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  • Research article
  • Open Access
  • Open Peer Review

Clinical applications and effectiveness of guided implant surgery: a critical review based on randomized controlled trials

BMC Oral HealthBMC series – open, inclusive and trusted201717:150

  • Received: 25 June 2017
  • Accepted: 4 December 2017
  • Published:
Open Peer Review reports

Nowadays implant placement protocols are widespread among clinicians all over the world. However, available literature, only partially analyses what can be potential benefits for the clinicians and patients, often focusing just on specific aspects, such as accuracy. The purpose of this review is to compare computer guided implant placement with conventional treatment protocols.

A search strategy according to the P-I-C-O format was developed and executed using an electronic MEDLINE plus manual search from 2000 up to December 2016. This review included only randomized controlled trials (RCTs) focusing on subjects treated with digital workflow for oral implant placement compared to conventional procedures. Data were extracted from eligible papers and analysed. All kinds of outcomes were considered, even patient-related and economical outcomes.

The search strategy revealed 16 articles; additional manual searches selected further 21 publications. Afterwards the evaluation of articles, only two studies could be selected for subsequent data extraction. The two identified RCTs analysed primary outcomes as prosthesis failure, implant failure, biological or prosthetic complications, and secondary outcomes as periimplant marginal bone loss. One RCT evaluated also the duration of treatment, post-surgical progress, additional treatment costs and patient satisfaction. The other RCT focused instead on evaluating eventual improvement of patient’s quality of life. In both selected studies, were not observed by the authors statistically significant differences between clinical cases treated with digital protocols and those treated with conventional ones. In one RCT, however post-surgical progress evaluation showed more patients’ self-reported pain and swelling in conventional group.

Within the limitation of this review, based on only two RCTs, the only evidence was that implant survival rate and effectiveness are similar for conventional and digital implant placement procedures. This is also confirmed by many other studies with however minor scientific evidence levels. Reduction of post-operative pain, surgical time and overall costs are discussed. Authors believe that scientific research should focus more in identifying which clinical situations can get greatest benefits from implant guided surgery. This should be done with research protocols such as RCT that assess comprehensively the advantages and disadvantages of fully digital surgical protocols.

  • Dental implant
  • Oral implantology
  • Image-guided surgery
  • Computer-guided implant

The use of the first osseointegrated implants to replace missing dental elements, almost 50 years ago, represented a huge evolution in dental rehabilitation techniques [1]. Over the years, many solutions have been proposed in order to improve the clinical performance of dental implants [2]. Implant shape has evolved with the introduction of not only cylindrical structures, of most efficient coil design and of better implant-prosthetic connections. Many surface treatments have also been suggested to modify the nanostructure of titanium, improving osseointegration processes and bone healing. The scientific literature agrees that implant-prosthetic rehabilitations have a 5-years survival rate of approximately 95% and greater than 89% after 10-years [3]. Nevertheless, the current trend in implant surgery is to further improve these clinical procedures by reducing total rehabilitation duration using, at the same time, less invasive surgical techniques. Guided implant protocols could help clinicians to simplify their procedures starting from the diagnostic phase up to the realization of the final prosthetic restoration.

The first and probably most important stage for the development of these new clinical procedures has been the introduction and the diffusion of three-dimensional (3D) imaging technique and computer technology [4]. They have allowed to improve traditional pre-surgical planning in which radiographic assessments, often through periapical and panoramic radiographs, study casts and direct inspection of the alveolar ridges, were used. The evaluation of 3D data, extracted from computerized tomography, but also more recently from optical scanner, together with modern implant planning software allow to carefully simulate surgical and prosthetic phases. Implant sites can be decided before surgery according to bone volume and quality, location of anatomical structures (nerves, vessels, sinuses), prosthetic and aesthetic evaluations [5]. Accurate one-to-one measurements of the width and height of bone in planned implant sites, as well as distances and angulations between implants from one side of an arch to another, can be predetermined without the distortions that are present in the two-dimensional radiology [6]. Implants and abutments can then be “virtually” planned, driven by knowledge of the position of the planned restoration. It also allows predetermination of prosthesis path of insertion, placement of screw chambers, componentry space, and pre-surgical abutment choices, as well as pre-surgical fabrication of individual abutments. An accurate virtual surgery planning allows sometimes to avoid bone augmentation procedures which are associated to an extension of treatment time and sometimes, unfortunately, also to major clinical complications [7]. Moreover, a careful three-dimensional positioning of the implants allows to obtain the best clinical results, especially as regards aesthetic aspects [8].

