l[ XWbb WXkjc[dji" XWhi"
eh Ä _d \WlekhWXb[ i_jkWj_edi Ä YWdj_b[l[h[Z#fedj_Y
Xh_Z][i WYYehZ_d] je 8hd[cWha$ M^[d _j Yec[i
je Z_ijh_Xkj_d] \ehY[i _dje j^[ _dj[h_eh e\ j^[ Xed["
fWj_[djim_j^c_d_cWbXed[^[_]^jWjj^[ekji[jWh[
WjWZ_iWZlWdjW][$?j_ifh[Y_i[bo_dj^[i[fWj_[djij^Wj
edboWicWbb\hWYj_ede\j^[el[hWbbcWij_YWjeho\ehY[i
m_bbX[Z_h[YjbojemWhZj^[_cfbWdjim^[dZ[i_]d_d]
j^[ikf[hijhkYjkh[$?dceijYWi[i"j^[Yh[ijWb_cfbWdji
_dj^[i[YWi[im_bbe\\[hedbohkZ_c[djWhoikffehj\eh
Wh[celWXb[Z[djkh[j^Wj"\ehj^[ceijfWhj"m_bbX[
f[h_eZedjWbbo ikffehj[Z$ M^_b[ j^_i _d_j_Wbbo i[[ci
je Wbb[l_Wj[ j^[ fheXb[c e\ Z[djkh[ h[j[dj_ed" j^[
Z_iWXb_d] beii e\ j[[j^ WdZ `Wm ikXijWdY[ _i dej
WYjkWbbo WZZh[ii[Z$ M[ Wi Z[dj_iji ^Wl[ X[[d WXb[
WdZYedj_dk[jeX[WXb[jecWa[ced[oedj^_ijof[
e\¼j^[hWfo½edboX[YWki[j^_iZ_iWX_b_jo_ih[bWj_l[bo
_dl_i_Xb[ WdZ X[YWki[ fWj_[dji Wh[ Wi^Wc[Z WdZ
kdm_bb_d] je Xh_d] j^[_h fheXb[c ekj _dje j^[ ef[d$
7i j^[ ceij h[Y[dj fkXb_YWj_ed Xo =eZXekj [j Wb$
(&&(i^emi"ikXf[h_eij[Wb_cfbWdjiWh[iec[j_c[i
ki[Z Ä Z[if_j[ j^[ \WYj j^Wj j^[o Wh[ Z_\\_Ykbj je
fheZkY[WdZZ_\\_Ykbjje_di[hjWdZj^Wjj^[oh[gk_h[
Wjme#ijW][ikh]_YWbWffheWY^Äjejh[Wji_jkWj_edie\
[njh[c[l[hj_YWbWjhef^oe\j^[Z_ijWbcWdZ_Xb[$
O[j_j_i`kijj^[i[l[h[boWjhef^_[ZcWdZ_Xb[j^Wj
e\\[hi" _d fh_dY_fb[" ]eeZ fh[h[gk_i_j[i \eh X[_d]
jh[Wj[Z m_j^ \_n[Z h[ijehWj_edi" i_dY[ j^[ ^_]^ b[l[b
e\ Xed[ h[ceZ[bb_d] _d j^_i jkXkbWh Xed[" YWki[Z
fh_cWh_bo Xo ijh[ii Zk[ je ckiYkbWh beWZi" YWd
h[ikbj _d [nY[bb[dj Xed[ h[][d[hWj_ed \ebbem_d]
_cfbWdjeij[ejecoWdZl[ho]eeZh[][d[hWj_edW\j[h
eij[eboi[ie\lWh_ekieh_]_di$
;l[d W icWbb dkcX[h e\ Z[djWb _cfbWdji YWd X[
ki[ZjeYh[Wj[_cfbWdj#h[ijehWj_edijhkYjkh[ij^Wj"_d
mWoii_c_bWhje[nj[hdWb\_nWjehi"YWdikffehjWijWXb[
h_]_ZXh_Z][edWcWdZ_Xb[ikX`[Yj[Zjejehi_ed$
 ¬ 
8ej^ B_daem '//&" _d Z[l[bef_d] ^_i jh_#
feZ_Wb ijhkYjkh[i" WdZ JWjkc '/., ^WZ fh_d#
Y_fWbbo h[Ye]d_p[Z j^Wj dej edbo j^[ \Wc_b_Wh
_dj[h\ehWc_dWb cWdZ_XkbWh h[]_ed Xkj if[Y_\_YWbbo
j^[ m[bb#c_d[hWb_p[Z Z_ijWb Wif[Yj e\ j^[ ^eh_pedjWb
cWdZ_XkbWhhWckiWdZj^[Wh[We\jhWdi_j_edjemWhZ
j^[WiY[dZ_d]hWckie\\[h[Zik_jWXb["ijWXb[_cfbWdj
fei_j_edi$
Ekh j^[hWf[kj_Y WffheWY^ jemWhZ j^[ jh[Wjc[dj
e\ j^[ [njh[c[bo Wjhef^_[Z cWdZ_Xb[ jWa[i _dje
Yedi_Z[hWj_edj^[h[ikbjieXjW_d[ZXoB_daem"JWjkc
WdZH_Y^j[h"m^_b[WZ^[h_d]jej^[fh_dY_fb[ie\8E?$
J^_i WffheWY^ ^Wi i^emd _ji[b\ je X[ W ikijW_dWXb[
bed]#j[hc j^[hWf[kj_Y YedY[fj j^Wj ^Wi X[Yec[ j^[
]ebZijWdZWhZ\eh\_n[Zh[ijehWj_edi_dj^[Wjhef^_[Z
cWdZ_Xb[$
È
4WOÈ#ONCEPTSÈFORÈ$EALINGÈÈ
WITHÈTHEÈ"IOMECHANICALÈ2EALITY
El[hj^[o[Whi"jmeZ_\\[h[djiY^eebi^Wl[Z[l[bef[Z
m_j^_dbWj[hWb_cfbWdjebe]o$
È
.UMEROUSÈ)MPLANTSÈINÈTHEÈ-ANDIBLE
J^[ <h[dY^ iY^eeb m_j^ IYehj[YY_ Wi _ji cW_d
fhejW]ed_ij\WlekhiWbWh][dkcX[he\8E?_cfbWdji
_dj^[cWdZ_Xb["ceijboX[jm[[di[l[dWdZjm[bl[$
7YYehZ_d]jej^_iiY^eeb"8E?_cfbWdjiWdZYh[ijWb
_cfbWdji Wh[ YecX_d[Z Xej^ _d j^[ cWn_bbW WdZ _d
j^[cWdZ_Xb[$J^[_cfbWdj#h[ijehWj_edioij[cij^ki
Yh[Wj[Z Wh[ h_]_Z WdZ Ze dej f[hc_j Wdo jehi_ed
WYheii cWn_bbWho%cWdZ_XkbWh h[]_edi" fhel_Z[Z
WYjkWb eii[e_dj[]hWj_ed ^Wi jWa[d fbWY[ WhekdZ Wbb
[deiiWb_cfbWdji$
J^[ ckbj_#_cfbWdj YedY[fj e\ j^[ <h[dY^ iY^eeb
_iYb_d_YWbboikYY[ii\kb$J^[_cfbWdjiki[Z_dYbkZ_d]
j^[ijhkYjkh[#jof[iYh[mii^emdec_Yhec[Y^Wd_YWb
WdY^ehW][X[YWki[j^[ikh\WY[[dbWh][c[djj^Wjj^_i
mekbZh[gk_h[Ze[idej[n_ij$J^[i[_cfbWdjiZedej
[l[d h[ikbj _d hWZ_ebe]_YWbbo Z[j[YjWXb[ ij_ckbki#
h[bWj[Z eij[eboi_i _\ j^[ eii[eWZWfj_l[ Z_ijWdY[
(', 9^Wfj[h'+È 4REATINGÈTHEÈ!TROPHIEDÈ-ANDIBLE

X[jm[[dj^[_cfbWdjWdZj^[Xed[_dYh[Wi[iWhekdZ c_d[hWb_pWj_ed _d j^[ _cc[Z_Wj[bo l_Y_d_jo$ J^_i

Y[hjW_d Yecfed[dji e\ j^[ _cfbWdj#h[ijehWj_ed
ioij[c"h[ikbj_d]_d_cfbWdjceX_b_jo$J^Wjj^[h[m_bb
WbmWoiX[_cfbWdjij^WjWh[ÄWdZckijX[ÄceX_b[
YWd X[ i[[d m^[d f[h_eZ_YWbbo h[cel_d] m_Z[#Ykf
?: Z[djkh[i _d fWj_[dji m_j^ W bWh][ dkcX[h e\
_cfbWdjif[h`Wm$M^[d_j_ij^[h[l[hi_Xb[Y^Wd][_d
j^[ eii[eWZWfj_l[ Z_ijWdY[ Wj j^[ beWZ#jhWdic_jj_d]
_dj[h\WY[WdZm^[d_j_ij^[Y^Wd][_dc_d[hWb_pWj_ed
j^Wj Y^WhWYj[h_p[i j^[ h[WYj_ed e\ j^[ `WmXed[ je
el[hboh_]_Z_cfbWdj#h[ijehWj_edioij[ci_iiec[j^_d]
j^Wj\khj^[hh[i[WhY^m_bb^Wl[jei^em$
?j _i [if[Y_Wbbo _d j^[ cWdZ_Xb[ j^Wj m[ Wh[
_dYh[Wi_d]bo l_[m_d] j^_i c[j^eZ Yh_j_YWbbo" X[YWki[
_j^WiX[[di^emdj^Wj_j_ikbj_cWj[bo_cfeii_Xb[je
fh[l[dj cWdZ_XkbWh jehi_ed WdZ X[YWki[ j^[ Z_iai
Wh[ h[f[Wj[Zbo ikX`[Yj[Z je l[ho ikXijWdj_Wb beWZi
j^WjcWoh[ikbj_deij[eboi_i$9edjhWhojecWij_YWjeho
beWZi"j^[i[beWZiWh[dejZ_ijh_Xkj[Zceh[[l[dbo_\
ceh[ _cfbWdji Wh[ _di[hj[Z0 hWj^[h" W ^_]^ Wcekdj
e\ j[di_ed _i Yh[Wj[Z _d j^[ ceij W\\[Yj[Z h[]_ed e\
j^[Z_iaj^Wj_cc[Z_Wj[boh[ikbji_dY^Wd][i_dXed[
c[Wdij^Wjj^[Z_iam_bbX[_dj[]hWj[Zceh[_dWceh[
ceX_b[eh[bWij_YcWdd[hh[bWj_l[jej^[ikhhekdZ_d]
Xed[$ IkXi[gk[djbo" j^[ _cfbWdj#h[ijehWj_ed ioij[c
m_bbX[\_hcbo_dj[]hWj[ZXWiWbbo_d\[m[hfe_djij^Wj
Wh[ b[ii YWfWXb[ e\ cel_d] h[bWj_l[ je [WY^ ej^[h"
_dYh[Wi_d] j^[ Y^WdY[ j^Wj ikijW_dWXb[ eij[edWb
Xed[ ijhkYjkh[i YWd Z[l[bef WdZ X[ cW_djW_d[Z
WhekdZj^[Z_iai$?j_iademdj^Wji[YedZWhoeij[edi
cWo h[WY^ kf je (&Yc _d b[d]j^ WdZ fh[\[h W
ib_]^jboYkhl[Z"jhW`[Yjeh_WbfWj^$J^[eX`[Yj_l[e\j^[
j^[hWfojeWY^_[l[Ybei[eii[eWZWfjWj_ede\j^[beWZ#
jhWdic_ii_edWh[Wim^_b[Wjj^[iWc[j_c[WY^_[l_d]
W^_]^b[l[be\c_d[hWb_pWj_ed$
?d dehcWb \kdYj_ed" j^[ cWdZ_Xb[ _i ikX`[Yj je
Yedj_dkeki\b[n_edWdZjehi_ed"Xej^e\m^_Y^cWd_\[ij
j^[ci[bl[i ed W c_YheiYef_Y b[l[b Wi W Z_ibeYWj_ed
e\ Z_\\[h[dj Xed[ bWo[hi h[bWj_l[ je [WY^ ej^[h$ ?d
j^_i fheY[ii" Yeh[i e\ _dYh[Wi[Z c_d[hWb_pWj_ed Wh[
Yh[Wj[Z_dj^[Z_h[Yj_ede\j^[jhW`[Yjeh_[i$8[jm[[d
j^[i[ Yeh[i" [bWij_Y h[]_edi m_bb Z[l[bef j^Wj f[hc_j
Z_ibeYWj_ede\j^[Xed[bWo[hi$

&IGÈ J^_icWdZ_Xb[mWijh[Wj[ZXofei_j_ed_d]\ekh8E?_cfbWdji_dijhWj[]_Yfei_j_edi$Dej[j^Wjj^[XWi[fbWj[ie\j^[
jmeWdj[h_eh_cfbWdjiWh[fei_j_ed[ZX[bemj^[c[djWbd[hl[$J^[Z_ijWb_cfbWdji^Wl[X[[dfei_j_ed[Zib_]^jboWXel[j^[d[hl[$
+ohi$feijef[hWj_l[f_Yjkh[1j^[_cfbWdji^Wl[X[[d[gk_ff[Zm_j^j^[Z[\_d_jl[Xh_Z][m_j^_d(*^ekhi$
È È 4WOÈ#ONCEPTSÈFORÈ$EALINGÈWITHÈTHEÈ"IOMECHANICALÈ2EALITYÈ ('-

;WY^_cfbWdjjhWdic_jiWZ_\\[h[djYecfed[dje\
j^[ el[hWbb \b[nkhWb \ehY[ je j^[ _cfbWdj#h[ijehWj_ed
ioij[c"[n[hj_d]Wd_d\bk[dY[edj^[ej^[h_cfbWdji
Wim[bb$
FWhj_YkbWhfheXb[ciWh[fei[ZXo_cfbWdjibeYWj[Z
_d j^[ fh[cebWh h[]_ed$ :k[ je j^[ YWkZWb jehi_ed
e\ j^[ cWdZ_Xb[ m^[d j^[ cekj^ _i ef[d[Z" j^[i[
Yedij_jkj[ W ^ofeceY^b_ed h[ikbj_d] _d WZZ_j_edWb
kdZ[i_hWXb[ \ehY[i WYj_d] ed Wbb Z_iai$ J^ei[ Z_iai
j^Wj X[Wh j^[ Xhkdj e\ Wbb ej^[h \ehY[i cWij_YWjeho
\ehY[i" \b[nkhWb \ehY[i ^Wl[ j^[ ]h[Wj[ij j[dZ[dYo
jemWhZ Z[c_d[hWb_pWj_ed" kbj_cWj[bo h[ikbj_d] _d
Yecfb[j[ Z[jWY^c[dj \hec j^[ Xed[ _d iec[ YWi[i$
J^[b_\[[nf[YjWdYoe\fh[cebWh8E?_iWbieh[ZkY[Z
Xoj^[\W_hbo^_]^fheXWX_b_joe\j^[b_d]kWbWif[Yje\
j^[ Z_ia bei_d] YedjWYj m_j^ j^[ Yehj_YWb Xed[$ J^[
h[Wied\ehj^_ih[bWj_l[h[fei_j_ed_d]e\j^[_dj[]hWj[Z
_cfbWdj_difWY[_ij^[b_d]kWbXed[Wffei_j_edj^Wj
eYYkhi _d jhk[ Xed[ ceZ[bb_d] Wi W h[ifedi[ je j^[
Y^Wd][ _d i^Wf[ j^Wj eYYkhi _d j^[ h[]_ed e\ j^[
YkhlWjkh[ e\ j^[ ^eh_pedjWb cWdZ_XkbWh hWcki" W
Y^Wd][ kbj_cWj[bo YWki[Z Xo j^[ eij[ejeco e\ j^[
cWdZ_Xb[$E\Yekhi["j^_ih[bWj_l[h[fei_j_ed_d]ckij
WbieX[i[[dWiWh[ifedi[je_dYh[Wi_d]cWij_YWjeho
\ehY[i$ J^[i[ WZZ[Z \ehY[i m_bb j[dZ je fh[i[hl[
j^[ d[mbo \ehc[Z Xed[ WdZ _dYh[Wi_d]bo h[ikbj _d
c_d[hWb_pWj_ed$
È
3TRATEGICÈ)MPLANTÈ0OSITIONING
?\j^[fWj_[djmWijh[Wj[Zki_d]j^[j[Y^d_gk[e\XWiWb
eii[e_dj[]hWj_ed?^Z[(&&'"j^[j[Y^d_gk[fh[\[hh[Z
Xo ki" edbo W \[m _cfbWdji m_bb X[ ijhWj[]_YWbbo

A B

C D

&IGÈÈ A ;njh[c[bo Wjhef^_[Z cWdZ_Xb[ m_j^ \ekh ijhWj[]_YWbbo fei_j_ed[Z 8E? _cfbWdji Wi WXkjc[dji$ J^[ _cfbWdj Wj
)- Ze[i dej i^em Y_hYkc\[h[dj_Wb c_d[hWb_pWj_ed1 ^em[l[h" _j _i dej ceX_b[$ EdY[ W]W_d" j^[ Wdj[h_eh Z_iai m[h[ fbWY[Z
_d\hWd[hlWbbo$ B J^[f[h_#_cfbWdjXed[ikXijWdY[_dj^_ihWZ_e]hWf^Ybei[#kfWff[WhiZWha[hj^Wdj^[ikhhekdZ_d]Xed[$J^[
ZWha[hh[]_ed_idejYb[WhboZ[b_c_j[Z1j^[_di[hj_edibej[n^_X_jideXedoYbeikh[Wjj^_ife_dj(o[Whifeijef[hWj_l[boWdZ_idej
b_a[bojeX[Ybei[Z_dj^[\eh[i[[WXb[\kjkh[$J^[_cfbWdj_i\kbbo\kdYj_edWbWdZckijdejX[h[cel[ZkdZ[hWdoY_hYkcijWdY[i$
?d W cWdZ_Xb[ j^Wj YecX_d[i i[l[h[ Wjhef^o WdZ ^_]^ Xed[ [bWij_Y_jo" j^[ Z[]h[[ e\ c_d[hWb_pWj_ed _d j^[ _dj[h\WY_Wb h[]_ed
YWddej X[ [nf[Yj[Z je X[ ^_]^[h1 j^_i hWZ_e]hWf^ j^ki i^emi j^[ X[ij feii_Xb[ jh[Wjc[dj h[ikbj \eh j^[ fWhj_YkbWh YWi[ Wj
^WdZ$ CÈD ;nWcfb[e\ijhWj[]_Y_cfbWdjfei_j_ed_d]_dj^[cWdZ_Xb[$J^[j^h[WZ[Zf_die\j^[Wdj[h_eh_cfbWdjiWh[kikWbbo
beYWj[Zb_d]kWbboe\j^[j[[j^$J^[WXkjc[djiWh[b[\jjefhejhkZ[j^hek]^ekjj^[\WXh_YWj_ede\j^[ikf[hijhkYjkh[_dj^[Z[djWb
bWXehWjehoWdZWh[dejjh_cc[Zkdj_bW\j[hZ[\_d_j_l[Y[c[dj_d]
('. 9^Wfj[h'+È 4REATINGÈTHEÈ!TROPHIEDÈ-ANDIBLE
fei_j_ed[Z$ >[h[" \ekh _cfbWdji m_bb kikWbbo X[
_di[hj[Z Wj *-" *)" )) WdZ )- \eh \_n[Z h[ijehWj_edi$
7bj^ek]^ j^[ XWiWb Wif[Yji e\ j^[ _cfbWdji j^Wj
jhWdic_jj^[beWZim_bbe\Yekhi[eii[e_dj[]hWj["j^[i[
`Wm#_cfbWdj#h[ijehWj_ed ioij[ci m_bb WYj \b[n_Xbo1
j^[ j^h[WZ[Z f_di m_bb i[hl[ Wi W \b[n_Xb[ _dj[h\WY[
X[jm[[dj^[beWZ#jhWdic_jj_d]eii[e_dj[]hWj[ZZ_iai
ed ed[ ^WdZ WdZ j^[ Xh_Z][ ed j^[ ej^[h" m_j^ j^[
Xh_Z][h[cW_d_d]h_]_Z$
J^_i ijhWj[]_Y fei_j_ed_d] Yh[Wj[i Wd WYY[fjWXb[
j[di_ed X[jm[[d j^[ _cfbWdj i_j[i Zkh_d] ki["
m_j^ j^[ \_n[Z h[ijehWj_ed WbmWoi WXiehX_d] WdZ
Yecf[diWj_d] \eh iec[ e\ j^[ j[di_edWb beWZ$ 8ed[
m_bb ]hem X[jm[[d j^[ _cfbWdji iec[j^_d] j^Wj
_i [Wi_[h je c[Wikh[ _d j^[ cWdZ_Xb[ j^Wd _d j^[
cWn_bbW l[hj_YWbbo WXel[ WdZ X[bem j^[ Z_iai i[[
<_]$/$/$ J^[ _dYh[Wi[ _d Xed[ lebkc[ _i YWki[Z
Xo j^[ _dYh[Wi[ _d cWij_YWjeho \ehY[i WdZ m_bb
Wff[Wh fWhj_YkbWhbo fhedekdY[Z _d YWi[i _d m^_Y^
j^[ fh[iikh[ fh[l_ekibo [n[hj[Z Xo j^[ fWj_[djÉi
h[celWXb[Z[djkh[_ih[cel[Z$
8WYj[h_WbWjjWYaiWjj^[_di[hj_edi_j[i"_$[$j^[i_j[i
e\ ckYeiWb f[d[jhWj_ed" fbWo W l[ho _di_]d_\_YWdj
heb[_d8E?"m^_Y^c[Wdij^Wjj^[Xed[lebkc[YWd
]hembWh][bokdh[ijh_Yj[Z"\ebbem_d]edbo\kdYj_edWb
h[gk_h[c[dji$;l[djkWbbo"e\Yekhi["j^_iXed[]hemj^
m_bbX[ijeff[ZXoj^[\_n[Zh[ijehWj_edfedj_Yi$
8o YedjhWij" Xed[ lebkc[ YWd ^WhZbo _dYh[Wi[ _d
WYh[ijWbZ_h[Yj_ed_dj^[YWi[e\_cfbWdj#h[ijehWj_ed
ioij[ci Yecfh_i_d] W bWh][ dkcX[h e\ _cfbWdji$ ?\
_cfbWdj beYWj_ed _i Z[j[hc_d[Z Xo ej^[h j^Wd `kij
ijhWj[]_Y Yedi_Z[hWj_edi" Yecfh[^[di_l[ _dj[h\WY[
YedjWYj fh[Zec_dWj[i" WdZ j^[ i^Wf[ e\ j^[ Xed[
Y^Wd][i edbo _d j^[ ^eh_pedjWb Z_c[di_ed" _\ Wj
Wbb$ :_iai m_j^ekj ikh\WY[ [dbWh][c[dj j[dZ je X[
h[Yecc[dZ[Z\ehj^_ijof[e\h[ijehWj_edi"X[YWki[
de\h_Yj_ed_iYh[Wj[Z_dYWi[im^[h[eii[eWZWfjWj_ed
_iWXi[djWhekdZY[hjW_dWh[Wie\j^[Z_iaiehZkh_d]
Y[hjW_db_c_j[Zf[h_eZi$Ed[YWddej[nf[YjWbbWh[Wi
e\ j^[ Z_ia je X[ \_hcbo _dj[]hWj[Z" m_j^ W ^_]^
Z[]h[[ e\ c_d[hWb_pWj_ed" Wj j^[ iWc[ j_c[" ]_l[d
j^[[njh[c[bo\b[n_Xb[[dl_hedc[dje\j^[Wjhef^_[Z
cWdZ_Xb[$ ?d iec[ YWi[i" [l[d \ekh 8E? _cfbWdji
c_]^jh[dZ[hj^[Wjhef^_[ZcWdZ_Xb[kdZkboh_]_Z$
M^_b[ j^[ Wjhef^_[Z cWdZ_Xb[ kikWbbo bWYai
[dek]^ l[hj_YWb Xed[ lebkc[ \eh j^[ _di[hj_ed e\
Yh[ijWb _cfbWdji" _j m_bb e\j[d ij_bb e\\[h ik\\_Y_[dj
Xed[ lebkc[ _d j^[ ^eh_pedjWb Z_c[di_ed$
M^[j^[h j^_i _i _d \WYj j^[ YWi[ YWd X[ l[h_\_[Z Xo
fWbf_jWj_ed$ J^_i Xed[ ikffbo _i efj_cWbbo kj_b_p[Z
Xo ^eh_pedjWbbo _di[hj[Z _cfbWdji e\ j^[ 8E? jof[$
?dj^[fWijm[WbmWoijh_[Zje_di[hjWcWn_ckce\
XWiWb _cfbWdji _d j^[ cWdZ_Xb[" \ebbem_d] ][d[hWb
_cfbWdjebe]_YWb\Wi^_edWim[bbWij^[<h[dY^iY^eeb$
J^[ X_ec[Y^Wd_YWb h[WYj_ed e\ j^[ cWdZ_Xb[ ^Wi
jWk]^jkij^Wjjh[Wjc[djYWdX[Wjb[WijWiikYY[ii\kb
_\ \[m[h _cfbWdji Wh[ ki[Z$ =[d[hWbbo if[Wa_d]" jme
je j^h[[ _cfbWdji cWo X[ _di[hj[Z _d j^[ Wdj[h_eh
h[]_ed$ ?d j^[ Z_ijWb h[]_edi e\ j^[ cWdZ_Xb[" ed[
_cfbWdjf[hgkWZhWdjYWdX[ki[Z$
?\ceh[_cfbWdjiWh[_di[hj[Z"j^[cWYhejhW`[Yjeh_Wb
ijhkYjkh[e\j^[cWdZ_Xb[_im[Wa[d[Z"iec[j^_d]j^Wj
m[ikX`[Yj_l[bo`kZ][jeX[WZ_iWZlWdjW]["[if[Y_Wbbo
i_dY[ ed[ ^Wi je [nf[Yj j^Wj j^[ cehf^ebe]o e\
j^[ Wjhef^_[Z cWdZ_Xb[ Y^Wd][i ceh[ ikXijWdj_Wbbo
\ebbem_d] _cfbWdjWj_ed j^Wj j^Wj e\ W cWdZ_Xb[ _d
m^_Y^j^[Xed[ikffbo_iX[jj[h$
È
!NTERIORÈ)MPLANTS
7i bed] Wi ik\\_Y_[dj l[hj_YWb ifWY[ _i WlW_bWXb["
;::I /%- =- eh ;:: '&%- =, j[dZ je X[ ki[Z$ ?\
j^[ _di[hj_ed e\ ZekXb[ Z_iai _i dej ikYY[ii\kb" i_p[
/I=/"/I=.eh[l[d/I=,YWdX[ki[Z_dij[WZ$M[
Wle_Z icWbb[h Z_iai m^[h[l[h feii_Xb[1 bWh][h Z_iai
Wh[ kikWbbo dej h[gk_h[Z$ Jh_fb[#Z_ia 8E? _cfbWdji
^Wl[fhel[djeX[l[hoki[\kb_dj^[Wdj[h_ehh[]_ed
e\j^[cWdZ_Xb[$
È
0OSTERIORÈ)MPLANTS
:[f[dZ_d] ed j^[ Wcekdj e\ WlW_bWXb[ l[hj_YWb WdZ
^eh_pedjWbXed[lebkc[";:7I/%'(=-eh;:7I/%'+
=+m_bbX[ki[Z$=[d[hWbbo";:7I_cfbWdjimehal[ho
m[bb\ehj^_i_dZ_YWj_ed"i_dY[j^[j^h[WZ[Zf_dWbmWoi
[dZi kf _d W fheij^eZedj_YWbbo \WlekhWXb[ c[Z_Wb
fei_j_ed m^[d _di[hj[Z bWj[hWbbo$ J^_i Wbbemi j^[
Y[djh_f[jWbh[iehfj_ede\j^[cWdZ_Xb[jeX[fWhj_Wbbo
Yecf[diWj[Z\ehWi[WhboWiZkh_d]_cfbWdjWj_ed$J^[
bed]_jkZ_dWb i^Wf[ e\ j^[ _cfbWdj o_[bZi [nY[bb[dj
fh_cWhoijWX_b_jo"WdZ[l[dm_Z[hcWdZ_Xb[ikikWbbo
debed][hh[gk_h[j^[ki[e\bWh][#Z_ia"hejWj_edWbbo
iocc[jh_YWb 8E? _cfbWdji1 c_d_cWbbo _dlWi_l[
_cfbWdjX[Zfh[fWhWj_edm_bbX[ik\\_Y_[dj$
;nf[h_[dY[ i^emi j^Wj Wbb i_jkWj_edi _d j^[
feij[h_eh cWdZ_Xb[ YWd X[ cWdW][Z ki_d] j^[i[
jme _cfbWdj jof[i WdZ Ä eYYWi_edWbbo Ä m_j^ ej^[h
;:7I_cfbWdji$J^[X[ij_cfbWdji_j[_ij^[Wdj[h_eh
[Z][ e\ j^[ WiY[dZ_d] cWdZ_XkbWh hWcki" m^_Y^
_i ijhed]bo c_d[hWb_p[Z" Wi YWd [Wi_bo X[ i[[d _d
hWZ_e]hWf^i e\ j^[ h[]_ed$ ?cfbWdji _di[hj[Z Wj j^[
[dZ e\ j^[ ibef[ eh X[bem j^[ Æm^_j[ b_d[Ç _d j^[
ehj^efWdjece]hWf^ Wh[ Wbceij d[l[h beij" Wj b[Wij
dej Wi bed] j^[ b_d[ Ze[i dej i^_\j _ji \kdYj_edWbbo
Z[j[hc_d[Zfei_j_ed$
<hec W fheij^eZedj_Y fe_dj e\ l_[m" Yecfb[j[
Xh_Z][h[ijehWj_ediWh[_di[hj[Z_dXej^fheY[Zkh[i$
?d ekh [nf[h_[dY[" Æjeej^#Xo#jeej^Ç _cfbWdjWj_ed
Wi ki[Z je X[ Yecced _d Yh[ijWb _cfbWdjebe]o
Yedij_jkj[iWdkdd[Y[iiWhojh[Wjc[djYeij\WYjeh$?j_i
dejieckY^j^[eYYbki_edj^Wjh[gk_h[iWZ`kijc[dj
Wi WZ`kij[Z Wi j^[ ]b_Z_d] cel[c[dj e\ j^[ j[[j^
fWij[WY^ej^[h"Wiademd\hecYecfb[j[Z[djkh[i_d
^kcWdiehjeej^h_Z][i_dX_hZi?^Z['/''$
È È )NFRANERVALÈ)MPLANTATIONÈ
È
)NFRANERVALÈ)MPLANTATION
?\ j^[ l[hj_YWb Xed[ ikffbo WXel[ j^[ cWdZ_XkbWh
d[hl[_ib[iij^Wd(cc"_d\hWd[hlWb_cfbWdj_di[hj_ed
_i_dZ_YWj[Z$;:7I_cfbWdjiWh[ceijbokdik_jWXb[\eh
j^_i fkhfei[" i_dY[ j^[ d[hl[ mekbZ [dZ kf X[_d]
beYWj[Z jee \Wh l[ij_XkbWhbo$ HWj^[h" j^[ kd_bWj[hWbbo
YkX_YWb ;:I _cfbWdji e\j[d /I =," /I =. eh j^[
ebZ[h hekdZ _cfbWdji / =. eh - =. Wh[ ki[Z$ <eh
Wd [nf[h_[dY[Z _cfbWdjebe]_ij" j^[ j[Y^d_gk[ e\
_d\hWd[hlWb _cfbWdj _di[hj_ed _i de ceh[ Z_\\_Ykbj
j^Wd ikfhWd[hlWb _di[hj_ed0 7 i^Whf Xed[#Ykjj_d]
XkhehhekdZXkh_iki[Zjeef[dj^[d[hl[YWdWb_d
j^[Xed[WdZje[nfei[j^[d[hl[$?j_i_cfehjWdjje
[nfbeh[ j^[ YWkZWb [nj[di_ed e\ j^[ d[hl[ YWdWb _d
ehZ[h je fh[l[dj ikXi[gk[dj [dYheWY^c[dj ed eh
jhWkcWjej^[d[hl["m^_Y^c_]^jc_]hWj[_dWYWkZWb
Z_h[Yj_ed kdZ[h Y[hjW_d Y_hYkcijWdY[i" YWki[Z Xo
j^[ Ykjj_d] _dijhkc[dj$ ?\ j^[ d[hl[ YWdWb _i dej
b_c_j[Z _d W YWkZWb Z_h[Yj_ed Xo Xed[" j^[ h_ia e\
ZWcW][jej^[d[hl[_ifWhj_YkbWhbo^_]^$?\j^[d[hl[
_i beYWj[Z ik\\_Y_[djbo \Wh je j^[ b_d]kWb i_Z[ m_j^_d
j^[ Wh[W i[b[Yj[Z" j^[ l[hj_YWb ibej _i fh[fWh[Z \_hij"
\hec l[ij_XkbWhbo" \ebbem[Z Xo W i[YedZ _d\hWd[hlWb
^eh_pedjWb _cfbWdj ibej$ ?\ j^[ d[hl[" m^[d \_hij
[nfei[Z" _i beYWj[Z jee \Wh l[ij_XkbWhbo" W Z_\\[h[dj
WdZceh[ik_jWXb[_cfbWdji_j[m_bb^Wl[jeX[\ekdZ
ceh[ Z_ijWbbo$ ?d ekh [nf[h_[dY[" _di[hj_ed \hec
l[ij_XkbWhbom_bbWbmWoiX[ikYY[ii\kb_dWYjkWbYb_d_YWb
fhWYj_Y[1 W\j[h Wbb Wdo cWdZ_XkbWh d[hl[ [n_ji j^[
cWdZ_Xb[_dWb_d]kWbZ_h[Yj_ed$?d\hWd[hlWb_di[hj_ed
\hecb_d]kWbbo_ij^[eh[j_YWbbo\[Wi_Xb["XkjjeZWj[m[
^Wl[ d[l[h ^WZ je h[iehj je j^_i c[j^eZ$ ;nfeikh[
WdZh[fei_j_ed_d]e\j^[cWdZ_XkbWhd[hl[_i^WhZbo
_dZ_YWj[Z \eh 8E? _cfbWdji" Xkj _j _i eYYWi_edWbbo
A B
('/
fhWYj_i[ZXoiec[_cfbWdjebe]_iji_di[b[Yj[ZifWj_Wb
i_jkWj_edi$
J^[ WYj_l_jo _d j^[ _cc[Z_Wj[ l_Y_d_jo e\ j^[
cWdZ_XkbWh d[hl[ YWdWb" [if[Y_Wbbo X[YWki[ e\ j^[
m_Z[ef[d_d]e\j^[\bWf_dWl[ij_XkbWhZ_h[Yj_edje
WYYecceZWj[Wd_dijhkc[dj-Ä'&cc_dZ_Wc[j[h_d
j^[Z[fj^e\j^[l[ij_Xkbkc"WffheWY^_d]j^[cWdZ_Xb[
\hecWbWj[hWbZ_h[Yj_edWdZj^[Yeccedboh[gk_h[Z
jhWYj_ed WdZ ib_]^j ceX_b_pWj_ed e\ j^[ cWdZ_XkbWh
d[hl[ e\j[d h[ikbj _d feijef[hWj_l[ fWhW[ij^[i_W$
>em[l[h" j^[i[ hWh[bo f[hi_ij X[oedZ j^h[[ cedj^i"
WdZj^Wjedbo_dj^[h[]_ede\j^[Y^_d$E\Yekhi["j^[
fWj_[djd[[ZijeX[Zkbo_d\ehc[Ze\j^_ifeii_X_b_jo$
?dfWj_[djim_j^[njh[c[boWjhef^_[Z`WmXed[i"iec[
_cfbWdjebe]_iji fheY[[Z Wi \ebbemi je [ZkYWj[ j^[_h
fWj_[dji0J^[fWj_[djh[Y[_l[iWc[djWbd[hl[XbeYa$
M^_b[j^[WdW[ij^[j_Y[\\[Yjij_bbf[hi_iji"j^[fWj_[dj
i_]diWZ[YbWhWj_edjej^[[\\[Yjj^Wj^[ehi^[YWd\[[b
j^[WdW[ij^[i_W"YWddejYedjhebj^[\beme\iWb_lW"WdZ
^WiZ_\\_YkbjoZh_da_d]$J^[fWj_[dj\khj^[hZ[YbWh[i
j^Wj^[ehi^[ademij^[i[[\\[YjijeX[Yedd[Yj[Z"_d
j^[mehije\YWi[i"m_j^_cfbWdjWj_edd[Whj^[d[hl[
WdZj^Wjj^[i[[\\[Yji"Wbie_dj^[mehijYWi["c_]^jX[
_hh[l[hi_Xb[1\khj^[hceh["j^Wj_dj^[l[homehije\Wbb
YWi[i"j^[dkcXd[iicWof[hi_ij\ehWb_\[j_c[Z[if_j[
j^[ _cfbWdj X[_d] beij \eh kdh[bWj[Z h[Wiedi$ 8o
j^[_hm_bb_d]d[iijei_]dikY^WZ[YbWhWj_ed"fWj_[dji
Z[cedijhWj[j^Wjj^[_cf[dZ_d]_cfbWdjfheY[Zkh[
c[WdiWbejjej^[cWdZj^Wjj^[oWh[h[WZojeWYY[fj
[l[d[njh[c[bokdfb[WiWdji_Z[[\\[Yji_\j^_i_djkhd
c[Wdi j^Wj j^[_h [Z[djkbeki ijWj[ WdZ j^[ d[[Z je
ki[ h[celWXb[ Z[djkh[i YWd X[ jh[Wj[Z ikYY[ii\kbbo$
Iec[fWj_[djiWh[kdm_bb_d]jei_]dj^_iZ[YbWhWj_ed$
J^_imekbZ_dZ_YWj[j^Wjj^[oWh[dejh[WZojeWYY[fj
i_Z[ [\\[Yji e\ j^[ jof[ c[dj_ed[Z Ä WdZ ceij
fheXWXboh[Wbbofh[\[hjea[[fb_l_d]m_j^h[celWXb[
Z[djkh[i$

&IGÈAB Jme[nWcfb[ie\_d\hWd[hlWb_cfbWdjWj_ed_d8E?j[Y^d_gk[$J^[d[hl[hekj[_i_dZ_YWj[ZXoj^[m^_j[Zejj[Zb_d[i$

?dj^[YWi[i^emd_dX"ed[mekbZ^Wl[X[[dWXb["_\edboXWh[bo"je_di[hjWZekXb[#Z_ia8E?_cfbWdjX[bemj^[d[hl[$>em[l[h"
j^_i mekbZ ^Wl[ WZZ_j_edWbbo m[Wa[d[Z j^[ cWdZ_XkbWh ijhkYjkh[i WdZ _dYh[Wi[Z j^[ h_ia e\ \hWYjkh[$ A J^[ _cfbWdj mWi
WZZ_j_edWbbocel[ZZ_ijWbbo"m^_Y^_im^oj^[l[hj_YWb_di[hj_edibej_iYb[Whbol_i_Xb[$J^_iWbbem[Zj^[c[i_Wb[Z][jeX[WZWfj[Z
ceh[Ybei[bo$J^[YWkZWbWdZl[ij_XkbWhb_c_jie\j^[Yehj_YWbXed[e\j^[d[hl[YWdWbZ_Zdejik\\[hWdoZWcW][L_Z[e-i^emi
j^[_cfbWdjWj_ede\j^[_cfbWdjii^emd_d<_]$'+$)W"X
((& 9^Wfj[h'+È 4REATINGÈTHEÈ!TROPHIEDÈ-ANDIBLE
?d i_jkWj_edi _d m^_Y^ W ikfhWd[hlWbbo _di[hj[Z
8E?_cfbWdjZe[idejW\\ehZik\\_Y_[djfh_cWhoijWX_#
b_jo"ed[cWoYedi_Z[hef[d_d]Wdej^[hibej"beYWj[Z
\khj^[hXWiWbbo"je_di[hjWZekXb[#Z_ia8E?_cfbWdj
3OLVINGÈ3TRATEGIES
ikY^j^Wjed[Z_ia_ibeYWj[ZWXel[WdZed[X[bemj^[
d[hl[$J^[d[hl[YWdWbkikWbbo\_ji[Wi_boX[jm[[dj^[
jmeZ_iai"m^ei[Z_ijWdY[\hec[WY^ej^[h_i)cc$
M^[d _di[hj_d] _cfbWdji _d j^[ Z_ijWb cWdZ_Xb["
h[]_edWb WdW[ij^[i_W XbeYa _d\_bjhWj_ed _i ijhed]bo
YedjhW_dZ_YWj[Z$ J^_i ]e[i je [dikh[ j^Wj j^[
d[hl[ _i dej ZWcW][Z$ 7i bed] Wi j^[ d[hl[ _i dej
WdW[ij^[j_p[Z" j^[ eij[ejeco _dijhkc[dj m_bb YWki[
ib_]^j fW_d ed WffheWY^ WdZ kdX[WhWXb[ fW_d ed
Wdo _dWZl[hj[dj Wjj[cfj je i[l[h j^[ d[hl[$ J^_i
_i ed[ h[Wied m^o m[ Wle_Z ef[hWj_d] ed fWj_[dji
m_j^ [njh[c[ Wjhef^_[i _d j^[ bem[h `Wm _d ][d[hWb
WdW[ij^[i_W0m[mekbZbei[j^[fWj_[djÉi\[[ZXWYa_d
j^[[l[dje\_cf[dZ_d]ZWcW][jej^[d[hl[$FWj_[dji
m^efh[\[hjeX[ef[hWj[Zed_d\kbbWdW[ij^[i_WWh[
_d\ehc[Z j^Wj j^[ h_ia e\ ZWcW][ je j^[ d[hl[ _i Wj
b[Wijj^[eh[j_YWbboib_]^jbo^_]^[h$ WdZ_\j^[\kdYj_edWb[gk_b_Xh_kc_icW_djW_d[Z$
?d YWi[i _d m^_Y^ j[[j^ ^Wl[ je X[ [njhWYj[Z _d
j^[ feij[h_eh cWdZ_Xb[" j^[ fheY[Zkh[ _i iec[m^Wj
Z_\\[h[dj0 ?\ j^[ j[[j^ YWddej X[ [njhWYj[Z m_j^ekj
XbeYa_d\_bjhWj_ed"j^_i_d\_bjhWj_edYWd_d\WYjij_bbX[
f[h\ehc[Z"i_dY[j^[Z[fj^e\j^[_cfbWdjeij[ejeco
YWd [Wi_bo X[ Yedjhebb[Z Xo mWjY^_d] j^[ Z[fj^ e\
j^[ [njhWYj_ed Wbl[eb_" \WY_b_jWj_d] iW\[ _cfbWdjWj_ed
_dj^[^WdZie\Wd[nf[h_[dY[Z_cfbWdjebe]_ijm_j^
Z[Y[djhWZ_e]hWf^iWj^_iZ_ifeiWb$
Iec[j_c[ifWj_[djim_bbh[fehjfW_dm^[dcWa_d]
W Ykj _d j^[ feij[h_eh cWdZ_Xb[$ J^_i fW_d cWo X[
YWki[Z Xo h[i_ZkWb d[hl[i e\ fh[l_ekibo [njhWYj[Z
j[[j^ehXoj^[ikYj_ed\ehY[ie\j^[^_]^#if[[ZZh_bb$
M^[dgk[ij_ed[Z"j^[fWj_[djm_bbbeYWb_p[j^_ijof[
e\fW_dZ_h[Yjbo_dj^[h[]_ede\j^[eij[ejeco"m^_b[
Wdo fW_d YWki[Z Xo jee Ybei[ Wd WffheWY^ je j^[
cWdZ_XkbWhd[hl[WbmWoiWbieW\\[Yjj^[h[]_ede\j^[
Y^_d$?dj^_ibWjj[hZWd][hekiYWi["j^[d"j^[fWj_[dj
m_bbbeYWb_p[j^[fW_d\khj^[hc[i_WbboWdZ_dj^[Y^_d
h[]_edWdZdejieb[bo_dj^[h[]_ede\j^[eij[ejeco$
M[ ^Wl[ hWh[bo m_jd[ii[Z fWhW[ij^[i_W e\ j^[
c[djWbd[hl[\ebbem_d]_d\hWd[hlWb_cfbWdjWj_ed$?d
deYWi[^Wij^[d[hl[Y[Wi[Zje\kdYj_edWbje][j^[h$
FWhW[ij^[i_W_ikikWbbob_c_j[Zjej^[h[]_edWhekdZ
j^[Y^_d$J^[WYjkWbYWki[e\j^[fWhW[ij^[i_W_ij^[
Yedi_Z[hWXb[ bWj[hWb ceX_b_pWj_ed e\ j^[ ckYeiWb
\bWf WYYecfWd_[Z Xo c[jWb YedjWYj je j^[ d[hl["
^W[cWjecW" e[Z[cW h[gk_h[Z je _di[hj \_hij j^[
Ykjj[hWdZbWj[hj^[_cfbWdj\hecWbWj[hWbZ_h[Yj_ed$
Ib_]^j jhWYj_ed YWd ceX_b_p[ j^[ cWdZ_XkbWh d[hl[
ie _j YWd X[ cel[Z ib_]^jbo WmWo \hec j^[ c[djWb
\ehWc[d$Iec[j_c[ij^_im_bbX[d[Y[iiWho"Xkj_jcWo
Wbie YWki[ j[cfehWho fWhW[ij^[i_W$ ?\ fWhW[ij^[i_W
Ze[ieYYkh"j^[fhe]dei_im_bbX[j^[X[jj[h"j^[ceh[
ikYY[ii\kb j^[ ^[Wb_d] fheY[ii fheY[[Zi Zkh_d] j^[
\_hij\[mm[[ai$
È
!SPECTSÈOFÈTHEÈ3TRATEGICÈ0OSITIONINGÈOFÈ"/)È
)MPLANTSÈANDÈ0ROBLEM
M^[d fbWY_d] 8E? _cfbWdji" m[ edbo Z[l_Wj[ \hec
j^[YedY[fje\ijhWj[]_Y_cfbWdjfei_j_ed_d]_\j^[h[
_idej[dek]^Xed[lebkc[Wjj^[fh[\[hh[Z_cfbWdj
i_j[eh_\Wd_cfbWdjYWddejX[_di[hj[Zj^[h[\ehej^[h
h[Wiedi$J^_icWoX[j^[YWi[_d[njh[c[f[h_eZedjWb
Z[ijhkYj_ed eh ikXi[gk[dj je _cfbWdj beii$ ?d j^[i[
YWi[i" _j m_bb kikWbbo X[ d[Y[iiWho je _di[hj ceh[
j^Wd \ekh _cfbWdji \eh Yecfb[j[ h[ijehWj_ed e\ j^[
cWdZ_Xb[ eh je _di[hj j^[ _cfbWdji _d W ijW][Z
WffheWY^_dehZ[hjeWbbemj^[cWdZ_Xb[jeXk_bZXed[
lebkc[_dW\kdYj_edWbboYehh[YjcWdd[hm_j^ekjj^[
Z[ijhkYj_l[ _d\bk[dY[ e\ h[celWXb[ Z[djkh[i$ J^h[[
m[bb#fei_j_ed[Z WXkjc[dji Wh[ ik\\_Y_[dj \eh iW\[
ikffehje\WXh_Z][_dj^[cWdZ_Xb[_\j^[\ehY[iWh[
dejjeeijhed]"[if[Y_WbboZkh_d]j^[^[Wb_d]f[h_eZ"
?j i[[ci je X[ be]_YWb WbmWoi je fbWY[ j^[ iWc[
dkcX[h e\ _cfbWdji e\ j^[ iWc[ i_p[ ed Xej^ i_Z[i
e\ j^[ cWdZ_Xb[ m^[d _dijWbb_d] Yecfb[j[ \_n[Z
Z[djkh[i$J^_iWle_Zikd_bWj[hWbh_]_ZYedd[Yj_edie\
j^[Xh_Z][$M[Zedejki[ZekXb[#Z_ia8E?_cfbWdji
Z_ijWbbo e\ j^[ c[djWb d[hl[" Wi m[ ^Wl[ eXi[hl[Z
j^Wjj^[Yh[ijWbZ_iae\j[dZe[idejh[cW_d_dj[]hWj[Z
m_j^j^[Xed[$
Bed]#j[hceXi[hlWj_ede\cWdoYWi[i^Wii^emd
ki j^Wj _cfbWdj beii eh eij[eboi_i fhWYj_YWbbo d[l[h
eYYkhh[Z _d j^[ Wdj[h_eh h[]_ed e\ j^[ cWdZ_Xb[$
J^_i_i_dW]h[[c[djm_j^j^[[nf[h_[dY[m_j^Yh[ijWb
_cfbWdj ioij[ci WdZ _i Y[hjW_dbo Wj b[Wij fWhj_Wbbo
em[Zjej^[\WYjj^Wj_dj^_ih[]_ed"bem[hcWij_YWjeho
\ehY[iW\\[Yjceh[ijWXb[Xed[ ikXijWdY[$Ceh[el[h"
j^_i Wh[W e\ j^[ Xed[ _i WbmWoi fh[fWh[Z \eh Xed[
Wffei_j_ed Zk[ je j^[ WYj_l_jo e\ j^[ jed]k[ WdZ
j^[ ckiYb[i j^Wj bem[h j^[ cWdZ_Xb[$ ?\ eij[eboi_i
eYYkhh[ZWjWbb"_jZ_Ziekd_bWj[hWbboWhekdZWZ_ijWb
8E? _cfbWdj$ J^[ h[Wied mWi kikWbbo el[hbeWZ Zk[
je fheij^eZedj_Y _cXWbWdY[ Ä e\j[d YecX_d[Z m_j^
_d\[Yj_edZk[jeWbWYae\fhef[hehWb^o]_[d[$
M[ m[h[ _d_j_Wbbo mehh_[Z WXekj j^[ YWi[i e\
kd_bWj[hWb Z_ijWb _cfbWdj beii$ Ed ceh[ Z[jW_b[Z
WdWboi_i e\ j^[ i_jkWj_ed m[ _dlWh_WXbo \ekdZ j^[
\ebbem_d] Yekhi[ e\ [l[dji0 FWj_[dji mekbZ Wff[Wh
\eh j^[_h hekj_d[ h[YWbb m_j^_d j^[ \_hij '(cedj^i
\ebbem_d] _cfbWdjWj_ed" kikWbbo m_j^ekj Wdo iocf#
jeciehm_j^edbol[hoc_bZiocfjeci$Hekj_d[ehj^e#
fWdjece]hWf^i i^em[Z Yb[Whbo l_i_Xb[ eij[eboi_i
WhekdZj^[Z_iae\WZ_ijWb_cfbWdj$Deeij[eboi_imWi
i[[dWhekdZWdoe\j^[ej^[h_cfbWdji$?dj^[i[YWi[i"
_cfbWdj h[fbWY[c[dj ckij X[ Yedi_Z[h[Z" jWa_d]
j^[ Yh_j[h_W e\ j^[ 8E? 9edi[diki _dje Zk[ WYYekdj
i[[ 9^Wfj[h(-$ Gk_j[ eXl_ekibo" j^ei[ _cfbWdji
dej W\\[Yj[Z Xo eij[eboi_i m_bb Wbh[WZo ^Wl[ jWa[d
È È !SPECTSÈOFÈTHEÈ3TRATEGICÈ0OSITIONINGÈOFÈ"/)È)MPLANTSÈANDÈ0ROBLEM
3OLVINGÈ3TRATEGIESÈ (('

&IGÈAnD J^[cWdZ_Xb[mWi
[njh[c[boWjhef^_[Z$7bb\ekh
_cfbWdjim[h[_d_j_Wbbo_di[hj[Z
_d\hWd[hlWbbo$J^[_cfbWdjWj*-
beei[d[ZWdZ^WZjeX[h[cel[Z$
J^[Xh_Z][mWib[\jikffehj[Z
edj^[h[cW_d_d]j^h[[_cfbWdji
kdj_bj^[Xed[^WZh[][d[hWj[Z$
C[Wdm^_b["ik\\_Y_[djXed[^WZ
\ehc[ZWXel[j^[d[hl["Wbbem_d]
ikfhWd[hlWb_di[hj_ede\Wi[YedZ
_cfbWdjWj*-$7d[mXh_Z][^WZ
A jeX[\WXh_YWj[Z\ehj^_iYWi[$
Iec[ki[hifh[\[hjeki[:[bh_d
WXkjc[djiWjb[Wijeded[Z_ijWb
8E?_cfbWdjm^[djh[Wj_d]
i[l[h[Wjhef^_[ie\j^[cWdZ_Xb[$
J^[i[WXkjc[djifhel_Z[ceh[
[bWij_Y_jo_di_Z[j^[Xed[#
_cfbWdj#fheij^[j_YWbioij[c$
?cfbWdjicWZ[\hec=hWZ[
'j_jWd_kci[[cje_dj[]hWj[
X[jj[h_dijhWj[]_Y_cfbWdj
fei_j_ed_d]ijhWj[]_[i"Wbj^ek]^
j^[oiec[j_c[i\hWYjkh[ceh[
[Wi_bo$M^[dm[_]^_d]kfj^[
Wbj[hdWj_l[i"ed[i^ekbZa[[f_d
c_dZj^WjW\hWYjkh[Z_cfbWdj_i
B [Wi_[hjeh[fbWY[j^WdWd_cfbWdj
m^_Y^Yh[Wj[ZWf[h_#_cfbWdj
Xed[eij[eboi_iZk[jejeeijhed]
WZ[i_]dehcWj[h_Wb

D
((( 9^Wfj[h'+È 4REATINGÈTHEÈ!TROPHIEDÈ-ANDIBLE

el[hj^[_dZkYj_ede\WbbcWij_YWjeho\ehY[i_djej^[ _cfbWdji ckij dej X[ fbWY[Z jee ^_]^ _d ehZ[h je
cWdZ_Xb[ \eh Wd Wffh[Y_WXb[ f[h_eZ" m_j^ekj Wdo h[jW_d [dek]^ Xed[ lebkc[ WXel[ j^[ Z_ia [l[d _d
ZWcW][ je j^[ Xed[ ikhhekdZ_d] j^[ Z_iai$ J^_i _i j^[[l[dje\Wbeiie\l[hj_YWbZ_c[di_ed$H[]WhZb[iie\
m^oj^[Xh_Z][YWdX[i^ehj[d[Zedj^[i_Z[W\\[Yj[Z j^[Xed[lebkc[WlW_bWXb[Wjj^[j_c[e\_di[hj_ed"Wbb
Xoeij[eboi_i$:[f[dZ_d]edj^[eYYbkiWbi_jkWj_ed"_j beWZ#jhWdic_jj_d]h[]_edickijX[beYWj[Zm^[h[ed[
YWdX[i^ehj[d[ZjeWffhen_cWj[boj^[h[]_ede\j^[ c_]^j[nf[Yjik\\_Y_[djXed[W\j[hXed[h[ceZ[bb_d]
i[YedZfh[cebWh$J^[Xh_Z][m_bbdejkikWbbo^Wl[je ^WiYec[jeWh[bWj_l[ijWdZij_bb$J^[eYYbkiWbfbWd[
h[cel[Z"X[YWki[W\_n[Zh[ijehWj_edYWdYedj_dk[je Yh[Wj[Z Xo j^[ Xh_Z][ _i j^[ edbo \_n[Z ijhkYjkh[ e\
X[ _dijWbb[Z ed W h[ZkY[Z dkcX[h e\ 8E? _cfbWdji h[\[h[dY[m_j^_dj^_iioij[c$Ceh[_d\ehcWj_edYWd
\eh W b_c_j[Z j_c[$ J^_i m_bb cW_djW_d j^[ fWj_[djÉi X[\ekdZ_d9^Wfj[h/$)$
cWij_YWjeho\kdYj_ed$ ?j_ideje\j[dj^Wjj^[[gk_b_XhWj_d]fheY[iie\Xed[
7\j[h Wffhen_cWj[bo ,Ä.m[[ai" W d[m _cfbWdj _i lebkc[YWdX[ieYb[WhboeXi[hl[Z_dhWZ_e]hWf^i"Wi
_di[hj[Z_\h[gk_h[Z$M[kikWbboWbbemj^[d[m_cfbWdj j^[ _cW][i m[ Wh[ Z[f[dZ[dj ed Wh[ ijh_Yjbo jme#
je^[Wb\ehWXekj,m[[ai_\_jmWifbWY[Z_dj^[iWc[ Z_c[di_edWb$ ?\ j^[ cWdZ_Xb[ Ze[i dej ikYY[[Z _d
beYWj_edWij^[fh[l_eki_cfbWdj$IkXi[gk[djbo"[_j^[h [nfWdZ_d]YhWd_Wbbo\eh\kdYj_edWbh[Wiedi"_jc_]^j
j^[cWdZ_XkbWhXh_Z][_i[nj[dZ[ZZ_ijWbbo"ehWd[m ]hembWj[hWbbo_dij[WZ"iec[j^_d]j^WjYWddejX[i[[d
\_n[Zh[ijehWj_ed_i\WXh_YWj[Z$ _dWijWdZWhZhWZ_e]hWf^$J^_iZ[if_j[j^[\WYjj^WjW
El[hbeWZWjj^[_djhWeii[ekiikh\WY[ii[[cijeX[ bWj[hWb _dYh[Wi[ _d cWdZ_XkbWh lebkc[ ckij WbmWoi
j^[cW_dYWki[\ehj^_ijof[e\_cfbWdjbeii$?ji[[ci X[ [nf[Yj[Z" i_dY[ _dYh[Wi[Z cWij_YWjeho \ehY[i
feii_Xb[j^Wj_j_idejedboY^[m_d]j^WjYh[Wj[ij^_i h[gk_h[_dYh[Wi[ZXed[lebkc[$?\8E?_cfbWdjiWh[
el[hbeWZ" Xkj \b[n_ed WdZ [nY[ii_l[ Xh_Z][ h_]_Z_jo$ _di[hj[Z_d_j_Wbboj^WjWh[`kijX_][dek]^jeYedd[Yj
:7 WXkjc[dji cWo i[hl[ X[jj[h je \khj^[h h[ZkY[ j^[ Yehj_YWb Xed[ ijhkYjkh[i" j^[i[ _cfbWdji cWo
j^[ij_\\d[iie\j^[Xed[#_cfbWdj#h[ijehWj_edioij[c$ ieed fhel[ je X[ jee icWbb$ ?d YWi[i _d m^_Y^ j^[
9edi[gk[dY[i b_a[ j^[i[ cWd_\[ij j^[ci[bl[i _d \kdYj_edWbboh[bWj[Z_dYh[Wi[_dcWdZ_XkbWhZ_Wc[j[h
j^[ \_hij jm[bl[ cedj^i W\j[h _di[hj_d] j^[ Xh_Z][$
7j Wdo j_c[ W\j[h j^Wj" j^[ XWiWb Z_iai Wh[ ie \_hcbo
ikhhekdZ[Z Xo Xed[ j^Wj el[hbeWZ _i ceh[ b_a[bo je
YWki[\hWYjkh[e\j^[\hWc[mehaXWh$J^ei[fWj_[dji
m^e i[[a jh[Wjc[dj [bi[m^[h[" [$]$ \eh h[b_d_d] eh
h[XWi_d] j^[ Z[djkh[ eh \eh j^[ _di[hj_ed e\ Yhemdi
eh Xh_Z][i _d j^[ effei_j[ `Wm" Wh[ [if[Y_Wbbo Wj
h_ia$ <h[gk[djbo" Z[dj_iji m_j^ekj Wdo [nf[h_[dY[ _d
_cfbWdjebe]o bWYa j^[ \[[b_d] \eh fhef[h eYYbkiWb
WZ`kijc[dj _d j^_i i_jkWj_ed Ä WdZ iec[j_c[i j^[o
cWodej[l[dh[Ye]d_p[j^[cWdZ_XkbWh_cfbWdjiWj
Wbb$J^_i_im^om[fbWY[]h[Wjm[_]^j_dekhfWj_[dj
[ZkYWj_ed ed _d\ehc_d] j^[ fWj_[dji m^e" _d j^[
_dj[h[ij e\ j^[_h emd iW\[jo WdZ ^[Wbj^" YWddej ]e
je `kij Wdo jh[Wjc[dj fhel_Z[h m_j^ j^[_h _cfbWdji
A
jei[[ajh[Wjc[dj$Cehf^ebe]_YWbY^Wd][iWii^emd
_d 9^Wfj[hi/" '. WdZ (, Wbie ^Wl[ je X[ jWa[d _dje
Yedi_Z[hWj_ed$ Dej[ j^Wj Wj j^[ edi[j e\ jh[Wjc[dj"
j^[\kdYj_edWbfWjj[hdYWddejX[ÆdehcWbÇWdZj^Wj
j^[h[ _i W Yekfb_d] X[jm[[d j^[ Z[djkh[i WdZ j^[
cWdZ_Xb[ j^Wj W\\[Yji j^[ cehf^ebe]o e\ j^[ Xed[
9WbZ[hWb[[jWb$'/.,$
E\fWhj_YkbWh_cfehjWdY[_ij^[[lWbkWj_ede\j^[
Xed[ lebkc[ ed j^[ cWdZ_XkbWh hWcki ed [_j^[h
i_Z[$?\cWij_YWjeho\kdYj_ed_i\WY_b_jWj[Z_dWh[]kbWh
WdZ [gk_b_XhWj[Z cWdd[h" j^[ Xed[ lebkc[ m_bb
kikWbbo_dYh[Wi[edj^[ceh[i[l[h[boWjhef^_[Zi_Z[
e\j^[cWdZ_Xb["WdZj^[eYYbki_ededj^_ii_Z[ckij
X[WZ`kij[ZWYYehZ_d]bo$J^[Wcekdje\h[ceZ[bb_d]
B
_dj^_iWh[We\j^[cWdZ_Xb[m_bbX[Yedi_Z[hWXb["WdZ
j^[ fheY[ii m_bb bWij i[l[hWb cedj^i$ 8o YedjhWij" W &IGÈÈ A IjWjki )cedj^i feijef[hWj_l[bo$ B IjWjki 'o[Wh
Z[ZkYj_ed _d h[bWj_l[ Xed[ cWii _i je X[ [nf[Yj[Z feijef[hWj_l[bo$J^[ckYeiW^WiijWhj[Zjeel[h]hemj^[Z_ijWb
ed j^[ YedjhWbWj[hWb i_Z[ e\ j^[ cWdZ_Xb[$ >[h[" j^[ Xh_Z][Yedd[Yjeh"YWki_d]fheXb[cim_j^ehWb^o]_[d[
È È !SPECTSÈOFÈTHEÈ3TRATEGICÈ0OSITIONINGÈOFÈ"/)È)MPLANTSÈANDÈ0ROBLEM 3OLVINGÈ3TRATEGIESÈ (()

_iYecfekdZ[ZXo[$]$^ehcedWbboh[bWj[Z[dZeij[Wb
h[iehfj_ed h[ZkY_d] j^[ m_Zj^ e\ j^[ Yehj_YWb Xed[
ijhkYjkh[i f[h i[" j^[i[ _cfbWdji cWo i_da _dje j^[
YWdY[bbeki Xed[ Wh[Wi WdZÆ\W_bÇ$ ?d ekh [nf[h_[dY["
j^[ki[e\Wiocc[jh_YWb8E?_cfbWdjij^WjfhejhkZ[
ik\\_Y_[djbo X[oedZ j^[ cWdZ_XkbWh Yehj_YWb Xed[
ijhkYjkh[i YWd h[ZkY[ j^[ _dY_Z[dY[ e\ j^_i jof[ e\
\W_bkh[Yedi_Z[hWXbo$
J^[ WZ`kijc[dj e\ j^[ eYYbkiWb fbWd[ ckij Wbie
X[ ]_l[d fhef[h Wjj[dj_ed0 FWj_[dji m^e ^Wl[ mehd
h[celWXb[ Z[djkh[i \eh cWdo o[Whi kikWbbo fh[i[dj
m_j^eYYbkiWbfbWd[j^Wjibef[ZemdmWhZjemWhZj^[
Z_ijWbWif[Yj$J^_ii_jkWj_edeYYkhiceh[\h[gk[djbo_d
fWj_[djim^e^WZh[jW_d[Ziec[Wdj[h_ehcWdZ_XkbWh
j[[j^el[hWbed][hf[h_eZ$?dj^[fh[i[dY[e\Wi[l[h[bo
Wjhef^_[ZcWdZ_Xb["j^[Z[dj_ijm_bbe\j[dZ[i_]dj^[
cWdZ_XkbWh h[celWXb[ Yecfb[j[ Z[djkh[ jee bem
_d ehZ[h \eh j^[ Z[djkh[ mWdZ[h_d] WhekdZ _d j^[
cekj^dejjeX[jeeckY^_dj^[mWo$<ebbem_d]j^[
_di[hj_ede\8E?_cfbWdji"_j_ifeii_Xb[jeYehh[Yjj^[
l[hj_YWbh[bWj_ed$J^_im_bbe\j[dX[gk_j[_da[[f_d]
m_j^ j^[ fWj_[djÉi Z[i_h[i" Xkj _j m_bb Wbie h[ikbj _d
JC@WZWfjWj_edWdZikXi[gk[dj`e_djh[fei_j_ed_d]$
8k_bZ_d]kfijhed][hcWij_YWjeho\ehY[i^Wij^[iWc[ A
[\\[Yj$9edi_Z[hWXb[WZ`kijc[djim_bbe\j[d^Wl[jeX[
cWZ[ Wj fheij^eZedj_Y \ebbem#kf i[ii_edi$ FWj_[dji
m^e YWddej WZ`kij je j^[ d[mbo ]W_d[Z l[hj_YWb
h[bWj_ed m_bb h[Y[_l[ ]hWZkWb ikXjhWYj_l[ jh[Wjc[dj
kdj_bj^[oWh[fb[Wi[Zm_j^j^[_heYYbki_ed$
Iec[j_c[i _j cWo X[ ik\\_Y_[dj je fhel_Z[ edbo
j^h[[ _cfbWdji \eh j^[ cWdZ_Xb[$ Jme [nWcfb[i YWd
X[i[[d_d<_]i$'+$-WÄZWdZ'+$.$
?d h[jheif[Yj" m[ de bed][h ikXiYh_X[ je j^[
iY_[dj_\_Y Yedl_Yj_ed" ie e\j[d h[\[hh[Z je _d j^[
b_j[hWjkh["j^Wjj^[c[Z_WbWdZYWkZWbjehi_ede\j^[
Wjhef^_[ZcWdZ_Xb[_iWdWXiebkj[YedjhW_dZ_YWj_ed
je fhel_Z_d] j^[ fWj_[dj m_j^ \_n[Z Yecfb[j[
h[ijehWj_edi$ 7j b[Wij m^[d _j Yec[i je 8E?" j^_i
Yedl_Yj_ed_ikd\ekdZ[Z\ehWibed]Wij^[j^h[WZ[Z
f_di e\ j^[ _cfbWdji _di[hj[Z Wh[ ik\\_Y_[djbo
bed] WdZ Wi bed] Wi j^[ `Wm i[]c[dji X[jm[[d
j^[ beWZ#jhWdic_jj_d] Z_iai Wh[ ik\\_Y_[djbo bWh][
je WYYecceZWj[ j^[ Z[\ehc_d] \ehY[i j^Wj j^[
cWij_YWjeho ckiYb[i [n[hj ed j^[ Xed[$ ?d ekh
[nf[h_[dY[" j^[ cej_ed e\ j^[ Wjhef^_[Z cWdZ_Xb[
jeb[hWj[i Xej^ ifb_dj[Z _cfbWdji _d j^[ Wdj[h_eh
B
h[]_ede\j^[cWdZ_Xb[WdZj^h[[#i_Z[Zeh\ekh#i_Z[Z
Y_hYkbWh ikffehj e\ j^[ ikfhWijhkYjkh[$7ZZ_j_edWb &IGÈÈ A BWj[hWb j[b[hWZ_e]hWf^ fh_eh je _cfbWdj j^[hWfo$
_cfbWdji_dj^[fh[cebWhh[]_ed"Wic[dj_ed[ZWXel[" J^[ jWia _i je [ij_cWj[ m^[j^[h j^[h[ _i ij_bb [dek]^ ifWY[
m_bbe\j[dX[beijm_j^ekjWdoZWcW][jej^[el[hWbb \eh cWn_bbWho _cfbWdji W\j[h [b[lWj_ed e\ j^[ eYYbkiWb fbWd[
fheij^eZedj_Y Z[i_]d$ J^_i _i m^o m[ ^Wl[ ijeff[Z X[oedZ j^[ i_dki eh _\ j^[ cWn_bbWho _cfbWdji mekbZ ^Wl[
je X[ beYWj[Z _d j^[ Wh[W e\ j^[ cWn_bbWho i_dki$ B BWj[hWb
_di[hj_d]j^[i[_cfbWdji_dj^[\_hijfbWY["h[ijh_Yj_d]
j[b[hWZ_e]hWf^X[\eh[WdZW\j[h_cfbWdjj^[hWfo$J^[eYYbkiWb
ekhi[bl[i jeÆiW\[Ç _cfbWdj i_j[i$ ?j i^ekbZ X[ dej[Z fbWd[ mWi [b[lWj[Z Z_ijWbbo$ J^[h[ m[h[ de fheXb[ci m_j^
_dj^_iYedj[njj^WjWbb_cfbWdjim[h[WbmWoibeWZ[Z ifWY[$ B[Wl_d] j^[ Z[djkh[ _d j^[ cekj^ _i _cfehjWdj \eh
_cc[Z_Wj[boXoWikf[hijhkYjkh[$ fh[ef[hWj_l[Z_W]dei_i$?\d[Y[iiWho"j^[eYYbkiWbikh\WY[iYWd
J^[ cWn_ckc dkcX[h e\ _cfbWdji j^Wj YWd X[fW_dj[Zm_j^YedjhWijb_gk_Z
X[ _di[hj[Z _d W `Wm _i X[jm[[d '& WdZ '(" m^_b[
((* 9^Wfj[h'+È 4REATINGÈTHEÈ!TROPHIEDÈ-ANDIBLE

A B

&IGÈAnD ?cfbWdjfei_j_edi*)WdZ)-m[h[kdWlW_bWXb[Zk[jefhedekdY[Zeij[eboi_i$<ehj^_ih[Wied"edbojme8E?_cfbWdji
YekbZ X[ _di[hj[Z" WdZ j^[ fWj_[dj h[Y[_l[Z W j[cfehWho Xh_Z][ c[jWb \hWc[meha m_j^ WYhob_Y Z[djkh[ j[[j^ WjjWY^[Z m_j^
Yecfei_j[$I_dY[j^_ih[ijehWj_edmeha[Zm[bbYb_d_YWbbo"j^[fWj_[djZ_ZdejmWdjWdoceZ_\_YWj_ediehWZZ_j_edWb_cfbWdji\ehWi
bed]Wijeej^)+mWiWXb[jeikffehjj^[Xh_Z][_dYedd[Yj_edm_j^j^[jme[n_ij_d]8E?_cfbWdji$J^_i^WiX[[dj^[YWi[dem\eh
cWdoo[Whi$?ji^ekbZX[dej[Z"^em[l[h"j^Wjj^[cWn_bbW"[gk_ff[Zm_j^W\kbbZ[djkh[Wii^emd^[h["YWd][d[hWj[edbob_c_j[Z
cWij_YWjeho\ehY[i"iej^Wjj^h[[WXkjc[dji_dj^[cWdZ_Xb[i^ekbZik\\_Y[[l[del[hj^[bed]j[hc

j^[ c_d_ckc dkcX[h h[gk_h[Z \eh W ijWXb[ \_n[Z ieb_Z bed]#j[hc h[ikbji m_j^ bWh][ fWj_[dj ]hekfi
h[ijehWj_ed _i ) _cfbWdji$ >em[l[h" j^h[[#_cfbWdj ^Wl[ X[[d h[fehj[Z \eh h[ijehWj_edi ikffehj[Z Xo
iebkj_edi Wh[ edbo feii_Xb[ _d [nY[fj_edWb YWi[i$ De j^h[[_cfbWdjiehWXkjc[dji$?d\_n[Zfheij^eZedj_Yi"
È È !SPECTSÈOFÈ4ENSIONÈ$ISTRIBUTIONÈ
Yecfb[j[ Xh_Z][i ikffehj[Z Xo dWjkhWb WXkjc[dji
fhel_Z_d] j^h[[#fe_dj ikffehj ed j^h[[ WXkjc[dji"
m_j^ de WZZ_j_edWb _cfbWdji _dlebl[Z" ^Wl[ X[[d
Z[iYh_X[ZIY^m[_a[hj'/..$
J^[ dkcX[h e\ _cfbWdji m_bb Wbie Z[f[dZ ed
m^Wj j^[ effei_d] Z[dj_j_ed _i b_a[ WdZ m^Wj
cWij_YWjeho \ehY[i ^Wl[ je X[ [nf[Yj[Z$ ;njh[c[bo
[bWij_YcWdZ_Xb[iYWde\j[dedboWYYecceZWj[j^h[[
_cfbWdjim_j^W^_]^[hZ[]h[[e\c_d[hWb_pWj_ed$
8E? Wbbemi W \WlekhWXb[ hWj_e e\ _cfbWdji je
cWij_YWjehokd_ji0<eh*eh+_cfbWdjif[h'(cWij_#
YWjeho kd_ji" j^_i hWj_e _i X[jm[[d '0) WdZ '0($*$ J^[
Yeij \eh cWj[h_Wbi \eh \_n[Z h[ijehWj_edi \eh ed[ `Wm
_i j^[h[\eh[ h[bWj_l[bo bem1 * eh + j_c[i Ï(&& m_bb
jhWdibWj[_djeWYeije\X[jm[[dÏ.&&WdZÏ'"&&&f[h
cWdZ_Xb[$J^[_d\[h_ehXed[gkWb_jo_dj^[cWn_bbW
cWa[i _j d[Y[iiWho je ki[ ZekXb[# WdZ jh_fb[#Z_ia
8E? _cfbWdji _d j^Wj `Wm$ J^_i _i m^o j^[ Yeij \eh
_cfbWdj_d]j^[cWn_bbW_iWffhen_cWj[bo)&^_]^[h
j^Wd\ehj^[cWdZ_Xb[$ X_j[ed]Wkp[fWZiWj)*WdZ**"Xkjedbob_]^jbo"kdj_b
È
4EMPORARYÈ2ESTORATION
J^[[n_ij_d]h[celWXb[Yecfb[j[Z[djkh[YWde\j[d
X[ Ykj XWYa je Xh_Z][ i^Wf[ WdZ Y[c[dj[Z ed j^[
WXkjc[dji$ ?\ j^[ Z[djkh[ _i dej WlW_bWXb[ eh _\ _j _i
kdik_jWXb[\hecWcWij_YWjehofe_dje\l_[m"eh_\_j
Ze[idejYel[hj^[_cfbWdji"j^[j[cfehWhoh[ijehWj_ed
YWd X[ \WXh_YWj[Z ki_d] Z[[f#ZhWm ifb_dji j^Wj m[
cWa[_dekhemdbWXehWjehoki_d]ijWdZWhZXh_Z][i$
7bj^ek]^_j_iik\\_Y_[dj"_dfh_dY_fb["je_dYbkZ[j^h[[
e\j^[_cfbWdji_di[hj[Z_dj^[j[cfehWhoh[ijehWj_ed"
_dYbkZ_d]\ekhehceh[WXkjc[dji_ih[Yecc[dZ[Z
Ä[if[Y_Wbbom^[h[j^[j[cfehWhoh[ijehWj_ed_ijeX[
mehd\ehWfhejhWYj[Zf[h_eZceh[j^Wd'(ZWoi$
((+
&IGÈ 7\j[hj^[8E?_cfbWdj
Wj)-mWibeij"deWZZ_j_edWb
_cfbWdjmWi_di[hj[Z"XkjWXh_Z][
m_j^WYWdj_b[l[h[ZXh_Z][mWi
\WXh_YWj[Z_dij[WZ$IjWjkii^emd
_i,o[Whifeijef[hWj_l[bo$J^_i
fheY[Zkh[mWiYedjhWhojeekh
][d[hWbj^[hWf[kj_YijhWj[]o1
YWdj_b[l[hiYWdh[ikbj_dl[ho^_]^
beWZiedj^[Z_ijWb_cfbWdji
È
!SPECTSÈOFÈ4ENSIONÈ$ISTRIBUTION
J^[ h[gk_h[c[dj m[ adem \eh Yh[ijWb _cfbWdji je
Yedd[Yjj^[ikf[hijhkYjkh[ijej^[_cfbWdjim_j^ekj
Yh[Wj_d] Wdo j[di_ed YWd ^WhZbo X[ c[j \eh j^[
8E? j[Y^d_gk[" [if[Y_Wbbo dej \eh _cc[Z_Wj[bo
beWZ[Z\_n[ZYecfb[j[h[ijehWj_edi_dj^[cWdZ_Xb[$
=_l[d j^[ f^oi_ebe]_YWb YedZ_j_edi e\ cWdZ_XkbWh
cel[c[dj" Yedi_Z[hWXb[ i^_\ji e\ Xed[ ijhkYjkh[
eYYkh m_j^_d j^_i jkXkbWh Xed[ WdomWo$ C[Z_Wb WdZ
YWkZWb\b[n_edYWdX[e\WcW]d_jkZ[e\kfje(cc$
J^[ \_hij j_c[ j^[ h[bWj_l[ fei_j_ed e\ j^[ _cfbWdj
i^W\ji _i \_n[Z _i m^[d j^[ cWdZ_XkbWh Xh_Z][ _i
Y[c[dj[Z$ J^[ h[bWj_ed j^ki Z[j[hc_d[Z X[jm[[d
Xh_Z][ WdZ _cfbWdji i^ekbZ cWa[ \eh W c_d_cWb
[bWij_YZ_ibeYWj_ede\j^[j^h[WZ[Zf_dh[bWj_l[jej^[
Z_ia$M^[d Y[c[dj_d] W Xh_Z][" m[ b[j ekh fWj_[dji
j^[Y[c[dj^WiYecfb[j[bo^WhZ[d[Z$?dfWj_[djim_j^
[njh[c[cWdZ_XkbWhWjhef^o"j^[h[bWj_l[fei_j_ede\
j^[ WXkjc[dji m_bb X[ Z[j[hc_d[Z Xo j^[" Wbceij
hWdZec" cWdZ_XkbWh ijWjki e\ j^[ fWj_[dj$ M[ ^Wl[
eXi[hl[Zj^Wjj^[ckiYb[iWh[WXb[jeX[dZj^_iXed[
Z[f[dZ_d] je W l[ho bWh][ [nj[dj ed j^[ fWj_[djÉi
ckiYkbWh \_jd[ii" ^[WZ feijkh[ WdZ Z[]h[[ e\ Xed[
c_d[hWb_pWj_ed$EdY[j^[Xh_Z][^WiX[[d_di[hj[Z"W
d[m [gk_b_Xh_kc e\ j[di_ed _i Yh[Wj[Z j^Wj _dYbkZ[i
j^[Xh_Z][WiWd_dj[hdWb\_nWjeh$?\ikY^Xh_Z][iWh[
h[cel[Z\ehWdoh[Wied"fWj_[djih[fehjj[di_edWdZ
fW_dWiWYedi[gk[dY[e\j^[h[celWb$
?\ j^[ cWdZ_XkbWh hWcki _i i[l[h[bo Wjhef^_[Z
WdZ [bWij_Y ed Xej^ i_Z[i" hWf_Z j^h[[#Z_c[di_edWb
Y^Wd][ickijX[[nf[Yj[Z$DehcWbh[ceZ[bb_d]WdZ
Y^Wd][i_dckiYkbWh\kdYj_edm_bbW\\[Yjj^[h[bWj_ed
X[jm[[dj^[_cfbWdji$?\W]h[Wj[hj_c[_dj[hlWbfWii[i
((, 9^Wfj[h'+È 4REATINGÈTHEÈ!TROPHIEDÈ-ANDIBLE
X[jm[[dj^[jh_Wb_di[hj_ede\j^[Xh_Z][\hWc[meha
WdZY[c[djWj_ed[$]$i[l[hWbZWoieh[l[dceh[j^Wd
W m[[a" ed[ mekbZ ^Wl[ je [nf[Yj j^[ fei_j_edWb
Y^Wd][ijeX[ie[nj[di_l[j^Wjj^[Xh_Z][debed][h
\_ji[nWYjboWjY[c[djWj_ed$
?d j^_i [l[dj" ed[ c_]^j Wjj[cfj je _di[hj j^[
Xh_Z][ je X[ mehd \eh jme eh j^h[[ ZWoi" Xkj dej je
Y[c[dj _j$ :kh_d] j^_i j_c[" j^[ Xh_Z][ cWo ^Wl[ W
\ehcWj_l[[\\[Yjedj^[`WmWdZm_bb\_dZ_jifei_j_ed
edY[j^[_cfbWdji^Wl[WZWfj[Zj^[_hfei_j_edijej^[
d[mi_jkWj_ed"WdWZWfjWj_edj^Wj_iceh[e\j[dj^Wd
dejgk_j[c_deh$
?\ j^[ Z_iYh[fWdY_[i Wh[ c_deh" WZ`kijc[dji je
j^[ikf[hijhkYjkh[WdZj^[ki[e\l[ho\_hcY[c[dj
cWo m[bb \WY_b_jWj[ _cc[Z_Wj[ Y[c[djWj_ed$ 7i j^[
jhWdi_j_ed ped[i X[jm[[d j^[ WXkjc[dji WdZ j^[
Yhemd fei_j_edi _d j^[ Xh_Z][ Wh[ WbmWoi beYWj[Z
ikfhWYh[ijWbbo" j^[ fh[i[dY[ eh WXi[dY[ e\ Wd [nWYj
ifWj_Wb ÆW]h[[c[djÇ e\ j^[i[ ijhkYjkh[i _i e\ de
_cfehjWdY[$ M^Wj _i _cfehjWdj _i je Z[i_]d j^[i[
Wh[Wi ie j^Wj de fbWgk[ eh YWbYkbki Z[fei_ji YWd
eYYkh$ Ed eYYWi_ed" YWkZWbbo [nj[dZ[Z WXkjc[dji
m_bbj^[h[\eh[^Wl[jeX[feb_i^[Zehi^ehj[d[Z$
J^[l[hoYedd[Yj_ede\dWjkhWbj[[j^XoXh_Z][ieh
Z[djkh[im_bbe\j[dh[ikbj_dh[bWj_l[iodY^hed_pWj_ed
e\ j^[ cel[c[dj WdZ ceX_b_jo e\ j^[i[ j[[j^$
IodY^hed_pWj_ed Ze[i dej kikWbbo _dYbkZ[ j^[ Xed[
h[]_ediWhekdZj^[j[[j^"X[YWki[_j_ij^[f[h_eZedjWb
j_iik[i j^Wj f[h\ehc j^_i [gk_b_XhWj_d] \kdYj_ed" \eh
_dijWdY[ Xo m_Z[d_d] j^[ f[h_eZedjWb ifWY[$ J^[
i_jkWj_ed_iZ_\\[h[djWhekdZ_cfbWdji0?\j^[_cfbWdji
Wh[eii[e_dj[]hWj[Z"j^[Xed[_dj^[_dj[h\WY_Wbh[]_ed
ckijcel[iodY^hedekibom_j^j^[_cfbWdj_dehZ[h
je fh[l[dj j^[ Yedd[Yj_ed Wh[W je bei[ _ji _dj[]h_jo
j^hek]^Xed[Wlkbi_ed$
?j _i YedY[_lWXb[ j^Wj j^_i _i W h[Wied \eh j^[
YhWj[h#i^Wf[ZWh[Wie\YebbWfi[ZXed[WhekdZYh[ijWb
_cfbWdjij^WjWh[iejof_YWbe\j^_iioij[c0X[YWki["Wi
m[^Wl[Wbh[WZoi^emd"Yh[ijWb_cfbWdji"jee"WY^_[l[
bWh][bo XWiWb _dj[]hWj_ed" o[j j^[ _cfbWdj \_njkh[ _i
h_]_Z_dj^[i[_cfbWdji"fehj_edie\j^[Yh[ijWbXed[
YWdbeei[d_\j^[_hZ_h[Yj_ede\cel[c[dj_iZ_\\[h[dj
\hec j^Wj e\ j^[ _cfbWdj$ J^[ bed][h j^[ _cfbWdj"
j^[ ]h[Wj[h j^[ Y^WdY[ e\ j^[ \_njkh[ jhWl[hi_d]
Xed[ Wh[Wi j^Wj Ze dej cel[ iodY^hedekibo$ J^[
h[gk_h[c[dj\ehWdkdbeWZ[Z^[Wb_d]f[h_eZ_ij^ki
cej_lWj[ZXoj^[\WYjj^Wjj^[_cfbWdj"kdZ[hc_deh
beWZ"cWo[n[hj_dj[h\WY_Wb[\\[Yjiedj^[ikhhekdZ_d]
Xed[ _d ehZ[h je _dj[]hWj[ \_hcbo _d Wbb h[]_edi _\
feii_Xb[$
8E? _cfbWdji" jee" h[bWj[ je Z_\\[h[dj h[]_edi
e\ j^[ Xed[ j^Wj Ze dej d[Y[iiWh_bo WYj cel[
iodY^hedekibo$ Je WY^_[l[ _dj[]hWj_ed e\ j^[ Z_iai"
^em[l[h" j^[ Xed[ _d j^[ _dj[h\WY_Wb h[]_ed e\ ed[
8E? _cfbWdj _i iodY^hed_p[Z Xo j^[ _cfbWdj _ji[b\"
m^_b[Z_\\[h[djh[]_edi[gk_ff[Zm_j^8E?_cfbWdji
cWo i^em ded#iodY^hedeki X[^Wl_ekh [l[d m^[d
ifb_dj[Z ki_d] W \kbb Xh_Z][$ 7d WZZ_j_edWb _cf[jki
\ehXed[h[ceZ[bb_d]_idehcWbcWij_YWjeho\kdYj_ed"
m^_Y^ ij_ckbWj[i Xed[ \ehcWj_ed Xo Yecfh[ii_l[
WdZ j[di_b[ \ehY[i$ J^[ ikYj_ed WdZ fh[iikh[ \ehY[i
j^Wj cW_djW_d j^[ \bem e\ dkjh_[dji ^Wl[ j^[ iWc[
[\\[Yj$ J^[ _dYb_dWj_ed e\ 8E? _cfbWdji je _dj[]hWj[
_i WffWh[djbo ijhed] [dek]^ je Wbbem W Yecfb[j[
cWdZ_Xb[ je X[ h[ijeh[Z m_j^ W Yedj_dkeki \_n[Z
Xh_Z][m^_b[Wjj^[iWc[j_c[el[hYec_d]j^[\b[n_ed
_dj^_i`Wm$J^_ijof[e\h[ijehWj_ed_iWiieY_Wj[Zm_j^
Yedi_Z[hWXb[Z_\\[h[dY[i_dj^[Z_h[Yj_edWdZ[nj[dj
e\ cel[c[dj m_j^_d j^[ lWh_eki _cfbWdj Wh[Wi$ ?d
[njh[c[ cWdZ_XkbWh Wjhef^o" m_j^ W ^_]^ Z[]h[[ e\
c_d[hWb_pWj_ed"_j_ifeii_Xb[j^Wjdeceh[j^Wd\ekh
8E?YWdX[_di[hj[ZYedYkhh[djbo<_]$'+$(W"X$
È
3UMMARY
J^[ 8E? j[Y^d_gk[ _i j^[ edbo ed[#ij[f ikh]_YWb
j[Y^d_gk[\ehfhel_Z_d]\_n[Zh[ijehWj_edi\ehfWj_[dji
m_j^[njh[c[cWdZ_XkbWhWjhef^o$<eh[j^_YWbh[Wiedi"
^em[l[h" YecfWh_iedi m_j^ Wbj[hdWj_l[ jh[Wjc[dj
ijhWj[]_[i Wh[ h[gk_h[Z0 Eii[eZ_ijhWYj_ed ^Wi
h[Y[djboX[[dWl[hofefkbWhikX`[Yj\ehZ_iYkii_ed$
Eii[eZ_ijhWYj_ed_ifeii_Xb[jeZWo_\j^[Xed[ikffbo
WXel[ j^[ cWdZ_XkbWh d[hl[ _i ceh[ j^Wd ,cc$
>em[l[h"j^[\W_bkh[hWj[_iij_bbX[jm[[d''WdZ'+
_d\[Yj_ed"beiie\Xed[Yel[hW][;m[hi(&&&$?\m[
WZZ j^[ ][d[hWbbo h[Ye]d_p[Z _dY_Z[dY[ e\ _cfbWdj
beii _d j^[ feij[h_eh h[]_ed e\ j^[ cWdZ_Xb[ '+
ed Wl[hW][" j^_i j[Y^d_gk[" m^_Y^" Wi m[ i^ekbZ
h[c[cX[h" h[gk_h[i Wj b[Wij jme WdZ kikWbbo j^h[[
je \ekh ikh]_YWb _dj[hl[dj_edi" YWhh_[i W jh[Wjc[dj
\W_bkh[ h_ia e\ (+ Ä W i_pWXb[ \_]kh[$7 ckY^ ceh[
_dlWi_l[ fheY[Zkh[ Ä Wbj^ek]^ ij_bb fhWYj_i[Z ZW_bo
Ä _i j^[ jhWdifbWdjWj_ed e\ ^_f" h_X eh fWh_[jWb
Xed[ WiieY_Wj[Z m_j^ Yedi_Z[hWXb[ [njhWehWb i_Z[
[\\[Yji WdZ W hWj[ e\ Yecfb_YWj_edi j^Wj _i Wj b[Wij
YecfWhWXb[jej^Wje\eij[eZ_ijhWYj_ed$;nf[h_[dY[Z
8E? ki[hi b_a[ je YWbb j^[ _cfbWdj j[Y^d_gk[i `kij
dWc[Z WdZ j^[ h[bWj[Z fh[fWhWjeho Wk]c[djWj_ed
c[Wikh[iÆ9_dZ[h[bbW j[Y^d_gk[iÇ$ ?dij[WZ e\ ki_d]
8E?_cfbWdjij^WjWh[WZWfj[Zjej^[WlW_bWXb[Xed[
ikffbojeX[]_dm_j^"_cfbWdjiWh[ki[Zj^WjZedej
\_jÄh[gk_h_d]j^[Xed[jeX[WZWfj[Zjej^ei[ded#
\_jj_d]_cfbWdjiWjWbbYeiji"ki_d]Yecfb_YWj[Z"h_iao
WdZ Yecfb_YWj_ed#fhed[ fh[fWhWjeho ikh][ho$ J^[
edboh[Wiedm^oj^[Yekhji^Wl[dejbed]i_dY[fkjW
ijefjej^[i[_d^kcWdÆjh[Wjc[djÇijhWj[]_[iÄm^_Y^
ed ieX[h eXi[hlWj_ed Wff[Wh gk_j[ kdj^_daWXb[ Ä _i
j^Wj fhWYj_YWbbo Wbb kd_l[hi_j_[i WdZ Z[djWb iY^eebi
jeZWoj[WY^j^_iZkX_ekic[j^eZWdZj^Wjj^[YWi[ie\
j^[fWj_[djij^kic_ijh[Wj[ZWh[hekj_d[boj^hemdekj
e\Yekhjedj^[XWi_ie\Æ[nf[hjÇef_d_ediXof[efb[
m^ei[ WYWZ[c_Y b_l[b_^eeZ Z[f[dZi ed h[Y[_l_d]
È È 3UMMARYÈ
]hWdji \hec Y[hjW_d gkWhj[hi$ ?j _i Yec_d] je X[
[ijWXb_i^[Zademb[Z][[l[d_dYekhjhkb_d]ij^Wj8E?
jh[Wjc[dj _i WiieY_Wj[Z m_j^ b[ii h_ia _d i_jkWj_edi
m^[h[ j^[ Xed[ ikffbo _i b_c_j[Z WdZ j^Wj _j mekbZ
^Wl[ je X[ fh[\[hh[Z je Yh[ijWb _cfbWdj jh[Wjc[dj
\ehj^_ih[WiedWbed[Q7=beYWbYekhje\D”hdX[h]"
=[hcWdo"hkb_d]*E,-%/-S$
M[ m_i^ je fe_dj ekj j^Wj _cfbWdj WdZ Xed[
beii YWd WdZ Ze eYYkh [l[d _\ j^[ 8E? j[Y^d_gk[
_i ki[Z$ >em[l[h" j^[ Wcekdj e\ Xed[ beii YWd X[
((-
b_c_j[ZXoYbei[bo\ebbem_d]j^[fWj_[djWdZXoj_c[bo
WdZ ademb[Z][WXb[ Z[djWb _dj[hl[dj_ed$ J^[ jof[
WdZ [nj[dj e\ Wdo beii[i kikWbbo f[hc_j W i[YedZ
_di[hj_ede\8E?_cfbWdjim_j^ekjWdoWk]c[djWj_ed
c[Wikh[i _d j^[ Wh[W e\ j^[ Xed[ X[Z Ä iec[j^_d]
j^Wj Y[hjW_dbo YWddej X[ iW_Z _d ceij i_c_bWh YWi[i
m^[h[Yh[ijWb_cfbWdjioij[ciWh[ki[Z$
?dj[h[ij_d] YWi[ ijkZ_[i ed j^[ jh[Wjc[dj
e\ Wjhef^_[Z cWdZ_Xb[i Wh[ Wbie Z_ifbWo[Z ed
mmm$Zedi_ced_$Yec$

#(!04%2È
4UBEROPTERYGOIDÈ3CREWS
È
)NTRODUCTION
I_dY[ fWdehWc_Y hWZ_e]hWf^i Wh[ eXjW_d[Z Xo
i[Yj_edWb_cW]_d]"j^[om_bbedboh[l[Wbj^[ijhkYjkh[i
beYWj[Z _d j^[ \eYki[Z fbWd[$ J^[ N#hWo ioij[c _i
WZ`kij[Z _d ikY^ W mWo j^Wj Xej^ j^[ cWn_bbW WdZ
j^[ cWdZ_Xb[ Wh[ Z[f_Yj[Z WXekj [gkWbbo m[bb _d
j^[ iWc[ _cW][" Z[if_j[ j^[ \WYj j^Wj Xej^ `Wmi
Wh[ dej _d j^[ iWc[ l[hj_YWb fbWd[ [l[d _d fWj_[dji
m_j^ _djWYj Z[dj_j_edi$ J^_i Z_iYh[fWdYo _i [l[d
]h[Wj[h _d [Z[djkbeki i_jkWj_edi" Wi j^[ cWn_bbW WdZ
cWdZ_Xb[ Wh[ Y^WhWYj[h_p[Z Xo W Y[djh_f[jWb WdZ
Y[djh_\k]Wb h[iehfj_ed fWjj[hd" h[if[Yj_l[bo$ J^[
Z_iYh[fWdYo _i ]h[Wj[ij _d j^[ jkX[hei_jo h[]_ed"
i_dY[j^[cWn_bbWWbceijWff[WhihekdZ_dj^WjWh[W"
WdZj^[Z_ijWbceijfWhjiWim[bbWij^[fWbWjWbXed[
WdZ j^[ ckiYkbWh fheY[ii[i e\ j^[ if^[de_Z Xed[
\Wbb Yecfb[j[bo ekji_Z[ j^[ EF= fbWd[$ J^[h[\eh["
_dWX_b_jo je Z[f_Yj Xed[ _d j^[ jkX[hei_jo Wh[W
ki_d] Yedl[dj_edWb fWdehWc_Y hWZ_e]hWf^i Ze[i
dej \khd_i^ Wdo [l_Z[dY[ e\ Xed[ h[iehfj_ed Xkj
Yedij_jkj[i W jof_YWb \Wbi[#d[]Wj_l[ \_dZ_d]$ J^[
Z_ijWb cWn_bbW _i `kij Wi ijWXb[ je h[iehfj_ed Wi j^[
cWdZ_XkbWh Wdj[h_eh i[]c[dj X[YWki[ _j ^WhXekhi
WjjWY^c[djie\fem[h\kbY^[m_d]ckiYb[i$J^[Xed[
lebkc[ _d j^Wj Wh[W _i kikWbbo WXkdZWdj Wi m[bb"
ie j^Wj bed] iYh[m _cfbWdji m_j^ ^_]^ WdY^ehW][
fej[dj_Wb YWd X[ h[WZ_bo _di[hj[Z$ M[ Ze j^_da j^Wj
j^_i ijhWj[]o _i _dZ_YWj[Z X[YWki[ _cfbWdji e\ j^_i
jof[m_bb^[bfje_cfhel[ijWX_b_joWdZikffehj_dj^_i
Wh[We\^_]^cWij_YWjeho\ehY[i$
Iec[ _cfbWdjebe]_iji cWo \_dZ j^[i[ Z[i_]di
^WhZjekdZ[hijWdZeh_dZ[[ZkdYWddoWj\_hiji_]^j$
Ed i[YedZ j^ek]^j" _j _i Yecfb[j[bo be]_YWb j^Wj
j^[ Xed[ ijhkYjkh[ _d j^[ Z_ijWb cWn_bbW i^ekbZ X[
kj_b_p[Z" Yedi_Z[h_d] j^[ WdWjec_YWb WdZ \kdYj_edWb
h[bWj_edi^_fi$ J^[ Xed[ _d j^[ jkX[hei_jo Wh[W
_i ademd je WZWfj je Wdo Y^Wd][i _d \kdYj_edWb
h[gk_h[c[djil[hogk_Yabo$Ceh[el[h"j^[jkX[hei_jo
h[]_ed _i [njh[c[bo m[bb lWiYkbWh_p[Z cWn_bbWho
WdZfWbWjWbWhj[h_[iWdZm[bb[nfei[Zje\kdYj_edWb
\ehY[ij^Wdaijej^[bWj[hWbfj[ho]e_ZckiYb[$>Wl_d]
ki[Zj^[i[jkX[hei_jo_cfbWdji\ehi[l[hWbo[Whi"ekh
[nf[h_[dY[ ^Wi X[[d j^Wj beii[i Wh[ [njh[c[bo hWh[$
 ¬ 
7iWcWjj[he\\WYj"m[^Wl[eXi[hl[Zedboed[YWi[
e\[Whbo_cfbWdjbeii"_dm^_Y^WYecfb[j[cWn_bbWho
Xh_Z][ WjjWY^[Z Xo j[cfehWho Y[c[djWj_ed X[YWc[
ceX_b[WdZmWi[l[djkWbbo^[bZ_dfbWY[edboXoj^[
iYh[mYedd[Yj_ed$
Ekh ZWjW Wbie i^em j^Wj de Z_ijWb 8E? _cfbWdj
^Wi [l[h X[[d beij _\ W jkX[hefj[ho]e_Z iYh[m ^WZ
X[[d _di[hj[Z Z_ijWbbo je _j Ä h[]WhZb[ii" Xo j^[ mWo"
e\m^[j^[hj^[iYh[m^WZX[[dbeWZ[Z$7bj^ek]^m[
^Wl["el[hj^[o[Whi"Yebb[Yj[ZikXijWdj_Wb[nf[h_[dY[
m_j^ YWi[i jh[Wj[Z m_j^ 8E? _cfbWdji edbo" m[
h[]kbWhbo_dYbkZ[j^[jkX[hefj[ho]e_ZiYh[m_djeekh
jh[Wjc[dji$ I_dY[ j^[i[ _cfbWdji YWddej X[ ki[Z _d
WbbfWj_[djiWb_a["d[_j^[hj^[ikh]_YWbfheY[Zkh[ideh
Wdo ikXi[gk[dj [lWbkWj_edi YWd X[ f[h\ehc[Z _d W
ZekXb[#Xb_dZ\Wi^_ed$
M[ ^Wl[ \h[gk[djbo ki[Z j^[ ijhWj[]o je _di[hj
jkX[hefj[ho]e_Z iYh[mi m_j^ekj _dYehfehWj_d]
j^[c_dj^[j[cfehWhoh[ijehWj_ed"j^kifeijfed_d]
j^[ \_dWb Z[Y_i_ed ed m^[j^[h je _dYehfehWj[ j^[c
_d j^[ Z[\_d_j_l[ h[ijehWj_ed kdj_b j^[ [dZ e\ j^[
j[cfehWho f^Wi[$ M[ kikWbbo Z[Y_Z[Z je [nYbkZ[
j^[ jkX[hefj[ho]e_Z iYh[m \hec j^[ h[ijehWj_ed
_\ \_hc WdY^ehW][ e\ Wbb 8E? _cfbWdji ^WZ X[[d
h[WY^[Z W\j[h j^[ j[cfehWho h[ijehWj_ed f^Wi[$ ?d
ekhl_[m"_j_iYedY[_lWXb[j^Wjj^[ZehcWdjcWYhe#
jhW`[Yjeh_[i _d j^[ Z_ijWb cWn_bbW YWd X[ ij_ckbWj[Z
je kdZ[h]e h[ceZ[bb_d] c[h[bo Xo _di[hj_d] j^[i[
jkX[hefj[ho]e_ZiYh[mim _j^ekj[l[hfkjj_d]j^[c_dje
Yb_d_YWbi[hl_Y[$J^_ih[eh_[djij^[cWYhe#jhW`[Yjeh_[i
m^_b[ Wj j^[ iWc[ j_c[ _dj[]hWj_d] WYj_lWj_d]
Wdo Z_ijWb 8E? _cfbWdji WdZ j^[ jkX[hefj[ho]e_Z
iYh[m$?\j^[cWYhe#jhW`[Yjeh_WbXed[ijhkYjkh[_idej
ik\\_Y_[djbo WZ`kij[Z" cWYhe#jhW`[Yjeh_[i cWo W\\[Yj
j^[_dj[]hWj_ede\8E?_cfbWdjiWYYehZ_d]jej^[&Ä'
hkb[" m^_Y^ _i fWhj_YkbWhbo jhk[ e\ Xed[ Wh[Wi ikY^
Wi j^[ Z_ijWb cWn_bbW _d m^_Y^ c[Y^Wd_YWb ijh[ii[i
Wh[bem$7dWbj[hdWj_l[[nfbWdWj_edmekbZX[j^Wjj^[
eij[ejeco \eh 8E? cWo WYjkWbbo dej X[ ik\\_Y_[djbo
_dlWi_l[ed_jiemdjeik\\_Y_[djboh[Yel[hj^[h[]_ed_d
j^[jkX[hefj[ho]e_ZWh[Wj^Wj_icWii_l[boikX`[Yj[Z
je \kdYj_edWb beWZi \hec _ji ijWj[ e\ eij[edWb h[ij$
J^[i[ Yedi_Z[hWj_edi c_]^j ^ebZ ]eeZ Wh]kc[dji
W]W_dij ijhWj[]_Y _cfbWdj fei_j_ed_d] Wbed[$ J^[
Z_h[Yj _cfbWdj#je#Xed[ ij_ckbWj_ed _d j^[ Yh[ijWb
fWhje\j^[Z_ijWbcWn_bbWYekbZWbie^[bfjecW_djW_d
()& 9^Wfj[h',È 4UBEROPTERYGOIDÈ3CREWS
j^_iXed[Yh[ijWbboe\j^[Z_ijWbceij8E?$J^ki"j^[h[
_io[jWbejjeX[h[i[WhY^[Z_dj^_i\_[bZ$
<bWf fheY[Zkh[0 j^[ _cfehjWdj fWhj _i j^Wj j^[
\bWf _i h[\b[Yj[Z ik\\_Y_[djbo \hec j^[ fWbWjWb Wif[Yj
jemWhZi j^[ l[ij_XkbWh i_Z[" Wbbem_d] j^[ Z[dj_ij je
YWh[\kbbo [nfbeh[ j^[ Z_ijec[Z_Wb WdWjeco e\ j^[
cWn_bbW$ <ebbem_d] _cfbWdj fbWY[c[dj" j^[ \bWf _i
Ybei[Z ki_d] Yedl[dj_edWb j[Y^d_gk[i$ Edbo j^[d _i
j^[\bWffkdY^[Zjeh[]W_dWYY[iijej^[_cfbWdj\eh
j^[ h[ijehWj_l[ ij[fi WdZ fbWY[c[dj e\ j^[ ^[Wb_d]
iYh[m$
J^[ jkX[hefj[ho]e_Z iYh[m _i _di[hj[Z eXb_gk[bo
_d W c[Z_Wb WdZ" Wj j^[ iWc[ j_c[" Z_ijWb Z_h[Yj_ed
_d b_d[ m_j^ j^[ cWn_bbWho WdWjeco$ J^[ Wd]b[i
m_j^ j^[ iW]_jjWb WdZ l[hj_YWb fbWd[i Wh[ WhekdZ
(&Ä*+Z[]h[[i1 _d iec[ YWi[i" j^[o cWo X[ [l[d
bWh][h$7\j[h j^[ h_Z][ ^Wi X[[d X_bWj[hWbbo [nfei[Z"
j^[ Xed[ YWl_jo _i YWh[\kbbo fh[fWh[Z m_j^ W Zh_bb Wj
bemif[[Z$?j_ih[Yecc[dZ[Zjeki[Wbem#fh[iikh[
_dj[hc_jj[dj Zh_bb_d] j[Y^d_gk[ je [dikh[ j^Wj j^[
Yehj_YWb XekdZWho _i dej [nY[[Z[Z$ J^_i m_bb Wbie
[b_c_dWj[ j^[ h_ia e\ l[ii[bi X[_d] _d`kh[Z _d j^[
fheY[Zkh[$ J^[ ]eWb e\ fh[fWhWj_ed _i je [ijWXb_i^
Yehj_YWb WdY^ehW][ e\ j^[ _cfbWdj j_f [_j^[h _d j^[
Wh[W e\ W i_dki%cWn_bbWho mWbb eh _d j^[ Wh[W e\ j^[
bWj[hWb fj[ho]e_Z ckiYb[ WjjWY^c[dj$ ?j _i j^[h[\eh[
i_cfb[ij je cekdj j^[ ikf[hijhkYjkh[ Xo c[Wdi e\
W iYh[m Yedd[Yj_ed" [l[d _\ Y[c[djWj_ed _i ki[Z ed
j^[ej^[hWXkjc[dji$?j_iWbiefeii_Xb[je_djheZkY[
j^[ jkX[hefj[ho]e_Z iYh[mi \hec Wd eXb_gk[ bWj[hWb
fWj^mWo _dje j^[ XWiWb h_Z][ i[]c[dj" m^_Y^ m_bb
[l[dh[_d\ehY[j^[_dYb_dWj_edW]W_dijj^[cWij_YWjeho
fbWd[$ ?d j^[ fWdehWc_Y N#hWo" j^[ _cfbWdj Wff[Whi
Wbceij^eh_pedjWb$
?j _i [ii[dj_Wb j^Wj j^[ Z_ijWb 8E? _cfbWdj WdZ
j^[ jkX[hefj[ho]e_Z iYh[m Wh[ _di[hj[Z ikY^ j^Wj
j^[o Ze dej _dj[h\[h[ m_j^ [WY^ ej^[h$ B_a[m_i["
[ijWXb_i^_d]j^[iYh[mYedd[Yj_edckijdej_dj[h\[h[
m_j^ Y[c[djWj_ed e\ Wdj[h_eh Xh_Z][ i[]c[dji WdZ
l_Y[ l[hiW$ M[ b_a[ je _di[hj j^[ jkX[hefj[ho]e_Z
iYh[m X[\eh[ _di[hj_d] j^[ ceij Z_ijWb 8E? _cfbWdj
je[dikh[j^Wjj^[efj_cWb[djhofe_dj_djej^[Xed[
_iij_bbkiWXb[$Iec[j_c[ij^[ikh][edcWoc_i`kZ][
j^[_cfbWdjWn_iWdZj^ki\W_bje_dYb_d[j^[Zh_bb_d]
fWj^ ik\\_Y_[djbo _d Z_ijWb Z_h[Yj_ed$ J^[ cWn_bbWho
i_dki m_bb ieed X[ h[WY^[Z _d j^Wj YWi[$ ?dij[WZ e\
Zh_bb_d]Wi[YedZY^Wdd[b"_j_ikikWbboX[jj[hjeijWhj
\hec j^[ Wbh[WZo [n_ij_d] Wf[hjkh[ WdZ" \hec j^[h["
Zh_bb j^[ i[YedZ Y^Wdd[b Xo ki_d] W ikXijWdj_Wbbo
Z_\\[h[dj_dYb_dWj_ed$?dj^_imWo"deWf[hjkh[im_bbX[
b[\j feijef[hWj_l[bo ed j^[ ikh\WY[ e\ j^[ Yh[ij$ J^[
Yehj_YWb Xed[ e\ j^[ cWn_bbWho i_dki m_bb dehcWbbo
Ybei[l[hom[bbXo_ji[b\$
7YYehZ_d] je IYehj[YY_" jkX[hefj[ho]e_Z iYh[mi
YWdX[el[h*&ccbed]$IYh[mie\ikY^Yedi_Z[hWXb[
b[d]j^ Wh[ edbo d[Y[iiWho _\ Z_ijWdY[i j^Wj Ze dej
YedjW_dWdoXed[^Wl[jeX[Yel[h[Z_dYheii_d]j^[
cWn_bbWho i_dki$ J^[_h b[d]j^ cWo _d_j_Wbbo eXiYkh[
&IGÈ J^[XWiWbcWn_bbW_dj^_i9J
iYWd_iWbceijhekdZ_di^Wf[
È È )NTRODUCTIONÈ ()'

B C

&IGÈAnD CWn_ckckj_b_pWj_ede\j^[WlW_bWXb[Xed[
ijhkYjkh[cWoiec[j_c[ic[Wdj^WjjkX[hefj[ho]e_ZiYh[mi
^Wl[jeX[_di[hj[ZWbceij^eh_pedjWbbo"j^kicekdj_d]j^[
ikf[hijhkYjkh[l_WWbWj[hWbfWj^mWo$?j_iWXiebkj[bod[Y[iiWho
je[dikh[j^Wjj^[iYh[m_iYb_d_YWbboWYY[ii_Xb[je[dWXb[
D
_cfh[ii_ed#jWa_d]WdZcekdj_d]e\j^[ikf[hijhkYjkh[

j^[_h kd_gk[ dWjkh[ YecfWh[Z je po]ecWj_Y iYh[mi"
kdj_b _j _i fe_dj[Z ekj j^Wj j^[ bWjj[h ^Wl[ j^[_h
[dZfe_dj _d j^[ po]ecWj_Y Xed[ hWj^[h j^Wd j^[
if^[de_ZXed[Wh[W$7YYehZ_d]bo"j^[_di[hj_edfWj^
e\jhk[po]ecWj_YiYh[mi_ieh_[dj[Zceh[jemWhZij^[
bWj[hWb Wif[Yj$ 7dej^[h Z_\\[h[dY[ _i j^Wj po]ecWj_Y
iYh[miWh[dejkikWbboeii[e_dj[]hWj[Z_dj^[Wbl[ebWh
Yh[ij X[YWki[ j^[ XWiWb ikffehj Wh[W m_j^_d j^[
po]ecWj_YXed[_iX_ec[Y^Wd_YWbboekje\iodYm_j^
j^[ Wbl[ebWh Yh[ij$ 8[YWki[ po]ecWj_Y iYh[mi Wh[
edbo _di[hj[Z _d i_jkWj_edi m^[h[ ^WhZbo Wdo Xed[
_i b[\j _d j^[ Wbl[ebWh Yh[ij" Yel[hW][ Xo Yedd[Yj_l[
j_iik[ _i _hh[b[lWdj _d j^_i Wh[W$7j b[Wij j^_i _i jhk[
\ehWibed]Wij^[cWn_bbWhoi_dkii^emidej[dZ[dYo
()( 9^Wfj[h',È 4UBEROPTERYGOIDÈ3CREWS

je X[Yec[ h[Ykhh[djbo _d\[Yj[Z1 ^em[l[h" j^_i _i X[h[]WhZ[ZWi¼fWhWbb[b½Z[f[dZiedj^[f[hif[Yj_l[

kdb_a[bo je ^Wff[d Zk[ je _ji ^_]^ h_]_Z_jo$ Ed j^[ jWa[d$?j_idej[dek]^jeXWi[j^_iWii[iic[djedWd
ej^[h^WdZ"_jmekbZWff[Whceh[h[WiedWXb[\hecW EF=$Ceh[el[h"i_dY[_j_iWbmWoiW]eeZ_Z[Wjea[[f
X_ebe]_YWbl_[mfe_djjeki[po]ecWj_YiYh[mim_j^W jh[Wjc[dji Wi i_cfb[ WdZ iW\[ Wi feii_Xb[" _cfbWdji
iceej^ikh\WY[Wbed]j^[Yh[ijWbi[]c[djm^[h[j^[o i^ekbZX[fbWY[Zh_]^j_dje[n_ij_d]Xed[ijhkYjkh[i
jhWdil[hi[j^[h_Z][WdZi_dkiÄ_dej^[hmehZi"dej hWj^[h j^Wd Wk]c[dj_d] j^[ Xed[ \_hij Xo ]hW\j_d]
je ki[ Wdo ikh\WY[ [dbWh][c[dj eh j^h[WZ_d] _d j^[ fheY[Zkh[i eh ]hemj^ fhefW]Wj_ed WdZ j^[d WZefj
_cfbWdji[]c[djYbei[jej^[cekj^$ WmW_j#WdZ#i[[ijhWj[]oWijem^[j^[hj^[d[mXed[
JkX[hefj[ho]e_Z iYh[mi YWd WdZ i^ekbZ eii[e# m_bb X[ WXb[ je ikffehj Wdo beWZ[Z _cfbWdji _d W
_dj[]hWj[ Wbed] j^[ [dj_h[ bed]_jkZ_dWb ikh\WY[ Wh[W$ ikijW_dWXb[cWdd[h$7domWo"jhk[¼fWhWbb[b_ic½Ze[i
J^[h[\eh[" ikh\WY[ [dbWh][c[dj Xo iWdZXbWij_d]
_i ceh[ e\ Wd WZlWdjW][ j^Wd W Z_iWZlWdjW][ ed
j^[i[ Z[i_]di$ M[ ki[ Yed[#i^Wf[Z IJ9# eh IJE#
jof[ Yecfh[ii_ed iYh[mi \eh j^[i[ Wffb_YWj_edi$
IYehj[YY_(&&'"edj^[ej^[h^WdZ"Z[cedijhWj[ij^[
ikYY[ii\kb ki[ e\ ded#iWdZXbWij[Z c_Yhe#j^h[WZ[Z
iYh[m#_cfbWdjim_j^[nj[hdWb^[nW]edWbYedd[Yj_ed$
J^[ fei_j_ed e\ j^[ jkX[hefj[ho]e_Z iYh[m _i
\WlekhWXb[ \eh Wdo _cfbWdjWj_ed Ä fWhjbo X[YWki[
W Z_h[Yj ikffbo e\ dkjh_[dji el[h i^ehj Z_ijWdY[i
[n_iji j^[ h[]_ed Z_ijWbbo e\ j^[ cWn_bbW ^Wi Wd
[njhWehZ_dWh_bo]eeZXbeeZikffbo\hecj^[cWn_bbWho
Whj[ho WdZ _ji l[ij_XkbWh WdZ _djhW#i_dki XhWdY^[i"
fWhjbo X[YWki[ W m_Z[ ckiYkbWh WjjWY^c[dj [n_iji
Wbed] j^[ bed]_jkZ_dWb Wn_i e\ j^[ _cfbWdj$ J^_i _i
m^o[l[dWbed]_cfbWdjikY^Wij^_ied[YWdX[m[bb
_dj[]hWj[Z Wbed] j^[ m^eb[ b[d]j^ e\ j^[ _cfbWdj"
i_dY[_j_i_dZ_h[YjYehj_YWbYedjWYj$

È
0ARALLELÈ)MPLANTÈ0LACEMENT

?j ^Wi X[[d Wh]k[Z j^Wj" YedjhWho je j^[ jhWZ_j_edWb

WffheWY^" jkX[hefj[ho]e_Z iYh[mi Wh[ dej _di[hj[Z
¼fWhWbb[b½m_j^j^[`WmWbj^ek]^j^_imekbZX[ceh[ &IGÈ J[b[hWZ_e]hWf^ e\ W cWn_bbW m_j^ jkX[hefj[ho]e_Z
Wffhefh_Wj[ WYYehZ_d] je iec[ Wkj^ehi$ M^Wj _i je iYh[mi_dfbWY[j[cfehWhof^Wi[

&IGÈ IJE jkX[hefj[ho]e_Z iYh[m )'cc _d b[d]j^ WdZ
*$'cc_dZ_Wc[j[h
&IGÈ J^[ Z_ia e\ Wd ?:E /%'( =, _cfbWdj mWi _di[hj[Z
XWiWbbo je j^[ heej Wh[W e\ j^[ [njhWYj[Z i[YedZ cebWh$ J^[
_dYb_dWj_ed e\ j^[ 8E? _cfbWdj \WY[i jemWhZi j^[ fWbWjWb
Wif[Yj$J^[jkX[hefj[ho]e_ZiYh[m"XoYedjhWij"_ieh_[dj[Z_d
WZ_ijec[Z_WbWdZYhWd_WbZ_h[Yj_ed$J^[iYh[m_cfbWdj_iij_bb
Yedd[Yj[Zjej^[_di[hj_edjeebm_j^j^[hWjY^[jYedd[Yj[Z
È È 0ARALLELÈ)MPLANTÈ0LACEMENTÈ ())

&IGÈAnC J^[ Wd]b[ X[jm[[d j^[ jkX[hefj[ho]e_Z iYh[m

WdZj^[8E?Wj'-i^ekbZdej[nY[[Z/&Z[]h[[iX[YWki[j^Wj
mekbZ cWa[ _j Z_\\_Ykbj eh _cfeii_Xb[ je _di[hj j^[ Xh_Z][$
?cfbWdji e\ jof[ ?: Wh[ fWhj_YkbWhbo m[bb ik_j[Z \eh j^_i
_dZ_YWj_ed"X[YWki[j^[[nj[hdWb^[nW]ed_idejl[hoZ[[fWdZ
X[YWki[Wi^ehj#j[hcZ[\ehcWj_ede\j^[Xed[_ji[b\m_bbWbbem
j^[ ^[n je idWf _d fbWY[ ckY^ [Wi_[h j^Wd _i j^[ YWi[ m_j^
_cfbWdjie\jof[?:EikY^Wij^ei[i^emd^[h[$?\d[Y[iiWho"
j^[ kdZ[hYkj X[jm[[d j^[ eYjW]edWb WXkjc[dj e\ j^[ iYh[m
WdZ j^[ Wdj[h_eh 8E? ckij X[ h[cel[Z ki_d] W jkd]ij[d#
YWhX_Z[ Ykjj[h$ M[ h[Yecc[dZ ki_d] WXkjc[dji e\ j^[ EI7
IJEehEI7IJ?jof[edj^[jkX[hefj[ho]e_ZiYh[miWim[bb$
7YY[ii \eh h[ijehWj_l[ ij[fi i^ekbZ X[ Yedi_Z[h[Z Wbh[WZo
C
Zkh_d]fbWY[c[dje\j^[_cfbWdji

dejdehcWbbo[n_ij_dj^[^kcWdXeZoXkj_iWded#
X_ebe]_YWb YedijhkYj e\ ^kcWd j^_da_d] e\\[h_d] de
WZlWdjW][im^Wjie[l[h$
J^[\ebbem_d]\_]kh[i_bbkijhWj[^emj^[f[hif[Yj_l[
Y^Wd][i _\ j^[ Wd]kbWh h[bWj_edi^_fi X[jm[[d j^[
cWij_YWjehofbWd[WdZj^[_cfbWdjWn_iWh[Wii[ii[Z
dejXoWdEF=Xkj"\eh_dijWdY["XoWj[b[hWZ_e]hWf^$

9Wi[IjkZo
7d_dj[h[ij_d][\\[Yj_ij^Wjj^[heeje\jeej^(+_idej
l_i_Xb[ _d <_]$',$/W" Xkj Yb[Whbo l_i_Xb[ _d <_]$',$/X
jWa[d bWj[h$7j j^[ iWc[ j_c[" j^[ _cfbWdji Wh[ l[ho
&IGÈ J^[XWiWbfbWj[e\j^[ceijZ_ijWb8E?_il[hoe\j[d [Wio je cWa[ ekj ed [_j^[h hWZ_e]hWf^$ 8E? WdZ
fei_j_ed[Z X[bem j^[ Yh[ijWb Wif[Yji e\ j^[ fj[ho]e_Z iYh[m$ iYh[m _cfbWdji Wh[ WbmWoi Yb[Whbo ZhWmd" Wi Wh[ j^[
J^_i fheY[Zkh[ h[gk_h[Z m[bb#jhW_d[Z j^h[[#Z_c[di_edWb cekdj[Zikf[hijhkYjkh[i"m^_b[iec[j[[j^cWodej
_cW]_dWj_edWdZZ[[fademb[Z][e\j^[WdWjeco
X[l_i_Xb[WjWbb_\Wdkd\WlekhWXb[bWo[hmWiY^ei[d
m^[djWa_d]j^[hWZ_e]hWf^$
()* 9^Wfj[h',È 4UBEROPTERYGOIDÈ3CREWS

A B

&IGÈAnC :[f[dZ_d]edj^[
f[hif[Yj_l["j^[Yh[ijWb_cfbWdji
_dj^[cWdZ_Xb[beeaWij^ek]^
j^[o^Wl[X[[d_di[hj[ZYehh[Yjbo
eh_dYehh[Yjboh[bWj_l[jej^[`Wm
C
ehcWij_YWjehofbWd[
È È 3UMMARYÈ ()+

A B

&IGÈAB M_j^kd_bWj[hWbh[YedijhkYj_edi_dj^[jkX[hei_joWh[W"j^[_cfbWdj_ji[b\m_bbYWki[[nj[di_l[h[ceZ[bb_d]$<ehY[i

e\ j^[ bWj[hWb fj[ho]e_Z ckiYb[ m_bb WYj ed j^[ Xed[ _d W Z_ijWb WdZ c[Z_Wb Z_h[Yj_ed" YWki_d] W ibem h[beYWj_ed e\ j^[ Z_ijWb
cWn_bbWhoXed[jemWhZij^[cWdZ_XkbWhYedZob[i$J^[ikf[hijhkYjkh[_iijWX_b_p[Z_d_jifei_j_edXoj^[eYYbki_ed"m^_Y^_im^o
de]WfieYYkhX[jm[[dj^[YhemdXbeYaWdZj^[WZ`WY[djWdj[h_ehjeej^$J^[Z_ijWbcWn_bbW_ij^kiikX`[Yj[ZjeWZ_ijWbYh[[f
e\ckiYkbWheh_]_d"m^_Y^c[Wdij^Wjdel[hofhedekdY[Zc_d[hWb_pWj_edYWdX[[nf[Yj[ZWjj^[8E?_cfbWdj_dj[h\WY[Zkh_d]
j^[\_hij*Ä,cedj^i$7i_dWdoXed[^[Wb_d]fheY[ii"YkckbWj_l[Xed[ZWcW][_iYWki[ZXoj^[cWij_YWjeho\ehY[i"m^_b[Wjj^[
iWc[j_c[j^[h[fW_hfheY[ii_dYh[Wi[ij^[fehei_joe\j^[Xed[[l[dWjWZ_ijWdY[\hecj^[Wh[We\j^[eij[ejeco$J^[ckiYkbWh
WjjWY^c[djWh[Wi"XoYedjhWij"Wh[kdb_a[bojeX[ikX`[YjjeWdoh[ceZ[bb_d]$<ehY[ie\j^[bWj[hWbfj[ho]e_ZckiYb[j[dZjeX[dZ
j^_ifWhje\j^[cWn_bbWZ_ije#c[Z_WbboI[_f[b'/+/"m^_b[_cfbWdjiWdZh[ijehWj_ediWh[^[bZ_dfbWY[XoeYYbki_ed

beWZ je j^[ Z_ijWb cWn_bbW WdZ m_j^ijWdZ j^[ \ehY[i

È
3UMMARY
J^[ jkX[hefj[ho]e_Z iYh[m _i W ]eeZ efj_ed \eh
i[Ykh_d] beWZ jhWdic_ii_ed _d j^[ h[]_ed e\ j^[
jkX[hei_jo WdZ j^[ if^[de_Z Xed[$ J^[ _cfbWdj _i
_di[hj[ZWjWdWd]b[e\Wffhen_cWj[bo(&Ä*+Z[]h[[i
\hec j^[ bWj[hWb WdZ \hec j^[ Wdj[h_eh _d W Z_ijWb#
c[Z_Wb Z_h[Yj_ed$ ?j kikWbbo fWii[i j^[ jkX[h fhef[h
eh XWh[bo jekY^[i _ji Wdj[h_eh Wif[Yj$ J^_i _cfbWdj"
[_j^[h Xo _ji[b\ eh _d Yed`kdYj_ed m_j^ W Z_ijWb 8E?
_cfbWdj" YWd Wiikc[ j^[ jWia e\ jhWdic_jj_d] j^[
e\ j^[ cWii[j[h WdZ j[cfehWb ckiYb[i$ :k[ je j^[
fhedekdY[Z Wd]kbWj_ed ]_l[d je j^_i _cfbWdj" j^[
ikf[hijhkYjkh[_ikikWbboWjjWY^[ZXoiYh[m_d]_jed"
[l[d _\ _j YWd X[ Y[c[dj[Z je j^[ Wdj[h_eh _cfbWdji
Wjj^[iWc[j_c[$?diec[WdWjec_YWbi_jkWj_edi"j^[
jh[Wjc[djh[ikbjm_bbX[ckbj_#Yehj_YWbWdY^ehW][e\
j^[_cfbWdj_dj^[Wbl[ebWhXed[_\ij_bbfh[i[dj"j^[
fWbWjWbXed["j^[eiif^[de_ZWb[WdZj^[Z_ijWbmWbb
e\ j^[ cWn_bbWho i_dki h[if[Yj_l[bo$ 7 YecX_dWj_ed
e\ j^[i[ h[ikbji i^ekbZ X[ Yedi_Z[h[Z Yehh[Yj WdZ
kikWbbo[njh[c[boijWXb[$

#(!04%2È
&UNCTIONALÈ0ROSTHODONTICÈ4REATMENTÈÈ
ANDÈ2ESTORATIONÈOFÈTHEÈ6ERTICALÈ
$IMENSIONÈINÈ#RANIOMANDIBULARÈ$ISEASE
È
)NTRODUCTION
?cfbWdji ^Wl[ X[[d m_Z[bo ki[Z je ikffehj \_n[Z
fheij^[j_Y h[ijehWj_edi i_dY[ j^[ [Whbo '/.&i$
?cfbWdjebe]_YWbjh[Wjc[djefj_edim[h["WdZij_bbWh["
W^_]^boYedjhel[hi_Wb_iik[_di_jkWj_ediY^WhWYj[h_p[Z
Xo WZlWdY[Z h_Z][ h[iehfj_ed WdZ i[l[h[ \ehci
e\ f[h_eZedj_j_i$ 7\j[h Wbb" j^[i[ YedZ_j_edi kikWbbo
_dlebl[ Xej^ j^[ cWn_bbW WdZ j^[ cWdZ_Xb[" WdZ
Zoi\kdYj_edi WiieY_Wj[Z m_j^ beii e\ j^[ l[hj_YWb
Z_c[di_edWh[hekj_d[bofh[i[dj$
?dj^_iY^Wfj[h"m[m_bbZ[iYh_X[^emj^[jh[Wjc[dj
YedY[fj \eh j^[ h[^WX_b_jWj_ed e\ j^[i[ fWj_[dji ^Wi
[lebl[Z" WdZ m[ m_bb Z_iYkii j^[ Ykhh[dj b_j[hWjkh[
ed j^[ ikX`[Yj$ J^[ Yb_d_YWb [nf[h_[dY[ j^Wj ^Wi
X[[d Yebb[Yj[Z m_j^ Zoi\kdYj_edWb fWj_[dji _i
Yedi_ij[dj m_j^ j^[ bed]#j[hc [nf[h_[dY[ WlW_bWXb[
\eh Yedl[dj_edWb jeej^#ikffehj[Z h[ijehWj_edi _d
j^[i[i_jkWj_edi$
>Wl_d]iW_Zj^Wj"ekhd[mbo]W_d[ZWX_b_jojejh[Wj
i_jkWj_edi e\ WZlWdY[Z h_Z][ h[iehfj_ed m_j^ 8E?
_cfbWdji^Wi"_dcWdoYWi[i"i_]d_\_YWdjbohW_i[Zj^[
ijWa[i m_j^ h[]WhZ je j^[ Yecfb[n_jo e\ fheij^[j_Y
c[Wikh[id[[Z[Zjeh[ijeh[\kdYj_edWdZcWij_YWj_ed$
J^[i[ h[gk_h[c[dji _dYbkZ[ f^oi_ej^[hWf[kj_Y
Wffb_YWj_ediWdZj^[YWhho_d]ekje\m^WjYec[iZemd
je W l[h_jWXb[ ¼mWba_d] iY^eeb½ \eh j^[ cWij_YWjeho
WffWhWjki$ J^[ Yedl[dj_edWb WffheWY^ ki[Z _d j^[
h[YedijhkYj_ed e\ dWjkhWb j[[j^ _i \h[gk[djbo dej Wd
efj_edX[YWki[_j_iWbbXkj_cfeii_Xb[jeWZ`kijj^[
cWij_YWjehofWjj[hd_dWd_cc[Z_Wj[WdZikijW_dWXb[
cWdd[h$ J^_i _i" Wced] ej^[h \WYjehi" Zk[ je j^[
d[mbo ]W_d[Z \kdYj_edWb ij_ckb_ _d\bk[dY_d] j^[
ifWj_Wb fei_j_edi e\ j^[ _cfbWdj X[Zi WdZ _dZkY_d]
d[mXed[\ehcWj_ed$
JhWZ_j_edWbbo" jh[Wjc[dj m_j^ Z[djWb _cfbWdji
^Wi X[[d h[]WhZ[Z Wi YedjhW_dZ_YWj[Z _d j^[
fh[i[dY[ e\ c_Z\WY[ fW_d" ^[WZWY^[i _dYbkZ_d]
eYY_f_jWb ^[WZWY^[i" Zoi\kdYj_edi" fWhW\kdYj_edi
eh Zoi]dWj^_W$ J^_i l_[m" m^_Y^ ^Wi X[[d Yh_j_Y_p[Z
fh[l_ekiboIfW^d'/./"'//,"Whei[\hecj^[\WYjj^Wj
WbbWjj[dZWdjiWjj^[<hWda\khj9edi[diki_dlWh_WXbo
ki[ZYh[ijWb_cfbWdjioij[ci$?dZ[[Z"j^[cW`eh_joe\
Wjj[dZWdji ki[Z h[celWXb[ h[ijehWj_edi Wj j^[ j_c["
 ¬ 
WdZ iec[ e\ j^[c [l[d meha[Z m_j^ f[h_eZedjWbbo
ikffehj[Z Z[djkh[i$ J^_i _i Z[if_j[ j^[ \WYj j^Wj
\_n[Z _cfbWdj#ikffehj[Z h[ijehWj_edi Wh[" m_j^ekj
[nY[fj_ed"j^[ceij[\\[Yj_l[c[j^eZjeh[^WX_b_jWj[
fWj_[dji m_j^ Zoi\kdYj_edi$ CkYeiW#ikffehj[Z
h[ijehWj_edi Wh[ Z[b[j[h_eki je j^[ _dj[]kc[djWb
ijhkYjkh[i WdZ m_bb j^[h[Xo YWki[ j^[ Xed[ lebkc[
je X[ \khj^[h h[ZkY[Z WdZ j^[ fheij^[j_Y ijhkYjkh[
jeh[Y[Z["[l[djkWbboh[ikbj_d]_dbeiie\j^[l[hj_YWb"
iW]_jjWbWdZbWj[hWbZ_c[di_edi$
J^[ fhejeYeb m[ ^Wl[ WZefj[Z _d ekh fhWYj_Y[ je
jh[Wj fWj_[dji m_j^ YhWd_ecWdZ_XkbWh Zoi\kdYj_ed
9C:_iZ[iYh_X[Z_dj^[\ebbem_d]fW][i$?dWbceij
Wbb e\ j^[i[ fWj_[dji" j^[ Yehh[Yj l[hj_YWb WdZ bWj[hWb
Z_c[di_edi ^Wl[ X[[d beij Wj j^[ X[]_dd_d] e\
jh[Wjc[dj$Iec[e\ekhfWj_[dji^WZfW_d\kbiocfjeci
e\ coeWhj^hefWj^o m_j^ i_]d_\_YWdjbo h[ZkY[Z JC@
\kdYj_ed" Wbie _dlebl_d] jhWdi_[dj [f_ieZ[i e\ jejWb
beiie\JC@\kdYj_edZk[je`Wcc_d]ehf[hcWd[dj
cWbfei_j_ed_d] m_j^ eh m_j^ekj eXijhkYj_ed e\ j^[
h[fei_j_ed_d]fWj^mWo$Iec[e\j^[[n_ij_d]ehfWij
cWb\kdYj_edicWoX[Z_W]dei[Zedj^[fWdehWc_YN#
hWoi[[9^Wfj[h'&\ehZ_W]deij_YZ[jW_bi$M^Wj_iXo
\Whceh[Z_\\_YkbjjeZ_W]dei[_ij^[_\_j_ifeii_Xb[
WjWbb_ij^[h[b_WX_b_joe\j^[Yecfb_WdY[$CWdo9C:
fWj_[djii[[cjeWZWfjjeWd[m_djhW#ehWbi_jkWj_ed
_cc[Z_Wj[boÄ_ji[[cijeX[j^[_hijhWj[]o_db_\["dej
jeYecfbW_dWdZjei^emeX[Z_[dY[_dj^[fh[i[dY[
e\ Zec_dWj_d] f[hiedi$ 7 Z[dj_ij Y[hjW_dbo m_bb X[
ikY^ W f[hied$ J^_i cWa[i \kdYj_edWb j^[hWfo eh
Wdoj^[hWfom^_Y^h[gk_h[iYecfb_WdY[WdZZ[jW_b[Z
h[fehje\Y^Wd][igk_j[Z_\\_Ykbj$
È
#LINICALÈ!PPROACH
J^[if[Yjhkce\Z_W]deij_Y[nWc_dWj_edif[h\ehc[Z
jel[h_\oYWi[ie\coeWhj^hefWj^o_ib_ij[ZX[bem$L[ho
e\j[d"^em[l[h"_jZe[idejjWa[Wbbe\j^[i[\WYjehije
[ijWXb_i^j^[Z_W]dei_i$J^[\ebbem_d]fe_djid[[Zje
X[Yedi_Z[h[Z_dj^[Yb_d_YWb[nWc_dWj_ed0
v 7XdehcWb cel[c[dj fWjj[hdi _d ibem cekj^
ef[d_d]WdZYbei_d]
v <h[dkbkc fei_j_ed e\ j^[ kff[h WdZ bem[h b_fi$
<W_bkh[ e\ j^[ \h[dkb_ je Ye_dY_Z[ _d j^[ l[hj_YWb
(). 9^Wfj[h'-È &UNCTIONALÈ0ROSTHODONTICÈ4REATMENT

fbWd[ _dZ_YWj[i j^Wj j^[ JC@i Wh[ \kdYj_edWbbo W_ZWh[edboki[\kb_\j^[fWj_[djh[fehjifW_d$J^[o

Z_ifbWY[Z$J^_ii_jkWj_edh[gk_h[ijh[Wjc[djkdb[ii Wh[dejd[Y[iiWho_dj^[fh[i[dY[e\fWj^ebe]_YWb
j^[ \kdYj_ed _i iocc[jh_Y$ 9Wl[ Iec[ fWj_[dji \_dZ_d]iWiZ[\_d[ZWXel[$
m^e ^Wl[ fh[l_ekibo kdZ[h]ed[ ehj^eZedj_Y :_\\[h[dj_Wb Z_W]dei_i W]W_dij iekhY[i e\ iocf#
jh[Wjc[dj cWo i^em Yedi_Z[hWXb[ c_Zb_d[ i^_\ji jeci ekji_Z[ j^[ fhel_dY[ e\ Z[dj_ijho _i Wbie
j^Wj i^ekbZ dej X[ h[WZ`kij[Z Xo fheij^[j_Y d[Y[iiWho$
c[Wdi$ )$ J^[\kdYj_edWbWdZeYYbkiWbi_jkWj_ed_iWdWboi[Z$
v C_Zb_d[i^_\j_dYbkZ_d]i_jkWj_edie\W][d[i_iWdZ J^_i cWo h[gk_h[ W ceZ[b WdWboi_i WdZ JC@
[njhWYj_ed h[]_ijhWj_ed$ M^Wj[l[h j^[ YWi[ cWo X[" Yb_d_YWb
v C_]hWj_ed e\ j[[j^ WdZ%eh Xed[ i[]c[dji _d j^[ [lWbkWj_ed e\ j^[ cWij_YWjeho \kdYj_ed _i W
mWa[ e\ [njhWYj_edi WdZ%eh kd_bWj[hWb ki[ e\ j^[ c_d_ckch[gk_h[c[dj$7dej^[hfWhWc[j[hjeX[
cWij_YWjehoioij[c [lWbkWj[Z _i j^[ ^WX_jkWb `Wm feijkh[ _d \kdYj_ed
WdZWjh[ij$J^[j[b[hWZ_e]hWf^cWofhel_Z[ki[\kb
7ZZ_j_edWb fWhWc[j[hi j^Wj cWo X[ [lWbkWj[Z _d\ehcWj_ed ed j^_i fWhWc[j[h Wi m[bb$ Dej[ j^Wj
_dYbkZ[0 JC@#h[]_ijhWj_ed cWo X[ ik_jWXb[ je WdWboi[ j^[
v Fei_j_ed e\ YedZob[i h[bWj_l[ je j^[ Whj_YkbWh fh[i[dj Z_i[Wi[$ <kdYj_edWb j^[hWfo ^em[l[h
[c_d[dY[i WbmWoiW_ciWjh[ijeh_d]Wd[m\kdYj_edWdZj^_i
v I^Wf[e\YedZob[i m_bb^Wl[kikWbbodej^_d]jeZem_j^j^[h[ikbjie\
v H[bWj_l[i_p[e\Xej^YedZob[i JC@#h[]_ijhWj_ed>_[biY^[h'/,'$
v :[\_d_j_ed e\ Xed[ ijhkYjkh[i _d iakbb ehj^e# JC@iekdZiWh[dejjeeh[b[lWdj\hecj^[Z[dj_ijÉi
fWdjece]hWf^i l_[mfe_dj$ H[i_b_[dY[ j[ij_d] m_bb Wbie fhel_Z[
v Ia[b[jWbfbWd[e\eYYbki_ed_dj[b[hWZ_e]hWf^i ki[\kb_d\ehcWj_ededj^[Ykhh[djh[bWj_l[fei_j_ed
v H[]_edi i^em_d] Z_\\[h[dj_Wb Z[]h[[i e\ e\ j^[ JC@i Wi Z[j[hc_d[Z Xo ckiYkbWh WdZ
c_d[hWb_pWj_ed ia[b[jWb\WYjehi$
v B_d[ \ehcWj_ed ed j^[ bem[h cWdZ_XkbWh cWh]_d
3_dYh[Wi[ZjhW`[Yjeho\ehcWj_ed Ç9hWd_ecWdZ_XkbWhZoi\kdYj_edÇ9C:_iWYebb[Y#
v 7do ej^[h [l_Z[dY[ e\ _dYh[Wi[Z jhW`[Yjeho \eh# j_l[ j[hc \eh Wdo iocfjecWj_Y eh WiocfjecWj_Y
cWj_ed Zoi\kdYj_edWh_i_d]_dYedd[Yj_edm _j^j^[cWij_YWjeho
v H[bWj_l[ Xed[ h[iehfj_ed ed Xej^ YedjhWbWj[hWb eh]Wd WdZ _ji d[_]^Xekh_d] ijhkYjkh[i$ :k[ je
i_Z[i j^[ kdif[Y_\_Y dWjkh[ e\ _ji _d_j_Wb cWd_\[ijWj_edi"
v Fei_j_ed WdZ lebkc[ e\ j^[ b_d[W eXb_gkW _d j^[ j^[ Z_W]dei_i e\ 9C: _i e\j[d cWZ[ j^hek]^ Wd
Z_ijWbcWdZ_Xb[ _dj[hZ_iY_fb_dWho [\\ehj$ ?Z[Wbbo" j^[ Z[dj_ij i^ekbZ
v Fhe]dei_ie\h[i_ZkWbjeej^ijhkYjkh[i YebbWXehWj[ m_j^ W f^oi_ej^[hWf_ij if[Y_Wb_p_d] _d
v ;dZWd][h[ZijhkYjkh[i 9C:IWdZ[h[jWb$'///$
FWj_[dji m^e i^em Yb_d_YWb eh hWZ_e]hWf^_Y
?dYWi[im^[h[[nj[di_l[h[^WX_b_jWj_ed_id[[Z[Z"_j_i [l_Z[dY[ e\ 9C: Z[if_j[ X[_d] WiocfjecWj_Y Wh[
WZl_iWXb[je[lWbkWj[j^[\ebbem_d]fWhWc[j[hiXWi[Z jh[Wj[Z WYYehZ_d] je ijWdZWhZ fhejeYebi Xkj Wh[
edj[b[hWZ_e]hWf^i0 \ebbem[Z kf ceh[ Ybei[bo XWi[Z ed i^ehj[h h[YWbb
v 9WkZWb [nj[di_ed e\ j^[ cWn_bbWho i_dki _dj[hlWbi$ 7do eYYbkiWb WZ`kijc[dji Wh[ cWZ[ _d
if[Y_\_YWbbo\ehZ[\_d_d]j^[eYYbkiWbfbWd[ j^[ f^Wi[ e\ bed]#j[hc fhel_i_edWb_pWj_ed$ J^[o
v EYYbkiWb fbWd[ WdZ _dYb_dWj_ed e\ j^[ Ykhl[ e\ YWd X[ h[Wb_p[Z i_cfbo Xo Yedl[hj_d] j^[ Xh_Z][ je
If[[ Wd eYYbkiWb ifb_dj ki_d] WXhWi_l[ _dijhkc[dji$ J^[
v 7lW_bWXb[Xed[lebkc[_dj^[Wh[We\j^[jkX[hei_jo Xh_Z][YWdX[WZ`kij[Zel[hj^[Yekhi[e\jh[Wjc[dj
\eh fbWdd_d] j^[ ZehiWb Xh_Z][ WXkjc[dj" [$]$ W WdZXk_bjkfm_j^Yecfei_j[Wid[[Z[Z$7YecX_d[Z
jkX[hei_joiYh[m WffheWY^ _dYbkZ_d] Xej^ eYYbkiWb WZ`kijc[dji WdZ
v Ia[b[jWbfbWd[e\eYYbki_ed f^oi_ej^[hWfom_bbi_]d_\_YWdjboh[ZkY[j^[ZkhWj_ed
WdZj^[Yeije\jh[Wjc[dj8kcWdd[jWb$'/./1IWdZ[h
7 fWdehWc_Y hWZ_e]hWf^ e\ j^[ iakbb m_bb fhel_Z[ [jWb$'/./1A[hiY^XWkc[jWb$(&&'$
WZZ_j_edWb_d\ehcWj_eded0 7dej^[hYeccediY[dWh_e_iWdj[h_ehZ_ifbWY[c[dj
v >eh_pedjWbia[b[jWbWiocc[jh_[i e\j^[YedZob[YecX_d[Zm_j^Wm_Z[d[ZZehiWbifWY[
v :_\\[h[dY[i_dckiYb[WjjWY^c[djWh[Wif[Y_\_YWbbo e\ j^[ JC@$ ?d j^_i i_jkWj_ed" j^[h[ _i W Y^WdY[ j^Wj
e\j^[cWii[j[hckiYb[Wjj^[cWdZ_Xb[ j^[ Wdj[h_ehbo Z_ifbWY[Z YedZob[i cWo h[i_ij X[_d]
($ ?d iocfjecWj_Y fWj_[dji" W ijWdZWhZ_p[Z ^[WZ# h[ijeh[Zjej^[Y[djhWbfei_j_edXoimWbbem_d]ehWdo
\WY[ fW_d gk[ij_eddW_h[ I_[X[hj '//( YWd X[ ej^[hcWd_fkbWj_edim^[dÆeYYbkiWbfbWd[h[YehZ_d]Ç
ki[Z Wi Z_W]deij_Y W_Z$ 7 fW_d Z_Who" je X[ a[fj _if[h\ehc[Z$J^[h[Wh[jmecW`eh[nfbWdWj_edi\eh
Xo j^[ fWj_[dji j^[ci[bl[i el[h (Ä*m[[ai" cWo j^_if^[dec[ded$>of[hjed_W_dj^[bWj[hWbfj[ho]e_Z
iec[j_c[iWbieX[ki[\kb$8ej^jof[ie\Z_W]deij_Y ckiYb[ j^Wj \W_b je h[iebl[ _cc[Z_Wj[bo Wh[ j^[
È È #-$
2ELATEDÈ0ROBLEMSÈ!FFECTÈTHEÈ&UNCTIONÈOFÈTHEÈ7HOLEÈ3KELETALÈ3YSTEMÈ
Yecced[ijeXijWYb[$J^[c[j^eZih[Yecc[dZ[Z_d
j^[ b_j[hWjkh[ je h[iebl[ ikY^ ^of[hjed_W _dYbkZ[
f^oi_ej^[hWf[kj_Y Wffb_YWj_edi" h[bWnWj_ed [n[hY_i[i
eh fioY^ejhef_Y Zhk]i" je dWc[ Xkj W \[m$ ?\ j^[i[
c[Wikh[iij_bb\W_bjeh[ijeh[j^[YedZob[ijej^[p[d_j^
fe_dje\j^[cWdZ_XkbWh\eiiW[_dWhWZ_e]hWf^_YWbbo
l_i_Xb[cWdd[h"_j_ij_c[jeYedi_Z[hj^Wjj^[ZehiWb
ifWY[ e\ j^[ JC@ cWo X[ `Wcc[Z =[hX[h '/-&$
Dej[ j^Wj h[fei_j_ed_d] e\ j^[ `e_dji h[gk_h[i iec[
\_nWj_ed e\ j^[ eYYbki_ed Xo _dj[hbeYa_d] Ykifi$ ?d
[bZ[hbofWj_[dji^em[l[hW][#h[bWj[ZWXhWZ[ZeYYbkiWb
ikh\WY[ii^ekbZj^[W_ce\j^[jh[Wjc[dj$M[^WdZb[
j^_i YedjhWZ_Yj_ed Xo _d_j_Wbbo Wia_d] j^[ Z[dj_ij
j[Y^d_Y_WdjeYh[Wj[YkifiWdZfhel_Z[Wj^_Ya[hbWo[h
e\Y[hWc_Yim^_Y^m_bbWbbemceh[]h_dZ_d]m_j^ekj
h[l[Wb_d] jee ckY^ e\ j^[ c[jWb Yeh[ e\ j^[ Xh_Z][
Zkh_d]j^[bWj[h\kdYj_edWbjh[Wjc[dj$
È
0ERSONALITYÈ$ISORDERSÈÈ
ANDÈ0OORÈ#OMPLIANCE
?j _i WbmWoi W ]eeZ _Z[W je WffheWY^ 9C: fWj_[dji
m_j^ iec[ YWkj_ed" i_dY[ dkc[heki ijkZ_[i ^Wl[
_dZ_YWj[Z j^Wj f[hiedWb_jo fheXb[ci Wh[ fh[lWb[dj
_d j^_i ]hekf :meha_d '//+1 Jkha '//-1 EWab[o
[j Wb$ '///1 B[l_jj '//&" m^_Y^ cWo i_]d_\_YWdjbo
W\\[Yjj^[ekjYec[e\jh[Wjc[dj$J^_d]iYWdX[Yec[
fWhj_YkbWhbo jhekXb[iec[ m_j^ WiocfjecWj_Y
9C: fWj_[dji kdm_bb_d] je WYY[fj j^[ dej_ed j^Wj
W iec[m^Wj b[d]j^o j^[hWfo Yedi_ij_d] e\ i[l[hWb
jh[Wjc[dj ij[fi _i d[Y[iiWho$ J^_i cWo h[ikbj _d W
ÆYWjY^ ((Ç i_jkWj_ed" Wi Xej^ Wbj[hdWj_l[i e\ [_j^[h
b[Wl_d]j^[Z[\_Y_[djeYYbkiWbh[bWj_ediWij^[oWh[eh
h[ijeh_d] Yehh[Yj h[bWj_edi cWo b[WZ je Yecfb_WdY[
fheXb[ci$=[d[hWbfhWYj_j_ed[hiWh[kikWbbodej_dW
fei_j_edjei_d]b[ekjWdZh[\ki[jejh[WjikY^fWj_[dji
_d W h[b_WXb[ cWdd[h$ J^[ fheXb[c _d m[bb ademd
_d ekh fhe\[ii_ed$ ?j ^Wi X[[d ik]][ij[Z je ^Wl[
Wbb fWj_[dji WXekj je kdZ[h]e cW`eh h[^WX_b_jWj_ed
Yecfb[j[ W ijWdZWhZ_p[Z gk[ij_eddW_h[" ie j^Wj j^[
Z[dj_ijZe[idej^Wl[jeh[boedÆi_]^jZ_W]dei_iÇWi
j^[ ieb[ Yh_j[h_ed IWdZ[h [j Wb$ '/./$ J^[ fWj_[djÉi
b_\[bed] Yecfb_WdY[ _i WXiebkj[bo [ii[dj_Wb je j^[
bed]#j[hcekjYec[e\_cfbWdjj^[hWfo$
J^[ h[gk_h[c[dj j^Wj _cfbWdj fWj_[dji ckij X[
iWd[ WdZ h[b_WXb[ ]e[i \Wh X[oedZ j^[ _d_j_Wb f^Wi[
e\_dijWbb_d]j^[_cfbWdj#h[ijehWj_edYecfb[n$J^[i[
\WYjehi ckij h[cW_d _djWYj [l[d _\ j^[ fWj_[djÉi
Y_hYkcijWdY[icWoY^Wd][_$[$_\^[ehi^[X[Yec[i
2ELATEDÈ0ROBLEMSÈ!FFECTÈTHEÈ&UNCTIONÈ
b[ii ceX_b[" c[djWbbo Wb[hj" m[bb i_jkWj[Z" [jY$ eh
_\ Wdo ej^[h i_jkWj_edi Wh_i[ j^Wj mekbZ dehcWbbo
_dZkY[^_ceh^[hjem_j^ZhWm\hecjh[Wjc[dj$?j_i
l[hoZ_\\_Ykbjje_Z[dj_\ofWj_[djim^eh[Wbboi^ekbZX[
[nYbkZ[Z\hecjh[Wjc[djedj^[i[]hekdZiX[YWki["
WjWj_c[m^[dj^[oWh[[Z[djkbekiWdZj^kiWYkj[bo
()/
_d d[[Z e\ j[[j^" [l[d j^ei[ m^e ^Wl[ de _dj[dj_ed
e\\kbboYecfbo_d]m_bbX[[W][hjefh[j[dZj^Wjj^[o
m_bb h[b_WXbo eXi[hl[ Wbb h[YWbb Wffe_djc[dji Zemd
j^[heWZ$?j_ij^[h[\eh[[ii[dj_Wbj^Wjj^[i_]d_\_YWdY[
e\ W Yecfb[n h[^WX_b_jWj_ed fheY[ii _i [nfbW_d[Z _d
kd[gk_leYWb j[hci [l[d X[\eh[ j^[ \_hij jh[Wjc[dj
ij[fiWh[jWa[d$
?j _i dej kdYecced j^Wj _d[nf[h_[dY[Z" ^eij_b[
eh [dl_eki Yebb[W]k[i Wjj[cfj je m_j^ZhWm fWj_[dji
Ä m^e ^Wl[ WYjkWbbo X[[d iWj_i\_[Z kf je j^_i fe_dj
Ä \hec j^[ \ebbem#kf h[]_c[d W\j[h ikYY[ii\kb
_cfbWdjj^[hWfo_dehZ[hjecWa[iec[ced[om_j^
j^[i[ fWj_[dji W\j[h Wbb$ ?d j^[ mehij#YWi[ iY[dWh_e"
j^[ocWa[j^ei[fWj_[djiX[b_[l[j^Wjj^[fheij^[j_Y
eh _cfbWdj jh[Wjc[dj ^Wi dej X[[d f[h\ehc[Z
fhef[hbo$Iec[e\j^[i[fWj_[djim_bbj^[djWa[b[]Wb
WYj_ed" j^_da_d] j^Wj j^[o Wh[ [dj_jb[Z je ZWcW][i$
?dj[h[ij_d]bo"deb[]WbWYj_ed^Wi[l[hX[[djWa[dXo
Wdo ed[ e\ ekh fWj_[dji m^e [nf[h_[dY[Z fheXb[ci
m_j^j^[_h_cfbWdji$J^[h[^Wl[X[[diec[fWj_[dji"
^em[l[h" m^e jeea b[]Wb WYj_ed Wbj^ek]^ j^[_h
_cfbWdj jh[Wjc[dj ^WZ X[[d fheY[[Z_d] WYYehZ_d]
je iY^[Zkb[$ J^[o [l[djkWbbo \W_b[Z X[YWki[ j^[_h
YbW_cim[h[kd\ekdZ[Z$7bbj^[i[YWi[im[h[Zk[je
c_iYekdi[bb_d]XoYecf[j_j_l[boc_dZ[ZZ[dj_iji$
J^[[l[djie\''I[fj[cX[h(&&'^Wl[cWZ[_jYb[Wh
je[l[hoXeZo^em[Wio_j_ijeZ[ijheoijhkYjkh[ij^Wj
^Wl[ X[[d [h[Yj[Z m_j^ ]h[Wj [\\ehj$ 8o j^[ iWc[
jea[d" [begk[dj Yebb[W]k[i m_bb WbmWoi X[ WXb[ je
fh[lW_b ed ]kbb_Xb[ fWj_[dji je Z_iYedj_dk[ W Yekhi[
e\ jh[Wjc[dj [l[d j^ek]^ j^[i[ fWj_[dji i^ekbZ
h[WbboX[]hWj[\kb\ehj^[]eeZfhe]h[iicWZ[_dj^[_h
Z[djWb h[^WX_b_jWj_ed$ ?d ekh [nf[h_[dY[" j^[ iekhY[
e\ ikY^ c_iYekdi[bb_d] ^Wi kikWbbo X[[d kd_l[hi_jo
Z[dj_ijim^ebWYaj^[h[gk_i_j[[nf[h_[dY[WdZ^Wl[
deb_WX_b_joeXb_]Wj_edim^Wjie[l[hYedY[hd_d]j^[_h
fhWYj_YWb meha WdZ Yekdi[bb_d] WYj_l_j_[i$ FWj_[dji
ckijh[Y[_l[WYb[WhmWhd_d]dejjejhkijj^[WZl_Y[
e\ j^[i[ Z[dj_iji$ I[[ Wbie 9^Wfj[h(,$,$ \eh ceh[
Z[jW_bi$J^[h[^Wl[X[[dikYY[ii\kbbWmYWi[iW]W_dij
j^_i jof[ e\ c_iYekdi[bb_d]$ Dej[" ^em[l[h" j^Wj
kd_l[hi_j_[im^eWh[edj^[fWohebbe\Yh[ijWb_cfbWdj
cWdk\WYjkh[hiXk_bZcW\_W#b_a[YeWb_j_edim_j^iec[
fhWYj_j_ed[hiW]W_diji_d]b[ZeYjehijh[Wj_d]fWj_[dji
Z_\\[h[djbo WdZ ikYY[ii\kbbo$ J^_i _i jhk[ e\ \eh Wbb
c[Z_YWb if[Y_Wbj_[i WdZ e\j[d Wbie _dikh[hi ^ebZ
iec[XWZYWhZi_dj^_i]Wc[$
È
#-$
OFÈTHEÈ7HOLEÈ3KELETALÈ3YSTEM
J^[h[Wh[jme]hekfie\9C:#h[bWj[ZfheXb[ci0
v FeijkhWbfheXb[cih[ijfei_j_ede\cWdZ_Xb["h[ij
fei_j_ede\YhWd_kc
v <kdYj_edWbfheXb[ci
(*& 9^Wfj[h'-È &UNCTIONALÈ0ROSTHODONTICÈ4REATMENT
J^[ bWjj[h ]hekf YWd X[ \khj^[h ikXZ_l_Z[Z _dje
Yehh[Yjfeijkh[Wjh[ijl[hikii_jkWj_edi_dm^_Y^j^[
feijkh[ _i _dYehh[Yj [l[d _d h[ij fei_j_ed$ 9ehh[Yj
\kdYj_ed _d j^[ fh[i[dY[ e\ Wd _dYehh[Yj feijkh[ Wj
h[ij_idejeXi[hl[Z_dfhWYj_Y[$
?d ej^[h mehZi0 ?\ j^[ h[ijehWj_ed _i _dYehh[Yjbo
XWi[Z ed j^[ h[ij fei_j_ed e\ j^[ `Wmi" Yehh[Yj
XWbWdY[Z \kdYj_ed m_bb d[l[h X[ WY^_[l[Z$ J^_i
_i m^o cWdo h[ijehWj_edi h[gk_h[ Yecfh[^[di_l[
c[Wikh[i _d Xej^ `Wmi$ Kd\ehjkdWj[bo" j^_i a_dZ e\
jh[Wjc[dj_idebed][hX[_d]Yedi_Z[h[ZWffhefh_Wj[
WdZ [Yedec_YWb Xo ^[Wbj^ _dikh[hi" WdZ _j ckij
_dYh[Wi_d]boX[dej[Zj^Wjj^[j[hciWdZYedZ_j_edi
e\^[Wbj^_dikhWdY[YedjhWYjidebed][hfhel_Z[\eh
eh\WY_b_jWj[j^[jh[Wjc[djm_j^ceh[Yecfb[n\_n[Z
h[ijehWj_edi$
J^[h[Wiedi\ehfeijkhWbfheXb[ciYWddejWbmWoi
X[ jhWYa[Z Zemd$ J^[ ceij b_a[bo [nfbWdWj_ed" Wi
_d ej^[h iodZhec[i W\\[Yj_d] `e_dji WdZ Xed[i" _i
kdh[iebl[ZfheXb[cij^Wj^Wl[X[[dh[fh[ii[Z\hec
YediY_ekid[ii$ J^[ h[ikbjWdj Wdn_[j_[i ]_l[ h_i[ je
WXdehcWbfioY^eiecWj_YijWj[ie\j[di_edj^WjcWo
cWd_\[ij j^[ci[bl[i _d gkWdj_jWj_l[bo WXdehcWb
\kdYj_ed e\ ckiYb[i WdZ ckiYb[ ]hekfi$ ?j _i m[bb
ademd j^Wj ijh_d][dj hkb[i" m^[j^[h _cfei[Z eh
i[b\#_cfei[Z"WdZX[^Wl_ekhWbfWjj[hdiYWd]_l[h_i[
je kdf^oi_ebe]_YWb ijWj[i e\ j[di_ed$ 9C: fWj_[dji
i[[cjeZ[l[befWl[hoif[Y_WbijhWj[]oe\WZWfjWj_ed
jeY^Wd][i$
J^[i[feijkhWbfheXb[cim_bbX[Yec[cWd_\[ij_d
j^[\ehce\jeej^c_]hWj_edh[bWj_l[boieedWdZm_bb"
_d[\\[Yj"X[f[hf[jkWj[ZXoj^_iZ[l[befc[dj$Kdb[ii
j^[fWj_[dj_iWXb[jeh[ijeh[WdZcW_djW_dWdWYj_l["
f^oi_ebe]_YWb \kdYj_edWb fWjj[hd e\ ^_i eh ^[h emd
WYYehZ"j^[i_jkWj_ed^WijeX[h[c[Z_[ZXoY^W_hi_Z[
\kdYj_edWb_dj[hl[dj_ed$
?dj^[K$I$"jeffei_j_edi_d_dZkijhoWdZXki_d[ii
Wh[e\j[de\\[h[ZjeijkZ[djim^e"Zkh_d]j^[_ho[Whi
_d Yebb[][" [nY[bb[Z _d ifehji WdZ f^oi_YWb WYj_l_j_[i
ÄWdZj^_i[l[d_\j^[_h]hWZ[iWh[ej^[hm_i[_d\[h_eh
je j^ei[ e\ ej^[h ijkZ[dji$ Ed[ e\ j^[ j^_d]i j^Wj
Y^WhWYj[h_p[ j^[i[ ifehji#eh_[dj[Z ijkZ[dji _i i[b\#
Wii[hj_edWdZj[Wcif_h_jWiWYWjWboijXej^f[hY[_l[Z
WiX[_d]j^[effei_j[e\WZWfjWX_b_jo$M^Wj_iceh[0
j^_i]hekfi^emib[ii_dj[hdWbj[di_edWdZj^[h[\eh[
b[iiZ_ii_fWj_ede\f[hiedWb[d[h]o$J^[ocWoYec[
^ec[j_h[ZWjd_]^j"Xkjj^[oWh[j_h[Z\hecj^[_hmeha"
dej \hec ^Wl_d] je a[[f kf j^[ WZWfj_l[ j[di_ed$
Kd\ehjkdWj[bo"j^_ih[Ye]d_j_ed^Wio[jjeh[WY^ekh
iY^eebi" \eh j^[ ceij fWhj$ Ed j^[ YedjhWho0 Ceh[
WdZ ceh[ÆYhWcc_d]Ç _i [nf[Yj[Z \hec ijkZ[dji Wj
W l[ho [Whbo W][" h[gk_h_d] ceh[ WdZ ceh[ ^ekhi W
ZWom^[dijkZ[dji^Wl[jei_jij_bbedj^[_hY^W_hi_dW
ceijkdf^oi_ebe]_YWbcWdd[h$J^[_hoekj^\kbXeZ_[i
mekbZWYjkWbboh[gk_h[j^[[nWYjeffei_j[0J^[cW_d
]hemj^ f^Wi[i h[gk_h[ W bej e\ f^oi_YWb [n[hj_ed"
kd_cf[Z[ZXoc[djWbijh[ii"_dehZ[h\ehj^[fhef[h
]hemj^_cfkbi[ic[Z_Wj[ZXoj^[ckiYb[ij^WjWh[
kbj_cWj[boh[ifedi_Xb[\ehYh[Wj_d]j^[iocc[jhoe\
j^[Xed[ijeX[i[djm_j^ik\\_Y_[dj_dj[di_jo$C[djWb
ij_\\d[ii m_bb h[ikbj _d ckiYkbWh ij_\\d[ii$ CkiYkbWh
ij_\\d[ii m_bb i^Wf[ j^[ Xed[ _d Wd kdf^oi_ebe]_YWb
cWdd[h" WZl[hi[bo W\\[Yj_d] j^[ \bem e\ XbeeZ WdZ
dkjh_[dji _d j^[ h[]_edi eh eh]Wdi W\\[Yj[Z Xo j^[
j[di_ed j^Wj WYYecfWd_[i j^[ ij_\\d[ii$ ?j _i dej
m_j^ekj h[Wied j^Wj ieY_[j_[i [n[hj_d] [njh[c[
c[djWb fh[iikh[ ed j^[_h oekj^ \eh [nWcfb[ _d
@WfWdWh[Y^WhWYj[h_p[ZXo^_]^\W_bkh[hWj[iWced]
WZkbji" m_j^ de f^oi_YWb h[i[hl[ X[_d] WlW_bWXb[ je
Yecf[diWj[ \W_bkh[ Wj meha$ <eh ceh[ Z[jW_bi WXekj
j^_icWjj[h"fb[Wi[h[\[hjemmm$ijo\ebe]_[#Y[dj[h$Y^$
J^Wj j^[i[ \WYjehi Wh[ _dj[hh[bWj[Z _i dej
_cc[Z_Wj[boWffWh[djWjWoekd][hW]["i_dY[ijhed]
]hemj^ _cfkbi[i e\\[h cWdo effehjkd_j_[i \eh
Yecf[diWj_ed WdZ i_dY[ j^[ ijhed] oekj^\kb j_iik[
jed[ [Wi_bo Yel[hi j^[ kdZ[hbo_d] Wiocc[jh_[i$
<kdYj_edWb eXi[hlWj_ed" ^em[l[h" m_bb _cc[Z_Wj[bo
h[l[Wb j^[ Yehh[Yj Z_W]dei_i je j^[ [nf[h_[dY[Z
Yb_d_Y_Wd$ 7iocc[jh_YWb \kdYj_ed _i Wd _cfehjWdj
h[Wied m^o cWdo Z[djWb h[ijehWj_edi Wh[ beij" m_j^
j^[dWjkhWbj[[j^WdZj^[ikhhekdZ_d]j_iik[iX[_d]
WXb[ je m_j^ijWdZ j^[ Y^Wbb[d][ ckY^ bed][h j^Wd
Z[djWb_cfbWdjiWdZj^[f[h_#_cfbWdjXed[$
Fei_j_edWb WdecWb_[i e\ j^[ `Wmi WdZ Z[dj_j_ed
Wh[ fhed[ je ÆY[c[dj_d]Ç Wiocc[jh_YWb \kdYj_edWb
[nYkhi_ed fWj^i$ J^_i Ze[i dej c[Wd" ^em[l[h" j^Wj
Z[djWb jh[Wjc[dj W_c[Z Wj cWij_YWjeho \kdYj_ed
YWdÆ^[WbÇ f^oi_YWb Z_i[Wi[i [bi[m^[h[ _d j^[ XeZo"
Wj W Z_ijWdY[ e\ W cWij_YWjeho eh]Wd$ >em[l[h" _\
\kdYj_edWbXbeYaie\j^[cWij_YWjehockiYb[iWdZj^[
h[b[Wi[e\XbeYa[ZfWj^mWoie\cel[c[djYWd]h[Wjbo
ikffehj j^[ h[iebkj_ed e\ XbeYa[Z ckiYb[i WdZ j^[
h[ijehWj_ed e\ \h[[Zec e\ ckiYkbWh cel[c[dj
j^hek]^ekj j^[ h[ij e\ j^[ XeZo7dZ" dej je \eh][j"
Wdo j_c[ W b_c_jWj_ed _i h[cel[Z" j^_i m_bb ]h[Wjbo
[d^WdY[j^[fWj_[djÉim[bb#X[_d]$
È
)NITIALÈ4REATMENT
J^[ jh[Wjc[dj h[gk_h[c[dji _d j^[ fh[i[dY[ e\
h[i_ZkWb Z[dj_j_ed m_bb kikWbbo _dlebl[ W Yecfb[n
XkdZb[e\[dZeZedj_Y"fheij^eZedj_YWdZf[h_eZedjWb
YedY[hdi$?dj^[[dZeZedj_YWh[dW"_j_ikikWbboWf_YWb
fheY[ii[i [nWY[hXWj[Z Xo eYYbkiWb jhWkcW j^Wj
d[[Z je X[ jh[Wj[Z$ Fheij^eZedj_Y YedY[hdi _dYbkZ[
fWhj_Wbbo [Z[djkbeki i_jkWj_edi" _dlebl_d] j^[ d[[Z
\eh jeej^ [bed]Wj_ed WdZ ^[dY[ j^[ jh[Wjc[dj e\
cWbeYYbki_ed$ M_j^ h[]WhZ je f[h_eZedjebe]o" j^[
i_jkWj_ed_i\h[gk[djboY^WhWYj[h_p[ZXo_d\bWccWj_edi
_$[$Yecfb[nf[h_eZedj_j_i[nWY[hXWj[ZXokdf^oi_e#
be]_YWbbeWZ_d]fWjj[hdi$
È È )MPLANTÈ4REATMENTÈ
M^[h[ fh[#jh[Wjc[dj e\ j^[ f[h_eZedj_kc
_i Yedi_Z[h[Z d[Y[iiWho Wj Wbb" ekh feb_Yo _i je
ced_jeh _d W hWf_Z ikYY[ii_ed e\ l_i_ji [$]$ \_l[
i[ii_edi _d j^[ \_hij m[[a$ Ej^[h j^Wd j^Wj" ekh
WYj_l_j_[i h[cW_d Yed\_d[Z je YWh[\kb iYWb_d] WdZ
heej fbWd_d]" Wi_Z[ \hec Wdo [dZeZedj_Y c[Wikh[i
eh [njhWYj_edi je X[ f[h\ehc[Z _d ^[Wl_bo _d\[Yj[Z
Wh[Wi$ :W_bo kbjhWiekdZ jh[Wjc[dj _d j^[ \_hij m[[a
e\ jh[Wjc[dj m_bb gk_Yabo [b_c_dWj[ Wdo fWj^e][d_Y
YecX_dWj_edi e\ c_Yheeh]Wd_ici WdZ i_]d_\_YWdjbo
h[ZkY[ j^[ Xb[[Z_d] _dZ[n WdZ h[Z_h[Yj_d] j^[ \bem
e\ XbeeZ _d j^[ ckYeiW WdZ ekj e\ j^[ Xed[$ J^[
_d\bWccWj_ed j[dZ[dYo e\ j^[ f[h_eZedj_kc Wi W
m^eb[ _i j^ki h[ZkY[Z" WdZ j^[ ZkhWj_ed e\ j^[
i_d]b[#ij[f Z[\_d_j_l[ h[^WX_b_jWj_ed m_bb X[ i^ehj[h$
J^_i YecX_dWj_ed e\ W i^ehj fh[jh[Wjc[dj iY^[Zkb[
WdZWed[#ij[fh[ijehWj_l[fheY[Zkh[m_bbWbie[dikh[
j^Wj j^[ fWj_[djÉi cej_lWj_edWb l[hl[ _i dej mehd
Zemd$?\Wbbj[[j^Wh[[njhWYj[Z"Wdof[h_eZedjWbfh[#
jh[Wjc[dj _i kdd[Y[iiWho$ ?d iec[ YWi[ [njhWYj_ed
cWoX[f[h\ehc[Z[Whb_[h"[if[Y_Wbbom^[dj^[]kci
Wh[[njh[c[bo_d\[Yj[ZWdZ[nY[ii_l[Wk]c[djWj_ed_i
fWhje\j^[jh[Wjc[djfbWd$
È
)MPLANTÈ4REATMENT
J^[ _cfbWdjWj_ed fheY[Zkh[ _i Wd _dZ_if[diWXb[
fWhje\j^[[Whbojh[Wjc[djf^Wi[_dehZ[hjeYh[Wj[
ijWXb[YedZ_j_edi\eh9C:#jh[Wjc[dj$J^_ijh[Wjc[dj
YedY[fj _i j^ki l[ho Z_\\[h[dj \hec fh[l_ekibo ki[Z
fhejeYebi h[bo_d] ed ed[ eh i[l[hWb _dj[hc[Z_Wj[
h[celWXb[ h[ijehWj_edi _d ehZ[h je ÆijWX_b_p[
eYYbki_edÇ" YecX_d[Z m_j^ ifb_dj j^[hWfo <[kh[h
'///$J^[Z[cWdZ_cfb_[Z_dj^ei[fh[l_ekiYedY[fji
j^Wjj^[Y^[m_d]\kdYj_edi^ekbZX[ijWX_b_p[Zfh_eh
je _cfbWdj jh[Wjc[dj YWddej feii_Xbo X[ c[j _d
j^[ fh[i[dY[ e\ WZlWdY[Z h_Z][ h[iehfj_ed" i_dY[
WY^_[l_d]ikY^ijWX_b_jo_i_dYecfWj_Xb[m_j^m[Wh_d]
W Z[djkh[$ 7\j[h Wbb" j^[ \kdYj_ed e\ j^[ jed]k[
WdZ Y^[m_d] ckiYb[i _d fWj_[dji m[Wh_d] Z[djkh[i
m_bb WbmWoi X[ cW_dbo Z_h[Yj[Z Wj imWbbem_d] \eeZ
m_j^ekjimWbbem_d]j^[Z[djkh[$
7i W c_d_ckc h[gk_h[c[dj _d j[hci e\ jeej^
[njhWYj_ed" j[[j^ j^Wj YWddej feii_Xbo ^Wl[ Wd
Wkn_b_Who \kdYj_ed _d h[ijehWj_l[ jh[Wjc[dj ckij X[
[njhWYj[Z$M[Zedejh[]WhZ[nY[ii_l[ceX_b_jojeX[
j^[ceij_cfehjWdjYh_j[h_ed\ehZ[Y_Z_d]m^[j^[hW
jeej^i^ekbZX[fh[i[hl[Z$?\j^[ceX_b_jo_ifh_cWh_bo
\kdYj_edWb _d dWjkh[ [nY[ii_l[ beWZ_d]" fh[cWjkh[
YedjWYji" c_Zb_d[ i^_\ji WdZ l[hj_YWb Xed[ beii _i
b_c_j[Z"m[kikWbboZ[Y_Z[jefh[i[hl[j^[jeej^$
J^[ikh]_YWbh[ijehWj_ed"_dYbkZ_d][njhWYj_edWdZ
_cfbWdjWj_ed" _i dehcWbbo f[h\ehc[Z _d W i_d]b[ ?di[hj_d] j^[ _cfbWdji WdZ W \_n[Z h[ijehWj_ed _d
i[ii_ed$ M[ edbo \Wlekh _cfbWdji el[h dWjkhWb j^[ iWc[ i[ii_ed m_bb [dikh[ W Z[\_d[Z fei_j_ed e\
WXkjc[dji_\j[[j^_dWijhWj[]_Yfei_j_edm_j^h[if[Yj j^[ cWdZ_Xb[ h[bWj_l[ je j^[ cWn_bbW$ <khj^[hceh["
(*'
jej^[fbWdd[ZXh_Z][j^WjWh[Wbh[WZof[h_eZedjWbbo
Yecfhec_i[Z mekbZ cWa[ j^[ Xh_Z][ ijhkYjkh[
YebbWfi[_\j^[oWh[beijZemdj^[heWZ$J^_iZ[Y_i_ed
je iWYh_\_Y[ dWjkhWb j[[j^ \eh j^[ iWa[ e\ _cfbWdji
X[Yec[id[Y[iiWhofWhj_YkbWhboe\j[d_dj^[Wh[We\
j^[YWd_d[i$
M^_b[Wbb_cfbWdjih[gk_h[Zjeikffehjj^[Xh_Z][
Wh[ fbWY[Z _cc[Z_Wj[bo" j^[ Z[dj_ij cWo m_i^ je
fh[i[hl[ if[Y_\_Y j[[j^ \eh fhel_i_edWb_pWj_ed WdZ
j^[d [njhWYj j^[c _d j^[ \_dWb ijW][ e\ jh[Wjc[dj$
Dej[j^WjY^Wd][i_dj^[cWij_YWjehofWjj[hdh[gk_h[i
j^[cWij_YWjehojem_j^ijWdZj^[_d_j_Wbj[dZ[dYoe\
h[bWfi[ je ebZ fWjj[hdi$ Iec[j_c[i _j cWo i[[c
WZl_iWXb[jeki[j[[j^WdZj^[_hl[hj_YWb[d]W][c[dj
_d j^[ Xed[ \eh j^_i fkhfei[ WdZ _d W bWj[h h[fbWY[
j^ei[ j[[j^ Xo ^eh_pedjWbbo [d]W][Z 8E? _cfbWdji$
J^_iWffheWY^_iki[Ze\j[d"m^[dijhWj[]_Y_cfbWdj
fbWY[c[dj_iZ[i_h[ZWdZjmeXh_Z][iWh[\WXh_YWj[Z
WdomWo$
:[bWo[Z [njhWYj_edi e\ j^_i jof[ cWo iec[j_c[i
Wbie X[ ki[\kb je W_Z f[h_eZedjWb h[][d[hWj_ed"
[if[Y_Wbbo _\ l[hj_YWb Xed[ beii Wj j^[i[ j[[j^ _i dej
i_]d_\_YWdjWdZ_\jeej^ceX_b_jo_ibem_iYWki[ZXo
Wd eYYbkiWb jhWkcW$ B_c_j_d] \WYjehi \eh j[cfehWho
jeej^ fh[i[hlWj_ed Wh[ Wf_YWb fheY[ii[i [cWdWj_d]
\hec j^[ j[[j^ _d gk[ij_ed j^Wj c_]^j `[efWhZ_p[
j^[d[mbo_dijWbb[Z_cfbWdji$Ceh[el[h"j^_ijof[e\
WffheWY^ _i b_c_j[Z je YWi[i _d m^_Y^ Wj b[Wij jme
Xh_Z][i Wh[ fbWdd[Z kdj_b j^[ h[ijehWj_l[ jh[Wjc[dj
_iZ[\_d_j_l[boYecfb[j[Z$Iec[fWj_[djib_a[jea[[f
WicWdoj[[j^Wifeii_Xb[\ehWibed]Wifeii_Xb[WdZ
j^[o Ze dej YWh[ e\ j^[o ^Wl[ je Xko W d[m Xh_Z][
[l[ho \[m o[Whi$ Ej^[h fWj_[dji \_dWdY_Wb h[iekhY[i
Wh[dejYecfWj_Xb[m_j^j^_ijh[Wjc[djWffheWY^WdZ
_dj^[i[YWi[im[i^ekbZcWa[ikh[jeh[Wbbo[njhWYj
Wbbj[[j^m_j^kdY[hjW_dfhe]dei_i$
J^[f[h_eZedjWbijhkYjkh[iWh[edbobeWZ[Zj^hek]^
\kdYj_edWb WZWfjWj_ed" i_dY[ j^[ ]Wfi Wh[ Ybei[Z
WdZ fej[dj_Wbbo _dj[h\[h_d] \WYjehi Wh[ [nYbkZ[Z Xo
[bed]Wj[ZWdZ_dj[hYkif_ZWj[Zj[[j^ehWdjW]ed_iji$
EX`[Yj_l[ie\j^[\_hijjh[Wjc[djij[f0
'$ H[ijehWj_ed e\ j^[ l[hj_YWb" bWj[hWb WdZ iW]_jjWb
Z_c[di_ediW]W_dijj^[XWYa]hekdZe\WdWjec_YWb
bWdZcWhai j[b[hWZ_e]hWf^" ehj^efWdjece]hWf^
e\j^[[dj_h[iakbb"fei_j_ede\\h[dkb_
($ :[Yecfh[ii_ede\j^[JC@i
)$ F^oi_ebe]_YWbYedZob[fei_j_edi_\feii_Xb[_dj^_i
[Whbof^Wi[
*$ H[iebkj_ed e\ coe\kdYj_edWb fheXb[ci Xo
f^oi_ej^[hWfo WdZ%eh Wdo e\ dkc[heki ej^[h
j[Y^d_gk[i
+$ IjWX_b_pWj_ede\j^[b_]Wc[djWffWhWjki
,$ >WX_jkWb_pWj_ede\\WlekhWXb[\kdYj_edWbfWjj[hdi
(*( 9^Wfj[h'-È &UNCTIONALÈ0ROSTHODONTICÈ4REATMENT
f^oi_ej^[hWf[kj_Y \kdYj_edWb jh[Wjc[dj YWd X[
WZc_d_ij[h[Z_dWYedjhebb[ZcWdd[hXokj_b_p_d]j^[
j[cfehWhoXh_Z][WiWj^[hWf[kj_Yifb_dj$
?dieZe_d]"j^[ckiYb[ih[ifedi_Xb[\ehY^[m_d]
WdZ ]k_ZWdY[ Wh[ Xk_bj kf WdZ YeehZ_dWj[Z Wi
d[[Z[Z$ J^[ ckiYb[i _dlebl[Z Wh[ \h[gk[djbo ie
^of[hjed_Y j^Wj j^[_h efj_cWb fei_j_ed YWddej X[
h[WY^[Z_cc[Z_Wj[bo$
J^[\kdYj_edWbjh[Wjc[dj_if[h\ehc[ZXo_di[hj_d]
W \_n[Z j[cfehWho h[ijehWj_ed cWZ[ e\ l[d[[h[Z
YWij_d]i$J^_ijof[e\fhel_i_edWb_pWj_edi[hl[iWiW
fheij^[j_Y ifb_dj j^Wj _dYh[Wi[i j^[ h[ZkY[Z l[hj_YWb
Z_c[di_ed$?jifkhfei[_ijme\ebZ0
'$ J^[ _cfbWdji Wh[ ijWX_b_p[Z _d j^[ f^Wi[ e\
eii[e_dj[]hWj_l[^[Wb_d]$
($ :k[je_jicWj[h_Wbfhef[hj_[i"j^[ijhkYjkh[YWdX[
h[ZkY[ZehWk]c[dj[ZXoYkificWZ[e\XedZ[Z
Yecfei_j[m^[d[l[hj^[d[[ZWh_i[i$
)$ 7bie"j^[l[hj_YWbZ_c[di_edYWdWbmWoiX[h[ZkY[Z
XWYa _d j^_i f^Wi[ _\ dej jeb[hWj[Z m[bb Xo j^[
fWj_[dj$ 9J _cW][i YWd X[ ki[Z je Wii[ii j^[
iW]_jjWbfei_j_ede\j^[YedZob[i_dj^[cWdZ_XkbWh
\eiiWjel[h_\oj^[j^[hWf[kj_Yfei_j_ede\YedZob[i
_d j^[ iW]_jjWb fbWd[ Wi Z[j[hc_d[Z Xo j^[ ifb_dj
j^[hWfo$Edj^[ej^[h^WdZ"j^[Yb_d_YWb\ebbem#kf
[nWc_dWj_edm_bbkikWbboo_[bZ[dek]^_d\ehcWj_ed
jeWbbemj^[_dj[hc[Z_Wj[ekjYec[e\jh[Wjc[djje
X[WZ[gkWj[bo[lWbkWj[Z$
Ekhf^oi_ej^[hWf_ijiWh[_dijhkYj[ZjeYed\_d[j^[_h
WYj_l_j_[ijeh[bWn_d][n[hY_i[iWdZWffb_YWj_ediZkh_d]
j^[ \_hij *&ZWoi WdZ je YWh[\kbbo ijWhj j^[ÆmWba_d]
YbWii[iÇ_\WXdehcWb_j_[iWh[fh[i[dj$7\j[hj^[_d_j_Wb
f^Wi[ e\ eii[e_dj[]hWj_l[ ^[Wb_d]" j^[ fheY[ii e\
h[Xk_bZ_d] j^[ cWij_YWjeho \ehY[i YWd X[ ijWhj[Z$
Dej[ j^Wj h[eh_[djWj_ed e\ j^[ cWij_YWjeho \kdYj_ed
\ebbem_d] h[ijehWj_ed e\ j^[ l[hj_YWb Z_c[di_ed WdZ
j^[ h[bWj[Z WZ`kijc[dj e\ j^[ eYYbkiWb fbWd[ l_W
j^[ fheij^[j_Y h[ijehWj_ed m_bb eYYWi_edWbbo _dlebl[
fheXb[ci _d j^[ jhWdi_j_edWb f^Wi[" Wbj^ek]^ j^[i[
fheXb[ciWh[kikWbboWc[dWXb[jef^oi_ej^[hWf[kj_Y
cWdW][c[dj$
F^oi_ej^[hWf[kj_Y i[ii_edi edbo ^Wl[ je X[
f[h\ehc[ZedY[ehjm_Y[Wm[[a$7\j[hj^h[[je\ekh
i[ii_edi" j^[ cWij_YWjeho ikh\WY[i Wh[ h[ZkY[Z eh
Xk_bjkfWid[[Z[Z\eheYYbkiWbWZ`kijc[dj$
?dekh[nf[h_[dY["j^[h[Wh[WbmWoiiec[fWj_[dji
m^e m_bb dej h[b_dgk_i^ j^[_h kd_bWj[hWb Y^[m_d]
fWjj[hdi W\j[h j^[ c_Zb_d[ ^Wi X[[d Yehh[Yjbo
h[WZ`kij[ZZ[if_j[h[Y[_l_d]f^oi_ej^[hWfoWdZX[_d]
WZced_i^[ZjeÆ[n[hY_i[ÇWdZjea[[fjhWYae\j^[_h
^WX_jkWbfWjj[hdi$J^_icWoh[ikbj_d[nY[ii_l[\ehY[i
WYj_d] ed j^[ beWZ#jhWdic_jj_d] _cfbWdj ikh\WY[i$
?cfbWdji W\\[Yj[Z Xo ikY^ el[hbeWZ i_jkWj_edi ^Wl[
jeX[h[fbWY[Z$BkYa_bo"8E?_cfbWdjiYWdX[h[fbWY[Z
m_j^ekjcW`ehfheXb[ci"Xkjj^_id[[ZijeX[Zed[_d
Wj_c[bocWdd[h_\Xed[beii_ijeX[Wle_Z[Z$
HW_i_d] j^[ eYYbki_ed je _ji ÆYehh[YjÇ l[hj_YWb
Z_c[di_ed_ie\j[dZ_\\_Ykbj_dj^[fh[i[dY[e\WZlWdY[Z
ckiYb[Zoi\kdYj_ed"i_dY[cWdoe\j^[i[fWj_[djim_bb
h[\ki[jeWYY[fjj^[_d_j_WbWZ`kijc[dj$D[l[hj^[b[ii"
Wiceej^cWij_YWjeho\kdYj_edYWdedboX[WY^_[l[Z
_\ j^[ l[hj_YWb h[bWj_edi Wh[ Wffhefh_Wj[bo _dYh[Wi[Z
\hecj^[fh[#[n_ij_d]i_jkWj_ed$Jem^Wj[nj[dj_j^Wi
jeX[_dYh[Wi[ZYWdedboX[[lWbkWj[Zm_j^^_dZi_]^j"
ed[e\j^[h[WiediX[_d]j^Wj"\hecWd[kheckiYkbWh
WdZ X_ec[Y^Wd_YWb f[hif[Yj_l[" j^[ h[ij fei_j_ed e\
j^[ cWdZ_Xb[ Z[f[dZi ed _ji m[_]^j$ J^[ m[_]^j e\
j^[cWdZ_Xb["_djkhd"Z[f[dZiedj^[jejWbcWiie\
j^[h[i_ZkWbZ[dj_j_edWdZXed[ijhkYjkh[$BWh][#ifWd
Xh_Z][i ed Wjhef^_[Z `Wmi m^_Y^ h[fbWY[ j[[j^ WdZ
ie\j#j_iik[ijhkYjkh[ij[dZje_dYh[Wi[j^[m[_]^je\
j^[cWdZ_Xb[ikXijWdj_Wbbo$?jcWojWa[WYedi_Z[hWXb[
m^_b[_dj^_ii_jkWj_ed\ehj^[d[kheckiYkbWhXWbWdY[
je X[ h[#[ijWXb_i^[Z$ ?j ckij X[ Yedi_Z[h[Z j^Wj Wdo
ceZ_\_YWj_edi je j^[ d[kheckiYkbWh i_jkWj_ed WdZ
l[hj_YWb Z_c[di_ed m_bb [l[djkWbbo Wbie X[ h[\b[Yj[Z
_d j^[ Xed[ cehf^ebe]o$ J^_i" jee" m_bb h[ikbj _d
WZWfjWj_edWb h[ifedi[i WdZ \[[ZXWYa c[Y^Wd_ici$
M[ckijYedi_Z[hj^WjWbj[hWj_edi_dXed[ijhkYjkh[
Wh[Zk[jejh_]][h_d]e\i[YedZWhoeij[ed\ehcWj_ed"
m^_Y^m_bbY^Wd][Xed[c_d[hWb_pWj_edWdZfehei_jo$
?d ehZ[h je eXjW_d j^[ iWc[ el[hWbb ijh[d]j^ _\ j^[
cWij_YWjehobeWZh[cW_dikdY^Wd][Z"j^[h[ckijX[
Wffei_j_ededej^[hi_j[ie\j^[`WmXed["m^_Y^m_bb
[djW_bWY^Wd][_dcehf^ebe]o$7dej^[h_dYh[Wi[_d
Xed[lebkc[_ib_a[bojeeYYkhW\j[hW\_n[Z_cfbWdj#
ikffehj[Zh[ijehWj_ed^WiX[[d_di[hj[ZWij^_im_bb
[b_c_dWj[Wdofh[iikh[ifeji$
?dYh[Wi_d]j^[l[hj_YWbZ_c[di_edm_bbY^Wd][j^[
^[WZfeijkh["m^_Y^\h[gk[djbo_dlebl[ij^[d[[Z\eh
f^oi_ej^[hWf[kj_Y jh[Wjc[dj Wbed] j^[ [dj_h[ if_dWb
YebkcdWij^[edbomWojefh[l[dj^of[hjed_We\j^[
ijWj_Y ckiYb[i \hec Yekdj[hWYj_d] j^[ _dYh[Wi[ _d
l[hj_YWbZ_c[di_ed$
9ecfkbi_l[^[WZfeijkh[iWh[eXi[hl[Z_dfWj_[dji
ki_d] X_\eYWb if[YjWYb[i ]bWii[i m_j^ jme Z_\\[h_d]
\eYki Wh[Wi$ EbZ[h fWj_[dji m^e j[dZ je m[Wh j^_i
jof[e\]bWii[i\eh^ekhifWhj_YkbWhbom^_b[j^[oWh[
dej h[WZ_d] \h[gk[djbo Z[l[bef ckbj_fb[ ckiYkbWh
Æh[ijfei_j_ediÇe\j^[YhWd_kcWdZ"Xo_cfb_YWj_ed"
e\ j^[ cWdZ_Xb[ h[bWj_l[ je j^[ YhWd_kc$ ?d j^_i
i_jkWj_ed" _j cWo X[ _cfeii_Xb[ jeÆYehh[YjboÇ WZ`kij
j^[eYYbki_ed[if[Y_Wbbom^[dY^Wd]_d]j^[l[hj_YWb
Z_c[di_ed$J^[[\\[Yjiedj^[JC@ie\fWj_[djim_j^
X_\eYWb if[YjWYb[i h[i[cXb[ j^ei[ i[[d _d Y^_bZh[d
W\j[h m[Wh_d] W X_edWjeh Wffb_WdY[ edbo \eh W \[m
^ekhi ZW_bo$ ?d cWdo YWi[i" j^[ h[ij fei_j_edi Wh[
ie h[cej[ \hec [WY^ ej^[h j^Wj j^[o YWddej X[
YecX_d[Z_dj[hcie\WÆbed]Y[djh_YÇ$?dekhl_[m"_j
_i[ii[dj_Wb\eh9C:fWj_[djijeZ_iYedj_dk[j^[ki[
e\X_\eYWbif[YjWYb[i$FWj_[djim_j^X_\eYWbif[YjWYb[i
h[gk_h[ X_\eYWb eYYbki_edi WdZ X_\eYWb cWij_YWj_edi$
J^ei[jh[Wjc[djefj_ediij_bb^Wl[jeX[_dl[dj[Z$
È È $EFINITIVEÈ0ROSTHETICÈ2ECONSTRUCTIONÈ
J^[ _iik[ e\ X_\eYWb if[YjWYb[i _i Wbie W j[bb_d]
[nWcfb[ \eh ^em h[WZ_bo iec[ fWj_[dji m_bb
WYY[fj i_jkWj_edi _cfei[Z ed j^[c$ 7\j[h Wbb" _j
jWa[i W i_]d_\_YWdj Z[]h[[ e\ _dZeb[dY[ je ^Wl[ j^[
ef^j^Wbcebe]_ij fh[iYh_X[ j^[ l_ikWb \eYki Wi m[bb
Wi j^[ WiieY_Wj[Z XeZo WdZ ^[WZ feijkh[i \eh j^[
fWj_[dj$Ceijf[efb[m_bbckY^hWj^[hXkoWdZm[Wh
jmei[fWhWj[if[YjWYb[im_j^Z_\\[h[dj\eYWbb[d]j^i"
Yedi_Z[h_d]j^[h[mWhZe\cW_djW_d_d]WijhW_]^j\_[bZ
e\l_i_edh[bWj_l[jej^[XeZoWdZ"\ehj^WjcWjj[h"Wd
kfh_]^j feijkh[ e\ j^[ XeZo _ji[b\$ J^[h[ Wh[ Wbie
j^ei[" ^em[l[h" m^e m_bb iWYh_\_Y[ j^[_h feijkhWb
_dj[]h_joceh[h[WZ_boX[YWki[j^[o^Wl[]hemdki[Z
jeWYY[fj_d]feijkhWbZ[\_Y_[dY_[iWdZYecf[diWj_d]
\eh j^[cÆ_dj[hdWbboÇ$ F[hiedWb_jo Z_iehZ[hi Wh[ dej
kdYecced _d j^_i YWj[]eho e\ f[efb[$ ?j i^ekbZ X[
c[dj_ed[Z j^Wj _cfbWdj fWj_[dji Wh[ dej jof_YWbbo
_dZeb[dj Y^WhWYj[hi" Yedi_Z[h_d] j^Wj j^[o cWa[ Wd
WYj_l[[\\ehjje][jh_Ze\j^[_h[Z[djkbekii_jkWj_ed
WdZ j^[_h Z[djkh[i" j^ki [nf[Yj_d] ceh[ \hec b_\["
Wi_jm[h[$Iec[j_c[i"^em[l[h"m[^Wl[X[[dkdZ[h
j^[_cfh[ii_edh[jheif[Yj_l[boj^WjfWj_[dji^WZdej
Yec[\eh_cfbWdjjh[Wjc[dje\j^[_hemdWYYehZXkj
^WZX[[df[hikWZ[ZjeZeieXoej^[hi$
?\ j^[ cWdZ_Xb[ i^emi fhedekdY[Z Wdj[h_eh eh
bWj[hWb Z_ifbWY[c[dj Wj j^[ ekji[j e\ jh[Wjc[dj"
h[fei_j_ed_d] je _ji Yehh[Yj fei_j_ed cWo YWki[
fheXb[ci X[YWki[ j^_i m_bb \ehY[ j^[ ie\j#j_iik[
ijhkYjkh[i"WdZj^[jed]k[_dfWhj_YkbWh"XWYamWhZi$
J^[i[ fWj_[dji m_bb YecfbW_d j^Wj j^[ Xh_Z][
h[ZkY[i j^[_h jed]k[ cel[c[dji$ J^_i i_jkWj_ed
YWd eYYWi_edWbbo X[ h[c[Z_[Z Xo _di[hj_d] W Xh_Z][
WhY^e\[nW]][hWj[Zm_Zj^ehXoYh[Wj_d]Wd[dZ#je#
[dZ eYYbki_ed _d j^[ Wdj[h_eh i[]c[dj$ 9h[Wj_d] Wd
Wdj[h_ehj…j[#W#j…j[eh[l[dWYheiiX_j[WiWh[ijehWj_l[
ij[f Zkh_d] j^[ jh[Wjc[dj m_bb ijef [nW]][hWj[Z
Wdj[h_eh cel[c[dji e\ j^[ cWdZ_Xb[ Zk[ je Wd
_dYh[Wi[ e\ Z_h[Yj WdZ ieY_Wb Yedjheb$ J^_i jh_Ya YWd
^[bfjeh[fei_j_edj^[`e_dji_dWceh[Z_ijWbh[ij_d]
fei_j_ed WdZ h[#WhhWd][ j^[ cWij_YWjeho \kdYj_ed$
Ij[fXoij[fl[hj_YWbh[ZkYj_ed_ikikWbbod[Y[iiWho_d
j^ei[YWi[i"X[YWki[j^[`e_djie\j[dh[gk_h[dejedbo
W ceh[ Z_ijWb fei_j_ed Xkj Wbie W ceh[ YhWd_Wb ed[$
Dej[j^Wjm^[dj^[cWdZ_Xb[h[bWfi[ijeWÆY[djh_YÇ
fei_j_ed"j^[Wdj[h_ehj[[j^cWo^Wl[jeX[WZlWdY[Z
je W fei_j_ed m^_Y^ _i \Wh ceh[ Wdj[h_eh j^Wd j^[
dWjkhWb Z[dj_j_ed _d ehZ[h je fhel_Z[ ifWY[ \eh j^[
ie\j j_iik[i [$]$ j^[ jed]k[$ Iec[ ifWY[ cWo X[
]W_d[ZXom_Z[d_d]j^[WhY^[i$FheXb[cie\j^_ijof[
Wh[ gk_j[ kdademd _d Yedl[dj_edWb Z[dj_ijho" i_dY[
i[l[h[ YWi[i e\ Wjhef^o YecX_d[Z m_j^ Zoi\kdYj_ed
Wh[kikWbbodejjh[WjWXb[m_j^\_n[Zfheij^[i[i$
9C: fWj_[dji ^Wl[ Wbie X[[d ademd je ^Wl[
W ^WhZ j_c[ ][jj_d] ki[Z je j^[_h d[mbo _dijWbb[Z
\_n[Z j[[j^$ J^[o Wh[ _d_j_Wbbo Wdn_eki je kdZ[h]e
jh[Wjc[dj"X[_d][njh[c[bokd^WffoWXekj^Wl_d]je
m[Wh W Z[djkh[" Xkj edY[ j^[ \_n[Z h[ijehWj_ed _i _d
(*)
fbWY[j^[o\_dZ_j^WhZjeWYY[fj^Wl_d]j[[j^_dj^[_h
cekj^j^WjYWddejX[h[cel[Z$J^[Z[i_h[[nfh[ii[Z
Xo fWj_[dji je ^Wl[ \_n[Z j[[j^ h[ijeh[Z m_bb WbmWoi
iekdZ f[h\[Yjbo fbWki_Xb[ je j^[ _cfbWdjebe]_ij$
Jho_d]je\_dZekjm^[j^[hif[Y_\_YfWj_[djicWo"Wj
^[Whj"dejmWdjje^Wl[\_n[Zj[[j^W\j[hWbb_if[h^Wfi
ed[e\^_ieh^[hb[iieXl_ekijWiai$
7cWij_YWjehoioij[cj^Wj^WiX[[dYecfh[^[di_l[bo
h[ijeh[ZWdZd[mboWZ`kij[Zm_bbjWa[j_c[jeÆi[jjb[Ç"
_\ edbo X[YWki[ e\ j^[ fhebed][Z c_d[hWb_pWj_ed
f^Wi[ _dlebl[Z$ ?\ j^[ _cc[Z_Wj[ ekjYec[ e\
jh[Wjc[dj _i ikY^ j^Wj j^[ fWj_[dj YWd WZWfj je j^[
d[mi_jkWj_ed"Wjb[Wij'(e\j[d(*cedj^im_bbfWii
X[\eh[j^[Z[]h[[e\eii_\_YWj_ed_iXWYajeXWi[b_d[
IYehj[YY_ [j Wb$ (&&'$ 7do \kdYj_edWb WZ`kijc[dji
f[h\ehc[Z _d j^[ feijef[hWj_l[ f^Wi[ m_bb ^Wl[ j^[
iWc[h[f[hYkii_ediedXed[h[ceZ[bb_d]Wiikh]_YWb
fheY[Zkh[i$ J^[ j^hkij e\ eij[edWb WYj_l_jo h[cW_di
kdZ[\_d[Z kdj_b j^[ Y^Wd][i _d ckiYb[ \kdYj_ed
WiieY_Wj[Z m_j^ j^[ bWij fheij^[j_Y WZ`kijc[dj ^Wl[
X[[d Yecfb[j[Z$ J^ehek]^ eii_\_YWj_ed YWddej jWa[
fbWY[ Wdo [Whb_[h j^Wd j^Wj$ <eh j^_i h[Wied m[
jWa[ N#hWoi [l[ho ,cedj^i Zkh_d] j^[ \_hij (o[Whi
W\j[h j^[ bWij ikh]_YWb eh Wdo cW`eh fheij^eZedj_Y
_dj[hl[dj_ed$J^[i[Wh[Yedi_Z[h[ZjeX[cW`eh_\j^[
\kdYj_edWbfWjj[hdiWh[Y^Wd][Z$
È
$EFINITIVEÈ0ROSTHETICÈ2ECONSTRUCTION
EdY[j^[fh[fWhWjehojh[Wjc[djij[fiWh[Yecfb[j[Z
WdZ j^[ _di[hj[Z _cfbWdji Wh[ ikYY[ii\kbbo
eii[e_dj[]hWj[Z"Wd[lWbkWj_edckijX[cWZ[m^[j^[h
_j _i d[Y[iiWho Wj Wbb je _di[hj Wdej^[h fheij^[j_Y
ijhkYjkh[$ CWdo jh[Wjc[dj fhel_Z[hi fheZkY[ [l[d
j^[ \_hij h[ijehWj_ed _d c[jWbbe#Y[hWc_Y j[Y^d_gk[$
?j_if[h\[Yjbofeii_Xb[jeb[Wl[Xh_Z][ib_a[j^ei[_d
fbWY["fhel_Z[Zj^Wjj^[oWh[W[ij^[j_YWbboWff[Wb_d]
_Z[Wbbom_j^fehY[bW_dl[d[[h_d]WdZj^[\ebbem_d]
Yh_j[h_WWh[c[j0
v 7do eYYbkiWb WZ`kijc[dji f[h\ehc[Z ed j^[
Xh_Z][^Wl[dejX[[d[nj[di_l[WdZWh[Yedi_Z[h[Z
WYY[fjWXb[Xoj^[fWj_[dj$
v Def^ed[j_YfheXb[ciehedboWYY[fj[Zf^ed[j_Y
fheXb[ci Wh[ fh[i[dj W\j[h j^[ ckYeiWb im[bb_d]
^Wih[iebl[Z$
v 7do]WfiX[jm[[dj^[Xh_Z][WdZj^[ckYeiWWh[
Yedi_Z[h[ZWYY[fjWXb[Xoj^[fWj_[dj$
?\ W i[fWhWj[ Z[\_d_j_l[ Xh_Z][ _i \WXh_YWj[Z" j^[
\ebbem_d]ij[fiWh[h[gk_h[Z0
v J^[ h[i_ZkWb j[[j^ Wh[ [nWc_d[Z edY[ W]W_d \eh
m^[j^[hj^[oi^ekbZX[fh[i[hl[Z$
v HWZ_e]hWf^iWh[eXjW_d[Zjel[h_\oj^[ikYY[ii\kb
eii[e_dj[]hWj_ed e\ 8E? _cfbWdji1 Wdo iYh[m
_cfbWdjiWh[WbieY^[Ya[Z\ehikYY[ii\kb^[Wb_d]$
(** 9^Wfj[h'-È &UNCTIONALÈ0ROSTHODONTICÈ4REATMENT

v 7ZZ_j_edWb ckYeiWb j^_dd_d] cWo X[ d[Y[iiWho" WffheWY^ _i je _di[hj edbo \[m _cfbWdji _d [WY^
dejWXbo _d j^[ jkX[hei_jo Wh[W" m^[h[ j^_i ij[f _i `Wm \eh h[^WX_b_jWj_ed ie Wi je Wle_Z ^ofeceY^b_ed
hekj_d[boh[gk_h[Z$ i_jkWj_edi$
J^[_iik[e\JC@fei_j_edh[YehZ_d]_iX[oedZj^[
EdY[ j^[i[ ij[fi Wh[ Yecfb[j[Z" j^[ d[m Z[\_d_j_l[ iYef[ e\ j^_i Z_iYkii_ed$7ZlWdY[Z Xed[ h[iehfj_ed
Xh_Z][ _i _di[hj[Z _d W i^ehj fheY[Zkh[$ Iec[j_c[i" _i l_hjkWbbo WbmWoi WiieY_Wj[Z m_j^ iocfjecWj_Y eh
j^[ [n_ij_d] \hWc[meha e\ j^[ \_hij Xh_Z][ YWd X[ WiocfjecWj_Y coeWhj^hefWj^o" m^_Y^ c[Wdi j^Wj
ki[Z\ehj^[Z[\_d_j_l[Y[hWc_YXk_bZ#kf$ Wdo jof[ e\ \WY[Xem h[]_ijhWj_ed _i kdd[Y[iiWho
M[^Wl[[nf[h_[dY[ZcWdoYWi[i_dm^_Y^fWj_[dji 9WhbiiedWdZCW]dkiied(&&&$I_dY[Wiocc[jh_YWb
h[\ki[Zje^Wl[bed]#j[hcj[cfehWhoXh_Z][ih[fbWY[Z fheij^[j_YekjYec[_iWd[ii[dj_Wbjh[Wjc[djeX`[Yj_l["
_dj^_if^Wi[e\jh[Wjc[djWbj^ek]^j^_imekbZ^Wl[ ej^[hj[Y^d_gk[i_dYbkZ_d]WfbWd[h[YehZ^Wl[fhel[Z
X[[dWXiebkj[boh[gk_h[Z\hecj^[Z[dj_ijÉiW[ij^[j_YWb je X[ W ki[\kb Wbj[hdWj_l[ je WhX_jhWho h[]_ijhWj_ed
eh [j^_YWb f[hif[Yj_l[$ Iec[ fWj_[dji `kij Ze dej IY^jjb'//-J^[>?F#cekdjioij[cZ[l[bef[Z\eh
\[[b b_a[ ^Wl_d] j^[ \_hij Xh_Z][ h[fbWY[Z X[YWki[ e\ j^_i fkhfei[ ^Wi j^[ WZlWdjW][ j^Wj j^[ >?F fbWd[
Wdo c_deh Z[\_Y_[dY_[i ]Wfi X[jm[[d Yhemdi WdZ Z[j[hc_d[Z_dj^[ceZ[bYWdX[Y^[Ya[ZXoWfbWd[
WXkjc[dji"l_i_Xb[c[jWbYecfed[dji"[jY$j^[o^Wl[ h[YehZ m_j^ j^[ ^[bf e\ j^[ >[WZ B_d[i c[Wikh_d]
]hemd ki[Z je WdomWo$ EbZ[h fWj_[dji _d fWhj_YkbWh Z[l_Y[$ I_dY[ j^[ ceZ[b _i WbmWoi cekdj[Z _d j^[
WjjWY^ceh[_cfehjWdY[je]eeZcWij_YWj_edWX_b_jo Whj_YkbWjehfWhWbb[bjej^[ikXi[gk[djeYYbkiWbfbWd["
m_j^ \_n[Z j[[j^ j^Wd je Wdo W[ij^[j_Y i^ehjYec_d]i _j _i [Wi_[h \eh j^[ Z[djWb j[Y^d_Y_Wd je \WXh_YWj[ W
j^WjmekbZkfi[jcWdooekd][hfWj_[dji[$]$j^ei[_d h[ijehWj_ed j^Wj _i Yedi_ij[dj m_j^ j^[ ^eh_pedjWb
WÆc_Z#b_\[Yh_i_iÇjej^[fe_dje\Z[ifW_h$ fbWd[$ J^[ cWij_YWjeho \kdYj_ed YWd j^[h[Xo WZWfj
I_dY[j^[jejWbWh[We\beWZ#jhWdic_jj_d]ikh\WY[i ceh[ hWf_Zbo1 W\j[h Wbb" j^_i WZWfjWj_ed kbj_cWj[bo
_iicWbb[h_d8E?_cfbWdjij^Wd_dYh[ijWbiYh[mieh Z[f[dZiedj^[iocc[jhoe\j^[cWij_YWj_edikh\WY[
Yob_dZ[hi"j^[_cc[Z_Wj[bobeWZ[Zh[ijehWj_ed^Wije h[bWj_l[jej^[XeZoWn_i$
X[Ybei[boced_jeh[ZWji^ehj_dj[hlWbifWhj_YkbWhbo_d
j^[[Whbofeijef[hWj_l[f^Wi[$7\j[hWbb"Yedi_Z[hWXb[ 9Wi[IjkZo'
JC@ Z_ibeYWj_edi Wh[ je X[ [nf[Yj[Z fh[Y_i[bo _d 7-&#o[Wh#ebZcWdfh[i[dj[Zm_j^^WX_jkWbWdj[h_eh
Zoi\kdYj_edWb Z[dj_j_edi \ebbem_d] j^[ _di[hj_ed e\ Z_ibeYWj_ed e\ j^[ b[\j JC@ Xo WhekdZ 'Yc$ J^[
_cfbWdj#ikffehj[Z Xh_Z][i$ M[ ^Wl[ je Z_ij_d]k_i^ fei_j_ed e\ j^[ h_]^j JC@" ^Wl_d] X[[d WZ`kij[Z
X[jm[[di^ehj#j[hc\kdYj_edWbWZWfjWj_edij^Wjm_bb [bi[m^[h[ Xo ki_d] W cWn_bbWho Yecfb[j[ Z[djkh[
kd\ebZ hWf_Zbo _d W cWjj[h e\ m[[ai WdZ bed]#j[hc WdZ W cWdZ_XkbWh fWhj_Wb Z[djkh[" Z_Z dej i[[c
h[Z[\_d_j_ed e\ \kdYj_edWb [d]hWci j^Wj m_bb jWa[ je X[ _d _ji Yehh[Yj fei_j_ed" [_j^[h Wi _dZ_YWj[Z Xo
' kf je (o[Whi WdZ Z[bWo j^[ Z[Yh[Wi[ e\ j^[ 8CK j^[ehj^efWdjece]hWf^$J^[fWj_[djYecfbW_d[Ze\
WYj_lWj_ed$ ij_\\d[ii_dj^[Wh[We\j^[Y^[m_d]WdZd[YackiYb[i$
?j _i Wbie d[Y[iiWho je fe_dj ekj j^Wj `Wm jehi_ed J[[j^*(Ä)(m[h[Zk[\eh[njhWYj_ed$J^[YedZ_j_ede\
WdZ j^[ ^ofeceY^b_ed i_jkWj_edi el[h _dZ_l_ZkWb j[[j^))WdZ*)mWiikY^j^Wjj^[oYekbZX[kj_b_p[ZWj
_cfbWdji cWo ]_l[ h_i[ je _djhki_l[ WdZ [njhki_l[ b[Wij\ehj^[bed]#j[hcj[cfehWhoXh_Z][$8ej^j[[j^
el[hbeWZ i_jkWj_edi$ <eh j^_i h[Wied" ekh fh[\[hh[Z i^em[ZdeceX_b_jo$

&IGÈÈ J^[Z_ii_c_bWhJC@
fei_j_ediWh[Yb[Whbol_i_Xb[_dj^[
fWdehWc_YhWZ_e]hWf^
È È $EFINITIVEÈ0ROSTHETICÈ2ECONSTRUCTIONÈ (*+

J^[ _cfbWdjWj_ed fheY[Zkh[ _dYbkZ[Z \_l[ 8E?
_cfbWdji _d j^[ cWn_bbW WdZ jme ijhWj[]_Y 8E?
_cfbWdji _d j^[ cWdZ_Xb[ ?^Z[ (&&'$ J[[j^ *(Ä
)( m[h[ [njhWYj[Z _d j^[ iWc[ i[ii_ed$ Bed]#j[hc
j[cfehWho Xh_Z][i cWZ[ e\ l[d[[h[Z YWij_d]i
m[h[ _di[hj[Z m_j^_d \_l[ ZWoi e\ j^[ _cfbWdjWj_ed
fheY[Zkh[$
De _d_j_Wb f[h_eZedjWb jh[Wjc[dj mWi f[h\ehc[Z"
i_dY[ j^[ h[i_ZkWb j[[j^ *) WdZ )) Z_Z dej h[gk_h[
ikY^jh[Wjc[dj$7j\_hij"_jmWiWXiebkj[bo_cfeii_Xb[
je ]k_Z[ j^[ b[\j JC@ je _ji h[jhWb fei_j_ed" Wi j^[
h[fei_j_ed_d]fWj^mWomWiXWZbo`Wcc[Z$
J^[ fWj_[dj mWi ieed WiocfjecWj_Y W\j[h j^[
Xh_Z][^WZX[[d_di[hj[ZWdZmWiWXb[jeY^[mie\j
\eeZ [l[d Zkh_d] j^[ ^[Wb_d] f^Wi[$ El[h j^[ d[nj
+cedj^i" j^[ b[\j JC@ mWi ]hWZkWbbo h[fei_j_ed[Z
Xoibemboh[ZkY_d]j^[l[hj_YWbZ_c[di_edfh_cWh_bo
_d j^[ b[\j i[]c[dj$ ?d [WY^ e\ j^[i[ i[ii_edi" j^[
eYYbki_edmWiWZ`kij[Zkdj_bj^[fWj_[dj\[bjj^Wjj^[
cWij_YWj_edfWjj[hdmWiXWbWdY[Z$M_j^_dWXekj(eh
)m[[aie\[WY^WZ`kijc[dj"j^[fWj_[djmekbZh[Wb_p[
j^Wj kd_bWj[hWb fh[cWjkh[ YedjWYji m[h[ fh[i[dj"
m^_Y^ m[h[ j^[d h[WZ`kij[Z WYYehZ_d]bo$ J^[ bed]#
j[hcj[cfehWhoXh_Z][mWij^kii_]d_\_YWdjboh[ZkY[Z
el[hj_c[$?jmWih[fbWY[Z\ehj^[\_hijj_c[m^[dj^[
h[i_ZkWbc[jWbijhkYjkh[mWi\_dWbboZ[[c[Zjeej^_d
\eh j^[ ikXijWdj_Wb Xh_Z][ ifWd _d j^[ cWdZ_Xb[$ 8o
j^Wj j_c[" j^[ hWZ_e]hWf^_Y fei_j_ed e\ Xej^ JC@i
mWiYbei[jeefj_cWbWdZX_bWj[hWbboXWbWdY[Z$
J^[ jh[Wjc[dj fbWd _dYbkZ[Z YedYec_jWdj
f^oi_ej^[hWfo" m^_Y^ j^[ fWj_[dj Z_Z dej Yecfbo
m_j^edWh[]kbWhXWi_i\ehfh_eh[d]W][c[dji$
9Wi[IjkZo(
7+/#o[Wh#ebZfWj_[djfh[i[dj[Zm_j^Wh[ZkY[Zh[i_ZkWb
Z[dj_j_ed WdZ h[gk[ij[Z je ^Wl[ W \_n[Z h[ijehWj_ed
_di[hj[Z$J^[Yb_d_YWb[l_Z[dY[\ehYhWd_ecWdZ_XkbWh
Zoi\kdYj_ed_dYbkZ[ZWi^_\j[ZZ[djWbc_Zb_d["i^_\j[Z
bWX_Wb\h[dkb_"Wim[bbWikd_bWj[hWbY^[m_d]_dYbkZ_d]
W bWj[hWb i^_\j e\ j^[ cWdZ_Xb[ WdZ h[ZkY[Z l[hj_YWb
Z_c[di_ed$
J^[fei_j_edie\j^[JC@iWh[hWj^[hiocc[jh_YWb"
WdZj^[Z[djWbc_Zb_d[^WiX[[dhek]^boWZ`kij[ZXo
j^[ fheij^[j_Y h[ijehWj_edi m^_Y^ ^Wl[ kd_bWj[hWbbo

&IGÈÈ Jho#_d e\ j^[ bed]#j[hc j[cfehWho Xh_Z][$ J^[ JC@i Wh[ ij_bb beYWj[Z _d kdf^oi_ebe]_YWb fei_j_edi$ J^_d c[jWb
ijhkYjkh[ ed j^[ b[\j i_Z[ e\ j^[ cWdZ_XkbWh Xh_Z][ [l[djkWbbofh[l[dj[Z j^[ i[h_[i e\ eYYbkiWb WZ`kijc[dji je X[ f[h\ehc[Z
edj^_iijhkYjkh[$J^[_cW][mWieXjW_d[ZZkh_d]jho#_dm_j^edbofWhje\j^[WXkjc[dji_dfbWY[$?dWZZ_j_edjej^[YedZob[
fei_j_edi"Wbiedej[j^[h[bWj_l[fei_j_edie\j^[j^h[WZ[Zf_di_dj^[cWn_bbWWdZcWdZ_Xb[

&IGÈÈ J^[h[jhWbJC@fei_j_ed_iedboh[WY^[ZW\j[hWXekj+cedj^i$J^[_cfbWdjh[fbWY_d]jeej^),^WZjeX[\b[n[Z_dc[Z_Wb
Z_h[Yj_edW\j[h_dYh[Wi_d]bo_dj[h\[h_d]m_j^j^[Y^[[aWh[W$J^[Xh_Z][mWiWZ`kij[Z1Wbb_cfbWdjim[h[m[bbeii[e_dj[]hWj[ZXo
j^Wjj_c[$I_dY[j^[JC@h[fei_j_ed_d]h[ZkY[Zjed]k[cel[c[dji"j^[Wdj[h_ehXbeYae\j^[i[YedZcWdZ_XkbWhijhkYjkh[mWi
j_bj[Z_dWdj[h_ehZ_h[Yj_ed$Fh_ehje_di[hj_d]j^[i[YedZh[ijehWj_ed_dj^[bem[h`Wm"_j_id[Y[iiWhojeYedi_Z[hm^[j^[hjme
ceh[_cfbWdjih[fbWY_d]j^[bem[hYWd_d[ic_]^jX[ki[\kb$9ecfWhWj_l[[lWbkWj_edie\j^_ijof[Wh[edbofeii_Xb[Xoki_d]j^[
iWc[hWZ_ebe]_YWbioij[cWdZj^[iWc[fei_j_ede\YhWd_e#cWdZ_XkbWhijhkYjkh[i
(*, 9^Wfj[h'-È &UNCTIONALÈ0ROSTHODONTICÈ4REATMENT

_dYh[Wi[Z j^[ l[hj_YWb Z_c[di_ed _d j^[ i[YedZ

gkWZhWdj$7ffWh[djbo"j^_i\kdYj_edWbh[ijehWj_ed^Wi
X[[dWY^_[l[ZWjj^[[nf[di[e\jhWdi_[djel[hbeWZ_d]
_dj^[j^_hZgkWZhWdj$
J^[ _cfbWdji m[h[ _di[hj[Z _d WYYehZWdY[ m_j^
Xed[ lebkc[ WlW_bWXb[ _d j^[ ijhWj[]_Y fei_j_edi
)- WdZ *-$ H[ijehWj_l[ h[YedijhkYj_ed mWi f[h\eh#
c[Z _d b_d[ m_j^ j^[ fei_j_ed Z[\_d[Z _d j^[ Whj_#
YkbWjeh"_dYbkZ_d]Wkd_bWj[hWb_dYh[Wi[e\j^[l[hj_YWb
Z_c[di_ed$' 7\j[h eii[e_dj[]hWj_l[ ^[Wb_d] e\ j^[
_cfbWdji"j^[c_Zb_d[mWiZ[\_d_j_l[boYehh[Yj[Z$
&IGÈÈ J^[ fh[ef[hWj_l[ i_jkWj_ed _i Y^WhWYj[h_p[Z Xo J^[WffheWY^j^Wj^Wi`kijX[[dZ[iYh_X[ZYh[Wj[i
eYYbkiWb YebbWfi[" c_Zb_d[ i^_\j WdZ lWh_WXb[ Wdj[h_eh Yhemd
ijWXb[YedZ_j_edim_j^h[]WhZjeijWj_YWdZZodWc_Y
b[d]j^i$;bed]Wj_ede\j[[j^'(WdZ''i[[ci[l_Z[dj
eYYbki_ed" JC@ h[i_b_[dY[ WdZ fei_j_ed e\ j^[
YedZob[i$J^[cWh]_dWbXed[b[l[bWjj^[_cfbWdjm_bb
[ii[dj_Wbboh[cW_dkdY^Wd][Z_\j^[fWj_[djYecfb_[i
m_j^ehWb^o]_[d[WdZh[YWbbh[gk_h[c[dji$>em[l[h"
i_dY[j^[l[hj_YWbXed[_i[nf[Yj[Zje]hem[if[Y_Wbbo
_dj^[cWdZ_Xb["ik\\_Y_[djifWY[i^ekbZX[b[\j_dj^[
Wh[We\j^[fedj_Yi\ehikXi[gk[djXed[Wffei_j_ed"
eh j^[ Xh_Z][ ckij X[ f[h_eZ_YWbbo h[ZkY[Z \hec
YWkZWbZ_h[Yj_ed$
<eh fWj_[dji m^e Ze dej m_i^ je ^Wl[ Xej^ `Wmi
h[ijeh[Z i_ckbjWd[ekibo" [_j^[h ed[ e\ j^[ jme
fhejeYebiX[bemYWdX[ki[Z_dij[WZ0

' 8[YWki[ Wd [nfh[ii_ed b_a[Ækd_bWj[hWb _dYh[Wi[ e\ l[hj_YWb

Z_c[di_edÇ_dlWh_WXbo]_l[ih_i[jeYed\ki_edWdZZ_iX[b_[\"
&IGÈÈ J^[c_Zb_d[i^_\j_iWbie[l_Z[djedcekj^ef[d_d]$ fWhj_YkbWhbo_df[h\ehcWdY[[lWbkWj_edi"j^_ijh[Wjc[djij[f
J^[ feij[h_eh h_Z][ _i ^[Wl_bo h[iehX[Z$ 9h[ijWb _cfbWdji Wh[ _i e\j[d Wbj[hdWj_l[bo h[\[hh[Z je WiÆkd_bWj[hWb eh X_bWj[hWb
YedjhW_dZ_YWj[Z_dj^_ii_jkWj_ed Yecf[diWj_ede\[bed]Wj_edm_j^c_Zb_d[WZ`kijc[djÇ$

&IGÈÈ Fh[ef[hWj_l[EF=$H_Z][h[iehfj_ed_dj^[feij[h_ehi[]c[dje\j^[cWdZ_Xb[_iijh_a_d]boWZlWdY[Z$J^[b[\jhWckie\
j^[cWdZ_Xb[_iW\\[Yj[Zceh[i[l[h[boWdZ_iYWkZWbbo[bed]Wj[Z$J^[EF=i^emiWjof_YWbYWi[e\9bWii??%(eYYbkiWbh[bWj_edi$
?d WZZ_j_ed je j^[ c_Zb_d[ i^_\j" j^[ JC@i Wh[ cWbfei_j_ed[Z h[bWj_l[ je j^[ jkX[hYb[i WdZ ^Wl[ eXjW_d[Z Wd kdf^oi_ebe]_YWb
cehf^ebe]o Xo \kdYj_edWb Z[\ehcWj_ed$ 7 Y^[m_d] i_Z[ YWddej h[WZ_bo X[ _Z[dj_\_[Z" Wbj^ek]^ _j beeai Wi j^ek]^ j^[ b[\j
hWckie\j^[cWdZ_Xb[_ih[iehX[Zceh[i[l[h[boWdZc_d[hWb_p[Zceh[ijhed]boWbed]j^[XedoYh[ijb_d[$7jWdohWj["j^[JC@
ijhkYjkh[i^Wl[X[[djhWkcWj_p[Zh[f[Wj[Zbo_dZ_\\[h[djZ_h[Yj_edi"WiWffWh[dj\hecj^[Wdj[h_eh\bWjj[d_d]WdZWffei_j_ede\
j^[h_]^jWdZb[\jYedZob[i"h[if[Yj_l[bo
È È $ISCUSSIONÈ
&IGÈÈ I_dY[ j^[ _cc[Z_Wj[ c_Zb_d[ WZ`kijc[dj mWi dej
jeb[hWj[Z" j^[ \_hij fheij^[j_Y h[YedijhkYj_ed mWi f[h\ehc[Z
m_j^j^[c_Zb_d[_d_jieh_]_dWbijWj[$J^[l[hj_YWbZ_c[di_ed
mWi_dYh[Wi[ZckY^je_jiZ[\_d_j_l[^[_]^j$I[YedZWhohW_i_d]
e\j^[X_j[mWif[h\ehc[ZXoWdel[h#Y[c[dj[ZXh_Z][_dj^[
b[\jcWdZ_Xb[
&IGÈÈ J^[ c_Zb_d[ mWi WZ`kij[Z Z[\_d_j_l[bo _d W i[YedZ
ij[f W\j[h eii[e_dj[]hWj_l[ ^[Wb_d] e\ j^[ _cfbWdji$ 7j j^_i
fe_dj"_jmWi[l_Z[djj^Wjj^[iocc[jh_YWbWff[WhWdY[mWidej
Wbj[h[Z Xo [bed]Wj_ed e\ jeej^ '' Xkj Xo [Yjef_Y [hkfj_ed e\
jeej^ () YecfWh[ <_]$'-$*$ J^_i mWi Yehh[Yj[Z Xo WZ^[i_l[
Yecfei_j[ Xk_bZ#kf e\ j^[ Wh[W ()Ä(- WdZ c_deh eYYbkiWb
WZ`kijc[dji _d j^[ WdjW]ed_ij Wh[W \eh Yecf[diWj_ed$ J^[
Z_W]dei_i mekbZ ^Wl[ X[[d \WY_b_jWj[Z Xo j^[ ki[ e\ W >?F#
cekdj" Yedi_Z[h_d] j^Wj Whj_YkbWj_ed XWi[Z ed W fbWd[
h[YehZ mekbZ Wbie fhel_Z[ j^[ Z[djWb j[Y^d_Y_Wd m_j^ X[jj[h
_d\ehcWj_ededWdo^eh_pedjWbZ_iYh[fWdY_[i
'$ J^[ effei_d] `Wm _i \_jj[Z m_j^ bed]#j[hc
j[cfehWho\_n[ZYef_d]ije[ijWXb_i^j^[d[Y[iiWho
WZ`kijc[dji_dj[hcie\l[hj_YWbZ_c[di_ed"Ykif
_dYb_dWj_edi" Ykhl[i e\ If[[ WdZ M_bied" c_Zb_d[
WdZ7<CFWd]b[i$
($ J^[ effei_d] `Wm _i dej WZ`kij[Z Wj Wbb" Xkj j^[
fWj_[dj _i _d\ehc[Z j^Wj j^[ i[YedZ h[ijehWj_ed
je X[ f[h\ehc[Z m_bb _dlebl[ i_]d_\_YWdj eYYbkiWb
WZ`kijc[dji _d j^[ Wbh[WZo h[ijeh[Z `Wm Wi m[bb$
J^_i _i dehcWbbo edbo Wd efj_ed _\ j^[ effei_d]
`Wm_ijeX[fh[i[hl[Z\ehiec[j_c[Z[if_j[X[_d]
f[h_eZedjWbbo ZWcW][Z WdZ _\ jh[Wjc[dj m_j^
Z[\_d_j_l[ i_d]b[#Yhemd h[ijehWj_edi _i de bed][h
(*-
mehj^m^_b[$ >em[l[h" j^[ _cfehjWdj fWhj _i j^Wj
j^[ fWj_[dj _i _d\ehc[Z Yecfh[^[di_l[bo WdZ
[cf^Wj_YWbbo"i_dY[j^[Xh_Z][j^Wj_i_di[hj[Z\_hij
kikWbbo^WijeX[h[ZkY[ZmWoZemd_djej^[c[jWb
\hWc[meha$
È
$ISCUSSION
B_jjb[ _i ademd WXekj j^[ [\\[Yji e\ _cfbWdj#
ikffehj[Z \_n[Z h[ijehWj_edi ed ijecWje]dWj^_Y
\kdYj_edi _d fWhj_Wbbo [Z[djkbeki fWj_[dji$ AdWX[
'//-YedYbkZ[Zj^Wjj^[Yb_d_YWb[nf[h_[dY[m_j^j^[
Z[iYh_X[Z \kdYj_edWb jh[Wjc[dj YedY[fj _i fei_j_l["
Wbj^ek]^_j_iij_bbjee[WhbojeYehheXehWj[j^_il_[m
Xobed]#j[hch[ikbji$
C[h_Yia[#Ij[hd '//(" '//+ eXi[hl[Z j^Wj f[Wa
cWij_YWjehobeWZim[h[bem[h_dfWhj_Wbbo[Z[djkbeki
fWj_[djim_j^_cfbWdj#ikffehj[Zh[ijehWj_edij^Wd_d
\kbbo Z[djkbeki fWj_[dji Xkj YedYbkZ[Z j^Wj \WYjehi
ikY^ Wi j^[ ijWj[ e\ j^[ h[i_ZkWb Z[dj_j_ed WdZ j^[
Z[i_]de\j^[h[ijehWj_ed^Wl[W]h[Wj[hX[Wh_d]edj^[
\kdYj_edWb fWjj[hdi Z[l[bef[Z Xo j^[ fWj_[dji j^Wd
j^[h[ZkY[ZjWYj_b[i[di_j_l_joe\[deiiWb_cfbWdji$
Ej^[h ijkZ_[i ^Wl[ Z[Wbj m_j^ j^[ [\\_Y_[dYo e\
cWij_YWj_ed WdZ d[kheckiYkbWh Yedjheb" Wbie
WdWboi_d] f[Wa cWij_YWjeho beWZi _d Yel[hZ[djkh[i
ikffehj[Z Xo _djWYj cWdZ_XkbWh YWd_d[i C[h_Yia[#
Ij[hd '//+1 C[h_Yia[#Ij[hd [j Wb$ '//($ De h[fehji
Wh[ WlW_bWXb[ _d j^[ b_j[hWjkh[ ed WYjkWb h[ijehWj_edi
_dfWj_[djim_j^cWd_\[ijcoeWhj^hefWj^oehedj^[
h[YedijhkYj_ed e\ W Yehh[Yj l[hj_YWb Z_c[di_ed Xo
YecX_d_d]h[i_ZkWbj[[j^m_j^_cfbWdji$?dekhl_[m"
j^_ibWYae\ZWjW_ifWhjboZk[jej^[b_c_j[ZhWd][e\
_dZ_YWj_edi\ehYh[ijWb_cfbWdji$
?dYh[ijWb_cfbWdji"j^[beWZ#jhWdic_jj_d]_dj[h\WY[
_iWbmWoieh_[dj[Zf[hf[dZ_YkbWhjej^[Z_h[Yj_ede\
j^[ cWij_YWjeho \ehY[$ ?j _i ikX`[Yj je j[di_b[ WdZ
jehi_l[\ehY[iZk[jejm_ij_d]e\j^[`WmZkh_d]cekj^
ef[d_d]%Ybeikh[WdZcWij_YWj_ed"m^_Y^h[ikbji_dW
Yecfb[j[boZ_\\[h[djX[^Wl_ekhYecfWh[ZjedWjkhWb
WXkjc[dji Zk[ je j^[ b_]Wc[djeki ikif[di_ed e\
dWjkhWb j[[j^$ 7i W feii_Xb[ h[ikbj" YecX_dWj_ed e\
dWjkhWb#jeej^ WXkjc[dji m_j^ Yh[ijWb _cfbWdji cWo
YWki[ fheXb[ci _d j^[ beWZ#jhWdic_jj_d] _dj[h\WY[
e\ j^[ _cfbWdj eh" \eh j^Wj cWjj[h" e\ j^[ dWjkhWb
WXkjc[dj$
Ed[ fWhj_YkbWh WZlWdjW][ e\ 8E? _cfbWdji _i j^[
Yedj_dkeki jh[Wjc[dj fhejeYeb" ijWhj_d] m_j^ Wd
_d_j_Wb fheY[Zkh[" m^_Y^ _i _cc[Z_Wj[bo \ebbem[Z
Xo Xk_bZ_d] kf W j^[hWf[kj_Y eYYbki_ed" WdZ j^[
JC@i Wh[ X[]_dd_d] je ijWX_b_p[ Wi m[bb$ 9h[ijWb
ioij[ci"m^[j^[hj^[oWh[f[h\ehc[Z_ded[ehjme
fheY[Zkh[i"Zedej^Wl[j^_iWZlWdjW][X[YWki[j^[o
_dlebl[WmW_j_d]f[h_eZe\i[l[hWbcedj^i"eh_dZ[[Z
o[Whi"kdj_bj^[Z[\_d_j_l[h[ijehWj_edYWdX[_di[hj[Z$
(*. 9^Wfj[h'-È &UNCTIONALÈ0ROSTHODONTICÈ4REATMENT

&IGÈÈ EF=eXjW_d[ZW\j[h_di[hj_ede\j^[\_hijfheij^[j_Yh[YedijhkYj_ed$<ebbem_d]_di[hj_ede\jme8E?_cfbWdji_dj^[
Z_ijWbcWdZ_Xb[WdZh[ijehWj_ede\j^[cWn_bbW"_d_j_Wbeij[eboi_i_ii[[dWhekdZj^[XWiWbfbWj[e\j^[_cfbWdj_dj^[bem[hb[\j
`Wm$J^[b[\j_cfbWdj"^em[l[h"i[[cijeeii[e_dj[]hWj[dehcWbbo

&IGÈÈ Jm[bl[cedj^ibWj[h"j^[i_jkWj_ed^Wih[l[hi[Z$M^_b[j^[XWiWbfbWj[_dfei_j_ed*-^Wifhef[hboeii[e_dj[]hWj[Z"j^[
f[h_#_cfbWdjWh[WWhekdZj^[YedjhWbWj[hWbZ_ia_iW\\[Yj[ZXoWd_dZ_ij_dYjboZ[b_c_j[ZY_hYkbWhped[e\eij[eboi_i$7jj^[iWc[
j_c["ed[][jij^[_cfh[ii_ededYecfWh_d]j^[EF=ij^Wjl[hj_YWbXed[beiiedXej^i_Z[i^WieYYkhh[ZWdZ_iWded]e_d]
fheY[ii$FeehehWb^o]_[d[_dj^[_d_j_Wbf^Wi[^Wib[Zjej^[\ehcWj_ede\f[h_#_cfbWdjckYei_j_iWhekdZj^[_cfbWdjh[fbWY_d]
jeej^)-

:kh_d] j^_i mW_j_d] f[h_eZ" j^[ `e_dj ijhkYjkh[i Wh[
h[f[Wj[Zbo jhWkcWj_p[Z Xo j[cfehWho h[ijehWj_edi
WdZXo[nj[dZ[Z_dj[hlWbi_dm^_Y^j^[fWj_[djiWh[
b[\jYecfb[j[bo[Z[djkbekim_j^deh[ijehWj_edWjWbb$
H[]kbWh ced_jeh_d] e\ eYYbkiWb YedjWYji _i
[ii[dj_Wb" fWhj_YkbWhbo m_j^_d j^[ \_hij jme o[Whi$
:k[ je j^[ h[ZkY[Z jWYj_b[ i[di_j_l_jo e\ [deiiWb
_cfbWdji" j^[ Y^WdY[i Wh[ j^Wj Wdo [Whbo YedjWYji
WdZ^of[hXWbWdY[Wh[WiWh[dejWih[WZ_bo_Z[dj_\_[Z
ed _cfbWdj#ikffehj[Z Wi ed jeej^#ikffehj[Z
h[ijehWj_edi@WYeXiWdZIj[[dX[h]^['//)1YecfWh[
Wbie9^Wfj[h(,$'$B_a[m_i["j^[fWj_[djij^[ci[bl[i
WffWh[djbo jWa[ bed][h je dej_Y[ Wdo ceX_b_jo e\
fheij^[j_Y ijhkYjkh[i Xk_bj ed _cfbWdji$ J^_i _i
fWhj_YkbWhbo jhk[ e\ fWj_[dji m^e ^WZ fh[l_ekibo
mehd _dWZ[gkWj[bo i[Wj[Z h[ijehWj_edi" m^e cWo
m[bb\[[bj^Wjj^[d[m_cfbWdj#ikffehj[ZXh_Z][\_ji
fh[Y_i[bo [l[d j^ek]^ _j _i ikXijWdj_Wbbo ceX_b[$ ?d
9C: fWj_[dji m[ ^Wl[ \ekdZ W ijhed] j[dZ[dYo je
WZWfjjeWd_dik\\_Y_[djcWij_YWjeho\kdYj_ed$M^_b[
WfWj_[djm_j^ekjj^_iZ_iehZ[hm_bbh[\ki[jeWYY[fj
Y^Wd][iX[oedZWY[hjW_db_c_j"j^[9C:fWj_[djm_bb
X[Xo\Whceh[jeb[hWdj$
J^[ Z[cWdZ fh[l_ekibo le_Y[Z" j^Wj _cfbWdj
WXkjc[dji i^ekbZ _dlWh_WXbo X[ beYWj[Z _d WjjWY^[Z
]_d]_lW_iYedi_Z[h[ZeXieb[j[jeZWo$?cfbWdjZ[i_]di
\[Wjkh_d] W iceej^ i^W\j" ikY^ Wi 8E? ioij[ci" Wh[
dej\kdYj_edWbboYecfhec_i[Zm^[dbeYWj[Z_d\h[[
]_d]_lW$ ?cfbWdji m^ei[ i^W\j _i hek]^[d[Z m^[h[
j^[of[d[jhWj[j^[ckYeiWi^ekbZWbmWoiX[_di[hj[Z
_dWjjWY^[Z]_d]_lW"eh\h[[ckYeiWb]hW\jii^ekbZX[
ki[ZjeYh[Wj[Wi_c_bWhboX[d[\_Y_Wb[dl_hedc[dj\eh
_cfbWdjikhl_lWb$
È È #ONCLUSIONÈ (*/

&IGÈÈ 7\j[h Wdej^[h '.cedj^i" j^[ l[hj_YWb Xed[ lebkc[ WXel[ Xej^ cWdZ_XkbWh _cfbWdji ^Wi _dYh[Wi[Z$ ?dik\\_Y_[dj
c_d[hWb_pWj_edWhekdZj^[_cfbWdjh[fbWY_d]jeej^)-Yedj_dk[i$M^[j^[hj^_i_cfbWdj_i]e_d]jeikhl_l[m_bbZ[f[dZedj^[
Xed[\ehcWj_edj[dZ[dYo_d_jiikhhekdZ_d]i$7jj^_ife_dj"_cfbWdjh[celWb_idej_dZ_YWj[Z[_j^[hWdZ[l[db[iib_a[boYecfWh[Z
jej^[i_jkWj_edi^emd_d<_]$'-$'&$?jckijX[h[c[cX[h[Zj^Wjbeiie\l[hj_YWbXed[_i\ehX_ec[Y^Wd_YWbh[WiediYecf[diWj[Z
_cc[Z_Wj[boXoW^eh_pedjWbXed[]hemj^_\j^[beWZh[cW_dij^[iWc[$J^_i_ied[e\j^[h[Wiedim^o8E?_cfbWdjii^ekbZX[
Y^ei[dbWh][[dek]^jeb[Wfekje\j^[Yehj_YWbW\j[h_di[hj_ed$J^[Xed[_i[nf[Yj[Zje]hemel[hj^ei[_cfbWdjiWh[W"i_dY[W
h_i[_d\kdYj_edWbij_ckbWj_edm_bbYh[Wj[WbWh][hXed[cWiiYecfWh[Zjej^[YedZ_j_ediWjj^[ijWhje\j^[jh[Wjc[dj

Xed[ _i WlW_bWXb[ \eh Yh[ijWb _cfbWdji$ ?\ j^[ bWj[hWb

È
#ONCLUSION
8E? _cfbWdji Wh[ W l_WXb[ XWi_i je h[Wb_p[ \_n[Z
h[ijehWj_edi W\j[h W i_d]b[ ikh]_YWb fheY[Zkh[ _d
fWj_[djii^em_d]cWd_\[ijehbWj[djcoeWhj^hefWj^o"
cWii_l[eYYbkiWbfbWd[Wbj[hWj_edehWYecfb[j[beii
e\ eh_[djWj_ed WdZ fbWd[" c_Zb_d[ i^_\j eh h[ZkY[Z
l[hj_YWbZ_c[di_ed$J^[_d_j_Wbbed]#j[hcj[cfehWho
Xh_Z][YWdX[ki[ZWiWifb_djWdZWbbemiZ_W]deij_Y
j^[hWf[kj_Y c[Wikh[i je X[ Wffb_[Z \eh eYYbkiWb
WZ`kijc[dj WdZ \eh j^[ Yh[Wj_ed e\ W f^oi_ebe]_YWb
cWij_YWj_ed fWjj[hd$ M[ Yedi_Z[h 8E? _cfbWdji je
X[ fWhj_YkbWhbo m[bb ik_j[Z _d j^[i[ i_jkWj_edi" Wi
j^[o Wle_Z j^[ b[d]j^o WdZ hekdZWXekj WffheWY^
e\ _di[hj_d] ckbj_fb[ j[cfehWho Z[djkh[i _d j^[
^[Wb_d] f^Wi[" m^_Y^ _i [if[Y_Wbbo jhekXb[iec[ \eh
JC@ fWj_[dji$ 7 i_d]b[#ij[f fheY[Zkh[ je _dijWbb
Xh_Z][i ikffehj[Z Xo 8E? _cfbWdji Wbed[ eh _d
YecX_dWj_edm_j^dWjkhWbj[[j^_iWbiel[hoki[\kb_\
j^[ cebWhi ^Wl[ X[[d beij WdZ dej [dek]^ l[hj_YWb
h[bWj_edi^Wl[Y^Wd][Z_dj^_ii_jkWj_ed"j^[l[hj_YWb
Z_c[di_ed YWd X[ _dYh[Wi[Z kd_bWj[hWbbo je h[WZ`kij
j^[c_Zb_d[$J^_ih[gk_h[c[dj_iWYjkWbbofh[i[dj_d
WbceijWbb_cfbWdjfWj_[dji$
C: fWj_[dji j[dZ je i^em b[ii Yecfb_WdY[ j^[d
ej^[h fWj_[dji WdZ j^[o Wh[ ceh[ e\j[d ikX`[Yj je
j^_hZ#fWhjo _d\bk[dY[i$ M^_b[ j^[_h Z[djWb fheXb[c
_ikikWbbo[Wiojejh[Wj"j^[_hc[djWbfheXb[cd[[Zi
WZZ_j_edWb Wjj[dZWdY[$ ?d ekh [nf[h_[dY[ 9C:
fWj_[dji hWh[bo [l[h \ebbem j^[ Z[dj_iji WZl_Y[ kdj_b
j^[ j^[hWfo _i \_d_i^[Z$ D[l[hj^[b[ii m[ Yedi_Z[h
9C:Z_iehZ[hiWiYehh[YjWXb[Zoi\kdYj_ediYecfWh[
je9^Wfj[h,$+$'$
JeikccWh_p["j^[Yb_d_YWb[nf[h_[dY[m_j^bWj[hWb
_cfbWdj ioij[ci Ze Wbbem Y[hjW_d YedYbki_edi je
X[ ZhWmd j^Wj h[Yecc[dZ j^[_h ki[ _d \kdYj_edWb
jh[Wjc[dj YedY[fji$ FWhj_YkbWhbo _d fWj_[dji m_j^
YhWd_ecWdZ_XkbWh Zoi\kdYj_ed" j^[ ik_jWX_b_jo
e\ 8E? _cfbWdji \eh Yh[Wj_d] j^[ XWi_i \eh bed]#
j[hc Yehh[Yj_ed e\ j^[ cWij_YWjeho \kdYj_ed _i m[bb
[ijWXb_i^[Z$

#(!04%2È
)MPLANTÈ4REATMENTÈÈ
!LONGÈTHEÈ-AXILLARYÈ3INUS
7
,POTUBOUJOPWJD
BOE
4
*IEF
J^[ \WYj j^Wj jeej^ beii _i kikWbbo WYYecfWd_[Z Xo
l[hj_YWb Xed[ beii WZZi je j^[ fheXb[ci e\ Yh[ijWb
_cfbWdjj^[hWfo_dj^[Z_ijWbcWn_bbW$
L[hj_YWb Xed[ beii Wbed] j^[ cWn_bbWho i_dki _i
\h[gk[djbo ZhWcWj_Y" Wi jme XWi_YWbbo kdh[bWj[Z
fheY[ii[i YecX_d[ je \ehc W iod[h]_ij_Y [\\[Yj$ <eh
ed[ j^_d]" [njhWYj_edi Wh[ Yeccedbo fh[Y[Z[Z Xo
f[h_eZedjWb Z[ijhkYj_ed WdZ \ebbem[Z Xo j_iik[
h[ceZ[bb_d]$ 8ej^ f^[dec[dW m_bb h[ZkY[ j^[
Wbl[ebWh h_Z][ _d W YhWd_Wb Z_h[Yj_ed$ <eh Wdej^[h
j^_d]"j^[cWn_bbWhoi_dkij[dZije[nfWdZcWii_l[bo
_dWYWkZWbZ_h[Yj_ed$
Jh[Wjc[djYedY[fjim_j^Yh[ijWb_cfbWdjij^[h[\eh[
h[boedfh[fWhWjehoWZ`klWdjj[Y^d_gk[ijeWk]c[dj
j^[ Z_ijWb i[]c[dj e\ j^[ cWn_bbW _\ j^[ l[hj_YWb
Xed[ lebkc[ _i _dWZ[gkWj[$ 9ecced j[Y^d_gk[i je
WY^_[l[ ikY^ Wk]c[djWj_ed _dYbkZ[ Xed[ ]hW\j_d]"
WbbefbWij_Y_dbWoicW_dbo_di_Z[j^[i_dki"WZZ_j_ed
e\ ikXijWdY[i j^Wj fhecej[ Xed[ \ehcWj_ed" eh Wdo
YecX_dWj_ed e\ j^[i[ c[j^eZi F_Wjj[bb_ [j Wb$ '///1
LWb[dj_d_[jWb$'//.1CY7bb_ij[h[jWb$'///1LWb[dj_d_
[jWb$(&&&$FWj_[djijh[Wj[ZXoWdoe\j^[i[WZ`klWdj
j[Y^d_gk[im_bbkdZ[h]eW]h[Wj[hdkcX[he\ikh]_YWb
fheY[Zkh[iWdZm_bbj^[h[\eh[X[[nfei[Zje]h[Wj[h
_dZ_l_ZkWb h_iai$ <khj^[hceh[" j^[i[ j[Y^d_gk[i Wh[
j_c[#Yedikc_d]WdZ[nf[di_l[$
JeZWo" j^Wdai je ceZ[hd 8E? j[Y^debe]o" j^[i[
WZ`klWdj j[Y^d_gk[i YWd X[ Wle_Z[Z$ I_dY[ j^[
jh[Wjc[djYedY[fjie\\[h[ZXo8E?Wh[l[hoZ_\\[h[dj
\hecj^[YedY[fjiki[Z_dYh[ijWb_cfbWdjebe]o"ki[hi
Wh[h[gk_h[ZjeijkZo[nj[di_l[boj^[ikX`[YjcWjj[h
X[\eh[ j^[o i[j ekj je f[h\ehc 8E?#XWi[Z _cfbWdj
jh[Wjc[djij^[ci[bl[iÄm^[j^[hWi\_hij#b_d[j^[hWfo
e\ fh[l_ekibo kdjh[Wj[Z fWj_[dji eh Wi \ebbem#kf
j^[hWfoe\fh[#jh[Wj[ZfWj_[dji$
È
6IEWSÈANDÈ3PECULATIONS
Ef_d_edi WdZ h[Yecc[dZWj_edi _d j^[ Z[djWb WdZ
_cfbWdjebe]_YWbb_j[hWjkh[lWhom_Z[bom^[d_jYec[i
jejh[Wjc[djijhWj[]_[iWdZh[gk_h[c[dji_dj^[Wh[W
e\j^[cWn_bbWhoi_dki"m^_Y^j[ij_\_[ijej^[WhX_jhWho
dWjkh[e\jh[Wjc[djZ[Y_i_edi$
 ¬ 
v CWdoZ[dj_ijim_bbh[\[hj^[_hfWj_[dji_cc[Z_Wj[bo
jeWdehWb%cWn_bbe\WY_Wbikh][ed_dj^[[l[dje\Wd
eheWdjhWb Yecckd_YWj_ed%\_ijkbW [$]$ \ebbem_d]
[njhWYj_ede\Wjeej^m_j^ekjWjj[cfj_d]jeYel[h
j^[ \_ijkbW j^[ci[bl[i eh [l[d WffhW_i_d] j^[
d[Y[ii_joe\ikY^Yel[hW][$
v 9h[ijWb _cfbWdji Wh[ kikWbbo dej ikffei[Z je
f[d[jhWj[j^[IY^d[_Z[h_Wdc[cXhWd[$
v 8o YedjhWij" j^[ eij[eiodj^[i_i iYh[mi ki[Z
_d jhWkcWjebe]o m_bb hekj_d[bo f[d[jhWj[ j^[
IY^d[_Z[h_Wdc[cXhWd[$
v Ceij po]ecWj_Y _cfbWdji Wbie f[d[jhWj[ bWh][
i[]c[djie\j^[IY^d[_Z[h_Wdc[cXhWd[$
v ?j^WiX[[dik]][ij[Zj^WjWk]c[djWj_edj^[hWfo
m_j^ lWh_eki Wk]c[djWj_ed cWj[h_Wbi i^ekbZ X[
Z_iYedj_dk[Z \ebbem_d] _d`kho je eh Z[ijhkYj_ed
e\j^[IY^d[_Z[h_Wdc[cXhWd["fhel_Z[Zj^Wjj^[
c[cXhWd[YWddejX[ikjkh[Zehh[fbWY[Z$
v 7d eZZ WffheWY^ fkj \ehmWhZ Wi W j^[hWf[kj_Y
c[Wikh[_dj^_iYedd[Yj_ed^WiX[[dje_djheZkY[
WZZ_j_edWb [njhWd[eki cWj[h_Wb _$[$ W h[iehXWXb[
c[cXhWd[ _dje j^[ cWn_bbWho i_dki$ J^_i
Z[if_j[ j^[ \WYj j^Wj j^[ ikXi[gk[dj h[iehfj_ed
e\ j^_i c[cXhWd[ m_bb jh_]][h Wd WZZ_j_edWb
_d\bWccWjehoh[ifedi[Ägk_j[Wi_Z[\hecj^Wj_j
WZZijej^[Wcekdje\[njhWd[ekicWj[h_Wbm_j^_d
j^[cWn_bbWhoi_dki$7ZZ_j_ede\j^_ic[cXhWd[_i
Yedi_Z[h[ZWj^[hWf[kj_YWZ`kdYj$
v 7dej^[h WffheWY^ j^Wj ^Wi X[[d ik]][ij[Z \eh
j^[ jh[Wjc[dj e\ [njh[c[ cWn_bbWho h[iehfj_ed _i
je h[cel[ Wbb i[]c[dji e\ j^[ XWiWb c[cXhWd[
WdZf[h\ehcj^[Wk]c[djWj_edWdZ_cfbWdjWj_ed
fheY[Zkh[i _d j^[ iWc[ i[ii_ed IW_b[h '/./$ ?d
ej^[hmehZi"j^[]hW\j_d]cWj[h_Wb_dj^[i_dkiWh[W
_idejYel[h[ZXoc[cXhWd[cWj[h_Wb"j^[hWj_edWb[
X[_d] j^Wj h[celWb e\ j^[ c[cXhWd[ _dYh[Wi[i
j^[ YedjWYj Wh[W X[jm[[d j^[ Xed[ ikh\WY[ WdZ
j^[ ]hW\j$ <khj^[hceh[" j^[ _cfbWdj _i _di[hj[Z
_cc[Z_Wj[bo$J^[Wkj^ehYedj_dk[ijeY^WhWYj[h_p[
j^_iWffheWY^Wi¼ikYY[ii\kb_d^_i^WdZi½$
v Ej^[h Wkj^ehi" Xo YedjhWij" h[fehj ^_]^ hWj[i e\
_cfbWdjbeii\ehed[#ij[ffheY[Zkh[iY^WhWYj[h_p[Z
Xo_cfbWdj_di[hj_ed_djeXed[XbeYa]hW\jikfed
h[celWbe\j^[c[cXhWd[>ejp'//'1A[dj'/./1
Ic_b[ WdZ >ebc[i '/.-1 MeeZ WdZ Ceeh[ '/..1
@[di[d[jWb$'//&1M_bj\Wd][jWb$'//,1=”ch”WdZ
(+( 9^Wfj[h'.È )MPLANTÈ4REATMENTÈ!LONGÈTHEÈ-AXILLARYÈ3INUS

AeYWa '//,1 Akda[b WdZ H[_Y^[hj (&&)1 H[][l [j v 9edijh_Yj_ed e\ j^[ eij_W Xo Y^hed_Y _d\bWc#
Wb$'//+1M[_d]Whj[jWb$'//,$7YYehZ_d]jej^[c" cWj_edi" feij#_d\[Yj_eki iYWhi eh Wkjedec_Y
j^[i[ _cfbWdj \W_bkh[i Wh[ [if[Y_Wbbo b_a[bo _d j^[ _dd[hlWj_ed fheXb[ci Yehh[bWj[i d[]Wj_l[bo m_j^
fh[i[dY[e\Z_ijWbh_Z][h[iehfj_ed$ j^[ l[dj_bWj_ed e\ j^[ cWn_bbWho i_dki$ J^[ 9E(
v ?d j^[ B[ <ehj ? eij[ejec_[i f[h\ehc[Z Zkh_d] Yedj[dj _dYh[Wi[i hWf_Zbo je *Ä+ m^_b[ j^[ E(
Yehh[Yj_ede\Z[dje\WY_WbZ[\ehc_j_[i"j^[_dj[]h_jo Yedj[dj Z[Yh[Wi[i je /$ J^_i h[Z_ijh_Xkj_ed e\
e\ j^[ cWn_bbWho i_dki _i Yecfb[j[bo Z[ijheo[Z" ]WihWj_ei_iWYYecfWd_[ZXoWi^_\j_df>cW_dbo
WdZ j^[ c[cXhWd[ _i bWh][bo h[cel[Z1 Wdo jemWhZij^[WY_Z_Yi_Z["m^_Y^Wbj[hij^[f^oi_Ye#
eij[eiodj^[i_icWj[h_WbiWh[_dZ_h[YjYedjWYjm_j^ Y^[c_YWbX[^Wl_ekhe\j^[dWiWbckYki$7iWh[ikbj
j^[cWn_bbWhoi_dkiFhe\\_jWdZM^_j['//'$ e\ WY_Z_\_YWj_ed" ][b \ehcWj_ed eYYkhi 7kij WdZ
:h[jjd[h'/-'17kij'/-,$
Je ikccWh_p[" j^[ fkXb_i^[Z [nf[h_[dY[ _i kjj[hbo
_dYedYbki_l[" WdZ ef_d_edi lWho m_Z[bo$ 7 kd_\ehc
Yb_d_YWb j^[eho eh Yedi_ij[dj ¼]ebZ ijWdZWhZ½ _i È
[l_Z[djboWXi[dj$ (ISTORICALÈ2EVIEW
Ceh[el[h"ekhYebb[W]k[i\hecj^[h[bWj[Z\_[bZe\
;DJWZZo[jWdej^[hZ_c[di_edjej^[Z_iYkii_edXo J^[\_hijWkj^ehjeZ[iYh_X[IY^d[_Z[h_Wdc[cXhWd[
ijh[ii_d]Yecfb[j[boZ_\\[h[djfe_dji0 [b[lWj_edWdZi_dkiWk]c[djWj_edmWiJWjkc'/.,$
v I[fjkcZ[l_Wj_ed_dj^[Wh[We\j^[c_ZZb[dWiWb 8eod[ kdZ @Wc[i '/.& Z[iYh_X[Z j^[_h j[Y^d_gk[
c[Wjki cWo XbeYa eh _cf[Z[ ZhW_dW][ \hec j^[ e\i_dki\beeh[b[lWj_ed_dWYhWd_WbZ_h[Yj_ed"Wim[bb
i[c_bkdWh ^_Wjki" m^_Y^ cWo i[h_ekibo W\\[Yj Wi j^[ ^eh_pedjWb eij[ejeco _d j^[ bWj[hWb cWn_bbW$
l[dj_bWj_ede\j^[cWn_bbWhoi_dki$ EdY[ W]W_d" _j mWi JWjkc '/., m^e ceZ_\_[Z j^_i
v ;nY[ii_l[ d[m j_iik[ \ehcWj_ed febofi" Yoiji" j[Y^d_gk[WdZZ[iYh_X[Zm^Wj^WiYec[jeX[ademd
[jY$cWoeYYkh_dj^[Wh[We\j^[cWn_bbWhoi_dki$ Wij^[Æm_dZemj[Y^d_gk[Ç$
J^[i[ ijhkYjkh[i" fWhj_YkbWhbo j^[ ckYeY[b[i" JeZWo j^[ j[Y^d_gk[ e\ i_dki \beeh [b[lWj_ed _i
m_bb \h[gk[djbo fhejhkZ[ ZemdmWhZi \hec j^[ m[bb [ijWXb_i^[Z WdZ m_Z[bo ki[Z HW]^e[XWh [j Wb$
ehX_jWb \beeh d[Wh j^[ ^_Wjki WdZ j[cfehWh_bo '///$ :[if_j[ j^[ \WYj j^Wj j^[ i_dki#b_\j fheY[Zkh[
XbeYaZhW_dW][$J^[cW_dfheXb[cm_j^j^[i[fhe# _i Yeccedbo ki[Z \eh Wk]c[djWj_ed e\ i[l[h[bo
jhki_edi_ij^Wjj^[ocWo_cfW_hej^[hijhkYjkh[i h[iehX[Z feij[h_eh cWn_bbW" Yecfb_YWj_edi _d j^[
Zk[jej^[_hifWj_Wb[nfWdi_ed$ \ehc e\ WYkj[ eh Y^hed_Y cWn_bbWho i_dki_j_i cWo
v ;dZeZedj_YfheXb[ci"m_j^ehm_j^ekjf[h_eZedjWb eYYkh H[][l [j Wb$ '//+1 =”ch” WdZ AeYWa '//,1
_dlebl[c[dj" _d j^[ fh[cebWhi WdZ [if[Y_Wbbo _d :ekZ=Wbb_[jWb$(&&'$J^[ikYY[iihWj[i]_l[d_dj^[
j^[ cebWhi cWo b[WZ je WYkj[ _d\bWccWj_ed e\ b_j[hWjkh[lWhoX[jm[[d-+WdZ/)$Feijef[hWj_l[
j^[ i_dki$ <eh j^[ ceij fWhj" ^em[l[h" j^[o b[WZ i_dki_j_iYWdX[[nf[Yj[Z_d.Ä'&e\YWi[i$<ebbem#kf
je Y^hed_Y fheb_\[hWj_l[ _d\bWccWjeho fheY[ii[i hWZ_e]hWf^ieXjW_d[Z_dj^[\_hijfeijef[hWj_l[m[[a
e\ j^[ i_dWb ckYeiW _d j^[ [nj[dZ[Z l_Y_d_jo e\ m[h[ Y^WhWYj[h_p[Z Xo jejWb eh fWhj_Wb hWZ_efWY_jo
j^[_h \eYki$ 7\j[h j^[ YWki[ e\ j^[ _d\bWccWj_ed _d '& ekj e\ '( cWn_bbWho i_dki[i \ebbem_d] i_dki
^Wi X[[d h[cel[Z Xo [dZeZedj_Y jh[Wjc[dj eh ]hW\j_d]$
[njhWYj_ed"[nY[ii_l[j_iik[j^Wj^Wi\ehc[Z_dj^[ ?d W ijkZo Xo J_Zm[bb [j Wb$ '//(" feijef[hWj_l[
i_dki m_bb ][d[hWbbo f[hi_ij$ IkY^ h[i_ZkWb j_iik[ i_dki_j_i eYYkhh[Z _d '& d3*. e\ fWj_[dji$ J^[i[
m_bbWYYkckbWj[m_j^W][$ Wkj^ehi eXi[hl[Z j^Wj j^[ hWj[ e\ feijef[hWj_l[
v Ded[j^[b[ii" Y^hed_Y YedZ_j_edi e\ j^[ cWn_bbWho i_dki_j_imWii_]d_\_YWdjbo^_]^[h_dfWj_[djim^e^WZ
i_dki _dlebl_d] j^[ i_dki \beeh h[]_ed WdZ j^[ W^_ijehoe\i_dki_j_i_dj^[\_hijfbWY[$I_dkih[l_i_ed
Z_ijWb i_dki mWbb Wh[ [njh[c[bo hWh[ WYYehZ_d] je fheY[Zkh[i m[h[ d[Y[iiWho _d * e\ j^[ W\\[Yj[Z
ejeh^_debWhod]ebe]_iji$ fWj_[dji$
v J^[ ckYeiW e\ j^[ cWn_bbWho i_dki _i [njh[c[bo ?dXej^ijkZ_[i"Wc_njkh[e\Wkjebe]ekiYWdY[bbeki
m[bblWiYkbWh_p[Z[l[dm^[h[_j_il[hoj^_d$ Xed[ WdZ ^oZhenoWfWj_j[ ]hWdkb[i mWi ki[Z Wi
v I_dkifW_d_idejYWki[ZXo_d\bWccWjehofheY[ii[i Wk]c[djWj_edcWj[h_Wb$
f[hi[XkjXoj_iik[^ofen_Wb[Wl_d]Wi_Z[WYkj[ 7 cW`eh YWki[ e\ feijef[hWj_l[ i_dki_j_i m[h[
fheY[ii[i_dlebl_d]ikffkhWj_edWdZfh[iikh[$ fWhj_Yb[ie\YWdY[bbekij_iik[YWfWXb[e\cW_djW_d_d]
v ?\j^[i[c_bkdWh^_Wjki_iXbeYa[Z\ehWd[nj[dZ[Z Y^hed_Y_d\bWccWjehofheY[ii[iW\j[hi^[ZZ_d]\hec
f[h_eZ e\ j_c[" j^_i ZhW_dW][ fWj^mWo cWo j^[cW_dWk]c[djWj_edWh[W$
b_j[hWbbo Ybej kf eh [l[d Æ^[Wb kfÇ h[f[Wj[Zbo$ 7\j[h i_dki [b[lWj_ed fheY[Zkh[i" W j^_Ya[d_d] e\
J^_i_i[if[Y_Wbbojhk[_dj^[fh[i[dY[e\ed]e_d] j^[IY^d[_Z[h_Wdc[cXhWd[_ie\j[di[[ded9JiYWdi1
fheb_\[hWj_l[_d\bWccWj_ediWdZm^[dj^[fh[iikh[ ^em[l[h"j^[fWj_[djiWh[kikWbboWiocfjecWj_Y$J^[
hWj_e \Wlekhi ZhW_dW][ e\ j^[ i_dki _dje j^[ ehWb j^_Ya[d_d] e\ j^[ c[cXhWd[ Wbed[ _i dej Wd YedjhW
YWl_jo[$]$j^hek]^WdeheWdjhWb\_ijkbW$ _dZ_YWj_ed\ehjh[Wjc[dj$
È È "IOMECHANICSÈ6ERSUSÈ6ENTILATIONÈ
È
.ATUREÈOFÈTHEÈ-AXILLARYÈ3INUS
J^[ j[hc ÆcWn_bbWho i_dkiÇ Ze[i dej Z[dej[ Wd
eh]Wd_d_jiemdh_]^j$M[Wh[jWba_d]WXekjW^ebbem
ifWY[m^ei[i^Wf[_iWYedi[gk[dY[e\cekj^"dei["
[Wh WdZ [o[ Z[l[befc[dj$ J^[ WdWjec_YWb \[Wjkh[i
e\ j^[ cWn_bbWho i_dki lWho m_Z[bo$ ?ji eii[eki
XekdZWh_[i WdZ Yedj[dj Wh[ Z_YjWj[Z [nYbki_l[bo
Xo j^[ d[_]^Xekh_d] WdWjec_YWb ijhkYjkh[i$ J^[
cWn_bbWho i_dki i^emi de j[dZ[dYo je Y^Wd][ _ji
cehf^ebe]oed_jiemd$
Edbo j^[ i_dki \beeh Yecfh_i[i W ceZ[hWj[bo
j^_YaXed[bWo[h\_bb[Zm_j^YWdY[bbekij_iik["m^_Y^
m_bb Z[]hWZ[ \ebbem_d] jeej^ beii$ J^[ c[Z_Wb mWbbi
i[fWhWj_d]j^[i_dki\hecj^[dei["m^_Y^edbo\ehc
W jhW`[Yj_b[ Yedd[Yj_ed X[jm[[d j^[ eYkbWh Xed[
ijhkYjkh[iWdZj^[cWn_bbW"Yedi_ijieb[boe\Yehj_YWb
j_iik[$J^[hee\e\j^[i_dkieXjW_di_jicehf^ebe]o
WiWh[ikbje\[o[Z[l[befc[djWdZZe[idejYedjW_d
Wdo YWdY[bbeki j_iik[ [_j^[h$ 7bb ej^[h mWbbi" jee"
Wh[ [nYbki_l[bo i^Wf[Z Xo j^[ WZ`WY[dj ie\j#j_iik[
ijhkYjkh[i$ J^[ edbo [nY[fj_ed _i j^[ i_dki \beeh"
m^ei[ cehf^ebe]o _i WZZ_j_edWbbo _d\bk[dY[Z Xo
^WhZj_iik[_$[$j^[Z[djWbheejif[d[jhWj_d]_djej^[
Xed[$
H[i_ZkWb h_Z][ lebkc[ \ebbem_d] jeej^ beii m_bb
WbmWoiX[bWh][h_dj^[Wdj[h_ehi[]c[djWdZfh[cebWh
h[]_edj^Wd_dj^[Z_ijWbh[]_edm^[h[j^[cebWhiWh[
beYWj[Z$ J^_i Z_\\[h[dY[ h[ikbji \hec j^[ \WYj j^Wj
jme Z[dj_j_edi [hkfj[Z _d j^[i[ h[]_edi Wj Wd W][
m^[dXed[]hemj^mWi\Wlekh[ZXo^ehced[i$8ej^
Z[dj_j_edi Xh_d] j^[ Xed[ j^[o d[[Z \eh WdY^ehW][
Wbed]m_j^j^[c"Wi_jm[h[$7iWh[ikbj"j^[Wcekdje\
Xed[WlW_bWXb[W\j[h[njhWYj_edWdZ_dj^[ikXi[gk[dj
f^Wi[ie\[Whbo_dlebkj_edWdZZ_iki[Wjhef^o_iij_bb
bWh][hj^Wd_dj^[Z_ijWbh[]_ed$
J^[ cWdZ_Xb[ _i ikX`[Yj[Z je X[dZ_d] ijh[ii[i
_d j^[ Wh[W e\ j^[ cWdZ_XkbWh Wd]b[" ie j^Wj Xed[
c_d[hWb_pWj_ed j[dZi je _dYh[Wi[ [l[d m^_b[ j^[
Xed[ lebkc[ _i Z[Yh[Wi_d]$ J^_i \WYj _i WffWh[dj
Xo j^[ [d^WdY[Z m^_j[ b_d[ b_d[W eXb_gkW _d j^[
fWdehWc_YhWZ_e]hWf^$?dj^[Z_ijWbcWn_bbW"^em[l[h"
j^_i\kdYj_edWbij_ckbki_ickY^icWbb[h"WdZj^[h[_i
de_dY[dj_l[f[hi[jefh[i[hl[l[hj_YWbXed[lebkc[$
J^[fWbWj[_ickY^b[iifhed[jeh[iehfj_edj^Wdj^[
l[ij_XkbWhmWbbie\j^[cWn_bbWhoXed[$J^_i_iZk[je
j^[ YedZ_j_ed_d] [\\[Yj e\ j^[ jed]k[" m^_Y^ a[[fi
[n[hj_d] Yedi_Z[hWXb[ fh[iikh[ ed Wbb Wh[Wi e\ j^[
fWbWjWb Xed[$ J^_i \WYj _i kj_b_p[Z je ]eeZ [\\[Yj \eh
j^[WdY^ehW][e\_cfbWdjiedj^[fWjWbWbi_Z[e\j^[
Wbl[ebWhXed[$
(+)
È
"IOMECHANICSÈ6ERSUSÈ6ENTILATION
?j_ijeekhX[d[\_jj^Wjj^[cWn_bbWhoi_dki_i[cfjo
WdZ dej \_bb[Z m_j^ Xed[ eh W \bk_Z" Wi j^_i mekbZ
ikXijWdj_Wbbo _dYh[Wi[ j^[ m[_]^j e\ ekh ^[WZ$
Efj_c_p_d]m[_]^jWdZc[Y^Wd_YWbfhef[hj_[iWjj^[
iWc[ j_c[ _i ed[ e\ j^[ XWi_Y fh_dY_fb[i e\ ia[b[jWb
WhY^_j[Yjkh[$ J^[ mWbbi e\ j^[ fWhWdWiWb i_dki[i
WdZ j^[ dWiWb YWl_jo Wh[ Z[i_]d[Z je fhel_Z[ ijWj_Y
ikffehj$ ;ii[dj_Wbbo" j^[o Wh[ Xo#fheZkYji e\ eYkbWh"
ehWbWdZY[h[XhWbie\j#j_iik[Z[l[befc[dj$<_bb_d]j^[
fWhWdWiWb i_dki[i m_j^ Xed[ mekbZ cWa[ de i[di[
\hec W X_ec[Y^Wd_YWb ijWdZfe_dj" ]_l[d j^[ icWbb
\kdYj_edWb h[gk_h[c[dji _dlebl[Z$ J^[o Wh[ edbo
\_bb[Zm_j^Xed[m^[h[j^[j[[j^Wh[$;l[dj^[h["j^[
Xed[m_bbedboX[cW_djW_d[Zkdj_bj^[j[[j^Wh[beij"
WdZedbojej^[[nj[djj^WjXed[_id[[Z[Zjec[[jj^[
ijhkYjkhWb h[gk_h[c[dji e\ j^[ YhWd_e\WY_Wb ioij[c$
9edjhWho je W \h[gk[djbo fkXb_i^[Z c_iYedY[fj_ed"
h_Z][ h[iehfj_ed _i dej YWki[Z Xo Æl[dj_bWj_edÇ Xkj
Xo j^[ X_ec[Y^Wd_Yi e\ Yedj_dkeki \kdYj_edWb
efj_c_pWj_ed$ J^[ beWZi e\ cWij_YWj_ed WdZ \WY_Wb
[nfh[ii_ed Wh[ ikijW_d[Z ieb[bo Xo Wd efj_cWbbo
Yed\_]kh[Z WhY^_j[Yjkh[ e\ j^_d Yehj_YWb mWbbi WdZ
WZ`klWdj i[fjW$ J^[ YedY[fj e\ i_dki l[dj_bWj_ed
mWi WZleYWj[Z Xo Z_ifkjWj_eki WdWjec_iji WhekdZ
(&o[WhiW]e"WdZiec[e\j^[i[_Z[Wi^Wl[ikhl_l[Z
jej^_iZWo$
;l[d_\bWh][Xedoi[]c[djie\j^[l[ij_XkbWhi_dki
mWbb Wh[ beij Zk[ je \hWYjkh[ eh eij[eboi_i" j^_i Ze[i
dej [l[d h[cej[bo `[efWhZ_p[ j^[ _dj[]h_jo e\ j^[
YhWd_e\WY_Wbioij[c$J^[eXi[hlWj_edj^Wj[l[dcW`eh
^eb[i_dj^[l[ij_XkbWhi_dkimWbbWh[ifedjWd[ekibo
\_bb[Z m_j^ Xed[ _d Zk[ Yekhi[ _dZ_YWj[i j^Wj j^[i[
Yehj_YWbWh[Wim_bbh[jW_d\ehY[jhWdic_ii_edjWiaije
c[[jj^[ijhkYjkhWbh[gk_h[c[djie\j^[iakbb[l[d_d
[Z[djkbekii_jkWj_edi$J^_i^[Wb_d]fheY[ii"^em[l[h"
fh[ikffei[ij^Wjj^[W\\[Yj[Zh[]_ed_idejjhWdil[hi[Z
Xoie\j#j_iik[ijhkYjkh[ij^Wjm[h[Z_ibeZ][ZZkh_d]W
ikh]_YWbfheY[Zkh[[$]$_dW9WbZm[bb#BkYfheY[Zkh["
m^[h[ j^[ Yecfb[j[ h[i[Yj_ed e\ _djhW#i_dki j_iik[i
b[WZijecWii_l[h[WYj_l[_d]hemj^e\j_iik[j^hek]^
j^[ Xedo Z[\[Yji" ed[ e\ j^[ cW`eh fheXb[ci X[_d]
j^[_dWZ[gkWj[XbeeZikffbo\ehj^_ij_iik[$?j_iWbie
d[Y[iiWho je a[[f j^[ WYY[ii WdZ ZhW_dW][ fWj^i je
WdZ\hecj^[Xed[ef[d"c[Wd_d]j^Wjj^[_di[hj_ed
e\ f[h_eZedjWbbo ikffehj[Z Z[djkh[i _i ekj e\ j^[
gk[ij_ed$
?d YedjhWij je l[ij_XkbWh ^eb[i" YWkZWb Wf[hjkh[i
_d j^[ Wh[W e\ j^[ fh[cebWhi WdZ \_hij cebWhi e\
h[iehX[Z h_Z][i cWo jkhd ekj je X[ fheXb[cWj_Y$
J^[i[Wf[hjkh[iWh[dej[Wi_boYel[h[ZWdZ^Wl[Wbem
j[dZ[dYo e\ ifedjWd[eki Xedo ^[Wb_d]$ 7ffWh[djbo"
j^[ YWkZWb h_Z][ i[]c[dji Wh[ XWh[bo d[[Z[Z \hec
WX_ec[Y^Wd_YWbijWdZfe_dj"iej^Wjj^[j[dZ[dYoe\
(+* 9^Wfj[h'.È )MPLANTÈ4REATMENTÈ!LONGÈTHEÈ-AXILLARYÈ3INUS

j^[ Xedo XWi[ je h[][d[hWj[ _d j^ei[ Wh[Wi _i icWbb$ j^[ Z_ijWb cebWhi Wh[ beYWj[Z m_bb j^[h[\eh[ h[i_ij
Iec[j_c[ij^[edboiebkj_edi\ehXedoYel[hW][_iXo Xed[_dlebkj_edj[dZ[dY_[iX[jj[hj^Wdj^[Wh[We\
bWh]["lWiYkbWhbof[Z_Yb[ZXed[]hW\jiehjefhel_Z[Wbb j^[\_hijcebWhehi[YedZfh[cebWh$
j^[ fh[h[gk_i_j[i \eh W cWYhejhW`[Yjeh_Wbbo eh_[dj[Z v J^[h[Wh[jmecW`ehh[Wiedi\ehj^[\WYjj^Wjj^[
Xedo i[b\#Ybeikh[$ J^[ po]ecWj_Ye#Wbl[ebWh Yh[ij Wdj[h_eh cWn_bbW _i fhej[Yj[Z h[bWj_l[bo m[bb \hec
bei[iceije\_jifhec_d[dY[[if[Y_Wbbo_d[Z[djkbeki h[iehfj_ed$<ehed[j^_d]"j^[YedZ_j_edi\ehXed[
cWn_bbW[$ J^[i[ Xed[ Wh[Wi" m^_Y^ Wh[ Z[i_]d[Z je fh[i[hlWj_ed Wh[ i_c_bWhbo \WlekhWXb[ Wi _d j^[
fhel_Z[ YhWd_ebWj[hWb ikffehj" m_bb hWf_Zbo [heZ[ cWdZ_Xb[Zk[jej^[YkhlWjkh[#h[bWj[Zel[hbWff_d]
Xo Z_iki[ Wjhef^o _d fWj_[dji m[Wh_d] Yecfb[j[ e\ jhW`[Yjeh_[i Wbie i[[ j^[ \_]kh[i f[hjW_d_d] je
Z[djkh[i$@kijb_a[WdoXed[ijhkYjkh["Wd[Z[djkbeki Meb\\ ÉibWm_d9^Wfj[h/$?d_j_Wbbo"j^[h[iehfj_ed
Wbl[ebWh h_Z][ m_bb X[^Wl[ WYYehZ_d] je <heijÉi _d j^_i Wh[W j[dZi je fhe]h[ii hWf_Zbo je j^[
d[kjhWb_pWj_ed j^[eho" j^[h[Xo bei_d] _ji hekdZ[Z fe_dj m^[h[ j^[ l[ij_XkbWh WdZ fWbWjWb Yehj_YWb
fhec_d[dY[ j^Wj _i Z_h[Yj[Z jemWhZi j^[ ehWb YWl_jo ijhkYjkh[ic[h][$IkXi[gk[djbo"^em[l[h"j^[i_jk#
edY[j^[Xed[#fh[i[hl_d]_d\bk[dY[e\j^[j[[j^^Wi Wj_ed ijWX_b_p[i WdZ j^[ l[hj_YWb Z_c[di_ed e\
Z_iWff[Wh[Z WdZ j^[ eij[edWb ioij[c _i _hh_jWj[Z j^[ h[i_ZkWb Xed[ m_bb X[ fh[i[hl[Z \eh o[Whi je
\eh iec[ h[Wied eh ej^[h$ Fej[dj_Wb jh_]][hi _dYbkZ[ Yec[$ J^[ i[YedZ h[Wied _i j^Wj cWij_YWjeho \eh#
^ehcedWb _d\bk[dY[i" ikh]_YWb _dj[hl[dj_ed WdZ Y[i Wh[ jhWdic_jj[Z _d W YhWd_Wb Z_h[Yj_ed" i_dY[
h[celWbe\j^[IY^d[_Z[h_Wdc[cXhWd[jh_]][hi$ j^[ cWdZ_Xb[ ijh_a[i W]W_dij j^[ Wdj[h_eh Xed[
J^[ \WYj j^Wj j^[ YWkZWb i_dki i[]c[dj _$[$ j^[ ijhkYjkh[i_dj^[ijob[e\W^Wcc[h$J^_i]_l[ih_i[
Wh[We\j^[\_hijcebWhi][d[hWbboh[gk_h[ib[iiXed[ jej^[\ehcWj_ede\XedoÆf_bbWhiÇWbed]m^_Y^j^[
_i[l_Z[dj\hec_jiXkb]_d]i^Wf[_dj^WjWh[W"m^_Y^ cWij_YWjeho\ehY[iWh[Z_ijh_Xkj[ZWij[[j^Wh[ij_bb
_i hWZ_e]hWf^_YWbbo l_i_Xb[ _d Wbceij Wbb _dZ_l_ZkWbi$ fh[i[dj$ D[l[hj^[b[ii" [l[d j^[ ijWXb[ Wdj[h_eh
M^[d j^[ i_dki [nfWdZi YWkZWbbo" j^[ heeji e\ j^[ Xed[ i[]c[dj _d j^[ kff[h `Wm YWd X[ Z[ijheo[Z
Z_ijWb j[[j^ Wh[ edbo Yel[h[Z m_j^ W j^_d bWo[h e\ _d j^[ fh[i[dY[ e\ h[i_ZkWb j[[j^ _d j^[ Wdj[h_eh
Yehj_YWb Xed[$ E\ Yekhi[ j^_i Ze[i dej W\\[Yj beWZ cWdZ_Xb[_\j^[fWj_[djm[WhiWYecfb[j[Z[djkh[
jhWdic_ii_ed"kdb[iih[ceZ[bb_d]YWki[ZXoY^Wd][i _dj^[cWn_bbW$
_d\kdYj_edeh_d\[Yj_edim_j^_dj^[i_dkiYWki[ij^_i v 8[jm[[dj^[Z_ijWbi[]c[dje\j^[cWn_bbWhoh_Z]["
Xed[ je Z_iWff[Wh Wi W h[ikbj e\ [nY[ii_l[ beWZ_d]$ m^_Y^ _i ikX`[Yj je \kdYj_edWb ijh[ii[i" WdZ _ji
I_c_bWhbo j^_d beWZ#jhWdic_jj_d] ijhkYjkh[i Wh[ Yheii#b_da[Z WdZ ^[dY[ ceijbo i[b\#ijWX_b_p_d]
\ehc[Z_dj^[^_fm^[d[dZefheij^[i[iWh[_di[hj[Z Wdj[h_eh i[]c[dj" j^[h[ _i Wd Wh[W e\ _dYh[Wi[Z
_dje ^_f Xed[ Wi _\ j^[o m[h[ Wd [bWij_Y XW]$ J^_i \b[n_ed YedjW_d_d] eij[edi j^Wj Wh[ eh_[dj[Z _d
Yed\_]khWj_ed" jee" Wbbemi Yedi_Z[hWXb[ beWZi je X[ j^[ Wdj[hefeij[h_eh fbWd[$ ?d j^_i ped[" hek]^bo
ikffehj[ZXoWc_d_ckcWcekdje\Xed["i_dY[j^[ Ye_dY_Z_d] m_j^ j^[ Wh[W e\ j^[ i[YedZ fh[cebWh
Z_h[Yj_ede\j^[beWZim_bb\Wlekhj^[fh[i[hlWj_ede\ WdZ\_hijcebWh"j^[c[Y^Wd_YWbijh[ii[iWh[bem[h$
Xed[$FehekiYeWj[Zikh\WY[i^Wl[i^emdjeX[l[ho >[dY[ j^[ Xed[ lebkc[ _i h[ZkY[Z je c_d_c_p[
[\\[Yj_l[_dj^[i[Wffb_YWj_edi$ m[_]^j WdZ efj_c_p[ j^[ jhW`[Yjeho$ J^_i _i edY[
J^ki j^[ i_dki ijWhji Æ[nfWdZ_d]Ç [l[d m^[d W]W_d j^[ jhWZ_j_edWb c_iYedY[fj_ed WXekj j^[
j[[j^ Wh[ ij_bb fh[i[dj" W fheY[ii j^Wj ]e[i ed m[bb h[Wiedi \eh j^_i Z[l[befc[dj f[hY[_l[Z Wi Wd
_dje ebZ W][$ Fh[l_eki Wkj^ehi ^Wl[ ^ofej^[i_p[Z Æ[nfWdi_edÇ e\ j^[ i_dki1 j^[ X_ec[Y^Wd_YWb
j^Wjj^_i[nfWdi_edc_]^jX[YWki[ZXoÆl[dj_bWj_edÇ _cfb_YWj_edi^Wl[ie\WhX[[del[hbeea[Z$Ed[e\
e\ j^[ i_dki WYYecfWd_[Z Xo ib_]^j Xkj Yedj_dkeki j^[ ceij _cfehjWdj h[Wiedi m^o j^[ Xed[ _d j^[
el[hfh[iikh[$ ?d ekh l_[m" j^_i _Z[W i^ekbZ X[ h[]_ed e\ j^[ kff[h \_hij cebWh _i kdijWXb[ _i j^[
WXWdZed[ZÄX[YWki[j^[cWii_l[\kdYj_edWb_dY[d# cWdd[h _d m^_Y^ j^[ Wh[W _i lWiYkbWh_p[Z0 J^[
j_l[i \eh Xed[ h[ceZ[bb_d] WdZ j^[ \ehcWj_ed e\ _d\hWehX_jWb Whj[ho WdZ j^[ _dj[hdWb WdZ [nj[hdWb
cWYhejhW`[Yjeh_[iWh[ckY^ceh[_d\bk[dj_Wb\WYjehi$ j[hc_dWj_edi e\ j^[ ikf[h_eh cWn_bbWho Whj[h_[i
i^em Wd Wdj[h_eh WdWijecei_i$ J^[h[\eh[" _\ ed[
7\j[h Wbb" j^[ YWkZWb i_dki h[]_ed _i ikX`[Yj je W eh ceh[ XhWdY^[i _d j^[ Wh[W e\ j^[ cWn_bbWho
lWh_[joe\\ehY[i"m^_Y^Wh[Z[jW_b[Z_dj^[\ebbem_d] i_dki Wh[ i[l[h[Z" j^[i[ ijhkYjkh[i YWddej X[
fWhW]hWf^i0 [nf[Yj[Z je h[Yel[h$ HWj^[h" j[hc_dWb XhWdY^[i
v Ed Xej^ i_Z[i e\ j^[ feij[h_eh XehZ[h e\ j^[ m_j^ W h[bWj_l[bo kd\WlekhWXb[ ZhW_dW][ i_jkWj_ed
cWn_bbW"j^[bWj[hWbfj[ho]e_ZckiYb[i[n[hjj[di_b[ m_bbX[Yh[Wj[Z$<eh8E?j^[hWfo"j^_ic[Wdij^Wj
\ehY[i _d W Z_ijWb WdZ l[ij_XkbWh Z_h[Yj_ed$ 7i W j^[ _dY_i_ed \eh j^[ j^h[WZ[Z f_d i[l[h_d] j^[
h[ikbj e\ j^[i[ \ehY[i" Xed[ lebkc[ _i fh[i[hl[Z Whj[h_[i _i edbo '$/cc _d i_p[" WdZ j^ki gk_j[
h[bWj_l[bo m[bb _d j^[ ckiYb[ WjjWY^c[dj Wh[W icWbb" m^_Y^ _i Wd WZlWdjW][$ J^[ _dY_i_ed \eh
_$[$j^[jkX[hei_jo"_dj^[fWbWjWbXed[Wh[W"WdZ j^[ Z_ia i^ekbZ" ^em[l[h" X[ fei_j_ed[Z ikY^
_d j^[ WZ`WY[dj Wh[Wi m^[h[ fj[ho]ecWn_bbWho j^Wj _j Ze[i dej Z_ihkfj j^[ XbeeZ ikffbo _d W
iYh[m _cfbWdji Wh[ WdY^eh[Z$ J^[ Wh[Wi m^[h[ bed]_jkZ_dWb Z_h[Yj_ed$ ?djhW#i_dki _di[hj_ed e\
È È "IOMECHANICSÈ6ERSUSÈ6ENTILATIONÈ
8E? _cfbWdji Wj Wd WZ[gkWj[ Z_ijWdY[ \hec j^[
i_dki\beeh_ij^[h[\eh[j^[c[j^eZe\\_hijY^e_Y[$
v 7iWh[ikbje\j^[WXel[#Z[iYh_X[Z\ehY[Z_ijh_Xkj_ed
WdZ jhW`[Yj_b[ WZWfjWj_ed e\ j^[ \kbbo Z[l[bef[Z
cWn_bbWho h_Z][" Wd Æ[njhki_edÇ e\ j^[ Z_ijWb
cWn_bbWho i[]c[dj h[bWj_l[ je j^[ cWdZ_XkbWh
Z[dj_j_ed_ib_a[bojeeYYkh[l[dm^_b[j^[dWjkhWb
Z[dj_j_ed _d j^[ cWn_bbWho feij[h_eh i[]c[dj _i
ij_bb _djWYj$ ?d j^_i fheY[ii" j^[ Wd]b[ X[jm[[d
9Wcf[hÉifbWd[WdZj^[fbWd[e\cWij_YWj_edm_bb
X[ Wbj[h[Z kdb[ii j^[ Wdj[h_eh Z[dj_j_ed [njhkZ[i
Wim[bbi[[9^Wfj[h-WdZj^[Yecc[djiedj^_hZ
cebWhi\eh\khj^[hZ[jW_bi$
v J^[ cWn_bbWho i_dki m_bb Yedj_dk[ je [nfWdZ
j^hek]^ekjb_\[h[]WhZb[iie\m^[j^[hj[[j^Wh[beij
ehfh[i[hl[Z$J^[YWkZWbi_dki\beehm_bbZ[iY[dZ
\khj^[h" m^_Y^ cWo eh cWo dej X[ WYYecfWd_[Z
Xo W YhWd_Wb i^_\j e\ j^[ Wbl[ebWh Yehj_YWb h_Z][$
<h[gk[djbo" j^[ gk[ij_ed e\ m^_Y^ c[Y^Wd_ic
Zec_dWj[i j^[ fheY[ii YWddej X[ Wdim[h[Z _d
h[jheif[YjWih[\[h[dY[fe_djiWh[bWYa_d]Xoj^Wj
j_c[$ B_a[m_i[" _j _i de bed][h feii_Xb[ je l[h_\o
m^[j^[hj^[cWn_bbWhoi_dki_i[nfWdZ_d]\khj^[h
[$]$Xoced_jeh_d]j^[Z[Yh[Wi[e\l[hj_YWbXed[
lebkc[edY[j^[Yehj_YWbXed[_dj^[YWkZWbi_dki
^Wi c[h][Z m_j^ j^[ Yehj_YWb Xed[ e\ j^[ Yh[ijWb
h_Z][$ ?j _i" ^em[l[h" h[WiedWXb[ je Wiikc[ \hec
W Yb_d_YWb ijWdZfe_dj j^Wj j^_i Xed[ i[]c[dj m_bb
Z[iY[dZ\khj^[h$
v 7\j[hWbb"j^[[nfWdi_ede\j^[i_dki_iYWki[ZXo
j^[ \WYj j^Wj j^[ _dd[h YedYWl_jo e\ j^[ Yehj_YWb
Xed[ ikh\WY[ _i jee bWh][ \eh W Xed[ ijhkYjkh[
j^Wj_iikX`[Yj[Zje\kdYj_edWbbeWZi$7YYehZ_d]je
<heijÉi\b[nkhWbd[kjhWb_pWj_edj^[eho<DJ"WXed[
ijhkYjkh[ikX`[Yj[Zje\kdYj_edWbbeWZim_bbWbmWoi
j[dZ je h[ZkY[ _ji _dd[h YkhlWjkh[$ ?d ekh YWi["
j^_i_iWYYecfb_i^[ZXoWd_dYh[Wi[e\j^[Y_hYkbWh
Y_hYkc\[h[dY[" m^_Y^ h[ZkY[i Wdo YedYWl_j_[i$
<DJ" ^em[l[h" h[gk_h[i j^Wj bed]_jkZ_dWb \ehY[i
WdZ jhW`[Yjeh_[i X[ fh[i[dj$ ?d ekh YWi[" j^[i[
mekbZ dehcWbbo X[ _dj[hhkfj[Z Xo Wdo h[i_ZkWb
j[[j^"Z[f[dZ_d]edj^[dkcX[h"i_p[WdZi^Wf[e\
j^[_hheeji<_]$'.$'$
v ?\j^[Xed[ijhkYjkh[iWhekdZj^[cWn_bbWhoi_dki
m[h[ WXb[ je Y^Wd][ j^[_h cehf^ebe]o m_j^ de
ej^[h\ehY[i_dlebl[Z"j^[omekbZÄ`kijb_a[YoijiÄ
WYgk_h[Wif^[h_YWbi^Wf[$7ced]ej^[hh[Wiedi"W
if^[h_YWbi^Wf[WbbemiWYecfb[j[bo^ece][d[eki
XbeeZikffbo$
v ?d 8E?" edY[ j^[ fheij^[j_Y ikf[hijhkYjkh[ _i
_di[hj[Z"j^[Yedj_dkekij[dZ[dYoe\j^[cWn_bbWho
i_dki je [nfWdZ _i dej Yekdj[hWYj[Z Xo Z_iYed#
j_dkeki cWij_YWjeho \ehY[i1 _j edbo Y^Wd][i _ji
[nj[djWdZZ_h[Yj_ed$
v J^[ cWn_bbWho i_dki YedjW_di l[hj_YWb i[fjW
j^hek]^m^_Y^\ehY[iWh[jhWdic_jj[Z_dWYhWd_Wb
Z_h[Yj_ed$ J^[i[ m_bb f[hi_ij [l[d _d j^[ [l[dj
(++
j^Wjceh[j[[j^Wh[[njhWYj[ZWdZj^[i_dki\beeh
jhWl[bi [nj[di_l[bo eh i^_\ji Yecfb[j[bo je j^[
YWkZWb Wif[Yj$ J^[i[ i[fjW cWo Wjhef^o je j^[
fe_dje\Z_iWff[Wh_d]Wbje][j^[h_\j^[jof["b[l[b
WdZ Z_h[Yj_ed e\ j^[ cWij_YWjeho \ehY[ j^[o Wh[
_dj[dZ[ZjeWXiehXY^Wd][i$
v ?\j^[Yehj_YWbWh[Wie\j^[i_dki_dj[h_ehmWbbWh[
dej _d c[Y^Wd_YWb \kdYj_ed" j^[d j^[ j[dZ[dYo
je [nfWdZ m_bb X[ icWbb[h$ J^Wj _i je iWo" dej
Wbb cWn_bbWho i_dki[i m_bb [nfWdZ" WdZ _\ j^[o
Ze" j^_i _i dej d[Y[iiWh_bo W Yedj_dkeki fheY[ii$
;nfWdi_edcWoY[Wi[WjWdoj_c[Wij^[\kdYj_edWb
beWZiWYj_d]edj^[cWh]_dWbWh[WiZ_c_d_i^$<eh
[nWcfb["j^[Z_ijh_Xkj_ede\\kdYj_edWbbeWZicWo
Y^Wd][_$[$beWZii^_\jjeej^[hWh[Wie\j^[iakbb"
ehj^[jejWbbeWZWYj_d]edj^[iakbbcWoZ[Yh[Wi[$
;l[d j^[ jejWb Xed[ cWii cWo Y^Wd][ Zk[ je
^ehcedWb _d\bk[dY[i$ J^[ ifWj_Wb b_c_jWj_edi Xo
if[Y_\_Y XehZ[h Wh[Wi [$]$ j^[ Xedo fWbWj[ m_bb
Wbie X[ W \WYjeh _d YWkZWb [nfWdi_ed$ 7dej^[h
j^_d] je a[[f _d c_dZ _i j^Wj Xed[ h[ZkYj_ed
_d W dWhhem h_Z][ m_bb ]_l[ h_i[ je fhedekdY[Z
YedYWl_j_[i_dj^[Wh[We\j^[i_dki\beeh"m^_Y^_i
Wbiekd\WlekhWXb[\hecWX_ec[Y^Wd_YWbl_[mfe_dj
<DJ$ J^[h[\eh[" j^[ h[i_ZkWb Xed[ ^[_]^j _i
iec[j_c[i eXi[hl[Z je h[cW_d [njh[c[bo ijWXb[
_dikY^YWi[i"WdZh[iehfj_edijWhji\hecj^[ehWb
YWl_johWj^[hj^Wdj^[i_dki$
v J^[ Xed[ _d j^[ jkX[hei_jo Wh[W _i h[i_ijWdj je
h[iehfj_ed$ J^_i _i Wjjh_XkjWXb[ je j^[ \WYj j^Wj
Wdo[nfWdi_ede\j^[cWn_bbWhoi_dki_dj^_iWh[W
mekbZ _cfbo Wd [dbWh][c[dj e\ j^[ YedYWl_jo$
&IGÈ ?dYh[Wi_d] beWZi l[hj_YWb Whhemi m_bb _dYh[Wi[ j^[
YedYWl_joY$J^_ifheY[ii_iYecf[diWj[Z\ehXoWffei_j_ed
ed j^[ YedYWl[ i_Z[ 9 WdZ Xed[ h[iehfj_ed ed j^[ Yedl[n
i_Z[ J e\ j^[ Xed[$ 7YYehZ_d]bo" j^[ c[ZkbbWho YWdWb m_bb
Wbiei^_\jjemWhZij^[h[iehfj_edi_Z[J$I_c_bWhYedZ_j_edi
Wh[ [dYekdj[h[Z _d j^[ cWn_bbWho i_dki ceij e\ j^[ j_c[$
I_dY[j^[YedYWl_joe\j^[icWbb_dd[hbkc[d_ihekj_d[bojee
fhedekdY[Z" [l[d c_dkj[ beWZi m_bb ij_ckbWj[ [nfWdi_ed e\
j^[Xed[j_iik[_dj^_iWh[W$?di_Z[j^[i_dkim[\_dZWÆ\heij
kfi_Z[ZemdÇi_jkWj_ed$<hecCWhj_d[jWb$'//.
(+, 9^Wfj[h'.È )MPLANTÈ4REATMENTÈ!LONGÈTHEÈ-AXILLARYÈ3INUS
8ed[ ijhkYjkh[i j^Wj Wh[ ikX`[Yj[Z je \kdYj_edWb
beWZi YWddej" ^em[l[h" WYY[fj ikY^ [dbWh][c[dj
e\YedYWl_j_[i$
v J^[h[\eh[" W][#h[bWj[Z _dlebkj_ed Ze[i dej jWa[
fbWY[ _d j^[ fWhWdWiWb i_dki[i A_jj[b WdZ =^h
'/,+$ J^[ YedjhWho _i j^[ YWi[0 _dlebkj_ed e\ j^[
Xed[ b_c_j_d] j^[ bkc[d m_bb h[ikbj _d \khj^[h
Æfd[kcWj_pWj_edÇ$
v M^[d _cfbWdji Wh[ fbWY[Z Wbed] j^[ cWn_bbWho
i_dki" Xej^ j^[ eij[ejeco WdZ j^[ Y^Wd]_d]
cWij_YWjeho \kdYj_ed e\ j^[ h[ijeh[Z j[[j^ m_bb
_dj[h\[h[m_j^Wh[ij_d]ioij[c$7iWYedi[gk[dY[e\
cWij_YWj_edWdZXed[h[ceZ[bb_d]"Xej^j^[i^Wf[
e\ j^[ cWn_bbWho i_dki WdZ j^[ [nj[h_eh i^Wf[ e\
j^[cWn_bbWcWoY^Wd][$<ehj^_ih[Wied"m[fh[\[h
j^[ jhWdi#i_dki WffheWY^ e\ _cfbWdj _di[hj_ed"
_d m^_Y^ j^[ _cfbWdj Z_ia h[cW_di Yb[Wh e\ j^[
i_dki\beeh$J^kij^[Xed[_dj^[i_dki\beehWh[W
_iWbbem[Zje\beWj\h[[bo"m^_Y^"_dekh[nf[h_[dY["
h[ZkY[ij^[h_iaj^Wj\khj^[hi_dki[nfWdi_edb[WZi
jeYWkZWb_pWj_ede\j^[_cfbWdjm_j^j^[feii_Xb[ v 8o YedjhWij" _\ j^[ i_dki _i Wk]c[dj[Z Xo
Yedi[gk[dY[e\fh[cWjkh[YedjWYjij^WjcWob[WZ
jeeij[eboi_iWdZ_cfbWdj\hWYjkh[$
J^[ \ebbem_d] fWhW]hWf^i Wh[ _dj[dZ[Z je l[h_\o
j^[fe_djihW_i[Z_dj^[fh[l_ekib_ijXoYedi_Z[h_d]
WZZ_j_edWbfhef[hj_[ie\Yehj_YWbXed[0
v ?\ [nj[di_l[ Wk]c[djWj_ed e\ j^[ i_dki _i
f[h\ehc[Z [$]$ m_j^ fWh_[jWb Xed[ WdZ [l[d
ikffb[c[dj[Zm_j^WB[<ehj?Zemd\hWYjkh["Wbb
Z_h[Yj h[bWj_edi^_fi e\ j^[ eij[edWb jhW`[Yjeh_[i
jej^[Y^[m_d]ckiYb[iWh[i[l[h[ZehZ[ijheo[Z$
Kdb[iij^[i[ijhkYjkh[ih[][d[hWj[ifedjWd[ekibo
_dj^[feijef[hWj_l[f^Wi["j^[beWZijhWdic_jj[Z v CkY^ ceh[ i[h_eki \ehci e\ i_dki [nfWdi_ed
Xoj^[d[mbo_dijWbb[Z_cfbWdjim_bbX[j^[fh_c[
Z[j[hc_dWdj e\ j^[ \kdYj_edWb eh_[djWj_ed e\ j^[
h[eh]Wd_p_d] Xed[$ >[dY[ j^[ Z_h[Yj ij_ckbki
e\ cWij_YWjeho \kdYj_ed [dikh[i j^Wj cW`eh
Xed[ Wh[Wi ikhhekdZ_d] j^[ _cfbWdji h[cW_d _d
\kdYj_ed$
v <eh i_dki Wk]c[djWj_ed m_j^ _b_WY Xed[ XbeYai
eh Wkjebe]eki YWdY[bbeki Y^_fi Wi ]hW\j_d]
cWj[h_Wb" j^[ _cfbWdji ^Wl[ je X[ _di[hj[Z
[_j^[h _cc[Z_Wj[bo eh _d Zk[ Yekhi[ X[\eh[ v ?dj[hdWb i_dki ]hW\j_d] WYYehZ_d] je Ikcc[hi
j^[ [dbWh][c[dj e\ j^[ YedYWl_jo j^Wj h[ikbji
\hec j^[ fheY[Zkh[ _i Yehh[Yj[Z Wi feijkbWj[Z
Xo <DJ$ <ebbem_d] _di[hj_ed e\ j^[ _cfbWdj" j^[
Yed\hedjWj_edX[jm[[dXed[WdZ_cfbWdjikh\WY[
[$]$Æ[njhWj[hh_jeh_Wb_p_d] h[ifedi[Ç WYYehZ_d] je
:edWj^ Yh[Wj[i Wd [\\[Yj_l[ _dY[dj_l[ \eh Xed[
fh[i[hlWj_ed$ J^[ cWij_YWjeho beWZi WYj_d] ed
j^[ _cfbWdji e\\[h WZZ_j_edWb Z_h[Yj WdZ _dZ_h[Yj
\kdYj_edWbij_ckb_\ehXed[fh[i[hlWj_ed$
v EdY[ _cfbWdji ^Wl[ X[[d _dijWbb[Z" j^[ i_dki
Ikh\WY[ ij_ckbki e\ kdbeWZ[Z _cfbWdj Ä j^[
i^[[hfh[i[dY[e\Wd[njhWd[ekicWj[h_Wb_dj^[
[deiiWb ifWY[ m_bb _d\bk[dY[ Xed[ h[ceZ[bb_d]
WdZXed[\ehcWj_ed%c_d[hWb_pWj_ed$
:_h[Yj \kdYj_edWb ij_ckbki e\ _cfbWdj Ä
[d^WdY[Z \ehY[ jhWdic_ii_ed Wbed] j^[ Xed[
_dj[h\WY[_d[deiiWb_cfbWdjibeWZ[ZXocWij_#
YWjeho\ehY[i1j^_ijof[e\ij_ckbkiWYjiX[oedZ
j^[_cc[Z_Wj[YedjWYjWh[W$
?dZ_h[Yj \kdYj_edWb ij_ckbki e\ _cfbWdj Ä jeh#
i_ed X[jm[[d j^[ YhWd_Wb Xed[i _i [d^WdY[Z
Wi j^[ WYj_l_jo e\ j^[ cWij_YWjeho ckiYb[i
_dYh[Wi[i1j^_iij_ckbkim_bb[l[dYWfjkh[Xed[
Wh[Wim^[h[de_cfbWdjiWh[_dijWbb[ZXkjm^[h[
ceZ[bb_d] _i fhecfj[Z `kij Xo j^[ _dYh[Wi[ _d
cWij_YWjehoWYj_l_jo$
WZZ_d] ded#h[iehXWXb[ [njhWd[eki cWj[h_Wb" j^[
\WYj j^Wj j^[ Xed[ Yedj[dj _i dej h[iehX[Z m_bb
Yekdj[hWYj j^[ j[dZ[dYo e\ j^[ i_dki je [nfWdZ$
7iWh[ikbj"j^[_dj[hlWbkdj_b_cfbWdjWj_edYWdX[
ckY^ bed][h$ I_dY[ j^[ ded#h[iehXWXb[ fWhj_Yb[i
fh[l[dj j^[ \ehcWj_ed e\ bed][h jhW`[Yjeh_[i"
j^[ YedYWl_jo YWddej X[ Yehh[Yj[Z [l[d _d YWi[i
m^[h[ X_eY^[c_YWb YedZ_j_edi Wh[ _Z[Wb$ Ded#
h[iehXWXb[ eh feehbo h[iehXWXb[ Wk]c[djWj_ed
cWj[h_Wbi X[^Wl[ b_a[ Æc_d_#_cfbWdjiÇ" _d j^Wj
j^[_h i^[[h fh[i[dY[ e\\[hi Wd _dY[dj_l[ \eh Xed[
fh[i[hlWj_ed$
Wh[ eXi[hl[Z m^[d feij[h_eh j[[j^ Wh[ beij Wj W
oekd] W][ j^Wd _d YWi[i m^[h[ jeej^ beii eYYkhi
bWj[h _d b_\[$ J^_i _i Zk[ je j^[ ^_]^[h 8CK
WYj_lWj_ed\h[gk[dYoi[[9^Wfj[h/$'_doekd][h
fWj_[dji" m^_Y^ _i ik\\_Y_[dj je fhecej[ Xed[
h[ceZ[bb_d] _d _ji[b\$ 8ed[ ijhkYjkh[i e\ ebZ[h
fWj_[dji Wh[ Y^WhWYj[h_p[Z Xo W ^_]^[h Z[di_jo
e\ i[YedZWho eij[edi" b[ii fehei_jo WdZ ijhed][h
c_d[hWb_pWj_ed$
m_bb h[l[hi[ j^[ ifWj_Wb Yed\_]khWj_ed$ ?dij[WZ
e\ W YedYWl_jo" j^[ f[h_#_cfbWdj Xed[ Wh[W _i
Y^WhWYj[h_p[Z Xo W Xed[ Yedl[n_jo \ebbem_d] j^_i
jof[e\fheY[Zkh[j^Wj_iceh[b_a[bojeh[i_ijXed[
h[iehfj_ed$ J^_i _i YecfekdZ[Z Xo j^[ _cfbWdj#
h[bWj[Zij_ckb_WYj_d]edj^_iXed[ijhkYjkh[WdZ
\Wlekh_d] j^[ fh[i[hlWj_ed$ J^[ Xed[ Z[l[befi
m_j^_d W m[bb#Z[\_d[Z Wh[W WdZ YWd X[ fh[i[hl[Z
_d j^[ _cc[Z_Wj[ l_Y_d_jo e\ j^[ _cfbWdj$ J^[
c[Y^Wd_ic_ii_c_bWhjej^[ed[i[[dm_j^dWjkhWb
cebWhheeji[nj[dZ_d]_djej^[cWn_bbWhoi_dki$
m_bb Yedj_dk[ je Y^Wd][ _ji ifWj_Wb [nj[di_ed _d
È È )MPLANTOLOGICALÈ!PPROACHESÈTOÈTHEÈ3INUSÈ!REAÈ
WYYehZWdY[m_j^j^[X_ec[Y^Wd_YWbh[Wb_j_[i$J^_i
_i fWhj_YkbWhbo jhk[ _d YWi[i e\ ijhWj[]_Y _cfbWdj
fbWY[c[dj m^[h[ b_jjb[ \kdYj_edWb ij_ckbki _i
[n[hj[ZZ_h[YjboXoj^[_cfbWdji$7jj^[iWc[j_c["
gkWb_jWj_l[ WdZ gkWdj_jWj_l[ Xed[ Y^Wd][i Wh[
b_a[bojeeYYkhWij^[cWij_YWjeho\ehY[i_dYh[Wi[
W\j[hZ[djkh[ieh[i^Wl[h[iebl[Z$J^[i[Wbj[hWj_edi
m_bb_dlebl[[_j^[h[d^WdY[Zc_d[hWb_pWj_ed_\j^[
Xed[lebkc[h[cW_diYedijWdjehWd_dYh[Wi[_d
jejWbXed[lebkc[$
È
)MPLANTOLOGICALÈ!PPROACHESÈÈ
TOÈTHEÈ3INUSÈ!REA
J^[h[ Wh[ jme XWi_Y YedY[fji \eh j^[ fbWY[c[dj e\
8E? _cfbWdji _d j^[ Z_ijWb cWn_bbW WdZ j^[ i_dki
Wh[W$
È
!UGMENTATION
"ASEDÈ)NSERTIONÈOFÈ"/)È)MPLANTS
?d j^[ '/.&i" Wd _cfbWdjWj_ed j[Y^d_gk[ mWi
_djheZkY[Z_dYedd[Yj_edm_j^Z_ia_cfbWdjijejh[Wj
(+-
j^[ Wh[W e\ j^[ cWn_bbWho i_dki _d j^[ fh[i[dY[ e\
_dik\\_Y_[dj l[hj_YWb Xed[ lebkc[$ J^_i _i WY^_[l[Z
Xo \_hij [b[lWj_d] j^[ c[cXhWd[ X[\eh[ _dijWbb_d]
j^[XWiWbboeii[e_dj[]hWj[Z_cfbWdji$J^[fheY[Zkh[
_i ijWhj[Z Xo f[h\ehc_d] Wd _dY_i_ed _d j^[ kff[h
c[i_WbWh[We\j^[Wdj[h_ehl[ij_XkbWhi_dkimWbb[$]$
_dj^[YWd_d[\eiiW"j^[dj^[c[cXhWd[_iYWh[\kbbo
[b[lWj[Z _d W ZehiWb" YWkZWb WdZ YhWd_Wb Z_h[Yj_ed$
7\j[h Zh_bb_d] j^[ _cfbWdj X[Z WdZ _di[hj_d] j^[
_cfbWdj"j^[YWl_joYh[Wj[Z_dj^[i_dki_i\_bb[Zm_j^W
]hW\j_d]cWj[h_Wb"iec[j_c[ic_n[Zm_j^Wkjebe]eki
YWdY[bbekiXed[j_iik[$8oWdZbWh]["j^_ifheY[Zkh[
^Wi o_[bZ[Z ]eeZ h[ikbji el[h j^[ fWij (&o[Whi$
Iec[j_c[i j^[ c[cXhWd[ hkfjkh[i m^[d [b[lWj[Z$
?d j^Wj YWi[" j^[ ikh][ed ckij Z[Y_Z[ m^[j^[h j^[
Wk]c[djWj_ed fheY[Zkh[ i^ekbZ X[ Yedj_dk[Z WdZ
Wd Wjj[cfj X[ cWZ[ je h[fW_h j^[ c[cXhWd[$ ?d
icea[hi" j^[ c[cXhWd[ _i l[ho j^_d WdZ j^[h[\eh[
hkfjkh[i ceh[ \h[gk[djbo$ 8o YedjhWij" ikY^ j[Wh_d]
hWh[bo eYYkhi _d c[cXhWd[i j^Wj Wh[ j^_Ya[d[Z Xo
Y^hed_Y _d\bWccWj_ed$ 7bie" j^[ _dYh[Wi[Z XbeeZ
ikffboWiieY_Wj[Zm_j^_d\bWccWj_edicWoWh]kWXbo
fhecej[j^[^[Wb_d]fheY[ii$
?d j^[eho" _j mekbZ X[ WZlWdjW][eki dej je
ef[d j^[ i_dki Yecfb[j[bo$ ?d fhWYj_Y[" ^em[l[h"

&IGÈAB J^[i[hWZ_e]hWf^i

_bbkijhWj[iWYWi[_dm^_Y^jme
ZekXb[Z_ia_cfbWdjim[h[
_di[hj[Z_dj^[h_]^jcWn_bbW
m_j^WZ`klWdji_dki\beeh
Wk]c[djWj_ed$J^[i[YedZ
hWZ_e]hWf^mWieXjW_d[Z+o[Whi
W\j[hj^[fheY[Zkh[$7bb_cfbWdji
^WZX[[d_cc[Z_Wj[bobeWZ[Z

B
(+. 9^Wfj[h'.È )MPLANTÈ4REATMENTÈ!LONGÈTHEÈ-AXILLARYÈ3INUS
m[ ^Wl[ eXi[hl[Z _d\[Yj_edi _d j^[ Wk]c[djWj_ed
Wh[W i[fWhWj[Z Xo j^[ Xedo i_dki m^[h[ j^[o Wh[
fWhj_YkbWhboZ_\\_YkbjjecWdW][$
7do^em"i_dY[beWZjhWdic_ii_ed_iYed\_d[Zjej^[
h_d]Wh[We\j^[Z_iai"j^[YkijecWhoWffheWY^ki[Z
m_j^Yh[ijWb_cfbWdjie\_djheZkY_d]W\_bb_d]cWj[h_Wb
_d ehZ[h je Yh[Wj[ W beWZ#jhWdic_jj_d] _cfbWdj X[Z
Ze[idej[l[de\\[hj^[eh[j_YWbWZlWdjW][i$
Ed[ Z_iWZlWdjW][ e\ j^_i j[Y^d_gk[ _i j^Wj j^[
o[j kdeh]Wd_p[Z Wk]c[djWj_ed cWj[h_Wb _i _d
Yedj_dkekiYedjWYjm_j^j^[ehWbYWl_joWij^[ckYeiW
_if[d[jhWj[ZXoj^[j^h[WZ[Zf_d$?dekh[nf[h_[dY["
_deh]Wd_Y Wk]c[djWj_ed cWj[h_Wbi Wh[ X[jj[h ik_j[Z
\ehj^_iWffheWY^"i_dY[Wdofeijef[hWj_l[YedjWYje\
^kcWdXed[]hW\jim_j^j^[ehWbYWl_jo_iWXiebkj[bo
SINUSÈ)NSERTIONÈOFÈ"/)È)MPLANTS
YedjhW_dZ_YWj[Z$
7dej^[h fheXb[cWj_Y \WYjeh _i j^Wj j^[ _dj[]h_jo
e\ j^[ c[cXhWd[ _di_Z[ j^[ i_dki _ji[b\ YWddej X[
l[h_\_[Z jee m[bb Zkh_d] j^[ fheY[Zkh[$ 7 ki[\kb
WffheWY^jei_dki]hW\j_d]_ij^[j[Y^d_gk[Z[iYh_X[Z
Xo:edi_ced_(&&)_dm^_Y^j^[c[cXhWd[_iedbo
Z_ibeZ][Z_dj^[icWbbWh[W_cc[Z_Wj[boikhhekdZ_d]
W fh[l_ekibo fh[fWh[Z Xed[ Yel[h$ IkXi[gk[djbo"
ikYj_ed _i Wffb_[Z j^hek]^ j^[ dei[" m^_Y^ m_bb
]hWZkWbbo [b[lWj[ j^[ c[cXhWd[ _d j^[ WXi[dY[ e\
Z_h[YjcWd_fkbWj_ed$J^_ij[Y^d_gk[_iiW_Zje_dlebl[
Wbem[h_dY_Z[dY[e\c[cXhWd[hkfjkh[$
?d i_jkWj_edi m^[h[ l[dj_bWj_ed YedZ_j_edi Wh[
_dWZ[gkWj[" Wd WZZ_j_edWb l[dj_bWj_ed fWj^mWo
ckij X[ Yedi_Z[h[Z$ Ed[ mWo e\ Yh[Wj_d] ikY^ W
fWj^mWomekbZX[je\[d[ijhWj[j^[Wh[We\j^[bem[h
dWiWb c[Wjki$ Iec[ ejeh^_debWhod]ebe]_iji ^Wl[
gkWb_\_[Zj^_iWffheWY^WieXieb[j["Wh]k_d]j^Wjj^[
ZhW_dW][ fWj^mWo \eh ckYki Xo j^[ Z[\_d[Z Y_b_kc
X[Wj _i dej W\\[Yj[Z Xo j^_i bWYa e\ l[dj_bWj_ed$ J^_i
l_[mfe_dj_iYehh[Yjm_j^h[]WhZjeY^hed_Yi_dki_j_i$
?d Yedd[Yj_ed m_j^ i_dki ]hW\j_d]" ^em[l[h" j^[
[l[djkWb_joe\WYkj[_d\[Yj_edWdZh[j[dj_edckijX[
Wl[hj[Z$J^[h[\eh["W\[d[ijhWj_edWiik]][ij[ZWXel[
_iWXiebkj[bo_dZ_YWj[ZWiWfh[YWkj_edW]W_dijWYkj[
[l[djieYYkhh_d]_dj^[i_dkiXej^Zkh_d]WdZW\j[h
j^[ Wk]c[djWj_ed fheY[Zkh[$ Ceh[ h[Y[djbo" iec[
ejeh^_debWhod]ebe]_iji ^Wl[ WZleYWj[Z j^[ ki[ e\
W ZhW_dW][ jkX[" je X[ _di[hj[Z _d j^[ bem[h dWiWb
c[WjkiWiWfh[ef[hWj_l[c[Wikh[$
H[]WhZ_d]j^[c[Z_kc#WdZbed]#j[hcceX_b_joe\
j^[_cfbWdj#h[ijehWj_edYecfb[n"j^[h[ikbjie\jhWdi#
i_dki _cfbWdjWj_ed m_j^ Wk]c[djWj_ed cWo lWho
ikXijWdj_Wbbo$J^[\ebbem_d]ekjYec[icWoeYYkh_d
WdoYecX_dWj_ed0
v J^[ 8E? _cfbWdj _i _dj[]hWj[Z _d j^[ l[ij_XkbWh
WdZfWbWjWbYehj_YWbXed[$
v J^[ 8E? _cfbWdj _i X[jj[h _dj[]hWj[Z _d j^[
Wk]c[djWj_ed Wh[W j^Wd _d j^[ Yehj_YWb Wh[W j^[
Wk]c[djWj_ed Wh[W cWo X[ ceX_b[ eh _cceX_b[
W]W_dijj^[Yehj_YWbWh[W$
:[f[dZ_d] ed j^[ i_jkWj_ed" [l[d ikYY[ii\kb _c#
fbWdji Wh[ b_a[bo je _dlebl[ iec[ ceX_b_jo e\ j^[
_cfbWdj#h[ijehWj_ed Yecfb[n$ J^_i _i jhk[ [if[Y_Wbbo
_\ fWfohWY[eki j^_d Xed[ ijhkYjkh[i m[h[ fh[i[dj
X[\eh[ j^[ jh[Wjc[dj mWi ijWhj[Z" Wi j^[i[ Ze dej
j[dZ je \Wlekh W kd_\ehc _dj[hYedd[Yj_ed X[jm[[d
j^[Yehj_YWbWdZj^[Wk]c[djWj_edcWj[h_Wb$7dej^[h
\WYjeh je Yedi_Z[h _i j^Wj j^[ \kdYj_edWb ij_ckb_ ed
Yehj_YWb Xed[ Wh[Wi cWo X[ h[ZkY[Z Xo j^[ _cfbWdj
X[_d] ie \_hcbo _dj[]hWj[Z _d j^[ Wk]c[djWj_ed
cWj[h_Wb j^Wj j^[ dWj_l[ Xed[ ijhkYjkh[ _d j^[ Wh[W
cWoZ_iWff[Wh$
È
4RANS
JhWdi#i_dki _dijWbbWj_ed e\ 8E? _cfbWdji _i jeZWo
W hekj_d[ fheY[Zkh[ _d Z[djWb _cfbWdjebe]o Aed#
ijWdj_del_Y(&&)$J^[ceij_cfehjWdjh[gk_h[c[dj
_dj^_iWffheWY^_ij^Wjj^[effei_j[Yehj_YWbijhkYjkh[
_$[$ j^[ fWbWjWb h_Z][ eh j^[ bWj[hWb dWiWb mWbb _i
iW\[bo h[WY^[Z WdZ j^Wj fh_cWho ijWX_b_jo e\ j^[
8E? _cfbWdj _i [dikh[Z Xej^ ed j^[ l[ij_XkbWh WdZ
ed j^[ effei_j[ i_Z[ i[[ L_Z[e /$ J^[ ^WhZ[h
fWhj _i je eXjW_d fh_cWho ijWX_b_jo _d j^[ l[ij_XkbWh
Xed[X[YWki[j^[dkc[hekiYkjj_d]fheY[Zkh[icWo
gk_Yabo ]_l[ h_i[ je _dWZl[hj[dj [nfWdi_ed e\ j^[
l[ij_XkbWh eij[ejeco ]Wf$ J^[ dkcX[h e\ Ykjj_d]
fheY[Zkh[i YWd X[ h[ZkY[Z Xo ki_d] j^[ d[m[h
][d[hWj_ed e\ Ykjj[hi ef[hWj[Z m_j^ YedjhW#Wd]b[
^WdZf_[Y[i$ J^[ h_ia e\ fbWY_d] j^[ eij[ejeco jee
^_]^_i]h[Wjboh[ZkY[Zm_j^j^[i[Ykjj[hi$Jh[Wjc[dj
kdZ[h WdW[ij^[i_W i^ekbZ ij_bb X[ Yedi_Z[h[Z _d
Wbl[ebWh h_Z][i Y^WhWYj[h_p[Z Xo feeh WYY[ii_X_b_jo
WdZ ijhed] h[iehfj_ed" i_dY[ WdW[ij^[j_p[Z fWj_[dji
m_bb dej f[h\ehc kdYedjhebb[Z cel[c[dji" ie j^Wj
j^[ ikh][ed YWd Z[lej[ ^_i m^eb[ Wjj[dj_ed je j^[
eij[ejeco$ JeZWo j^[ j[Y^d_YWb _dZ_YWj_edi \eh
WdW[ij^[i_WWh[]h[Wjboh[ZkY[ZXoj^[WlW_bWX_b_joe\
YedjhW#Wd]b[^WdZf_[Y[i$
J^[ YWi[ h[fehj _d <_]$'.$*WÄY _bbkijhWj[i j^[
fej[dj_Wb e\ j^[ 8E? ioij[c _d j^[ ded#Wk]c[dj[Z
i_dkicWn_bbWh_[i0
;l[d ceij 8E? ki[hi Wj ed[ j_c[ Wjj[cfj[Z
je Y_hYkcl[dj j^[ cWn_bbWho i_dki$ J^_i WffheWY^
^Wi X[[d WXWdZed[Z" ^em[l[h" XWi[Z ed bed]#j[hc
eXi[hlWj_ediWdZ_cfhel[c[djicWZ[jej^[_cfbWdj
Z[i_]d0
v JeZWo m[ adem \hec bed]#j[hc eXi[hlWj_edi
j^Wj j^[ ikhl_lWb hWj[ e\ 8E? _cfbWdji _i ]h[Wjbo
_d\bk[dY[Z Xo j^[ Z_ia Z_Wc[j[h$ J^[ fheXWX_b_jo
e\ ikhl_lWb _i ^_]^[ij m_j^ Z_ia Z_Wc[j[hi e\ Wj
b[Wij '(cc hWj[ e\ _cfbWdj beii0 2&$+$ J^_i
ikf[h_eh ekjYec[ e\ 8E? _cfbWdji m_j^ bWh][#
Z_Wc[j[h Z_iai _i Wjjh_Xkj[Z je j^[_h X[jj[h \ehY[
Z_ijh_Xkj_ed"Yehj_YWbXed[ikffehjWdZfhej[Yj_ed
W]W_dij_d\[Yj_ed$
È È )MPLANTOLOGICALÈ!PPROACHESÈTOÈTHEÈ3INUSÈ!REAÈ
A v 7 cWn_bbWho i_dki m_j^ _djWYjÆWkjeYb[Wd_d] \kd#
B dei[Xbem_d]ehfh[iikh[Yecf[diWj_edckij"e\
C ehWb YWl_jo je j^[ i_dki _d j^[ cWdd[h e\ W YWdZb[
&IGÈÈ A BWj[hWb _di[hj_ed e\ W ZekXb[#Z_ia 8E? _cfbWdj
j^hek]^j^[cWn_bbWhoi_dki$ B J^[_di[hj_ed]WfmWiYbei[Z
m_j^ W c_njkh[ e\ Wkjebe]eki Xed[ WdZ 8_e#Eii$ C 8E?
_cfbWdjfbWY[ZijhW_]^jj^hek]^j^[i_dki_dj^[Wh[We\jeej^
'-$Edboed[[Z][e\j^[8E?_cfbWdjfhejhkZ[i\hecj^[Xed[$
J^_i beWZ_d] Wh[W _i ik\\_Y_[dj [l[d \eh _cc[Z_Wj[ beWZ_d] _\
j^[cWij_YWj_ed_im[bbXWbWdY[Z
v ?d cWdo YWi[i" j^[i[ bWh][#Z_Wc[j[h _cfbWdji
YWddej feii_Xbo X[ _di[hj[Z _d j^[ ikXWdjhWb
(+/
Wh[W [l[d _\ Wd Wd]kbWj[Z hWj^[h j^Wd ^eh_pedjWb
_di[hj_ed fWj^ _i i[b[Yj[Z$ <h[gk[djbo" [l[d
_cfbWdji m_j^ W Z_ia Z_Wc[j[h e\ '&cc Wh[ dej
Wd efj_ed$ J^[h[\eh[" _j _i hekj_d[bo d[Y[iiWho je
Yedi_Z[hWceh[YhWd_Wbikh]_YWbWffheWY^$
v =hWdkbecWi" Yoiji WdZ ej^[h kdZ[i_hWXb[ j_iik[
\ehcWj_edi YWd X[ h[cel[Z h_]^j j^hek]^ j^[
eij[ejeco ]Wf m^[d j^[ jhWdi#i_dki WffheWY^ _i
i[b[Yj[Z$
v 7do _cfbWdj#h[bWj[Z _d\bWccWj_edi j^Wj c_]^j
feii_XboeYYkhieed[hehbWj[hmekbZgk_YaboW\\[Yj
WdZ Z[ijheo W Yedi_Z[hWXb[ fWhj e\ j^[ el[hWbb
Xed[ ijhkYjkh[" m^_Y^ _i h[ZkY[Z WdomWo$ J^_i
[l[djkWb_jo _i Wle_Z[Z _\ j^[ beWZ#jhWdic_jj_d]
_dj[h\WY[ _i WdY^eh[Z [bi[m^[h[ je X[]_d m_j^$
?d j^Wj YWi[" ceij jof[i e\ _d\bWccWj_ed m_bb X[
WXb[ je fWii j^[ dWhhem h[i_ZkWb h_Z][ m_j^ekj
_d\b_Yj_d]cW`ehZWcW][$
Yj_edÇ e\\[hi ]eeZ ZhW_dW][ fWj^mWoi je Z[Wb
m_j^ fej[dj_Wb _d\bWccWj_edi$ FWhj_YkbWhbo _d j^[
_d_j_Wbf^Wi[e\mekdZ^[Wb_d]"j^[ZhW_dW][cWo
meha Xej^ mWoi Ä _$[$ _dje j^[ ehWb YWl_jo Wi
m[bb Wi _dje j^[ i_dki Wh[W$ >[dY[ j^[h[ _i de
d[[Z je j[hc_dWj[ j^[ _cfbWdjWj_ed fheY[Zkh[
_$[$_dijWbbWj_ede\8E?_cfbWdjim_j^ekjWZ`klWdj
i_dki Wk]c[djWj_ed _\ j^[ i_dki c[cXhWd[ _i
f[h\ehWj[Z$ IkY^ Wd _dY_Z[dj Ze[i dej f[h i[
h[gk_h[ \khj^[h jh[Wjc[dj$ J^[ fWj_[dj i^ekbZ
X[ _d\ehc[Z" ^em[l[h" je h[c[cX[h je X[ ][djb[
m_j^ j^_i Wh[W$ 7do Wffb_YWj_ed e\ fh[iikh[ Wi _d
Yekhi["X[ijh_YjboWle_Z[Z$
J^_iZ[l[befc[djmWijh_]][h[ZXo]hem_d][l_Z[dY[
j^Wjj^[^[Wb_d]fheY[iiW\j[h_dWZl[hj[djef[d_d]e\
j^[ i_dki Zkh_d] 8E? _cfbWdjWj_ed fheY[Zkh[i mWi
][d[hWbbo kd[l[dj\kb$ ?d j^_i mWo" ikh][edi m[h[
]hWZkWbbo [dYekhW][Z je hekj_d[bo ki[ j^[ ded#
Wk]c[dj[ZcWn_bbWhoi_dkiWiWd_cfbWdjWj_edi_j[$
?d ekh [nf[h_[dY[" j^[ ikh\WY[ ijhkYjkh[ e\ j^[
_cfbWdj_d][d[hWbWdZe\j^[j^h[WZ[Zf_d_dfWhj_YkbWh
_i[if[Y_Wbbo_cfehjWdj_dj^_ijof[e\fheY[Zkh[$J^[
\ehc[h Z_ia _cfbWdji m_j^ j^[_h ikh\WY[#[d^WdY[Z
i^W\jiki[Zje\WlekhYheii#YedjWc_dWj_ed\hecj^[
m_Ya$ IYh[m _cfbWdji Wh[ ademd je _dlebl[ i_c_bWh
fheXb[ci$?d8E?_cfbWdji"m^_Y^\[Wjkh[Wiceej^
ikh\WY[ Wbed] j^[ j^_d i^W\j j^h[WZ^ebZ[hi" j^_i
jof[ e\ fheXb[c _i Wbceij ded#[n_ij[dj$ Ki_d] j^_i
YedY[fj" j^[h[ _i de d[[Z je Yh[Wj[ Wd WZZ_j_edWb
l[dj_bWj_ed fWj^mWo _d j^[ cWn_bbWho i_dki kdb[ii
j^[fWj_[dj^WiW^_ijehoe\i_dkifheXb[cieh"ceh[
_cfehjWdjbo"_\_djhWef[hWj_l[l[h_\_YWj_edi^emij^Wj
WZ[gkWj[l[dj_bWj_ed_ifh[i[dj$Dej[j^Wjj^[l[hj_YWb
_cfbWdj i[]c[dji Ze dej eii[e_dj[]hWj[" m^_Y^ _i
m^o _d\bWccWj_edi _d j^_i Wh[W m_bb dej fh_cWh_bo
(,& 9^Wfj[h'.È )MPLANTÈ4REATMENTÈ!LONGÈTHEÈ-AXILLARYÈ3INUS

B
È È )MPLANTOLOGICALÈ!PPROACHESÈTOÈTHEÈ3INUSÈ!REAÈ (,'

&IGÈÈ A El[hl_[m 9J iYWd e\ j^[ cWn_bbW j^h[[ i[Yj_edi" Z_ijWdY[ )cc i^em_d] [njh[c[ Xed[ h[iehfj_ed$ B 9heii#
i[Yj_edWb _cW]_d] e\ j^[ h_]^j cWn_bbW _dZ_YWj[Z j^Wj j^[ Xed[ lebkc[ WlW_bWXb[ _d j^[ Wdj[h_eh i[]c[dj mWi WZ[gkWj[$ 8ed[
^[_]^j mWi" ^em[l[h" \Wh X[bem '&cc1 j^[ po]ecWj_Ye#Wbl[ebWh Yh[ij mWi l[ho \bWj$ 7 ]h[Wj[h Wcekdj e\ h[i_ZkWb Xed[ mWi
WlW_bWXb[ Wj j^[ jhWdi_j_ed ped[ \hec j^[ c[Z_Wb i_dki mWbb je j^[ fWbWj[ WdZ bWj[hWb dWiWb mWbb$ J^_i ijhkYjkh[ mWi W ik_jWXb[
WdY^ehW][fe_dj\ehj^[Z_ijWb_cfbWdj$J^[fWbWjWbWhj[ho_iYb[Whbol_i_Xb[$I[]c[dj[Z_cfbWdjfbWY[c[djm_j^ekjfheij^[j_Y
XWbWdY_d]jej^[YedjhWbWj[hWbi_Z[YekbZdejX[f[h\ehc[Zm_j^ekjWk]c[djWj_ed$Ki_d]j^[Wdj[h_ehh_Z][\ehWdY^ehW][mekbZ
fh[ikcWXbo^Wl[Yh[Wj[ZikXijWdj_Wbf^ed[j_YfheXb[ciWdZh[dZ[h[Zj^[bWXehWjehomehal[hoZ_\\_YkbjWim[bb$ C :_c[di_edi$
7dWh[We\j^_Ya[d[ZckYeiWYWdX[i[[d_dj^[Z_ijWbi[]c[dje\j^[h_]^ji_dki$J^[fWhj_WbZ[djkh[_dj^[cWdZ_Xb[_il_i_Xbo
Y^WhWYj[h_p[ZXoeYYbkiWbikh\WY[ie\Yecfei_j[fhejhkZ_d]\hecj^[eYYbkiWbfbWd[$J^[8E?_cfbWdjim[h[beWZ[Z_cc[Z_Wj[bo
ed_di[hj_ed