Guided implant surgery (GIS) allows to transfer planned rehabilitation project directly into surgical field. The clinician can choose between several guided methods; first, surgical guides can be divided into “static” and “dynamic”. The latter are represented by guided navigation methods in which a computer-guided navigation system helps the clinician in real time during the implant positioning through visual imaging tools on a monitor. These methods, although very interesting in future perspective are currently not particularly widespread. “Static” methods instead include the use of surgical templates that can be produced by conventional procedures, modifying a radiographic scan prosthesis, or by Computer-Aided Design/Computer-Aided Manufacturing (CAD/CAM) technologies (milling or stereolithography). Surgical guides can be tooth, bone or mucosa supported, with or without stabilization pins. Some guided systems use, for each patient, different templates with different sleeves size, while others use only one template. A further differentiation is given by the modality of implant screwing after implant site preparation: some systems provide fully guided implant insertion through the same drilling template; other methods may require the manual insertion of the implant after removing the surgical template.

Guided implants insertion often allows mini-invasive surgeries without the necessity to elevate a surgical flap. A further advantage of guided techniques is to have, at the time of surgery, a prefabricated fixed prosthesis, based on planned implants position, able to connect newly inserted implants and to easily achieve a functional and aesthetic immediate loading [9]. However even for implant guided surgery there are disadvantages which must be clearly evaluated. As first, like all new methods, this type of surgery requires a learning period for the dentist, for the technician and in general for the entire dental team. Time required for guided implant pre-surgical planning is definitely longer compared with traditional protocols. Economic aspects must also be evaluated regarding formation, instrumentation, surgical templates realization.

Due to the huge number of protocols among which the clinician can choose and their rapid evolution, the literature does not often provide accurate information about the real advantages or disadvantages that guided implant insertion protocols can provide for the clinician or for the patient. Therefore, the purpose of this review is to evaluate, through highest evidence level studies (RTCs), which are real clinical advantages and disadvantages of computer GIS compared to conventional treatment protocols.

To ensure a systematic review of the available literature, the following steps were followed: question formulation, definition of electronic database search strategy, retrieval of publications, studies selection, data extraction and evaluation.

As a first step, the following questions, that could fulfil the purpose of this work, were formulated: which are clinical advantages and disadvantages of computer guided implant placement compared to conventional treatment protocols? Regarding medical and economic aspect, in which clinical situations guided surgery could be justified?

Based on the PICO criteria, a search strategy was developed and executed in MEDLINE (PubMed) electronic database. Search terms were selected and then grouped into categories for “Problem” – “Intervention” – “Control” – “Outcome”. The search strategy was assembled from a combination of qualified Medical Subject Headings [MeSh-Terms] as well as unspecific free-text words in simple or multiple conjunctions [Table 1]. Only works published from January 2000 up to December 2016 in English language were considered. An additional manual search of the bibliographies of all selected full-text articles was performed. Furthermore, searching was also conducted in dental literature using free-text terms and phrases.
Table 1

Overview of the electronic search strategy including source of database, timeline, and P-I-C-O definition for study selection

From January 2000, up to December 2016

{(« Dental Implant » [MeSH]) OR (« Oral Implant » [MeSH]) OR (« endosseous implant » [MeSH]) OR (« implant placement ») OR (« dental implant graft » [MeSH]) OR (« dental implant graftless ») OR (« dental implant flapless » [MeSH]) OR (« dental implant flap » [MeSH]) OR (« Alveolar Ridge Augmentation/methods » [MeSH]) OR (« Alveolar Bone Loss/surgery » [MeSH])} AND