A
B

C D

&IGÈÈA 7\j[hh[ijeh_d]j^[\_hijgkWZhWdjm_j^WXh_Z][ifWdd_d]\hecjeej^'-jejeej^')"_dYbkZ_d]Wikffehj_l[_cfbWdj
h[fbWY_d] jeej^ ', WdZ W heej j_f h[i[Yj_ed Wj jeej^ ')" Xej^ i_dki[i ^WZ W ib_]^jbo hWZ_efWgk[ Wff[WhWdY[$ J^[ _cfbWdj
h[fbWY_d] jeej^ ', h[cW_d[Z Yb[Wh e\ j^[ i_dki Wh[W$ BÈ C 9J iYWd eXjW_d[Z '(cedj^i W\j[h j^[ _cfbWdjWj_ed fheY[Zkh[$
J^[b[\ji_dkim_j^j^[jhWdi#i_dki8E?_cfbWdji_if[h\[YjbohWZ_ebkY[dj"m^_b[j^[kdjh[Wj[Zh_]^ji_dki_iij_bbYedi_Z[hWXbo
hWZ_efWgk[$ D <ebbem_d][njhWYj_ede\j[[j^(*WdZ(,"WjejWbe\j^h[[8E?_cfbWdjim[h[fbWY[Z_dj^[b[\jcWn_bbW"Wbbe\j^[c
[nj[dZ_d]_djej^[i_dki$Jmem[[aiW\j[hj^[fheY[Zkh["j^[b[\ji_dkimWiij_bbYedi_Z[hWXbohWZ_efWgk[$9ecfb[j[bohWZ_ebkY[dj
Wh[Wim[h[l_i_Xb[_dj^[Z_ijeYhWd_WbWh[W"_dZ_YWj_d]j^Wjh[iehfj_ede\j^[ijhkYjkh[i\_bb_d]j^[i_dki^WijWa[dfbWY[$J[[j^m[h[
[njhWYj[ZWdZh[fbWY[ZXo_cfbWdji_dj^[iWc[fheY[Zkh["WdZ_cfbWdjim[h[_cc[Z_Wj[bobeWZ[Z
(,( 9^Wfj[h'.È )MPLANTÈ4REATMENTÈ!LONGÈTHEÈ-AXILLARYÈ3INUS
ifh[WZjej^[Xed[$J^_i_im^[h[8E?_cfbWdjiZ_\\[h
\hec eij[eiodj^[i_i fbWj[i" m^[h[ eii[e_dj[]hWj_ed
Wbed] j^[ iYh[m j^h[WZ _i Wd eXl_eki h[gk_h[c[dj$
7bj^ek]^ j^_i _dj[]hWj_ed _i WY^_[l[Z _d j^[ [Whbo
f^Wi["eij[eiodj^[i_i_dj^[YhWd_e\WY_Wbh[]_edWdZ
[if[Y_Wbbo _d j^[ Wh[W e\ j^[ \hedjWb i_dki m_bb
\h[gk[djbo _dlebl[ beei[d_d] e\ j^[ iYh[mi WdZ W
fhedekdY[Z j[dZ[dYo jemWhZi eij[eboi_i Zemd j^[
heWZ X[YWki[ j^[h[ _i de ie\j#j_iik[ bWo[h X[jm[[d
j^[iYh[mWdZj^[Xed[e\\[h_d]dkjh_j_edWdZifWj_Wb
b_c_jWj_edWjj^[iWc[j_c[$
J^[\_]kh[iX[bem_bbkijhWj[WYWi[e\8E?_cfbWdji
_di[hj[Zm_j^j^[jhWdi#i_dkiWffheWY^<_]$'.$+WÄZ$
?d j^[ fh[ef[hWj_l[ EF=" j^[ cWn_bbWho i_dki[i ed
Xej^ i_Z[i Wh[ fWhj_Wbbo hWZ_efWgk[$ ?d j^[ i[YedZ
gkWZhWdj"[njhWYj_ede\j[[j^_i_dZ_YWj[Z$
È
3PATIALÈ&INDINGSÈ!FTERÈ.ON
AUGMENTEDÈ i_dki_iWhWf_ZWdZded#_hh_jWj_l[fheY[ii$
)MPLANTATION
DeijkZ_[iWh[o[jWlW_bWXb[edm^[j^[h8E?_cfbWdji
i^ekbZfh[\[hWXboX[_di[hj[Zd[Whj^[i_dki\beeheh
_d W ceh[ YhWd_Wb fei_j_ed m_j^ j^[ Z_ia h[cW_d_d]
Yb[Whe\j^[i_dki\beeh$?dj^[eho"j^[bWjj[hWffheWY^
Z[\_d_j[bo^Wi_jic[h_ji$8o_dlebl_d]b[iiZ[ijhkYj_ed
e\XWiWbc[cXhWd[Wh[Wi"_jc_]^jX[b[iiZ[b[j[h_eki
jej^[^[Wb_d]fheY[ii$
7do bWh][ j_iik[ \ehcWj_edi ikY^ Wi ]hWdkbecWi
eh Yoiji _d j^[ i_dki \beeh Wh[W dehcWbbo d[[Z je
X[ h[cel[Z$ 7domWo" j^[o j[dZ je X[ ik\\_Y_[djbo
ceX_b_p[Z eh Z[ijheo[Z Xo j^[ Ykjj[h jhWdil[hi_d]
j^[ i_dki WdZ YWd j^[d X[ [Wi_bo h[cel[Z j^hek]^
j^[_di[hj_ed]Wf$7iWYedi[gk[dY["^em[l[h"cW`eh
i[]c[dji e\ j^[ Xedo i_dki m_bb X[ ijh_ff[Z e\ Wdo
c[cXhWd[ m^Wjie[l[h" m^_Y^ cWo Ä Wj b[Wij _d
j^[ehoWdZm^[dYecX_d[Zm_j^[nj[di_l[_djhWehWb
\bWfh[\b[Yj_edÄW\\[Yjj^[dkjh_j_ede\j^[Xed[$
Ie\j#j_iik[cWdW][c[dj_dj^[Z_ijWbcWn_bbW_iW
fWhj_YkbWhbo _cfehjWdj jef_Y$ ;nj[di_l[ fWbWjWb \bWf
h[\b[Yj_ed" \eh [nWcfb[ je [nfei[ j^[ fWbWjWb Whj[ho"
YWddej X[ h[Yecc[dZ[Z XWi[Z ed ekh [nf[h_[dY[
X[YWki[ Wdo _dWZl[hj[dj _d`kho je j^[ l[ii[b m_bb
X[ Z_\\_Ykbj je cWdW][ _d j[hci e\ ^W[ceijWi_i$ ?\"
Z[if_j[ YWh[\kb ^WdZb_d] e\ j^[ Ykjj[h" j^[ fWbWjWb
Whj[ho eh Wdo e\ _ji j[hc_dWb XhWdY^[i Wh[ _d`kh[Z
W\j[h Wbb" j^[ Xb[[Z_d] m_bb WZlWdY[ je j^[ i_dki eh
j^[ ehWb YWl_jo j^hek]^ j^[ dWhhem eij[ejeco ]Wf$
?d ceij YWi[i" j^[ Xb[[Z_d] m_bb X[ ijeff[Z Xo `kij
_di[hj_d]j^[_cfbWdj$7jj^_ife_dj"Wjb[Wijed[YWd
jWa[Yec\ehj\hecj^[\WYjj^Wjj^[Z[i_h[ZX_Yehj_YWb
WdY^ehW][ ^Wi X[[d fei_j_l[bo Yed\_hc[Z WdZ j^Wj
j^[ XbeeZ ikffbo d[[Z[Z \eh Xed[ h[][d[hWj_ed
_i fh[i[dj Wi m[bb$ D[l[hj^[b[ii" _j _i [ii[dj_Wb j^Wj
j^[ Ykjj[h _i WZlWdY[Z YWh[\kbbo" i_dY[ Yecfb[j[
i[l[hWdY[ e\ j^[ cW_d XhWdY^ e\ j^[ fWbWjWb Whj[ho
ckijX[Wle_Z[ZWjWbbYeiji$
<hec Wd WdWjec_YWb ijWdZfe_dj" jhWdi#i_dki
_di[hj_ede\8E?_cfbWdjicWob[WZjeWdoed[e\j^[
\ebbem_d]iY[dWh_ei0
'$ J^[_cfbWdjjhWdil[hi[ij^[i_dkim_j^ehm_j^ekj
ZWcW]_d] j^[ IY^d[_Z[h_Wd c[cXhWd[$ ?d [dZ
fei_j_ed"^em[l[h"j^[_cfbWdj_idej_dYedjWYjm_j^
j^[i_dki$J^[IY^d[_Z[h_Wdc[cXhWd[[\\[Yj_l[bo
^[WbiWXel[j^[ikh]_YWbi_j[WdZ[l[djkWbboYel[hi
j^[[dj_h[Wh[WedWXWi[e\dWjkhWbXed[$
($ J^[_cfbWdjjhWdil[hi[ij^[i_dkim_j^ehm_j^ekj
ZWcW]_d] j^[ IY^d[_Z[h_Wd c[cXhWd[$ ?d [dZ
fei_j_ed" fWhj e\ j^[ beWZ#jhWdic_jj_d] b[]i" Xkj
dejj^[j^h[WZ[Zf_d"Wh[beYWj[Z_dj^[i_dkiWh[W$
J^[ IY^d[_Z[h_Wd c[cXhWd[ [\\[Yj_l[bo ^[Wbi
WXel[ j^[ _cfbWdj i_j[ WdZ [l[djkWbbo Yel[hi dej
edboXed[XkjWbiefWhje\j^[_cfbWdjikh\WY[$@kij
b_a[m_j^[Wh_cfbWdji"el[h]hemj^e\_cfbWdji_j[i
m_j^ IY^d[_Z[h_Wd c[cXhWd[ _d j^[ cWn_bbWho
)$ J^[ _cfbWdj jhWdil[hi[i j^[ Xedo i_dki m_j^ eh
m_j^ekj ZWcW]_d] j^[ IY^d[_Z[h_Wd c[cXhWd[$
?dj^[[dZfei_j_ed"fWhje\j^[beWZ#jhWdic_jj_d]
b[]iWim[bbWij^[j^h[WZ[Zf_dWh[beYWj[Z_dj^[
i_dkiWh[Wm_j^ekjX[_d]ikffehj[ZXoXed[$J^[
IY^d[_Z[h_Wd c[cXhWd[ [\\[Yj_l[bo ^[Wbi WXel[
j^[ _cfbWdj i_j[ WdZ [l[djkWbbo Yel[hi ckY^ e\
j^[_cfbWdjikh\WY[$7beei[XkjYe^[h[djWdZm[bb
lWiYkbWh_p[Z ie\j#j_iik[ d[jmeha Z[l[befi _di_Z[
j^[i_dki"[nj[dZ_d]\hecj^[Z_iai[]c[djiZemd
jej^[i_dki\beeh$
*$ J^[ _cfbWdj jhWdil[hi[i j^[ i_dki m_j^ eh
m_j^ekj _d\b_Yj_d] [nj[di_l[ XWiWb ZWcW][ je j^[
IY^d[_Z[h_Wdc[cXhWd[$?dj^[[dZfei_j_ed"fWhj
e\j^[beWZ#jhWdic_jj_d]b[]iWim[bbWij^[j^h[WZ[Z
f_d Wh[ beYWj[Z _d j^[ i_dki Wh[W m_j^ekj X[_d]
ikffehj[ZXoXed[$J^[IY^d[_Z[h_Wdc[cXhWd[
[\\[Yj_l[bo^[WbikdZ[hj^[beWZ#jhWdic_jj_d]b[]i
WdZ _i f[d[jhWj[Z Xo j^[ j^h[WZ[Z f_d$ ?d W bWj[h
f^Wi["j^[c[cXhWd[cWoel[h]hemfWhjie\j^[
b[]i WdZ ]_l[ h_i[ je YecfWhjc[djWb_pWj_ed" Wi
eYYWi_edWbbo Wbie i[[d _d ded#_cfbWdj[Z i_dki[i
IebWh[jWb$'//.$J^_iYecfWhjc[djWb_pWj_edYWd
edboX[WY^_[l[Z_\j^[_cfbWdj_i_di[hj[ZWjiec[
Z_ijWdY[\hecj^[i_dki\beeh$
?j _i Yb_d_YWbbo _cfehjWdj je Z_\\[h[dj_Wj[ X[jm[[d
j^[i[ iY[dWh_ei X[YWki[ j^[o m_bb h[gk_h[ Z_\\[h[dj
j^[hWf[kj_YWffheWY^[i_\Yecfb_YWj_edieYYkh$
IY[dWh_e ' _i b_a[bo je ]_l[ h_i[ je iec[ c_bZ
i_dki_j_iWjj^[ceij"m^_Y^m_bbh[iebl[ifedjWd[ekibo
_d Zk[ Yekhi[ _\ j^[ i[Yh[j_ed fWj^mWoi Wh[ _djWYj$
?\ ZhW_dW][ fWj^mWoi Wh[ bWYa_d] m^[d _d\[Yj_ed
eYYkhi" W \_ijkbW \eh ZhW_dW][ m_bb [c[h][ Wj b[Wij
_d j^[ Wh[W e\ j^[ bWj[hWb eij[ejeco _$[$ _d j^[ Z_ia
Wh[W"fh[ikcWXboX[YWki[j^_i_im^[h[j^[ckYeiW
_ij^_dd[ij$
È È 3PATIALÈ&INDINGSÈ!FTERÈ.ON
AUGMENTEDÈ)MPLANTATIONÈ (,)
J^[iWc[^[Wb_d]ekjYec[Wi_diY[dWh_e'YWdX[
[nf[Yj[Z\ehiY[dWh_e($
IY[dWh_e)kikWbbo_dlebl[ij^[fh[i[dY[e\beei[bo
WhhWd][Z ie\j#j_iik[ ijhkYjkh[i WhekdZ j^[ jhWdi#
i_dkiZ_iaWh[W$
IY[dWh_e * cWo ]_l[ h_i[ je jhk[ YecfWhj#
c[djWb_pWj_ed" m_j^ W bem[h YecfWhjc[dj j^Wj _i
XWiWbbo WdZ bWj[hWbbo Z[b_c_j[Z Xo Xed[ mWbbi WdZ
Yedd[Yj[Z je j^[ ehWb YWl_jo Xo j^[ j^h[WZ[Z f_d$
J^[h[\eh["j^[h[_iWY^WdY[e\_d\[Yj_edieYYkhh_d]
j^Wj h[cW_d Yed\_d[Z je j^[ bem[h YecfWhjc[dj
WdZ Wh[ dekh_i^[Z Xo j^[ j^h[WZ[Z f_d WYj_d] _d
j^[ cWdd[h e\ W YWdZb[ m_Ya" fWhj_YkbWhbo _\ _j ^Wi
W hek]^ ikh\WY[$ ?d YWi[i ikY^ Wi j^[i[" Z[ijhkYj_ed
e\ j^[ c[cXhWd[ _d W i_dkiWb Z_h[Yj_ed i^ekbZ
X[ Yedi_Z[h[Z je ef[d W ZhW_dW][ fWj^mWo _d j^_i
Z_h[Yj_ed$ 7i Wd WZ`kdYj_l[ c[Wikh[" j^[ i_j[ e\
ckYeiWb f[d[jhWj_ed YWd X[ jh[Wj[Z m_j^ 8[jWZ_d["
WbmWoi Wiikc_d] j^Wj j^[ dWjkhWb ZhW_dW][ fWj^mWo
jemWhZi j^[ ^_Wjki _i kdeXijhkYj[Z$ J^[ c[cXhWd[
YWd X[ Z[ijheo[Z Xo c_d_cWbbo _dlWi_l[ c[Wdi"
[$]$ m_j^ f[h_eZedjWb fheX[i$ J^[i[ fheX[i i^ekbZ"
_\ feii_Xb[" dej X[ Wffb_[Z Wbed] j^[ j^h[WZ[Z f_d$
?\ j^_i YWddej X[ Wle_Z[Z X[YWki[ j^[ ifWY[ \eh
cWd_fkbWj_ed _i b_c_j[Z" m[ h[Yecc[dZ ki_d]
WZZ_j_edWb c[Wikh[i W_c[Z Wj Z_i_d\[Yj_d] j^[ i_j[
e\fheX_d]$
?d\[Yj_edi _d j^[ kff[h YecfWhjc[dj Wh[ hWh[bo
eXi[hl[Z m_j^ 8E? _cfbWdji \[Wjkh_d] W iceej^
i^W\j$ J^ei[ j^Wj Ze eYYkh j[dZ je X[ h[jhe]hWZ[
hWj^[h j^Wd ehj^e]hWZ[ _$[$ WiY[dZ_d] Wbed] j^[
j^h[WZ[Z f_d WdZ ^Wl[ de YWkiWb h[bWj_edi^_f m_j^
j^[_cfbWdj$J^[h[\eh["m^[d[l[hWfWj_[djfh[i[dji
&IGÈ >_ijebe]_YWbf_Yjkh[
jWa[dW\j[h_djhW#i_dki
_cfbWdjWj_ed_dj^[Ze]$J^[
_cfbWdji_j[_iel[h]hemdXo
IY^d[_Z[h_Wdc[cXhWd[$D[m
Xed[_i\ehc[ZWjj^[eij[ejeco
]WfWdZZ[fei_j[Zedj^[eii[eki
YWkZWbXekdZWhoe\j^[i_dki$J^[
Z_iaWh[W_i[l[dboel[h]hemd
XoIY^d[_Z[h_Wdc[cXhWd[_dW
ded#_hh_jWj_l[cWdd[h
m_j^ iocfjeci" _j _i d[Y[iiWho je jhWYa Zemd j^[
iekhY[ WdZ YWki[ e\ j^[ _d\[Yj_ed$ ?\ _j _i Zk[ je
eXijhkYj_ede\j^[dWjkhWbZhW_dW][fWj^mWoi"Wdo
Wjj[cfjjeh[iebl[j^[i_jkWj_edXoXWiWb\[d[ijhWj_ed
e\j^[c[cXhWd[_idejedboZeec[Zje\W_bkh[Xkj
m_bb W]]hWlWj[ j^[ i_jkWj_ed$7\j[h Wbb" j^_i WffheWY^
mekbZ Wbbem j^[ _d\[Yj_ed je ifh[WZ j^hek]^ekj j^[
_cfbWdj i_j[$ ?\ j^Wj _i j^[ YWi[" j^[ iekhY[ e\ j^[
fheXb[cd[[ZijeX[[b_c_dWj[Zh_]^jWmWoXoikh]_YWb
_dj[hl[dj_ed[$]$XoWdejeh^_debWhod]ebe]_ij$7do
i[fjkc Z[l_Wj_edi eh Yoiji cWo Wbie j[cfehWh_bo
XbeYa j^[ ZhW_dW][ fWj^mWo \hec ed[ i_Z[ eh j^[
ej^[h$ JeZWo j^[o YWd X[ ef[d[Z Xo c_d_cWbbo
_dlWi_l[ c[Wdi WdZ b[\j _d fbWY[$7dej^[h fej[dj_Wb
YWki[ je X[ Yedi_Z[h[Z _i Z[\_d_j_l[ eYYbki_ed e\
j^[ ^_Wjki _ji[b\$ ?d\[Yj_edi cWo" e\ Yekhi[" Wbie
[cWdWj[\hecWdoh[i_ZkWbj[[j^ehheejYWdWb\_bb_d]
cWj[h_Wb$
M^Wj[l[h j^[ YWi[ cWo X[" _d\[Yj_edi _d
Yedd[Yj_edm_j^8E?_cfbWdjickijX[jh[Wj[Zl[ho
im_\jboX[YWki[j^[_cfbWdj"m^_Y^_i_dcWij_YWjeho
\kdYj_ed" _i b_WXb[ je YWki[ eij[eboi_i ed XWYj[h_Wb
YedjWc_dWj_ed m^[d XehZ[hb_d[ b[l[bi e\ beWZ
jhWdic_ii_ed Wh[ h[WY^[Z$ J^_i _i" kd\ehjkdWj[bo"
Wd _iik[ m^[h[ j^[ Yb_d_YWb h[gk_h[c[dji e\ 8E?
_cfbWdjebe]o Z[l_Wj[ Yedi_Z[hWXbo \hec j^[
YkijecWho j^_da_d] e\ ejeh^_debWhod]ebe]_iji WdZ
][d[hWb fhWYj_j_ed[hi$ J^[ bWjj[h" _d fWhj_YkbWh" j[dZ
jeYWki[Yedi_Z[hWXb[Z[bWoi$KdWmWh[e\j^[if[Y_\_Y
h[gk_h[c[dji e\ 8E? _cfbWdji" j^[o iec[j_c[i
[dYekhW][ j^[_h fWj_[dji je jWa[ Wdj_X_ej_Yi \eh
i[l[hWb m[[ai X[\eh[ j^[ Wffhefh_Wj[ ikh]_YWb ij[fi
YWd X[ jWa[d$ FheYhWij_dWj_d] _d j^_i mWo WbmWoi
(,* 9^Wfj[h'.È )MPLANTÈ4REATMENTÈ!LONGÈTHEÈ-AXILLARYÈ3INUS
YWhh_[ij^[h_iae\i[YedZWho_cfbWdjbeii"i_dY[j^[
_d\[Yj_ed cWo X[Yec[ [ijWXb_i^[Z Xo kd\WlekhWXb[
ifWj_Wb YedZ_j_edi WdZ m_bb ]hWZkWbbo WZlWdY[
je j^[ fe_dj e\ _dlebl_d] fh[l_ekibo kdW\\[Yj[Z
WdZ m[bb _dj[]hWj[Z beWZ#jhWdic_jj_d] Z_ia Wh[Wi$
CeX_b[ _cfbWdji i^ekbZ X[ ced_jeh[Z l[ho Ybei[bo
WdZ" m^[d _d ZekXj" h[cel[Z$ ?djhki_ed ceX_b_jo
_d fWhj_YkbWh" m_j^ eh m_j^ekj Y^hed_Y _d\[Yj_ed"
cWo YWki[ j^[ l[ij_XkbWh Xed[ e\ j^[ i_dki mWbb je
Z[]hWZ[$ JhW]_YWbbo" fWj_[dji m_bb de bed][h h[fehj
fheXb[ci m_j^ j^[_h dei[ W\j[h j^[ ^_Wjki ^Wi X[[d
eYYbkZ[Z"Xkjj^[o\[[bj^Wjj^[ÆedboÇfheXb[cdem
_i h[Ykhh[dj Z_iY^Wh][ \hec W \_ijkbW j^Wj cWo ^Wl[
\ehc[Z _d j^[ Wh[W e\ j^[ j^h[WZ[Z f_d eh Z_ia eh"
[l[dceh[Yeccedbo"Wjiec[h[cej[i_j[\hecj^[
_cfbWdj$7bie"iec[_dY_i_edij^Wjm[h[cWZ[_dj^[
l[ij_XkbWh i_dki mWbb je \_hij _dijWbb W 8E? _cfbWdj
cWo[dZkff[hcWd[djboWim[Waifeji_dj^[i_dki
mWbb"j^kiX[_d]Wfh[\[hh[Zi_j[\eh\_ijkbW\ehcWj_ed
Zk[jeel[hfh[iikh[$
<hecm^Wj^WiX[[diW_Zie\Wh"_jYb[Whbo\ebbemi
j^WjZ_bWjehoWdj_X_ej_Yjh[Wjc[djWbed["Wifh[iYh_X[Z
Xo m[bb#c[Wd_d] ][d[hWb fhWYj_j_ed[hi" _i XekdZ je
\W_bfWhj_YkbWhbo_\j^[_d\bWccWj_ed_iYWki[ZXoWd
eYYbkZ[Z eh Ybejj[Z ^_Wjki WdZ j^[ fh[iikh[ hWj_e _i
h[l[hi[ZjemWhZij^[ehWbYWl_jo$7biedej[mehj^o_i
j^[ m[bb#ademd \WYj j^Wj _hh[l[hi_Xb[ Wbj[hWj_edi e\
j^[fWhWdWiWbi_dki[iWh[b[iib_a[bo_dfWj_[djim_j^
W i^ehj ^_ijeho e\ i_dki_j_i$ ?dj[hl[dj_edi W_c[Z Wj
ijWX_b_p_d]l[dj_bWj_edYWdkikWbboiWl[j^[i_jkWj_ed"
i_dY[ j^[ [f_j^[b_kc m_bb d[l[h X[ Z[ijheo[Z
Yecfb[j[boWdZh[][d[hWj_ed\hecj^[h[i_ijWdjXWiWb
Y[bbbWo[hYWdX[[nf[Yj[Z_dWbceijWbbYWi[iedY[j^[
l[dj_bWj_ed_iXWYajedehcWb>[hX[h^ebZ'/.($
J^[ fWj_[dj i^ekbZ X[ _d\ehc[Z _d WZlWdY[
j^Wj jhWdi_[dj WYkj[ i_dki_j_i WdZ dei[ Xb[[Z_d]
Wh[ Yecced eYYkhh[dY[i W\j[h _cfbWdji ^Wl[ X[[d
_dijWbb[Z Wbed] j^[ i_dki Wh[W$ C_bZ i_dki_j_i m_bb
eYYkh Wbceij _dlWh_WXbo _d ikY^ YWi[i WdZ YWd
X[ Æjh[Wj[ZÇ m_j^ Z[Yed][ijWdj dei[ Zhefi$ ?j _i
d[Y[iiWhojea[[f_dc_dZj^Wjj^[[dj_h[i_dkiWh[W
m_bbX[Yecfb[j[bo\_bb[Zm_j^XbeeZW\j[hj^[ikh]_YWb
fheY[Zkh[$J^[XbeeZm_bb[l[dYeW]kbWj[_dj^[i_dki
m_j^ekj" ^em[l[h" X[Yec_d] eh]Wd_p[Z$ ?dij[WZ" _j
m_bb Z_i_dj[]hWj[ WdZ X[ [lWYkWj[Z \hec j^[ i_dki
_d W dWjkhWb mWo$ ;l[ho ZWo j^[ fWhWdWiWb i_dki[i
Wh[ _hh_]Wj[Z Xo Wffhen_cWj[bo ed[ b_jh[ e\ ckYki"
m^_Y^ dWjkhWbbo ZhW_di _dje j^[ f^Whodn j^hek]^
j^[ c_ZZb[ dWiWb c[Wjki$ J^_i dWjkhWb _hh_]Wj_ed _i
[\\[Yj_l[[dek]^jeYb[Whj^[cWn_bbWhoi_dkie\XbeeZ
W\j[h_cfbWdjWj_edfheY[Zkh[i$
7bj[hdWj_l[ ^[Wb_d] fheY[ii[i \ebbem_d] _cfbWd#
jWj_ed Wbed] j^[ i_dki Wh[W m_j^ j^[ IY^d[_Z[h_Wd
c[cXhWd[ef[d[ZcWo_dYbkZ[0
'$ <bWfikjkh_d]_iikYY[ii\kb"fhel_Z_d]ijWXb[Ybeikh[
j^Wj_iYWfWXb[e\m_j^ijWdZ_d]_djhWehWbfh[iikh[i$
Ceij e\ j^[ ikffkhWj_ed jWa[i fbWY[ m_j^_d j^[
i_dki" _$[$ b_jjb[ ckYki _i ZhW_d[Z e\\ Wbed] j^[
j^h[WZ[Zf_d$J^_ijof[e\^[Wb_d]fheY[ii_iedbo
feii_Xb[_\j^[i_dki_im[bbl[dj_bWj[Z$
($ <bWf ikjkh_d] cWo X[ _dYecfb[j[" eh cWo jkhd
ekjjeX[_dYecfb[j[XoYb_d_YWbcWd_\[ijWj_ediWj
W bWj[h j_c[$ Ceij e\ j^[ ckYki ZhW_di e\\ Wbed]
j^[ j^h[WZ[Z f_d$ J^_i jof[ e\ ^[Wb_d] fheY[ii _i
XWi_YWbboZ[i_hWXb[X[YWki[_j_i\Wij[hWdZ_dlebl[i
b[ii Z_iY^Wh][ j^hek]^ j^[ dWiWb c[Wjki[i$ ?d
iec[YWi[i"j^[i_dkicWoX[i[Wb[ZXkjWfWiiW][
_i Yh[Wj[Z WdomWo Zk[ je kdZ[hfh[iikh[$ J^[i[
fWj_[dji m_bb dej_Y[ W YhWYa_d] eh ]kh]b_d] de_i[
ed imWbbem_d] \eeZ eh imWbbem_d] [cfjo$ J^_i
f^[dec[ded m_bb kikWbbo h[iebl[ m_j^_d W \[m
ZWoiWdZXWi_YWbboZ[cedijhWj[ij^Wjj^[fh[iikh[
Yecf[diWj_edjWa[ifbWY[_dj^[ceh[\WlekhWXb[
Z_h[Yj_ed"_$[$\hecj^[i_dkijemWhZij^[ehWbYWl_jo$
J^_i e\\[hi iec[ fhej[Yj_ed W]W_dij WiY[dZ_d]
_d\[Yj_edi$7ffb_YWj_ede\8[jWZ_d[jej^[ikh]_YWb
Wh[W WdZ _hh_]Wj_ed m_j^ Y^beh^[n_Z_d[ ]bkYedWj[
iebkj_edie\\[hiWZZ_j_edWbfhej[Yj_ed$7bie"edY[W
fWiiW][WiZ[iYh_X[ZWXel[_il[h_\_[Z"WZZ_j_edWb
c[Wdi e\ i[Wb_d] j^[ i_dki YWd X[ Yedi_Z[h[Z"
ikY^Wi_djheZkY_d]W\_Xh_dc[cXhWd[eXjW_d[Z
\hecWkjebe]ekiXbeeZ$J^[efj_ede\h[#ikjkh_d]
j^[\bWfi^ekbZdejX[Yedi_Z[h[ZWdoj_c[ieed
kdb[ii j^[ gkWb_jo e\ j^[ ckYeiW _i h[Wbbo ]eeZ$
?\ j^[ Wcekdj e\ ckYeiW mWi XWh[bo ik\\_Y_[dj
Wj j^[ j_c[ e\ \_hij ikjkh[ \ebbem_d] j^[ _cfbWdj
fheY[Zkh[" j^[d j^[h[ _i de h[Wied je [nf[Yj W
X[jj[h h[ikbj i^ehjbo j^[h[W\j[h$ ?dZ[[Z" W i[YedZ
ikjkh[f[h\ehc[ZWjj^_ife_djmekbZZWcW][j^[
iYWdjoj_iik[[l[d\khj^[h$
È
3ECONDARYÈ)MPLANTÈ0LACEMENTÈÈ
!LONGÈTHEÈ-AXILLARYÈ3INUS
8ed[beiiWiieY_Wj[Zm_j^j^[beiie\Yh[ijWb_cfbWdji
e\j[dh[ikbji_dWi_jkWj_ed_dm^_Y^j^[i_dki\beeh_i
Yel[h[Z Xo dej^_d] Xkj i[l[hWb bWo[hi e\ ie\j j_iik[$
9Wi[iikY^Wij^[i[YWdkikWbboX[cWdW][Zl[ho[Wi_bo
Xo8E?_cfbWdji"fhel_Z[Zj^WjWik\\_Y_[djlebkc[e\
l[ij_XkbWh WdZ fWbWjWb Yehj_YWb Xed[ ijhkYjkh[i _i
ij_bb WlW_bWXb[$ <khj^[hceh[" j^[i[ Xed[ ijhkYjkh[i
i^ekbZ X[ [ii[dj_Wbbo _djWYj WdZ e\\[h ]eeZ ikffehj
\eh _cfbWdji$ FheXb[ci cWo Wh_i[ _d Yedd[Yj_ed
m_j^ feijef[hWj_l[ i_dki Ybeikh[" [if[Y_Wbbo _d ded#
Yecfb_WdjfWj_[dji"i_dY[WdoWffb_YWj_ede\fh[iikh[
_dj^[dWiWbWh[W_ijeX[ijh_YjboWle_Z[ZfWhj_YkbWhbo
_dj^[fh[i[dY[e\h[ZkY[Zie\j#j_iik[ijhkYjkh[i$
J^[ckYef[h_eij[Wb\bWf\ehi[YedZWho_cfbWdjWj_ed
ckijX[fh[fWh[Z_djmebWo[hi$Ki_d]j^_iWffheWY^"
_j _i e\j[d feii_Xb[ je i[fWhWj[ j^[ Æc[cXhWd[Ç
\hec j^[ ckYef[h_eij[Wb \bWf _d j^[ Xed[#\h[[ Wh[W
WdZ cel[ _j _dje j^[ i_dki _d j^[ cWdd[h e\ W
È È 4ROUBLESHOOTINGÈ
i_dki\beeh[b[lWj_ed$J^_ie\\[hii[l[hWbWZlWdjW][i"
Wj b[Wij _d j^[eho$ 7do _d\bWccWj_ed m_bb kikWbbo
h[cW_dYed\_d[Zjej^[YWkZWbYecfWhjc[dj$Edj^[
ej^[h^WdZ"_\j^[c[cXhWd[_iYecfb[j[boh[cel[Z"
ef[d[ZehZ[ijheo[Z"j^[_cfbWdji_j[_ib_a[bojeX[
Yel[h[Z m_j^ d[m c[cXhWd[ Wj W f^oi_ebe]_YWbbo
\WlekhWXb[ j_c[" Z[f[dZ_d] ed j^[ feijef[hWj_l[
YedZ_j_edi YedY[hd_d] fh[iikh[ WdZ _d\bWccWj_ed$
Ikh][ediki_d]j^[jme#bWo[hfh[fWhWj_edj[Y^d_gk[
m_bb\h[gk[djboh[Wb_p[j^Wjj^[Wh[W\WY_d]jemWhZij^[
i_dki^WiWbh[WZoeXjW_d[ZW^WhZjhWo#b_a[ijhkYjkh["
_dZ_YWj_d]j^Wjh[#eii_\_YWj_ed^WieYYkhh[Z$Fhel_Z[Z
j^Wj]eeZfWbWjWbikffehj^WiX[[dl[h_\_[Z"j^[d[m
i_dki mWbb _di_Z[ j^[ eii_\_[Z ijhkYjkh[ YWd X[ ki[Z
je YWh[\kbbo _dijWbb 8E? _cfbWdji$ ?d YWi[i ikY^ Wi
j^[i[" WZZ_j_edWb Z_W]dei_i ki_d] jece]hWf^o YWd
X[ [cfbeo[Z _d W fWhj_YkbWhbo ki[\kb cWdd[h je
[nfbeh[ j^[ cWn_ckc WlW_bWXb[ Xed[ lebkc[$7bie"
j^[ fh[ef[hWj_l[ jh[Wjc[dj fbWdd_d] m_j^ h[]WhZ je
j^[fheij^[j_Yikf[hijhkYjkh[_i]h[Wjbo\WY_b_jWj[ZXo
j^[i[jece]hWf^_YijkZ_[i$
È
4ROUBLESHOOTING
J^h[[cW`eh\WYjehicWo]_l[h_i[jeYecfb_YWj_edi0
v ?d\[Yj_edi [cWdWj_d] \hec j^[ j[[j^1 j^[i[ cWo
Yh[Wj[fheb_\[hWj_l[fheY[ii[i_dj^[i_dki"j^[h[Xo
eXijhkYj_d] ZhW_dW][ WdZ cW_djW_d_d] Y^hed_Y
_d\bWccWj_ed$
v ?d\bWccWjeho fheY[ii[i _di_Z[ j^[ kff[h Yec#
fWhjc[djkdh[bWj[Zjej^[_cfbWdj$
v ?d\bWccWjeho fheY[ii[i _di_Z[ j^[ YecfWhjc[dj
j^Wj^WhXekhij^[_cfbWdj$
<_hije\Wbb"_jm_bbX[d[Y[iiWhojeWZZh[iij^[gk[i#
j_ed e\ m^[j^[h j^[ _cfbWdj YWd X[ fh[i[hl[Z$ J^[
h[Wied_d]ckijX[Wi\ebbemi0
7d Wjj[cfj Wj fh[i[hlWj_ed cWa[i i[di[ _\
j^[ Z[dj_ij _i WXb[ je [b_c_dWj[ j^[ YWki[ e\
_d\bWccWj_edWim[bbWi[dikh[Yecfb[j[ijWX_b_#
pWj_ed e\ j^[ _cfbWdj Zkh_d] j^[ _dj[hl[dj_ed$
?\Xej^YedZ_j_ediWh[dejc[j"j^[_dj[hl[dj_ed
YWddej X[ h[]WhZ[Z Wi ikYY[ii\kb" WdZ j^[
_cfbWdji^ekbZX[[nfbWdj[Z$J^[][d[hWbhkb[
_dZ[Wb_d]m_j^ceX_b[_cfbWdjickijX[0_\_d
ZekXj"jWa[_jekj
J^[ hWj_edWb[ X[^_dZ j^_i fh_dY_fb[ _i gk_j[ i_cfb[0
W 8E? _cfbWdj j^Wj YWd X[ h[#ijWX_b_p[Z m_j^_d j^[
Xed[[$]$XohejWj_edZe[idej^Wl[jeX[h[fbWY[Z$
(,+
?d j^Wj YWi[" Wdo _d\bWccWj_ed j^Wj cWo X[ fh[i[dj
Wim[bbYWdZhW_de\\ifedjWd[ekiboZkh_d]WdZW\j[h
j^[fheY[Zkh[$J^[h[ikbjWdjXb[[Z_d]YWdX[kj_b_p[Z
\ehXed[^[Wb_d]"WdZj^[\kdYj_edWbij_ckbki]e_d]
\hecj^[_cfbWdjZ_h[Yjbo_djej^[Xed[m_bbfhecej[
j^[h[ceZ[bb_d]fheY[ii$Ded[e\j^_im_bbX[feii_Xb[
_\ j^[ _d\bWccWj_ed f[hi_iji" WdZ j^[ \kdYj_edWb
ij_ckb_m_bbX[WXi[djkdb[iij^[_cfbWdj_if[h\[Yjbo
ijWX_b_p[Z$
I_dki Yecfb_YWj_edi cWo eYYkh Zk[ je [nY[ii_l[
beWZ_d] e\ W Z_ijWb _cfbWdj [$]$ Zk[ je W bef#i_Z[Z
cWij_YWj_ed fWjj[hd" m^_Y^ cWo b[WZ je _cfbWdj
ceX_b_joWij^[Z_ia_iW\\[Yj[ZXoel[hbeWZeij[eboi_i$
J^_ifheY[iim_bbkikWbbofhe]h[iiibemboel[hm[[ai
ehcedj^i$C[Wdm^_b["Wdoej^[h_cfbWdjiYedjW_d[Z
_d j^[ iWc[ _cfbWdj#h[ijehWj_ed Yecfb[n m_bb ^Wl[
je ikffehj ceh[ fem[h\kb beWZi$ ;nf[h_[dY[ ^Wi
i^emd" ^em[l[h" j^Wj j^ei[ h[cW_d_d] _cfbWdji Wh[
f[h\[YjboYWfWXb[e\jeb[hWj_d]j^[]h[Wj[h\ehY[i$;l[d
cWn_bbWho Xh_Z][i ikffehj[Z Xo edbo \ekh ijhWj[]_Y
8E?_cfbWdjim_bbX[cW_djW_d[Z_dW]eeZijWj[\ehW
b_c_j[Zf[h_eZe\j_c[_\edboj^h[[e\j^[i[_cfbWdji
^Wl[ \kbb beWZ#X[Wh_d] YWfWY_jo$ J^_i eXi[hlWj_ed
YWd X[ kj_b_p[Z je ]eeZ [\\[Yj Xo b[Wl_d] j^[ Xh_Z][
_d fbWY[ m^_b[ h[cel_d] j^[ ceX_b[ 8E? _cfbWdj Wj
j^[[Whb_[ijYedl[d_[dY[$7jb[Wijj^[l[ij_XkbWhXed[
Z[\[Yj_dj^[i_dkimWbbi^ekbZ^[Wbm_j^_d.m[[ai"
ie j^Wj j^[ i[YedZWho _cfbWdjWj_ed YWd dehcWbbo
X[ f[h\ehc[Z Xo j^Wj j_c[$ I[YedZ _cfbWdjWj_ed
fheY[Zkh[i kikWbbo _dlebl[ ceh[ [nj[di_l[ Xed[
h[ceZ[bb_d]j^Wd\_hij_cfbWdjWj_edfheY[Zkh[iZk[
je j^[ YkckbWj_l[ h[ceZ[bb_d] _dY[dj_l[i \hec j^[
j_c[X[\eh[[nfbWdjWj_ed"j^[j_c[W\j[h[nfbWdjWj_ed"
WdZj^[j_c[e\i[YedZ_cfbWdjWj_ed$J^[h[\eh["j^[
d[m _cfbWdj i^ekbZ dej X[ fkj _d \kdYj_ed kdZ[h
j^[ [n_ij_d] eh d[mbo cWZ[ Xh_Z][ \eh Wj b[Wij ,Ä
.m[[ai$ J^_i _dj[hlWb cWo X[ ec_jj[Z _\ YedZ_j_edi
Wh[ \WlekhWXb[" [$]$ _d j^[ fh[i[dY[ e\ W bWh][ Xed[
lebkc[ WdZ ]eeZ Yehj_YWb \_nWj_ed$ ?cc[Z_Wj[
beWZ_d] e\ j^[ i[YedZWho _cfbWdji i^ekbZ Wbie X[
Yedi_Z[h[Z_\WZZ_j_edWb_cfbWdjidejWXbofj[ho]e_Z
iYh[mim[h[_di[hj[ZWdZj^[bef#i_Z[ZcWij_YWj_ed
fWjj[hdmWiikYY[ii\kbboYehh[Yj[Z$
J^[ [nfbWdjWj_ed fheY[Zkh[ ^Wi je X[ fbWdd[Z
m_j^j^[ijhWj[]_Y]eWbe\\WY_b_jWj_d]_cfbWdjWj_ede\
Wdej^[h 8E? _cfbWdj [_j^[h _d j^[ iWc[ i[ii_ed eh
Wj W bWj[h j_c[$ ;l[d j^[ _dY_i_ed ^Wi je X[ fbWdd[Z
m_j^j^_ieX`[Yj_l[_dc_dZ$Ded#Wkj^eh_p[ZZ[dj_iji
kikWbbo \hec WYWZ[c_W j[dZ je b[Wl[ X[^_dZ
kdd[Y[iiWh_bo bWh][ ^eb[i _d j^[ l[ij_XkbWh i_dki
mWbb ed h[cel_d] 8E? _cfbWdji$ J^[i[ Z[\[Yji m_bb
dej Ybei[ _\ j^[ ikXi[gk[dj jh[Wjc[dj Yedi_iji _d
ckYeiW#Xehd[h[ijehWj_edi$?j_ij^[h[\eh[_cfehjWdj
j^Wj YedZ_j_edi Wh[ Yh[Wj[Z Zkh_d] j^[ [nfbWdjWj_ed
fheY[Zkh[ j^Wj m_bb Wbbem _cc[Z_Wj[ fbWY[c[dj e\
W \_n[Z h[ijehWj_ed$ :emd je j^h[[ _djWYj _cfbWdji
m_bb ik\\_Y[ je ikffehj ikY^ W ijhkYjkh[ el[h j^[
(,, 9^Wfj[h'.È )MPLANTÈ4REATMENTÈ!LONGÈTHEÈ-AXILLARYÈ3INUS
h[gk_h[Z _dj[hlWb e\ )Ä*cedj^i$ 9h[Wj_d] W iceej^
cWij_YWjeho \kdYj_ed WdZ Wle_Z_d] Wdo jof[ e\
h[celWXb[ h[ijehWj_ed Wh[ j^[ edbo fh[h[gk_i_j[i
\eh d[m Xed[ \ehcWj_ed je eYYkh$ 8o de c[Wdi
i^ekbZj^[[nfbWdjWj_edfheY[Zkh[X[f[h\ehc[ZXo
Z[dj_ijiWdZikh][edim^em[h[d[l[hjhW_d[Z_d8E?
j[Y^debe]o$ F[efb[ m^e ^Wl[ d[_j^[h j^[ d[Y[iiWho
cWj[h_Wbi deh j^[ h[gk_i_j[ [nf[h_[dY[ \eh j^_i jof[
e\ jh[Wjc[dj Wh[ i_cfbo dej _d W fei_j_ed je e\\[h
ikY^jh[Wjc[dj$J^[edbojh[Wjc[djj^[oYWde\\[h_i
jeh[cel[j^[ceX_b[_cfbWdji"m^_Y^_iWYhkZ[WdZ
_dWZ[gkWj[WffheWY^$;nfbWdjWj_edc_icWdW][c[dj"
m^[j^[h Xo ki_d] W j[Y^d_YWbbo \bWm[Z WffheWY^ eh
Xo Z[bWo_d] j^[ fheY[Zkh[" YWd _d\b_Yj Yedi_Z[hWXb[
ZWcW][$BkYa_bo"j^_iZWcW][YWdkikWbboX[h[l[hi[Z
Xof[h\ehc_d]Wi[YedZ8E?jh[Wjc[dj$?di[hj_ede\
ckYeiW#Xehd[ h[ijehWj_edi \ebbem_d] j^[ h[celWb
e\ 8E? _cfbWdji eh [njhWYj_ed e\ dWjkhWb j[[j^" \eh
j^WjcWjj[hm_bbb[WZjeXed[h[iehfj_edWiWh[ikbj
e\ ikffh[ii[Z XbeeZ ikffbo$ ?\ \eh de ej^[h h[Wied"
j^[c[h[\WYjj^WjWh[celWXb[h[ijehWj_edi^ekbZX[
_di[hj[Z\ebbem_d]8E?[nfbWdjWj_edkikWbboWcekdji
jecWbfhWYj_Y[$
?j i^ekbZ X[ c[dj_ed[Z j^Wj ijhWj[]_Y WXkjc[dj
fei_j_ed_d]m_bbl_hjkWbboWbmWoiikYY[[Z_di[Ykh_d]
[dek]^Xed[WhekdZj^[i_j[e\\_hij_cfbWdjWj_ed$
?\ikYY[ii\kbWZWfjWj_ede\j^[cWij_YWj_edfWjj[hd
i[[cikdb_a[bo_$[$WX_bWj[hWbboXWbWdY[ZijWj[YWddej
X[ h[WY^[Z" j^[ Z[dj_ij i^ekbZ Yedi_Z[h Z[i_]d_d]
j^[i[YedZWhoh[ijehWj_edWiWi[]c[djWbh[ijehWj_ed
ikffehj[Z Xo i[l[hWb _cfbWdji h[]WhZb[ii e\ j^[
Xh_Z][j^Wj^WiX[[db[\j_dfbWY[$Jej^_i[dZ"Wjb[Wij
j^h[[fh[\[hWXbo\ekheh\_l[_cfbWdjiWh[_di[hj[Z
ed j^[ W\\[Yj[Z i_Z[ WdZ \_jj[Z m_j^ W Xh_Z][ \eh
ijWX_b_pWj_ed$ ?d j^_i mWo" cWij_YWjeho \ehY[i WYj_d]
WYheii j^[ WhY^ \hec j^[ YedjhWbWj[hWb i_Z[" m^_Y^
cWo_dlebl[cWii_l[b[l[hW][\ehY[i"Wh[[b_c_dWj[Z$
I[]c[djWbh[ijehWj_edie\j^_ijof[kikWbboh[ifedZ
m[bbje_cc[Z_Wj[beWZ_d][l[dm^_b[j^[WiieY_Wj[Z
Xed[_i_dj^[fheY[iie\h[ceZ[bb_d]$
?\j^[XedobWj[hWbi_dkimWbb_ic_ii_d]Zkh_d]j^[
i[YedZWhofheY[Zkh["Wdofeijef[hWj_l[_d\bWccWj_ed
m_bbX[WXb[jeifh[WZWbed]j^[j^h[WZ[Zf_dWdZcWo
[l[d Z[l[bef _dje W Y^[[a WXiY[ii$ ;Whbo Z[j[Yj_ed
e\ ikY^ fheY[ii[i WdZ j^[_h jh[Wjc[dj WYYehZ_d]
je Yedl[dj_edWb ikh]_YWb fhejeYebi Wh[ cWdZWjeho
h[gk_h[c[dji$
?d\bWc[Z_cfbWdjWj_edWh[WiYWdX[_hh_]Wj[Zm_j^
>(E( )Ä+ Wj Wdo j_c[ Xo YWh[\kbbo WZlWdY_d] W
j^_d YWddkbW _d W fWbfWjeho \Wi^_ed kf YhWd_Wbbo
kdZ[h Yedj_dkeki _hh_]Wj_ed$ 9edj_dk_d] h[\bkn e\
j^[ _hh_]Wj_ed \bk_Z ed h[WY^_d] j^[ XWiWb fbWj[
ik]][ijij^Wjedboed[YecfWhjc[djcWo[n_ijZk[je
i_dkiYbeikh[e\j^[i_j[d[]Wj_l[_hh_]Wj_edWjj[cfj$
7bj[hdWj_l[bo"j^[h[_iWbieWY^WdY[j^Wjj^[fWhWdWiWb
i_dkicWoX[Yecfb[j[bohWZ_efWgk["m^_Y^d[[Zije
X[l[h_\_[ZXohWZ_e]hWf^_YZ_\\[h[dj_WbZ_W]dei_i$
DehcWbbo" _\ j^[ cWn_bbWho i_dki YWddej X[
^[hc[j_YWbboi[Wb[Zeh_\_jh[ef[diW\j[hiec[ZWoi"
j^[ _cfbWdj YWd X[ b[\j _d fbWY[ Wbb j^[ iWc[$ J^[
ckYeiW YWd X[ _dZkY[Z je ]hWdkbWj[ Xo Wffbo_d]
>(E()&$M^[j^[hh[#ikjkh_d]cWoX[Wffhefh_Wj[
ckij X[ Z[Y_Z[Z fhkZ[djbo" i_dY[ j^[ feijef[hWj_l[
gkWb_joehgkWdj_joe\ckYeiW_ikikWbbo_dWZ[gkWj["
m^_Y^ _i b_a[bo je h[ikbj _d [l[d ceh[ Z[^_iY[dY[i$
?d ceij icea[hi" ^em[l[h" Wd Wjj[cfj Wj Yel[hW][
m_bbX[_dZ_YWj[ZW\j[hWhekdZ(m[[aiX[YWki[>(E(
[jY^_d]_ihWh[boikYY[ii\kb_dj^_ifWj_[dj]hekf$
FWj_[dji Z_ih[]WhZ_d] j^[ _dijhkYj_ed je Wle_Z
dei[ Xbem_d] eh Wdo ej^[h Wffb_YWj_ed e\ fh[iikh[
id[[p_d]"jh_fiedYWXb[YWhiehW[hefbWd[i_dlebl_d]
fh[iikh[Yecf[diWj_edm_bb\_dZikY^fh[iikh[cWo
h[ikbj_ddWiWbckYki\bem_d]_djej^[cWn_bbWhoi_dki$
?dY_Z[djie\j^_ijof[_dj^[_cc[Z_Wj[feijef[hWj_l[
Yekhi[j[dZjeh[dZ[h_cfbWdjih[fbWY_d]\_hijcebWhi
kdiWblW][WXb[ edY[ [nY[ii_l[ Wcekdji e\ ckYki
^Wl[WYYkckbWj[ZWjj^[bem[ijfe_dje\j^[cWn_bbWho
i_dki$?\j^Wj_ij^[YWi["j^[_cfbWdjiW\\[Yj[Zi^ekbZ
X[ h[fbWY[Z _d Zk[ Yekhi[$ M[ ^Wl[ eXi[hl[Z" j_c[
WdZ W]W_d" j^Wj fWj_[dji m^e m[dj j^hek]^ j^_i
[nf[h_[dY[edY[m_bbX[ifWh[Zj^[iWc[c_i\ehjkd[
\hec ^Wff[d_d] W]W_d ed ^[[Z_d] j^[ h[b[lWdj
_dijhkYj_edij^[i[YedZj_c[WhekdZ$
È
-ORPHOLOGICALÈ!LTERATIONSÈÈ
INÈTHEÈ$ISTALÈ-AXILLA
?dj^[Z_ijWbh_Z][i[]c[dj"Y[hjW_dXed[fhef[hj_[i
cWo" _d Yed`kdYj_ed m_j^ j[cfehWbbo ijW]][h[Z
[l[dji"]_l[h_i[jeikXijWdj_WbXed[beii0
v <ebbem_d]jeej^beii"j^[Yehj_YWbi_dki\beehm_bb"_d
j^[bed][hj[hc"[nj[dZYWkZWbbom^_b[j^[Wbl[ebWh
Xed[_ih[iehX[Z_dWYhWd_WbZ_h[Yj_ed$M^_b[Xej^
j[dZ[dY_[ijWa[dje][j^[hZeh[ZkY[j^[jejWbXed[
lebkc["j^[oWYj_deffei_j[Z_h[Yj_edi"iej^Wjj^[
h[iehfj_edfheY[iim_bbkikWbboYec[jeWijWdZij_bb
W\j[h W m^_b[$ J^[ \h[gk[dYo e\ 8CK WYj_lWj_edi
m_bbikXi[gk[djboWZWfjjej^[ioij[c_Y^ehcedWb
i_jkWj_ed" m^_Y^ _i m^o \khj^[h h[iehfj_ed _d W
YhWd_WbZ_h[Yj_edm_bbfhe]h[iiedboibembo$
v D[l[hj^[b[ii"j^[eh_[djWj_ede\cWYhejhW`[Yjeh_[i
kikWbbo b[Wl[i iec[j^_d] je X[ Z[i_h[Z$ J^[
_dY[dj_l[ \eh h[eh_[djWj_ed _i" ^em[l[h" dej
fem[h\kb[dek]^jeheki[j^[eij[edWbioij[c\hec
_jih[ij_d]ijWj[je_dZkY[\khj^[hh[iehfj_ed$
v <ebbem_d] _cfbWdjWj_ed m[ i[[ beYWb h[fW_hi _d
j^[ f[h_#_cfbWdj Xed[ j_iik[ WdZ bWh][#iYWb[
h[ceZ[bb_d] e\ j^[ `Wm 7ja_died [j Wb$ '/--$ ?d
j^_i fheY[ii" j^[ cWYhejhW`[Yjeh_[i Wh[ h[Wb_]d[Z
jemWhZi j^[ bWj[hWb fj[ho]e_Z ckiYb[" m^_Y^ _i
kikWbbo WjjWY^[Z c[Z_Wbbo WdZ YhWd_Wbbo e\ j^[
cWn_bbWhoWbl[ebWhh_Z][$
È È -ORPHOLOGICALÈ!LTERATIONSÈINÈTHEÈ$ISTALÈ-AXILLAÈ (,-

A B C

E F

GÈ H IÈ

&IGÈAnI Bed]_jkZ_dWb i[Yj_ed e\ j^[ Wbl[ebWh h_Z][ A _bbkijhWj_d] j^[ fh[ef[hWj_l[ fei_j_ed WdZ eh_[djWj_ed e\ j^[ Xed[
YWkZWbbo e\ j^[ cWn_bbWho i_dki ieb_Z b_d[ WdZ j^[ efj_c_p[Z Wb_]dc[dj e\ j^[ cWYhejhW`[Yjeh_[i W\j[h j^[ eij[edWb ioij[c
^Wih[jkhd[Zje_jih[ij_d]fei_j_edZejj[Zb_d[$?cfbWdjWj_edB_i\ebbem[ZXobWh][#iYWb[Xed[h[ceZ[bb_d]$?\j^[fei_j_ed
e\j^[8E?_cfbWdj_ikd\WlekhWXb["_jcWo[dZkfWjj^[[Z][e\j^[Wbl[ebWhXed["c[Wd_d]j^Wj_jm_bbdebed][hX[XWiWbbo
eii[e_dj[]hWj[ZWih[gk_h[ZCÈDWbj^ek]^ikY^XWiWbeii[e_dj[]hWj_ed^WZ_d_j_WbboX[[dWY^_[l[Z$I_dY[j^[j[dZ[dYoe\j^[
Xed[ je c_d[hWb_p[ m_bb dem X[ l[ho bem _d j^_i Wh[W" j^[ h_ia j^Wj j^[ _cfbWdj _i Yecfb[j[boÆ[njhWj[hh_jeh_Wb_p[ZÇ \hec j^[
Xed[D_ih[bWj_l[bo^_]^$ E 7Yheii#i[Yj_edehj^e]edWbbojej^[i[Yj_edi^emd_d D$Dej[j^Wjj^[fWbWjWbWif[Yjie\j^[8E?
_cfbWdjcWoh[cW_d\_hcboWdY^eh[Z_dj^[fWbWjWbXed["m^_Y^_ifhej[Yj[ZW]W_dijh[iehfj_ed"\ehWbed]f[h_eZe\j_c["[l[d
j^ek]^j^[l[ij_XkbWh#Yh[ijWbWif[Yje\j^[Xed[^WiWbh[WZoX[[dh[iehX[Z$;nfbWdjWj_ed_idej_dZ_YWj[Z_dj^_ii_jkWj_ed$JhWdi#
i_dki_cfbWdjiWle_Zj^_ifheXb[c"Wij^[i_dki\beeh_idehcWbboX[jj[hfhej[Yj[ZW]W_dijh[iehfj_edG$7fWbWjWbbo_dYb_d[Z
eh_[djWj_ede\j^[8E?_cfbWdjFm_bb_cfhel[j^[Y^WdY[ie\_cfbWdjikhl_lWbWim[bb$8E?_cfbWdjim_j^ckbj_fb[l[ij_XkbWh
Z_iai<_]$*$'+^Wl[WbWh][hYedjWYjikh\WY[m_j^j^[l[ij_XkbWhWbl[ebWhXed[$J^[_hXed[#fh[i[hl_d][\\[Yj_ij^[h[\eh[]h[Wj[h
YecfWh[Zjei_d]b[#Z_ia_cfbWdji$Kdb[iia[fj_dfbWY[Xoj^[Xh_Z]["j^[8E?_cfbWdjmekbZc_]hWj[YhWd_WbboWbed]m_j^j^[
ikhhekdZ_d]Xed[$I[[9^Wfj[h(,$'\ehWbj[hdWj_l[Z[l[befc[djie\j^[ifWj_Wbh[bWj_edi^_fi$ HÈI Dej[j^Wjj^[iWc[fWjj[hd
e\Xed[h[iehfj_edWii^emd_dAnEcWoX[eXi[hl[ZW\j[hjh[Wjc[djim_j^Yh[ijWb_cfbWdji_cfbWdji
(,. 9^Wfj[h'.È )MPLANTÈ4REATMENTÈ!LONGÈTHEÈ-AXILLARYÈ3INUS

È
2ADIOGRAPHICÈ#ASEÈ3TUDIES

&IGÈAnC ?djhW#i_dkiYecfb_YWj_edkdjh[Wj[Z$J^h[[o[WhiW\j[hWd_cfbWdj^WZX[[d_di[hj[Zjeh[fbWY[jeej^(,"j^[_cfbWdj
i_j[ mWi _dlebl[Z m_j^ W i_dki_j_i Z[l[bef_d] _d j^[ b[\j cWn_bbW$ <W_bkh[ je f[h\ehc j^[ h[gk_h[Z ;DJ _dj[hl[dj_ed \_hij ]Wl[
h_i[ je h[Ykhh[dj Ybeikh[ e\ j^[ dWjkhWb ZhW_dW][ fWj^mWoi" \ebbem[Z Xo \_ijkbWj_ed je j^[ ehWb YWl_jo$ ;l[djkWbbo j^[ _d\[Yj_ed
ifh[WZel[hj^[[dj_h[Z_iaWh[We\j^[Z_ijWb_cfbWdj$J^[_cfbWdjh[fbWY_d]jeej^(,^WZX[Yec[ceX_b[WdZhejWj[Z$?djhki_ed
ceX_b_jomWiWbiefh[i[dji_dY[WbbXed[YedjWYj^WZX[[dbeij\ebbem_d]hejWj_ed$J^[h[\eh["j^_i_cfbWdj^WZjeX[h[cel[Z$
J^[8E?_cfbWdjh[fbWY_d]jeej^(*mWidejW\\[Yj[ZXoj^[_d\bWccWj_ed$J^[ejeh^_debWhod]ebe]_ij\W_b[ZjeYecfbom_j^j^[
_cfbWdjebe]_ijÉih[gk[ijjef[h\ehc\[d[ijhWj_edjej^[dei[$J^[fWj_[dj"\ebbem_d]j^[b_d[e\b[Wijh[i_ijWdY["_d_j_WbboYecfb_[Z
m_j^j^[ejeh^_debWhod]ebe]_ijÉiik]][ij_edikdj_bj^[_cfbWdjmWi[l[djkWbbobeij$Jeej^')_i\hWYjkh[Z1j^[Wh[WikhhekdZ_d]
j^[_djhWhWZ_YkbWhfeiji^emic_bZeij[eboi_i$Yi^emij^[iWc[fWj_[djiW\j[hh[celWbe\j^[ceX_b[8E?_cfbWdjWdZj^[d[m
8E?_cfbWdjh[fbWY[c[dj,m[[aibWj[h1j^[9JiYWdmWijWa[d/cedj^iW\j[hj^[i[YedZ_cfbWdjfbWY[c[dj
È È 2ADIOGRAPHICÈ#ASEÈ3TUDIESÈ (,/

&IGÈAnD 9JiYWdie\Wb[\jcWn_bbWXejjecjejef_dj^[fh[i[dY[e\Y^hed_Yi_dki_j_i$J^h[WZ[Zf_dWh[WiWh[l_i_Xb[_d
_cW][iAWdZB$ C 7Z_iaWh[Wm_j^ib_]^jboj^_Ya[d[Zi_dkiWbckYeiWbem[hYecfWhjc[dj$ D J^[YecfWhjc[djWXel[j^[
_cfbWdj"m^_Y^_iYecfb[j[bohWZ_efWgk[1j^kij^[_cfbWdj_idejW\\[Yj[ZXoj^[_d\bWccWjehofheY[ii
(-& 9^Wfj[h'.È )MPLANTÈ4REATMENTÈ!LONGÈTHEÈ-AXILLARYÈ3INUS

&IGÈÈA <ebbem#kf9JiYWdieXjW_d[Z,cedj^iW\j[hfkhkb[dji_dki_j_i$J^[cWn_bbWhoi_dki_idemYb[Wh$J^[_djhW#i_dki
Z_ia_idejYel[h[ZXockYeiWWdZi^emi]eeZX_Yehj_YWbWdY^ehW][$J^[i_dki_j_i^WZX[[djh[Wj[ZXo_hh_]Wj_edm_j^+>(E(
Wbed]j^[j^h[WZ[Zf_d$7\j[h[ijWXb_i^_d]j^WjZhW_dW][mWidej_cf[Z[Z"Wi_dZ_YWj[ZXo\e[jehedYWh[\kb_hh_]Wj_ed"j^[[dj_h[
i_dkimWi\bki^[ZekjXoh[jhe]hWZ[_hh_]Wj_ed"h[ikbj_d]_dbWh][Wcekdjie\fkhkb[djZ_iY^Wh][$J^[_cfbWdj"Zk[je_jif[h\[Yjbo
ijWXb[WdY^ehW]["YekbZX[b[\j_dfbWY[$Dej[j^Wjj^[Yehj_YWbWdY^ehW][mekbZ^Wl[X[[dX[jj[hij_bb_\j^[_cfbWdj^WZX[[d
_dijWbb[ZWhekdZ)$+cc\khj^[hZ_ijWbbo$
È È 2ADIOGRAPHICÈ#ASEÈ3TUDIESÈ (-'

&IGÈÈB J^[_cfbWdjedj^[YedjhWbWj[hWbi_Z[_i
WdY^eh[ZX_Yehj_YWbbo_dWjhWdi#i_dkifei_j_edWim[bb$Dej[
j^Wjj^[Z_iaiWh[m[bbeii_\_[Z$J^[h_]^j_cfbWdj^WZX[[d
ceX_b[WdZmWihejWj[Z"_dWYehh[Yj_l[fheY[Zkh["jei[Ykh[
fWbWjWbWdY^ehW][e\j^[Wd]b[Z_cfbWdjfehj_ed"YWf_jWb_p_d]
edj^[\WYjj^Wjj^[Y[djh[e\hejWj_ed_ibeYWj[Z\Whj^[h
\hecj^[ÆWd]b[Çj^Wd\hecj^[^Wb\#hekdZ[Zi_Z[Zkh_d]
hejWj_ed$J^_iWffheWY^edbomehai_\WfWbWjWbXed[]Wf
_ifh[i[dj$J^[Wd]b[YWdj^[dX[hejWj[Z^ec[Xoki_d]W
ifh_d]WYY[b[hWjeh[$]$9hemd#9b_Yai$ C 8E?_cfbWdj_dj^[
Wh[We\jeej^'-"fbWY[Z_dc_d_cWbh[i_ZkWbXed[m_j^]eeZ
fWbWjWbWdY^ehW][iWc[_cfbWdjWi_d<_]$'.$')X
(-( 9^Wfj[h'.È )MPLANTÈ4REATMENTÈ!LONGÈTHEÈ-AXILLARYÈ3INUS

&IGÈAB I_dY[j^[

[bed]Wj_ede\j^[bem[hcebWhied
j^[h_]^jmWiWi[l[h[eXijWYb[je
[gkWbcWij_YWj_ed"j^[i[j[[j^^WZ
jeX[[njhWYj[Z$?dj^[kff[h`Wm"
Xej^8E?_cfbWdjiedj^[b[\ji_Z[
h[Y[_l[ZjhWdi#i_dkifbWY[c[dj

B
È È 2ADIOGRAPHICÈ#ASEÈ3TUDIESÈ (-)

&IGÈAnC ?cc[Z_Wj[boW\j[h
Xej^kff[hYWd_d[i^WZX[[d
[njhWYj[Z"i_n8E?_cfbWdjim[h[
_di[hj[Z_dj^[cWn_bbWWdZW
\kbbXh_Z][WmWifhel_Z[Z$
7bb_cfbWdjim[h[fbWY[Z_d
Z_h[YjYedjWYjm_j^j^[ef[d
i_dki$Em_d]dejb[Wijjej^[
fWj_[djÉiX[jj[hY^[m_d]WX_b_jo"
j^[f[h_eZedjWbbo_dlebl[Zbem[h
cebWhi^WZX[Yec[gk_j[ceX_b[
edbo,cedj^ibWj[hWdZ^WZje
X[[njhWYj[ZX$<_l[o[WhiW\j[h
_cfbWdjfbWY[c[dj_dj^[kff[h
`Wm"j^[EF=i^emiWikYY[ii\kb
h[ijehWj_edWdZZ[di[Xed[
ijhkYjkh[i_dj^[cWn_bbW
A

C
(-* 9^Wfj[h'.È )MPLANTÈ4REATMENTÈ!LONGÈTHEÈ-AXILLARYÈ3INUS
È
4RAININGÈFORÈ3INUSÈ0ROCEDURES
<eh X[]_dd[hi" jhWdi#i_dki _cfbWdjWj_ed YWd iec[#
j_c[iX[Z_\\_Ykbj"Z[if_j[j^[WlW_bWX_b_joe\Yecfkj[h#
Wii_ij[Z jece]hWf^o 97J$ M[ h[Yecc[dZ
fhWYj_Y_d] j^[ fheY[Zkh[ ed hWm []]i$ J^[ []]i
h[Y[_l[ W ^eb[ ed ed[ i_Z[ ie j^Wj j^[ Yedj[dji YWd
hkdekj$Edj^[effei_j[i_Z[e\j^[[cfjo[]]i^[bb"
m[YWddemfhWYj_Y[j^[eij[ejeco\eh8E?_cfbWdji$
?j _i i_cfb[ij je fbWY[ 8?E _cfbWdji Wj j^[ ceh[
fe_dj[Z [dZ e\ j^[ []]$7ZlWdY[Z fhWYj_Y_Wdi meha
m_j^j^[\bWj[dZeh[l[dj^[i_Z[$?j_i_cfehjWdjje
Yh[Wj[j^[YWl_johWf_ZboWdZ_ded[ijh[jY^"Wle_Z_d]
h[jekY^[i WdZ _dijhkc[dj h[ijWhji$ J^_i _i Wbie W
]eeZeffehjkd_jojeÆ\[[bÇj^[Z_\\[h[djX[^Wl_ekhe\
hejWho _dijhkc[dji _d YedjhW#Wd]b[i _d YecfWh_ied
m_j^jkhX_d[i$?\j^[jhW_d_d]fheY[Zkh[_if[h\ehc[Z
C
m_j^ekj [cfjo_d] j^[ []] \_hij" j^[ \[[b_d] YWd X[
i_c_bWh je j^[ ed[ m^[d ckYeY[bW[ WdZ Yoiji Wh[
[dYekdj[h[ZXoj^[Ykjj_d]_dijhkc[dj$
È
#ONCLUSIONS
JhWdi#i_dki _di[hj_ed e\ 8E? _cfbWdji _i W hekj_d[
ikh]_YWbWffheWY^\ehYh[Wj_d]WdY^ehW][fe_dji\eh
ikXi[gk[dj _di[hj_ed e\ \_n[Z h[ijehWj_edi$ ?d ekh
[nf[h_[dY[" Wk]c[djWj_ed e\ j^[ cWn_bbWho i_dki
Xo i_dki \beeh [b[lWj_ed _d j^[ Wh[W e\ j^[ _cfbWdj
X[Z Ze[i dej e\\[h Wdo WZlWdjW][i el[h jhWdi#i_dki
_cfbWdjWj_ed$ J^[ bWjj[h WffheWY^ c_d_c_p[i j^[
Wcekdj e\ [njhWd[eki cWj[h_Wb _djheZkY[Z WdZ
b[Wl[iheec\ehikffkhWj_ed\hecj^[eij[ejeco]Wf
WdZj^hek]^j^[dWjkhWbfWiiW][i$
&IGÈÈA J^_i_cfbWdj_ihWj^[hjeeicWbb\ehj^[
eij[ejecoh[]_ed$J^[[]]i^[bb"^em[l[h"^Wi^WhZboX[[d
ZWcW][Z$ B ?dj^_iYWi["j^[i[b[Yj[ZfWj^j^hek]^j^[
i_dki^WZX[[djeei^ehj"WdZfWhjie\j^[[]]i^[bb\hWYjkh[Z
Wij^[_cfbWdjmWi_di[hj[Z"c[Wd_d]j^Wjj^[YWl_jomWi
dej^_]^[dek]^$ C Dkc[hekiWjj[cfjiWh[d[Y[iiWhoje
WYgk_h[j^[j[Y^d_gk[e\cWdW]_d]\hW]_b[Xed[ijhkYjkh[i
È È #OMPLIANCEÈ (-+

J^[ fh[h[gk_i_j[i \eh ikYY[ii\kb jhWdi#i_dki

_cfbWdjWj_edWh[0
v L[hj_YWb _cfbWdj i^W\ji _Z[Wbbo e\ j^[ iceej^
hWj^[hj^Wdikh\WY[#[d^WdY[Zjof[
v Ik_jWXb[ [dl_hedc[dj je WY^_[l[ ]eeZ fh_cWho
ijWX_b_jo
v Ik_jWXb[ [dl_hedc[dj je _djheZkY[ Z_iai e\
WZ[gkWj[Z_Wc[j[h
v I[YedZWho fheij^[j_Y ijWX_b_pWj_ed e\ WXkjc[dji"
WYYecfWd_[Z Xo W m[bb#XWbWdY[Z cWij_YWjeho
\kdYj_ed WdZ [l[d Y^[m_d] fWjj[hd j^[ bWjj[h
X[_d]WYedZ_j_ei_d[gkWded\eh_ie[bWij_YXed[#
_cfbWdj#h[ijehWj_ed Yecfb[n XWi[Z ed ijhWj[]_Y
_cfbWdjfbWY[c[dj WdZ if[YkbWj_edi j^[o ][j je ^[Wh _d j^[i[ e\\_Y[i
È
#OMPLIANCE
J^[ ki[ e\ Wffhefh_Wj[ ikh]_YWb WdZ fheij^[j_Y Wf#
fheWY^[i_iWXWi_Yh[gk_h[c[dje\8E?_cfbWdjebe]o$
F[h^Wfi [l[d ceh[ _cfehjWdj" ^em[l[h" _i j^[
h[gk_h[c[djje[dikh[j^[fWj_[djiÉ]eeZYecfb_WdY[
j^hek]^ekj j^[ Z[iYh_X[Z jh[Wjc[dj ij[fi$ ?j _i
d[Y[iiWho je h[c[cX[h j^Wj fWj_[dji m_j^ i_dki
fheXb[cim_bbj[dZjeYedikbjW][d[hWbfhWYj_j_ed[h
eh ejeh^_debWhod]ebe]_ij \_hij" WdZ j^Wj cWdo e\
j^[cm_bbX[ceh[_cfh[ii[ZXoWdoc_ijWa[dl_[mi
j^Wd Xo j^[ \WYjkWbbo Yehh[Yj [nfbWdWj_edi ]_l[d Xo
m[bb#gkWb_\_[Z8E?_cfbWdjebe]_iji$FWj_[djickijX[
[dYekhW][Zjei[[j^[8E?_cfbWdjebe]_ij\_hij$

#(!04%2È
"ARÈ!TTACHMENTSÈONÈ"/)È)MPLANTS
È
)NDICATIONS
?cfbWdjjh[Wjc[djjeikffehjh[celWXb[h[ijehWj_edi
_i j^[ [nY[fj_ed hWj^[h j^Wd j^[ hkb[ Xkj cWo X[
Z[i_hWXb[_diec[fWj_[dji\ehWdkcX[he\h[Wiedi$
J^[\ebbem_d]\WYjehicWofhecfjj^[Z[dj_ijjejWa[
j^_ihekj[_dif[Y_\_YYWi[i$
v J^[fWj_[djZe[idejh[`[Yjm[Wh_d]WZ[djkh[ekj
e\ ^WdZ$ ?d YWi[i ikY^ Wi j^[i[" j^[ fWj_[dj ckij
[nfh[iibo Yed\_hc ^_i eh ^[h m_bb_d]d[ii je m[Wh
W Z[djkh[$ Dej[ j^Wj j^[i[ YWi[i Wh[ [njh[c[bo
hWh[$8[_d]_d\ehc[Zj^Wjj^[h[_ided[[Zjem[Wh
W Z[djkh[" j^[ lWij cW`eh_jo e\ fWj_[dji m_bb de
bed][h\_dZj^_iefj_edWYY[fjWXb[$
v J^[ fWj_[dj _i kdm_bb_d] je m[Wh Wd [f_j^[i_i
eh W h[ijehWj_ed \[Wjkh_d] f_da fehY[bW_d je
Yecf[diWj[\ehc_ii_d]]_d]_lW"Wbj^ek]^^[^Wi
X[[d _d\ehc[Z j^Wj j^[h[ _i de ej^[h h[WiedWXb[
mWo je h[fbWY[ c_ii_d] ie\j#j_iik[ ijhkYjkh[i Xo
\_n[Zfheij^eZedj_Yi$
v ?cfbWdjjh[Wjc[dj_iedbof[h\ehc[Zjeefj_c_p[
h[j[dj_ed e\ Wd [n_ij_d] Z[djkh[ fWhj_YkbWhbo _d
j^[cWdZ_Xb[$
v J^[ fWj_[dj YWddej W\\ehZ W \_n[Z h[ijehWj_ed$
J^[ iYef[ e\ j^_i _dZ_YWj_ed _i b_c_j[Z" i_dY[ j^[
bWXehWjehoYeije\Wief^_ij_YWj[ZXWhWjjWY^c[dj
\[Wjkh_d] beYai" fh[Y_i_ed WjjWY^c[dji" [jY$ _i
hek]^boedWfWhm_j^j^[Yeije\Wd_d[nf[di_l[
\_n[Z Y[hWc_Y Xh_Z][$ ?d jeZWoÉi Yecf[j_j_l[
cWha[j" j^[ Z[dj_ij _i _d W ]eeZ fei_j_ed je
_d\bk[dY[j^[fh_Y[e\Z[djWbmehaedX[^Wb\e\^_i
eh^[hfWj_[dji$
v 8ed[gkWb_joehgkWdj_jo_dj^[Wdj[h_ehcWdZ_Xb[
Wh[dejWZ[gkWj[\ehYh[ijWb_cfbWdji$
È
#OSTÈ#ONSIDERATIONS
J^[\_hijj^_d]jeYedi_Z[h_ij^Wjj^[dkcX[he\8E?
_cfbWdjih[gk_h[Z\eh_cc[Z_Wj[beWZ_d]_i[ii[dj_Wbbo
j^[iWc["h[]WhZb[iie\m^[j^[hWh[celWXb[eh\_n[Z
h[ijehWj_ed_ijeX[ki[Z$?dj^_ih[]WhZ"8E?_cfbWdji
Z_\\[h i_]d_\_YWdjbo \hec Yh[ijWb _cfbWdji$ 7j b[Wij
 ¬ 
i_n" Xkj fh[\[hWXbo [_]^j" bed] Yh[ijWb _cfbWdji Wh[
h[Yecc[dZ[Z \eh \_n[Z h[ijehWj_edi _d j^[ cWn_bbW1
i_n Yh[ijWb _cfbWdji Wh[ iW_Z je X[ h[gk_h[Z _d j^[
cWdZ_Xb[$
H[celWXb[ cWdZ_XkbWh h[ijehWj_edi d[[Z je X[
ikffehj[Z Xo \ekh Yh[ijWb _cfbWdji _\ _cc[Z_Wj[
beWZ_d] _i _dj[dZ[Z$ ?\ j^[h[ _i W ^[Wb_d] f^Wi[
X[\eh[beWZ_d]"WZ[djkh[YWdWbieX[fbWY[Zededbo
jme Yh[ijWb _cfbWdji \_jj[Z m_j^ XWbb h[jW_d[hi" [l[d
j^ek]^ j^_i WffheWY^ _i iec[m^Wj fheXb[cWj_Y0
\_hijbo" j^[ jejWb WXi[dY[ e\ beWZ_d] _d j^[ ^[Wb_d]
f^Wi[YWddejX[]kWhWdj[[Z1WdZ"i[YedZbo"j^[beii
e\ed[e\j^[i[_cfbWdjimekbZYedij_jkj[Wi[h_eki
Yb_d_YWbi[jXWYa$
8Whi WdZ h[celWXb[ Z[djkh[i ed 8E? Wh[ iec[#
j_c[iYedi_Z[h[Z]eeZiebkj_ediWbie_dj^[cWn_bbW$
J^_icWoWffbo[if[Y_WbbojeYWi[im_j^i[l[h[iW]_jjWb
Z_iYh[fWdY_[i WdZ fWj_[dji m_j^ ademd if[[Y^
fheXb[cim^eZedejmWdjjebei[jed]k[#je#Z[djkh[
YedjWYj$ HWh[bo m_bb W Y^Wd][ _d jh[Wjc[dj fbWdi X[
d[Y[iiWho \eh j^_i h[Wied0 fWj_[dji YWd X[ im_jY^[Z
XWYa\hec\_n[Zh[ijehWj_edijeWXWhWdZWh[celWXb[
Z[djkh[$ ?d ceij YWi[i" fioY^ebe]_YWb fheXb[ci Wh[
j^[kdZ[hbo_d]h[Wied\ehj^_iZ[l[befc[dj$
?dj^[i[YWi[i"j^[ki[e\ceh[j^Wd\ekh_cfbWdji
_ih[Yecc[dZ[Z\ehXWhWjjWY^c[dji_dj^[cWn_bbW"
X[YWki[ beWZi YWddej X[ Yedjhebb[Z Wi m[bb Wi m_j^
\_n[Z Xh_Z][i$ J^[ [dl_hedc[dj X[bem Z[djkh[i _i
eYYbki_l[ WdZ dej \WlekhWXb[ \eh [_j^[h j[[j^ eh
_cfbWdji$ J^[ i[b\#Yb[Wd_d] fhef[hj_[i e\ _cfbWdji
_d Yedd[Yj_ed m_j^ Xh_Z][i WdZ j^[ Z_iiebkj_ed e\
Z[Xh_iWdZ\bk[djiWb_lWm_j^Wf[hcWd[dj[nY^Wd][
e\ b_gk_Zi _i j^[ fh[\[hh[Z [dl_hedc[dj \eh 8E?
_cfbWdji$
?\ ed[ e\ j^[ 8E? _cfbWdji _i _d YedjWYj m_j^
j^[ ef[d cWn_bbWho i_dki" Wdo fh[iikh[ \hec j^[
Z[djkh[ edje j^[ ]_d]_lW ckij X[ ijh_Yjbo Wle_Z[Z$
IkY^ eYYbki_l[ fh[iikh[ c_]^j YWki[ Z[Xh_i" iWb_lW
WdZ XWYj[h_W je X[ jhWdifehj[Z _dje j^[ cWn_bbWho
i_dki Wj W j_c[ m^[d j^[ c[cXhWd[ WdZ j^[ Xedo
fhej[Yj_ed ^Wl[ dej o[j X[[d h[][d[hWj[Z$ 8Wh#
ikffehj[Z Z[djkh[i ckij X[ fbWY[Z YWh[\kbbo WdZ
b[Wl[[dek]^ifWY[\ehW_hWdZb_gk_Zije[iYWf[WdZ
[nY^Wd][$ M^[d[l[h feii_Xb[" m[ Wle_Z cWn_bbWho
XWh h[YedijhkYj_edi" WdZ m[ jho je Yedl_dY[ j^[
fWj_[djjeefj\ehWY^[Wf\_n[ZXh_Z][[$]$8heiWcb[
(-. 9^Wfj[h'/È "ARÈ!TTACHMENTSÈONÈ"/)È)MPLANTS
Xh_Z][i _dij[WZ$ 7\j[h _dijWbb_d] e\ 8E? _cfbWdji"
XWhi WdZ Z[djkh[i" m[ h[Yecc[dZ j^Wj fWj_[dji
jWa[ ekj j^[ Z[djkh[ \eh Wj b[Wij .^ W ZWo je Wbbem
ikffkhWj_edWdZi[b\#Yb[Wd_d]$?cc[Z_Wj[beWZ_d]e\
j^[XWhi_ifeii_Xb["fhel_Z[Z[dek]^_cfbWdji^Wl[
X[[dfbWY[Z$
7 cW`eh h[Wied h[celWXb[ ikf[hijhkYjkh[i Wh[
ki[Z\eh_cfbWdj#ikffehj[ZcWn_bbWhoh[ijehWj_edi_i
j^[jhWZ_j_edWbbo^_]^_dY_Z[dY[e\_cfbWdjbeiim_j^
Yh[ijWb Z[i_]di$ ?d ej^[h mehZi0 _cfbWdji kdZ[h XWh
WjjWY^c[dji YWd X[ h[cel[Z ceh[ [Wi_bo WdZ b[ii
[nf[di_l[bo j^Wd _cfbWdji kdZ[h \_n[Z h[ijehWj_edi$
7i bed] Wi ed[ _cfbWdj _i b[\j" j^[ fWj_[dj m_bb ij_bb
Yedi_Z[hj^_ijeX[Wd_cfbWdj#ikffehj[Zh[ijehWj_ed$
8o YedjhWij" m^[d 8E? _cfbWdji Wh[ ki[Z" \_n[Z
h[ijehWj_ediWh[WbmWoij^[X[jj[hWbj[hdWj_l[X[YWki[
j^[ h_ia e\ _cfbWdj beii _i Yedi_Z[hWXbo icWbb[h _d
j^ei[_cfbWdji$7bie"j^[h[ikbj_d]cWij_YWjeho\ehY[i
cWoX[[Wi_[hjeYedjhebm_j^Xh_Z][i$
Ed j^[ ej^[h ^WdZ" _cc[Z_Wj[ fbWY[c[dj e\ W
XWh d_Y[bo ifb_dji j^[ _cfbWdji _d YWi[i m^[d l[ho
b_jjb[Xed[lebkc[_iWlW_bWXb[$J^[efj_edjeh[cel[
j^[ Z[djkh[ \eh cWdo ^ekhi [l[ho ZWo Wle_Zi Wbb
fej[dj_WbboZ[ijhkYj_l[\ehY[iX[oedZj^[d[Y[iiWho
Y^[m_d] \ehY[i ikY^ Wi Xhkn_ic WdZ Yb[dY^_d] Wj
d_]^jWdZZkh_d]j^[ZWo$
8ej^ _d j^[ cWn_bbW WdZ _d j^[ cWdZ_Xb[" 8E?
_cfbWdj#ikffehj[Z XWh h[ijehWj_ed h[gk_h[i \ekh je
jm[bl[ _cfbWdji _\ j^[ Xed[ ikffbo Wj j^[ ijhWj[]_Y
_cfbWdji fei_j_edi _i ]eeZ Ä WdZ Z[f[dZ_d] ed j^[
jof["beYWj_edWdZifWde\j^[h[ijehWj_ed$?dYb_d_YWb
fhWYj_Y[" \_l[ eh i_n 8E? _cfbWdji Wh[ _di[hj[Z ed
Wl[hW][$ 7bmWoi fbWY[ [dek]^ _cfbWdji _d j^[ \_hij
ef[hWj_edjeWle_Zi[YedZWho_cfbWdjWj_edi[ii_edi1
d[l[hkdZ[h#[gk_fj^[cWn_bbW
J^[ _cfbWdjebe]_YWb XWi_i \eh W 8E?#XWi[Z \_n[Z
h[ijehWj_ed" m^_Y^ _dYbkZ[i j^[ _cfbWdji WdZ j^[
_cfbWdjWj_ed fheY[Zkh[" _i m_j^_d j^[ iWc[ fh_Y[
hWd][WiWd_cfbWdj#ikffehj[Zh[celWXb[h[ijehWj_ed
XWi[ZedYh[ijWb_cfbWdji$?dej^[hmehZi"j^[[njhW
ced[o\ehj^[8E?#XWi[Z\_n[Zh[ijehWj_ed]e[i_dje
j^[ fheij^[j_Y ikf[hijhkYjkh[ WdZ j^[ ^_]^[h jejWb
\[[Y^Wh][ZXoj^[Z[dj_ij$<ehj^[fWj_[dj"m^e][ji
W X[jj[h gkWb_jo e\ b_\[ _d h[jkhd" j^_i _i ced[o m[bb
if[dj$
È
!ESTHETICÈ#ONSIDERATIONS
9ecf[diWj_ed \eh c_ii_d] ie\j#j_iik[ ijhkYjkh[i _i
fWhj_YkbWhbo _cfehjWdj _d j^[ cWn_bbWho Wdj[h_eh
i[]c[dj$ ?\ ikY^ Yecf[diWj_ed YWddej X[ fhel_Z[Z
Xo \_n[Z fheij^eZedj_Yi" j^[ eXl_eki iebkj_ed _i je
_di[hj Wd [f_j^[i_i Wbed] m_j^ j^[ \_n[Z h[ijehWj_ed$
<_n[Z h[ijehWj_edi YWd X[ Z[i_]d[Z ckY^ ceh[
Z[b_YWj[bo j^Wd h[celWXb[ h[ijehWj_edi$ 7domWo" j^[
lWij cW`eh_jo e\ fWj_[dji Wh[ kdYec\ehjWXb[ WXekj
Z[djkh[i WdZ j^[ \[[b_d] e\ ¼Z_iWX_b_jo½ WiieY_Wj[Z
m_j^ m[Wh_d] j^[c$ J^[o l[ho ckY^ fh[\[h j^[
i[Ykh[\[[b_d]e\\_n[Zj[[j^$7XWh[bol_i_Xb[]_d]_lWb
[f_j^[i_iikh[bo_ij^[b[ii[h[l_bm^[dYecfWh[ZjeW
h[celWXb[Z[djkh[$J^[\WXh_YWj_ede\ikY^[f_j^[i[i
_i_d[nf[di_l[j^[i[ZWoi$J^[_hcW_dZ_iWZlWdjW][_i
j^Wjj^[od[[ZjeX[h[fbWY[ZWjb[Wij[l[hoej^[ho[Wh"
Zk[ je m[Wh e\ j^[ ikh\WY[ ijhkYjkh[i WdZ ]hWZkWb
Z_iYebekhWj_ed$ D[l[hj^[b[ii" Wd [f_j^[i_i YWd e\j[d
Wle_Z j^[ d[[Z \eh Wd WZZ_j_edWb Xh_Z][$ EdY[ j^[
ckYeiWb im[bb_d] ^Wi X[[d h[iebl[Z" j^[o YWd X[
h[fbWY[Z je _cfhel[ if[[Y^$ 7[ij^[j_YWbbo" j^[o Wh[
X[d[\_Y_Wb Xo Yel[h_d] j^[ ]Wfi X[jm[[d j[[j^ WdZ
h[bWj[Z ckYeiW" WdZ j^[o YWd X[ kj_b_p[Z je WZ`kij
jeej^b[d]j^$
?d j^[ cWdZ_Xb[" ikY^ W[ij^[j_Y WdZ f^ed[j_Y
fheXb[ciWh[XWi_YWbbo_hh[b[lWdj$Jh[Wjc[djfbWdd_d]
\eh cWdZ_XkbWh h[ijehWj_edi m_bb j^[h[\eh[ \eYki ed
cWij_YWjeho WdZ ie\j#j_iik[ h[gk_h[c[dji" Wi m[bb
Wiedj^[h[gk_h[c[dje\]eeZWYY[ii_X_b_jo\ehehWb
^o]_[d[$
È
)MPLANTÈ0OSITIONINGÈFORÈ"ARÈ!TTACHMENTSÈ
6ERSUSÈ&IXEDÈ"RIDGES
8Wi[Z ed ekh Yb_d_YWb [nf[h_[dY[" m[ Wh[ jeZWo
Yed\_Z[dj j^Wj XWh h[ijehWj_edi ikffehj[Z Xo
W YecX_dWj_ed e\ 8E? WdZ iYh[m _cfbWdji Wh[ W
l[ho h[b_WXb[ jh[Wjc[dj ceZWb_jo$ J^[ efj_ed e\
WZZ_d] i_d]b[#kd_j iYh[m _cfbWdji mekbZ ik]][ij
_ji[b\ _d Wh[Wi m_j^ _djWYj ^[Wb[Z ckYeiW eh _\
ijhkYjkh[i_dlebl_d]ZekXb[#Z_ia8E?_cfbWdjid[[Z
je X[ ijWX_b_p[Z W]W_dij hejWj_ed$ 7dej^[h efj_ed
_d j^_i i_jkWj_ed mekbZ X[ je ki[ i_d]b[#Z_ia 8E?
Z[i_]dim^ei[_cfbWdj^[WZ\ehciWh_]_Z"WdZ^[dY[
ded#hejWj_edWb" [dj_jo m_j^ j^[ j^h[WZ[Z f_d$ 7d
WZZ_j_edWb iYh[m _cfbWdj cWo Wbie X[ kdd[Y[iiWho
m^[diYh[m[Zikf[hijhkYjkh[iXWi[Zed?:"?:Eeh
?:EJ_cfbWdjiWh[ki[Z$
I_dY[ j^[ cWdZ_XkbWh Wdj[h_eh i[]c[dj _i ^_]^bo
h[i_ijWdjjeXed[h[iehfj_ed_dl_hjkWbboWbbfWj_[dji"
_cfbWdj beii _i [njh[c[bo hWh[ _d j^_i Wh[W$ 7bie"
j^[ Z[Y_i_ed je _di[hj W XWh#ikffehj[Z h[celWXb[
Z[djkh[ _i dej _hh[l[hi_Xb[" Wi Z_ijWb _cfbWdji je
ikffehjW\_n[ZXh_Z][YWdX[WZZ[ZWjWdoj_c[$Ekh
][d[hWbfeb_Yo_ije_di[hj\ekh_cfbWdji"iej^Wjj^[
h[ijehWj_edYWdX[_cc[Z_Wj[bobeWZ[Z$
J^[i_jkWj_ed_dj^[cWn_bbW_iZ_\\[h[dj$?\_cfbWdj
fbWY[c[dj _i Yed\_d[Z je j^[ cWn_bbWho Wdj[h_eh
i[]c[dj m^_Y^ _i j^[ ijWdZWhZ WffheWY^ m_j^
Yh[ijWb _cfbWdji" j^[i[ _cfbWdji mekbZ ^Wl[ je X[
_di[hj[Z YWd_d[#je#YWd_d[$ ?\ j^[ fWj_[dj _i ]e_d]
je h[gk[ij W \_n[Z h[ijehWj_ed bWj[h ed" j^[ Z[djWb
j[Y^d_Y_Wd m_bb dej ^Wl[ jee cWdo efj_edi b[\j je
È È 5PGRADINGÈ-ANDIBULARÈ"ARÈ2ESTORATIONSÈ
¼cel[½j^[h[ijehWj_ed\ehmWhZjec[[jW[ij^[j_Yeh
f^ed[j_Yd[[Zi"i_dY[j^[_cfbWdj[c[h][dY[fe_dji"
WdZ^[dY[j^[_cfbWdj#h[ijehWj_ed_dj[h\WY[i"m_bbX[
beYWj[Z_dWdkdZ[i_h[Z"el[hbofWbWjWbfei_j_ed$
Edj^[ej^[h^WdZ"_\j^[_cfbWdjiWh[dejfbWY[Z
_dj^[Wh[We\j^[\ekh_dY_iehi"j^[edboikXi[gk[dj
d[[Z \eh _cfbWdji" Zk[ je [nfWdi_ed e\ j^[ i_dki"
j[dZijeX[_dj^[Wh[We\j^[i[YedZcebWhi$?dj^_i
i_jkWj_ed" j^[ efj_ed \eh j^[ Z[djWb j[Y^d_Y_Wd je
cel[j^[Wdj[h_ehXh_Z][\ehmWhZh[cW_di_djWYj"Wi
j^[ ifWY[ \eh j^_i cWde[klh[ _i dej b_c_j[Z Xo j^[
fWbWjWb fei_j_ed e\ Wdo Wdj[h_eh _cfbWdj [c[h][dY[
fe_dji$
M[ Yedi_Z[h 8E? _cfbWdji je X[ _dZ_YWj[Z
[if[Y_Wbbo _d YWi[i m^[h[ j^[ h[cW_d_d] YWd_d[i
^Wl[ je X[ [njhWYj[Z WdZ j^[ cWdZ_XkbWh Z[djkh[
h[Z[i_]d[Z Wi W Yecfb[j[ Z[djkh[$ J^[i[ fWj_[dji
Wh[ikZZ[dbo\WY[Zm_j^Wl[hokdfb[Wi_d]i_jkWj_ed"
X[YWki[ j^[_h Z[djkh[ Ze[i dej dehcWbbo h[cW_d _d
fbWY[Wdobed][h$?dj^_ii_jkWj_ed"jmefioY^ebe]_YWb
\WYjehi Yec[ _dje fbWo0 \_hijbo" j^[ fWj_[dj d[[Zi
h[WiikhWdY[ j^Wj Wd _cfhel[c[dj _i feii_Xb[1 WdZ
i[YedZbo"^_ieh^[hm_bb_d]d[iijeif[dZced[oed
_cfbWdji_igk_j[Yedi_Z[hWXb[Wjj^_ife_dj$
?jjWa[iiec[fWj_[djij^[[nf[h_[dY[e\^Wl_d]je
b_l[m_j^Wfeehboh[jW_d[ZZ[djkh[X[\eh[j^[om_bb
Yedi_Z[h_cfbWdjjh[Wjc[dj$CeijfWj_[dji"^em[l[h"
Wh[ WmWh[ j^Wj j^[o YWddej [nf[Yj je X[ WXb[ je
m[Wh Wd WYY[fjWXbo h[jW_d[Z Z[djkh[ edY[ j^[ bWij
h[cW_d_d]YWd_d[_i]ed[$J^[i[fWj_[djim_bbh[gk[ij
jeX[_cc[Z_Wj[bojh[Wj[Zm_j^_cfbWdjiWdomWo$
M^[d j^[ _iik[ e\ feijef[hWj_l[ fW_d _i Wbie
\WYjeh[Z_d"_jX[Yec[iYb[Whj^Wj_cc[Z_Wj[_cfbWd#
jWj_ed Zkh_d] j^[ [njhWYj_ed fheY[Zkh[ _i j^[ ceij
[\\_Y_[dj WffheWY^$ ;njhWYj_ed e\ j^[ bWij h[cW_d_d]
YWd_d[WdZh[celWbe\j^[]hWdkbWj_edj_iik[m^_Y^
_i e\j[d [nj[di_l[ m_bb kikWbbo b[Wl[ X[^_dZ W ^k][
YhWj[h$ J^[ edbo h[WiedWXb[ j^[hWfo j^Wj YWd X[
_cc[Z_Wj[boWZc_d_ij[h[Z_dj^_ii_jkWj_ed_ijefbWY[
W8E?_cfbWdj$
J^[ ¼KpdWY^ iYh[m½ Z[l[bef[Z Xo :h$ 7be_i
7hgk_dj_dj^['/-&imWiWj[Y^d_gk[j^Wjh[gk_h[Zde
Yekdj[h#iYh[m_d]$?jmWiXWi[ZedWbed]c[ZkbbWho
iYh[m _di[hj[Z _dje j^[ cWdZ_Xb[ \hec W YWkZWb
Z_h[Yj_ed$ J^[ m[Wa fe_dj e\ j^_i Z[i_]d mWi j^[
Yedj_dkekij^h[WZki[ZXoj^[cWdk\WYjkh[h"m^_Y^
mWi ikiY[fj_Xb[ je XWYj[h_Wb WYYkckbWj_ed el[h j^[
o[Whi" iec[j_c[i ]_l_d] h_i[ je fhe]h[ii_l[ f[h_#
_cfbWdj_j_i _d W YWkZWb Z_h[Yj_ed m_j^ j^[ feii_Xb[
Yedi[gk[dY[e\eij[eboi_i$J^[fWdehWc_YhWZ_e]hWf^
_d <_]$'/$'& X[bem _bbkijhWj[i W YWi[ _d m^_Y^ j^[
KpdWY^iYh[mmWiki[ZjeikffehjWXWhWjjWY^c[dj$
J^_i\[cWb[fWj_[djfh[i[dj[ZWjekhe\\_Y[X[YWki[e\
f[hi_ij[djikffkhWj_ed_dj^[Y^_dWh[WW\j[hi^[^WZ
mehd j^[ ijhkYjkh[ \eh WXekj (&o[Whi$ 9edi_Z[h_d]
j^[ b_\[ifWd e\ j^_i h[ijehWj_ed" _j _i \W_h je iWo j^Wj
j^[ _cfbWdjebe]_YWb WdZ fheij^[j_Y ekjYec[ e\ j^[
(-/
eh_]_dWbfheY[Zkh[^WZX[[d[nY[[Z_d]boikYY[ii\kb$
J^[ _cfbWdj h[fbWY_d] jeej^ )) ^WZ je X[ h[cel[Z
Zk[ je h[Ykhh[dj \_ijkbWj_ed _d j^[ Y^_d Wh[W$ J^h[[
8E? _cfbWdji m[h[ fbWY[Z _d j^[ iWc[ i[ii_ed$
BWj[h j^Wj ZWo" j^[ ebZ Z[djkh[ mWi Yedd[Yj[Z je
j^[ _cfbWdji l_W W XWh WjjWY^c[dj$ IkXi[gk[djbo"
m^[d j^[ XWXo \_d][h#i_p[Z Z[\[Yji ^WZ Ybei[Z" Wd
WZZ_j_edWb iYh[m _cfbWdj mWi _di[hj[Z j^hek]^ W
c_d_cWbbo _dlWi_l[ jhWdickYeiWb hekj[ je fhej[Yj
j^[ ijhkYjkh[ W]W_dij hejWj_ed$ M_j^ j^_i WZZ_j_edWb
_cfbWdj"j^[j^h[[8E?_cfbWdji[l[djkWbboeXjW_d[Z
j^[_hZ[\_d_j_l[ijWX_b_jo$
È
)MPLANTÈ3ELECTIONÈFORÈ"ARÈ2ESTORATIONS
M^[d[l[h j^[ Xed[ lebkc[ _d j^[ cWdZ_XkbWh
Wdj[h_eh i[]c[dj _i WZ[gkWj[ \eh Yh[ijWb _cfbWdji"
j^[ i_cfb[ij WffheWY^ _i je WYjkWbbo ki[ Yh[ijWb
_cfbWdji$;l[diYh[m_cfbWdjij^WjmekbZi[[cjeX[
kd\WlekhWXb[ \hec W X_ec[Y^Wd_YWb ijWdZfe_dj Wh[
f[h\[Yjbo i[hl_Y[WXb[ _d j^_i i_jkWj_ed" WdZ j^[o Wh[
i_cfb[hje_dijWbb$8E?_cfbWdji"XoYedjhWij"i^ekbZ
X[Yedi_Z[h[Z_\Xed[h[iehfj_ed_ifh[i[djdejWXbo
_dj^[YWd_d[Wh[Weh_\WbbWdj[h_ehj[[j^d[[ZjeX[
[njhWYj[Z$ J^[i[ i_jkWj_edi Wh[ Yeccedbo eXi[hl[Z
m^[d[l[hh[i_ZkWbYWd_d[ii^emikXijWdj_WbceX_b_jo
WdZf[h_eZedjWb_dlebl[c[djW\j[h^Wl_d]ikffehj[Z
h[celWXb[h[ijehWj_edi$
È
5PGRADINGÈ-ANDIBULARÈ"ARÈ2ESTORATIONS
FWj_[dji m^ei[ cWdZ_XkbWh Wdj[h_eh i[]c[dj ^Wi
X[[d ikYY[ii\kbbo jh[Wj[Z m_j^ W XWh#ikffehj[Z
h[celWXb[ Z[djkh[ m_bb \h[gk[djbo Yec[ XWYa
h[gk[ij_d] WZZ_j_edWb _cfbWdj jh[Wjc[dj _d j^[
feij[h_ehi[]c[djWdZ\_n[ZXh_Z][i$J^[oWh[dejWi
W\hW_Ze\_cfbWdjiWdZ_cfbWdjikh][hoWij^[oki[Z
je X[" WdZ j^[o adem \hec [nf[h_[dY[ j^Wj _cfbWdj
jh[Wjc[djmehai\ehj^[c$FWj_[dji]h[WjboWffh[Y_Wj[
j^[ _cfhel[Z gkWb_jo e\ b_\[ i^ehjbo W\j[h _cfbWdj
jh[Wjc[dj WdZ Wh[ j^[h[\eh[ m_bb_d] je [dZkh[ j^[
fW_dWdZ[nf[dZ_jkh[e\\khj^[hjh[Wjc[dj$7bie"j^[
_d_j_Wb _dl[ijc[dj m_bb de bed][h X[ \[bj W\j[h iec[
j_c[$
8E?_cfbWdjiYecX_d[m[bbm_j^Yh[ijWb_cfbWdji
fbWY[Z _d j^[ Wdj[h_eh i[]c[dj$ ?d ekh [nf[h_[dY["
i_ckbjWd[eki _cc[Z_Wj[ beWZ_d] e\ ikY^ YecX_d[Z
ijhkYjkh[iYWd"^em[l[h"edboX[h[Yecc[dZ[Z_\j^[
Z[i_]diki[Z_dj^[Wdj[h_ehi[]c[djm_bbWbbemj^[i[
_cfbWdji je X[ WdY^eh[Z _d Yehj_YWb Xed[ Wi m[bb$
Iec[ki[hi[cfbeoX_Yehj_YWbiYh[miEhWbjhed_Yi_d
j^_ii_jkWj_ed$IcWbb[h#Z_Wc[j[hAEIiYh[mii^ekbZ
(.& 9^Wfj[h'/È "ARÈ!TTACHMENTSÈONÈ"/)È)MPLANTS

9Wi[IjkZ_[i*
&IGÈÈA Fh[ef[hWj_l[
hWZ_e]hWf^$ B 7\j[hj^[
]hWdkbWj_edj_iik[WdZWbbded#
_dj[]hWj[Z_cfbWdji[]c[dji
^WZX[[dh[cel[Z"[njh[c[bo
bWh][YhWj[hih[cW_d[Z_dj^[
cWdZ_Xb[$D[l[hj^[b[ii"j^h[[
8E?_cfbWdjiYekbZX[_di[hj[Z
h_]^jWmWo$Fh_cWhoijWX_b_jomWi
_cc[Z_Wj[boWY^_[l[Z$ C 7\j[h
j^[Z[\[Yji^WZ^[Wb[Z"WiYh[m
_cfbWdjmWi_di[hj[Z$8ed[
h[iehfj_ed_dj^[Wdj[h_eh
i[]c[djmWib_a[bojeeYYkh
WiW\kdYj_ede\cWdZ_XkbWh
h[ceZ[bb_d]_dWYYehZWdY[m_j^
A j^[d[m\kdYj_edWbeh_[djWj_ed
WdZj^[^[Wb_d]fej[dj_Wbe\j^[
h[i_ZkWbXed[$J^[j^h[WZ[ZfWhj
e\j^[iYh[m_cfbWdj_iiec[m^Wj
[nfei[Z\ehj^_ih[Wied$F[h_#
_cfbWdj_j_i_idejj^[YWki[\eh
j^_i[nfeikh["i_dY[j^[Xed[
ijhkYjkh[^WhXekh_d]j^[_cfbWdj
_iYedl[n_dYh[ijWbZ_h[Yj_ed"
m^[h[WiXed[beiiWiieY_Wj[Z
m_j^f[h_#_cfbWdj_j_imekbZ
X[Y^WhWYj[h_p[ZXoWjhWo#
b_a[YedYWl[YebbWfi[i[[Wbie
9^Wfj[h/$($M_j^8E?_cfbWdji"
_jZe[idejcWjj[hm^[j^[hWdZ
jem^Wj[nj[djj^[j^h[WZ[Zf_d
_il[hj_YWbboWdY^eh[ZÆ_di_Z[j^[
Xed[Ç

C
È È 5PGRADINGÈ-ANDIBULARÈ"ARÈ2ESTORATIONSÈ (.'

A D

B E

&IGÈÈ A H[i_ZkWb Z[dj_j_ed _d j^[ Wdj[h_eh cWdZ_Xb[$ 8ej^ YWd_d[i WdZ j^[ \_hij fh[cebWh ed j^[ b[\j m[h[ ^_]^bo
ceX_b[$ B J^[ i_jkWj_ed mWi Zk[ je W h[celWXb[ YbWif Z[djkh[ j^Wj ^WZ X[[d mehd m_j^ekj [deiiWb ikffehj _d j^[ Z_ijWb
Wh[W$ C <ebbem_d][njhWYj_ede\jeej^*)"m^_Y^b[\jWd_cfh[ii_l[bobWh][Xed[Z[\[Yj"Wd;:-=._cfbWdjmWiX_Yehj_YWbbo
_di[hj[Z_dj^[XWiWbcWdZ_XkbWhi[]c[dj$7ZekXb[#ehjh_fb[#Z_ia8E?_cfbWdj"_di[hj[Z_djej^[Z_ijec[Z_WbXed[mWbbi"mekbZ
^Wl[X[[dWdefj_edWim[bb$J^[ki[e\8E?_cfbWdji_dj^_ii_jkWj_ed_iijh_YjboYed\_d[ZjeZ[i_]di\[Wjkh_d]Wiceej^ikh\WY[
e\j^[j^h[WZ[Zf_d$ D 9h[ijWb_cfbWdjiYWdX[_di[hj[Z_dj^[Wdj[h_ehi[]c[dj$?dj^_iif[Y_\_YYWi["m[ki[ZYecfh[ii_ed
iYh[mie\j^[AEIjof["m^_Y^m[h[_di[hj[Z_dWjhWdi]_d]_lWbWffheWY^$ E <ebbem_d][njhWYj_ede\j[[j^))WdZ)*"Wl[hj_YWb
eij[ejeco\ehW8E?_cfbWdjmWif[h\ehc[Z$ F J^[eij[ejeco_iWZlWdY[Zjej^[Y[djh[e\j^[cWdZ_Xb[$
(.( 9^Wfj[h'/È "ARÈ!TTACHMENTSÈONÈ"/)È)MPLANTS

G K

H L

I M

J
N

&IGÈÈG 7\j[hf[h\ehc_d]j^[^eh_pedjWbeij[ejec_[i"j^[ZekXb[#Z_ia8E?_cfbWdj_i_di[hj[Z\hecj^[bWj[hWbWif[Yjki_d]
][djb[ ^Wcc[h#ijob[ ijhea[i$ H ?j _i _cfehjWdj j^Wj j^[ b_d]kWb Yehj_YWb Xed[ _i WYjkWbbo h[WY^[Z$ J^[ fei_j_ed e\ j^_i 8E?
_cfbWdjmWi_Z[Wb;::I/%-=-$ I J^[_cfbWdjWj_edfheY[Zkh[mWi_cc[Z_Wj[bo\ebbem[ZXomekdZYbeikh[WdZ_cfh[ii_ed#
jWa_d]$ J I_b_Yed[ _cfh[ii_ed m_j^ h[i_d WdWbe]k[i h[Z 3 ?7*1 ]h[o 3 ?7+$ K J^[ XWh WjjWY^c[dj _i mWn[Z kf XWi[Z ed
fh[#\ehc[ZYWij_d]iXkjjedi3F7I81h[Z3F7*1]h[o3F7+$7\j[h\WXh_YWj_d]j^[XWh"j^[iWc[ceZ[b_iki[Zjeh[b_d[j^[
Z[djkh[$ L J^[XWhWjjWY^c[djYWdX[Y[c[dj[ZWdZj^[Z[djkh[_di[hj[Zedj^[iWc[ZWo$ M <ebbem#kfWj,cedj^i$ N ?d
j^_iif[Y_\_YYWi["j^h[[XWbbh[jW_d[him[h[ki[Z$J^[c_ZZb[h[jW_d[hh[cW_di[cfjoZkh_d]j^[^[Wb_d]f^Wi[$
È È 5PGRADINGÈ-ANDIBULARÈ"ARÈ2ESTORATIONSÈ (.)

&IGÈÈO Fh[ef[hWj_l[
EF=$ P Feijef[hWj_l[EF=
m_j^cWdZ_XkbWhXWhWjjWY^c[dj
_di[hj[Z$ Q EF=Wjj^['(#
cedj^\ebbem#kf$C[Wdm^_b["W
\_n[Zh[ijehWj_ed^WZX[[dfbWY[Z
_dj^[cWn_bbWWim[bb

Q
(.* 9^Wfj[h'/È "ARÈ!TTACHMENTSÈONÈ"/)È)MPLANTS

&IGÈÈA J^_ifh[ef[hWj_l[
EF=i^emij^WjWc_]hWj[Z
\_hijfh[cebWh_ibeYWj[Z
eXb_gk[bo_dj^[_cfbWdjWj_ed
Wh[W$ B D[l[hj^[b[ii"Wed[#ij[f
WffheWY^jeikh]_YWbh[celWb
WdZ_cfbWdjWj_edmWiij_bb
feii_Xb[$J^[_cfbWdji_j[im[h[
YWh[\kbboi[b[Yj[Zje[dikh[Wd
[l[dWdZXWbWdY[ZXed[b[l[b
\ehWbb_cfbWdji$J^[AEIiYh[m
h[fbWY_d]jeej^)*mWi_di[hj[Z_d
WicWbbh[i_ZkWbh_Z][ijhkYjkh[
d[njjej^[heejWh[W$J^[8E?
_cfbWdjmWiZ_W]edWbbo_di[hj[Z
A
WYheiij^[\ehc[hYhemdWh[W_d
WdWdj[hec[i_WbZ_h[Yj_ed$ C 8o
j^[j_c[e\j^[)#o[Wh\ebbem#
kf"WXWbWdY[ZXed[b[l[bmWi
fh[i[djWhekdZWbb_cfbWdji$J^[
[njhWYj_edWh[WmWiedY[W]W_d
\_bb[Zm_j^Xed[$;dek]^l[hj_YWb
Xed[]hemj^^WZjWa[dfbWY[
Wbed]j^[8E?_cfbWdjjemWhZi
j^[Yh[ijje[\\[Yj_l[boYbei[j^[
Z[\[Yj$DeWk]c[djWj_edmWi
h[gk_h[Z

C
È È 5PGRADINGÈ-ANDIBULARÈ"ARÈ2ESTORATIONSÈ (.+

&IGÈ J^h[[#o[Wh\ebbem#kf
e\WXWhWjjWY^c[djikffehj[Z
Xo\ekh8E?_cfbWdji$I_no[Whi
\ebbem#kffWdehWc_Yf_Yjkh[

&IGÈÈA Fh[ef[hWj_l[
fWdehWc_Yl_[m$ B 7\j[h
[njhWYj_ed"_cc[Z_Wj[
_cfbWdjWj_edWdZfbWY[c[dje\
WY[c[dj[ZXWhm_j^YWijXWbb
WjjWY^c[dji$7jb[Wijed[ceh[
iYh[m_cfbWdjckijX[fbWY[Z
W\j[hj^[_d_j_Wb^[Wb_d]f[h_eZ$

B
(., 9^Wfj[h'/È "ARÈ!TTACHMENTSÈONÈ"/)È)MPLANTS
dej X[ ki[Z kdb[ii j^[o Wh[ \_hcbo eii[e_dj[]hWj[Z
Xo j^Wj j_c[" i_dY[ j^[_h WdY^ehW][ cWo dej h[i_ij
j^[ \b[nkhWb \ehY[i e\ j^[ cWdZ_Xb[$ H[ijehWj_edi
ikffehj[ZXo\ekhiYh[m_cfbWdjiWdZjmeZ_ijWb8E?
_cfbWdji Wh[ h[bWj_l[bo i_cfb[ je h[Wb_p[ WdZ e\\[h W
]eeZfhe]dei_i$
Ed[ _cfehjWdj Wif[Yj je Yedi_Z[h _i j^Wj j^[
j^h[WZ[Z f_di e\ j^[ Z_ijWb 8E? _cfbWdji ckij X[
WZ[gkWj[bobed]X[YWki[W\kbb#WhY^Xh_Z][m_bbb_c_j
j^[ \b[nkhWb cel[c[dji e\ j^[ cWdZ_Xb[ WdZ j^[
Yh[ijWb Xed[ _i b_a[bo je ]hem edY[ j^[ Z[djkh[ ^Wi
X[[dh[cel[Zi[[9^Wfj[h/$)$
9Wi[i ikY^ Wi j^[i[ Wh[ hWh[ _d ekh fhWYj_Y[
X[YWki[ m[ ^Wl[ WbmWoi X[[d _d W fei_j_ed je e\\[h
\_n[Z fheij^eZedj_Y iebkj_edi Wi Wd Wbj[hdWj_l[ je
h[celWXb[ Z[djkh[i$ Kf]hWZ_d] je \_n[Z Xh_Z][i _i"
^em[l[h"Wd_cfehjWdjjef_Y\ehWbbj^ei[Z[dj_ijim^e
^Wl[ _di[hj[Z dkc[heki XWh#ikffehj[Z h[celWXb[
h[ijehWj_ediel[hj^[o[WhiX[YWki[j^[oZ_Zdej^Wl[
WYY[iije8E?j[Y^debe]o$Kf]hWZ_d]jeXh_Z][iYWd
Yedi_Z[hWXbohW_i[j^[_dYec[e\j^[i[Z[dj_iji"WdZ
j^[_hfWj_[djim_bb\_dWbboX[WXb[je[d`eoW¼Z[djkh[#
\h[[½b_\[

#(!04%2È
!ESTHETICS
È
)NTRODUCTION
?d i_jkWj_edi e\ WZlWdY[Z Xed[ h[iehfj_ed" _j _i
d[Y[iiWho je Z_iYkii m_j^ j^[ fWj_[dj m^[j^[h j^[
jh[Wjc[dj i^ekbZ Yedi_ij ieb[bo e\ h[fbWY_d] j^[
c_ii_d]j[[j^ehm^[j^[hWZZ_j_edWbc[Wikh[ii^ekbZ
X[jWa[djeYecf[diWj[\ehj^[c_ii_d]Xed[lebkc[
Wbed] j^[ h_Z][$ IkY^ Wk]c[djWj_l[ j[Y^d_gk[i Wh[
[nf[di_l[ WdZ j_c[#Yedikc_d]$ J^[ if[Yjhkc e\
Wffb_YWXb[ j[Y^d_gk[i hWd][i \hec h[bWj_l[bo i_cfb[
fheY[Zkh[i XWi[Z ed [njhWd[eki ]hW\j_d] cWj[h_Wbi
kfje[nj[di_l[ikh]_YWbfhejeYebi_dm^_Y^Wkjebe]eki
Xed[ _i ^Whl[ij[Z \hec j^[ ^_f _b_WY Xed[ eh
YhWd_kcfWh_[jWbXed[$Eii[eZ_ijhWYj_ed_iWdej^[h
j[Y^d_gk[jeceZ_\oj^[i^Wf[e\Xed[ijhkYjkh[i$
FWj_[dji" ^em[l[h" Ze dej kikWbbo i[[ Wd _cfbWd#
jebe]_ijX[YWki[j^[oWh[mehh_[ZWXekjj^[lebkc[
e\ j^[_h ]_d]_lWb eh Xed[ ijhkYjkh[i$ J^[_h \_hij WdZ
\eh[ceijZ[i_h[_ije^Wl[\_n[Zj[[j^j^WjWh[iW\[bo
WdY^eh[ZWdZe\\[hWYY[fjWXb[W[ij^[j_Yi$J^[fWj_[dj
i^ekbZ ded[j^[b[ii X[ _d\ehc[Z j^Wj j^[ efj_ed e\
Xed[ ]hW\j_d] WdZ ie\j#j_iik[ Wk]c[djWj_ed Ze[i
[n_ij$ 7j j^[ iWc[ j_c[" j^[ \ebbem_d] c_d_cWbbo
_dlWi_l[Wbj[hdWj_l[ii^ekbZX[Z_iYkii[ZWim[bb0
v ?dcWdoYWi[i"_jedbojWa[iWib_]^j[bed]Wj_ede\
j^[l_i_Xb[Yhemdi[]c[djijeWY^_[l[iWj_i\WYjeho
W[ij^[j_YiWdZYh[Wj[j^[_bbki_ede\dWjkhWbj[[j^$
v F_da Y[hWc_Yi YWd X[ ki[Z je Yecf[diWj[ \eh
c_ii_d]]_d]_lW"fhel_Z[Zj^WjWZ[gkWj[h[bWj_edi
X[jm[[d j^[ ie\j WdZ ^WhZ j_iik[ ijhkYjkh[i Wh[
WlW_bWXb[$
v ;f_j^[i[i i^ekbZ X[ Yedi_Z[h[Z Wi m[bb FebbWYa
(&&'$J^[i[Z[l_Y[i[dWXb[j^[Z[dj_ijjeefj_c_p[
jeej^ b[d]j^ [l[d _d fWj_[dji m_j^ W ^_]^ ic_b[
b_d["WdZj^[oe\\[h]eeZikffehj\ehj^[ie\j#j_iik[
ijhkYjkh[i$;f_j^[i[iYWdX[h[cel[ZjeYb[Wdj^[
fheij^[j_Y ijhkYjkh[" WdZ j^[o Wh[ fWhj_YkbWhbo
ki[\kb_d][h_Wjh_Y_cfbWdjebe]o$?dekh[nf[h_[dY["
ebZ[h fWj_[dji j[dZ je m[Wh j^[_h [f_j^[i[i
_dYh[Wi_d]bo b[ii \h[gk[djbo el[h j^[ o[Whi" [l[d
j^ek]^ j^_i cWo Yecfhec_i[ W[ij^[j_Yi$ EbZ[h
fWj_[dji j[dZ je mehho b[ii WXekj W[ij^[j_Yi Xkj
_dYh[Wi_d]boYedj[djj^[ci[bl[im_j^^Wl_d]\_n[Z
j[[j^WdZj^[_hdehcWbY^[m_d]\kdYj_edh[ijeh[Z$
 ¬ 
FWj_[dj Yekdi[bb_d] i^ekbZ Wbie Z[Wb m_j^ j^[
_iik[ m^[j^[h j^[ fWj_[dj _i m_bb_d] eh" \eh j^Wj
cWjj[h" WXb[ je ^Wl[ Wdo _dlWi_l[ fheY[Zkh[i \eh
¼h[ZW[ij^[j_Yi½f[h\ehc[Z$7k]c[djWj_l[jh[Wjc[dj
ceZWb_j_[ikikWbbo_dlebl[[nj[dZ[Zf[h_eZie\j_c[
Zkh_d] m^_Y^ j^[ fWj_[dj _i dej Wbbem[Z je m[Wh
Wdo h[ijehWj_ed m^Wjie[l[h$ ?d ekh [nf[h_[dY[" j^_i
h[gk_h[c[dj _i ekj e\ j^[ gk[ij_ed \eh j^[ lWij
cW`eh_joe\fWj_[djiWdomWo$7bie"j^[Yeijie\j^[i[
WZ`klWdj fheY[Zkh[i _dYbkZ_d] ^eif_jWb_pWj_ed WdZ
WdW[ij^[i_W Wh[ [nY[ii_l[ YecfWh[Z je j^[ Yeiji
e\ _cfbWdjWj_ed WdZ h[ijehWj_l[ jh[Wjc[dj Wi ikY^$
J^[h[\eh[" j^[ lWij cW`eh_jo e\ fWj_[dji m_bb dej X[
WXb[jeW\\ehZj^[c$;nj[di_l[fheY[Zkh[i_dm^_Y^j^[
fWj_[dj_idejWbbem[Zjem[WhWdojof[e\h[ijehWj_ed
\eh[nj[dZ[Z_dj[hlWbiWh[[nY[[Z_d]boXkhZ[diec[$
Mec[d_dfWhj_YkbWhj[dZjeX[WXiebkj[boh[bkYjWdj
je X[ i[[d m_j^ekj j[[j^$ <khj^[hceh[" ]hW\j_d]
fheY[Zkh[i WbmWoi YWhho j^[ h_ia e\ WZl[hi[ [\\[Yji
Wj j^[ Zedeh i_j[" m^_Y^ _i dej je X[ _]deh[Z [_j^[h$
7bbj^_d]iYedi_Z[h[Z"icWhjfWj_[djim^e^Wl[X[[d
Yecfh[^[di_l[bo _d\ehc[Z m_bb WbmWoi efj \eh j^[
c_d_cWbbo_dlWi_l[fheY[Zkh[WdZ\ehj^[j[Y^debe]o
j^Wj m_bb Xh_d] WXekj j^[ Z[i_h[Z ekjYec[ Wi ieed
Wi feii_Xb[$ J^[h[\eh[" j^[ fh[\[hh[Z WffheWY^ m_bb
dehcWbbo_dlebl[j^[ki[e\8E?_cfbWdjikdb[iij^[h[
Wh[WdoYecf[bb_d]h[Wiedijef[h\ehcWk]c[djWj_ed"
Xed[]hW\j_d]eheii[eZ_ijhWYj_edW\j[hWbb[$]$Wjj^[
fWj_[djÉi _di_ij[dY[$ IYh[m _cfbWdji cWo Wbie X[
Wffb_YWXb[ _\ j^[ l[hj_YWb Xed[ lebkc[ _i WZ[gkWj[
WdZ[WhbobeWZ_d]feii_Xb[$
Kd\ehjkdWj[bo" ceij Z[djWb bWXehWjeh_[i Wh[ dej
m[bbl[hi[Z_d\WXh_YWj_d][f_j^[i[i$J[Y^d_Y_Wdim_j^
j^_iWX_b_joWh[^WhZjeYec[Xo"m^_Y^cWoX[ed[e\
j^[h[Wiedim^oj^_ij[Y^d_gk[_idejjWk]^jWjceij
kd_l[hi_j_[i$
Ed[ i^ekbZ Wbie Yedi_Z[h j^Wj d[mbo _dj[]hWj[Z
\_n[Z h[ijehWj_edi YWd Y^Wd][ j^[ i[b\#_cW][ e\
fWj_[djiiehWZ_YWbboj^Wjiec[e\j^[ccWoZ[i_h[je
^Wl[ ceh[ [nj[di_l[ W[ij^[j_Y _cfhel[c[dji cWZ[
Zemd j^[ heWZ$ M^_b[ dej fWhj_YkbWhbo Yecced
_d Z[dj_ijho" j^_i _i W m[bb#ademd f^[dec[ded _d
Yeic[j_Yikh][ho$EdY[j^[\_hijYeic[j_YfheY[Zkh[
^Wi X[[d f[h\ehc[Z" j^[ fWj_[djÉi Z[cWdZi m_bb
h_i[ \khj^[h$ J^[i[ fWj_[dji d[l[h \W_b je \_dZ d[m
Z[\[Yji j^Wj d[[Z _cfhel[c[dj$ J^[o m_bb kdZ[h]e
(.. 9^Wfj[h(&È !ESTHETICS
b_feikYj_ed e\ j^[ WXZec[d" \ebbem[Z Xo W \WY[b_\j"
h[ZkYj_ed ikh][ho \eh fhejhkZ_d] [Whi" dWiWb
iYkbfjkh[" WdZ ie ed WdZ ie \ehj^$ Iec[ e\ j^[i[
fWj_[dj#ikh][ed h[bWj_edi^_fi [lebl[ _dje W ijWj[ e\
Z[f[dZ[dY[$
8Wi_YWbbo"j^[h[_idej^_d]mhed]m_j^¼[iYWbWj_d]½
j^[j^[hWfoZemdj^[heWZ$<eh[nWcfb["j^[fWj_[dj
cWom_i^je^Wl[Xed[Wk]c[djWj_edf[h\ehc[Zje
][jh_Ze\Wd[f_j^[i_i$J^_ife_djcWoWYjkWbboX[m[bb
jWa[d"Yedi_Z[h_d]j^Wjj^[iW\[joe\j^[i[fheY[Zkh[i
_iiW_Zje^Wl[_cfhel[ZXoh[Y[djZ[l[befc[dji$7j
Wdo hWj[" W ckjkWb Z_iYkii_ed ^Wi je X[ YedZkYj[Z
m_j^j^[fWj_[djjeZ[\_d[Wd[mjh[Wjc[dj]eWb$EdY[
W]W_d" Wd kdZ[hijWdZ_d] ckij X[ h[WY^[Z ed j^[
\_dWdY_Wb Yedi[gk[dY[i" m^_Y^ ckij X[ ekjb_d[Z je
j^[fWj_[dj_dYb[Whj[hci$
M[ ^Wl[ X[[d \WY[Z m_j^ fWj_[dji m^e ikZZ[dbo
X[YWc[Z_iiWj_i\_[Zm_j^j^[_h_d[nf[di_l[[f_j^[i_i
W\j[hcWdoo[Whie\Yb_d_YWbi[hl_Y[\ehdeWffWh[dj
h[Wied$ Kf]hWZ_d] Wd [f_j^[i_i je W Xed[#]hW\j
A B
iebkj_ed _i" e\ Yekhi[" dej Yel[h[Z Xo mWhhWdjo$ ?d
\WYj"Wd[m[f_j^[i_iikXij_jkj[ZW\j[h'Ä)o[WhimekbZ
dejX[Yel[h[ZXomWhhWdjo[_j^[h$7\j[hWbb"[f_j^[i[i
Wh[ ckY^ b[ii ZkhWXb[ j^Wd j^[ WiieY_Wj[Z Y[hWc_Y
Xh_Z][i" Z[f[dZ_d] ed j^[ fWj_[djÉi \eeZ WdZ \bk_Z
_djWa[$
È
#ASEÈ3TUDIESÈ)LLUSTRATINGÈTHEÈ5SEÈÈ
OFÈ'INGIVALÈ%PITHESES
Iec[ f^ed[j_Y fheXb[ci YWd Wbie X[ jh[Wj[Z m_j^
W if[Y_Wb jof[ e\ fWbWjWb [f_j^[i_i" m^_Y^ jof_YWbbo
[nj[dZi el[h j^[ fei_j_edi '+Ä(+" Yecf[diWj[i \eh
Z_\\[h[dY[i _d Xed[ ^[_]^j" WdZ Yel[hi j^[ ]Wf Wj
j^[ Xh_Z][ cWh]_d$ J^[i[ Z[l_Y[i h[gk_h[ \_hc
c[Y^Wd_YWb WdY^ehW][$ Ki[Z _d j^[ h_]^j mWo" j^[o
Wh[ Wd [njh[c[bo i_cfb[ WdZ [\\[Yj_l[ mWo je Z[Wb
m_j^_hh[]kbWhl[hj_YWbWdZ^eh_pedjWbXed[b[l[bi$

&IGÈÈAÈB
7[ij^[j_YWbbofb[Wi_d]
]_d]_lWb[f_j^[i_i
X[\eh[WdZW\j[h
_di[hj_ed$ C 9Whjh_Z][#
XWi[ZIodi_b-&ioij[c
C :h$>_dp:[djWb">[hd[
m_j^Yebekhi\ehijW_d_d]
È È 'INGIVALÈ6OLUMEÈ#OMPENSATIONÈBYÈ0INKÈ#ERAMICSÈ (./

A A

B
B
&IGÈÈA J^_ifWhj_Wbbo_cfbWdj#ikffehj[ZcWn_bbWhoXh_Z][
_i WiieY_Wj[Z m_j^ W l[ho kdi_]^jbo _hh[]kbWh Xed[ b[l[b$
9ehh[Yj_d] j^[ Xed[ b[l[b mekbZ ^Wl[ _dlebl[Z WZZ_j_edWb
Wk]c[djWj_l[ehikXjhWYj_l[c[Wikh[i$J^[bWjj[hmekbZ^Wl[
el[hbo h[ZkY[Z j^[ l[hj_YWb _cfbWdj b[d]j^$ B ;f_j^[i_i \eh
ie\j#j_iik[ WZ`kijc[dj$ Dkc[heki _dlWi_l[ fheY[Zkh[i ed
ie\j#WdZ^WhZ#j_iik[ijhkYjkh[imekbZ^Wl[X[[dh[gk_h[Zje
eXjW_dWi_c_bWhW[ij^[j_YekjYec[
Kd\ehjkdWj[bo" ceij Z[djWb bWXehWjeh_[i Wh[ dej
m[bb#l[hi[Z _d \WXh_YWj_d] [f_j^[i[i$ J[Y^d_Y_Wdi
m_j^j^_iWX_b_joWh[^WhZjeYec[Xo$J^[fheY[iie\
_cfh[ii_ed#jWa_d]\ehWd[f_j^[i_iWdZ_ji_di[hj_ed
h[gk_h[iYedi_Z[hWXb[[nf[h_[dY["m^_Y^cWoX[ed[
e\ j^[ h[Wiedi m^o j^_i j[Y^d_gk[ _i jeZWo iYWhY[bo
jWk]^jWdZWffb_[ZWjj^[kd_l[hi_j_[i$
=_d]_lWb [f_j^[i[i Wh[ m[bb WYY[fj[Z Xo fWj_[dji"
i_dY[j^[oiebl[cW`ehfheXb[ci$J^[j[[j^Wh[\_hcbo
_d fbWY[" WdZ j^[ fWbWj[ _i \h[[$ ?d ej^[h mehZi" j^[
jed]k[m_bbedY[W]W_dh[ijedj^[fWbWj["iej^Wjj^[
i[di[i e\ jWij[ WdZ ic[bb Wh[ dej _cfW_h[Z$ EbZ[h
fWj_[djiWh[dejedbob[iiYedY[hd[ZWXekjW[ij^[j_Y
\WYjehi" Xkj cWdo e\ j^[c ^Wl[ jhekXb[ Yef_d]
m_j^ j^[ j[Y^d_YWb h[gk_h[c[dji e\ ehWb ^o]_[d[$ 7
\_n[Z _cfbWdj#ikffehj[Z Xh_Z][ YecX_d[Z m_j^ W
h[celWXb[[f_j^[i_im_bbe\\[hZ_ij_dYjWZlWdjW][i_d
j^_ih[if[YjWim[bb$7iWcWjj[he\\WYj"_d\bWccWj_edi
Wh[ l_hjkWbbo d[l[h eXi[hl[Z m_j^ iebkj_edi e\ j^_i
jof[" i_dY[ j^[o Wh[ [njh[c[bo m[bb WYY[ii_Xb[ \eh
ehWb ^o]_[d[ WdZ Yb[Wd_d] [l[d m_j^ j^[ [f_j^[i_i
_di[hj[Z$ J^[h[\eh[" j^[ Z[iYh_X[Z WffheWY^ e\\[hi
&IGÈAB D_Y[boYb[WdWXb[Xh_Z][mehaed8E?WdZ[f_j^[i_i
je Yel[h j^[ ]Wf X[jm[[d Xh_Z][ WdZ ie\j j_iik[$ J^[ -&#
o[Wh#ebZ \[cWb[ fWj_[dj _d_j_Wbbo Z[cWdZ[Z j^[ [f_j^[i_i Xkj
ijeff[Z m[Wh_d] _j W\j[h '(cedj^i$ J^[ [f_j^[i_i ^Wi cWZ[
_j[Wi_[hjeWZWfjjej^[d[mfheij^[j_YWbi_jkWj_edWdZ[Wi[Z
_d_j_Wbif[[Y^fheXb[ci
YhkY_WbWZlWdjW][ifWhj_YkbWhbo_d][h_Wjh_YfWj_[dji$
?dej^[hmehZi"[l[debZ[hfWj_[djiYWdX[Yed\_Z[djbo
jh[Wj[Zm_j^_cfbWdjiWdZ\_n[ZXh_Z][i_dj^_imWo$
;f_j^[i[i ckij X[ h[d[m[Z W\j[h WXekj (o[Whi$ ?\
j^[o Wh[ dej h[d[m[Z" j^[ _dd[h ikh\WY[ _$[$ j^[
ikh\WY[_dYedjWYjm_j^j^[f[h_#_cfbWdjckYeiWm_bb
X[Yec[\_bj^oWdZm_bbYWki[ZWcW][XoYh[Wj_d]Wd
eYYbki_l[h[i[hle_he\Z[Xh_iWdZXWYj[h_W$
È
'INGIVALÈ6OLUMEÈ#OMPENSATIONÈÈ
BYÈ0INKÈ#ERAMICS
7bj[hdWj_l[bo je Wd [f_j^[i_i" _j _i Wbie feii_Xb[ je
XWa[ f_da Y[hWc_Yi edje j^[ Xh_Z][$ J^_i efj_ed _i
fh[\[hWXb[_di_jkWj_edim^[h[deie\j#j_iik[ikffehj
_ib[\jm^Wjie[l[h"dejWXbo_dj^[fh[i[dY[_dYbWii???
h[bWj_edi^_fi$J^[b[d]j^e\j^[kff[hb_f_iWdej^[h
_cfehjWdjYh_j[h_ededm^_Y^jeXWi[j^[Z[Y_i_ed\eh
ehW]W_dijf_daY[hWc_Yi$
(/& 9^Wfj[h(&È !ESTHETICS

A B

C D

&IGÈAnD 7\j[h j^[ fWj_[dj ^WZ mehd W fWhj_Wb Z[djkh[ \eh cWdo o[Whi" iec[ j[[j^ ^WZ je X[ h[cel[Z X[YWki[ e\ i[l[h[
f[h_eZedjWbZ[\[YjiWdZYoiji$Fei_j_ed()i^em[ZWd[if[Y_Wbbokdi_]^jboZ[\[Yj[nj[dZ_d]_dWl[hj_YWbWdZ^eh_pedjWbZ_h[Yj_ed$
J^[ jeej^%_cfbWdj#ikffehj[Z Xh_Z][ mWi Z[i_]d[Z ikY^ j^Wj j^[ Yhemdi YWc[ je X[ beYWj[Z Wj j^[ Yehh[Yj fei_j_ed$7\j[h Wd
_dj[hlWbe\WhekdZ*cedj^i"Wd[f_j^[i_imWi_di[hj[ZjeYel[hj^[Z[\[Yj_l[ijhkYjkh[i$J^[fWj_[djmWid[l[hb[\jm_j^ekjW
\_n[Zh[ijehWj_edWjWdoj_c[

9ehh[Yj fbWY[c[dj e\ j^[ j^h[WZ[Z f_di _d j^[ 8hd[cWha iYh[mi" j^[ jhWdi_j_edWb ped[i X[jm[[d
iW]_jjWb fbWd[ _i Wbie _cfehjWdj je WY^_[l[ efj_cWb _cfbWdjWdZWXkjc[djd[[ZjeX[ikh]_YWbboWb_]d[Z
W[ij^[j_Yi$?\ijhWj[]_YWXkjc[djfei_j_ed_d]_iki[Z" Wjj^[b[l[be\j^[Wbl[ebWhYh[ij$7iWh[ikbj"^em[l[h"
j^[_cfbWdjebe]_ijd[[Zije[dikh[j^WjWdWZ[gkWj[ Wdo ceX_b_jo e\ j^[ l[hj_YWb _cfbWdj i[]c[dj m_bb
Z_ia#je#Z_ia Z_ijWdY[ _i cW_djW_d[Z$ Iec[j_c[i _j ceh[b_a[bo_deYkbWj[_d\[Yj_edi_djej^[Xed["j^[h[Xo
_id[Y[iiWhojefbWY[j^[_cfbWdjiWjZ_\\[h[djb[l[bi fhecej_d]Xed[beii$?dWZZ_j_ed"WX_ebe]_YWbm_Zj^
_d ehZ[h je Wle_Z Wdo b[l[h \ehY[i j^Wj cWo [c[h][ m_bb[lebl[WdZ]_l[h_i[jel[hj_YWbXed[beiiWim[bb$
[$]$Xo[nY[ii_l[Wdj[h_ehYedjWYjim^_b[j^[Xed[_i
m[Wa[d[Z_dj^[h[ceZ[bb_d]f^Wi[\hecZ_ibeZ]_d]
j^[ fWbWjWb Xed[ ¼^ehi[i^e[ Zemd\hWYjkh[½$ Ed È
j^[ ej^[h ^WdZ" j^[ j^h[WZ[Z f_di ckij dej kdZkbo !ESTHETICÈ)MPACTÈOFÈ&UNCTIONALÈ!DAPTATIONS
_dj[h\[h[ m_j^ j^[ jed]k[ X[YWki[ j^[o Wh[ b_a[bo je
kdZ[h]ei_]d_\_YWdjX[dZ_d]_\j^[oZe$ 7i m_bb X[ [nfbW_d[Z _d j^[ Y^Wfj[h ed \ebbem#kf
fhejeYebi"j^[\kdYj_edWbWZWfjWj_edijWa_d]fbWY[_d
j^[mWa[e\_cfbWdj#XWi[Zh[ijehWj_l[jh[Wjc[djm_bb
È È h[gk_h[WZ`kijc[djijeX[cWZ[_dehZ[hjeYh[Wj[WdZ
#REATINGÈANÈ%MERGENCEÈ0ROFILE cW_djW_d W XWbWdY[Z ijWj[ e\ j^[ h[ijehWj_ed$ M^_b[
WZ`kijc[djie\j^_ijof[d[[ZjeX[f[h\ehc[ZedW
FWj_[djim^em_i^Wd[c[h][dY[fhe\_b[m_bbX[\WY[Z b_\[bed]XWi_i"j^[_hiYef[m_bbZ[Yh[Wi[W\j[hj^[\_hij
m_j^ ]h[Wj[h ehWb ^o]_[d[ Y^Wbb[d][i$ CkY^ Wi m_j^ jmeo[Whie\Yb_d_YWbi[hl_Y[$8Wi_YWbbo"j^[oWbied[[Z
È È 0ATIENTSÈ!ESTHETICÈ$EMANDSÈINÈ#LINICALÈ0RACTICEÈ (/'

A B

C D

&IGÈAnD <WXh_YWj_ed e\ W fWbWjWb [f_j^[i_i$ FWbWjWb _cfh[ii_ed#jWa_d] _i f[h\ehc[Z ki_d] Yedl[dj_edWb [f_j^[i_i#h[bWj[Z
j[Y^d_gk[i$J^[[f_j^[i_i_imWn[Zkfedj^[ceZ[bWdZ_dl[ij[Z$EdY[_j^WiX[[d\_d_i^[Z"_j_iYWh[\kbboWZ`kij[Z$J^[[f_j^[i_i
^WijeX[ik\\_Y_[djbobWh][jea[[f_jiW\[bo_dfbWY[WjWbbj_c[i

je X[ f[h\ehc[Z ed jeej^#ikffehj[Z h[ijehWj_edi"
Z[djkh[i WdZ _dZ[[Z ed dWjkhWb j[[j^ Wi m[bb$ ?\
\eh de ej^[h h[Wied" ikXjhWYj_l[ WZ`kijc[dji Wh[
_cfehjWdj ie j^Wj j^[ h[ijehWj_ed cWjY^[i j^[ W][#
if[Y_\_YZ[]h[[e\WXhWi_edWjWbbj_c[i$:k[jej^[_h
eii[e_dj[]hWj_ed"_cfbWdj#ikffehj[Zh[ijehWj_ediWh[
ckY^ ceh[ Ybei[bo b_da[Z je Wbj[hWj_edi _d Xed[
cehf^ebe]o j^Wd jeej^#ikffehj[Z h[ijehWj_edi$
J^[h[\eh["WdoY^Wd][i_dXed[cehf^ebe]oXhek]^j
WXekj Xo d[mbo WZWfj[Z fWjj[hdi e\ cWij_YWj_ed
[djW_bj^[d[[Z\ehceh[[nj[di_l[WZ`kijc[djij^Wd
Wh[dehcWbboh[gk_h[Zm_j^dWjkhWbj[[j^$
?j_ij^[h[\eh[Wffhefh_Wj[jef[h\ehcWZ`kijc[dji
[nj[di_l[bo WdZ \h[gk[djbo$ J^[ Y^Wbb[d][ _i j^Wj
j^[i[ WZ`kijc[dji m_bb ieed[h eh bWj[h [nfei[ j^[
c[jWb Yecfed[dj e\ F<C Xh_Z][i$ Kd\ehjkdWj[bo" _j
_idejj[Y^d_YWbbo\[Wi_Xb[Wjfh[i[djjeki[Wj^_Ya[h
Y[hWc_Y bWo[h fhef^obWYj_YWbbo" Wi j^[o Wh[ ceh[
ikiY[fj_Xb[jeY^_ff_d]"Wi_Z[\hecj^[\WYjj^Wjj^[h[
_ie\j[di_cfbodej[dek]^l[hj_YWbifWY[\ehj^_ijof[
e\[nW]][hWj[ZXk_bZ#kf$?di_jkWj_edim^[h[WZZ_j_l[
WZ`kijc[dji Wh[ feii_Xb[" W Yecfei_j[ h[ijehWj_ed
YWd X[ Wffb_[Z _djhWehWbbo je efj_c_p[ W[ij^[j_Yi$
7bie" j^[ Z_ijWb cWn_bbW YWd e\j[d X[ h[ZkY[Z ceh[
[nj[di_l[bo j^Wd j^[ cWdZ_Xb[ \khj^[h _dYh[Wi_d]
j^[ d[]Wj_l[ _dYb_dWj_ed e\ j^[ Ykhl[ e\ If[[" ie
j^Wj j^[ [nfei[Z c[jWb _i de bed][h W[ij^[j_YWbbo
h[b[lWdj$ ?d ekh [nf[h_[dY[" ^em[l[h" j^[ d[Y[iiWho
WZ`kijc[dji Wh[ \h[gk[djbo ie [nj[di_l[ j^Wj j^[
eh_]_dWb h[ijehWj_ed ^Wi je X[ h[#l[d[[h[Z eh h[#
\WXh_YWj[Zm_j^_dj^[\_hij*.cedj^i$
È È
0ATIENTSÈ!ESTHETICÈ$EMANDSÈÈ
INÈ#LINICALÈ0RACTICE
M^Wj fWj_[dji [nf[Yj \hec _cfbWdj jh[Wjc[dj ^Wi
b_jjb[ je Ze m_j^ j^[ _Z[Wbi ^[bZ Xo Z[dj_iji$ M^_b[
oekd][hfWj_[djij[dZjeWjjWY^]h[Wj_cfehjWdY[je
W[ij^[j_Yi" j^[ h[gk_h[c[dj e\ W fW_d#\h[[ Y^[m_d]
\kdYj_ed X[Yec[i j^[ el[hh_Z_d] YedY[hd bWj[h _d
b_\[$ ?d j^[ YWi[ _bbkijhWj[Z X[bem <_]$(&$/" jeej^
'( mWi [njhWYj[Z WdZ h[fbWY[Z m_j^ W jh_fb[#Z_ia
8E? _cfbWdj" m^_Y^ mWi edY[ W]W_d \_jj[Z m_j^ j^[
fh[#[n_ij_d] Yhemd h[ijehWj_ed$ J^[ fWj_[dj Z_Z dej
(/( 9^Wfj[h(&È !ESTHETICS

A B

&IGÈÈAnD J^[Z[djWb
j[Y^d_Y_Wdm_bbedbo^Wl[[dek]^
ifWY[\ehWYehh[Yjbofei_j_ed[Z
h[ijehWj_edc[[j_d]f^ed[j_Y
h[gk_h[c[dji_\de_cfbWdjiWh[
fbWY[Z_dj^[Wh[W'(Ä(($Edj^[
ej^[h^WdZ"j^[j^h[WZ[Zf_di
i^ekbZdejkdZkbo_dj[h\[h[
m_j^jed]k[cel[c[dji"WdZ
WZ[gkWj[Z_ia#je#Z_iaZ_ijWdY[i
ckijX[[dikh[Zedj^[fWbWjWb
Wif[Yje\j^[h_Z][je[dikh[Xed[
_dj[]h_jo$ E H[ijehWj_ediXWi[Z
edijhWj[]_Y_cfbWdjfbWY[c[dj_d
E
j^[cWn_bbWWdZcWdZ_Xb[

m_i^ je ^Wl[ W d[m Yhemd h[ijehWj_ed \WXh_YWj[Z fWj_[dj Yecc[dZ[Z j^[ iebkj_ed \eh _ji i_cfb_Y_jo
Xkj mWi l[ho ]hWj[\kb j^Wj j^[ h[ijehWj_ed ^[ ^WZ WdZ_d[nf[di_l[d[ii$
mehd \eh (&o[Whi YekbZ X[ h[ki[Z$ ?d \WYj" j^[ FWj_[djiÉ[nf[YjWj_edicWolWhom_Z[bo$
È È 0ATIENTS@È!ESTHETICÈ$EMANDSÈINÈ#LINICALÈ0RACTICEÈ (/)

A B C

D E

&IGÈAnE?dj[]hWj_d]f_daY[hWc_Yi_djej^[Xh_Z][_iWik_jWXb[c[j^eZjeWZ`kijjeej^b[d]j^WdZfhel_Z[dWjkhWbikffehj
jej^[kff[hb_f$J^[i[]_d]_lWbcWiaim_bbcW_djW_dj^[_bbki_ede\WdWjkhWbZ[dj_j_ed[l[dm^[dj^[fWj_[dj_i_d\kbbic_b[
m_j^ekjYecfhec_i_d]if[[Y^WdZcWij_YWj_ed$J^_ihWZ_e]hWf^mWieXjW_d[Z+o[WhiW\j[hj^[cWn_bbW^WZX[[dh[ijeh[Z$J^[
fWhj_Wb Z[djkh[ _d <_]$(&$+Z ^WZ X[[d h[cel[Z$ J^[ Xh_Z][ mWifei_j_ed[ZX[\eh[j^[`Wm$J^_iZ[i_]d"_\fhef[hbo[n[Ykj[Z"
e\\[hi efj_cWb i[b\#Yb[Wd_d] WdZ ]eeZ WYY[ii \eh _dj[hZ[djWb Xhki^[i WdZ \beii$ A J^[ Xh_Z][ h[fbWY[i dej edbo j^[ j[[j^
Xkj Wbie fWhji e\ j^[ Wbl[ebWh h_Z][" j^[h[Xo ikffehj_d] j^[ kff[h b_f$ B DWjkhWb fei_j_ed e\ j^[ kff[h b_f ed ib_]^j cekj^
ef[d_d]$ C J^[cekj^YWdX[Ybei[Zm_j^ekjijhW_d_d]$ D F_daY[hWc_YWh[Wijeikffehjj^[ie\j#j_iik[ijhkYjkh[i[if[Y_Wbbo
d[Whj^[kff[hb_fWdZdWiebWX_Wb\ebZYWdX[ki[ZckY^_dj^[iWc[mWoWij^[oWh[ki[Z_dh[celWXb[h[ijehWj_edi$M^_b[
j^[YebekhZ_\\[h[dY[YecfWh[Zjej^[dWjkhWb]_d]_lWm_bbh[cW_d"_jm_bbh[cW_d_dl_i_Xb[_dh[Wbb_\[Zk[jej^[WZ[gkWj[b[d]j^
e\j^[fWj_[djÉikff[hb_f$J^[Wiocc[jh_YWbi^Wf[e\j^_i]_d]_lWbcWiamWiZ[b_X[hWj[boZ[i_]d[ZjeYecf[diWj[\ehlebkc[
Z[\_Y_ji$J^[fWbWjWbWYY[ii\ehehWb^o]_[d[_ikd_cf[Z[Z
(/* 9^Wfj[h(&È !ESTHETICS

B
A

&IGÈÈA J^[ fWj_[dj h[gk[ij[Z j^Wj j^[ Z_Wij[cWi d[Wh j^[ bWj[hWb _dY_iehi i^ekbZ X[ h[cel[Z WdZ j^[ [bed]Wj[Z i^Wf[ e\
j^[j[[j^Yehh[Yj[Z$:k[jeWZlWdY[Zf[h_eZedjWbZ[ijhkYj_edWjj^[bWj[hWb_dY_iehi"_jmWiZ[Y_Z[Zj^Wjjeej^fh[i[hlWj_edmWi
dejWdefj_ed$ B I_jkWj_edW\j[h,o[Whi$J^[Wdj[h_ehj[[j^m[h[\_jj[Zm_j^YhemdXbeYaiYedd[Yj_d]j^[bWj[hWbWdZY[djhWb
_dY_iehi$J^[ckYeiWbijhkYjkh[iWj8E?_cfbWdji'(WdZ((Wh[f[h\[YjbodehcWb$ C J^[ie\jj_iik[ih[cW_d[ZX[Wkj_\kbWdZ
j^[[c[h]_d]fhe\_b[mWiijWXb[[l[dW\j[h,o[Whi

&IGÈ I_jkWj_ed,cedj^iW\j[h[njhWYj_ede\j^[bWj[hWb_dY_ieh"\ebbem[ZXo_di[hj_ede\Wjh_fb[#Z_ia8E?_cfbWdj;888I
-=,WdZh[_dj[]hWj_ede\j^[fh[#[n_ij_d]Yhemdh[ijehWj_ed_dj^[iWc[i[ii_ed$J^[YhemdmWih[ki[Zedj^[fWj_[djÉih[gk[ij$
7Zc_jj[Zbo"Wd[mYhemded_cfbWdj'(mekbZ^Wl[Zed[b_jjb[je_cfhel[j^[el[hWbbWff[WhWdY[

#(!04%2È
-ECHANICSÈ-EETSÈ"IOMECHANICS
È
'ENERALÈ#ONSIDERATIONS
J^[j[Y^d_gk[e\XWiWbeii[e_dj[]hWj_edZhWmiedj^[
[cf_h_YWb \_dZ_d] j^Wj j^[ `Wm Xed[ _i Yedj_dkekibo
ikX`[Yj[ZjeZ[\ehcWj_edWdZjehi_ed$8E?_cfbWdji
Wh[ j^[h[\eh[ _di[hj[Z _d ikY^ W mWo j^Wj j^[o Wh[
iec[m^Wj ceh[ h_]_Z j^Wd j^[ `Wm _ji[b\ _d ehZ[h
je Wle_Z jejWb _ie[bWij_Y_jo$ Ed j^[ ej^[h ^WdZ" j^[
h_]_Z_jo ckij dej h[WY^ W fe_dj m^[h[ j^[ _cfbWdj#
Xed[_dj[h\WY[_iikX`[Yj[Zjef[Wa\ehY[ij^WjmekbZ
]_l[h_i[jeeij[eboi_iehWlkbi_ed$
J^[Yehh[Yjb[l[be\[bWij_Y_joYWdX[WY^_[l[ZXo
efj_c_p_d]j^[\ebbem_d]fWhWc[j[hi0
v I^Wf[" i_p[ WdZ Z[i_]d e\ j^[ beWZ#jhWdic_jj_d]
_cfbWdji[]c[dji
v B[d]j^" Z_Wc[j[h" i^Wf[ WdZ ^[dY[ ijWX_b_jo e\
j^[j^h[WZ[Zf_d
v JhWdi_j_edWbped[iX[jm[[dj^[j^h[WZ[Zf_dWdZ
j^[Z_ia\hWc[meha
v CeX_b_joX[jm[[dj^[j^h[WZ[Zf_dWdZWXkjc[dj
XocWj[h_WbWdZZ[i_]d WY^_[l[Zm_j^Wd_ie[bWij_YXed[#_cfbWdj#h[ijehWj_ed
v CWj[h_Wb e\ j^[ _cfbWdj WYYehZ_d] je _ji Z[i_]d
WdZi_j[e\Wffb_YWj_ed
Ijh_Yjbo if[Wa_d]" [WY^ _cfbWdj mekbZ ^Wl[ je X[
i[b[Yj[Z ikY^ j^Wj _ji [bWij_Y_jo _Z[Wbbo cWjY^[i _ji
if[Y_\_Y Xedo [dl_hedc[dj$ <ehjkdWj[bo" Yb_d_YWb
fhWYj_Y[ i^emi j^Wj j^[ ^kcWd `Wm Xed[ _i ^_]^bo
WZWfj_l[_ji[b\$?j_iX_ebe]_YWbboYWfWXb[e\jeb[hWj_d]
W ikXijWdj_Wb XWdZm_Zj^ e\ _cfbWdj Z[i_]di" [l[d _\
j^[o cWo Z[l_Wj[ ikXijWdj_Wbbo \hec j^[ ¼Yehh[Yj½
Z[i_]d$ J^_i Yecf[diWj_ed _i cW_dbo fhel_Z[Z
Xo j^[ Yehj_YWb Xed[i ijhkYjkh[" m^_Y^ _i YWfWXb[
e\ WY^_[l_d] Z_\\[h[dj Z[]h[[i e\ eii_\_YWj_ed _d
h[ifedi[je_dYec_d]beWZi$7\j[hWbb"[l[dj^[ceij
[bWij_Yjof[e\j_jWd_kcWlW_bWXb[_iij_bbjm_Y[Wih_]_Z
WiWl[hW][Yehj_YWbXed[ijhkYjkh[i_dj^[^kcWd`Wm$
J^[eii[e_dj[]hWj_ede\8E?_cfbWdji_ided[j^[b[ii
]h[Wjbo `[efWhZ_p[Z Xo kd_bWj[hWb Y^[m_d] fWjj[hdi"
i_dY[j^[Xed[ijhkYjkh[i_dm^_Y^j^[oWh[[cX[ZZ[Z
Wh[ ikXijWdj_Wbbo ceh[ h_]_Z _d Yecfh[ii_l[ j^Wd _d
j[di_b[ ped[i$ J^[ h_ia e\ _cfbWdj beii _i j^[h[\eh[
^_]^[h_dfkh[boj[di_b[ped[i"Zk[jej^[bem[hZ[]h[[
e\c_d[hWb_pWj_ed_dj^[_dj[h\WY[Wh[W_\Zec_dWj[Z
 ¬ 
Xo cWYhejhW`[Yjeh_[i WdZ j^[ bem[h h[_dj[]hWj_ed
j[dZ[dYo _d j^[ [l[dj e\ WZl[hi[ h[WYj_edi ikY^ Wi
_d\[Yj_ed#h[bWj[Zeij[eboi_i$J^[h[WZ[h_ih[\[hh[Zje
9^Wfj[h'&\ehWZ[jW_b[ZZ_iYkii_ed$
9ehj_YWb Xed[ i^emi W l[ho XheWZ if[Yjhkc
e\ WZWfj_l[ h[WYj_edi$ ;l[d c_dkj[ Y^Wd][i _d
c_d[hWb_pWj_edm_bb]h[WjboWbj[hj^[[bWij_YX[^Wl_ekh
e\ j^[ _cfbWdj i[[ Wbie JWXb[/$'$ J^[h[\eh[" ]h[Wj
Wjj[dj_ed ckij X[ fW_Z dej edbo je j^[ cWj[h_Wb
fhef[hj_[i e\ _cfbWdji Xkj Wbie je j^[_h ijhkYjkhWb
Z[i_]dWdZje^emj^[oWh[Yedd[Yj[Zm_j^j^[Xh_Z][$
?\ Wbb j^[i[ fWhWc[j[hi Wh[ WZ[gkWj[bo efj_c_p[Z"
8E?_cfbWdjim_bbX[WXb[jeikffehj[l[dj^[ceij
Z[cWdZ_d]e\h[ijehWj_ediikY^WiYecfb[j[Xh_Z][i
_dj^[cWdZ_Xb[$J^[Yedl[dj_edWbj[Y^d_gk[mekbZ
X[jejh[Wjj^[cWdZ_Xb[m_j^i[fWhWj[Xh_Z][i"m^_Y^
h[gk_h[ij^[ki[e\ckbj_fb[_cfbWdjiWieffei[Zje
ijhWj[]_Y _cfbWdj fei_j_ed_d]$ M^_b[ 8E? _cfbWdji
Wh[ f[h\[Yjbo ik_jWXb[ \eh j^_i jof[ e\ Wffb_YWj_ed
Wi m[bb" \kbb _dj[]hWj_ed e\ Wbb beWZ#jhWdic_jj_d]
ikh\WY[i Wj W ^_]^ Z[]h[[ e\ c_d[hWb_pWj_ed YWddej
X[ h[Wb_p[Z _d j^_i mWo$ J^_i eX`[Yj_l[ YWd edbo X[
ioij[c XWi[Z ed ijhWj[]_Y _cfbWdj fei_j_ed_d]$ ?d
ekh[nf[h_[dY["WXekjj^h[[je\_l[8E?_cfbWdjiWh[
dehcWbboh[gk_h[Zjeh[Wb_p[Yecfb[j[Xh_Z][i_dj^[
cWdZ_Xb[$
IjkZ_[i e\ XehZ[hb_d[ i_jkWj_edi WdZ jh[Wjc[dj
\W_bkh[i ^Wl[ ^[bf[Z W ]h[Wj Z[Wb _d kdZ[hijWdZ_d]
^em 8E? _cfbWdji meha WdZ ^em j^[o i^ekbZ X[
Wffb_[Z$
?cfbWdj beii[i Wh[ YWki[Z Xo jme cW_d c[Y^W#
d_ici0
v El[hbeWZeij[eboi_im_j^ehm_j^ekj_d\[Yj_ed
v <hWYjkh[ih[bWj[ZjejhWkcWeh\Wj_]k[
El[hbeWZeij[eboi_iYh[Wj[iWi_jkWj_ed_dm^_Y^j^[
_cfbWdj_idebed][h_d_cc[Z_Wj[YedjWYjm_j^j^[
Xed[$ ?d j^_i i_jkWj_ed" eii[e_dj[]hWj_ed cWo ]_l[
mWoje\_Xhe_dj[]hWj_ed$J^[_iik[e\h[_dj[]hWj_ed_i
Z_iYkii[Z_d9^Wfj[h(,$)$J^[h[WZ[h_iWbieh[\[hh[Z
jej^[Z_iYkii_ede\j^[&Ä'fhef[hjo_d9^Wfj[h/$'je
b[Whdceh[WXekjj^[[\\[Yje\eij[eboi_iedj^[beWZ#
jhWdic_jj_d] ikh\WY[i$ 7do YedYec_jWdj _d\[Yj_edi
Wh[ Z[b[j[h_eki dej edbo X[YWki[ j^[o YWddej ZhW_d
e\\ fhef[hbo Xkj Wbie X[YWki[ j^[o cWo Wbj[h j^[
(/, 9^Wfj[h('È -ECHANICSÈ-EETSÈ"IOMECHANICS

cWjh_n_dWd_hh[l[hi_Xb[\Wi^_ed$7biedej[j^Wjj^[ YhWYai l_i_Xb[ Wj bWh][h cW]d_\_YWj_edi$ <hWYjkh[i

Yecckd_YWj_ed m_j^ j^[ ehWb YWl_jo Wj j^[ ckYeiWb
f[d[jhWj_edfe_djcWofhecej[Yheii#YedjWc_dWj_ed
_dj^[cWdd[he\WYWdZb[m_Ya"[if[Y_Wbbom^[dj^[
_cfbWdjikh\WY[_ihek]^$
<hWYjkh[i e\ 8E? _cfbWdji Wh[ jof_YWbbo \Wj_]k[
\hWYjkh[i$ JhWkcW#h[bWj[Z \hWYjkh[i Wh[ hWh[$ M^[d
j^[o Ze eYYkh" j^[o Wh[ Wbceij _dlWh_WXbo Zk[ je
_Wjhe][d_Y j[hj_Who el[hbeWZ_d]" m^_Y^ cWo _dYbkZ[
ikf[h# eh _d\hWeYYbkiWb ped[i Yh[Wj[Z Xo kd[l[d
WXhWi_l[WZ`kijc[dji$
È
&OLLOW
5PÈOFÈ&RACTUREDÈ"/)È)MPLANTS
J^[gk[ij_edjem^_Y^jof[e\\hWYjkh[i8E?_cfbWdji
Wh[ikiY[fj_Xb[mWiWZZh[ii[ZXo[nWc_d_d]_cfbWdji
j^Wj^WZX[[dh[cel[Z\hecYb_d_YWbi[hl_Y[\ebbem_d]
_djhWehWb\hWYjkh[$7bb\hWYjkh[Zikh\WY[im[h[Yb[Wd[Z
_d(&d_jh_YWY_Zm^_Y^Ze[idejW\\[Yjj_jWd_kc
\ehi[l[hWb^ekhiX[\eh[WdWboi_i$
J^[i[ fWhji h[l[Wb Y^WhWYj[h_ij_Yi e\ f[hcWd[dj
\hWYjkh[" Wi WffWh[dj \hec ]heel[i WdZ i[YedZWho
eYYkh dej edbo Wbed] j^[ [bWij_Y m[X XWhi Xkj Wbie
Wbed] j^[ h_d] ijhkYjkh[" Z[cedijhWj_d] j^Wj ped[i
e\ Z_\\[h[dj ^WhZd[ii YWd Wbie X[ fh[i[dj Wbed] j^[
h_d] ijhkYjkh[" m^_Y^ _i dej f[h i[ [bWij_Y$ J^_i _i
[if[Y_Wbbo jhk[ e\ 8E? _cfbWdji j^Wj m[h[ \b[n[Z
Zkh_d]_di[hj_ed"i_dY[j^[i[\b[n[Zped[iWh[WbmWoi
^WhZ[hj^Wdj^[h[cW_d_d]i[]c[djie\j^[h_d]$
È
#ONCLUSION
<Wj_]k[\hWYjkh[iWh[j^[\hWYjkh[jof[ceijYeccedbo
eXi[hl[Zm_j^8E?_cfbWdji$J^[Z[dj_iji^ekbZdej
Wffboel[hbo\ehY[\kbijhea[ijej^[j^h[WZ[Zf_dWdZ
j^[ Wh[W e\ j^[ m[X XWhi Zkh_d] j^[ _cfbWdjWj_ed
fheY[Zkh[jeWle_ZWdobeYWbWbj[hWj_edie\j^[[bWij_Y
fhef[hj_[i e\ j^[ j_jWd_kc" Wi ikY^ i_j[i e\ h[ZkY[Z
[bWij_Y_jo mekbZ YWhho Wd _dYh[Wi[Z h_ia e\ \hWYjkh[$
8E? _cfbWdji m_bb" ^em[l[h" hWh[bo \hWYjkh[ Wbed]
j^[bem[hfehj_ede\j^[j^h[WZ[Zf_d$J^[\WYjj^Wj
fem[h\kb \ehY[i e\ Wdo jof[ m_bb _dlWh_WXbo W\\[Yj
j^[ ijhkYjkhWb kd_\ehc_jo e\ j^[ _cfbWdj ckij Wbie
X[ Yedi_Z[h[Z m^[d[l[h _cfbWdj#ikffehj[Z Xh_Z][i

A B

C D

&IGÈAnDJ^_i\hWYjkh[Z_cfbWdjh[l[WbiWZ_ij_dYji^ekbZ[h[l[dkdZ[hj^[b_]^jc_YheiYef[$7ceh[Z_ij_dYjh[fh[i[djWj_ed
_ieXjW_d[ZXoiYWdd_d][b[Yjhedc_YheiYefo$M^_b[j^[kff[hi[]c[dje\j^[i^ekbZ[h^WiX[[dXbkhh[Ziec[m^WjXoWXhWi_ed"
j^[eh_]_dWb\hWYjkh[ikh\WY[_iYb[Whbol_i_Xb[_dj^[bem[hi[]c[dj
È È &%-È!NALYSISÈOFÈ$IFFERENTÈ,OADINGÈ3ITUATIONSÈ (/-

A B

C D

&IGÈAnDJ^_i_cfbWdjWbieh[l[Wbijof_YWbi_]die\\Wj_]k[\hWYjkh[$Edboj^[l[hobWij\hW]c[djXh[WaiXo\ehY[_dj^_ijof[
e\\hWYjkh[$J^[\Wj_]k[ped[_ibeYWj[Z_dj^[kff[h_cfbWdji[]c[djhWj^[hj^Wd_dj^[bem[hi[]c[dj_$[$kdb_a[_d<_]$('$'$
El[hbeWZ#h[bWj[Z \W_bkh[ e\ 8E? _cfbWdji YWd j^ki eYYkh _d h[ifedi[ je [_j^[h [njhki_l[ eh _djhki_l[ \ehY[i$ J^_i \_dZ_d] ^Wi
_cfehjWdj _cfb_YWj_edi \eh j^[ Yb_d_YWb meha m_j^ 8E? _cfbWdji$ :k[ je j^[ cWdd[h _d m^_Y^ beWZi Wh[ Z_ijh_Xkj[Z Xo j^[
Xh_Z]["iec[_cfbWdjiWh[ikX`[Yj[Zje]h[Wj[h[njhki_l[j^Wd_djhki_l[\ehY[i$:_ijWb8E?_cfbWdji_dj^[cWn_bbWWh[iec[j_c[i
ikX`[Yj[Z je Yedi_Z[hWXb[ [njhki_l[ \ehY[i _d j^[ fh[i[dY[ e\ Wdj[h_eh Y^[m_d] fWjj[hdi" m^_Y^ Wh[ dej ik\\_Y_[djbo XWbWdY[Z
Xo_djhki_l[\ehY[i$J^[beWZ_i][d[hWj[ZXoeXb_gk[ikh\WY[YedjWYjiedj^[Wdj[h_ehj[[j^"m^_b[j^[YWd_d[_cfbWdjiWh[j^[
\kbYhkce\j^[b[l[h\ehY[ih[ikbj_d]_d[njhki_ed

Wh[h[cel[Z$Ifh_d]WYY[b[hWjehi9hemd9b_Ya"[jY$ X[fh[i[dj_dl_leX[YWki[_d\b[n_Xb[WdY^ehW][e\j^[
i^ekbZ X[ ki[Z l[ho YWh[\kbbo$ Fh[\[hWXbo" ^em[l[h" _cfbWdjXWi[mekbZej^[hm_i[YWki[Wdo\hWYjkh[ije
j^[oi^ekbZdejX[ki[ZWjWbb$Ijhed]\ehY[ie\j^_i eYYkh ed j^[ Yh[ijWb i_Z[ e\ j^[ _cfbWdj eh" _d j^[
jof[m_bbb[Wl[j^[Wbj[hdWj[\b[nkhWbijh[d]j^e\j^[ fh[i[dY[e\WZlWdY[Zl[hj_YWbXed[h[iehfj_ed"Wbed]
ijhkYjkh[ _cfW_h[Z [l[d _\ j^[ _cfbWdj Ze[i dej j^[bem[hfehj_ede\j^[j^h[WZ[Zf_d$
\hWYjkh[ ekjh_]^j$ Iec[ _cfbWdji cWo dej \hWYjkh[
_cc[Z_Wj[bo ed Wffbo_d] W ifh_d] WYY[b[hWjeh Xkj
È
i^ehjboj^[h[W\j[h$7jWdohWj["Wdo_cfbWdj\hWYjkh[i
#ONCLUSION
m_bbX[ikXijWdj_Wbbo[nf[Z_j[ZZkh_d]Yb_d_YWbi[hl_Y[
Ekh WdWboi_i e\ \hWYjkh[Z _cfbWdji ik]][iji
edY[ j^[ [bWij_Y fej[dj_Wb e\ j^[ cWj[h_Wb ^Wi X[[d
j^Wj h[i_b_[dj X[^Wl_ekh _d j^[ ifed]_eki Xed[
[nY[[Z[Z Xo fbWij_Y Z[\ehcWj_ed WdZ Xo ijhkYjkhWb
\Wj_]k[_dZkY[Zl_Wc[Y^Wd_YWb_cfWYji$ YecfWhjc[dj ckij X[ fh[i[dj _d l_le X[YWki[
_d\b[n_Xb[ WdY^ehW][ e\ j^[ _cfbWdj XWi[ mekbZ
ej^[hm_i[ YWki[ Wdo \hWYjkh[i je eYYkh ed j^[
È Yh[ijWb i_Z[ e\ j^[ Xed[ eh" _d j^[ fh[i[dY[ e\
&%-È!NALYSISÈOFÈ$IFFERENTÈÈ WZlWdY[Z l[hj_YWb Xed[ h[iehfj_ed" WhekdZ ^Wb\mWo
,OADINGÈ3ITUATIONS kfj^[j^h[WZ[Zf_d$?\m[[l[hmekbZ^Wl[j^[Y^e_Y[
X[jm[[d Wd el[hbeWZ eij[eboi_i WdZ W \hWYjkh[ m[
7ijkZoe\\hWYjkh[Z_cfbWdjiik]][ijij^Wjh[i_b_[dj mekbZZ[Y_Z[\ehW\hWYjkh[i_dY[j^_ifheXb[c_il[ho
X[^Wl_ekh_dj^[ifed]_ekiXed[YecfWhjc[djckij [Wiojejh[Wj$
(/. 9^Wfj[h('È -ECHANICSÈ-EETSÈ"IOMECHANICS

&IGÈÈA J^_iWdWboi_ih[ijiedj^[
Wiikcfj_edj^Wjj^[_cfbWdj_i\_hcbo
WdY^eh[ZkdZ[hWl[hoicWbbWcekdje\
Xed[$J^_ii_jkWj_ed"m^_Y^_iYeccedbo
eXi[hl[Z_dj^[Z_ijWbcWdZ_Xb["_dlebl[i
f[WabeWZiedj^[bem[h[dZe\j^[
j^h[WZ[Zf_d$<hWYjkh[_iceh[b_a[bo
jeeYYkhWXel[j^[hWZ_ki$ B IWc[
i_jkWj_ed"bWj[hWbl_[m"XWi[ZedW/%'(=-
;:7I_cfbWdj$ C J^[Xbk[XWhim_j^_d
j^[h_d]ijhkYjkh[_dZ_YWj[j^[bWh][
WdY^ehW][ped[Wbed]m^_Y^j^[_cfbWdj
_i\_hcbo[cX[ZZ[Z_dj^[Xed[YWl_jo

C
È È 7EBÈ"ARÈ$ESIGNÈANDÈ3TRESSÈ$ISTRIBUTIONÈ
È
7EBÈ"ARÈ$ESIGNÈANDÈ3TRESSÈ$ISTRIBUTION
9heii[Zm[XXWhiWh[YWfWXb[e\WXiehX_d]hejWj_edWb
\ehY[i_dWbbZ_h[Yj_edi$J^[oWh[j^[h[\eh[[if[Y_Wbbo
WZlWdjW][eki$7iWh[ikbj"j^[_cfbWdjYWdX[_di[hj[Z
bed]_jkZ_dWbbo" eXb_gk[bo eh Z_W]edWbbo m_j^ekj
W\\[Yj_d] j^[ beWZ Z_ijh_Xkj_ed eh j^[ eh_[djWj_ed
e\ \hWYjkh[i$ J^[ \ebbem_d] \_]kh[i _dZ_YWj[ j^[
cWn_ckcZ_ibeYWj_edfWj^ie\W=,_cfbWdji^W\j$
È #ONCLUSION
8E? _cfbWdji Wh[ ikX`[Yj[Z je fbWij_Y Z[\ehcWj_ed$
J^[o Wh[ ik\\_Y_[djbo [bWij_Y je Yecf[diWj[ \eh `Wm
(//
&IGÈÈA 8oYedjhWij"_\j^[_cfbWdj
\_njkh[_iWdY^eh[ZXoeii[e_dj[]hWj_ed
m_j^_dj^[l[hj_YWbXed[ijhkYjkh[
WhekdZ^Wb\mWokfj^[j^h[WZ[Zf_d"Wdo
\hWYjkh[imekbZ^Wl[jeeYYkhfh[Y_i[bo
_dj^Wjped[$<hWYjkh[ie\j^_ijof[
m_bbedboeYYkhW\j[hWbed]f^Wi[e\
eii[e_dj[]hWj_ed"m^[dXej^j^[[dj_h[
j^h[WZ[Zf_dWdZj^[m[XXWhiWh[Ybei[bo
eii[eWZWfj[Z$ B IWc[i_jkWj_ed\hec
WbWj[hWbl_[m"XWi[ZedW/%'(=-;:7I
_cfbWdj
Z[\ehcWj_ediZkh_d]cWij_YWj_ed$7iWfh[h[gk_i_j[\eh
j^_i[bWij_Y_jo"j^[_cfbWdjickij"Xoj^[_hijhkYjkhWb
Z[i_]d" Wbbem j^_Ya[d_d] _d Wh[Wi j^Wj Wh[ Wj h_ia
e\ \hWYjkh[$ J^[ cWij_YWjeho beWZi Wh[ jhWdic_jj[Z
WdZ Z_ijh_Xkj[Z j^hek]^ j^[ h_d] ijhkYjkh[ e\ 8E?
Z[i_]di$?j_ij^[h[\eh[_cfehjWdjj^WjWdofhe`[Yj_d]
h_d]i[]c[djiWh[dejYkje\\WdZj^kiZ_ihkfj[Z"Wi
j^_i mekbZ ]_l[ h_i[ je f[Wa ijh[ii[i Wbed] j^[ h_d]
ikh\WY[" j^ki fh[fWh_d] j^[ ]hekdZ \eh eij[eboi_i$
7do X[dZ_d] e\ h_d] ijhkYjkh[i m_bb Wbie _d\bk[dY[
j^[cWj[h_WbWdZ"_dj^[bed]hkd"W\\[Yjj^[Wbj[hdWj[
\b[nkhWbijh[d]j^e\j^[_cfbWdj$
J^[ <;C ijkZ_[i fh[i[dj[Z _d ^_i Y^Wfj[h
ikXijWdj_Wj[ ekh YbW_c j^Wj j^[ XWiWb fbWj[i e\ 8E?
_cfbWdji Wh[ dej _d\b[n_Xbo WdY^eh[Z _d j^[ [deiiWb
ifWY[XkjY^WhWYj[h_p[ZXoh[i_b_[djX[^Wl_ekh$
)&& 9^Wfj[h('È -ECHANICSÈ-EETSÈ"IOMECHANICS

&IGÈ <eh X[jj[h \ehY[ Z_ijh_Xkj_ed jemWhZi j^[ hekdZ[Z

&IGÈ Bed]_jkZ_dWb Z_ibeYWj_ed &$',(cc$ J^[ cWn_ckc i_Z["j^[i[YedZm[XXWh_ieh_[dj[Zbed]_jkZ_dWbbo
\ehY[ Z[f[dZi ed j^[ ][ec[jho e\ j^[ i[b[Yj[Z d[jmeha$ J^[
kff[h _cfbWdj i[]c[dji _i" ^em[l[h" ceh[ h_]_Z j^Wd j^[
bem[h WdZ bWh][h \hWc[meha i[]c[dj$ Dej[ j^Wj Wd el[hbo
h_]_ZZ[i_]djemWhZij^[Y[djh[e\j^[m[XXWhicWom[Wa[d
j^[ f[h_f^[hWb h_d] ijhkYjkh[i" fWhj_YkbWhbo m^[d j^[ XWiWb
_cfbWdjX[Z_iWiocc[jh_YWb

&IGÈ Jme jhWdil[hiWb m[X XWhi h[ikbj _d ]eeZ \b[nkhWb

Z_ijh_Xkj_ed_\j^[bed]_jkZ_dWb\ehY[ijemWhZij^[m[XXWhWh[
hejWj_edWbikf[he#_d\[h_ehZ_ibeYWj_ed_dj^_i]hWf^$J^[m[X
XWhiWh[b[iih[i_ijWdjje\ehY[ijhWl[bb_d]bWj[hWbbo_$[$\hecj^[
b[\jjej^[h_]^j_dj^_i]hWf^

&IGÈ ?cfbWdj Z[i_]di \[Wjkh_d] j^h[[ m[X XWhi ^Wl[

X[[dZ[l[bef[ZWim[bb$J^[_hcW_dWZlWdjW][_ij^Wjj^[oWh[
h[i_ijWdjje_cfWYj#h[bWj[Zjehi_ed
È È 7EBÈ"ARÈ$ESIGNÈANDÈ3TRESSÈ$ISTRIBUTIONÈ )&'

A B

&IGÈAB Ijh[iiZ_ijh_Xkj_ededWd;:7I/%'*=-_cfbWdj_dded#beWZ[Zl[hikibeWZ[ZYedZ_j_ed$J^[_cfbWdj_iWiikc[Zje

X[X_bWj[hWbboWdY^eh[Z_dXed[i[[WbieL_Z[e)\ehH[WbFbWo[hedj^[[dYbei[Z:L:

7bieYedi_Z[hj^[\ebbem_d]fe_djim_j^h[]WhZje h[ij$ J^[i[ Z_\\[h[dY[i cWo [l[d X[ WffWh[dj _d

kd_bWj[hWbbo\bWjZ[i_]di$ j[hcie\hWZ_efWY_jo$
v M^_b[ j^[ hekdZ i_Z[ e\ j^[ XWiWb fbWj[ b[\j v Iec[j_c[i j^[ h_d] cWo dej X[ [cX[ZZ[Z _d
i_Z[ _d <_]$('$'& m_bb X[ WdY^eh[Z _d W i_d]b[ X_eZodWc_YWbbo iodY^hed_p[Z Xed[ ijhkYjkh[i
^ece][d[eki Xed[ Wh[W" j^[ \bWj i_Z[ ed j^[ Wbed] _ji [dj_h[ ikh\WY[$ J^[i[ i_jkWj_edi Wh[
h_]^jcWoYel[hWh[Wie\lWho_d]c_d[hWb_pWj_ed$ Y^WhWYj[h_p[ZXoh[ZkY[Zc_d[hWb_pWj_edWim[bb$
J^_i _i jof_YWbbo j^[ YWi[ _d j^[ fei_j_edi e\ j^[ v½ J^[ &Ä' fhef[hjo e\ j^[ Xed[ _i dej [l[dbo
\_hij WdZ i[YedZ fh[cebWhi" m^[h[ j^[ Wdj[h_eh Z_ijh_Xkj[Z Wbed] j^[ XWiWb fbWj[i e\ bWh][h
i_Z[e\j^[_cfbWdjYec[ijeX[beYWj[Z_dWdWh[W _cfbWdji"[_j^[h$
e\ ]h[Wj[h ijWX_b_jo j^Wj _i c[Y^Wd_YWbbo ceh[ Wj
  ¬ 
#(!04%2È

0RIMARYÈ!UGMENTATIONÈÈ
5SINGÈ"/)È)MPLANTS
5
.BJFS
7
,POTUBOUJOPWJD
BOE
4
*IEF

j_iik[i" [if[Y_Wbbo _\ j^[ _cfbWdj _i _d_j_Wbbo ceX_b[

È Ä iec[j^_d] j^Wj cWo YWki[ fWj_[dji Yedi_Z[hWXb[
)NTRODUCTION Z_iYec\ehj$ IcWbb[h Z_ia Z_Wc[j[hi Wh[ Z_\\_Ykbj je
X[dZWdZWffei[jej^[Wbl[ebWhh_Z][m_j^ekjhkdd_d]
8WiWb eii[e_dj[]hWj[Z _cfbWdji Wh[ Z[i_]d[Z ikY^ Wh_iae\\hWYjkh_d]j^[h[if[Yj_l[`Wmi[]c[dj$
j^Wjj^[oW\\ehZefj_ckcWdY^ehW][ehh[j[dj_ed\eh
Z[djWb h[ijehWj_edi [l[d _d j^[ i[l[h[bo Wjhef^_[Z
cWn_bbW eh cWdZ_Xb[$ 7do Wk]c[djWj_ed c[Wikh[i È
m_j^ j^[ ieb[ eX`[Yj_l[ e\ ijWX_b_p_d] Wd _cfbWdj eh 0RIMARYÈ!UGMENTATIONÈ#LINICALÈ0ROCEDURE
_cfbWdji Wh[ j^[h[\eh[ kdd[Y[iiWho$ J^[ ikh]_YWb
fheY[Zkh[_if[h\ehc[ZWiWed[#ij[ffheY[Zkh[WdZ ?dj^[i[YWi[i"Wckbj_#_cfbWdjWffheWY^WiZ[iYh_X[Z
_ih[bWj_l[boded#jhWkcWj_Y$ _d9^Wfj[h-YWdX[h[Yecc[dZ[Z"m_j^WXekj^Wb\
D[l[hj^[b[ii" j^[h[ Wh[ i_jkWj_edi _d m^_Y^ e\j^[j^h[WZ[Zf_diWdY^eh[Z_dj^[Wbl[ebWhh_Z][$
Yedjhebb[ZXed[Wk]c[djWj_edcWoX[WdWZlWdjW][$ =_l[d j^[ if[Y_Wb i_jkWj_ed" j^[ i^W\j b[d]j^
M[ X[b_[l[ W lWb_Z _dZ_YWj_ed \eh Wk]c[djWj_ed je i[b[Yj[Z i^ekbZ X[ h[bWj_l[bo bWh][$ J^[ Z_iai e\ j^[
[n_ij _\ j^[ Z_c[di_edi e\ j^[ fWj_[djÉi cWn_bbW Wh[ 8E? _cfbWdj i^ekbZ X[ _di[hj[Z _dje j^[ Xed[ Wj
h[ZkY[Z bWj[hWbbo eh iW]_jjWbbo WdZ" m^_b[ _j YWd ij_bb b[Wij ^Wb\ mWo" _$[$ kf je j^[_h cWn_ckc Z_Wc[j[h$
WYYecceZWj[_cfbWdji"j^[h[m_bbX[deehWbceijde Ed[ iebkj_ed j^Wj ik]][iji _ji[b\ _i bWj[hWb h_Z][
ifWY[\ehj^[j^h[WZ[Zf_d$ Wk]c[djWj_ed$ J^[ Z[i_]d e\ j^[ 8E? _cfbWdji _i
J^[i[ h[i_ZkWb h_Z][i m_bb X[ Wbceij Yecfb[j[bo Wbceij_Z[Wb\ehWk]c[djWj_edfkhfei[i$
Yecfei[Z e\ Yehj_YWb Xed[" m_j^ YWdY[bbeki Xed[ J^[XkYYWbbo[nj[dZ_d]Z_iai[]c[djim_bbijWX_b_p[
Yecfb[j[bo WXi[dj$ Iec[j_c[i" Wbb j^Wj _i b[\j _i W j^[ Yedjekhi e\ j^[ Wk]c[dj[Z Wh[W f[h\[Yjbo Xo
i_d]b[ bWo[h e\ Yehj_YWb Xed[ j^Wj de bed][h Wbbemi ifWdd_d] j^[ f[h_eij[kc WYheii j^[ Wk]c[djWj["
Wdo Xed[ ifb_jj_d]$ J^[ EF= m_bb kikWbbo i^em W _d W cWdd[h h[c_d_iY[dj e\ j[dj feiji" h[b_WXbo fh[#
Xed[lebkc[j^Wji[[cijeX[_Z[WbÄWdZdejkdj_bW l[dj_d] j^[ YebbWfi[ e\ j^[ f[h_eij[kc Ä W fheY[#
9JiYWd_if[h\ehc[Zm_bbj^[\kbb[nj[dje\Wjhef^o Zkh[ ej^[hm_i[ [cfbeo[Z ki_d] j_jWd_kc c[i^$
X[Yec[ WffWh[dj$ J^_i _i j^[ ie#YWbb[Z ad_\[#[Z][ J^_i c[Wdi0 ?j _i dej Wk]c[djWj_ed j^Wj \WY_b_jWj[i
h_Z][$8ed[gkWb_jom_bbWbieX[_d\[h_eh_dceijYWi[i$ _cfbWdjWj_ed"Xkj_j_i8E?_cfbWdjij^WjYh[Wj[_Z[Wb
J^_ijof[e\Wjhef^_[Zh_Z][_ie\j[d\ekdZ_d\[cWb[ YedZ_j_edi\ehWk]c[djWj_ed$
fWj_[dji$ Feii_Xb[ Wbj[hdWj_l[i je 8E? _cfbWdji Wh[ ?j _i e\ Yekhi[ Wbie feii_Xb[ je _di[hj WZZ_j_edWb
_cfbWdjebe]_YWb bWj[hWb h_Z][ Wk]c[djWj_ed eh j^[ h[iehXWXb[c[cXhWd[iikY^WiF[h_ei("m^_Y^m_bbX[
ki[e\l[hoj^_dYecfh[ii_ediYh[mi$;l[die"j^[8E? Yecfb[j[boh[iehX[ZW\j[hW\[mm[[aii[[L_Z[e.$
_cfbWdjefj_edm_bbd[WhboWbmWoiij_bbX[WlW_bWXb[_d Ej^[hfhWYj_Y_Wdi^Wl[ki[Z\_Xh_dc[cXhWd[ij^[o
fh_dY_fb["Wibed]Wij^[if[Y_\_YfheXb[cih[bWj[Zje eXjW_d[Z Xo Y[djh_\k]_d]" c[cXhWd[i j^Wj YWd X[
j^_iYedZ_j_edWh[iebl[Z$ [dh_Y^[Zm_j^8#J9F$
?\ j^[ Ykj cWZ[ \eh j^[ j^h[WZ[Z f_d _i [nj[dZ[Z ?d ehZ[h je [d^WdY[ j^[ lWiYkbWh_pWj_ed e\ j^[
jee \Wh fWbWjWbbo" j^[ ZWd][h e\ \hWYjkh[ YWki[Z Wk]c[djWj_ed X[Z WdZ je Yh[Wj[ ifhekj_d] h[]_edi
Xo Yecfb[j[ i[Yj_ed_d] e\ j^[ Wbl[ebWh h_Z][ _i \ehj^[beYWbXed[ikXijWdY["j^[ikhhekdZ_d]Yehj_YWb
Yedi_Z[hWXb[ Wbl[ebWh Zemd\hWYjkh[$ ?d WZZ_j_ed" j_iik[ i^ekbZ h[Y[_l[ ckbj_fb[ f[h\ehWj_edi$ 8ed[
j^[ _cfbWdji c_]^j X[ fei_j_ed[Z l[ho \Wh fWbWjWbbo" h[fbWY[c[dj cWj[h_Wb eh Wkjebe]eki Xed[ WjjWY^[Z
m^_Y^ cWo bWj[h h[ikbj _d Yedi_Z[hWXb[ h[ijehWj_l[ ki_d] j^[ FHF fbWj[b[j#h_Y^ fbWicW j[Y^d_gk[ YWd
fheXb[ci$9edl[hi[bo"_\j^[beYWj_ede\j^[j^h[WZ[Z X[ WZWfj[Z X[jm[[d j^[ _cfbWdj Z_iai e\ ZekXb[ eh
f_d _i ed j^[ XkYYWb e\ j^[ h_Z][" fh_cWho ijWX_b_jo jh_fb[8E?_cfbWdjikfjej^[m_Zj^e\j^[l[ij_XkbWh
cWoe\j[dX[jeem[Wa$ Z_ia[Z][$7dej^[hc[j^eZj^Wj^Wifhel[d_jilWbk[
7 fhedekdY[Z [nY[ii eh el[hbWf e\ j^[ 8E? Z_ia _iWc[cXhWd[e\Wkjebe]eki\_Xh_d\ehYel[h_d]j^[
cWo YWki[ fW_d Zk[ je _hh_jWj_ed e\ j^[ f[h_eij[Wb Wk]c[djWj[$
)&* 9^Wfj[h((È 0RIMARYÈ!UGMENTATIONÈ5SINGÈ"/)È)MPLANTS
&IGÈ 7\j[h_di[hj_ede\Wjh_fb[8E?_cfbWdj"bWh][fehj_edi
e\j^[Yh[ijWbZ_iaih[cW_dekji_Z[j^[Xed[
&IGÈ J^[Z[\[YjYWdX[Ybei[Zm_j^Wc_njkh[e\W\_Xh_d
c[cXhWd[WdZ8#J9F$7fWhWYh[ijWb_dY_i_ed_ih[Yecc[dZ[Z
je[dikh[j^Wjj^[i_j[_ij_]^jboYbei[Z
J^[ ckYef[h_eij[Wb \bWf _i ikjkh[Z _dje fbWY["
cWa_d] ikh[ j^Wj de _dj[hdWb j[di_ed _i Yh[Wj[Z1
iec[j_c[ij^[\bWfm_bb^Wl[jeX[ceX_b_p[Zib_]^jbo
\hecXWiWbbo$M_j^Y_hYkbWh_di[hj_edWdZ_dj[]hWj_ed
_dje Yecfb[j[ \_n[Z Z[djkh[i" j^[ _cfbWdji cWo X[
beWZ[Z _cc[Z_Wj[bo$ J^_i _i m^o W \_n[Z bed]#j[hc
fhel_i_edWbh[ijehWj_ed_i_di[hj[Zl[hoieed$
J^[fheY[Zkh[`kijZ[iYh_X[ZYWdWbieX[ki[Z\eh
jme#mWbb Xedo Z[\[Yji \ebbem_d] j^[ [njhWYj_ed e\
f[h_eZedjWbboYecfhec_i[ZcWn_bbWhocebWhi$>[h["
jeej^[_cfbWdjZ_iaim_bbfh[l[djj^[Wk]c[djWj[\hec
YebbWfi_d]$ J^[ h_]_Z F[h_ei( c[cXhWd[ c[dj_ed[Z
_i ik_jWXb[ \eh j^_i _dZ_YWj_ed Wi m[bb" iWl_d] j^[
fWj_[dj j^[ _dYedl[d_[dY[ e\ XbeeZ m_j^ZhWmWb \eh
j^[fheZkYj_ede\\_Xh_dc[cXhWd[i$
&IGÈ 7 feii_Xb[ Wbj[hdWj_l[ je \_bb_d] m_j^ \_Xh_d c[c#
XhWd[i_ij^[fbWY[c[dje\Wh_]_Z>7%febobWYj_Z[c[cXhWd["
\ebbem[Z Xo \ebZ_d] XWYa j^[ ckYef[h_eij[Wb \bWf L_Z[e .$
J^[ Wk]c[djWj_ed fheY[Zkh[ cWo X[ f[h\ehc[Z Wbie Wj Wdo
j_c[ bWj[h" W\j[h j^[ _cfbWdj _i _dj[]hWj[Z$ ?d j^[ YWi[ i^emd
^[h["Wk]c[djWj_ed_iWdefj_ed
&IGÈ ?\"\ehh[Wiedie\ifWY[ehX[YWki[j^[h[i_ZkWbh_Z][
_i jee icWbb" j^[ j^h[WZ[Z f_d _i dej Yel[h[Z Xo dWj_l[ Xed["
fbWY[c[dj e\ W c[cXhWd[ _i d[Y[iiWho je fh[l[dj j^[ ie\j
j_iik[i \hec ]hem_d] _dje j^[ ifWY[ X[jm[[d j^[ j^h[WZ[Z
f_dWdZj^[eh_]_dWbYehj_YWbXed[$?diec[YWi[iÄ[if[Y_Wbbo
_d j^[ Z_ijWb cWdZ_Xb[ Ä j^[ j^h[WZ[Z f_d cWo hkd fWhWbb[b
je j^[ h_Z][ ekji_Z[ j^[ ckYeiW YecfWh[ 9Wi[ IjkZo + _d
9^Wfj[h'*
È
#ONCLUSION
<ebbem_d] [WY^ ikh]_YWb fheY[Zkh[ _dlebl_d] j^[
Xed[" h[WYj_l[ ^of[h[c_W WdZ ikXi[gk[dj WXiebkj[
h[ZkYj_ed e\ j^[ XbeeZ \bem ckij X[ [nf[Yj[Z$ J^[
bWjj[h m_bb b[WZ je W ib_]^j Wjhef^o e\ j^[ `WmXed[
kdb[ii\kdYj_edWbeh^ehcedWbij_ckbWj_edi^_\jj^[
ÆXed[ XWbWdY[Ç$ J^[ _di[hj_ed e\ Xed[ h[fbWY[c[dj
cWj[h_Wb WdZ j^[ fbWY[c[dj e\ c[cXhWd[i cWo
^Wl[Wfei_j_l[_d\bk[dY[edj^[el[hWbbXWbWdY[\ehW
b_c_j[Zf[h_eZ$Dej[Wbiej^WjWk]c[dj[ZWh[WicWo
cWjkh[jeX[Yec['#Wh[WiWim[bb"m^_Y^cWoY^Wd][
j^[ijWj_YXWbWdY[e\j^[cWij_YWjeho^WhZj_iik[i$
È È #ONCLUSIONÈ )&+

A B

&IGÈÈA <ebbem_d]_di[hj_ede\WZekXb[#Z_ia8E?_dj^[cWdZ_Xb["j^[Yh[ijWbZ_ia_iXWh[boYel[h[Zm_j^Xed[$7bj^ek]^ed[
mekbZ[nf[Yjj^[Xed[jekbj_cWj[boYel[hj^[[nfei[ZfWhje\j^[Z_iaWbbXo_ji[b\Zk[jej^[ij_ckb_YWki[ZXoh[]kbWh\kdYj_ed"
iec[fhWYj_Y_Wdifh[\[hYel[h_d]j^[eij[ejecoibeji$7ffb_YWj_ede\femZ[heh]hWdkbWj[\hecjh_YWbY_kcf^eif^Wj[\hecj^[
f^WhcWYocWo[d^WdY[j^[h[][d[hWj_ede\Xed[$CWdoki[hifh[fWh[\_Xh_dc[cXhWd[i\hecj^[fWj_[djÉiemdXbeeZ$J^[i[
c[cXhWd[i YedjW_d FHF WdZ fhel_Z[ fhej[Yj_ed \eh j^[ Xed[ W]W_dij j^[ [Whbo _d]hemj^ e\ ie\j j_iik[i$ <_Xh_d c[cXhWd[i
Wh[ m[bb \kdYj_ed_d] WdZ W Y^[Wf Wbj[hdWj_l[ je ej^[h c[cXhWd[i e\ Wbb a_dZi" m^_Y^ Wh[ e\\[h[Z Xo j^[ Z[djWb _dZkijho WdZ
h[Yecc[dZ[ZXoj^[kd_l[hi_j_[i$A[[f_dc_dZj^WjWdoWZZ_j_edWb\eh[_]dcWj[h_WbfbWY[Z_dj^[^kcWdXeZoc_]^jX[j^[
YWki[e\_d\[Yj_ed$ B ?dj^[fh[i[djYWi["h[iehXWXb[jh_YWbY_kcf^eif^Wj[mWiki[Z\ehYel[hW][$J^[_djheZkYj_ede\ded#
h[iehXWXb[cWj[h_Wbi_djej^[cWdZ_Xb[_idejh[Yecc[dZ[ZX[YWki[j^[h[_iWh_iaj^Wjj^[cWj[h_Wbc_]^jc_]hWj[jemWhZj^[
c[djWbd[hl["m^[h[_jYWdYWki[bWij_d]fWhW[ij^[i_Wi$ C 7iWdWbj[hdWj_l[jej^[_djheZkYj_ede\Xed[h[fbWY[c[djcWj[h_Wb"W
h[iehXWXb[c[cXhWd[YWdX[ijh[jY^[ZWYheiij^[j^h[WZ[Zf_dWdZfbWY[ZbWj[hWbboel[hj^[eij[ejecoibeji$Dej[j^Wjj^[ibeji
m_bbZ[\_d_j_l[boYbei[m_j^ekjj^ei[c[Wikh[i_dj^[YWi[i^emd^[h[m_j^j^[XWi[#fbWj[iX[_d]Yel[h[ZXodWj_l[Xed[
  ¬ 
#(!04%2È