{(« Image-guided surgery » [MeSH]) OR (« computer assisted surgery» [MeSH]) OR (« guided surgery ») OR (« computer guided ») OR (« surgical innovation ») OR (« Computer-Aided Design »)} AND

{(« Conventionnal surgery ») OR (« open flap ») OR (“muccoperiosteal flap”) AND

{(« accuracy » [MeSH]) OR (« patient-based outcome ») OR (« costs, costs analysis » [MeSH]) OR (« treatment duration ») OR (« treatment ease ») OR (« practitioner-based outcomes ») OR (« success » [MeSH]) OR (« survival » [MeSH]) OR (« postoperative sequel ») OR (« aesthetics, dental » [MeSH]) OR (« prosthetic outcome »)

Only randomized controlled studies comparing digital workflow for oral implant placement with conventional procedures in alveolar crest were included. Inclusion criteria were also:
  • at least five patients in each group;

  • minimum follow-up of 6 months after loading;

  • presence of clinical, radiographic, patient-centred outcomes or economical evaluations;

Studies that dealt with zygomatic or pterygoid implants, orthodontic mini-implants were outside the scope of this review.

All authors independently read and exanimated titles and abstracts of all studies identified with electronic and hand search and recommended their inclusion or exclusion according to defined criteria. When at least one author considered that a publication met inclusion criteria, full text was obtained and evaluated for its eligibility. Disagreements about inclusion or exclusion were resolved by discussion. Afterwards It was also conducted a search within references of full-text publications evaluated. After assessment process, the following data were extracted from eligible studies: authors, year of publication, study design, patients’ population, type of surgical intervention, primary and secondary outcomes. All the authors performed full-text articles evaluation and data extraction together during 1st Conference meeting of the Digital Dental Society (DDS) in Milan, Italy, 16th–17th September 2016; all disagreements were resolved by discussion. In the same way, it has been assessed the risk of bias for eligible studies using Cochrane Collaboration’s tool for assessing risk of bias [10].

Included studies

Evaluation process of articles selected for this review is schematically shown in Fig. 1. The search strategy carried out in MEDLINE (PubMed) electronic database revealed 14 articles; additional manual searches selected further 21 publications. Afterwards the evaluation of the 37 abstracts there were found only four works who respected inclusion criteria. Of these publications, after full text analyses, two were excluded as one did not present a follow-up period [11], while the other did not show a control group in which conventional surgical procedures were used [12]. Finally, only two papers complied with all inclusion criteria [13, 14]. Data extracted from these two papers were reported in Table 2.
Fig. 1
Fig. 1

Flow-chart depicting the electronic and manual search result

Table 2

Summary table of included studies

Study design

Surgical guide

Primary outcomes

Secondary outcomes

Vercruyssen et al. 2014 [13]

RCT, 1y F/U

59 patients (72 fully edentulous jaws)

60 jaws divided in 5 groups (each one n = 12), treated with 5 different surgical template, 4–6 implants for each jaw

2 groups bone-supported stereolithographic templates, 2 groups mucosa-supported templates, 1 group pilot-drill template

Prosthesis failure, implant failure, biological or prosthetic complications

Peri-implant marginal bone loss, clinical implant evaluation (BOP, paque, pockets), patient’s quality of life improvement

Pozzi et al. 2014 [14]

RCT, multicentrical, 1y F/U

51 patients, fully or partially edentulous jaws (some post-extractive placement)

25 patients treated with guided implant surgery

Stereolithographic surgical templates, stabilized with silicon index and 2–3 anchor pins

Prosthesis failure, implant failure, biological or prosthetic complications

Peri-implant marginal bone loss, time and sessions for rehabilitation delivery, complication time, post-surgical pain, swelling, consumption of painkillers and patient satisfaction, additional treatment cost

Descriptive analysis

Two RCTs could be selected for analysis [13, 14]. They both compare implant placement with 3D planning and dedicated digital guide versus free-hand placement (conventional placement). They both evaluated success rate (prosthesis failure, implant failure, biological or prosthetic complications) with different study design.