(ISTOLOGYÈOFÈ"/)È)MPLANTS

^kcWd eh_]_d WdZ eXjW_d[Z fkh[bo Xo Y^WdY[1 j^[

È cW`eh_jo m[h[ eXjW_d[Z Xo Z[i_]d[Z [nf[h_c[dji
(ISTOLOGICALÈ3TUDIES \hecZe]i$

È
È
(ISTOLOGICALÈ!NALYSISÈOFÈ(UMANÈ%XPLANTÈ3PECIMENS
)NTRODUCTION
J^[ \ebbem_d] f_Yjkh[i <_]i$()$'" ()$( m[h[ jWa[d
\hechWdZecboYebb[Yj[Z^kcWd[nfbWdjif[Y_c[di
>_ijebe]_YWb ijkZ_[i e\\[h lWbkWXb[ _di_]^ji$ I_dY[ W \ebbem_d]h[celWbe\Wd;:7#jof[_cfbWdj\[Wjkh_d]
]h[WjcWdo^_ijebe]_YWbijkZ_[i^Wl[X[[dfkXb_i^[Z W h_XX[Z WdZ iWdZXbWij[Z j^h[WZ[Z f_d \eh ikh\WY[
_dj^[\_[bZe\Yh[ijWb_cfbWdjebe]o"_jmWiWdeXl_eki [dbWh][c[dj$
WffheWY^ je ][d[hWj[ Yehh[ifedZ_d] ZWjW \eh 8E?
_cfbWdjiWim[bb$
J^[ \ebbem_d] _iik[i m_bb X[ Z_iYkii[Z _d j^_i
jh_fWhj_j[Y^Wfj[h0
v >em lWbkWXb[ Wh[ ^_ijebe]_YWb ZWjW \hec Wd_cWb
[nf[h_c[dji"WdZZej^[oh[fh[i[djj^[i_jkWj_ed
_d j^[ ^kcWd `Wmi5 Je WZZh[ii j^_i gk[ij_ed"
m[ YecfWh[Z j^[ ^_ijebe]_YWb Y^WhWYj[h_ij_Yi e\
if[Y_c[dieXjW_d[Z\hecZe]iWdZ^kcWdi$
v ?i j^[ ijWXb[ _dj[]hWj_ed e\ 8E? _cfbWdji h[Wbbo
fhel_Z[ZXoYehj_YWbikffehj"eh_ij^[Xed[WXb[je
[ijWXb_i^YedjWYjjeej^[h_cfbWdji[]c[dji_dj^[
feijef[hWj_l[f^Wi[5?\ie"m^WjWh[j^[YedZ_j_edi
\eh j^_i je ^Wff[d5 >em YWd j^[ h[bWj_l[bo icWbb &IGÈ J^_i;:7_cfbWdjh[l[WbiXed[WYYkckbWj_edWbed]
_ji XWiWb WdZ bWj[hWb ikh\WY[i kf je X[bem j^[ \_hij h_X e\ j^[
beWZ#jhWdic_jj_d] ikh\WY[i e\\[h WZ[gkWj[ j^h[WZ[Z f_d$ J^[ jejWb Xed[ ^[_]^j WXel[ j^[ _cfbWdj Z_ia
ijWX_b_jo5 Je m^Wj [nj[dj Ze[i eii[e_dj[]hWj_l[ mWi WhekdZ (Ä)cc$ J^[ Z_ia mWi beYWj[Z `kij WXel[ j^[
^[Wb_d]e\j^[_cfbWdjZ[f[dZedZ_h[Yjfh_cWho cWn_bbWhoi_dki
YedjWYjX[jm[[d_cfbWdjWdZXed[5
v M^[h[ _i Xed[ h[ceZ[bb_d] jWa_d] fbWY[ Wj j^[
j_c[e\if[Y_c[dYebb[Yj_ed_$[$edY[j^[_cfbWdj
_im[bb_dj[]hWj[ZWdZ^WiX[[d_dYb_d_YWbi[hl_Y[
\eh W bed] j_c[5 :e 8E? _cfbWdji ij_ckbWj[
h[ceZ[bb_d]_dceh[h[cej[Xed[Wh[Wi"eh_ij^[
[\\[YjYed\_d[Zje_ji_cc[Z_Wj[ikhhekdZ_d]i5
v :e 8E? _cfbWdji Z_\\[h _d Wdo mWo \hec iYh[m
_cfbWdjiYedY[hd_d]j^[h[ifedi[je0
Ä Den_eki W][dji _djheZkY[Z Zkh_d] j^[ fheY[#
Zkh[5
Ä Fh[#[n_ij_d]_d\bWccWj_edi5

È
(ISTOLOGICALÈ3PECIMENS
7dkcX[he\^_ijebe]_YWbif[Y_c[diWiieY_Wj[Zm_j^
8E?_cfbWdjim[h[WdWboi[Z$Jmeif[Y_c[dim[h[e\
&IGÈ 9[djhWb fehj_ed e\ j^[ m[X XWh e\ j^[ iWc[
_cfbWdj$ 7]W_d" l_hjkWbbo j^[ [dj_h[ ikh\WY[ Wh[W _i f[h\[Yjbo
eii[e_dj[]hWj[Z
)&. 9^Wfj[h()È (ISTOLOGYÈOFÈ"/)È)MPLANTS

J^[d[njif[Y_c[d<_]$()$)_iWl[ij_XkbWhh_d]
i[]c[dj e\ Wd ;:7I _cfbWdj j^Wj mWi h[cel[Z
W\j[hWhekdZ'o[Whe\Yb_d_YWbi[hl_Y[_dj^[fei_j_ed
e\ jeej^ )- c[i_eZ_ijWb l_[m$ Edbo j^[ ikh\WY[#
[dbWh][Zfehj_ede\j^[h_d]mWi[nfbWdj[Z$
Jme ^kcWd [nfbWdj if[Y_c[di [n^_X_j[Z Z_h[Yj
YedjWYje\j^[ikhhekdZ_d]Xed[ijhkYjkh[m_j^j^[
_cfbWdji$ ?d ed[ YWi[" j^[ ikh\WY[#[dbWh][Z fehj_ed
e\ j^[ j^h[WZ[Z f_d h[l[Wb[Z Z_h[Yj Xed[ YedjWYj
Wi m[bb$ 8ej^ \_dZ_d]i Ä _$[$ Z_h[Yj eii[e_dj[]hWj_ed
Wbed] j^[ h_d] ijhkYjkh[i" _dYbkZ_d] j^[ m[X XWhi"
WdZWbed]j^[ikh\WY[#[dbWh][Zi^W\jfehj_ediÄm[h[
Yedi_ij[djm_j^j^[^_ijebe]_YWb\_dZ_d]ieXjW_d[Z_d
Wd_cWbif[Y_c[di$

È &IGÈ <kbbo eii[e_dj[]hWj[Z h_d] Z_ia Wh[W$ J^[ Z_ijWdY[

(ISTOLOGICALÈ!NALYSISÈOFÈ!NIMALÈ3PECIMENS
J^[^_ijebe]_YWbif[Y_c[di_bbkijhWj[Z_dj^[\ebbem_d]
fWhW]hWf^i ^WZ X[[d Yebb[Yj[Z '*Ä'.m[[ai W\j[h
_cfbWdjWj_ed$ J^[ [nf[h_c[dji ^WZ eh_]_dWbbo X[[d
f[h\ehc[Z je [lWbkWj[ Xed[ \ehcWj_ed fWjj[hdi ed
8E?_cfbWdjie\Z_\\[h[djikh\WY[jof[i$
7jejWbe\\_l[Ze]i^WZX[[djh[Wj[Zm_j^_cfbWdji
\ehj^_ifkhfei[$7bbWd_cWbim[h[(&Ä(+cedj^iebZ
Wjj^[j_c[e\_cfbWdjWj_ed"j^Wj_i"Wbbe\j^[cm[h[
\kbbo ]hemd$ J^[ fh[cebWhi e\ Wbb Ze]i ^WZ X[[d
h[cel[Z)cedj^iX[\eh[j^[fheY[Zkh[$?ded[YWi["
j^[ ^eh_pedjWb fehj_edi e\ j^[ bem[h YWd_d[i m[h[
b[\j _d fbWY[ _d ehZ[h je i_ckbWj[ _cfbWdj#_dZkY[Z
_djhWXedojeej^jhWkcWWdZjel[h_\o^emj^[j_iik[
h[WYjijeikY^jhWkcW$
:e]i'WdZ(m[h[jh[Wj[Zm_j^j^h[[8E?_cfbWdji
[WY^ ed j^[ b[\j i_Z[ e\ j^[ `Wm$ J^[ jme Wdj[h_eh
_cfbWdji m[h[ _cc[Z_Wj[bo beWZ[Z m_j^ c[jWbb_Y
YhemdXbeYai"m^_b[j^[j^_hZ_cfbWdjmWib[\jm_j^ekj
h[ijehWj_ed<_]$()$*$
<khj^[hceh[" j^h[[ ieb_Z iYh[m _cfbWdji 7bb\_j"
IJ? m[h[ _di[hj[Z ed j^[ h_]^j i_Z[ e\ j^[ `Wm \eh
YecfWh_ied" W]W_d \ebbem[Z Xo _cc[Z_Wj[ beWZ_d]
e\ j^[ jme Wdj[h_eh _cfbWdji m_j^ c[jWbb_Y Yhemd
XbeYai$ :k[ je Wd [hheh Xo j^[ ikh]_YWb j[Wc" j^[
_cfbWdjX[Zi_dZe](m[h[fh[fWh[Zm_j^j^[iWc[
X[jm[[d j^[ j_jWd_kc WdZ j^[ Xed[ ijhkYjkh[ mWi fheZkY[Z
Whj_\_Y_Wbbo Zkh_d] j^[ fheY[ii e\ \_nWj_ed WdZ Zho_d]$ J^[
i[YedZWhoeij[edim[h[Z_W]edWbboYkj_dWYYehZWdY[m_j^j^[
fh_dY_fb[Z_h[Yj_ede\beWZjhWdic_ii_ed_dj^[cWdZ_Xb[
_dijhkc[djij^Wj^WZX[[dki[Z_cc[Z_Wj[boX[\eh[_d
Ze]'$J^[_cfbWdji_j[i_dZe](m[h[j^[h[\eh[ceh[
YedjWc_dWj[ZWdZb[iiij[h_b[\ebbem_d]fh[fWhWj_ed$
J^[_cfbWdjif[Y_c[die\Xej^Ze]im[h[Yebb[Yj[Z
*cedj^iW\j[h_cfbWdjWj_ed<_]i$()$*Ä()$,$
7dej^[h _cfbWdj#j_iik[ if[Y_c[d Ze] ) mWi
eXjW_d[ZW\j[hWdkdbeWZ[Zieb_ZiYh[m_cfbWdj7bb\_j"
IJ?^WZX[[d_di[hj[ZjeijkZoXed[h[][d[hWj_ed$?d
WZZ_j_ed"WXed[Z[\[YjmWi_dZkY[Zedj^[l[ij_XkbWh
Wif[YjX[bemj^[_cfbWdjYebbWh"iej^Wjed[#j^_hZe\
j^[ _cfbWdj ikh\WY[ mWi Z[dkZ[Z$ J^[ ikXi[gk[dj
c[cXhWd[#XWi[Z Wjj[cfj Wj Wk]c[djWj_ed Z_Z dej
_d\bk[dY[ j^[ h[][d[hWj_l[ fheY[ii _d W i_]d_\_YWdj
mWo$J^[if[Y_c[di\hecj^_iWd_cWbm[h[Yebb[Yj[Z
)cedj^iW\j[h_cfbWdjWj_ed<_]$()$-$
De Wdj_X_ej_Yi m[h[ ki[Z Zkh_d] j^[ fheY[Zkh[$
J[jhWYoYb_d[ _$l$ mWi WZc_d_ij[h[Z Wi W bWX[b 'm[[a
X[\eh[if[Y_c[dYebb[Yj_ed$

&IGÈ BWj[hWbhWZ_e]hWf^e\WZe]Éi
cWdZ_Xb[m_j^8E?_cfbWdji_dfbWY[$
7bb_cfbWdjZ_iai\[Wjkh[WZ_Wc[j[he\
'&cc$J^[Z_ia#je#Z_iaZ_ijWdY[e\j^[
b[\j_cfbWdj_i)cc
È È (ISTOLOGICALÈ3TUDIESÈ
&IGÈ :e]Éi cWdZ_Xb[ m_j^ j^h[[ _cfbWdji ed [WY^ i_Z[
e\ j^[ `Wm$ J^[ fh[i[dY[ e\ Wjjh_j_ed ed j^[ c[jWbb_Y Yhemd
h[ijehWj_edi _dZ_YWj[i j^Wj j^[ _cfbWdji m[h[ ikX`[Yj[Z je
WZ[gkWj[\kdYj_edWbbeWZ_d]
&IGÈ J^[Z_iaie\j^[Wdj[h_eh_cfbWdjfhe`[Yj[Z\hecj^[
l[ij_XkbWh Xed[ ikh\WY[ \ebbem_d] _di[hj_ed$ J^_i i_jkWj_ed _i
gk_j[YeccedboeXi[hl[Z_d^kcWdfWj_[djiWim[bb
8ed[XbeYaiYedjW_d_d]j^[_cfbWdjim[h[Yebb[Yj[Z
\eh ^_ijebe]_YWb WdWboi_i" Zh_[Z ki_d] [ijWXb_i^[Z
j[Y^d_gk[i" WdZ [cX[ZZ[Z _d feboc[j^WYhobWj[$ Kf
je i_n ]hekdZ i[Yj_edi \eh [WY^ 8E? _cfbWdj" WdZ
ed[ i[Yj_ed \eh [WY^ iYh[m _cfbWdj" m[h[ eXjW_d[Z
Fb[dYa'/.,$
7bbiYh[m_cfbWdji\[Wjkh[ZWiWdZXbWij[Z[deiiWb
ikh\WY[$ J^[ 8E? _cfbWdji \hec Ze] ' m[h[ i^ej#
f[[d[Zkdj_bj^[ikh\WY[im[h[f[h\[Yjboiceej^$?d
Ze]("j^[beWZ#jhWdic_jj_d]ikh\WY[mWi[dbWh][Zkf
je j^[ XehZ[h e\ j^[ j^h[WZ[Z f_d m_j^ Wbkc_d_kc
en_Z[$
?dZe]i*WdZ+"_cfbWdjim[h[fbWY[ZXej^_dj^[
cWn_bbWWdZ_dj^[cWdZ_Xb[$Iec[_cfbWdji[]c[dji
m[h[beYWj[ZWbed]j^[cWn_bbWhoi_dki$7bb_cfbWdji
_dZe]i)WdZ*m[h[_di[hj[ZkdYb[Wd[ZkdZ[hded#
ij[h_b[ YedZ_j_edi$ ?d Ze] *" jhWdieii[eki b_]Wjkh[i
)&/
&IGÈ IYh[m _cfbWdj _d j^[ cWdZ_Xb[ W\j[h ded#beWZ[Z
^[Wb_d]
&IGÈ J^_i f_Yjkh[ _bbkijhWj[i ^em Yeff[h b_]Wjkh[i WdZ
fbWij_Y Yel[hi m[h[ Wffb_[Z je eXijhkYj ZhW_dW][ YedZ_j_edi
_dj^[cWdZ_Xb[e\Ze]*"j^ki_dZkY_d]i[l[h[eij[eco[b_j_i
WiieY_Wj[Zm_j^Xed[d[Yhei_i
m[h[ fbWY[Z j^Wj _dZkY[Z cWii_l[ _d\bWccWj_ed e\
j^[Wbl[ebWhckYeiWWdZj^[cWdZ_XkbWhXed[$
J^_i [nf[h_c[dj mWi Z[i_]d[Z je _dl[ij_]Wj[
m^[j^[hj^[]eeZ^[Wb_d]h[ikbjieXjW_d[ZW\j[hded#
ij[h_b[_di[hj_ede\8E?_cfbWdjij^[\_hijj_c[WhekdZ
mWiWhWdZecehioij[cWj_Y\_dZ_d]$7dej^[hfkhfei[
mWi je \_dZ ekj m^[j^[h eii[e_dj[]hWj_l[ ^[Wb_d] e\
8E?_cfbWdji_dZe]iYWdX[fh[l[dj[ZWjWbb$
È
(ISTOLOGICALÈ2ESULTSÈFORÈ"/)È)MPLANTS
7bb _cfbWdji j^Wj ^WZ X[[d _di[hj[Z kdZ[h ij[h_b[
YedZ_j_ediWdZ_cc[Z_Wj[bobeWZ[Zm[h[WiieY_Wj[Z
m_j^ Yecfh[^[di_l[ ceZ[bb_d]$ 7ced] j^[ 8E?
_cfbWdji" j^_i ceZ[bb_d] mWi Wbceij [nYbki_l[bo
eXi[hl[Zedj^[b_d]kWbi_Z[$
)'& 9^Wfj[h()È (ISTOLOGYÈOFÈ"/)È)MPLANTS
J^[ 8E? _cfbWdji j^Wj ^WZ X[[d _di[hj[Z _d
Ze] ( kdZ[h ded#ij[h_b[ YedZ_j_edi m[h[ \ekdZ je
X[ [gkWbbo m[bb eii[e_dj[]hWj[Z Wi j^[ _cfbWdji
_d Ze] '$ J^[ h[ceZ[bb_d] fheY[ii[i Yh[ijWbbo je
j^[ _cfbWdj Z_ia m[h[" ^em[l[h" ikXijWdj_Wbbo ceh[
Yecfh[^[di_l[ W\j[h ded#ij[h_b[ _di[hj_ed$ B_d]kWb
h[ceZ[bb_d]" Xo YedjhWij" mWi c_d_cWb _d _d\[Yj[Z
i_j[i <_]$()$'-$ M^_b[ j^[ fheY[ii e\ Xed[ ^[Wb_d]
mWi WffWh[djbo ibem[h W\j[h ded#ij[h_b[ _di[hj_ed"
Ybei[ eii[eWZWfjWj_ed e\ j^[ beWZ#jhWdic_jj_d]
_cfbWdj i[]c[dji mWi d[l[hj^[b[ii WY^_[l[Z _d
fh_dY_fb[$
J^[ Xkbao _cfbWdj XeZo _di[hj[Z kdZ[h ij[h_b[
YedZ_j_edi Wbie \W_b[Z je _dZkY[ ikXf[h_eij[Wb
ceZ[bb_d] _d j^[ fh[cebWh Wh[W e\ j^[ cWdZ_Xb[ _d
j^[WXi[dY[e\_cc[Z_Wj[beWZ_d]$
È
(ISTOLOGICALÈ2ESULTSÈFORÈ#RESTALÈ)MPLANTS
J^[ _cc[Z_Wj[bo beWZ[Z iYh[m _cfbWdji m[h[
WiieY_Wj[Z m_j^ Xej^ b_d]kWb WdZ l[ij_XkbWh
ceZ[bb_d]$ 7ffei_j_edWb b_d]kWb ceZ[bb_d] mWi
ceh[ fhedekdY[Z" ^em[l[h$ J^[ Yh[ijWb _cfbWdji
m[h[ WiieY_Wj[Z m_j^ h[ceZ[bb_d] ed j^[ l[ij_XkbWh
bed]_jkZ_dWb i_Z[ e\ j^[ _cfbWdj" m^_b[ b_d]kWb
h[ceZ[bb_d]YecfWh[Zjej^[fh[ef[hWj_l[i_jkWj_ed
mWibWh][boWXi[dj$
7i [nf[Yj[Z" de eii[e_dj[]hWj_ed mWi eXi[hl[Z
m_j^ j^[ Yh[ijWb _cfbWdji j^Wj ^WZ X[[d _di[hj[Z
kdZ[hded#ij[h_b[YedZ_j_edi\ebbem[ZXo_cc[Z_Wj[
beWZ_d]$J^[`Wmi[]c[dji_dgk[ij_edZ_Zdejh[l[Wb
WdoikXf[h_eijWbceZ[bb_d]$?d\WYj"j^[h[mWi^WhZbo
Wdo e\ j^[ fh[#[n_ij_d] eij[edWb Xed[ ijhkYjkh[
b[\j$ 7bceij j^[ [dj_h[ `Wm mWi f[hlWZ[Z Xo mel[d
Xed[$M^_b[eii[e_dj[]hWj_edmWiWY^_[l[Zm_j^j^[
j^_hZ _fi_bWj[hWb _cfbWdj" m^_Y^ ^WZ X[[d b[\j ded#
beWZ[Z" j^_i _cfbWdj mWi dej WiieY_Wj[Z m_j^ Wdo
ceZ[bb_d] \hec j^[ f[h_eij[kc [_j^[h$ 7ffWh[djbo
j^[`Wmi[]c[dj^WZX[[dikX`[Yj[ZjefhedekdY[Z
eij[eco[b_j_i j^Wj mWi ikXi[gk[djbo h[fW_h[Z Xo
mel[d Xed[ \ehcWj_ed$ 7bb Yh[ijWb _cfbWdji m^_Y^
^WZ X[[d _di[hj[Z kdZ[h ded#ij[h_b[ YedZ_j_edi
bWYa[Z _dj[]hWj_ed Xo ^_ijebe]_YWb Yh_j[h_W" m^[h[Wi
Wbb Yh[ijWb _cfbWdji m^_Y^ ^WZ X[[d _di[hj[Z kdZ[h
ij[h_b[YedZ_j_edi^Wl[X[[d_dj[]hWj[Zm[bb_djej^[
Xed[$
È
$ISCUSSIONÈANDÈ#LINICALÈ!PPLICATION
8ed[ j_iik[ h[i[cXb[i j^[ ijhkYjkhWb fhef[hj_[i e\
Yecfei_j[ cWj[h_Wb Xo f[hc_jj_d] YhWYa \ehcWj_ed
m^_b[ h[i_ij_d] YhWYa fhefW]Wj_ed je fh[l[dj
Zemdh_]^j\W_bkh[CWhj_dWdZ8khh'/./$
@kZ]_d] \hec _ji WhY^_j[Yjkh[" j^[ cWdZ_Xb[
_i [ii[dj_Wbbo W bed] jkXkbWh Xed[ 7i^cWd WdZ
lWd 8kia_ha '/.-$ :k[ je j^[ ijhed] \b[n_ed WdZ
j^[ WiieY_Wj[Z el[hbWff_d] e\ jhW`[Yjeh_[i" j^[
_dj[h\ehWc_dWb Wh[W _i W fWhj_YkbWhbo ijWXb[ fbWY[
je _di[hj _cfbWdji$ ?d j^[ feij[h_eh i[]c[dj e\
j^[ cWdZ_Xb[" j^[ jof_YWb jkXkbWh Xed[ ijhkYjkh[ _i
bWh][boh[#[ijWXb_i^[Z_dj^[f^Wi[e\Xed[h[iehfj_ed
\ebbem_d]jeej^beii$
J^[Xed[jkhdel[hhWj[_dj^[cWdZ_Xb[_iademd
jeX[l[ho^_]^8Woi'/.,$?dWZZ_j_ed"7ja_died[j
Wb$ '/-- Z[cedijhWj[Z j^Wj Xed[ Z[di_jo lWh_[Z _d
Z_\\[h[djh[]_edie\j^[cWdZ_Xb[WdZj^WjWdoZWcW][
_d\b_Yj[ZjeXed[ijhkYjkh[iZkh_d]h[ceZ[bb_d]Z_Z
dej ^Wl[ j^[ iWc[ [\\[Yj j^hek]^ekj j^[ cWdZ_Xb[$
<ebbem_d] jeej^ [njhWYj_ed" Xed[ Z[di_jo _d Wh[Wi
[nY[[Z_d] j^[ Wbl[ebW Y^Wd][Z$ ?d j^[ _d_j_Wb f^Wi["
j^[Z[di_jomekbZZ[Yh[Wi[X[YWki[jkdd[bb_d]8CKi
mekbZ _dYh[Wi[ j^[ fehei_jo e\ j^[ `Wm$ J^[ [\\[Yji
e\ _cfbWdjWj_ed mekbZ ifh[WZ ckY^ b_a[ mWl[i _d W
fedZedj^hem_d]Wijed[$J^[jkdd[bb_d]i[YedZWho
eij[edi 8CKi mekbZ _dZkY[ jhWdi_[dj m[Wa[d_d]
e\Xed[ijhkYjkh[i[l[d_dWh[Wij^Wjm[h[beYWj[Z\Wh
WmWo \hec j^[ Wbl[ebki$ J^[ Wh[W e\ j^[ [njhWYj_ed
ieYa[j mWi W\\b_Yj[Z Xo Z_iki[ Wjhef^o$ J^_i fheY[ii
mWiZ[bWo[Z_dYWi[im^[h[j^[[njhWYj_edieYa[jmWi
\_bb[Z m_j^ Yh[ijWb _cfbWdji" m^_Y^ mekbZ fhecej[
Xed[ c_d[hWb_pWj_ed je j^[ fe_dj m^[h[ j^[ Z[]h[[
e\ Xed[ Z[di_jo mekbZ iec[j_c[i [l[d [nY[[Z
j^[ eh_]_dWb b[l[b$ D_d[ cedj^i W\j[h _cfbWdjWj_ed"
^em[l[h"h[iehfj_edfheY[ii[ij^WjWZl[hi[boW\\[Yj[Z
j^[ fh[i[hlWj_ed e\ Wbl[ebWh Xed[ m[h[ i[[d _d j^[
Wh[We\j^[ded#beWZ[Z_cfbWdj$
Ed XWbWdY[" j^[ [nf[h_c[dji f[h\ehc[Z Xo
7ja_died[jWb$o_[bZ[Zde[l_Z[dY[e\WdoY^Wd][ied
j^[b_d]kWbi_Z[e\j^[cWdZ_Xb[\ebbem_d]_di[hj_ed
e\ Yh[ijWb _cfbWdji" m^_Y^ _i XWi_YWbbo _d a[[f_d]
m_j^ ekh emd \_dZ_d]i eXjW_d[Z m_j^ kdbeWZ[Z
_cfbWdj\_njkh[i$J^[[nj[djjem^_Y^j^[[dj_h[Xed[
ijhkYjkh[ m_bb h[WYj je j^[ _cfbWdj fheY[Zkh[ Wbie
Z[f[dZiedj^[i_p[e\j^[_cfbWdjh[bWj_l[jej^[i_p[
e\j^[`Wm$
J^[h[ikbjie\j^_i\ebbem#kf_dl[ij_]Wj_edik]][ij
j^Wj j^[ \kdYj_edWbbo _dZkY[Z fhefW]Wj_ed e\
YhWYaiWdZc_YheYhWYaiYWki[ZXoj^[_cfbWdjWj_ed
fheY[Zkh[m_bb]_l[h_i[jeWfheY[iie\ikXf[h_eij[Wb
ceZ[bb_d] j^Wj m_bb [dikh[ j^[ Yedj_dk_jo e\ j^[
`Wm$ ?d j^[ WXi[dY[ e\ Wdo Y^[m_d] beWZi WYj_d]
ed j^[ _cfbWdji" j^[ YhWYai m_bb dej fhefW]Wj[ Xkj
Wh[ Wbbem[Z je ^[Wb beYWbbo" ie j^Wj WZZ_j_edWb Xed[
lebkc[ je fh[i[hl[ j^[ Yedj_dk_jo e\ j^[ `Wm _i dej
h[gk_h[Z$
?\j^[\ehcWj_ede\d[mXed[Ze[idejjWa[fbWY[
W\j[h _cfbWdji ^Wl[ X[[d _di[hj[Z _d j^[ cWdZ_Xb["
j^[Y^WdY[iWh[j^Wjj^[fh_dY_fWbbeWZ#jhWdic_jj_d]
jhW`[Yjeh_[i m_bb h[cW_d kdY^Wd][Z 7ja_died [j Wb$
'/--$<khj^[hijkZ_[iWh[d[[Z[Zjeb[Whdceh[WXekj
j^[\Wj[e\WdoXed[ijhkYjkh[ij^WjWh[d[mbo\ehc[Z
W\j[h _cfbWdjWj_ed fheY[Zkh[i$ =[d[hWbbo if[Wa_d]"
È È (ISTOLOGICALÈ3TUDIESÈ
j^[ \khj^[h h[ceZ[bb_d] fheY[ii YWd X[ [nf[Yj[Z je
Z[l[bef_dWYYehZWdY[m_j^Meb\\ ÉibWmMeb\\'./("
m^_Y^_dYbkZ[ij^[\ebbem_d]YedY[fji0
v J^[Xed[ijhkYjkh[_iefj_c_p[Z\ehijh[d]j^WdZ
m[_]^j$
v½ J^[ jhWX[YkbW[ Wh[ WhhWd][Z _d WYYehZWdY[ m_j^
j^[cW_dZ_h[Yj_ede\\ehY[i$
v J^[ Xed[ ijhkYjkh[ h[]kbWj[i _ji[b\ j^hek]^ Y[bbi
h[WYj_d]jec[Y^Wd_YWbijh[ii$
?\j^[d[mbo\ehc[ZXed[ijhkYjkh[ih[cW_dbeYWb_p[Z
WdZ kdZ[h]e c_d[hWb_pWj_ed" j^[d j^[ Y^WdY[i
Wh[ j^Wj ej^[h Wh[Wi m^ei[ fh[i[hlWj_ed _i dej W
fh_dY_fWb YedY[hd m_bb X[ ikX`[Yj[Z je h[ceZ[bb_d]$
J^_i YekbZ c[Wd j^Wj j^[ fheXWX_b_jo e\ bed]#j[hc
_cfbWdj ikhl_lWb cWo lWho Z[f[dZ_d] ed m^[j^[h
_cc[Z_Wj[ eh Z[bWo[Z beWZ_d] _i ki[Z" i_dY[ Xej^
YedY[fji _dlebl[ Z_\\[h[dj fh[YedZ_j_edi \eh bed]#
j[hc h[ceZ[bb_d] e\ j^[ `Wm Wh[Wi ^WhXekh_d] j^[
_cfbWdj i_j[i$ Ed j^[ ej^[h ^WdZ" i_jkWj_edi Wh[ je
X[ [nf[Yj[Z _d m^_Y^ j^[ d[mbo _dijWbb[Z _cfbWdji
m_bb YWki[ j^[ cWij_YWjeho \kdYj_ed je _cfhel[
WdZ j^[ Y^[m_d] \ehY[i je _dYh[Wi[$7ffWh[djbo" j^[
d[mbo\ehc[ZXed[ijhkYjkh[iWh[fh[i[hl[Z_dj^_i
i_jkWj_ed X[YWki[ j^[o Wh[ d[[Z[Z$ J^[ h[WZ[h _i
h[\[hh[Zje9^Wfj[h/\ehWZ[jW_b[ZZ_iYkii_ede\j^_i
jef_Y_dYbkZ_d]h[b[lWdjYb_d_YWbeXi[hlWj_edi$
?\bed]jkXkbWhXed[iWh[ikX`[Yj[Zje_dYh[Wi_d]
beWZi"fWhj_YkbWhbo_dj^[Yedj[nje\hWf_Z]hemj^_d
oekd]_dZ_l_ZkWbi"mel[dXed[_iXk_bjkf\hecj^[
f[h_eij[WbWh[W"WdZ[dZeij[WbWffei_j_ed_ieXi[hl[Z
Wi m[bb @Wmehia_ WdZ Kj^e\\ '/.,$ Fheb_\[hWj_ed e\
mel[dXed[\hecj^[f[h_eij[kccWo"^em[l[h"Wbie
[dik[_dWZkbjiWiWh[ikbje\\Wj_]k[ZXed[ijhkYjkh[i
@e^died[jWb$'/,)1Kj^e\\WdZ@Wmehia_'/.+$
J^[fh_dY_fWbh[ceZ[bb_d]c[Y^Wd_iceXi[hl[Z_d
ebZ[hfWj_[dji_dYedd[Yj_edm_j^_dYh[Wi[ZbeWZ_d]
_i" ^em[l[h" [dZeij[Wb Wffei_j_ed @Wmehia_ [j Wb$
'/.&$ EbZ[h fWj_[dji i^em W icWbb[h h[Wffei_j_ed
hWj[j^Wdoekd][h_dZ_l_ZkWbi"WdZj^[Z_Wc[j[he\j^[
jkXkbWhXed[_idejeXi[hl[Zje_dYh[Wi[$J^[WXel[
_dl[ij_]Wj_ediYedY[hd[Zi_jkWj_edi_dm^_Y^j^[beWZ
_dYh[Wi[iYedj_dkekibom_j^ekji_]d_\_YWdjdkcX[hi
e\ YhWYai WdZ i[h_eki _d`kh_[i [$]$ Xo _cfbWdjWj_ed
fheY[Zkh[ijej^[Yehj_YWbXed[ijhkYjkh[$
J^[ \WYj j^Wj Xed[ \hWYjkh[i ^[Wb_d] _d W Ykhl[Z
fei_j_ed m_bb ijhW_]^j[d ekj el[h j^[ o[Whi kdZ[h
f^oi_ebe]_Y beWZ_d] YedZ_j_edi ^Wi X[[d ademd \eh
W bed] j_c[ @Wdi[d '/(&1 8Wii[j '/,+$ <heij '/,*
feijkbWj[Zj^Wjj^[Xed[h[WYj_edZe[idejfh_cWh_bo
h[ikbj\hecYecfh[ii_l[WdZj[di_b[\ehY[iXkj\hec
W j[dZ[dYo e\ j^[ _dYec_d] \ehY[i je ceZ_\o j^[
[nY[ii_l[YkhlWjkh[e\j^[Xed[$?jckijj^[h[\eh[X[
[nf[Yj[Zj^Wjj^[fheY[iie\Xed[Wffei_j_edm_bbX[
h[l[hi[Z_dj^[Yekhi[e\\khj^[hh[ceZ[bb_d]m^[d
j^[`Wm\kdYj_edm_bbh[jkhdje_ji_d_j_WbijWj[_dj^[
bed] j[hc$ J^[ fheij^[j_Y h[ijehWj_ed _i W cW`eh
)''
Z[j[hc_dWdje\bed]#j[hc`Wm\kdYj_ed$?dj^_imWo"
j^[ cWij_YWjeho YedY[fj i[b[Yj[Z Xo j^[ Z[dj_ij ^Wi
W Z[Y_i_l[ _cfWYj ed j^[ fheXWX_b_jo e\ bed]#j[hc
ikhl_lWb e\ [deiiWbbo WdY^eh[Z h[ijehWj_edi$ J^_i _i
fWhj_YkbWhbojhk[e\_cfbWdjiikX`[Yj[Zje_cc[Z_Wj[
beWZ_d]$
7d _dj[h[ij_d] gk[ij_ed _d Yedd[Yj_ed m_j^ j^[
fh[i[djijkZo_im^[j^[hj^[WZZ_j_edWbikXf[h_eij[Wb
ceZ[bb_d] cWo ^Wl[ X[[d _dZkY[Z Xo ]h[Wj[h
cWij_YWjehobeWZi$7jb[WijikY^WYedd[Yj_edmekbZ
Wff[Wh fbWki_Xb[ _d j^[eho" i_dY[ j^[ WXi[dY[ e\
eii[e_dj[]hWj_ed WdZ beWZ_d] e\ _cfbWdji mekbZ X[
b_a[bojeYWki[fW_d\kbiocfjeci"j^ki]_l_d]h_i[je
Wle_ZWdY[fWjj[hdiWdZh[ZkY[ZY^[m_d]\ehY[i$M^Wj
Wh]k[i W]W_dij j^_i Wiikcfj_ed _i j^[ \WYj j^Wj de
ceZ[bb_d]mWieXi[hl[ZbWj[hWbbojej^[8E?_cfbWdji
j^Wj^WZX[[d_di[hj[ZkdZ[hded#ij[h_b[YedZ_j_edi
Wbj^ek]^j^[i[_cfbWdjim[h[_cc[Z_Wj[bobeWZ[ZWi
m[bb$ ?j i[[ci ceh[ b_a[bo j^Wj j^[ [ijWXb_i^c[dj e\
\h_Yj_edWb Xed[ WZ^[i_ed mWi Z[bWo[Z m_j^ j^[ 8E?
_cfbWdji WdZ fh[l[dj[Z m_j^ j^[ Yh[ijWb \_njkh[i"
ikY^ j^Wj j^[ _d_j_Wb YhWYa YekbZ X[ h[fW_h[Z _d j^[
_dj[hlWb$?dj^_imWo"j^[h[mekbZ^Wl[X[[dded[[Z
\ehikXf[h_eij[WbceZ[bb_d]$<khj^[hceh["WZ[bWo[Z
^[Wb_d]c[Y^Wd_icm_j^]h[Wj[h_d_j_Wbh[iehfj_ede\
j^[ebZXed[Wh[WimekbZWbieh[ikbj_dWceh[[bWij_Y
_cfbWdjX[Z_dj^[[Whbofeijef[hWj_l[f^Wi["j^[h[Xo
fh[l[dj_d]YhWYafhefW]Wj_ed$7h[bWj_edi^_fX[jm[[d
_cfbWdjjof[WdZj^[Wcekdje\d[mbo\ehc[ZXed[
YekbZdejX[eXi[hl[Z"m^_Y^_iYedi_ij[djm_j^j^[
h[ikbji eXjW_d[Z Xo HkX_d WdZ BWdoed '/.*$ J^[
\ehcWj_ed e\ mel[d Xed[ Wi W hWf_Z h[ifedi[ je
[nY[ii_l[ \b[nkhWb ijh[ii[i ed j^[ i_Z[ e\ _dYh[Wi_d]
Yedl[n_jo _i Wd ¼Wbb#eh#dej^_d]½ h[ifedi[ X[YWki[
d[_j^[hj^[dkcX[he\beWZ_d]YoYb[idehj^[ijh[ii
b[l[bi^Wl[Wdo[\\[Yjedj^[Z[]h[[jem^_Y^j^[Xed[
lebkc[_dYh[Wi[i$
<ebbem_d] j^[ \ehcWj_ed e\ d[m Xed[ \hec W
f[h_eij[Wb Z_h[Yj_ed" j^[h[ _i de _dY[dj_l[ \eh j^[
ebZ Xed[ Wh[Wi W\\[Yj[Z Xo _cfbWdjWj_ed je _dYbkZ[
j^[ cWYheiYef_Y YhWYai" m^_Y^ [nj[dZ h_]^j _dje
j^[ Yehj_YWb Xed[ bWo[h" _d j^[ h[fW_h meha$ 7\j[h
Wbb" j^[ YhWYai ^Wl[ Z[l[bef[Z bed]_jkZ_dWbbo Wbed]
j^[ cWdZ_Xb[" ie j^Wj j^[ \hWYjkh[ Wh[Wi Wh[ ib_]^jbo
ceX_b[ W]W_dij [WY^ ej^[h$ HWj^[h" j^[ mel[d Xed[
ijhkYjkh[i Wh[ Wbh[WZo X[_d] f[hlWZ[Z Xo eij[edWb
WYj_l_jo" m^_b[ cWYheYhWYai Wh[ dej ioij[cWj_YWbbo
h[fW_h[Z$
?d\bWccWjeho fheY[ii[i e\ [deiiWb eh_]_d Wh[
YWfWXb[ e\ _d\b_Yj_d] i[h_eki ZWcW][ je Xed[
ijhkYjkh[im_j^_dWi^ehjf[h_eZe\j_c[$?dh[ifedi[
je j^_i" Yedi_Z[hWXb[ Wcekdji e\ mel[d Xed[ cWo
X[ \ehc[Z \hec j^[ [dZeij[Wb WdZ f[h_eij[Wb
ikh\WY[i$?dj^[fh[i[dY[e\Yh[ijWb_cfbWdj\_njkh[i"
h[d[m[Z f[hlWi_ed e\ j^[i[ Wh[Wi Xo eij[edi mWi
dej Z[cedijhWXb[ Zkh_d] j^[ eXi[hlWj_ed f[h_eZ$
J^[ b[l[b e\ ZWcW][ _d\b_Yj[Z je Xed[ ijhkYjkh[i _i"
)'( 9^Wfj[h()È (ISTOLOGYÈOFÈ"/)È)MPLANTS
XoYedjhWij"ckY^bem[h_\_d\[Yj_ediWh[_djheZkY[Z
Zkh_d] j^[ _di[hj_ed fheY[Zkh[ \eh 8E? _cfbWdji
Ä m^_Y^ ^Wi X[[d ademd je [nf[h_[dY[Z 8E? ki[hi
WbbWbed]$
8E?_cfbWdjiYWdWbieX[_di[hj[Z_df[h_eZedjWbbo
_dlebl[ZWh[WiÄ\eh[nWcfb[_di_d]b[#ij[ffheY[Zkh[i
h_]^j W\j[h [njhWYj_d] Wdo j[[j^ j^Wj m[h[ YWkiWbbo
h[bWj[Z je j^[ f[h_eZedjWb fheXb[c i[[ 9^Wfj[h.$
J^[ ]eeZ h[ikbji eXjW_d[Z _d j^[i[ Wh[Wi Wh[
fh[ikcWXbo Zk[ je j^[ _dYh[Wi[Z XbeeZ ikffbo WdZ
ik\\_Y_[dj ikffkhWj_ed je j^[ WiieY_Wj[Z ie\j#j_iik[
ijhkYjkh[ih[bWj[Zjej^[_d\bWccWjehofheY[ii$
J^[ eXi[hlWj_edi cWZ[ Xo @eei [j Wb$ (&&) j^Wj
deZ_\\[h[dY[iX[jm[[dj^[Yh[ijWbWdZWf_YWb_cfbWdj
h[]_edi m[h[ fh[i[dj ed Xej^ j^[ Y[bbkbWh WdZ j^[
_deh]Wd_Yi_Z[e\j^[_dj[h\WY[W\j[h_cc[Z_Wj[beWZ_d]
^Wl[ X[[d Yed\_hc[Z$ :_\\[h[dY[i _d Xed[ h[WYj_ed
m[h[" ^em[l[h" fh[i[dj X[jm[[d j^[ l[ij_XkbWh WdZ
b_d]kWbi_Z[i$J^_imWiWYjkWbboWd[nf[Yj[Z\_dZ_d]"
Yedi_Z[h_d]j^[icWbbb_a[b_^eeZe\WY^_[l_d]_d_j_Wb
_dj[]hWj_ed e\ h_]_Z Yh[ijWb _cfbWdj Z[i_]di _dje
j^[ l_iYe[bWij_Y [dl_hedc[dj e\ b_l[ Xed[ ed Wbb
i_Z[i e\ j^[ _cfbWdj" Wj j^[ iWc[ j_c[" WdZ Wj j^[
iWc[ ^_]^ Z[]h[[ e\ c_d[hWb_pWj_ed$ H[ceZ[bb_d]
ed ed[ i_Z[ e\ j^[ l[hj_YWb _cfbWdj ikh\WY[ edbo
cWo Wbie h[ikbj _d j^[ X_ec[Y^Wd_YWbbo d[Y[iiWho
WZWfjWj_ed e\ [bWij_Y_jo$ 7do ckjkWb i^_\ji X[jm[[d
Xed[bWo[hi"_dYbkZ_d]j^ei[i^_\jij^WjZeijWhj\hec
YhWYaiehc_YheYhWYai"m_bbWbieW\\[Yjj^[Z[]h[[e\
c_d[hWb_pWj_ed _d j^[ _dj[h\WY[ Wh[W$ Ceh[ ijkZ_[i
Wh[ d[[Z[Z je WZZh[ii j^[ gk[ij_ed ^em WdZ m^o
j^[ Xed[ YedZ_j_edi WhekdZ j^[ _cfbWdj X[Yec[
^ece][d[eki$>em[l[h"m^_b[j^[ijkZ_[iXo@eei[j
Wb$Yel[h[ZWdeXi[hlWj_edf[h_eZe\kfje'*ZWoi"j^[
^_ijebe]_YWb_cfbWdjif[Y_c[diWdWboi[Z_dekhemd
ijkZo^WZX[[d_dYb_d_YWbi[hl_Y[\ehceh[j^Wdj^h[[
cedj^i$Ikhfh_i_d]bo"j^[Z[]h[[e\fh_cWhoijWX_b_jo
WY^_[l[Z_dj^[_d_j_Wbf^Wi["m^_Y^WffWh[djboYWc[
\hecj^[b_d]kWbi_Z[e\j^[`Wm"mWi]eeZ[dek]^je
[dikh[Wiceej^fheY[iie\^[Wb_d]kdZ[hcWij_YWjeho
\kdYj_edWdZcW_djW_d_d]eii[e_dj[]hWj_ed$
7ii[dpW [j Wb$ (&&)" Xo YedjhWij" eXi[hl[Z de
Z_\\[h[dY[i X[jm[[d beWZ[Z WdZ kdbeWZ[Z _cfbWdji
_dj[hcie\Xed[Wffei_j_ed$J^[i[Wkj^ehiZ_Zdej"
^em[l[h" WdWboi[ j^[ cWdZ_Xb[ Wj bWh][ Xkj edbo
beea[Z Wj j^[ Xed[ ijhkYjkh[i j^Wj m[h[ Z_h[Yjbo _d
YedjWYj m_j^ j^[ _cfbWdji$ J^_i ]hekf Wbie \ekdZ
h[ceZ[bb_d]_dj^[Yh[ijWbWif[Yjie\j^[Xed[$
7j Wdo hWj[" j^[ h[WYj_ed e\ f[h_#_cfbWdj Xed[
ijhkYjkh[i _d j^[ cWdZ_Xb[ \ebbem_d] _cc[Z_Wj[
beWZ_d]Wff[WhijeX[_d\bk[dY[ZdejieckY^Xoj^[
ikh\WY[Z[i_]de\j^[_cfbWdjWiXoj^[cWij_YWjeho
\ehY[iYecX_d[Zm_j^`Wm\b[n_ed$7\j[hWbb"j^[iWc[
iWdZXbWij[Zikh\WY[im[h[fh[i[djXej^b_d]kWbboWdZ
l[ij_XkbWhbo"WdZYecfb[j[boZ_\\[h[djh[WYj_edim[h[
\ekdZed[_j^[hi_Z[e\j^[_cfbWdji$
È
#LINICALÈ!PPLICATIONÈnÈ"/)È)MPLANTSÈÈ
ANDÈ*AWÈ&RACTURES
?dfWj_[djim_j^^ehcedWbXed[ijh[d]j^Z[\_Y_[dY_[i"
j^[h[ _i W ]h[Wj[h h_ia j^Wj YhWYa fhefW]Wj_ed Xo
_cc[Z_Wj[beWZ_d]coYWki[`Wm\hWYjkh[i$
M[ eXi[hl[Z j^h[[ YWi[i e\ `Wm \hWYjkh[ _d j^[
cWdZ_Xb[W\j[h8E?_cfbWdji^WZX[[d_di[hj[ZWdZ
_cc[Z_Wj[bo beWZ[Z _d ed[ cWb[ WdZ jme \[cWb[
fWj_[djiademdjeik\\[h\heccWha[Zeij[efehei_i$
7bb j^h[[ YWi[i ^[Wb[Z ifedjWd[ekibo m_j^ekj W
fheXb[ckdZ[hh[ZkY[ZcWij_YWjehobeWZ_d]b_gk_Z
Z_[j$ 7bb \hWYjkh[i eYYkhh[Z W\j[h ,Ä.m[[ai W\j[h
j^[ fbWY[c[dj e\ j^[ _cfbWdji" WdZ Wbb Xed[i \hWY#
jkh[Z Wbed] WdZ X[bem j^[ j^h[WZ[Z f_d$ 7bb beWZ#
jhWdic_jj_d]Z_iai_dWh[WiZ_ijWdj\hecj^[j^h[WZ[Z
f_d m[h[ m[bb _dj[]hWj[Z Xo j^[ j_c[ j^[ \hWYjkh[
eYYkhh[Z" ikY^ j^Wj WZ[gkWj[ Ye^[i_ed e\ j^[ `Wm
mWi[dikh[Z$Ed[cWoj^[h[\eh[YWkj_ekiboYedYbkZ[
j^WjW\_nWj[kh_dj[hd[_dj^[\ehce\W\_n[ZXh_Z][
ikffehj[ZXo8E?_cfbWdjiYWdX[Yedi_Z[h[ZWiWd
Wbj[hdWj_l[ eh ikffb[c[djWho jh[Wjc[dj efj_ed je
fbWj[ eij[eiodj^[i_i _d \hWYjkh[i e\ j^[ [Z[djkbeki
h[iehX[ZcWdZ_Xb[$J^_iWffheWY^mekbZe\\[hi[l[hWb
WZlWdjW][i$<_hije\Wbb"_jmekbZWbbemj^[f^oi_Y_Wdje
cW_djW_dehh[#[ijWXb_i^Wf^oi_ebe]_YWb`Wm\kdYj_ed
_d W j_c[bo cWdd[h$ <khj^[hceh[" j^[ cWdZ_Xb[
mekbZX[iocc[jh_YWbbom[Wa[d[Z_dWZZ_j_edjej^[
\hWYjkh[#h[bWj[Z [bWij_Y Wbj[hWj_edi" j^ki [dWXb_d] W
iocc[jh_YWbh[ceZ[bb_d]WdZc_d[hWb_pWj_edfheY[ii
j^hek]^ekj j^[ [dj_h[ `Wm$ J^[ iceej^ fheY[ii e\
\hWYjkh[ ^[Wb_d] \ebbem_d] j^[ _di[hj_ed e\ 8E?
_cfbWdji\ehYecfb[j[cWdZ_XkbWhXh_Z][ic_]^jX[
ikffehj[ZXoj^[\WYjj^WjceZ[bb_d]WdZh[ceZ[bb_d]
eYYkhi i_ckbjWd[ekibo WdZ iocc[jh_YWbbo Wj Wbb
_cfbWdj i_j[i" ikY^ j^Wj f[Wa ijh[ii[i Wh[ Wle_Z[Z$
?j Wff[Whi j^Wj fWj_[dji m_j^ eij[efehei_i m^e Wh[
fhed[ je _dYkhh_d] ifedjWd[eki \hWYjkh[i Wh[ m[bb
fhWYj_i[Z_dWle_Z_d]if[Y_\_YXed[ijhkYjkh[i$Kdb_a[
kdjhW_d[ZZ[dj_iji"j^[oj[dZjeh[]WhZ`Wm\hWYjkh[i
dej Wi W i[h_eki Yecfb_YWj_ed Xkj Wi W h[bWj_l[bo
dehcWb[l[djkWb_jo$
<_]kh[i()$''Ä()$')Z[cedijhWj[j^WjYedZ_j_edi_d
j[hcie\Xed[c_d[hWb_pWj_edcWolWhoikXijWdj_Wbbo
[l[d Wj Z_\\[h[dj ^eh_pedjWb b[l[bi e\ j^[ iWc[ 8E?
_cfbWdj$J^[h[\eh["_\cWdZ_XkbWh\hWYjkh[ieYYkh_d
ed[Wh[W"j^[ej^[h[nj[hdWbWh[Wie\j^[^eh_pedjWb
beWZ#jhWdic_jj_d] ikh\WY[i cWo Xej^ jWa[ YWh[ e\
j^[ beWZ jhWdic_ii_ed WdZ [dikh[ j^[ Ye^[i_ed e\
j^[ `Wm$ 9khh[o '/.' h[fehj[Z [njh[c[bo ]h[Wj
Z_\\[h[dY[i X[jm[[d j^[ c[Y^Wd_YWb fhef[hj_[i e\
Yehj_YWb Xed[ ijhkYjkh[i e\ Z_\\[h[dj eh_]_di [l[d
m_j^j^[Z_\\[h[dY[i_dc_d[hWb_pWj_edX[_d]h[bWj_l[bo
icWbb$M^WjWffb_[ijeZ_\\[h[djif[Y_[iWbieWffb_[i
jeZ_\\[h[djWh[Wi_dj^[Xed[ie\ed[_dZ_l_ZkWb$
8E? _cfbWdji Wff[Wh X[jj[h ik_j[Z \eh j^[ jh[Wj#
c[dj e\ \hWYjkh[#fhed[ eij[efehei_i fWj_[dji
È È (ISTOLOGICALÈ3TUDIESÈ
j^Wd Yh[ijWb _cfbWdji Zk[ je j^[ iceej^ ikh\WY[
e\ j^[_h l[hj_YWb Yecfed[dj$ 9h[ijWb _cfbWdji ^Wl[
W ijhkYjkhWb h[gk_h[c[dj \eh ikh\WY[ [dbWh][c[dj
_d j^[ l[hj_YWb _cfbWdj fWhj$ J^[o YWhho W ^_]^
h_ia e\ _d\[Yj_ed _d j^[ _dj[h\WY[ Wh[W Wbed] j^[
ikh\WY[#[dbWh][Z l[hj_YWb _cfbWdj Wn_i \ebbem_d]
[Whbo`Wm\hWYjkh[i8_d][h'/./$J^[\WYjj^WjbeWZ
jhWdic_ii_edcWodebed][hX[feii_Xb[_dj^_iWh[W
W\j[h\hWYjkh[_i_hh[b[lWdj\eh8E?X[YWki[j^[beWZ#
jhWdic_jj_d] ikh\WY[i Wh[ beYWj[Z _d j^[ fhej[Yj[Z
[dl_hedc[dj e\ j^[ XWiWb Yehj_YWb Xed[ ijhkYjkh[
WdomWo$ <khj^[hceh[" ekh _cfbWdjWj_ed [nf[h_c[dj
kdZ[hded#ij[h_b[YedZ_j_ediik]][ijij^Wj_d\[Yj_edi
YWddejX[YWk]^j_dj^[Xed[WhekdZ\h[i^bo_di[hj[Z
8E? _cfbWdji$ <khj^[h ijkZ_[i Wh[ d[[Z[Z je b[Whd
ceh[ WXekj j^_i f^[dec[ded$ 9h[ijWb _cfbWdji" Xo
YedjhWij"bWYaWdobWj[hWbbeWZ#jhWdic_jj_d]i[]c[dji"
ie j^Wj j^[_h l[hj_YWb Yecfed[dji" m^_Y^ \[Wjkh[ Wd Xed[edj^[effei_j[i_Z[e\j^[c_ii_d]kbdW$Edbo
[dbWh][Zikh\WY[\ehbeWZjhWdic_ii_ed"m_bbgk_Yabo
X[ fefkbWj[Z Xo c_Yheeh]Wd_ici _d j^[ mWa[ e\
ceX_b_joehceX_b_p_d]\hWYjkh[iJebcWdWdZA[bb[h
'//'$ <eh j^_i h[Wied" j^[ fheXWX_b_jo e\ ikhl_lWb e\
Yh[ijWb_cfbWdji_d\hWYjkh[Z`Wmi_i]h[Wjboh[ZkY[Z$
HeX[hj [j Wb$ '/.* h[fehj[Z W ^_]^[h _dY_Z[dY[ e\lebkc[WdZifWj_Wbfei_j_ed$
e\Xed[\hWYjkh[iW\j[h_cc[Z_Wj[beWZ_d]e\[deiiWb
j_jWd_kc _cfbWdji j^Wd W\j[h kdbeWZ[Z ^[Wb_d]
_d \[ckhi e\ hWXX_ji$ ?d j^[i[ [nf[h_c[dji" jme
_cfbWdji[WY^m[h[_djheZkY[Zbed]_jkZ_dWbboWbed]
j^[ \[ckh e\ [WY^ hWXX_j WdZ fki^[Z WfWhj m_j^ W
Yecfh[ii_ed ifh_d]$ 7bb \hWYjkh[i eYYkhh[Z m_j^_d
j^[\_hij-ZWoi1de\hWYjkh[im[h[eXi[hl[ZW\j[hj^[
^[Wb_d]f^Wi[^WZX[[dYecfb[j[Z$7YYehZ_d]bo"j^[
ifh[WZe\c_YheYhWYaiW\j[hikh]_YWbijh[iic_]^jX[
Wd_cfehjWdjh[Wied\ehj^[beiie\fh_cWho_cfbWdj
ijWX_b_jo$J^[c_YheYhWYai_dj^[[nf[h_c[djWbi[j#kf
ki[ZXoHeX[hj[jWb$m[h[fhefW]Wj[ZXoj^[ifh_d]i
je ikY^ W bWh][ [nj[dj j^Wj ifedjWd[eki \hWYjkh[i
eYYkhh[Z gk_Yabo [l[d m^[d j^[ Wd_cWbi m[h[ edbo
[nfei[ZjedehcWb\kdYj_edWbijh[ii[i$
J^[ \hWYjkh[i eXi[hl[Z _d ekh emd ijkZo" m^_Y^
eYYkhh[Z m_j^_d ,Ä.m[[ai e\ _cfbWdjWj_ed" mekbZ
hWj^[hik]][ijj^Wj_dYh[Wi_d]fehei_jo_dZkY[ZXoh[#
ceZ[bb_d]m_bb[l[difh[WZjeceh[h[cej[`WmWh[Wi"
m^_b[ W h[WYj_l[ _dYh[Wi[ e\ c_d[hWb_pWj_ed h[dZ[hi
Wh[Wij^Wj^Wl[d[l[hX[[d_d`kh[Z_dYh[Wi_d]boXh_jjb["
ikY^j^Wjj^[o[l[djkWbbo\hWYjkh[IYkbboWdZ8[ij[h#
cWdd'/.($J^[bWh][Z_\\[h[dY[iX[jm[[dj^[^_ije#
be]_YWbi[Yj_edie\ed[_cfbWdjZ[cedijhWj[j^Wjj^[
Z[]h[[e\c_d[hWb_pWj_edcWolWho]h[Wjbo[l[dm_j^_d
j^[iWc[`WmWh[WWdZWhekdZj^[iWc[_cfbWdj$
È
#LINICALÈ!PPLICATIONÈnÈ)MPLANTÈ0ROCEDURESÈINÈ)NFECTEDÈ
!REASÈANDÈ0ERIODONTALLYÈ)NVOLVEDÈ2EGIONSÈÈ
SEEÈ#HAPTERÈÈFORÈ$ETAILS cWdZ_Xb[ YWd X[ [njh[c[bo ijWXb[ _i WffWh[dj
?dekhl_[m"j^[ikYY[ii\kb_dj[]hWj_ede\8E?_cfbWdji
j^Wj m[h[ YedjWc_dWj[Z Wj j^[ j_c[ e\ _di[hj_ed YWd
)')
X[ Wjjh_Xkj[Z je j^[ \WYj j^Wj _d\[Yj_edi YWd gk_Yabo
ikffkhWj[ j^hek]^ j^[ m_Z[ ^eh_pedjWb WdZ l[hj_YWb
_di[hj_ed ibej$ 9h[ijWb _cfbWdj \_njkh[i" Xo YedjhWij"
m_bbYbei[j^[ZhW_dW][fWj^mWob_a[WYeha_dWXejjb[$
FbWY[c[dj e\ ij[h_b[ iYh[m _cfbWdji cWo meha
^em[l[h _d f[h_eZedjWbbo _dlebl[Z `Wmi " Wi bed]
Wi j^[ eij[ejeco Wh[W _i a[[f Yb[Wd [dek]^$ J^[
^[Wb_d] _d f[h_eZedjWbbo _d\[Yj[Z i_j[i mWi ibem[h
_d_j_Wbbo" h[WY^_d] b[l[bi e\ j^[ ded Z_i[Wi[Z i_j[i
W\j[h'(m[[aiCWhYWYY_d_[jWb$(&&)$
È
#LINICALÈ!PPLICATIONÈnÈ-ORPHOLOGICALÈ#HANGESÈÈ
OFÈTHEÈ*AWBONEÈ!FTERÈ)MMEDIATEÈ,OADING
=eeZi^_f [j Wb$ '/-/ Z[cedijhWj[Z j^Wj j^[ \_hij
h[WYj_ed je eYYkh W\j[h ikh]_YWb i[fWhWj_ed e\ j^[
kbdW _d f_]i mWi ikXijWdj_Wb \ehcWj_ed e\ mel[d
)cedj^ibWj[h"j^[i[ijhkYjkh[i^WZh[iehX[Z"m^_b[
d[m mel[d Xed[ ^WZ \ehc[Z ed j^[ i_Z[ e\ j^[
c_ii_d] kbdW _dij[WZ$ M^Wj ^WZ ^Wff[d[Z mWi Wd
Wjj[cfje\j^[h[cW_d_d]Xed[ijhkYjkh[jeWZWfjje
j^[i_jkWj_edXoh[fbWY_d]j^[c_ii_d]kbdW_dj[hci
J^[\ebbem_d]YedYbki_ediYWdX[ZhWmd\hecj^_i
[nf[h_c[dj0
v ?\Yedi_Z[hWXb[j[di_b[ijh[ii[iWh[fh[i[djedj^[
i_Z[e\j^[Xed[m_j^_dYh[Wi_d]Yedl[n_jo"mel[d
Xed[ _i Z[fei_j[Z _d j^Wj Wh[W l[ho gk_Yabo$ J^_i
_d_j_Wb h[WYj_ed eh_]_dWj[i \hec j^[ f[h_eij[kc$
M[eXi[hl[Zi_c_bWhh[WYj_edim_j^8E?_cfbWdji
_dZe]iÉcWdZ_Xb[i$
v >em[l[h"_d=eeZi^_fÉi[nf[h_c[dj"W\j[h)cedj^i
j^[ Z_ii[Yj[Z Xed[ mWi h[fbWY[Z ed j^[ i_Z[
j^Wj ^WZ ]hemd ceh[ Yedl[n Wi W h[ikbj e\ beWZ
WdZ \kdYj_ed$ J^_i \_dZ_d] mWi Yedi_ij[dj m_j^
<heijÉi \b[nkhWb d[kjhWb_pWj_ed j^[eho Xkj YekbZ
dejX[Yed\_hc[Z_dj^[Ze]iÉcWdZ_Xb[i"_dm^_Y^
ceZ[bb_d]^WZeYYkhh[Z[nYbki_l[boedj^[b_d]kWb
i_Z[" WdZ j^[ Xed[ ]W_d[Z j^[h[ i[[c[Z je ^Wl[
ijWX_b_p[Z$
v J^[ _cc[Z_Wj[bo beWZ[Z Yh[ijWb _cfbWdji m[h[
WiieY_Wj[Z m_j^ Xej^ b_d]kWb WdZ l[ij_XkbWh
h[ceZ[bb_d]Wjj^[[dZe\j^[eXi[hlWj_edf[h_eZ$
v M^_b[j^[ZkhWj_ede\j^[i[[nf[h_c[djimWijee
i^ehj je [ijWXb_i^ m^[j^[h j^[ d[mbo ceZ[bb[Z
Xed[ mWi ]e_d] je X[ fh[i[hl[Z _d j^[ bed] hkd"
j^[h[ Wh[ iec[ _dZ_YWj_edi j^Wj j^_i mWi ]e_d]
jeX[j^[YWi[Xej^m_j^j^[Yh[ijWb_cfbWdjiWdZ
m_j^ j^[ 8E? _cfbWdji$ 7\j[h Wbb" j^[ ceZ[bb_d]
ped[ij^Wjm[h[ij_bbeXi[hl[ZXo=eeZi^_f[jWb$
m_j^_d W \[m m[[ai e\ j^[ ikh]_YWb fheY[Zkh[ ed
j^[ YedYWl[ i_Z[ m[h[ edY[ W]W_d h[iehX[Z W\j[h
)cedj^i$ J^[ \WYj j^Wj ceZ[bb_d] ped[i _d j^[
\hecj^[^_]^fh[lWb[dY[e\Xedoekj]hemj^ijeh_
cWdZ_XkbWh_i_dYb_d_YWbfhWYj_Y[$
)'* 9^Wfj[h()È (ISTOLOGYÈOFÈ"/)È)MPLANTS

v 9b_d_YWbbo" j^[ \ebbem_d] YWd X[ i[[d m_j^ \W_b_d]
8E?_cfbWdji0?\W8E?_idebed][h_dj[]hWj[ZZk[
je Wd _d\[Yj_ed h[WY^_d] Zemd je j^[ XWiWb fbWj["
b_d]kWbXed[Wffei_j_edi_c_bWhjej^[\ehcWj_ed
e\ W cWdZ_XkbWh jehki YWd X[ eXi[hl[Z$ J^_i
\ehcWj_ede\Xed[_ifhee\e\Y^Wd][i_dj^[&Ä'
fhef[hj_[i _di_Z[ j^[ cWdZ_Xb[" WdZ _j _dZ_YWj[i
j^Wj j^[ _cfbWdj fh[l[dji j^[ h[]kbWh \ehcWj_ed
e\ eij[edi WdZ h[]kbWh beWZ jhWdic_ii_ed$ J^[
_cfb_YWj[Z 8E? _cfbWdji kikWbbo ^Wl[ je X[
h[fbWY[Z$
\WYjehi$ Ded[ e\ j^[i[ Wjj[cfji" ^em[l[h" fh[#
l[dj[Z j^[ ikYY[ii\kb _dj[]hWj_ed e\ 8E? _cfbWdji
_d j^_i ijkZo$ Dej[" ^em[l[h" j^Wj iec[ e\ j^[i[
[nf[h_c[dji m[h[ f[h\ehc[Z m_j^ iceej^ _cfbWdj
ikh\WY[im^_b[WbbiYh[m_cfbWdjij^Wjm[h[_di[hj[Z
kdZ[h ded#ij[h_b[ YedZ_j_edi \[Wjkh[Z [deiiWb beWZ#
jhWdic_jj_d]ikh\WY[ij^Wj^WZX[[dYh[Wj[Zj^hek]^
iWdZXbWij_d]$

È #ONCLUSIONS
?cc[Z_Wj[ beWZ_d] e\ _cfbWdji m_bb h[ikbj _d
fhefW]Wj_ed e\ c_YheYhWYai _dZkY[Z Xo j^[
_cfbWdjWj_ed fheY[Zkh[$ 9h[ijWb _cfbWdj \_njkh[i
m_bb _dZkY[ h[WYj_l[ ceZ[bb_d] ed j^[ b_d]kWb WdZ
l[ij_XkbWh i_Z[ e\ j^[ cWdZ_Xb[ Xo j^[_h l[hj_YWb
dejY^ [\\[Yj$ 8E? _cfbWdji j^Wj ^Wl[ X[[d fbWY[Z
j^hek]^Wl[ij_XkbWh_di[hj_edfWj^"XoYedjhWij"edbo
_dlebl[Wb_d]kWbboeh_[dj[ZdejY^[\\[Yj$
9h[ijWb_cfbWdj\_njkh[ij^WjWh[dejeii[e_dj[]hWj[Z
m_bb dej _dlebl[ Wdo \h_Yj_edWb WZ^[i_ed Wj j^[
_cfbWdj#Xed[ _dj[h\WY[" WdZ YhWYa fhefW]Wj_ed
YWddejX[Z[cedijhWj[Z$M_j^ekj_cc[Z_Wj[beWZ_d]"
Yecf[diWj_edWbceZ[bb_d]Ze[idej[l[djWa[fbWY[
m^[d l[ho Xkbao h[bWj_l[ je j^[ i_p[ e\ j^[ `Wm
Yh[ijWb\_njkh[iWh[_di[hj[ZWdZj^[l[ij_XkbWhXed[
lebkc[ _i WZZ_j_edWbbo h[ZkY[Z$ 8E? _cfbWdji Wh[
h[bWj_l[bo h[i_ijWdj je Wdo _d\[Yj_edi fh[i[dj m_j^_d
j^[ Xed[ eh _djheZkY[Z Zkh_d] j^[ fheY[Zkh[$ 8ej^
j^[fheij^[j_YYedY[fjWdZj^[YedY[fje\_cc[Z_Wj[
beWZ_d] m_bb _d\bk[dY[ j^[ bed]#j[hc cehf^ebe]o &IGÈ :ekXb[#Z_ia8E?_cfbWdjXej^j^[j^h[WZ[Zf_dWdZ
e\ j^[ Xed[ ijhkYjkh[i WhekdZ [deiiWb _cfbWdji$ j^[Yh[ijWbZ_iaWh[l_i_Xb[m_j^WYhemdXbeYah[ijehWj_ed$J^[
J^[ Z[l[befc[dj WdZ fhefW]Wj_ed e\ c_YheYhWYai ebZYehj_YWbXed[b_d[icWbbXbWYaWhhemi_iYb[Whbol_i_Xb[$Je
fhel_Z[_d\ehcWj_ededm^[j^[hWdZjem^Wj[nj[dj j^[ h_]^j" j^[h[ _i d[mbo \ehc[Z Xed[ ZWha Xbk[$ B_d]kWbbo"
[deiiWb_cfbWdjim[h[_cc[Z_Wj[bobeWZ[Z_dWd_cWb j^[h[_id[m\ehcWj_ede\mel[dXed[$J^[Yedd[Yj_l[j_iik[
_d j^[ i^W\j Wh[W [nj[dZi X[bem j^[ Yhemd" WdZ j^[h[ _i
[nf[h_c[dji$ de [f_j^[b_Wb ]hemj^ _d W YWkZWb Z_h[Yj_ed$ J^[ ie\j#j_iik[
?cc[Z_Wj[ beWZ_d] e\ Yh[ijWb WdZ XWiWb _cfbWdji ijhkYjkh[i WhekdZ 8E? _cfbWdji Ze dej i[[c je ^Wl[ W
_d Ze]iÉ cWdZ_Xb[i m_bb ]_l[ h_i[ je bWj[hWb Xed[ bWo[h[Z ijhkYjkh[ X_ebe]_YWb m_Zj^ b_a[ j^[ ed[ Z[iYh_X[Z
Wffei_j_ed$ 9h[ijWb _cfbWdji j^Wj Wh[ Wbbem[Z je m_j^Yh[ijWb_cfbWdji$J^[_cfbWdj^WiX[[djh[Wj[ZXoi^ej#
^[Wb _d W ded#beWZ[Z ijWj[ Wh[ dej WiieY_Wj[Z m_j^ f[[d_d] \eh W iceej^ kd_\ehc ikh\WY[$ J^[ _cfbWdj ^WZ dej
Xed[ Wffei_j_ed$ 7ffei_j_edWb Xed[ ceZ[bb_d] _i X[[d_di[hj[Z_dWdefj_cWbboY[djh_Yfei_j_ed$J^[if[Y_c[d
WbieWXi[dj_\eii[e_dj[]hWj_ede\Yh[ijWb_cfbWdji_i Ze[i h[l[Wb" ^em[l[h" j^Wj j^[ Yh[ijWb fbWj[ ^WZ f[d[jhWj[Z
j^[ b_d]kWb Yehj_YWb Xed[ ijhkYjkh[ Wj ed[ if[Y_\_Y beYWj_ed$
fh[l[dj[ZXo_d\[Yj_ed$ J^[ beWZ#jhWdic_jj_d] Wh[W e\ j^[ Yh[ijWb fbWj[ ^Wi X[[d
?d YedjhWij je j^[ Z[l[befc[dji i[[d m_j^ j^[ efj_cWbboeii[e_dj[]hWj[Zh[ZWhhem$;nj[di_l[h[ceZ[bb_d]
Yh[ijWb_cfbWdji_dekhijkZo"ded#ij[h_b[_di[hj_ede\ _i eXi[hl[Z WXel[ j^[ Yh[ijWb Z_ia WdZ l[ij_XkbWhbo je j^[
8E?_cfbWdjiZ_Zdejfh[l[djj^[_heii[e_dj[]hWj_ed j^h[WZ[Z f_d$ J^[ XWiWb h_d] i[]c[dj l_i_Xb[ _d j^_i f_Yjkh[
[l[dm^[d_cc[Z_Wj[beWZ_d]mWiki[Z$7ffei_j_edWb YWc[jeX[beYWj[Z_dWc[ZkbbWhoifWY[]h[[dWhhem
ceZ[bb_d] Wi eXi[hl[Z W\j[h ij[h_b[ _cfbWdjWj_ed
fheY[Zkh[imWi"^em[l[h"dejeXi[hl[Z$
M[ Wjj[cfj[Z je Yh[Wj[ YedZ_j_edi kdZ[h m^_Y^
eii[e_dj[]hWj_ed e\ 8E? _cfbWdji mekbZ \W_b Xo
i[b[Yj_d] eij[eco[b_j_Y Wh[Wi eh Z[djWb heeji Wi
_di[hj_ed i_j[i" eh Xo _di[hj_d] [njh[c[bo Z_hjo WdZ
_d\[Yj[Z _cfbWdji" eh Xo YecX_d_d] j^[i[ WZl[hi[
 È È (ISTOLOGICALÈ3TUDIESÈ )'+

&IGÈ HWZ_e YedjhWij _cW][ _bbkijhWj_d] W YWkZe#

B
l[ij_XkbWh_dYh[Wi[e\Xed[c_d[hWb_pWj_ed$J^[ikXf[h_eij[Wbbo
\ehc[Z Xed[ ijhkYjkh[ jef h_]^j _i ij_bb kdZ[hc_d[hWb_p[Z$
J^[ fWhj_Wbbo h[ceZ[bb[Z Xed[ X[jm[[d j^[ l[ij_XkbWh Z_ia
i[]c[djiedj^[_di[hj_edi_Z[h[l[WbiXh_]^jYeh[ie\^_]^[h
c_d[hWb_pWj_ed

&IGÈAB 8ed[Wffei_j_ede\WhekdZ'$+cc_iWbiei[[d

ed j^[ b_d]kWb Wif[Yj h_]^j Wj W Z_ijWdY[ e\ WhekdZ )cc
\hecj^[j^h[WZ[Zf_d$J^[ebZYehj_YWbXed[b_d[^WZWbceij
Yecfb[j[bo Z_iiebl[Z Xo j^Wj j_c[$ 9bei[ eii[eWZWfjWj_ed _i
fh[i[dj \hec WXel[ j^[ XWiWb Z_ia Zemd je j^[ c[ZkbbWho
YecfWhjc[dje\j^[cWdZ_Xb[$J^[h[Wh[de_dZ_YWj_edij^Wj
eii[e_dj[]hWj_ed _i _cfW_h[Z _d Wdo mWo Xo j^[ h[i_ZkWb heej
ijhkYjkh[$ F[h\[Yjbo _d\bWccWj_ed#\h[[ c[ZkbbWho ifWY[ m_j^
[dZeij[Wb d[m Xed[ \ehcWj_ed$ J^[ Æj[dj [\\[YjÇ ]_l[i h_i[
je d[m Xed[ \ehcWj_ed X[bem j^[ f[h_eij[kc e\ j^[ ib_]^jbo
fhe`[Yj_d] XWiWb fbWj[ X$ J^[ XWiWb fbWj[" Wbj^ek]^ beYWj[Z
_d j^[ Xed[#\h[[ c[ZkbbWho ifWY[" _i el[h]hemd m_j^ W j^_d
bWo[he\d[mXed[\hecWYh[ijWbZ_h[Yj_ed$J^[h[i_ZkWbheej
ijhkYjkh[edboW\\[Yjij^[_dj[]hWj_ede\j^[beWZ#jhWdic_jj_d]
ikh\WY[jej^[[nj[djj^Wj_j_iWXb[je_d\bk[dY[j^[Z_h[Yj_ede\
h[ceZ[bb_d]$Ij[h_b[_di[hj_edWjWZ_ia^[_]^je\&$-cc
&IGÈ Edbem[h_d]j^[hWZ_Wj_ed_dj[di_jo"Z_\\[h[dY[i_d
Z[di_joX[Yec[WffWh[dj_dj^[XWiWb`Wmi[]c[djWim[bb
)', 9^Wfj[h()È (ISTOLOGYÈOFÈ"/)È)MPLANTS
&IGÈ 7 Yecfb[j[bo Z_\\[h[dj c_d[hWb_pWj_ed fWjj[hd _i
i[[d edbo )cc \hec j^[ i[Yj_ed Z[f_Yj[Z _d <_]i$()$'' WdZ
()$'(
&IGÈ 7 ded#eii[e_dj[]hWj[Z _cfbWdj j^Wj mWi
_cc[Z_Wj[bo beWZ[Z W\j[h _di[hj_ed Ze] (" h_]^j i_Z[$ De
\ehY[i Wh[ jhWdic_jj[Z Z_h[Yjbo je j^[ Xed[ _cfbWdj Yeh[
Z_Wc[j[h0 )$,cc$ De WZZ_j_l[ \ehcWj_ed e\ d[m Xed[ e\
f[h_eij[Wbeh_]_d_il_i_Xb[$?dij[WZ"Wbceijj^[[dj_h[`WmXed["
m^_Y^ ^WZ fh[l_ekibo X[[d Y^WhWYj[h_p[Z Xo _d\bWccWjeho
h[iehfj_ed" mWi d[mbo [ijWXb_i^[Z Wi mel[d Xed[$ J^[
^_ijebe]_YWbWff[WhWdY[_iYedi_ij[djm_j^Wfeij#eij[eco[b_j_Y
ijWj[$ 9edd[Yj_l[#j_iik[ h[i_Zk[i e\ _d\bWccWj_ed Wh[ ij_bb
l_i_Xb[_dj^[c[ZkbbWhoifWY[
&IGÈ Eii[e_dj[]hWj[Z iYh[m _cfbWdj j^Wj mWi _cc[Z_#
Wj[bo beWZ[Z W\j[h _di[hj_ed$ J^[ \ehcWj_ed e\ d[m Xed[ ed
j^[ b_d]kWb WdZ l[ij_XkbWh i_Z[i _i Yb[Whbo l_i_Xb[$ J^[ Xed[
ijhkYjkh[ WhekdZ j^[ j^h[WZ mWi [nj[di_l[bo h[ceZ[bb[Z Wi
m[bb Xbk[ Wh[Wi$ J^[ Yeh[ Z_Wc[j[h mWi )$,cc$ J^[ d[mbo
ceZ[bb[ZWdZh[ceZ[bb[ZXed[ijhkYjkh[iYWdX[_Z[dj_\_[ZXo
j^[_hXbk[Yebekh$;nj[di_l[h[ceZ[bb_d]edbojeeafbWY[Wbed]
j^[l[hj_YWb_cfbWdjWn_iedj^[l[ij_XkbWhi_Z[$Edj^[b_d]kWb
i_Z[" j^[ fh[#[n_ij_d] Xed[ ijhkYjkh[ _i ij_bb fh[i[dj" Wbceij
kdY^Wd][Z$7ceZ[hWj[Wcekdje\[dZeij[WbXed[Wffei_j_ed
_i fh[i[dj Wi m[bb$ J^[ l[ij_Xkbe#Yh[ijWb Xed[ ijhkYjkh[ mWi
h[ceZ[bb[Z_d_ji[dj_h[jo
&IGÈ 8ed[ ceZ[bb_d] m_bb ifh[WZ je ded#h[ijeh[Z `Wm
Wh[Wiedj^[_cc[Z_Wj[bobeWZ[Zi_Z[_dj^[_cc[Z_Wj[l_Y_d_jo
e\ j^[ beWZ[Z _cfbWdji$ KdbeWZ[Z _cfbWdji" Xo YedjhWij"
h[l[Wb icWbb[h Wcekdji e\ h[ceZ[bb[Z Xed[ Wbed] j^[ beWZ#
jhWdic_jj_d]_dj[h\WY[$J^[ZWha[hb_d[il_i_Xb[_dj^_if_Yjkh[
Wh[jhk[\hWYjkh[b_d[iX[YWki[j^[oWh[dejZ_h[Yjbo_djekY^
m_j^j^[_cfbWdj$J^[\hWYjkh[i_dj^_iWh[W^WZWbh[WZoX[[d
[b_c_dWj[ZXoh[ceZ[bb_d]e\j^[Xed[ijhkYjkh[_cc[Z_Wj[bo
ikhhekdZ_d]j^[_cfbWdjYb[Whbol_i_Xb[Xo_jiZ_ij_dYjYebekh"
Wced] ej^[h \WYjehi$ J^_i _cfbWdj" jee" h[l[Wbi ckY^ ceh[
[nj[di_l[ h[ceZ[bb_d] ed j^[ l[ij_XkbWh j^Wd ed j^[ b_d]kWb
i_Z[e\j^[l[hj_YWb_cfbWdjWn_i
È È (ISTOLOGICALÈ3TUDIESÈ )'-

&IGÈ 9Jel[hl_[meXjW_d[Z*cedj^iW\j[h_di[hj_ed$J^[
Wjj[cfjje_dZkY[ckYeiWbWbj[hWj_ediehY^hed_Y_d\bWccWj_ed
Xo_di[hj_d]WYedjWc_dWj[Z_cfbWdj_djej^[cWn_bbWhoi_dki
mWidejikYY[ii\kb

&IGÈ J^_i8E?_cfbWdj_im[bbeii[e_dj[]hWj[ZWbed]_ji
XWiWbh_d]WdZbem[hfehj_ede\_jij^h[WZ[Zf_dWj*cedj^i
Wbj^ek]^_j^WZX[[d_di[hj[Z_dWYedjWc_dWj[ZijWj[kdZ[h
ded#ij[h_b[ YedZ_j_edi \ebbem[Z Xo _cc[Z_Wj[ beWZ_d]$ J_do
h[i_Zk[i e\ _d\[Yj_ed Wh[ ij_bb l_i_Xb[ _d j^[ c[ZkbbWho ifWY[$
7bb l_i_Xb[ Yehj_YWb Wh[Wi m[h[ h[Xk_bj m_j^ fb[n_\ehc Xed[$
J^[ \ehcWj_ed e\ d[m Xed[ _d j^[ Wh[W e\ j^[ j^h[WZ[Z f_d
Wff[Wh[Z je X[ Z[bWo[Z _d YecfWh_ied m_j^ _cfbWdji j^Wj
^WZ X[[d _di[hj[Z kdZ[h ij[h_b[ YedZ_j_edi$ ?d YedjhWij je
j^[if[Y_c[dZ[f_Yj[Z_d<_]$()$(-"m^_Y^mWiYebb[Yj[ZW\j[h
j^[iWc[ZkhWj_ede\i[hl_Y["h[ceZ[bb_d]e\j^[mel[dXed[
ijhkYjkh[iWdZWdoc_ii_d]Wh[Wi^WiWbh[WZoX[[d_d_j_Wj[ZWj
cWdoi_j[i$D[m\ehcWj_ede\jhW`[Yjeh_Wbboeh_[dj[ZjhWX[YkbW[
_iWbiekdZ[hmWo$
J^[ ceh[ fhedekdY[Z _dlW]_dWj_ed e\ ie\j#j_iik[ i[]c[dji
_dj^[l[hj_YWbeij[ejecoibej_dZ_YWj[ij^WjYedd[Yj_l[#j_iik[
ijhkYjkh[ij^Wj^WZWZlWdY[Z_djej^[Wh[W\_hijWh[]hWZkWbbo
X[_d] Z_ifbWY[Z Xo j^[ d[mbo \ehc[Z Xed[ ijhkYjkh[i$
J^_i _cfbWdj \[Wjkh[i W ikh\WY[#[dbWh][Z Wf_YWb fehj_ed e\
j^[ j^h[WZ[Z f_d" m^_Y^ _i Wbh[WZo Y^WhWYj[h_p[Z Xo Ybei[
eii[eWZWfjWj_ed WdZ eii[e_dj[]hWj_ed _d j^_i f_Yjkh[$ J^[
bWj[hWb_di[hj_edibejiWh[bWh][bo\_bb[Zm_j^Xed[Wim[bb$EdY[
W]W_d" j^[ bWh][ Wcekdji e\ mel[d Xed[ ZWha Xed[ ed j^[
cWh]_de\j^[if[Y_c[dWh[_dZ_YWj_l[e\Wfeij#eij[eco[b_j_Y &IGÈ J^_i_cfbWdj^WZX[[dX[dj_dWdWYj_l[[\\ehjXo
ijWj[ j^[ Ze] j^Wj WffWh[djbo [nf[h_[dY[Z j^[ j^h[WZ[Z f_d Wi W
Z_iYec\ehj$J^[Ze]a[fjX_j_d]j^[c[i^e\j^[YW][kdj_bj^[
j^h[WZ[Z f_d de bed][h _dj[h\[h[Z$ J^_i Z_Z dej f[h i[ W\\[Yj
j^[ fhe]h[ii e\ _cfbWdj ^[Wb_d]$ J^[ c[cXhWd[ _d j^[ Wh[W
e\j^[cWn_bbWhoi_dki^WZedY[W]W_del[h]hemdj^[_cfbWdj
i_j[" Wbie _dlebl_d] jhk[ ceZ[bb_d]$ Dej Wbb [deiiWb _cfbWdj
i[]c[djim[h[eii[e_dj[]hWj[ZXoj^Wjj_c[$Eii[eWZWfjWj_ed
e\ j^[ m[X XWh Z[l[befi \hec j^[ cWh]_d" `kij b_a[ _d j^[
cWdZ_XkbWh if[Y_c[di$ H[i_Zk[i e\ W fWij _d\bWccWj_ed Wh[
l_i_Xb[ Wi ZWha Wh[Wi$ De ceh[ i_]di e\ _d\bWccWj_ed Wh[
fh[i[dj_dj^[cWn_bbWhoWdZdWiWbi_dki[i$J^[l[ij_XkbWhZ_ia
i[]c[djmWiX[djkfmWhZideji^emd
)'. 9^Wfj[h()È (ISTOLOGYÈOFÈ"/)È)MPLANTS
È
(ARD
4ISSUEÈ(EALINGÈÈ j[Wce\Y[bbij^Wj_i\ehc[Z\hecWicWbbfefkbWj_ed
ANDÈ)MMEDIATEÈ,OADING
È
)NTRODUCTION
J^[h[ Wh[ jme [ii[dj_Wb c[Y^Wd_ici e\ Xed[
^[Wb_d]0 Z_h[Yj ^[Wb_d] WdZ _dZ_h[Yj ^[Wb_d]$ :_h[Yj
^[Wb_d] YWd edbo eYYkh _\ Xej^ Xed[ ikh\WY[i Wh[ _d
_cc[Z_Wj[YedjWYj"ikY^j^Wjj^[8CKiYWdZ_h[Yjbo
jhWdil[hi[j^[\hWYjkh[]Wf$?dZ_h[Yj^[Wb_d]eYYkhi_\
j^[\hWYjkh[Z\hW]c[djiWh[beYWj[Z\Whj^[hWfWhj$
?dZ_h[Yj ^[Wb_d] eh_]_dWj[i Xej^ \hec j^[
f[h_eij[kcWdZ\hecj^[c[ZkbbW$J^[f[h_eij[kc_i
Yecfei[Ze\jmebWo[hi0W\_Xheki[nj[hdWbbWo[hWdZ
WY[bb#h_Y^_dd[hbWo[hademdWij^[ÆYWcX_kcÇ$J^[
eij[eXbWijie\j^[f[h_eij[kcYedj_dkekibofheZkY[
W j_do Wcekdj e\ bWc[bbWh Xed[ _d WZkbj ^kcWdi"
m^_Y^ YWki[i j^[ bed] jkXkbWh Xed[i je X[Yec[
]hWZkWbbo j^_Ya[h$ ;l[d c_deh jhWkcWj_Y _cfWYji
m_bb WXhkfjbo _dZkY[ j^[ f[h_eij[kc je Z[l[bef
ceh[ eij[eXbWiji" m^_Y^ m_bb j^[d fheZkY[ W bWh][
Wcekdj e\ mel[d Xed[ m_j^_d W l[ho i^ehj j_c[$ ?\
\hWYjkh[ ^Wi eYYkhh[Z" j^[i[ mel[d Xed[ ijhkYjkh[i
m_bbXh_Z][j^[]Wfje\ehcj^[f[h_eij[WbYWbbki$J^[
l[hj_YWb ibeji _d j^[ Xed[ W\j[h j^[ _di[hj_ed e\ 8E?
_cfbWdjiWh[&$,Ä&$/cc^_]^"m^_Y^Wbbemifh_cWho
^[Wb_d]WiWh[]kbWhWdim[h\ehj^[XeZo$
J^[ [dZeij[Wb Xed[ ikh\WY[i Wh[ Yel[h[Z dej
Xo c[cXhWd[i Xkj Xo Xed[ b_d_d] Y[bbi" m^_Y^ Ze
dej" ^em[l[h" fWhj_Y_fWj[ _d Xed[ ^[Wb_d]$ JhWkcW
m_bb _dZkY[ j^[ \ehcWj_ed e\ W c[ZkbbWho YWbbki"
m^_Y^" Z[if_j[ X[_d] b[ii Yedif_Ykeki" Wff[Whi
je ^Wl[ W ]h[Wj[h heb[ _d Xh_d]_d] WXekj _d_j_Wb
\hW]c[dj Ye^[i_ed$ 9edjhWho je fh[l_eki iY_[dj_\_Y
j^_da_d]" _j _i jeZWo X[b_[l[Z j^Wj j^[ XbeeZ Y[bbi
[njhWlWiWj[Z\hecj^[\hWYjkh[#_dZkY[Zhkfjkh[iZe
dej fWhj_Y_fWj[ _d Xed[ ^[Wb_d]$ J^[ ifWY[ X[jm[[d
j^[f[h_eij[WbWdZj^[[dZeij[WbYWbbkim_bbdehcWbbo
\_bbm_j^YWhj_bW][$
J^[^[Wb_d]fheY[ii\Wbbi_djej^h[[Z_ij_dYjf^Wi[i
e\_d\bWccWj_ed"h[fW_hWdZceZ[bb_d]$J^[\ebbem_d]
fh_dY_fb[_iYhkY_WbWdZWffb_[ikd_l[hiWbboXej^\hec
j^[ikh]_YWbWdZ\hecj^[h[ijehWj_l[l_[mfe_dj0
EdY[ j^[ fheY[ii e\ Xed[ ^[Wb_d] ^Wi X[[d
_d_j_Wj[Z" [l[ho ikYY[ii_l[ ij[f _d j^[ fheY[ii
m_bb Z[f[dZ ed j^[ fh[Y[Z_d] ed[$7do Z[l_W#
j_edi \hec j^[ dehcWb i[gk[dY[ e\ [l[dji Wh[
ceh[ b_a[bo je ]_l[ j^[ fheY[ii W mhed] jkhd
j^Wd je ijef _j$ EdY[ Wd [hheh ^Wi eYYkhh[Z" _j
YWddejX[kdZed[Ä_$[$j^[h[m_bbX[demWoe\
h[ijeh_d]j^[eh_]_dWbijWj[$
<hWYjkh[ ^[Wb_d] _i dej [\\[Yj[Z Xo fh[#[n_ij_d]
eij[eXbWijiehY^edZheXbWijiXkjXoWYecfb[j[bod[m
e\ij[cY[bbiif[Y_\_YWbbo\ehj^[fkhfei[Wj^WdZ$?\
j^[^[Wb_d]fheY[iijWa[iWmhed]jkhd"j^[[n_ij_d]
j[Wc e\ Y[bbi m_bb dej X[ WXb[ je iWl[ j^[ i_jkWj_ed
X[YWki[ j^[o m_bb ^Wl[ [dj[h[Z W Z_\\[h[dj f^Wi[
e\ j^[_h Y[bbkbWh b_\[ Xo j^Wj j_c[$ J^_i _i Yedi_ij[dj
m_j^j^[m[bb#ademd\WYjj^WjWdoh[i_ZkWbj_iik[_d
j^[ \hWYjkh[ ]Wf d[[Zi je X[ h[cel[Z cWdZWjeh_bo
WdZh[fbWY[ZXoWXed[]hW\j_\j^[\hW]c[dji\W_bje
kd_j[$;b[Yjh_Yi_]dWbiWh[YWfWXb[e\jh_]][h_d]Wd[m
YWiYWZ["jee$
9eYY_W [j Wb$ '/.& fe_dj[Z ekj j^Wj j^[h[ m[h[
Z_\\[h[dY[i _d j^[ eh_]_di e\ eij[eYbWiji WdZ eij[e#
XbWiji$ 7\j[h W \[cWb[ fWj_[dj ^WZ h[Y[_l[Z W Xed[
jhWdifbWdj X[YWki[ e\ Wd eij[eYbWije][d[j_YWb Z_i#
ehZ[h\hecWcWb[Zedeh"^[heij[eYbWiji[n^_X_j[Z
cWb[OY^heceiec[i"m^_b[^[heij[eXbWijiYedj_dk[Z
je X[ \[cWb[$ J^_i mekbZ _dZ_YWj[ j^Wj j^[ jme Y[bb
b_d[i^Wl[Z_\\[h[djeh_]_di1Wbie"j^[eij[eXbWijfh[#
Ykhieh Y[bbi _d j^[ Xed[ cWhhem ceij fheXWXbo Z_Z
dej ikhl_l[ j^[ jhWdifbWdjWj_ed$ Eij[eYbWiji j^ki
fheXWXbo Z[h_l[ \hec ^W[cWjefe_[j_Y Y[bb b_d[i"
m^_b[ c[i[dY^ocWb ij[c Y[bbi Wh[ j^[ eh_]_d e\ j^[
eij[eXbWiji$ ?j i[[ci j^Wj eij[eXbWiji ifh_d] \hec
W i[b\#ikijW_d_d] fefkbWj_ed e\ c[i[dY^ocWb Y[bbi
\ebbem_d]j^[Ykjj_d]Yed[\hec_jieh_]_d$
?d j^[ _d_j_Wb f^Wi[ e\ _d\bWccWj_ed" j^[ Y[bbi
h[gk_h[Z \eh j^[ ^[Wb_d] fheY[ii Wh[ WYj_lWj[Z$
FW_d WdZ im[bb_d] m_bb Wbie Yedjh_Xkj[ je j^[
_cceX_b_pWj_ed$ 7ZZ_j_edWb ifb_dj_d] _i fhel_Z[Z
Xo ^oZheijWj_Y fh[iikh[$ J^[h[ m_bb X[ ^W[cWjecW
\ehcWj_ed" lWieZ_bWjWj_ed" [nkZWj_ed e\ i[hkc" WdZ
_d\_bjhWj_ede\_d\bWccWjehoY[bbi$J^_if^Wi[m_bbbWij
\eh)Ä-ZWoi$
?d j^[ h[fW_h f^Wi[" j^[ YWbbki _i \ehc[Z Wi
Z[iYh_X[ZWXel[\hecgk_YabofheZkY[Zmel[dXed[$
?\j^[XbeeZikffbo_i_dik\\_Y_[dj"YWhj_bW][\ehcWj_ed
_i ceh[ b_a[bo je eYYkh j^Wd Xed[ \ehcWj_ed$ Ed[
e\ j^[ cW_d h[Wiedi \eh ikY^ _dik\\_Y_[dj XbeeZ
ikffbo _i bWYa e\ _cceX_b_pWj_ed$ 7bj[hdWj_l[bo" j^[
Z_\\[h[dj_Wj_ed fheY[ii YWd X[ _cf[Z[Z Xo j^[ l[ho
dWjkh[ e\ j^[ beWZi _d j^[ h[fW_h Wh[W 9Whj[h [j Wb$
'/..$J^[YWhj_bW]_dekih[]_edi_dj^[l_Y_d_joe\j^[
\hWYjkh[b_d[im_bbdehcWbboeii_\o`kijb_a[Wdomel[d
Xed[ijhkYjkh[i$J^[j[hcfi[kZeWhj^hei_iZ[iYh_X[i
\hWYjkh[ ^[Wb_d] e\ bed] Xed[ \hW]c[dji m^[h[ j^_i
eii_\_YWj_ed Ze[i dej eYYkh$M_j^ h[]WhZ je _cfbWdj
^[Wb_d]"Wi_c_bWhi_jkWj_ed_ih[\[hh[ZjeWi\W_bkh[e\
eii[e_dj[]hWj_ed eh \_Xhe_dj[]hWj_ed$ M_j^_d ed[ eh
jmem[[ai"WY[hjW_dWcekdje\c_d[hWbi_iZ[fei_j[Z
je\ehcj^[XedoYWbbki$J^_iWh[W_ih[bWj_l[boh_]_Z
X[YWki[ _ji Yheii i[Yj_ed _i bWh][h j^Wd j^Wj e\ j^[
eh_]_dWbXed[ijhkYjkh[$
J^[h[ceZ[bb_d]f^Wi[_i_d_j_Wj[ZedY[j^[Xed[
kd_ed ^Wi X[[d h[[ijWXb_i^[Z$ ?d j^_i f^Wi[" j^[
È È (ARD
4ISSUEÈ(EALINGÈANDÈ)MMEDIATEÈ,OADINGÈ )'/
\hWYjkh[ i_j[ _i Xk_bj XWYa je _ji eh_]_dWb lebkc[$7j
j^[iWc[j_c["j^[[nj[hdWbi^Wf[e\j^[[dj_h[Xed[
ijhkYjkh[YWdX[WZ`kij[Zjeh[\b[Yjj^[Ykhh[djijWj[
e\ c[Y^Wd_YWb h[gk_h[c[dji$ J^[i[ h[WYj_edi fbWo
Wd _cfehjWdj heb[ m_j^ 8E? _cfbWdji Wi m[bb" i_dY[
j^[ bWj[hWb eij[ejeco j^hek]^ m^_Y^ j^[ _cfbWdj _i
_di[hj[Z m_bb heki[ j^[ ZehcWdj cWYhejhW`[Yjeh_Wb
ioij[cjef[h\ehch[ceZ[bb_d]WYj_l_j_[iedj^[ed[
^WdZWdZje][d[hWj[WZZ_j_edWbXed[ijhkYjkh[ied
j^[ej^[h$
J^[ X[^Wl_ekh e\ \hWYjkh[ [dZi WdZ ^em j^[o
^[WbkdZ[hbeWZlWhom_Z[bom_j^_dj^[^kcWdXeZo$
8hea[dh_Xi"\eh[nWcfb["m_bbWbmWoi^[Wb"[l[dm^[d
Yedi_Z[hWXb[ ceX_b_jo _i _dlebl[Z$ H_Xi ^Wl[ d[l[h
X[[dZ[cedijhWj[Zdejje^[WbW\j[h\hWYjkh[$JkXkbWh
Xed[i"^em[l[h"X[^Wl[gk_j[Z_\\[h[djbo$J^[h_iae\
\hWYjkh[ ]Wf Z_ibeYWj_ed m_bb \h[gk[djbo h[ikbj _d
ÆcWbkd_edÇe\j^[\hWYjkh[[dZi$Edj^[ej^[h^WdZ"
^em[l[h"_j_im[bbademdj^WjWZ[gkWj[ceX_b_pWj_ed
e\ fWj_[dji m_j^ \hWYjkh[i m_bb fhecej[ j^[ ^[Wb_d]
fheY[ii$7ffWh[djbo"j^[Z[]h[[e\YWbbki\ehcWj_ed_i
_dl[hi[bofhefehj_edWbjej^[Z[]h[[e\ceX_b_pWj_ed$
J^[ YWbbki _i h[_d\ehY[Z Xo ceZ[hWj[ beWZ_d] [$]$
m[_]^ji eh Z_ijhWYj_ed [\\ehji$ ;nY[ii_l[ beWZ_d]
m_bb"e\Yekhi["Z_ihkfjj^[ioij[c$?d\WYj"j^[h[_ide
i_cfb[Wdim[hjej^[gk[ij_ed^emckY^beWZ_d]eh
ceX_b_pWj_ed _i jeb[hWXb[ WdZ WYjkWbbo YedZkY_l[ je
Xed[h[fW_h$
J^[ \ebbem_d] \WYjehi YWd _dj[h\[h[ m_j^ ijWX_b_#
pWj_ed ijWX_b_jo eh fhef[h cWjh_n \ehcWj_ed WhekdZ
8E?_cfbWdji0
v J^[ \_hij \ebbem#kf l_i_j _i iY^[Zkb[Z m_j^_d
j^[ \_hij )Ä,m[[ai$ Dej[ j^Wj 8E? _cfbWdji YWd
X[Yec[ ceX_b[" Xkj j^[o m_bb dej \Wbb ekj$ J^[o
Z_\\[h \hec Yh[ijWb _cfbWdji _d j^_i h[if[Yj$
CeX_b_jo e\ 8E? _cfbWdji _i e\j[d h[l[hi_Xb[ ed
h[ZkY_d] j^[ fheij^[j_Y beWZ" fhel_Z[Z j^Wj Wd
WZ[gkWj[ \kdYj_edWb fWjj[hd _i fh[i[dj$ J^[h[
Wh[ Wbie i_jkWj_edi" ^em[l[h" _d m^_Y^ _cfbWdji
^Wl[ je X[ h[fbWY[Z Wbed] m_j^ j^[ fheij^[j_Y
ijhkYjkh[$M^_b[ _j _i e\j[d m_i[ je WZefj W mW_j#
WdZ#i[[ ijhWj[]o X[\eh[ cWa_d] j^[ Z[\_d_j_l[
jh[Wjc[djZ[Y_i_ed"j^[ki[\kbd[iie\j^_iijhWj[]o
_i [njh[c[bo Z_\\_Ykbj je [nfbW_d je fWj_[dji WdZ
_dikhWdY[ fhel_Z[hi Wb_a[$ ?j _i ij_bb W Yeccedbo
WYY[fj[Z Ze]cW j^Wj Wdo ceX_b[ _cfbWdji
i^ekbZ X[ h[fbWY[Z _cc[Z_Wj[bo je Wle_Z Wdo
bWj[ Yedi[gk[dY[i$ J^_i Ze]cW" ^em[l[h" Ze[i
dejWffboje8E?_cfbWdji$7doed[m^e^Wi[l[h
m_jd[ii[Z ^em 8E? _cfbWdji ]W_d ijh[d]j^ W\j[h
X[_d] j[cfehWh_bo Z[jWY^[Z \hec j^[ fheij^[j_Y
ikf[hijhkYjkh[ehW\j[hY^Wd][i_dj^[cWij_YWjeho
fWjj[hd" ademi j^Wj j^_i f^_beief^o Ze[i dej
^ebZ kf je iYhkj_do$ Ekh ^_ijebe]_YWb ijkZ_[i
Z[cedijhWj[Z j^Wj i[YedZWho Xed[ YedjWYj YWd
X[ WY^_[l[Z j^Wdai je eii[eWZWfjWj_ed WdZ ]Wf
`kcf_d]$ J^[ ib_]^j ceX_b_jo e\ j^[ j^h[WZ[Z
f_d ]_l[i h_i[ je Yecfh[ii_l[ \ehY[i Zkh_d]
f^oi_ebe]_YWbcWij_YWj_ed"m^_Y^Wh[YWfWXb["f[h
i["e\jh_]][h_d]j^[\ehcWj_ede\d[mXed[$
v Ded#Wn_Wb \ehY[i YWd WYj ed kdbeWZ[Z _cfbWdji
_dj^[WXi[dY[e\fei_j_edWbijWX_b_joWifhel_Z[Z
Xo j^[ Xh_Z][$ J^[ _cfbWdj#Xed[ _dj[h\WY[ _i
Yedj_dkWbbo WdZ [nY[ii_l[bo ceX_b_p[Z _d j^_i
i_jkWj_ed$ J^[ WXi[dY[ e\ _cc[Z_Wj[ cWij_YWjeho
beWZ_d]cWoX[ik\\_Y_[djh[Wied\eh8E?_cfbWdj
beii"fWhj_YkbWhbo_\^_]^=#lWbk[iWiieY_Wj[Zm_j^
]h[Wj b[l[hW][ \ehY[i Wh[ _dlebl[Z$ Dej[ j^Wj j^[
\ehY[e\j^[jed]k[Ze[idejij[c\hecWckiYb[
WjjWY^[Z je j^[ cWdZ_Xb[ eh j^[ cWn_bbW" ie j^_i
\ehY[ Ze[i dej Yekdj[hij_ckbWj[ f[h_#_cfbWdj
Xed[ Wh[Wi eh cWYhejhW`[Yjeh_[i _di_Z[ j^[ Xed[$
J^[jed]k[\ehY[ieb[bomehai_dj^[Z_h[Yj_ede\
beei[d_d]j^[_cfbWdj$<khj^[hceh["j^[kdbeWZ[Z
8E? _cfbWdj _i dej \b[n[Z WdZ ^[dY[ i^emi de
j[dZ[dYo je ikffehj ikffkhWj_ed _d Wd ekjmWhZ
Z_h[Yj_ed$ J^_i cWo ikffehj _dl[hi[ XWYj[h_Wb
_dlWi_ed$9h[ijWb_cfbWdji"jee"YWdX[beijkdb[ii
j^[o Wh[ fkj _dje Yb_d_YWb i[hl_Y[ _d Zk[ Yekhi[
:[[c[jWb$(&&($
È
)MMEDIATEÈ,OADINGÈ6ERSUSÈ
)MMEDIATEÈ)MPLANTATION
?cc[Z_Wj[beWZ_d][dikh[ij^Wjj^[Y^[m_d]\kdYj_ed
_i gk_Yabo WZZh[ii[Z _d j^[ fheY[ii e\ h[ijeh_d] j^[
cWij_YWjeho ioij[c$ J^_i WffheWY^ _i Wbie [\\_Y_[dj
\hec W fheY[ZkhWb l_[mfe_dj" j^ki b_c_j_d] j^[ Yeij
e\_cfbWdjjh[Wjc[dj$J^[h[\eh["_cc[Z_Wj[beWZ_d]
_i Yedi_Z[h[Z Z[i_hWXb[ Xo Z[dj_iji WdZ fWj_[dji
Wb_a[$
<_hije\Wbb"j^[_iik[e\_cc[Z_Wj[beWZ_d]ckijX[
i[fWhWj[Z\hecj^[_iik[e\_cc[Z_Wj[_cfbWdjWj_ed$
9h[ijWb _cfbWdjebe]o Ze[i dej ^Wl[ W ijWdZWhZ
WffheWY^ je j^[ gk[ij_ed e\ i_d]b[#ij[f fheY[Zkh[i
_dlebl_d] [njhWYj_ed WdZ _cfbWdjWj_ed _d j^[ iWc[
i[ii_ed$<ehed[j^_d]"j^[h[_iWbmWoiWh_iae\Wf_YWb
eij_j_i^_ZZ[dkdZ[hehWhekdZj^[Wf[ne\j^[heeji$
<eh Wdej^[h" j^[ YehedWb Wh[Wi e\ Yh[ijWb _cfbWdji
j[dZ je X[ dWhhem[h j^Wd j^[ Yehh[ifedZ_d] Z[djWb
heej Wh[Wi$ J^[ ikYY[ii e\ _cc[Z_Wj[ _cfbWdjWj_ed
j^[ _cfbWdj _i kikWbbo _di[hj[Z Wj Wd Wd]b[ je
cWn_c_p[ j^[ _dj[h\WY[ Wh[W j^ki Z[f[dZi ed j^[
fh[i[dY[e\ik\\_Y_[djWcekdjie\_djWYjXed[Wf_YWbbo
je j^[ [njhWYj[Z jeej^ je [dikh[ fh_cWho ijWX_b_jo$
?cfbWdji _di[hj[Z _d j^_i mWo Wh[ dej dehcWbbo
[b_]_Xb[\eh_cc[Z_Wj[beWZ_d]X[YWki[e\j^[WZl[hi[
b[l[h i_jkWj_ed X[jm[[d j^[ ded#ikffehj[Z YehedWb
_cfbWdj i[]c[dj WdZ j^[ i[]c[dj [cX[ZZ[Z _d
j^[ Xed[$ J^[h[\eh[" j^[ h[Yecc[dZ[Z WffheWY^
_i je f[h\ehc jme i[fWhWj[ fheY[Zkh[i _dlebl_d]
j^[ ki[ e\ c[cXhWd[ Yel[hW][ DeY_j_ [j Wb$ (&&&"
[if[Y_Wbbo_\WZ`klWdjXed[]hW\j_d]_if[h\ehc[ZWi
)(& 9^Wfj[h()È (ISTOLOGYÈOFÈ"/)È)MPLANTS
m[bb$ Kd\ehjkdWj[bo" j^_i WffheWY^ _i dej Yedi_ij[dj
m_j^j^[kd_l[hiWbZ[i_h[e\WbbfWj_[djije^Wl[j^[_h
Y^[m_d]\kdYj_ed_cc[Z_Wj[boh[ijeh[Z$
7bb j^[ fheXb[ci j^Wj ^Wl[ `kij X[[d Z_iYkii[Z
Wh[dejdehcWbboWd_iik[m_j^8E?_cfbWdji$J^[_h
Z[i_]d Wbbemi Wdo eij_j_Y fki je ikffkhWj[ j^hek]^
j^[ eij[ejeco ibeji" m^_b[ j^[ _cfbWdj XeZo _i ^[bZ
Xo_d\[Yj_ed#\h[[fWbWjWb%b_d]kWbXed[ijhkYjkh[ij^Wj
Wh[Wbceij_dlWh_WXbo_djWYj$
È
)MMEDIATEÈ,OADINGÈ6ERSUSÈ$ELAYEDÈ,OADING
<_hije\Wbb"WZ[Y_i_edckijX[cWZ[Xom^Wjj_c[j^[
_cfbWdji m_bb X[ h[WZo je WYY[fj cWij_YWjeho beWZi$
IfW^d '//- Z[l[bef[Z W YedY[fj je Z_\\[h[dj_Wj[
Yecced i_jkWj_edi \hec [nY[fj_edWb i_jkWj_edi$
9ecced i_jkWj_edi mWhhWdj _cc[Z_Wj[ beWZ_d]"
m^_b[[nY[fj_edWbi_jkWj_edi_dlebl[W^[Wb_d]f[h_eZ
e\ *&ZWoi X[\eh[ j^[ ikf[hijhkYjkh[ _i _di[hj[Z$
M^_b[j^_iYedY[fji^ekbZdejX[Wffb_[Zh[b_]_ekibo"
_j Ze[i [nfbW_d j^[ Yehh[Yj j[cfehWb i[gk[dY[ e\
8E?#XWi[Zh[ijehWj_l[jh[Wjc[dji$
9eccedi_jkWj_edih[]kbWhYWi[iWh[Z[\_d[ZWi
\ebbemi0
v Fh[i[dY[e\Wbl[ebWhh_Z][
v 8ed[gkWb_joe\?"??eh???WYYehZ_d]jeC_iY^
v 9ed]hk[dY[X[jm[[d`WmWhY^WdZZ[djWbWhY^
v 7Z[gkWj[fh_cWhoijWX_b_joe\j^[_cfbWdji
v Defh[#[n_ij_d]Xed[b[i_ediWhekdZj^[_cfbWdj
i_j[
;nY[fj_edWbYWi[iWh[Z[\_d[ZWi\ebbemi0
v 7Xi[dY[e\WdWbl[ebWhh_Z][
v 8ed[gkWb_joe\???eh?LWYYehZ_d]jeC_iY^
v½ BWYae\Yed]hk[dY[X[jm[[d`WmWhY^WdZZ[djWb
WhY^
v ?dWZ[gkWj[fh_cWhoijWX_b_joe\j^[_cfbWdji
v Fh[l_eki ikh][ho WhekdZ j^[ _cfbWdj i_j["
[if[Y_Wbbo_\&Ä'fhef[hj_[iWh[_dlebl[Z
?dej^[hmehZi"j^[WlW_bWXb[Xed[ijhkYjkh[[$]$Xo
j^h[[#Z_c[di_edWb_cW]_d]_idejj^[ieb[Yh_j[h_ed
_d Z[Y_Z_d] \eh eh W]W_dij _cc[Z_Wj[ beWZ_d]$
Ej^[h \WYjehi _d j^[ [gkWj_ed _dYbkZ[ j^[ ifWj_Wb
Yed\_]khWj_ed e\ j^[ ikf[hijhkYjkh[" cWij_YWjeho
h[bWj_edi" j^[ b[l[hW][ WiieY_Wj[Z m_j^ jeej^ b[d]j^"
j^[ Ykhh[dj WdZ fbWdd[Z cWij_YWjeho \kdYj_ed" fh[#
[n_ij_d] Xed[ b[i_edi [$]$ Xo fWij _cfbWdjWj_ed
fheY[Zkh[i" WdZ ie \ehj^$ 7 ^[Wb_d] f^Wi[ _i
[if[Y_Wbbo _dZ_YWj[Z \eh cWn_bbWho _cfbWdj i_j[i j^Wj
m[h[ ikX`[Yj[Z je ikh][ho X[\eh[ X[YWki[ j^[h[ _i W
^_]^fheXWX_b_joj^Wjj^[jhWdi_j_ed\hecmel[dXed[
jeeij[edWbXed[^WidejX[[dYecfb[j[Z$
8o YedjhWij" Wdo fheXb[ci h[bWj[Z je j^[
_cfbWdjWj_ed fheY[Zkh[ _ji[b\ [$]$ [njh[c[ h_Z][
h[iehfj_ed Ze dej [dj[h j^[ [gkWj_ed ed m^[j^[h
_cc[Z_Wj[ eh Z[bWo[Z beWZ_d] i^ekbZ X[ ki[Z$ J^[
iWc[_ijhk[e\Wdoed]e_d]ie\j#j_iik[_d\bWccWj_edi
[$]$W\j[h[njhWYj_d]j[[j^_df[h_eZedjWbbo_dlebl[Z
i_j[i$7iWcWjj[he\\WYj"j^[_dYh[Wi[ZXbeeZikffbo
WiieY_Wj[Z m_j^ Y^hed_Y _d\bWccWj_edi _i XWi_YWbbo
YedZkY_l[jej^[ikYY[ii\kbekjYec[e\8E?_cfbWdji
XoWle_Z_d]Wdo_d\bWccWj_edi_dj^[^[Wb_d]f[h_eZ$
J^_i_i_dYedjhWijjeYh[ijWb_cfbWdjZ[i_]di"m^_Y^
Zedej_dlebl[WdoikffkhWj_edfWj^mWoiX[YWki[j^[
edboef[d_d]WlW_bWXb[\ehj^[Xed[jeZ_iY^Wh][fki
_iXbeYa[ZXoj^[_cfbWdj\_njkh[_ji[b\$
:[bWo[Z beWZ_d] _i ki[Z _d Wbb Æ[nY[fj_edWb
i_jkWj_ediÇ m^[h[ _cc[Z_Wj[ beWZ_d] _i YedjhW#
_dZ_YWj[Z WYYehZ_d] je j^[ WXel[ Yh_j[h_W$ ?d j^Wj
YWi["j^[h[ijehWj_ed_i_di[hj[ZWhekdZ,m[[aiW\j[h
j^[_cfbWdjWj_edfheY[Zkh["m^[dj^[fh_cWhof^Wi[
e\Xed[^[Wb_d]^WiX[[dYecfb[j[Z$
?d bWh][#ifWd h[ijehWj_edi" [WY^ e\ j^[ _cfbWdji
_dlebl[ZYWdX[beWZ[Z_dWYYehZWdY[m_j^_jiif[Y_\_Y
h[gk_h[c[dji$ ?d ej^[h mehZi" _\ [dek]^ _cfbWdji
Wh[ fh[i[dj je ikffehj j^[ j[cfehWho h[ijehWj_ed"
Wdo WZZ_j_edWb _cfbWdji j^Wj m[h[ _di[hj[Z Wj j^[
iWc[j_c[Xkjh[gk_h[W^[Wb_d]f[h_eZcWoh[cW_d
Z[jWY^[Z\hecj^[j[cfehWhoh[ijehWj_edXkjm_bbX[
_dYehfehWj[Z_dj^[Z[\_d_j_l[h[ijehWj_ed$9edl[hi[bo"
_\ if[Y_\_Y _cfbWdji Wh[ \ekdZ je X[ el[hbo ceX_b[
_d W \ebbem#kf [nWc_dWj_ed eh _d j^[ fheY[ii e\
\WXh_YWj_d]Wdej^[hfheij^[j_YijhkYjkh["j^[Z[dj_ij
cWo Z[Y_Z[ dej je h[Yedd[Yj j^[c Xkj je mW_j WdZ
i[[ m^[j^[h j^[ Xed[ m_bb h[][d[hWj[ WdZ ]W_d _d
ijh[d]j^"j^kiWbbem_d]j^[_cfbWdjjeeii[e_dj[]hWj[
W]W_d$J^[oYWdX[h[Yedd[Yj[Zjej^[ijhkYjkh[bWj[h$
M_j^Yh[ijWb_cfbWdjjof[i"j^[i[lWh_ekiWbj[hdWj_l[i
e\ beWZ_d] _dZ_l_ZkWb _cfbWdji ed W i[fWhWj[ XWi_i
Wh[ dej Wd efj_ed$ 9h[ijWb _cfbWdji Wh[ hekj_d[bo
Zeec[ZedY[j^[oi^emYb_d_YWbceX_b_joWdZi_]die\
_d\bWccWj_ed$J^[om_bb[_j^[h\WbbekjifedjWd[ekibo
_d j^[i[ i_jkWj_edi eh ^Wl[ je X[ h[cel[Z$ CeX_b_jo
e\ W Yh[ijWb _cfbWdj WkjecWj_YWbbo _cfb_[i j^Wj j^[
Xed[ _dj[]hWj_ed ^Wi X[[d beij$ 8E? _cfbWdji Wh[
gk_j[Z_\\[h[dj_dj^_ih[if[YjX[YWki[j^[oYWdWbie
X[Yec[ ceX_b[ Xo h[l[hi_Xb[ el[hbeWZ eij[eboi_i$
EdY[ j^[ W\\[Yj[Z _cfbWdji Wh[ \h[[Z \hec j^[_h
beWZ#X[Wh_d] fheij^[j_Y \kdYj_ed eh edY[ j^[ beWZi
Wh[ Yehh[Yj[Z WdZ h[ZkY[Z" j^[ _d^[h[dj \kdYj_edWb
ijh[ii[i m_j^_d j^[ Yehj_YWb ijhkYjkh[ m_bb ]W_d j^[
kff[h^WdZ$J^_im_bb_dcWdoYWi[ib[WZjeh[d[m[Z
eii[eWZWfjWj_ed e\ j^[ _cfbWdji'$ IkXi[gk[djbo" j^[
_cfbWdji YWd X[ h[ijeh[Z je Yb_d_YWb i[hl_Y[$ J^_i
WffheWY^ YWd edbo meha Wi bed] Wi de _d\[Yj_edi
' J^[ j[hc Æeii[eWZWfjWj_edÇ _dZ_YWj[i j^[ j[dZ[dYo e\
Yehj_YWb Xed[ je Ybei[ Wdo ]Wfi Wbed] _ji ikh\WY[$ 7do
kdZ[hc_d[hWb_p[Z eh Yedd[Yj_l[#j_iik[ i[]c[dji Wh[
Yecf[j_j_l[bo Z_ifbWY[Z _d j^[ fheY[ii kdj_b Ybei[ YedjWYj
e\ j^[ Yehj_YWb Xed[ ijhkYjkh[ je j^[ _cfbWdj ikh\WY[ _i
[ijWXb_i^[Z$7 j^_d h[i_ZkWb bWo[h e\ Yedd[Yj_l[ j_iik[ m_bb
h[cW_d"^em[l[h$J^_i_iWbiej^[YWi[_dÆeii[e_dj[]hWj_edÇ$
È È (ARD
4ISSUEÈ(EALINGÈANDÈ)MMEDIATEÈ,OADINGÈ )('
^Wl[ WZlWdY[Z je j^[ Yehj_YWb Wh[W m[Wa[d[Z Xo
bem c_d[hWb_pWj_ed$ ?\ _d\[Yj_ed eYYkhi" j^[ Xed[
j_iik[ m_bb jkhd je ]hWdkbWj_ed j_iik[ j^Wj Ze[i dej
h[c_d[hWb_p[$ 7i W h[ikbj" \kdYj_edWb ij_ckb_ m_bb
h[Z[\_d[ j^[ ijh[ii jhW`[Yjeh_[i m_j^_d j^[ Yehj_YWb
Xed[ WdZ cel[ j^[c WmWo \hec j^[ _cfbWdj i_j[$
J^_i i_j[ X[Yec[i W &#Wh[W$ J^[ edbo mWo je cWa[
j^[i[ jhW`[Yjeh_[i h[jkhd WdZ je h[ZkY[ ie\j#j_iik[
\ehcWj_ed_iXoikh]_YWb_dj[hl[dj_ed$
CWjh_n \ehcWj_ed \eh feijef[hWj_l[ Xed[ h[fW_h
jWa[i fbWY[ X[jm[[d ZWoi '( WdZ *& W\j[h j^[
_cfbWdjWj_ed fheY[Zkh[$ 8E? _cfbWdji i^ekbZ dej
X[ h[fei_j_ed[Z Zkh_d] j^Wj j_c[$ ?j _i j^[h[\eh[
h[Yecc[dZ[Z je b[Wl[ j^[ j[cfehWho eh Z[\_d_j_l[
Xh_Z][ _d fbWY[ WdZ dej je cWa[ Wdo ceZ_\_YWj_edi
je j^[ fheij^[j_Y ijhkYjkh[ W\j[h ZWo '' WdZ X[\eh[
ZWo *'$ <W_bkh[ je ^[[Z j^_i WZl_Y[ cWo fh[l[dj
j^[ Z[l[befc[dj e\ W kd_\ehcbo j[njkh[Z cWjh_n"
m^_Y^ m_bb [l[djkWbbo h[ikbj _d Wd _d\[h_eh Xed[
ijhkYjkh[Y^WhWYj[h_p[ZXofeehc_d[hWb_pWj_ed$Iec[
ki[hi YbW_c" ed j^[ XWi_i e\ Xed[ f^oi_ebe]o" j^Wj
ceZ_\_YWj_edi je j^[ fheij^[j_Y Z[i_]d i^ekbZ dej
X[f[h\ehc[ZW\j[hj^[_d_j_Wbf^Wi[e\_d\bWccWj_ed
_$[$ W\j[h ZWo - WdZ dej X[ h[ikc[Z" _\ d[Y[iiWho"
X[\eh[ j^[ _d_j_Wb f^Wi[ e\ c_d[hWb_pWj_ed ^Wi X[[d
Yecfb[j[Z_$[$X[\eh[ZWo*'$J^[h[\eh[j[cfehWho
h[ijehWj_edi Wh[ kikWbbo _di[hj[Z h_]^j Zkh_d] j^[
ikh]_YWbfheY[Zkh[_dj^[i[YWi[i$
J^[ fkXb_i^[Z l_[mi ed _cc[Z_Wj[ beWZ_d] Wh[
XWi_YWbbo _d W]h[[c[dj$ 7YYehZ_d] je IpckYab[h#
CedYb[h [j Wb$ (&&&" j^[ WlW_bWXb[ Xed[ ijhkYjkh[
d[[Zi je X[ WZ[gkWj[ _d gkWdj_jo WdZ gkWb_jo \eh
_cc[Z_Wj[ beWZ_d]" Wd efj_c_p[Z _cfbWdj Z[i_]d
ckij X[ ki[Z" j^[ _cfbWdji ^Wl[ je X[ WZ[gkWj[bo
bed]" Wd WZ[gkWj[ ikh]_YWb WffheWY^ ^Wi je X[
ki[Z" WdZ j^[ fheij^[j_Y ikf[hijhkYjkh[ ckij X[
X_ec[Y^Wd_YWbbo efj_c_p[Z$ >WhjcWdd (&&&
h[fehj[Z j^Wj _cc[Z_Wj[ beWZ_d] YWd edbo meha _\
j^[ \ehY[i WYj_d] ed j^[ _dj[h\WY[ Ze dej YWki[ j^[
_cfbWdjWdZj^[Xed[jecel[h[bWj_l[je[WY^ej^[h"
i_dY[j^_imekbZb[WZjeYedd[Yj_l[j_iik[\ehcWj_ed
kdb[ii W if[Y_Wb cWYheZ[i_]d _i ki[Z$ 7YYehZ_d]
je j^Wj Wkj^eh" j^[ Yeccedbo ki[Z icWbb _cfbWdj
Z[i_]diYWdedboX[ikX`[Yj[Zje_cc[Z_Wj[beWZ_d]
_\if[Y_\_YYedZ_j_ediWh[c[j$
J^[\[Wi_X_b_joe\_cc[Z_Wj[beWZ_d]mWiWbh[WZo
Z[cedijhWj[ZXoB[Z[hcWdd'/--"(&&)_dj^['/-&i
XWi[Zed\ekhiYh[m_cfbWdji_dj^[Wdj[h_ehi[]c[dj
e\ j^[ cWdZ_Xb[" jWa_d] WZlWdjW][ e\ j^[ \WYj j^Wj
j^_iWh[W_i[njh[c[bom[bbc_d[hWb_p[Z$?dWZZ_j_ed"
^[ ki[Z _cfbWdji m_j^ W \WlekhWXb[ cWYheZ[i_]d
WdZYedd[Yj[Zj^[cXoc[Wdie\WXWhWjjWY^c[dj$
7iikcfj_edi je j^[ [\\[Yj j^Wj XbeeZ#Xehd[ ]hemj^
\WYjehi[$]$FHFYWdWYY[b[hWj[Xed[\ehcWj_ed^Wl[
d[l[hX[[dikXijWdj_Wj[Z$FHFcWoX[ki[Zje]eeZ
[\\[Yj"^em[l[h"jefheZkY[^_]^#gkWb_jo"_d[nf[di_l[
WdZX_eYecfWj_Xb[Wkjebe]ekic[cXhWd[i\ehZ[\[Yj
Yel[hW][$ JeZWo _j _i WYY[fj[Z j^Wj j^[ ekjYec[ e\
_cc[Z_Wj[beWZ_d]e\iYh[m_cfbWdjiZ[f[dZiedj^[_h
dkcX[hWdZZ_ijh_Xkj_edWdZj^[jof[e\Yedd[Yj_ed
ki[Z$ ?cfbWdji i^ehj[h j^Wd '&cc i^ekbZ dej X[
ki[Z WYYehZ_d] je j^[i[ Wkj^ehi$ <khj^[hceh[" j^[
_cfbWdjickijX[WXiebkj[boijWXb[$7dej^[hYedY[fj
je [dWXb[ _cc[Z_Wj[ beWZ_d] e\ Yh[ijWb _cfbWdji
m_j^Wj[cfehWhoh[ijehWj_ed_ije_di[hjWZZ_j_edWb
_cfbWdji kikWbbo j^_d Yecfh[ii_ed iYh[mi m_j^ W
iceej^ ikh\WY[ X[jm[[d j^[ bWh][#Z_Wc[j[h cW_d
\_njkh[i$J^[fkhfei[e\j^[i[j[cfehWhoWZZ_j_edWb
_cfbWdji _i je ikffehj j^[ j[cfehWho h[ijehWj_ed
kdj_bj^[^[Wb_d]fheY[iiWhekdZj^[cW_d_cfbWdji
_i Yecfb[j[Z Ib_memia_ (&&'$ CWikh (&&' ki[i
ckbj_fb[ Wdj[h_eh iYh[m _cfbWdji kikWbbo \_l[ je
i[l[d_cfbWdjijeikffehj\_n[Zh[ijehWj_edi_dj^[
cWdZ_Xb[$ HecWdei [j Wb$ (&&' eXjW_d[Z i_c_bWh
Xed[ h[ifedi[i m_j^ _cc[Z_Wj[ beWZ_d] Wi m_j^
Z[bWo[Z beWZ_d]" fhel_Z[Z j^Wj j^[ _cfbWdji m[h[
WZ[gkWj[bo ifb_dj[Z$ =k_Z[b_d[i \eh Z[bWo[Z beWZ_d]
WdZ fhebed][Z ^[Wb_d] f[h_eZi Wi fkXb_i^[Z Xo j^[
:=PCA%:=?_d(&&'ZedejWffboje8E?$
;d][ba[ [j Wb$ (&&( ki[Z Wd _dj[h[ij_d] _cfbWdj
Z[i_]d\[Wjkh_d]Wd[deiiWbi[]c[djj^Wj_i[dbWh][Z
m_j^ W iYh[m j^h[WZ m^_b[ j^[ _cfbWdj ikh\WY[ _i
d[l[hj^[b[ii iceej^ Wj j^[ ckYeiWb f[d[jhWj_ed
fe_dj$ J^[o Yedd[Yj ikXf[h_eijWb ¼[nj[di_ed
[b[c[dji½ Wbed] j^[ Wbl[ebWh h_Z][ ki_d] Xed[
iYh[mi$ J^[i[ [b[c[dji Wh[ bWj[h h[cel[Z$ J^_i
WffheWY^ Z[cedijhWj[i j^Wj Z[dj_iji _dYh[Wi_d]bo
h[Wb_p[ j^[ ]h[Wj ki[\kbd[ii e\ j^[ Yehj_YWb Xed[ \eh
WdY^eh_d] WdZ [Whbo beWZ_d] e\ _cfbWdji$ 7\j[h Wbb"
j^_ih[Wb_pWj_ed^Wi[Whb_[hb[Zjej^[Z[l[befc[dje\
8E?_cfbWdji$
M[X[b_[l[j^Wjj^[^[Wb_d]fheY[iiW\j[h_di[hj_ed
e\ 8E? _cfbWdji _i fhecej[Z Xo j^[ eij[ejeco#
h[bWj[Zijh[ii[ifWhj_YkbWhbo_dj^[cWdZ_Xb[WYj_d]
ed j^[ ikhhekdZ_d] Xed[ ijhkYjkh[$ ?d j^_i mWo"
W\j[h8E?_cfbWdjfheY[Zkh[iW]h[Wj[hij_ckbki\eh
^[Wb_d] _i fhel_Z[Z j^Wd W\j[h fbWY[c[dj e\ Yh[ijWb
_cfbWdji$J^[bWj[hW\\[Yjj^[Yehj_YWbXed[ijhkYjkh[
XkjkikWbbodejcWYhejhW`[Yjeh_[i$D[l[hj^[b[ii"[l[d
W\j[h j^[ fbWY[c[dj e\ iYh[m _cfbWdji" h[ceZ[bb_d]
m_bb ]e X[oedZ j^[ WYjkWb _cfbWdj Wh[W 7ja_died
[j Wb$ '/--$ ?d WZZ_j_ed" j^[ h[fW_h m_bb W\\[Yj j^[
YWdY[bbeki ijhkYjkh[i ¼[njhWj[hh_jeh_Wb_p_d] h[i#
fedi[½WYYehZ_d]je:edWj^$
È
3TRATEGIESÈTOÈ!CHIEVEÈ)NTEGRATIONÈÈ
INÈ6ARIOUSÈ,OCATIONS
Ekh^_ijebe]_YWbijkZohW_i[ZWdkcX[he\gk[ij_edi
YedY[hd_d] j^[ _dj[]hWj_ed e\ Z[djWb _cfbWdji$ <_hij
e\ Wbb" j^[ YedZ_j_edi \eh _cfbWdj ^[Wb_d] Wh[ dej
_Z[dj_YWb_dj^[cWn_bbWWdZcWdZ_Xb[$9edi_Z[hj^[
\ebbem_d]Wif[Yji0
)(( 9^Wfj[h()È (ISTOLOGYÈOFÈ"/)È)MPLANTS
v ?d j^[ cWdZ_Xb[" m[ fbWY[ j^[ beWZ#jhWdic_jj_d]
ikh\WY[ e\ j^[ _cfbWdji bed]_jkZ_dWbbo je j^[
Z_h[Yj_ede\j^[i[YedZWhoeij[edi"j^kikj_b_p_d]
j^[ ^_]^ j[dZ[dYo e\ ifedjWd[eki Xedo ^[Wb_d]
_d ijh[ii Wh[Wi \eh _cfbWdj _dj[]hWj_ed$ IjhWj[]_Y
_cfbWdj fbWY[c[dj _i \WlehWXb[ X[YWki[ _j jWa[i
WZlWdjW][e\`Wm\b[n_ed$J^[^[Wb_d]j[dZ[dYo_d
j^[Z_ijWbcWdZ_Xb["m^_Y^_iikX`[Yj[Zjefem[h\kb
c[Y^Wd_YWbbeWZi"_ifWhj_YkbWhbo]eeZ_dWh[Wie\
^_]^c[Y^Wd_YWbijh[ii$J^_iijWj[c[dj_ijhk[\eh
Xej^j^[cWdZ_XkbWhWd]b[WdZj^[_dj[h\ehWc_dWb
h[]_ed$J^[^[Wb_d]j[dZ[dYo_i[if[Y_Wbbo]eeZ\eh
fWhWc[Z_Wd_cfbWdji"i_dY[j^[l[hj_YWbeij[ejeco
_i beYWj[Z _d Wh[Wi e\ ^_]^ i^[Wh_d] \ehY[i$ M[
adem \hec \hWYjkh[ ikh][ho j^Wj fWhWc[Z_Wd
cWdZ_XkbWh \hWYjkh[i WbmWoi h[gk_h[ j^[ ki[ e\
jmefbWj[im^_b[c[Z_Wd\hWYjkh[iYWdX[jh[Wj[Z
m_j^ed[fbWj[$J^_ih[gk_h[c[dj_iZk[jej^[^_]^
j[dZ[dYoe\fWhWc[Z_Wd\hWYjkh[ikh\WY[ijei^[Wh
W]W_dij[WY^ej^[h[l[d_dib_]^jcekj^ef[d_d]$
J^[iWc[i^[Wh\ehY[i]h[Wjbo[nf[Z_j[j^[^[Wb_d]
fheY[iiW\j[h_di[hj_ede\8E?_cfbWdjiWdZ[dikh[
WijWXb[ekjYec[$
v ?dj^[cWn_bbW"j^[i_jkWj_ed_iZ_\\[h[dj$J^_i`Wm
_dlebl[i W ckY^ icWbb[h Z[]h[[ e\ \b[n_ed" WdZ
j^[h[ _i de Yedi_ij[dj cW_d Z_h[Yj_ed e\ \ehY[i$
?dWYYehZWdY[m_j^j^[&Ä'hkb["j^[Xed[h[]_ed
WhekdZ j^[ i[YedZ fh[cebWh WdZ \_hij cebWh
m_bb j^[h[\eh[ dej X[ i_]d_\_YWdjbo h[Xk_bj W\j[h
[njhWYj_d]j^[i[j[[j^$J^[Xed[ijhkYjkh[ibeYWj[Z
Z_ijWbbo WdZ Wdj[h_ehbo je j^_i h[]_ed Wh[ ckY^
ceh[ ijWXb[ Zk[ je j^[ ]h[Wj[h ckiYb[ ijh[ii[i
_dlebl[Z$M^_b[ijhWj[]_Y_cfbWdjfbWY[c[dj_iWd
efj_ed _d fh_dY_fb[" _ji ekjYec[ m_bb Z[f[dZ ed
m^[j^[hj^[^[Wb_d]fheY[ii_ifem[h\kb[dek]^je
h[i_ijj^[Y^[m_d]\ehY[i$?\j^Wj_idejj^[YWi["j^[
_cfbWdj#h[ijehWj_ed ioij[c m_bb Z[Yecf[diWj[$
?\ ckbj_fb[ _cfbWdji Wh[ _di[hj[Z" j^[ eij[edWb
ijhkYjkh[ e\ j^[ cWn_bbW m_bb X[ beij Yecfb[j[bo"
WdZ j^[ Y^[m_d] \ehY[i m_bb fh[lW_b W]W_dij j^[
ckiYkbWh _d\bk[dY[i _d Z[\_d_d] j^[ Z_h[Yj_ed e\
^[Wb_d]$
v J^[ feij[h_eh i[]c[dj e\ j^[ cWn_bbW _i Wd
[nY[[Z_d]bo bem#ijh[ii Wh[W$ 7do iYh[m _cfbWdji
_di[hj[Z_dj^WjWh[Wm_bbj^[h[\eh[jWa[Wbed]j_c[
je _dj[]hWj[$ <khj^[hceh[" j^[ ^[Wb_d] fheY[ii
m_bb Z[f[dZ ceh[ ^[Wl_bo ed j^[ _cfbWdj#Xed[
_dj[hWYj_ed j^Wd ed j^[ ^[Wb_d] j[dZ[dYo e\ j^[
cWYhejhW`[Yjeh_[i$
È
)MMEDIATEÈ,OADINGÈANDÈTHEÈ.EEDÈÈ
FORÈ#ONTINUOUSÈ0ROSTHETICÈ!DJUSTMENTS
J^[ \ebbem_d] Yedi_Z[hWj_edi [bkY_ZWj[ j^[ _iik[ e\
_cc[Z_Wj[beWZ_d]\hecWZ_\\[h[djf[hif[Yj_l[0
v J^[fWj_[djimWdj_cc[Z_Wj[beWZ_d]$
v 8o _cc[Z_Wj[bo beWZ_d] j^[ Xed[ j^Wj ^Wi X[[d
_d`kh[Z Xo j^[ _cfbWdjWj_ed fheY[Zkh[" j^[
Z_h[Yj_ede\^[Wb_d]YWdX[Z[\_d[Z_dWZlWdY[$
v Edj^[ej^[h^WdZ"cWdofWj_[djim_bbij_bb[n^_X_j
W Z[b[j[h_eki \kdYj_edWb fWjj[hd m^[d j^[ \_hij
h[ijehWj_ed _i _di[hj[Z$ EdY[ j^[ cWij_YWjeho
ikh\WY[i ^Wl[ X[[d h[Xk_bj" j^[ ckiYb[ WYj_l_jo
WdZ \kdYj_edWb fWjj[hd m_bb Y^Wd][ WYYehZ_d]bo"
m^_Y^ m_bb [l[djkWbbo ]_l[ h_i[ je cehf^ebe]_YWb
Wbj[hWj_edie\j^[`WmXed[_ji[b\$
v 7iWYedi[gk[dY["j^[cWij_YWjehoikh\WY[id[[Zje
X[WZ`kij[ZXoWZZ_j_l[WdZ%ehikXjhWYj_l[c[Wdi$
?d iec[ i_jkWj_edi" j^[ d[Y[iiWho WZ`kijc[dji
mekbZX[ie[nj[di_l[j^Wj_jcWoX[i_cfb[hWdZ
b[ii[nf[di_l[jeh[fbWY[j^[cWij_YWjehoikh\WY[i
Wbje][j^[h$ J^_i WffheWY^ m_bb Wbie [dWXb[ j^[
Z[dj_ijjeYehh[YjWdoY^Wd][ij^Wjj^[ie\j#j_iik[
h[bWj_edicWo^Wl[kdZ[h]ed[_dj^[c[Wdj_c[$
J^[ d[nj ]eWbi je X[ WY^_[l[Z _d j^[ bed][h j[hc
Wh[ je [dikh[ j^Wj j^[ _cfbWdji X[Yec[ WdY^eh[Z
_d W bWij_d] cWdd[h" j^Wj j^[ Xed[ ijhkYjkh[i h[WY^
cWjkh_jo" WdZ j^Wj j^[ cWij_YWjeho \kdYj_ed" m^_Y^
^WZX[[d]hWZkWbbobeijel[hj^[o[Whi"m_bbX[\kbbo
h[ijeh[Z$ ?d cWdo YWi[i" j^_i h[eh]Wd_pWj_ed e\ beij
\kdYj_ediedj^[XWi_ie\ia[b[jWbXed[ijhkYjkh[im_bb
h[gk_h[WZZ_j_edWbij[fi$<eh_dijWdY["_jcWoX[Yec[
d[Y[iiWho je _di[hj Yecfb[c[djWho eh WZZ_j_edWb
fheij^[j_Y h[ijehWj_edi eh je h[fbWY[ Wdo _cfbWdji
j^Wj Wh[ de bed][h WXb[ je \kb\_b j^[_h jWia e\ beWZ
jhWdic_ii_ed$
J^_iYecfh[^[di_l[h[eh]Wd_pWj_ede\j^[cWij_#
YWjeho \kdYj_ed YWd edbo X[ WY^_[l[Z _d W dkcX[h
e\ ikYY[ii_l[ ij[fi Ä i_c_bWh je ikYY[ii_l[ bWo[hi e\
fW_dj" m^[h[ [WY^ i_d]b[ bWo[h i^ekbZ X[ Wbbem[Z je
Zho ie j^Wj _j YWd fhef[hbo ieb_Z_\o X[\eh[ j^[ d[nj
bWo[h _i Wffb_[Z$ ?d j^[ lWij cW`eh_jo e\ YWi[i" j^[
\_hij ij[f ckij X[ je _di[hj W \_n[Z h[ijehWj_ed Wi
j^[ Z[fWhjkh[ fe_dj \eh Wbb \khj^[h fheij^[j_Y WdZ
\kdYj_edWb jh[Wjc[dj$ Iec[j_c[i _j cWo X[ ki[\kb
je \kdYj_edWbbo _cfhel[ eh h[fbWY[ j^[ fh[#[n_ij_d]
Z[djkh[ X[\eh[ Wdo _cfbWdji Wh[ _di[hj[Z" Xkj j^[i[
YWi[i Wh[ l[ho hWh[$ 7\j[h Wbb" _j _i gk_j[ _cfeii_Xb[
je WY^_[l[ W ijWj[ e\ f^oi_ebe]_YWb \kdYj_ed _d j^[
fh[i[dY[ e\ W Z[djkh[" de cWjj[h ^em m[bb _j _i
h[jW_d[Z" WdZ j^[ fheY[ii e\ cehf^ebe]_YWb Xed[
WZWfjWj_ed YWd edbo X[]_d edY[ j^[ Y^[m_d] \ehY[i
Wh[jhkbo]k_Z[Z_djej^[[deiiWbifWY[$
Iec[ fWj_[dji cWo Y^eei[ je b[Wl[ j^[ b[d]j^o
fWj^e\^Wl_d]j^[_hY^[m_d]\kdYj_edh[ijeh[Z_dW
È È (ARD
4ISSUEÈ(EALINGÈANDÈ)MMEDIATEÈ,OADINGÈ )()

Yecfh[^[di_l[cWdd[hedY[j^[_cfbWdjiWdZW\_hij
fheij^[j_Y h[ijehWj_ed ^Wl[ X[[d _di[hj[Z$ FWj_[dji
m^eZhefekje\j^[fheij^[j_Yh[^WX_b_jWj_edfhejeYeb
W\j[h ^Wl_d] h[Y[_l[Z Yecfh[^[di_l[ _d\ehcWj_ed
X[\eh[jh[Wjc[djm_bbkikWbboZeieX[YWki[j^[o^Wl[
X[[d_bbWZl_i[Z¼c_iYekdi[bb[Z½Xo\[bbemZ[dj_iji$
?d ekh [nf[h_[dY[" ikY^ c_iYekdi[bb_d] _i fh[lWb[dj
[l[dWjkd_l[hi_j_[i$7\j[hWbb"j^[ijW\\fhel_Z_d]j^_i
¼Yekdi[bb_d]½ ^Wl[ kikWbbo X[[d jhW_d[Z [nYbki_l[bo
_dYh[ijWb_cfbWdjebe]o"Wi_Z[\hecj^[\WYjj^Wjj^[_h
`kZ][c[dj _i \bWm[Z Xo i[h_eki ademb[Z][ Z[\_Y_ji
WdZ bWYa e\ Yb_d_YWb [nf[h_[dY[$ Dej[" ^em[l[h" j^Wj
[l[hofWj_[dj_ikbj_cWj[boj^[WhY^_j[Yje\^_ieh^[h
emd \ehjkd[$ 7Zkbj fWj_[dji Wh[ \h[[ je Y^eei[ WdZ
^Wl[ je Z[Y_Z[ \eh j^[ci[bl[i ^em j^[o mekbZ b_a[
jeX[jh[Wj[Z$Je]kWhZW]W_dijWdofheXb[cih[bWj[Z
je b[]Wb WYj_ed" j^[ fWj_[dj _d\ehcWj_ed i^ekbZ X[ A
ZeYkc[dj[Z_dmh_j_d]"fh[\[hWXboki_d]WijWdZWhZ
\ehcWjikY^Wij^[9^[YakfH[fehj\ehc$

È
/NLYÈ,OADEDÈ"/)È)MPLANTSÈÈ
#ANÈ3TIMULATEÈTHEÈ"ONE
J^[ Xed[ \kdYj_edi Z[iYh_X[Z _d 9^Wfj[h/ Wh[
_cfW_h[Z Xo _cfbWdjWj_ed fheY[Zkh[i$ 7i m[ ^Wl[
[nfbW_d[Z" Z[\ehcWj_ed e\ j^[ _cfbWdj m_j^ j^[
ikXi[gk[djikYj_ed#fkcf[\\[Yjedj^[Xed[_dlebl[i
WdkcX[he\Z[i_hWXb[[\\[Yji$J^[i[[\\[Yji"^em[l[h"
fh[ikffei[ j^Wj j^[ _cfbWdj _i beWZ[Z$ J^[h[\eh["
_cc[Z_Wj[beWZ_d]e\8E?_cfbWdj_iWbmWoiW]eeZ
_Z[WX[YWki[_jm_bb`kcf#ijWhjj^[\beme\dkjh_[dji$
Ekh [nf[h_[dY[ ^Wi X[[d j^Wj kdbeWZ[Z 8E?
_cfbWdjii^emWd_dYh[Wi[Zj[dZ[dYojemWhZifbWgk[
WYYkckbWj_ed$ <khj^[hceh[" Z[bWo[Z beWZ_d] Ze[i B
dej i[[c je e\\[h Wdo WZlWdjW][i el[h _cc[Z_Wj[
beWZ_d] _d j[hci e\ _cfbWdj ikhl_lWb$ M[ j^[h[\eh[ &IGÈAB <;C WdWboi_i e\ Wd kdbeWZ[Z l[hiki W beWZ[Z
8E?_cfbWdj"Wiikc_d]bWj[hWbYedjWYj_dj^[cWh]_dWh[WWi_d
h[Yecc[dZ ki_d] _cc[Z_Wj[ beWZ_d] m^[d[l[h Yehj_YWbXed[WdY^ehW][i[[WbieL_Z[e)
feii_Xb[$

È
3UMMARY
?cc[Z_Wj[ _di[hj_ed e\ 8E? _cfbWdji _i kikWbbo
feii_Xb[ _\ j^[ ^eh_pedjWb Xed[ lebkc[ _i WZ[gkWj[$
J^[gk[ij_edm^[j^[h_cc[Z_Wj[beWZ_d]_ifeii_Xb[
Wim[bbZ[f[dZiedj^[Xed[gkWb_jo"j^[fh[i[dY[e\
fh[#[n_ij_d] Xed[ b[i_edi" j^[ ifWj_Wb Yed\_]khWj_ed
e\j^[fbWdd[Zikf[hijhkYjkh["j^[fh_cWhoijWX_b_jo"
WdZ j^[ fh[i[dY[ eh WXi[dY[ e\ j^[ Wbl[ebWh h_Z][$
J^[ l[hj_YWb Xed[ lebkc[" Xo YedjhWij" _i dej W
h[b[lWdj Z[Y_i_ed Yh_j[h_ed$ ?cc[Z_Wj[ beWZ_d] e\
8E? _cfbWdji \eh i_d]b[#jeej^ h[ijehWj_edi ckij X[
WffheWY^[Z`kijWiYWkj_ekiboWim_j^Yh[ijWb_cfbWdj
Z[i_]di$ J^_i jof[ e\ WffheWY^ d[[Zi je X[ Ybei[bo
ced_jeh[ZWdZh[gk_h[i]eeZfWj_[djYecfb_WdY[$
J^[ '(%*&#ZWoi hkb[ ckij X[ ^[[Z[Z je [dikh[
j^Wjj^[Z_h[YjYedjWYjWjj^[_cfbWdj#Xed[_dj[h\WY[
_ifh[i[hl[Z$7doifWj_WbceZ_\_YWj_ediX[jm[[dj^[
ikh\WY[i _dlebl[Z ckij X[ Wle_Z[Z _d j^[ f^Wi[ e\
_dY_f_[dj Xed[ h[fW_h$ J^_i _i j^[ edbo mWo je Wle_Z
[Whbo beii e\ j^[ YedjWYj Wbed] j^[ _dj[h\WY[ WdZ je
[dikh[Wiceej^fheY[iie\Xed[^[Wb_d]$
7d [gkWbbo _cfehjWdj Z[j[hc_dWdj e\ _cfbWdj
ijWX_b_jo_im^[d"m^[h[WdZ^em[nj[di_l[boj^[`Wm
_dm^_Y^j^[fheY[Zkh[^WiX[[df[h\ehc[Z_i]e_d]
jeX[h[ceZ[bb[Z$J^[ijWX_b_joe\cWn_bbWho_cfbWdji
_i]h[Wjbo_d\bk[dY[ZXol[ij_XkbWhXed[h[ceZ[bb_d]"
i_dY[j^[h[ceZ[bb_d]_iYWfWXb[e\_dj[h\[h_d]m_j^
j^[ cWYhejhW`[Yjeh_[i _d Wd WZl[hi[ cWdd[h _\ bem
cWij_YWjehoijh[ii[iWh[fh[i[dj$
)(* 9^Wfj[h()È (ISTOLOGYÈOFÈ"/)È)MPLANTS

7dej^[h _cfehjWdj Yedi_Z[hWj_ed _i m^Wj \kdY# e\ ikh\WY[ _dlebl[Z" eii[eWZWfjWj_ed je Z_\\[h[dj
j_edWb Wbj[hWj_ed j^[ Xed[ ijhkYjkh[i m_bb kdZ[h]e$ _cfbWdj Wh[Wi _i WY^_[l[Z Wj if[Y_\_Y fe_dj _d j_c[
?j jWa[i [nf[h_[dY[ je Wdj_Y_fWj[ j^[ j[cfehWb WdZ W\j[h _cfbWdjWj_ed$ J^_i iY^[Zkb[ m_bb X[ _bbkijhWj[Z
ifWj_WbZ_c[di_ede\j^[i[Y^Wd][i"WdZj^[edbomWo X[bem$ <hec W Yb_d_YWb fe_dj e\ l_[m" j^_i fheY[ii
je _d\bk[dY[ j^[c _i Xo f[h_eZ_YWbbo WZ`kij_d] j^[ cWd_\[iji_ji[b\Wi_dYh[Wi_d]ijWX_b_joe\j^[_cfbWdj
cWij_YWjeho ikh\WY[i$ Kd_bWj[hWb Y^[m_d] WdZ i_Z[ el[hj^[\_hijcedj^ie\ki[$
im_jY^_d] YWd ]_l[ h_i[ je i_jkWj_edi m^[h[ j[di_b[ J^[bed]#j[hcekjYec[e\8E?_cfbWdji"^em[l[h"
ped[i Wh[ h[Xk_bj _dje Yecfh[ii_l[ ped[i WdZ l_Y[ Z[f[dZidejieckY^edj^[beYWbWZWfj_l[h[ifedi[
l[hiW"m^_Y^^WiYedi[gk[dY[i\eh_cfbWdjijWX_b_jo Wi ed j^[ gk[ij_ed m^[j^[h j^[ `WmXed[ Wi ikY^
WdZ\ehj^[ijWX_b_joe\j^[Xed[#_cfbWdj#h[ijehWj_ed YWdh[cW_dijWXb[_dj^[_cfbWdjWj_edWh[WWdZ^em
ioij[ciWim[bb$ ckY^ ijh[d]j^ _j YWd WjjW_d kdZ[h j^[ fh[lW_b_d]
M^_b[ j^[ c_d[hWb_p[Z cWjh_n m_bb edbo jWa[ Y_hYkcijWdY[i$
WhekdZ '(cedj^i je X[ h[ijeh[Z _d j^[ _cc[Z_Wj[
l_Y_d_jo e\ j^[ _cfbWdji" j^[ h[#Xk_bZ_d] e\ d[m
È
cWYhejhW`[Yjeh_[i Wi W h[ikbj e\ Wbj[h[Z \kdYj_ed
/SSEOADAPTATIONÈANDÈ'APÈ*UMPING
WdZ Wbj[h[Z l[hj_YWb Z_c[di_ed m_bb \h[gk[djbo jWa[
bed][h$ M[ j^[h[\eh[ fh[\[h je b[Wl[ j^[ _di[hj[Z <_]kh[i()$('Ä()$() _bbkijhWj[ ^em j^[ Xed[ _d j^[
ikf[hijhkYjkh[ _d fbWY[ \eh Wd [nj[dZ[Z f[h_eZ e\ _cfbWdj X[Z Yecf[j[i m_j^ Yedd[Yj_l[ j_iik[ _d
j_c[" fh[\[hWXbo i[l[hWb cedj^i eh o[Whi" WdZ j^[d
h[fbWY[ _j edY[ if[Y_\_Y h[Wiedi [$]$ W[ij^[j_Y eh
f^ed[j_YfheXb[ciWh_i[$
=eeZXed[ij_ckbWj_edWdZWdWZ[gkWj[ikYj_ed#
fkcf \kdYj_ed m_bb edbo X[ fh[i[dj _\ j^[ _cfbWdji
Wh[ beWZ[Z _d W h^oj^c_YWb cWdd[h$ 8E? _cfbWdji
i^ekbZ X[ _cc[Z_Wj[bo beWZ[Z m^[d[l[h feii_Xb["
jWa_d]_djeYedi_Z[hWj_ed^emckY^beWZh[i_ijWdY[
j^[Xed[feii[ii[Z_dj^[\_hijfbWY[$

È
-OREÈ(ISTOLOGICALÈ&INDINGSÈÈ
ANDÈ#LINICALÈ#ONSIDERATIONS

È
)NTRODUCTION
J^[ _iik[ e\ eii[e_dj[]hWj_ed" m^_Y^ j[dZi je
X[ _d j^[ \eh[]hekdZ e\ Z_iYkii_edi Xo Yh[ijWb &IGÈ <ehcWj_ed e\ d[m Xed[ ed j^[ XWiWb Z_ia \hec
_cfbWdjebe]_iji" _i h[Wbbo edbo ed[ e\ j^[ Wif[Yji X[bemWdZ\hecWXel[$J^[Z_iaWh[Wi_dj^[bWh][c[ZkbbWho
_dlebl[Z _d Yb_d_YWb _cfbWdjebe]o$ E\ Yekhi[" j^[ ifWY[i e\ j^[ Ze]Éi cWdZ_Xb[ ^WZ dej X[[d fefkbWj[Z m_j^
beWZ#jhWdic_jj_d] _cfbWdj h[]_edi Wh[ ikffei[Z je Xed[Xoj^Wjj_c[
jhWdic_j j^[ \ehY[i Z_h[Yjbo je j^[ Xed[" m_j^ de
i_]d_\_YWdjWcekdjie\Yedd[Yj_l[j_iik[_dlebl[Z$?d
8E? _cfbWdji" _j _i dej edbo j^[ _cc[Z_Wj[ fh_cWho
eii[e_dj[]hWj_ed j^Wj fbWoi W heb[" Xkj Wbie j^[
i[YedZWhoYedjWYj[ijWXb_i^[Zm_j^j^[Xed[ikh\WY[$
7\j[hWbb"j^[eij[ejecoibejiWh[i_]d_\_YWdjbobWh][h
j^Wdj^[ifWY[eYYkf_[ZXoj^[_cfbWdji$J^[h[\eh["
i[YedZWho YedjWYj ^Wi je X[ [ijWXb_i^[Z [if[Y_Wbbo
WhekdZ j^[ Wf[hjkh[i m_j^_d j^[ Z_iai$ Ekh ijkZ_[i
Z[cedijhWj[Z Xej^ fh_cWho eii[e_dj[]hWj_ed WdZ
i[YedZWho eii[eWZWfjWj_ed e\ 8E? _cfbWdji$ :_h[Yj
WZWfjWj_ed je j^[ _cfbWdj _i W h[ifedi[ W_c[Z Wj
h[fW_h_d]j^[bWj[hWbeij[ejecoj^WjmWiYkj_djej^[
Yehj_YWbXed[$?jWff[Whi"^em[l[h"j^Wjj^[YWdY[bbeki &IGÈ CW]d_\_[Z i[Yj_ed \hec <_]$()$('$ J^[ XWiWb Z_ia
Xed[ _i Wbie YWfWXb[ e\ WZWfj_d] je j^[ _cfbWdj Xo i[]c[djmWi_dj[]hWj[ZXoWYecX_dWj_ede\eii[eWZWfjWj_ed
mWoe\Wi[YedZWhoh[ifedi[$:[f[dZ_d]edj^[jof[ WdZ]Wf`kcf_d]
È È -OREÈ(ISTOLOGICALÈ&INDINGSÈANDÈ#LINICALÈ#ONSIDERATIONSÈ
&IGÈ J^_ii[Yj_edYb[Whbo_bbkijhWj[ij^[_dY_f_[djbWj[hWb
eii[eWZWfjWj_ed je j^[ Y[djhWb m[X XWh" *cedj^i W\j[h j^[
_cfbWdjfheY[Zkh[
fefkbWj_d]j^[_cfbWdjikh\WY[$J^[ZWhaXbk[Yebekh
_dZ_YWj[iWh[Wie\d[mXed[\ehcWj_ed$
J^_i fefkbWj_ed cWo X[ W ]hWZkWb fheY[ii
eh_]_dWj_d] \hec _d_j_Wbbo _dj[]hWj[Z Z_ia Wh[Wi$
Eii[eWZWfjWj_edYWdWbieZ[l[bef"^em[l[h"j^hek]^
j^[\ehcWj_ede\d[mXed[\hecWbWj[hWbZ_h[Yj_ed$
;nf[h_[dY[\hecehj^efW[Z_Yikh][ho^Wii^emd
j^WjW¼Xed[Xh_Z][½edj_jWd_kc_cfbWdjiYWdZ[l[bef
WYheiicW`ehZ_ijWdY[i$J^_iX[^Wl_ekhe\j^[Xed[_i
ademdWi¼]Wf`kcf_d]½$J^[d[mbo\ehc[ZXed[_i
Z[fei_j[Z h_]^j ed j^[ _cfbWdj ikh\WY[" ie j^Wj j^[
j[hc ¼eii[e_dj[]hWj_ed½ _i jhkbo `kij_\_[Z ^[h[$ J^[
iWc[]hemj^fWjj[hdmWiWbieeXi[hl[Zed^_ijebe]_YWb
i[Yj_edi e\ j^[ iWc[ 8E? _cfbWdj$ Eh[dij[_d [j Wb$
(&&& i^em[Z j^Wj" Wbj^ek]^ _cfbWdj ijWX_b_jo Wj
j^[j_c[e\fbWY[c[dj_iYb[WhboZ[i_hWXb["_jcWodej
X[ Wd WXiebkj[ fh[h[gk_i_j[ je eii[e_dj[]hWj_ed eh
jebed]#j[hcikhl_lWb$I[l[hWb\WYjehicWo_d\bk[dY[
j^[Z[Y_i_edjeh[cel[ehh[fbWY[WceX_b[_cfbWdj$
>7#YeWj_d]i_]d_\_YWdjbo_cfhel[Zj^[f[h\ehcWdY[
e\Xej^ceX_b[WdZ_cceX_b[_cfbWdjiWjfbWY[c[dj
je )o[Whi feij#fbWY[c[dj$ J^[ ki[ e\ j^[ j[hc
×eii[e_dj[]hWj_edÆ ^Wi X[Yec[ l[ho \Wi^_edWXb[ _d
Z[djWb_cfbWdjebe]o$IpckYab[hWdZ:kXhk_bb['//&"
^em[l[h" [nfbW_d[Z j^Wj ed j_jWd_kc ikh\WY[i jhk[
eii[e_dj[]hWj_edYWddejX[[nf[Yj[Z$J^[o\ebbem[Z"
j^Wj×eii[e_dj[]hWj_edÆ"Wii[[d_dX_eWYj_l[ikh\WY[i
_idejWh[gk_h[c[dj\ehikYY[ii_d_cfbWdjZ[dj_ijho$
Ekh _dl[ij_]Wj_edi i^em" j^Wj Xed[ YWd Z[b_X[hWj[bo
]hem _dje YedjWYj m_j^ _djhW#Xedo ikh\WY[i _\ j^[
\kdYj_edWb ij_ckbki _i ]_l[d$ 9edjWYji eYYkh [Whb_[h"
^em[l[h" _\ j^[ ikh\WY[ _i iWdZXbWij[Z$ <eh 8E?
Xej^YedY[fjimeha0ikYY[ii\kb_cfbWdjjh[Wjc[dj_i
feii_Xb[m_j^iceej^WdZiWdZXbWij[Z_cfbWdji$
)(+
&IGÈ I[Yj_edWbl_[me\<_]$()$()$J^[h_d]Wh[Wl_i_Xb[_d
j^[Y[djh[_ifefkbWj[Zm_j^Xed[\hecWXel[Xo]Wf`kcf_d]$
8[bemj^[Z_ia_ij^[fh[#[n_ij_d]Xed[ijhkYjkh[i[fWhWj[ZXo
j^[eij[ejecob_]^jXbk["jem^_Y^d[mXed[_iWZZ[ZZWha
XhemdXo[dZeij[WbWffei_j_ed$J^_iX[^Wl_ekh_ifWhje\j^[
i[b\#jhWX[YkbWj_d]c[Y^Wd_ice\j^[Xed[
È
2ELATIVEÈ-OVEMENTÈOFÈ0ROSTHODONTICALLYÈÈ
,OADEDÈ)MPLANTS
J^[ j^h[WZ[Z f_d _i Z[di[bo fefkbWj[Z Xo Xed[
kf je WhekdZ &$+cc WXel[ j^[ Yh[ijWb Z_ia$ J^[
Xed[ Wffei_j_ed Wh[W ef[di jkb_f#ijob[ jemWhZi
j^[ Yh[ijWb Wif[Yj$ J^[ ifWY[ j^ki ef[d[Z _i \_bb[Z
m_j^ Yedd[Yj_l[ j_iik[$ J^[ j^h[WZ[Z f_d _i beYWj[Z
fh[Y_i[bo WXel[ j^[ Wbl[ebWh _d\[h_eh d[hl[ Wj W
Z_ijWdY[ e\ WhekdZ &$-cc$ J^[ h_d] i[]c[dji Wh[
fei_j_ed[ZWi\ebbemi0
v 9h[ijWbWdZXWiWbl[ij_XkbWhi[]c[djiWh[beYWj[Z
ekji_Z[ e\ j^[ Xed[$ J^[o Wh[ ikhhekdZ[Z Xo
Yedd[Yj_l[j_iik[$
v J^[XWiec[Z_Wbi[]c[dj_ibeYWj[Z_dWc[ZkbbWho
ifWY[ WdZ _i ikhhekdZ[Z Xo Y_hYkbWhbo WhhWd][Z
Yedd[Yj_l[j_iik[$
v =eeZXed[WZWfjWj_edYh[ijeb_d]kWbbo_dj^[beWZ#
jhWdic_jj_d]h_d]Wh[W$
v½ J^[l[ij_XkbWhijkcfXWh_iZ[di[bofefkbWj[ZXo
Xed[Wbed]j^[l[hj_YWbi[]c[djWim[bb$
v 8ej^ j^[ m[X XWh e\ j^[ Yh[ijWb fbWj[ WdZ j^[
j^h[WZ[Zf_dX[jm[[dj^[Z_iaiWh[dejfefkbWj[Z
XoXed[$
v J^[ \ehcWj_ed e\ d[m Xed[ XWiWbbo je j^[
j^h[WZ[Zf_dYekbZX[Wh[WYj_edje^oZheZodWc_Y
fh[iikh[$
v½ J^[×ebZÆ Yehj_YWb Xed[ b_d[ _i [Wi_bo l_i_Xb[ jef
h_]^j$ <ehcWj_ed e\ d[m Xed[ WXel[ j^_i b_d[
ed j^[ h_]^j$ J^[ _cfbWdj _dYh[Wi_d]bo bei[i _ji
Y[djh_Yfei_j_ed_dj^_imWoWdZ_iZ_ibeYWj[Z_dW
l[ij_XkbWhZ_h[Yj_edh[bWj_l[jej^[Xed[$
)(, 9^Wfj[h()È (ISTOLOGYÈOFÈ"/)È)MPLANTS

WdZ ijWX_b_p[ ceh[ ibembo _d j^[i[ YWi[i$ 7j Wdo

hWj[" c[Y^Wd_YWb ijWX_b_pWj_ed YWd edbo eYYkh m^[d
j^[ _di[hj_ed ibeji ^Wl[ X[[d Ybei[Z m_j^ Xed[ WdZ
m^[dd[mXed[_i]hem_d]\hecj^[i_Z[jemWhZj^[
j^h[WZ[Zf_d$7j_cfbWdjij^Wj^Wl[X[[diWdZXbWij[Z
XWiWbbo"m[eXi[hl[_dYh[Wi_d]Wffei_j_ed\hecXWiWbbo
je Yh[ijWbbo i[[ <_]$()$(." m^_b[ m_j^ _cfbWdji
j^Wj Wh[ Yecfb[j[bo iceej^" j^[ Wif[Yji j^Wj m_bb
eii[eWZWfj\_hijWh[j^[c_ZZb[jekff[hfWhjie\j^[
j^h[WZ[Z f_d i[[ <_]$()$(.Y$M^[d W 8E? _cfbWdj
^WiX[[d_di[hj[ZZ_h[Yjbo_djej^[[njhWYj_edieYa[j"
_j cWo jWa[ X[jm[[d , WdZ ),cedj^i X[\eh[ j^[
Xed[h[fW_hfheY[ii^WiYecfb[j[bo\_bb[Zj^[Z[\[Yj
Yh[Wj[Z Xo j^[ [njhWYj_ed e\ j^[ jeej^$ :kh_d] j^_i
j_c["j^[8E?m_bbWff[WhjeX[ceX_b["Wbj^ek]^_ji
ijWX_b_jom_bb_dYh[Wi[jej^[jekY^el[hj_c[$

&IGÈ J^[ el[hl_[m Yb[Whbo i^emi j^Wj j^[ _cfbWdj mWi
beYWj[Z bWj[hWbbo je j^[ Y[djh[ e\ j^[ cWdZ_XkbWh Xed[ [l[d
W\j[h _di[hj_ed$ ?d ej^[h mehZi" efj_cWb X_Yehj_YWb WdY^ehW][
mWi dej WY^_[l[Z Zkh_d] _di[hj_ed i[[ Wbie <_]$()$)$
7iocc[jh_YWb Xed[ ]hemj^ ^Wi WZZ_j_edWbbo h[_d\ehY[Z j^[
h[bWj_l[bWj[hWbfei_j_ed
È
)NSERTINGÈ)MPLANTSÈ.EARÈORÈ)NSIDEÈ$ENTALÈ2OOTS
J^[ d[mbo \ehc[Z Xed[ ed j^[ l[ij_XkbWh Wif[Yj
Wff[Whi[l[db[iicWjkh[j^Wdj^[b_d]kWbboceZ[bb[Z
Xed[ WdZ [n^_X_ji W iceej^ ijhkYjkh[ m_j^ekj Wdo
h[Y[ii_edi$<_]$()$(/

È
4ETRACYCLINEÈ&LUORESCENCEÈ%VALUATION
J^[ ikjkh[ Wh[W _i de bed][h l_i_Xb[$ J^[ fhe\_b[
e\ j^[ WXkjc[dj WdZ ikf[hijhkYjkh[ _i cWff[Z J^[ Wd_cWbi m[h[ bWX[bb[Z m_j^ W i_d]b[ Zei[ e\
je j^[ ckYeiW$ J^[h[ Wh[ de i_]di e\ ie\j#j_iik[ j[jhWYoYb_d[WhekdZ'm[[aX[\eh[if[Y_c[dYebb[Yj_ed$
_d\bWccWj_ed"Z[if_j[j^[\WYjj^Wjj^[fe_djWjm^_Y^ 7\j[hj^_if[h_eZ"j[jhWYoYb_d[\bkeh[iY[dY[YWdedbo
j^[ WXkjc[dj c[[ji j^[ j^h[WZ _i dej ^[hc[j_YWbbo X[ eXi[hl[Z _d WYj_l[ i[YedZWho eij[edi WdZ d[mbo
i[Wb[Z$ \ehc[Z mel[d Xed[" m^_b[ Wdo fh[#[n_ij_d] Xed[
;f_j^[b_Wb j_iik[ [nj[dZi de Z[[f[h j^Wd j^[ ijhkYjkh[im_bb^Wl[WZWhaWff[WhWdY[$
WXkjc[dj%Yhemd$J^[ifWY[X[bemj^_ib[l[b_i\_bb[Z
m_j^Yedd[Yj_l[j_iik[$?dej^[hmehZi"j^[ckYeiWb
È
i[]c[djZ_h[YjboX[bemj^[ikf[hijhkYjkh[Ze[idej
2ADIOLOGICALÈ!NALYSISÈÈ
h[l[WbWjhk[[f_j^[b_Wbj[hc_dWj_edb_d[$
OFÈTHEÈ(ISTOLOGICALÈ3ECTIONS
J^[b_d_d]e\j^[c[ZkbbWhoifWY[im_j^[dZeij[Wbbo
\ehc[Zd[mXed[cWofeii_Xboh[\b[Yjj^[[\\ehjie\ C_YhehWZ_e]hWf^_Y [nWc_dWj_edi Wbbem ki dej edbo
j^[ Xed[ je Yecf[diWj[ \eh j^[ eij[ejeco#h[bWj[Z je Z_ij_d]k_i^ fh[ef[hWj_l[ Xed[ Wh[Wi \hec d[mbo
\ehc[ZXed[Wh[WiXkjWbiejeZ[j[hc_d[j^[Z[]h[[
Xed[ beii[i$ ?\ _j _i h[Wbbo WZlWdjW][eki je WY^_[l[
beWZ jhWdic_ii_ed Wj j^[ l[hj_YWb Wif[Yji e\ j^[ e\ c_d[hWb_pWj_ed m_j^_d j^[ _dZ_l_ZkWb Xed[ Wh[Wi$
_cfbWdj" h[gk_h[i \khj^[h Z_iYkii_ed$ 9edi_Z[h_d] J^[XWiWbXed[i[]c[dji_dj^[cWdZ_Xb[Wh[ijhed]bo
j^[fe_djicWZ[_d9^Wfj[h."j[di[_dj[]hWj_edWdZ h[i_ijWdj je h[ceZ[bb_d]" m^_Y^ _i m^o [l[d ^_]^bo
c_d[hWb_pWj_ed Wj j^[ jhWdi_j_ed Wh[W je j^[ ckYeiWc_d[hWb_p[ZXed[YWdf[hi_ijj^[h[\ehWYedi_Z[hWXb[
m_bbZ[\_d_j[boWbj[hj^[Z_h[Yj_edie\f[h\ki_ed"m^_Y^ f[h_eZ e\ j_c[$ J^[ bem Z[]h[[ e\ _dj[hYedd[Yj_ed
cWojkhdekjZ_iWZlWdjW][eki$ e\ j^[i[ Wh[Wi _d eij[efehei_i fWj_[dji _i ed[ e\
j^[ h[Wiedi m^o j^[_h cWdZ_Xb[i m_bb eYYWi_edWbbo
\hWYjkh[ W\j[h _cfbWdj _di[hj_ed$ <hWYjkh[i _d j^[i[
È
YWi[i Ze dej kikWbbo eYYkh kdj_b W\j[h i_n m[[ai" Wj
)NFLUENCEÈOFÈ3URFACEÈ0ROPERTIESÈÈ
m^_Y^ fe_dj j^[ h[fW_h#h[bWj[Z h[ceZ[bb_d] fheY[ii
ONÈTHEÈ$EGREEÈOFÈ)NTEGRATION
^Wi [dYecfWii[Z bWh][ Wh[Wi WdZ j^[ h[cW_d_d]
?\ 8E? _cfbWdji Wh[ _di[hj[Z _d h[]_edi j^Wj Wh[ ^_]^bo c_d[hWb_p[Z Wh[Wi YWd de bed][h h[i_ij j^[
_d\[Yj[Z"_jm_bbjWa[WY[hjW_dj_c[kdj_bj^[_d\[Yj_ed \ehY[ij^[oWh[[nfei[Zje$
h[i_Zk[ ^Wi \bemd ekj ikffkhWj_ed$ J^_i _i m^o
m[ mekbZ ^Wl[ je [nf[Yj j^[ _cfbWdj je _dj[]hWj[
È È -OREÈ(ISTOLOGICALÈ&INDINGSÈANDÈ#LINICALÈ#ONSIDERATIONSÈ )(-

&IGÈÈ A I[Yj_edWb l_[m e\ j^[ XWiWb _cfbWdj i[]c[dj$ Fh_cWho eii[eWZWfjWj_ed _d j^[ XWiWb h[]_ed e\ j^[ j^h[WZ[Z f_d
_i kdb_a[bo je eYYkh X[YWki[ j^[ _cfbWdj \[Wjkh[i W Yecfb[j[bo iceej^ ikh\WY[$ B J^[ XWiWb fehj_ed e\ j^[ j^h[WZ[Z f_d _i
ikhhekdZ[Z m_j^ Yedd[Yj_l[ j_iik[" h[\b[Yj_d] j^[ h[i_b_[dY[ YWki[Z Xo j^[ cWij_YWjeho \ehY[i$ KdZ[h cWij_YWjeho beWZ" j^[
Y[djhWbbobeYWj[Z_cfbWdji[]c[dj_iZ_ibeYWj[Z_dWYWkZWbZ_h[Yj_ed$J^[Xed[_ji[b\_ibeYWj[ZWjWZ_ijWdY[e\&$*cc\hecj^[
_cfbWdjWdZ^WiWkd_\ehcbohekdZ[Zcehf^ebe]o$Dei_]die\_d\bWccWj_edWh[fh[i[dj$J^[eij[ejecoWh[WYbei[iX[jm[[dj^[
_cfbWdji[]c[djij^h[WZ[Zf_dWdZh_d]Z_ia_dWXh_Z][#b_a[\Wi^_ed$Dej[j^Wjj^[]Wfl_i_Xb[^[h[X[jm[[dj^[_cfbWdjWdZ
j^[Xed[m_bb][jicWbb[hel[hj_c[$J^[ceh[j^[Xed[WZ^[h[iZ_h[Yjbojej^[_cfbWdj"j^[ceh[ijWXb[_jm_bbX[Yec[Yb_d_YWbbo$
J^[fheY[iie\ijWX_b_pWj_edcWojWa[o[WhiWdZj^[h[ikbjZ[f[dZibWh][boedj^[[\\[Yje\j^[cWij_YWjeho\ehY[i$El[hbeWZ_d]
cWoZ[Yh[Wi[ijWX_b_jo"]h_dZ_d]e\cWij_YWjehoikh\WY[iWdZXWbWdY_d]j^[X_j[m_bbb[WZjeW^_]^[hZ[]h[[e\c_d[hWb_pWj_ed
WdZWbWh][hWZWfjWj_edWh[W$J^[ZWha[hXbk[Wh[Wi_dZ_YWj[j^[Z_h[Yj_ede\Xed[]hemj^WdZj^Wj\khj^[hWZWfjWj_ed_ijWa_d]
fbWY[$ C ?\j^[_cfbWdjikh\WY[_iiceej^_dj^[Wh[We\j^[XWi[#fbWj["j^[d[mbo\ehc[ZXed[m_bbWjWfh[Y_i[Z_ijWdY[\ebbem
j^[ i^Wf[ e\ j^[ _cfbWdj ;:I '& ='&$ Eii[eWZWfjWj_ed Wj j^[ j^h[WZ[Z f_d _i \ekdZ Wj W bWj[h ijW][ e\ j^[ X_ec[Y^Wd_YWb
_dYehfehWj_ed$9ecfWh[<_]$()$()

d[m Xed[ \ehcWj_ed ZWha Xbk[" [nj[dZ_d] [l[d

È
$IRECTIONÈOFÈ)MPLANTÈ)NTEGRATION
?dWbbZ_iai[]c[dji"j^[fheY[iie\Xed[^[Wb_d]Xo
m^_Y^ j^[ _cfbWdji X[YWc[ _dj[]hWj[Z _dlWh_WXbo
fheY[[Z[Z \hec j^[ f[h_f^[ho jemWhZi j^[ Y[djh[$
?dcWdoYWi[i"j^[Xed[c[Z_Wbbojej^[h_d]^WZdej
X[[d d[mbo \ehc[Z Xo j^[ j_c[ e\ WdWboi_i$ J^[i[
i[]c[dji d[Wh j^[ h_d] Wh[ WlW_bWXb[ \eh fhel_Z_d]
dkjh_j_ed\hecj^[Y[djh[e\j^[`Wm$
C[Z_Wb d[m Xed[ \ehcWj_ed mWi eXi[hl[Z X[bem
j^[ [gkWjeh e\ j^[ `Wm$ :hW_dW][ Wh[Wi m_j^ekj
Z_h[Yj eii[eWZWfjWj_ed Wh[ ij_bb fh[i[dj jemWhZi j^[
Yh[ijWb Wif[Yj$ J^[ _di[hj_ed i_Z[ [n^_X_ji Z[di[
X[bem j^[ l[ij_XkbWh [Z][ e\ j^[ h_d]$ B[ii d[m
Xed[ _i \ehc[Z jemWhZi j^[ h_]^j i_Z[" m^[h[ W b[ii
\WlekhWXb[ ZhW_dW][ i_jkWj_ed WdZ W icWbb[h Z[]h[[
e\ c[Y^Wd_YWb Xed[ m[Wa[d_d] Wh[ fh[i[dj$ ?d j^_i
ijW][ e\ ^[Wb_d]" j^[ jhWX[YkbWh ijhkYjkh[i Wh[ ij_bb
Wb_]d[Z m_j^ j^[ Z_h[Yj_ed e\ ZhW_dW][ \hec _di_Z[
j^[Xed[$
È $ISCUSSION
7ja_died [j Wb$ '/-- Z[cedijhWj[Z Z_\\[h[dj
h[]_edWb Xed[ Z[di_j_[i _d f_]i" Ze]i WdZ ^kcWdi$
<ebbem_d]jeej^[njhWYj_ed"Xed[Z[di_jo_dj^[Wh[Wi
X[oedZ j^[ Wbl[ebWh ieYa[j Y^Wd][Z$ ?d j^[ _d_j_Wb
)(. 9^Wfj[h()È (ISTOLOGYÈOFÈ"/)È)MPLANTS

A B D

C
E

&IGÈÈA M_j^iWdZXbWij[Z_cfbWdjikh\WY[i"j^[j^h[WZ[Zf_dm_bbWbh[WZoX[fefkbWj[ZXoj^_ij_c[Xej^Xoeii[eWZWfjWj_ed
XejjecWdZ]Wf`kcf_d]Y[djh[$Ikh\WY[#[dbWh][Z_cfbWdjiWh[WYj_l[boWffheWY^[ZXod[mXed[$ B J^[j^h[WZ[Zf_d_i
\_hij_dj[]hWj[Z\hecjefWdZ\hecX[bemm^_b[j^[bWj[hWbWffei_j_edfheY[[Ziceh[ibembo$M[Wjjh_Xkj[j^_ijej^[ceijbol[hj_YWb
eh_[djWj_ede\j^[cWij_YWjeho\ehY[i"h[ikbj_d]_dj^[Z_h[Yj_ede\j^[Wbj[hdWj_d]fh[iikh[[n[hj[Zedj^[b_gk_ZWdZYedd[Yj_l[
j_iik[ X[_d] fh[Zec_dWdjbo l[hj_YWb$ J^[ Xed[ l_hjkWbbo jh_[i je ijef Wdo cel[c[dj m_j^_d _ji ijhkYjkh[$ C <ehcWj_ed e\
Æ\_d][h#i^Wf[ZÇ d[m Xed[ h[WY^_d] _dje j^[ Yedd[Yj_l[ j_iik[ _i eXi[hl[Z _d j^[ Y[djh[ e\ j^[ j^h[WZ[Z f_d Wbed] _ji [dj_h[
b[d]j^$ Fh[ikcWXbo" j^[ \ehcWj_ed e\ j^_i d[m Xed[ _i jh_]][h[Z Xo Y^[m_d] \ehY[i j^Wj j^[ _cfbWdj jhWdic_ji j^hek]^ j^[
ie\j j_iik[$ J^[ j^h[WZ[Z f_d e\ j^_i _cfbWdj _i iWdZXbWij[Z _d j^Wj Wh[W$M[ ikif[Yj j^Wj j^[ Yedj_dkeki l[hj_YWb cel[c[dji
e\j^[iceej^j^h[WZ[Zf_d_dZkY[ZXocWij_YWj_edWh[dejYedZkY_l[jej^[\ehcWj_ede\Yedd[Yj_l[j_iik["iej^Wjj^[Xed[
_i _dYh[Wi_d]bo WXb[ je Z_ifbWY[ j^[ j_iik[ \hec W bWj[hWb Z_h[Yj_ed$ Dej[ j^Wj j^_i ^_ijebe]o mWi ]W_d[Z edbo )Ä*cedj^i W\j[h
j^[_di[hj_ede\j^[_cfbWdjWdZj^WjZ_h[YjYedjWYjjej^[l[hj_YWb_cfbWdjfWhjm_bbkikWbboZ[l[befbWj[h$J^_im_bbh[ikbj_dW
Yb_d_YWbboZ[j[YjWXb[_dYh[Wi[_dijWX_b_pWj_ede\j^[_cfbWdj$9ecfWh[je<_]$()$(-[$ D J^[d[mXed["m^_Y^_iYedif_YkekiXo
_jiceh[_dj[di[Yebekh"_i]hem_d]jemWhZij^[j^h[WZ[Zf_d$?j_iYedY[_lWXb[j^Wjj^[f^oi_ebe]_YWbceX_b_joe\j^[j^h[WZ[Zf_d
Y^Wd][ifh[iikh[YedZ_j_edi_dj^[Yedd[Yj_l[j_iik[YecfWhjc[dj"j^kiij_ckbWj_d]d[mXed[\ehcWj_ed$J^_imekbZ[nfbW_d
m^o8E?_cfbWdjiYWdX[Yec[_dYh[Wi_d]boijhed][hZkh_d]Yb_d_YWbi[hl_Y[_\j^[ofeii[iiik\\_Y_[djbobed]j^h[WZ[Zf_diWdZ
WZ[i_]dj^Wjf[hc_ji[bWij_YZ[\ehcWj_ed$ E ?d8E?m_j^Wfeb_i^[ZXWi["bWj[hWbeii[eWZWfjWj_edcWojWa[fbWY[_dWceh[
Yh[ijWbh[]_ede\j^[j^h[WZ[Zf_d\_hij$J^_imWoj^[_cfbWdjiX[Yec[ceh[WdZceh[ijWXb[$Dej[j^Wjj^[l[hj_YWb_di[hj_edibej
_iYecfb[j[boYbei[ZW\j[h*cedj^i"Wbj^ek]^j^[_cfbWdj^WZX[[d_di[hj[Z_dWYedjWc_dWj[ZijWj[$J^[_cfbWdj^WZX[[dX[dj
Xoj^[Ze]ÉiY^[m_d]\ehY[$Ed[fWhje\j^[XWiWbfbWj[mWidejWdY^eh[ZYehj_YWbbo

f^Wi[" j^[ Z[di_jo mekbZ Z[Yh[Wi[ Zk[ je W ]h[Wj[h
Z[]h[[e\fehei_jo$J^[jkdd[bb_d]i[YedZWhoeij[edi
8CKimekbZ_dZkY[Xed[h[ceZ[bb_d][l[d_dj^[
Wh[Wi ikhhekdZ_d] j^[ Wbl[eb_$ 7\j[h _d_j_Wb ^[Wb_d]"
h[iehfj_edmWieXi[hl[Z_dj^[Wh[We\j^[[njhWYj_ed
ieYa[j$J^[h[iehfj_edmWiZ[bWo[Z_\Yh[ijWb_cfbWdji
^WZ X[[d _di[hj[Z _d j^[ Wh[W e\ j^[ ieYa[j" WdZ
Xed[ Z[di_jo mWi \ekdZ je X[ _dYh[Wi[Z1 _d \WYj"
j^[ Xed[ Z[di_jo mekbZ iec[j_c[i [l[d h_i[ WXel[
j^[ XWi[b_d[ b[l[b$ D_d[ cedj^i W\j[h _cfbWdjWj_ed"
^em[l[h"h[iehfj_edfheY[ii[ij^WjWZl[hi[boW\\[Yj[Z
j^[ fh[i[hlWj_ed e\ Wbl[ebWh Xed[ m[h[ i[[d _d j^[
_cfbWdjWh[W$EdXWbWdY["^em[l[h"j^[[nf[h_c[dji
f[h\ehc[Z Xo 7ja_died [j Wb$ o_[bZ[Z de [l_Z[dY[
È È -OREÈ(ISTOLOGICALÈ&INDINGSÈANDÈ#LINICALÈ#ONSIDERATIONSÈ
B XWiWb Z_ia _i beYWj[Z c[Z_Wbbo _d j^[ c[ZkbbWho ifWY[ Xkj _i
&IGÈÈ A Jkdd[bb_d] e\ W i[YedZWho eij[ed WhekdZ j^[
l[ij_XkbWhXWiWbh_d]fehj_edWjWd[Whbof^Wi[e\h[\_bb_d]$J^_i
m_bbYbei[j^[]WfX[jm[[dj^[XWi[e\j^[j^h[WZ[Zf_dWdZj^[
fh[#[n_ij_d]Xed[b_]^jXbk["m^_Y^_i\_bb[Zm_j^Yedd[Yj_l[
j_iik[$ B 8CKiY^Wd][j^[Z_h[Yj_ede\j^[_hjkdd[bb_d]m_j^
h[if[Yj je j^[ \ehY[i _cfei[Z ed j^[c$ J^[ j^_Yad[ii e\ j^[
h[Xk_bjWh[WZ[f[dZiedj^[\ehY[cW]d_jkZ[$H_]^j?\j^[f[Wa
j[di_b[ijh[iicel[ijej^[b[\ji_Z[\hecj^[8CKÉife_dje\
l_[m"j^[h[iehfj_edWh[Wcel[iWbie$J^_imWo8CKif[h\ehc
Yehh[Yj_l[ij[[h_d]$9ecfWh[<_]$()$(."m^[h[j^[8CKedj^[
b[\ji_Z[e\j^[XWi[#fbWj[Y^Wd][i_jiZ_h[Yj_edjm_Y[$:hWm_d]
\hecCWhj_d[jWb$'//.
e\ Wdo Y^Wd][i ed j^[ b_d]kWb i_Z[ e\ j^[ cWdZ_Xb[
\ebbem_d]_di[hj_ede\Yh[ijWb_cfbWdji$
8ej^ jeej^ [njhWYj_ed WdZ j^[ _di[hj_ed e\
c[jWbb_Y _cfbWdji m_bb ij_ckbWj[ Xed[ h[ceZ[bb_d]$
Ded[j^[b[ii"_dj[hdWbijhkYjkh[e\j^[Xed[m_bbij_bb
h[cW_d kdY^Wd][Z [l[d _\ iec[ e\ j^[ j[[j^ Wh[
[njhWYj[Zeh_cfbWdji_di[hj[Z7ja_died[jWb$'/--$
7ja_died [j Wb$ feijkbWj[Z W f[h_f^[hWbbo
eh_[dj[Z iY^[c[ e\ ]hemj^ WdZ h[][d[hWj_ed _d
f_]iÉcWdZ_Xb[i"m^_Y^bWh][boWffb_[ijej^[^kcWd
cWdZ_Xb[Wim[bb$
J^[h[ _i ik\\_Y_[dj [nf[h_c[djWb [l_Z[dY[ j^Wj
Xed[]hemj^_dj^[cWdZ_Xb[_i_d\bk[dY[ZXobeWZ#
h[bWj[Z ijh[ii[i [$]$ Xo ckiYb[ WjjWY^c[dji WdZ
)(/
&IGÈ =hekdZi[Yj_ed-0J^_i]hekdZi[Yj_ed_bbkijhWj[i
j^[f[h_f^[hWb[dZe\j^[_cfbWdj$Fh[ikcWXbo"j^[Ykj^Widej
X[[d m^ebbo l[hj_YWb h[bWj_l[ je j^[ _cfbWdj$ J^[ f[h_eij[Wb
Æj[dj [\\[YjÇ ^Wi _dZkY[Z j^[ \ehcWj_ed e\ d[m Xed[ ed j^[
XWiWbZ_ia$M_j^ekjj^_i\ehcWj_ede\d[mXed["j^[f[h_eij[Wb
j_iik[_dj^_ifWhje\j^[i[Yj_edYekbZdejX[a[fjWmWo\hec
j^[ Z_ia Wj Wbb$ J^[ _di[hj_ed Wh[Wi Wh[ Ybei[Z Xo Xed[$ J^[
Yel[h[Zm_j^Wj^_dbWo[he\d[mbo\ehc[ZXed[\hecWYh[ijWb
Z_h[Yj_ed$J^_iXed[Wff[Whije^Wl[WZlWdY[ZWbed]j^[Z_ia"
eh feii_Xbo \hec W Z_ijWb Z_h[Yj_ed$ B_d]keYh[ijWb ceZ[bb_d]
_i je X[ eXi[hl[Z ^[h[ Wi m[bb$ J^[ h[i_ZkWb heej Ze[i dej
^Wl[Wdej_Y[WXb[[\\[Yjedj^[_cfbWdj$J^[YWdY[bbekiWh[Wi
X[jm[[dj^[Yh[ijWbfbWj[WdZj^[heeji[[cje^Wl[ie\j[d[Z
Xoeij[edWbh[ceZ[bb_d]
ej^[h \kdYj_edWb c[Y^Wd_ici$ =hemj^ _i h[ZkY[Z
_\ ckiYb[i Wh[ h[cel[Z Ceeh[ '/-)$ 8o h[cel_d]
ckiYb[i kd_bWj[hWbbo" j^[ Z_h[Yj_ed e\ ]hemj^ YWd X[
ceZ_\_[ZIY^kcWa[h'/,.$Jeej^[hkfj_edWdZj^[
i^[[hfh[i[dY[e\j[[j^m_bb_d\bk[dY[Xed[h[ceZ[bb_d]
WdZ^[dY[Xed[ijhkYjkh[P[d]e[jWb$'/-)$
J^[i[ \_dZ_d]i m[h[ Yed\_hc[Z _d ekh ijkZo$
IYh[m _cfbWdji ed j^[ YedjhWbWj[hWb i_Z[ m[h[ ki[Z
_dWbbWd_cWbi$M^_b[j^[i[\_njkh[im[h[ikYY[ii\kbbo
_dj[]hWj[Z Xo ^[Wb_d]" cW`eh Wcekdji e\ b_d]kWb
Xed[Wffei_j_edm[h[edboeXi[hl[Z_\j^[l[ij_XkbWh
Yehj_YWbXed[^WZX[[dh[cel[ZZkh_d]_di[hj_ed$
J^[ \_dZ_d]i Xo 7ja_died [j Wb$ m[h[ Yed\_hc[Z
je j^[ [nj[dj j^Wj h[ceZ[bb_d] jeea fbWY[ ed W
bWh][ iYWb[ \ebbem_d] j^[ _di[hj_ed e\ 8E? _cfbWdji$
H[ceZ[bb[Z Wh[Wi _dYbkZ[Z j^[ l[hj_YWb ibej ed j^[
l[ij_XkbWhWif[Yj$?diec[YWi[i"j^[[dj_h[l[ij_XkbWh
Xed[ijhkYjkh[WXel[j^[Yh[ijWbZ_iamWih[ceZ[bb[Z$
<heijÉi c[Y^WdeijWj j^[eho mWi Yed\_hc[Z _d ekh
))& 9^Wfj[h()È (ISTOLOGYÈOFÈ"/)È)MPLANTS
B &IGÈ J^_i i[Yj_ed _bbkijhWj[i j^[ Wh[W e\ j^[ h_]^j
&IGÈÈA J^_i i[Yj_ed i^emi W jh_fb[ 8E? _cfbWdj j^Wj
^WZ X[[d _di[hj[Z Z_h[Yjbo _dje j^[ heej e\ j^[ bem[h YWd_d[$
J^[ d[m Xed[ ]hemi Wbed] j^[ _cfbWdj _dje j^[ eij[ejeco
Wh[W$ ?j YWddej" ^em[l[h" ]hem _dje j^[ \hWYjkh[ Wh[W e\ j^[
jeej^ h_]^j$ J^ki j^[ _cfbWdj ikh\WY[ i[[ci je ^Wl[ Wd
eii[eYedZkYj_l[ [\\[Yj kdZ[h j^[i[ YedZ_j_edi$ J^[ _cfbWdj
_i dej ikX`[Yj[Z je cWij_YWjeho beWZi WdZ _i m[Z][Z _di_Z[
j^[jeej^"WiWffWh[djedj^[XWiWbWdZY[djhWbZ_iaib[\jWdZ
h_]^j"h[if[Yj_l[bo$ B =e_d]ZemdWXekj)ccZ[[f[h_dje
j^[jeej^"_jYWdX[i[[dj^WjXed[Ybei[ij^[]WfX[jm[[dj^[
_cfbWdjWdZj^[j^h[WZ[Zf_d[l[dX[^_dZj^[bWjj[h"j^Wj_i"ed
j^[i_Z[effei_j[j^[_di[hj_edibej"X[jm[[dj^[XWiWbWdZj^[
c_ZZb[Z_ia$J^[i_jkWj_ed_dj[hcie\dkjh_[djikffbockijX[
hWj^[hkd\WlekhWXb[_dj^_iWh[W
ijkZ_[i$ 7YYehZ_d] je <heij" _dj[hdWb h[ceZ[bb_d]
m_bb _dYh[Wi_d]bo ]_l[ h_i[ je fehei_j_[i" m^_Y^
mekbZ" ^em[l[h" kbj_cWj[bo h[ZkY[ j^[ c[Y^Wd_YWb
beWZ h[i_ijWdY[ e\ j^[ Xed[$ ?d j^[ fh[i[dY[ e\
beWZ_d]" Xed[ Wffei_j_ed WdZ Xed[ h[iehfj_ed m_bb
X[_dXWbWdY["iej^Wjj^[jejWbXed[lebkc[h[cW_di
kdY^Wd][Z Ijeh[o '/-+$ J^[ beWZ h[i_ijWdY[ YWd
edbo X[ _dYh[Wi[Z Xo ceZ[bb_d] _$[$ h[Wb d[m Xed[
\ehcWj_ed" m^_Y^ _i \ekdZ ed j^[ b_d]kWb Wif[Yj"
m^_Y^^WZdejX[[dikX`[Yj[Zje\bWf\ehcWj_ed$
cWdZ_XkbWh iocf^oi_i$ ;l[d kd_Yehj_YWbbo WdY^eh[Z ZekXb[#
Z_ia8E?_cfbWdjii^emh[]kbWheii[e_dj[]hWj_edWbed]j^[_h
[deiiWb ikh\WY[i" m^_Y^ _i Wbie jhk[ e\ j^[ Wh[Wi _di_Z[ j^[
heej$J^[Xed[m_bb]hemjhWdil[hi[boj^hek]^j^[jeej^kdZ[h
j^[i[ [nf[h_c[djWb YedZ_j_edi" \ehc_d] W d[m jhW`[Yjeh_Wb
ijhkYjkh[$J^[\WYjj^Wjd[mXed[_iWbie\ehc_d]l[ij_XkbWhbo
jej^[Xed[_dZ_YWj[ij^Wjl[ii[biWh[]hem_d]j^hek]^j^[h_d]
ijhkYjkh[e\j^[_cfbWdjZ_iaWiWfh[YkhiehjeXed[\ehcWj_ed$
?j_ikdb_a[bo"^em[l[h"j^WjXed[]hemj^j^hek]^j^[jeej^_i
_dZkY[ZXo\kdYj_edWbh[Wiedi$?dehZ[hjei[[Xed[Wbie_di_Z[
j^[l[ij_XkbWhZ_ia#h_d]i_jmekbZ^Wl[X[[dd[Y[iiWhojefbWY[
Wc[cXhWd[
J^[ dWjkh[ WdZ [nj[dj e\ Wffei_j_ed _i Z[j[hc_d[Z
Xoj^[\ebbem_d]\WYjehi0
v ?di[hj_ed e\ 8E? _cfbWdji _i WiieY_Wj[Z m_j^
ijhkYjkhWb Xed[ beii$ J^[ c_ii_d] Xed[ lebkc[
^Wi je X[ Xk_bj Xo j^[ Xed[ _ji[b\ Wi gk_Yabo Wi
feii_Xb[_dehZ[hjeWle_Z\hWYjkh[i$
v 8ed[ Wffei_j_ed mWi _dlWh_WXbo eXi[hl[Z ed j^[
b_d]kWbi_Z["[l[dm^[dj^[_cfbWdjmWi_di[hj[Z
_djej^[Xed[_dWf[h\[Yjboiocc[jh_YWbcWdd[h$
BeWZ_d]e\j^[_cfbWdjZe[idejY^Wd][j^[i_j[e\
ceZ[bb_d][_j^[h$J^_iik]][ijij^Wjj^[YkhlWjkh[
e\j^[`WmXed[ckij_if[hcWd[djboWbj[h[ZXoj^[
fheY[Zkh["m^_Y^_ij^[d\ebbem[ZXo\kdYj_edWbbo
_dZkY[Z ijhkYjkhWb Yecf[diWj_ed WYYehZ_d] je
Meb\\ ÉibWmh[]WhZ_d]Y^Wd][i_dXed[cehf^ebe]o$
7i_c_bWhfheY[iiYWdX[eXi[hl[Z_dj^[^kcWd
cWdZ_Xb[" m^[h[ 8E? _cfbWdji ^Wl[ W icWbb[h
ijWj_ij_YWb Y^WdY[ e\ ikhl_lWb _d j^[ Wh[W e\ j^[
fh[cebWhi$;nf[h_[dY[Zki[hiWh[m[bbWmWh[j^Wj
_cfbWdji fbWY[Z _d j^_i h[]_ed j[dZ je X[ b[ii
ijWXb[ j^Wd" \eh _dijWdY[" _cfbWdji _d j^[ Wh[W e\
j^[i[YedZcebWhi$
v J^[_cfb_YWj_edi\ehYb_d_YWbmehaWh[Wi\ebbemi0
9ecfb[j[ Xh_Z][i _d j^[ cWdZ_Xb[ ikffehj[Z
Xo 8E? _cfbWdji i^ekbZ Wle_Z j^[ Wh[W e\ j^[
fh[cebWhi" i_dY[ j^[ _cfbWdji Wh[ cW_djW_d[Z _d
Wl[ij_XkbWhfei_j_edXoj^[Xh_Z][m^_b[j^[d[m
Xed[]hemj^_ieh_[dj[Z_dWb_d]kWbZ_h[Yj_ed$
È È -OREÈ(ISTOLOGICALÈ&INDINGSÈANDÈ#LINICALÈ#ONSIDERATIONSÈ ))'

B B

&IGÈAB <bkeh[iY[dj Xed[ Wh[Wi Wh[ eXi[hlWXb[ Wbed]
j^[ _cfbWdj Z_iai [l[d X[\eh[ Wdo Z_h[Yj Xed[ Wffei_j_ed _i
fh[i[dj"_dZ_YWj_d]j^Wjc_d[hWb_p[ZcWjh_n_iX[_d]Z[fei_j[Z
v J^[ _cfbWdji Ze dej i[[c je _d\bk[dY[ j^[
Z_h[Yj_ede\eij[edWbWYj_l_jo_dj^[Yehj_YWbXed[$
?\ bed] jkXkbWh Xed[i Wh[ ikX`[Yj[Z je _dYh[Wi_d]
beWZi _d oekd] _dZ_l_ZkWbi" mel[d Xed[ _i Xk_bj kf
\hec j^[ f[h_eij[Wb Wh[W" WdZ [dZeij[Wb Wffei_j_ed
_ieXi[hl[ZWim[bb@Wmehia_WdZKj^e\\'/.,$J^[
fh_dY_fWbh[ceZ[bb_d]c[Y^Wd_iceXi[hl[Z_debZ[h
fWj_[dji _d Yedd[Yj_ed m_j^ _dYh[Wi[Z beWZ_d] _i"
^em[l[h"[dZeij[WbWffei_j_ed@Wmehia_[jWb$'/.&$
EbZ[hfWj_[djii^emWicWbb[hh[Wffei_j_edhWj[j^Wd
oekd][h_dZ_l_ZkWbi"WdZj^[Z_Wc[j[he\j^[jkXkbWh
Xed[_idejeXi[hl[Zje_dYh[Wi[$
J^[h[\eh[" j^[ eXi[hlWj_edi cWZ[ c_]^j ^Wl[
X[[dYWki[ZXoWbj[hWj_edi_dY^[m_d]\kdYj_edZk[
jec_ii_d]j[[j^$
&IGÈAnC 7\j[h)cedj^i"j^[d[mboceZ[bb[Zmel[dXed[
ijhkYjkh[i Wh[ X[_d] f[hlWZ[Z Xo eij[edi" m^_Y^ ik]][iji
j^Wj j^[i[ Wh[Wi Wh[ ikX`[Yj[Z je \kdYj_edWb beWZ_d] WdZ m_bb
X[ fh[i[hl[Z _d W bWij_d] cWdd[h$ 7Yj_l[ eij[edi Wh[ edbo
ifehWZ_YWbbo eXi[hl[Z _d YhWYa Wh[Wi" _dZ_YWj_d] j^Wj j^[h[ _i
de \kdYj_edWb ij_ckbki \eh j^[i[ YhWYa ped[i je X[ h[fW_h[Z$
J^[h[fW_hfheY[ii[iWh[jWa_d]fbWY[dejieckY^Wbed]j^[
YhWYaiWiYedY[djh_YWbboWbed]j^[[nj[hdWbXed[cWh]_di
=eeZ Xed[ WZWfjWj_ed je [deiiWbbo _di[hj[Z
_cfbWdji _i Yedi_ij[dj m_j^ <heijÉi d[kjhWb_pWj_ed
j^[eho <DJ <heij '/,*$ <eh ed[ j^_d]" j^[ Xed[
^WiWYedj_dkekij[dZ[dYojeijhW_]^j[dekj@Wdi[d
))( 9^Wfj[h()È (ISTOLOGYÈOFÈ"/)È)MPLANTS

&IGÈ F[h_f^[hWb i[]c[dji e\ Wd I#jof[ ZekXb[#Z_ia

_cfbWdj$ J^[ XWiWb Z_ia _i beYWj[Z _d j^[ c[ZkbbWho ifWY[
ed j^[ h_]^j" ikY^ j^Wj Xed[ WZWfjWj_ed YWddej X[ WY^_[l[Z$
J^[ fehj_edi l_i_Xb[ _d j^[ Y[djh[ e\ j^[ Yh[ijWb Z_ia Wff[Wh
je X[ beYWj[Z \Wh c[Z_Wbbo ed j^[ _cfbWdj$ J^[ h[]_ed e\ j^[
eij[ejeco Ykj e\ j^[ Yh[ijWb fbWj[ i^emi W ped[ e\ _dYh[Wi[Z
c_d[hWb_pWj_ed Wj _ji \beeh$ J^_i i[Yj_ed Wbie h[l[Wbi j^[
\ehcWj_ed e\ d[m Xed[ ed j^[ l[ij_XkbWh Wif[Yj m^[h[ j^[
B f[h_eij[kcmWia[fjWmWo\hecZ_iai[]c[djidejl_i_Xb[_d
j^_ii[Yj_ed

'/(&$ <eh Wdej^[h" j^[ fh[i[dY[ e\ YedYWl_j_[i m_bb

WbmWoi _dZkY[ Xed[ \ehcWj_ed$ J^[ h_d] Z_iai WdZ
j^h[WZ[Z f_di Wh[ ikhhekdZ[Z Xo YedYWl_j_[i W\j[h
j^[ _di[hj_ed fheY[Zkh[$ J^[ h[ceZ[bb_d] fheY[ii
W_c[Z Wj Yecf[diWj_d] \eh j^[i[ YedYWl_j_[i mekbZ
j^kiYWki[j^[_cfbWdjjeX[Yec[_dj[]hWj[Z$?dekh
l_[m" j^_i X[^Wl_ekh e\ j^[ Xed[ fbWoi Wd [ii[dj_Wb
heb[ _d j^[ cWh]_dWb Z[fei_j_ed e\ Xed[ ijhkYjkh[i
jej^[Z_iai$?\m[_]deh[j^[fh[i[dY[e\j^[_cfbWdj
\ehWcec[dj"m[Wh[b[\jm_j^W^[Wl_boYedYWl[Xed[
ikh\WY["m^_Y^mekbZf[hi[_dZkY[Xed[\ehcWj_ed$
7YYehZ_d]jej^_ij^[eho"j^[_cfbWdjZe[idej_dZkY[
Xed[\ehcWj_edXof^oi_YWbWYj_edXkjXoj^[\WYjj^Wj
_jifh[i[dY[_iWiieY_Wj[Zm_j^^[Wl_boYedYWl[Xed[
ijhkYjkh[i_dZkY_d]Yecf[diWj_edWbXed[\ehcWj_ed$
&IGÈAB 8E? _cfbWdji _d \kbb \kdYj_ed [n^_X_j Xed[ h[#
ceZ[bb_d]WhekdZj^[beWZ#jhWdic_jj_d]Z_iai$J^[h[ceZ[bb#
_d]_iceh[fhedekdY[ZWbed]j^[XWiWbZ_iaZk[jej^[^_]^[h
b[l[be\beWZjhWdic_ii_ed$J^[Yh[ijWbZ_ia_iYedd[Yj[Zjej^[
j^h[WZ[Zf_dXoed[m[XXWhedbo"j^ki^Wl_d]W]h[Wj[hZ[]h[[
e\h[i_b_[dY[m^_b[j^[b[l[be\h[ceZ[bb_d]_iicWbb[hX[YWki[
j^[\kdYj_edWbij_ckb_]_l_d]h_i[jeYedj_dkekiWZWfjWj_edWh[
b[iifhedekdY[Z_dj^_iWh[W$J^[h[ceZ[bb_d]Yecfh_i[iWh[Wi
j^WjWh[beYWj[Zceh[j^Wd'$+ccWmWo\hecj^[Z_ia$J^[h[
_i^WhZboWdoh[ceZ[bb_d]Z_h[Yjboedj^[Z_ia"_dZ_YWj_d]j^Wj
j^[ Xed[ _d j^[ _dj[h\WY[ Wh[W _i ijWXb[$ BeWZ#h[bWj[Z YhWYai
Wh[ Z[l[bef_d] Ybei[ Xo$ J^[ Z_ia#je#Z_ia _dj[hlWb _i icWbb1
j^[dj^[Z_h[Yj_edWb[\\[YjicWo_d\bk[dY[eh[l[dYWdY[b[WY^
ej^[h ekj" m^_Y^ m_bb b[WZ je j^[ \ehcWj_ed e\ _d\[h_eh Xed[
ijhkYjkh[i$?\j^[Z_iaiWh[\Whj^[hWfWhj_dj^_iif[Y_\_YYWi[0
)cc"j^[i[[\\[YjiYWddebed][h_d\bk[dY[[WY^ej^[h
J^_i jof[ e\ _dj[]hWj_ed fh[ikffei[i j^Wj WZ[gkWj[
\b[nkhWb\ehY[iWh[fh[i[djWdZ_ij^[h[\eh[Wh[b[lWdj
c[Y^Wd_ic _d j^[ cWdZ_Xb[ Xkj Wbie _d cWn_bbWho
Wh[Wi_dlebl_d]\b[n_ed$J^[f[h_f^[hWbZ_iai[]c[dji
Wff[Whje_dj[]hWj[X[jj[hj^Wdj^[Y[djhWbed[i$
IWdZXbWij[Z WdZ ^oZhenoWfWj_j[#YeWj[Z _cfbWdji
Wh[ademdje^Wl[WbWh][hXed[_dj[h\WY[Wh[Wj^Wd
Ze iceej^ _cfbWdji M[_dbW[dZ[h [j Wb$ '//($ J^[
ijkZ_[i fh[i[dj[Z _d j^_i Y^Wfj[h Z[cedijhWj[ j^Wj
8E? _cfbWdji YWd Wbie _dlebl[ W bWh][ YedjWYj Wh[W
e\ j^[ h[b[lWdj beWZ#jhWdic_jj_d] ikh\WY[i _\ j^[
\ebbem_d]YedZ_j_ediWh[c[j0
v J^[ _cfbWdji ckij X[ ikX`[Yj[Z je cWij_YWjeho
beWZiZkh_d]^[Wb_d]$
È È -OREÈ(ISTOLOGICALÈ&INDINGSÈANDÈ#LINICALÈ#ONSIDERATIONSÈ
A v Defh_cWhoYed]hk[dY[ckijX[fh[i[djX[jm[[d
B Z_\\[h[dY[iÄeh^Wl[dejX[[dWXb[je_dj[hfh[jWdo
C ceZ[bb_d]#h[bWj[Z Xed[ Wffei_j_ed m^_b[ j^[
&IGÈÈA C_YhehWZ_e]hWf^_Y el[hl_[m$ 7j \_hij i_]^j" j^[
_cfbWdj i[[ci je bWYa X_Yehj_YWb WdY^ehW][$ Ej^[h i[Yj_edi
e\j^[iWc[_cfbWdji^em"^em[l[h"j^Wjj^[Yh[ijWbZ_iamWi
X_Yehj_YWbbo WdY^eh[Z W\j[h Wbb$ ?j _i _cfeii_Xb[ je YWfjkh[
j^[ j^h[[#Z_c[di_edWb i_jkWj_ed e\ Wd _cfbWdj XWi[Z ed
W i_d]b[ i[Yj_ed$ J^_i \WYj i^ekbZ Wbie X[ Yedi_Z[h[Z \eh
hWZ_e]hWf^_Y Z_W]dei_i$ B Fehei_j_[i WhekdZ j^[ Z_iai
_dZ_YWj[ j^Wj Yedj_dkeki h[ceZ[bb_d] _i fh[i[dj$ J^[ ^_]^[ij
b[l[be\c_d[hWb_pWj_ed_ieXi[hl[Zh_]^jbWj[hWbbojej^[Z_ia"
_dZ_YWj_d]j^Wjj^[_cfbWdj_iX[_d]_dj[]hWj[Z\hecWbWj[hWb
Z_h[Yj_edWdZj^Wjj^[cW_dZ_h[Yj_ede\\ehY[i_iWbWj[hWbed["
Wbj^ek]^j^[Z_h[Yj_ede\Y^[m_d]_il[hj_YWb$ C Edj^[i_Z[
e\ j^[ _di[hj_ed j^[ Xed[ _i Ybei[Z m_j^ bWc[bbWh Xed[ WdZ
ZhW_d[Zm_j^cWdoYWf_bbWh_[i
)))
j^[ _cfbWdj WdZ j^[ eij[ejec_p[Z YWl_jo [$]$ _d
j^[Wh[We\j^[j^h[WZ[Zf_d$
v J^[ _cfbWdj fheY[Zkh[ ckij X[ f[h\ehc[Z h_]^j
W\j[h[njhWYj_ed$
J^[ _iik[ m^[j^[h [b[Yjh_Y f^[dec[dW cWo Yed#
jh_Xkj[jej^[_dj[]hWj_ede\8E?_cfbWdji^WiX[[d
h[f[Wj[Zbo Z_iYkii[Z Zkh_d] j^[ fh[fWhWj_ed e\ j^_i
Xeea$ :ekXb[#Z_ia 8E? _cfbWdji YWd _dZ[[Z X[
YecfWh[ZjeYWfWY_jehi"WdZj^[[deiiWbWdZ_djhWehWb
ifWY[i Wh[ ademd je _dlebl[ Y^Wh][ Z_\\[h[dY[i$
>em[l[h"m[^Wl[dejeXi[hl[ZWdo[\\[Yjie\j^[i[
_dZ_YWj_edijej^_i[\\[YjYehh[Yjbo"Wij^[YWi[cWoX[$
M[Z_ZikXijWdj_Wj[j^[^ofej^[i_ij^Wjj^[ia[b[j_p[Z
ijhkYjkh[ e\ 8E? _cfbWdji ^Wi Wd eii[e_dj[]hWj_l[
[\\[Yj Xo _di[hj_d] 8E? _cfbWdji _dje Z[djWb heeji"
i_dY[ _d]hemj^ e\ Xed[ Ze[i dej eYYkh _d Z[djWb
heeji_dj^[WXi[dY[e\_cfbWdji$
È
3UMMARY
'$ 7\j[h_di[hj_ede\8E?_cfbWdji"j^[cehf^ebe]o
e\ j^[ cWdZ_XkbWh `WmXed[ YWd Y^Wd][ Xo
fei_j_ede\j^[_cfbWdjih[cW_dikdY^Wd][Z$
($ 7 Xh_Z][ mekbZ cW_djW_d j^[ _cfbWdj _d fbWY["
m^[h[Wi j^[ \kdYj_edWb \ehY[i m_bb _dZkY[ j^[
[nj[hdWb Xed[ ijhkYjkh[ je Y^Wd][ _ji beYWj_ed
h[bWj_l[jej^[_cfbWdj$
)$ 8E? _cfbWdji \[Wjkh_d] W Yecfb[j[bo iceej^
ikh\WY[\_hijX[Yec[eii[e_dj[]hWj[ZWbed]j^[beWZ#
jhWdic_jj_d] h_d]i WdZ bWj[h Wbed] j^[ j^h[WZ[Z
f_d$J^_i_dj[]hWj_edYWdX[Z[cedijhWj[ZXej^_d
Yehj_YWbWdZ_dYWdY[bbekiXed[ijhkYjkh[i$
*$ 7 j^h[WZ[Z f_d j^Wj _i ik\\_Y_[djbo Wj h[ij cWo
X[Yec[eii[e_dj[]hWj[ZWim[bb$J^_i_idej"^em#
[l[h"h[b[lWdj\ehj^[ikhl_lWbWdZfhef[h\kdYj_ed
e\j^[_cfbWdj$
+$ 8E? _cfbWdji m^ei[ j^h[WZ[Z f_d _i ikh\WY[#
[dbWh][Z Wbed] _ji XWiWb fehj_ed m_bb X[Yec[
_dj[]hWj[ZWbed]j^_ifehj_edm_j^_dWdeXi[hlWj_ed
f[h_eZe\j[dm[[ai"m^[h[WiWiceej^Z[i_]dm_bb
dej^Wl[X[Yec[_dj[]hWj[ZXoj^Wjj_c[$
,$ ?\j^[l[ij_XkbWhf[h_eij[kc_ia[fjWmWoXo_cfbWdj
i[]c[dji _d W j[dj#ijob[ cWdd[h" d[m Xed[ m_bb
X[ WXb[ je \ehc X[bem j^[ f[h_eij[kc$ >[Wl_bo
fhejhkZ_d] _cfbWdj i[]c[dji" ^em[l[h" Wff[Wh
je eXijhkYj Xed[ \ehcWj_ed _d j^_i [nf[h_c[djWb
i[j#kf$?dej^[hmehZi"_dYh[Wi[ZXed[\ehcWj_ed
m_bbeYYkhm^[h[j^[f[h_eij[kc_i[b[lWj[Zm^_b[
_dlebl_d]de]Wfjej^[fh[#[n_ij_d]Yehj_YWbXed[
ijhkYjkh[$
))* 9^Wfj[h()È (ISTOLOGYÈOFÈ"/)È)MPLANTS

A B

C D

&IGÈÈA J^[XWiWbcWdZ_XkbWhfehj_edie\j^[_cc[Z_Wj[bobeWZ[ZiYh[m_cfbWdjim[h[WiieY_Wj[Zm_j^ceh[h[ceZ[bb_d]
WdZb[iic_d[hWb_pWj_edWjj^[j_c[e\WdWboi_i$J^[d[mboceZ[bb[ZXed[b[\ji^emiW^_]^[hZ[]h[[e\c_d[hWb_pWj_edWdZ
Ze[idejh[l[WbWdofehei_joWiieY_Wj[Zm_j^h[ceZ[bb_d]$ B ?dYh[ijWb_cfbWdjij^Wjm[h[Wbbem[Zje^[WbkdbeWZ[Z"j^[XWiWb
fehj_ede\j^[cWdZ_Xb[i^emib_jjb[h[ceZ[bb_d]"m^_b[j^[Wh[WibWj[hWbjej^[_cfbWdjWh[h[ceZ[bb[ZWbceijYecfb[j[bo$J^ki
j^[XWiWbfehj_ede\j^[cWdZ_Xb[_ic_d[hWb_p[Zceh[ijhed]bo$ CÈD :_\\[h[dj_WbYedjhWijWZ`kijc[djh[l[Wbij^Wjj^[ceZ[bb[Z
Wh[Wjefh_]^j_idejm[bbc_d[hWb_p[ZXkj^WiX[[dYedi_Z[hWXboh[ceZ[bb[Z_dj^_iijW][e\j^[^[Wb_d]fheY[ii$J^[_cfbWdj
mWi_di[hj[Zi_ckbjWd[ekibom_j^j^[_cfbWdje\<_]$()$)-edj^[YedjhWbWj[hWbi_Z[e\j^[cWdZ_Xb[$IcWbbm^_j[ifeji_dj^[
kff[hWdZh_]^jfWhje\j^[f_Yjkh[YWdZZWh[Whj[\WYji$
È È -OREÈ(ISTOLOGICALÈ&INDINGSÈANDÈ#LINICALÈ#ONSIDERATIONSÈ
&IGÈ J^[Z[di[Xed[Wffei_j_ed_dj^[beWZ#jhWdic_jj_d]
Wh[We\j^[Z_ia_iYb[Whbol_i_Xb[$Mel[dXed[_ieXi[hl[Z_d
j^[ibejWh[W$=hekdZi[Yj_ed-
&IGÈ 7bj^ek]^j^_iZ_iaWh[W_idejYehj_YWbboWdY^eh[Z"
j^[ beWZ#jhWdic_jj_d] i[]c[dj e\ j^[ Yh[ijWb Z_ia _i" edY[
W]W_d" m[bb eii[eWZWfj[Z$ D[mbo \ehc[Z Xed[ ekji_Z[ e\ j^[
Yehj_YWb Xed[ WdZ ed _ji h_]^j ZWha Xbk[ jWa[i j^[ \ehc e\
mel[dXed[j^Wj^WiX[[dfWhj_WbboYedl[hj[Zjeeij[edWbXed[
Xoj^_ij_c[$J^[fh[#[n_ij_d]Yehj_YWbb_d[b_]^jXbk[WdZj^[
d[mboceZ[bb[ZXed[edj^[h_]^j"_dj[hhkfj[ZXoYedd[Yj_l[
j_iik["Wh[m[bbl_i_Xb[
-$ CeZ[bb_d]#h[bWj[Z Xed[ Wffei_j_ed Ze[i dej
h[gk_h[ j^[ f[h_eij[kc je X[ [b[lWj[Z _d W
f[hcWd[djehj[cfehWhocWdd[h$
.$ M^[j^[h W b_d]kWb _di[hj_ed fWj^ cWo X[ WZlWd#
jW][eki_dj^[feij[h_ehi[]c[dje\j^[cWdZ_Xb[
h[cW_dijeX[l[h_\_[Z$?j_iYedY[_lWXb["^em[l[h"
j^Wj W b_d]kWb _di[hj_ed fWj^ cWo _d\bk[dY[ j^[
_djhWXedoijh[iii_jkWj_ed_dWZ_\\[h[djmWo"ikY^
j^Wjj^[dejY^[\\[Yje\j^[_cfbWdj_i[b_c_dWj[Z
ehh[ZkY[Z$J^_icWoWffbo[if[Y_WbbojecWdZ_Xb[i
m^ei[l[ij_XkbWhYecfed[dj_iceh[fhedekdY[Z
j^Wdj^[b_d]kWbed[$
/$ 8E? _cfbWdji [n^_X_j \kdYj_edWbbo l_jWb Wh[Wi e\
eii[e_dj[]hWj_ed_dj^[h_d]Wh[W$
))+
&IGÈ =hekdZ i[Yj_ed (0L_[m[Z \hec j^[ iWc[ Z[fj^"
j^[ beWZ#jhWdic_jj_d] Z_ia [n^_X_ji Ybei[ eii[eWZWfjWj_ed
Yh[ijWbbo WdZ l[ij_XkbWhbo$ FWhj e\ j^[ YWkZWb Wif[Yj _i Wbie
eii[eWZWfj[Z$J^[d[mbo\ehc[ZXed[^WiWiec[m^WjZWha[h
Yebekh$J^[beWZ#jhWdic_jj_d]ikh\WY[e\j^_i_cfbWdji^emiW
c_deh cWdk\WYjkh[#h[bWj[Z Z_\\[h[dY[ jemWhZi j^[ j^h[WZ[Z
f_d0J^[Wh[Wm^[h[j^[Z_iac[[jij^[l[hj_YWbYecfed[dj_i
ib_]^jbo hekdZ[Z ]h[[d Whhem" WdZ j^[ Xed[ ]hemi WhekdZ
j^_i hekdZ[Z Wh[W$ J^[ bem[h fehj_ed e\ j^[ jhWdi_j_edWb
ped[ ^Wi W ad_\[#[Z][ i^Wf[ WdZ _i dej WiieY_Wj[Z m_j^ Wdo
Xed[ ]hemj^ h[Z Whhem$ J^[ Z_iai e\ Wbb 8E? _cfbWdji
Wh[ m[bb eii[e_dj[]hWj[Z W\j[h *cedj^i [nY[fj m^[h[ j^[o
jhWdil[hi[ j^[ c[ZkbbWho Wh[Wi _d Ze]i Xkj _dlWh_WXbo i^em
W ded#eii[e_dj[]hWj[Z ped[ _d j^[ Y[djh[$ M[ ik]][ij j^Wj
f[h\ki_edfWj^iWh[X[_d]fh[i[hl[Z_dj^Wjped[jecW_djW_d
j^[dkjh_[djikffboZkh_d]WYj_l[h^oj^c_YWbY^[m_d]$M[Wbie
ikif[Yjj^Wjj^[^_]^beWZ#jhWdic_ii_edYWfWY_jof[hcc(e\
j^[i[dWhhemh_d]Z_iaiYWdedboX[W\\ehZ[Z_dj^[fh[i[dY[
e\efj_cWbdkjh_j_ed
'&$8ed[ ceZ[bb_d] _i eXi[hl[Z _d j^[ \ebbem_d]
Wh[Wi0
Ä B_d]kWbboWXel[j^[Xed[[gkWjehWdZYh[ijWbbo
_$[$edj^[effei_j[i_Z[e\j^[_di[hj_edfWj^$
Jhk[Xed[Wffei_j_ed_dWYh[ijWbZ_h[Yj_edYWd
X[ Z[cedijhWj[Z$ J^[ d[mbo \ehc[Z Wh[Wi Wh[
beYWj[Zekji_Z[e\j^[Yehj_YWbXed[$
Ä J^[_di[hj_edibejiWh[Ybei[Zm_j^eij[edWbXed[
_diec[Wh[WiWdZm_j^mel[dXed[_dej^[hi$
Ä J^[ XWi[#fbWj[i Wh[ WbmWoi eii[e_dj[]hWj[Z
\hecWf[h_f^[hWbZ_h[Yj_ed$
Ä 8Wi[#fbWj[ i[]c[dji d[Wh j^[ j^h[WZ[Z f_d"
eh Z_ia i[]c[dji j^Wj Wh[ \bWj%iceej^" Wh[
eii[e_dj[]hWj[Z je icWbb[h [nj[dj$ Iec[j_c[i
j^[o Wh[ ^WhZbo eii[e_dj[]hWj[Z Wj Wbb$ J^[o
Wh[ kikWbbo ikhhekdZ[Z Z_h[Yjbo Xo Yedd[Yj_l[
j_iik["m^_Y^Ze[idej[nYbkZ[Z_h[Yj_dj[]hWj_ed
Zemdj^[heWZ$
Ä <kdYj_edWbboh[bWj[Z^oZheijWj_Yfh[iikh[im_bb
_dYh[Wi_d]bo]_l[h_i[jeXedo[dYWfikbWj_edje
j^[fe_dje\Z_h[Yjeii[eWZWfjWj_ed$
Ä H[i_ZkWb heeji Ze dej i[[c je W\\[Yj Xedo
_dj[]hWj_ed e\ j^[ _cfbWdj eh j^[ fheY[ii e\
Xed[h[fW_hWiikY^$
)), 9^Wfj[h()È (ISTOLOGYÈOFÈ"/)È)MPLANTS
&IGÈ J^[ \_dZ_d] j^Wj j^[ l[ij_XkbWh h_d] fehj_ed mWi
_dj[]hWj[Z [Whb_[h%X[jj[h j^Wd j^[ Y[djhWb fehj_ed e\ j^[ h_d]
mWiYed\_hc[Z_dWbbej^[h8E?_cfbWdji$7ffWh[djbo"j^[h[_i
de\kdYj_edWb_dY[dj_l[\ehj^[\ehcWj_ede\d[mXed[_dj^[
Y[djhWbWif[Yj
&IGÈ J^[j^h[WZ[Zf_d_dj^_ii[Yj_ed_i_dYedjWYjm_j^
Xed[ je Wbceij '&&" m^_b[ j^[ Y[djhWbbo beYWj[Z Xed[ _d
j^[ beWZ#jhWdic_jj_d] Z_ia Wh[W ^WZ dej h[][d[hWj[Z Xo j^Wj
j_c[ *cedj^i W\j[h _cfbWdjWj_ed$ J^[ eij[ejeco ibej mWi
Ybei[Z Xo i[l[hWb Xed[ Xh_Z][i Y^WhWYj[h_p[Z Xo _dYh[Wi_d]
Yed\bk[dY[
''$J^[ Z_ijWdY[ X[jm[[d j^[ h[ijehWj_ed WdZ j^[
Xed[ b[l[b h[cW_di YedijWdj$ ?\ j^[ ijhkYjkh[ _i
beYWj[Z _d Wd Wh[W j^Wj [n^_X_ji l[hj_YWb Xed[
Wffei_j_ed"j^[ckYeiWX[Yec[ij^_dd[hWdZj^[
Xed[Yedjekhm_bb\ebbemj^[fheij^[j_YijhkYjkh[$
'($?dj^_i[nf[h_c[dj"m[eXi[hl[Z^_]^boc_d[hWb_p[Z
Wh[Wi e\ l[hj_YWb ceZ[bb_d] Wj W Z_ijWdY[ \hec
Yh[ijWb _cfbWdj \_njkh[i kdZ[h YedZ_j_edi e\
_cc[Z_Wj[beWZ_d]$?d8E?_cfbWdji_di[hj[ZkdZ[h
YecfWhWXb[ YedZ_j_edi" ^em[l[h" j^[ ceZ[bb_d]
Wh[Wi m[h[ ikX`[Yj[Z je ^[Wlo h[ceZ[bb_d]" j^ki
i^em_d] W icWbb[h Z[]h[[ e\ c_d[hWb_pWj_ed$
7YYehZ_d]bo" j^[ ijWj_YWbbo ikffehj_d] Xed[ Wh[Wi
m[h[eXi[hl[Z_dj^[XWiWbfehj_ede\j^[`Wm$
&IGÈ :_h[YjXed[Wffei_j_ededj^[c[Z_WbWif[Yjedbo
jWa[i fbWY[ _\ j^[ h_d] Z_ia Wh[W fhe`[Yji \Wh [dek]^ \hec
j^[ Xed[ b[\j$ J^[ j^h[WZ[Z f_d e\ j^_i _cfbWdj _i fWhj_Wbbo
eii[e_dj[]hWj[Z W\j[h edbo *cedj^i" Z[if_j[ _ji iceej^
ikh\WY[$ J^[ _cfbWdj mWi _di[hj[Z _d W YedjWc_dWj[Z ijWj[
WdZmWiWYj_l[boX[djÆekje\j^[mWoÇXoj^[Ze]Wbed]m_j^
j^[ Yhemd" fh[ikcWXbo X[YWki[ j^[ ^[_]^j e\ j^[ j^h[WZ[Z
f_d"WdZ^[dY[e\j^[Yhemd"mWidejYehh[YjboWZ`kij[Z$J^[
_cfbWdj^WZj^[h[\eh["_dWcWdd[he\if[Wa_d]"Y[hjW_dboX[[d
ikX`[Yj[Zje_cc[Z_Wj[beWZ_d]
&IGÈ ;:7I'&%'*=-"bed]_jkZ_dWbi[Yj_ed$8E?_cfbWdji
j^Wj Wh[ _djheZkY[Z _d W YedjWc_dWj[Z ijWj[ m_bb ij_bb Wbbem
bWj[hWbXed[WZWfjWj_edWbed]j^[j^h[WZ[Zf_d$J^[c[ZkbbWho
ifWY[i[n^_X_jh[i_ZkWb_d\[Yj_ed$9ehj_YWbYedjWYji_j[iWh[dej
l_i_Xb[ ed j^_i i[Yj_ed$ D[_j^[h ^Wi Z_h[Yj Xed[ YedjWYj X[[d
[ijWXb_i^[Z_dj^[XWiWbi[]c[dji$J^[b[l[be\YedjWc_dWj_ed
ki[Z_dj^_i_di[hj_edfheY[Zkh[c_]^jWbiefh[l[dj_dj[]hWj_ed
e\j^[XWiWbZ_ia$:hW_dW][\hec_di_Z[j^[Xed[j^hek]^j^[
_di[hj_ed ibej _i de bed][h feii_Xb[ edY[ j^[ ibej _i Ybei[Z$
Fh[#[n_ij_d] Xed[ ijhkYjkh[i Wh[ _dZ_YWj[Z Xo j^[ b_]^j Xbk[
Yebekh$ 7XkdZWdjbo lWiYkbWh_p[Z ]hWdkbWj_ed j_iik[ _i l_i_Xb[
WhekdZ j^[ _cfbWdj Xhemd$ ?di_Z[ j^[ ]hWdkbWj_ed j_iik["
j^[ie\jj_iik[_i_dYh[Wi_d]boZ_ifbWY[ZXod[mbo\ehc[ZXed[
ZWhaXbk[$J^_i_d]hemj^Yec[i\hecj^[f[h_f^[hoWhekdZ
j^[j^h[WZ[Zf_d$J^[XWiWbi[]c[djie\j^[j^h[WZ[Zf_dWh[
WffWh[djbofh[\[hh[Zi_j[ie\WZWfjWj_ed
È È -OREÈ(ISTOLOGICALÈ&INDINGSÈANDÈ#LINICALÈ#ONSIDERATIONSÈ ))-

&IGÈ :[di_joZ_ijh_Xkj_ed
e\Yehj_YWbXed[ijhkYjkh[i_d
j^h[[f_]iÉ`Wmi\ebbem_d]lWh_eki
ikh]_YWbfheY[Zkh[i0'(cedj^i
W\j[hjeej^[njhWYj_edjef1
'(cedj^iW\j[hjeej^[njhWYj_ed
WdZ_cfbWdjWj_edc_ZZb[1
(,cedj^iW\j[hjeej^[njhWYj_ed
WdZ_cfbWdjWj_edXejjec
7ja_died[jWb$'/--

&IGÈ J^[Whhemi_dZ_YWj[j^[cW_dZ_h[Yj_ede\]hemj^
kdZ[hd[Wj^j^[f[h_eij[Wbikh\WY[$J^[_hi_p[ih[\b[Yjj^[
h[bWj_l[Wcekdjie\d[mXed[7ja_died[jWb$'/--$9ecfWh[
je9Wi[IjkZo-_d9^Wfj[h/$(0Xed[i^_\ji_di_Z[j^[
cWdZ_Xb[[l[dW\j[hj^[]hemj^Wh[\ekdZWdZj^[Z_h[Yj_ed
e\i^_\jicWoX[Z_\\[h[dj\hecm^Wj_ii^emd_dj^_iZhWm_d]
)). 9^Wfj[h()È (ISTOLOGYÈOFÈ"/)È)MPLANTS
ÈÈ
7HATÈISÈTHEÈCLINICALÈSITUATIONÈWEÈCANÈEXPECTÈAFTERÈ
IMPLANTATIONÈANDÈPROSTHETICÈTREATMENT j^_iY^Wfj[hZ[cedijhWj[$J^[XWiWbh_d]i[]c[dji
Beea_d]Wjj^[lWh_ekiWif[Yjie\`WmXed[WZWfjWj_ed
Z_iYkii[Z _d j^[ fh[l_eki Y^Wfj[hi" j^[ \ebbem_d]
eXi[hlWj_ediWh[e\fWhj_YkbWhYb_d_YWbh[b[lWdY[0
Ä H[\b[Yj_d] W i_jkWj_ed _d m^_Y^ _cfbWdjWj_ed
^Wi dej jWa[d fbWY[" m[ \_dZ j^Wj Wdo ikh]_YWb
_dj[hl[dj_ed"[njhWYj_edehY^Wd][i_dcWij_YWjeho
fWjj[hdi h[ijehWj_edi" fheij^[j_Y c[Wikh[i" fW_d"
Wle_ZWdY[cel[c[djiWdZj^[b_a[_d\bk[dY[j^[
Y^WhWYj[h_ij_Yie\j^[`WmXed[$J^[WYjkWb[\\[Yji
cWolWhoZ[f[dZ_d]edj^[fh[lW_b_d]^ehcedWb
i_jkWj_ed$
Ä 9^Wd][i _d feijkh[ eh _d j^[ ijWj_Y i_jkWj_ed e\
j^[ XeZo f[h i[" m^_Y^ YWd h[ikbj _d f[hcWd[dj
Y^Wd][i _d j^[ YhWd_e\WY_Wb h[]_ed kdb[ii
Yecf[diWj[Z\ehehjh[Wj[ZWffhefh_Wj[bo"Z[i[hl[
if[Y_WbWjj[dj_ed$
Ä M^[j^[hehdejj^[eh_]_dWbc_d[hWb_pWj_edb[l[b_i
h[ijeh[Z \ebbem_d] ed[ e\ j^[ i_jkWj_edi ekjb_d[Z
WXel[ m_bb bWh][bo Z[f[dZ ed j^[ ^ehcedWb
i_jkWj_edWdZedj^[fh[lW_b_d]cWij_YWjeho\ehY[i$
J^[ [bWij_Y_jo e\ Xed[i e\ _Z[dj_YWb i^Wf[ WdZ
i_p[" Wi m[bb Wi j^[ Z_ijh_Xkj_ed e\ j^[ &#Wh[Wi
WdZ j^[ '#Wh[Wi" cWo lWho jh[c[dZekibo" WdZ
_cfbWdjebe]_iji ^Wl[ d[nj je de mWo e\ adem_d]
eh]k[ii_d]_dWZlWdY[m^Wjj^[[bWij_Yi_jkWj_ed
m_bbkbj_cWj[boX[$
Ä J^[ ifWj_Wb i[gk[dY[ e\ 8E? _cfbWdj _dj[]hWj_ed
YWd Z_\\[h gk_j[ cWha[Zbo" Wi j^[ _bbkijhWj_edi _d
m_bb kikWbbo X[ j^[ \_hij je _dj[]hWj[$ J^[ d[nj
Wh[Wi je _dj[]hWj[ m_bb X[ j^[ m[X XWhi WdZ j^[
XWiWb Wif[Yj e\ j^[ j^h[WZ[Z f_d" fhel_Z[Z j^[i[
Wh[Wi Wh[ ikh\WY[#Wh[W [dbWh][Z <_]i$ ()#(- WÄX$
9ecfb[j[bo iceej^ 8E? _cfbWdji" Xo YedjhWij"
m_bb _dj[]hWj[ _d j^[ c_ZZb[ eh [l[d j^[ Yh[ijWb
h[]_ede\j^[j^h[WZ[Zf_d\_hij<_]i$()#(-["()#
(+" ()#** [jY$$ :[f[dZ_d] ed j^[ j^_Yad[ii WdZ
b[d]j^e\j^[j^h[WZ[Zf_dWdZedj^[cWj[h_WbWdZ
j^_Yad[iie\j^[m[XXWh"Yedi_Z[hWXb[lWh_Wj_edi
_dj^[Yb_d_YWbceX_b_joe\j^[j^h[WZ[Zf_dckij
X[ [nf[Yj[Z1 ^em[l[h" j^_i m_bb dej _d\bk[dY[ j^[
fhe]dei_ie\j^[8E?_cfbWdj$
Ä J^[ ceX_b_jo e\ j^[ YedijhkYj_ed _i WZZ_j_edWbbo
_d\bk[dY[Z Xo j^[ jhWdi#`Wm h[ceZ[bb_d] fheY[ii
<_]$()#*+$
Ä ?\ fh_cWho eh i[YedZWho Wk]c[djWj_ed _i
f[h\ehc[Z" ed[ YWd [nf[Yj j^[ j_c[ h[gk_h[Z
\eh Yb_d_YWb ijWX_b_pWj_ed je X[ bed][h$ H[iehXWXb[
Xed[#h[fbWY[c[dj cWj[h_Wbi jWa[ bed][h je
WjjW_d W m[bb#Z[\_d[Z b[l[b e\ Yb_d_YWb ijWX_b_jo
j^Wd Ze[i eh_]_dWb Xed[$ Ded#h[iehXWXb[ Xed[
h[fbWY[c[djcWj[h_WbiYWdfh[l[djj^[\ehcWj_ed
e\ bed] eij[edi WdZ j^[h[\eh[ ^Wl[ W beYWb [\\[Yj
edd[mXed[\ehcWj_ed"_d^_X_j_d]j^[\ehcWj_ed
e\cWYhejhW`[Yjeh_[iWdZXed[h[iehfj_ed$

#(!04%2È
#OUNSELLINGÈANDÈ#ASEÈ!CCEPTANCE
.JDIBFM
;BDI
FWj_[dji YWd edbo b[]Wbbo Yecc_j je Z[djWb _cfbWdj
jh[Wjc[dj_\j^[om[h[_d\ehc[Z_dWdWZ[gkWj[WdZ
Yecfh[^[di_l[cWdd[hE[^b[h(&&)1H_[i[jWb$(&&(1
led P_[]d[h (&&'1 IY^_dd[dXkh] (&&&1 HWjW`YpWa
(&&&1=W_iXWk[h'//+"'//-1<WbbiY^”ii[b'/.+1Add_d]
'/./1:[kjiY^'/.)$J^_ifh_dY_fb[_ikd_l[hiWbbolWb_Z
_d j^[ ;khef[Wd WdZ Dehj^7c[h_YWd b[]Wb ioij[ci
WdZ_iWbe]_YWbYedi[gk[dY[e\[l[hofWj_[djÉih_]^j
je i[b\#Z[j[hc_dWj_ed WdZ f[hiedWb b_X[hjo <_iY^[h
WdZB_b_['///$?j_i_dYkcX[djedj^[_cfbWdjebe]_ij"
XWi[Zed^_iademb[Z][e\j^[b_j[hWjkh[WdZ^_iemd
[nf[h_[dY[" je Yh_j_YWbbo WffhW_i[ WdZ h[#Z[\_d[ j^[
fh[Y_i[ c[Wd_d] e\ ¼WZ[gkWj[½" ¼Yecfh[^[di_l[½
WdZ¼ijWj[e\j^[Whj½edWYedj_dkekiXWi_i$:[dj_iji
Wh[dej][d[hWbboh[gk_h[Zje_d\ehcj^[_hfWj_[djie\
WdoekjZWj[Zjh[Wjc[djj[Y^d_gk[i_\d[m[h"i_cfb[h"
Y^[Wf[hehb[ii_dlWi_l[j[Y^d_gk[iWh[WlW_bWXb[$J^[o
Wh[h[gk_h[Z"^em[l[h"je_d\ehcj^[_hfWj_[djie\Wdo
d[mj[Y^d_gk[iademdjeo_[bZi_c_bWhh[ikbji_\j^[o
e\\[h jWd]_Xb[ X[d[\_ji \eh j^[ fWj_[dj" [l[d j^ek]^
j^[i[ j[Y^d_gk[i cWo dej X[ m_Z[bo ki[Z =[hcWd
:[djWb 7iieY_Wj_ed (&&)$ J^_i fhel_i_ed YWd cWa[
_j cWdZWjeho \eh ki[hi e\ jhWZ_j_edWb j[Y^d_gk[i
je _d\ehc j^[_h fWj_[dji e\ 8E?" fWhj_YkbWhbo m^[d
_dZ_YWj_edi i^em j^Wj j^[ fWj_[dj Ze[i dej m_i^ je
X[jh[Wj[Zm_j^Xed[]hW\ji^Whl[ij[Z\hecj^[_b_WY
Yh[ijehiakbb$
J^[h[gk_h[c[dje\fWj_[dj_d\ehcWj_edWdZYWi[
WYY[fjWdY[ _d\ehc[Z Yedi[dj ]_l[i h_i[ je W bWh][
dkcX[h e\ b[]Wb gk[ij_edi$' J^[ h[WZ[h cWo \_dZ
_j ki[\kb je Yedi_Z[h j^[i[ hkb[i e\ j^kcX _d ZW_bo
Yb_d_YWb fhWYj_Y[0 ^em [nj[di_l[bo W fWj_[dj d[[Zi
je X[ _d\ehc[Z m_bb Z[f[dZ ed _ j^[ _dlWi_l[d[ii
e\ j^[ fbWdd[Z jh[Wjc[dj1( j^[ _cfehjWdY[ e\
Yeic[j_Y%W[ij^[j_Y Yedi_Z[hWj_edi1) __ j^[ i[l[h_jo
Wdo _dZ_l_ZkWb h_iai fh[i[dj1* ___ j^[ dkcX[h e\
Wbj[hdWj_l[ jh[Wjc[dj efj_edi WlW_bWXb[1 _l j^[
Z[]h[[jem^_Y^j^[i[b[Yj[Zj[Y^d_gk[Z_\\[hi\hec
Yedl[dj_edWb j[WY^_d] WdZ l j^[ Z[]h[[ je m^_Y^
j^[fWj_[djm_i^[ijeX[_d\ehc[Z$I_dY[j^[fWj_[djiÉ
\h[[Zec e\ Z[Y_i_ed _i fWhWcekdj" _j _i [ii[dj_Wb
j^Wj j^[_h W[ij^[j_Y [nf[YjWj_edi" j^[_h m_bb_d]d[ii
je ]e m_j^ekj W beWZWXb[ Z[dj_j_ed \eh W Y[hjW_d
f[h_eZ e\ j_c[" WdZ j^[_h el[hWbb `kZ][c[dj e\
j^[ i_jkWj_ed fWhj_YkbWhbo h[]WhZ_d] j^[ h_ia e\
WZ`klWdj ikh][ho \eh Xed[ jhWdifbWdjWj_ed m[h[
 ¬ 
jWa[d_djeWYYekdj_dj^[YWi[WYY[fjWdY[$?dfhWYj_Y["
j^[ \ebbem_d] f_[Y[i e\ _d\ehcWj_ed hekj_d[bo med
fWj_[djiWhekdZje\Wlekh_d]8E?jh[Wjc[dj0_8E?
jh[Wjc[dj _i b[ii _dlWi_l[" Wi j^[h[ _i de d[[Z \eh W
i[YedZ fheY[Zkh[ kdZ[h ][d[hWb WdW[ij^[i_W1 WdZ
__ j^[ efj_ed e\ ki_d] Yedl[dj_edWb j[Y^d_gk[i
_dYbkZ_d] Xed[ ]hW\j_d] _i dehcWbbo ij_bb _djWYj _\
8E? jh[Wjc[dj m[h[ je \W_b >[jp (&&'$ J^_i _i
Zk[ je j^[ ¼YecfWhWj_l[ \W_bkh[ fWjj[hdi½ e\ Xej^
_cfbWdj jof[i0 m^_b[ beii e\ j^[ Wf_YWb i[]c[dj e\
iYh[m_cfbWdjiW\j[heii[e_dj[]hWj_edhekj_d[bo]_l[i
h_i[ je Xed[ beii" de ikY^ [\\[Yj _i i[[d m_j^ 8E?
_cfbWdji$ Jh[Wjc[dj m_j^ 8E? _cfbWdji h[cW_di
Wd efj_ed" Wbj^ek]^ X[Yec_d] ceh[ Z_\\_Ykbj" [l[d
m^[h[ Xed[ Wk]c[djWj_ed fheY[Zkh[i \eh Yh[ijWb
_cfbWdji^Wl[\W_b[Z$DWjkhWbbo"j^[h[_iWbieWdkff[h
b_c_j je ^em ckY^ _d\ehcWj_ed W fWj_[dj d[[Zi" eh
_dZ[[ZYWdjWa[$J^[i[_dZ_l_ZkWb\WYjehid[[ZjeX[
Yedi_Z[h[ZWim[bb$
9Wh[\kbfWj_[dj[lWbkWj_ed_ifWhj_YkbWhbo_dZ_YWj[Z
m_j^ 9C: fWj_[dji" i_dY[ dkc[heki ijkZ_[i ^Wl[
_dZ_YWj[Z j^Wj f[hiedWb_jo fheXb[ci Wh[ fh[lWb[dj
_d j^_i ]hekf :meha_d '//+1 Jkha '//-1 EWab[o
'///1B[l_jj'//&m^_Y^cWoi_]d_\_YWdjboW\\[Yjj^[
ekjYec[e\jh[Wjc[dj$J^_d]icWoX[Yec[[if[Y_Wbbo
jhekXb[iec[m_j^WiocfjecWj_Y9C:fWj_[djim^e
h[\ki[jekdZ[hijWdZj^[d[Y[ii_jo\ehYecfh[^[di_l[
jh[Wjc[dj WdZ \ebbem#kf jh[Wjc[dj$ IkY^ fWj_[dji
m_bb Wbie Wbbem j^[ci[bl[i je X[ m_j^ZhWmd \hec
' ;$]$gk[ij_ediYedY[hd_d]j^[j_c_d]e\fWj_[dj_d\ehcWj_ed1
j^[h[gk_h[c[dje\eXjW_d_d]YWi[WYY[fjWdY[_dmh_j_d]1j^[
^WdZb_d]e\c_dehieh\eh[_]d#bWd]kW][fWj_[dji1j^[efj_ed
e\ h[dekdY_d] _d\ehcWj_ed _\ W fWj_[dj Ze[i dej m_i^ je
X[ _d\ehc[Z eh e\ fhel_Z_d] WZZ_j_edWb _d\ehcWj_ed _d
Yedd[Yj_edm_j^kd[nf[Yj[Z_djhWef[hWj_l[[l[dji$
( ;$]$_\j^[_d\[h_ehWbl[ebWhd[hl[_ib_a[bojeX[_d`kh[ZZk[
je_jiYbei[fhen_c_jojej^[ikh]_YWbi_j["j^[fWj_[dj^Wije
X[_d\ehc[Z_dkd[gk_leYWbj[hciWXekjj^[fej[dj_Wbh_ia
e\f[hcWd[djYedi[gk[dY[i$
) EB= Ikf[h_eh 9ekhj e\ Ckd_Y^ hkb_d] (*K ''-%.+ e\ '/
I[fj[cX[h '/.+1 fWj_[dji kdZ[h]e_d] Yeic[j_Y ikh][ho
ckijX[_d\ehc[ZWXekjj^[h_iai_dlebl[Zm_j^¼kdifWh_d]
\hWdad[ii½$
* 7mWhZ_d]e\ZWcW][i\eh¼fW_dWdZik\\[h_d]½\ebbem_d]j^[
ki[e\Wd_Ya[b#YedjW_d_d]Xh_Z][Z[if_j[[l_Z[dY[e\d_Ya[b
Wbb[h]o1EB=Ikf[h_eh9ekhje\8h[c[dhkb_d])K(.%&&
e\')<[XhkWho(&&'$
)*& 9^Wfj[h(*È #OUNSELLINGÈANDÈ#ASEÈ!CCEPTANCE
j^[hWfo Xo ¼j^_hZ#fWhjo ef_d_edi½ Wbb jee m_bb_d]bo"
\h[gk[djbo m_j^ W l_[m je Wle_Z_d] j^[ jh[Wjc[dj
Yeiji$
:[dj_ijiWh[dejkikWbbo_dWfei_j_edje[lWbkWj[j^[
f[hiedWb_jo ijhkYjkh[i e\ JC@ fWj_[dji X[\eh[^WdZ$
J^[h[\eh[" j^[o WbmWoi hkd W ikXijWdj_Wb h_ia" m^[d
Z[Y_Z_d]jejh[WjikY^fWj_[dji"e\X[_d]kdd[Y[iiWh_bo
ZhWmd_djebWmik_ji$
?j ]e[i m_j^ekj iWo_d] j^Wj j^[h[ _i Wd _dYh[Wi[Z
Z[cWdZ\ehc[Z_YWb_d\ehcWj_edWdZZeYkc[djWj_ed
\eh fWj_[dji m^e j^[ci[bl[i WZc_j j^Wj j^[o ik\\[h
\hec W Z[dj_ij f^eX_W$ ?j _i _d j^[ Z[dj_ijÉi emd
_dj[h[ijjec[[jj^_iZ[cWdZ$
:[if_j[ X[_d] fej[dj_Wbbo j_c[#Yedikc_d] WdZ
jhekXb[iec[ je j^[ fe_dj e\ ijhW_d_d] j^[ Z[dj_ij#
fWj_[dj h[bWj_edi^_f" j^[ [\\ehj fkj _dje fWj_[dj
_d\ehcWj_edm_bbkbj_cWj[bojkhdekjjeX[X[d[\_Y_Wb
\ehXej^fWhj_[i_dlebl[Z$J^[fWj_[dj"\eh^_ifWhj"m_bb
X[ WXb[ je cWa[ Wd Wkjedeceki Z[Y_i_ed _d \Wlekh
e\ W if[Y_\_Y _cfbWdjebe]_YWb jh[Wjc[dj ceZWb_jo
j^Wjh[gk_h[i^_ibed]#j[hcYecc_jc[dj\ebbem#kf
l_i_ji m_j^ Y[hj_\_[Z 8E? _cfbWdjebe]_iji" b_\[ijob[
h[gk_h[c[dji _dYbkZ_d] ehWb ^o]_[d[ WdZ jeXWYYe
ki[" eh ^Wl_d] j^[ h[ijehWj_edi Y^[Ya[Z Xo ioij[c
ki[hi _\ fheXb[ci eYYkh$ 7i j^[ fWj_[dj [cXhWY[i
j^[WZlWdjW][ie\_cfbWdjjh[Wjc[dj_d][d[hWb"WdZ
j^[ 8E? ioij[c _d fWhj_YkbWh" e\ ^_i emd \h[[ m_bb"
^[ Wbie WYY[fji j^Wj j^_i Z[Y_i_ed m_bb [djW_b ceh[
Z[Y_i_edijeX[cWZ[Zkh_d]ehW\j[hjh[Wjc[dj$<eh
_dijWdY["^[WYY[fjiWifWhje\^_ifh_cWhoZ[Y_i_ed
j^Wj h[ijeh_d] j[[j^ _d if[Y_\_Y `Wm Wh[Wi je \kbb
beWZWX_b_jo cWo YWki[ j^[ \ehY[i ed Wdo kdh[ijeh[Z
h[i_ZkWbj[[j^je_dYh[Wi[iehWf_Zboj^Wjj^[i[j[[j^
cWo ^Wl[ je X[ h[fbWY[Z m_j^ _cfbWdji Wi m[bb$+
8[_d] _d\ehc[Z WXekj j^_i [l[djkWb_jo" j^[ fWj_[dj
_iWmWh[j^Wjj^[jh[Wjc[djekjYec[cWoej^[hm_i[
X[ _d `[efWhZo$ FWj_[dji ^Wl[ je X[ _d\ehc[Z j^Wj
j^[_h fh_cWho YWi[ WYY[fjWdY[ cWo h[gk_h[ j^[_h
WYj_l[ Yecc_jc[dj el[h o[Whi" eh _dZ[[Z Z[YWZ[i"
WdZ j^Wj \khj^[h Z[Y_i_edi cWo ^Wl[ je X[ cWZ[
m_j^ h[]WhZ je Wdo \ebbem#kf jh[Wjc[dji _d ej^[h
`Wm Wh[Wi$ J^[h[\eh[" Wi W be]_YWb Yedi[gk[dY[ e\
^_iYWi[WYY[fjWdY["j^[fWj_[dj[dj[hiWdeXb_]Wj_ed
je X[ jh[Wj[Z Xo W Y[hj_\_[Z 8E? _cfbWdjebe]_ij WdZ
je h[\[h Wdo YecfbW_dji [nYbki_l[bo je j^_hZ#fWhjo
[nWc_d[hi m^e feii[ii f[hj_d[dj c[j^eZebe]_YWb
[nf[h_[dY[>[jp(&&'1PWY^(&&($J^[i[ikXijWdj_Wb
_cfb_YWj_edie\fh_cWhoYWi[WYY[fjWdY[Wh[j^[\b_f
i_Z[e\j^[[nj[di_l[fWj_[dj_d\ehcWj_edfhel_Z[ZWj
j^[X[]_dd_d]e\jh[Wjc[dj$
Iec[ fWj_[dji bWj[h Z[d_[Z j^Wj j^[o m[h[ [l[h
_d\ehc[Z" m^[j^[h j^[o i_cfbo \eh]ej WXekj j^[
Z_iYkii_ed" m^[j^[h j^[o m[h[ _hh_jWj[Z X[YWki[
j^[o WiYh_X[Z Wdo kd[nf[Yj[Z Z[l[befc[dji je
cWbfhWYj_Y["ehm^[j^[hj^[_hfh_lWj[^[Wbj^_dikh[h
ehbWmo[h^WZfe_dj[Zekjj^Wjj^_ifeii_X_b_jo[n_iji$
?d j^_i i_jkWj_ed" j^[ Z[dj_ij m_bb ^Wl[ je fhel[ j^Wj
j^[ fWj_[dj mWi Zkbo _d\ehc[Z" m^_Y^ _i W Z_\\_Ykbj
jWia_\deWffhefh_Wj[ZeYkc[djWj_ed_iWlW_bWXb[$
7jfh[i[dj"_jcWoij_bbX[kdkikWb\ehZ[dj_iji_d
iec[ Yekdjh_[i je ^Wl[ j^[_h fWj_[dji i_]d \ehcWb
jh[Wjc[dj YedjhWYji" Wbj^ek]^ j^_i _i Yecced
fhWYj_Y[_dej^[h\_[bZie\c[Z_Y_d[dejWXboikh][ho
WdZWdW[ij^[i_ebe]o$Iec[fWj_[djim_bbX[fkje\\
Xo j^[i[ Yecfh[^[di_l[ W]h[[c[dji je j^[ fe_dj e\
Z[Y_Z_d]W]W_dijjh[Wjc[dj$J^[Z[dj_ijcWomWdjje
a[[fjhWYae\j^[i[YWi[i"Wij^[i[ZeYkc[djicWo^[bf
^_cjefhel[_dej^[hYWi[ij^Wj_j^WiWbmWoiX[[d^_i
feb_Yo je _d\ehc ^_i fWj_[dji Yecfh[^[di_l[bo WdZ
^ed[ijbo [dek]^ \eh iec[ fWj_[dji je ]_l[ kf j^[_h
fbWde\^Wl_d]_cfbWdjjh[Wjc[djf[h\ehc[Z$?dj^[
\kjkh[" fWj_[dji m^e Ze dej m_i^ je i_]d W mh_jj[d
W]h[[c[dj Wh[ _dYh[Wi_d]bo ]e_d] je ^Wl[ jhekXb[
\_dZ_d]WdoZ[dj_ijim_bb_d]jejh[Wjj^[cWjWbb$,
J^[ 8E? _cfbWdjebe]_ij i^ekbZ WbmWoi a[[f _d
c_dZj^Wj^_ifWj_[djiYWddejfeii_XboZ[Y_Z[\eheh
W]W_dijWd_cfbWdj#XWi[ZZ[djWbjh[Wjc[djceZWb_jo
¼e\ j^[_h emd \h[[ m_bb½ kdb[ii j^[o ^Wl[ X[[d
[nj[di_l[bo_d\ehc[Z$?dZ[[Z"fWj_[djim^em[h[dej
WZ[gkWj[bo _d\ehc[Z eh \eh m^ec de Wffhefh_Wj[
ZeYkc[djWj_ed _i WlW_bWXb[ cWo [l[d X[ [dj_jb[Z
je ZWcW][i [l[d _\ j^[ _cfbWdjWj_ed fheY[Zkh[ ^Wi
X[[d ikYY[ii\kbbo Yecfb[j[Z eh _\ _ji ik_jWX_b_jo _i
Yed\_hc[ZedboXoikXi[gk[dj\_dZ_d]i$-
8Wi[Z ed Z[Y_i_edi Xo =[hcWd Yekhji e\ \_dWb
Wff[Wb" _j Ze[i dej Wff[Wh `kij_\_[Z Wdo bed][h je
gkWb_\o XWiWb eii[e_dj[]hWj_ed Wi Wd kdYecced
_cfbWdjj[Y^d_gk[$<khj^[hceh["j^[h[Wh[i_jkWj_edi"
fWhj_YkbWhbo j^ei[ Y^WhWYj[h_p[Z Xo [njh[c[ h_Z][
h[iehfj_ed" _d m^_Y^ 8E? _cfbWdji Wh[ j^[ edbo
+ If[Y_\_YWYY[fjWdY[e\j^_i\WYjckijX[eXjW_d[ZZk[jej^[
kd[db_]^j[d[Zdej_ede\fWj_[djij^Wj_dZ_l_ZkWb`WmWh[Wi
Wh[XWi_YWbbokdh[bWj[Zje[WY^ej^[h"iej^Wjjh[Wjc[djYWd
WbmWoiX[Yed\_d[Zjeif[Y_\_YWh[Wij^WjWh[WYkj[bo_dd[[Z
e\h[ijehWj_l[c[Wikh[i$
, J^[\kdZWc[djWb_cfehjWdY[e\fWj_[dj_d\ehcWj_edX[_d]
fhef[hbo ZeYkc[dj[Z X[Yec[i Yb[Wh _d YWi[i m^[h[ j^[
_d\ehcWj_ed ZeYkc[dj ^Wi X[[d beij WdZ j^[ fWj_[dj bWj[h
Z[d_[ij^Wj^[ehi^[mWi[l[h_d\ehc[Z$7bbj^Wjj^[Z[dj_ij
YWdZe_dj^_ii_jkWj_ed_ijhojeZ[cedijhWj[XWi[Zed^_i
ZeYkc[djWj_edWlW_bWXb[\ehWbWh][dkcX[he\i_c_bWhYWi[i
j^Wj ^[ ^Wi WbmWoi _d\ehc[Z ^_i fWj_[dji$ J^[ fWj_[dj" Xo
YedjhWij"m_bb\eYkiedj^[i_d]kbWh_j_[ie\^_iif[Y_\_YYWi[
_d Wd Wjj[cfj je Z[\[Wj j^_i b_d[ e\ h[Wied_d]$ J^[ mh_jj[d
_d\ehcWj_ed \ehc cWo j^[d eXjW_d j^[ Z[Y_i_l[ heb[ e\ W
lekY^[h0_\j^[Z[Xjeh_ikdWXb[jefheZkY[j^[lekY^[h"j^[d
j^[Yh[Z_jehm_bbX[WXb[jecWa[^_cfWojm_Y[$?dekhYWi[
Wj^WdZ"j^_ic[Wdij^Wjj^[fWj_[djm_bbX[WXb[je^ebZj^[
Z[dj_ijb_WXb[\ehZWcW][i$
- 8=> =[hcWd <[Z[hWb 9ekhj hkb_d] L? PH (,,%&(" D@M
(&&)"'.,(e\'.CWhY^(&&)$
. B= :_ijh_Yj 9ekhj e\ IWWhXh”Ya[d hkb_d] ',I '&%// e\ ,
CWhY^ (&&(1 B= :_ijh_Yj 9ekhj e\ :k_iXkh] hkb_d] *E
').%/- e\ (( I[fj[cX[h (&&)1 EB= Ikf[h_eh 9ekhj e\
:”ii[bZeh\hkb_d]*K(&+%/-e\'-Del[cX[h'//.1Wbiei[[
DL[hiP'///"*-)$
È È )NFORMEDÈ#ONSENTÈTOÈ)MPLANT
"ASEDÈ$ENTALÈ4REATMENTÈ )*'
jh[Wjc[dj efj_ed b[\j X[YWki[ Yh[ijWb _cfbWdji m_bb
hekj_d[bo \W_b _d j^[i[ YWi[i$ ?d ej^[h mehZi" 8E?
_cfbWdji Wh[ j^[ fh[Zec_dWdj _cfbWdjebe]_YWb
WffheWY^ _d j^[i[ if[Y_\_Y i_jkWj_edi$ J^[o ckij
jeZWoX[Yedi_Z[h[Z[gk_lWb[djjeYh[ijWb_cfbWdji$.
9edi[gk[djbo" [cXWha_d] ed Yh[ijWb _cfbWdj
jh[Wjc[dj m_j^ekj ^Wl_d] _d\ehc[Z j^[ fWj_[dj e\
8E?#XWi[Ziebkj_edicWoÄZ[f[dZ_d]edj^[if[Y_\_Y
_dZ_YWj_edi WdZ j^[ ikX`[Yj_l[ XWi[b_d[ i_jkWj_ed
Ä jkhd ekj je X[ kdbWm\kb$ ?\ W fWj_[dj" W\j[h X[_d]
_d\ehc[ZWXekjj^[8E?ioij[c"ij_bbefji\ehYh[ijWb
_cfbWdj jh[Wjc[dj _dYbkZ_d] _b_WY Yh[ij ]hW\j_d]"
j^[ gk[ij_ed cWo Wh_i[ \eh j^[ _cfbWdjebe]_ij
m^[j^[hj^_ijof[e\jh[Wjc[dj_iWYjkWbbo_dZ_YWj[Z"
Yedi_Z[h_d] j^Wj W 8E?#XWi[Z WffheWY^ mekbZ
X[ b[ii _dlWi_l[ WdZ" _dZ[[Z" ceh[ b_a[bo je Xh_d]
WXekjWikYY[ii\kbekjYec[_dj^_ifWj_[dj$=e_d]Xo
kd_l[hiWb fh_dY_fb[i" j^[ Z[dj_ij mekbZ ^Wl[ je jkhd
j^[fWj_[djÉih[gk[ijZemdX[YWki[j^[jh[Wjc[dj_i
de bed][h `kij_\_[Z \hec W c[Z_YWb l_[mfe_dj1 _\ ^[
f[h\ehci j^[ jh[Wjc[dj WdomWo" ^[ c_]^j X[ b_WXb[
\ehZWcW][i$/
?j_iWbied[Y[iiWhojeh[c[cX[hj^Wj[l[dj^[ceij
Yecfh[^[di_l[ fWj_[dj _d\ehcWj_ed Xo c[Wdi e\ W
ijWdZWhZfh_dj[Z\ehccWo\W_b_\if[Y_\_YWif[Yjie\
j^[YWi[Wj^WdZWh[dejYel[h[Z$?j_ij^[h[\eh[ki[\kb
je ikffb[c[dj j^[ ZeYkc[djWj_ed je X[ i_]d[Z Xo
j^[fWj_[djm_j^ia[jY^[iWdZdej[i"fh[\[hWXbo_dj^[
fWj_[djÉi fh[i[dY[$ J^_i m_bb Xebij[h kf j^[ Z[dj_ijÉi
YWi[_dj^[[l[dje\b[]WbZ_ifkj[i$FheXb[ciWh_i_d]
\hecikXi[gk[djYbW_cijej^[[\\[Yjj^Wjj^[fWj_[dj
^WZdejh[Y[_l[ZWbbfW][ie\j^[fWj_[dj_d\ehcWj_ed
^WdZekjYWdX[Wle_Z[ZXoWia_d]j^[fWj_[djjei_]d
[WY^i_d]b[fW][$JeWle_ZWdoc_ikdZ[hijWdZ_d]iWi
je j^[ _dZ_l_ZkWb dWjkh[ e\ j^[ jh[Wjc[dj YedjhWYj"
j^[Z[dj_iji^ekbZ[dikh[j^WjWbbif[Y_\_YWif[Yjie\
j^[ fh[ef[hWj_l[ i_jkWj_ed Wh[ YWh[\kbbo _dYbkZ[Z _d
j^[fWj_[djÉiYWi[WYY[fjWdY[$
È
)NFORMEDÈ#ONSENTÈTOÈ)MPLANT
"ASEDÈÈ Yecc_jc[dj X[YWki[ Wbb h[b[lWdj \ebbem#kf
$ENTALÈ4REATMENT
)È
'ENERAL
J^[Z[dj_ij^Wi[nWc_d[Zc[WdZYebb[Yj[Zco
fh[ef[hWj_l[ijWjki$?^Wl[X[[d_d\ehc[Zm^Wj
co _djhWehWb i_jkWj_ed beeai b_a[ WdZ ^em _j
/
;$]$ [njhWYj_ed e\ [_]^j ^[Wbj^o j[[j^ X[YWki[ W fWj_[dj
j^_dai j^[o Wh[ j^[ ieb[ YWki[ e\ ^[h ^[WZWY^[i$ 7i W
][d[hWb hkb[" Z[dj_iji i^ekbZ d[l[h Wbbem j^[ci[bl[i je X[
imWo[Z"d[_j^[hXofWj_[djidehXo_dikhWdY[fhel_Z[hi"je
[n[Ykj[ if[Y_\_Y jh[Wjc[dj ceZWb_j_[i W]W_dij j^[_h X[jj[h
`kZ][c[dj$
mekbZZ[l[befi^ekbZ?Z[Y_Z[dejjekdZ[h]e
Wdo a_dZ e\ Z[djWb h[ijehWj_l[ jh[Wjc[dj$ J^[
Z[dj_ij ^Wi [nfbW_d[Z je c[ _d Z[jW_b j^Wj
h[ijehWj_l[ Z[djWb jh[Wjc[dj _i h[gk_h[Z$ ? mWi
WXb[ je [nfh[ii co l_[mi ed j^_i WdZ ? ^Wl[
YedYbkZ[Z j^Wj h[ijehWj_l[ Z[djWb jh[Wjc[dj
i^ekbZX[f[h\ehc[Z$
? kdZ[hijWdZ j^Wj j^[ \ebbem_d] ceZ[i e\
Z[djWbh[YedijhkYj_edmekbZX[Wdefj_ed0
v 9ecfb[j[%fWhj_WbZ[djkh[m_j^ekj_cfbWdji
v
v
D[nj" ? mWi _d\ehc[Z WXekj j^[ dWjkh[ WdZ
j[Y^debe]oe\Z[djWb_cfbWdjebe]o$J^[Z[dj_ij
[nfbW_d[Z je c[ j^Wj _cfbWdji Wh[ _di[hj[Z
X[bem j^[ b[l[b e\ j^[ ]kci _dje j^[ `Wm _d
ehZ[hjeh[fbWY[ed[ehi[l[hWbj[[j^$<ebbem_d]
W f[hiedWb Z_iYkii_ed" ? ^Wl[ Z[Y_Z[Z j^Wj
_cfbWdjebe]_YWbjh[Wjc[dji^ekbZX[f[h\ehc[Z
edc[$
J^[ Z[dj_ij ^Wi [nfbW_d[Z je c[ j^Wj
Z_\\[h[djc[j^eZie\Z[djWb_cfbWdjebe]o[n_ij
WdZ ^Wi ekjb_d[Z j^[_h XWi_Y \[Wjkh[i$ ? mWi
jebZ j^Wj YedYbki_l[ ijkZ_[i ed j^[ ik_jWX_b_jo
WdZ bed][l_jo e\ Z_\\[h[dj _cfbWdj ioij[ci
Wh[ dej WlW_bWXb[$ J^[ ceij Yedl[dj_edWb WdZ
ceij m_Z[bo ki[Z c[j^eZ _$[$ j^[ ÆYh[ijWbÇ
j[Y^d_gk["m^_Y^kikWbboh[gk_h[iXed[]hW\ji
\hecj^[f[bl_iehej^[hbeYWj_edie\j^[XeZo
jeX[jhWdifbWdj[Zjej^[`Wm"^WiX[[dekjb_d[Z
jec[$?^Wl[cWZ[kfcoc_dZ_d\Wlekhe\j^[
d[m[hWdZb[ii_dlWi_l[_cfbWdjiXWi[Zedj^[
fh_dY_fb[ e\ ÆXWiWb eii[e_dj[]hWj_edÇ 8E?$ ?
kdZ[hijWdZj^Wjj^_ic[j^eZmWiedY[h[]WhZ[Z
WiÆkdehj^eZenÇXkjj^Wj_j^Wij^[WZlWdjW][e\
i^ehj[h ^[Wb_d] f[h_eZi WdZ dej _dlebl_d] j^[
d[[Z\ehXed[]hW\j_d]Wic[dj_ed[ZWXel[$
? kdZ[hijWdZ j^Wj co Z[Y_i_ed je X[
jh[Wj[Zm_j^8E?_cfbWdjim_bbX[Wbed]#j[hc
[nWc_dWj_edi WdZ i[YedZWho jh[Wjc[dji ^Wl[
je X[ f[h\ehc[Z Xo Z[dj_iji m^e Wh[ \Wc_b_Wh
m_j^j^_ij[Y^d_gk[_dj^[ehoWdZfhWYj_Y[$
7i\WhWij^[jh[Wjc[djij[fiWh[YedY[hd[Z"
j^[ Z[dj_ij ^Wi jebZ c[ j^Wj W l[hj_YWb f_d
m_j^ W ^eh_pedjWb ijWX_b_pWj_ed fbWj[ cWZ[ e\
j_jWd_kc"fehY[bW_dehfbWij_Ym_bbX[_di[hj[Z
j^hek]^ W bWj[hWb fWj^mWo j^Wj _i Ykj _dje
co `Wm$ J^[ Z[dj_ij [nf[Yji j^Wj _j m_bb X[
d[Y[iiWhojekj_b_p[Wi[]c[dje\j^[cWn_bbWho
i_dkijeWdY^ehj^[_cfbWdji"iej^Wjj^[i_dki
fh[ikcWXbo d[[Zi je X[ ef[d[Z Xo ikh]_YWb
c[Wdi WdZ Wk]c[dj[Z m_j^ ]hW\j_d] cWj[h_Wb
WdZWkjebe]ekiXed[$
)*( 9^Wfj[h(*È #OUNSELLINGÈANDÈ#ASEÈ!CCEPTANCE
? kdZ[hijWdZ j^Wj Wdo kd[nf[Yj[Z Yecfb_#
YWj_edi eYYkhh_d] Zkh_d] j^[ _cfbWdjWj_ed
fheY[Zkh[cWocWa[_jd[Y[iiWhoje[nj[dZj^[
iYef[e\j^[fheY[Zkh[$?W]h[[j^Wjjh[Wjc[dj
i^ekbZ X[ Yedj_dk[Z WdZ Wffhefh_Wj[ Z[djWb
c[Wikh[i jWa[d _d j^_i i_jkWj_ed$ I[YedZWho
jh[Wjc[djie\j^_ia_dZcWojof_YWbbo_dYbkZ[0
v H[fbWY[c[dj e\ _cfbWdji eh _di[hj_ed e\
WZZ_j_edWb_cfbWdji
v ;nj[di_ed eh WZWfjWj_ed e\ [n_ij_d] fhe#
ij^[j_YijhkYjkh[i
v ?di[hj_ed e\ h[celWXb[ Z[djkh[i _dij[WZ e\
\_n[ZXh_Z][i"ehceZ_\_YWj_edijej^[jh[Wj#
c[djfbWd
J^[ Z[dj_ij ^Wi [nfbW_d[Z je c[ j^Wj j^[
fbWdd[Z h[ijehWj_ed m_bb _dYbkZ[ j^[ \ebbem_d]
_cfbWdji_dj^[\ebbem_d]`WmWh[Wi0
v
v
v
8Wi[Z ed j^[ c[Z_YWb ^_ijeho ademd je j^[
Z[dj_ij" ? ^Wl[ X[[d _d\ehc[Z j^Wj co YWi[
_dlebl[i j^[ \ebbem_d] _dZ_l_ZkWb h_iai m_j^
h[if[Yj je j^[ WXel[#c[dj_ed[Z jh[Wjc[dj
fbWd$
v
v
v
))È
3URGICALÈ0ROCEDUREÈANDÈ)MPLANTATION
?^Wl[X[[d_d\ehc[Zj^Wjj^[fbWdd[Z_cfbWd#
jWj_edcWo][d[hWbbo_dlebl[j^[\ebbem_d]h_iai
WdZYecfb_YWj_edi0
v 8ed[\hWYjkh[
v 9ebbWfi[_djej^[cWn_bbWhoi_dki
v ?d`khojed[hl[
v <W_bkh[e\_cfbWdj^[Wb_d]
v ?d`khojeekj]e_d]ZkYje\iWb_lWho]bWdZ
J^[ Z[dj_ij ^Wi fe_dj[Z ekj je c[ _d Z[jW_b
m^Wj Yedi[gk[dY[i cWo Wh_i[ je c[ _\ j^[i[
h_iaiX[Yec[h[Wb$
?kdZ[hijWdZj^WjhWZ_e]hWf^iWh[eXjW_d[Z
WdZ f^eje]hWf^i jWa[d Zkh_d] j^[ ikh]_YWb
fheY[Zkh[$<khj^[hceh["WZZ_j_edWbhWZ_e]hWf^i
m_bb X[ f[h_eZ_YWbbo eXjW_d[Z _d j^[ \ebbem#
kf f^Wi[$ ? ]_l[ Yedi[dj j^Wj j^_i jof[ e\
hWZ_e]hWf^_YZ_W]dei_im_bbX[f[h\ehc[Z$
)))È
0OSTOPERATIVEÈ0HASE
? ^Wl[ X[[d _d\ehc[Z j^Wj kdfb[WiWdj [l[dji
ikY^ Wi im[bb_d]" fW_d" _d\[Yj_edi WdZ ][d[hWb
cWbW_i[cWoeYYkh_dj^[feijef[hWj_l[f^Wi[$
Ej^[h feii_Xb[ [l[dji _dYbkZ[ dkcXd[ii e\
j^[ b_fi eh j[[j^ WdZ e\ j^[ jed]k[" Y^[[a eh
Y^_d$ J^[ [nWYj ZkhWj_ed e\ j^[i[ [l[dji YWd#
dej X[ fh[Z_Yj[Z$ 7j j^[_h mehij" j^[o cWo X[
_hh[l[hi_Xb[ _$[$ d[l[h ]e_d] je h[iebl[$ J^[
Z[dj_ij ^Wi [nfbW_d[Z je c[ j^Wj _\ YedZ_j_edi
Wh[ kd\WlekhWXb[" WdZ dejWXbo _\ Wdo fh[#
[n_ij_d] YedZ_j_edi e\ j^[ cWn_bbWho i_dki[i
Wh[ fh[i[dj" fheY[Zkh[i e\ j^_i jof[ cWo ]_l[
h_i[ je Y^hed_Y bed]#bWij_d] fW_d$ 7ZZ_j_edWb
_d\[Yj_edie\j^[Y^[[aehlWiYkbWhioij[cehe\
j^[ikhhekdZ_d]j_iik[iWh[Wbiefeii_Xb[$
?^Wl[X[[d_d\ehc[Zj^WjikYY[ii\kb^[Wb_d]
e\j^[_cfbWdjiYWddejX[]kWhWdj[[Z$?\\W_bkh[
eYYkhi"j^[_cfbWdjkikWbbo^WijeX[h[cel[Z
_cc[Z_Wj[bo$J^[j_c[e\_cfbWdjh[celWbm_bb
X[Z[j[hc_d[ZXoj^[Z[dj_ij$?dcWdoYWi[i"_j
m_bbX[feii_Xb[je_di[hjWd[m_cfbWdjWjj^[
iWc[i_j[ehWd[WhXoi_j[$
)6È
,IFEÈWITHÈ)MPLANTS
? ^Wl[ X[[d _d\ehc[Z j^Wj j^[h[ _i de mWo je
Z[\_d[ _d WZlWdY[" eh fh[Z_Yj m_j^ Y[hjW_djo"
j^[ X[^Wl_ekh e\ j^[ Xed[ eh ]kci _d j^[
^[Wb_d] f^Wi[$ J^[ lWh_eki ikYY[ii_l[ ij[fi e\
fheij^[j_Y h[ijehWj_ed \ebbem_d] _cfbWdjWj_ed
m[h[ ekjb_d[Z je c[$ Hekj_d[ \ebbem#kf [nW#
c_dWj_edi m_bb dehcWbbo X[ f[h\ehc[Z Wj ,#
cedj^ _dj[hlWbi W\j[h j^[ fh_cWho jh[Wjc[dj
^Wi X[[d Yecfb[j[Z$ I^ehj[h _dj[hlWbi cWo X[
d[Y[iiWho_diec[YWi[i$
?^Wl[X[[d_d\ehc[Zj^WjcoYebbWXehWj_ed
ÄWibed]Wij^[_cfbWdjiWh[_dj[]hWj[Z_dco
`Wmi" [l[d _\ d[Y[iiWho bed]#j[hc" _i [ii[dj_Wb
Xej^ je j^[ ikYY[ii\kb ekjYec[ e\ jh[Wjc[dj
WdZ je Wle_Z Wdo i[jXWYai W\j[h W ikYY[ii\kb
ekjYec[ ^WZ Wbh[WZo X[[d eXjW_d[Z$ J^[
Z[dj_ij^Wi[nfbW_d[Zjec[j^Wjh[ijeh_d]j[[j^
_d if[Y_\_Y `Wm Wh[Wi je \kbb beWZWX_b_jo cWo
YWki[ j^[ \ehY[i ed Wdo kdh[ijeh[Z h[i_ZkWb
j[[j^ je _dYh[Wi[ ie hWf_Zbo j^Wj j^[i[ j[[j^
cWo Wbie ^Wl[ je X[ h[fbWY[Z m_j^ _cfbWdji
je ijWX_b_p[ j^[ ikYY[ii\kb ekjYec[ Wbh[WZo
eXjW_d[Z$ ? ^Wl[ X[[d _d\ehc[Z j^Wj f[h_eZ_Y
È È )NFORMEDÈ#ONSENTÈTOÈ)MPLANT
"ASEDÈ$ENTALÈ4REATMENTÈ )*)

\ebbem#kf[nWc_dWj_ediWdZjh[Wjc[djim_bbX[ d[Y[iiWhojeh[cel[ed["i[l[hWbehWbb_cfbWdji$
h[gk_h[ZW\j[h_cfbWdjim[h[fbWY[ZWdZ\_jj[Z ?\YedZ_j_ediWh[kd\WlekhWXb["_jcWo[l[dX[#
m_j^d[mj[[j^%fheij^[j_Yh[ijehWj_edi$?diec[ Yec[ d[Y[iiWho je h[fbWY[ W \_n[Z Xh_Z][ m_j^
YWi[i"j^[i[h[gk_h[c[djim_bbh[cW_d_dfbWY[ WZ[djkh[$
\ehcWdoo[WhijeYec[$
? i^Wbb Yecfbo m_j^ j^[ d[Y[iiWho \ebbem#
kf l_i_ji _dYbkZ_d] Yb_d_YWb WdZ hWZ_e]hWf^_Y
[nWc_dWj_edi$
? Wc WmWh[ j^Wj \ebbem#kf jh[Wjc[dji cWo 6È
_dlebl[ j^[ d[[Z je h[fbWY[ _cfbWdji" je fbWY[
WZZ_j_edWb _cfbWdji" je [nfWdZ eh WZ`kij fhe#
ij^[j_YijhkYjkh[i"je_di[hjZ[djkh[i_dij[WZe\
\_n[ZXh_Z][i"ehjeceZ_\oj^[jh[Wjc[djfbWd
_dej^[hmWoi$
J^[Z[dj_ij^Wi[nfbW_d[Zjec[j^WjZ[djWb
[nWc_dWj_ed Ä fh[\[hWXbo Xo j^[ jh[Wj_d] 8E?
_cfbWdjebe]_ijÄi^WbbX[h[gk_h[Z_cc[Z_Wj[bo
WiieedWi?dej_Y[WdoY^Wd][iedj^[_di[hj[Z
_cfbWdj eh [nf[h_[dY[ Z_\\_Ykbj_[i m_j^ ehWb
^o]_[d[$ ? ^Wl[ X[[d _d\ehc[Z j^Wj dej Wbb
Z[dj_iji f[h\ehc _cfbWdjebe]_YWb fheY[Zkh[i
eh Wh[" \eh j^Wj cWjj[h" \Wc_b_Wh m_j^ _cfbWd#
jebe]_YWbijhWj[]_[i$?kdZ[hijWdZj^Wjj^[edbo
Z[dj_iji m^e YWd X[ [nf[Yj[Z je e\\[h Wkj^e#
h_jWj_l[ Yekdi[bb_d] WdZ ^[bf Wh[ j^ei[ m^e
^Wl[ X[[d jhW_d[Z _d" WdZ Wh[ Wkj^eh_p[Z je
f[h\ehc"jh[Wjc[djm_j^if[Y_\_Y_cfbWdjjof[i$
?d[c[h][dY_[i"?YWd\_dZZ[dj_ijiWkj^eh_p[Z
je f[h\ehc _cfbWdj jh[Wjc[dj XWi[Z ed j^[
j[Y^d_gk[ e\ XWiWb eii[e_dj[]hWj_ed 8E? _d
j^[?dj[hd[jWjmmm$[nf[hZ[dj$d[j$
? kdZ[hijWdZ j^Wj _cfbWdj jh[Wjc[dj m_bb
e\j[d _dYh[Wi[ j^[ Y^[m_d] \ehY[i$ J^_i ]eeZ
Y^[m_d] WX_b_jo cWo" ^em[l[h" b[WZ je ^[Wlo
eh [nY[ii_l[ beWZ_d] _d ej^[h fWhji e\ co
cekj^$7iWYedi[gk[dY["i_jkWj_edicWoWh_i[
_d m^_Y^ ej^[h fWhji e\ j^[ Z[dj_j_ed%ej^[h
j[[j^ ^Wl[ je X[ h[fbWY[Z eh ikffb[c[dj[Z Xo
_cfbWdjiWim[bb$
J^[ Z[dj_ij ^Wi [nfbW_d[Z je c[ j^Wj co
i[b\#f[h\ehc[Z ehWb ^o]_[d[ WhekdZ j^[
_cfbWdji ^Wi je X[ c[j_Ykbeki _\ j^[ ekjYec[
e\ jh[Wjc[dj _i je X[ W bWij_d] ikYY[ii$ ? ^Wl[
X[[d _d\ehc[Z j^Wj icea_d]" WbYe^eb WXki[
WdZ fWhW\kdYj_edWb ijh[ii[i [$]$ ef[d_d] e\
Xejjb[i eh ki_d] j[[j^ Wi Wd W_Z _d WYj_l_j_[i
ej^[h j^Wd _dY_i_d] WdZ Y^[m_d] \eeZ cWo
`[efWhZ_p[ j^[ jh[Wjc[dj ekjYec[$ J^[ iWc[
_i jhk[ e\ _dlebkdjWho fWjj[hdi ikY^ Wi jeej^
]h_dZ_d]Zkh_d]ib[[f$
?kdZ[hijWdZj^WjWdoY^Wd][i_dco^[Wbj^
YedZ_j_ed cWo d[]Wj_l[bo W\\[Yj j^[ ikYY[ii\kb
ekjYec[ e\ _cfbWdjWj_ed [l[d o[Whi W\j[h
j^[ fheY[Zkh[$ ?d j^_i i_jkWj_ed" j^[ j^[hWfo
cWo d[[Z je X[ Y^Wd][Z" eh _j cWo X[Yec[
,ASTINGÈ.EGATIVEÈ%FFECTSÈONÈ!ESTHETICSÈ
3PEECHÈORÈ#HEWING
J^[ Z[dj_ij ^Wi _dZ_YWj[Z je c[ j^Wj j^[ d[m
j[[j^Wh[]e_d]jeZ_\\[h_dj[hcie\j^_Yad[ii"
b[d]j^WdZm_Zj^\hecj^[dWjkhWbj[[j^m^_Y^
j^[o h[fbWY[$ I_dY[ jeej^ beii _i \ebbem[Z Xo
l[hj_YWbWdZ^eh_pedjWbXed[beii"j^[fh[l_eki
W[ij^[j_YiYWddejX[Yecfb[j[boh[ijeh[Z_dj^[
cW`eh_jo e\ YWi[i$ B_a[m_i[" _j _i _cfeii_Xb[ _d
j^[ cW`eh_jo e\ YWi[i je Xk_bZ kf Ykifi _d j^[
Wh[We\j^[YWd_d[i$
? kdZ[hijWdZ j^Wj bWh][#iYWb[ _cfbWdj
h[ijehWj_edi_dj^[cWn_bbWcWoh[ikbj_dbWij_d]
if[[Y^fheXb[ci"[if[Y_Wbbom_j^j^[iWdZ\ 
iekdZi"X[YWki[m^[dj[[j^Wh[beij"j^[lebkc[
e\ j^[ Xed[ m_bb X[ h[ZkY[Z Wi m[bb$ ?d ceij
YWi[i"j^_ii_jkWj_edYWdX[_cfhel[Z]hWZkWbbo
_d W cWjj[h e\ o[Whi Xo Z[b_X[hWj[ jhW_d_d]$
<Wj_]k[m_bb_dYh[Wi[WdofheXb[cim_j^if[[Y^
WdZ fhedkdY_Wj_ed$ Je m^Wj [nj[dj _dZ_l_ZkWb
fWj_[dji ]hem WYYkijec[Z je Xh_Z][i YWddej
X[ fh[Z_Yj[Z$ Iec[ fWj_[dji cWo ikX`[Yj_l[bo
[nf[h_[dY[ _dYh[Wi[Z iWb_lW fheZkYj_ed Wb#
j^ek]^j^[h[_ideiY_[dj_\_Y[l_Z[dY[\ehj^_i"
m^_Y^ cWo [nWY[hXWj[ Wdo if[[Y^ fheXb[ci$
Ej^[h fWj_[dji cWo [nf[h_[dY[ Zhod[ii e\ j^[
cekj^ eh b_fi$ <ebbem_d] j^[ beii e\ dWjkhWb
j[[j^" b_\[bed] i^h_daW][ e\ j^[ `WmXed[ WdZ
]kci YWddej X[ [nYbkZ[Z$ J^_i cWo ]_l[ h_i[
jekdZ[i_hWXb[l_i_Xb[]WfiX[jm[[dj^[Xh_Z][
WdZj^[]kci"m^_Y^YWdkikWbboX[Yehh[Yj[Z
Xo_di[hj_d]d[mXh_Z][ijhkYjkh[ieh]_d]_lWb
cWiai$
C[jWb cWh]_di cWo f[hcWd[djbo h[cW_d
l_i_Xb[ _d j^[ Wh[W e\ j^[ _cfbWdj WXkjc[dji$
<WlekhWXb[ fWjj[hdi e\ eYYbki_ed X_j[ WdZ
cWij_YWj_ed Y^[m_d] YWd kikWbbo edbo X[
eXjW_d[Z_\eYYbkiWbWZ`kijc[djiWh[f[h\ehc[Z
edj[[j^"Z[djkh[iehh[ijehWj_edi_dj^[effe#
i_d] `Wm Wi m[bb$ ?d iec[ i_jkWj_edi" _j cWo
[l[d X[ d[Y[iiWho je [nj[dZ j^[i[ WXhWi_l[
WZ`kijc[dji Zemd je j^[ c[jWb \hWc[meha e\
Yhemd h[ijehWj_edi eh je f[h\ehc heej YWdWb
jh[Wjc[dji$
? kdZ[hijWdZ j^Wj j^[ Y^[m_d] \kdYj_ed _i
Y^Wd]_d]j^hek]^ekjb_\[$L_hjkWbboWbbfWj_[dji
)** 9^Wfj[h(*È #OUNSELLINGÈANDÈ#ASEÈ!CCEPTANCE
m_bb h[gk_h[ f[h_eZ_Y Y^[Yai WdZ WZ`kijc[dji
e\ j^[ Y^[m_d] ikh\WY[i WdZ j^[ Y^[m_d]
\kdYj_ed ed W b_\[bed] XWi_i$ I_dY[ eYYbkiWb
WZ`kijc[dji m_j^ WXhWi_l[ _dijhkc[dji eh
ej^[h Z[l[befc[dji cWo b[WZ je beii e\ j^[
l[hj_YWb Z_c[di_ed [l[d W\j[h o[Whi" eYYbkiWb
ikh\WY[i_dj^[cekj^cWoiec[j_c[i^Wl[je
X[Wk]c[dj[Z$?di_jkWj_edim^[h[j^[Y^[m_d]
\kdYj_ed^WikdZ[h]ed[[njh[c[Y^Wd][i"_j_i
dej kdYecced j^Wj [dj_h[ Xh_Z][ ijhkYjkh[i
^Wl[ je X[ h[fbWY[Z cW_dbo \eh W[ij^[j_Y
h[Wiedi$
J_Ya j^[ Wffhefh_Wj[ Xen[i X[bem$ Fb[Wi[
h[jkhd j^_i \ehc je j^[ Z[dj_ij h[]WhZb[ii
e\ m^[j^[h oekh Z[Y_i_ed _i \eh eh W]W_dij
jh[Wjc[dj$
R ?^Wl[de\khj^[hgk[ij_edi$
R ?m_i^j^[fheY[Zkh[jeX[f[h\ehc[Z$
R ? Ze dej m_i^ j^[ fheY[Zkh[ je X[ f[h#
\ehc[Z$
?^Wl[h[Y[_l[ZYef_[ie\j^[i[ZeYkc[dji0j^[
Yeij[ij_cWj["j^[8E?9edi[diki"j^[\WYji^[[j
\ehfWj_[djim_j^_cfbWdjh[ijehWj_edi"WdZj^_i
YedjhWYj$
?j_iW]h[[Zj^WjWdoZ_ifkj[iYedY[hd_d]j^[
[n[Ykj_ed eh ekjYec[ e\ j^[ Z[djWb _cfbWdj
jh[Wjc[dj j^Wj cWo Wh_i[ _d Yedd[Yj_ed m_j^
j^_i YedjhWYj i^Wbb X[ WhX_jhWj[Z _d W X_dZ_d]
WdZ Z[\_d_j_l[ cWdd[h Xo Wd _dZ[f[dZ[dj
[nf[hj$ J^_i [nf[hj ^Wi je X[ Wd Wkj^eh_p[Z
8E? _cfbWdjebe]_ij WdZ i^Wbb X[ Wffe_dj[Z Xo
j^[ fh[i_Z[dj e\ j^[ ;khef[Wd 7YWZ[co \eh
?cc[Z_Wj[?cfbWdjebe]o;khef_iY^[d7aWZ[#
c_[\”hIe\ehj_cfbWdjebe]_[";7I?$
?d j^[ [l[dj j^Wj Wdo e\ j^[ fhel_i_edi e\
j^_iW]h[[c[djWh[i^emdjeX[kd[d\ehY[WXb["
ikY^ fhel_i_edi i^Wbb X[ b_c_j[Z eh [b_c_dWj[Z
je j^[ c_d_ckc [nj[dj d[Y[iiWho WdZ j^[
W]h[[c[dji^Wbbej^[hm_i[h[cW_d_d\kbb\ehY[
WdZ [\\[Yj$ J^[ kd[d\ehY[WXb[ fhel_i_edi
i^Wbb X[ h[fbWY[Z Xo i_c_bWh fhel_i_edi j^Wj
ceij Ybei[bo Wffhen_cWj[ j^[ _dj[dj_ed e\ j^[
kd[d\ehY[WXb[ fhel_i_edi WdZ j^[ fh[ikc[Z
_dj[dje\Xej^fWhj_[ijej^_iW]h[[c[dj$
:Wj[0
:[dj_iji_]dWjkh[
FWj_[dji_]dWjkh[
 YedjhWYji$
?d \eh[di_Y fhWYj_Y[" _iik[i ikY^ Wi m^[j^[h 8E?
mekbZ ^Wl[ X[[d Wd Wbj[hdWj_l[ jh[Wjc[dj efj_ed"
mekbZ ^Wl[ X[[d c[Z_YWbbo `kij_\_[Z" eh mekbZ ^Wl[
X[[dj^[jh[Wjc[dje\Y^e_Y["Wh[hekj_d[bo[lWbkWj[Z
Xo Yekhj#Wffe_dj[Z Z[djWb [nf[hji$ Je j^_i [nj[dj"
j^[ fheY[Zkh[ _i ijhW_]^j\ehmWhZ WdZ be]_YWb$ ?ji
fhWYj_YWb_cfb_YWj_edi_dZ_ifkj[im_j^fWj_[djicWo"
^em[l[h"YWki[jhekXb[$?j_ikdYecced\eh=[hcWd
Yekhji je ^[Wh YedjhWZ_Yjeho [nf[hj ef_d_edi" i_dY[
Yekhj [nf[hji Wh[ Wffe_dj[Z WdZ Yecc_ii_ed[Z Xo
j^[ Yekhji j^[ci[bl[i$'& 7i j^[i[ Yekhj#Wffe_dj[Z
[nf[hji Wh[ i[bZec h[Yhk_j[Z \hec Wced] j^[
hWdai e\ j^[ ceij [nf[h_[dY[Z fhWYj_j_ed[hi" j^[
h[Wb gk[ij_ed _i dej ie ckY^ m^[j^[h j^[ fWj_[dj
mWi Yecfh[^[di_l[bo WdZ WZ[gkWj[bo _d\ehc[Z Xo
j^[ Z[dj_ij Wi m^[j^[h j^[ Yekhj#Wffe_dj[Z [nf[hj
feii[ii[ij^[iWc[b[l[be\[nf[hj_i[Wij^[Z[dj_ij$
;nf[h_[dY[i^emij^Wjj^_i_idejdehcWbboj^[YWi[$
?j_ij^[h[\eh[kh][djboh[Yecc[dZ[Zje^Wl[j^ei[
YWdZ_ZWj[im^e"XWi[Zedj^[_hfWijYWh[[hi"bWYaj^[
d[Y[iiWhofhWYj_YWb[nf[h_[dY[h[cel[Z\hecj^[b_ij
_d WZlWdY[$ ?dij[WZ" _j _i h[Yecc[dZ[Z je ^Wl[ Wd
[nf[h_[dY[Z ki[h e\ j^[ 8E? ioij[c dec_dWj[Z Wi
WhX_jhWjeh Wi ieed Wi j^[ fWj_[dj \_hij [nfh[ii[i ^_i
eh^[hYecfbW_dji"hWj^[hj^WdjemW_j\ehWbWmik_jje
X[_dij_jkj[ZWdZj^[d_di_ijedWYecf[j[dj[nf[hj
je X[ Wffe_dj[Z Xo j^[ Yekhj$ 7 l_WXb[ WffheWY^
Wbed] j^[i[ b_d[i ^Wi X[[d Z[\_d[Z Xo j^[ ?9: WdZ
;7I? fhe\[ii_edWb WiieY_Wj_edi _d j^[_h ¼9edi[diki
ed8E?½$
J^[ Z[cWdZ j^Wj Yekhj#Wffe_dj[Z [nf[hji ckij
^Wl[ W Ykhh[dj WdZ lWb_Z hWj_d] \eh j^[ fheZkYj
Wj _iik[ _i XWi[Z ed cWdZWjeho h[gk_h[c[dji _d
Wl_Wj_ed$D[l[hj^[b[ii"YekhjieYYWi_edWbboj^_daj^Wj
j^[oYWdij_bb^ebZedjeWbeYWb[nf[hj[l[dm^[d_j_i
Yb[Whj^Wjj^_iZ[dj_ijbWYaij^[WX_b_joje[lWbkWj[j^[
8E?j[Y^d_gk[_dWYecf[j[djcWdd[h$?dj^WjYWi["
j^[b[]WbfheY[[Z_d]im_bbX[fWii_d]j^hek]^i[l[hWb
_dijWdY[i" m^_Y^ _i kd^[bf\kb je fWj_[dj WdZ Z[dj_ij
Wb_a[" Wi j^[_h Yecced ]eWb e\ ^Wl_d] j^[ Z[djWb
h[^WX_b_jWj_edYecfb[j[Z_i_dZ[\_d_j[boZ[bWo[Z$
M_j^ j^[i[ Yedi_Z[hWj_edi _d c_dZ" _j _i h[Yec#
c[dZ[ZjeW]h[[m_j^j^[fWj_[dj_dWZlWdY[j^WjWdo
Z_ifkj[i_dYedd[Yj_edm_j^_cfbWdjj^[hWfoi^WbbX[
h[\[hh[ZjeWdWhX_jhWbjh_XkdWb\ehif[[Zoi[jjb[c[dj
hWj^[hj^WdjeWfkXb_YYekhj$If[[Zoi[jjb[c[djm_bb
X[d[\_jj^[Z[dj_ijWdZj^[fWj_[djWb_a["WiWdo[hhehi
YWd X[ Yehh[Yj[Z WdZ j^[ h[ikbji efj_c_p[Z m_j^ekj
kdd[Y[iiWho Z[bWoi$ J^[ hekj[ e\ WhX_jhWj_ed _i W
l_WXb[Wbj[hdWj_l[XWi[ZedYkhh[dj;Kh[]kbWj_edi''
Xkjh[gk_h[iYecfh[^[di_l[fWj_[dj_d\ehcWj_edWdZ
'& ?d=[hcWdoWdZIm_jp[hbWdZ1j^[i_jkWj_ed_iZ_\\[h[dj_dj^[
KA"\eh_dijWdY["m^[h[j^[Yekhj[nf[hjiWh[i[b[Yj[ZXoj^[
fWhj_[ij^[ci[bl[i$
'' 9ekdY_b:_h[Yj_l[/)%');;9edkd\W_hj[hci_dYedikc[h
È È !RBITRATIONÈ!GREEMENTÈ
Wmh_jj[dWhX_jhWj_edW]h[[c[djjeX[i_]d[ZXoj^[
fWj_[dj$7iWcfb[W]h[[c[dj_ifh_dj[ZX[bem$
È
!RBITRATIONÈ!GREEMENT
9edYbkZ[ZX[jm[[d0
Ä:[dj_ijÄ
FhWYj_Y[ijWcf
WdZ
Ch$%Ci$
ÄFWj_[djÄ
J^[ fWj_[dj ^Wi Wkj^eh_p[Z j^[ Z[dj_ij je
f[h\ehc Z[djWb _cfbWdj jh[Wjc[dj XWi[Z ed
j^[fheY[Zkh[e\XWiWbeii[e_dj[]hWj_ed8E?$
?d j^[ \ehcWb fWj_[dj _d\ehcWj_ed i[ii_ed" j^[
Z[dj_ij ^Wi _dZ_YWj[Z je j^[ fWj_[dj _d Z[jW_b
j^[ Z_\\[h[dj dWjkh[ e\ j^_i c[j^eZ YecfWh[Z
je ej^[h j[Y^d_gk[i$ J^[ fWj_[djÉi Z[Y_i_ed
je kdZ[h]e j^_i jof[ e\ jh[Wjc[dj i^Wbb X[
be]_YWbbo [nj[dZ[Z je Wdo Z_ifkj[i Wh_i_d] _d
Yedd[Yj_edm_j^j^[jh[Wjc[dj"_dj^[i[di[j^Wj
WdoikY^Z_ifkj[ii^WbbX[[nYbki_l[boh[\[hh[Z
je_dZ[f[dZ[dj[nf[hjim^efeii[iiif[Y_Wb_p[Z
j^[eh[j_YWb WdZ fhWYj_YWb ademb[Z][ e\ j^_i
j[Y^d_gk[$ <khj^[hceh[" Xej^ fWhj_[i W]h[[
j^WjWdoZ_ifkj[iel[hjh[Wjc[djij[fiWbh[WZo
jWa[d eh je X[ jWa[d d[nj d[[Z je X[ i[jjb[Z
ceh[if[[Z_boj^Wd_ikikWbboj^[YWi[_dfkXb_Y
bWmik_ji je Wle_Z Wdo Yedi[gk[dj_Wb ZWcW][
Wh_i_d]\hecfhebed][ZZ[bWoi$J^[h[\eh["Xej^
fWhj_[iW]h[[edj^[\ebbem_d]fheY[Zkh[0
8ej^ fWhj_[i i^Wbb X[ [dj_jb[Z je h[\[h Wdo
Z_ifkj[i el[h j^[ [n_ij[dY[ e\ mWhhWdjo eh
b_WX_b_joYbW_ciW]W_dijj^[Z[dj_ijjeWdWhX_jhWb
jh_XkdWb"m^_Y^m_bbjWa[W\_dWbZ[Y_i_edm_j^ekj
h[Yekhi[ je bWm$ ?j _i W]h[[Z j^Wj Wdo Z_ifkj[i
i^Wbb X[ i[jjb[Z ed j^[ XWi_i e\ PFE ™™ '&(+Ä
'&*. =[hcWd YeZ[ e\ Y_l_b fheY[Zkh[$ ?\ j^_i
W]h[[c[dj _i YedYbkZ[Z ekji_Z[ j^[ ;K Wh[W"
j^[hkb[i\ehj^[WhX_jhWj_edfheY[Zkh[i^WbbX[
]el[hd[Z Xo j^[ h[b[lWdj bWmi e\ j^[ Yekdjho
_d m^_Y^ j^[ W]h[[c[dj _i YedYbkZ[Z$ J^[
fhel_i_edie\j^_iW]h[[c[djZedejWffbojeWdo
Z[XjYebb[Yj_edfheY[[Z_d]i"_$[$\[[ifWoWXb[je
j^[ Z[dj_ij i^Wbb ij_bb X[ Yebb[Yj_Xb[ j^hek]^
j^[ h[]kbWh Yekhji e\ bWm$ 7do Z[Xj Yebb[Yj_ed
fheY[[Z_d]i i^Wbb" ^em[l[h" X[ ikif[dZ[Z _\
WhX_jhWj_edfheY[[Z_d]iWh[_dij_jkj[Z$
)*+
J^[ c[cX[hi je j^[ WhX_jhWb jh_XkdWb i^Wbb
X[ dec_dWj[Z Xo j^[ fh[i_Z[dj e\ j^[ beYWb
Z[djWb WiieY_Wj_ed" m^e m_bb Wbie dec_dWj[
WdZ Yecc_ii_ed W j^_hZ#fWhjo [nWc_d[h \hec
j^[ hWdai e\ Wkj^eh_p[Z [nWc_d[hi m^e Wh[
c[cX[hi e\ j^[ ;khef[Wd 7YWZ[c_Y IeY_[jo
\eh?cfbWdjebe]o;7I?1;khef_iY^[7aWZ[c_[
\”h Ie\ehj_cfbWdjebe]_[ [$L$" ;h\khj[h IjhWœ[
'/" .+)., ;Y^_d]" =[hcWdo _\ W j^_hZ#fWhjo
[nWc_dWj_ed_iZ[[c[Zd[Y[iiWho$
J^[jh_XkdWbi^Wbbh[WY^W\_dWbZ[Y_i_eded
m^[j^[hj^[Z[djWb%_cfbWdjjh[Wjc[dj^WiX[[d
f[h\ehc[Z Yehh[Yjbo eh m^[j^[h W jh[Wjc[dj
[hheh^WieYYkhh[Z$?\_jYedYbkZ[ij^WjWd[hheh
^WieYYkhh[Z"j^[jh_XkdWbi^WbbWbieZ[Y_Z[ed
m^[j^[h WdZ ^em ckY^ Yecf[diWj_ed \eh
cWj[h_Wbeh_ccWj[h_WbZWcW][i^WbbX[fWoWXb[$
<_dWbbo" j^[ jh_XkdWb i^Wbb Wbie Z[Y_Z[ m^_Y^
fWhjoi^WbbYel[hj^[Yeijie\j^[fheY[[Z_d]i$
J^[Yeijie\Wdo[nf[hjef_d_ediYebb[Yj[ZedW
fh_lWj[XWi_iWh[dejh[_cXkhiWXb[$
?\j^[fWj_[djikXc_jiW\ehcWbef_d_ed_iik[Z
Xo Wd Wkj^eh_p[Z [nWc_d[h \hec j^[ hWdai e\
;7I? X[\eh[ WhX_jhWj_ed fheY[[Z_d]i Wh[ _dij_#
jkj[Z" j^[ Z[dj_ij i^Wbb WYY[fj j^_i ef_d_ed" ie
j^Wj WhX_jhWj_ed _i de bed][h d[Y[iiWho$ ?\ j^[
[nWc_d[hYedYbkZ[ij^WjWjh[Wjc[dj[hheh^Wi
eYYkhh[Z" j^[ Z[dj_ij m_bb ikXc_j j^[ YWi[ je
^_i fhe\[ii_edWb b_WX_b_jo _dikhWdY[ fhel_Z[h
\eh beii Wii[iic[dj$ ?\ WhX_jhWj_ed _i _dij_jkj[Z
ed j^[ Z[dj_ijÉi _d_j_Wj_l[" j^[ fWj_[dj WYY[fji
jekdZ[h]eWdoYb_d_YWbWdZhWZ_e]hWf^_Y[nW#
c_dWj_edih[gk_h[Z_dj^_iYedd[Yj_ed$
J^[ WhX_jhWb fheY[[Z_d]i i^Wbb X[ [n[Ykj[Z
_d WYYehZWdY[ m_j^ j^[ W\eh[c[dj_ed[Z b[]Wb
fhel_i_edi$7do[l[djkWb_j_[idejYel[h[ZXoWdo
e\j^[i[b[]Wbfhel_i_edii^WbbX[^WdZb[Z_dj^[
X[ij _dj[h[ij e\ j^[ fWhj_[i _dlebl[Z" W_c[Z Wj
fhej[Yj_d]j^[_h\_dWdY_Wb_dj[h[ijWdZ[dWXb_d]
Wif[[Zoi[jjb[c[dj$?dj^[[l[djj^WjWdoe\j^[
fhel_i_edi e\ j^_i W]h[[c[dj Wh[ i^emd je X[
kd[d\ehY[WXb["ikY^fhel_i_edii^WbbX[b_c_j[Z
eh[b_c_dWj[Zjej^[c_d_ckc[nj[djd[Y[iiWho
WdZ j^[ W]h[[c[dj i^Wbb ej^[hm_i[ h[cW_d _d
\kbb\ehY[WdZ[\\[YjWdZ"XomWoe\h[c[Zo"X[
Yedijhk[ZWiW][d[hWbWhX_jhWj_edW]h[[c[dj$
? ^Wl[ h[WZ j^[ fhel_i_edi e\ ™™ '&(+Ä'&*.
PFE WdZ _j[c 'g e\ j^[ 7dd[n je 9ekdY_b
:_h[Yj_l[/)%');;9edkd\W_hj[hci_dYedikc[h
YedjhWYji"m^_Y^Wh[fh_dj[Zel[hb[W\$
:[dj_iji_]dWjkh[
FWj_[dji_]dWjkh[
)*, 9^Wfj[h(*È #OUNSELLINGÈANDÈ#ASEÈ!CCEPTANCE
7dej^[h fh_dj[Z \ehc _i ki[Z \eh j^[ WYjkWb
jh[Wjc[dj YedjhWYj" m^_Y^ [dWXb[i j^[ Z[dj_ij je
Z[\_d[WijWdZWhZ_p[Zh[bWj_edi^_fm_j^^_ifWj_[dji
m^_b[ _dYbkZ_d] j^[ if[Y_Wb Y^WhWYj[h_ij_Yi e\ [WY^
_dZ_l_ZkWbYWi[$J^_i_iWdeXl_ekij^_d]jeZeX[YWki[
b[]Wb fhel_i_edi ed c[Z_YWb jh[Wjc[dj YedjhWYji Ze
dej [l[d [n_ij _d ;khef[Wd Yekdjh_[i j^Wj ^Wl[ W
YeZ[e\Y_l_bfheY[Zkh[i[dWYj[Z$7mh_jj[djh[Wjc[dj
YedjhWYjYWd[b_c_dWj[kdY[hjW_dj_[i\ehXej^fWhj_[i$
:[dj_iji i^ekbZ WbmWoi ki[ ikY^ W YedjhWYj X[\eh[
Z[djWb _cfbWdj jh[Wjc[dj$ 7 mh_jj[d YedjhWYj m_bb
Wbie ]_l[ j^[ fWj_[dj Wd effehjkd_jo je [n[hY_i[
YedjhWYjkWb Z_iYh[j_ed" j^[h[Xo [d^WdY_d] j^[ _Z[W
e\ Yedikc[h i[b\#Z[j[hc_dWj_ed$ IkY^ YedjhWYjkWb
Z_iYh[j_ed Ze[i dej [n_ij _d ;d]bWdZ WdZ IYejbWdZ"
\eh _dijWdY[" m^[h[ j^[ lWij cW`eh_jo e\ fWj_[dji
Wh[ jh[Wj[Z Xo f^oi_Y_Wdi e\ j^[ C[Z_YWb >[Wbj^
I[hl_Y[_dj^[WXi[dY[e\Wdo_dZ_l_ZkWbYedjhWYjkWb
h[bWj_edi^_fm^Wjie[l[h<_iY^[hWdZB_b_['///$
J^[ jh[Wj_d] Z[dj_ij i^ekbZ jWa[ WZlWdjW][ e\
j^[[n_ij_d]iYef[e\YedjhWYjkWbZ_iYh[j_ed"j^[h[Xo
jWa_d] ^_i fWj_[dji Wi i[h_ekibo Wi Wdo fWhjo je W
YedjhWYj Xo Wbbem_d] j^[c je [n[hY_i[ j^[_h i[b\#
Z[j[hc_dWj_ed _d j^[_h Z[Y_i_ed je kdZ[h]e 8E?
jh[Wjc[dj$
J^[ jh[Wjc[dj YedjhWYj ckij Wbie _dYbkZ[
\_dWdY_WbYedi_Z[hWj_edi"dejb[WijX[YWki[j^[ifeki[
YWd X[ _dYbkZ[Z _d j^[ \_dWdY_Wb h[ifedi_X_b_j_[i
Wi m[bb kdZ[h Ykhh[dj =[hcWd bWm I[Yj_ed ')+-"
=[hcWd 9_l_b 9eZ[$ <khj^[hceh[" j^[ Z[dj_ij YWd
h[i[hl[ j^[ h_]^j je f[h\ehc Yehh[Yj_l[ eh WZ`kij_l[
\ebbem#kf jh[Wjc[dji" [if[Y_Wbbo ed j^[ fheij^[j_Y
ikf[hijhkYjkh[$ J^[ fWhj_[i cWo mWdj je W]h[[ ed
W Zemd fWoc[dj" m^_Y^ mekbZ dehcWbbo YedY[hd
j^[ cWj[h_Wbi WdZ bWXehWjeho Yeiji$ J^[ jh[Wjc[dj
YedjhWYj _i Wbie j^[ ceij Wffhefh_Wj[ c[Z_kc je
_d\ehc j^[ fWj_[dj j^Wj de ijWj[c[dji YWd X[ cWZ[
Xo j^[ Z[dj_ij ed m^[j^[h j^[ Yeiji e\ j^[ fbWdd[Z
jh[Wjc[djm_bbX[Yel[h[ZXofkXb_Yehfh_lWj[^[Wbj^
_dikhWdY[fhel_Z[hi$?j^WiX[[dfe_dj[Zekj[Whb_[h
j^Wj j^[ _iik[ e\ fWj_[dj _d\ehcWj_ed _i ]W_d_d]
_dYh[Wi_d] _cfehjWdY[ _d Z[dj_ijho$ J^_i _i jhk[
dej edbo e\ j^[ Yb_d_YWb Xkj Wbie e\ j^[ \_dWdY_Wb
_cfb_YWj_edie\jh[Wjc[dj$J^[Z[dj_ijcWoX[b_WXb[
\ehZWcW][i_\^[Ze[idejkd[gk_leYWbbo_d\ehcj^[
fWj_[djj^Wjj^[h[Yecc[dZ[Zjh[Wjc[djcWodejX[
Yel[h[ZXoj^[_dikhWdY[fhel_Z[h$BWijbo"j^[Z[dj_ij
cWomWdjjeYedi_Z[h^Wl_d]j^[fWj_[dji_]dWfWf[h
_dijhkYj_d]j^[fWj_[djÉi_dikhWdY[fhel_Z[hjecWa[
j^[Z[dj_ijÉi\[[fWoWXb[Z_h[Yjbojej^[Z[dj_ij$
I_dY[ j^[ iYef[ e\ _cfbWdj j^[hWf_[i _i kikWbbo
ckY^bWh][hj^Wdj^Wje\dehcWbZ[djWbjh[Wjc[dji"
ki[hi Wh[ _dYh[Wi_d]bo h[bo_d] ed mh_jj[d YedjhWYji
jeZ[\_d[j^[j[hcie\jh[Wjc[dj$Ed[h[Wied\ehj^_i
ijhWj[]o _i je h[c_dZ fWj_[dji e\ j^[_h YedjhWYjkWb
eXb_]Wj_edi WdZ je _d\ehc j^[c j^Wj j^[ jh[Wjc[dj
ekjYec[cWoX[kdiWj_i\WYjehokdb[iij^[oWYj_l[bo
Yecfbom_j^Wbbh[gk_h[c[djiedWYedj_dkekiXWi_i$
L[hockY^Wi_dehj^eZedj_Yjh[Wjc[dji"j^[gkWb_jo
e\fWj_[djYecfb_WdY[cWoX[Z[Y_i_l[\ehj^[bed]#
j[hcikYY[iie\Z[djWb_cfbWdjjh[Wjc[dj$7bj^ek]^
j^[i[\WYjickijWbh[WZo^Wl[X[[d[nfbW_d[ZZkh_d]
j^[ fWj_[dj _d\ehcWj_ed i[ii_ed" W mh_jj[d YedjhWYj
j^Wj_iikXi[gk[djboi_]d[ZXoj^[fWj_[djm_bbcWa[
Wdo \W_bkh[ je WYj_l[bo YebbWXehWj[ _d j^[ jh[Wjc[dj"
WdZ Wdo bWYa e\ Yecfb_WdY[" W l_ebWj_ed e\ j^[
fWj_[djÉi YedjhWYjkWb eXb_]Wj_ed je fhej[Yj ^_i emd
_dj[h[iji" m_j^ j^[ b[]Wb _cfb_YWj_ed j^Wj ^[ cWo
\eh\[_jWbbYbW_ci$
7i W Yedi[gk[dY[" kdZ[h]e_d] Wdo \ebbem#kf
jh[Wjc[dj m_j^ W ded#Wkj^eh_p[Z Z[dj_ij m_bb X[ _d
l_ebWj_ed e\ j^[ fWj_[djÉi YedjhWYjkWb eXb_]Wj_edi"
de cWjj[h ^em h[fkjWXb[ j^_i Z[dj_ij cWo X[ _d
ej^[h\_[bZi$8Wi[Zedekh[nf[h_[dY[_dIm_jp[hbWdZ"
j^[ hWj[ e\ 8E? _cfbWdji h[iYk[Z \hec jhWdi_[dj
fheXb[cWj_Yi_jkWj_ediXoded#Wkj^eh_p[ZZ[dj_iji^Wi
X[[dl_hjkWbbop[he$?dej^[hmehZi"m^[d[l[hfWj_[dji
jkhd[Z je W kd_l[hi_jo Z[djWb Yb_d_Y _d =[hcWdo eh
Im_jp[hbWdZX[YWki[e\fheXb[cim_j^8E?_cfbWdji"
j^[Y^WdY[im[h[Wbceij'&&j^Wj^[ehi^[[dZ[Zkf
kdZ[h]e_d][nfbWdjWj_edWdZ_di[hj_ede\Wh[celWXb[
Z[djkh[_dij[WZe\][jj_d]Yecf[j[djjh[Wjc[djXWi[Z
edj^[fh_dY_fb[ie\8E?$J^_i[nf[h_[dY[_i_di^Whf
YedjhWij je j^[ 2' hWj[ e\ fheij^[j_Y ijhkYjkh[i
f[hcWd[djbo beij _d j^[ c[Z_kc j[hc Wced] 8E?
ki[hi$ J^_i YecfWh_ied i^emi ^em _cfehjWdj _j
_i j^Wj \ebbem#kf [nWc_dWj_edi Wh[ f[h\ehc[Z Xo
gkWb_\_[ZZ[dj_iji_dWj_c[bocWdd[h$
:[djWb _cfbWdjebe]_iji Ze dej fhec_i[ j^[_h
fWj_[dji"WdZWh[dejh[gk_h[ZjeWY^_[l["WikYY[ii\kb
ekjYec[f[hi[$J^[oedbokdZ[hjWa[jecWa[[l[ho
[\\ehjjemWhZiWikYY[ii\kbekjYec[$'(7d[nY[fj_ed
jej^_ihkb[^WiX[[dWYademb[Z][ZkdZ[hK$I$bWm_d
YWi[im^[h[j^[f^oi_Y_Wd]hWdjiWmWhhWdjoedY[hjW_d
ekjYec[i" m^_Y^ Wffb_[i fWhj_YkbWhbo je Yeic[j_Y
jh[Wjc[dji$')I_c_bWhj[dZ[dY_[i^Wl[X[[d_Z[dj_\_[Z
Wced] W[ij^[j_Y ikh][edi WdZ h[ijehWj_l[ Z[dj_iji
_d <hWdY[ F[dd[Wk '//,$ ?d =[hcWdo" W fWj_[djÉi
YecfbW_djmWiZ_ic_ii[ZW\j[h^[hZ[dj_ij^WZki[Z
j^[ Xh_]^j[ij i^WZ[ WlW_bWXb[ _d W h[ijehWj_ed m^_b[
j^[fWj_[djcW_djW_d[Zj^Wji^[^WZX[[d]kWhWdj[[Z
j^[Æm^_j[ijm^_j[ÇXkjmWi\Wc_b_Whm_j^m^_j[ij^Wj
m[h[[l[dm^_j[hj^Wdj^[i^WZ[e\^[hh[ijehWj_ed$'*
J^[Z[dj_ijm_bbd[l[hX[WXb[je[dikh[WikYY[ii\kb
ekjYec[m_j^Y[hjW_djoWdZi^ekbZcWa[j^_ife_dj
'( ?d <h[dY^ bWm" j^[ f^oi_Y_WdÉi eXb_]Wj_ed _i Z[\_d[Z dej Wi
eXb_]Wj_ed Z[ hƒikbjWj Xkj Wi eXb_]Wj_ed Z[ ceo[di$ 8o j^[
iWc[jea[d"j^_ijof[e\YedjhWYj_idejWM[hal[hjhW]XkjW
:_[dijl[hjhW]kdZ[h=[hcWdbWm$
') >Wma_dil$CY=[^[".*D$>$''*"'*,7$,*''/(/$
'* 9ekhjhkb_d].K,+%/.WjEB=:”ii[bZeh\e\'-:[Y[cX[h
'//. Fhej^[j_a c_j a[hWc_al[hXb[dZ[j[d Ahed[d0 ÆZWi
m[_œ[ij[M[_œÇ$
È È $ENTALÈ4REATMENTÈ#ONTRACTÈ)MPLANTÈ4REATMENT È
Yb[Wh je ^_i fWj_[dji$ If[Y_\_YWbbo" ^[ cWo mWdj je
_dZ_YWj[ j^Wj m^_b[ j^[ _cfbWdj cWdk\WYjkh[h YWd
]hWdjWmWhhWdjoedj^[cWj[h_Wbehj^[_cfbWdjWj_ed
ioij[c" j^[h[ _i de mWo \eh j^[ Z[dj_ij je ]hWdj W
mWhhWdjoedj^[_cfbWdjWj_edfheY[Zkh[$
9edi[gk[djbo"j^[_iik[e\b_WX_b_joYWdedboYec[
_dm^[h[j^[Z[dj_ijcWo^Wl[d[]b[Yj[Z^_ieXb_]Wj_ed
jemehajemWhZiWikYY[ii\kbekjYec[m_j^Zk[YWh[$
?dj^Wji_jkWj_ed"j^[XkhZ[de\j^[fhee\h[ijiedj^[
fWj_[dj$?\^_iYWi[_iikijW_d[Z"_j_iWiikc[Zj^Wjj^[
\Wkbj b_[i m_j^ j^[ f^oi_Y_Wd" m^e m_bb j^[d ^Wl[ Wd
effehjkd_jo je Y^Wbb[d][ j^[ YWi[$'+ ?d j^_i mWo" j^[
c[Z_YWbb_WX_b_joh[]_c[_d=[hcWdoWdZj^[;khef[Wd
Kd_ed ^Wi Z[l[bef[Z l[ho ckY^ _d j^[ Z_h[Yj_ed e\
Æh_ia#XWi[ZÇ ijh_Yj b_WX_b_jo" b[Wd_d] Yb[Whbo jemWhZi
K$I$ bWm$', ?j _i" ^em[l[h" [gkWbbo _cfehjWdj j^Wj j^[
fWj_[dj^_ci[b\ikffehjij^[Z[dj_ijÉi[\\ehjijemWhZiW
ikYY[ii\kbekjYec[XoWYj_l[boeXi[hl_d]j^[Z[dj_ijÉi
jh[Wjc[dj#h[bWj[Z h[Yecc[dZWj_edi" Xo WXijW_d_d]
\hecYekdj[hfheZkYj_l[X[^Wl_ekh"WdZXoYecfbo_d]
m_j^f[h_eZ_Y\ebbem#kfl_i_ji$Kd\ehjkdWj[bo"_j_idej
kdYecced\ehfWj_[djije[nf[Yj\WhjeeckY^\hec
j^[Z[dj_ijWdZj^[Z[djWbjh[Wjc[djm^_b[j^[_hemd
m_bb_d]d[iijeWYj_l[boikffehjj^[bed]#j[hcikYY[ii
e\ jh[Wjc[dj b[Wl[i W bej je X[ Z[i_h[Z$ 7 mh_jj[d
jh[Wjc[djYedjhWYjm_bb[dWXb[j^[Z[dj_ijjecej_lWj[
j^[fWj_[djedWYedj_dkekiXWi_i$
È
$ENTALÈ4REATMENTÈ#ONTRACTÈÈ
)MPLANTÈ4REATMENT coZ[dj_ij^Wi^WdZ[Zel[hWc[Z_YWbgk[ij_ed#
:[djWbe\\_Y[0
Jh[Wj_d]Z[dj_ij0
FWj_[dj0
:Wj[e\X_hj^0
7ZZh[ii0
F^ed[^ec[%e\\_Y[0
EYYkfWj_ed%[cfbeo[h0
?dikhWdY[fhel_Z[h0
<Wc_boZ[dj_ij_\Wffb_YWXb[0
'+ J^[;K9ekdY_b:_h[Yj_l[e\/Del[cX[h'//&edi[hl_Y[i
Wbh[WZo _dYbkZ[Z W fhel_i_ed Whj_Yb[ '" fWhW]hWf^ ( je
j^[ [\\[Yj j^Wj j^[ XkhZ[d e\ fhee\ \eh i[hl_Y[ fhel_Z[hiÉ
d[]b_][dY[i^ekbZX[h[l[hi[Z$J^[Z_h[Yj_l[mWim_j^ZhWmd1
fh[ikcWXbo"j^[YedY[fjm_bbX[h[_djheZkY[ZZ[b[][\[h[dZW
_dWd[m9ekdY_b:_h[Yj_l[edc[Z_YWbfhe\[ii_edi$=[hcWd0
:_[C[Z_p_d^W\jkd]dWY^Z[cd[k[dIY^kbZh[Y^jkdZZ[c
d[kd[dIY^WZ[dih[Y^j"@P(&&("+..$
', J^[ \WYj j^Wj WjjW_dWXb[ ZWcW][i ^Wl[ h[WY^[Z dem^[h[
d[Whj^[b[l[be\j^[ikci_dlebl[Z_dj^[KI_iZk[jej^[
\WYj j^Wj KI bWm fhel_Z[i \eh Æfkd_j_l[ ZWcW][iÇ je X[
WmWhZ[Z _d WZZ_j_ed je h[]kbWh ZWcW][i X[YWki[ Wbb YWi[i
e\ cWbfhWYj_Y[ ^Wl[ Yh_c_dWb fheY[[Z_d]i Wi W hekj_d[
YehebbWho$
)*-
7\j[h Yecfh[^[di_l[ Yekdi[bb_d] WdZ \ehcWb
fWj_[dj _d\ehcWj_ed" j^[ fWj_[dj Wkj^eh_p[i
j^[ Z[dj_ij je f[h\ehc j^[ \ebbem_d] _cfbWdj
jh[Wjc[dj0
J[[j^%`Wmi[]c[dj0
?cfbWdj%cWdk\WYjkh[h0
:[i_]d0
9eij[ij_cWj[0
J^[ Z[dj_ij _i [djhkij[Z m_j^ j^[ jWiai e\
Yebb[Yj_d] j^[ fWj_[djÉi c[Z_YWb ^_ijeho" je
fhel_Z[ _d\ehcWj_ed WXekj Z[djWb _cfbWdj
jh[Wjc[dj" je _cfb[c[dj W YedYh[j[ jh[Wjc[dj
fbWd" je _di[hj j^[ _cfbWdji" WdZ je f[h\ehc
j^[_cc[Z_Wj[\ebbem#kfYWh[$7doZ[djWbjh[Wj#
c[djij[fij^WjcWoX[Yec[d[Y[iiWhoZkh_d]
_cfbWdjWj_ed _d ceZ_\_YWj_ed eh [nj[di_ed e\
j^[jh[Wjc[djfbWdWh[dejYel[h[ZXoj^[Yeij
[ij_cWj[$ J^[ iWc[ _i jhk[ e\ j^[ \ebbem#kf
[nWc_dWj_edi"m^_Y^m_bb^Wl[jeX[f[h\ehc[Z
[l[hoi_ncedj^iW\j[hj^[jh[Wjc[dj^WiX[[d
Yecfb[j[Z$
?^Wl[_d\ehc[ZcoZ[dj_ijYecfh[^[di_l[bo
e\coZ[djWbWdZc[Z_YWbXWYa]hekdZ"jhkj^\kbbo
Yecfb[j[Z j^[ c[Z_YWb ^_ijeho \ehc" WdZ ?
^Wl[dejm_j^^[bZ_d\ehcWj_ededWdoZ_i[Wi[i
WdZ YedZ_j_edi _d j^[ fWj_[dj _d\ehcWj_ed
Z_iYkii_ed$ ? W]h[[ je Yedj_dk[ je fhel_Z[ j^[
Z[dj_ijm_j^Wbbc[Z_YWbWdZZ[djWbXWYa]hekdZ
_d\ehcWj_ededcoemd_d_j_Wj_l[$?dWZZ_j_ed"
dW_h["m^_Y^?W]h[[je\ehmWhZjeX[Yecfb[j[Z
Xo co ][d[hWb fhWYj_j_ed[h$ ? W]h[[ je h[b[Wi[
co ej^[h f^oi_Y_Wdi WdZ Z[dj_iji \hec j^[_h
Yed\_Z[dj_Wb_jo h[gk_h[c[dj jemWhZi j^[ Z[d#
j_ij" WdZ ? W]h[[ j^Wj j^_i YedjhWYj YWd X[
fh[i[dj[Zjecoej^[hf^oi_Y_WdiWdZZ[dj_iji
jefhel[j^_ih[b[Wi[\hecYed\_Z[dj_Wb_jo$J^_i
YbWki[i^WbbX[_d\ehY[\ehj^[ZkhWj_ede\j^[
jh[Wjc[djeh\ebbem#kfjh[Wjc[djeh\ehWibed]
Wihekj_d[\ebbem#kf[nWc_dWj_ediWh[h[gk_h[Z"
eh \eh W cWn_ckc e\ j^h[[ o[Whi \ebbem_d]
_cfbWdjWj_ed"m^_Y^[l[h_ibed][h$
?WcWmWh[j^Wjj^[jh[Wjc[dj?^Wl[Z[Y_Z[Z
je kdZ[h]e _i XWi[Z ed W if[Y_Wb _cfbWdjWj_ed
j[Y^d_gk[8E?WdZj^[h[\eh[W]h[[je^Wl[Wdo
\ebbem#kf jh[Wjc[dji f[h\ehc[Z Xo if[Y_Wbbo
jhW_d[Z Z[dj_iji edbo$ ? W]h[[ je ^Wl_d] j^[i[
\ebbem#kf [nWc_dWj_edi f[h\ehc[Z" kikWbbo
Wj i_n#cedj^ _dj[hlWbi" [nYbki_l[bo Xo Z[dj_iji
if[Y_Wbbo jhW_d[Z _d j^[ 8E? j[Y^d_gk[$ ?\" _d
Wd [c[h][dYo i_jkWj_ed" W Z[dj_ij c[[j_d]
j^_i Yh_j[h_W _i dej WlW_bWXb[ ed i^ehj dej_Y[" ?
i^Wbb ZhWm j^[ ej^[h Z[dj_ijÉi Wjj[dj_ed je j^[
Æ9edi[diki ed 8E?Ç" m^_Y^ mWi ^WdZ[Z el[h
)*. 9^Wfj[h(*È #OUNSELLINGÈANDÈ#ASEÈ!CCEPTANCE
jec[WiWdWdd[njej^_iYedjhWYj$EdY[j^[
[c[h][dYojh[Wjc[dj^WiX[[dYecfb[j[Z"?i^Wbb
_cc[Z_Wj[bo _d\ehc co 8E? _cfbWdjebe]_ij
WdZfhel_Z[^_cm_j^j^[WZZh[iie\j^[Z[dj_ij
m^ef[h\ehc[Zj^[[c[h][dYojh[Wjc[dj$
? kdZ[hijWdZ j^Wj j^[ f[h_eZ_Y \ebbem#kf
jh[Wjc[dji WdZ WZZ_j_edWb c[Wikh[i if[Y_\_[Z
_d j^[ _d\ehcWj_ed i^[[j W_c[Z Wj Xh_d]_d]
WXekj eh cW_djW_d_d] W ikYY[ii\kb ekjYec[
Wh[ [ii[dj_Wb je j^[ ekjYec[ e\ jh[Wjc[dj WdZ
j^Wj _j _i co eXb_]Wj_ed je Yecfbo m_j^ j^[c$
7do l_ebWj_ed e\ j^_i fhel_i_ed cWo X[ _dj[h#
fh[jWXb[ Wi Yedjh_Xkjeho d[]b_][dY[" m^_Y^
cWo iec[j_c[i YWdY[b ekj Wdo Yedjh_Xkjeho
d[]b_][dY[edj^[Z[dj_ijÉifWhj$
?\ WdZ m^[d Yecfb_YWj_edi eYYkh m_j^ j^[
_cfbWdji W\j[h j^[ Yecfb[j[Z jh[Wjc[dj" ?
i^Wbb WbmWoi fh[i[dj j^[ ijWjki je j^[ 8E?
_cfbWdjebe]_ij \_hij WdZ m_j^ekj Z[bWo je ]_l[
^_cWdeffehjkd_jojef[h\ehcZ_W]dei_iWdZ
\ebbem#kf jh[Wjc[dj$ J^_i h[gk_h[c[dj Wffb_[i
if[Y_\_YWbbo je Wdo _d\bWccWjeho fheY[ii[i _d
j^[`WmWh[WWdZjeeYYbkiWbWZ`kijc[dji$
J^[ Z[dj_ij i^Wbb f[h\ehc \ebbem#kf jh[Wj#
c[dj _\ j^[ _cfbWdjWj_ed fheY[Zkh[ _dlebl[Z
jh[Wjc[dj [hhehi eh _\ j^[h[ Wh[ Wdo ej^[h
h[Wiedi m^o ikXi[gk[dj WZ`kijc[dji X[Yec[
d[Y[iiWhoWiWZ_h[Yjh[ikbje\j^[_cfbWdjWj_ed
fheY[Zkh[$
J^[ Z[dj_ij ^Wi _d\ehc[Z c[ j^Wj _cfbWd#
jebe]_YWb jh[Wjc[dji Wh[ ijh_Yjbo fh_lWj[ i[h#
l_Y[i" kdb_a[bo je X[ h[_cXkhi[Z Xo _dikhWdY[
fhel_Z[hi$ 7do h[ZkYj_edi" [l[d _\ j^[o Wh[
Yed\_d[Zje_dZ_l_ZkWbi[hl_Y[iehfWhjij^[h[#
e\" i^Wbb X[ Yel[h[Z Xo j^[ fWj_[dj _d j^[_h
[dj_h[jo$
J^[ \[[ fWoWXb[ je j^[ Z[dj_ij i^Wbb X[ Zk[
W\j[hj^[jh[Wjc[dj^WiX[[dYecfb[j[Z$8[\eh[
j^[_cfbWdj_i_di[hj[Z"j^[fWj_[dji^Wbbh[Y[_l[
Wd _dle_Y[ \eh j^[ _cfbWdj#h[bWj[Z i[hl_Y[i
f[h\ehc[Z Xo j^[ Z[djWb bWXehWjeho$ J^[
Z[dj_ij cWo h[gk_h[ j^[i[ [nf[dZ_jkh[i je X[
h[_cXkhi[ZX[\eh[j^[_cfbWdj_i_di[hj[Z$
? ^Wl[ Z_iYkii[Z j^[ jh[Wjc[dj fbWd WdZ
Yeij [ij_cWj[ m_j^ co ifeki[" fWhj_YkbWhbo
m_j^ h[]WhZ je j^[ W[ij^[j_Y h[ikbji j^Wj YWd
X[ WY^_[l[Z m_j^ j^_i jh[Wjc[dj Xkj Wbie m_j^
h[if[Yj je _ji \_dWdY_Wb _cfb_YWj_edi$ >Wl_d]
j^ehek]^bo Yedi_Z[h[Z Wbb fe_dji _d gk[ij_ed"
? ^Wl[ Z[Y_Z[Z je [dj[h _dje j^_i YedjhWYj
WdZ je ^Wl[ j^[ fhefei[Z _cfbWdj jh[Wjc[dj
f[h\ehc[Z$
?d j^[ [l[dj j^Wj Wdo e\ j^[ fhel_i_edi e\
j^_iW]h[[c[djWh[i^emdjeX[kd[d\ehY[WXb["
ikY^ fhel_i_edi i^Wbb X[ b_c_j[Z eh [b_c_dWj[Z
je j^[ c_d_ckc [nj[dj d[Y[iiWho WdZ j^[
W]h[[c[dji^Wbbej^[hm_i[h[cW_d_d\kbb\ehY[
WdZ [\\[Yj$ J^[ kd[d\ehY[WXb[ fhel_i_edi
i^Wbb X[ h[fbWY[Z Xo i_c_bWh fhel_i_edi j^Wj
ceij Ybei[bo Wffhen_cWj[ j^[ _dj[dj_ed e\ j^[
kd[d\ehY[WXb[ fhel_i_edi WdZ j^[ fh[ikc[Z
_dj[dje\Xej^fWhj_[ijej^_iW]h[[c[dj$
? ^Wl[ h[Y[_l[Z Yef_[i e\ j^[ Yeij [ij_cWj["
j^[_d\ehc[Z Yedi[dj" j^[ 8E? 9edi[diki" j^[
WhX_jhWj_edW]h[[c[djWdZj^_iYedjhWYj$
:Wj[0
:[dj_iji_]dWjkh[
FWj_[dji_]dWjkh[
;dYbeikh[i
9eij[ij_cWj[
8E?Yedi[diki
7hX_jhWj_edW]h[[c[dj
?d\ehc[ZYedi[dj
J^_d]iX[Yec[Yecfb_YWj[Zm^[dfWj_[djiWh[m_j^#
ZhWmd \hec 8E? jh[Wjc[dj Xo ¼[nf[hji½ ed j^[
_d_j_Wj_l[e\_dikhWdY[fhel_Z[hi[$]$=[hcWdfWj_[dji
Yel[h[Z Xo fh_lWj[ _dikhWdY[$ FWj_[dji m^e Wh[
Z_iikWZ[Z\hecYecfbo_d]m_j^j^[h[gk_h[Z\ebbem#
kffhejeYebm_bbhkdj^[h_iae\bei_d]_cfbWdji"Xed[
lebkc[ WdZ fheij^[j_Y ijhkYjkh[i$ J^_i fe_dj ckij
X[ [nj[di_l[bo Z_iYkii[Z m_j^ fWj_[dji _d WZlWdY[
X[YWki[WdoWjj[cfjiXo_dikhWdY[fhel_Z[hijeimWo
j^[c m_bb jWa[ fbWY[ _d j^[ [Whbo \ebbem#kf f^Wi[$
?j _i h[Yecc[dZ[Z je Wia fWj_[dji m^e Wh[ Yel[h[Z
Xo_dikhWdY[\ehWZlWdY[fWoc[djje]kWhZW]W_dij
Wdo Wjj[cfji Xo j^[ _dikhWdY[ fhel_Z[h je Yed\ki[
cWjj[hiX[YWki[_j_i_cfeii_Xb[jefh[Z_Yjj^[c[djWb
[\\[Yjie\j^_iijhWj[]oedj^[fWj_[dj$
<W_bkh[jef[h\ehcj^[d[Y[iiWhoicWbbWZ`kijc[dji
_d j^[ [Whbo feijef[hWj_l[ f^Wi[ cWo ]_l[ h_i[ je
ceZ[hWj[ehi[l[h[fheXb[ciZemdj^[heWZ$?dcWdo
YWi[i"j^[i[kdd[Y[iiWhoZ[l[befc[dji"m^_Y^YekbZ
^Wl[ X[[d Wle_Z[Z _d j^[ \_hij fbWY[" m_bb [l[djkWbbo
YWki[ j^[ fheij^[j_Y ijhkYjkh[ WdZ j^[ _cfbWdji je
X[beij$Edbom^[dfWj_[djiYec[jeh[Wb_p[el[hj^[
o[Whi j^Wj j^[ Xb[Wa fh[Z_Yj_edi e\ j^[ _dikhWdY[
Z[dj_ijiWdZ[nf[hjim[h[kd\ekdZ[Zm_bbj^[oh[]W_d
j^[_hYed\_Z[dY[_dj^[8E?_cfbWdjebe]_ij$J^[h[\eh["
j^[ fhe]dei_i e\ _cfbWdj#h[ijehWj_ed ioij[ci _d
j^[i[ fWj_[dji m_bb Z[f[dZ ed m^[j^[h j^[ jh[Wj_d]
Z[dj_ij ^Wi X[[d WXb[ je Yh[Wj[ YedZ_j_edi _d j[hci
e\ JC@ WdZ ckiYb[ \kdYj_ed" X[\eh[ j^[ fWj_[dj
ikhh[dZ[hijej^[_d`kh[hÉil[hXWbedibWk]^j"j^WjWh[
ijWXb[[dek]^jebWijekji[l[hWbo[WhiZkh_d]m^_Y^
È È $ENTALÈ4REATMENTÈ#ONTRACTÈ
Yecf[j[dj\ebbem#kf[nWc_dWj_edicWodebed][hX[
f[h\ehc[Z$
?j_i[l_Z[dj\hecj^[Yehh[ifedZ[dY[e\fWj_[dji
m_j^ j^[_h fh_lWj[ ^[Wbj^ _dikh[hi j^Wj j^[ bWjj[h
^Wl[WmWoe\Wjj[cfj_d]jeZ_ihkfjj^[Yed\_Z[dj_Wb
h[bWj_edi^_f X[jm[[d j^[ fWj_[dj WdZ j^[ f^oi_Y_Wd$
J^[_dikhWdY[fhel_Z[h_i"_d^_iemdkdZ[hijWdZ_d]"
W Yekdi[bbeh WdZ ]k_Z[ m^e WdWbop[i jh[Wjc[dj
iY[dWh_ei j^Wj jkhd ekj je X[ j_c[#Yedikc_d] WdZ
[nf[di_l[ \eh j^[ fWj_[dj" _d WZZ_j_ed je ]_l_d]
Yecf[j[djc[Z_YWbWZl_Y[WdZh[\[hh_d]j^[fWj_[djje
Wffhefh_Wj[jh[Wjc[dj\WY_b_j_[i$J^[ijWj[ZeX`[Yj_l[
_ije[dikh[efj_cWbc[Z_YWbYWh[WjWYY[fjWXb[Yeiji
Æ^[Wbj^ cWdW][c[djÇ$7i W feii_Xb[ Yedi[gk[dY["
j^[_dikh[hcWoY^WhWYj[h_p[j^[fbWdd[Zjh[Wjc[dj
m_j^ 8E? _cfbWdji WiÆdej `kij_\_[Z \hec W c[Z_YWb
fe_dj e\ l_[mÇ$ 7bj^ek]^ j^_i Y^WhWYj[h_pWj_ed
XWi_YWbbo h[\[hi je j^[ _dikhWdY[ jWh_\\" [l[d m[bb#
_d\ehc[Z fWj_[dji m_bb hekj_d[bo kdZ[hijWdZ _j je
_cfbo Wd Wbb[]Wj_ed e\ cWbfhWYj_Y[ eh [l[d \hWkZ$ ?j
]e[i m_j^ekj iWo_d] j^Wj ikY^ c_iYedY[fj_edi m_bb
W\\[Yj j^[ fWj_[dj#Z[dj_ij h[bWj_edi^_f _d W d[]Wj_l[
mWo$?dikhWdY[fhel_Z[hiWbieikffehjj^[_hYb_[dji_d
\[dZ_d] e\\ kd`kij_\_[Z Z[cWdZi Xo f^oi_Y_Wdi WdZ
Wh[[l[dWXb[jee\\[hb[]WbYekdi[bb_d]_dj^_ii_jkWj_ed
X[YWki[ j^[ YWi[i hekj_d[bo Ye_dY_Z[ m_j^ j^[_h h[#
\kiWbje]hWdjX[d[\_jiÆX[d[\_jcWdW][c[djÇ$J^_i
cWoh[ikbj_dWi_jkWj_edm^[h[Z_iXkhi[c[dje\j^[
X[d[\_j je j^[ fWj_[dj _i WjjWY^[Z je j^[ YedZ_j_ed
j^Wj j^[ fWj_[dj jhWdi\[hi Wdo `kij_\_[Z YbW_ci j^Wj
cWo fh[ikcWXbo Wh_i[ _d ^_i \Wlekh" j^ki [dWXb_d]
j^[_dikhWdY[fhel_Z[hjeh[YbW_cj^[Z[dj_ijÉi\[[Wj
WbWj[hj_c[_\Yecfb_YWj_edieYYkheh_\WYecfbW_dj
_ijeX[beZ][ZWije_dik\\_Y_[djfWj_[dj_d\ehcWj_ed$
J^[h[\eh[" j^[ 8E? _cfbWdjebe]_ij i^ekbZ Z[l[bef
W ijhWj[]o _d WZlWdY[ Wi je m^[j^[h ^[ m_i^[i je
Yehh[ifedZm_j^_dikhWdY[fhel_Z[hiWjWbbehfhel_Z[
j^[cm_j^jh[Wjc[dj#h[bWj[ZZeYkc[dji"WdZ_dm^Wj
i_jkWj_edi^[cWom_i^jeZeie$Iec[Z[djWbfhWYj_Y[i
ki[Wdej^[hWffheWY^j^Wj_i\Wc_b_Wh\hecj^[K$I$"
_$[$ j^[o YWhho ekj Wbb Yehh[ifedZ[dY[ Z_h[Yjbo m_j^
j^[ _dikhWdY[ fhel_Z[hi WdZ [l[djkWbbo fh[i[dj Wd
el[hWbb YedY[fj je j^[_h fWj_[dji j^Wj _dYbkZ[i Xej^
j^[ lWh_eki jh[Wjc[dj efj_edi WdZ j^[ h[if[Yj_l[
ikcij^Wjj^[_dikh[hYecc_jijeh[_cXkhi[$
J^Wda\kbbo"fheXb[cie\j^_ia_dZWh[b[iiYecced
m^[h[ Z[djWb _cfbWdj jh[Wjc[dji Wh[ dej Yel[h[Z
Xo _dikhWdY[ fhel_Z[hi _d j^[ \_hij fbWY[ dejWXbo
_d <hWdY[" Im_jp[hbWdZ" 7kijh_W WdZ j^[ 9[djhWb
;khef[Wd Yekdjh_[i$ ?d j^[i[ Yekdjh_[i" _dikhWdY[#
h[bWj[Z gk[ij_edi edbo Wh_i[ _d Yedd[Yj_ed m_j^
WYY_Z[dji"ehm_j^ioij[c_YehYed][d_jWbYedZ_j_edi
[$]$ W][d[i_i" ia[b[jjWb Z[\ehc_j_[i" [jY$$ ?d j^[i[
i_jkWj_edi" ^em[l[h" _dikhWdY[ fhel_Z[hi _d j^ei[
Yekdjh_[i m_bb ijW][ j^[ iWc[ a_dZ e\ ^Whb[gk_dWZ[
j^Wj=[hcWd_dikh[hiZe][d[hWbbo$B_a[_d=[hcWdo"
jh[Wj_d] _dikh[Z fWj_[dji _d W Yeij#[\\_Y_[dj cWdd[h
)*/
^Wi X[Yec[ l_hjkWbbo _cfeii_Xb[ _d j^ei[ Yekdjh_[i
Zk[jej^[Yecfb[nWZc_d_ijhWj_ede\j^[i[YWi[i$
J^[h[ _i WbmWoi W Y^WdY[ j^Wj fWj_[dji m^e ^Wl[
8E?_cfbWdji_dj^[_hcekj^m_bbl_i_jWdej^[hZ[dj_ij
m^e_idejWY[hj_\_[Zki[he\j^[8E?j[Y^debe]o$IkY^
i_jkWj_edicWo"\eh_dijWdY["Wh_i[m^[dfWj_[djiWh[ed
lWYWj_ed$<W_bkh[e\j^[fWj_[djje_d\ehcWdohWdZecbo
i[b[Yj[ZZ[dj_ijie\j^[8E?9edi[dikicWoYedij_jkj[
Wl_ebWj_ede\^_iYedjhWYjkWbeXb_]Wj_edijemWhZij^[
_cfbWdjebe]_ij$ 7\j[h Wbb" ][d[hWb fhWYj_j_ed[hi Wh[
kikWbbokdWmWh[e\j^[if[Y_\_Yh[gk_h[c[djie\8E?
_cfbWdji WdZ cWo j^[h[\eh[ f[h\ehc _dWffhefh_Wj[
jh[Wjc[dj ij[fi$ J^[o cWo [l[d h[cel[ _cfbWdji
_d W fh[cWjkh[ \Wi^_ed Wbj^ek]^ [nfbWdjWj_ed _i
dej _dZ_YWj[Z$ ?d j^_i i_jkWj_ed" j^[h[ cWo X[ W YWi[
W]W_dij W Z[dj_ij m^e f[h\ehc[Z j^_i jh[Wjc[dj _d
l_ebWj_ed e\ j^[ 8E? 9edi[diki" m^_Y^ YedjW_di
_dijhkYj_edih[]WhZ_d]j^[h[celWbe\8E?_cfbWdji$
J^[ 8E? 9edi[diki YWd X[ h[]WhZ[Z Wi W ]k_Z[b_d[
_iik[ZXoWÆif[Y_Wb_p[ZieY_[joÇ<WY^][i[bbiY^W\j"'-
m^_Y^kdZ[h=[hcWdbWmfej[dj_Wbbo_cfb_[ij^Wjj^[
XkhZ[de\j^[fhee\_ih[l[hi[ZWdZmekbZj^kih[ij
ed j^[ ded#Y[hj_\_[Z Z[dj_ij$'. >em[l[h" j^[h[ ^Wl[
X[[ddeYekhjZ[Y_i_edijej^_i[\\[Yjo[j$'/B_a[m_i["
_\ _cfbWdj _di[hj_ed Xo W ded#Y[hj_\_[Z Z[dj_ij \W_bi"
_j_ikdb_a[boj^Wjj^[XkhZ[de\fhee\h[]WhZ_d]j^[
ZWcW][^Wl_d]X[[dYWki[ZXoj^[Xh[WY^e\Zkjom_bb
X[h[l[hi[Zieb[boX[YWki[j^[Z[dj_ij_idejY[hj_\_[Z
eh ^Wi dej ^[[Z[Z Wdo kdademd _dijhkYj_edi Xo
j^[cWdk\WYjkh[h$Edj^[ej^[h^WdZ"_jm_bbX[[Wio
je ^ebZ j^_i Z[dj_ij h[ifedi_Xb[ \eh c_i`kZ]_d] ^_i
WX_b_j_[i BWk\i WdZ K^b[dXhkYa (&&($ 7\j[h Wbb" _j
_ij^[Z[dj_ijÉih[ifedi_X_b_jo"X[\eh[f[h\ehc_d]Wdo
a_dZe\jh[Wjc[dj"jeWii[ii^_iemdj^[eh[j_YWbWdZ
fhWYj_YWbademb[Z][e\j^[c[j^eZi_dlebl[Z$?dehZ[h
jefhel[^_iif[Y_Wb_p[Z[nf[hj_i[Wiioij[cki[h"^[
m_bb^Wl[jefheZkY[j^[Y[hj_\_YWj_edZeYkc[dj$(&
'- J^[h[ Wh[ Ykhh[djbo WhekdZ '*& e\ j^[i[ c[Z_YWb
ieY_[j_[i _d =[hcWdo" m^_Y^ ^Wl[ fkXb_i^[Z ]k_Z[b_d[i
WdZ h[Yecc[dZWj_edi e\ lWho_d] b[]Wb \ehY[ mmm$kd_$
Zk[ii[bZeh\$Z[%MMM%7MC<%Wmc\b[_j$^jc$
'. J^[ i_jkWj_ed YWd X[ YecfWh[Z je W l_ebWj_ed e\ :?D
ijWdZWhZi _d YedijhkYj_ed mehai" m^_Y^ _i Wiikc[Z je X[
j^[YWkiWj_l[\WYjeh_\ZWcW][^WieYYkhh[Z$
'/ 7YYehZ_d] je P_[]b[hÉi B[_jb_d_[d _c 7hpj^W\jkd]ih[Y^j"
L[hiH (&&)" +*+" j^_i jof[ e\ h[]kbWjeho \hWc[mehai ^Wi
dejcWZ[WZ[Y_i_l[_cfWYjedWdobWmik_jiXhek]^j_dXo
fWj_[dji Xkj ^Wi fbWo[Z Wd _di_]d_\_YWdj heb[ _d Yekhj je
ZWj[$ <eh Z_\\[h[dj ef_d_edi _d j^[ b_j[hWjkh[" i[[ <_]][d[h"
H[Y^jb_Y^[7if[aj[ led B[_jb_d_[d" :[kjiY^[ PW^dhpjb_Y^[
P[_jiY^h_\j"(&&)"''$
(&J^[ ki[ e\ W if[Y_Wb_p[Z ioij[c Xo ki[hi m^e ^Wl[ de
Y[hj_\_YWj_ed \eh j^_i ioij[c cWo X[ _d l_ebWj_ed e\ ™ ''
8[hk\iehZdkd]Z[hC8E#u'//-%(&&&"m^_Y^ij_fkbWj[ij^Wj
f^oi_Y_WdiWXekjjef[h\ehcjh[Wjc[djkdZ[hjWa[jeki[W
YediY_[dj_eki c[j^eZebe]o m_j^ Wffhefh_Wj[ [nWc_dWj_ed
WdZjh[Wjc[djj[Y^d_gk[i$
)+& 9^Wfj[h(*È #OUNSELLINGÈANDÈ#ASEÈ!CCEPTANCE
:[if_j[ j^[i[ \WYji" j^[ _cfehjWdY[ e\ j^[ 8E?
9edi[diki i^ekbZ dej X[ kdZ[h[ij_cWj[Z$ ?\ W 8E?
_cfbWdj_ih[cel[ZehZWcW][ZXoWZ[dj_ijYedjhWho
jej^[fhel_i_edi_dj^[9edi[diki"j^[fWj_[djmekbZ
^Wl[ je fhel[ j^Wj j^[ Z[dj_ij WYj[Z _d Xh[WY^ e\
^_i Zkj_[i$7 Yekhj#Wffe_dj[Z [nf[hj mekbZ ^Wl[ je
l[h_\o"XWi[ZedhWZ_e]hWf^i"m^[j^[hj^[9edi[diki
_dYbkZ[i jh[Wjc[dj _dijhkYj_edi \eh j^[ if[Y_\_Y
i_jkWj_ed Wj ^WdZ j^Wj j^[ Z[dj_ij \W_b[Z je ^[[Z$ ?\
j^[8E?_cfbWdjmWih[cel[ZWbj^ek]^h[celWbmWi
dej _dZ_YWj[Z" j^[ edbo mWo \eh j^[ Z[dj_ij je Wle_Z
b_WX_b_jo W\j[h Wbb mekbZ X[ je h[\kj[ j^Wj ^[ WYj[Z
_dWd[]b_][djmWo$J^_iYWi[mekbZX[hWj^[hm[Wa"
^em[l[h"_\j^[fWj_[dj^WZ_dZ_YWj[Zj^[dWc[e\j^[
8E?ioij[ceh[l[dfh[i[dj[Zj^[9edi[dikijej^[
Z[dj_ij$?\j^[Z[dj_ijj^[dcW_djW_dij^WjWdoZWcW][
je j^[ 8E? _cfbWdj _i dej j^[ h[ikbj e\ ^_i meha" ^[
m_bb ^Wl[ je fheZkY[ j^[ Z_W]deij_Y hWZ_e]hWf^i ie
j^Wj ^_i fWhj _d j^[ jh[Wjc[dj YWd X[ Z[\_d[Z ceh[
Ybei[bo$ ?\ hWZ_e]hWf^i m[h[ dej eXjW_d[Z" j^_i \WYj
m_bb ^Wl[ je [dj[h j^[ WffhW_iWb e\ [l_Z[dY[ Wi m[bb$
?\j^[ded#Wkj^eh_p[ZZ[dj_ijfh[lW_biedj^[fWj_[dj
je jWa[ b[]Wb WYj_ed W]W_dij j^[ 8E? fhel_Z[h" _j
_i h[Yecc[dZ[Z je Xh_d] _d W j^_hZ#fWhjo dej_Y[
W]W_dij j^[ Z[dj_ij" j^ki ZhW]]_d] ^_c _dje j^[
bWmik_j$ J^_i m_bb WkjecWj_YWbbo bWo j^[ \ekdZWj_ed
\ehWb_WX_b_joYWi[W]W_dijj^[Z[dj_ijm^eh[cel[Z
j^[ 8E? _cfbWdj YedjhWho je j^[ _dijhkYj_edi _d j^[
9edi[diki_\deXh[WY^e\ZkjodejWXbodel_ebWj_ed
W]W_dij j^[ 9edi[diki YWd X[ [ijWXb_i^[Z W]W_dij
j^[8E?ki[h$
7doWbj[hWj_ede\Wd[n_ij_d]8E?_cfbWdj_di_jk
Xo W ikXi[gk[dj i[YedZWho jh[Wjc[dj fhel_Z[h
cWo l_ebWj[ I[Yj_ed ( e\ j^[ =[hcWd h[]kbWj_ed
ed j^[ ki[ e\ c[Z_YWb fheZkYji" kdb[ii if[Y_\_YWbbo
Wffhel[Z Xo Wd Wkj^eh_pWj_ed ZeYkc[dj _iik[Z Xo
j^[cWdk\WYjkh[h$
Ed[ c_]^j [l[d Wia j^[ gk[ij_ed m^[j^[h j^[
YedYh[j[ h[Wb_pWj_ed WdZ _cfb[c[djWj_ed e\ W
jh[Wjc[dj fbWd i^ekbZ dej X[ Yedi_Z[h[Z W Yh[Wj_l[
WYj_l_jo ed j^[ fWhj e\ j^[ 8?E _cfbWdjebe]_ij WdZ
m^[j^[h Wdo ceZ_\_YWj_ed e\ j^[ jh[Wjc[dj h[ikbj
_i dej W l_ebWj_ed e\ j^[ Yefoh_]^j bWm ed j^[ fWhj
e\ j^[ i[YedZWho jh[Wjc[dj fhel_Z[h$ @kij b_a[ W
5PÈ2EPORT
ZhWm_d] [n[Ykj[Z Xo Wd WhY^_j[Yj Wi m[bb Wi j^[
Xk_bZ_d]YedijhkYj[Zedj^[XWi_ie\j^_iZhWm_d]Wh[
Xej^fhej[Yj[ZW]W_dijWdoikXi[gk[djceZ_\_YWj_ed
Xo Wdo j^_hZ fWhjo XWi[Z ed _dj[bb[YjkWb fhef[hjo
b[]_ibWj_ed" j^[ iWc[ fhej[Yj_ed YekbZ X[ W\\ehZ[Z
W Z[djWb jh[Wjc[dj fbWd WdZ _ji h[Wb_pWj_ed$ ?d Xej^
j^[i[YWi[i"^_]^bo_dZ_l_ZkWbZ[i_]d[hiebkj_ediWh[
Yh[Wj[Z XWi[Z ed j^[ _d_j_Wb XWi_Y if[Y_\_YWj_edi e\
j^[Ykijec[h$M^[dfbWdd_d]j^[_di[hj_ede\Z[djWb
_cfbWdji _dYbkZ_d] j^[ fheij^[j_Y ikf[hijhkYjkh["
_j _i kf je j^[ _cfbWdjebe]_ij je i[b[Yj j^[ _cfbWdj
ioij[cki[Z"jeYWh[\kbbo[lWbkWj[Z_\\[h[djjh[Wjc[dj
Wbj[hdWj_l[iWdZjeZ[j[hc_d[j^[dkcX[he\_cfbWdji
jeX[_di[hj[ZWdZj^[_h[\\[Yj_l[fei_j_ed_d]Wbbj^[
mWojeZ[i_]d_d]j^[fhefehj_edie\j^[h[ijehWj_ed$
?j _i dej ]hWjk_jeki j^Wj j^[ h[ikbj e\ j^_i YWh[\kb
fbWdd_d] WdZ _ji [n[Ykj_ed _i YWbb[Z W ÆZ[djWb
WZehdc[djÇehÆjeej^`[m[bb[hoÇXoiec[eXi[hl[hi$
?j_ij^[Z[djWbikh]_YWbWif[Yje\j^[fheY[Zkh[j^Wj
ceijYb[WhboZ[cedijhWj[ij^[Yh[Wj_l[dWjkh[e\j^[
fheY[ii$ <eh j^[ i[YedZWho jh[Wjc[dj fhel_Z[h je
YedjWYj j^[ eh_]_dWb 8E? _cfbWdjebe]_ij _i j^[h[\eh[
dej edbo _d j^[ _dj[h[ij e\ efj_c_p_d] j^[ Z[djWb
jh[Wjc[dj fheY[ii \eh j^[ X[d[\_j e\ j^[ fWj_[dj Xkj
WbiejeiW\[]kWhZj^[8E?_cfbWdjebe]_ijÉi_dj[bb[YjkWb
fhef[hjoYbW_ci$
J^[ \ebbem#kf f^Wi[ e\j[d h[l[Wbi j^Wj h[ijeh_d]
j[[j^ _d if[Y_\_Y `Wm Wh[Wi je \kbb beWZWX_b_jo cWo
YWki[ j^[ \ehY[i ed Wdo kdh[ijeh[Z h[i_ZkWb j[[j^
je _dYh[Wi[ ie hWf_Zbo j^Wj j^[i[ j[[j^ cWo ^Wl[ je
X[ h[fbWY[Z m_j^ _cfbWdji Wi m[bb je ijWX_b_p[ j^[
Wbh[WZoeXjW_d[ZikYY[ii\kbekjYec[$J^[feii_X_b_jo
e\ _dYbkZ_d] Wdo h[i_ZkWb j[[j^ _d j^[ fheij^[j_Y
ijhkYjkh[ i^ekbZ X[ Z_iYkii[Z X[\eh[ j^[ jh[Wjc[dj
_i ijWhj[Z$ 7do \b[nkhWb WdZ h[cel_d] \ehY[i WYj_d]
ed_cfbWdj#ikffehj[ZijhkYjkh[i_djem^_Y^h[i_ZkWb
j[[j^m[h[_dYehfehWj[ZWim[bbcWoh[ikbj_dWd[[Z
jeh[fbWY[j^[ikf[hijhkYjkh[ehje_di[hjWZZ_j_edWb
_cfbWdji _d j^[ \ebbem#kf f^Wi[$ J^_i Z[l[befc[dj
YekbZX[Wle_Z[ZXoh[cel_d]j^[h[i_ZkWbZ[dj_j_ed
h_]^j WmWo$ J^[h[\eh[" j^[ fWj_[dj _d\ehcWj_ed \ehc
_dYbkZ[iWfWiiW][jej^[[\\[Yjj^Wjf[h_eZ_Y\ebbem#
kf [nWc_dWj_edi WdZ jh[Wjc[dji m_bb X[ h[gk_h[Z
W\j[h_cfbWdjim[h[fbWY[ZWdZ\_jj[Zm_j^d[mj[[j^%
fheij^[j_Y h[ijehWj_edi WdZ j^Wj i_jkWj_edi e\ j^_i
a_dZcWoWh_i[\ehcWdoo[WhijeYec[$
Mh_jj[dY^[Yab_iji\eh\ebbem#kfWdZcW_dj[dWdY[
fkhfei[i Wh[ m_Z[bo ki[Z WdZ Yeccedbo WYY[fj[Z
_dej^[hif^[h[ie\b_\[Wim[bb$J^[Y^[Ya#kfh[fehj
fhefei[Z X[bem YecX_d[i [b[c[dji e\ Z_W]dei_i"
fWj_[dj _d\ehcWj_ed WdZ Yecfb_WdY[ _dijhkYj_edi$
7Yefoe\j^_ih[fehji^ekbZX[^WdZ[Zel[hjej^[
fWj_[dj$
È
#HECK
:[WhCh$%Ci$"
?d jeZWoÉi hekj_d[ [nWc_dWj_ed" j^[ \ebbem_d]
\_dZ_d]im[h[eXjW_d[Z0
QSEhWb^o]_[d[$J^[Wh[WiWhekdZj^[_cfbWdj
WXkjc[djim[h[dejYb[Wd[dek]^$?dfWhj_YkbWh0
QScWn_bbW
QSb[\j QSh_]^j
QS_di_Z[ QSekji_Z[ QScWdZ_Xb[
QSb[\j QSh_]^j
QS_di_Z[ QSekji_Z[
È È $ENTIST|SÈ7ARRANTYÈ/FFERÈ
QS9b[dY^_d]%]h_dZ_d]$OekhY^[m_d]ioij[c_i
el[hbeWZ[Z X[YWki[ oekh j[[j^ Wh[ [nY[ii_l[bo
WYj_l[$
QSIcea_d]$ Kd\WlekhWXb[ Yedi[gk[dY[i Wh[
l_i_Xb[edj^[j[[j^WdZ]kci$
QSOekhY^[m_d]fWjj[hd_ikd[l[d"_$[$oek^Wl[
fh[\[hWXboki[Zed[i_Z[\ehY^[m_d]$
QS?d jeZWoÈi hekj_d[ [nWc_dWj_ed" oek m[h[
_d\ehc[Z j^Wj j^[ \ebbem_d] jh[Wjc[dj WdZ
)+'
EdY[ j^[ _d_j_Wb jh[Wjc[dj ^Wi X[[d Yecfb[j[Z
ikYY[ii\kbbo eh j^[ \_hij h[YWbb i[ii_ed ^Wi X[[d
Yecfb[j[Z" j^[ fWj_[dj YWd X[ cej_lWj[Z \eh ceh[
bed]#j[hcYeef[hWj_ed$J^[jh[Wjc[djfhel_Z[hYekbZ
e\\[h W mWhhWdjo \eh j^[ ZkhWX_b_jo e\ j^[ jh[Wjc[dj
h[ikbj WY^_[l[Z" W mWhhWdjo" ^em[l[h" j^Wj YekbZ X[
_dlea[Z edbo _\ j^[ fWj_[dj ^_c# eh ^[hi[b\ Ze[i
[l[hoj^_d]jef[hf[jkWj[j^[\WlekhWXb[ijWjkigke0
Z_W]deij_Y h[gk_h[c[dji Wh[ fh[i[dj$ J^[
d[Y[iiWhoij[fii^ekbZX[jWa[dXooekh\Wc_bo
Z[dj_ijehXoki$J^[oi^ekbZX[f[h\ehc[Z
QSWiieedWifeii_Xb[
QSJ^[h[Wh[dej[dek]^Y^[m_d]kd_jiWlW_bWXb[$
J^[h[_iWh_iaj^Wjj^_icWoZWcW][oekhZ[dj_#
j_edWiWm^eb[$Oek^Wl[X[[d_d\ehc[Ze\j^[
\ebbem_d]jh[Wjc[djefj_edi0
QSEd[ehi[l[hWb_cfbWdji^Wl[jeX[jh[Wj[Z%
h[fbWY[Z$ Fb[Wi[ cWa[ Wd Wffe_djc[dj _cc[#
Z_Wj[bo$
QS
QS_dZk[Yekhi[WdZeYYWi_edWbbo
QS
?d jeZWoÈi hekj_d[ [nWc_dWj_ed" oek m[h[
_d\ehc[Z WXekj m^Wj oek i^ekbZ X[ Ze_d] je
WYj_l[boikffehjj^[jh[Wjc[djWdZjecW_djW_d
_jiikYY[ii\kbekjYec[$
QS?j_ih[Yecc[dZ[Zj^Wjoekgk_jicea_d]$
QSFb[Wi[ cWa[ Wd [\\ehj je \_dZ ekj m^_Y^
jeej^ Wh[Wi WdZ Ykifi _dj[h\[h[ m_j^ oekh
Y^[m_d] m^_b[ oek Wh[ [Wj_d]$ =[j XWYa je ki
_cc[Z_Wj[boje^Wl[j^[Yehh[ifedZ_d]eYYbkiWb
WZ`kijc[djicWZ[$
QS<ebbem j^[ Yb[Wd_d] _dijhkYj_edi ]_l[d _d
j^[ [dYbei[Z \WYj i^[[j" WdZ ki[ j^[ \ebbem_d]
WZZ_j_edWbjeebi0
QS?dj[hZ[djWbXhki^
QS:[djWb\beiim_j^%m_j^ekjj^h[WZ[h[dZ
QSIe\jjeej^Xhki^Z[i_]d[Z\ehY^_bZh[d $$$$$$$$$$$$$$$$$$mehaYel[h[ZXoj^[mWhhWdjo"fhel_Z[Z
QS?j _i h[Yecc[dZ[Z j^Wj oek f[h_eZ_YWbbo
kdZ[h]efhe\[ii_edWbZ[djWb^o]_[d[$
QSFb[Wi[ WbmWoi _d\ehc j^[ jh[Wj_d] Z[dj_ij
if[Y_\_YWbbo"WdZedoekhemd_d_j_Wj_l["e\Wdo
Z_i[Wi[i" Wbb[h]ebe]_YWb fheXb[ci eh Wdo ej^[h
Y^Wd][i_doekh\kdZWc[djWb^[Wbj^ijWjkiWdZ
f[hiedWbZWjW$
QSFb[Wi[ iY^[Zkb[ j^[ d[nj hekj_d[ Y^[Ya#
kf Wffe_djc[dj \eh$$$ ?\ oek [nf[h_[dY[ Wdo
fW_dehiocfjeciX[\eh[j^WjZWj["YedjWYjki
_cc[Z_Wj[bo$
:Wj[0
FWj_[dji_]dWjkh[:[dj_iji_]dWjkh[
$EARÈ0ATIENT
Dem j^Wj j^[ _d_j_Wb jh[Wjc[dj ^Wi X[[d
Yecfb[j[Z ikYY[ii\kbbo WdZ W ijWXb[ ijWj[ ^Wi
X[[d WY^_[l[Z" oek c_]^j Wia oekhi[b\ m^Wj
oek d[[Z je eXi[hl[ m^_b[ b_l_d] m_j^ Z[djWb
_cfbWdji$ <_hij e\ Wbb" _j cWo X[ ki[\kb je h[#
h[WZ j^[ i[Yj_ed [dj_jb[ZÆB_\[ m_j^ ?cfbWdjiÇ
e\ j^[ ?d\ehc[Z 9edi[dj \ehc oek i_]d[Z
X[\eh[jh[Wjc[dj$Oekj^kiWbh[WZoademWXekj
j^[ _cfehjWdY[ e\ h[]kbWh Y^[Ya#kfi" h[YWbb
i[ii_edi WdZ feii_Xbo Yehh[Yj_edi f[h\ehc[Z
Xo gkWb_\_[Z Z[dj_iji$ M[ mekbZ b_a[ je _dl_j[
oek je Wff[Wh \eh j^[i[ h[]kbWh Wffe_djc[dji"
WdZm[mekbZWbieb_a[je]_l[oekWd_Z[We\j^[
Yeij e\ j^[i[ Wffe_djc[dji$7j j^[ iWc[ j_c["
m[mekbZb_a[jee\\[hoekWmWhhWdjo"XWi[Zed
h[]kbWhWdZfei_j_l[fWj_[djYeef[hWj_ed"m^_Y^
m_bb ^[bf oek [dikh[ j^[ fh[i[hlWj_ed e\ j^[
jh[Wjc[djh[ikbjWY^_[l[Zie\Wh$
È
$ENTISTSÈ7ARRANTYÈ/FFER
J^[Z[dj_ije\\[hij^[fWj_[djWi[l[d#o[Wh%kdb_c_j[Z
Yecfh[^[di_l[ mWhhWdjo e\ j^[ ZkhWX_b_jo e\ j^[
jh[Wjc[djh[ikbjeXjW_d[Zm_j^h[]WhZjej^[_cfbWdji
WdZfheij^eZedj_Ymeha_dj^[h[]_ede\jeej^$$$$$$$$$$$
j^[fWj_[dji^emi"_dj^[[l[djj^Wj^[ehi^[cWa[i
Wdo YbW_ci kdZ[h j^_i mWhhWdjo" j^Wj ^[ eh i^[ ^Wi
Wff[Wh[Z\ehWjb[WijjmeWddkWbh[YWbbWffe_djc[dji
ceh[ _\ h[gk_h[Z WdZ _\ ie ehZ[h[Z Xo j^[ Z[dj_ij
m_j^W8E?#Y[hj_\_[ZZ[dj_ij$
? ^[h[Xo ]_l[ co Z[dj_ijÉi e\\_Y[ f[hc_ii_ed je
h[c_dZ c[ e\ _cf[dZ_d] h[YWbb Wffe_djc[dji$ J^[
[nj[dj e\ j^[ [nWc_dWj_ed WdZ Wdo Z_W]deij_Y eh
j^[hWf[kj_Y c[Wikh[i m_bb X[ Z[j[hc_d[Z Xo j^[
Z[dj_ijWjj^[h[YWbbi[ii_ed$J^[i[Wbe\WdoY[hj_\_[Z
8E? Z[dj_ij i[[ iWcfb[ el[hb[W\ i[hl[i Wi fhee\
j^Wjj^[h[if[Yj_l[h[YWbbi[ii_edmWiYecfb[j[Z$
?W]h[[jeX[_dle_Y[ZWYYehZ_d]jej^[\ebbem_d]
ijW]][h[Z fh_Y[ b_ij fkXb_i^[Z Xo j^[ ;khef[Wd
7YWZ[c_YIeY_[jo\eh?cfbWdjebe]o;7I?[$L$lWb_Z
Wif[h*<[XhkWho(&&*0
)+( 9^Wfj[h(*È #OUNSELLINGÈANDÈ#ASEÈ!CCEPTANCE

$PTU
PG
JOJUJBM
#BTJD
DIBSHF
$PNQSFIFOTJWF
4VSDIBSHF
GPS

4VSDIBSHF
GPS
MPTT
5PUBM
&63

USFBUNFOU
$PNQSFIFOTJWF
XBSSBOUZ
GPS
BOZ
XPSL
DFSBNJD
WFOFFST
SFQMBDFNFOU
QFS
ZFBS
&63
XBSSBOUZ
UIBU
JODMVEFT
OBUVSBM


UFFUI

 
m
 





 
m
 





 
m
 





 
BOE
BCPWF




 

J^[ WXel[ ijW]][h[Z fh_Y[ b_ij _dYbkZ[i j^[ Yeij" v ?\j^[h[]_ijhWj_ed\ehc\ehj^[\Wc_bof^oi_Y_Wd

h[bWj[Zjej^[mWhhWdj[Zmeha"e\ eh Z[dj_ij mWi dej [n[Ykj[Z WYYkhWj[bo WdZ
v 7jb[WijjmeWddkWb[nWc_dWj_ediWdZWbbZ[djWb \W_j^\kbbo$
jh[Wjc[dj$ v ?\ j^[ h[YWbb Wffe_djc[dji Wh[ [nY[[Z[Z Xo
v½ 7bb Z_W]deij_Y c[Wikh[i hWZ_e]hWf^i WdZ Wbb ceh[j^Wdjmecedj^i$
\ebbem#kf[nWc_dWj_edi$ v ?\ W Y[hj_\_[Z Z[dj_ij _i dej Yedikbj[Z _d j^[
v 7do Yehh[Yj_edi _d j^[ Z[djWb bWXehWjeho [l[dj e\ Wdo YecfbW_dji eh _\" _d j^[ [l[dj e\
l[d[[hi WdZ Z[djWb Yehh[Yj_edi [$]$ eYYbkiWb Z[djWb [c[h][dYo jh[Wjc[dj" YedjWYj m_j^ W
WZ`kijc[dje\Xh_Z][i"WdZh[fbWY[c[dj_dj^[ Y[hj_\_[ZZ[dj_ij_idejjWa[d_cc[Z_Wj[bo$
[l[dje\Xh_Z][\W_bkh["Wibed]WiikY^j^[hWfo v ?\ j^[ fWj_[dj bWj[h h[\ki[i je Yecfb[j[ j^[
Wff[WhijeX[fhec_i_d]$ h[Yecc[dZ[Z jh[Wjc[dj" j^Wj _i" _\ ^[ eh i^[
h[\ki[i je ^Wl[ ^_i eh ^[h Yecfb[j[ Y^[m_d]
J^[fh_Y[ib_ij[ZZedej_dYbkZ[j^[Yeije\0 \kdYj_ed h[ijeh[Z" _dYbkZ_d] bWj[h _d i_jkWj_ed
v Fhe\[ii_edWb jeej^ Yb[Wd_d] WdZ f[h_eZedjWb _dm^_Y^j[[j^%Yhemdi%Xh_Z][iWh[beij_dej^[h
jh[Wjc[dj h[]_edi$
v H[celWbe\l_i_Xb[c[jWbWiWh[ikbje\WZ`kij# v ?\ j^[ mWhhWdjo meha ^Wi X[[d ZWcW][Z Xo
c[dji d[Y[iiWho je cW_djW_d j^[ Y^[m_d] [nj[hdWb _d\bk[dY[i WYY_Z[dj" ded#Y[hj_\_[Z
\kdYj_ed$ jh[Wjc[djfhel_Z[hi"fWj_[djX[^Wl_ekhdejYed#
v =[d[hWb Z[djWb i[hl_Y[i ekji_Z[ j^[ h[]_ed e\ ZkY_l[jefhef[hj^[hWfo$
j^[mWhhWdj[Zmeha$
?d j^[ [l[dj j^Wj j^[ mWhhWdjo _i fhef[hbo WdZ
J^_imWhhWdjom_bbX[le_Z_dWdoe\j^[\ebbem_d] `kij_\_WXbo _dlea[Z" j^[ W\\b_Yj[Z Z[djWb _cfbWdj
i_jkWj_edi0 _dYbkZ_d]j^[ikf[hijhkYjkh[m_bbX[h[fbWY[Z\h[[
v ?\j^[fWj_[dj^WiWdej^[hZ[djWbehehj^eZedj_Y e\Y^Wh][jej^[fWj_[djXoj^[jh[Wj_d]f^oi_Y_Wd"
jh[Wjc[dj f[h\ehc[Z j^Wj cWo _d\bk[dY[ j^[ eh" Xo fh_eh ckjkWb W]h[[c[dj" Xo Wdej^[h 8E?#
mWhhWdj[Zmeham_j^ekjfh_ehYedikbjWj_edm_j^ Y[hj_\_[ZZ[dj_ij$
WdZj_c[bo\ebbem#kf[nWc_dWj_edXoj^[Y[hj_#
\_[ZZ[dj_ij[$]$d[mZ[djWbmeha_dj^[effe#
'PMMPXVQ

4FBM
PG

$IFDLVQ
i_d]`Wm"heejYWdWbjh[Wjc[dje\W\\[Yj[Zj[[j^"
BQQPJOUNFOU
#0*
PGGJDF
SFQPSU
EBUFE
[jY$$ $PNQMFUJPO

v ?\ j^[ fWj_[dj Ze[i dej [dikh[ WZ[gkWj[ ehWb PG
JOJUJBM
USFBUNFOU
^o]_[d[ehZe[idej^edekhj^[h[Yecc[dZWj_ed
\ehfhef[hYWh[e\j^[Z[djWbmehaWdZj^[ehWb *OJUJBM
USFBUNFOU

YWl_joWjbWh][$ JOUFSSVQUFE
v ?\ j^[ fWj_[dj Ze[i dej ikXc_j je W jh[Wjc[dj
eh c[Z_YWb [nWc_dWj_ed h[Yecc[dZ[Z Xo j^[ 
Z[dj_ij f^oi_ej^[hWfo" c[Z_YWb Y^[Ya#kfi" 
ej^[h c[Z_YWb [nWc_dWj_edi" XbeeZ WdWboi[i
Zk[jeej^[h_bbd[ii[i$ 

$ISCLAIMERJ^[Wkj^ehicWa[deYbW_cij^WjWdoe\ b[]WblWb_Z_joe\j^[\ehckbWj_ediki[Z_dj^[fh_dj[Z
j^[ijWj[c[djicWZ[_dj^_iY^Wfj[hWh[b[]WbbolWb_Z$ \ehci_dYbkZ[ZWiiWcfb[i$
?d fWhj_YkbWh" j^[o i^Wbb dej X[ h[ifedi_Xb[ \eh j^[

#(!04%2È
,EGALÈ!SPECTSÈOFÈ4HERAPEUTICÈ
!LTERNATIVESÈANDÈ#OSTSÈÈ
#OURTÈ$ECISIONSÈANDÈ(EALTHÈ)NSURERS
.JDIBFM
;BDI
È
)NTRODUCTION
M_j^ [l[ho _cfbWdj fheY[Zkh[" j^[ Z[djWb
_cfbWdjebe]_ij _i \WY[Z m_j^ j^[ \WYj j^Wj j^[ Xed[
i_jkWj_ed_i_dlWh_WXboZ_\\[h[dj_dZ_\\[h[djfWj_[dji$
?dWYjkWbfhWYj_Y["j^_i^Wib[ZjeWi_jkWj_edm^[h["
_\j^[h[_idej[dek]^Xed[lebkc[WlW_bWXb[_dj^[
cWn_bbWehcWdZ_Xb["j^[Xed[e\j^[h[if[Yj_l[`Wm
m_bbX[h[Xk_bjjeik_jj^[h[gk_h[c[djie\WYecced
jof[e\_cfbWdj_dj^[lWijcW`eh_joe\YWi[i$
J^[ikh]_YWbj[Y^d_gk[j^WjYedj_dk[ijeX[ki[Z
jeZWo_\_dik\\_Y_[djl[hj_YWbXed[lebkc[_ifh[i[dj_i
WYecX_dWj_ede\Wd_b_WYYh[ij]hW\jWdZWYedYkhh[dj
eh ikXi[gk[dj _di[hj_ed e\ W Yh[ijWbbo \hec j^[
Wbl[ebWh h_Z][ _di[hj[Z iYh[m# eh Yob_dZ[h#i^Wf[Z
_cfbWdj\_njkh[$J^_ij[Y^d_gk[_ih[]kbWhboWiieY_Wj[Z
m_j^WdkdikffehjWXbo^_]^XkhZ[dedj^[fWj_[djÉi
^[Wbj^$ 8[YWki[ e\ j^[ bWh][ dkcX[h e\ ki[hi e\
iYh[m _cfbWdji" dkc[heki ikh]_YWb j[Y^d_gk[i m[h[
Z[l[bef[Z_dj^[fWijZ[i_]d[Zjef[hc_jj^[_di[hj_ed
e\ iYh[m _cfbWdji [l[d _d i_jkWj_edi m^[h[ Xed[
WlW_bWX_b_jo_ibem$J^[kdZ[hbo_d]fh_dY_fb[i[[cije
X[j^Wjm^[h[l[h_dik\\_Y_[djXed[lebkc[_iWlW_bWXb["
Xed[ lebkc[ ckij X[ ][d[hWj[Z" eh Xed[ j_iik[
jhWdifbWdj[Z"_dehZ[hjeW\\ehZh[j[dj_edjej^[iYh[m
_cfbWdji$;if[Y_Wbbo\ehj^[[nj[di_l[bofd[kcWj_p[Z
cWn_bbWho i_dki" W fheY[Zkh[ ^Wi \h[gk[djbo X[[d
ki[Z _d j^[ fWij '+o[Whi m^[h[ Wkjebe]eki Xed[
cWj[h_Wb _i ^Whl[ij[Z \hec j^[ fWj_[djÉi emd _b_WY
Yh[ij"fWh_[jWbXed["ehed[ehceh[h_XiWdZfbWY[Z
edje j^[ cWn_bbWho i_dki \hec YWkZWbbo X[bem$
J^[Xed[]hW\j_i_dj[dZ[Zje_dj[hYedd[Yjm_j^j^[
[n_ij_d] Xed[" e\\[h_d] j^[ iYh[m _cfbWdji j^Wj Wh[
_di[hj[Z YedYkhh[djbo eh ikXi[gk[djbo ik\\_Y_[dj
WdY^ehW][$J^_i_ij^[fheY[Zkh[\Wlekh[ZWj=[hcWd
kd_l[hi_j_[i WdZ [cfbeo[Z Xo j^[ ]h[Wj cW`eh_jo e\
cWn_bbe\WY_Wbikh][edi$J^[jhWdifbWdjWj_ede\Xed[
_dje j^[ `Wm h[]_ed _i m^Wj cWa[i j^[ `Wmi ik_jWXb[
\ehYh[ijWb_cfbWdjj^[hWfo_dj^[\_hijfbWY[$
?j_im[bbademdj^Wjj^[h_iaie\j^_ij[Y^d_gk[Wh[
[dehceki$J^[jhWdifbWdj[ZXed[cWo\W_b"fWhj_Wbbo
eh Yecfb[j[bo" je Yedd[Yj m_j^ j^[ cWn_bbWho i_dki$
J^[ jhWdifbWdj cWo X[ beij" h[ikbj_d] _d fkhkb[dj
_d\[Yj_ed e\ j^[ cWn_bbWho i_dki WdZ WZZ_j_edWb
 ¬ 
Yedi_Z[hWXb[ beii e\ beYWb Xed[ ikXijWdY[$ ?\ j^[
_cfbWdjim[h[fbWY[ZWjj^[iWc[j_c[Wij^[]hW\j[Z
Xed[" j^[o" jee" Wh[ beij _d j^_i i_jkWj_ed$ FheXb[ci
_d Yel[h_d] j^[ ie\j#j_iik[ Z[\[Yji cWo h[gk_h[
WZZ_j_edWb ikh][ho" m^_Y^ cWo h[ikbj _d ZWcW][ je
WZ`WY[djijhkYjkh[i"dejWXboj^[iWb_lWho]bWdZi$
;l[d_\j^[Xed[]hW\j^[WbiikYY[ii\kbbo"Zk[jej^[
WXi[dY[e\WZ[gkWj[lWiYkbWh_pWj_ede\j^[jhWdifbWdj
ed[mekbZ^Wl[je[nf[Yjj^[jhWdifbWdjjeX[Yec[
d[Yhej_Y"Wjb[Wij_dfWhj"fei_d]Wd_d\[Yj_ed^WpWhZ"
eh [bi[ j^[ jhWdifbWdj[Z j_iik[ c_]^j Xo ibembo
h[iehX[Z$ J^[ _b_WY Yh[ij ]hW\j _i e\j[d h[cel[Z Wj
j^[ ^eif_jWb" _d ][d[hWb WdW[ij^[i_W$ Ed jef e\ j^[
kikWb h_iai WiieY_Wj[Z m_j^ ][d[hWb WdW[ij^[i_W" j^[
Yedi[gk[dY[ie\h[cel_d]Xed[\hecj^[_b_WYYh[ij
WbieX[Whc[dj_ed_d]0M^_b[-+e\j^[fWj_[djiWh[
WXb[ je mWba m_j^ekj YhkjY^[i W\j[h jme m[[ai" j^[
XWbWdY[e\Z_h[YjZWcW][jej^[^_f_iYedi_Z[hWXb[
b[ii\WlekhWXb[$)&e\j^[fWj_[djim_bbdejX[WXb[
jem[WhWX[bjW]W_d\ehj^[h[ije\j^[_hb_l[i$FW_db[ii
[h[Yj ]W_j _i e\j[d feii_Xb[ W]W_d edbo W\j[h cedj^i
eh[l[do[Whie\fhWYj_i[m_j^ZW_boceX_b_jojhW_d_d]
WdZf^oi_ej^[hWfo$
7bb j^_i Wbj^ek]^ iYh[m _cfbWdji ^Wl[ X[Yec[
eXieb[j[ WdomWo \eh cWdo _dZ_YWj_edi j^Wdai je
j^[ Z[l[befc[dj e\ ej^[h" \Wij[h WdZ b[ii ijh[ii\kb
j[Y^d_gk[i$ ?d fWhj_YkbWh" XWiWb eii[e_dj[]hWj[Z
_cfbWdji" W lWh_[jo e\ Z_ia _cfbWdji" YWd X[ ki[Z
je h[ijeh[ [l[d W i[l[h[bo Wjhef^_[Z cWn_bbW eh
cWdZ_Xb[$
È
3CREWÈ)MPLANTSÈ#OMBINEDÈÈ
WITHÈ)LIACÈ#RESTÈ"ONEÈ'RAFTSÈnÈÈ
3TILLÈhTHEÈ3TATEÈOFÈTHEÈ!RTv
Ki_d]iYh[m_cfbWdji_dYecX_dWj_edm_j^jhWdifbWdji
e\ Wkje][deki Xed[ XbeYai \hec j^[ fWj_[djÉi _b_WY
Yh[ijcWoYedij_jkj[XeZ_bo_d`kho[$]$kdZ[hI[Yj_ed
(()e\=[hcWdoÉiF[dWb9eZ[$J^[ij[WZo]hemj^e\
j^[ XeZo e\ c[Z_YWb ademb[Z][ WdZ j^[ [l[h ceh[
\_d[bo Z_\\[h[dj_Wj[Z j^[hWf[kj_Y c[Wikh[i cWa[ _j
Z_\\_Ykbj\ehj^[YekhjiWdZ\ehc[Z_YWbfhe\[ii_edWb
WiieY_Wj_ediWb_a[jeZ[\_d[Yh_j[h_W\ehZk[Z_b_][dY[
Wih[gk_h[ZXo"[$]$I[Yj_ed(-,e\j^[=[hcWd9_l_b
)+* 9^Wfj[h(+È ,EGALÈ!SPECTSÈOFÈ4HERAPEUTICÈ!LTERNATIVESÈANDÈ#OSTS

9eZ[$J^[_Z[WjeZ[h_l[j^[Yh_j[h_W\ehZk[Z_b_][dY[ i_dY[ de bed]#j[hc fhe]dei_i YWd [l[h X[ WYYehZ[Z

\hec j^[ ]k_Z[b_d[i e\ fhe\[ii_edWb WiieY_Wj_edi je jh[Wjc[dj c[j^eZi j^Wj Wh[ cel_d] \ehmWhZ$+
^Wi X[[d Z_iYkii[Z Xo <_]][d[h (&&) WdZ P_[]b[h J^[ h[gk_h[c[dji je X[ c[j Xo ikY^ W bed]#j[hc
(&&)$ J^_i _i Wbie jhk[ e\ j^[ \_[bZ e\ Z[djWb WdZ fhe]dei_iWh[Z_\\_YkbjjeZ[\_d["]_l[dj^[hWf_Zif[[Z
cWn_bbe\WY_Wb ikh][ho :[kjiY^ '/.)1 8=>P -1 H>P e\ Z[l[befc[dj _d j^[ \_[bZ e\ c[Z_YWb j[Y^debe]o$
'+'1<WbbiY^”ii[b'/.+1=W_iXWk[h'//+"'//-1Add_d] J^[ikYY[iiijWj_ij_Yi\ehXej^ioij[ciYWde\Yekhi[
'/./1 E[^b[h (&&)1 HWjW`YpWa (&&&1 H_[i [j Wb$ (&&(1 X[ YecfWh[Z$ 7 h[ijh_Yj_l[ cec[dj _i j^[ \WYj j^Wj
IY^_dd[dXkh](&&&1ledP_[]d[h(&&'$ Wkj^ehi j[dZ je fkXb_i^ edbo ijkZ_[i _d m^_Y^ j^[_h
?b_WY Yh[ij Xed[ ]hW\ji _d j^[ci[bl[i YWd Wbh[WZo meha mWi ikYY[ii\kb1 \W_bkh[i Wh[ fkXb_i^[Z ckY^
Yedij_jkj[Wjh[Wjc[dj[hhehX[YWki[Wdej^[hikh]_YWb ceh[ hWh[bo" X[YWki[ Ze_d] ie Ze[i dej Yedjh_Xkj[
j[Y^d_gk[ Ä j^[ 8E? j[Y^d_gk[ Ä _i WlW_bWXb[ je j^[ jej^[Wkj^ehÉiijWdZ_d]_dj^[iY_[dj_\_YYecckd_jo$
Z[dj_ijj^Wj_ib[iijWn_d]edj^[fWj_[djZkh_d]ikh][ho ?dWZZ_j_ed"Æfei_j_l[ÇfkXb_YWj_ediWdZj^[_hWkj^ehi
_ji[b\WdZ^Wi\[m[hWZl[hi[[\\[Yji$7Ikf[h_eh9ekhj Wh[][d[hWbboifedieh[ZXo_dj[h[ij[ZfWhj_[iikY^Wi
hkb_d]' Yedi_Z[hi ikh][ho _d ][d[hWb WdW[ij^[i_W cWdk\WYjkh[hi$
je X[ W jh[Wjc[dj [hheh ieb[bo ed j^[ ijh[d]j^ e\
j^[ WZl[hi[ [\\[Yji" i_dY[ j^[ ikh][ed ^WZ W b[ii
%XCURSIONÈ3UCCESSÈ3TATISTICSÈÈ
jWn_d]Wbj[hdWj_l[Wj^_iZ_ifeiWb$J^[b_j[hWjkh["jee"
FORÈ!LTERNATIVEÈ4REATMENTÈ-ETHODS
Yedi_Z[hij^[i[b[Yj_ede\WYedi_Z[hWXboceh[jWn_d]
jh[Wjc[djc[j^eZjeX[Wl_ebWj_ede\j^[ikh][edÉi M_j^h[]WhZjei_ckbjWd[ekiedbWoeij[efbWijo_dj^[
eXb_]Wj_ed je f[h\ehc j^[ b[Wij _dlWi_l[ fheY[Zkh[ cWn_bbWYedYkhh[djikffehj_l[Xed[fbWY[c[djWdZ
j^Wj"j^[h[\eh["c[[jij^[Z[\_d_j_ede\XeZ_bo_d`kho" _cfbWdj_di[hj_ed"M_dj[h[jWb$'//-"_dj^[_hh[l_[m
Wi bed] Wi W b[ii _dlWi_l[ o[j [gkWbbo fhec_i_d] Whj_Yb["h[fehjj^[\ebbem_d]_cfbWdjbeiihWj[i0
jh[Wjc[dj c[j^eZ [n_iji$ ?d j^_i YWi[" j^[ ikh][edÉi
WYj_edi l_ebWj[ j^[ cWn_c e\ h_ia c_d_c_pWj_ed "VUIPS
:FBS
-PTT
SBUF

:FBST

fh_ckc d_b deY[h[$ ?d j^[ fWj_[djÉi X[ij _dj[h[ij"



QPTUPQFSBUJWFMZ
e\ jme [gk_lWb[dj jh[Wjc[dj Wbj[hdWj_l[i" W ikh][ed
,BIOCFSH
FU
BM



ckij][d[hWbboi[b[Yjj^[c[j^eZj^Wj_ib[iijWn_d]
"EFMM
FU
BM



edj^[fWj_[dj$(7Z[Y_i_ed_d\Wlekhe\Wceh[_dlW# /ZTUSÕN
FU
BM



i_l[ fheY[Zkh[ cWo Yedij_jkj[ W jh[Wjc[dj [hheh 8BHOFS


OE
kdb[iij^[jh[Wjc[djfhel_Z[hYWdY_j[WYecf[bb_d] /FVLBN



h[Wied _d W if[Y_\_Y i_jkWj_ed$ J^_i fh_dY_fb[ Wbie
^ebZi_\Wjh[Wjc[djfhel_Z[hmWdjijeZ[Y_Z[W]W_dij 8[jj[h h[ikbji YWd X[ eXjW_d[Z ki_d] j^[ jme#ij[f
j^[ 8E? j[Y^d_gk[ _d j^[ fh[i[dY[ e\ W i[l[h[bo c[j^eZ m_j^ i[YedZWho _cfbWdjWj_ed ;ii[h WdZ
Wjhef^_[ZcWn_bbW$ :”hiY^ '//,$ J^_i ijkZo Z_h[Yjbo YecfWh[Z j^[
M_j^j^[iYh[m_cfbWdjj[Y^d_gk[m_j^_b_WYYh[ij
Xed[ ]hW\j" j^[ fWj_[dj ik\\[hi ikh]_YWb _dj[hl[dj_ed
Wjj^[^_fXed[kdZ[h][d[hWbWdW[ij^[i_WWiieY_Wj[Z
' EB= Ikf[h_eh 9ekhj e\ Pm[_Xh”Ya[d hkb_d]" C[ZH '/.)"
m_j^ j^[ feijef[hWj_l[ i[gk[bW[ Z[iYh_X[Z WXel[$
'/*$
J^[fWj_[djckijWYY[fjWfhejhWYj[Z^[Wb_d]f[h_eZ" ( J^[_Z[W_iWYjkWbbojh_l_WbWdZedbod[[ZijeX[jhWdi\[hh[Z
m^_b[ XbWZ[ eh Z_ia _cfbWdji YWd X[ beWZ[Z W\j[h je j^[ Yedj[nj ed ^WdZ0 Wdo jeej^ [njhWYj_ed j^[ ceh[
edbo W \[m ZWoi m_j^ekj Wdo ikh]_YWb _dj[hl[dj_ed _dlWi_l[ c[Wikh[ ckij X[ fh[Y[Z[Z Xo Wd Wjj[cfj je
\eh ^Whl[ij_d] Wkjebe]eki Xed[ X[_d] d[Y[iiWho fh[i[hl[ j^[ jeej^" [$]$ Xo [dZeZedj_Y jh[Wjc[dj eh ej^[h
IfW^d '//($ 7 Z_ijh_Yj Yekhj) ^[WhZ [nf[hji WdZ Yedi[hlWj_l[c[j^eZi$CWdof[hj_d[dj[nWcfb[i\hecYekhj
Z[j[hc_d[Zj^[Z[Y_Z_d]\WYjehjeX[j^Wjj^[ki[e\ hkb_d]i YWd X[ \ekdZ _d E[^b[h (&&)$ E\ Yekhi[" j^[ hkb[
W8E?_cfbWdjYekbZWle_ZWXed[]hW\j_dWfWj_[dj e\ cWn_ckc fh[i[hlWj_ed e\ jeej^ ikXijWdY[ _d jeej^
fh[fWhWj_ed ckij X[ eXi[hl[Z Wi m[bb" W hkb[ j^Wj" Wced]
m_j^ fhedekdY[Z cWn_bbWho Xed[ Wjhef^o WdZ j^Wj
ej^[hj^_d]i"W_ciWjc_d_c_p_d]j^[[nj[dje\j^[ikh]_YWb
j^[_cfbWdjYekbZX[beWZ[Z_cc[Z_Wj[boZk[jej^[ fheY[Zkh[$
i^ehj^[Wb_d]j_c[$* ) BWdZ][h_Y^jZ_ijh_YjYekhje\:k_iXkh]Hkb_d]*E').%/-
FhejW]ed_iji e\ Yh[ijWb _cfbWdjebe]o h[]kbWhbo e\((I[fj[cX[h(&&)$
fe_dj je X[jj[h Y^WdY[i e\ ikYY[ii j^[_h c[j^eZ * J^[YekhjiWmdeh[Wiedjehkb[edm^[j^[hehdejWYh[ijWb
e\\[hiWdZjej^[_hWbb[][Zo[Whie\eXi[hlWj_edWdZ fheY[Zkh[ mekbZ ^Wl[ X[[d WYY[fjWXb[ WYYehZ_d] je j^[
[cf_h_YWb fhee\" iec[j^_d] j^Wj j^[ 8E? j[Y^d_gk[ ijWhje\j^[Whj_dZ[dj_ijho$
+ 7bed]#j[hcfhe]dei_iYWdX[e\\[h[ZedboW\j[hWc[j^eZ
_i iW_Z dej je e\\[h0 W bed]#j[hc fhe]dei_i _i iW_Z
^Wi X[[d ki[Z el[h W Y[hjW_d f[h_eZ e\ j_c[$ J^[ WXi[dY[
je X[ WXi[dj$ J^[ iWc[ Z_ijh_Yj Yekhj" _d _ji hkb_d] e\ ikY^ W fhe]dei_i Wbed[ Ze[i dej _d _ji[b\ d[]Wj[
`kij h[\[hh[Z je" Yekdj[h[Z m_j^ j^[ Wh]kc[dj j^Wj [gk_lWb[dY[$
j^[WXi[dY[e\ikY^Wfhe]dei_iZe[idejc[Wdj^Wj  ?dWZZ_j_ed"Z_ia_cfbWdjiWbie^Wl[WZlWdjW][iel[hYedl[d#
j^[ jme ioij[ci YWddej X[ Yedi_Z[h[Z [gk_lWb[dj" j_edWbYh[ijWb_cfbWdji$
È È 3CREWÈ)MPLANTSÈ#OMBINEDÈWITHÈ)LIACÈ#RESTÈ"ONEÈ'RAFTSÈ )++

ed[#ij[fWdZj^[jme#ij[fc[j^eZ0M^_b[)+e\j^[ 7d _dj[h[ij_d] ijkZo _d j^_i Yedj[nj _i j^Wj e\
_cfbWdji m[h[ beij m_j^ j^[ ed[#ij[f c[j^eZ" edbo IYehj[YY_ '/// m^[h[ Yh[ijWb WdZ XWiWb _cfbWdji
+$+ m[h[ beij m_j^ j^[ jme#ij[f c[j^eZ$ J^[ jejWb m[h[ _di[hj[Z _d j^[ iWc[ fWj_[dji$ >[h[" -( \_n[Z
mW_j_d] j_c[ je [nfeikh[ j^_hZ ef[hWj_ed \eh j^[ Xh_Z][i ed -.) _cfbWdji '*( ijhkYjkh[Z Yh[ijWb
jme#ij[f c[j^eZ mWi ''$*cedj^i$ ?d ceij YWi[i" _cfbWdjiWdZ,*'Z_ia_cfbWdjim[h[\ebbem[Zel[h
fWj_[djiYekbZX[fhel_Z[Zm_j^j[cfehWhoYecfb[j[ Wf[h_eZe\X[jm[[d'&cedj^iWdZ*o[Whi$Ded[e\
Z[djkh[i *m[[ai W\j[h _cfbWdjWj_ed$ I_dY[ Xej^ j^[ j^[ _cfbWdji mWi beij$ CkY^ ceh[ _cfehjWdj j^Wd
Wk]c[djWj_edfheY[Zkh[WdZj^[[nfeikh[fheY[Zkh[ j^[ Yedi_Z[hWj_ed e\ j^[ _cfbWdj ikYY[ii[i _i j^[
d[Y[ii_jWj[iec[j_c[_dm^_Y^WZ[djkh[YWddejX[ hWj_e e\ ,*' 8E? _cfbWdji je '*( iYh[m _cfbWdji$
mehd"j^[jejWbÆjeej^b[iiÇf[h_eZm_bbX[edj^[ehZ[h J^_i hWj_e _cfh[ii_l[bo i^emi j^Wj W m[bb#l[hi[Z
e\,Ä.m[[ai$;ii[hWdZ:”hiY^ZedejWZZh[iiYWi[i _cfbWdjebe]_ij m^e _i \h[[ \hec _dZkijho _dj[h[iji
e\Xed[]hW\jbeiiYWki_d]j^[jh[Wjc[djYekhi[jeX[ WdZm^e_i[gkWbboYedl[hiWdjm_j^Yh[ijWbWdZXWiWb
WXehj[Z[l[dX[\eh[Wdo_cfbWdjim[h[[l[hfbWY[Z$ _cfbWdjefj_edi"^WiWZ[gkWj[jeebi\ehXej^ioij[ci
J^[Xed[]hW\jef[hWj_ed_d_ji[b\YekbZX[Wiie# WdZa[[fi_dijeh[Wi[b[Yj_ede\_cfbWdji\hecXej^
Y_Wj[Zm_j^WYecfb_YWj_edhWj[e\'+Ä(&edWl[hW][$ ioij[ci mekbZ ki[ 8E? _cfbWdji m_j^ W \h[gk[dYo
KdbeWZ[ZXed[ÄWdZj^_i_dYbkZ[iXed[jhWdifbWdj[Z \ekhje\_l[j_c[i^_]^[hj^Wd\ehiYh[m_cfbWdj$
_dje j^[ cWn_bbWho i_dki Ä bei[i kf je .& e\ _ji J^WjdejWi_d]b[8E?_cfbWdj_iki[ZWj=[hcWd
lebkc[m_j^_dWo[Wh$ kd_l[hi_j_[ijeZWockijj^[h[\eh[X[em[Zjej^[Z_#
:[f[dZ_d]edj^[lebkc[WdZgkWb_joe\j^[Xed[ ijehj_d] _d\bk[dY[ [n[hj[Z Xo h[fh[i[djWj_l[i e\
_dj^[cWn_bbW"Xej^bem[hWdZ[l[d^_]^[hbeiihWj[i _dZkijho ifediehi m^e [ijWXb_i^ iYh[m _cfbWdj
^Wl[X[[dh[fehj[Z\ehiYh[m_cfbWdji0 ioij[ci _d j^[ cWha[j Xo mWo e\ j^[i[ kd_l[hi_j_[i
WdZ^Wl[j^[_hfheif[Yj_l[Ykijec[hih[Y[_l[Wed[#
"VUIPS
:FBS
-PTT
SBUF

:FBST
i_Z[Z"ibWdj[Z[ZkYWj_ed_dj^[ki[e\j^[i[ioij[ci




QPTUPQFSBUJWFMZ Ä Wbb Wj j^[ [nf[di[ e\ j^[ jWnfWo[h" e\ Yekhi[$ ?j
_i j^[h[\eh[ d[Y[iiWho je l_[m j^[ Æh[ikbjiÇ e\ j^[
+BGGJO


 kd_l[hi_joÆh[i[WhY^Ç_dj^[b_]^je\j^[\WYjj^Wjj^[
'SJCFSH


 _dZkijho Zedehi e\ ie#YWbb[ZÆj^_hZ#fWhjo ij_f[dZiÇ
m_bb _d\bk[dY[ j^[ Z_h[Yj_ed j^Wj kd_l[hi_jo h[i[WhY^
?d ][d[hWb" _j cWo X[ iW_Z j^Wj j^[ fheXWX_b_jo e\ jWa[i$ <eh j^_i h[Wied" Æ[nf[hjÇ Yekhj ef_d_edi Xo
ikhl_lWb\ehYh[ijWb_cfbWdji_dj^[cWn_bbW_dYh[Wi[i kd_l[hi_jo fhe\[iiehi m_j^ _dWZ[gkWj[ fhWYj_YWb
m_j^ j^[ b[d]j^ e\ j^[ _djhWeiiWb fehj_ed e\ j^[ ademb[Z][WdZ[nf[h_[dY[cWol[hom[bb^Wl[jeX[
_cfbWdj$ J^[ ceh[ l[hj_YWb Xed[ _i fh[i[dj fh_eh je l_[m[Z ceij Yh_j_YWbbo m^[d _j Yec[i je Wii[ii_d]
Wk]c[djWj_ed"j^[X[jj[hj^[_cfbWdjm_bbX[h[jW_d[Z$ j^[ lWbk[ e\ Wd _ddelWj_l[ jh[Wjc[dj c[j^eZ$ Edbo
J^[eh[j_YWbbo"bWh][h_cfbWdjZ_Wc[j[hic_]^je\\[hW hWh[bom_bb_jX[feii_Xb[je][jWYekhjjeZ_ic_iiWd
]h[Wj[hWdY^eh_d]ikh\WY[m_j^_dj^[Xed[1_dWYjkWb kdik_jWXb[Æ[nf[hjÇ_dWdWYjkWbYekhjYWi[$,
fhWYj_Y[" ^em[l[h" j^[ WZlWdjW][i e\ bWh][h _cfbWdj ;l[d_\j^[ef[hWj_d]Z[dj_ijÄfeii_Xb[X[YWki[e\
Z_Wc[j[hi ekjm[_]^ j^[ X[d[\_ji _d j^[ cWn_bbW Wi \[Whe\j^[kd^eboWbb_WdY[X[jm[[d_dZkijhoWdZj^[
m[bbWi_dj^[cWdZ_Xb[$ kd_l[hi_j_[ifhel_Z_d]j^[Æ[nf[hjiÇ_dj^[[l[dje\W
?\ j^[ fheY[Zkh[i \eh fh[fWh_d] j^[ _cfbWdj X[Z jh_WbÄmekbZfh[\[hdejjeki[j^[8E?j[Y^d_gk["^[
jhWdifbWdjWj_ed"Wk]c[djWj_ed"Z_ijhWYj_edWdZWdo ehi^[YekbZij_bbe\j[dWle_Zj^[_b_WYYh[ijef[hWj_ed
ej^[h fheY[Zkh[i Wh[ f[h\ehc[Z i[fWhWj[bo" [WY^ Xo ki_d] W c_njkh[ e\ _dZkijh_Wb Xed[ h[fbWY[c[dj
fheY[Zkh[Yedij_jkj[iWi[fWhWj[c[Z_YWbh_ia$FWj_[dji
ckijX[_d\ehc[Ze\j^[Wffhen_cWj[_dZ_l_ZkWbh_ia
\_]kh[iWdZfeii_Xb[Yedi[gk[dY[i"Wim[bbWie\j^[
, ?d W YWi[ ^[WhZ Xo j^[ EB= ikf[h_eh Yekhj e\ >Wcc
ikce\j^[h_iaie\WbbfheY[Zkh[ih[gk_h[ZjeeXjW_d
jh[Wjc[djikYY[ii$ (&K',/%/.YedY[hd_d]Fhe\[iieh@eei\hecCkdij[h"j^[
Æ[nf[hjÇ mWi dej Z_ic_ii[Z kdj_b _j ^WZ X[[d fhel[d j^Wj"
9ecfWhWj_l[ ZWjW ed 8E? ikYY[ii hWj[i YWd X[ YedjhWho je ^_i ijWj[c[dj" j^[ Z_ia _cfbWdji j^Wj m[h[ j^[
\ekdZWi\ebbemi0 ikX`[Yje\j^[YekhjYWi[^WZd[l[hX[[dh[cel[ZWjWbb"deh
d[[Z[ZjeX[h[cel[Z"WdZkdj_b[l[dj^[Yekhj^WZjWa[d
dej[ e\ j^[ \WYj j^WjÆKI <:7 WffhelWbÇ Ä YbW_c[Z Xo j^[
"VUIPS
:FBS
-PTT
SBUF

:FBST
iWc[Æ[nf[hjÇ je X[ W fh[h[gk_i_j[ \eh cWha[j_d] W ioij[c




QPTUPQFSBUJWFMZ _d=[hcWdoWdZ\ehYeijh[_cXkhi[c[djXo=[hcWd^[Wbj^
_dikh[hiÄ_ie\WXiebkj[bodeYedi[gk[dY[^[h[$J^[h[Wied
4QBIO


 ]_l[d \eh j^[ Z_ic_iiWb" ^em[l[h" mWi dej j^[ eXl_ekibo
4DPSUFDDJ


 \Wbi[WdZed[#i_Z[ZijWj[c[djicWZ[1hWj^[hj^[YekhjY_j[Z
%POTJNPOJ
FU
BM


 j^Wj_jÆmekbZX[kdh[WiedWXb[edj^[fWhje\j^[Yekhjje
*IEF.VUUFS


 \khj^[hXkhZ[dj^[[nf[hjm_jd[iim_j^j^[[\\ehje\^Wl_d]
jefWhj_Y_fWj[_dj^_ijh_WbÇ$
)+, 9^Wfj[h(+È ,EGALÈ!SPECTSÈOFÈ4HERAPEUTICÈ!LTERNATIVESÈANDÈ#OSTS
cWj[h_WbiWdZWkjebe]ekiXed[\ehh[ZkY_d]j^[i_p[
e\j^[cWn_bbWhoi_dki$?dj^[i[YWi[i"j^[cWn_bbWho
i_dki _i WYY[ii[Z \hec j^[ cekj^ WdZ j^[ c_njkh[
_djheZkY[Z\hecj^[h[$?\j^[WlW_bWXb[l[hj_YWbXed[
^[_]^j_dj^[_cfbWdjh[]_ed_iWjb[Wij+cc"iYh[m
_cfbWdjicWoX[fbWY[ZWjj^[iWc[j_c[$BeWZ_d]YWd
X[[\\[Yj[ZW\j[h,Ä/cedj^i$J^[b_j[hWjkh["^em[l[h"
h[fehjim_Z[boZ_l[h][djikYY[iihWj[i\ehj^_iÆi_dki
]hW\j_d]Çj[Y^d_gk["hWd]_d]\hec/+je-&$J^[i[
Z_\\[h[dY[ic_]^jX[em[Zjej^[Z_\\[h[dj_dZ_YWj_edi
_d j^[ Z_\\[h[dj ijkZo WdZ je Z_\\[h[dY[i _d h[i_ZkWb
Xed[ lebkc[$ ?d WZZ_j_ed" j^[ jof[ e\ h[ijehWj_ed
WdZ j^[ h[i_ZkWb Z[dj_j_ed fbWo Wd _cfehjWdj heb["
Wi j^[ \ebbem_d] h[Wied_d] i^emi0 A^ekho '///
h[fehji ed (', i_dki ]hW\j fWj_[dji m_j^ *,- Yh[ijWb
_cfbWdjiWdZedbo(.beij_cfbWdji$J^_ic[Wdij^Wj
WdWl[hW][e\($',_cfbWdjimWi_di[hj[Zf[hfWj_[dj$
J^_ic[Wdij^WjceijfWj_[djickij^Wl[fh[i[dj[Z
m_j^ W kd_bWj[hWb YWdj_b[l[h i_jkWj_ed j^Wj Ze[i dej
[nfei[j^[_cfbWdjije[nY[ii_l[cWij_YWjeho\ehY[i$
Ed j^[ YedjhWho0 j^[ cWij_YWjeho beWZ _i kikWbbo
Z_ijh_Xkj[ZWced]j^[h[cW_dZ[he\j^[Z[dj_j_ed_d
j^[i[YWi[i$?cfbWdjikf[hijhkYjkh[iWh[b[\j"m^ebbo
eh _d fWhj" _d ie#YWbb[Z _d\hW#eYYbki_ed$ ?cfbWdji
_d _d\hW#eYYbki_ed eh Yecfb[j[bo ded#\kdYj_edWb
_cfbWdji^Wl[WckY^^_]^[hfheXWX_b_joe\ikhl_lWb
j^Wd _cfbWdji kdZ[h \kdYj_edWb beWZ" X[YWki[ j^[
Z[b[j[h_ekibWj[hWb\ehY[i_dj^[YebbWhh[]_edj^WjYWd
h[ikbj_dj^[\ehcWj_ede\Xed[YhWj[hiWdZkbj_cWj[bo
[l[d_cfbWdjbeiiWh[WXi[dj$J^_ifheY[Zkh[mekbZ
e\Yekhi[X[_dYedY[_lWXb[_dYecfb[j[bo[Z[djkbeki
fWj_[dji" i_dY[ j^[_h _cfbWdj#ikffehj[Z Z[djkh[i
Wh[WbmWoiikX`[Yjjej^[\kbb_cfWYje\cWij_YWjeho
\ehY[i$
7dej^[h YedYbki_ed j^Wj YWd X[ ZhWmd \hec j^[
\_]kh[iWXel[_ij^Wjj^[Wl[hW][W][e\j^[fWj_[dji
ckij^Wl[X[[dYecfWhWj_l[bobem"i_dY[ceijYWi[i
_dlebl[Zedbokd_bWj[hWbYWdj_b[l[hi_jkWj_edi$Oekd][h
fWj_[djiWh[ceh[\WlekhWXboi_jkWj[Zm^[d_jYec[i
je_cckd[h[ifedi[iWdZlWiYkbWh_pWj_ed$J^[ijkZo
ijWj[i j^Wj j^[ W][ e\ j^[ fWj_[dji mWi X[jm[[d ((
WdZ,/o[Whi$F[h^Wfij[bb_d]bo"j^[_hWl[hW][W][mWi
dej]_l[d$
7ij^[WXel[^Wii^emd"j^[ÆiY_[dj_\_Yh[ikbjiÇe\
WbbijkZ_[ickijX[[nWc_d[Z_dZ[jW_bWdZY^[Ya[Z\eh
be]_YWbfbWki_X_b_joWdZh[b[lWdY[$:_h[YjYecfWh_ied
X[jm[[dZ_\\[h[djijkZ_[i_id[Whbo_cfeii_Xb["i_dY[
ijkZo Z[i_]di kikWbbo Z_l[h][ ]h[Wjbo" WdZ _d ceij
YWi[i"Y[hjW_dZ[jW_bi_cfehjWdj\ehWdo[lWbkWj_ede\
j^[ijkZoWh[c_ii_d]$
7 i_c_bWhbo _dlWi_l[ fheY[Zkh[ \hWk]^j m_j^
i_c_bWhbo ]h[Wj h_iai je j^[ fWj_[dj _i h[fei_j_ed_d]
j^[ cWn_bbW eh cWdZ_Xb[$ ?\ j^[ ifWj_Wb h[bWj_edi^_f
e\ Xej^ `Wmi _i _dYehh[Yj" j^_i m_bb h[ikbj _d
Yedi_Z[hWXb[ kdf^oi_ebe]_YWb beWZ_d] e\ j^[ j[[j^
WdZ" W\j[h [l[djkWb jeej^ beii" _d Wd _dWX_b_jo je
[Wj m_j^ h[celWXb[ Z[djkh[i$ <eh j^_i h[Wied" _j _i
Wjj[cfj[ZjeYehh[YjeYYbkiWbZ_iYh[fWdY_[i_d[Whbo
oekj^ Xo ehj^eZedj_Y c[Wdi ]hemj^ Yedjheb$ ?\
j^[Z_iYh[fWdY_[ih[cW_dkdjh[Wj[Z"j^_im_bbkikWbbo
^Wl[WYb[WhboWZl[hi[_cfWYjedj^[ijWj_Yi_jkWj_ed
e\j^[Z[dj_j_edel[hj^[fWj_[djÉib_\[$
J^_i _i m^o" _d [Whb_[h o[Whi" _j mWi h[Y[_l[Z
fheY[Zkh[j^Wjj^[`Wmim[h[Xhek]^jYbei[hje][j^[h
Xo ikh]_YWb c[Wdi" Wj j^[ bWj[ij m^[d Wd _dWX_b_jo
je m[Wh Z[djkh[i X[YWc[ cWd_\[ij$ J^[ h_iai e\
j^_i ikh][ho" el[h WdZ WXel[ j^[ h_ia e\ ][d[hWb
WdW[ij^[i_W"_dYbkZ[fWhW[ij^[i_We\j^[cWdZ_XkbWh
d[hl["_d\[Yj_edi"ZWcW][jeh[i_ZkWbj[[j^"WdZÄ_d
j^[cWn_bbWÄ\kbbehfWhj_Wbd[Yhei_ie\j^[h[beYWj[Z
Xed[ i[]c[dj$ J^[i[ h_iai _dYh[Wi[ m_j^ j^[ W][ e\
j^[ fWj_[dj$ ?d WZZ_j_ed" Wbie Z[f[dZ_d] ed j^[ W][
e\j^[fWj_[dj"ioij[c_Yh_iaiWbie[n_ijZ_WX[j[iWdZ
cWdo ej^[hi$ IW_b[h h[fehji W bed]#j[hc h[ikbj e\
,$(+ e\ beij _cfbWdji W\j[h Wd Wl[hW][ +(cedj^i
m_j^ YedYkhh[dj B[ <ehj ? eij[ejeco cWn_bbWho
h[beYWj_ed0j^[cWn_bbW_ii[fWhWj[Z\hecj^[h[ije\
j^[YhWd_kcWdZh[WjjWY^[Zje_j_dWceh[\WlekhWXb[
fei_j_ed" m^[h[ j^[ cWn_bbW X[Yec[i h[WjjWY^[Z je
j^[ YhWd_kc WdZ _di[hj_ed e\ iYh[m _cfbWdji _dje
j^[ cWn_bbW$ J^_i h[ikbj _dZ_YWj[i j^Wj Wj b[Wij j^[
_cfbWdj ikYY[ii Ze[i dej ik\\[h ed WYYekdj e\ j^[
WZZ[Z _dlWi_l[ ikh]_YWb fheY[Zkh[ Ä fhel_Z[Z" e\
Yekhi[" j^Wj j^[h[ _i [dek]^ l[hj_YWb Xed[ WlW_bWXb[
\eh_di[hj_d]Yh[ijWb_cfbWdji$
7j b[Wij j^[ h_iai fei[Z Xo WYY[iieho ikh][ho
YWd X[ h[ZkY[Z eh Wle_Z[Z jeZWo Xo ki_d] j^[ 8E?
j[Y^d_gk[0?dWi_d]b[fheY[Zkh["kikWbbof[h\ehc[Z
ed Wd ekjfWj_[dj XWi_i" Wj b[Wij \ekh _cfbWdji Wh[
_di[hj[Zf[h`Wm_dijhWj[]_Yfei_j_edi"_cfbWdjij^Wj
m_bb ikXi[gk[djbo ikffehj W fheij^[j_Y ijhkYjkh[$
8o efj_c_p_d] j^[ fei_j_edi e\ j^[ WXkjc[dji" [l[d
bWh][hWcekdjie\b[l[hW][YWdX[d[kjhWb_p[Z\hec
j^[ fe_dj e\ l_[m e\ Xej^ j^[ h[ijehWj_ed WdZ j^[
_cfbWdji WdZ jhWdi\[hh[Z je j^[ `WmXed[ m_j^ekj
YWki_d] ZWcW][$ @Wm h[fei_j_ed YWd X[ Wle_Z[Z"
WdZ fWj_[dji YWd X[ fhel_Z[Z m_j^ WZ[gkWj[ WdZ
\kdYj_edWb\_n[ZZ[djkh[i$
È
)MPLANTOLOGISTSÈANDÈ"/)È$ISCLOSUREÈÈ
4HEÈ'ERMANÈ,EGALÈ3ITUATION
M^[j^[hj^[ki[e\8E?j[Y^d_gk[i^WZX[[dfh[\[hWXb[
eh[l[dcWdZWjeho_dW]_l[djh[Wjc[dji_jkWj_ed_i
iec[j^_d] j^Wj m_bb e\j[d ^Wl[ je X[ Z[j[hc_d[Z
h[jheif[Yj_l[bo$ >em[l[h" [l[ho _cfbWdjebe]_ij m_bb
^Wl[ je Z[j[hc_d[ ^_i eh ^[h emd fei_j_ed ed
m^_Y^Wbj[hdWj_l[jh[Wjc[djc[j^eZijeX[e\\[h[Zje
fWj_[djim_j^_dj^[\hWc[mehae\fWj_[djZ_iYbeikh[$
?dWYjkWbh[Wb_jo"Z[dj_ije\j[dZedej_d\ehcfWj_[dji
e\ej^[h_cfbWdjebe]_YWbj[Y^d_gk[iikY^Wij^[8E?
j[Y^d_gk[$?\j^Wj_ij^[YWi["j^[Yedi[djedj^[fWhj
È È )MPLANTOLOGISTSÈANDÈ"/)È$ISCLOSUREÈ
e\j^[fWj_[djje^Wl[Wkjebe]ekiXed[h[cel[ZWdZ
ikXi[gk[djbojhWdifbWdj[ZcWoX[le_Z\hecWb[]Wb
fe_dje\l_[mX[YWki[j^[fWj_[djmWidej_d\ehc[Z
e\WdWbj[hdWj_l[jh[Wjc[djc[j^eZj^Wj_ib[iijWn_d]
edj^[fWj_[djiXkjWjb[Wij[gkWbbo[\\[Yj_l[$
J^[ eX`[Yj_l[ e\ fWj_[dj Z_iYbeikh[ _i je [nfbW_d
je j^[ fWj_[dj j^[ d[Y[ii_jo WdZ j^[ [nj[dj e\ j^[
jh[Wjc[dj h[gk_h[Z$- Je X[ WXb[ je [lWbkWj[ j^[
d[Y[ii_joe\WfheY[Zkh["fWj_[djickijX[_d\ehc[Z
e\[n_ij_d]jh[Wjc[djWbj[hdWj_l[i"i_dY[j^[oYWddej
cWa[Wd_d\ehc[ZZ[Y_i_edej^[hm_i[$FWj_[djickij
ademÆhek]^boÇm^Wjj^[oWh[Yedi[dj_d]je"X[YWki[
ej^[hm_i[ j^[o YWddej \h[[bo Z[Y_Z[ m^[j^[h je
WYY[fjj^[jh[Wjc[djh_ia$.
:[dj_iji Z_iYkii_d] _b_WY Yh[ij Xed[ ]hW\ji m_j^
j^[_h fWj_[dji m_bb WbmWoi ^Wl[ je _d\ehc j^[c e\
j^[ h_iai b_ij[Z _d j^[ _djheZkYjeho i[Yj_ed e\ j^_i
Y^Wfj[h"j^Wj_i"j^[om_bb^Wl[jeb[jj^[cademj^Wj
_j_ifeii_Xb[j^Wjj^[Xed[jeX[jhWdifbWdj[ZcWoeh
cWodejX[Yecfb[j[boh[jW_d[Z"j^Wjj^[jhWdifbWdj
cWo j^[h[\eh[ X[ beij" j^Wj fkhkb[dj _d\[Yj_edi cWo
eYYkh" WdZ j^Wj WZZ_j_edWb ikh][ho cWo X[Yec[
d[Y[iiWho8[^h[di[jWb$(&&'/$;l[dm^[dh[cel_d]
Xed[XomWoe\WXed[fkdY^ijWdp[cWoh[ikbj_d
_djhWef[hWj_l[Xb[[Z_d]"c[Z_WbehbWj[hWbf[h\ehWj_ed
eh feijef[hWj_l[ fW_d" ^W[cWjecWi" i[di_j_l_jo
fheXb[ci"]W_jfheXb[ci"eh^_f\hWYjkh[$
M_j^ekjZekXj"_d\ehc_d]fWj_[djiWXekjWbj[hdWj_l[
jh[Wjc[dj c[j^eZi YWd i_]d_\_YWdjbo _d\bk[dY[ j^[_h
Z[Y_i_edi" [if[Y_Wbbo _\ j^[ Wbj[hdWj_l[i Wh[ b[ii
_dlWi_l[$'&FWj_[djiYWddejademXoj^[ci[bl[im^Wj
jh[Wjc[dj Wbj[hdWj_l[i j^[o ^Wl[$ J^_i _i m^o j^[
ikh][ed" XWi[Z ed ^_i fhe\[ii_edWb ademb[Z][" m_bb
^Wl[ je fe_dj ekj j^ei[ Wbj[hdWj_l[i je j^[ fWj_[dj
C_Y^Wbia_'//-1FWbWdZj#>[_dh_Y^i(&&)$
J^_i _i m^o _d\ehc_d] fWj_[dji e\ [n_ij_d] [gk_#
lWb[dj jh[Wjc[dj Wbj[hdWj_l[i Wh[ Yedi_Z[h[Z Wd
[ii[dj_WbWdZ_dZ_if[diWXb[fWhje\j^[ikh][edÉiZkjo
e\ Z_iYbeikh["'' i_dY[ Z_\\[h[dj jh[Wjc[dj c[j^eZi
YWd ^Wl[ Z_\\[h[dj jh[Wjc[dj h[ikbji" Y^WdY[i e\
ikYY[ii" WdZ h_iai e\ \W_bkh[$'( J^[ ikh][ed ^Wi Wd
eXb_]Wj_ed je fbWki_Xbo [nfbW_d j^[ WZlWdjW][i WdZ
Z_iWZlWdjW][i e\ j^[ lWh_eki jh[Wjc[dj efj_edi je
j^[ fWj_[dj$') FWj_[dji ckij X[ ]_l[d W Y^e_Y[ _\ W
Y^e_Y[[n_iji$J^[Yekhji^Wl[Yedi_ij[djbo^[bZj^Wj
ikY^WY^e_Y[Ze[i[n_ij_\"Wjj^[j_c[e\jh[Wjc[dj"
j^[h[ _i W YedYh[j[ Wbj[hdWj_l[ m_j^ W bem[h h_ia eh
XkhZ[d eh m_j^ ]h[Wj[h Y^WdY[i e\ ikYY[ii WdZ j^Wj
j^_i Wbj[hdWj_l[ _i WlW_bWXb[ WdZ fhWYj_YWb IY^[bb_d]
WdZ ;hb_d][h (&&)$ ?\ j^[h[ Wh[ i[l[hWb jh[Wjc[dj
c[j^eZi m_j^ Z_\\[h[dj h_iai WdZ Y^WdY[i j^Wj Wh[
[gkWbbo_dZ_YWj[Z\hecWc[Z_YWbfe_dje\l_[m"j^Wj
_i"_\j^[h[_iWjhk[Y^e_Y[j^WjfWj_[dji^Wl["fWj_[dji"
^Wl_d] h[Y[_l[Z W Yecfh[^[di_l[ Z_iYbeikh[ Xo j^[
ikh][ed"ckijX[b[\jjeZ[Y_Z[\ehj^[ci[bl[im^Wj
jh[Wjc[dj _i je X[ f[h\ehc[Z WdZ m^Wj h_iai j^[o
Wh[m_bb_d]je_dYkh$'*Eh"ceh[i_cfbofkj0FWj_[dji
)+-
YWdedboY^eei[Wced]Z_\\[h[djjh[Wjc[djefj_edi
_\ j^[o Wh[ \Wc_b_Wh m_j^ j^[i[ efj_edi$ J^[ Yekhji'+
^ebZ j^Wj j^_i _i j^[ YWi[ [if[Y_Wbbo _\ j^[h[ _i W
ik_jWXb[ Wbj[hdWj_l[ j^Wj mekbZ ifWh[ fWj_[dji \hec
^Wl_d]jekdZ[h]eikh][ho_d][d[hWbWdW[ij^[i_W$
?d j^[_h Z_iYbeikh[" jh[Wjc[dj fhel_Z[hi ckij
WZZh[ii j^ei[ jef_Yi j^Wj h[Ye]d_pWXbo i[[c je X[
e\ _dj[h[ij je fWj_[dji$ J^[i[ jef_Yi m_bb h[]kbWhbo
_dYbkZ[WbemdkcX[hWdZ_dj[di_joe\_dj[hl[dj_edi"
cWn_ckc fh[i[hlWj_ed e\ jeej^ ikXijWdY[" WdZ W
h[ijehWj_ed e\ cWij_YWjeho \kdYj_ed m_j^ c_d_ckc
^[Wb_d]j_c[i$7bbj^[i[fe_dji^_]^b_]^jWZlWdjW][i
e\ j^[ 8E? j[Y^d_gk[$ A[[f_d] _dj[h[ij[Z fWj_[dji
_]dehWdje\j^[ccWoh[dZ[hj^[fWj_[djÉi?d\ehc[Z
9edi[dj h[]WhZ_d] Yh[ijWb _cfbWdji WdZ Xed[ ]hW\j
jh[Wjc[dj_dlWb_Z$
J^[ ikh][ed mekbZ [l[d X[ eXb_][Z je _d\ehc
j^[ fWj_[dj e\ j^[ 8E? j[Y^d_gk[ _\ ed[ m[h[ je
\ebbem j^[ Wh]kc[dj j^Wj j^_i j[Y^d_gk[ _i ij_bb
Wd Ækdehj^eZenÇ j[Y^d_gk[$', J^[ ikh][ed
ckij _d\ehc j^[ fWj_[dj [l[d e\ j^[ [n_ij[dY[ e\
Ækdehj^eZenÇ j[Y^d_gk[ Wi bed] Wi j^_i j[Y^d_gk[
cWa[i i[di[ \hec c[Z_YWb fe_dj e\ l_[m"'- m^_Y^
_i dej Z[d_[Z Xo j^[ fhejW]ed_iji e\ Yedl[dj_edWb
_cfbWdjebe]_YWb c[j^eZi _d j^[ YWi[ e\ 8E?$ J^_i
h[cW_di jhk[ [l[d _\ j^[ Z_iYbei_d] ikh][ed YWddej
f[h\ehcj^_ij[Y^d_gk[WdZmekbZ^Wl[jeh[\[hj^[
fWj_[dj [bi[m^[h[$ ?d gk[ij_edi YedY[hd_d] b_WX_b_jo"
ikh][edi ckij WZZh[ii eX`[Yj_edi je j^[ fh[lW_b_d]
Yedi[diki$ Del[b c[j^eZi ckij X[ Z_iYbei[Z [l[d
_\j^[iY_[dj_\_YZ_iYekhi[YedY[hd_d]j^[i[c[j^eZi
^Wi dej X[[d Yecfb[j[Z IY^[bb_d] WdZ ;hb_d][h
(&&)" Wi bed] Wi j^[h[ Wh[ i[h_eki fhejW]ed_iji e\
j^[i[ c[j^eZi _d j^[ \_[bZ e\ c[Z_YWb iY_[dY[ j^Wj
- 8L[h\= =[hcWd 9edij_jkj_edWb Yekhj hkb_d]" D@M '/-/"
'/)&$
. 8=>=[hcWd<[Z[hWb9ekhjhkb_d]"D@M'//("-+*1D@M
'/-*"'*(($
/ J^_ifkXb_YWj_ed"^em[l[h"b[Wl[ied[jemedZ[hm^oedbo/'
e\)/.fWj_[djijh[Wj[ZWdZ\ebbem[Z_dj^[iWc[mWom[h[
_dYbkZ[Z _d j^[ ijWj_ij_Yi$ Edbo j^[ Z[iYh_fj_ed e\ feii_Xb[
Yecfb_YWj_edi YWd X[ Yedi_Z[h[Z ki[\kb _d j^_i meha$ J^[
ijWj_ij_YiWh[kdkiWXb[\eheXjW_d_d]iY_[dj_\_Y[l_Z[dY[$
'& 8=>=[hcWd<[Z[hWb9ekhjhkb_d]"D@M'//("-+*$
'' 8=>=[hcWd<[Z[hWb9ekhjhkb_d]"D@M'/.."-,+$
'( 8=>=[hcWd<[Z[hWb9ekhjhkb_d]"L[hiH'/-*"-+($
') 8=>=[hcWd<[Z[hWb9ekhjhkb_d]"L[hiH'/./".+'.+(1
EB=Ikf[h_eh9ekhje\9ebe]d[hkb_d]"D@M'/-."',/&$
'* 8=>=[hcWd<[Z[hWb9ekhjhkb_d]"D@M'/.("('('1D@M
'/.'",))1D@M'/.'"')'/$
'+ 8=>=[hcWd<[Z[hWb9ekhjhkb_d]"D@M'/-*"'*((1EB=
Ikf[h_eh9ekhje\AWhbihk^[hkb_d]"L[hiH'/-."+*/1EB=
Ikf[h_eh9ekhje\9[bb[hkb_d]"C[ZH'/.*"())$
', B= :_ijh_Yj 9ekhj e\ 7WY^[d Hkb_d] '' E *.*%/+ e\ ,
I[fj[cX[h'///"kdfkXb_i^[Z$
'- H= =[hcWd ?cf[h_Wb 9ekhj hkb_d]" @M '/'(" .+-1 8=>
=[hcWd<[Z[hWb9ekhjhkb_d]"D@M'/,("'-.&$
)+. 9^Wfj[h(+È ,EGALÈ!SPECTSÈOFÈ4HERAPEUTICÈ!LTERNATIVESÈANDÈ#OSTS
YWddej X[ Z_ic_ii[Z Wi YhWii ekji_Z[hi$'. J^[ 8E?
j[Y^d_gk[ c[[ji j^[i[ YedZ_j_edi0 Dkc[heki Yekhj
Z[Y_i_edi \eh m^_Y^ j^[ Yekhji ^[WhZ [nf[hji \hec
j^[\_[bZ^Wl[Yed\_hc[Zj^Wjj^_ijh[Wjc[djceZWb_jo
h[ikbji _d Wj b[Wij YecfWhWXb[ ^[Wb_d] ikYY[ii WdZ
j^[h[\eh[^WijeX[Yedi_Z[h[Z[gk_lWb[djjeh[Y[_l[Z
jh[Wjc[djc[j^eZi$'/
7 fWj_[djÉi ?d\ehc[Z 9edi[dj YWd edbo X[ lWb_Z
_\ j^[ Z_iYbeikh[ _dYbkZ[Z Wbb ik_jWXb[ jh[Wjc[dj
c[j^eZ WYYehZ_d] j^[ Ykhh[dj ijWj[ e\ j^[ Whj _d
c[Z_YWbiY_[dY[$(&?dj^[\_[bZe\Z[djWb_cfbWdjebe]o"
j^_i_dYbkZ[ij^[8E?j[Y^d_gk[$('
:_iYbeikh[ckijWbieX[cWZ[((WXekjj^[h[ikbji
e\ j^[ ef[hWj_ed WdZ ed j^[ fWj_[djÉi feijef[hWj_l[
ijWjki$J^_imekbZcWa[_jYb[Whjej^[fWj_[djij^Wj
iYh[m eh Yob_dZ[h _cfbWdj Ä ^em[l[h m_Z[bo ki[Z
Ä cWo dej c[[j j^[_h h[gk_h[c[dji Zk[ je j^[_h
fhejhWYj[Z ^[Wb_d] j_c[i$ 8bWZ[ WdZ Z_ia _cfbWdji"
Xo YedjhWij" YWd X[ beWZ[Z ckY^ [Whb_[h$ Ceh[el[h"
fWj_[dji jh[Wj[Z m_j^ j^[ 8E? Ze dej ^Wl[ je ik\\[h
\hecj^[W\j[hcWj^ie\Xed[]hW\jh[celWb$J^[oWh[
WbieifWh[Zj^[_di[hj_ede\Wj[cfehWhoh[celWXb[
Z[djkh[W\j[h[njhWYj_ede\h[i_ZkWbZ[dj_j_ed$
?\ fWj_[dji bWj[h Z[YbWh[ j^Wj j^[o mekbZ ^Wl[
efj[Z \eh j^[ Wbj[hdWj_l[ jh[Wjc[dj _\ _j ^WZ X[[d
ZkboZ_iYbei[Zjej^[c"j^[jh[Wjc[djfhel_Z[hcWo
X[ikX`[YjjeY_l_bb_WX_b_jo$:WcW][icWoWbie_dYbkZ[
j^[ Yeij e\ ikXi[gk[dj jh[Wjc[dj$ FWj_[dji jh[Wj[Z
m_j^ iYh[m _cfbWdji" j^[d" YekbZ YbW_c dej edbo
Yecf[diWj_ed \eh _d`kho Xkj Wbie j^[ Yeij e\ Z_ia
_cfbWdj jh[Wjc[dj _\ j^[ _cfbWdj jh[Wjc[dj j^[o
h[Y[_l[ZjkhdiekjjeX[_dWZ[gkWj[eh\Wkbjo$
È
#OSTÈ2EIMBURSEMENTÈBYÈ'ERMANÈÈ
0RIVATEÈ(EALTHÈ)NSURERS
=[hcWdfh_lWj[^[Wbj^_dikh[hih[\ki[jeh[_cXkhi[
fWj_[dji \eh 8E? _cfbWdj jh[Wjc[dj" Y_j_d]" Wced]
ej^[h j^_d]i" j^Wj 8E? Wi W j[Y^d_gk[ _i dej jWk]^j
Wj j^[ kd_l[hi_jo WdZ j^Wj _j _i j^[h[\eh[ dej W fWhj
e\j^[Yedl[dj_edWbj[WY^_d]ie\j^[h[Y[_l[ZZ[djWb
h[f[hjeho$
M^[j^[h jh[Wjc[dj Yeiji Wh[ h[_cXkhiWXb[ Xo
fh_lWj[^[Wbj^_dikh[hi_iZ[j[hc_d[ZXoWf[hj_d[dj
i[Yj_ed_d=[hcWdbWmi[Yj_ed'fWhW('e\j^[C8%
AAijWdZWhZj[hci\eh^[Wbj^Yeiji$J^_ifhel_i_ed
ijWj[i j^Wj j^[ c[Z_YWb jh[Wjc[dj e\ j^[ _dikh[Z
f[hied ckij X[ Æd[Y[iiWho \hec W c[Z_YWb fe_dj
e\ l_[mÇ$ M^Wj jh[Wjc[dj _i c[Z_YWbbo d[Y[iiWho _i
dej Z[j[hc_d[Z Xo j^[ f^oi_Y_WdÉi eh j^[ fWj_[djÉi
ikX`[Yj_l[ l_[mi 8WY^ WdZ Cei[h (&&)1 C_Y^Wbia_
'//- Xkj Xo eX`[Yj_l[ Yh_j[h_W$() J^[ =[hcWd
<[Z[hWbYekhj^WiZ[l[bef[Zj^[\ebbem_d]ie#YWbb[Z
[lWbkWj_ed\ehckbW07jh[Wjc[djc[j^eZ_id[Y[iiWho
\hecWc[Z_YWbfe_dje\l_[m_\j^[eX`[Yj_l[c[Z_YWb
\_dZ_d]i WdZ iY_[dj_\_Y ademb[Z][ Wj j^[ j_c[ e\
jh[Wjc[dj cWa[ _j c[Z_YWbbo `kij_\_WXb[ je Yedi_Z[h
j^Wjc[j^eZd[Y[iiWhoÇ$(*
Dej[j^Wjj^[d[Y[ii_joe\Wc[Z_YWbjh[Wjc[djZe[i
dej^Wl[jeX[Yed\_hc[Zkd[gk_leYWbboXoiY_[dj_\_Y
ijWdZWhZi Ä ]_l[d j^[ _cfedZ[hWXb[i j^Wj ie e\j[d
cWd_\[ij j^[ci[bl[i m_j^_d c[Z_Y_d[" j^_i mekbZ
b[WZ je bWh][#iYWb[ Z[lWbkWj_ed e\ j^[ fhej[Yj_ed
j^Wjj^[fWj_[dji^ekbZ[d`eo_dj^[[l[dje\_bbd[ii$
IY_[dj_\_Y Wh]kc[dji m_j^_d c[Z_Y_d[ WdZ c[Z_YWb
h[i[WhY^ ckij dej X[ YedZkYj[Z Wj j^[ [nf[di[ e\
fWj_[dji" [if[Y_Wbbo i_dY[ j^[i[ m_bb e\j[d X[ _d de
fei_j_edje[lWbkWj[j^[fheiWdZYedie\j^[lWh_eki
jh[Wjc[dj c[j^eZi j^[ci[bl[i C_Y^Wbia_ '//-$
=_l[d j^_i fe_dj" _j _i ik\\_Y_[dj \eh j^[ lWb_Z_jo e\ W
h[_cXkhi[c[djYbW_ckdZ[hj^[bWmj^Wjj^[eX`[Yj_l[
c[Z_YWb\_dZ_d]iWdZiY_[dj_\_Yademb[Z][Wjj^[j_c[
jh[Wjc[dj_iX[]kdcWa[_j`kij_\_WXb[jeYedi_Z[hj^Wj
jh[Wjc[djd[Y[iiWhoÇ(+8WY^WdZCei[h(&&($?j_i
dej d[Y[iiWho j^Wj j^[ Z_ifkj[Z jh[Wjc[dj c[j^eZ
_i ki[Z Xo W cW`eh_jo e\ f^oi_Y_Wdi$(, Æ@kij_\_WXb[Ç
c[Wdij^Wjj^[jh[Wjc[djc[j^eZckijX[Æik_jWXb[Ç
\eh WY^_[l_d] j^[ Z[i_h[Z jh[Wjc[dj h[ikbj$(- J^[i[
YedY[fji ^Wl[ X[[d Yed\_hc[Z Xo i[l[hWb \_dWb WdZ
ded#Wff[WbWXb[ hkb_d]i Xo =[hcWd Yekhji"(. XWi[Z
ed[nj[di_l[[nf[hjef_d_edi$
'. 8=>=[hcWd<[Z[hWb9ekhjhkb_d]"D@M'//,"---$
'/ B= :_ijh_Yj 9ekhj e\ :k_iXkh] Hkb_d] * E ').%/- e\
(( I[fj[cX[h (&&)1 B= :_ijh_Yj 9ekhj e\ IWWhXh”Ya[d
Hkb_d]',I'&%//e\,CWhY^(&&(1EB=Ikf[h_eh9ekhje\
:”ii[bZeh\Hkb_d]*K(&+%/-e\'-Del[cX[h'//.$
(&8=>=[hcWd<[Z[hWb9ekhjhkb_d]"D@M'//."'-.*1EB=
Ikf[h_eh 9ekhj e\ 9ebe]d[ hkb_d]"L[hiH '//-" '+)*1 EB=
Ikf[h_eh9ekhje\:”ii[bZeh\hkb_d]"D@M'//-"(*+-$
(' B= :_ijh_Yj 9ekhj e\ :k_iXkh] Hkb_d] * E ').%/- e\
(( I[fj[cX[h (&&)1 B= :_ijh_Yj 9ekhj e\ IWWhXh”Ya[d
Hkb_d]',I'&%//e\,CWhY^(&&(1EB=Ikf[h_eh9ekhje\
:”ii[bZeh\Hkb_d]*K(&+%/-e\'-Del[cX[h'//."DL[hiP
'///"*-)"*-+$
((8=>=[hcWd<[Z[hWb9ekhjhkb_d]"D@M'/.*"')/+1D@M
'/-,"),)$
() 8=> =[hcWd <[Z[hWb 9ekhj hkb_d] ?L PH (-.%&' e\ '(
CWhY^(&&)1EB=Ikf[h_eh9ekhje\:”ii[bZeh\hkb_d]*K
((+%&' e\ ) <[XhkWho (&&(1 8=> =[hcWd <[Z[hWb 9ekhj
hkb_d]"L[hiH'//'"/.-1L[hiH'/-."(-(1L[hiH'/-/"(('1EB=
Ikf[h_eh9ekhje\>WcXkh]hkb_d]"L[hiH'/,+"'-*1EB=
Ikf[h_eh 9ekhj e\ <hWda\khj hkb_d]" L[hiH '/.'" *+(0 B=
:_ijh_Yj9ekhje\>WcXkh]hkb_d]"L[hiH'/+(")/,$
(*8=>=[hcWd<[Z[hWb9ekhjhkb_d]"D@M'/-/"'(+&$
(+ 8=>=[hcWd<[Z[hWb9ekhjhkb_d]"L[hiH'/-/"(((1L[hiH
'/-."(-/1L[hiH'//'"/.-1L[hiH'//,"'((+$
(,EB=Ikf[h_eh9ekhje\>Wcchkb_d]"L[hiH'/-."*'*$
(- 8=>=[hcWd<[Z[hWb9ekhjhkb_d]"L[hiH'/-/"((($
(.B= :_ijh_Yj 9ekhj e\ :k_iXkh] Hkb_d] * E ').%/- e\
(( I[fj[cX[h (&&)1 B= :_ijh_Yj 9ekhj e\ IWWhXh”Ya[d
Hkb_d]',I'&%//e\,CWhY^(&&(1EB=Ikf[h_eh9ekhje\
:”ii[bZeh\Hkb_d]*K(&+%/-e\'-Del[cX[h'//."DL[hiP
'///"*-)"*-+$
È È #OSTÈ2EIMBURSEMENTÈBYÈ'ERMANÈ0RIVATEÈ(EALTHÈ)NSURERSÈ
7h[ifedi[XoWfh_lWj[^[Wbj^_dikh[hjej^[[\\[Yj
j^Wjj^[fWj_[djc_]^jh[Y[_l[Wj[b[iYef[Z[djkh[eh
Yed_YWbYhemdi_ikdj[dWXb[$J^_ijof[e\h[ijehWj_ed
Z_ijh_Xkj[i j^[ cWij_YWjeho \ehY[i WYheii W h[ZkY[Z
dkcX[h e\ j[[j^" YWki_d] j^[_h fh[cWjkh[ beii
j^hek]^el[hbeWZ_d]$?j_ijhk[j^Wjj^[Z[djkh[YWdX[
YedijhkYj[ZikY^j^Wjj^[j[[j^Wh[ikX`[Yj[Zjeedbo
Wc_dehf[hY[djW][e\j^[cWij_YWjeho\ehY[i$?dj^[i[
YWi[i"j^[cWij_YWjeho\ehY[iWh[jhWdic_jj[ZZ_h[Yjbo
jej^[Wbl[ebWhh_Z]["YWki_d]_jih[iehfj_ed$J^_im_bb
ZWcW][ j^[ Z[djkh[ X[Z X[oedZ h[Ye]d_j_ed WdZ
X[oedZWdo^ef[e\X[_d]ki[\kb$Ab[ca[[jWb$'//&
[nWc_d[Z j^[ h[gk_h[Z fheij^eZedj_Y cW_dj[dWdY[
e\ _cfbWdj#ikffehj[Z Yed_YWb Yhemd Z[i_]di$ J^[o
\ekdZj^Wj"el[hWf[h_eZe\+o[Whi"/,Yecfb_YWj_edi
^WZ je X[ WZZh[ii[Z _d // _cfbWdji \eh j^_i jof[ e\
ikf[hijhkYjkh[$7ffhen_cWj[bo+&e\j^[cWn_bbWho
_cfbWdji^WZX[[dbeijel[hj^[eXi[hlWj_edf[h_eZ$
J^[ cWdZ_XkbWh _cfbWdji jkhd[Z ekj je X[ ceh[
ZkhWXb[$D[l[hj^[b[ii"Ab[ca[[jWb$kbj_cWj[boWhh_l[Z
Wj j^[ YedYbki_ed j^Wj Yed_YWb Yhemdi Wh[ _dZ_YWj[Z
ed _cfbWdji edbo m_j^ ]h[Wj h[i[hlWj_ed$ @e^Wdiied
WdZFWbcgl_ij'//&fe_dj[Zekj_dj^[_hijkZoj^Wj
j^[ cW_dj[dWdY[ b[l[b h[gk_h[Z _i bem WdomWo m_j^
\_n[Z h[ijehWj_edi ed _cfbWdji$ M^o fh_lWj[ ^[Wbj^
_dikh[himekbZij_bbh[\[hfWj_[djijeWbb[][ZboY^[Wf[h
¼ceh[ [Yedec_YWb" ceh[ [nf[Z_[dj½ h[celWXb[
h[ijehWj_edi h[cW_di kdYb[Wh$ ?d j^[ bed] j[hc" j^_i
iebkj_ed _i Y[hjW_dbo ceh[ [nf[di_l[ Ä [if[Y_Wbbo
_d j^[ cWn_bbW Ä i_dY[ j^[ _cfbWdji j^Wj Wh[ beij
m_bb ieed[h eh bWj[h ^Wl[ je X[ h[fbWY[Z WdZ W d[m
ikf[hijhkYjkh[ \WXh_YWj[Z$7 :_ijh_Yj 9ekhj hkb_d](/
ijWj[ij^Wj_cfbWdj#ikffehj[Zh[ijehWj_ediWh[jeX[
Yedi_Z[h[Z c[Z_YWbbo d[Y[iiWho _d j^[ i[di[ e\ j^[
^[Wbj^ _dikh[hiÉ j[hci _\ j^[ [nf[Yj[Z cW_dj[dWdY[
Yeij e\ W YWij \hWc[meha Z[djkh[ ikffehj[Z Xo
j[b[iYef_YYhemdimekbZX[Yedi_Z[hWXbo^_]^[hel[h
j^[o[Whi$
J^[ eX`[Yj_ed h[]kbWhbo le_Y[Z Xo fh_lWj[ ^[Wbj^
_dikh[hi_db[]WbfheY[[Z_d]iXhek]^jXoj^[_hYb_[dji
m_j^h[]WhZjeh[_cXkhi[c[djYbW_ci"dWc[boj^Wjj^[
8E?j[Y^d_gk[_idejWc[j^eZ][d[hWbboh[Ye]d_p[Z
Xoc[Z_YWbiY_[dY["YWdY[hjW_dbodebed][hX[lWb_Z
jeZWo$ 7YYehZ_d] je j^[ =[hcWd <[Z[hWb 9ekhj")&
j^[h[Wh[ej^[hWif[YjijeX[Yedi_Z[h[ZX[oedZm^Wj
_i][d[hWbboYedi_Z[h[Zj^[Yedl[dj_edWbj[WY^_d]e\
j^[ h[Y[_l[Z Z[djWb h[f[hjeho$ 7 h[WiedWXb[ fWj_[dj
m_bbWYjXWi[Zedj^[Wiikcfj_edj^Wj"_dj^[_dj[h[ij
e\j^[Yecckd_joe\j^[_dikh[Z"j^[Yeij\ehj^ei[
jh[Wjc[djc[j^eZij^Wj^Wl[i^emdj^[ci[bl[ijeX[
fhec_i_d] _d Yb_d_YWb fhWYj_Y[ m_bb X[ h[_cXkhiWXb[$
>em[l[h"j^[_h[\\_YWYockijX[[gk_lWb[djjej^Wje\
j^ei[ c[j^eZi Yedl[dj_edWbbo WYY[fj[Z$)' >[[Z_d]
j^[i[ fh_dY_fb[i" Z_ia _cfbWdj jh[Wjc[dj _i dem
Yedi_Z[h[Z [gk_lWb[dj Xo j^[ Yekhji jeZWo")( [l[d _\
ed[jWa[ij^[l_[mj^Wjj^_ij[Y^d_gk[_iWie#YWbb[Z
kdehj^eZen j[Y^d_gk[$ Ed[ Ikf[h_eh 9ekhj)) ^Wi
)+/
Yed\_hc[Z" XWi[Z ed W c[Z_YWb [nf[hj ef_d_ed" j^Wj
j^[Z_ia_cfbWdjioij[c^WiWZlWdjW][iel[hYh[ijWb
_cfbWdji _d j^Wj j^[ bWjj[h fh[ikffei[ W ikYY[ii\kb
Xed[ jhWdifbWdj$ J^[ Z_ia _cfbWdj ioij[c Ze[i dej
h[gk_h[ Wk]c[djWj_ed e\ j^[ `WmXed[ ki_d] _b_WY
Yh[ij Xed[ ]hW\ji" WdZ j^[ Yehj_YWb ikffehj f[hc_ji
\Wij[heh_cc[Z_Wj[beWZ_d]e\j^[_cfbWdji$
@kijb_a[Yedl[dj_edWb_cfbWdji"8E?_cfbWdji^Wl[
X[[d Wffhel[Z Wi c[Z_YWb fheZkYji m_j^ekj h[i[h#
lWj_ed" X[_d] [gk_lWb[dj je Yedl[dj_edWb ioij[ci
[l[d_dj^_ih[if[Yj$
H[_cXkhi[c[dj \eh 8E? _cfbWdj jh[Wjc[dj ^Wi
Wbie X[[d h[\ki[Z X[YWki[ e\ j^[ fej[dj_Wbbo ^_]^[h
Yeij YecfWh[Z je Yedl[dj_edWb jh[Wjc[dj c[j^eZi$
M_j^h[]WhZjefh_lWj[^[Wbj^_dikhWdY[bWm"ef_d_edi
^Wl[ X[[d Z_l_Z[Z Wi je m^[j^[h Yeij YWd X[ Wd
_iik[m^[dZ[j[hc_d_d]m^[j^[hWif[Y_\_Yc[Wikh[
_i `kij_\_[Z$ Ed ed[ ^WdZ" _j ^Wi X[[d ^[bZ j^Wj
Yeij _i dej W Yh_j[h_ed _d Z[j[hc_d_d] j^[ c[Z_YWb
`kij_\_YWj_ed e\ W fheY[Zkh[" i_dY[ j^[ h[b[lWdj bWmi
Ze dej WZZh[ii j^[ gk[ij_ed e\ Yeij" W_c_d] Wj W
fkh[bo c[Z_YWb Wii[iic[dj _dij[WZ$ J^[ effei_d]
l_[m)* ^Wi X[[d j^Wj \hec j^[ fe_dj e\ l_[m e\ W
^[Wbj^_dikh[h"¼c[Z_YWbd[Y[ii_jo½YWddejX[l_[m[Z
m_j^ekj_ji[Yedec_YWif[Yji"Wi^[Wbj^_dikh[hi^Wl[
jefhej[Yjj^[ci[bl[i\hec^Wl_d]je\eejkd\eh[i[[d
X_bbi\ehm^_Y^j^[fWj_[djWbed[_ih[ifedi_Xb[8WY^
WdZ Cei[h (&&)1 8WY^ '/-/$ I_dY[ ^[Wbj^ _dikh[hi
YWddej _d\bk[dY[ j^[ eYYkhh[dY[ WdZ [nj[dj e\ j^[
ZWcW][Yel[h[Z"_jib_WX_b_jo\ehh[_cXkhi[c[djckij
X[b_c_j[Z_dj^[_dj[h[ije\[Yedec_Y[\\_Y_[dYo$
7h[Y[djZ[Y_i_edXoj^[=[hcWd<[Z[hWb9ekhj)+
^Wi Y^Wd][Z j^[ b[]Wb i_jkWj_ed m^[d _j Yec[i je
[lWbkWj_d] j^[ d[Y[ii_jo e\ W c[Z_YWb jh[Wjc[dj$ Ie
\Wh"j^[d[Y[ii_jomWiWii[hj[Zedbo_\j^[Wbj[hdWj_l[
jh[Wjc[dj mWi [gk_lWb[dj WdZ dej ceh[ [nf[di_l[$
>em[l[h" j^[h[ _i dej^_d] _d j^[ ^[Wbj^ _dikh[hiÉ
j[hci WdZ YedZ_j_edi j^Wj mekbZ _d\ehc fWj_[dji
e\ j^[ _dikh[hiÉ _dj[dj_ed je h[ijh_Yj j^[ci[bl[i je
e\\[h_d] h[_cXkhi[c[dj \eh j^[ Y^[Wf[ij c[j^eZ
WlW_bWXb[$ ?d j^[ l_[m e\ j^[ <[Z[hWb 9ekhj" W ]_l[d
(/B=:_ijh_Yj9ekhje\Ijkjj]WhjHkb_d](-E)&*%&'e\'+@kbo
(&&($
)&8=>=[hcWd<[Z[hWb9ekhjhkb_d]"L[hiH'//)"/+-$
)' 8=>=[hcWd<[Z[hWb9ekhjhkb_d]"L[hiH'//)"/,&$
)( B= :_ijh_Yj 9ekhj e\ :k_iXkh] Hkb_d] *E').%/- e\ ((
I[fj[cX[h(&&)1B=:_ijh_Yj9ekhje\IWWhXh”Ya[dHkb_d]
',I '&%// e\ , CWhY^ (&&(1 EB= Ikf[h_eh 9ekhj e\
:”ii[bZeh\Hkb_d]*K(&+%/-e\'-Del[cX[h'//."DL[hiP
'///"*-)"*-+$
)) EB=Ikf[h_eh9ekhje\:”ii[bZeh\Hkb_d]*K(&+%/-e\'-
Del[cX[h'//."DL[hiP'///"*-)$
)*EB=Ikf[h_eh9ekhje\9ebe]d[hkb_d]"h!i"'//+"*)'$
)+ 8=> =[hcWd <[Z[hWb 9ekhj Hkb_d] ?L PH (-.%&' e\ '(
CWhY^(&&)"L[hiH(&&)"+.'"+.*$
),& 9^Wfj[h(+È ,EGALÈ!SPECTSÈOFÈ4HERAPEUTICÈ!LTERNATIVESÈANDÈ#OSTS
h[Ye]d_p[Z c[Z_YWb jh[Wjc[dj Ze[i dej bei[ j^[
gkWb_\_YWj_ed e\ ¼d[Y[iiWho½ c[h[bo X[YWki[ _j _i
ceh[ [nf[di_l[ j^Wd Wdej^[h jh[Wjc[dj j^Wj" _d j^[
l_[m e\ j^[ ^[Wbj^ _dikh[h" _i [gk_lWb[dj Xkj b[ii
[nf[di_l[$
?j ckij X[ [nf[Yj[Z j^Wj j^[ ^[Wbj^ _dikh[hi m_bb
h[WYj je j^_i `kh_Z_YWb Y^Wd][ Xo Wc[dZ_d] j^[_h
j[hciWdZYedZ_j_edi$J^[\ebbem_d]Wif[Yjii^ekbZ
X[Yedi_Z[h[Z_dj^_ih[]WhZ0
FWj_[djiWh[kdZ[hdeeXb_]Wj_edjeYedi_Z[hYeij
Wif[Yji eh je a[[f j^[ Yeij e\ c[Z_YWb YWh[ Wi bem
Wifeii_Xb[8WY^'/-/$C[Z_YWbjh[Wjc[dj^Wiedbo
X[[dYedi_Z[h[Z¼kdd[Y[iiWho½_\i[l[hWbjh[Wjc[dj
efj_edi[n_ijj^WjWh[c[Z_YWbbo[gk_lWb[djXkjm^[h[
j^[ Yeij e\ ed[ jh[Wjc[dj _i [gkWb je i[l[hWb j_c[i
j^[Yeije\Wdej^[hjh[Wjc[djWdZj^[b[Wij[nf[di_l[
jh[Wjc[dj _i dej i[b[Yj[Z), 8WY^ WdZ Cei[h (&&)1
FhbiiWdZCWhj_d'//.$J^Wjj^[Yeije\jh[Wjc[dj
_dYbkZ[i j^[ Yeij e\ feij#jh[Wjc[dj cW_dj[dWdY[
YWh[_iWdWYY[fj[Z\WYj$)-
Dem 8E? _cfbWdj jh[Wjc[dj _i [cf^Wj_YWbbo dej
i[l[hWbj_c[iceh[[nf[di_l[j^WdZ[djkh[jh[Wjc[dj$
M_j^ W Z[djkh[" W cW_dj[dWdY[ Yeij h[b_d_d]i e\
Ï(+& W o[Wh \eh '&o[Whi d[[Zi je X[ Yedi_Z[h[Z$).
J^[ Yeij e\ \WXh_YWj_d] W Z[djkh[ m_j^ j[b[iYef[
Yhemdi ed dWjkhWb WXkjc[dji WdZ _cfbWdji" _d ed[
[nWcfb["YWc[jeWffhen_cWj[boÏ'&"&&&$7ZZjej^_i
j^[Yeij\ehWj[cfehWhoZ[djkh[WdZ\ehh[b_d_d]ie\
Wffhen_cWj[boÏ."&&&jejWb$J^_i[njhWYeije\Ï'."&&&
i^ekbZX[YecfWh[Zjej^[Yeij\eh8E?jh[Wjc[dje\
Wffhen_cWj[bo Ï(("&&& Ä j^_i _i WZc_jj[Zbo ib_]^jbo
ceh[[nf[di_l["Xkj_jY[hjW_dbo_ideji[l[hWbj_c[i
ceh[[nf[di_l[j^Wdj^[Yedl[dj_edWbfheij^eZedj_Y
iebkj_ed$
<_dWbbo"WdoYeijYecfWh_iedckijX[ceejWdomWo
X[YWki[j^[jmej[Y^d_gk[im[Wh[Z_iYkii_d]Wh[dej
Wj Wbb YecfWhWXb[ m^[d beea_d] Wj j^[ jh[Wjc[dj
ikYY[ii Ä m^_Y^ mekbZ X[ W fh[h[gk_i_j[ \eh j^[
lWb_Z_jo e\ Wdo ikY^ YecfWh_ied$ :[djkh[ h[b_d_d]i"
W\j[hWbb"Wh[edboh[gk_h[Z_\j^[`WmXed[X[bemj^[
Z[djkh[ _i bei_d] lebkc[$ Eh" je fkj _j Z_\\[h[djbo0
I_cfb[f[h_eZedjWbboikffehj[ZZ[djkh[iWh[_dWdZe\
j^[ci[bl[iWZkX_eki\ehce\jh[Wjc[dj"[l[dj^ek]^
j^[ ]h[Wj cW`eh_jo e\ Z[dj_iji" m_j^ j^[_h fWj_[djÉi
Yedi[dj" Yedj_dk[ je fhel_Z[ h[celWXb[ Z[djkh[i$
?dYbkZ_d] j^[ Yeij e\ j^_i jh[Wjc[dj ceZWb_jo _d W
),EB= Ikf[h_eh 9ekhj e\ 9ebe]d[ hkb_d]" h!i '//+" +)'1 ijeh_d] j^[ fWj_[djÉi cWij_YWjeho \kdYj_ed _i WbmWoi
EB=Ikf[h_eh9ekhje\AWhbihk^[Hkb_d]'(K',.%/+e\(' edbo W\\ehZWXb[ WdZ h[_cXkhiWXb[ m_j^_d j^[ b_c_ji
CWhY^'//,"kdfkXb_i^[Z$
)- B=:_ijh_Yj9ekhje\9ebe]d[Hkb_d]()E')/%/,"kdfkX#
b_i^[Z$
). B=:_ijh_Yj9ekhje\9ebe]d[Hkb_d]()E')/%/,"kdfkX#
b_i^[Z$
)/B=:_ijh_Yj9ekhje\:k_iXkh]Hkb_d]*E').%/-e\((I[f#
j[cX[h(&&)$
YecfWh_iede\h[bWj_l[YeijWiWX[dY^cWha\_]kh[_i
e\Yekhi[ekje\j^[gk[ij_ed$
9ecfWh_ied e\ j^[ Yeij e\ 8E? _cfbWdji m_j^
j^[ Yeij e\ Yh[ijWb _cfbWdji _dYbkZ_d] Xed[ ]hW\j"
WdZ _dYbkZ_d] j^[ Yeij e\ WdW[ij^[i_W WdZ j^[
ikf[hijhkYjkh[_dXej^YWi[i"^Wii^emdj^Wjj[dZ_ia
_cfbWdjim[h[_di[hj[ZWjWYeije\Ï)+"&&&"YecfWh[Z
je Yedl[dj_edWb Yh[ijWb _cfbWdji Wj Ï(-"&&&)/ ?d de
mWoWh[8E?_cfbWdjii[l[hWbj_c[iceh[[nf[di_l[
7do Z_\\[h[dY[ _d Yeij j^Wj Ze[i [n_ij _i XWbWdY[Z"
\hecj^[fe_dje\l_[me\j^[fWj_[dj"Xoj^[\WYjj^Wj
j^[h[_ideWZZ_j_edWbikh]_YWbi_j[Wjj^[^_fXed[WdZ
j^Wj de WZZ_j_edWb ef[hWj_ed _d ][d[hWb WdW[ij^[i_W
_ih[gk_h[Z$
JWa_d]Wbbe\j^[WXel[\WYji_djeZk[Yedi_Z[hWj_ed"
8E? _cfbWdj jh[Wjc[dj m_bb h[]kbWhbo ^Wl[ je X[
YbWii_\_[Z Wi c[Z_YWbbo d[Y[iiWho Wi Z[\_d[Z Xo j^[
j[hci WdZ YedZ_j_edi e\ j^[ ^[Wbj^ _dikh[hi$ I_dY[
j^[^[Wbj^_dikhWdY[YecfWd_[iWh[ijh_l_d]jeWle_Z
WZZ_j_edWb Yekhj Z[Y_i_edi" j^[o ^Wl[ _dYh[Wi_d]bo
X[[dm_bb_d]jei[jjb[ekje\Yekhj$JeWle_ZYh[Wj_d]
W fh[Y[Z[dj" [l[d _\ j^[o Wh[ fh[fWh[Z je f_Ya kf
j^[ Yeij e\ W 8E? jh[Wjc[dj" _d j^[_h h[bWj_edi^_f
m_j^ j^[ fWj_[dj" iec[ ^[Wbj^ _dikh[hi ^Wl[ X[[d
fhefei_d] j^[ \ebbem_d] fheY[Zkh[0 7 Z[djWb
jh[Wjc[dj fbWd ikXc_jj[Z je j^[ ^[Wbj^ _dikh[h j^Wj
if[Y_\_[iYedl[dj_edWb_cfbWdjjh[Wjc[dj_iWffhel[Z$
J^[ fWj_[dj WYjkWbbo h[Y[_l[i 8E? jh[Wjc[dj" \eh
m^_Y^ ^[ eh i^[ _i X_bb[Z fh_lWj[bo$ ?d WZZ_j_ed"
j^[ fWj_[dj h[Y[_l[i Wd WZZ_j_edWb" \_Yj_j_eki _dle_Y[
\eh ikXc_ii_ed je j^[ ^[Wbj^ _dikh[h Yel[h_d] j^[
Yedl[dj_edWb _cfbWdj jh[Wjc[dj j^Wj mWi Wffhel[Z
Xkj dej WYjkWbbo f[h\ehc[Z" WdZ _i h[_cXkhi[Z ed
j^[XWi_ie\j^_i\_Yj_j_eki_dle_Y[$H[ikbj0J^[fWj_[dj
fWoi j^[ Z[dj_ij XWi[Z ed Wd _dle_Y[ \eh j^[ 8E?
jh[Wjc[dj1j^[^[Wbj^_dikh[hh[_cXkhi[ij^[fWj_[dj
Wi _\ ^[ eh i^[ ^WZ kdZ[h]ed[ W Yedl[dj_edWb WdZ
feii_Xbo ekjZWj[Z jh[Wjc[dj Ä m^_Y^ _i Wbie m^Wj
Wff[Whi_dj^[ijWj_ij_YWbZWjW$
Fh_lWj[ ^[Wbj^ _dikh[hi Wh[ WYj_l[bo \_]^j_d] j^[
8E?j[Y^d_gk[cW_dboX[YWki["_\_jm[h[jeX[Yec[
Yecced ademb[Z][ j^Wj j^_i j[Y^d_gk[ [n_iji" j^_i
mekbZh[ikbj_dcWdoceh[jh[Wjc[djYWi[i\ehm^_Y^
j^[^[Wbj^_dikh[hmekbZ^Wl[jefWo$J^ei[fWj_[dji
j^Wj i^o WmWo \hec [nj[di_l[ Xed[ ]hW\j ef[hWj_edi
m_bb h[WZ_bo WlW_b j^[ci[bl[i e\ j^[ efj_edi e\\[h[Z
j^[c Xo j^[ c_d_cWbbo _dlWi_l[ 8E? j[Y^d_gk[ Ä _\
j^[o^Wl[WY^WdY[jeb[WhdWXekj_j$
<hec j^[ fe_dj e\ l_[m e\ W ^[Wbj^ _dikh[h" h[#
e\m^Wj_ic[Z_YWbbod[Y[iiWho$
Ed[c_]^j][jiWhYWij_Y[dek]^je\[[bj^Wjj^_i_iie
X[YWki[[l[dfWj_[djim_j^j^[i_cfb[ije\h[celWXb[
Z[djkh[im_bbX[gk_j[\kdYj_edWb[dek]^jeYedj_dk[
cWa_d]j^[_hcedj^bo_dikhWdY[fWoc[dji\ehcWdo
o[WhijeYec[$7dZm^Wjceh[YWdm[[nf[Yj5

#(!04%2È
-AINTENANCE
È
2ECALL
È
)NTRODUCTION
H[YWbb i[ii_edi i^ekbZ \ebbem W ijWdZWhZ_p[Z fbWd
ie j^Wj dej^_d] _i el[hbeea[Z$ 7bb \_dZ_d]i Wh[
Yecckd_YWj[Z je j^[ fWj_[dj$ ?cfehjWdj \_dZ_d]i
WdZ j^ei[ \_dZ_d]i h[gk_h_d] j^[ Yeef[hWj_ed eh
iec[ WYj_l_jo ed j^[ fWhj e\ j^[ fWj_[dji YWd X[
ZeYkc[dj[Z_dmh_j_d]$J^[]k_Z[b_d[\ebbem[ZYekbZ
X[j^[9^[Ya#kfH[fehj<ehc7''"WYefoe\m^_Y^
_i _dYbkZ[Z m_j^ j^[ fWj_[djÉi Z[djWb h[YehZi" m^_b[
j^[eh_]_dWb_i^WdZ[Zjej^[fWj_[dj$
È
)MPLANTÈ2ECALLÈ#HECKLIST
Fh[b_c_dWh_[i0 EXi[hl[ fWj_[djÉi ]W_j" i^ekbZ[h" WdZ
^[WZ fei_j_ed \eh iocc[jho$ Dej[ Wdo Y^Wd][i WdZ
Z_iYkiij^[cm_j^j^[fWj_[djm^[h[Wffhefh_Wj[$
'$ Gk[ij_edjej^[fWj_[dj0¼:eoek\[[biec[j^_d]_i
mhed]Äj^Wjiec[j^_d]c_]^j^Wl[Xhea[de\\eh
beei[d[Zehej^[hm_i[Y^Wd][Z5½
($ Gk[ij_edjej^[fWj_[dj0¼?\oekYbei[oekhcekj^
ibembo"m^[h[Zeoekhj[[j^jekY^\_hij5½
EXi[hl[0 :e[i j^[ cekj^ ef[d eh Ybei[ _d W
ijhW_]^j b_d[5 ?i j^[h[ Wdo i^_\j eh Z_ifbWY[c[dj
W\j[h j^[ \_hij YedjWYj5 ?j _i h[Yecc[dZ[Z je eX#
i[hl[ j^[ `Wm Ybeikh[ \hec W fei_j_ed Z_h[Yjbo _d
\hedje\j^[fWj_[dj$;l[dj^[icWbb[ijcel[c[dji
eh Z[l_Wj_edi WdZ j^[ ib_]^j[ij jm_jY^ e\ j^[
cWij_YWjehockiYb[iYWdfhel_Z[_cfehjWdj^_dji$
?ij^[X_j[fbWd[ij_bbYehh[YjWdZ_djWYjiW]_jjWbbo"
^eh_pedjWbbo5 ?i j^[ 7FC< Wd]b[ ij_bb _d [gk_b_#
Xh_kcedXej^i_Z[i5
)$ 9^[Ya j^[ Y[djh_Y h[bWj_ed \_hij$ J^[d b[j j^[
fWj_[dj cWa[ Y^[m_d] cel[c[dji ed j^_Ya[h
Whj_YkbWj_d]fWf[h$EXi[hl[j^[Z_h[Yj_ed
Ä <hec\hedjjeXWYaWdZ\hecXWYaje\hedj
Ä ;nYkhi_l[cel[c[djiX_bWj[hWbbo
?\ j^[ fWj_[djÉi [nYkhi_l[ cel[c[dji Wh[ dej
iocc[jh_YWb0 7b[hj j^[ fWj_[dj je j^[ ed[#i_Z[Z
Y^[m_d]cel[c[dji_dehZ[hje[dYekhW][^_cje
 ¬ 
eXi[hl[^_ci[b\WdZjejhW_d^_iY^[m_d]fheY[ii$
8WbWdY[ZY^[m_d]YWdX[jhW_d[ZWj^ec["Y^[m_d]
]kc _d \hedj e\ j^[ c_hheh \eh )'&c_d$ J^[
fWj_[dji^ekbZdej[m^[h[j^[h[Wh[fheXb[cieh
_cfhef[hYedjWYjiZkh_d]j^_i[n[hY_i[$Fh[cWjkh[
YedjWYji ckij WbmWoi X[ h[cel[Z _cc[Z_Wj[bo"
h[]WhZb[ii e\ ^em b_jjb[ j_c[ ^Wi ]ed[ Xo i_dY[
j^[ bWij l_i_j je j^[ Z[dj_ij$ ?j _i _cfeii_Xb[ je
Wdj_Y_fWj[m^[dWij_\\ehj[di[cWij_YWjehockiYb[
Wfh_c[YWdZ_ZWj[_ij^[bWj[hWbfj[ho]e_ZckiYb[
c_]^j bei[ _ji j[di_ed" WdZ i_c_bWhbo0 m^[d j^[
ckiYkbWhbo Z[j[hc_d[Z ifWj_Wb fei_j_ed e\ j^[
cWdZ_Xb[ WdZ j^[ h[ikbj_d] cel[c[dj efj_edi
c_]^j X[ Wbj[h[Z$ J^_i _i W Y^WdY[ \eh cWa_d]
iec[fhe]h[iijemWhZj^[h[ijehWj_ede\WdehcWb
cWij_YWjeho \kdYj_ed" WdZ ikY^ Wd effehjkd_jo
i^ekbZ WbmWoi X[ jWa[d _cc[Z_Wj[bo$ ?\ [nj[di_l[
Y^Wd][i_dj^[cWij_YWjehoioij[cWh[dej[ZWdZ
WYYecceZWj[Z Xo WZ`kij_d] j^[ eYYbki_ed" j^[
h[ikbjm_bbW]W_d^Wl[jeX[\ebbem[ZYbei[boÄj^[i[
Y^Wd][i_dj^[cWij_YWjehoioij[ccWoj^[ci[bl[i
^Wl[Yedi[gk[dY[i\ehj^[cehf^ebe]oe\j^[`Wmi
WdZj^[ci[bl[i]_l[h_i[jej^[d[[Z\eheYYbkiWb
WZ`kijc[dj$ 9edjhWho je m^Wj dej W \[m Z[dj_iji
i[[cjej^_da"Xed[ih[WYjgk_YaboXokdZ[h]e_d]
bWh][cehf^ebe]_YWbY^Wd][iWdZ_dl_i_Xb[Y^Wd][i
_dZ_ijh_Xkj_ede\&#Wh[WiWdZ'#Wh[Wi$8ed[j_iik[
_idejWjWbbXhWZojhef^_Yj_iik[$
*$ ?dif[YjWdZ"_\d[Y[iiWho"Yehh[Yjj^[cWij_YWj_ed
ikh\WY[i WdZ eYYbkiWb YedjWYji$ M^_b[ Ze_d] ie"
cWa[ ikh[ j^[ fWj_[djÉi cWdZ_Xb[ _i _d W dWjkhWb
fei_j_ed WdZ j^[ fWj_[dj _i i_jj_d] _d W h[bWn[Z
fei_j_ed$ :e dej [nWc_d[ m^_b[ j^[ fWj_[dj _i
bo_d]Zemd$9ed\_hcoekh\_dZ_d]iWij^[fWj_[dj
_ii_jj_d]ijhW_]^j"eh[l[dijWdZ_d]kf"WdZWij^[
fWj_[dj _i _dYb_d_d] ^_i ^[WZ ib_]^jbo \ehmWhZ$ ?d
j^[ \_hij WZ`kijc[dj i[ii_edi" Wbbem j^[ fWj[dj je
mWba WdZ h[ij Zkh_d] j^[ i[ii_ed \eh iec[ j_c["
[$]$'Ä(^$
+$ 9^[Yam^[j^[h_dZ_l_ZkWb_cfbWdji^Wl[beei[d[Z
ehm^[j^[hj^[ikf[hijhkYjkh[_ii_jj_d]beei[boed
Wdoe\j^[_cfbWdji$
,$ 9^[Yaj^[ZhW_d_d]\WY_b_j_[iWjWbbj^h[WZ[Zf_di$
<eh[WY^_cfbWdj"j^[j^h[WZ[Zf_dckijX[Yb[Whbo
l_i_Xb[ \hec Wj b[Wij ed[ Wif[Yj$ ?\ j^_i _i dej j^[
YWi[" f[h\ehc Wd Wffhefh_Wj[ ]_d]_l[Yjeco$ ?d
),( 9^Wfj[h(,È -AINTENANCE
Ze_d]ie"jhojeYh[Wj[WY_hYkbWh#i^Wf[ZifWY[$J^[
j^h[WZ[Z f_d ckij dej X[ ZWcW][Z hek]^[d[Z
m_j^j^[iYWbf[b$
-$ 9^[Yajei[[_\WZ[djWbfheX[j_fYWdX[_di[hj[Z
kdZ[hd[Wj^ Wbb fedj_Y ifWY[i m_j^ekj c[[j_d]
h[i_ijWdY[$?\j^_i_idejj^[YWi["j^[XWi[ie\j^[
fedj_Yi ^Wl[ je X[ h[ZkY[Z$ J^_i _i [if[Y_Wbbo
_cfehjWdj _d j^[ YWi[ e\ m_Z[#ifWd Xh_Z][i eh _\
iec[ h[]_edi e\ j^[ `Wm ^WZ W icWbb[h l[hj_YWb
Z_c[di_ed j^Wd j^[ _cfbWdj i_j[i Wj j^[ j_c[
jh[Wjc[djmWiX[]kdi[[I[Yj$/$)\ehZ[jW_bi$
.$ ;gkWbbo ZWd][heki Wh[ YedjWYji X[jm[[d j^[
Xh_Z][ WdZ j^[ cWn_bbWho ckYeiW j^Wj c_]^j
Wh_i[ X[jm[[d j^[ dWiWb if_d[ WdZ j^[ Xh_Z][$
J^[i[ YedjWYji ckij X[ h[cel[Z m_j^ Wcfb[
cWh]_d_dehZ[h\ehj^[XWbWdY[e\\ehY[iX[jm[[d
j^[ _cfbWdji dej je X[ _cfW_h[Z WdZ ie j^Wj de
^ofeceY^b_ed YWd Z[l[bef _d j^_i Wh[W$ Fh[iikh[
edj^[Xed[m_bbgk_Yabo][d[hWj[ceh[WdZ^WhZ[h
Xed[ikXijWdY[$7h[WYedjWYjiWYheiii[l[hWbj[[j^
YWki[\[m[hfheXb[cij^WdZefe_djYedjWYji$
A
B
/$ ?d\ehcj^[fWj_[dje\j^[d[Y[ii_joe\h[]kbWhh[YWbb
Wffe_djc[dji$=_l[WZZ_j_edWb_dijhkYj_edi_dehWb
^o]_[d[_\d[Y[iiWho$7iaj^[fWj_[dj_\^[ij_bb^Wi
j^[ \ebZ[h m_j^ j^[ _dijhkYj_edi \eh ehWb ^o]_[d[
WdZ j^[ [c[h][dYo dkcX[hi$ I^ekbZ j^Wj dej
X[ j^[ YWi[" j^[ fWj_[dj i^ekbZ X[ ^WdZ[Z W d[m
\ebZ[h <ehc +W _cc[Z_Wj[bo$ Dej[ j^[ l[hi_ed
dkcX[he\j^[\ebZ[hedj^[fWj_[djY^Whj$
'&$?\ h[gk_h[Z0 <_bb _d j^[ Y^[Ya#kf h[fehj WdZ \_b[
_j m^_b[ ^WdZ_d] ed[ Yefo je j^[ fWj_[dj je jWa[
^ec[$
È
)NDICATIONÈFORÈ2ADIOGRAPHS
?dYh[ijWb_cfbWdjebe]o"j^[b_j[hWjkh[WbmWoiYWbbi\eh
ÆYedjhebhWZ_e]hWf^iÇjeX[jWa[d_cc[Z_Wj[boW\j[h
j^[ _cfbWdji ^Wl[ X[[d _di[hj[Z$ M[ Ze dej j^_da
j^Wj j^_i _i d[Y[iiWho _d j^[ YWi[ e\ 8E? _cfbWdji"
X[YWki[ j^[i[ _cfbWdji Wh[ _di[hj[Z m_j^ W \kbbo
ef[d b_d[ e\ i_]^j WdZ X[YWki[ _j _i dej feii_Xb[
WdomWojel[h_\oj^[Yehh[YjX_Yehj_YWbfei_j_edki_d]
Yedl[dj_edWbhWZ_ebe]_YWbioij[ci$?jcWoX[^[bf\kb
je Y^[Ya j^[ i[Wj_d] e\ j^[ Xh_Z][ hWZ_ebe]_YWbbo eh
je Z[j[Yj [nY[ii Y[c[dj Zkh_d] j^[ feijef[hWj_l[
f^Wi["m^[h[j^[l_[m_ie\j[deXijhkYj[Zim[bb_d]i"
c_deh Xb[[Z_d]$ EdY[ j^[ ikf[hijhkYjkh[ ^Wi X[[d
_di[hj[Z"hWZ_e]hWf^im_bbZeYkc[djj^[dkcX[he\
Yhemdi"fedj_Yi"WdZ_cfbWdj#ikffehj[ZWjjWY^c[dji
\ehikXi[gk[djX_bb_d]$
7\j[h j^Wj fe_dj" m[ h[Yecc[dZ jWa_d]
hWZ_e]hWf^i Wj ,#cedj^ _dj[hlWbi$ J^[ bWij hekj_d[
hWZ_e]hWf^e\j^_ii[h_[i_ijWa[dW\j[h(o[Whi$7\j[h
j^Wj" hWZ_e]hWf^i m_bb kikWbbo edbo X[ h[gk_h[Z _\
fheXb[ciWh_i[eh_\j^[h[Wh[dWjkhWbj[[j^b[\j_dj^[
`Wmm^ei[ijWjkickijX[_dif[Yj[ZhWZ_ebe]_YWbbo$
?\[nj[di_l[Wh[Wi^Wl[X[[dh[ijeh[Z"WfWdehWcW
hWZ_e]hWf^ehj^efWdjece]hWf^"EF=YWdX[ki[\kb
X[YWki[_jl_ikWb_p[iWdZZeYkc[djiY^Wd][i_dXed[
ijhkYjkh["ikY^Wid[mjhW`[Yjeh_WbWb_]dc[dji$
?d j^[ [l[dj j^Wj _dZ_l_ZkWb _cfbWdji Wh[ dej
Yb[Whbo l_i_Xb[ ed j^[ EF=" W icWbb[h hWZ_e]hWf^ e\
j^[h[if[Yj_l[Wh[WYWdX[jWa[d$EYYWi_edWbbo_jcWo
X[d[Y[iiWhojejWa[Wjece]hWf^_dehZ[hjel[h_\o
X_Yehj_YWbWdY^ehW][$
È
3AFEGUARDÈ)NFORMATIONÈÈ
ANDÈ4HERAPEUTICÈ)NFORMATIONÈ$URINGÈ2ECALL
?d ehZ[h je X[ WXb[ je fhel[ Ä _d j^[ [l[dj e\ Wdo
&IGÈAB ?dj^[Wh[We\j^[Wdj[h_ehdWiWbif_d["ik\\_Y_[dj
ifWY[ckijX[Yh[Wj[ZkdZ[hd[Wj^j^[fedj_Yi$J^_iXed[Wh[W
_igk_j[h[i_ijWdjjeh[iehfj_ed"WdZ_dj^[[l[djj^Wjj^[Xh_Z][
Wi W m^eb[ _djhkZ[i" j^[ fedj_Yi m_bb jekY^ j^[h[" Yh[Wj_d] W
^ofeceY^b_edWdZb_c_j_d]j^[\h[[cel[c[dje\j^[Xh_Z][$W
J^[Wh[WX[\eh[]h_dZ_d]j^[XWi[Wh[We\WÆ8heiWcb[ÇXh_Z][
i[[9^Wfj[h''$($ B J^[h[ikbje\j^[fheY[Zkh[
Z_iW]h[[c[dji eh bWmik_ji Ä j^Wj j^[ fWj_[dj ^WZ
X[[d_d\ehc[Ze\Z[l[bef_d]fheXb[ci"Z[\_Y_[dY_[i
_d ehWb ^o]_[d[ WdZ WZZ_j_edWb jh[Wjc[dj d[[Zi
_d W j_c[bo cWdd[h" _j m_bb e\j[d X[ ki[\kb je ]_l[
h[Yecc[dZWj_ediWdZ_dijhkYj_edijej^[fWj_[dj_d
mh_jj[d\ehc$CWdofWj_[djiWh[W\hW_ZWdZ_di[Ykh[
È È 2ECALLÈ
Zkh_d]j^[_hl_i_jjej^[Z[djWbe\\_Y[WdZcWodejX[
WXb[ je h[c[cX[h Wbb j^[ _d\ehcWj_ed j^[o h[Y[_l[Z
edY[j^[o^Wl[b[\jj^[h[$
J^[ fWj_[dj YWhh_[i j^[ XkhZ[d e\ fhee\ m_j^
h[]WhZ je j^[ \_hij fWhj e\ j^[ Y^[Ya#kf h[fehj
iW\[]kWhZ _d\ehcWj_ed1 m_j^ h[]WhZ je j^[ i[YedZ
fWhjj^[hWf[kj_Y_d\ehcWj_ed"j^[XkhZ[de\fhee\
h[ijim_j^j^[jh[Wjc[djfhel_Z[h$
?j _i _cfehjWdj je _d\ehc j^[ fWj_[dj e\ j^[ j_c[
e\j^[d[njhekj_d[Wffe_djc[djWdZje_dijhkYjj^[
fWj_[djjeYedjWYjj^[Z[djWbe\\_Y[\ehWd_cc[Z_Wj[
Wffe_djc[dj _d j^[ [l[dj j^Wj fW_d eh Z_iYec\ehj
eYYkhiehj^WjWdoY^Wd][icWd_\[ijj^[ci[bl[i$
>Wl_d]j^[fWj_[dji_]dj^[h[Yecc[dZWj_edWdZ
a[[f_d]WYefocWa[ii[di[_\j^[jh[Wjc[djfhel_Z[h
YWhh_[i j^[ XkhZ[d e\ fhee\ eh _\ ^[ ademi eh ^Wi
h[WiedjeWiikc[j^Wjj^[fWj_[dj_ikdm_bb_d]je\ebbem
j^[ _dijhkYj_edi WdZ jh[Wjc[dj h[Yecc[dZWj_edi$
J^_i cWo eYYkh" \eh [nWcfb[" m^[d ej^[h Z[dj_iji
^Wl[ cWZ[ ej^[h" kd\ehjkdWj[bo kikWbbo _dYehh[Yj"
jh[Wjc[dj h[Yecc[dZWj_edi Ä [if[Y_Wbbo _\ j^[i[
_dYehh[Yj jh[Wjc[dj h[Yecc[dZWj_edi Wh[ cWZ[ Xo
kd_l[hi_jo Z[dj_iji eh ej^[h Æif[Y_Wb_ijiÇ$ ?d j^_i
YWi[" j^[ fWj_[dj cWo X[ [njh[c[bo" WdZ iec[j_c[i
_hh[l[hi_Xbo"Yed\ki[Z$
È
/CCLUSALÈ!DJUSTMENTSÈANDÈ#OMPENSATIONÈÈ
OFÈ#HANGESÈINÈTHEÈ"ONEÈ-ORPHOLOGY
M_j^ Z[djkh[i" _j _i eXl_eki j^Wj Y^Wd][i ed j^[
eYYbkiWb\WY[^[_]^jWh[jeX[[nf[Yj[ZIc_j^'/-+$
J^[ iWc[ Wffb_[i je _cfbWdj jh[Wjc[dji _d cWdo
YWi[i$ ?\ _dj[]hWj[Z iYh[m _cfbWdji Wh[ ki[Z" j^[
f^Wi[ e\ Xed[ h[ceZ[bb_d] m_bb cW_dbo ^Wl[ jWa[d
fbWY[ _d j^[ kdbeWZ[Z f[h_eZ$ >[dY[" m^[d j^[
&IGÈ 7\j[h fbWY[c[dj e\ j^[ kff[h Xh_Z][ _d _cc[Z_Wj[
beWZ" j^[ cWij_YWj_ed WdZ j^[ h[bWj_edi^_f X[jm[[d j^[ jme
WhY^[i m_bb X[ h[]kbWh$ >em[l[h" _d j^[ YWi[ i^emd ^[h["
j^[ Z_ijWb Xed[ Wh[W ^Wi W j[dZ[dYo je i^h_da _d W YhWd_Wb
Z_h[Yj_ed$J^_iYWdX[eXi[hl[Zgk_j[\h[gk[djbo$7dWbj[hdWj_l[
Z[l[befc[dj_iZ[iYh_X[Z_d<_]$'.$-
),)
Xh_Z][iehZ[djkh[iWh[_dijWbb[Zedj^[_cfbWdji"\[m
\khj^[hl[hj_YWbY^Wd][iWh[eXi[hl[Z$?dj^_ih[if[Yj"
jh[Wjc[dj m_j^ 8E? _cfbWdj kdZ[h _cc[Z_Wj[ beWZ
YedZ_j_edi i^emi W Z_\\[h[dj Z[l[befc[dj$ Jof_YWb
Y^Wd][i _d Wdj[h_eh eh feij[h_eh \WY[ ^[_]^j Wh[
i^emd_d<_]i$(,$*WdZ(,$+$
J^[h[ Wh[ dkc[heki h[Wiedi m^o _j cWo X[
d[Y[iiWhojecWa[ikXjhWYj_l[ehWZZ_j_l[Yehh[Yj_edi
je_cfbWdj#ikffehj[ZXh_Z][i0
% J^[l[hj_YWbXed[b[l[bY^Wd][i_dXej^`Wmii[[
9^Wfj[hi/$) WdZ '.$ J^[i[ ceZ_\_YWj_edi Wh[
ckY^ ceh[ [nj[di_l[ j^Wd ed[ c_]^j [nf[Yj$ ?\"
\eh [nWcfb[" j^[ Z_iai _d Yecfb[j[ cWdZ_XkbWh
h[ijehWj_ediWh[hW_i[ZXo'Ä(ccWdZ"Wjj^[iWc[
j_c[i"j^[Z_ijWbZ_iai_dj^[cWn_bbWWh[bem[h[ZXo
'Ä(cc"Wh[ZkYj_ede\j^[Xh_Z][YedijhkYj_ede\
A
&IGÈÈ A <ebbem_d] _djhki_ed e\ j^[ cWn_bbWho Z_ijWb 8E?
_cfbWdj"fh[cWjkh[YedjWYji_dj^[Wdj[h_ehfWhje\j^[WhY^[i
Wh[ \ekdZ$ J^_i cWo jh_]][h Wd kdmWdj[Z Wdj[h_eh Y^[m_d]
fWjj[hd$?dj^_ii_jkWj_ed"j^[h[_ideY^WdY[e\Wdo[gk_b_XhWj[Z
cWij_YWjeho \kdYj_ed Z[l[bef_d]" i_dY[ j^[ l[ij_XkbWh Ykifi
YWddej jekY^ _d j^[ [dj[h f^Wi[ Y\$ <_]$'&$/$ J^[ Z[dj_ij
m_bb e\j[d X[ kdWXb[ je h[Ye]d_p[ j^[ i_jkWj_ed _cc[Z_Wj[bo"
[$]$ _\ j^[ _dYh[Wi[Z h[i_b_[dY[ e\ j^[ j[cfehecWdZ_XkbWh
`e_dj XWh[bo Wbbemi Z_ijWb \kdYj_edWb YedjWYj$ ?j _i d[Y[iiWho
je eXi[hl[ j^[ cWij_YWjeho fWjj[hd _d W h[Wb_ij_Y i_jkWj_ed
[$]$ki_d]ik\\_Y_[djboj^_YaX_j[h[]_ijhWj_edfWf[h$ B J^[
Y^Wd][_dfei_j_ede\j^[Z_ijWb_cfbWdj_ii^emd\hecZ_ijWbbo$
7ij^[m_Zj^e\j^[cWn_bbW_dYh[Wi[i"j^[\khj^[hkfoek]e"
j^[ 8E? _cfbWdj ckij X[ Y^ei[d je X[ m_Z[ [dek]^$ J^[
WZZ_j_edWb_di[hj_ede\WjkX[hefj[ho]e_ZiYh[m_cfbWdjcWo
^[bfijWX_b_p[j^[l[hj_YWbZ_c[di_edi
),* 9^Wfj[h(,È -AINTENANCE

A B

C D E

&IGÈÈA ?\WZ`kij_d]j^[Wdj[h_ehj[[j^_idejWdefj_ed"j^[Xk_bZkfe\j^[Z_ijWbfedj_YickijX[Yedi_Z[h[Z$J^_if_Yjkh[
i^emij^[Xk_bZkfe\j^[cWn_bbWhoXh_Z][ÄWfheY[Zkh[j^Wj_ihWh[boh[gk_h[Z$ B M^[j^[hj^[kff[hehbem[hWhY^^WijeX[
Xk_bjkfZ[f[dZiedj^[eYYbkiWbfbWd[0WbbWZ`kijc[djickijX[cWZ[m_j^h[if[Yjjej^[[ijWXb_i^[ZYkhl[ie\If[[WdZM_bied
WdZj^[^eh_pedjWbfbWd[$J^[cWdZ_XkbWhj[[j^ckijX[Xk_bjkfceh[\h[gk[djboj^Wdj^[cWn_bbWhoXh_Z]["iej^_i_ij^[\_hij
efj_ed_dj^[jh[Wjc[dje\bWj[hWbded#eYYbki_ed$ CnE H[iehfj_ede\Xed[_dj^[Z_ijWbcWn_bbW_iWbieWkikWbZ[l[befc[djm_j^
Yh[ijWb_cfbWdji$J^[Z[Yh[Wi[_dj^[Z_ijWbl[hj_YWbZ_c[di_ed_iYecf[diWj[ZXo[njhki_ede\j^[cebWhie\j^[bem[h`Wm"ehXo
W]hWZkWbWZ`kijc[dje\j^[`e_dji$?dcWdoYWi[i"^em[l[h"Xk_bZ#kfiWh[d[Y[iiWho_dehZ[hjeh[#[ijWXb_i^j^[Z_ijWbl[hj_YWb
Z_c[di_ediWdZfh[l[djZ[ijhkYj_edi_dj^[Wh[We\j^[`e_dj

(Ä*cc_dWbb_ih[gk_h[Z_dj^[Z_ijWbWh[W_dehZ[h
je edY[ W]W_d [dikh[ kd_d^_X_j[Z cWij_YWjeho
\kdYj_ed$J^_im_bbY[hjW_dboh[gk_h[Wh[ZkYj_ed_d
j^[Wh[We\j^[Xh_Z][\hWc[meha$7dej^[hWif[Yj
jeYedi_Z[h_ij^Wjj^[Z[l[befc[dje\Wfh[\[hh[Z
Y^[m_d] i_Z[ h[gk_h[i Wd kd[gkWb Wcekdj e\
WZWfjWj_ededXej^i_Z[i$
% CWij_YWjeho \ehY[i WdZ cWij_YWjeho \kdYj_edi
_dYh[Wi[" m^_Y^ cWo Wbie b[WZ je Y^Wd][i _d j^[
fei_j_edie\j^[j[cfehecWdZ_XkbWh`e_dji$
% J^[cWij_YWj_edfWjj[hdY^Wd][i"m^_Y^WkjecW#
j_YWbboY^Wd][ij^[i^Wf[e\j^[`WmXed[iWim[bb$
% <ebbem_d]Y^Wd][i_dl[hj_YWbZ_c[di_ed"b[l[hW][
WdZ j[di_ed X[jm[[d j^[ Xed[i WdZ j^[ ckiYb[i % 8o YedjhWij m_j^ Yecfb[j[ Z[djkh[ jh[Wjc[dj"
m_bb Y^Wd][ Wi m[bb" Yh[Wj_d] d[m jhW`[Yjeh_[i _d
j^[ Xed[$ J^_i" jee" m_bb b[WZ je cehf^ebe]_YWb
Y^Wd][i$ J^[ [nj[dj e\ j^[i[ Y^Wd][i _i icWbb[h
_\ de Y^Wd][i _d l[hj_YWb Z_c[di_ed ^WZ X[[d % 7djW]ed_iji cWo Yedj_dk[ je cel[ eh i^_\j" [l[d
d[Y[iiWho$
% ;WY^ h[YWbb i[ii_ed m_bb i^em Z_\\[h[dY[i _d
ckiYkbWhijWj[WdZZ_\\[h[dY[i_d`Wmcehf^ebe]o$
J^[Z[dj_ijm_bb^Wl[jeWii[iim^[j^[hehdejje
h[ifedZjej^[i[Y^Wd][iXoWZ`kij_d]j^[eYYbkiWb
ijhkYjkh[i$ J^[ eYYbki_ed YWd d[l[h X[ \_dWb_p[Z"
_$[$eYYbkiWbWZ`kijc[dj_id[l[hYecfb[j["m^[dW
h[ijehWj_ed_i\_hij_di[hj[Z$
% F[h_eZedjWbbo _dlebl[Z Z[dj_j_edi m_bb YWki[
i_]d_\_YWdj Y^Wd][i _d ckiYkbWh \kdYj_ed _\ j^[
cWij_YWjeho \ehY[i ^WZ fh[l_ekibo X[[d h[ZkY[Z
Zk[jefW_d#h[bWj[Z\[[ZXWYah[WYj_edi$?dWZZ_j_ed"
ceh[fhedekdY[ZWdZ\Wij[hh[ceZ[bb_d]ckijX[
[nf[Yj[Z _d j^[i[ Z[dj_j_edi" m^_Y^ YWddej X[
Yedi_Z[h[ZijWXb[fh[ef[hWj_l[bo$
h[fei_j_ed_d] W Xh_Z][ ed 8E? _cfbWdji _i dej
kikWbbo feii_Xb[" i_dY[ j^[ Xh_Z][ m_bb X[ \_hcbo
Y[c[dj[Z_dfbWY[$
_\ W \_n[Z Xh_Z][ ikffehj[Z Xo 8E? _cfbWdji _i
fh[i[dj_dj^[jh[Wj[Z`Wm$
È È 2ECALLÈ ),+

% ?dYh[Wi[Z cWij_YWjeho \ehY[i m_bb YWki[ j^[

ckiYb[ijei^ehj[ddej_Y[WXbo"m^_Y^cWob[WZje
fh[cWjkh[ YedjWYji" [if[Y_Wbbo ed j^[ feij[h_eh
h[]_ed$J^[d[[Z\eheYYbkiWbWZ`kijc[dji_dj^_i
h[]_edm_bbX[\h[gk[djWdZ[nj[di_l[$7Z`kijc[dji
Wh[X[ijcWZ[jej^[cWn_bbW_dehZ[hje^Wl[j^[
X_j[fbWd[ceh[Ybei[boWffheWY^9Wcf[hÉifbWd[
WdZ je cW_djW_d W \WlekhWXb[ Z_ijh_Xkj_ed e\
\ehY[iAWjedW'/./$
% J^[`WmXed[#h[ij_d]ioij[cie\i[YedZWhoeij[edi
_iZ_ijkhX[Z"WdZj^[[nj[hdWbbol_i_Xb[cehf^ebe]o
Y^Wd][i Zkh_d] h[fW_h YecfWh[ je <_]$/$,
i^em_d] W feii_Xb[ Wbj[hdWj_l[ Z[l[befc[dj m_j^
deY^Wd][il_i_Xb[\hecekji_Z[$ &IGÈ ?\ j^[ Z_ijWb _cfbWdj _i fei_j_ed[Z _d j^[ Wdj[h_eh
fWhje\ehX[bemj^[cWn_bbWhoi_dki"[njhki_ede\j^[_cfbWdj
J^[][d[hWbhkb[iWh[0 _ib_a[bojeeYYkh_dYWi[im_j^ijhWj[]_Y_cfbWdjfei_j_ed_d]$
J^_i cWo X[ W h[ikbj e\ j^[ [nfWdi_ed e\ j^[ cWn_bbWho
i_dki" j^[ i^ehj[d_d] e\ j^[ l[hj_YWb Y^[m_d] ckiYb[i cc$
'$ J^[\_hijWZ`kijc[dj_i[njh[c[bo_cfehjWdj" fj[ho]e_Z[ki c[Z_Wb_i WdZ cc$ cWii[j[h WdZ h[fei_j_ed_d]
Xkjd[l[hfeii_XboYehh[Yjeh\_dWb$ e\ j^[ `e_dji$ KdmWdj[Z [Whbo YedjWYji Wh[ \ekdZ ed j^[ \_hij
($ IkXi[gk[dj WZ`kijc[dji Wh[ ceh[ _cfeh# cebWhi$ J^[i[ YedjWYji ckij X[ h[cel[Z h[]kbWhbo kdj_b j^[
cWij_YWjehoioij[cWdZj^[eij[edWbioij[ciYec[jeWijWXb[
jWdj$ h[ijW]W_d$<ehj^[eij[edWbioij[cj^_icWojWa['Ä(o[Whii[[
)$ L[hj_YWb Z_c[di_ed ckij X[ h[Xk_bj W\j[h W L_Z[ei(+WdZ(-WdZYecfWh[<_]$(,$(je(,$*Xi^em_d]j^[
i[h_[i e\ ]h_dZ_d] WZ`kijc[dj _d ehZ[h je effei_j[ Z[l[befc[dj _\ j^[ Z_ijWb 8E? _i fei_j_ed[Z X[^_dZ
cW_djW_dWd[gk_b_Xh_kc$7Z`kij_d]j^[h[\eh[ j^[cWn_bbWhoi_dki1YecfWh[Wbieje<_]$/$*)
c[Wdi Xk_bZ_d] kf j^[ Ykhl[i e\ If[[ WdZ
M_bied$
*$ ;l[d m_j^ekj Wdo WZ`kijc[dji" j^[ l[hj_YWb
Z_c[di_ed cWo X[ beij edbo Xo Y^Wd][i _d
j^[ cehf^ebe]o e\ j^[ Xed[ m^_Y^ \ebbem
\kdYj_edWbY^Wd][i$J^[h[\eh[h[]kbWhced_#
jeh_d]e\j^[i_jkWj_ed_id[Y[iiWho$

I_dY[ j^[ WXel[ c[dj_ed[Z Y^Wd][i jWa[ fbWY[

]hWZkWbbo eh ikZZ[dbo" _j _i kikWbbo dej feii_Xb[ je
Z[Y_Z[ Wbh[WZo W\j[h cedj^i" m^[j^[h eh dej j^[
cWij_YWjeho \kdYj_ed mWi _dijWbb[Z Yehh[Yjbo _d j^[
X[]_dd_d]$J^_i\WYj^WijeX[h[c[cX[h[Z"m^[d[l[h
j^_igk[ij_ed_ihW_i[Z_dYekhjYWi[i$KikWbbo_jYWd
edbo X[ ijWj[Z" j^Wj [_j^[h j^[ cW_dj[dWdY[ eh &IGÈ I[[<_]$(,$+
Yecfb_WdY[ cWo ^Wl[ X[[d _dik\\_Y_[dj eh j^Wj
\kdYj_edWbfheXb[ci^Wl[dejX[[dZ_iYel[h[Zehj^Wj
_j cWo ^Wl[ X[[d _cfeii_Xb[ je Z_iYel[h \kdYj_edWb
Y^Wd][i eh j^Wj \kdYj_edWb Y^Wd][i ^Wl[ eYYkhh[Z i^ekbZ[nf[YjfW_d\kbi[diWj_edi_dj^[h[]_edie\j^[
hWf_Zbo$ 7i [nfbW_d[Z _d 9^Wfj[h'-" 9C: fWj_[dji fh[#[n_ij_d]_cfbWdjijeeYYkhWffhen_cWj[bo*m[[ai
i^em W ijhed] j[dZ[dYo je el[hbo WZWfj je W mhed]
W\j[hj^[d[m_cfbWdji^Wl[X[[dfbWY[Z$J^_ifW_d_i
eYYbkiWb i_jkWj_ed m_j^ekj ]_l_d] j^[ Z[dj_ij j^[ WYedi[gk[dY[e\j^[h[ceZ[bb_d]fheY[ii"WfheY[ii
d[Y[iiWho_d\ehcWj_edjef[h\ehcWZ`kijc[dj$ j^Wj Ä Wi 9^Wfj[h/ ^Wi i^emd Ä WbmWoi _dYbkZ[i
[nj[di_l[ Wh[Wi e\ j^[ `Wm$ >em[l[h" j^_i fW_d m_bb
Z_iWff[WhWbbXo_ji[b\"debWj[hj^WdW\j[hj^h[[je\ekh
È
cedj^i"j^Wj_i"edY[j^[h[ceZ[bb_d]fheY[ii^WiX[[d
3PECIALÈ#ONSIDERATIONSÈ7HENÈ)NSERTINGÈÈ
Yecfb[j[Z$ D[l[hj^[b[ii" j^[ cWij_YWjeho \kdYj_ed
AÈ3ECONDÈ2OUNDÈOFÈ)MPLANTS
ckij X[ Y^[Ya[Z WdZ" _\ d[Y[iiWho" Yehh[Yj[Z" i_dY[
?\ 8E? _cfbWdji Wh[ WZZ[Z \eh _dijWdY[ \ebbem_d] ed[mekbZ^Wl[je[nf[Yjcehf^ebe]_YWbY^Wd][ije
j^[[njhWYj_ede\j[[j^jeW`Wmj^WjWbh[WZoYedjW_di j^[Xed[ij^Wjm_bbd[[ZjeWZ`kijc[djXomWoe\j^[
W dkcX[h e\ m[bb#c_d[hWb_p[Z 8E? _cfbWdji" ed[ eYYbkiWbikh\WY[i$
),, 9^Wfj[h(,È -AINTENANCE

A
h[bWj_ed"j^[fWj_[djm_bb[nf[h_[dY[h[ceZ[bb_d]
je Wd [nj[dj ed[ mekbZ kikWbbo WiieY_Wj[ edbo
m_j^ ikh]_YWb fheY[Zkh[i$ J^_i _i m^o _j _i ie
_cfehjWdjjeWbie\ebbemj^[i[fWj_[djiYbei[bo
WdZjeWZ`kijj^[eYYbki_edWjdWhhem_dj[hlWbi"
Wi m[bb Wi je _dijhkYj j^[ fWj_[dj dej je [n[hj
[nY[ii_l[ cWij_YWjeho \ehY[i \eh ,Ä.m[[ai Ä
`kij Wi Wj j^[ j_c[ e\ j^[ _di[hj_ed e\ j^[ \_hij
ikf[hijhkYjkh[$
Fh[#beWZi ed _dj[]hWj[Z _cfbWdji Wh[ ceh[
^Whc\kbj^WdedebZ_dj[]hWj[Z8E?_cfbWdji
X[YWki[j^[Xed[WhekdZj^[Z_iai^WiWbh[WZo
B c_d[hWb_p[Z$ J^[ h_ia e\ \hWYjkh[i _i Yehh[i#
fedZ_d]bo^_]^[h$H[#ki_d]j^[[n_ij_d]Xh_Z][
\hWc[mehaii^ekbZX[fh[\[hh[Z$

È
4HEÈ-OBILITYÈÈ
OFÈ%$È)MPLANTSÈ!GAINSTÈ!BUTMENTS

J^[ \_d[ j^h[WZ C(&$(+ e\ j^[ ;:#jof[ 8E?

_cfbWdj cWo Z[l[bef W Y[hjW_d Wcekdj e\ ceX_b_jo
W]W_dijj^[WXkjc[dj"[if[Y_Wbbo_\edboW\[m_cfbWdji
&IGÈAB ?\ j^[ cWdZ_Xb[ _i _cfbWdj[Z WdZ j^[ Z_ijWb 8E?
_cfbWdj_i[b[lWj[Z"fh[cWjkh[YedjWYjim_bbeYYkhZ_ijWbbo$J^[i[
fh[cWjkh[YedjWYjiYWd^Wl[lWh_ekieh_]_di$Eded[^WdZ"j^[
_dYh[Wi_d]cWij_YWjeho\ehY[iWh[WYYecfWd_[ZXoi^ehj[d[Z
l[hj_YWbcWij_YWjehockiYb[i"m^_Y^cWoYedjh_Xkj[jemWhZW
h[ZkYj_ed_difWY[WlW_bWXb[\ehj^[j[cfehecWdZ_XkbWh`e_dj$
Edj^[ej^[h^WdZ"jhk[cehf^ebe]_YWbY^Wd][icWoeYYkh_d
j^[ Xed[ ?^Z[ (&&)" m^_Y^ mekbZ YWki[ j^[ 8E? _cfbWdji
je X[ Z_ibeYWj[Z _d W Yh[ijWb Z_h[Yj_ed i[[ 9Wi[ IjkZo - _d
9^Wfj[h/$' ceZ_\oj[di_edX[jm[[dj^[_dZ_l_ZkWb_cfbWdjij^Wj
J^_i fW_d ckij X[ Z_\\[h[dj_Wj[Z Z_W]deij_YWbbo
\hec fW_d m^ei[ eh_]_d b_[i _d j^[ ckiYb[i$ J^[
Z[dj_ij"^em[l[h"m_bb[Wi_boX[WXb[jeWiY[hjW_dWdZ
beYWj[ j^[ ckiYkbWh eh_]_d _d j^[i[ YWi[i" m^_Y^
cWo Wbie X[ WiieY_Wj[Z m_j^ coe][bei_i$ FWj_[dji
m_bb X[ j[cfj[Z je Wjjh_Xkj[ ckiYkbWh fW_d je j^[
Z_ijWb_cfbWdjie\Xej^`WmickiYkbWhjh_]][hfe_dj
iodZhec[$ CkiYkbWh fheXb[ci cWo X[ jh[Wj[Z Xo
`Wm#ijh[jY^_d] [n[hY_i[i a[[f_d] j^[ cekj^ m_Z[
ef[d\eh'c_d"i[l[hWbj_c[iZW_boWdZi[b\#cWiiW][
fWj_[dji Wh[ kikWbbo ]eeZ Wj beYWj_d] j^[_h emd
coe][bei[i WdZ YWd Æjh[WjÇ j^[c" \eh [nWcfb[" Wj
È
d_]^jm^_b[mWjY^_d]j[b[l_i_ed$
#ONCLUSION
?\ _dj[]hWj[Z 8E? _cfbWdji Wh[ fhel_Z[Z m_j^
d[m ikf[hijhkYjkh[i j^Wj Y^Wd][ j^[ l[hj_YWb
m[h[_di[hj[Zf[h`Wm$J^[h[Wied\ehj^_i_iWib_]^j
fbWij_Y Z[\ehcWj_ed e\ j^[ _cfbWdj eh WXkjc[dj
j^h[WZ$ J^_i i_jkWj_ed m_bb cWd_\[ij _ji[b\ je j^[
fWj_[dji Xo W ib_]^j ÆYb_Ya_d]Ç de_i[ Wi j^[o cel[
j^[_h`Wmi$J^[\_hijj_c[j^_ide_i[eYYkhi_ikikWbbo
W\j[h WXekj ,m[[ai$ DehcWbbo" j^_i Yb_Ya_d] iekdZ
m_bbZ_iWff[WhWbbXo_ji[b\W\j[hW\[mm[[ai"X[YWki[
Yedj_dkeki h[ceZ[bb_d] e\ j^[ `Wm m_bb Yh[Wj[ eh
m_bb YWki[ j^[ j^h[WZi je X[Æm[Z][ZÇ W]W_dij [WY^
ej^[h W]W_d$ H[ceZ[bb_d] Yh[Wj[i j[di_ed X[jm[[d
j^[ Xedo _cfbWdj X[Zi _dj[]hWj_ed" ^em[l[h" _i
fh[i[hl[Z$7ibed]Wij^[jh[Wjc[djfhel_Z[hYWdX[
ikh[ j^Wj j^[ WXkjc[dji m[h[ \_hcbo iYh[m[Z edje
j^[j^h[WZ[Zf_d"j^[h[_ided[[Z\ehWdoj^[hWf[kj_Y
c[Wikh[i$ >em[l[h" _j _i d[Y[iiWho je h[Wiikh[ j^[
fWj_[dj WdZ je ZekXb[#Y^[Ya j^[ ijWX_b_jo e\ j^[
_cfbWdji$
J^[ fWj_[djÉi ikYY[ii\kb i[b\#eXi[hlWj_ed WdZ ^_i
m_bb_d]d[ii je i[[a ^_i jh[Wjc[dj fhel_Z[hÉi WZl_Y[
_cc[Z_Wj[bo_iWX[^Wl_ekhj^Wji^ekbZX[h[_d\ehY[Z
XofhW_i[$
J^[ b_l_d] ^kcWd YhWd_kc ^Wi de WXiebkj[ h[\[#
h[dY[ fe_dji m^Wjie[l[h$ Deh Ze _cfbWdji Yedij_#
jkj[ ikY^ WXiebkj[ h[\[h[dY[ fe_dji" [l[d _\ j^[o
Wh[ eii[e_dj[]hWj[Z$ ?cfbWdji YWd Y^Wd][ j^[_h
È È 4ROUBLESHOOTINGÈ ),-

&IGÈAB Iec[j_c[W\j[h

j^[8E?_cfbWdj_dWh[W)-^WZ
X[Yec[ceX_b[Wbbj^[_cfbWdj#
fheij^[j_YWbioij[cbWYa[Zj^[
d[Y[iiWhoZ_ijWbikffehjed
ed[i_Z[$J^[_cfbWdjmWidej
h[fbWY[Z_dWj_c[bo[dek]^
cWdd[h$J^_ih[ikbj[Z_dYhWYai
e\j^[ej^[h_cfbWdjiWdZi[l[h[
ceX_b_joe\j^[_cfbWdj_d
H[]_ed**$J^[fWj_[djZ_Zdej
h[fehjWdofW_d$;l[d_dj^_i
h[WbbokdZ[i_hWXb[i_jkWj_ed^[
mWi^Wffoje^Wl[j[[j^m^_Y^
m[h[ceh[Æ\_n[ZÇj^Wdj^[
Z[djkh[^[^WZmehdX[\eh[$J^[
YWi[^WZjeX[h[Zed[WdZj^_i
mWif[h\ehc[Z_ded[ikh]_YWb
_dj[hl[dj_ed0Wbb_cfbWdjim[h[
[nY^Wd][Z$Ed[XWi[#fbWj[
A mWib[\j_dj^[Xed[$J^[h[_i
iec[Z_iYkii_edWXekjb[Wl_d]
_dj[]hWj[ZXWi[#fbWj[i_dj^[
Xed[$J^[i[fbWj[iWh[\eh[_]d
XeZ_[iWdZj^[oWh[debed][h
ij_ckbWj[ZW\j[hj^[j^h[WZ[Zf_d
^WiX[[dh[cel[Z$M[kikWbbo
jWa[Wbbe\j^[_cfbWdjekj
m^[d[l[hj^_ii[[cifeii_Xb[

fei_j_edi Wbed] m_j^ j^[ ikhhekdZ_d] Xed[$ J^_i

\WYj ^Wi je X[ WYYecceZWj[Z Xo ceZ_\o_d] j^[
h[ijehWj_l[ ikf[hijhkYjkh[$ J^[ [nj[dj e\ j^[ d[Y[#
iiWho ceZ_\_YWj_edi _i _cfeii_Xb[ je fh[Z_Yj WdZ
Wbceij _cfeii_Xb[ je Yedjheb$ H[]kbWh j^ehek]^
h[YWbb[nWc_dWj_ediWh[_dZ_if[diWXb[\ehjh[Wjc[dj
ikYY[ii$ 9^Wd][i _d Xed[ cehf^ebe]o eYYkh
W\j[h \kdYj_edWb Y^Wd][i Wi m[bb Wi W\j[h ikh]_YWb
_dj[hl[dj_edi$ J^[ Y^Wd][i Wh[ YkckbWj_l[ WdZ Wh[
_d\bk[dY[ZXoY^Wd][i_dXWi_Yj[di_edWdZj^[b[d]j^
e\j^[W\\[Yj[ZckiYb[i$J^[d[Y[iiWhoceZ_\_YWj_edi
m_bbkikWbboX[ie[nj[di_l[j^Wj_jm_bbdejWbmWoiX[
feii_Xb[jefh[l[djc[jWb\hecX[Yec_d]l_i_Xb[d[nj
je j^[ Y[hWc_Y l[d[[hi$ ;if[Y_Wbbo _d fWj_[dji m_j^
l[ho^_]^W[ij^[j_Y[nf[YjWj_edi"j^_im_bbd[Y[ii_jWj[
\WXh_YWj_ede\Wd[mh[ijehWj_ed\hecj_c[jej_c[$
È
4ROUBLESHOOTING
5IF
QMBZFS
PO
UIF
PQQPTJUF
TJEF
XJMM
BMXBZT
HJWF
ZPV

BOPUIFS
DIBODF
)F
LOPXT
UIBU
ZPVS
WJDUPSZ
JT
IJT

WJDUPSZ
5IFSF
BSF
UXP
WJDUPSJFT
GPS
FBDI
EFGFBU
FWkbe9e[b^e
È
4HEREÈ!REÈ-OREÈ3OLUTIONSÈ4HANÈ0ROBLEMS
M^[j^[h W jh[Wjc[dj c[j^eZ _i h[Wbbo \_j je X[
ki[Z _d Yb_d_YWb fhWYj_Y[ _i Z[j[hc_d[Z dej b[Wij Xo
ed[ gk[ij_ed0 ?\ W i_d]b[ Yecfed[dj \W_bi" m_bb _j X[
feii_Xb[ je cWa[ WZ[gkWj[ h[fW_hi WdZ Yehh[Yj_edi
_dWcWdd[hj^Wj_ii_cfb[WdZj^Wjj^[fWj_[djYWd
W\\ehZ5
),. 9^Wfj[h(,È -AINTENANCE
EYYWi_edWbbo" Y[c[dj[Z Xh_Z][i m_bb Yec[ beei[
\hec_dZ_l_ZkWbXh_Z][WXkjc[dji$J^_i_i"e\Yekhi["
kdZ[i_hWXb["WdZ_jcWoh[ikbj_dj^[WZZ_j_edWbbeii
e\ Y[c[djWj_ed ed ej^[h WXkjc[dji$ J^_i _d jkhd
cWo YWki[ _dYecfWj_Xb[ el[hbeWZ [\\[Yji" b[l[hW][
\ehY[i eh l_XhWj_edi j^hek]^ h[iedWdY[$ ?\" ^em[l[h"
WXh_Z][_iikffehj[ZXo\[m[hWdZ\[m[hWXkjc[dji"
WdZ \_dWbbo edbo ed[ bWij WXkjc[dj" j^[ _cfbWdj
YWhho_d]j^_iWXkjc[djcWokbj_cWj[bo\hWYjkh[$
?cfbWdj \hWYjkh[i Wh[ de ceh[ \h[gk[dj _d 8E?
_cfbWdjij^Wd_dYh[ijWb_cfbWdji$>em[l[h"h[fW_h_d]
j^[ ZWcW][ _i kikWbbo ckY^ [Wi_[h _d j^[ YWi[
e\ 8E? _cfbWdji j^Wd \eh Yh[ijWb _cfbWdji$ J^[
\hWYjkh[ fheY[ii kikWbbo [djW_bi cWj[h_Wb \Wj_]k[ _d
j^[ h[]_ed e\ j^[ XWiWb fbWj[$ ?\ j^_i XWiWb fbWj[ _i
h[fbWY[Z _d j_c[" de WZZ_j_edWb ZWcW][ m_bb eYYkh$
?\ h[fbWY[c[dj _i Z[bWo[Z" j^[ ceX_b[ j^h[WZ[Z f_d
cWoYWki[XWYj[h_Wb_deYkbWj_ed"m^_Y^_djkhdcWo
h[ikbj_dj^[beiie\Xed[lebkc[ijhkYjkhWbYebbWfi[
WhekdZj^[j^h[WZ[Zf_dWdZceh[fW_dZkh_d]WdZ
W\j[hj^[h[fbWY[c[djef[hWj_ed$
<_hij e\ Wbb" j^[ jh[Wjc[dj fhel_Z[h m_bb [nWc_d[
j^[ efj_ed e\ h[cel_d] j^[ Xh_Z][$ ?d j^_i h[if[Yj"
iYh[m Xh_Z][i ed ?: eh ?:E%?::E%?:EJ _cfbWdji
Wh[ [Wi_[h je ^WdZb[$ >em[l[h" iYh[m Xh_Z][i Wh[
ceh[ Z_\\_Ykbj je h[fW_h$ ?\ j^[ Xh_Z][ _ji[b\ ^Wi
eYYbkiWbef[d_d]im[][d[hWbboh[Yecc[dZ^Wl_d]
j^ei[ ef[d_d]i Yh[Wj[Z Zkh_d] j^[ \WXh_YWj_ed e\
j^[ Xh_Z][i" ed[ c_]^j Wjj[cfj je ki[ ik_jWXb[
_dijhkc[dji je beei[d j^[ Xh_Z][ \hec _ji ikffehj"
WXkjc[djXoWXkjc[dj$JhWdil[hiWb]heel[iWffb_[Z
_d j^[ ded#l_i_Xb[ Wh[W e\ j^[ WXkjc[dj m_j^ W
jkd]ij[dYWhX_Z[Xkhc_]^jWbie]_l[iec[b[l[hW][
\ehfej[dj_WbXh_Z][h[celWb$
?\_j_idejfeii_Xb[jeh[cel[j^[Xh_Z][_dehZ[h
je h[#Y[c[dj _j" j^[h[ Wh[ jme ki[\kb jh[Wjc[dj
Wbj[hdWj_l[i0
% ?\ W ik\\_Y_[djbo m_Z[ ]Wf _i fh[i[dj X[jm[[d j^[
Xh_Z][ WdZ j^[ WXkjc[dj m^[h[ j^[ beei[d_d]
eYYkhh[Z" eh _\ ikY^ W ]Wf YWd X[ Yh[Wj[Z Xo
ki_d]WXkhehej^[hhejWho_dijhkc[dj"_jm_bbX[
feii_Xb[ je h[WjjWY^ j^[ Xh_Z][ je j^[ WXkjc[dj
ki_d] WYhobWj[#XWi[Z Y[c[dj$ J^_i h[gk_h[i j^Wj
j^[ ]Wf X[jm[[d j^[ Xh_Z][ WdZ j^[ WXkjc[dj
je X[ Yb[Wd[Z WdZ Wdo ]h[Wio h[i_Zk[ je X[
h[cel[Z"iec[j^_d]j^Wj_i[Wi_boWY^_[l[Zki_d]
^oZhe][d f[hen_Z[ WdZ [j^Wdeb$ Iec[ jh[Wjc[dj
fhel_Z[hi b_a[ je h_di[ j^[ ]Wf m_j^ 8[jW_ieZedW
\eh Z_i_d\[Yj_ed \_hij$ Cedec[h _i ikXi[gk[djbo
_djheZkY[Z" Wjj[cfj_d] je m[j Wbb ikh\WY[i _d j^[
fheY[ii$J^_d#\bem_d]Y[c[dj_d]WYhobWj[ikY^Wi
9[hW\_n=[djWXo9[hWl[h"<hWda\khj%=[hcWdo"eh
FWjj[hdH[i_dYWddemX[_djheZkY[Z_djej^[]Wf$
>[h[_jm_bbfeboc[h_p[m_j^_dj^[j_c[if[Y_\_[Z
Xoj^[cWdk\WYjkh[h$:kh_d]j^_ij_c["j^[fei_j_ed
e\j^[Xh_Z][i^ekbZdejX[Y^Wd][Zje[dikh[j^Wj
j^[WYhobWj[cWjh_n_idejZWcW][Z$
% ;if[Y_Wbbo _d i_jkWj_edi _d m^_Y^ j^[ d[[Z \eh
Xh_Z][ h[WjjWY^c[dj Ye_dY_Z[i m_j^ W Z[i_h[ je
[\\[YjY^Wd][i_dcWij_YWjehofWhWc[j[hiikY^Wi
hW_i_d] j^[ X_j[" WZWfj_d] j^[ Ykhl[i e\ If[[ WdZ
M_bied" WZ`kijc[dji je j^[ effei_d] Z[dj_j_ed"
el[hXh_Z][i YWd X[ ki[\kb$ J^[ WZlWdjW][i e\
el[hXh_Z][i YecfWh[Z je j^[ \WXh_YWj_ed e\ W
Yecfb[j[bo d[m Xh_Z][ YWd X[ ikccWh_p[Z Wi
\ebbemi0
% J^[fei_j_edWbWdZj[di_edWbh[bWj_edi^_fie\j^[
_cfbWdjm_bbh[cW_dkdY^Wd][Z$J^_i_ifWhj_YkbWhbo
Z[i_hWXb[_\j^[_cfbWdjim[h[fbWY[ZijhWj[]_YWbbo
eh _\ W d[[Z je cWa[ Y^Wd][i WdZ WZ`kijc[dji
^Wi Wh_i[d m_j^_d j^[ \_hij '(Ä(*cedj^i W\j[h
j^[ _cfbWdji m[h[ fbWY[Z$ J^[ c_d[hWb_pWj_ed
fheY[ii h[cW_di kdZ_ijkhX[Z" WdZ j^[ _cfbWdj#
Xed[_dj[h\WY[m_bbdejX[Z_ijkhX[Z$
% J^[ fWj_[dj m_bb Yedj_dk[ je m[Wh W \_n[Z
h[ijehWj_ed$
% H[fW_h _i b[ii Yeijbo j^Wd j^[ \WXh_YWj_ed e\ W
Yecfb[j[bod[mikf[hijhkYjkh[$E\j[dedbobWj[hWb
i[]c[djid[[ZjeX[[nY^Wd][Zi[[<_]$'-$-
% J^[ jh[Wjc[dj _i kikWbbo b[ii [nj[di_l[ WdZ m_bb
j^[h[\eh[fhe]h[iiceh[gk_Yabo$
<WXh_YWj_ed e\ W d[m Xh_Z][ cWo X[ Yedi_Z[h[Z _\
kdZ[i_hWXb[WdZdej_Y[WXb[]WfiX[jm[[dj^[Xh_Z][
WdZj^[Wbl[ebWhh_Z][^Wl[ef[d[ZZk[jeh[iehfj_ed
e\j^[ie\jj_iik[i[if[Y_Wbbo\ebbem_d][njhWYj_edi_d
j^[Wdj[h_ehcWn_bbW"]Wfij^Wjc_]^jX[[b_c_dWj[Z
_d j^[ Yekhi[ e\ \WXh_YWj_d] WdZ _di[hj_d] W d[m
Xh_Z][$
7ced] j^[ ceij \h[gk[dj _dZ_YWj_edi \eh el[h#
Xh_Z][iWh[jh[Wjc[djim_j^Yedi_Z[hWXb[fei_j_edWb
WdecWb_[i e\ j^[ j[cfehecWdZ_XkbWh `e_dji Wj j^[
ekji[j$J^[fheY[iie\dehcWb_pWj_edWdZh[ZkYj_ed
e\ j^[ `e_dj fei_j_ed m_bb _d_j_Wbbo YWki[ h[i_ijWdY[
edj^[fWhje\j^[ckiYb[i"WdZj^[eYYbkiWbikh\WY[i
m_bb ^Wl[ je X[ WZ`kij[Z m_j^ iec[ \h[gk[dYo$ ?j
_i kikWbbo j^[ \_hij Xh_Z][ j^Wj _i X[_d] h[ZkY[Z eh
Wk]c[dj[Z m_j^ Yecfei_j[ _d j^_i Yedj[nj$ J^[
Yedi[gk[dY[i e\ eYYbkiWb WZ`kijc[dj WdZ j^[ h_ia
e\ Yecfei_j[ beii YWd Xej^ X[ jh[Wj[Z Xo _di[hj_d]
Wd el[hXh_Z][$ El[hXh_Z][i j^ki Wbie i[hl[ Wi
f[hcWd[dj ifb_dji m_j^ l[ho Wff[Wb_d] W[ij^[j_Y
fhef[hj_[i$ ?j _i Wd WZlWdjW][ je l[d[[h Wbb Xh_Z][i
m_j^ Y[hWc_Yi \hec j^[ ijWhj$ 9[hWc_Yi Wh[ [Wio je
WZ`kij" WdZ W\j[h [jY^_d] m_j^ Y[hWc_Y [jY^_d] ][b"
WdoWZZ_j_l[ceZ_\_YWj_ede\j^[cehf^ebe]oe\j^[
eYYbkiWbikh\WY[iYWdX[[Wi_boXk_bjkfm_j^WZ^[i_l[
Yecfei_j[$?\"XoYedjhWij"WYecfei_j[l[d[[h_iki[Z
_d ed[ e\ j^[ jme `Wmi" j^[ ceh[ WXhWi_ed#h[i_ijWdj
Y[hWc_Y cWj[h_Wb YWd ef[d kf \kdYj_edWb fWj^i _d
j^[Z[dj_j_ede\j^[effei_j[`Wm"m^_Y^"m^_b[_jcWo
fhej[Yjj^[_cfbWdjijeWY[hjW_d[nj[dj"cWoWbieX[
j^[ ijWhj_d] fe_dj e\ Wd kdZ[i_hWXb[ bWj[hWb_pWj_ed
e\ j^[ cWij_YWjeho \kdYj_ed$ H[]kbWh h[YWbbi Wh[
È È 4ROUBLESHOOTINGÈ ),/

_cfehjWdjÄ[if[Y_Wbbo_dj^[\_hij(Ä)o[WhiW\j[hj^[
\_hij_dijWbbWj_ede\Wfheij^eZedj_Yikf[hijhkYjkh[eh
\ebbem_d]Wbj[hWj_edijeWd[n_ij_d]ikf[hijhkYjkh[$
?\"Xo^_dZi_]^j"j^[fei_j_ede\j^[_cfbWdji^W\j
Z[j[hc_d[Z_djhWef[hWj_l[boXWi[Zedj^[WlW_bWXb[
Xed[ lebkc[ jkhdi ekj je X[ b[ii \WlekhWXb[" j^[
fheXb[c _i e\j[d [Wi_bo iebl[Z ki_d] Wd el[hXh_Z][$
J^[ eh_]_dWb Xh_Z][ _i fh[fWh[Z" j^[ j^h[WZ[Z f_d
_i h[fei_j_ed[Z Xo \b[n_d] m_j^_d j^[ b_c_ji e\ j^[
cWj[h_Wb" WdZ Wd _cfh[ii_ed _i jWa[d e\ j^[ d[m
fei_j_ed$
IcWbb[h" kdl[d[[h[Z el[hXh_Z][i Wh[ \WXh_YWj[Z
je WjjWY^ h[fbWY[c[dj _cfbWdji je [n_ij_d] Xh_Z][i$
Fh_ehjeh[fbWY_d]j^[_cfbWdj"j^[h[i_ZkWbXh_Z][_i &IGÈ 7ij^[el[hXh_Z][_iX[_d]]hekdZZemd"j^[Z_ijWb
fh[fWh[Z" WdZ j^[ Xh_Z][ ikh\WY[ e\ j^[ el[hXh_Z][ WXkjc[dj YWd _d_j_Wbbo i[Ykh[ j^[ m_Z[#ifWd Xh_Z][$ J^[
_i ceZ[bb[Z _d WYhobWj[ [$]$ FWjj[hd H[i_d$ ?j WXkjc[dj m_bb dej X[ Ykj kdj_b j^[ l[ho [dZ$ J^[ Y[hWc_Y
_i _cfehjWdj je cWa[ ikh[ j^Wj j^[i[ ij[fi Wh[ l[d[[h^WiWbh[WZoX[[dbWh][boh[cel[Z$KdZ[hYkji"^em[l[h"
f[h\ehc[Z X[\eh[ Wdo ikh]_YWb _dj[hl[dj_ed je a[[f ckij dej X[ Yh[Wj[Z$ L[hj_YWb ]heel[i YWd X[ ]hekdZ _d je
Wdo fh[fWhWj_ed Z[Xh_i \hec [dj[h_d] j^[ \h[i^bo fh[l[djh[celWb_dWZ_ijWbZ_h[Yj_ed
ikjkh[Z mekdZ$ EdY[ j^[ d[m _cfbWdj _i _d fbWY["
j^[ WXkjc[dj YWd X[ iYh[m[Z edje j^[ _cfbWdj
_cc[Z_Wj[boWdZYedd[Yj[Zm_j^j^[el[hXh_Z][fWhj
fh[l_ekibo ceZ[bb[Z _d WYhobWj[ ki_d] i[b\#Ykh_d]
WZ^[i_l[ WYhobWj[$ J^_i j[cfbWj[ YWd X[ _dl[ij[Z
_cc[Z_Wj[bo WdZ YWij _d c[jWb$ ?d j^_i cWdd[h" j^[
fWj_[djYWde\j[dX[fhel_Z[Zm_j^WZ[\_d_j_l[\_n[Z
h[ijehWj_ed edbo W cWjj[h e\ 'Ä(^ \ebbem_d] j^[
h[fbWY[c[dje\Wd_cfbWdj$
<eh W l[d[[h[Z el[hXh_Z][" j^[ [n_ij_d] Xh_Z][ _i
fh[fWh[Z eYYbkiWbbo WdZ ed j^[ bWX_Wb WdZ b_d]kWb
Wif[Yjiel[hWZ_ijWdY[Yehh[ifedZ_d]jeWXekjjme
X_Ykif_Zi$ 9Wh[ ckij X[ jWa[d je [dikh[ j^Wj de
kdZ[hYkjiWh[Yh[Wj[Z_dj^[Wh[W_dm^_Y^j^[Xh_Z][
m_bb bWj[h X[ Y[c[dj[Z$ L[hj_YWb ]heel[i i^ekbZ X[
_dYbkZ[Zjem_j^ijWdZh[celWbWdZi^[Wh\ehY[i$J^[
Z_ijWdY[X[jm[[dj^[WXkjc[djWdZj^[Xh_Z][ÆZ_[Ç &IGÈ J^[Yecfb[j[Zel[hXh_Z][WdZj^[ceZ[b"eYYbkiWb
ckij X[ ik\\_Y_[dj je f[hc_j bWj[h _di[hj_ed e\ j^[ l_[m$ J^[ ib_]^jbo jeej^#b_a[ \ehci ed j^[ h[i_ZkWb Xh_Z][
Xh_Z][$ m_bbbWj[hWbbemj^[Z[djWbj[Y^d_Y_WdjeXk_bZkfj^[Y[hWc_Y
?\"Wjj^[j_c[e\_cfbWdjWj_ed"j^[Xed[ikffbo^WZ l[d[[h je j^[ h[gk_h[Z j^_Yad[ii WdZ Wdj_Y_fWj[ j^[ i^Wf[ e\
X[[d_dik\\_Y_[djjef[hc_jfWhWbb[b_p_d]XoX[dZ_d] j^[jeej^
j^[WXkjc[dji"j^_iYWdkikWbboX[f[h\ehc[Zi[l[hWb
cedj^ibWj[h1j^[el[hXh_Z][YWdX[WjjWY^[Zjej^[
Xh_Z][ je WYYecceZWj[ j^[ d[m fei_j_ed e\ j^[
_cfbWdj$

9Wi[IjkZo(
J^[\ebbem_d]j^h[[f_Yjkh[ii^emZ_\\[h[djij[fije
X[f[h\ehc[Zm^[d\WXh_YWj_d]Wdel[hXh_Z][$
El[hXh_Z][iWh[Y[c[dj[Z_dfbWY[ki_d]Z[\_d_j_l[
Y[c[dj"\eh[nWcfb[]bWii#_edec[hY[c[djikY^Wi
9[c8Wi[
J^[efj_ede\ceZ_\o_d]Wikf[hijhkYjkh[hWj^[h
j^Wd ^Wl_d] je \WXh_YWj[ W Yecfb[j[bo d[m ed[ m_bb
Wbie cWa[ _j [Wi_[h \eh j^[ jh[Wjc[dj fhel_Z[h je
Æ_iebWj[Ç _dZ_l_ZkWb _cfbWdji j^Wj c_]^j X[ ikX`[Yj
jeel[hbeWZ_d]$J^[i[_iebWj[Z_cfbWdjiYWdbWj[hX[
h[Yedd[Yj[Zki_d]WicWbbel[hXh_Z][$ &IGÈ BWj[hWbl_[me\j^[el[hXh_Z][edj^[ceZ[b
)-& 9^Wfj[h(,È -AINTENANCE

9Wi[IjkZo)
A C

9Wi[IjkZo*
H[fbWY_d] Wd _cfbWdj _d j^[ c_ZZb[ e\ j^[ Xh_Z][
m_j^ekj h[cel_d] j^[ Xh_Z][ YWd X[ WY^_[l[Z
edbo _\ Wd WYY[ii fWj^ YWd X[ Yb[Wh[Z \eh W bWj[hWb
eij[ejeco0
J^_i fheY[Zkh[ Wbie ^Wi j^[ WZlWdjW][ j^Wj j^[
Xh_Z][f[hi[h[cW_di\_hcbo_d_jifbWY[$J^[j[di_edWb
h[bWj_edi^_fi X[jm[[d Wbb j^[ ej^[h _cfbWdji m_bb
h[cW_d kdW\\[Yj[Z$ 7bie" j^[ fWj_[dj Yedj_dk[i je
m[Wh W \_n[Z h[ijehWj_ed" WdZ j^[ Yeij e\ j^[ h[fW_h
_i h[bWj_l[bo bem$ Ed[ j^_d] je Yedi_Z[h _i j^Wj j^[
&IGÈÈ AÈ B C[jWb \hWc[ \eh YecX_d[Z Y[c[dj_d] ed
j^[ Z_ijWbceij 8E? _cfbWdj WdZ j^[ Xh_Z][ WdZ iYh[m_d]
edje j^[ fj[ho]e_Z iYh[m$ C BWj[hWb Wif[Yj e\ j^[ mWn
ceZ[bbWj_ed$ D ?djhW#ehWb l_[m e\ j^[ WZ`kijc[dj f_[Y[$
E EYYbkiWb l_[m$ ?j _i h[Yecc[dZ[Z je ki[ edbo j[cfehWho
Y[c[djje\_bbj^[iYh[m^eb[\ehj^[jkX[hefj[ho]e_ZiYh[m
\hWYjkh[ e\ W 8E? _cfbWdj m_bb X[ j^[ h[ikbj e\ l[ho
ijhed]\ehY[ij^Wjm_bb_dlWh_WXboWbieW\\[Yjj^[ej^[h
_cfbWdji m_j^_d j^[ iWc[ `Wm#_cfbWdj#h[ijehWj_ed
ioij[c$J^[i[YWi[i^Wl[jeX[\ebbem[Zl[hoYbei[bo$
H[fbWY_d] W 8E? _cfbWdj h[gk_h[i W Y[hjW_d ia_bb"
Xkjj^_i_dj[h[ij_d]jWia^Wij^[_dlWbkWXb[WZlWdjW][
e\]_l_d]j^[ki[hWd_d#Z[fj^kdZ[hijWdZ_d]\ehj^[
jh[Wjc[dj fheY[Zkh[ WdZ \eh j^[ X[d[\_ji e\ X[_d]
WXb[ je meha _d j^[ Z[fj^ e\ j^[ j^h[[#Z_c[di_edWb
Xed[ifWY[$FheXb[ciWdZj^[_hiebkj_edim_bbWbmWoi
j[WY^kiceh[j^WdWdohekj_d[jWia$
È È 4ROUBLESHOOTINGÈ )-'

A F

&IGÈÈA Fh[fWh[ZWh[We\j^[Xh_Z][fh_ehjeikh]_YWb
_dj[hl[dj_ed$ B J^[j^h[WZ[Zf_d^WiX[[di[l[h[Z
\hecj^[Xh_Z][$J^[WjjWY^c[djYekbZWbh[WZoX[
WYYecceZWj[Z$ C J^[_cfbWdjebe]_ijd[[ZiW]eeZl_[m
e\j^[_cfbWdji_j[$ DÈE J^[_cfbWdjYWddemX[h[cel[Z
_dWl[ij_XkbWhZ_h[Yj_ed$ F <khj^[hXWiWbbo"Wd[meij[ejeco
_icWZ[\ehj^[h[fbWY[c[dj_cfbWdj;:I'&='&_dj^_i
YWi[$J^[l[hj_YWbfei_j_ede\j^[d[m_cfbWdj"WdZj^kie\
j^[WXkjc[dj"_i[nY[bb[dj$ G J^[el[hXh_Z][_iY[c[dj[Z
ki_d]]bWii#_edec[hY[c[dj$Ä?\WdWZZ_j_edWb_cfbWdj_ije
X[_dj[]hWj[Z_djej^[Xh_Z]["Wl[hoi_c_bWhfheY[Zkh[YWdX[
\ebbem[Z
)-( 9^Wfj[h(,È -AINTENANCE
È
&RACTURESÈATÈTHEÈ4HREADEDÈ0IN
<hWYjkh[iWjj^[j^h[WZ[Zf_dWh[l[hohWh[$?\j^[oZe
eYYkh"j^[\hWYjkh[i_j[m_bbkikWbboX[beYWj[ZZ_h[Yjbo
X[bemj^[m_Z[d[Zb[Z][e\j^[j^h[WZ$
J^[hWfo0 <hWYjkh[i X[bem j^[ j^h[WZ[Z f_d YWd
X[ jh[Wj[Z Xo h[cel_d] j^[ ikf[hijhkYjkh[ WdZ Xo
fbWY_d] W d[m j^h[WZ[Z f_d ed j^[ Xkjj e\ j^[ ebZ
ed[$J^[h[_iWif[Y_WbjeebJ7F:j^WjYWdX[ki[Z
je][j^[hm_j^j^[H7J(hWjY^[jjeWY^_[l[j^_i]eWb$
J^[_cfbWdjebe]_iji^ekbZ\_hijX[Yec[\Wc_b_Whm_j^
j^[ ki[ e\ j^[i[ _dijhkc[dji Xo fhWYj_i_d] ekji_Z[
j^[cekj^$J^[J7F:jeebm_bbfh[iij^[d[mj^h[WZ
_die\j=hWZ['"(j_jWd_kcedjej^[h[i_ZkWbf_d$
?\j^[beYWj_ede\j^[\hWYjkh[i_j[_i_cc[Z_Wj[bo
X[bem j^[ b[Z][ e\ j^[ j^h[WZ" j^[ h[fW_h fheY[Zkh[
m_bbh[ikbj_dWd_cfbWdjj^Wj_iWXekj*cci^ehj[h
j^Wd X[\eh[$ Je X[ WXb[ je h[_di[hj j^[ [n_ij_d]
Xh_Z]["j^[bed][hJI:**WXkjc[dj_iki[Z_dfbWY[
e\j^[JI:*ehWJI:++_dfbWY[e\j^[JI:+$J^[
feb_i^[Z fWhj" m^_Y^ _i *cc bed][h _d Wd Wf_YWb
Z_h[Yj_ed" YWd X[ ikda _dje j^[ ckYeiW _\ d[[Z[Z$
M[ ki[ J[hhWYehjh_b e_djc[dj Wi W \_bb_d] c[Z_kc
\ehj^[_dj[hdWbj^h[WZ_d]e\j^[WXkjc[dj$J^[d[m
WXkjc[dj YWd Wbie X[ WjjWY^[Z m_j^ h[i_d Y[c[dj
[$]$9[hW\_n=[djWXo9[hWl[h"<hWda\khj%=[hcWdo$
J^[h[ _i de Z_h[Yj h[fbWY[c[dj cWjY^ \eh JI://
WXkjc[dji$ ?j _i feii_Xb[ je ki[ W JI:* WXkjc[dj"
Xkj bWh][ ef[d ifWY[i m_bb h[cW_d _di_Z[ j^[ Yhemd
j^Wj Wh[ X[ij fh[#\_bb[Z m_j^ h[i_d Y[c[dj$ ?j _i Wbie
feii_Xb[jeYWijWc[jWb_dj[h\WY[jeX[Y[c[dj[Zeh
]bk[Z_dfbWY[$
È
0ENETRATIONÈOFÈTHEÈ-UCOSAÈÈ
BYÈAÈ$ISK
?d l[ho hWh[ YWi[i" fWhji e\ j^[ Z_ia eh Z_iai cWo
f[h\ehWj[ j^[ ckYeiW WdZ X[Yec[ [nfei[Z _d j^[
ehWbYWl_jo$J^[ceijfheXWXboi_ji\ehj^_ije^Wff[d
_i j^[ Wh[W e\ j^[ WjjWY^[Z ckYeiW eh Wh[Wi W]W_dij
m^_Y^ celWXb[" ckiYb[#ikffehj[Z ie\j j_iik[i
jed]k[" Y^[[a Wh[ fh[ii[Z$ F[h\ehWj_ed cWo eYYkh
ifedjWd[ekibo eh X[ fhelea[Z _dj[dj_edWbbo [$]$ Xo
Wdej^[hZ[dj_ijeh_dWZl[hj[djbo[$]$XojWXb[mWh[$
Iec[j_c[i fWj_[dji Wh[ coij_\_[Z Xo j^[ fehj_edi
e\ j^[ Z_iai j^[o YWd i[[ j^hek]^ j^[ j^_d ckYeiW"
WdZ iec[ e\ j^[c m_bb ijWhj jekY^_d] WdZ fh[ii_d]
_dj^[i[Wh[Wi$
J^[hWfo0J^[ceij_cfehjWdjj^_d]_ijeWZZh[ii
j^[fheXb[c_cc[Z_Wj[bo"i_dY[j^[f[h\ehWj_edi_j[i
m_bbX[beYWj[Z_dj^[h[]_ede\j^[ikh\WY[#[dbWh][Z
WdZbeWZ#jhWdic_jj_d]b[]ie\j^[_cfbWdj"m^_Y^Wh[
ceh[ fhed[ je _d\[Yj_edi j^Wd j^[ Yh[ijWb beYWj_edi
m^[h[ j^[ j^h[WZ[Z f_di [c[h][$ I_d]b[#Z_ia 8E?
_cfbWdjij^WjWff[WhceX_b[m_bbceijfheXWXbo^Wl[
jeX[h[fbWY[Z$M_j^j^[i[_cfbWdji"Wdo_d\[Yj_edcWo
gk_YaboW\\[Yjj^[[dj_h[Z_ia"iec[j^_d]j^WjYWdX[
Yedi_Z[h[Z_hh[l[hi_Xb[ZWcW][$M_j^ckbj_#Z_ia8E?
_cfbWdji WdZ ijWXb[ i_d]b[#Z_ia 8E? _cfbWdji" j^[
\ebbem_d]j^[hWf[kj_YWbj[hdWj_l[iWh[WlW_bWXb[0
% 7k]c[djWj_edki_d]c[cXhWd[iF[h_ei("\_Xh_d[
c[cXhWd["[jY$$
% I^ehj[d_d] j^[ Z_ia \hec l[ij_XkbWhbo ki_d] W
jkd]ij[dYWhX_Z[Ykjj[h$
% 8[dZ_d]j^[Z_iaekje\j^[mWo"feii_XboYel[h_d]
_jm_j^Wc[cXhWd[$
È
#ONCLUSION
?\ j^[ i_jkWj_ed e\ XWbWdY[ Y^Wd][i" j^[ \ebbem_d]
fheXb[cicWoeYYkh0
% Beei[d_d] e\ ikfhWijhkYjkh[i \hec j^[
WXkjc[dji
% L[d[[h cWj[h_Wb Y[hWc_Yi eh Yecfei_j[ _i
Y^_ff_d]e\\
% Eij[eboj_Y WYj_ed jWa[i fbWY[ WhekdZ iec[ XWi[#
fbWj[i
% <hWYjkh[ie\XWi[#fbWj[iehj^h[WZ[Zf_dieYYkh$
7bb j^[i[ Z[l[befc[dji Wh[ dehcWb Z[l[befc[dji
\eh YWi[i ekj e\ h[]kbWh Yedjheb$ >[dY[ _j YWd edbo
X[ c[dj_ed[Z W]W_d" j^Wj h[]kbWh ced_jeh_d] WdZ
WZ`kij_d] _i [njh[c[bo d[Y[iiWho" [if[Y_Wbbo _d j^[
\_hij (o[Whi W\j[h j^[ \_hij _dijWbbWj_ed e\ W `Wm#
_cfbWdj#fheij^[j_Yi ioij[c eh W\j[h cW`eh Y^Wd][i
e\j^_iioij[c$
È
,OSSÈOFÈ3TABILITYÈANDÈ2EINTEGRATION
È
2EASONSÈFORÈ)MPLANTÈ,OSS
:[djWb _cfbWdj beii YWd ^Wl[ cWdo h[Wiedi$ J^[
\ebbem_d]\WYjehicWoYedjh_Xkj[0
% Kdf^oi_ebe]_YWbbeWZ_d]
% ?d\[Yj_ede\[deiiWbikh\WY[i
% 9edjWc_dWj_ede\j^[_cfbWdjX[Zehj^[_cfbWdj
_ji[b\
% ?dWZ[gkWj[YWh[ehcW_dj[dWdY[
% Beiie\Xed[ijWX_b_jo
% 8ed[h[iehfj_ed
% ;dZeYh_debe]_YWbY^Wd][i
% Kd\WlekhWXb[WXkjc[djjefebe]oeh_dWZ[gkWj[=
lWbk[
% JhWkcWf^oi_YWb\_]^ji"ifehjiehjhW\\_YWYY_Z[dji"
[jY$
M_j^j^[[nY[fj_ede\jhWkcW"i[l[hWbe\j^[i[\WYjehi
m_bbkikWbboYecX_d[jeYWki[_cfbWdjbeii$
È È ,OSSÈOFÈ3TABILITYÈANDÈ2EINTEGRATIONÈ
È
4REATMENTÈOFÈ4RAUMAÈ2ESULTS
J^[h[ Wh[ i[l[hWb feii_Xb[ h[Wiedi m^o Wd [dj_h[
_cfbWdj#h[ijehWj_ed ioij[c _d ed[ eh Xej^ `Wmi
ikZZ[dbo eh _dYh[Wi_d]bo bei[i _ji ijWX_b_jo$ Iec[ e\
j^[i[h[Wiedic_]^jX[WYkj[jhWkcW"Y^hed_Yel[hbeWZ
Zk[ je Y^Wd][i _d eYYbki_ed" e\j[d Wbie _hh[]kbWh
cWij_YWjehofWjj[hdiehXhkn_icehikf[hijhkYjkh[i
Yec_d]beei[\heced[ehi[l[hWbWXkjc[dji$M_j^_d
j^[ Xed[ _ji[b\" h[ZkY[Z c_d[hWb_pWj_ed WhekdZ j^[
Xed[#_cfbWdj _dj[h\WY[ YWd X[ h[ifedi_Xb[ \eh W
fhe]h[ii_l[ beii e\ ijWX_b_jo$ ?\ W m[bb#eh]Wd_p[Z
cWjh_n _i Wbh[WZo fh[i[dj Wj j^[ j_c[ Wd _dijWX_b_jo
eYYkhi"h[c_d[hWb_pWj_ed_ifeii_Xb[WdZW\WlekhWXb[
h[ifedi[jej^[hWfoceh[b_a[bo$>em[l[h"_\eij[eYbWiji
^Wl[ Wbh[WZo YWki[Z ijhkYjkhWb ZWcW][ eh" mehi[" _\
\_XheXbWiji^Wl[X[[d_cfb_YWj[ZFWf[jWb$(&&)"j^[
fhe]dei_i _i ckY^ ceh[ kd\WlekhWXb[1 j^[ fheY[ii
m_bbkikWbboX[_hh[l[hi_Xb["WdZj^[_cfbWdjiW\\[Yj[Z
i^ekbZ X[ Yedi_Z[h[Z \eh h[fbWY[c[dj$ FWhj_YkbWhbo
XWZ f^Wi[i \eh WYY_Z[dji" _d ekh eXi[hlWj_ed" Wh[
j^[ \_hij ,cedj^i \ebbem_d] [_j^[h _cfbWdjWj_ed eh
_di[hj_ede\Wd[mikf[hijhkYjkh[$?dXej^YWi[i"j^[
Z[]h[[e\c_d[hWb_pWj_edWjj^[j_c[e\j^[WYY_Z[dj
mekbZ X[ \W_hbo bem" m_j^ [nj[di_l[ h[ceZ[bb_d] _d
j^[fheY[iie\jWa_d]fbWY[$?\Xej^j^[_cfbWdjiWdZ
j^[ ikf[hijhkYjkh[ ^WZ h[cW_d[Z kdY^Wd][Z \eh
ceh[j^Wd'o[Whfh_ehjej^[WYY_Z[dj"ceh[_cfbWdj
\hWYjkh[iXkj\[m[h`Wm\hWYjkh[iWh[eXi[hl[Z$
JhWkcW#h[bWj[ZZWcW][YWki[i]h[Wj[hfheXb[ci_d
j^[cWn_bbWj^Wd_dj^[cWdZ_Xb[$J^[cW_dfheXb[c
_i j^Wj c_Yhe\hWYjkh[i Wi m[bb Wi cWYhe\hWYjkh[i _d
j^[ Xed[ WdZ Z[jWY^c[dj e\ j^[ Xed[ cWo eYYkh
Wbed] j^[ beWZ#jhWdic_jj_d] Z_iai m_j^ekj YWki_d]
ik\\_Y_[dj Xb[[Z_d] je WYjkWj[ j^[ YWiYWZ[Z Xed[#
^[Wb_d] fheY[ii$ H[_dj[]hWj_ed e\ j^[ _cfbWdj ckij
j^[h[\eh[ X[ [\\[Yj[Z Xo eii[eWZWfjWj_ed eh Xo ]Wf
`kcf_d]" Xkj j^[i[ Wjj[cfji e\j[d \W_b X[YWki[ e\
W bWYa e\ ijWX_b_pWj_ed WdZ j^[ Yedj_dk[Z _d\bk[dY[
e\ cWij_YWjeho \ehY[i$ ?d j^[i[ YWi[i" ckbj_fb[ beYWb
ikh]_YWb _dj[hl[dj_edi cWo X[ _dZ_YWj[Z _d ehZ[h je
YWki[Xb[[Z_d]$?j_iWbiefeii_Xb[je_di[hjWZZ_j_edWb
iYh[m _cfbWdji Wbj^ek]^ [dek]^ _cfbWdji ^Wl[
Wbh[WZoX[[d_di[hj[Z1j^ei[_cfbWdjid[[Zdej[l[d
d[Y[iiWh_bo X[ Yedd[Yj[Z je j^[ Xh_Z][$ ?dZ_l_ZkWb
c_d_fbWj[i cWo Wbie _dYh[Wi[ ijWX_b_jo" WdZ j^[_h
l[ho _di[hj_ed _d _ji[b\ cWo WYY[b[hWj[ WdZ fhecej[
h[][d[hWj_ed Zk[ je j^[ [dik_d] Xb[[Z_d] WdZ
\bWf \ehcWj_ed _dj[di_\_[Z h[]_edWbbo WYY[b[hWj[Z
f^[dec[ded$ M^_b[ cWij_YWjeho \ehY[i fhecej[
c_d[hWb_pWj_ed _d j^[ _dj[h\WY_Wb h[]_ed m^[d j^[
_cfbWdjebe]_YWb i_jkWj_ed _i ijWXb[" j^[o m_bb YWki[
j^[[nWYjeffei_j[\ebbem_d]WYY_Z[dji"X[YWki[j^[h[
m_bbX[defei_j_l[WdY^ehW][_dj^[Xed[$?hed_YWbbo"
j^[d" j^[ XWi[b_d[ i_jkWj_ed _i ceh[ \WlekhWXb[ _\
j^[ _cfbWdji Xh[Wa _d j^[ WYY_Z[dj WdZ ^Wl[ je X[
h[fbWY[Z j^Wd _\ j^[o Ze dej Xh[Wa WdZ j^[ \_hij
)-)
Yb_d_YWb_cfh[ii_edj[cfjij^[_cfbWdjebe]_ijjejho
WdZ fh[i[hl[ j^[ [n_ij_d]" ded#\hWYjkh[Z _cfbWdji$
FWj_[dji m_j^ ceh[ [nj[di_l[ ijhkYjkhWb _cfbWdj
ZWcW][ Wh[ ceh[ b_a[bo je W]h[[ je _cc[Z_Wj[
h[_cfbWdjWj_ed j^Wd j^ei[ m^e Æ^WZ X[[d bkYaoÇ1
j^[ bWjj[h Wh[ dej Wi [Wi_bo Yedl_dY[Z j^Wj ikh]_YWb
_dj[hl[dj_ed _i h[gk_h[Z Wbj^ek]^" ikX`[Yj_l[bo" j^[
Xh_Z][i[[cijeX[ij_bb\_hcbo_dfbWY[$
?d cWij_YWjeho \kdYj_edWb el[hbeWZ" j^[ i_jkWj_ed
_i gk_j[ Z_\\[h[dj0 M^[d _j Yec[i je Z_W]deij_Yi" _j
_i _cfehjWdj je h[YWf_jkbWj[ j^[ ^[Wb_d] ^_ijeho \eh
j^[ _cfbWdji W\\[Yj[Z$ ?\ ^[Wb_d] mWi kd[l[dj\kb
ed bWj[ beWZ_d] eh _\ j^[ fh_cWho ^[Wb_d] fheY[ii[i
m[h[ d[Whbo f[h\[Yj ed _cc[Z_Wj[ beWZ_d]" ed[
mekbZceijbo[nf[Yjh[c_d[hWb_pWj_ede\j^[cWjh_n
ikhhekdZ_d] j^[ _cfbWdj Wi ieed Wi j^[ jhWkcWj_Y
_d\bk[dY[_ih[cel[Zehd[kjhWb_p[Z$>em[l[h"_\j^[
fheXb[ci eYYkhh[Z l[ho [Whbo Ä j^Wj _i" _d j^[ \_hij
)Ä,cedj^iW\j[h_cfbWdjWj_edÄj^[Y^WdY[jeiebl[
j^[cm_bbX[icWbb[h"WdZj^[[\\ehjh[gk_h[Zjeiebl[
j^[c m_bb X[ ]h[Wj[h$ ?j _i fWhj_YkbWhbo _cfehjWdj
je Z[j[hc_d[ [nWYjbo j^[ _cfbWdj jof[0 ;l[d bWh][
Wcekdji e\ ceX_b_jo YWd X[ jh[Wj[Z Wi bed] Wi j^[
beWZ#jhWdic_jj_d] ikh\WY[i e\ j^[ _cfbWdj ^Wl[ dej
X[[diWdZXbWij[Z$?dWZZ_j_ed"ikh]_YWb_dj[hl[dj_ed
_ifeii_Xb[m_j^j^[i[_cfbWdji_dehZ[hje[b_c_dWj[
ikYY[ii\kbbo Wdo _d\[Yj_ed d[nj je j^[ Z_iai$ M_j^
j^[i[ ikh\WY[i" _j _i Wbie [Wi_[h je WZefj W mW_j#WdZ#
i[[Wjj_jkZ["m^_b[Z[bWo[Zj^[hWfo^WifhWYj_YWbbode
WZlWdjW][im_j^8E?_cfbWdjim_j^ikh\WY[#[dbWh][Z
beWZ#jhWdic_jj_d]ikh\WY[i$J^[[bWij_Yfhef[hj_[ie\
j^[ 8E? _cfbWdj Wbie fbWoi Wd _cfehjWdj heb[ m^[d
Wdim[h_d] j^[ gk[ij_ed m^[j^[h Wd _cfbWdj i^ekbZ
X[ b[\j Wi _i" h[cel[Z eh b[\j _d fbWY[ Xkj kdbeWZ[Z
\ehj^[j_c[X[_d]$J^WjWbed[_ih[Wied[dek]^m^o
Wdo ikXi[gk[dj jh[Wjc[dj fhel_Z[Z i^ekbZ Yedikbj
m_j^j^[fh_cWho_cfbWdjebe]_ij$EXl_ekibo"_jmekbZ
X[i^[[h^Wff[dijWdY[_\Wdej^[hZ[dj_ijm^ei[edbo
jhW_d_d]_i_dYh[ijWb_cfbWdjebe]om[h[jeWii[iiWbb
j^[i[Wif[YjiYehh[Yjbom_j^ekjj^ehek]^jhW_d_d]_d
XWiWbeii[e_dj[]hWj_edj^[hWfo$
7dej^[h Z[j[hc_dWj_ed j^Wj ckij X[ cWZ[ _i
m^[j^[hj^[Z_iaehfWhjij^[h[e\^Wl[Wbh[WZoX[[d
ikf[h_d\[Yj[Z$ ?\ j^Wj _i j^[ YWi[" ijWX_b_pWj_ed YWd
debed][hX[[nf[Yj[Z"i_dY[]hWdkbWj_edj_iik[m_bb
d[l[h X[ Yedl[hj[Z je Xed[ j_iik[ eh c_d[hWb_p[Z
Z_h[Yjbo"WdZWbieX[YWki[]hWdkbWj_edj_iik[Ze[idej
f[hc_jeii[eWZWfjWj_edeh]Wf`kcf_d]$
Ded[j^[b[ii" j^[ _hh[l[hi_Xb[ beii e\ j^[ Xedo
_dj[]hWj_ed e\ W beWZ#jhWdic_jj_d] h[]_ed Ze[i dej
d[Y[iiWh_boc[Wdj^Wjj^[_cfbWdj_ibeij$Ed[c_]^j"
\eh_dijWdY["jhojeWY^_[l[h[_dj[]hWj_ede\j^[Z_iaXo
mWoe\i[YedZWhoWk]c[djWj_ed$>em[l[h"_jYWdWbie
X[ik\\_Y_[djjei_cfboh[cel[j^[]hWdkbWj_edj_iik[
WhekdZj^[Z_ia$J^[]WfX[jm[[dj^[Yehj_YWbXed[
WdZ j^[ beWZ#jhWdic_jj_d] ikh\WY[i YWd X[ Xh_Z][Z
m_j^ Xedo j_iik[ \ehc[Z _d j^[ dehcWb cWdd[h" Xo
)-* 9^Wfj[h(,È -AINTENANCE
YWiYWZ[Z Xed[ ^[Wb_d] W\j[h Xb[[Z_d]$ ?d i_c_bWh
i_jkWj_edi" m[ ^Wl[ Wbie gk_j[ ikYY[ii\kbbo _di[hj[Z
Xed[h[fbWY[c[djcWj[h_Wbe\^kcWdeh_]_d"'[$]$_d
][b" cWjh_n" eh fkjjo \ehc" Wj b[Wij m^[h[ j^[ i_j[ Wj
m^_Y^ j^[i[ cWj[h_Wbi m[h[ WZZ[Z Z_Z dej Z_h[Yjbo
Yecckd_YWj[ [_j^[h m_j^ j^[ ehWb YWl_jo eh j^[
cWn_bbWhoi_dki$?dj^[bWjj[hYWi[ÄYedd[Yj_edm_j^
j^[cWn_bbWhoi_dkiÄYel[h_d]j^[l[ij_XkbWhWif[Yj
e\ j^[ Z[\[Yj m_j^ W c[cXhWd[ _i h[Yecc[dZ[Z$
<_Xh_dc[cXhWd[ieXjW_d[Z\hecWkjebe]ekiXbeeZ
YWdX[ki[Z\ehj^_ifkhfei[$
7i ^_ijebe]_YWb ijkZ_[i ^Wl[ i^emd" W 8E?
_cfbWdj j^Wj _i ij_bb h[bWj_l[bo ijWXb[ WdZ j^Wj _i
ij_bb _cfb_YWj[Z _d j^[ el[hWbb beWZ#jhWdic_ii_ed
fheY[ii cWo ]W_d _d eii[e_dj[]hWj_ed ikh\WY[ _\ j^[
cWij_YWjeho beWZ _i h[ZkY[Z$ J^_i m_bb Wbie _dYh[Wi[
j^[ Z[]h[[ e\ c_d[hWb_pWj_ed e\ j^[ cWjh_n$ J^[i[
8E? _cfbWdji i^ekbZ j^[h[\eh[ X[ Æ_iebWj[ZÇ \hec
j^[ikf[hijhkYjkh[$J^_i[\\[Yj_l[boc[Wdif^oi_YWbbo
i[fWhWj_d]j^[_cfbWdj\hecj^[Xh_Z][$?jYWdbWj[hX[
h[Yedd[Yj[ZXomWoe\Wdel[hXh_Z]["\eh[nWcfb[$7d
Æ_iebWj[ZÇ_cfbWdji^ekbZ[n^_X_jdej_Y[WXbo]h[Wj[h
ijWX_b_joW\j[h,Ä'&m[[ai$?dfh_dY_fb["h[_dj[]hWj_ed
YWd X[ ikYY[ii\kb _d [_j^[h `Wm$ J^[ Y^WdY[ e\
h[_dj[]hWj_ed" ^em[l[h" _i bem[h _d Wh[Wi ikX`[Yj je
\b[n_ed cWdZ_XkbWh fh[cebWhi eh _d Wh[Wi m^[h[
h[iehfj_edcWofej[dj_Wbbofh[lW_bi[YedZcWn_bbWho
fh[cebWh WdZ \_hij cWn_bbWho cebWh$ J^[ Y^WdY[ e\
h[_dj[]hWj_ed _i j^[ bWh][h" j^[ \khj^[h XWiWbbo j^[
Z_iaiWh[beYWj[Z$Eded[^WdZ"j^[_djhWXedoXbeeZ
ikffbo _i X[jj[h _d j^[i[ Wh[Wi" ed j^[ ej^[h ^WdZ"
j^[ Wb_]dc[dj e\ j^[ i[YedZWho eij[edi _i ceh[
\WlekhWXb[_d\hedje\j^[dWhhem[hWdZZ[[f[hheeji
e\j^[d[_]^Xekh_d]j[[j^[if[Y_Wbbo_dj^[l_Y_d_jo
e\ cebWhi" ie j^Wj h[fW_hi j[dZ je X[ ceh[ b_a[bo
^[h[$ ?d WZZ_j_ed" bWh][h Z_iai m_j^ W ^_]^[h Y^WdY[
e\ ikhl_lWb YWd kikWbbo X[ _di[hj[Z _d j^[ Z[[f[h
XWiWbh[]_edi"m^_Y^Wh[WbieX[jj[hfhej[Yj[ZW]W_dij
_d\[Yj_ed$
?j \ebbemi \hec j^[ WXel[ j^Wj fhWYj_YWbbo de ed[
[nY[fj j^[ eh_]_dWb jh[Wjc[dj fhel_Z[h m_bb X[ _d W
fei_j_ed je h[Wbbo adem WdZ Wffh[Y_Wj[ j^[ [dj_h[
Yekhi[ e\ jh[Wjc[dj WdZ ^[Wb_d] WdZ je cWa[ j^[
Yehh[Yjjh[Wjc[djZ[Y_i_ediXWi[Zed[nf[h_[dY[$?j_i
j^[h[\eh[h[Yecc[dZ[Zje^Wl[WdoikY^jh[Wjc[dj
f[h\ehc[Z kdZ[h j^[ ikf[hl_i_ed e\ j^[ eh_]_dWb
jh[Wjc[djfhel_Z[h$
J^[jof_YWbi^Wf[e\Yh[ijWb_cfbWdji"XoYedjhWij"
Ze[i dej Wbbem j^[c j^[ ijhkYjkhWb WXiehfj_ed e\
\ehY[i1 j^[o YWddej fWhj_Y_fWj[ _d fhefh_eY[fj_ed"
'
M[Ykhh[djboki[:odW]hW\j$J^[edbo_dZ_YWj_edh[ijh_Yj_ed"
_dekh[nf[h_[dY["_ij^[ki[e\:odW]hW\j_dj^[h[]_ede\
j^[ m_Z[bo ef[d[Z _dYbkZ_d] c[cXhWd[ cWn_bbWho i_dki"
[if[Y_Wbbo _d Yedd[Yj_ed m_j^ j^[ [nfbWdjWj_ed e\ _d\[Yj[Z
8E? _cfbWdji eh m_j^ i[YedZWho Wk]c[djWj_ed d[Wh 8E?
m^[dikf[h_d\[Yj_ede\j^[Z_iaWh[Wi_iikif[Yj[Z$
&IGÈ 7\j[h j^[ Yhemd XbeYa ^WZ beei[d[Z \hec jeej^
)-" j^[ edbo ikffehj \eh j^[ Xh_Z][ mWi j^[ _cfbWdj$ J^_i
i_jkWj_ed mWi Æjh[Wj[ZÇ Xo eYYbkiWb WZ`kijc[dj Xo W Z[dj_ij
m_j^ekjWdo[nf[h_[dY[e\8E?m^eZ_Zdejh[Ye]d_p[j^Wjj^[
ikf[hijhkYjkh[^WZbeei[d[Z$J^[_cfbWdj[n^_X_j[Z9bWii???
ceX_b_jobWj[hWbboWdZYWki[Zj^[fWj_[djfW_d$7jof_YWbi_]d_i
WY_hYkbWhXbWYaWh[WWhekdZj^[c[i_WbWdZZ_ijWbh_d]Wh[Wie\
j^[Z_ia"j^Wj_i"Wh[Wim^_Y^Wh[beYWj[ZY[djhWbbo_dj^[Xed[
WdZ j^[o Wh[ dej Wc[dWXb[ je h[fW_hi Wj j^[ Xed[#
_cfbWdj_dj[h\WY[$Hek]^ikh\WY[ie\Yh[ijWb_cfbWdji
m_bbfhecej[f[h_#_cfbWdj_d\[Yj_edj^WjcWohWf_Zbo
ifh[WZ_dWXWiWbZ_h[Yj_ed_\j^[_cfbWdji^emij^[
ib_]^j[ijceX_b_jo$F[h_eij[WbfW_dm_bbX[dej_Y[Zje
fWj_[djim^[dZ_iaibeei[d"fhel_Z[Zj^Wjiec[fWhji
e\j^[Z_iai[nj[dZX[oedZj^[_cc[Z_Wj[Xed[$J^_i
_ied[h[Wiedm^oj^[8E?_cfbWdji[b[Yj[Zm_bbj[dZ
je X[ bWh][h hWj^[h j^Wd icWbb[h" m_j^ Z_ia cWh]_di
ib_]^jbofhejhkZ_d]eded[ehXej^i_Z[i$
J^[hWfo0 J[cfehWho _iebWj_ed$ J^[hWf[kj_Y
Wbj[hdWj_l[0H[fbWY[c[dje\j^[_cfbWdjXoed[m_j^
W^_]^[h=lWbk[$
?\ j^[h[ _i W ]h[Wj Z_ijWdY[ X[jm[[d j^[ Z_ia WdZ
j^[ c_d[hWb_p[Z Xed[" j^[h[ m_bb X[ de jhk[" Z_h[Yj
beWZ jhWdic_ii_ed$ ?iebWj[Z _cfbWdji Ze dej Yedjheb
j^[ eh_[djWj_ed e\ j^[ eij[edi" WdZ Xed[ ]hemj^ _i
ij[[h[ZXoh[cej[jhW`[Yjeh_Wb\ehcWj_l[\ehY[i$J^_i
c[Wdij^Wjfhef[heii[eWZWfjWj_edcWoh[eYYkh$E\
Yekhi[" j^_i ^Wff[di ceij [Wi_bo m^[h[ cWij_YWjeho
\ehY[i WYj \h[gk[djbo WdZ ijhed]bo0 j^[ Wh[W e\ j^[
cWdZ_XkbWh Wd]b[ WdZ WXkjc[dji ikX`[Yj[Z je
cWij_YWjeho\ehY[i_dj^[cWn_bbW$
J^[ikffehjWdZel[hWbbXWbWdY[e\j^[h[cW_d_d]
ikf[hijhkYjkh[i eh j^[_h fWhji ckij X[ ik\\_Y_[dj
je Wle_Z YebbWj[hWb ZWcW][ je ej^[h _cfbWdji eh
WXkjc[dji$ Ed W ijh_Yjbo j[cfehWho XWi_i" WdZ
ik\\_Y_[djbo \Wh h[cel[Z j[cfehWbbo \hec Wdo
_dj[hl[dj_edW\\[Yj_d]j^[Xed["h[celWXb[Z[djkh[i
cWo X[ _di[hj[Z$ M^[d Ze_d] ie" c[j_Ykbeki YWh[
ckij X[ jWa[d je [dikh[ j^Wj j^[ Z[djkh[ Ze[i dej
[n[hj Wdo bWj[hWb \ehY[i ed j^[ _cfbWdji Wi _j cel[i
j^hek]^ j^[ ehWb YWl_jo WdZ j^Wj j^[ h[]_ed WXel[
j^[ j^h[WZ f_di h[cW_di kdYel[h[Z ed fhejhWYj[Z
ki[ e\ j^[ j[cfehWho" [if[Y_Wbbo _d j^[ cWn_bbW$
È È ,OSSÈOFÈ3TABILITYÈANDÈ2EINTEGRATIONÈ
&IGÈ I_n cedj^i bWj[h" j^[ Xed[ h[]_ed WhekdZ j^[
_cfbWdj ^WZ h[c_d[hWb_p[Z je j^[ fe_dj m^[h[ W d[m ikf[h#
ijhkYjkh[ YekbZ X[ fbWdd[Z$ J^[ Xed[ h[]_edi WhekdZ j^[
_cfbWdj i^em ceh[ fhedekdY[Z h[c_d[hWb_pWj_ed Ä W Z_h[Yj
Yedi[gk[dY[ e\ j^[ 'Ä&Ä' fhef[hj_[i e\ j^[ Xed[$ J^Wj m[bb#
c_d[hWb_p[ZXed[_ifh[i[djedj^[Yh[ijWbWif[Yje\j^[Z_ia
]_l[i W \WlekhWXb[ fhe]dei_i$ ?\" ed j^[ ej^[h ^WdZ" j^[i[
Xed[ h[]_edi m[h[ dej _cfb_YWj[Z _d beWZ jhWdic_ii_ed" j^[
fhe]dei_i mekbZ X[ b[ii \WlekhWXb[$ J^[i[ f_Yjkh[i Wbie
fhel_Z[Wdej^[hb[iied0ed[N#hWoedbo_ihWh[bo[l[h[dek]^
jeYec[jeWYehh[Yj`kZ][c[djedj^[ijWjkie\W8E?_cfbWdj$
<heced[f_Yjkh[ed[YWddej[njhWYj_d\ehcWj_ededm^[j^[h
j^[ _cfbWdj _i fh[i[djbo _dj[]hWj_d] eh bei_d] _dj[]hWj_ed$ 7
^_ijehoe\f_Yjkh[i_ih[gk_h[ZjeYec[jeWYehh[YjZ[Y_i_eded
^emjejh[Wjj^[8E?_cfbWdj
IkYj_ed \ehY[i YekbZ h[ikbj _d j^[ _deYkbWj_ed m_j^
ehWb XWYj[h_W" m^_Y^ _d j^_i mWo c_]^j [l[d h[WY^
j^[cWn_bbWhoi_dki$?\8E?_cfbWdji_dYedjWYjm_j^
j^[cWn_bbWhoi_dkiWh[jeX[h[dZ[h[Zf[hcWd[djbo
ded#\kdYj_edWb" _j _i iW\[h je h[cel[ j^[_h j^h[WZ[Z
f_diYecfb[j[bo$
?\ j^[ ijhWj[]_Y _cfbWdj fei_j_edi Wh[ dej fhe#
l_Z[Z m_j^ ijWXb[" _dj[]hWj[Z WXkjc[dji" j^[
el[hWbbh[ijehWj_l[Z[i_]dm_bbX[WjYedi_Z[hWXb[
h_ia$
?\[nY[ii_l[Wdj[h_ehYedjWYji^Wl[X[[dZ_W]dei[ZWi
j^[YWki[e\el[hbeWZ"j^[l[hj_YWbZ_c[di_edYWdX[
_dYh[Wi[Z[$]$XofbWY_d]Yecfei_j[edj^[eYYbkiWb
ikh\WY[iehXo_di[hj_d]Wdel[hXh_Z][jei^_\jiec[
e\j^[beWZjej^[Z_ijWb_cfbWdji$
)-+
&IGÈ 7k]c[dj_d]j^[cebWhh[]_ed_dj^[cWdZ_Xb[WdZ
j^[fh[cebWhh[]_ed_dj^[cWn_bbWZ[[f[dij^[Ykhl[e\If[[
WdZ _dYh[Wi[i j^[ l[hj_YWb Z_c[di_ed \ebbem_d] J^_[bcWdd
'/).$ Dej[ j^Wj _d j^_i ZhWm_d] Wbie YedjWYji _d j^[ \hedj
h[]_ed Wh[ h[#[ijWXb_i^[Z$ M_j^ 8E?" h[Yh[Wj_d] W el[hX_j[ _i
dejWZl_iWXb[m^[h[Wih[Yh[Wj_d]el[h#`[j_iWbmWoifeii_Xb[
C_ii_d]ehbeijYedjWYjiedj^[XWbWdY_d]i_Z[YWd
WbmWoiX[h[ijeh[ZXoWk]c[dj_d]eYYbkiWbikh\WY[i
m_j^Yecfei_j[ehWdel[hXh_Z][$
?cfbWdji j^Wj Wh[ fei_j_ed[Z _d Wh[Wi e\ b[ii
c_d[hWb_pWj_edeh_dWh[WiikX`[Yjje\b[n_edijWdZW
bem[hY^WdY[e\ikhl_lWbm^[dj^[oX[Yec[ceX_b[
ehbeei[d$
?\j^[Ykhl[e\If[[Wff[WhijeX[_dik\\_Y_[dj"j^[
cebWhh[]_ed_iWk]c[dj[Z_dj^[cWdZ_Xb[WdZj^[
fh[cebWhh[]_ed_dj^[cWn_bbW$
E\Yekhi["j^[jh[Wjc[djfhel_Z[hckijX[WmWh[
e\j^[cWn_ckcWY^_[lWXb[ijh[d]j^e\Wd_cfbWdj#
h[ijehWj_ed ioij[c$7d [njh[c[bo Wjhef^_[Z cWn_bbW
m_j^fWfohWY[ekiXed[mWbbiWdZedboW\[m_cfbWdji
m_bb jWa[ cWdo o[Whi je WY^_[l[ j^[ iWc[ Yb_d_YWbbo
fWbfWXb[ ijh[d]j^ j^Wj ioij[ci _d j^[ cWii_l[
cWdZ_Xb[ WjjW_d Z_h[Yjbo W\j[h _cfbWdjWj_ed$ Ij_bb"
j^[cWn_bbWhoXed["^em[l[hi[l[h[boWjhef^_[Z"YWd
X[ jhW_d[Z Xo fhejhWYj[Z Yedj_dkeki \kdYj_ed" _ji
lebkc[ WdZ c_d[hWb_pWj_ed m_bb _cfhel[ j^Wdai je
Yehh[YjbeWZjhWdic_ii_ed\hec\ehcWj_l[cWij_YWjeho
\ehY[i$
?diec[YWi[i"ikYY[ii_iWY^_[l[ZXoWYecX_dWj_ed
e\ c[Wikh[i$ <ebZ_d] XWYa W \bWf WdZ h[cel_d]
]hWdkbWj_ed j_iik[ cWo fWl[ j^[ mWo je h[d[m[Z
eii[eWZWfjWj_ed$7jj^[iWc[j_c["Wdej^[h_cfbWdj
cWo iec[j_c[i X[ _di[hj[Z d[Wh j^[ ZWcW][Z
_cfbWdj"m^_Y^_ij^[dWbbem[Zje^[Wb\_hij$
<ebbem#kf Wffe_djc[dji Wj Ybei[ _dj[hlWbi Xo
gkWb_\_[Z jh[Wjc[dj fhel_Z[hi Wh[ fWhj_YkbWhbo
_cfehjWdj _d YWi[i _d m^_Y^ ijWX_b_jo _i ZekXj\kb$
:[dj_ijidejjhW_d[Z_d8E?_cfbWdjebe]om_bbkikWbbo
Yecc_j ]hWl[ [hhehi Zkh_d] \ebbem#kf j^Wj YWd X[
)-, 9^Wfj[h(,È -AINTENANCE

jhWY[ZXWYajej^[_h[nf[h_[dY[m_j^Yh[ijWb_cfbWdji$
J^[ocWodejX[WXb[jeZ_ij_d]k_i^h[b_WXboX[jm[[d
_cfbWdji je X[ h[fbWY[Z WdZ _cfbWdji j^Wj Wh[ ij_bb
i[hl_Y[WXb[1 j^[o cWo h[cel[ Yh[ijWb fbWj[i jee
bWj[ eh dej Wj Wbb1 WdZ j^[o cWo Z[bWo fhef[h
jh[Wjc[dj je j^[ fe_dj m^[h[ j^[ _cfbWdji _d j^[
[dj_h[ `Wm ckij X[ h[cel[Z WdZ ej^[hi _cfbWdj[Z$
7dej^[h fheXb[c _i j^Wj Yh[ijWb _cfbWdjebe]_iji Ze
dej WYjkWbbo ^Wl[ j^[ d[Y[iiWho jeebi WdZ _cfbWdji
WlW_bWXb[jefhef[hboWii_ijj^[fWj_[dji$
M[^Wl[eYYWi_edWbboeXi[hl[Z^emWi_d]b[iYh[m
_cfbWdj [if[Y_Wbbo _d j^[ cWn_bbW cWo Yecfb[j[bo
Z[ijWX_b_p[Wd_cfbWdj#h[ijehWj_edioij[cej^[hm_i[ A
ikffehj[Z edbo Xo 8E? _cfbWdji$ 9edY[_lWXbo"
j^[ ]h[Wj ijWX_b_jo e\ j^[ iYh[m fh[l[dji [bWij_Y
h[Z_ijh_Xkj_ed e\ j^[ cWij_YWjeho \ehY[i je Wbb
Z_iai$ J^[ _cfbWdj#h[ijehWj_ed ioij[c de bed][h
\kbbo Yecf[diWj[i \eh _djhWehWb cel[c[dji$ 7\j[h
h[cel_d] j^[ iYh[m _cfbWdji WdZ h[fbWY_d] j^[c
Xo 8E? _cfbWdji" X[jj[h _dj[]hWj_ed e\ j^[ el[hWbb
ioij[cWdZijWX_b_pWj_ede\j^[h[ijehWj_edYekbZX[
eXi[hl[Z_dWbbYWi[i$

È
!VOIDINGÈ0ERMANENTÈ"ONEÈ$EFECTS B

?cfbWdjbeiiYWki[iXed[beiiÄh[]WhZb[iie\j^[jof[
e\_cfbWdj$J_c[boh[celWbe\_cfbWdjicWoh[ZkY[
j^[[nj[dje\Xed[beii$
>em[l[h"j^[h[Wh[iec[Z_\\[h[dY[iX[jm[[dj^[
Xed[beiifWjj[hdm_j^8E?_cfbWdjiWdZm_j^Yh[ijWb
_cfbWdji$
?\Yh[ijWb_cfbWdjiWh[beijik\\_Y_[djbo[WhboÄj^Wj
_i"X[\eh[j^[_hXWiWbWif[YjiWh[_dj[]hWj[ZÄj^_i_i
W lWbkWXb[ WZlWdjW][" X[YWki[ j^[ Wcekdj e\ Xed[
beii m_bb X[ c_d_cWb _d j^[i[ YWi[i$ B[ii \ehjkdWj[
Wh[ j^ei[ fWj_[dji m^ei[ XWiWb _cfbWdj Wif[Yji Wh[
_dj[]hWj[Z m[bb WdZ m^e Z[l[bef Wd kdijeffWXb[
f[h_#_cfbWdj_j_i_dj^[Yh[ijWbh[]_ed$J^[i[_cfbWdji
Wh[e\j[dh[cel[ZjeebWj["e\j[ddejkdj_bj^[[nj[dj
e\ fW_d WdZ Z[ijhkYj_ed ^Wi ]hemd X[oedZ Wdo
h[WiedWXb[ fhefehj_ed$ Iec[j_c[i j^[ jh[Wjc[dj
fhel_Z[h jh_[i je a[[f j^[ _cfbWdj WdZ h[ijehWj_ed
_dehZ[hjecWa[_jj^hek]^j^[mWhhWdjof[h_eZ$?j
_i ceijbo j^[ _dYehh[Yj WZl_Y[ Xo ej^[h Z[dj_iji
j^Wj YWki[ fWj_[dji je m_j^^ebZ j^[_h WffhelWb \eh
jee bed]$ 9hWj[h#ijob[ YebbWfi[ _i jof_YWb e\ Yh[ijWb
_cfbWdj beii$ J^[o e\j[d h[ZkY[ j^[ Xed[ lebkc[
WlW_bWXb[ \eh Wdo ikXi[gk[dj _cfbWdj je j^[ fe_dj
m^[h[h[_cfbWdjWj_ed_idebed][hWdefj_ed$
8WiWb_cfbWdjiWh[ckY^b[iifhed[je[Whbobeii"
Xkjj^[oWh[e\j[dgk_YabobeWZ[Zm_j^Wh[ijehWj_ed"
YWki_d]Yedi_Z[hWXb[cWj[h_Wbbeii[ijej^[jh[Wjc[dj
fhel_Z[h_dj^ei[YWi[im^[h[[Whbo_cfbWdjbeiiZe[i
_d \WYj eYYkh$ Eij[eboi_i fWjj[hdi _d XWiWb _cfbWdji
Wh[Y^WhWYj[h_p[ZXoj^[beiie\XWiWbXed[Wh[Wi$J^_i
jof[e\eij[eboi_i_ickY^[Wi_[hjejh[Wjj^WdYh[ijWb
&IGÈAB 9hWj[h#ijob[ Yh[ijWb Xed[ h[iehfj_ed m_j^
ikXi[gk[dj f[hcWd[dj Xed[ beii _d Yh[ijWb _cfbWdji$ J^_i
_cfbWdj i^ekbZ ^Wl[ X[[d h[cel[Z ckY^ [Whb_[h$ B EdY[
j^[i[jme_cfbWdjiWh[h[cel[Z"8E?_cfbWdjicWoX[fbWY[Z
_cc[Z_Wj[bo
YebbWfi["X[YWki[eh_\j^[Yel[h_d]Xed[fehj_edi
Wh[ij_bbfh[i[dj"\ehc_d]WYoij#b_a[_djhWXedob[i_ed$
J^_id[l[hYWki[iWdofheXb[ci_dj^[cWdZ_Xb[18E?
_cfbWdjebe]_ijiademj^Wjj^[Xed[ikffboZkh_d]W
i[YedZ_cfbWdjWj_ed_iWbmWoi]h[Wj[hj^Wdj^[\_hij
j_c[WhekdZ$
7ii^emd_d<_]$(,$'.WÄY"j^[Yehj_YWbmWbbiWhekdZ
WbWh][YoijWh[ik\\_Y_[djjeikffehjW8E?_cfbWdj$
J^[ j^h[WZ[Z f_d _ji[b\ \WY_b_jWj[i j^[ jhWdic_ii_ed
e\fh[iikh[\ehY[i\hecj^[Xed[bkc[d"i[hl_d]j^[
iWc[fkhfei[WiWYoijiYh[m$
7bj[hdWj_l[bo" d[m 8E? _cfbWdji cWo X[ fbWY[Z
d[nj je eij[eboj_Y Wh[Wi WhekdZ beij 8E? _cfbWdji$
<_]kh[(,$'/WÄYi^emiWd[nWcfb[$
J^[cWdZ_Xb[j^kiWbmWoi^[WbiXo_ji[b\$>[Wb_d]
fheY[[Zij^[\Wij[h"j^[ceh[WYj_l[boj^[cWij_YWjeho
\kdYj_ed_iki[Z$J^_i_im^o_j_ifh[\[hWXb[je_di[hj
W\_n[Zh[ijehWj_edh_]^jWmWo$
J^[i_jkWj_ed_dj^[cWn_bbW_ii_c_bWh_dfh_dY_fb[$
>em[l[h" Z[dj_iji e\j[d i^o WmWo \hec WYj_l[bo
WZZh[ii_d] W cWn_bbWho i_jkWj_ed m_j^ i_]d_\_YWdjbo
h[ZkY[Z Xed[ ikffbo$ Kdb_a[ j^[ cWdZ_Xb[" j^[
cWn_bbWZe[idejYedi_ije\ed[ieb_ZXed[$HWj^[h"j^[
cWn_bbWhoi_dkiYh[Wj[iWi_d]b[#bWo[hXed[ikXijhWj[
È È ,OSSÈOFÈ3TABILITYÈANDÈ2EINTEGRATIONÈ )--

B
B

C C

&IGÈAnC 8E? _cfbWdj" _di[hj[Z _dje j^[ bkc[d e\ W &IGÈAnC El[hbeWZ YWki[Z fhedekdY[Z eij[eboi_i Wj )-$
hWZ_YkbWhYoijWjj^[j_c[e\Yoij[Yjeco$I_jkWj_edW\j[h/B J^[ _cfbWdj ^WZ je X[ h[cel[Z$ 7j j^[ iWc[ j_c[" W d[m
WdZ (* C cedj^i$ 9ecfb[j[ h[][d[hWj_ed e\ j^[ cWdZ_Xb[ _cfbWdj mWi _di[hj[Z Wj )," WdZ j^[ fWj_[dj _cc[Z_Wj[bo
_di_Z[j^[YoijWh[W
m_j^ b_jjb[ \b[n_ed WdZ ZhWcWj_YWbbo h[ZkY[Z XbeeZ
ikffbo$J^_i_im^o_j_iYh_j_YWbjejh[Wjj^[fheXb[c
fWj_[djm_j^\_n[Zh[ijehWj_edi_dehZ[hdejjeh[ZkY[
j^[ XbeeZ ikffbo Wdo \khj^[h WdZ je cW_djW_d j^[
h[Y[_l[ZWdej^[h\_n[ZXh_Z][$ BÈC i^em^emj^[Z[\[Yj^WZ
X[[d\_bb[ZWj,WdZ'(cedj^i"h[if[Yj_l[bo$?j_i_cfehjWdjje
h[cel[_cfbWdji_dj_c[\ehj^[Yel[h_d]Xed[fehj_ediij_bb
jeX[_djWYj$J^_i_id[l[hfeii_Xb[_\eij[eboi_ieYYkhiWhekdZ
Yh[ijWb_cfbWdji$Dej[Wbiej^Wjj^[jWiae\beWZjhWdic_ii_ed
\ehj^[`Wm_idejh[ZkY[Z_\j^[Xed[WhekdZi_d]b[8E?i^emi
eij[eboi_i$ Ej^[h Xed[ i[]c[dji ckij Y^Wd][ _dje '#h[]_edi"
j^kih[fbWY_d]j^[h[]_edjkhd_d]_djeW&#h[]_ed
)-. 9^Wfj[h(,È -AINTENANCE
A Wbl[ebWhd[hl[
h[i_ZkWb Xed[ lebkc[$ 7i <_]$(,$('W"X i^emi" j^_i
_i[ii[dj_Wbbojhk[[l[d_dj^[YWi[e\Wk]c[djWj_ed
fheXb[ci_dYh[ijWb_cfbWdjebe]o$
?\_cfbWdjiWh[h[cel[Z\hecj^[feij[h_ehcWn_bbW"
j^[ l[ij_XkbWh Xed[ Z[\[Yji Wbceij d[l[h Ybei[ _\ W
Z[djkh[XWi[Yh[Wj[iWi_jkWj_edj^Wj\Wlekhid[Yhej_Y
j_iik[ h[WYj_edi$ :kh_d] \ebbem#kf [nWc_dWj_edi e\
Wbbj^[fWj_[djief[hWj[ZWjekhYb_d_Y"m[dej[Zj^Wj
j^[fheXWX_b_joe\ikYY[iie\Wi[YedZ_cfbWdjWj_ed_d
j^[Z_ijWbcWn_bbW_ii_]d_\_YWdjbo^_]^[hj^Wdj^Wje\
Wi[YedZ_cfbWdjWj_ed"[l[dZ[if_j[ehX[YWki[e\5
&IGÈÈA 7bb\ekh8E?
_cfbWdji^WZjeX[_di[hj[Z
ikXd[hlWbbo$ B 8[YWki[j^[8E?
_cfbWdjWj*-Z_Zdej_dj[]hWj["
_j^WZjeX[i[fWhWj[Z\hecj^[
Xh_Z][WdZh[cel[Z$J^[Xh_Z][
h[cW_d[Z_dfbWY[\ehj^[j_c[
X[_d]$ C 7\[mm[[aibWj[h"W
d[m_cfbWdjYekbZX[_di[hj[Z
Z_ijWbbojej^[eh_]_dWb_cfbWdj
i_j[$?dj^_iYWi["_jX[YWc[
d[Y[iiWhoje\WXh_YWj[Wd[m
Xh_Z][$J^[_cfbWdjiWj))"*)WdZ
)-m[h[fbWY[ZX[bemj^[_d\[h_eh
j^[h[ZkY[ZXed[ikffbo$?dj^[Z_ijWbcWn_bbWWj'-"
(-"m[^WZjeh[fbWY[WXekj,e\j^[\_hij_cfbWdj"
Xkj edbo ' e\ j^[ i[YedZ _cfbWdji$ Ikhfh_i_d]bo"
j^[d" 8E? j^[hWfo m_bb X[ j^[ iW\[h" j^[ b[ii Xed[ _i
WlW_bWXb[Wjj^[ekji[j$M[^Wl[d[l[h^WZWi_jkWj_ed
_d m^_Y^ W fWj_[dj m^e Wff[Wh[Z \eh jh[Wjc[dj _d
W j_c[bo cWdd[h WdZ m^e \ebbem[Z j^hek]^ ed
j^[ jh[Wjc[dj YekbZ dej X[ fhel_Z[Z m_j^ W \_n[Z
h[ijehWj_ed" feii_Xbo Zk[ je ed[ eh ceh[ e\ j^[
\ebbem_d]h[Wiedi0
È È ,OSSÈOFÈ3TABILITYÈANDÈ2EINTEGRATIONÈ )-/

A mWijeebem$8kje\Yekhi["[l[d
% J^[h[bWj_l[XbeeZikffbo_iX[jj[h_dfhefehj_ed
jej^[h[cW_d_d]Xed[lebkc[$
% J^[ WXiebkj[ XbeeZ ikffbo _i X[jj[h Wj j^[ j_c[
e\ ikh][ho Zk[ je fh[l_eki _dj[hl[dj_edi WdZ
_d\[Yj_edi$
% FWj_[dj Yecfb_WdY[ ^Wi _cfhel[Z" Wi ^Wi i[b\#
eXi[hlWj_ed e\ cWij_YWjeho X[^Wl_ekh WdZ
fh[cWjkh[YedjWYji$
% J^[jejWbcWij_YWjeho\ehY[mWih[ZkY[ZWjb[Wij
j[cfehWh_bo$
% J^[ Wd_iejhef_Y fhef[hj_[i e\ j^[ Xed[ m[h[
Y^Wd][Z _d W \WlekhWXb[ Z_h[Yj_ed0M^_b[" Zkh_d]
j^[ \_hij _cfbWdjWj_ed" j^[ i[jkf e\ j^[ beWZ#
X[Wh_d] Wif[Yji e\ j^[ cWn_bbW mWi eh_[dj[Z
jemWhZi j^[ j[[j^ fh[l_ekibo beij" d_Y[ Wdj[h_eh#
Z_ijWb jhW`[Yjeh_[i Wh[ fh[i[dj Zkh_d] j^[ i[YedZ
_cfbWdjWj_ed" ^[Wl_bo _d\bk[dY[Z Xo j^[ ckiYb[i
&IGÈAB<ebbem_d]
[njhWYj_ede\Wbbj^[cWn_bbWho
j[[j^"j^[cWn_bbWhoi_dki
mWiWk]c[dj[ZX_bWj[hWbbo
ki_d]8_e#Eii$>em[l[h"j^[
cWj[h_WbhWf_Zboi^em[ZWd
_d\bWccWjehoh[WYj_ed"h[gk_h_d]
[nj[di_l[ikh]_YWb_dj[hl[dj_ed$
?cc[Z_Wj[boW\j[hmWhZ"W
Yecfb[j[h[celWXb[Z[djkh[
mWi_di[hj[Zj^Wjh[ikbj[Z_dj^[
Z[iebWj[i_jkWj_edi[[d_dB$?\j^[
fWj_[dj^WZd[l[hh[Y[_l[Zj^[
h[celWXb[Z[djkh["WbWh][hfWhj
e\j^[cWn_bbWhoijhkYjkh[iYekbZ
fheXWXbo^Wl[X[[diWl[Z$J^[
fWj_[djmWiikXi[gk[djbojebZj^Wj
i^[YekbZd[l[hh[Y[_l[_cfbWdji
W]W_dX[YWki[j^[Xed[ikffbo
j^_iYWi[ÄZ[if_j[j^[[njh[c[
Yb_d_YWbWjhef^oÄYWdX[jh[Wj[Z
ki_d]8E?_cfbWdjiWjWdoj_c[
WjjWY^[Z je j^[ Z_ijWb cWn_bbW$ J^_i _i m^o Ä _\
\eh de ej^[h h[Wied Ä Wdo h[celWXb[ Z[djkh[
ckijX[ijh_YjboWle_Z[ZX[YWki[_jmekbZY^Wd][
j^[ Z_h[Yj_ed e\ j^[ eij[edWb cWYhejhW`[Yjeh_[i
Xo [n[hj_d] Z_\\ki[ fh[iikh[$ J^[ _di[hj_ed e\
f[h_eZedjWbbo ikffehj[Z h[ijehWj_edi f[h i[
_i Z[jh_c[djWb je j^[ \ehcWj_ed e\ d[m Xed[
ikXijWdY[$
E\fWhj_YkbWh_cfehjWdY[_ij^[Z_h[Yj_ede\j^[Ykj
m^[d h[cel_d] _cfbWdji \hec j^[ Z_ijWb cWn_bbW$
J^[_cfbWdji^ekbZX[WYY[ii[Z\hecXWiWbbohWj^[h
j^Wd\hecYh[ijWbbo8_dZ[hcWdd[jWb$(&&'_dehZ[h
dej je eXijhkYj j^[ XbeeZ ikffbo WdZ _d ehZ[h dej
je ^Wl[ j^[ j[cfehWho _d\[Yj_ed i_j[ Ye_dY_Z[ m_j^
j^[Wh[W_dm^_Y^j^[Xed[ikXijWdY[ceijkh][djbo
d[[ZijeX[fh[i[hl[Z$J^[\bWf_ij^[h[\eh[_d_j_Wbbo
).& 9^Wfj[h(,È -AINTENANCE
Yh[Wj[Zedbo_dj^[ckYeiWWdZ_dj^[]_d]_le#XkYYWb
\ebZ"WikikWb_dWB[<ehj?eij[ejeco$>em[l[h"j^[
Xb[[Z_d]m_bbkikWbboX[iec[m^Wjceh[fhedekdY[Z
_d j^_i Wh[W$ IkXi[gk[djbo" j^[ f[h_eij[Wb j_iik[ WdZ
j^[l[ij_XkbWhXed[_dj^[h[]_ede\j^[Yh[ijWbfbWj[
m_bbX[i[l[h[Z$J^_ifheY[Zkh[_ii_c_bWhjej^Wjki[Z
m^[dYh[Wj_d]Wd;ZbWd#C[bY^`Wh\bWf$M^_b[ki_d]W
][d[heki_djhWXedo_dY_i_ed"j^[YhWd_WbWif[Yje\j^[
Xed[_i[Wi_bo\b[n[ZkfmWhZ"WdZj^[_cfbWdjYWdX[
h[cel[Z Ä Xkj dej kdj_b j^[ j^h[WZ[Z f_d ^Wi X[[d
Ykjeh_dckbj_#Z_ia_cfbWdjij^[lWh_ekiZ_iai^Wl[
X[[di[fWhWj[Z$
7ZZ_j_edWb f[hj_d[dj Z[iYh_fj_edi Ä [if[Y_Wbbo _d
Yedd[Yj_edm_j^j^[ijhkYjkh[ie\j^[cWn_bbWhoi_dki
ÄYWdX[\ekdZ_d9^Wfj[h'.$
TREATMENT
È
3UMMARY
=_l[dfhef[hj_[iWdZfeii_Xb[h[WYj_edie\j^[Xed[
WiZ[jW_b[Z_d9^Wfj[h/"j^[jh[Wjc[dje\_cfbWdjiWj
f[h_be\beiiYWdX[ikccWh_p[ZWi\ebbemi0
% ?\ j^[ cWjh_n WhekdZ _cfbWdji _i Z[\_Y_[dj _d
c_d[hWb_pWj_ed"o[j\kdYj_edWb"WdWjj[cfji^ekbZ
X[cWZ[je_cfhel[j^[cWjh_nX[\eh[Yedi_Z[h_d]
Y^Wd][i je j^[ ikf[hijhkYjkh[$ J^_i h[gk_h[i
Yh[Wj_d] W \bWf Wi \Wh WmWo \hec j^[ j^h[WZ[Z
f_d Wi feii_Xb[" h[cel_d] Wdo ]hWdkbWj_ed
j_iik[" feii_Xbo Wk]c[djWj_ed WdZ Yel[hW][ m_j^
W h[iehXWXb[ c[cXhWd[" \ebbem[Z Xo W mW_j_d]
f[h_eZ \eh j^[ Xed[ je ^[Wb$ ?d j^[ cWn_bbW j^_i
m_bb h[gk_h[ Wj b[Wij \ekh cedj^i1 j^[ cWdZ_Xb[
m_bb iec[j_c[i ^[Wb \Wij[h$ IkXi[gk[djbo" j^[
ikf[hijhkYjkh[ YWd X[ h[fbWY[Z$ M[ b_a[ je ki[
i[c_#h_]_Zf[h\ehWj[Zc[cXhWd[edWfebobWYj_Z[
XWi[" \_bb[Z m_j^ ^oZhenobWfWj_j[ Wj W l[ho ^_]^
b[l[b$ J^_i i[hl[i je a[[f j^[ f> lWbk[ Z[i_hWXbo
^_]^"m_j^j^[febobWYj_Z[X[_d]h[iehX[Zgk_Yabo$
% ?\ 8E? _cfbWdji m^ei[ _dj[h\WY[ Wh[Wi Wh[
Z[\_Y_[dj_dc_d[hWb_pWj_edWh[beWZ[Zm_j^Wd[m
ikf[hijhkYjkh[m_j^ekjWdoc[Wikh[ijefhecej[
X[jj[h _dj[]hWj_ed Wi `kij Z[iYh_X[Z ed[ ckij
[nf[Yj [l[d j^ei[ ikh\WY[i j^Wj Wh[ ij_bb m[bb
c_d[hWb_p[Z je X[ ikX`[Yj[Z je h[ceZ[bb_d] Zk[
je Y^Wd]_d] beWZi WdZ bei_d] j^[_h _dj[]hWj_ed"
WZl[hi[boW\\[Yj_d]j^[YWfWY_joe\j^[_cfbWdjje
jhWdic_j beWZi$ J^_i cWo Yecfhec_i[ Wd [dj_h[
fheij^eZedj_Y Z[i_]d eh [l[d YWki[ _ji beii _\
ijWX_b_p_d]c[Wikh[iWh[dejjWa[d_dj_c[$
% ?j_iWbiefeii_Xb[jeWZZ\khj^[h_cfbWdjim^_Y^
j[cfehWh_bojWa[el[hj^[ijWX_b_pWj_edjWiam^_b[
Yehh[Yj_d] Wdo fheXb[ci ikh]_YWbbo Wj j^[ iWc[
j_c[ WdZ je beWZ j^[ d[m _cfbWdji YedYkhh[djbo
m_j^ j^[ ebZ ed[i$ J^_i c[Wdi j^Wj j^[ d[m
_cfbWdji ^Wl[ je X[ fbWdd[Z ikY^ j^Wj j^[o YWd
X[Wh j^[ [dj_h[ cWij_YWjeho beWZ" [_j^[h Wbed[ eh
_dYed`kdYj_edm_j^ijWXb[[n_ij_d]_cfbWdji$
% :_h[Yjbo fhel_Z_d] [dZWd][h[Z _cfbWdji m_j^ W
d[mikf[hijhkYjkh[m_j^ekjWZZ_d]_cfbWdjiWdZ
m_j^ekj WZZh[ii_d] cWjh_n \ehcWj_ed _i XWh[bo
fhec_i_d]WdZWjb[Wij^_]^boh_iao$
J^[ i_jkWj_ed Z[iYh_X[Z WXel[ _i kikWbbo kdademd
\hec Yh[ijWb _cfbWdji X[YWki[ c_d[hWb_pWj_ed
Z[\_Y_[dY_[i WhekdZ j^[ l[hj_YWb fWhj e\ j^[ _cfbWdj
m_bb YWki[ j^[ _cc[Z_Wj[ beii e\ j^[ _cfbWdj$ J^_i
_i ed[ e\ j^[ h[Wiedi m^o XWi_Y c_ikdZ[hijWdZ_d]i
kikWbbo Ze dej f[hc_j [l[d j^[ ceij [nf[h_[dY[Z
Yh[ijWb_cfbWdjebe]_ijijecWa[Wfei_j_l[Yedjh_Xkj_ed
je8E?j^[hWfo$
È
!DDITIONALÈ3URGICALÈ0OST
È )NTRODUCTION
El[hj^[ki[\kbb_\[e\8E?_cfbWdji"[l[djicWoeYYkh
j^Wj d[Y[ii_jWj[ WZZ_j_edWb ikh]_YWb _dj[hl[dj_ed _d
_iebWj[Zh[]_ediWhekdZ[n_ij_d]_cfbWdji$
EYYWi_edWbbo" ckYeiWb fheb_\[hWj_ed cWo X[
eXi[hl[Z _d j^[ h[]_ed e\ j^[ j^h[WZ[Z f_d$ Ed[
h[Wied\ehj^_iYekbZX[WdWYjkWb_dYh[Wi[_dckYeiWb
lebkc[0j^_ieYYkhidej_d\h[gk[djbo"[if[Y_Wbbo_dj^[
m[bb#a[hWj_p_d[ZcWn_bbW$Edj^[ej^[h^WdZ"j^[Xed[
lebkc[e\j^[`Wm_ji[b\c_]^jWbie_dYh[Wi[$J^_i_i
[if[Y_Wbbo i[[d _d j^[ cWdZ_Xb[ \ebbem_d] Z[djkh[#
h[bWj[Z Wjhef^o$ ?\" Zkh_d] j^[ Yekhi[ e\ Wd _dYh[Wi[
_d ie\j eh ^WhZ j_iik[ lebkc[ _d W Yh[ijWb Z_h[Yj_ed"
fWhjie\j^[j^h[WZ[Zf_dYedjWc_dWj[Zm_j^Z[Xh_i
[dZkfX[bemj^[ckYeiW"j^_icWo_dZkY[ckYeiWb
im[bb_d] WdZ ckYei_j_i$ J^[i[ im[bb_d]i YWd X[
Z_\\[h[dj_Wj[Z Z_W]deij_YWbbo \hec jhk[ eij[eboi_i _d
j^[ XWi[#fbWj[ h[]_ed _d j^Wj j^[ hWZ_e]hWf^ i^emi
de _dlebl[c[dj e\ j^[ beWZ#X[Wh_d] h[]_edi" WdZ
de fW_d _i \[bj ed Ybei_d] j^[ `Wmi$ J^[ Wffhefh_Wj[
j^[hWfo _i l[dj_d] e\ j^[ _d\[Yj[Z h[]_edi _d beYWb
WdW[ij^[i_WWdZj^_dd_d]e\j^[ckYeiW$7dofWhjie\
j^[_cfbWdj[nfei[Z_dj^[fheY[iij^_im_bbkikWbbo
X[j^[j^h[WZ[Zf_diYWdX[Yb[Wd[Zki_d]^oZhe][d
f[hen_Z[$
?\ W ikXijWdj_Wb _dYh[Wi[ _d Xed[ lebkc[ YWki[i
j^[ckYeiWjeYedjWYjj^[XWiWbikh\WY[e\j^[Xh_Z]["
fh[iikh[ifejicWoWbieX[eXi[hl[Z$J^_icWoYWki[
j^[Xh_Z][jel_hjkWbbofkdY^j^[ckYeiW"Wi_jkWj_ed
j^Wj" _\ b[\j kdjh[Wj[Z" cWo h[ikbj _d im[bb_d]i j^Wj
m_bb ]h[Wjbo _cfh[ii Z[dj_iji dej \Wc_b_Wh m_j^ j^[
Z_W]dei_i e\ j^_i YedZ_j_ed$ J^[ j^[hWfo _i i_cfbo
][d[heki h[b_[\ e\ j^[ fedj_Y h[]_edi \hec XWiWbbo"
ki_d][$]$\_d[Z_WcedZYkjj[hi$Fh[iikh[i_j[ie\j^_i
jof[ m_bb X[ ceij \h[gk[djbo eXi[hl[Z _d j^[ Z_ijWb
cWdZ_Xb[$8kjj^[oYWdWbieeYYkh_dj^[cWn_bbW"i_dY[
d[_j^[hj^[8E?_cfbWdjidehj^[8E?ikf[hijhkYjkh[
e\\[h Wdo [\\[Yj_l[ h[i_ijWdY[ je j^[ l[dj_bWj_ed#
È È !DDITIONALÈ3URGICALÈ0OST
TREATMENTÈ ).'

ikffehj[Z WdZ \kdYj_ed#h[bWj[Z [nfWdi_ed e\ j^[

cWn_bbWhoi_dkiWdZj^[h[ceZ[bb_d]e\j^[Xed[i[[
<_]$*$(+Y$

È
3ECONDARYÈ!UGMENTATION
J^[h[ Wh[ i[l[hWb feii_Xb[ h[Wiedi m^o i[YedZWho
Wk]c[djWj_ed c_]^j X[ d[Y[iiWho WdZ ceh[ Yb[l[h
j^Wdfh_cWhoWk]c[djWj_ed0
% 8ed[ h[Y[ii_ed Zk[ je \kdYj_ed#h[bWj[Z Xed[
h[ceZ[bb_d]Ä[if[Y_WbboWjj^[l[ij_XkbWhWif[Yji
e\ j^[ Z_iai m_bb edbo X[ l_i_Xb[ W\j[h i[l[hWb
cedj^i$
% 7ZZ_j_edWbXed[lebkc[_iZ[i_hWXb[\ehbed]#j[hc
ijWX_b_pWj_ede\j^[8E?_cfbWdji$
% I[l[h[ f[h_eZedjWb _d\[Yj_edi ^WZ fh[l[dj[Z
fh_cWhoWk]c[djWj_edX[YWki[j^[h[mWiWh_iae\
j^[Wk]c[dj[Zi_j[X[Yec_d]_d\bWc[Z$ &IGÈ J^_i ^_ijebe]_YWb Z[jW_b i^emi j^[ j[dj#ijob[
% 7k]c[djWj_ed _d j^[ h[]_ed e\ j^[ cWn_bbWho \ehcWj_ed e\ d[m Xed[ ZWha Xbk[ X[bem j^[ f[h_eij[kc
i_dki _i h[gk_h[Z fh_eh je fbWY_d] WZZ_j_edWb Äed[e\j^[feii_Xb[Yed\_]khWj_ediW\j[hj^[h[fei_j_ed_d]e\
_cfbWdji m^[h[ j^[ c[cXhWd[ ^WZ fh[l_ekibo j^[ckYef[h_eij[Wb\bWf"[l[dm_j^ekjfbWY_d]Wc[cXhWd[
X[[dZ_iYedj_dkeki$
% 8ed[ ^Wi dej \ehc[Z _d iec[ Wh[Wi e\ j^[ beWZ#
jhWdic_jj_d]ikh\WY[iZk[jeel[hbeWZeh_d\[Yj_ed"
ehj^[Xed[\ehcWj_ed%Xed[^[Wb_d]YWiYWZ[mWi
_hh[l[hi_XboZ_ijkhX[Z$

?\ j^[ f[h_eZedjWb j_iik[i Wh[ Yecfhec_i[Z" _j _i

h[Yecc[dZ[Z je h[ijh_Yj _d_j_Wb jh[Wjc[dj je
[njhWYj_ed" mekdZ WdZ Xed[ Yb[Wd_d] WdZ _cfbWd#
jWj_ed$ J^[ _cfbWdj i_j[ i^ekbZ X[ \_hcbo Ybei[Z1
ed j^[ ej^[h ^WdZ" ik\\_Y_[dj ikffkhWj_ed ckij X[
\WY_b_jWj[Z je Wle_Z kdd[Y[iiWho im[bb_d]" fW_d WdZ
feijef[hWj_l[Yecfb_YWj_edi$
7k]c[djWj_ed _i j^[d f[h\ehc[Z _d W i[fWhWj[
ij[f"W\j[h(Ä*m[[ai1j^_iYWdm[bbX[Zed[W\j[hj^[
_cfbWdj^WiX[[dbeWZ[Z$J^[_dY_i_edckijijWoi^o
e\ j^[ j^h[WZ[Z f_d Xkj Wbbem ]eeZ Yel[hW][ e\ j^[
Wk]c[dj[Z i_j[$ ?d cWdo YWi[i" j^[ ckYef[h_eij[Wb
\bWfZ_ifbWY[ZjeYel[hj^[[njhWYj_edmekdZiYWdX[
fWhj_Wbboh[jkhd[Zje_jieh_]_dWbfei_j_edWjj^[iWc[
j_c[$ J^_i jof[ e\ i[YedZWho Wk]c[djWj_ed WhekdZ
Wd _cfbWdj j^Wj _i Wbh[WZo \kdYj_edWbbo beWZ[Z ^Wi
fhel[dikYY[ii\kb$?jjWa[iWZlWdjW][e\j^[[n_ij_d] &IGÈ ?dj^[iWc[cWdd[h"j^[fhe`[Yj_d]fWhje\j^[Z_iY
lWiYkbWh_pWj_ed e\ j^[ \ehc[hbo f[h_eZedjWbbo YWdX[b[\jekjXoj^[Xed[m^[d_dj[]hWj_d]j^[_cfbWdj$?d
_dlebl[Z j_iik[i WdZ j^[ [n_ij_d] ^[Wb_d] fheY[ii j^_iYWi["j^[ibejim_bbX[Ybei[Zm_j^d[mXed["Xkjj^[XbeeZ#
h[ikbj_d]\hecj^[_cfbWdjWj_ed_ji[b\m_j^ekjh_ia_d] \_bb[ZifWY[kdZ[hj^[f[h_eij[kc_idejh[eh]Wd_p[Zje\ehc
d[mXed[$J^[i[Yj_edi_d<_]i$(,$((WdZ(,$()m[h[Z[h_l[Z
Wdo _d\[Yj_ed e\ j^[ Wk]c[djWj_ed cWj[h_Wb _ji[b\$ \hec j^[ iWc[ fh[fWhWj_ed$ Jee bWh][ Z_ijWdY[i X[jm[[d j^[
:kh_d]i[YedZWhoWk]c[djWj_ed"j^[_cfbWdji_j[_i Z_ia h_d]i WdZ j^[ Xed[ fh[l[dj j^[ Æj[dj#[\\[YjÇ WdZ cWo
Wbiefhel_Z[Zm_j^WZZ_j_edWb\h[i^XbeeZ"m^_Y^cWo h[gk_h[fbWY[c[dje\Wc[cXhWd[
]h[Wjbo WYY[b[hWj[ Xed[ ^[Wb_d]$ I_cfbo b_\j_d] j^[
f[h_eij[Wbj_iik[iW]W_d"\_bb_d]j^[cm_j^WZZ_j_edWb
XbeeZ _djhWef[hWj_l[bo" cWo j^ki h[ikbj _d l[ho d_Y[ Wk]c[djWj_ed"m_j^ehm_j^ekjc[cXhWd[Yel[hW][
eii_\_YWj_ede\YedYWl[Xed[Wh[Wi$ _dje W i_jkWj_ed Wi _d <_]$(,$()" i_dY[ j^[ Y^WdY[i
?d W i[YedZ ikh]_YWb fheY[Zkh[" W i_jkWj_ed Wi e\ ^[Wb_d] Wh[ Wj b[Wij Wi ]eeZ W\j[h j^[ i[YedZ
_d <_]$(,$() YWd X[ jhWdi\ehc[Z m_j^ eh m_j^ekj fheY[Zkh[ Wi W\j[h j^[ \_hij ed[$ M^[d _j Yec[i je
).( 9^Wfj[h(,È -AINTENANCE
cWa_d] j^[ _dY_i_ed" j^[ i[YedZ fheY[Zkh[ ^Wi j^[
WZZ[Z WZlWdjW][ j^Wj j^[ Wh[W e\ j^[ j^h[WZ[Z f_d
YWdX[b[\jekj$
;l[d i[YedZWho Wk]c[djWj_ed _d j^[ Wh[W e\ j^[
cWn_bbWhoi_dki_ji[b\_ifeii_Xb[_dfh_dY_fb[$
Feii_Xb[ _dZ_YWj_edi Wh[ W Yecfhec_i[Z Xed[
ikffbo Ä Z[j[Yj[Z Zkh_d] _cfbWdjWj_ed Ä d[Wh j^[
l[ij_XkbWh mWbb e\ j^[ cWn_bbWho i_dki eh kd_bWj[hWb
ceX_b_jo e\ j^[ _cfbWdj _d j^[ iWc[ h[]_ed$
C_YheceX_b_jo e\ fheij^eZedj_Y eh_]_d YWddej X[
WZZh[ii[Z _d j^[ iWc[ cWdd[h" [l[d _\ j^[ el[hWbb
Xed[ ikffbo _i bem WdZ ^Wi X[[d Z[cedijhWj[Z eh
ikif[Yj[ZjeX[j^[h[Wiedm^oj^[_cfbWdj_idejWi
ijWXb[_dj^[X[]_dd_d]$<_hijÄehWjb[WijWjj^[iWc[
j_c[ÄWdofheij^eZedj_YYWki[ie\j^[fheXb[cm_bb
^Wl[jeX[[nfbeh[Z$
?d Ze_d] ie" j^[ IY^d[_Z[h_Wd c[cXhWd[ i^ekbZ
X[b[\jkdZWcW][Z"`kijWi_di_dkib_\jef[hWj_edi_d
Yh[ijWb_cfbWdjebe]o$?\j^[c[cXhWd[_if[d[jhWj[Z"
j^[ _cfbWdjebe]_ij m_bb ^Wl[ je Z[Y_Z[" XWi[Z ed
Yb_d_YWb[nf[h_[dY["m^[j^[hjeYedj_dk[ehjeWXehj
j^[ef[hWj_ed$J^[_djheZkYj_ede\Xed[h[fbWY[c[dj
cWj[h_WbckijX[Yedi_Z[h[ZYWh[\kbbo_dj^[[l[dje\
Wdef[di_dki$
J[Whi _d j^[ c[cXhWd[ _d j^[ci[bl[i Wh[ dej
W YedjhW_dZ_YWj_ed \eh Yedj_dk_d]$ Jh_YWbY_kc
f^eif^Wj[ eh YWbY_kc ikbf^Wj[ femZ[hi _d icWbb
Zei[i Wh[ l[ho ikYY[ii\kb j^[hWf[kj_Y WZ`kdYji _d
4ISSUEÈ
j^[ eij[ejeco h[]_ed$ J^[ Xed[#\h_[dZbo i^_\j _d
j^[ f> lWbk[ _d j^[ [dj_h[ \bWf h[]_ed" j^[ [nY[bb[dj
Wdj_c_YheX_Wb [\\[Yj e\ j^[i[ ikXijWdY[i fbki j^[
_cc[Z_Wj[ beYWb WlW_bWX_b_jo e\ YWbY_kc" m^_Y^ _i"
W\j[hWbb"XWi_YcWj[h_Wb\ehXed[h[fW_h"WbbYedjh_Xkj[
jej^_iikYY[ii$M^[j^[hÄWih[fehji_dj^[b_j[hWjkh[
ik]][ij Ä e_bo YWbY_kc fh[fWhWj_ed e\\[h [l[d ceh[
WZlWdjW][i_iiec[j^_d]m[^Wl[dejo[jX[[dWXb[je
WiY[hjW_d$Iec[fh[fWhWj_edi^Wl[Z[\_d_j[bofhel[d
j^[_hlWbk[_dh[Xk_bZ_d]Xed[:_[jpWdZ8Whj^ebc[i
'//.$
Ed[ i^ekbZ Wbie Yedi_Z[h j^Wj W f[h\ehWj_ed e\
j^[c[cXhWd[f[hi[c_]^jfhel_Z[fei_j_l[ZhW_d#
W][ e\ Wdo _d\[Yj_eki h[i_Zk[ _d j^[ Z_h[Yj_ed e\
j^[ i[c_bkdWh ^_Wjki" m^_Y^ c_]^j X[ Z[i_hWXb[ _d
iec[ YWi[i$ ;njhWYj_edi _d _d\[Yj[Z i_j[i \ebbem[Z
Xo 8E? _cfbWdj fbWY[c[dj Wh[ feii_Xb[" ^em[l[h"
_cc[Z_Wj[ Wk]c[djWj_edi Wh[ dej h[Yecc[dZ[Z$
J^[Wk]c[djWj_edcWj[h_Wbj[dZijeieWakfXWYj[h_W
WdZfh[l[djikffkhWj_ed"m^_Y^_iceh[d[Y[iiWho_d
_d\[Yj[ZifWY[ij^Wd_dYb[WdXed[i_j[i$
È
&REEÈ-UCOSALÈ'RAFTS
7i m_j^ dWjkhWb j[[j^ WdZ Yh[ijWb _cfbWdji" ed[
i^ekbZ Yedi_Z[h j^[ d[Y[ii_jo e\ [b_c_dWj_d]
kdZ[i_hWXb[[nfeikh[e\j^[j^h[WZ[Zf_dXoXkYYWb
eh bWX_Wb \h[dkb_$ ;if[Y_Wbbo j^[ bWX_Wb \h[dkb_ e\j[d
^Wl[WZ[jh_c[djWb[\\[Yj_\j^[_cfbWdj_ifei_j_ed[Z
d[Wh j^[ c[Z_Wd WdZ i^ekbZ X[ h[beYWj[Z eh" X[jj[h
ij_bb" h[cel[Z Wbje][j^[h$ J^_i YWd X[ Zed[ _d beYWb
WdW[ij^[i_Wki_d]Wd[b[Yjheikh][hokd_j$?\_dZekXj"
j^[Z[Y_i_edi^ekbZX[_d\Wlekhe\h[celWb$
<h[[ ckYeiWb ]hW\ji Wh[ ij_bb e\j[d h[Yecc[dZ[Z
WdZf[h\ehc[ZjeZWojeYbei[j^[mekdZi\ebbem_d]
j^[ fbWY[c[dj e\ Yh[ijWb _cfbWdji$ J^[_h _dZ_YWj_ed
_i dem b_c_j[Z" ^em[l[h" i_dY[ _j ^Wi X[Yec[
Yecced ademb[Z][ j^Wj iceej^ l[hj_YWb fWhji e\
j^[ _cfbWdj m_j^ekj ikh\WY[ [dbWh][c[dj YWd [Wi_bo
X[ b[\j ijWdZ_d] _d _di_Z[ j^[ ceX_b[ ckYeiW$ J^_i
_i [gkWbbo jhk[ e\ 8E? _cfbWdji$ O[j iec[j_c[i W
]_d]_lWb fheXb[c" ikY^ Wi W h[Ykhh_d] ckYei_j_i _d
j^[ Wh[W e\ j^[ j^h[WZ[Z f_d" c_]^j eYYWi_edWbbo X[
h[Wied[dek]^jeYedi_Z[hW\h[[ckYeiWb]hW\j$J^[
h[gk_i_j[ j[Y^d_gk[ _i de Z_\\[h[dj \hec j^Wj ki[Z
_d j^[ Z[djWj[ `Wm$ J^[ ikYY[ii e\ Z_h[Yjbo Yel[h_d]
Wd [nfei[Z i[Yj_ed e\ Wd _cfbWdj _d l_i_Xb[ Wh[Wi
_i e\j[d b_c_j[Z$ ?d Wdo [l[dj" j^[ ]hW\j ckij X[
m_Z[ [dek]^ je Yel[h j^[ Xed[ ][d[hekibo Wi m[bb$
Ej^[h fheY[Zkh[i ikY^ Wi YehedWb ib_Z_d] \bWfi WdZ
[if[Y_Wbbo \[[ ]_d]_lWb Yedd[Yj_l[ j_iik[ ]hW\ji cWo
X[mehj^Yedi_Z[h_d]"i_dY[edboj^[oYWdX[ki[Zje
Yh[Wj[WZZ_j_edWbie\j#j_iik[lebkc[$
È
)MPLANTÈ2EPLACEMENTÈ$UEÈTOÈ3OFT
0ROBLEMS
;if[Y_Wbbo_dj^[Z_ijWbcWdZ_XkbWhh[]_ed"h[Ykhh_d]
feijef[hWj_l[_d\bWccWjehofheY[ii[icWoX[i[[d_d
j^[h[]_ede\j^[j^h[WZ[Zf_d"[$]$WiWYedi[gk[dY[
e\cWii_l[ie\j#j_iik[im[bb_d]WdZ_dj^[fh[i[dY[e\
fhedekdY[ZY[djh_\k]Wbh[iehfj_ed$
FWhje\j^[fheXb[cm_bbWbmWoiX[j^Wjj^[_cfbWdj
mWifbWY[Zjee\WhZ_ijWbbo$D[l[hj^[b[ii"j^[ikh][ed
_i kikWbbo dej je XbWc[ _d j^[i[ i_jkWj_edi Ä j^[
Z_ijWb fbWY[c[dj YWd ^Wl[ X[[d W h[ikbj e\ j^[ \WYj
j^Wj j^[ edbo fbWY[ m^[h[ &Ä(cc e\ l[hj_YWb Xed[
WXel[ j^[ c[djWb d[hl[ YekbZ X[ \ekdZ mWi j^[
WiY[dZ_d] h[]_ed je j^[ YhWd_Wb e\ j^[ cWdZ_XkbWh
d[hl[i[[9^Wfj[h/$)$?\_d\bWccWj_edWhekdZj^[
j^h[WZ[Zf_dh[Ykhi"_cfbWdjh[fbWY[c[dji^ekbZX[
Yedi_Z[h[Z$
<_hij" j^ek]^" ed[ mekbZ ^Wl[ je jho je Yedjheb
j^[i_jkWj_edXo][d[hekij^_dd_d]e\j^[ie\jj_iik[$
Feijef[hWj_l[ _di[hj_ed e\ ijh_fi eh Wjj[cfji je
h[cel[ j^[ j_iik[ m_j^ W jWcfedWZ[ kikWbbo W\\ehZ
b_jjb[ h[b_[\" i_dY[ j^[ jWcfedWZ[ _ji[b\ m_bb X[ j^[
iekhY[ e\ W d[m _d\[Yj_ed WdZ WZZ_j_edWb im[bb_d]$
7i j^[ imebb[d ie\j j_iik[i Wh[ h[cel[Z ikh]_YWbbo"
j^[ j^h[WZ[Z f_d i^ekbZ X[ Yb[Wd[Z m_j^ +Ä'&
^oZhe][d f[hen_Z[ iebkj_ed$ J^_i m_bb e\j[d h[cel[
YedjWc_dWj_edi" WdZ j^[ i[b\#^[Wb_d] fheY[ii m_bb
h[ikbj _d W XWbWdY[Z ifWj_Wb WhhWd][c[dj e\ ie\j
j_iik[i"_cfbWdji"WdZikf[hijhkYjkh[$
È È #OMPLIANCEÈ#OMPLICATIONSÈANDÈ,ONG
TERMÈ4REATMENTÈ3UCCESSÈ ).)

?\ ikh]_YWb _dj[hl[dj_ed _i h[gk_h[Z" W ZhW_d _i

ckY^ceh[b_a[bojeX[h[gk_h[Zj^WdWjWcfedWZ[$
Bocf^Wj_YZhW_dW][ijWhj_d]_dj^[c[Z_Wbh[]_ede\
j^[YbWl_YkbWWdZWiY[dZ_d]kfj^[d[Yajej^[h[]_ed
e\j^[cWdZ_XkbWhWd]b[m_bbe\j[dX[ikYY[ii\kb$7j
b[WijjmeZhW_dW][i[ii_edie\Wffhen_cWj[bo'+c_d
WZWoWh[h[Yecc[dZ[Z$J^[\_hijjmei[ii_edim_bb
fh[Y[Z[j^[ikh]_YWb_dj[hl[dj_ed$;_j^[hj^[fWj_[dj
_i jWk]^j ^em je f[h\ehc bocf^Wj_Y ZhW_dW][" eh
^[ _i h[\[hh[Z je W f^oi_ej^[hWf_ij$ J^_i jh[Wjc[dj
i^ekbZ X[ h[mWhZ[Z m_j^ ikYY[ii W\j[h W cWn_ckc
e\)ZWoi$?\de_cfhel[c[dj_ii[[d"Wdej^[hhekdZ
e\ YWh[\kb j^_dd_d] WdZ ikffb[c[djWho Wdj_i[fj_Y
j^[hWfo ki_d] 8[jW_ieZedW WdZ ^oZhe][d f[hen_Z[ &IGÈ ?\deZhW_dW][_ifeii_Xb[X[bemj^[jhWdi_j_edped[
cWoX[Yedi_Z[h[Z$ jej^[WXkjc[dj"iec[ie\jj_iik[m_bb^Wl[jeX[h[cel[Z$J^_i
?\" ^em[l[h" _dWYY[ii_Xb[ \eY_ e\ YedjWc_dWj_ed YWdX[Zed[XobWi[h"[b[Yjheikh][hoehiYWbf[b$9Wh[ckijX[
jWa[ddejjeiYhWjY^ehZWcW][j^[_cfbWdjikh\WY[
Wh[ _cfWYj[Z _d j^[ Z[fj^ e\ j^[ j^h[WZ[Z f_d eh
X[bemj^[XWh"Wbbj^[c[Wikh[ifh[l_ekiboZ[iYh_X[Z
Wh[ XekdZ je \W_b" WdZ h[fbWY[c[dj e\ j^[ _cfbWdj
i^ekbZX[Yedi_Z[h[Z$?j_iWdWZlWdjW][_\Wd_dj[h#
lWb e\ Wj bWij )Ä/cedj^i _i eXi[hl[Z X[jm[[d j^[
_d_j_Wb _cfbWdjWj_ed WdZ j^[ h[fbWY[c[dj" X[YWki[
\kdYj_edWbh[ceZ[bb_d]m_bbYh[Wj[d[mXed[Yh[ijWbbo
e\ j^[ cWdZ_XkbWh d[hl[ Zkh_d] j^_i f[h_eZ" m^_Y^
m_bbkbj_cWj[boWbbemWceh[Wdj[h_ehfei_j_ede\j^[
d[m_cfbWdj_dWbceijWbbYWi[i$
?\ j^[ \_hij _cfbWdj ^WZ X[[d beYWj[Z ik\\_Y_[djbo
\Wh Z_ijWbbo" j^[ d[m _cfbWdj cWo X[ fbWY[Z \khj^[h
c[Z_Wbbo"[l[d_dWfei_j_eddejfh[l_ekiboikh]_YWbbo
W\\[Yj[Z" iec[j^_d] j^Wj c_]^j [l[d fhecej[ W
Z[Y_i_ed_d\Wlekhe\_cc[Z_Wj[\kdYj_edWbbeWZ_d]$
&IGÈ J^[iWc[YWi[W\j[hh[ZkY_d]j^[cWh]_dWb]_d]_lW$
È J^[feb_i^[Zj^h[WZ[Zf_d_i[Wi_bol_i_Xb[$J^[h[b_[\[dikh[i
!DDITIONALÈ!SPECTSÈOFÈ0OST IMPLANTATION j^[\beme\b_gk_Z\hecj^[_cfbWdjh[]_ed

?\j^[fei_j_ede\j^[eh_]_dWb_cfbWdjmWiWffhefh_Wj["
o[jWie\j#j_iik[fheXb[cmWiYWki[ZXoehWb^o]_[d[
Z[\_Y_[dY_[i eh d_Yej_d[ WXki[ Zkh_d] j^[ _d_j_Wb
^[Wb_d] f^Wi[" _j m_bb e\j[d X[ feii_Xb[ je h[#_di[hj È
Wd _cfbWdj e\ j^[ iWc[ jof[ _d j^[ iWc[ fei_j_ed$
TERMÈ
?d j^[i[ YWi[i" ]hWdkbWj_ed j_iik[ m_bb X[ fh[i[dj
X[bemj^[j^h[WZ[Zf_dj^WjckijX[h[cel[ZX[\eh[
_di[hj_d] j^[ i[YedZ _cfbWdj$ ?j _i WZl_iWXb[ je
Yel[hj^[Wh[We\j^[j^h[WZ[Zf_dm_j^Wde_djc[dj
YedjW_d_d]\WjjoWY_ZiikY^WiJ[hhWYehjh_bWdj_X_ej_Y
e_djc[djXoF\_p[h$J^_if[hc_jibWj[hWbikffkhWj_ed
m^_b[ fh[l[dj_d] j^[ _djheZkYj_ed e\ Z_hj WdZ
Z[Xh_i Wbed] j^[ j^h[WZ[Z f_d Zkh_d] j^[ _d_j_Wb
feijef[hWj_l[ f^Wi[$ <eh fWj_[dji m^e icea[ WdZ
m^e fhWYj_i[ ZekXj\kb ehWb ^o]_[d[ WdZ dkjh_j_edWb
^WX_ji" W i[YedZ _cfbWdjWj_ed _d Yecfhec_i[Z
h[]_edi i^ekbZ X[ feijfed[Z je W i[YedZ ikh]_YWb
_dj[hl[dj_ed$J^_im_bb_cfhel[Yecfb_WdY[b[Whd_d]
\hec XWZ [nf[h_[dY[ WdZ j^[ Y^WdY[i e\ ^[Wb_d]
Zkh_d]ikXi[gk[dj_cfbWdjWj_edi$
#OMPLIANCEÈ#OMPLICATIONSÈANDÈ,ONG
4REATMENTÈ3UCCESS
È
#OMPLIANCEÈANDÈ#OMPLIANCEÈ'ROUPSÈÈ
!È$EFINITION
9ecfb_WdY[_ih[WiedWXb["Yedi_ij[djYeef[hWj_eded
j^[fWhje\j^[fWj_[djWih[gk_h[ZjeWY^_[l[jh[Wjc[dj
ikYY[iiEB="Ikf[h_eh9ekhj">WcXkh](&&)$BWYa
e\ fWj_[dj Yecfb_WdY[ _i W i[h_eki Xh[WY^ e\ j^[
YedjhWYj X[jm[[d Z[dj_ij WdZ fWj_[dj$ 9ecfb_WdY[
_iWbieWfh_c[\WYjeh_dWiikh_d]jh[Wjc[djikYY[ii$
Ed[ mekbZ j^[h[\eh[ Wiikc[ j^Wj fWj_[dji mekbZ
Ze[l[hoj^_d]_dj^[_hfem[hje[dikh[Wd[nY[bb[dj
jh[Wjc[dj h[ikbj Xo Z[cedijhWj_d] Yecfb_WdY[$
Ikhfh_i_d]bo [dek]^" j^ek]^" j^_i _i iec[j_c[i dej
j^[YWi[$
).* 9^Wfj[h(,È -AINTENANCE
=eeZ Yecfb_WdY[ m_bb X[ iec[j^_d] Z_\\[h[dj
Zkh_d] [WY^ jh[Wjc[dj f^Wi[$ 9ecfb_WdY[ _dYbkZ[i
WdoX[^Wl_ekhedj^[fWhje\j^[fWj_[djm_j^_dj^[
\hWc[meha e\ j^[ jh[Wjc[dj h[gk_h[Z Wj W if[Y_\_Y
cec[dj_dehZ[hjeWY^_[l[jh[Wjc[djikYY[ii$?dj^[
YWi[e\8E?j^[hWfo"j^_imekbZ_dYbkZ[0
% ?dYWi[ie\_cc[Z_Wj[beWZ_d]"Wle_ZWdY[e\^WhZ
\eeZ1Yecfb_WdY[m_j^j^[_cfbWdjebe]_ijÉiZ_[jWho
_dijhkYj_edi kdj_b beWZ#h[i_ijWdj eii[eWZWfjWj_ed
^WieYYkhh[Z$
% ?cc[Z_Wj[dej_\_YWj_ede\j^[jh[Wjc[djfhel_Z[h
_\ j^[h[ Wh[ Wdo dejWXb[ Y^Wd][i eh [l[dji _d
eYYbki_ed"j^[^[Wb_d]fheY[ii[jY$
% H[b_WXb[Wff[WhWdY[Wjh[YWbbWffe_djc[dji$
% 9edi[djjej^[d[Y[iiWho[gk_b_XhWj_edfheY[Zkh[i
Wj_dj[hlWbiZ[j[hc_d[ZXoj^[_cfbWdjebe]_ij$
% Fhef[hehWb^o]_[d[m_j^h[]WhZjeXej^_cfbWdji
WdZWdoh[i_ZkWbdWjkhWbj[[j^$
% 9edi[dj je YedYec_jWdj jh[Wjc[dj0 [njhWYj_edi"
h[ijehWj_edi_dej^[hfWhjie\j^[cekj^[jY$
% De Xbem_d] e\ dei[ _\ j^[ cWn_bbWho i_dki mWi
ef[d[Z$
% 9ecfb_WdY[ m_j^ ej^[h YedYec_jWdj jh[Wjc[dj
c[Wikh[i0 f^oi_ej^[hWfo" jhW_d_d] [n[hY_i[i"
jh[Wjc[dj_dj^[effei_j[`Wm"[jY$
9ecfb_WdY[ehded#Yecfb_WdY[YWdijWhj[l[dX[\eh[
j^[ jh[Wjc[dj ^Wi [l[d X[[d ijWhj[Z$ ?\ W fWj_[dj
\W_bi" Z[if_j[ ^Wl_d] h[Y[_l[Z f[hj_d[dj _dijhkYj_edi
\hec j^[ jh[Wjc[dj fhel_Z[h" je _d\ehc ^_c e\ Wdo
_dYh[Wi[Z ^[Wbj^ h_iai j^Wj d[[Zi je X[ Yedi_Z[h[Z
_d jh[Wjc[dj fbWdd_d] Z_WX[j[i" jeXWYYe icea_d]"
fh[l_ekiikh][hoWjj^[_cfbWdjWj_edi_j["Z_ijkhXWdY[
e\ ckiYkbWh YeehZ_dWj_ed" ckiYkbWh Z_ii[Yj_ed WdZ
cWdo ej^[hi" j^_i ec_ii_ed Yedij_jkj[i W Xh[WY^ e\
YedjhWYj BWk\i WdZ K^b[dXhkYa (&&($ J^[ fWj_[dj
Wbed[_ih[ifedi_Xb[_\j^[jh[Wjc[dj_ikdikYY[ii\kb
Zk[ je ded#Yecfb_WdY[1 j^[ jh[Wjc[dj fhel_Z[h
YWddej\ehY[j^[fWj_[djjecWa[Wif[Y_\_YijWj[c[dj"
je h[\hW_d \hec icea_d]" eh je h[jkhd ed W if[Y_\_Y
ZWo$ >em[l[h" j^[ Z[dj_ij ckij [ZkYWj[ j^[ fWj_[dj
Wi je j^[ Yedi[gk[dY[i e\ ded#Yecfb_WdY[ BWk\i
WdZK^b[dXhkYa(&&($M[b_a[jeki[j^[9^[Ya#kf
H[fehj\ehc\ehj^_ifkhfei[$
Ed[ \WYjeh j^Wj ]h[Wjbo _d\bk[dY[i Yecfb_WdY[ _i
Z_ijWdY[$Ekh[nf[h_[dY[i^emij^Wjj^[\Whj^[hWmWo
fWj_[djib_l[\hecj^[jh[Wjc[djfhel_Z[h"j^[]h[Wj[h
j^[fheXWX_b_joj^Wjj^[i[fWj_[djiZedeja[[fj^[_h
fWhje\j^[Z[Wb$9ecfb_WdY[Z[Yh[Wi[i\khj^[h_\j^[
fWj_[djiWh[debed][h\kbboceX_b[$?dj^_ii_jkWj_ed"
fWj_[djiWdZh[bWj_l[im_bbj^_dajm_Y[X[\eh[Z[Y_Z_d]
j^WjWl_i_jjej^[Z[djWbe\\_Y[_id[Y[iiWho\hecj^[
fe_dje\l_[me\j^[fWj_[djÄWdZWjj^Wjfe_dj_jcWo
X[jeebWj[$8[YWki[e\j^[_hZ[djWb^_ijeho"fWj_[dji
^Wl[Z[l[bef[ZWm_Z[cWh]_de\jeb[hWdY["WdZ_j_i
WcWp_d] ^em ckY^ j^[o Wh[ m_bb_d] je X[Wh WdZ je
h_ia"edbojeiWl[j^[ci[bl[ij^[jhekXb[e\Wfeii_Xbo
iec[m^Wjb[d]j^_[hjh_f$
J^[jof_YWb[nj[dje\fWj_[djYecfb_WdY[WdZj^[_h
_d\bk[dY[ ed j^[ jh[Wjc[dj fheY[ii WdZ jh[Wjc[dj
h[ikbji _d XWiWb _cfbWdjebe]o ^Wi X[[d WdWboi[Z
\eh W icWbb" Yedi[Ykj_l[ fWj_[dj iWcfb[ el[h Wd
eXi[hlWj_ed f[h_eZ e\ ''o[Whi '//& je (&&'%(&&($
FWj_[djim[h[Z_l_Z[Z_dje\ekhYecfb_WdY[]hekfi0
'ROUPÈ ) FWj_[dji m^e c[j j^[_h eXb_]Wj_edi
c[j_Ykbekibo0 J^[o h[b_WXbo Wff[Wh[Z \eh h[YWbb
Wffe_djc[dji WdZ i^em[Z kf _cc[Z_Wj[bo _d j^[
[l[dj e\ Wdo Yecfb_YWj_edi$ J^_i ]hekf Yecfh_i[Z
WXekj)Ä+e\WbbfWj_[dji$
'ROUPÈ)) FWj_[dji m^e c[j j^[_h eXb_]Wj_edi m_j^_d
W m_Z[ cWh]_d e\ jeb[hWdY[0 M^[d Yecfb_YWj_edi
eYYkhh[Z"j^[oi^em[ZkfedboW\j[h[nj[dZ[ZZ[bWoi"
eh j^[o Z_Z dej i^em kf Wj Wbb _d j^[ [l[dj e\
Yecfb_YWj_ediXkjWff[Wh[ZÄWjX[ijÄ\ehj^[d[nj
hekj_d[ h[YWbb Wffe_djc[dj$ J^_i ]hekf Yecfh_i[Z
WXekj)+e\WbbfWj_[dji$
'ROUPÈ ))) FWj_[dji m^e c[j j^[_h eXb_]Wj_edi edbo
W\j[h j^[o ^WZ ik\\[h[Z iec[ ZWcW][0 8[\eh[ j^Wj
ZWcW][^WZeYYkhh[Z"j^[oZ_ZdejWff[Wh\ehhekj_d[
h[YWbbWffe_djc[djiedj_c["dej[l[d_\Æedj_c[Ç_i
]_l[d W l[ho ][d[heki _dj[hfh[jWj_ed$ J^_i ]hekf
Yecfh_i[Z Wdej^[h )+ e\ j^[ fWj_[dji$ EdY[ j^[
fheXb[cim[h[iebl[Z^em[l[h"fWj_[djYecfb_WdY[_d
j^_i]hekf_cfhel[Zjej^[fe_djj^Wj"W\j[h''o[Whi"
fhWYj_YWbbo Wbb \ehc[h =hekf ??? fWj_[dji YekbZ X[
Wii_]d[Zje]hekfi?WdZ??_dj^Wjj^[odemWff[Wh[Z
h[b_WXbo\ehj^[_hh[YWbbWffe_djc[dji$M[\ekdZj^_i
Z[l[befc[djÄWdZj^[fWj_[djÉiWX_b_jojeb[Whd\hec
c_ijWa[iÄgk_j[ikhfh_i_d]$
'ROUPÈ )6 FWj_[dji m^e Z_Z dej c[[j Wdo eh j^[_h
eXb_]Wj_edi WdZ m^e m[h[ dej Wj Wbb m_bb_d] je ^Wl[
j^[_h h[ijehWj_edi h[#[lWbkWj[Z$ Kf je (+ e\ Wbb
fWj_[dji^WZjeX[fbWY[Z_dj^_iYWj[]eho$
È
)NITIALÈ#OMPLIANCE
;lWbkWj_ede\j^[fWj_[djh[YehZii^em[Zj^WjZ_i[Wi[i
e\j^[ehWbckYeiWWdZ^of[hXWbWdY[m[h[dej[ZWdZ
jh[Wj[ZWjb[WijedY["XkjkikWbboceh[\h[gk[djbo"\eh
Wbb e\ j^[ fWj_[dji Zkh_d] j^[ ''o[Whi j^[ _cfbWdj#
h[ijehWj_ed ioij[c mWi _d \kdYj_ed$ El[hWbb" ehWb
^o]_[d[mWimehi[_dfWj_[djim_j^h[i_ZkWbdWjkhWb
j[[j^ j^Wd _d fWj_[dji m^ei[ Z[dj_j_ed Yedi_ij[Z
[nYbki_l[bo e\ _cfbWdj#ikffehj[Z h[ijehWj_edi$ J^[
[nfbWdWj_edm[^Wl[\ehj^_i_ij^Wjj^[Yb[Wd_d][\\ehj
_i]h[Wj[h\ehdWjkhWbj[[j^j^Wd\eh8E?_cfbWdjiWdZ
h[ijehWj_edi$
7bb )* fWj_[dji Wff[Wh[Z \eh j^[ h[YWbb l_i_ji
W\j[h ,m[[ai$ DehcWb ^[Wb_d] mWi \ekdZ Xej^
Yb_d_YWbbo WdZ hWZ_ebe]_YWbbo _d Wbb fWj_[dji Wj j^_i
j_c[$ 7bb _cfbWdji" _dYbkZ_d] j^ei[ j^Wj m[h[ dej
È È #OMPLIANCEÈ#OMPLICATIONSÈANDÈ,ONG
TERMÈ4REATMENTÈ3UCCESSÈ ).+
beWZ[Z" m[h[ ik_jWXb[ \eh j^[ _di[hj_ed e\ Z[\_d_j_l[
\_n[Z h[ijehWj_edi Wj j^_i fe_dj$ M^[h[ Wffhefh_Wj["
fh[l_ekibo _iebWj[Z feij#beWZ[Z _cfbWdji m[h[ dem
WYj_lWj[Z$ Dej W i_d]b[ _cfbWdj ^WZ je X[ h[fbWY[Z
Wj j^_i j_c[" WdZ dej W i_d]b[ WZZ_j_edWb _cfbWdj
^WZ je X[ _dYehfehWj[Z$ >em[l[h" _d j^h[[ fWj_[dji
*$("^oZhenobWfWj_j[ehXed[Y^_fif[d[jhWj[Zj^[
ckYeiW$J^[om[h[_dlWh_WXboh[cel[Zm_j^ekjWdo
WZl[hi[h[WYj_edi$
I[l[d fWj_[dji fh[i[dj[Z m_j^ i_dki_j_\ehc
YecfbW_dji" m^_Y^ m[h[ _d_j_Wbbo jh[Wj[Z m_j^ Zhk]i
WdZ m_j^ Z[Yed][ijWdj c[Wikh[i$7bb i[l[d fWj_[dji
m[h[ [nWc_d[Z [dZeiYef_YWbbo" ki_d] j^[ Wf[hjkh[
_dj^[bem[hdWiWbc[WjkiYh[Wj[ZZkh_d]j^[_d_j_Wb
ikh][ho$ J^_i Wf[hjkh[ mWi kikWbbo XbeYa[Z Xo j^Wj
j_c[" Xkj mWi [Wi_bo h[#ef[d[Z Xo _di[hj_d] j^[
[dZeiYef[ i^[Wj^$ ?d jme fWj_[dji" j^[ cWn_bbWho
i_dki^WZjeX[h_di[ZZk[jefWj^ebe]_YWb\_dZ_d]i$
>em[l[h" de _cfbWdji ^WZ je X[ h[cel[Z Zk[ je
Yecfb_YWj_edi h[bWj[Z je j^[ cWn_bbWho i_dki$ 7bb
h[i_ZkWb YecfbW_dji \_dWbbo Z_iWff[Wh[Z m^[d Wd
WZZ_j_edWb m_Z[ c[Wjejeco mWi f[h\ehc[Z _d j^[
bem[hehc_ZZb[dWiWbc[Wjki$
È
4YPICALÈ2ESULTSÈINÈ$IFFERENTÈ#OMPLIANCEÈ'ROUPS
'ROUPÈ ) 7 jof_YWb h[fh[i[djWj_l[ e\ j^_i ]hekf _i W
fWj_[dj m^e Wff[Wh[Z (' j_c[i ijWdZWhZ YWi[0 ('
j_c[i_d''o[Whi"_dYbkZ_d]j^[i[ii_edih[gk_h[Z\eh
_di[hj_ede\j^[j[cfehWhoWdZZ[\_d_j_l[h[ijehWj_edi$
J^[ikf[hijhkYjkh[im[h[d[l[hh[cel[ZWdZd[l[h
^WZj^[_heYYbki_edY^Wd][Z"`kijXWbWdY[Zj^h[[j_c[i
Xo eYYbkiWb WZ`kijc[dj$ J^[ fWj_[djÉi WdjW]ed_ij_Y
Z[dj_j_ed _i Yecfei[Z e\ h[ijehWj_edi ikffehj[Z
Xo dWjkhWb WXkjc[dji$ Feijef[hWj_l[ hWZ_e]hWf^i
m[h[ jWa[d [_]^j j_c[i m_j^_d ''o[Whi Ä X[YWki[ e\
_cf[dZ_d] _cfbWdj jh[Wjc[dj _d j^[ effei_j[ `Wm
Wced]ej^[hh[Wiedi$
'ROUPÈ )) [n^_X_ji ]h[Wj[h Z[l_Wj_edi \hec j^[
ijWdZWhZ YWi[$ J^[ jm[bl[ fWj_[dji Wff[Wh[Z (/
j_c[i ed Wl[hW][ ijWdZWhZ YWi[0 (' j_c[i$ ?d d_d[
e\j^[i[fWj_[dji"ikf[hijhkYjkh[im[h[h[cel[ZWdZ
h[_di[hj[Z W jejWb e\ ', j_c[i" e\ m^_Y^ i[l[d j_c[i
W\j[h h[fW_h_d] l[d[[hi eh f[h\ehc_d] h[ijehWj_l[
meha_dj^[h[]_ede\j^[eYYbkiWbfbWd[$<ekhe\j^[i[
fWj_[djibeij_cfbWdjiÄj^h[[_cfbWdjiZk[je\hWYjkh[
WdZ j^h[[ _cfbWdji W\j[h el[hbeWZ eij[eboi_i" m^_Y^
Yehh[ifedZije))e\j^[fWj_[dji_dj^_i]hekf$Ed
j^[ej^[h^WdZ"ded[e\j^[\hWYjkh[Z_cfbWdji^WZje
X[h[fbWY[Z_dehZ[hjecW_djW_dj^[\kdYj_ede\j^[
_cfbWdj#h[ijehWj_ed ioij[c$ ?d Wbb YWi[i" j^[i[ m[h[
j^[h[ikbjie\jof_YWbfheij^eZedj_YfheXb[ciZk[je
_dYehh[YjehZ[bWo[Zjh[Wjc[dj$EYYbkiWbWZ`kijc[dji
Zkh_d]h[YWbbl_i_jim[h[f[h\ehc[Z,(j_c[i_dj^_i
fWj_[dj]hekf$
J^[ '( =hekf ??? fWj_[dji Yecfh_i[Z j[d mec[d
WdZ jme c[d$ J^[ WZl[hi[ Yedi[gk[dY[i e\ bWYa e\
Yecfb_WdY[ m[h[ ceij dej_Y[WXb[ _d j^[i[ _d_j_Wbbo
kdh[b_WXb[fWj_[dji$J[dfWj_[dji.)e\j^_i]hekf
beijed[_cfbWdj[WY^Äd_d[_dj^[cWn_bbWWdZed[
_dj^[cWdZ_Xb[$J^[i[beii[im[h[YWki[ZXo\hWYjkh[
j^h[[ehf[h_#_cfbWdjeij[eboi_ii[l[d$E\j^[j[d
_cfbWdji beij" i_n m[h[ h[fbWY[Z$ Ed[ WZZ_j_edWb
_cfbWdj[WY^mWih[fbWY[Z_djmefWj_[djiZkh_d]j^[
eXi[hlWj_edf[h_eZ$
J^[ ikf[hijhkYjkh[ beei[d[Z Ä edY[ eh i[l[hWb
j_c[i Ä _d Wbb fWj_[dji e\ j^_i ]hekf" \eh W jejWb e\
(, _dijWdY[i$ 7 d[m Yecfb[j[ _cfbWdj#ikffehj[Z
h[ijehWj_ed ^WZ je X[ \WXh_YWj[Z i[l[d j_c[i _d j^_i
]hekf$
9Wh[ WdZ cW_dj[dWdY[ e\ j^[ ikf[hijhkYjkh[i
e\j[d bWfi[Z el[h fhejhWYj[Z f[h_eZi _d j^_i ]hekf$
D[l[hj^[b[ii" j^[ _dZ_l_ZkWb fWj_[dji _d j^_i ]hekf
h[jkhd[Z \eh W Yb_d_Y l_i_j ed Wl[hW][ *( j_c[i _d
''o[Whi$ EYYbkiWb WZ`kijc[dj mWi f[h\ehc[Z )(.
j_c[i$?d\ekhYWi[iÄWbbcWn_bbWhoÄj^[Yh[ijWbXWiWb
fbWj[ie\j^[?::_cfbWdji^WZjeX[h[cel[ZW\j[h
f[h_eZie\X[jm[[d)WdZ-o[Whi$?dj^[i[YWi[ij^[
eij[eboj_Y fheY[ii mWi bWj[h eXi[hl[Z je ^Wl[ Yec[
jeWijWdZij_bb$
H[b_WXb[_d\ehcWj_ededj^[hWf[kj_YekjYec[mWi
kdWlW_bWXb[\eh=hekf?LfWj_[dji$7YYehZ_d]jej^[_h
emd [Whb_[h ijWj[c[dji" Wj b[Wij ^Wb\ e\ j^[c ^WZ
h[celWXb[ h[ijehWj_edi _dij[WZ e\ \_n[Z ed[i$ J^_i
i^emi j^Wj" Wi W hkb[" j^[ jh[Wjc[dj ]eWb YWddej X[
WY^_[l[Zm_j^ekjgkWb_\_[Z\ebbem#kf$
'ROUPÈ ))) fWj_[dji fh[i[dj[Z m_j^ fheij^eZedj_Y
Yecfb_YWj_edi ,* j_c[i" m^_Y^ ed Wl[hW][ \_hij
Wff[Wh[ZW\j[hWffhen_cWj[bo*$)o[Whi$:kh_d]j^[''#
o[WheXi[hlWj_edf[h_eZ")&$'e\j^[ikf[hijhkYjkh[i
^WZjeX[h[#cWZ[Wjb[WijedY[Äj^_iW\\[Yj[Zded[
e\j^[fWj_[dji_d=hekf?"Xkj(&$+e\j^[fWj_[dji
_d=hekf??WdZW\kbb-&e\j^[fWj_[dji_d=hekf
???$H[cWa[i^WZj^kiX[Yec[d[Y[iiWhofh_cWh_bo
_d =hekf ??? Ä cW_dbo X[YWki[ fWj_[dji ^WZ mW_j[Z
jee bed] X[\eh[ i[[a_d] fhe\[ii_edWb Wii_ijWdY[
W\j[h j^[ \_hij i_]di e\ Yecfb_YWj_edi ^WZ X[]kd je
cWd_\[ij j^[ci[bl[i$ J^_i _i m^o" _d iec[ YWi[i"
WZlWdY[Z eij[eboi_i fh[l[dj[Z _cfbWdji \hec X[_d]
h[fbWY[Z_dj_c[\ehj^[_di[hj_ede\Wd[m_cfbWdj_d
j^[iWc[beYWj_ed$J^[Yedi[gk[dY[mWij^WjWd[m
ikf[hijhkYjkh[^WZjeX[\WXh_YWj[Z"j^[Yeije\m^_Y^
^WZjeX[Xehd[Xoj^[fWj_[dji$
?d i[l[hWb YWi[i" jh[Wjc[dj fhel_Z[hi bWYa_d] j^[
Wffhefh_Wj[jhW_d_d]^WZjWa[dZ[bWo_d]ehZemdh_]^j
mhed]jh[Wjc[djc[Wikh[ij^WjZ_Zdej^_d]jeiebl[
j^[[n_ij_d]fheXb[ciXkj"WiWhkb["hWj^[hW]]hWlWj[Z
j^[c$ M[ iWm Wdo hWj_edWb" fhe\[ii_edWbbo `kij_\_[Z
feij#jh[Wjc[dj [\\ehji ^Wl_d] X[[d f[h\ehc[Z Xo W
ded#Wkj^eh_p[Zi[YedZWhojh[Wjc[djfhel_Z[hÄdej
_dWi_d]b[YWi[$:[bWo[Zjh[Wjc[dj\ehYecfb_YWj_edi"
)., 9^Wfj[h(,È -AINTENANCE
_d ekh [nf[h_[dY[" _i j^[ ed[ \WYjeh j^Wj fei[i j^[
]h[Wj[ij h_ia e\ Xed[ beii$ EYYWi_edWbbo m[ ]ej j^[
_cfh[ii_ed j^Wj j^[ i[YedZWho jh[Wjc[dj fhel_Z[h
_dj[dj_edWbbo Z[bWo[Z jh[Wjc[dj" feii_Xbo ^ef_d]
j^Wj j^[ _cfbWdji mekbZ X[ [Wi_[h je h[cel[ \hec
h[]_edi m_j^ ceh[ fhedekdY[Z eij[eboi_i$ J^_i
mekbZe\Yekhi[Yedij_jkj[Wi[l[h[YWi[e\c[Z_YWb
cWbfhWYj_Y[$
7bb 'ROUPÈ )6 fWj_[dji WdZ ^Wb\ j^[ =hekf ???
fWj_[dji h[fehj[Z Wj iec[ fe_dj Zkh_d] j^[ h[YWbb
i[ii_edi j^Wj ki[hi e\ Yecf[j_d] _cfbWdj ioij[ci"
\h[gk[djbo [l[d h[fh[i[djWj_l[i e\ kd_l[hi_jo Z[djWb
iY^eebi" ^WZ jh_[Z je a[[f j^[c \hec kdZ[h]e_d]
j^[ h[gk_h[Z 8E? \ebbem#kf jh[Wjc[dj$ J^[o Wbie
h[fehj[Z bei_d] \W_j^ _d j^[ fheY[Zkh[ Ä Wj b[Wij
j[cfehWh_boÄWdZ^Wl_d]c_ii[Zj^[_hWffe_djc[dji
X[YWki[ j^[o de bed][h iWm Wdo fe_dj _d a[[f_d]
j^[c$
M[ X[b_[l[ j^Wj" _d j^[ =hekf ?L fWj_[dji" j^[
d[]Wj_l[ fhef^[i_[i Xo j^[ i[YedZWho jh[Wjc[dj
fhel_Z[hiX[YWc[h[Wb_joX[YWki["WdZedboX[YWki["
Wffhefh_Wj[\ebbem#kfjh[Wjc[djmWidejf[h\ehc[Z$
FWj_[djim^e^WZX[[d[nWc_d[ZWjWkd_l[hi_joYb_d_Y
Wj iec[ fe_dj WdZ d[l[h Yedikbj[Z Wd Wkj^eh_p[Z
i[YedZWhojh[Wjc[djfhel_Z[hW]W_dijeeZj^[mehij
Y^WdY[e\bed]#j[hcjh[Wjc[djikYY[ii$J^[Y^WdY[i
j^Wj j^[ ikf[hijhkYjkh[i YWd h[cW_d \kdYj_edWb Wh[
p[he\ehj^_ifWj_[dj]hekf$
?dmec[d"j^[_hikX`[Yj_l[WffhelWbehZ_iWffhelWb
e\ j^[ W[ij^[j_Y Wff[WhWdY[ e\ j^[ ikf[hijhkYjkh[
fbWoi W Z[j[hc_d_d] heb[ \eh Yecfb_WdY[$ ?\ j^[o
Ze dej b_a[ j^[_h Xh_Z][" j^[o iec[j_c[i h[\ki[ je
Wff[Wh\ehWdoi[hl_Y[ehh[fW_hmeha$7\j[hÄkikWbbo
Ä (Ä*o[Whi" Xkj Wj b[Wij W\j[h , eh -o[Whi" j^_i m_bb
_dlWh_WXbo h[ikbj _d j^[ ikf[hijhkYjkh[ X[Yec_d]
kdkiWXb[$
7docejehl[^_Yb[mekbZbed]i_dY[^Wl[h[\ki[Z
jehkd_\ikX`[Yj[Zjej^[iWc[jof[e\ded#i[hl_Y[$
>em[l[h" j^[ fWj_[dji _dlebl[Z ^Wl[ X[Yec[
_cf[hl_ekijehWj_edWbWh]kc[dji$
È
3UMMARY
Bed]#j[hcjh[Wjc[djikYY[ii_d_j_Wbboh[gk_h[iYbei[
\ebbem#kf" WdZ ikXi[gk[dj h[YWbbi [l[ho ,cedj^i"
XoWZ[dj_ij\Wc_b_Whm_j^8E?_cfbWdji$?dj^[[l[dj
j^Wj fheXb[ci eYYkh" h[YWbb l_i_ji ^Wl[ je X[ ifWY[Z
ceh[ Ybei[bo$ FWj_[dj Yecfb_WdY[ h[]kbWh \ebbem#
kf l_i_ji" _cc[Z_Wj[ h[WYj_ed i^ekbZ fheXb[ci
eYYkh" Yecfb_WdY[ m_j^ j^[ jh[Wjc[dj fhel_Z[hÉi
_dijhkYj_edifbWoiWheb[m^ei[_cfehjWdY[YWddej
X[ kdZ[h[ij_cWj[Z Ä fh[Y_i[bo Wi _d ehj^eZedj_Y
jh[Wjc[dj$
?\ fWj_[dji ^Wl[ je jhWl[b jee \Wh" j^_i cWo X[ Wd
_dZkY[c[djjeia_fd[Y[iiWhoh[YWbbl_i_jiehjei[[a
j^[ WZl_Y[ e\ ded#gkWb_\_[Z i[YedZWho jh[Wjc[dj
fhel_Z[hi"m^e_dceijYWi[imekbZX[j^[_hfh[l_eki
\Wc_boZ[dj_iji$
J^_i_iWYjkWbboWdej^[hWif[Yje\j^[Z[Y_i_edWi
jem^[j^[hjejh[WjWfWj_[djm_j^8E?_cfbWdji$Edbo
_\j^[fheif[Yje\fWj_[djYecfb_WdY[_i[nY[bb[djWdZ
_\fWj_[dji^Wl[X[[dj^ehek]^bo[ZkYWj[ZWXekjj^[
kdYedZ_j_edWb d[[Z \eh \ebbem#kf l_i_ji i^ekbZ 8E?
_cfbWdji X[ _di[hj[Z _d fWj_[dji m^e ^Wl[ je jhWl[b
\Wh'&&Ä'+&ac$
Dkc[hekifWj_[djiYekbZY[hjW_dboX[i[hl[ZckY^
X[jj[h_\Ybei[Yeef[hWj_edm[h[feii_Xb[X[jm[[dj^[
_cfbWdjebe]_ij#ikh][edWdZWdoi[YedZWhojh[Wjc[dj
fhel_Z[h$ >em[l[h" ikY^ Wif_hWj_edi h[]kbWhbo \W_b
X[YWki[ fWj_[dji Ze dej _d\ehc j^[ _cfbWdjebe]_ij
_d WZlWdY[ e\ j^[_h _dj[dj_ed je Y^Wd][ fhel_Z[hi
WdZ X[YWki[ j^[ i[YedZWho jh[Wjc[dj fhel_Z[h Ä
e\j[d j^[ \Wc_bo Z[dj_ij eh Wd _cfbWdjebe]_ij m^e
_i W fhejW]ed_ij e\ W Yecf[j_d] ioij[c Äh[\ki[i
je YedjWYj j^[ Z[dj_ij m^e f[h\ehc[Z j^[ _d_j_Wb
_cfbWdjWj_ed$
J^[fWj_[djim^e^WZX[[d\ebbem[ZbeijWdWl[hW][
e\i_nmehaZWoiZkh_d]j^[[dj_h[eXi[hlWj_edf[h_eZ
e\ ''o[Whi$ J^_i Ze[i dej _dYbkZ[ jhWl[b j_c[$
=hekf?fWj_[dji^WZje_dl[ijb[iij^Wd,^e\jejWb
WYjkWbjh[Wjc[djj_c[_d[b[l[do[Whi$
Ed[e\j^[h[Wiedi\ehbemYecfb_WdY[cWol[ho
m[bb X[ j^[ \WYj j^Wj j^[ jh[Wjc[dj ]eWb _i WY^_[l[Z
iegk_Yabo$CWdofWj_[djiYecfb[j[bo\eh][jj^Wjj^[o
^Wl[Z[djWb_cfbWdji_dj^[\_hijfbWY[WdZj^Wjj^_i_i
WiieY_Wj[Zm_j^iec[eXb_]Wj_ediedj^[_hfWhj$J^Wj
fWj_[djiWh[jho_d]jei[[aWbj[hdWj_l[jh[Wjc[dj_dij[WZ
e\ Yecfbo_d] m_j^ j^[ _cfbWdjebe]_ijÉi _dijhkYj_edi
\eh h[YWbb cWo Wbie X[ j^[ h[ikbj e\ Wd [\\ehj je
h[Y[_l[Z[djWbi[hl_Y[im_j^ekj_dYkhh_d]Wdoekj#e\#
feYa[j [nf[di[i" _$[$ i[hl_Y[i j^Wj Wh[ h[_cXkhiWXb[
Xo fh_lWj[ ^[Wbj^ _dikh[hi$ ?d Im_jp[hbWdZ" m^[h[
j^[ fWj_[dji j^[ci[bl[i ^Wl[ je fWo \eh Wbb Z[djWb
i[hl_Y[i" edbo +Ä. e\ j^[ fWj_[dji [dZ kf ed
=hekf?Lj^WjijkXXehdboh[\ki[iWffhefh_Wj[\ebbem#
kf jh[Wjc[dj$M[ [ij_cWj[ j^Wj +& e\ j^[ fWj_[dji
_dj^_i]hekfbei[j^[_hh[ijehWj_edikXi[gk[djjej^[
beiie\Wi_d]b[_cfbWdj"m^_Y^YekbZ[Wi_bo^Wl[X[[d
jh[Wj[ZXoj_c[bofhe\[ii_edWb_dj[hl[dj_ed$
7 jejWb e\ ,$)+ e\ j^[ _cfbWdji _d =hekfi ?Ä???
mWi beij$ B[ii j^Wd ^Wb\ e\ j^[ _cfbWdji beij ^WZ
je X[ h[fbWY[Z$ ?cfbWdji dej beYWj[Z Wj ijhWj[]_Y
fei_j_edi m[h[ dej h[fbWY[Z$ 7h[Wi _d Xej^ `Wmi
j^WjWh[ikX`[Yjje^_]^\b[n_edWh[b[iiWc[dWXb[je
h[c_d[hWb_pWj_ed Ä Zk[ je el[hbeWZ eh je j^[ \ehY[i
e\\b[n_edj^[ci[bl[iÄiej^WjZ_iaih[_dj[]hWj[b[ii
h[WZ_bo_dj^[i[h[]_edi$
?dWickY^WiW\ebbem#kf[nWc_dWj_edmWifeii_Xb[
W\j[h ''o[Whi" m[ \ekdZ j^Wj Wbb 8E? fWj_[dji ^WZ
WY^_[l[Z j^[ jh[Wjc[dj eX`[Yj_l[ e\ ^Wl_d] j^[_h
`Wmi h[ijeh[Z m_j^ \_n[Z ikf[hijhkYjkh[i WdZ ^WZ
X[[d WXb[ je cW_djW_d j^Wj i_jkWj_ed$ >em[l[h" j^[
È È )))
!DVISEDÈ"/)È0ATIENTSÈ ).-

dkcX[h WdZ [nj[dj e\ Yecfb_YWj_edi mWi ckY^ ^Wi Z[l[bef[Z _d Z[djWb iY_[dY[" W cel[c[dj
bem[h_dj^[]hekfYbWii_\_[ZWiÆh[b_WXb[Ç$Kdh[b_WXb[ j^Wj [l[hoed[ ijeb_Zbo \ebbemi$ ;l[hoj^_d] j^Wj
fWj_[djiik\\[hceh[WdZceh[i[l[h[Yecfb_YWj_edi ^Wff[di je [dZ kf ekji_Z[ j^_i cW_dijh[Wc _i
X[YWki[j^[o\W_bjejWa[WZlWdjW][e\j^[fh[l[dj_l[ Yedi_Z[h[Z kdiY_[dj_\_Y WdZ d[[Zi je X[ \ek]^j$
c[Wikh[ijeX[jWa[dZkh_d]hekj_d[h[YWbb"iec[j^_d] J^[mWoj^[kd_l[hi_j_[iWYj_iZec_dWj[ZXoj^[_h
j^WjYWki[ijof_YWbfheXb[ciWdZZWcW][$ Z[f[dZ[dY[edj^_hZ#fWhjo\_dWdY_d]hWj^[hj^Wd
Ded[ e\ j^[ fWj_[dji jh[Wj[Z m_j^ 8E? _cfbWdji iY_[dj_\_Y [j^_Yi$ J^_i f^[dec[ded _i Wbb jee
YbWii_\_[Z _d =hekfi ?Ä??? [nf[h_[dY[Z jh[Wjc[dj \Wc_b_Wh\hecej^[hh[b_]_ekimWhiZkh_d]j^[fWij
\W_bkh[_dj^[i[di[e\debed][hX[_d]WXb[jem[Wh \[mY[djkh_[i$
\_n[Zh[ijehWj_edi$ )$ 4HEÈIMPLANTSÈAREÈTOOÈLONG
J^[Z[djWb\Wj[e\j^[=hekf?LfWj_[dji"m^em[h[ J^_i Wh]kc[dj _i h[bWj[Z je j^[ \WYj j^Wj Yh[ijWb
beijjeh[YWbb"h[cW_dikdademd$ _cfbWdjebe]_iji Wh[ ki[Z je fbWY_d] j^[ _dj[h\WY[
X[jm[[d j^[ _cfbWdj WdZ j^[ WXkjc[dj%Yhemd
ikX]_d]_lWbbo _d Wbb YWi[i$ <eh 8E?" ^em[l[h" j^_i
È _i dej Wj Wbb ijWdZWhZ fheY[Zkh[$ 7d _dj[h[ij_d]
)LL
!DVISEDÈ"/)È0ATIENTS lWh_Wj_ed ed j^_i Wh]kc[dj j^Wj _i Wi eh_]_dWb Wi
_j _i jof_YWb ^Wi h[Y[djbo X[[d fkj \ehmWhZ Xo W
El[hj^[o[Whi"cWdo8E?fWj_[djim_bbX[_dYedjWYj =[hcWd fhe\[iieh0 J^_i fhe\[iieh _dif[Yj[Z j^[
m_j^ ej^[h Z[dj_iji" WdZ j^[h[ m_bb e\j[d X[ YWi[i 8E?_cfbWdjedWhWZ_e]hWf^WdZ\ekdZj^Wjj^[
e\ fWhWbb[b jh[Wjc[dj$ H[]h[jjWXbo" j^ek]^" W \[m e\ Xed[ b[l[b m^_Y^ mWi \kbbo Yehh[Yj mWi beYWj[Z
j^ei[ Z[dj_iji m_bb X[ j^[ jof[ j^Wj YWddej i^kj kf WjWffhen_cWj[boj^[c_ZmWofe_dje\j^[Z_ijWdY[
WXekj j^_d]i j^[o adem dej^_d] WXekj$ J^[o YWd X[jm[[d j^[ j^h[WZ[Z f_d WdZ j^[ Yh[ijWb Z_ia$
X[ ie ikYY[ii\kb _d dej i^kjj_d] kf j^Wj [l[d iec[ >[ _dj[hfh[j[Z j^_i W]W_dij j^[ XWYa]hekdZ e\
fWj_[djim^eWh[Yecfb[j[boiWj_i\_[Zm_j^j^[_h8E? ^_i Yh[ijWb _cfbWdjebe]o [nf[h_[dY[ Wi c[Wd_d]
jh[Wjc[dj [dZ kf m_j^ZhWm_d] \hec _j Ä m_j^ j^[ j^Wj ^Wb\ e\ j^[ l[hj_YWb Xed[ ckij ^Wl[ X[[d
iWZ h[ikbj j^Wj Wdo d[Y[iiWho \ebbem#kf jh[Wjc[dj beijWbh[WZoWc_iYedY[fj_edj^Wjh[gk[ij_d]j^[
_i dej fhel_Z[Z _d W fhe\[ii_edWb cWdd[h" eh _\ _j _i XWi[b_d[ hWZ_e]hWf^ `kij c_]^j ^Wl[ iWl[Z ^_c
fhel_Z[Z"_jcWoX[jeebWj[$J^_iY^Wfj[hm_bbWjj[cfj \hec ][jj_d]$ >[ Yedl_dY[Z j^[ fWj_[dj" je ^Wl[
jeYecc[djedWdkcX[he\Wbb#jee#\Wc_b_Whb_d[ie\ j^[ _cfbWdj h[cel[Z _cc[Z_Wj[bo _d j^[ Xed[
Z_iYkii_ed j^Wj 8E? fWj_[dji ^Wl[ X[[d jh[Wj[Z je XbeYa$ 8Wi[Z ed m^Wj ^[ ad[m WXekj Yh[ijWb
el[hj^[o[Whi$ _cfbWdji" ^[ mWi WYYkijec[Z je i[[_d] l[hj_YWb
?j _i gk_j[ ikhfh_i_d] je i[[ `kij ^em Z[l_eki j^[ Xed[ beii WdZ ad[m j^Wj j^ei[ _cfbWdji ^WZ je
_Z[WiWh[j^Wjiec[e\ekhYecf[j_jehi_dj^[Z[djWb X[ h[cel[Z _\ ^Wb\ j^[ Xed[ ^[_]^j _i beij Zk[
_cfbWdjebe]_YWb cWha[j Yec[ kf m_j^ WdZ m^Wj je j^[ X[^Wl_ekh e\ j^[ _cfbWdj$ J^Wj de i_]d
Wh]kc[dji Wh[ ckij[h[Z _d ehZ[h je Z_iYh[Z_j j^[ e\ _d\bWccWj_ed mWi fh[i[dj Z_Z dej W\\[Yj j^_i
mehae\j^[8E?_cfbWdjebe]_ij$7bb[][Zbo^kceheki fem[hh[i[WhY^[hWdZ^_iZ_W]deij_YYedYbki_ed$
Yecc[djiÆm^Wja_dZe\ia_feb[iWh[j^ei[5ÇYWd
mh[Wa Wi ckY^ fioY^ebe]_YWb ^WleY Wi ed[ e\ j^[ FWj_[dji"gk_j[kdZ[hijWdZWXbo"j[dZjeX[kdZ[hj^[
\ebbem_d]"fWj[djbo\Wbi["ijWj[c[dji$ _cfh[ii_edj^Wjj^[Z[dj_ijimeha_d]Wjkd_l[hi_j_[i
'$ 4HEÈSYSTEMÈISÈOBSOLETEÈnÈ4HEÈSYSTEMÈISÈTOOÈNEW ckijX[fWhj_YkbWhboademb[Z][WXb[WdZia_bb[Z$M^Wj
TOOÈOLD j^[oZedejadem_ij^WjZ[dj_ijijhkboYecc_jj[Zje
?dj[h[ij_d]bo [dek]^" Xej^ j^[i[ Wh]kc[dji Wh[ j^[_h fhe\[ii_ed ieed X[Yec[ Z_i[dY^Wdj[Z m_j^
dej_d\h[gk[djbofhefei[ZXoj^[iWc[fhejW]ed_ij j^[ WYWZ[c_Y Yb_cWj[" fh[\[hh_d] je ]e WdZ ef[d
Wj j^[ iWc[ j_c[$ Ceij fWj_[dji m_bb h[Wb_p[ j^Wj j^[_hemdZ[djWbe\\_Y[ehYb_d_Y_dij[WZ$Kd_l[hi_j_[i
edboed[e\j^[cYWdX[jhk[WjWj_c[$>em[l[h" j^[h[\eh[ e\j[d ^Wl[ h[]h[jjWXbo \[m [nf[h_[dY[Z
_\Wbeje\ZhWcWj_YjWb[dj_i[cfbeo[Z"j^[h[ikbji fhWYj_Y_Wdi$
cWoX[gk_j[jhW]_Y$ *$ 4HEÈ IMPLANTSÈ AREÈ DIFFICULTÈ ORÈ IMPOSSIBLEÈ TOÈ RE

($ 4HEREÈISÈNOÈSCIENTIFICÈEVIDENCE MOVE
J^_iWh]kc[djm_bbe\j[dX[^[WhZ_dWdWYWZ[c_Y J^_iWh]kc[dj_iZh_l[dXojmeZ_\\[h[djWif[Yji0
[dl_hedc[djÄWjkd_l[hi_j_[iZ[f[dZ_d]edj^_hZ# Ed ed[ ^WdZ" Yh[ijWb _cfbWdjebe]_iji [nf[Yj je
fWhjo h[i[WhY^ ]hWdji$ 9[hjW_d iY_[dj_\_Y `ekhdWbi i[[ l[hj_YWb Xed[ beii Wbed] j^[ l[hj_YWb Wn_i Wj
Wh[ Yedi_ij[dj cWdZWjeho h[WZ_d] Wj kd_l[hi_j_[i j^[ _cfbWdj" WdZ j^[o Wh[ ki[Z je j^[i[ _cfbWdji
WdZ Z[djWb iY^eebi" WdZ [l[hoed[ ademi ^Wl_d]jeX[h[cel[Ziec[m^[h[Zemdj^[b_d[$
[l[hoj^_d] j^Wj _i fkXb_i^[Z _d j^[i[ `ekhdWbi$ J^_i c[Wdi j^Wj" m^[d i[b[Yj_d] Wd _cfbWdj" ed[
7doj^_d] j^Wj _i fkXb_i^[Z _d ej^[h `ekhdWbi _i Yh_j[h_edm_bbX[jeZeWib_jjb[ZWcW][Wifeii_Xb[
Yedi_Z[h[Z dej h[l_[m[Z Ä dej iY_[dj_\_Y Ä dej m^[d j^[ i[b[Yj[Z _cfbWdj _i kbj_cWj[bo h[cel[Z
h[b[lWdj$ 7 ie#YWbb[Z cW_dijh[Wc cel[c[dj Ä W Yh_j[h_ed j^Wj _i e\ Yekhi[ ceij Wffhefh_Wj[
).. 9^Wfj[h(,È -AINTENANCE
kdZ[hj^[Y_hYkcijWdY[i$
Ed j^[ ej^[h ^WdZ" ceij Yh[ijWb _cfbWdjebe]_iji
Wh[ dej WmWh[ e\ j^[ \WYj j^Wj j^_iÆZ[i_]d[Z#_dÇ
Xed[beiiZe[idejeYYkhm_j^8E?_cfbWdjiWdZ
j^Wj j^[ ijWj[ e\ j^[ _cfbWdj _i ]eeZ [l[d m^[h[
j^[hWZ_e]hWf^i^emij^Wjj^[j^h[WZ[Zf_d_idej
eii[e_dj[]hWj[Z$
?\ W 8E? _cfbWdj _i dej eii[e_dj[]hWj[Z" _j YWd +$ 4HEÈIMPLANTSÈMUSTÈBEÈREMOVED
X[ h[cel[Z m_j^_d i[YedZi$ 8kj _\ W 8E? _i
eii[e_dj[]hWj[Z" _j m_bb dej dehcWbbo ^Wl[ je X[
h[cel[Z _d j^[ \_hij fbWY[$ 8E? WZl[hiWh_[i j^ki
jWa[j^[_hemd_d\ehcWj_edZ[\_Y_jiWdZjkhdj^[c
WhekdZ je ki[ j^[c Wi Wh]kc[dji$ J^ei[ m^e
Wh]k[_dj^_icWdd[hc_]^j[gkWbbom[bbYedi_Z[h
WHebbiHeoY[I_bl[hI^WZemWXWZYWhX[YWki[j^Wj
YWh_iceh[Z_\\_YkbjjeZ[ijheoj^Wdej^[hi$$$$
8E?_cfbWdjebe]_iji_di[hj8E?_cfbWdjifh[Y_i[bo
X[YWki[ j^[o adem j^Wj j^[o Wh[ ijWXb[ WdZ m[bb
h[jW_d[Z$J^[omekbZd[l[hfh[\[hWiYh[m_cfbWdj
i_cfboX[YWki[_j_i[Wi_[hjeh[cel[$
J^[ fheXb[c m_j^ j^_i Z_iYkii_ed Wi W m^eb[ _i
j^Wjj^[fWj_[dj_iX[_d]jWba[Z_djeX[b_[l_d]j^Wj
j^[ _cfbWdj m_bb kbj_cWj[bo ^Wl[ je X[ h[cel[Z
WdomWo WdZ j^Wj j^Wj mekbZ X[ W l[ho Z_\\_Ykbj ,$ 9OUÈ DOÈ NOTÈ HAVEÈ ENOUGHÈ BONEÈ FORÈ IMPLANTSÈ
fheY[ii$ J^[ fWj_[dj m_bb X[Yec[ W\hW_Z e\ j^[
[dj_h[ jh[Wjc[dj" m_j^ ^_i [dj_h[ j^ek]^j fheY[ii
h[lebl_d] WhekdZ j^[ gk[ij_ed e\ j^[ ^em WdZ
m^[d e\ _cfbWdj h[celWb Ä hWj^[h j^Wd ed j^[
gk[ij_edWijem^[j^[hehdejj^[_cfbWdj^Wije
X[ h[cel[Z _d j^[ \_hij fbWY[$ J^_i cWo Yed`kh[
kfWi_jkWj_ed_dm^_Y^j^[fWj_[djÉiZ[i_h[jefkj
j^[h[celWbe\j^[_cfbWdjiX[^_dZj^[cWiieed
Wifeii_Xb[X[Yec[iWd_Zƒ[\_n[$?dj^_ii_jkWj_ed"
j^[8E?_cfbWdjebe]_ijm_bb^Wl[jeZ[Y_Z[eded[
e\i[l[hWbfeii_Xb[Yekhi[ie\WYj_ed$
<_hij e\ Wbb" ^[ m_bb _d\ehc ^_i fWj_[dj j^Wj _j _i j^[c j^Wj j^[_h Z[djkh[ eh Xh_Z][ _d \WYj mehai
edbo l[ho hWh[bo j^Wj 8E? _cfbWdji ^Wl[ je X[
h[cel[ZWdZj^Wjj^_ih[celWbÄi^ekbZ_jX[Yec[
d[Y[iiWho Ä _i W cWjj[h e\ W \[m c_dkj[i WdZ de
fheXb[ci$>em[l[h"iec[fWj_[djim_bb^Wl[]ed[
ie \Wh j^Wj j^[o de bed][h X[b_[l[ j^_i WdZ _di_ij
edh[celWb$
Ä ?\ _j _i Yecfb[j[bo Yb[Wh j^Wj j^[ fWj_[dj m_bb
dej X[ Z_iikWZ[Z" m[ Yedi_Z[h j^_i je X[ W
fkh[bo fioY^ebe]_YWb _dZ_YWj_ed \eh _cfbWdj
h[celWb$>em[l[h"j^[i_jkWj_edm_bb^Wl[jeX[
j^ehek]^boZeYkc[dj[Z$
Ä ?j _i h[Yecc[dZ[Z je f[hiedWbbo f[h\ehc
j^[ h[celWb m^_Y^ WffWh[djbo _i _dZ_YWj[Z
fioY^ebe]_YWbbo" X[YWki[ j^[ ZWcW][ YWki[Z
Xo ded#Wkj^eh_p[Z Z[djWb ikh][edi cWo X[
[nj[di_l[$
 FWj_[djim^e\_dZj^Wjj^[_h8E?_cfbWdji^Wl[
h[Wbbo X[[d h[cel[Z m_j^_d W \[m c_dkj[i"
WdZ m_j^ekj Wdo Yecfb_YWj_edi" m_bb ceh[
e\j[d j^Wd dej X[ heoWbbo ikhfh_i[Z" WdZ _j
m_bb gk_Yabo ZWmd ed ed[ eh Wdej^[h e\ j^[i[
fWj_[djij^Wjj^[_hZ[Y_i_ed^WZX[[dj^[mhed]
ed[$ Ej^[h fWj_[dji cWo dej h[Wb_p[ j^_i kdj_b
bWj[h$ 8kj _d ceij YWi[i" j^[i[ fWj_[dji m_bb
ieed h[gk[ij h[_cfbWdjWj_ed$ J^[ Yecfb_WdY[
e\fWj_[djim^e^Wl[]ed[Zemdj^_ifWj^m_bb
kikWbboX[]eeZ"Wij^[o^Wl[b[Whd[Z\hecXWZ
[nf[h_[dY[$
J^ei[ m^e" m_j^ekj WZ[gkWj[bo jhW_d_d]" h[cel[
8E?_cfbWdjiehWZleYWj[j^[_hh[celWbfheXWXbo
_dj[dZjeYb[Whj^[\_[bZe\ef[hWj_ed"Wi_jm[h[
\ehj^[_hemdj^[hWfo$I_dY[j^[cWdk\WYjkh[hiWh[
YWh[\kbjefhel_Z[Xej^j^[8E?_cfbWdjiWdZj^[
h[gk_i_j[ jeebi edbo je Wkj^eh_p[Z 8E? ki[hi" j^[
W\\[Yj[ZZ[dj_ijiWh[\WY[Zm_j^j^[fheXb[cj^Wj
j^[oYWddejjh[Wjj^[i[fWj_[dji\ehWibed]Wij^[
8E?_cfbWdjiYedj_dk[jeX[fh[i[dj_dj^[cekj^$
Iec[^em" iec[m^[h[" j^[ 8E? _cfbWdj m_bb X[
h[cel[Z WdomWo" \ebbem[Z" dej _d\h[gk[djbo" Xo
Wjj[cfji je ^ebZ j^[ 8E? jh[Wjc[dj fhel_Z[h
h[ifedi_Xb[ \eh WdÆ[hhehÇ eh ej^[hm_i[ je XbWc[
^_c \eh j^[ Wbb[][Z d[[Z je h[cel[ j^[ 8E?
_cfbWdj$
nÈ 4HEREÈ HASÈ ALWAYSÈ BEENÈ INSUFFICIENTÈ BONEÈ SUB
STANCEÈFORÈIMPLANTS
J^_i Wh]kc[dj _i XWi[Z ed j^[ Yedi_Z[hWj_ed
Äm^_Y^_iYehh[Yj_d_ji[b\Äj^WjYh[ijWb_cfbWdji
m_bb edbo X[ \kdYj_edWb _d j^[ c[Z_kc j[hc _\
j^[_h b[d]j^ _i Wj b[Wij '&Ä')cc$ ?\" ^em[l[h"
edbo )cc e\ Xed[ Wh[ WlW_bWXb[" _cfbWdjWj_ed
_i _cfeii_Xb[" i[[d \hec j^[ fe_dj e\ l_[m e\
j^[ Yh[ijWb _cfbWdjebe]_ij$ FWj_[dji j^[ci[bl[i
de bed][h kdZ[hijWdZ j^[ YedjhWZ_Yj_ed" \hec
W Y[hjW_d fe_dj ed$ ;l[d _\ _j _i fe_dj[Z ekj je
iec[j^_d] ed[ mekbZ WYjkWbbo [nf[Yj j^[c je
^Wl[ dej[Z \eh j^[ci[bl[i" iec[ fWj_[dji ijWhj
ikXiYh_X_d] je j^[ Yh[[Z j^Wj j^[h[ _i jee b_jjb[
Xed[ WlW_bWXb[ WdZ j^Wj ikXi[gk[dj fheXb[ci
m_bbX[_d[l_jWXb[$M[^Wl[i[[dfWj_[dji_dYekhj
m^e ijkXXehdbo _di_ij[Z j^Wj j^[o i^ekbZ d[l[h
^Wl[ ^WZ Wdo Z[djWb _cfbWdji _di[hj[Z Ä WdZ Wi
j^[o m[h[ cWa_d] j^[_h fe_dj" j^[o m[h[ ^Wff_bo
Y^[m_d]WmWoedj^ei[l[ho_cfbWdjim^_b[[Wj_d]
bkdY^ _d j^[ Yekhj^eki[ YW\[j[h_W$ 8kj [l[d j^[
fWj_[dji m^e beij j^[_h YWi[ e\j[d ^WZ j^[_h bWj[#
medYh[[Zb[\jkdW\\[Yj[Z$
?j _i e\j[d _cfeii_Xb[ je Yedl_dY[ fWj_[dji
m^e X[b_[l[ j^[o Wh[ _bb eh h[gk_h[ jh[Wjc[dj
e\ j^[ \WYj j^Wj j^[o Wh[ WYjkWbbo gk_j[ ^[Wbj^o
if[Y_c[di$Edj^[ej^[h^WdZ"jho_d]jeZeie
_idejiec[j^_d]j^WjZ[dj_ijiehf^oi_Y_WdiWh[
fWhj_YkbWhbofhed[je$
È È )LL
!DVISEDÈ"/)ÈPATIENTSÈ )./
D[l[hj^[b[ii"ekh8E?fWj_[djim_bbiec[j_c[i^Wl[
jeh[#b[Whdj^Wjj^[oWh[^[Wbj^o"j^Wjj^[h[_idej^_d]
mhed]m_j^j^[c"Z[if_j[_dj[bb_][dY[jej^[YedjhWho$
Iec[f[efb[YWddejb_l[m_j^j^_ijhkj^$M_j^ej^[h
f[efb[" _j _i ej^[hi m^e mWdj j^[c dej je b_l[ m_j^
j^_i jhkj^" m^e \[hl[djbo mWdj j^_i jhkj^ je X[ kd#
jhk[($
-$ 4HEÈIMPLANTÈSYSTEMÈISÈEXOTIC
J^_iWh]kc[dj]_l[ij^[mehZÆ[nej_YÇWdkdZ[h#
jed[ e\ ÆijhWd][Ç eh Ækd\_j \eh _ji fkhfei[Ç$ M[
i_cfbo Yekdj[h j^_i Wh]kc[dj m_j^ j^[ \WYj j^Wj
<[hhWh_ eh IWWX YWhi Wh[ fheXWXbo [gkWbbo [nej_Y
WdZj^Wjj^[8E?j[Y^d_gk[jeZWo_ij^[j[Y^d_gk[
ceij\h[gk[djboki[Z_dj^[i_d]b[#ijW][jh[Wjc[dj
e\ [njh[c[bo Wjhef^_[Z `Wmi0 X[_d] j^[ edbo
j[Y^d_gk[j^Wje\\[hij^_iefj_ed_dj^[\_hijfbWY[$
.$ 3UEÈTHEÈ"/)ÈDENTIST

J^_iWh]kc[dj_ifkj\ehmWhZ[_j^[h_d_iebWj_edeh
_dYecX_dWj_edm_j^ed[e\j^[ej^[hWh]kc[dji
b_ij[Z$
M^[j^[h j^[ 8E? fWj_[dj \ebbemi j^_i WZl_Y[ m_bb
Z[f[dZed^_ib[l[be\m_iZecWjjW_d[Z$;nf[h_[dY[
i^emij^Wjedboj^ei[fWj_[djim^e^Wl[dej^_d]
mhed]m_j^j^[c_d\WYjik[j^[_hZ[dj_ijiej^[hi
^Wl_d] W h[Wb fheXb[c WdZ X[_d] j^Wda\kb \eh
j^[ 8E? Z[dj_ijÉi ^[bf$ 7dZ [l[d j^ei[ fWj_[dji
kikWbbo edbo ik[ _\ j^[o ^Wl[ b[]Wb _dikhWdY[ eh
_\ j^[ ijWj[ f_Yai kf j^[ b[]Wb X_bb Wi _j Ze[i _d
=[hcWdo m^[d W fheif[Yj_l[ fWhjo je W bWmik_j
_iWd_dZ_][dj$J^[ÆWZl_i[hÇm^eh[Yecc[dZ[Z
[njhWYj_d]j^[8E?_cfbWdjm^emekbZX[b_WXb[
\eh ZWcW][i \hec e\\[h_d] _dYehh[Yj c[Z_YWb
WZl_Y[kikWbboh[cW_dikdik[Z)$
(
>_bZ[]WhZAd[\edY[ikccWh_p[Zj^_i_dWied]0ÆM^Wj5Oek
Wh[ \[[b_d] m[bb5M[ ckij X[ WXb[ je Ze iec[j^_d] WXekj
j^Wj$Ç Eh" if[Wa_d] m_j^ 9^h_ij_Wd Ceh][dij[hd WdZ ^_i
FWbcijhcÉibWm0ÆM^WjckijdejX[YWddejX[Ç\hecJ^[
?cfeii_Xb[<WYj"=WbbemIed]i"'/,)
) ?d Im_jp[hbWdZ" kd_l[hi_j_[i Wh[ kikWbbo m[bb fhej[Yj[Z
W]W_dij ikY^ bWmik_ji YbW_c_d] _dYehh[Yj c[Z_YWb WZl_Y["
i_dY[YWdjedWbbWmij_fkbWj[iWijWjk[e\b_c_jWj_edie\edbo
jme o[Whi" iec[j_c[i [l[d m_j^ j^[ h[gk_h[c[dj j^Wj j^[
bWmik_j ^Wi je X[ Z[Y_Z[Z X[\eh[ j^Wj j_c[ b_c_j [nf_h[i$
8o j^[ j_c[ j^[ fWj_[dj h[Wb_p[i j^Wj _j mWi j^[ kd_l[hi_jo
j^Wjc_i_d\ehc[ZWdZc_ijh[Wj[Z^_c"hWj^[hj^Wdj^[8E?
Z[dj_ij W]W_dij m^ec j^[ eh_]_dWb bWmik_j mWi Xhek]^j"
(o[WhicWol[hom[bb^Wl[fWii[Z"c[Wd_d]j^Wjj^[ijWjkj[
e\b_c_jWj_ed_d\Wlekhe\j^[kd_l[hi_joZ[djWbYb_d_YmekbZ
Wffbo$

#(!04%2È
&ROMÈ+NOWLEDGEÈANDÈ3KILLÈTOÈ!CTION
È
1UALITYÈ!SSURANCEÈ2EQUIRESÈ!TTENTIONÈÈ
TOÈ$ETAIL
;nf[h_[dY[Z ^eki[a[[f[hi m_bb adem [nWYjbo m^Wj
j^[o ^Wl[ je fWo Wjj[dj_ed je m^[d YWh_d] \eh
^eki[fbWdji$ J^[o m_bb Yedi_Z[h lWh_eki \WYjehi0 j^[
i_p[ e\ j^[ fej" j^[ i_p[ WdZ dWjkh[ e\ j^[ fbWdj"
_ji beYWj_ed" j^[ gkWb_jo e\ j^[ ie_b" j^[ i_p[ e\
j^[ m_dZemi" ^[Wj_d] WdZ l[dj_bWj_ed" ikdb_]^j" j^[
i[Wied_dY_Z[djikdb_]^jWd]b[i"Wcekdje\ikdb_]^j"
[nY[ii_l[ ^[Wj _d ikcc[h" j^[ bWij j_c[ j^[ fbWdj
mWih[fejj[Z"WdZh[]kbWhmWj[h_d]WdZ\[hj_b_pWj_ed
Ä je dWc[ `kij W \[m e\ j^[c$ Iec[ \WYjehi m_bb
X[ _cc[Z_Wj[bo eXl_eki je Wdoed[ Ä ej^[h \WYjehi
X[bed] je j^[ h[Wbc e\ j^[ ^eki[a[[f[hÉi if[Y_Wb
ademb[Z][$
7dZ _\ Y[hjW_d fbWdji Wh[ j[cfehWh_bo [nfei[Z je
_dYb[c[dj YedZ_j_edi [$]$ Zk[ je j^[ ^eki[a[[f[hÉi
WXi[dY[" j^[ ^eki[a[[f[h m_bb ceij Y[hjW_dbo X[
WXb[jeh[ijeh[j^ei[fbWdjijej^[_h\ehc[hl_]ekhXo
]_l_d]j^[c[njhWWjj[dj_edWdZ[njhWYWh[$J^_icWo
h[gk_h[if[Y_Wbc[Wikh[iikY^Wiif[Y_WbWjj[dj_edje
j^[ZeiW][e\ikdb_]^j"mWj[h"eh^[Wj$8kjj^_i_im^Wj
j^[^eki[a[[f[h_i[nf[h_[dY[Z_d$
>eki[a[[f[hi m^e adem j^[o Wh[ ]e_d] je X[
]ed[Ä_\edbo\ehW\[mZWoiÄm_bbjWa[Wffhefh_Wj[
fh[YWkj_edi" ikY^ Wi fbWY_d] Y[hjW_d fbWdji _d j^[
i^WZ[ WdZ je mh_j[ _dijhkYj_edi \eh YWh[ \eh [WY^
e\ j^[ fbWdji j^Wj Wh[ [Wio je kdZ[hijWdZ$ J^[i[
_dijhkYj_edim_bbjWa[_djeYedi_Z[hWj_edXej^[Whb_[h
[nf[h_[dY[ m_j^ j^[ fbWdji WdZ [Whb_[h [nf[h_[dY[
m_j^ikXij_jkj[YWh[jWa[hi$9[hjW_dÆ^[bf[hiÇ"^em[l[h
m[bb#c[Wd_d]" m^e Wh[ Wfj je Zhemd j^[ fbWdji _d
mWj[h hWj^[h j^Wd ]_l_d] j^[c j^[ YWh[ j^[o d[[Z
m_bbX[YWj[]eh_YWbboa[fjWmWo\hecj^[fbWdjiXoj^[
^eki[a[[f[h" m^e _i f[h\[Yjbo WmWh[ j^Wj j^[ fbWdji
Wh[kdb_a[bojeikhl_l[j^_i_]dehWdjÆYWh[Ç$
J^[ Z[j[hc_d_d] Wif[Yj _i j^[ fhejW]ed_ijÉi
[nf[h_[dY[ WdZ m_bb_d]d[ii je WZ`kij je j^[ if[Y_Wb
d[[Zie\[WY^fbWdjWdZjeb[j[WY^fbWdj^Wl[[nWYjbo
j^[jof[WdZWcekdje\YWh[j^Wj_jh[gk_h[i$
 ¬ 
:PV
POMZ
TFF
XIBU
ZPV
LOPX
IPX
UP
TFF
Ie m^o i^ekbZ j^_d]i X[ Z_\\[h[dj _d XWiWb
eii[e_dj[]hWj_ed5
J^[ fh[l_eki Y^Wfj[hi ^Wl[ i^emd m^Wj Z[]h[[
e\ Z[jW_b ckij X[ Wjj[dZ[Z je _d _dijWbbWj_ed"
cW_dj[dWdY[WdZjhekXb[i^eej_d]$>emYWdiec[ed[
m^e ^Wi d[l[h i[[d" Zed[ eh h[WZ WXekj Wbb j^_i"
iec[ed[ m^e cWo bWYa j^[Æ\[[bÇ \eh Xed[ Z[di_jo
WdZj^[d[Y[iiWho[nf[h_[dY[YedY[hd_d]j^[]hemj^
fej[dj_Wb e\ j^[ \kdYj_edWb_p[Z Xed[" iec[ed[ m^e
Ze[i dej adem j^[ ^_ijeho e\ j^[ _dZ_l_ZkWb 8E?
_cfbWdj _d _ji if[Y_\_Y Xed[ [dl_hedc[dj Ä YWddej
adem_jX[YWki[^[^Widejifea[djej^[jh[Wjc[dj
fhel_Z[h Ä WdZ m^e ^Wi dej X[[d jhW_d[Z _d j^[
if[Y_\_Y j[Y^debe]o Ä ^em YWd iec[ed[ b_a[ j^Wj
WY^_[l[h[WiedWXb[feij#jh[Wjc[djh[ikbji57bbe\j^Wj
feii_Xbo _d W i_jkWj_ed _d m^_Y^ Z[Yecf[diWj_ed e\
j^[ ioij[c Wff[Whi _cc_d[dj5 7\j[h Wbb" j^_i _i ed[
e\ j^[ ijWdZWhZ i_jkWj_edi YWki_d] fWj_[dji je ][j W
i[YedZef_d_edehY^Wd][jh[Wjc[djfhel_Z[hi$
?jYWd^WhZboX[Wikhfh_i[j^Wjdeed[^Wio[ji[[d
Wdo ded#Wkj^eh_p[Z jh[Wjc[dj fhel_Z[hi Ä [l[d Wj
kd_l[hi_jo^eif_jWbiÄikYY[ii\kbbojh[WjWdZcW_djW_d
W Z_\\_Ykbj 8E?#XWi[Z `Wm%_cfbWdj%Z[djkh[ ioij[c$
Kdb[ii j^[ fWj_[dj cWdW][i je Z_iieY_Wj[ ^_ci[b\
\hec_]dehWdjjh[Wjc[djfhel_Z[hiWdZ_dij_jkj_edi"
h[Wb_p_d] j^Wj j^[o YWddej eh m_bb dej h[Wbbo ^[bf
^_c" W d[]Wj_l[ jh[Wjc[dj ekjYec[ m_bb X[ ^_i \Wj[$
Iebl_d] W fheXb[c h[gk_h[i WYj_ed Ä Xkj WYj_ed e\
j^[ h_]^j a_dZ" Yedi_ij[dj WdZ Yedjhebb[Z WYj_ed Wj
j^[ h_]^j j_c[ Ä WdZ _j h[gk_h[i if[Y_\_Y ademb[Z][
WdZ f[hiedWb [nf[h_[dY[ m_j^ 8E? _cfbWdji" jWa_d]
j^[fWj_[djÉiY_hYkcijWdY[i_dj^[_h[dj_h[joWdZj^[
jh[Wjc[dj^_ijehojeZWj[_djeZk[WYYekdj$
I_dY[ded[e\j^_iYWdX[[nf[Yj[Z\hecZ[dj_iji
jhW_d[Z _d Yh[ijWb _cfbWdjebe]o" j^[ h[b[lWdj
fhe\[ii_edWbWiieY_Wj_edi^Wl[_iik[ZÄ\ehj^[i[YedZ
j_c[ dem Ä W 8E? 9edi[diki ijWj[c[dj W_c[Z Wj
fh[l[dj_d]_dYehh[Yjjh[Wjc[djWdZcWbfhWYj_Y[$J^[
Wkj^eh h[Yecc[dZi fh_cWh_bo je ^WdZ fWj_[dji W
Yefoe\j^[Æ8E?9edi[dikiÇi[[X[bemje^WdZje
WdoikXi[gk[djjh[Wjc[djfhel_Z[h_dehZ[h\ehj^Wj
f[hiedjeb[Whdceh[WXekjj^[if[Y_\_Yh[gk_h[c[dji
e\j^[jh[Wjc[dji_jkWj_ed$
)/( 9^Wfj[h(-È &ROMÈ+NOWLEDGEÈANDÈ3KILLÈTOÈ!CTION
È
"/)È#ONSENSUS
È
$EFINITION
8E?_cfbWdjijhWdic_jbeWZifWhWbb[bjej^[YWkiWj_l[
\ehY[ l_W ed[ eh ceh[ Z_iai eh h_d]i$ J^[ j^h[WZ[Z
f_d jhWdic_ji j^[ cWij_YWjeho \ehY[i je j^[ XWiWb
Wkj^ehÉi dej[0 eii[e_dj[]hWj[Z eh eii[eWZWfj[Z
[b[c[dji$
J^[Yecfed[djie\8E?_cfbWdjiWh[0
v BeWZ#jhWdic_jj_d][b[c[dji[$]$h_d]i"Z_iai YWi[$J^_i_im^oj^[?9:^WifkXb_i^[Zj^[\ebbem_d]
v J^h[WZ[Zf_d
v Ed[ eh ceh[ m[X XWhi X[jm[[d j^[ beWZ#
jhWdic_jj_d][b[c[djiWdZj^[j^h[WZ[Zf_d
v 7Xkjc[dj
I_dY[ j^[ [Whb_[h Z[iYh_fj_l[ j[hcÆZ_ia _cfbWdjÇ _i
Wffb_YWXb[ edbo je hejWj_edWbbo iocc[jh_YWb \ehci
e\ \ehY[#jhWdic_jj_d] ikh\WY[i ed _cfbWdji" _j m_bb
X[ h[fbWY[Z Xo j^[ j[hc ÆXWiWbbo eii[e_dj[]hWj[Z
_cfbWdjÇ8E?$
È
!UTHORIZATION
8E? cWdk\WYjkh[hi m_bb i[bb j^[_h _cfbWdji WdZ '$ HWZ_ebe]_YWbbo" W Yb[Whbo Z[b_c_j[Z XbWYa Wh[W _i
WYY[iieh_[iedbojeWkj^eh_p[Zki[hij^Wj^Wl[h[Y[_l[Z
W j^ehek]^ _djheZkYj_ed _dje j^[ ioij[c j^hek]^
_dj[di_l[WdZYedj_dkekijhW_d_d]$7kj^eh_pWj_edm_bb
X[cW_djW_d[ZXoWjj[dZ_d]Yedj_dk_d][ZkYWj_ed$ ($ HWZ_ebe]_YWbbo" W Yb[Whbo Z[b_c_j[Z XbWYa Wh[W _i
È
#ONSULTANTS
Ed h[gk[ij" j^[ ?9: m_bb dec_dWj[ gkWb_\_[Z Yed#
ikbjWdji$ 9edikbjWdji ckij ^Wl[ X[[d Wkj^eh_p[Z
kd_dj[hhkfj[Zbo\ehWjb[Wij+o[WhiWdZckijX[WXb[
jeZ[cedijhWj[Wjb[Wij+&Yecfb[j[Z8E?jh[Wjc[dj
YWi[i$
È
0REPARATIONÈOFÈTHEÈ)MPLANTÈ"ED
J^[ _cfbWdj X[Z YWd X[ fh[fWh[Z ki_d] hejWj_d]
_dijhkc[dji$ J^[ _dijhkc[dji ki[Z Wh[ fh_cWh_bo
WZ[gkWj[bo Yeeb[Z jkhX_d[i WdZ ^_]^#if[[Z Wd]b[Z
^WdZf_[Y[i$
È
"/)È)MPLANTSÈ#OMBINEDÈWITHÈ.ATURALÈ4EETHÈÈ
ANDÈ#RESTALÈ)MPLANTS
J^[h[ Wh[ Yedi_Z[hWXb[ Z_\\[h[dY[i _d Z_W]deij_Yi
8E? YWd X[ YecX_d[Z m_j^ dWjkhWb j[[j^ m_j^ b[ii X[jm[[d8E?WdZYh[ijWb_cfbWdji$J^_i9edi[diki_i
j^Wd 9bWii ? ceX_b_jo WdZ m_j^ eii[e_dj[]hWj[Z eh j^[\_hijZeYkc[djjeikccWh_p[j^[ceij_cfehjWdj
fh_cWho ijWXb[" Yb_d_YWbbo _dYedif_Ykeki Yh[ijWb
_cfbWdji$
È
,OADINGÈBYÈ0ROSTHETICÈ3TRUCTURES
7i W hkb[" 8E? Wh[ ikX`[Yj[Z je [Whbo beWZ_d]" _$[$
X[\eh[ZWo'(feijef[hWj_l[bo$
?dif[Y_WbYWi[i"beWZ_d]YWdX[Z[bWo[Zkdj_bW\j[h
ZWo*&feijef[hWj_l[bo$
:_iYkii_edi Yedj_dk[ je Wh_i[ Wced] ded#
Wkj^eh_p[Z Z[dj_iji _dZ_YWj_d] Yedi_Z[hWXb[ kdY[h#
jW_djo m^[d _j Yec[i je [lWbkWj_d] W if[Y_\_Y 8E?
]k_Z[b_d[hkb[YedY[hd_d]j^[h[celWbe\8E?0
'UIDELINEÈ2ULE9b_d_YWbehhWZ_ebe]_YWbWii[iic[dji
Xo j^[ci[bl[i" m_j^ekj ademb[Z][ e\ j^[ XWi[b_d[
i_jkWj_ed" Wh[ _dik\\_Y_[dj \eh [lWbkWj_d] W 8E?$
?d WZZ_j_ed je Wii[ii_d] j^[ _dZ_l_ZkWb _cfbWdj"
j^[ fhe]dei_i WdZ ijWj_Y _dj[]h_jo e\ j^[ el[hWbb
Z[i_]dWdZj^[jh[Wjc[djikYY[iijeZWj[d[[ZjeX[
Yedi_Z[h[Z$
È
)NDICATIONSÈFORÈTHEÈ2EMOVALÈÈ
OFÈ"ASALÈ/SSEOINTEGRATEDÈ)MPLANTS
l_i_Xb[ WhekdZ j^[ XWiWb Z_ia" WdZ j^[ _cfbWdj
[n^_X_jil[hj_YWbceX_b_jo[nY[[Z_d]'cc$
eh
l_i_Xb[ WhekdZ j^[ XWiWb fbWj[" WdZ j^[h[ Wh[
Yb_d_YWbi_]die\_d\bWccWj_ed$
De_dZ_YWj_ed\ehh[celWb_ifh[i[dj_\edboed[e\
j^[\ebbem_d]eXi[hlWj_edi_icWZ[0
WJ^[ hWZ_ebe]_YWb XbWYa Wh[W Ze[i dej _dlebl[
j^[XWiWbfbWj[$
XJ^[XbWYaWh[WW\\[Yjiedboj^[j^h[WZ[Zf_d$
Y Im[bb_d] WdZ WXiY[ii[i Wh[ fh[i[dj _d j^[
l[ij_XkbWhehb_d]kWb%fWbWjWbckYeiW$
ZJ^[ _cfbWdj _i fW_d\kb m^[d X_j_d] ed _j" Xkj
j^[h[_iedboWfWhj_WbehdeXbWYaWh[Wl_i_Xb[
WhekdZj^[XWiWbfbWj[$
[ EdbofWhjie\j^[fbWj[iehedboj^[Yh[ijWbfbWj[
Wh[W\\[Yj[ZXoj^[hWZ_ebe]_YWbXbWYaWh[W$
\ 9hWj[h#ijob[ Xed[ YebbWfi[ _i fh[i[dj edbo
WhekdZj^[j^h[WZ[Zf_d$
È
#OMMENTSÈONÈTHEÈ"/)È#ONSENSUS
È È #OMMENTSÈONÈTHEÈ"/)È#ONSENSUSÈ
Z_W]deij_Y ij[fi j^Wj Wh[ _cfehjWdj \eh [lWbkWj_d]
8E?$J^[h[Wh[Yedi_Z[hWXb[Z_\\[h[dY[i_dZ_W]deij_Yi
X[jm[[dYh[ijWbWdZXWiWb_cfbWdji$D[l[hj^[b[ii"j^[
Z[jW_bi j^Wj Wh[ _cfb_Y_j _d j^[ f^hWi_d] \h[gk[djbo
h[cW_d eXiYkh[ je cWdo ikXi[gk[dj jh[Wjc[dj
fhel_Z[him_j^de8E?[nf[h_[dY[e\j^[_hemd$Dej[
j^WjÆfW_dÇWbed[_idejWd_dZ_YWj_ed\ehj^[h[celWb
e\ Wd 8E? _cfbWdj$ >[Wlo fW_d cWo X[ YWki[Z Xo
h[]kbWhh[ceZ[bb_d]_\_jjWa[ifbWY[kdZ[hd[Wj^j^[
f[h_eij$ ?d j^_i YWi[ _j jWa[i W bej e\ [nf[h_[dY[ je
Z_ij_d]k_i^WXWYj[h_Wb_d\[Yj_ed\hech[]kbWh^[Wb_d]
fheY[Zkh[i$ ;if[Y_Wbbo Wk]c[dj[Z i_j[i YWd i^em
[nj[di_l[ h[ceZ[bb_d] WdZ im[bb_d] m_j^ j^[ fW_d
hWZ_Wj_d]el[hiec[Z_ijWdY[i\ehi[l[hWbcedj^i$
È
#ONSULTANTSÈ2ULE
;nf[hji WdZ YedikbjWdji Wh[ Yedikbj[Z ed cWdo
Wh[Wie\[l[hoZWob_\[$JeX[WXb[jeZ[b_l[hh[Wb_ij_Y
ef_d_edi"^em[l[h"YedikbjWdjickijX[\Wc_b_Whm_j^
j^[ fheXb[ci Wj ^WdZ \hec j^[_h emd [nf[h_[dY[$
Kd\ehjkdWj[bo"j^[YekhjihWh[boY^Wbb[d][j^[XWYa#
]hekdZ e\ YedikbjWdji _d ekh \_[bZ Ä gk_j[ YedjhWho
je m^Wj _i ijWdZWhZ fheY[Zkh[ m_j^" [$]$ Wl_Wj_ed
YedikbjWdjim^eWh[h[gk_h[Zje^ebZWlWb_Zb_Y[di["
Wjj^[j_c[e\YedikbjWj_ed"\ehj^[W_hYhW\jj^[oWh[
[lWbkWj_d]$ Fh_lWj[ ^[Wbj^ _dikh[hi ki[ W ioij[c e\
ie#YWbb[ZÆe\\_Y_Wb Z[djWb [nWc_d[hiÇ" m^e" ^em[l[h"
Wh[Z[f[dZ[djedj^[^[Wbj^_dikh[hi\ehj^[_h_dYec[
WdZm^ei[_dYb_dWj_edje^[bfiWl[j^[^[Wbj^_dikh[hi
iec[ ced[o YWd X[ gk_j[ fW_d\kb Wj j_c[i$ EdY[
j^[ 8E? 9edi[diki mWi fkXb_i^[Z" ^em[l[h" edbo W
\[m YWi[i ^Wl[ X[Yec[ ademd _d m^_Y^ j^[ Yekhji
Z[l_Wj[Z\hecj^[YedikbjWdjihkb[e\j^[9edi[diki$
?d j^[i[ YWi[i" ded#Wkj^eh_p[Z YedikbjWdji YekbZ Wj
b[WijX[fh[l[dj[Z\heccWa_d]fhedekdY[c[djied
ioij[c#if[Y_\_Ygk[ij_edi$
J^_i^WiWYY[b[hWj[Zj^[fheY[Zkh[i"jej^[X[d[\_j
e\ j^[ fWj_[dji" m_j^ Wbb fWj_[dji WdZ j^[_h Z[dj_iji
kbj_cWj[bo[d`eo_d]j^[h[_cXkhi[c[djiZk[j^[c$
È
!UTHORIZATION
8E?WdZWYY[iieh_[iWh[Z_if[di[ZedbojeWkj^eh_p[Z
jh[Wjc[djfhel_Z[hi$?d=[hcWdo"XWi[Zedj^[C[Z_#
YWb :[l_Y[ :_h[Yj_l[ WdZ f[hj_d[dj dWj_edWb b[]_i#
bWj_ed"j^[oWh[h[ijh_Yj[Zjeki[ehi[hl_Y[XogkWb_\_[Z
f[hiedd[bm_j^Wffhefh_Wj[jhW_d_d]$J^_ifhel_i_ed
^WiX[[dcWZ[\ehj^[fhej[Yj_ede\fWj_[dji$:kh_d]
j^[fh[ef[hWj_l[fWj_[dj_d\ehcWj_edf^Wi["fWj_[dji
Wh[_d\ehc[ZWXekjj^[\WYjj^Wjj^[oYWddej]eje`kij
Wdojh[Wjc[djfhel_Z[hm_j^j^[_h_cfbWdji$>em[l[h"
iec[fWj_[djim_bb\eh][jj^_iW\j[hWdkcX[he\o[Whi$
J^[h[ _i j^ki W ZWd][h j^Wj 8E?#jh[Wj[Z fWj_[dji"
]_l[dj^[\_[hY[Yecf[j_j_ededj^[cWha[j\ehZ[djWb
)/)
_cfbWdjebe]o"cWo[b[YjjeYedj_dk[j^[_hjh[Wjc[dj
m_j^Z[dj_ijim^eWh[dejWkj^eh_p[Z8E?fhel_Z[hi"
fkjj_d]j^[WZlWdjW][ie\8E?jh[Wjc[djWjh_ia$
<hec W b[]Wb fe_dj e\ l_[m" j^[ i_jkWj_ed _i gk_j[
Yb[Wh0 J^ei[ m^e e\\[h jh[Wjc[dj eh YedikbjWj_edi
m_j^ekj X[_d] fhef[hbo Wkj^eh_p[Z" j^ei[ m^e
Ze dej _d\ehc j^[_h fWj_[dji WXekj j^[_h bWYa e\
Wkj^eh_pWj_edWdZm^eYWddejZ[cedijhWj[j^Wjj^[o
^Wl[ eXjW_d[Z Yecfh[^[di_l[ [nf[hj_i[ [bi[m^[h[
m_bb ^Wl[ je X[Wh j^[ \kbb h_ia e\ ^_i eh ^[h WYj_ed$
:[dj_iji m^e" _d j^[ WXi[dY[ e\ 8E? Wkj^eh_pWj_ed"
jh[Wj fWj_[dji m_j^ 8E? _cfbWdji _d fbWY[ WdZ meha
ed j^[_h Xed[#_cfbWdj#h[ijehWj_ed Yecfb[n hkd W
Yedi_Z[hWXb[jh[Wjc[djh_ia$
<hec j^[ fe_dj e\ l_[m e\ b_WX_b_jo" j^[h[ _i
de Z_\\[h[dY[" _\ W fWj_[dj _i dej h[\[hh[Z je W
Yecf[j[dj fhWYj_Y_Wd" _i dej jh[Wj[Z Yehh[Yjbo
ehh[Y[_l[i_dWffhefh_Wj[WZl_Y["Wijem^[j^[h
j^_ieYYkhh[Zm_j^j^[Z[dj_ijadem_d]ehdej
adem_d]j^[WYjkWbZ_W]dei_i$
FWj_[djiYWddejX[[nf[Yj[Zje[ZkYWj[j^[_hjh[Wjc[dj
fhel_Z[hi ed Z[jW_bi e\ j^[_h c[Z_YWb i_jkWj_ed WdZ
j^[jh[Wjc[djc[j^eZ$
Ed[j^_d]j^WjYedj_dk[ijeikhfh_i[_ij^WjcWdo
fWj_[djimekbZd[l[hjWa[j^[_hYWhjeW]WhW][e\W
Z_\\[h[djXhWdZ"m^_b[edj^[ej^[h^WdZj^[oc_]^j
m[bbd[]b[Yjje^Wl[j^[_h_cfbWdjiWdZh[ijehWj_edi
\ebbem[ZXoWdWkj^eh_p[Z8E?_cfbWdjebe]_ijedbo$
M_j^ h[]WhZ je ej^[h \_[bZi e\ c[Z_Y_d[" j^[
\Wc_bo f^oi_Y_Wd mekbZ d[l[h j^_da e\ j_da[h_d]
m_j^WYWhZ_WYfWY[cWa[h_cfbWdj[ZXoWif[Y_Wb_p[Z
YWhZ_ebe]_ij$Kd\ehjkdWj[bo"j^[_d^_X_j_edj^h[i^ebZ
b_c_j_ie\j[dij_bbjeebem_dYh[ijWb_cfbWdjebe]_iji$'
Ed[fheXb[c"\ehdem"_ij^Wjj^[h[Wh[deWkj^eh_p[Z
eh [nf[h_[dY[Z 8E? if[Y_Wb_iji Wj j^[ kd_l[hi_j_[i$
Fh[Y_i[bo m^[h[ fWj_[dji [nf[Yj je \_dZ Y[djh[i
e\ [nY[bb[dY[ WdZ Yecf[j[dY[" j^[o YWd Yekdj ed
' J^[ bWj[ :h$ =kbZ[d[h \hec 8[hd[" m^[d Y^WhWYj[h_p_d]
Z[dj_iji" ki[Z je jWba Ä Wj ceij ^Wb\ _d `[ij Ä WXekj j^[
Ybk[b[iiWdZj^[ademb[Z][WXb["j^[kdiYhkfkbekiWdZj^[
kdYediY_[dj_eki$ J^_i cWa[i W d_Y[ \ekh#\_[bZ jWXb[ m^[h[
%FOUJTUT
,OPXMFEHFBCMF
$MVFMFTT
$POTDJFOUJPVT


6OTDSVQVMPVT

9
[WY^Z[dj_ijYWdX[Wii_]d[ZW\_[bZ0
N J^ei[m^ej_da[hm_j^8E?m_j^ekjWkj^eh_pWj_edX[bed]
_dj^[ZWd][hekiYWj[]ehoe\j^[Ybk[b[iikdiYhkfkbeki$
)/* 9^Wfj[h(-È &ROMÈ+NOWLEDGEÈANDÈ3KILLÈTOÈ!CTION
][jj_d]j^[b[Wij^[bfÄWdZm^Wj_imehi["j^[bWYae\
Yecf[j[dY[kikWbbo]e[ikdWZc_jj[Z$
;nf[h_[dY[ ^Wi i^emd j^Wj j^[ _dY_Z[dY[ e\
Yecfb_YWj_ediWdZj^[beiihWj[_dYh[Wi[_dfhefehj_ed
je j^[ j_c[ ifWd Zkh_d] m^_Y^ j^[ fWj_[dji h[Y[_l[
de eh _d[nf[hj feij#jh[Wjc[dj" iec[j^_d] j^Wj mWi
[n[cfb_\_[Z _d 9^Wfj[h(,$+ Xo eXi[hlWj_edi ed W
fWj_[djYe^ehjel[h''o[Whi$
7dej^[hi_cfb[[nWcfb[0
M^_b[ _d[nf[h_[dY[Z Z[dj_iji" Wi j^[o Y^[Ya j^[
fWj_[djÉicekj^"m_bbYedi_Z[hj^[ÆYbei[WZWfjWj_edÇ
e\ m_Z[ ifWdi e\ fedj_Yi je j^[ ehWb ckYeiW
gk_j[ _ddeYkeki eh [l[d Z[i_hWXb[" l_[m_d] ikY^
ifWj_Wb h[bWj_edi m_bb iekdZ j^[ WbWhc X[bbi \eh
Wbb 8E? _cfbWdjebe]_iji0 _d j^_i i_jkWj_ed ed[ m_bb
^Wl[ je ikif[Yj j^Wj W ]h[Wj Wcekdj e\ l[hj_YWb
Xed[ ^Wi d[mbo Z[l[bef[Z WdZ j^Wj j^[ fedj_Yi
Wh[_dX_ec[Y^Wd_YWbbo_dYecfWj_Xb[^ofeceY^b_ed
i_jkWj_edi"m_j^kdYedjhebb[Z\ehY[iX[_d][n[hj[Zed
j^[WZ`WY[djbeWZ#jhWdic_jj_d]Z_iai$
J^[fhe\[ii_edWbWiieY_Wj_ediWh[jWia[Zjeifh[WZ
j^[ mehZ WXekj XWiWb eii[e_dj[]hWj_ed _cfbWdji
j^hek]^ fkXb_YWj_edi WdZ fh[i[djWj_edi WdZ j^ki
je fhej[Yj fWj_[dji \hec kdgkWb_\_[Z \ebbem#kf
jh[Wjc[djWdZkdd[Y[iiWhoYecfb_YWj_edi$
È
%VALUATIONÈOFÈTHEÈ#OMPLETEÈ4REATMENTÈ0ROCESS
7i j^[ fh[l_eki Y^Wfj[hi ^Wl[ i^emd" 8E?i Wh[ _d
YedijWdj _dj[hWYj_ed m_j^ j^[ ikhhekdZ_d] Xed["
feii_Xbom_j^Wbj[hdWj_d]f^Wi[ie\Z[c_d[hWb_pWj_ed
WdZ h[c_d[hWb_pWj_ed$ >ehcedWb" \kdYj_edWb WdZ
cWij_YWjeho\WYjehi_d\bk[dY[j^[Z_h[Yj_ed_dm^_Y^
j^_d]iZ[l[bef$Edboj^[eh_]_dWbjh[Wjc[djfhel_Z[h
m_bb adem j^[ XWi[b_d[ i_jkWj_ed WdZ X[ WXb[ je
h[c[cX[h m^Wj j^[ Xed[ gkWb_jo mWi WdZ m^_Y^
_cfbWdji Yedieb_ZWj[Z eh m[h[ ceX_b_p[Z Zkh_d]
m^_Y^ f[h_eZi$ 7 i_d]b[ hWZ_e]hWf^ m_bb ^WhZbo j[bb
j^[ eXi[hl[h Wdoj^_d]$ Ceh[ _d\ehcWj_ed YekbZ X[
eXjW_d[Z \hec ckbj_fb[ hWZ_e]hWf^i jWa[d Wj _dj[h#
lWbie\(eh)cedj^i"X[YWki[XoeXi[hl_d]j^[Z_\\[#
h[dY[iX[jm[[dj^[_cW][i_j_ifeii_Xb[jeZ[j[hc_d[
_d m^Wj Z_h[Yj_ed" gkWb_jWj_l[ WdZ gkWdj_jWj_l[" j^[
Xed[ Z[l[befi WdZ m^Wj ^Wff[di _d j^[ _dj[h\WY_Wb
h[]_ed$
J^[ Z[l[befc[dj e\ Wd _cfbWdj#h[ijehWj_ed
Yecfb[n m_bb Wbie h[gk_h[ YedjhWij_l[ [lWbkWj_ed$
?j i^ekbZ X[ dej[Z j^Wj [l[d Wd [nY[bb[djbo
_dj[]hWj[Z_cfbWdj#h[ijehWj_edYecfb[nm_bbcWa[W
YecfWhWj_l[bo^_]^boceX_b[_cfh[ii_edel[hWbed]
j_c[o[Whi"j^Wj_i_\j^[_cfbWdjiWh[beYWj[Z_dj^[
cWn_bbWWdZj^[cWn_bbWhoXed[_il[hoZ[b_YWj[$J^_i
_iem[Z[nYbki_l[bojej^[\WYjj^Wjj^[fWfohWY[eki
kdjhW_d[ZXed[mWbbie\\[hdeh[i_ijWdY[_dj^[ci[bl[i
WdZ j^Wj" j^[h[\eh[" j^[ [dj_h[ `Wm i[]c[dj j^Wj
h[Y[_l[Z j^[ _cfbWdji _i ceX_b[$ Edbo cWdo o[Whi
bWj[h m_bb Yedj_dkeki \kdYj_ed YWki[ Xed[ lebkc[
WdZ fWbfWXb[ \_hcd[ii je _dYh[Wi[$ J^ei[ m^e
YWd l_ikWb_p[ j^[ jWYj_b[ Z_\\[h[dY[ X[jm[[d W ij[Wa
Xed[ WdZ W Y^_Ya[d Xed[ m_bb X[ WXb[ je Wffh[Y_Wj[
j^[ Z_\\[h[dY[i _d [bWij_Y_jo j^Wj cWo [n_ij X[jm[[d
Yecfb[j[bo^[Wbj^oXed[i$
J^_i i_jkWj_ed ckij X[ Z_ij_d]k_i^[Z \hec
h[ijehWj_edi bei_d] j^[_h \_hc Yedd[Yj_ed m_j^
_dZ_l_ZkWb WXkjc[dji j^Wj m_bb Wbie YWki[ Xh_Z][
ceX_b_jo$J^_i"^em[l[h"h[gk_h[i_cc[Z_Wj[h[c[Z_Wb
WYj_ed"i_dY[beei[Xh_Z][icWoYWki[_cXWbWdY[i_d
beWZ Z_ijh_Xkj_ed _d j^[ Xed[" fej[dj_Wbbo b[WZ_d]
je el[hbeWZ eij[eboi_i eh _cfbWdj \hWYjkh[$ J^[ jme
i_jkWj_ediWh[Z_\\_YkbjjeZ_ij_d]k_i^_\j^[Xh_Z][_i
ijWX_b_p[ZXockbj_fb[WjjWY^c[djiWdZj^[_cfbWdji
Wh[dej_dif[Yj[Z_dZ_l_ZkWbbo$
È
0ROBINGÈASÈAÈ$IAGNOSTICÈ!DJUNCT
È
0ROBINGÈASÈAÈ$IAGNOSTICÈ-EASUREÈÈ
!ROUNDÈ.ATURALÈ4EETHÈANDÈ#RESTALÈ)MPLANTSÈ
%!3)È!SSESSMENT
FheX_d]_ied[e\j^[h[Ye]d_p[ZZ_W]deij_Yc[j^eZi
_dZ[j[hc_d_d]j^[f[h_eZedjWbfeYa[ZZ[fj^e\j[[j^$
<eh j^_i h[Wied" dkc[heki Wkj^ehi ^Wl[ Z[iYh_X[Z
f[h_eZedjWb fheX_d] WhekdZ Yh[ijWb _cfbWdji Wi W
Z_W]deij_Yc[j^eZ"ki_d]j^[h[ikbjiWiWd_cfehjWdj
Yh_j[h_ed\ehjh[Wjc[djikYY[ii$
J^[fheX_d]Z[fj^feYa[jZ[fj^_ij^[Z_ijWdY[
X[jm[[d j^[ ]_d]_lWb cWh]_d WdZ j^[ Z[fj^ je
m^_Y^ W f[h_eZedjWb fheX[ YWd X[ _di[hj[Z m^[d W
]_l[d Wcekdj e\ fh[iikh[ _i [n[hj[Z$ J^[ h[bWj_l[
WjjWY^c[djb[l[b_ij^[Z_ijWdY[X[jm[[dj^[Z[[f[ij
fheX_d]Z[fj^m_j^_dj^[feYa[ZWdZWZ[\_d[Zfe_dj
ed j^[ jeej^$ J^[ kff[h fe_dj e\ h[\[h[dY[ ed j^[
jeej^ \eh Z[j[hc_d_d] j^[ h[bWj_l[ WjjWY^c[dj b[l[b
m_bbkikWbboYe_dY_Z[m_j^j^[Z[dje[dWc[b`kdYj_ed"
m^_Y^_i[Wiojei[[?9:'///$
:[j[hc_d_d]fheX_d]Z[fj^_iW_c[ZWjc[Wikh_d]
j^[ Yb_d_YWb WjjWY^c[dj j^Wj _i Wd _dZ_YWjeh e\
f[h_eZedjWb ^[Wbj^$ ?j ckij X[ Yedi_Z[h[Z j^Wj
j^[ ijWjki e\ j^[ ]_d]_lWb j_iik[i f[h i[ 7hc_jW][
'//+" j^[ \ehY[ [n[hj[Z Zkh_d] fheX_d] WdZ ej^[h
_Wjhe][d_Y fWhWc[j[hi >Wii[b [j Wb$ '/-)1 CecX[bb_
[jWb$'//("j^[jof[WdZi^Wf[e\j^[fheX[WdZWdo
eXijhkYj_ediYhemdi"YedYh[c[dji1cWYheZ[i_]de\
_cfbWdji"ckbj_fb[WXkjc[dji7jWii_(&&&cWoWbb
[n[hjYedi_Z[hWXb[_d\bk[dY[edfheX_d]h[ikbji$?j_i
\h[gk[djbo _cfeii_Xb[ je Z[j[hc_d[ j^[ WYjkWb Xed[
b[l[b ki_d] f[h_eZedjWb fheX[i$ H[fheZkY_X_b_jo e\
j^[fheX_d]fheY[ii_ib_c_j[Z1lWh_Wj_edie\¦'cc
ckijX[[nf[Yj[Z_dYb_d_YWbi_jkWj_edi$
È È 0ROBINGÈASÈAÈ$IAGNOSTICÈ!DJUNCTÈ
J^[ \kdYj_ed WdZ ijWjki e\ Yh[ijWb _cfbWdji (
_i e\j[d Z[j[hc_d[Z Xo fheX_d]$ HWZ_e]hWf^i Wh[
b_c_j[Z Xo j^[_h jme#Z_c[di_edWb dWjkh[ WdZ j^[
Z[bWo m_j^ m^_Y^ _ji h[ikbji Wh[ WlW_bWXb[ J^[_bWZ[
'/,&1 Wbie X[YWki[ _j Ze[i dej i^em Wdo ^WhZ#
j_iik[ Z[ijhkYj_ed kdj_b j^[ ZWcW][ ^Wi X[Yec[
Yedi_Z[hWXb[7bXh[ajiied[jWb$'/.,1BWd]WdZ>_bb
'/--18[dZ[h'//&$
J^[ j[hc ÆdehcWb X_ebe]_YWb m_Zj^Ç _d Yh[ijWb
_cfbWdji h[\[hi je W i_jkWj_ed _d m^_Y^ j^[h[ _i
Xedo WjjWY^c[dj Wj j^[ XWi[" \ebbem[Z W Yedd[Yj_l[
j_iik[ ped[ e\ '$+Ä($&cc m_Zj^ WXel[ WdZ W ped[
m_j^ [f_j^[b_Wb YedjWYj e\ ($&Ä($+cc WXel[ j^Wj$
FheX_d] _d j^_i h[]_ed _dj[dZi je Z[cedijhWj[ j^Wj
deceh[j^WdWZ[i_hWXb[fheX_d]Z[fj^e\deceh[
j^Wd )Ä*cc [n_iji$ IYh[m j^h[WZi WdZ hek]^d[ii
Wj j^[ _cfbWdj ikh\WY[ h[ZkY[ j^[ fheXWX_b_jo j^Wj W
Yehh[Yj c[Wikh[c[dj YWd X[ cWZ[ Gk_hod[d [j Wb$
'//'$ J^[ ZWcW][ j^Wj _i YWki[Z Xo fheX_d] Wj j^[
Yh[ijWb_cfbWdji_j[_iWii[ii[ZZ_\\[h[djboXoZ_\\[h[dj
Wkj^ehi$7i_dj[[j^"^[Wb_d]e\fheX_d]ZWcW][m_bb
kikWbboeYYkhm_j^_djmem[[aiJWobehWdZ9WcfX[bb
'/-($FheX_d]d[WhYh[ijWb_cfbWdjim_j^_dj^[\_hij
j^h[[ cedj^i feij#_di[hj_ed i^ekbZ X[ Wle_Z[Z _d
ehZ[hdejjeZ_ijkhXj^[dehcWb^[Wb_d]fheY[ii$
M^_b[ fheX_d] i^ekbZ dej YWki[ Wdo ZWcW][ je
Æ^[Wbj^oÇ Yh[ijWb _cfbWdji CYA_ddo [j Wb$ '/.+" _j
^WiX[[di^emdXoc_YheX_ebe]_YWb[nWc_dWj_edj^Wj
feYa[jiWXel[+cc_dZ[fj^Wh[fej[dj_Wbfhej[Yj_l[
X_ebe]_YWb d_Y^[i \eh fWj^e][di _djheZkY[Z _dje j^[
ehWbYWl_joHWc[iWdZB_da'/.)1HWc[i[jWb$'/.*$
FheX_d] Z[fj^i e\ ,cc eh ceh[ WhekdZ Yh[ijWb
_cfbWdji _dZ_YWj[ W Yh_j_YWb jh[Wjc[dj i_jkWj_ed
CecX[bb_[jWb$'/.-$
FheX_d]WhekdZYh[ijWb_cfbWdji^Wij^[eX`[Yj_l[
je c[Wikh[ j^[ b[l[b e\ Xed[ j^Wj YWd ij_bb X[ Yed#
i_Z[h[ZÆWjjWY^[ZÇ$:k[jej^[h[i_ijWdY[\ekdZ_dj^[
Z[fj^e\j^[feYa[j"ed[mekbZ^Wl[jeWiikc[j^Wj
j^[Æh[WbÇ Xed[ b[l[b YWd d[l[h X[ WiY[hjW_d[Z m_j^
Yh[ijWb _cfbWdji$ BWd] WdZ 8hW]][h '//' ijWj[ j^Wj
_d\bWccWj_ed e\ j^[ cWh]_dWb f[h_eZedj_kc m_bb
ijhed]bo_d\bk[dY[j^[fheX_d]h[ikbj$7hekdZ^[Wbj^o
_cfbWdji"_jmWifeii_Xb[jecel[j^[j_fe\j^[fheX[
je m_j^_d &$.cc e\ j^[ [\\[Yj_l[ Xed[ cWh]_d"
m^_b[_jmWifeii_Xb[jeWffheWY^jem_j^_d&$(cc
( J^[j[hcÆYh[ijWb_cfbWdjÇ_iWYebb[Yj_l[j[hc\eh_cfbWdji
m^ei[ ceij _cfehjWdj beWZ#jhWdic_jj_d] ikh\WY[i Wh[
beYWj[Z_dj^[Wh[We\j^[l[hj_YWb_cfbWdjWn_iWdZj^WjWh[
_di[hj[Z_djej^[`Wm\hecj^[Wbl[ebWhYh[ij$J^_ij[hcj^ki
_dYbkZ[i iYh[m" Yob_dZh_YWb WdZ Yed_YWb _cfbWdji WdZ Wbie
XbWZ[_cfbWdji$J^[X_Yehj_YWbiYh[mh[fh[i[djiWXehZ[hb_d[
YWi[1 m^_b[ j^_i _cfbWdj _i _di[hj[Z Yh[ijWbbo" Xo Z[i_]d
WdZ Xo l_hjk[ e\ _ji cWYheijhkYjkh[ WdZ c_YheijhkYjkh["
_j Ze[i dej ^Wl[ Wdo l[hj_YWb beWZ#jhWdic_jj_d] ikh\WY[i$
<kdYj_edWbbo" j^[d" j^_i jof[ e\ _cfbWdj mekbZ ^Wl[ je X[
Y^WhWYj[h_p[Z Wi W Yh[ijWbbo _di[hj[Z 8E? Ä X[YWki[ e\ _ji
_dj[dZ[ZbWj[hWbWdZYehj_YWbikffehj_\dej^_d][bi[$
)/+
_d _d\[Yj[Z j_iik[$ ?d Yh[ijWb _cfbWdji" j^[ _d\[Yj[Z
jhWdi_j_ed f[h_eZ \hec Xed[ je Yedd[Yj_l[ j_iik[
dehcWbbofh[i[djim_j^beYWbeij[eco[b_j_YWh[Wi$
?d Wdo [l[dj" c[Wikh[c[dj [hhehi d[Wh _cfbWdji
Wh[ WbmWoi YecfWhWj_l[bo ]h[Wj[h j^Wd d[Wh dWjkhWb
j[[j^;_Ya^ebp[jWb$(&&'1CecX[bb_[jWb$'/.-$
?j ckij Wbie X[ dej[Z j^Wj el[hbeWZ i_jkWj_edi
WYYecfWd_[ZXol[hj_YWbeij[eboi_i]e_d]Wbbj^[mWo
jei_]d_\_YWdjbo_dYh[Wi[Z_cfbWdjceX_b_jom_bbdej
b[WZjeWd_dYh[Wi[_dfheX_d]Z[fj^Wi_ij^[YWi[e\
fbWgk[#WiieY_Wj[ZXed[YebbWfi[?i_Zeh['//-$J^_i
cWo X[ YWki[Z Xo j^[ \WYj j^Wj j^[ _d\bWccWjeho
h[WYj_ed"m^_Y^_d_ji[b\_ided#XWYj[h_Wb"_ib[iiifWY[#
Yedikc_d]WdZ_dj[di[edc[Y^Wd_YWbel[hbeWZ"cWa#
_d]j^[_di[hj_ede\j^[fheX[ceh[Z_\\_Ykbj$
?dWZZ_j_edjej^[h[ikbje\Z[fj^c[Wikh[c[dji"
Xb[[Z_d] ed fheX_d] _i [lWbkWj[Z Wi Wd _dZ_YWjeh
e\ j^[ f[h_eZedjWb ^[Wbj^ e\ dWjkhWb j[[j^$ FheX_d]
YWdj^kio_[bZjmeh[ikbji0?\Xb[[Z_d]_idejfh[i[dj"
]eeZ f[h_eZedjWb ^[Wbj^" j^Wj _i" W ijWXb[ i_jkWj_ed
_i Wiikc[Z je [n_ij$ J^_i [nf[h_[dY[ YWddej X[
jhWdi\[hh[Z Z_h[Yjbo je _cfbWdji$ J^[ fheX_d] \ehY[
X[_d] [gkWb" Xb[[Z_d] m_bb eYYkh ceh[ \h[gk[djbo
WhekdZÆ^[Wbj^oÇ_cfbWdjij^WdWhekdZ^[Wbj^oj[[j^
_d Z[dj_j_edi m^ei[ ^[Wbj^ ijWjki _i YecfWhWXb[
BWd] [j Wb$ '//*1 ;h_Yied [j Wb$ '/.,$ :_\\[h[dj
Wkj^ehi eXjW_d[Z Z_\\[h[dj h[ikbji m^[d beea_d]
Wj j^[ Yehh[ifedZ[dY[ X[jm[[d Xb[[Z_d] WdZ f[h_#
_cfbWdjj_iik[Xh[WaZemd$
DW[hj[jWb$'//.WdZIWbY[jj_[jWb$'//-\ekdZ
de Yehh[bWj_ed X[jm[[d Xb[[Z_d] ed fheX_d] WdZ
cWh]_dWbXed[beii$Ic_j^be\\WdZ<h_jp'/.("edj^[
ej^[h^WdZ"i^em\ehXbWZ[_cfbWdjij^WjXb[[Z_d]
edfheX_d]WdZhWZ_ebe]_YWbbo[l_Z[djXed[beiiWh[
j^[ ceij h[b_WXb[ _dZ_YWjehi e\ f[h_#_cfbWdj j_iik[
Xh[WaZemd$
?d_j_WbfheX_d]d[WhWd_cfbWdj"j^[d"^WiWY[hjW_d
Z_W]deij_Y lWbk[$ ?\ ej^[h fWhWc[j[hi j^Wj c_]^j
_dZ_YWj[ Z_i[Wi[ Wh[ WXi[dj" ^em[l[h" j^[ h[ikbji Wh[
^WhZboYedYbki_l[$M^Wj_i_cfehjWdj_ije\ebbemj^[
Z[l[befc[djel[hj_c["Wj)#je,#cedj^_dj[hlWbi$
<eh Yh[ijWb _cfbWdji" j^[d" j^[ \ebbem_d] YWd X[
iW_ZedfheX_d]0
'$ <ehfheX_d]jeX[ki[\kb"Wh[b_WXb[WdZh[fheZkY_Xb[
c[Wikh_d]fe_djedj^[_cfbWdjehikf[hijhkYjkh[
_ih[gk_h[Z$J^_ife_djckijX[[nWc_d[ZWj[WY^
fheX_d]$
($ :WcW][ Xo j^[ fheX_d] fheY[ii _i dej [nf[Yj[Z
Wi bed] Wi W fheX_d] Z[fj^ e\ Wffhen_cWj[bo
+cc _i dej [nY[[Z[Z WdZ Wi bed] Wi j^[ ikh\WY[
e\j^[_cfbWdj_idej_hh[l[hi_XboZWcW][ZehYed#
jWc_dWj[Z$
)$ Ki_d] j^[ iWc[ fheX_d] \ehY[" fheX_d] Z[fj^i
m_bb X[ ]h[Wj[h WhekdZ Yh[ijWb _cfbWdji j^Wd
WhekdZdWjkhWbj[[j^$J^_i_iZk[jej^[Z_\\[h[dj
ijhkYjkh[ e\ j^[ f[h_#_cfbWdj j_iik[i$ FheX_d]
Z[fj^i _d _d\bWccWjeho f[h_#_cfbWdj i_jkWj_edi
)/, 9^Wfj[h(-È &ROMÈ+NOWLEDGEÈANDÈ3KILLÈTOÈ!CTION
m_bb X[ ]h[Wj[h" \eh j^[ iWc[ Xed[ b[l[bi" j^Wd _d
_d\bWccWj_ed#\h[[i_jkWj_edi$
FheX_d] Z[fj^ _i ed[ e\ i[l[hWb fWhWc[j[hi je X[
Wii[ii[Z_dj^[[lWbkWj_ede\Yh[ijWb_cfbWdji$
È
0ROBINGÈNEARÈ"/)
Ed[ j^_d] Wbb Yh[ijWb _cfbWdji ^Wl[ _d Yecced _i
j^Wj Xej^ j^[ jhWdic_ii_ed e\ \ehY[ WdZ j^[ Xed[
h[j[dj_ed _i Wiikh[Z edbo Wbed] j^[ l[hj_YWb Wn_i e\
j^[ _cfbWdj Ä dej b[Wij X[YWki[ j^[i[ _cfbWdji bWYa
ej^[hYecfed[djiikY^Wij^[beWZ#jhWdi\[hh_d]Z_ia$
?d XWiWb eii[e_dj[]hWj[Z _cfbWdji") Xo YedjhWij" j^[
i_jkWj_ed_igk_j[Z_\\[h[dj0
:[f[dZ_d] ed j^[ ikh\WY[ j[njkh[" Yedl[dj_edWb
eii[e_dj[]hWj_ed Wbed] j^[ _cfbWdjÉi l[hj_YWb Wn_i _i
dej h[gk_h[Z Ä _dZ[[Z _cfeii_Xb[ _\ j^[ ikh\WY[ _i
Yecfb[j[bo iceej^ WdZ kdijhkYjkh[Z$ 8E? [n^_X_j
ijhkYjkhWbh[i_b_[dY[WdZWbceij_ie[bWij_Yfhef[hj_[i
YecfWh[ZjeXed[?^Z[(&&)$
J^[h[ Wh[ i[l[hWb \WYjehi j^Wj fh[YbkZ[ ki \hec
YWhho_d]el[hj^[Yh[ijWb_cfbWdj[nf[h_[dY[je8E?0
v 8o YedjhWij m_j^ Yh[ijWb _cfbWdji" 8E? _cfbWdji
Zedej[n^_X_jWdo_d^[h[djfhe]h[ii_l[Xed[beii$
C_ii_d]l[hj_YWbXed[ehl[hj_YWbXed[beii_idej
W fWhWc[j[h _d Wii[ii_d] j^[ ijWjki eh fhe]dei_i
e\j^[_cfbWdj$DehZefheX_d]Z[fj^ie\,cceh
ceh[ WhekdZ Yh[ijWb _cfbWdji _dZ_YWj[ W Yh_j_YWb
jh[Wjc[dji_jkWj_ed$
v J^[ beWZ ed j^[i[ _cfbWdji _i jhWdic_jj[Z l_W
ed[ eh i[l[hWb XWiWb fbWj[ _di[hj[Z X_Yehj_YWbbo
eh ckbj_Yehj_YWbbo _d Wh[Wi j^Wj j[dZ je X[ iW\[
\hec _d\[Yj_ed WdZ j^Wj Wh[ beYWj[Z \Wh \hec j^[
ckYeiWb [c[h][dY[ i_j[$ :kh_d] _di[hj_ed" j^[
Xed[ _i WYY[ii[Z Xo Yh[Wj_d] W bWj[hWb J#i^Wf[Z
eij[ejeco$ ?d j^[ cWdZ_Xb[" j^[ l[hj_YWb WdZ
^eh_pedjWb eij[ejeco ]Wfi j[dZ je Ybei[ hWf_Zbo
m_j^ Xed[$ :k[ je j^[ ijh[ii#h[bWj[Z j[di_ed"
ijhW_]^j" Yedj_dkeki ikXf[h_eij[Wb Xed[ Ybeikh[
YWd X[ [nf[Yj[Z _d j^_i h[]_ed W\j[h edbo W \[m
cedj^i$ >[h[" j^[ Xed[ h[][d[hWj_ed ij_ckbki
eh_]_dWj[i _d j^[ `Wm _ji[b\" m^_Y^ _i ikX`[Yj je
cWii_l[jehi_ed_ddehcWb\kdYj_ed$J^[i[ijh[ii#
h[bWj[Zij_ckb_Wh[dejfh[i[dj_dj^[cWn_bbWjej^[
iWc[ Z[]h[[$ J^[ Xedo eij[ejeco m_bb j^[h[\eh[
Ybei[ceh[ibembo"ijWhj_d]Wjj^[f[h_eij[kc$
v J^[ fei_j_ed e\ j^[ l[hj_YWb eij[ejeco YWddej
X[ Z[j[hc_d[Z feijef[hWj_l[bo Xo jh[Wjc[dj
fhel_Z[hi m^e ^Wl[ dej j^[ci[bl[i _di[hj[Z
j^[ _cfbWdji$ I_dY[ j^[ _cfbWdj YWd X[ _di[hj[Z
[_j^[h bWj[hWbbo eh eXb_gk[bo" WdZ \hec b_d]kWbbo
eh \hec l[ij_XkbWhbo _d j^[ cWdZ_Xb[" WdZ [l[d
bed]_jkZ_dWbbo j^hek]^ j^[ `WmXed[" j^[ l[hj_YWb
eij[ejeco cWo X[ beYWj[Z Wdom^[h[ _d j^[
`Wm$ I_dY[ j^[ `Wm _i \b[n_Xb[ WdZ j^[ _cfbWdj#
h[ijehWj_ed ijhkYjkh[ m_bb WbmWoi X[ ib_]^jbo
ceX_b[" eii[eWZWfjWj_ed YWddej X[ [nf[Yj[Z _d
j^[ h[]_ed e\ j^[ j^h[WZ[Z f_di$ <eh j^_i h[Wied"
[WY^ fheX_d] Ä [l[d d[Wh Yecfb[j[bo Æ^[Wbj^oÇ
_cfbWdji Ä YWhh_[i W h_ia e\ kdYedjhebb[Z Zhefi
edjej^[Z[fj^e\j^[`Wm"h[ikbj_d]_dWhWdZec"
ded#h[fheZkY_Xb["Z_W]deij_YWbbomehj^b[iih[ikbj$
v :kh_d] Z[fj^ c[Wikh[c[dji Xo fheX_d]" j^[
iceej^cWY^_d[Zikh\WY[e\j^[j^h[WZ[Zf_die\
8E?YWd[Wi_boX[iYhWjY^[Zehhek]^[d[Z$Hek]^
ikh\WY[i" ^em[l[h" fhecej[ ikXi[gk[dj fbWgk[
WYYkckbWj_ed$ J^_i cWo [ijWXb_i^ W fWj^ \eh
_d\[Yj_ed_dZ[[f[hh[]_edi"[if[Y_WbboYedi_Z[h_d]
j^[ _d^[h[dj feii_X_b_jo e\ _cfbWdj h[i_b_[dY[ _d
8E?$
v J^[b_j[hWjkh[edYh[ijWb_cfbWdjebe]oi^emij^Wj
fWj^e][dicWoikhl_l[_dfeYa[jie\Wffhen_cWj[bo
+ccehceh[_dZ[fj^$;if[Y_Wbbom^[dj^[fheX[
h[WY^[ij^[Yh[ijWbfbWj[e\8E?"j^[h[_iWh_iae\
_d\[Yj_ed_dj^[h[]_ede\j^WjfbWj[$?d\[Yj_edcWo
j^[d ifh[WZ ^eh_pedjWbbo Wbed] j^[ fbWj[" YWki_d]
_hh[l[hi_Xb[ ZWcW][ je j^[ eii[e_dj[]hWj_ed e\
j^[ Z_iai$ 9b_d_YWb cWdW][c[dj e\ j^_i i_jkWj_ed
_ikikWbboedbofeii_Xb[Xoh[cel_d]j^[W\\b_Yj[Z
Z_ia _d W j_c[bo cWdd[h Ä j^Wj _i" X[\eh[ j^[
_d\[Yj_ed ifh[WZi _d j^[ Z_h[Yj_ed e\ j^[ bem[h
Z_iai WdZ Xo j^ehek]^ Yb[Wd_d] e\ j^[ i_j[ Xo
ikh]_YWb_dj[hl[dj_ed$
v ?\fheX_d]_i[\\[Yj[Z_dj^[cWn_bbW"_dj^[h[]_ed
e\j^[cWn_bbWhoi_dki"j^[h[_iWbmWoiWZWd][he\
f[d[jhWj_d]Wbbj^[mWo_djej^[i_dki$Jh[Wjc[dj
fhel_Z[him_bbe\j[di[[ah[i_ijWdY[Zkh_d]fheX_d]"
WdZj^_ih[i_ijWdY[cWoX[Z_\\_YkbjjeZ[j[Yj]_l[d
j^[Z[b_YWj[Xed[ijhkYjkh[_dj^_iWh[W$KikWbbo"de
_d\[Yj_edYWdX[Yec[[ijWXb_i^[ZX[jm[[dj^[ehWb
YWl_jo"j^[8E?WdZj^[cWn_bbWhoi_dkiWdZWiY[dZ
je j^[ i_dki Ä de cWjj[h ^em j_]^j j^[ ifWj_Wb
h[bWj_edi$9b_d_YWb[nf[h_[dY[i^emi"^em[l[h"j^Wj
fheX_d] _d WdZ e\ _ji[b\ cWo YWki[ _d\[Yj_ed$
7ffWh[djbo" f[d[jhWj_d] fheX[i YWd _djheZkY[
fWj^e][di Z_h[Yjbo _dje j^[ cWn_bbWho i_dki$ J^_i
_djheZkYj_ed" ceh[el[h" _i [\\[Yj[Z Xo mWo e\ Wd
kddWjkhWbfWj^"m_j^defh_cWhoh[i_ijWdY[_dj^[
WdWjec_YWbijhkYjkh[i$
v J^[h[ _i de fe_dj _d fheX_d] _d i_jkWj_edi m^[h[
Wi_dki_j_i^WiWbh[WZocWd_\[ij[Z_ji[b\Yb_d_YWbbo"
i_dY[ _j _i _cfeii_Xb[ WdomWo je Z[cedijhWj[
j^[ fh[i[dY[ e\ j^_i _d\[Yj_ed WdZ _ji [nj[dj1
j^_i mekbZ ^Wl[ je X[ Zed[ Xo hWZ_e]hWf^ eh Xo
W 97J iYWd$ ?d WZZ_j_ed" fheX_d] c_]^j b[WZ je
kdZ[i_hWXb[i^_\j_d]ehc_n_d]e\fWj^e][di_\j^[
iekhY[e\j^[i_dki_j_i_idejbeYWj[Z_dj^[_cfbWdj
h[]_ed WdZ _\ ie\j#j_iik[ ijhkYjkh[i Wh[ ZWcW][Z
Xoj^[fheX[j^Wj_ii[[a_d]jeZ[j[YjXedoikffehj
AedijWdj_del_Y(&&)$
v J^[ Yekhi[ e\ Æ_cfbWdjebe]_YWb Xh[WaZemdÇ _d
8E? _i l[ho Z_\\[h[dj \hec WdWbe]eki fheY[ii[i
È È 0ROBINGÈASÈAÈ$IAGNOSTICÈ!DJUNCTÈ
m_j^Yh[ijWb_cfbWdji$J^[ceij\h[gk[djh[Wiedi
\ehj^[beiie\8E?Wh[beiie\eii[eWZWfjWj_ed_d
j^[ Wh[W e\ j^[ beWZ#jhWdic_jj_d] i[]c[dji [$]$
X[YWki[e\el[hbeWZeij[eboi_ieh_cfbWdj\hWYjkh[
ceij \h[gk[djbo X[YWki[ e\ W beei[d_d] e\ j^[
h[ijehWj_l[ ijhkYjkh[i eh X[YWki[ e\ eij[eboi_i
ed _cfbWdji _dj[]hWj[Z _dje j^[ iWc[ _cfbWdj#
h[ijehWj_edYecfb[n"edbo_dWZ_\\[h[djbeYWj_ed$
El[hbeWZi_jkWj_edim_j^ikXi[gk[djeij[eboi_iWj
j^[beWZ#jhWdic_jj_d]i[]c[djie\8E?YWddejX[
Z_W]dei[ZXoZ[fj^fheX_d]$HWj^[h"j^_ih[gk_h[i
hWZ_ebe]_YWbehYb_d_YWb[nWc_dWj_ed$DehYWd8E?
\hWYjkh[iX[h[b_WXboZ[j[Yj[ZXofheX_d]$
È
3UMMARY
7do_dlWi_l[WYj_l_joedj^[fWhje\j^[Z[dj_ijckij
X[ fh[Y[Z[Z Xo Wd [lWbkWj_ed e\ j^[ fej[dj_Wb h_iai
WdZ j^[ feii_Xb[ X[d[\_ji$ IkY^ _dlWi_l[ WYj_l_j_[i
_dYbkZ[ j^[ WYj e\ fheX_d] d[Wh j[[j^ WdZ _cfbWdji$
Je`kij_\ofheX_d]"j^[h[ikbj_d]c[Wikh[c[djckij
X[ h[fheZkY_Xb[ WdZ Wj j^[ iWc[ j_c[ Yb_d_YWbbo
h[b[lWdj$ 7i j^[h[ _i WbmWoi j^[ ZWd][h" [if[Y_Wbbo
)/-
_d bed][h 8E?" e\ bei_d] Yedjheb Zkh_d] fheX_d] \eh
feYa[j Z[fj^ WdZ Wi j^[ cWh]_dWb Xed[ b[l[b WdZ
bWj[hWbWZWfjWj_ed_dj^[Wh[We\j^[j^h[WZ[Zf_dWh[
e\ de Yedi[gk[dY[ \eh _cfbWdj fhe]dei_i WdomWo"
WdofheX_d]d[Wh8E?_iWjX[ijfe_djb[iiWdZWjmehij
ZWd][hekiWdZj^h[Wj[dijeYecfhec_i[j^[f^oi_YWb
_dj[]h_jo e\ j^[ fWj_[dj [nWc_d[Z$ J^[ fej[dj_Wb
ZWcW][ e\ fheX_d] _i Yecfb[j[bo _dYecc[dikhWj[
m_j^WdoYedY[_lWXb[Z_W]deij_YX[d[\_j$
M_j^ ]eeZ h[Wied" j^[ Æ8E? 9edi[dikiÇ 8[iY^
'/// Ze[i dej c[dj_ed fheX_d] Wi W Z_W]deij_Y
WZ`kdYj\ehZ[j[hc_d_d]j^[ijWjkiWdZfhe]dei_ie\
8E?_cfbWdji$H[Yecc[dZWj_edi\hecj^[b_j[hWjkh[
ed Yh[ijWb _cfbWdjebe]o Wh[ dej Wffb_YWXb[ je 8E?"
i_dY[ j^[ \kdYj_edWb fh_dY_fb[ e\ 8E? _i Yecfb[j[bo
Z_\\[h[dj$
) 8WiWb eii[e_dj[]hWj[Z _cfbWdji Wh[ W ikXi[j e\ j^[ bWj[hWb
_cfbWdji$ J^[o Wh[ _di[hj[Z bWj[hWbbo _dje j^[ XWiWb `Wm
Xed[ eh _dje j^[ Wbl[ebWh Xed[" ki_d] W J#i^Wf[Z WYY[ii
eij[ejeco$8E?^Wl[debeWZ#jhWdic_jj_d]ikh\WY[i_dj^[_h
l[hj_YWbWif[Yj$

2EFERENCES
7Z[bb H" B[a^ebc K [j Wb '//& H[YedijhkYj_ed e\ i[l[h[bo
h[iehX[Z [Z[djkbeki cWn_bbW[ ki_d] eii[e_dj[]hWj[Z
\_njkh[i _d _cc[Z_Wj[ Wkje][deki Xed[ ]hW\ji$ ?dj @ EhWb
CWn_bbe\WY?cfb+0())Ä(*,
7bXh[ajiiedJ'/.+8ed[j_iik[h[ifedi[0J_iik[#_dj[]hWj[Z
fheij^[i[i$CeiXo"BedZed
7bXh[ajiiedJ"PWhX="Mehj^_d]jed:F[jWb'/.,J^[bed]#
j[hc [\\_YWYo e\ Ykhh[djbo ki[Z Z[djWb _cfbWdji0 W h[l_[m
WdZfhefei[ZYh_j[h_We\ikYY[ii$?dj@EhWbCWn_bbe\WY?cfb
'0''Ä(+
7hc_jW][=9'//+CWdkWbf[h_eZedjWbfheX_d]_dikffehj_l[
f[h_eZedjWbjh[Wjc[dj$F[h_eZedjebe]o(&&&0))Ä)/
7hijWZJ'/,+J^[_d\bk[dY[e\j^[b_fiedcWdZ_XkbWhh[ij
fei_j_ed_d[Z[djkbekifWj_[dji$@Fheij^[j:[dj'+0(-Ä)*
7i^a_dWpoBH'//.KIF*"+(("+/,
7i^cWdH8"lWd8kia_haM9'/.-J^[[bWij_Yfhef[hj_[ie\W
^kcWdcWdZ_Xb[$7Zl:[djH[i'0,*Ä,-
7ii[dpW 8" IYWhWde 7 [j Wb (&&) 9h[ijWb Xed[ h[ceZ[bb_d]
_d beWZ[Z WdZ kdbeWZ[Z _cfbWdji WdZ j^[ c_Yhe]Wf0 W
^_ijebe]_YWbijkZo$?cfbWdj:[dj_ijho'(0()+Ä()/
7jWii_<(&&&F[h__cfbWdjfheX_d]0Fei_j_l[iWdZd[]Wj_l[i$
?cfb:[dj_ijho''0)+,Ä),'
7ja_diedF@"MeeZ^[WZ9'/,.9^Wd][i_d^kcWdcWdZ_XkbWh
ijhkYjkh[m_j^W][$7hY^EhWb8_eb')0'*+)Ä'*,)
7ja_died F@" MeeZ^[WZ 9" Fem[bb A '/-* J^[ _d\bk[dY[ e\
h[ceZ[bb_d]edcWdZ_XkbWhXed[ijhkYjkh[$EhWb?cfbWdjeb
*0(,)Ä(/)
7ja_diedF@"Fem[bbA"MeeZ^[WZ9'/--9ehj_YWbijhkYjkh[
e\j^[f_]cWdZ_Xb[W\j[hj^[_di[hj_ede\c[jWbb_Y_cfbWdji
_djeWbl[ebWhXed[$7hY^EhWb8_eb((0).)Ä)/'
7kij H '/-, C[Wikh[c[dji e\ j^[ eij[Wb i_p[ WdZ eno][d
j[di_ed_dj^[cWn_bbWhoi_dki$?djH^_deb'*0*)Ä**
7kijH":h[jjd[h8'/-'L[dj_bWjehoijkZ_[i_dj^[cWn_bbWho
i_dki$?djH^_deb/0,/Ä-.
7l_iL'/,'J^[i_]d_\_YWdY[e\j^[Wd]b[e\j^[cWdZ_Xb[0Wd
[nf[h_c[djWbWdZYecfWhWj_l[ijkZo$7c@F^oi7dj^hefeb
'/0++Ä,'
8WX ?" =Wp_j :" CWiiWhWmW 7" I[bW @ '/.+ H[celWb e\ j_X_Wb
cWhhem_dZkY[i_dYh[Wi[Z\ehcWj_ede\Xed[WdZYWhj_bW][
_dhWjcWdZ_XkbWhYedZob[$9WbY_\J_iik[?dj)-0++'Ä+++
8WY^F'/-/C[Z_p_d_iY^[Dejm[dZ_]a[_jZ[h>[_bX[^WdZbkd]
kdZijWj_edh[DkbbZ_j$L[hiH'/-/0-/(Ä-/-
8WY^F"Cei[h>(&&):_[fh_lWj[AhWda[dl[hi_Y^[hkd]")hZ
[Zd$C”dY^[d
8Wa[h BM '/(( J^[ _d\bk[dY[ e\ j^[ \ehY[i e\ eYYbki_ed ed
j^[Z[l[befc[dje\j^[Xed[ie\j^[iakbb$?dj@Ehj^eZEhWb
Ikh]HWZ_e].0(+/Ä(.'
8Wbi^_J@"Meb\_d][h=@'///:[djWb_cfbWdji_dj^[Z_WX[j_Y
fWj_[dj0Wh[jheif[Yj_l[ijkZo$?cfbWdj:[dj_ijho.0)++Ä)+/
8WhX[h:>(&&'9edi[hlWj_l[cWdW][c[dje\j^[\hWYjkh[Z
Wjhef^_Y [Z[djkbeki cWdZ_Xb[$ @ EhWb CWn_bbe\Wn Ikh]
+/0-./Ä-/'
 ¬ 
8Wii[j97B'/,+;b[Yjh_YWb[\\[Yji_dXed[$IY_7c(')0'.Ä(+
8Woi H7 '/., J^[ fWj^ef^oi_ebe]o WdZ WdWjeco e\
[Z[djkbekiXed[beii$?d0<edi[YWH@":Wl_iM>[ZiH[Yed#
ijhkYj_l[ fh[fheij^[j_Y ehWb WdZ cWn_bbe\WY_Wb ikh][ho$
IWkdZ[hi"F^_bWZ[bf^_W"F7
8[^h[di ; [j Wb (&&' Aecfb_aWj_ed[d X[_ kdZ dWY^
AdeY^[d[djdW^c[WkiZ[c8[Ya[daWcc$:jiY^PW^dhpjb
P+,0,,Ä,.
8[bi[hK9">WddWc7='/.+J^[_d\bk[dY[e\Wbj[h[Zmeha_d]
i_Z[eYYbkiWb]k_ZWdY[edcWij_YWjehockiYb[iWdZh[bWj[Z
`Wmcel[c[dj$@Fheij^[j:[dj+)0*&,Ä*')
8[dZ[h ? '//& <WYjehi _d\bk[dY_d] j^[ hWZ_e]hWf^_Y
Wff[WhWdY[e\Xedob[i_edi$@;dZeZ'0))Ä*&
8[iY^ A@ '/// Aedi[diki pk 8E?$ IY^m[_p CedWjiiY^h
PW^dc'&/0/-'Ä/-(
8[ohed>'/,/Efj_cWbeYYbki_ed$:[djWb9b_d_YiDehj^7c
')0+)-Ä++*
8^WjjWY^WjooW D '/// 8_bWj[hWb Y^hed_Y cWn_bbWho i_dki_j_i
W\j[hj^[i_dki#b_\jfheY[Zkh[$7c@EjebWhod]eb(&0'))Ä')+
8_[hcWdd 8" IY^[jjb[h : '/-* ;h][Xd_ii[ Z[h Fhe][d_[#
ef[hWj_ed[d _d Z[h M[ijZ[kjiY^[d A_[\[hab_d_a$ <ehjiY^h
A_[\[h#=[i_Y^jiY^_h'.0'+/Ä',(
8_dZ[hcWdd?"7ZkjC"Pe^WhH"8W^Wh>"<W_X_i^:"OW\\W7
(&&'7bl[ebWh Xed[ h[iehfj_ed \ebbem_d] YehedWb l[hiki
Wf_YWbWffheWY^_dWckYef[h_eij[Wb\bWfikh][hofheY[Zkh[
_dj^[cWdZ_Xb[$@F[h_eZedjeb-(0')*.Ä'.+)
8_d][h J '/./ Eij[eco[b_j_i kdZ fWj^ebe]_iY^[ <hWajkh
dWY^ [deiiWb[h ?cfbWdjWj_ed _c Kdj[ha_[\[h$ P PW^dhpjb
?cfbWdjeb+0'(Ä'*
8bWjj[h\[_d B" FWod[ >I '/.+ 9b_d_YWb bed]#j[hc ijkZo e\
Yecfb[j[Z[djkh[m[Wh[hi$@Fheij^[j:[dj+)0+,Ä,'
8bec;@"L[h^[_`@="Z[8b_[Ya#>e][hlehij@C":_I_bl_eB"Ab[_d
9F '//. 9ehj_YWb Xed[ _d]hemj^ _d ]hemj^ ^ehced[#
beWZ[Z]heel[Z_cfbWdjim_j^YWbY_kcf^eif^Wj[YeWj_d]i
_d]eWj\[ckhi$8_ecWj[h_Wbi'/0(,)Ä(-&
8eZ[dXkh] H '/.) :[h hpjb_Y^[ Akdij\[^b[h Wbi
<kdaj_ediX[]h_\\ p_l_bh[Y^jb_Y^[h :e]cWj_a$ @kh$
:_ii[hjWj_ed"C”dY^[d
8eea A" AWhbiied I" @[cj J '//( <kdYj_edWb WZWfjWj_ed je
\kbb WhY^ \_n[Z fheij^[i_i ikffehj[Z Xo eii[e_dj[]hWj[Z
_cfbWdji _d j^[ [Z[djkbeki cWdZ_Xb[$ 9b_d EhWb ?cfb H[i
)0'-Ä('
8eia[h >" @ehZWd H:" Fem[hi CE" lWd F[bj7M@ '//' 8ed[
_dZkYj_edWdZXed[beiiXoki[e\j^[JC?$EhWbIkh]EhWb
:_W]d(0'.Ä(.
8ejY^m[o;7":kfh[[C7"FebbWYaIH"B[l_d[;C"BWkh[dY_d
9J (&&) J_iik[ [d]_d[[h[Z Xed[0 c[Wikh[c[dj e\
dkjh_[djjhWdifehj_dj^h[[#Z_c[di_edWbcWjh_Y[i$@8_ec[Z
CWj[hH[i,-70)+-Ä),-
8ekY^[h B@" Pm[c[h J@" F\bk]^e[\j < '/+/ 9Wd X_j_d] \ehY[
X[ki[ZWiWYh_j[h_ed\ehh[]_ij[h_d]l[hj_YWbZ_c[di_ed5@
Fheij^:[dj/0+/*Ä+//
*&& 2EFERENCES
8eod[ F@" @Wc[i H7 '/.& =hW\j_d] e\ j^[ cWn_bbWho i_dki
\beeh m_j^ Wkje][deki cWhhem WdZ Xed[$ @ EhWb Ikh]
).0,')Ä,',
8hWZb[o @9 '/-+ 7 hWZ_ebe]_YWb _dl[ij_]Wj_ed _dje j^[ W][
Y^Wd][i e\ j^[ _d\[h_eh Z[djWb Whj[ho$ 8h @ EhWb Ikh]
')0.(Ä/&
8hWdZj >> '//, ;_d\”^hkd] _d Z_[ ?cfbWdjebe]_[$ KhXWd
kdZIY^mWhp[dX[h]"C”dY^[d
8hd[cWhaF?"Il[diied8"lWdIj[[dX[h]^[:'//+J[d#o[Wh
ikhl_lWb hWj[i e\ \_n[Z fheij^[i[i ed \ekh eh i_n _cfbWdji
WZ ceZkc 8hd[cWha _d \kbb [Z[djkb_ic$ 9b_d EhWb ?cfb
H[i,0((-Ä()'
8h[c[ @" 8_[^b L" IY^kbj[ M [j Wb '//) :[l[befc[dj WdZ
\kdYj_edWb_jo e\ _ie[bWij_Y Z[djWb _cfbWdji e\ j_jWd_kc
Wbbeoi$8_ecWj[h_Wbi'*0..-Ä./(
8h_]^j_d9J">[ff[dijWbbH8'/-'Eno][dj[di_ed_dped[ie\
j^[[f_f^oi[WbfbWj["j^[c[jWf^oi_YWdZZ_Wf^oi_i$@8ed[
@e_djIkh]+)70-'/Ä-(.
8eea A [j Wb '//( <kdYj_edWb WZWfjWj_ed je \kbb#WhY^ \_n[Z
fheij^[i_i ikffehj[Z Xo eii[e_dj[]hWj[Z _cfbWdji _d j^[
[Z[djkbekicWdZ_Xb[$9b_dEhWb?cfbWdjiH[i)0'-Ä('
8kcWdd 7 [j Wb '/./ :[h Ij[bb[dm[hj Z[h 7k\X_iiiY^_[#
d[dj^[hWf_[ X[_ <kdaj_ediijhkd][d _c ijecWje]dWj^[d
Ioij[c$:jiY^PW^dhpjbP**0'*Ä',
8khh :8" CWhj_d H8" IY^W\\b[h C8" HWZ_d ;B '/.+ 8ed[
h[ceZ[bb_d]_dh[ifedi[je_dl_le\Wj_]k[c_YheZWcW][$@
8_ec[Y^Wd_Yi'.0'./Ä(&&
8khh :8" <ehmeeZ CH" <o^h_[ :F" CWhj_d H8" IY^W\\b[h
C8" Jkhd[h 9> [j Wb '//- 8ed[ c_YheZWcW][ WdZ
ia[b[jWb \hW]_b_jo _d eij[efehej_Y WdZ ijh[ii \hWYjkh[i$ @
8ed[C_d[hWbH[i'(0,Ä'+
8kppW ;F" I^_Xb_ @7" 8WhX[_he H>" Z[ 7bX[h]Wh_W 8WhXei[ @H
(&&) ;\\[Yji e\ [b[YjhecW]d[j_Y \_[bZ ed Xed[ ^[Wb_d]
WhekdZYecc[hY_Wbbofkh[j_jWd_kcikh\WY[0>_ijebe]_YWdZ
c[Y^Wd_YWbijkZo_dhWXX_ji$?cfbWdj:[dj_ijho'(0'.(Ä'.+
9WbZ[hWb[ FC" Heii[jje C" F[ppeb_ C '/., 8_ec[Y^Wd_YWb
WdWboi_i e\ Yekfb_d] X[jm[[d cWdZ_Xb[ WdZ h[celWXb[
fWhj_Wb Z[djkh[i$ ?d0 8_ec[Y^Wd_Yi0 8Wi_Y WdZ Wffb_[Z
h[i[WhY^$ I[b[Yj[Z fheY[[Z_d]i e\ j^[ \_\j^ c[[j_d] e\
j^[ ;khef[Wd IeY_[jo e\ 8_ec[Y^Wd_Yi" I[fj '/.," 8[hb_d$
CWhj_dkiD_`^e\\":ehZh[Y^j
9Whbiied=;'/--8[jj^`ZeYYbki_ed[dil[hj_aWbWZ_c[di_ed$
JWdZbaWhj_Zd_d][d",/0*,*Ä*-'
9Whbiied =;" CW]dkiied J (&&& 8[^WdZbkd] j[cfe#
hecWdZ_Xkbh[h<kdaj_ediijhkd][d_dZ[hFhWn_i$Gk_dj#
[ii[dp"8[hb_d
9Whbiied=;"?d][hlWbb8"AeYWa='/.(;\\[Yje\_dYh[Wi_d]
l[hj_YWb Z_c[di_ed ed j^[ cWij_YWjeho ioij[c _d ikX`[Yji
m_j^dWjkhWbj[[j^$@Fheij^[j:[dj*'0(.*Ä(./
9Whj[h :H" 8b[dcWd FH" 8[Wkfh[ =I '/.. 9ehh[bWj_edi
X[jm[[dc[Y^Wd_YWbijh[ii^_ijehoWdZj_iik[Z_\\[h[dj_Wj_ed
_dW_d_j_Wb\hWYjkh[^[Wb_d]$@Ehj^efW[ZH[i,0-),Ä-*.
9^_a^Wd_B":_Y^Wcf@"=k_bX[hj<"8[hjhWdZ@9(&&'8hkn_ic["
iodZhec[ Wb]eZoi\edYj_edd[b Z[i Whj_YkbWj_edi j[cfehe#
cWdZ_XkbW_h[i$ JhW_j[c[dj fWh bW jen_d[ Xejkb_gk[$ xjkZ[
ikh''+&YWi$?cfbWdjeZedj_[+&0(-Ä),
9^h_ij[di[dHM'/,+Kd_j[ZIjWj[iFWj[dj)"*-*"+)-
9bkd[#9eij[8@'/-+<h[dY^FWj[dj()&(-'+
9eYY_W F<" Ah_l_j M" 9[hl[daW @" 9bWmied 99 [j Wb '/.&
IkYY[ii\kb Xed[ cWhhem jhWdifbWdjWj_ed \eh _d\Wdj_b[
cWb_]dWdjeij[ef[jhei_i$D;d]b@C[Z)&(0-&'Ä-&.
9khh[o @: '/.' M^Wj _i Xed[ \eh5 Fhef[hjo#\kdYj_ed
h[bWj_edi^_fi _d Xed[$ ?d0 9el_d I9 [Z C[Y^Wd_YWb
fhef[hj_[i e\ Xed[$ 7c[h_YWd IeY_[jo e\ C[Y^Wd_YWb
;d]_d[[hi"D[mOeha"ff')Ä(,
:[Y^em F9" >obWdZ[h MB (&&& ;bWij_Y fhef[hj_[i WdZ
cWij_YWjeho Xed[ ijh[ii _d j^[ cWYWgk[ cWdZ_Xb[$ 7c @
F^oi7dj^hefeb''(0++)Ä+-*
:[[c BF" 8Wii_ekdo C7" :[[c J; (&&( J^[ i[gk[dj_Wb
\W_bkh[ e\ eii[e_dj[]hWj[Z ikXc[h][Z _cfbWdji$ ?cfb
:[dj_ijho''0(*)Ä(*.
Z[bF_bWhH_ei9WbleC"Ckbb[h;"=Wh]7A(&&&?cc[Z_Wj[
beWZ_d] e\ j_jWd_kc ^[n[Z iYh[m#jof[ _cfbWdji _d j^[
[Z[djkbeki fWj_[dj0 9Wi[ h[fehj$ ?cfbWdj :[dj_ijho /0)+'Ä
)++
:[kjiY^;'/.):_[>W\jkd]Z[iPW^dWhpj[iX[_pW^dhpjb_Y^[h
8[^WdZbkd]$L[hiH'/.)0//)Ä//-
:=PCA" :=? (&&' B[X[di[hmWhjkd] led ?cfbWdjWj[d kdZ
?cfbWdjWjbW][hd$8:?Paedah[j"'0(,
:_[jp =" 8Whj^ebc[i F '//. 9WbY_kc^oZhen_Z kdZ
AdeY^[dh[][d[hWj_ed$8oXbei"C”dY^[d
:e^Wd :" :edi_ced_ @C" DWlWhhe =" =Wkbj_[h < (&&)
9edY[djh[i fbWgk[jjW_h[i0 j[Y^debe]_[i" X_ebe]_[ WiieY_ƒ["
Wffb_YWj_ed Yb_d_gk[i" WdWboi[i ^_ijebe]_gk[i$ J[Y^debe]_[
[jX_ebe]_[WiieY_ƒ[$?cfbWdjeZedj_[+&0+Ä)+
:edi_ced_ @C (&&) B[Yjkh[ Wj ;7I?#9ed]h[ii$ FejiZWc"
=[hcWdo
:edi_ced_ @C" 8[hcej F" 8W^c F" IWbWcW @F (&&&
BÉ_cfbWdjebe]_[XWiWb[0kd[h[ifedi[[dkdi[kbj[cfiWjeki
b[i fheXb[c[i Z[djW_h[i" o Yecfh_i b[i YWi _d_cfbWdjWXb[i
dVWoWdj fWi ZVei [j h[\kiWdj b[i ]h[\\[i$ ?cfbWdjeZedj_[
)-0)+Ä**
:ekZ=Wbb_IA"B[Xem_jpH7"=_WYY^_H@"=b_YacWdH"@WYeXi
@8(&&'9^hed_Yi_dki_j_iYecfb_YWj_d]i_dkib_\jikh][ho$
7c@H^_deb'+0'.'Ä'.,
:meha_d I< '//+ F[hiedWb WdZ ieY_Wb _cfWYj e\ ehe\WY_Wb
fW_d$ ?d0 <h_Yjed @H" :kXd[h H8 [Zi Ehe\WY_Wb fW_d WdZ
j[cfehecWdZ_XkbWhZ_iehZ[hi$HWl[dFh[ii"D[mOeha
;X[h^WhZj:'/,.I[bXijX[ij_cckd]ih[Y^jZ[iFWj_[dj[dkdZ
hpjb_Y^[7k\abhkd]if\b_Y^j$@kh$:_ii[hjWj_ed"AWhbihk^[
;Ya[hjI"C[hWmI"M[Wl[h7"Be^i[9(&&';Whbo[nf[h_[dY[
m_j^ m_Z[ fbWj\ehc Ca ?? _cfbWdji$ ?dj @ EhWb CWn_bbe\WY
?cfb',0(&.Ä(',
;Z[bcWd7;'/-.Kd_j[ZIjWj[iFWj[dj*"'.-",&/
;_Ya^ebpF"=hejaWcfB<"Ij[l[b_d]>[jWb(&&'H[fheZkY_X_b_jo
e\ f[h_#_cfbWdj fheX_d] ki_d] W \ehY[#Yedjhebb[Z fheX[$
9b_dEhWb?cfbWdjH[i'(0'+)Ä'+.
;d][ba[M(&&&F9JME&'%/)--+7'
;d][ba[M"IjW^hI"IY^mWhpmbb[hM(&&(;d^WdY[c[dje\
fh_cWhoijWX_b_joe\Z[djWb_cfbWdjiki_d]Yehj_YWbiWj[bb_j[
_cfbWdji$?cfbWdj:[dj_ijho''0+(Ä+-
;djiY^[_Zkd][d Z[i 8kdZ[i][h_Y^ji^e\[i _d P_l_biWY^[d
8=>P-"(&,
;djiY^[_Zkd][dZ[iH[_Y^i][h_Y^ji^e\[i_dP_l_biWY^[dH=P
'+'")+(
;h_Yied ?" B[a^ebc K" 8hd[cWha F? [j Wb '/., 7 Yb_d_YWb
[lWbkWj_ed e\ \_n[Z Xh_Z][ h[ijehWj_edi ikffehj[Z Xo j^[
YecX_dWj_ede\j[[j^WdZeii[e_dj[]hWj[Z_cfbWdji$@9b_d
F[h_eZedjeb')0)&-Ä)'(
;h_aiied H7 [j Wb '/.( J^[hcWb _d`kho je Xed[$ 7 l_jWb
c_YheiYef_Y Z[iYh_fj_ed e\ ^[Wj [\\[Yji$ ?dj @ EhWb Ikh]
''0''+
;iY^b[h @ '/+( ;b[ajhef^oi_ebe]_iY^[ kdZ fWj^ebe]_iY^[
Kdj[hikY^kd] Z[i AWkioij[ci1 :jiY^ PW^dhpjb P[_jiY^h
-0')))Ä'))/
;ii[h;":”hiY^>='//,?cfbWdjWj[dWY^7k\bW][hkd]ifbWij_a
Z[h^eY^Wjhef^_iY^[dCWn_bbW$:jiY^PW^dhpjbP+'0,*Ä,,
;m[hiH'//.7k]c[djWj_l[C[j^eZ[d_dWcXkbWdj[hFhWn_i$
Fh[i[djWj_edWj7I?E"P”h_Y^
È È 2EFERENCESÈ
;m[hiH(&&&B[Yjkh[Wj+$?dj[hdWj_edWb[iM_dj[hjh[\\[d"Ij$
@WaeX"7kijh_W"CWhY^(&&&
<WbbiY^”ii[b A> '/.+ :_[ Ij[bbkd] Z[h a”dijb_Y^[d PW^d#
[_df\bWdpkd] _c Wbb][c[_d[d 7hpjh[Y^j$ C[ZH '/.+0'*-Ä
'+'
<[kh[hD'///A_[\[h][b[daX[iY^m[hZ[dWkipW^dhpjb_Y^[h
kdZ f^oi_ej^[hWf[kj_iY^[h I_Y^j0 KhiWY^[d Ä :_W]dei[
ÄJ^[hWf_[$AhWda[d]ocdWij_a+'0(&++Ä(&+/
<_YWjHF'/.+?Z_efWj^_YXed[d[Yhei_ie\j^[\[cehWb^[WZ$@
8ed[@e_djIkh],-80)Ä/
<_]][d[h B (&&) H[Y^jb_Y^[ 7if[aj[ led B[_jb_d_[d$ :j
PW^dhpjb_Y^[P[_jiY^h_\j''0''Ä')
<_iY^[h =" B_b_[ > '/// uhpjb_Y^[ L[hWdjmehjkd] _c
[khef_iY^[d H[Y^jil[h]b[_Y^$ >Wbb[iY^[ IY^h_\j[d pkc
H[Y^j"8WdZ-$Abd
<_iY^[h#8hWdZ_[i ; '/.+ Pkh :[\_d_j_ed Z[i H[p_Z_li dWY^
ef[hWj_l[h Fhe][d_[$ :jiY^ P CkdZ A_[\[h =[i_Y^jiY^_h
/0),&Ä),,
<hWdp A@" >Wdi[d A '//- 7k\abhkd]if\b_Y^j Wki hpjb_Y^[h
kdZ `kh_ij_iY^[h I_Y^j" (dZ [Zd$ >Wdi CWhi[_bb[#L[hbW]"
C”dY^[d
<h_X[h] 8" D_bied > [j Wb '//- J^[ i[b\#jWff_d] 8hWd[cWah
_cfbWdj0+#o[Whh[ikbjie\Wfheif[Yj_l[)#Y[dj[hijkZo$9b_d
EhWb?cfbH[i.0(-/Ä(.+
<hecel_Y^ E" ?^Z[ I '/// :[h _dj[hd[ I_dkib_\j \”h XWiWb
eii[e_dj[]h_[hj[?cfbWdjWj[$:[djWbIf_[][b'0)'Ä*+
<heij >C '/,* CWj^[cWj_YWb [b[c[dji e\ bWc[bbWh Xed[
h[ceZ[bb_d]$J^ecWi"Ifh_d]\_[bZ
<heij>C'/,*J^[bWmie\Xed[ijhkYjkh[$J^ecWi"Ifh_d]#
\_[bZ
=W_iXWk[h = '//+ Pkh >W\jkd] Z[i PW^dWhpj[i X[_ D[hl[d#
bi_ed[d$L[hiH'//+0'(Ä(&
=W_iXWk[h = '//- PW^dhpjb_Y^#Y^_hkh]_iY^[ ;_d]h_\\[ Wki
^W\jkd]ih[Y^jb_Y^[hI_Y^j$L[hiH'//-0(-*Ä(.+
=[hX[h 7 '/-& Eaabki_edib[^h[" Eaabki_ediZ_W]deij_a
kdZ Eaabki_ediX[^WdZbkd] _c MWdZ[b kdi[h[h 7if[aj[$
IY^m[_pCedWjiY^hPW^dc[Z%HCIE.&0**-Ä*-&
=[hcWd :[djWb 7iieY_Wj_ed (&&) FWj_[dji H_]^ji 9^Whj[h"
ZhWmdkfedX[^Wb\e\j^[=[hcWdC_d_ijh_[ie\@kij_Y[WdZ
>[Wbj^%IeY_Wb I[Ykh_jo m_j^ fWhj_Y_fWj_ed e\ j^[ =[hcWd
:[djWb7iieY_Wj_ed"WiWc[dZ[ZEYjeX[h(&&)
=_WlWh[i_ =" <_d_ C" 9_]WZW 7 (&&) >_ijecehf^ec[jh_Y
WdZ c_Yhe^WhZd[ii Wii[iic[dji e\ i^[[f Yehj_YWb Xed[
ikhhekdZ_d] j_jWd_kc _cfbWdji m_j^ Z_\\[h[dj ikh\WY[
jh[Wjc[dj$@8_ec[ZCWj[hH[i,-70''(Ä'(&
=b_cY^[hC@"A[dpehW@;'/-/J^[X_ebe]oe\eij[ed[Yhei_i
e\ j^[ ^kcWd \[cehWb ^[WZ WdZ _ji Yb_d_YWb _cfb_YWj_edi$
:_iYkii_ed e\ j^[ [j_ebe]o e\ j^[ fWj^ebe]_YWb i[gk[bW[1
Yecc[djiedjh[Wjc[dj$9b_dEhj^ef'*&0(-)Ä)'(
=eZXekj CH" Fe_jhWi O (&&( <kbb cekj^ \_n[Z _cfbWdj
h[^WX_b_jWj_ed \eh W fWj_[dj m_j^ YecX_dWj_ed iodZhec[$
?djCEhWb?cfbWdjeb'0()Ä(.
=ebZ^WX[h8'/+.J^[[\\[Yje\^of[hen_WedXed[h[iehfj_ed
_dj_iik[Ykbjkh[$7hY^FWj^eb,,0,)+Ä,*'
=ec[i C;" I_aWl_jiWi L?" 8[^hWl[i^ ;" H[_i HB" C_aei
7= (&&) ;\\[Yj e\ \bem f[h\ki_ed ed j^[ eij[e][d[j_Y
Z_\\[h[dj_Wj_ed e\ Xed[ cWhhem ijhecWb Y[bbi Ykbjkh[Z ed
ijWhY^#XWi[Zj^h[[#Z_c[di_edWbiYW\\ebZi$@8_ec[ZCWj[h
H[i,-70.-Ä/+
=eeZi^_f 7;" BWdoed B;" CY<_[ > '/-/ <kdYj_edWb
WZWfjWj_ed e\ Xed[ je _dYh[Wi[Z ijh[ii$ @ 8ed[ @e_dj Ikh]
,'70+)/Ä+*,
=ekbZ CI" F_Yjed F97 '/,, J^[ h[bWj_ed X[jm[[d
_hh[]kbWh_j_[ie\j^[j[[j^WdZf[h_eZedjWbZ_i[Wi[$8h:[dj
@'('0(&Ä(+
*&'
=hW\>B">[cfh_Y^7"H_Y^j[h@">[hhcWddJ"H[cc[hXWY^J
'///=[hcWdfWj[dj:;'//&-*(&7'
=h_cc="8h[_jb_Y^;'/,'Ah_j_iY^[8[m[hjkd]Z[hEf[hW#
j_edi[h][Xd_ii[ led '/' Fhe][d_[\bb[d kdj[h X[iedZ[h[h
8[h”Yai_Y^j_]kd]Z[iL[h\W^h[diledEXm[][i[h%:WbFedj$
:jiY^PW^dCkdZA_[\[h^[_ba,'0(/+Ä)')
=heii C:"7hX[b =" >[hi^ael_jp ? (&&' J^h[[#Z_c[di_edWb
\_d_j[[b[c[djWdWboi_ie\j^[\WY_Wbia[b[jededi_ckbWj[Z
eYYbkiWbbeWZ_d]$@EhWbH[^WX_b(.0,.*Ä,/*
=”ch” E" AeYWa > '//, 7Ykj[ cWn_bbWho i_dki_j_i \hec
Z[djWb_cfbWdj$@CWhcWhWKd_l:[djWb<WY(0++'Ä++)
=odj^[h=M"CWhX'//.:[djWb_cfbWdj_dijWbbWj_edm_j^ekj
Wdj_X_ej_Y fhef^obWn_i$ EhWb Ikh] EhWb C[Z EhWb FWj^eb
EhWbHWZ_eb;dZe.+0+&/Ä+''
>WdWk HB '/(. :_[ 7hj_akbWj_edi#Gk_dj$ PW^dhpjb_Y^[
HkdZiY^Wk).0'+,.Ä'+-(
>WhWbZiedJ"9Whbiied=;'/--8_j[\ehY[WdZehWb\kdYj_ed
_d fWj_[dji m_j^ eii[e_dj[]hWj[Z ehWb _cfbWdji$ IYWdZ @
:[djH[i.+0(&&Ä(&.
>WhZjcWdd =" FhiY^[b F" Ejj HM '/./ AWkah\j[ kdZ
cWn_cWb[ A_[\[hiY^b_[œah\j[ led JejWbfhej^[i[djh][hd
lehkdZdWY^8_ii^[Xkd]$:jiY^PW^dhpjbP**0(,Ä(/
>WhjcWdd >@ (&&& Fhe kdZ AedjhW pkh ie\ehj X[bWij[j[d
;_dp[bpW^d_cfbWdjWj_ed$PW^dWhpjM_hjiY^W\jFhWn_i'0/*Ä
/+
>Wii[b JC" =[hcWdd C7" IWn[h KF '/-) F[h_eZedjWb
fheX_d]0?dj[h#_dl[ij_]Wj_edZ_iYh[fWdY_[iWdZYehh[bWj_edi
X[jm[[d fheX_d] \ehY[ WdZ h[YehZ[Z Z[fj^$ >[bl EZedj
7YjW'-0).Ä*(
>Wjjd[hH"<heij>C'/,)C[Wdia[b[jWbW][0_jiYWbYkbWj_ed"
WdZj^[eh[j_YWb[\\[Yjiedia[b[jWbjhWY[hf^oi_ebe]oWdZed
j^[f^oi_YWbY^WhWYj[h_ij_Yie\Xed[$>[dho<ehZ>eifC[Z
8kbb''0(&'Ä(',
>[cf\_d] M '//+ 7k\abhkd]if\b_Y^j kdZ 7hpj^W\jkd]$
;Yec[ZBWdZiX[h]'//+0,-Ä,.
>[hX[h^ebZ 9 '/.( F^oi_ebe]_[ kdZ FWj^ef^oi_ebe]_[ Z[h
DWi[dd[X[d^^b[d$7hY^Ejeh^_debWhod]eb()+0'Ä*&
>[jp = (&&' :_[ <hW][ dWY^ Z[h ?cfbWdjWjmW^b$ PCA
'-0+',Ä+(&
>_ZZ_d] @" BWpWh <" Pbb[h @; '/// ;hij[ ;h][Xd_ii[ X[_
Z[h l[hj_aWb[d :_ijhWaj_edieii[e][d[i[ Z[i Wjhef^_[hj[d
7bl[ebWhaWcci$CkdZA_[\[h=[i_Y^jiY^_h'0-/Ä.)
>_[biY^[hM'/,'PkhA_[\[h][b[da#:_W]deij_aWk\hdj][d#
ebe]_iY^[c=[X_[jkdj[hPk^_b\[dW^c[a_d[cWje]hW\_iY^[h
IjkZ_[d Z[h aedZobh[d 8[m[]kd]iXW^d[d$ :jiY^ PW^d#
hpjbP[_jiY^h',0'('&Ä'('-
>ehem_jpIB"I^Wf_he>>'/++CeZ_\_YWj_ede\iakbbWdZ`Wm
WhY^_j[Yjkh[ \ebbem_d] h[celWb e\ j^[ cWii[j[h ckiYb[ _d
j^[hWj$7c@F^oi7dj^hef')0)&'Ä)&.
>ejpM'//':_[ikXWdjhWb[7k]c[djWj_edc_j^ecebe][c
AdeY^[d pkh IY^W\\kd] [_d[i ijWX_b[d [deiiWb[d
?cfbWdjWjbW][hi$PCA,0,
>kW`_Wd =" 8We^kW @" @][h ?" 7hpj ; [j Wb (&&) CWj[h_Wbi
X[Yec[ _di[di_j_l[ je \bWmi Wj dWdeiYWb[0 B[iiedi \hec
dWjkh[$FD7I'&&0++/-Ä+,&&
>kc[h_djW A" HW^aWce 7" >WWl_aae A '//- 9ecfWh_ied
X[jm[[dY[f^Wbec[jh_YYbWii_\_YWj_edc[j^eZi\ehiW]_jjWb
`Wmh[bWj_edi^_fi$;kh@EhWbIY_'&+0(('Ä((-
>kd[a[ < '/./ :Wi I[akdZ[d#F^dec[d _d Z[h D[khWb#
j^[hWf_[",j^[Zd$AWhb<$>Wk]L[hbW]">[_Z[bX[h]
>obWdZ[h MB '/-/ J^[ \kdYj_edWb i_]d_\_YWdY[ e\ fh_cWj[
cWdZ_XkbWh\ehc$@Cehf^eb',&0(()Ä(*&
?9:?cfbWdjehWbYbkX:[kjiY^bWdZ'///Aedi[dikipk8E?$
IY^m[_pCedWjiiY^hPW^dc[Z'&/0/-'Ä/-(
*&( 2EFERENCES
?^Z[ A '/'' {X[h Wd][Xb_Y^[ PW^dWdbW][d X[_ L][bd$
?dWk]khWbZ_ii[hjWj_ed"8[hb_d
?^Z[I'//.IWd_[hkd]c_jXWiWbeii[e_dj[]h_[hj[d?cfbWd#
jWj[d$9ebb[]CW]Wp_d+0').Ä'*,
?^Z[ I '/// <_n[Z fheij^eZedj_Yi _d ia[b[jWb 9bWii ???
fWj_[dji m_j^ fWhj_Wbbo [Z[djkbeki `Wmi WdZ W][ h[bWj[Z
fhe]dWj^_ic0 J^[ XWiWb eii[e_dj[]hWj_ed fheY[Zkh[$
?cfbWdj:[dj_ijho.0(*'Ä(*,
?^Z[ I (&&' H[ijehWj_ed e\ j^[ Wjhef^_[Z cWdZ_Xb[ ki_d]
XWiWb eii[e_dj[]hWj[Z _cfbWdji WdZ \_n[Z fheij^[j_Y
ikf[hijhkYjkh[i$?cfbWdj:[dj_ijho'&0*'Ä*+
?^Z[ I (&&( Eij[ejec_[ X[_ 8E?#?cfbWdjWj[d0M_[ a”^b[d5
:[djWbif_[][b)0*(Ä*)
?^Z[ I (&&) 7ZWfjWj_edi \edYj_ed[bb[i Z[ bW ^Wkj[kh Z[
bÉei f[h_#_cfbWdjW_h[ Wfh„i _cfbWdjWj_ed Z[ 8E? ZWdi bW
cWdZ_Xkb[$?cfbWdjeZedj_['(0()Ä))
?^Z[I"Ckjj[h;(&&)L[hieh]kd]led<h[_[dZi_jkWj_ed[dc_j
XWiWbeii[e_dj[]h_[hj[d?cfbWdjWj[d8E?X[_h[Zkp_[hj[c
l[hj_aWb[cAdeY^[dWd][Xej$:jiY^PW^dhpjbP+.0/*Ä'&(
?^Z[I"IfW^d<F0;khef[WdFWj[dj/.(+&)/+$+
?^Z[I"IfW^d<F0;khef[WdFWj[dj7ffb_YWj_ed;F&/)+/*/
7'
?^Z[I"IfW^d<F0Im_iiFWj[dj9>,/&*',
?d][hlWbb 8 '/-* H[bWj_ed X[jm[[d ^[_]^j e\ j^[ Whj_YkbWh
jkX[hYb[ e\ j^[ j[cfehecWdZ_XkbWh `e_dj WdZ \WY_Wb
cehf^ebe]o$@Fheij^[j:[dj**0'+Ä(*
?d][hlWbb 8" J^_bWdZ[h 8 '/-* H[bWj_edi^_f X[jm[[d \WY_Wb
cehf^ebe]oWdZWYj_l_joe\j^[cWij_YWjehockiYb[i$@EhWb
H[^WX_b'0')'Ä'*-
?dij_jkj IjhWkcWdd 7=" MWbZ[dXkh] '//* :=XhC = /* ')
/,)$,
?i\ehj @" <be[h 8" Aed[Ypdo D"LebbcWh >9" 8kjpbW\\ C (&&(
I^Wh[Z Z[Y_i_ed cWa_d]$ :jiY^ c[Z MeY^[diY^h_\j
'(-0(&('Ä(&(*
?i_Zeh[<'//-9b_d_YWbfheX_d]WdZhWZ_e]hWf^_YWii[iic[dj
_dh[bWj_edjej^[^_ijebe]_YWbXed[b[l[bWjehWb_cfbWdji_d
ceda[oi$9b_dEhWb?cfbWdjH[i.0(++Ä(,*
@WYeXiH"Ij[[dX[h]^[:'//)9ecfWh_iedX[jm[[d_cfbWdj#
ikffehj[Zfheij^[i[iWdZj[[j^h[]WhZ_d]fWii_l[j^h[i^ebZ
b[l[b$?dj@EhWbCWn_bbe\Wn?cfbWdji.0+*/Ä+*
@W\\_dH7"8[hcWdd9[jWb'//'J^[[nY[ii_l[beiie\8hWd[#
cWha\_njkh[i_dJof[?LXed[0W+#o[WhWdWboi_i$@F[h_e#
Zedjeb,(0(Ä*
@Wdi[dC'/(&EdXed[\ehcWj_ed0_jih[bWj_edjej[di_edWdZ
fh[iikh[$Bed]cWdi"BedZed
@Wjkfehd 8 '/.' Pkh H[p_Z_lj[dZ[dp dWY^ Fhe][d_[#
Ef[hWj_ed[d$:_ii[hjWj_ed"Kd_l[hi_joe\Ckd_Y^
@Wmehia_ P<=" B_iaelW#A_Wh C" Kj^e\\ >A '/.& ;\\[Yj e\
bed]#j[hc _cceX_b_pWj_ed ed j^[ fWjj[hd e\ Xed[ beii _d
ebZ[hZe]i$@8ed[@e_djIkh],(80'&*Ä''&
@Wmehia_P<="Kj^e\\>A'/.,H[l[hi_X_b_joe\dedjhWkcWj_Y
Z_iki[ eij[efehei_i Zkh_d] _ji WYj_l[ f^Wi[$ 8ed[ -0*)'Ä
*)/
@[di[d @" AhWdjp H" I_cedi[d ;" I_dZ[j#F[j[hied I '//&
H[YedijhkYj_ed e\ j^[ i[l[h[bo h[iehX[Z cWn_bbW m_j^
Xed[]hW\j_d]WdZeii[e_dj[]hWj[Z_cfbWdji07fh[b_c_dWho
h[fehj$@EhWbCWn_bbe\WYIkh]*.0(-Ä))
@[hdX[h] =H" 8WaZWi^ C8" A[[dWd AC '/.) H[bWj_edi^_f
X[jm[[d fhen_cWb jeej^ ef[d YedjWYji WdZ f[h_eZedjWb
Z_i[Wi[$@F[h_eZedjeb+*0+(/Ä+))
@e^Wdiied="FWbcgl_ijI'//&9ecfb_YWj_edi"ikffb[c[djWho
jh[Wjc[dj" WdZ cW_dj[dWdY[ _d [Z[djkbeki WhY^[i m_j^
_cfbWdj#ikffehj[Z \_n[Z fheij^[i[i$ ?dj @ Fheij^eZedj
)0./Ä/(
@e^died B9" IjhWZ\ehZ >J" =[_i HM" :_d[[d @H [j Wb '/,)
>_ije][d[i_ie\ijh[ii\hWYjkh[i$@8ed[@e_djIkh]*+70'+*(Ä
'+*,
@eei K"Lebbc[h :" Ab[_d^[_dp @ (&&& ;_d\bkii Z[h ?cfbWd#
jWj][ec[jh_[ Wk\ Z_[ IjhW_dl[hj[_bkd] _c f[h__cfbWdjh[d
AdeY^[d$CkdZA_[\[h=[i_Y^jiY^_h*0'*)Ä'*-
@eeiK"<_bb_[iJ"M_[icWdd>F"C[o[hK(&&)Fh_chaed]hk[dp
kdZ AdeY^[dp[bbl[h^Wbj[d Wd Z[h =h[dp\bY^[ led ie\ehj
X[bWij[j[d?cfbWdjWj[d$PPW^dhpjb?cfb'/0'.Ä((
@kbb_[j @C '/-( BÉ_cfbWdj jh_Z_c[di_edd[b$ ?d\ehc :[dj
+)0(-Ä)'
@kbb_[j@C'/-+Kd_j[ZIjWj[iFWj[dj)"/(+"./(
@kd]<'/+(:_[;bWij_p_jjZ[hIa[b[jj[_b[Z[i=[X_iiioij[ci$
J[_b'$IjecW>[_Z[bX[h]+0-*Ä/)
@kd] < '/+/ L[hdZ[hkd][d Z[i Fhej^[i[dbW][hi kdj[h Z[h
J[_bfhej^[i[$:[kjiY^PW^dhpjbP.0'&+Ä'&-
AW^dX[h] A;" Doijhc ;" 8WhjXebZiied B '/./ 9ecX_d[Z
ki[e\Xed[]hW\jiWdZ8hWd[cWha\_njkh[i_dj^[jh[Wjc[dj
e\ i[l[h[bo h[iehX[Z cWn_bbW[$ ?dj @ EhWb CWn_bbe\WY ?cfb
*0(/-
AWjedWJH'/./J^[[\\[Yje\YkifWdZ`Wmcehf^ebe]oed
j^[\ehY[ie\j^[j[[j^WdZj^[j[cfehecWdZ_XkbWh`e_dj$@
EhWbH[^WX',0(''Ä('/
AWjp[dX[_ii[hA'/./7kijh_WdFWj[dj7J)/(+.(8$CWn_bbWho
i_dki_cfbWdj
AWmW^WhW>'/./Kd_j[ZIjWj[iFWj[dj*"/,*".&'
AWmWckhW O '/-* <hedj_[hi e\ ehWb f^oi_ebe]o$ I$ AWh][h"
8Wi[b
A[dj @D '/./ I_ckbjWd[eki cWn_bbWho i_dki \beeh Xed[
]hW\j_d]WdZfbWY[c[dje\^oZhenobWfWj_j[#YeWj[Z_cfbWdji$
@EhWbCWn_bbe\WYIkh]*-0().Ä(*+
A[hb[o ;H '/,+ J^[ c_YheiYef_Y Z[j[hc_dWj_ed e\ W][ _d
^kcWdXed[$7c@F^oi7dj^hef()0'*/Ä',*
A[hd 8H" BWk\i 7 '/// :_[ hpjb_Y^[ 7k\abhkd]if\b_Y^j$
Ifh_d][h"8[hb_d"f.
A[hiY^XWkcJ[jWb(&&'Ab_d_iY^[;h\W^hkd][dc_jF^oi_e#
j^[hWf_[ X[_ FWj_[dj[d c_j iY^c[hp^W\j[d <kdaj_edi#
ijhkd][d$:jiY^PW^dhpjbP+,0+()Ä+(,
A^ekho < '/// 7k]c[djWj_ed e\ j^[ i_dki \beeh m_j^
cWdZ_XkbWhXbeYaWdZi_ckbjWd[eki_cfbWdjWj_ed0W,#o[Wh
Yb_d_YWb_dl[ij_]Wj_ed$?dj@EhWbCWn_bbe\WY?cfb'*0++-Ä+,*
A_³h J^ecWi '//* 8ed[ f[h\ki_ed WdZ eno][dWj_ed$
IYWdZ_dWl_Wd Kd_l[hi_jo Fh[ii"7YjW Ehj^ef IYWdZ" Ikffb
(+-0'Ä*'
A_c C_d#@kd] '/./ 7k\abhkd]if\b_Y^j _c 7hpjh[Y^j$ @kh$
:_ii$"=jj_d][d
A_jj[b="=^h>'/,+8[ij_cckd]ledD[X[d^^b[d]hœ[d$
PBWhod]ebH^_deb**0+/Ä,.
Ab[ca[ @" MWbj^[h M" >[d[hi C '//& Fhej^[j_iY^[h
;h^Wbjkd]iWk\mWdZ X[_ _cfbWdjWj][jhW][d[d Aedkiahed[
daedijhkaj_ed[d$PPW^dhpjb?cfbWdjeb'(0(/Ä)*
AdWX[ P '//- :_[ H[^WX_b_jWj_ed Z[i \kdaj_edi][ijhj[d
FWj_[dj[dc_j_cfbWdjWj][jhW][d[cPW^d[hiWjpWkiJ_jWd$
PW^dhpjb_Y^[?cfbWdjebe]_[')0(-Ä).
AdWki 7 [j Wb (&&& ;h\W^hkd][d c_j feij[h_eh[d
7Xij”jpkd]i_cfbWdjWj[d$:jiY^PW^dhpjbP++0*,'Ä*,*
AeXb_d ?" H[_b 8 '/-* I[di_j_l_jo e\ j^[ bem[h b_f W\j[h fhe#
j[Yj_ed eh h[i[Yj_ed e\ j^[ _d\[h_eh Wbl[ebWh d[hl[ _d fhe#
][d_Wef[hWj_edi$<ehjiY^hA_[\[h=[i_Y^jiY^_h'.0'+'Ä'+*
Add_d] 7 '/./ Pkh H[Y^jidWjkh Z[i PW^dWhpjl[hjhW][i$
L[hiH'/./0(()Ä()&
AedijWdj_del_Y L (&&) 7if[aj[ Z[h _cfbWdjebe]_iY^[d
L[hieh]kd]c_j8E?_c8[h[_Y^Z[iI_dkicWn_bbWh_i$PCA
'/0+,.Ä+-+
È È 2EFERENCESÈ
AedijWdj_del_Y L" ?^Z[ I" 9kj_be 8 (&&( :[h Æab[_d[
H[_\[dm[Y^i[bÇ Ä 7kijWkiY^ [_d[i 8E? kdj[h Z[h leh#
^WdZ[d[d \[iji_jp[dZ[d L[hieh]kd]$ :[dj ?cfbWdjeb
,0)+.Ä),'
Aeh_ej^JMF">WddWc7='//*:[\ehcWj_ede\j^[^kcWd
cWdZ_Xb[ Zkh_d] i_ckbWj[Z jeej^ Yb[dY^_d]$ @ :[dj H[i
-)0+,Ä,,
AhW\j;'/,({X[hZ_[8[Z[kjkd]Z[hAWkahW\j\”hZWiAWk#
][iY^[^[d$PW^dhpjbFhWn_i')0'(/Ä')&
Akda[b C" H[_Y^[hj J; (&&) I_dki_j_i cWn_bbWh_i dWY^
_dj[hd[cI_dkib_\j$PC/)0+(Ä+)
Akhj_i7@'/..Kd_j[ZIjWj[iFWj[dj*"-,."/+,
BWdZ_i M@ '//+ J^[ ijh[d]j^ e\ W YWbY_\_[Z j_iik[ Z[f[dZi
_dfWhjedj^[ceb[YkbWhijhkYjkh[WdZeh]Wd_pWj_ede\_ji
Yedij_jk[djc_d[hWbYhoijWbi_dj^[_heh]Wd_YcWjh_n$8ed[
',0+))Ä+**
BWd]DF"8hW]][hK'//'F[h_eZedjWbZ_W]dei_i_dj^['//&i$
@9b_dF[h_eZedjeb'.0)-&Ä)-/
BWd]DF">_bbMH'/--HWZ_e]hWf^i_df[h_eZedj_Yi$@9b_d
F[h_eZedjeb*0',Ä(.
BWd]D"M[jp[b7"Ij_Y^>'//*>_ijebe]_YfheX[f[d[jhWj_ed
_d ^[Wbj^o WdZ _d\bWc[Z f[h_#_cfbWdj#j_iik[i$ 9b_d EhWb
?cfbWdjH[i+0'/'Ä(&'
BWk\i7"K^b[dXhkYaM(&&(>WdZXkY^Z[i7hpjh[Y^ji$9>
8[YaL[hbW]"C”dY^[d
BWpWh<[jWb'///AdY^[hd[H[][d[hWj_edZ[iKdj[ha_[\[hW
bl[ebWh\ehjiWjp[ic_j>_b\[Z[hl[hj_aWb[dAWbbkiZ_ijhWaj_ed$
:jiY^PW^dhpjbP+*0+'Ä+*
B[Z[hcWdd F: '/-- Lebbfhej^[j_iY^[ L[hieh]kd] Z[i
Wjhef^_[hj[d FheXb[ckdj[ha_[\[hi c_j >_b\[ led 98I#
?cfbWdjWj[d$Gk_dj[ii[dp"8[hb_d"f'("H[\$De$+,/.
B[Z[hcWdd F: '/-- ;hij[ Lehij[bbkd] Z[h B[Z[hcWdd#
IY^hWkX[ Wki J_jWd \”h Z_[ ie\ehjij[]fhej^[j_iY^[ L[h#
ieh]kd] Z[i pW^dbei[d Wjhef^_[hj[d Kdj[ha_[\[hi _d Z[h
H[]_e _dj[h\ehWc_dWb_i$ Fh[i[djWj_ed Wj 7I?E" Bk]Wde"
Im_jp[hbWdZ
B[Z[hcWdd F:" C[][hj : (&&) Pkh Ie\ehjX[bWijkd] led
?cc[Z_Wjij[][dWk\IY^hWkX[d_cfbWdjWj[d$:[dj?cfbWdjeb
-0'&&Ä'&.
B[l_jjIH'//&Fh[Z_Yj_l[lWbk[e\j^[JC@iYWb[_dZ[j[Yj_ed
fioY^ebe]_YWbfheXb[ciWdZded#JC@Z_iehZ[hi_dfWj_[dji
m_j^j[cfehecWdZ_XkbWhZ_iehZ[hi$@9hWd_ecWdZ_XFhWYj
.0((+Ä())
B_[Xb H" ;m[hi H '/.& A_[\[h][b[dail[hdZ[hkd][d dWY^
a_[\[hehj^efZ_iY^[d Ef[hWj_ed[d$ :jiY^ PW^dhpjb P
)+0'(.Ä')*
B_c A7 (&&& :[j[hc_dWj_ed e\ l[hj_YWb Z_c[di_edi Xo
X_j_d]\ehY[$CWbWoi_Wd:[djWb@-0()Ä).
B_dZgk_ij BM" 9Whbiied =; '/.( 9^Wd][i _d cWij_YWjeho
\kdYj_ed _d Yecfb[j[ Z[djkh[ m[Wh[hi W\j[h _di[hj_ed e\
Xh_Z][i ed eii[e_dj[]hWj[Z _cfbWdji _d j^[ bem[h `Wm$
?d0 B[[ 7@9" 7bXh[ajiied J" 8hd[cWha F? [Zi 9b_d_YWb
Wffb_YWj_ede\X_ecWj[h_Wbi$@e^dM_b[o"9^_Y^[ij[h
B_daemB'//&?cfbWdjZ[dj_ijhojeZWo$7ckbj_Z_iY_fb_dWho
WffheWY^"lebi'Ä)$F_YY_d"FWZelW"?jWbo
B_did[ I" IY^c_Zj#8[[h K" =ejjmWbZ C" =h”dZ[h C" Ae[Ya
8 (&&* AWkahW\j X[_ FWj_[dj[d c_j :[\[aj[d _c A_[\[h#
X[h[_Y^$:jiY^PW^dhpjbP+/0/.Ä'&'
Be]_delW DA" Ah[Y^_dW O[A '//. J^[ c_YheY_hYkbWj_ed _d
f[h_eZedjWb j_iik[i0 ($ J^[ WYj_ed e\ j^[ h[]kbWh ki[ e\
Y^[m_d]]kc$IjecWjebe]_oW--0()Ä(*
Be]_delW DA" PW_ji[lW ?L" =k[i[lWO '//. J_c[ Yekhi[ e\
f[h_eZedjWb^[ceZodWc_Yi_dh[]kbWhWdZi^ehjj[hc]kc
Y^[m_d]$IjecWjebe]_oW--0(+Ä(-
*&)
Bkij_] @F" BedZed :" :eh 8B" OWdae H (&&) KbjhWiekdZ
_Z[dj_\_YWj_ed WdZ gkWdj_jWj_l[ c[Wikh[c[dj e\ XbeeZ
ikffbojej^[Wdj[h_ehfWhje\j^[cWdZ_Xb[$EhWbIkh]EhWb
C[ZEhWbFWj^ebEhWbHWZ_eb;dZeZ/,0,(+Ä,(/
B”jpC(&&(B[X[dibkij$FWjbeY^"C”dY^[d
CWY_djei^ H8 '/.' ;nf[h_[dY[ m_j^ j^[ iW]_jjWb eij[ejeco
e\ j^[ cWdZ_XkbWh hWcki0 W ')#o[Wh h[l_[m$ @ 9hWd_e#
CWn_bbe\WY_WbIkh]/0'+'Ä,+
CWa_A"C_bb[h7@"EaWdeJ">WjY^[h:"OWcW]kY^_J"AeXWoWi^_
>" I^_XWiWa_ O (&&' 9ehj_YWb Xed[ c_d[hWb Z[di_jo _d
Wiocc[jh_YWbcWdZ_Xb[i0Wj^h[[#Z_c[di_edWbgkWdj_jWj_l[
Yecfkj[Z jece]hWf^o ijkZo$ ;kh @ Ehj^eZedj_Yi ()0('-Ä
()(
CWdied @:" BkYWi H8 '/,( 7 c_YhehWZ_e]hWf^_Y ijkZo e\
j^[ W][ Y^Wd][i _d j^[ ^kcWd cWdZ_Xb[$ 7hY^ EhWb 8_eb
-0-,'Ä-,/
CWhYWYY_d_7C"DelW[i78@h[jWb(&&)?cc[Z_Wj[fbWY[c[dj
e\_cfbWdji_djef[h_eZedjWbbo_d\[Yj[Zi_j[i_dZe]i$FWhj
(0 \bkeh[iY[dY[ c_YheiYefo ijkZo$ ?dj @ EhWb CWn_bbe\WY
?cfbWdji'.0.'(Ä/
CWh]edWh H" IWaWakhW 9;" [j Wb (&&) J^[ _d\bk[dY[ e\
Z_WX[j[i c[bb_jki WdZ _dikb_d j^[hWfo ed X_ec[Y^Wd_YWb
h[j[dj_ed WhekdZ Z[djWb _cfbWdji0 W ijkZo ed hWXX_ji$
?cfbWdj:[dj_ijho*0)))Ä))/
CWhamWhZj C '/.) L[h]b[_Y^[dZ[ Kdj[hikY^kd][d Z[h
H[Y^jifh[Y^kd] Z[i 8=> kdZ Z[h 8[hk\i][h_Y^j[ pkh
IjhW\XWha[_j kdZ 7^dZkd] Z[i hpjb_Y^[d 8[^WdZbkd]i#
\[^b[hi$@kh$:_ii$"C”dY^[d
CWhj_dH8"8khh:8'/.(7^ofej^[j_YWbc[Y^Wd_ic\ehj^[
ij_ckbWj_ed e\ eij[edWb h[ceZ[bb_d] Xo \Wj_]k[ ZWcW][$ @
8_ec[Y^Wd_Yi'+0')-Ä')/
CWhj_d H8" 8khh :8 '/./ J^[ ijhkYjkh[" \kdYj_ed" WdZ
WZWfjWj_ede\YecfWYjXed[$HWl[dFh[ii"D[mOeha
CWhj_d H8" 8khh :8" I^Wha[o D7 '//. Ia[b[jWb j_iik[
c[Y^Wd_Yi$Ifh_d][h"D[mOeha
CWhn H;" =Wh] 7A '//. 8ed[ ijhkYjkh[" c[jWXeb_ic" WdZ
f^oi_ebe]o0 _ji _cfWYj ed Z[djWb _cfbWdjebe]o$ ?cfbWdj
:[dj-0(,-Ä(-,
CWikhH(&&'7kY^iY^m_[h_][WdWjec_iY^[<bb[add[dWd
[_d[cJW]l[hieh]jm[hZ[d$:PMIf[p_Wb+0')Ä',
CY7ZWc 8bWa[ : '/-, Jeej^ beWZ_d] WdZ YkifWb ]k_ZWdY[
WdZ]hekf\kdYj_edeYYbki_edi$@Fheij^[j:[dj)+0(.)Ä(/&
CY7bb_ij[h 8I" CWh]eb_d C:" 9e]Wd 7=" 8kYa :" >ebb_d][h
@E" BodY^ I; '/// ;_]^j[[d#cedj^ hWZ_e]hWf^_Y WdZ
^_ijebe]_Y [lWbkWj_ed e\ i_dki ]hW\j_d] m_j^ Wdeh]Wd_Y
Xel_d[Xed[_dj^[Y^_cfWdp[[$?dj@EhWbCWn_bbe\WY?cfb
'*0),'Ä),.
CYA_ddo HL" Aehj^ :9" Ij[\b_a :; '/.+ 9b_d_YWb ijWdZWhZ
\eh Z[djWb _cfbWdji$ ?d0 9bWha @M [Z 9b_d_YWb Z[dj_ijho$
>Whf[hHem"F^_bWZ[bf^_W
C[ZHC[Z_p_dh[Y^j$Ifh_d][h">[_Z[bX[h]$LWh_ekio[WhiWdZ
_iik[i
C[hY_[hF"BW\edjWdjH'/-/H[i_ZkWbWbl[ebWhh_Z][Wjhef^o0
9bWii_\_YWj_edWdZ_d\bk[dY[e\\WY_Wbcehf^ebe]o$@Fheij^[j
:[dj*'0/&Ä'&&
C[hY_[hF"L_d[j7'/.)<WYjehi_dlebl[Z_dh[i_ZkWbWbl[ebWh
h_Z][Wjhef^oe\j^[cWdZ_Xb[$@9Wd:[dj7iid+0))/Ä)*)
C[h_Yia[#Ij[hd H: '//( J^h[[#Z_c[di_edWb \ehY[
c[Wikh[c[dji ed cWdZ_XkbWh _cfbWdji ikffehj_d] el[h#
Z[djkh[i$?dj@EhWbCWn_bbe\WY?cfbWdji-0'.+Ä'/*
C[h_Yia[#Ij[hd H: '//+ EYYbkiWb \ehY[ WdZ ehWb jWYj_b[
i[di_X_b_joc[Wikh[Z_dfWhj_Wbbo[Z[djkbekifWj_[djim_j^
?J?_cfbWdji$?dj@EhWbCWn_bbe\WY?cfbWdji'&0)*+Ä)+)
C[h_Yia[#Ij[hd H: (&&& CWdW][c[dj e\ j^[ [Z[djkbeki
fWj_[dj$9b_dEhWb?cfbH[iIkffb''0'&.Ä'(+
*&* 2EFERENCES
C[h_Yia[#Ij[hd H: (&&( ?dWk]khWb b[Yjkh[$ Kd_l[hi_jo e\
8[hd[
C_Y^Wbia_ < '//- PW^d#uhpjb_Y^[7k\abhkd]if\b_Y^j ”X[h
Z_[ ;hiWjp\^_]a[_j led >[_bX[^WdZbkd]iaeij[d$ L[hiH
'//-0')-Ä'*'
C_dW]_"7aWcWjik"CWjikd]W"IWje'/..@EhWbH[^WX(+0/&(Ä
/&-
C_bb[i_#IY^eX[b=7"C_bb[i_M"=bWi[h9"MWjp_d][h<"Abk]9"
;m[hiH(&&&J^[bW#i^Wf[Zeij[ejeco\ehl[hj_YWbYWbbki
Z_ijhWYj_ed_dj^[cebWhh[]_ede\j^[cWdZ_Xb[0Wj[Y^d_YWb
dej[$@9hWd_e#CWn_bbe\WYIkh](.0'-,Ä'.&
C_iY^ 9; (&&& EX`[Yj_l[ li$ ikX`[Yj_l[ c[j^eZi \eh
Z[j[hc_d_d]l[hj_YWbZ_c[di_ede\eYYbki_ed$Gk_dj[ii[dY[
?dj)'0(.(Ä(.(
Cbb[h ; '/,, J^[ Y^[m_d] WffWhWjki$ 7YjW F^oi_ebe]_YW
IYWdZ,/0',,Ä'-*
CecX[bb_7" C”^b[ J" 8hW]][h K [j Wb '/.- 9ecfWh_ied e\
f[h_eZedjWb WdZ f[h__cfbWdj fheX_d] Z[fj^ \ehY[ fWjj[hd
WdWboi_i$9b_dEhWb?cfbWdjiH[i.0**.Ä*+*
CecX[bb_ 7" LWd Eeij[d C79" IY^khY^ ; [j Wb '/.- J^[
c_YheX_ejW WiieY_Wj[Z m_j^ ikYY[ii\kb eh \W_b_d] eii[e#
_dj[]hWj[Z j_jWd_kc _cfbWdji$ EhWb C_YheX_Wb ?cckdeb
(0'*+Ä'+'
CecX[bb_ 7" C”^b[ J" <h_]] H '//( :[fj^ \ehY[ fWjj[hdi
e\ f[h_eZedjWb fheX_d]$ 7jjWY^c[dj ]W_d _d h[bWj_ed je
fheX_d]\ehY[$@9b_dF[h_eZedjeb'/0(/+Ä)&&
Ceeh[ M@ '/-) 7d [nf[h_c[djWb ijkZo e\ j^[ \kdYj_edWb
Yecfed[djie\j^[]hemj^_dj^[hWjcWdZ_Xb[$7YjW7dWj
.+0)-.Ä).+
Ceh_ I" 8khh :8 '//) ?dYh[Wi[Z _djhWYehj_YWb h[ceZ[bb_d]
\ebbem_d]\Wj_]k[ZWcW][$8ed['*0'&)Ä'&/
Ckbb[dZ[hC=">k_ia[iH"M[_dWdi>'//*7f^oi_ebe]_YWb
WffheWY^ je j^[ i_ckbWj_ed e\ Xed[ h[ceZ[b_d] Wi W i[b\#
eh]Wd_pWj_edWb Yedjheb fheY[ii$ @ 8_ec[Y^Wd_Yi (-0'/).Ä
')/*
C”bb[hA>'///=[hcWdFWj[dj:;'//&(.,'7'
C”bb[h#>[hpe] H" B_dZeh\ >> '//, :Wi +#cc#8hd[cWha#
?cfbWdjWj _c EX[ha_[\[h#I[_j[dpW^dX[h[_Y^$ :jiY^ PW^d#
hpjbP(0'&,Ä''&
DW[hj?"=_pWd_I"Lkobij[a[C[jWb'//.+#o[WhhWdZec_p[Z
Yb_d_YWb jh_Wb ed j^[ _d\bk[dY[ e\ ifb_dj[Z WdZ kdifb_dj[Z
ehWb_cfbWdji_dj^[cWdZ_XkbWhel[hZ[djkh[j^[hWfo"fWhj
?0F[h_#_cfbWdj#ekjYec[$9b_dEhWb?cfbWdjiH[i/0'-&Ä'--
D^h_JE";jj_d][hHB"BWc;M'/.-HWZ_e]hWf^_Y\_dZ_d]i"
h_Z][ h[iehfj_ed WdZ ikX`[Yj_l[ YecfbW_dji e\ Yecfb[j[
Z[djkh[fWj_[dji$?dj@Fheij^eZedj_Yi'&0'.)Ä'./
DWdZW AI" C[hem MM" IWiiekd_ L '/,. H[fei_j_ed_d] e\
j^[ cWii[j[h ckiYb[ WdZ _ji [\\[Yj ed ia[b[jWb \ehc WdZ
ijhkYjkh[$ IY^eeb e\ :[dj_ijho FkXb_YWj_edi"M[ijL_h]_d_W
Kd_l[hi_jo"Ceh]Wdjemd")-0)&*Ä)&.
DWkcWdd C" BWd][ AF (&&) 7di_Y^j[d kdZ J[Y^d_a pkh
H[aedijhkaj_ed [dZeZedj_iY^ X[^WdZ[bj[h P^d[$ :jiY^
PW^dhpjbP+0(.&Ä(.+
D[k\[bZ @E '/+. 9^Wd][i _d j^[ jhWX[YkbWh fWjj[hd e\ j^[
cWdZ_Xb[ \ebbem_d] j^[ beii e\ j[[j^$ @ Fheij^[j :[dj
.0,.+Ä,/-
D[kaWc <M '//, Ab_d_iY^[ ;h\W^hkd][d pkh L[hieh]kd]
Z[i Wjhef^_iY^[d EX[ha_[\[hi _d AecX_dWj_ed c_j
AdeY^[djhWdifbWdjWj[d kdZ ?cfbWdjWj[d$ :[kjiY^
PW^dhpjbP+'0'&Ä',
DeY_j_<>"Ij[\Wd_9C"CWY^WZeC7D[jWb(&&&>_ijec[jh_Y
[lWbkWj_ed e\ Xed[ h[][d[hWj_ed WhekdZ _cc[Z_Wj[
_cfbWdji fWhj_Wbbo _d YedjWYj m_j^ Xed[0 W f_bej ijkZo _d
Ze]i$?cfbWdj:[dj_ijho/0)('Ä)(-
Dej^Zkh\j > '/,' IWhaec[hp[k]kd] X[_ HWjj[d ZkhY^
_cfbWdj_[hj[<h[cZahf[h$J^[hC^CWdd^[_c.0(,(Ä(.+
Doijhc ;" AW^dX[h] ;" =kdd[ A '//) 8ed[ ]hW\ji WdZ
8hWd[cWha _cfbWdji _d j^[ jh[Wjc[dj e\ j^[ i[l[h[bo
h[iehX[Z cWn_bbW0 W (#o[Wh bed]_jkZ_dWb ijkZo$ ?dj @ EhWb
CWn_bbe\WY?cfb.0*+Ä+)
EWab[oC[jWb'///:[dj_ijiÉWX_b_jojeZ[j[YjfioY^ebe]_YWb
fheXb[ci _d fWj_[dji m_j^ j[cfehecWdZ_XkbWh Z_iehZ[hi
WdZY^hed_YfW_d$@7c:[dj7iieY''.0-(-Ä)&
E[^b[h A (&&) PW^dc[Z_p_d_iY^[h IjWdZWhZ _d Z[h H[Y^j#
ifh[Y^kd]$:[kjiY^7[hpj[L[hbW]=cX>"Abd
E[ncWdd 8" =[eh] 7 '/./ :_[ p_l_bh[Y^jb_Y^[ >W\jkd] Z[i
PW^dWhpj[i$M[hd[h":”ii[bZeh\"cWh]_ddej[*&.
EB=>WcXkh]"i[[=HKHH#HH(&&)"'&+H[Wied_d]7
Eh[dij[_d?>"JWhdem:F"Cehh_i><"EY^_I(&&&J^h[[#o[Wh
feij#fbWY[c[djikhl_lWbe\_cfbWdjiceX_b[WjfbWY[c[dj$
7ddF[h_eZedjeb+0)(Ä*'
Ejj='/-&<h[cZahf[hiWhaec[$Ifh_d][h"8[hb_d
EjjM; '/.)LehWkii[jpkd][d Z[h p_l_bh[Y^jb_Y^[d >W\jkd]
Z[i7hpj[i$@kh$:_ii$"P”h_Y^
FWbWdZj#>[_dh_Y^i (&&) 8”h][hb_Y^[i =[i[jpXkY^" ,)j^ [Zd$
C”dY^[d"i[Yj_ed(*("cWh]_ddej[)-
FWfJ[jWb(&&)Eij[eYbWij#_dZ[f[dZ[djXed[h[iehfj_edXo
\_XheXbWij#b_a[Y[bbi$7hj^h_j_iH[iJ^[h.+0',)Ä'-)
F[bb_ii_[h9'/.-<WYj[khifeZWb[jeYkbW_h[ZWdib[ijhekXb[i
Zk jedki feijkhWb$ ?dWk]khWb Z_ii[hjWj_ed" CWhi[_bb["
<hWdY[
F[dd[Wk@'//,BWh[ifediWX_b_jƒZkcƒZ[Y_d$9eddW_iiWdY[
ZkZhe_j"(„c[ƒZ$:Wbbep"9ebb
F[jhelD"FebbWYaIH(&&)9ecfWhWj_l[WdWboi_ie\Z_\\ki_l[
WdZ ijh[ii _dZkY[Z dkjh_[dj jhWdifehj [\\_Y_[dYo _d j^[
bWYkdWh#YWdWb_YkbWh ioij[c e\ eij[edi$ 8_eh^[ebe]o
*&0)*-Ä)+)
F[jhel D" FebbWYa I" 8be]e[lW H '/./ 7 Z_iYh[j[ ceZ[b
\eh ijh[Wc_d] fej[dj_Wbi _d W i_d]b[ eij[ed$ @ 8_ec[Y^
((0+'-Ä+('
F\[_\\[h I '//. LWh_WX_b_jo _d eij[ed i_p[ _d h[Y[dj ^kcWd
fefkbWj_edi$7c@F^oi7dj^hefeb'&,0('/Ä((-
F_Wjj[bb_C"<Wl[he=7"IYWhWde7"Ehi_d_="F_Wjj[bb_7'///
8ed[ h[WYj_edi je Wdeh]Wd_Y Xel_d[ Xed[ 8_e#Eii ki[Z
_di_dkiWk]c[djWj_edfheY[Zkh[i0W^_ijebe]_Ybed]#j[hc
h[fehj e\ (& YWi[i _d ^kcWdi$ ?dj @ EhWb CWn_bbe\WY ?cfb
'*0.)+Ä.*&
FbWdWi F '//( BW hƒ^WX_b_jWj_ed d[khe#eYYbkiWb[$ CWiied"
FWh_i
Fb[dYa > @h '/., J^[ c_YheiYef_Y [lWbkWj_ed e\ ^WhZ#
j_iik[ _cfbWdji$ ?d0 M_bb_Wci :< [Z J[Y^d_gk[i e\
X_eYecfWj_X_b_joj[ij_d]$9H9Fh[ii"8eYWHWjed"ff)+Ä.'
FebbWa=M(&&'FhkpdW:WidelW[f_j[pW$?d0I_ckd[a7[Z
:[djWbd_?cfbWdjebe]_["DkYb[ki>A
Fhe\\_jMH"M^_j[ HF '//' Ikh]_YWb#ehj^eZedj_Y jh[Wjc[dj$
CeiXoO[Wh8eea"Ij$Bek_i"8Wbj_ceh[
Fhbii @" CWhj_d 7 '//.L[hi_Y^[hkd]il[hjhW]i][i[jp" C”d#
Y^[d"™'C8AA"dej[(8W
Gk_hod[d C" LWd Ij[[dX[h]^[ :" @WYeXi H [j Wb '//' J^[
h[b_WX_b_jo e\ feYa[j fheX_d] WhekdZ iYh[m#jof[ _cfbWdji$
9b_dEhWb?cfbH[i(0'.,Ä'/(
HW]^e[XWh =C" 8Wj[dXkh] H>A" J_cc[d]W DC" L_ii_da
7" H[_dij[cW > '/// CehX_Z_jo WdZ Yecfb_YWj_edi e\
Xed[ ]hW\j_d] e\ j^[ \beeh e\ j^[ cWn_bbWho i_dki \eh j^[
fbWY[c[dj e\ [dZeii[eki _cfbWdji$ CkdZ A_[\[h =[i_Y^ji
9^_hIkffb)0,+Ä,/
HWc[i J;" B_da 99 '/.) C_YheX_ebe]o e\ \W_b_d] Z[djWb
_cfbWdji_d^kcWdi0;b[Yjhedc_YheiYef_YeXi[hlWj_edi$@
EhWb?cfbWdjeb''0/)Ä'&&
È È 2EFERENCESÈ
HWc[iJ;"HeX[hjiJM"JWjkc>@h[jWb'/.*J^[ikX]_d]_lWb
c_Yhe\behW WiieY_Wj[Z m_j^ ^kcWd Z[djWb _cfbWdji$ @
Fheij^[j:[dj+'0+(/Ä+)*
HWjW`YpWa J (&&& :[h FWj_[dj _d Z[h ?cfbWdjebe]_[$ ?d0
M[_iiXkY^?cfbWdjebe]_[$8:?P"8edd"ff'&-Ä',+
H[][l ;" Ic_j^ H7" F[hhejj :>" Fe]h[b C7 '//+ CWn_bbWho
i_dki Yecfb_YWj_edi h[bWj[Z je [dZeii[eki _cfbWdji$ ?dj @
EhWbCWn_bbe\WY?cfbWdji'&0*+'Ä*,'
H_Y^j[h ;@ '/., ;_d 8[_jhW] pkh ;hbkj[hkd] Z[i 8[]h_\\i
ÆIjeiiZcf\kd]Ç _d Z[h ?cfbWdjebe]_[$ P PW^dhpjb
?cfbWdjeb(0(-&Ä(-)
H_[i >" IY^d[_Z[h A>" =heœXbj_d] H (&&( PW^dWhpjh[Y^j$
Ifh_d][hL[hbW]"8[hb_d
HeX[hj M;" Ic_j^ HA" P_bX[hcWd O" CepiWho F=" Ic_j^ HI
'/.* Eii[eki WZWfjWj_ed je Yedj_dkeki beWZ_d] e\ h_]_Z
[dZeii[eki_cfbWdji$7c@Ehj^eZedj.,0/+Ä'''
HecWdei="Je^9"I_Wh9"ImWc_dWj^Wd:"Ed]7":edWj^A"
OWWYeX >" D[djm_] = (&&' F[h_#_cfbWdj Xed[ h[WYj_edi
je _cc[Z_Wj[ beWZ[Z _cfbWdji$ 7d [nf[h_c[djWb ijkZo _d
ceda[oi$@F[h_eZedjeb-(0+&,Ä+''
Hej^[ I (&&) :Wi ?Z[dj_\_p_[h[d [_d[i ?cfbWdjWj[i$ :[h
?cfbWdjWj#Ij[YaXh_[\"J[_b'$PW^dFhWn-0*.(Ä*./
HkX_d9J"BWdoedB;'/.*H[]kbWj_ede\Xed[\ehcWj_edXo
Wffb_[ZZodWc_YbeWZi$@$8ed[@e_djIkh]7c,,0)/-Ä*&(
IW_b[h >< '/./ 7 d[m c[j^eZ e\ _di[hj_d] [dZeii[eki
_cfbWdji_djejWbboWjhef^_[ZcWn_bbW[$@9hWd_ecWn_bbe\WY
Ikh]'-0(//Ä)&+
IW_b[h ><" BeY^[h C9 '//, BWd]p[_j[h][Xd_ii[ dWY^ L[h#
ieh]kd]Z[iWjhef^_iY^[dEX[ha_[\[hic_jAdeY^[djhWdi#
fbWdjWj[dkdZ?cfbWdjWj[d$:jiY^PW^dhpjbP+'0+/Ä,)
IWaW8"Mh[[7"7dZ[hiB"=kdZbWY^AA(&&(;nf[h_c[djWb
WdZ YecfWhWj_l[ ijkZo e\ j^[ XbeeZ ikffbo je j^[
cWdZ_XkbWh Yehj[n _d =jj_d][d c_d_f_]i WdZ _d cWd$ @
9hWd_ecWn_bbe\WYIkh])&0('/Ä((+
IWbY[jj_ @C" Ceh_Whjo @:" 9eef[h B< [j Wb '//- J^[ Yb_d_YWb"
c_YheX_Wb WdZ ^eij h[ifedi[ Y^WhWYj[h_ij_Yi e\ j^[ \W_b_d]
_cfbWdj$?dj@EhWbCWn_bbe\WY?cfb'(0)(Ä*(
IWdY^_i @C" F[dWhheY^W C" Ieb[h < (&&) 8_\_Z cWdZ_XkbWh
YWdWb$EhWbCWn_bbe\WYIkh],'0*((Ä*(*
IWdZ[h7" @WaijWj >@"7^b[hi CE '/// 9hWd_e#cWdZ_Xkbh[
:oi\kdaj_ed[dÄ[_d[7k\]WX[\”hZ[dF^oi_ej^[hWf[kj[d$
AhWda[d]ocdWij_a+'0(&)+Ä(&*'
IWdZ[hC[jWb'/./AhWda[d]ocdWij_iY^[8[^WdZbkd]led
FWj_[dj[d c_j aWkckiakbh[d <kdaj_ediijhkd][d$ :jiY^
PW^dhpjbP**0'(Ä'*
IWiiekd_L'/,/7YbWii_\_YWj_ede\ia[b[jWb\WY_Wbjof[i$7c
@Ehj^eZedj++0'&/Ä''+
IWje I '/.- 7bj[hWj_ed e\ eYYbkiWb fbWd[ Zk[ je feij[h_eh
Z_iYh[fWdYo h[bWj[Z je Z[l[befc[dj e\ cWbeYYbki_ed Ä
?djheZkYj_ed je Z[djkh[ \hWc[ WdWboi_i$ 8kbb AWdW]WmW
:[dj9ebb'+0''+Ä'()
IYW_\[H">ebj@'/,/DWjkhWbeYYkhh[dY[e\Ykif_Z]k_ZWdY[$
@Fheij^[j:[dj((0((+Ä((/
IY^[bb_d] F" ;hb_d][h H (&&) :_[ 7k\abhkd] ”X[h 8[^WdZ#
bkd]iWbj[hdWj_l[d$C[ZH(&&)0))'Ä))*
IY^_dd[dXkh]M(&&&8[iedZ[h^[_j[dZ[i7hpj^W\jkd]ih[Y^ji
X[_pW^dhpjb_Y^[h8[^WdZbkd]$C[ZH(&&&0'.+Ä'/&
IY^b_[f^Wa[ >" D[kaWc <M (&&& B[X[di[hmWhjkd] led
?cfbWdjWj[d kdZ ?cfbWdjWjbW][hd$ :[kjiY^ PW^dhpjb P
++0+.-Ä+..
IY^bkdZ ;> '//) Pkh >W\jkd] Z[i 7dij^[i_ij[d Wki
`kh_ij_iY^[hI_Y^j$C[ZH'//)0'.,Ä'.-
IY^c_Z@">cc[hb[9"BWd]DF"Ikjj[h<'//'Im_iiFWj[dj
9>,.-,-(7+
*&+
IY^c_Z C@ '/.' C[Z_p_d_iY^ dejm[dZ_][ >[_bX[^WdZbkd]
kdZfh_lWj[AhWda[dl[hi_Y^[hkd]$D@M)*0(+&*Ä(+&+
IY^d_jcWdd F7"Me^hb[ FI" HkX[dij[_d =; [j Wb '//- J[d#
o[Wh h[ikbji \eh 8hd[cWha _cfbWdji _cc[Z_Wj[bo beWZ[Z
m_j^ \_n[Z fheij^[i[i Wj _cfbWdj fbWY[c[dj$ ?dj @ EhWb
CWn_bbe\WY?cfb'(0*/+Ä+&)
IY^jjb H '//- :[h ^[_b[dZ[ Fkbi$ :_[ d[kheckiakbh[
J^[hWf_[c_jJ;DI$?99CE8h_[\*
IY^h[ci >J '/-+ {X[h c_jX[ij_cc[dZ[ <Wajeh[d \”h ZWi
8[^WdZbkd]ih[ikbjWj$:jPW^dhpjbP[_jiY^h)&0*)'Ä*)+
IY^kcWa[h =>" :eabWZWb C '/,. {X[h kdj[hiY^_[Zb_Y^[
I[akdZhl[hdZ[hkd][d Wc IY^Z[b Wbi <eb][ led
AWkckia[bZ_ii[aj_ed[d$7YjW7dWj,/0)-.Ä)/(
IY^”fXWY^ F" >”hp[b[h C" =hkdZ[h K '//* ?cfbWdj#j_iik[
_dj[h\WY[i \ebbem_d] jh[Wjc[dj e\ f[h_#_cfbWdj_j_i ki_d]
]k_Z[Zj_iik[h[][d[hWj_ed$9b_dEhWb?cfbH[i+0++Ä,+
IY^”iib[h8'/.,:_[?d#L_jhe#<[hj_b_iWj_edWbic[Z_p_d_iY^[
dejm[dZ_][>[_bcWœdW^c[$L[hiH'/.,0)((Ä)(*
IY^mWhp ; '//. <;C#7dWboi[ pk :_iaei '&=+" :_iaei 7
'(=+ kdZ :_iaei '&=+ ;::$ 9ekhi[ meha$ J[Y^d_akc
HWff[him_b%Im_jp[hbWdZ"'//-%'//.j[hc
IY^m[_a[hj;E'/..Ckbj_fb[YWdj_b[l[hi_d\_n[Zfheij^[i[i$
?i^_oWak;khe7c[h_YW?dY$"Ij$Bek_i
IYehj[YY_='/.+;khef[WdFWj[dj&('*/,(8'
IYehj[YY_='/.-Kd_j[ZIjWj[iFWj[dj*".'+"/-*
IYehj[YY_ = '/.. xjkZ[ YecfWhWj_l[ Z[ bɃY^Wk\\[c[dj behi
Zk\hW_iW][Z[bÉei$?dZkijh_[i:[djW_h[i('0)*Ä)-
IYehj[YY_ = '/.. BÉ_cfbWdj Z[djW_h[ jh_Yehj_YWb$ J^[i_i" <WY$
EZedj$Z[CWhi[_bb[
IYehj[YY_='/..Kd_j[ZIjWj[iFWj[dj*"-((",.-
IYehj[YY_='///?cc[Z_Wj[\kdYj_ede\Yehj_YWbboWdY^eh[Z
Z_ia#Z[i_]d _cfbWdji m_j^ekj Xed[ Wk]c[djWj_ed _d
ceZ[hWj[bo je i[l[h[bo h[iehX[Z Yecfb[j[bo [Z[djkbeki
cWn_bbW[$@EhWb?cfbWdjeb(+0-&Ä-/
IYehj[YY_ = [j Wb '//& :_ia_cfbWdj ioij[c$ ?d0 BWd[o M"
JebcWd:[ZiJ_iik[_dj[]hWj_ed_dehWb"ehj^ef[Z_YWdZ
cWn_bbe\WY_Wb h[YedijhkYj_ed$ Gk_dj[ii[dY[" 9^_YW]e" ff
)+&Ä*&+
IYehj[YY_="C_iY^9"8[dd[hA(&&'?cfbWdjiWdZh[ijehWj_l[
Z[dj_ijho$:kd_jp"BedZed
IYehj[YY_ =" C_iY^ 9" EZ_d = (&&) ?cfbWdjebe]_[ XWiWb[0
kd[WffheY^[j^[hWf[kj_gk[\edZ[[[ikhbWfh[kl[$?cfbWd#
jeZedj_['(0)+Ä*-
IYehj[YY_C":eciF'/.-B[:_ia_cfbWdj$7YjkWbEZedjeijec
'+/0+('Ä+).
IYkbboJ@"8[ij[hcWdd='/.(Ijh[ii\hWYjkh[ÄWfh[l[djWXb[
jhW_d_d]_d`kho$C_b_jWhoC[Z'*-0(.+Ä(.-
I[_f[b9C'/+/JhW`[Yjeh_[ie\j^[`Wm$7YjWEZedjebIYWdZ
.0.(Ä'/'
I^[hde\\7<"9ebm[bb@7"8_d]^WcI<'//*?cfbWdj\ehJof[
?? Z_WX[j_Y fWj_[dji0 _dj[h_c h[fehj$ ?cfbWdj :[dj_ijho
)0'.)Ä'.+
I_[X[hj='//(=[i_Y^ji#kdZAef\iY^c[hp[d$>Wdi[h"M_[d
Ib_memia_ 9 (&&' ?cfbWdjWjfhej^[j_a0 fhel_ieh_iY^" WX[h
\[iji_jp[dZ$?cfbWdjebe]_[@)0-&Ä-+
Ic_b[ :=" >ebc[i H; '/.- I_dki b_\j fheY[Zkh[ ki_d]
feheki^oZhenobWfWj_j[0Wfh[b_c_dWhoYb_d_YWbh[fehj$EhWb
?cfbWdjeb.0(
Ic_j^8>'/-+9^Wd][i_deYYbkiWb\WY[^[_]^jm_j^h[celWXb[
fWhj_WbZ[djkh[i$@Fheij^[j:[dj)*0(-.Ä(.+
Ic_j^be\\ C" <h_jp C; '/.( Ki[ e\ XbWZ[ _cfbWdji _d W
i[b[Yj[ZfefkbWj_ede\fWhj_Wbbo[Z[djkbekiWZkbji$7ed[#
o[Whh[fehj$@F[h_eZedjeb+)0*')Ä*'.
*&, 2EFERENCES
IebWh F" 7he =" Kbc 9 '//. :_[ 7kim_hakd][d Z[i PW^d#
l[hbkij[iWk\Z_[7dWjec_[Z[hCWn_bbW$IY^m[_pCedWjiiY^h
PW^dc[Z'&.0.-'Ä.-+
IebWhF"=[o[h^e\[hK"JhWnb[h>[jWb'///8beeZikffboje
j^[ cWn_bbWho i_dki h[b[lWdj je i_dki \beeh [b[lWj_ed fhe#
Y[Zkh[i$9b_dEhWb?cfbH[i'&0)*Ä**
Iebj[ipK"I_[][b[:'/.*;_d\bkiiZ[hIj[_\_]a[_jZ[i?cfbWd#
jWjcWj[h_Wbi Wk\ Z_[ _c AdeY^[d [hp[k]j[d IfWddkd][d$
:[kjiY^PW^dhpjbP)/0'.)Ä'.,
Iecc[h8"IWjjb[h=(&&'8ejkb_dkcjen_d_dZ[hij^[j_iY^[d
C[Z_p_d$8bWYam[bb"8[hb_d
IfW^d<F'/--Ab_d_iY^[Kdj[hikY^kd][dpkjh_Z_c[di_edWb[d
?cfbWdjWj[d$:_ii[hjWj_ed$HMJ>7WY^[d"=[hcWdo
IfW^d <F '/.& >ebe]hWf^_iY^[ ?dj[h\[hec[jh_[ pkh
p[hijhkd]i\h[_[d {X[hfh”\kd] jh_Z_c[di_edWb[h ?cfbWd#
jWj[$EhWb?cfb'&0+'.Ä+(+
IfW^d <F '/./ '+ @W^h[ Jh_Z_c[di_edWb[ ?cfbWdjWj[$ :PM
'/0*(Ä*,
IfW^d <F '//( L[hbWk\ijkZ_[0 _cfbWdjWjX[bWij[j[ EX[h#
a_[\[hWk]c[djWj_ed[dc_j:_ia#?cfbWdjWj[d$PW^dhpjb_Y^[
FhWn_i*)0*).Ä**+
IfW^d <F '//( Pm[_ @W^hp[^dj[ _d <kdaj_ed Ä ie\ehj
X[bWijXWh[h EX[ha_[\[hpW^d[hiWjp Wk\ jh_Z_c[di_edWb[d
?cfbWdjWj[d$PW^dhpjb_Y^[FhWn_i*)0+
IfW^d<F'//,:_[7dm[dZkd]led:_ia#?cfbWdjWj[ddWY^
fWheZedj_j_i#X[Z_d]j[cPW^dl[hbkij$PW^dhpjb_Y^[FhWn_i
*-0*,Ä+&
IfW^d<F'//-Ikhb[\edZ[c[djZ[bWY^Wh][_cc[Z_Wj[Zk
Z_ia_cfbWdj$?cfbWdjeZedj_[(-0,)Ä,.
IfW^d<F'//-Pkh\kdaj_ed[bb[dAehh[ajkhledEaabki_ed
kdZ 7hj_akbWj_ed Z[h pW^dX[ijWdZih[Zkp_[hj[d 7bj[hi#
fhe][d_[$8WiWbeiie_dj[]hWj_edil[h\W^h[d[hi[jp[diY^m[h[
:oi]dWj^_[#9^_hkh]_[$)$Mehai^ef:_ia_cfbWdj$7:<9ed#
]h[ii"FWh_i"Del[cX[h'//-
IfW^d<F'///=[hcWdFWj[dj:;'//*./'&7'$?cfbWdjWj
pkcbWj[hWb[d;_diY^kX_d][\hij[A_[\[h^^bkd][d$
Ifhedi[dF>"AeebijhW@>"=_da[b<9"M[_`iM7"LWba@"FhW^b#
7dZ[hi[d 8 '//- H[bWj_edi^_f X[jm[[d j^[ eh_[djWj_ed
WdZcec[djWhcie\j^[^kcWd`WmckiYb[iWdZdehcWb
YhWd_e\WY_Wbcehf^ebe]o$;kh@Ehj^eZedj_Yi'/0)')Ä)(.
Ijeh[o7J'/,(F^oi_ebe]oe\WY^Wd]_d]l[hj_YWbZ_c[di_ed$
@Fheij^[j:[dj'(0/'(Ä/('
Ijeh[o ; '/-+ =hemj^ WdZ h[ceZ[bb_d] e\ Xed[ WdZ Xed[i$
:[djWb9b_d_YiDehj^7c'/0**)Ä*++
Ijh[[bH'/.&Kd_j[ZIjWj[iFWj[dj*")**"-+-
Ik[dW]WA"IWjeJ"D_i^_]WmW="C_dW]_I'//-H[bWj_edi^_f
X[jm[[d i_p[ e\ Z[djkh[ \ekdZWj_ed Wh[W WdZ h[iehfj_ed
e\Wbl[ebWhh_Z][_dj^[[Z[djkbekicWdZ_Xb[$@EhWbH[^WX
(*0)'+Ä'/
Im[hZbem >87 '/,* He[dj][dY[f^Wbec[jh_Y ijkZo e\
l[hj_YWbZ_c[di_edY^Wd][i_d_cc[Z_Wj[Z[djkh[fWj_[dji$
@Fheij^[j:[dj'*0,)+Ä,*/
IpckYab[h#CedYb[h I" :kXh_bb[ @> '//& ?i eii[e_dj[]hWj_ed
Wh[gk_h[c[dj\ehikYY[ii_d_cfbWdjZ[dj_ijho59b_dCWj[h
+0(&'Ä(&.
IpckYab[h#CedYb[hI"F_Wjj[bb_7"<Wl[he=7":kXhk_bb[@>'//,
8ed[h[ifedi[je[WhbobeWZ_d]0j^[[\\[Yje\ikh\WY[ijWj[$
?d0:Wl_Zel_jY^P"DehjedB7[Z8_ebe]_YWbc[Y^Wd_ici
e\ jeej^ cel[c[dj WdZ YhWd_e\WY_Wb WZWfjWj_ed$ >WhlWhZ
IeY_[joe\Ehj^eZedj_Yi"8eijed"ff,''Ä,'.
IpckYab[h#CedYb[hI"F_Wjj[bb_7"<Wl[he=7":kXh_bb[@>(&&&
9edi_Z[hWj_edifh[b_c_dWhojej^[Wffb_YWj_ede\[WhboWdZ
_cc[Z_Wj[ beWZ_d] fhejeYebi _d Z[djWb _cfbWdjebe]o$ 9b_d
EhWb?cfbH[i''0'(Ä(+
JWbb]h[d7 '/+- 9^Wd][i _d WZkbj \WY[ ^[_]^j Zk[ je W]_d]"
m[Wh WdZ beii e\ j[[j^ WdZ fheij^[j_Y jh[Wjc[dj$ 7YjW
EZedjebIYWdZIkffb(*0'+
JWbb]h[d 7" JhoZ[ = '/., 9^Wd][i _d `Wm h[bWj_edi WdZ
WYj_l_joe\cWij_YWjehockiYb[i_dfWj_[djim_j^_cc[Z_Wj[
Yecfb[j[kff[hZ[djkh[i$@EhWbH[^WX')0)''Ä)(*
JWbb]h[d 7" C_pkjWd_ >" JhoZ[ = '/./ 7 jme#o[Wh a_d[i_e#
]hWf^_YijkZoe\cWdZ_XkbWhcel[c[djfWjj[hdi_dZ[djkh[
m[Wh[hi$@Fheij^[j:[dj,(0+/*Ä,&&
JWc_7;" DWii[h F"L[hXe]j E" IY^W\\b[h C8 Adej^[ JWj[ CB
(&&(J^[heb[e\_dj[hij_j_Wb\bk_Z\bem_dj^[h[ceZ[bb_d]
h[ifedi[je\Wj_]k[beWZ_d]$@8ed[C_dH[i''0(&)&Ä(&)-
JWjkc > '/., CWn_bbWho WdZ i_dki _cfbWdj h[YedijhkYj_ed$
:[dj9b_dDehj^7c)&0(&-Ä((/
JWl[i :H (&&( Efj_ckc _deh]Wd_Y _ed YedY[djhWj_edi \eh
^[cWjefe_[i_iYkbjkh[i$C[Z>ofej^[i[i+.0((+Ä((.
JWobeh 7" 9WcfX[bb C '/-( H[WjjWY^c[dj e\ j^[ ]_d]_lWb
[f_j^[b_kcjej^[jeej^$@F[h_eZedjeb*)0(.'Ä(/)
J^[ 7c[h_YWd 7YWZ[co e\ F[h_eZedjebe]o (&&' =beiiWho
e\ f[h_eZedjWb j[hci$ J^[ 7c[h_YWd 7YWZ[co e\
F[h_eZedjebe]o"9^_YW]e
J^[_bWZ[@'/,&7d[lWbkWj_ede\j^[h[b_WX_b_joe\hWZ_e]hWf^i
_dj^[c[Wikh[c[dje\Xed[beii_df[h_eZedjWbZ_i[Wi[$@
F[h_eZedjeb)'0'*)Ä'+)
J^_[bcWdd A '/). 8_ec[Y^Wd_a Z[h FWhWZ[djei["
_diX[iedZ[h[ 7hj_akbWj_ediWki]b[_Y^ ZkhY^ ;_diY^b[_\[d"
leb$).$>[hcWddC[kii[h"B[_fp_]
J_Zm[bb @A" 8b_`Zehf F7" Ije[b_d]W F@" 8hekdi @8" >_dZ[hai
< '//( 9ecfei_j[ ]hW\j_d] e\ j^[ cWn_bbWho i_dki \eh
fbWY[c[dje\[dZeij[Wb_cfbWdji$7fh[b_c_dWhoh[fehje\
*.fWj_[dji$?dj@EhWbCWn_bbe\WYIkh]('0(&*Ä(&/
JebcWd :;" A[bb[h ;; '//' CWdW][c[dj e\ cWdZ_XkbWh
\hWYjkh[i_dfWj_[djim_j^[dZeii[eki_cfbWdji$?dj@EhWb
CWn_bbe\WY?cfb,0*(-Ä*),
Jk[hf @9 (&&) ?ij Z_[ _dijhkc[dj[bb[ <kdaj_ediWdWboi[
[_d[[cf\[^b[dim[hj[CWiidW^c[pkh:_W]deij_aahWd_e#
cWdZ_Xkbh[h <kdaj_ediijhkd][d5 :jiY^ PW^dhpj P
+.0*--Ä*.'
Jkha : '//- FioY^eieY_Wb WdZ X[^Wl_ehWb Wii[iic[dj e\
fWj_[dji m_j^ JC@ Z_iehZ[hi0 :_W]deij_Y WdZ jh[Wjc[dj
_cfb_YWj_edi$EhWbIkh]EhWbC[ZEhWbFWj^eb.)0,+Ä-'
Kj^e\\ >A" @Wmehia_ P<= '/.+ F[h_eij[Wb ijh[ii _dZkY[Z
h[WYj_edih[i[cXb_d]ijh[ii\hWYjkh[i$9b_dEhj^efH[bH[i
'//0(.)Ä(/'
KjpA>'//-L[hdZ[hkd]Z[hEaabki_eddWY^Z[c;_d\”][d
ledJejWbfhej^[i[d$PMH'&,0,+/Ä,,/
LWb[dj_d_ F" 7X[dikh :" :[diWh_ :" =hWp_Wd_ @D" >Wcc[hb[
9><'//.>_ijebe]_YWb[lWbkWj_ede\8_e#Eii_dW(#ijW][
i_dki\beeh[b[lWj_edWdZ_cfbWdjWj_edfheY[Zkh[$9b_dEhWb
?cfbH[i/0+/Ä,*
LWb[dj_d_ F" 7X[dikh :" M[dp 8" F[[jp C" IY^[da H (&&&
I_dki ]hW\j_d] m_j^ feheki Xed[ c_d[hWb X_e#eii \eh
_cfbWdj fbWY[c[dj0 7 +#o[Wh ijkZo ed '+ fWj_[dji$ ?dj @
F[h_eZedj_YiH[ijehWj_l[:[dj(&0(*+Ä(+)
lWd B_dZ[hd @@ (&&& 8ejkb_dkcjen_d _d Z[h CkdZ#A_[\[h#
=[i_Y^jiY^_hkh]_[$>e\\cWdd"CW_dp
led B”Z_d]^Wki[d C" FecWheb_ 7 '/., 7dWjec_[ Z[h
AdeY^[dijhkajkh[d \”h [deiiWb[ kdZ ikXf[h_eijWb[
?cfbWdjWj[Z[hA_[\[h$:[hPW^dWhpj'0*,Ä+(
ledMem[hdD"Ijebjp[A'/-.I[nWdZW][Z_\\[h[dY[i_dXed[
cehf^ebe]oe\cWdZ_Xb[i$IYWdZ@:[djH[i.,0*-.Ä*.+
led P_[]d[h 9 (&&' 7hpj^W\jkd]0 H[Y^jb_Y^[ FheXb[c[ X[_
Z[hpW^dhpjb_Y^#fhej^[j_iY^[dL[hieh]kd]$C:H++0'&..Ä
'&/*
È È 2EFERENCESÈ
Lei[=F"AkXWbW7B'/+/8ed[ijh[d]j^Ä_jih[bWj_edi^_fje
n#hWoZ[j[hc_d[ZWi^Yedj[dj$>kc8_eb)'
MW]d[h M '//+ BWd]p[_j[h][Xd_ii[ l[hiY^_[Z[d[h ?cfbWd#
jWjioij[c[$ Fh[i[djWj_ed Wj j^[ ?J? 9ed]h[ii" Abd" '+%',
I[fj[cX[h
MWd] B" <h_jjed IF" 9em_d IF" M[_dXWkc I '/// <bk_Z
fh[iikh[h[bWnWj_edZ[f[dZikfedeij[edWbc_YheijhkYjkh[0
ceZ[bb_d] Wd eij[edWb X[dZ_d] [nf[h_c[dj$ @ 8_ec[Y^
)(0,,)Ä-(
MWd] B" <h_jjed IF" M[dXWkc I" 9em_d I9 (&&) Ed Xed[
WZWfjWj_edZk[jel[dekiijWj_i$@8_ec[Y^),0'*)/Ä'*+'
MWi^Xkhd IB '/*- J^[ h[bWj_ed e\ j^[ j[cfehWb ckiYb[ je
j^[\ehce\j^[iakbb$7dWjH[Y//0()/Ä(*.
M[_Xh_Y^ =" <e_jp_a 9" Ak\\d[h > (&&( B_\[#j^h[Wj[d_d]
ehWb ^[cehh^W][ W\j[h _cfbWdjWj_ed _dje j^[ Z_ijWb h_]^j
cWdZ_Xb[$CkdZA_[\[h=[i_Y^jiY^_h,0**(Ä**+
M[_d]Whj :" @eei K" IY^[da H" IjhkX @H '//, ;_dbW][hkd]
led AdeY^[djhWdifbWdjWj[d kdZ i_ckbjWd[ [deiiWb[
?cfbWdjWj_ed _c I_dki cWn_bbWh_i e^d[ A_[[h^^b[d#
IY^b[_c^WkjfhfWhWj_ed$:jiY^PW^dhpjbP+'0'(*Ä'(,
M[_dbW[dZ[h C" A[dd[o ;8" B[ael_YL" 8[kc[h @ [j Wb '//(
>_ijecehf^ec[jho_dXed[Wffei_j_edWhekdZj^h[[jof[i
e\[dZeii[ekiZ[djWb_cfbWdji$?dj@EhWbCWn_bbe\WY?cfb
'0*/'Ä*/,
M[bbaWcf B (&&& 7kim[_jkd] Z[h 7k\abhkd]if\b_Y^j[d _d
Z[hpW^dhpjb_Y^[d?cfbWdjebe]_[$P7kH'/0'()Ä'(+
M_bj\Wd] @" C[hj[d >7" 8[Ya[h >@ '//, Ab_d_iY^[" hdj#
][debe]_iY^[ kdZ i_dkiaef_iY^[ DWY^aedjhebb[d dWY^
I_dkiXeZ[d[b[lWj_ed$PPW^dhpj?cfbWdjeb'(0.&Ä.*
*&-
M_dj[hC"<[_\[b>"J_diY^[hj@"CWhnH'//-CW]d[jl[hWda[hj[
fhej^[j_iY^[ L[hieh]kd] dWY^ EdbWo#Eij[efbWij_a$ P
PW^dhpjb_Y^[?cfbWdjeb')0,.Ä-(
M_jj ; '/,) A_[\[hm_da[b kdZ AWkckiakbWjkh$ <ehjiY^h_jj[
Z[hA_[\[hehj^efZ_[(*0(/+Ä(//
Meb\\ @ './( :Wi =[i[jp Z[h JhWdi\ehcWj_ed Z[h AdeY^[d$
L[hbW]7k]$L>_hiY^mWbZ"8[hb_d
MeeZ HC" Ceeh[ :B '/.. =hW\j_d] e\ j^[ cWn_bbWho i_dki
m_j^ _djhWehWbbo ^Whl[ij[Z Wkje][deki Xed[ fh_eh je
_cfbWdjfbWY[c[dj$?dj@EhWbCWn_bbe\WY?cfb)0(&/
N_c[d[p#<ol_[B7">W\\W`[[7:"IeYhWdiaoII(&&&C_YheX_Wb
Yecfei_j_ede\ikfhW#WdZikX]_d]_lWbfbWgk[_dikX`[Yji
m_j^WZkbjf[h_eZedj_j_i$@9b_dF[h_eZedjeb(-0-((Ä-)(
OW\\[ 7" <_d[ D" 8_dZ[hcWdd ? '//* H[]_edWb WYY[b[hWj[Z
f^[dec[ded _d j^[ cWdZ_Xb[ \ebbem_d] ckYef[h_eij[Wb
ikh][ho$@F[h_eZedjeb,+0-/Ä.)
PWY^ C (&&( :_[ ?cfbWdjWj_edic[j^eZ[dmW^b kdZ Z[h[d
Aeij[d\eb][$PW^dWhpjMeY^[('0'-
P[d]e 7D" FWmbka H@" 8Wii[jj 97B '/-) Ijh[ii#_dZkY[Z
X_e[b[Yjh_Yfej[dj_Wbi_dj^[Z[dje#Wbl[ebWhYecfb[n$7c@
Ehj^eZ,*0'-Ä(-
P_[]b[h >8 (&&) B[_jb_d_[d _c 7hpj^W\jkd]ih[Y^j$ L[hiH
+*0+*+Ä+*/
P_ii[h = '/-- DWY^aedjhebb[d kdZ ;h][Xd_ii[ a_[\[h#
ehj^efZ_iY^[h Ef[hWj_ed[d '/,*Ä'/-,$ :jiY^ P CkdZ
A_[\[h=[i_Y^jiY^_h'0'&)Ä'&/
P_jj[h>"Fb[da>'//)CWj[h_WbYedi_Z[hWj_edi$?d0MWjp[a=
[Z ;dZeii[eki _cfbWdji0 iY_[dj_\_Y WdZ Yb_d_YWb Wif[Yji"
9^Wf)$Gk_dj[ii[dY["8[hb_d"ff,)Ä//
!NNEXÈ)È2ECOMMENDEDÈ#UTTERÈ3EQUENCE
!.(!.'

De$ YeZ[ I:' I:( I:) I7 H[Yecc[dZ[Z9kjj[h#I[gk[dY[

 ;:%;:9

*,'&(+ ;:-=+ &$,#&$.    *,(('*

*,'&(. ;:-=. &$,#&$.    *,(('*

*,'&(. ;:/=. &$,#&$.    *,(('* *,((+/#Meh

       *,((('#M
        *,((,'#,eh
        *,((,'#*Meh
        *,((,'#,M
   
*,'&*. ;:/=. &$,#&$.    *,(('*

*,'&+. ;:'&=. &$,#&$.    *,(('*   *,((,(#*eh

         *,((,(#,eh
         *,((,(#*Meh
         *,((,(#,Meh
         *,((,(#.MÇ

*,'&.& ;:9'(=,#.         *,((,*#,Meh

 J_'+Ce         *,(('*
  &$,#&$.    *,((,*

De$ 9eZ[ I:' I:( I:) I7 H[Yecc[dZ[Z9kjj[h#I[gk[dY[

 ;:I

*,'*(, ;:I-=, &$-#&$/

*,'**) ;:I/=) &$-#&$/

È

*,'**+ ;:I/=+ &$-#&$/

¬È

*,'**, ;:I/=, &$-#&$/

*,'**/ ;:I/=/ &$-#&$/



 *'&

De$ 9eZ[ I:' I:( I:) I7 H[Yecc[dZ[Z9kjj[h#I[gk[dY[

 ;:I

        *,((,'#,eh
        *,((,'#*Meh
!NHANG

       *,((+/#Meh *,((,'#,M
*,'*+' ;:I/='' &$-#&$/    *,(('* *,((('#M

*,'*+* ;:I'&=* &$-#&$/       *,((,(#*eh

*,'*++ ;:I'&=+ &$-#&$/       *,((,(#,eh

*,'*+. ;:I'&=, &$-#&$/       *,((,(#*Meh

*,'*,& ;:I'&=. &$-#&$/       *,((,(#,Meh

*,'*,( ;:I'&='& &$-#&$/       *,((,(#.M

*,'*,, ;:I'(=,#=/ &$-#&$/        *,((,*#*eh

          *,((,*#,eh
          *,((,*#*Meh
          *,((,*#,M

De$ 9eZ[ I:' I:( I:) I7 9kjj[h#9eZ[

 ;:7I

*,'-(/ ;:7I-%'*=/ &$,#&$.    *,(('* *,((+/#Meh

*,'-++ ;:7I/%'(=+ &$,#&$.    *,(('* *,((('#M *,((,'#,eh

*,'-+- ;:7I/%'(=- &$,#&$.    *,(('*  *,((,'#*M

*,'-,+ ;:7I/%'+=+ &$,#&$.    *,(('*  *,((,'#,M

*,'--' ;:7I'&%'*=+#=/
          *,((,*#*eh
          *,((,*#,eh
          *,((,*#*Meh
  &$,#&$.    *,(('*    *,((,*#,M

 È

De$ 9eZ[ I:' I:( I:) I7 H[Yecc[dZ[Z9kjj[h#I[gk[dY[    

;::

*,''** ;::/=* &", &",  ) *,(('*

        *,((,'#,eh
 ;::/=+       *,((,'#*Meh
*,''*+  &", &",  ) *,(('*  *,((,'#,M

 ;::/%-=+      *,(()-eh
*,'((+  &", &",  ) *,(('* *,(()-#M

 ;::'&=+        *,((,(#*Meh
*,'',+  &", &",  ) *,(('*   *,((,(#,M

De$ 9eZ[ I:' I:( I:) I7 H[Yecc[dZ[Z9kjj[h#I[gk[dY[

 ;::I

 ;::I/%-=- &$,#&$. &",  )   *,((,'#,eh

        *,((,'#,Meh
*,'+'*        *,((,'#*Meh

 ;::I'&=* &$,#&$. &",  )

*,'+(&         *,((,'#,Meh
         *,((,'#*Meh
         *,((,(#,M

 ;::I'&=+ &$,#&$. &",  )
*,'+('

 ;::I'&%-
 =*#=. &$,#&$. &",  )
*,'+(*

 ;::I'&%-=. &$,#&$. &",  ) *,(('* *,(()-eh

*,'+(,       *,(()-#M

 ;::I'(%.=+"
 =,"=-"=. &$,#&$. &",  )     *,((,*#*eh

!NNEXÈ)È2ECOMMENDEDÈ#UTTERÈ3EQUENCEÈ
*''
 *'(

De$ 9eZ[ I:' I:( I:) I7 H[Yecc[dZ[Z9kjj[h#I[gk[dY[

 ;::I

*,'+)&          *,((,*#,M
!NHANG

De$ 9eZ[ I:' I:( I:) I7 H[Yecc[dZ[Z9kjj[h#I[gk[dY[

 ;:::

 ;:::/%-%-
 =)#=-
*,'('&  &", &", &", ) *,(('* *,((++eh *,((,'#,M

 ;:::'&%-%-
 =)#=-
*,'(')  &", &", &", ) *,(('* *,((++#M  *,((,(#,M

De$ 9eZ[ I:' I:( I:) I7 H[Yecc[dZ[Z9kjj[h#I[gk[dY[

 ;:::I

 ;888I-
 =)#=-
 ;:::I-
 =)#=-
       *,((++eh
*,'/(+  &", &", &", ) *,(('* *,((++#M

De$ 9eZ[ I:' I:( I:) I7 H[Yecc[dZ[Z9kjj[h#I[gk[dY[

 ;:N77I

*,'.&+ ;:N77I'&%(&=+ &$-#&$/

*,'.&, ;:N77I'&%(&=, &$-#&$/       *,(((#*Meh

*,'.&- ;:N77I'&%(&=- &$-#&$/    *,(('* *,((+/#Meh  *,((,(#,M

*,'.&. ;:N77I'&%(&=. &$-#&$/     *,((('#M

*,'.&/ ;:N77I'&%(&=/ &$-#&$/


 È

De$ 9eZ[ I:' I:( I:) I7 H[Yecc[dZ[Z9kjj[h#I[gk[dY[

 ;:N7:I

 ;:N7:I       *,((,'#,eh    
/%'*=+       *,((,'#,Meh    *,'.)+ 
&$-#&$/      *,((,'#*Meh

*,'.)- ;:N7:I
 /%'*=-
*,'.)-  &$-#&$/

 ;:N7:I'(%'-
 =+#=-         *,((,*#*eh
          *,((,*#,eh
          *,((,*#*Meh
       *,((+/#Meh   *,((,*#,M
*,'.(*  &$-#&$/    *,(('* *,((('#M

De$ 9eZ[ I:' I:( I:) I7 H[Yecc[dZ[Z9kjj[h#I[gk[dY[

 ;N::I

 ;N::I
 '(%/=+Ç         *,((,*#,eh
*,')&.  &$-#&$/ &",  + *,(('*    *,((,*#,M

       *,((*+#,M   *,((,(#,M
*,')'& ;N::I'(%'&=, &$-#&$/ &",  +  eh*,((*+   eh*,((,(

*,')'( ;N::I'*%'&=, &$-#&$/ &",  + *,(('*

*,')(( ;N::I'+%/=- &$-#&$/ &",  + *,(('*

*,')(* ;N::I'.%'+#
 '&%'(=* &$-#&$/ &",  + *,(('*    *,((,*#,M

!NNEXÈ)È2ECOMMENDEDÈ#UTTERÈ3EQUENCEÈ
*')
 *'*

De$ 9eZ[ I:' I:( I:) I7 H[Yecc[dZ[Z9kjj[h#I[gk[dY[

 ;8

       *,((+/#Meh *,((,'#,eh
*,',,) ;8/=) &$,#&$.    *,(('* *,((('#M *,((,'#.M
!NHANG

 ;8'(=,       *,((,'#*Meh
        *,((,'#,M  *,((,*#,Meh
*,',-(  &$,#&$.        *,((,*#,

I:) I:'#)3J^_Yad[iie\XWi[fbWj[0h_d]jeY[dj[h
I:( I73_dj[h#Z_iaZ_ijWdY[
I:'
3UBJECTÈ)NDEX

! 9ecfb_WdY[/)"()/").* Ä [nj[hdWbYedd[Yj_ed)("),
9edZob[i"Z_W]deij_Y(). Ä _dj[hdWbYedd[Yj_ed)("*+
7Xkjc[dj*& 9ekhjYedikbjWdjihkb[)/) Ä beii,-
Ä i[b[Yj_ed',, 9kjj[h)+"),"*,"+* Ä Wbed]cWn_bbWhoi_dki(+'
7[ij^[j_Yi'-("'-, 9h[ijWb_cfbWdji)/)"),*")-, Ä fei_j_ed,+
7d]b[9bWii Ä i[b[Yj_ed+-
Ä 9bWii?'.* Ä jh[Wjc[dj%9C:()/
Ä 9bWii??'/- $ Ä X[dZ_d]+(",&",+
Ä 9bWii???(&- ?dj[]hWj_ed*/")&+"
7bj[hdWj_l[jh[Wjc[dji)+) :[bh_d7Xkjc[dj** Ä eii[e#_dj[]hWj_ed)(.")))
7jhef^oe\@Wmi :_W]deij_Yi-& Ä eii[e#WZWfjWj_ed)(+
Ä cWdZ_XkbWh(',"('/ :_ia_cfbWdj(,"*+ Ä ]Wf`kcf_d])(*
Ä cWn_bbWho(+' :ekXb[j^h[WZiYh[m*) Ä hWZ_e#c_Yhe]hWf^o)')
7k]c[djWj_ed.")&) :oi\kdYj_ed-' Ä ded#eii[e_dj[]hWj[Z_cfbWdji)',
Ä fh_cWho)&) ?dj[hdWb8E?Z[i_]d*+
Ä i[YedZWho).' ?dj[h#Z_iaZ_ijWdY[(-",,"''/
Ä i_dki(+- %
7kj^eh_pWj_ed)/'
;d]hWci',& ,
;f_j^[i[i(..
" ;l_Z[dY[-"."+,"+-",,"'&&"'/( BWXehWjeho[gk_fc[dj'-+
;njhWYj_ed.. BWj[beWZ_d])'.")/&
8WhYedd[Yj_ed(-. BWj[hWbHWZ_e]hWf^i-&"(()
8Wi[fbWj['*' BeWZ
8b[[Z_d],' & Ä jhWdic_ii_ed(-"(/-
8CK'&) Ä Z_ijh_Xkj_ed"_dj[hdWb(/)")('
8CKWYj_lWj_ed\h[gk[dYo'&, <b[nkhWb d[kjhWb_pWj_ed j^[eho <DJ BeWZ_d]fbWd.&"()*")'.
8CKjkdd[bb_d])(/  (++ BeWZZ[\ehcWj_edZ_W]hWc'-)
8E?Z[\_d_j_ed)/( <ekhj^Z_c[di_ed)"'')"'(( Bocf^Wj_YZhW_dW][,*
8E?Yedi[diki)/( <hWYjkh[i
8ed[ Ä e\Xed[')*"')+")'(
Ä c[Y^Wd_YWbfhef[hj_[i''. Ä e\_cfbWdji'-)"(/*"),-")-' -
Ä Yecfh[ii_ed%j[di_ed
 '(,"'+."'-, CWYhe#JhW`[Yjeh_[i/'
Ä l[hj_YWb]hemj^'(- ( CW_dj[dWdY[),'
Ä ^ehcedWb[\\[Yi')' CWij_YWj_ed'+/"','
Ä \hWYjkh[i >_ijebe]o)&- Ä 8WbWdY[',(
Ä dkjh_[djikffbo')/ Ä ^kcWdif[Y_c[d)&-")&. Ä 9oYb[_d%ekj')
Ä c_d[hWb_pWj_edXWbWdY[ Ä Wd_cWbif[Y_c[d)&. Ä 7le_ZWdY[fWjj[hdi'+'
 ')."'**"('- >_ijehoe\8E?'( Ä Kd_bWj[hWbY^[m_d]fWjj[hd'+'
Ä h[iehfj_ed),) >_ijehoe\_cfbWdji_j[-) Ä Cel[c[djh[ijh_Yj_ed()/
Ä Z[\[Yji)-- >_ijehoe\Y^[m_d]fWjj[hdi'+,"(). CWn_bbWhoi_dki()")'+
8ejkb_dkc#Jen_d.+ Ä YecfWhjc[dji(,(
8heiWcb[jof[Xh_Z]['(+"((*"'-/ C[cXhWd[i)&)
) C[Z_YWj_ed"fh[#ef[hWj_l[,)
C_YhehWZ_e]hWf^o(',")')")))
# ?bbWZl_i[ZfWj_[dji).- CeZ[bb_d])'*")',
?di[hj_edjeebi*' Ced_jeh"_djhW#ef[hWj_l[,*
9Wi[WYY[fjWdY[)*& ?d\hW#d[hl[_cfbWdjfbWY[c[dj('/
9^[m_d]fWjj[hd(&+ ?cc[Z_Wj[_cfbWdjfbWY[c[dj)',
9^[Yakf#H[fehj)+& ?cc[Z_Wj[beWZ_d].&")',")''")(&")/( .
9eeb_d]c[Z_kc+*"++ ?cfbWdj
Ä Z[i_]d(,"(. D[kheckiYkbWhYedjheb',&
*', 3UBJECTÈ)NDEXÈ
/ 3
EYYbkiWbWZ`kijc[dji),)
Eij[efehei_i')*
El[hXh_Z][),/"
El[h#Yedjekh_d]'.&
El[hbeWZ',-
0
FWj_[djiZ[cWdZi.
FWhW#\kdYj_ed.*
F[h_eZedjWb_d\[Yj_ed/+
F[hiedWb_joZ_iehZ[hi()/
F^oi_ej^[hWfo(*(
FbWj\ehci)(
Fh[Y_i_edcWY^_d_d]*
FheX_d]Z[fj^)/(
Fheij^[j_YWZ`kijc[dji),)
2 Ä ijhWj[]_Y_cfbWdjfbWY[c[dj
HWZ_e]hWf^i,/"),'
H[\b[n[i',&
H[beWZ_d]%Y^Wd][e\beWZ)-*
H[ceZ[bb_d]'')"
H[i_b_[dY[(/")'"(/,
IYehj[YY_=$'("*+
I[ZWj_ed,*
Icea_d]/"(,"+)
If[[Ykhl['+,"',*
Ikh\WY[7h[W)&
I#Jof[_cfbWdji)-
4 7
J7F_dijhkc[dj*-
J[cfehWhoh[ijehWj_edi
 .."'-*"((+
J^_hZcebWhi./
Jh[Wjc[djfhejeYeb--
JhWdi\[h9ef_d]*'
JhWkcW)-)
Jh[Wjc[djfbWd--
Ä ckbj_fb[_cfbWdjjh[Wjc[dj
 fbWd-/
 -."/("('-"((&"((*
Ä jhWdii_dkifbWY[c[dj(+.
Ä [lWbkWj_ede\fheY[ii)/(
Jh_fb[#Z_ia)/
JkX[hefj[ho]e_ZiYh[m-&"()&
6
L[dj_bWj_ede\cWn_bbWhoi_dki(+)
L[hj_YWbZ_c[di_ed
 '(,"')'"'-'"'-("(&'"().
Ä kd_bWj[hWbhW_i_d]e\X_j['+("(*-
L[hj_YWbXed[]hemj^(((
L[d[[h_d]'--
MWhhWdjo)+'
MekdZ^[Wb_d]+/
Me[^b[hYkhl['-)
Meb\\VibWm'(&"(+*
8
N#hWoi,/"),(