Vercruyssen et al. [13] performed a randomised 6-arm, non-blinded, controlled trial with 59 fully edentulous patients for the placement of 4 to 6 implants in the lower or upper jaw. Evaluation was done 1 year after placement of the final restoration. There were two arms with bone-supported guide (24 patients) of two different brands, two arms with mucosa-supported guide (24 patients) of two different brands, one arm with free-hand navigation (12 patients) and one arm with guides only for pilot drill (12 patients). In the free-hand group implants were inserted using only images and measures from the planning software as a reference. In both mucosa groups, flapless surgeries were performed. The success rate at 1 year from the final loading was similar in all groups with no implant lost and then no significant difference. Evaluation of bleeding and pocket probing depth are also recorded after 1 year of follow-up but without any statistically significant difference between groups. No significant differences in peri-implant marginal bone loss could be also observed. For all treatment groups, a significant improvement in quality of life was observed at 1-year follow-up but no differences between groups were observed. This study presents a high degree of risk of bias only about randomization process especially as regard the assessment of the primary and secondary outcomes through the follow-up period.

Pozzi et al. [14] performed a randomised 2-arm, non-blinded, controlled trial with 51 fully or partially edentulous patients. Twenty-six patients were treated with conventional protocol, 25 with guided techniques. In both groups, whenever possible, flapless surgeries were performed. However, in some cases, depending on the operator’s judgment, flaps had to be elevated to better check implant sites. This occurred mostly in the control group where the implants were inserted free-hand. Patients were treated by 3 practitioners (20 and 20 patients for two clinicians and 11 for the last one) achieving a multicenter study design. For data analysis patients’ treatment were categorized, depending on the different clinical conditions, in different degrees of complexity (simple cases had almost 9 mm bone height and 7 mm bone width, complex cases had bone height between 7 and 9 mm and less than 7 mm of bone width). It must be noticed than in the computer-guided group more post-extractive implants, more complex cases and full edentulous maxillae were treated compared with conventional surgery group. One year after definitive prosthetic placement, authors didn’t find statistically significant differences between groups for the number of patients who had implant failures (1/26 in conventional versus 0/25 in computer-guided), for the number of patients experiencing complications (4/26 versus 5/25) and for peri-implant bone loss (0.80 +/− 0.29 mm for the conventional group versus 0.71 +/− 0.25 mm for guided). The treatment overall duration in days (from CBCT to provisional prosthesis delivery) was similar for the two groups. Statistically significant more pain and swelling was reported in the conventional group (P = 0.002 for postoperative pain, P = 0.024 for postoperative swelling). Surgical time from anaesthesia to suture was similar in both groups but we have to keep in mind that more complex cases were treated with guided surgery. Satisfaction, aesthetic and function, of the patient 1 year after prosthetic placement were the same for the two groups. For the computer-guided group, there were extra costs due to the protocol. Bias sources in this work originate mainly from the non-blinded outcomes evaluation and from the matter that, despite patients’ randomization, the computer-guided surgery group has more cases considered complex compared to the control group.

As regards the accuracy of the digital guided implant surgery, several works have been published in recent years with the aim to scientifically assess the accurateness of these techniques. Cassetta and his colleagues published two works evaluating the accuracy of a computer-designed surgical guide comparing three-dimensional positions of planned and placed implants. In the first one they compared preoperative and postoperative computed tomographic images of 116 implants [15]. They observed quite high deviation values between the postoperative position and the preoperative plan at the coronal and apical portions of implants, as well as in the angulation of implants. Even if these deviations do not seem to have clinical significance authors concluded suggesting the necessity of always keeping a safety zone of at least 2 mm to avoid critical anatomical structures injuries. In the other study they assessed, in 28 completely edentulous subjects, the influence of some clinical factors in determining the precision of the surgical guide and of implants inserted, through the comparison of pre-operative and post-operative computed tomography (CT) [16]. The effect of surgical management of the guide (fixed or unfixed), arch (maxilla or mandible), and smoking habit (normal or hyperplastic mucosa) on accuracy was evaluated. They observed that in maxilla, thanks to greater supporting surface, and with the fixation of the surgical guide, accuracy of the guides was improved. They also reported a greater global coronal and global apical deviation in smoking patients due to the increased thickness of mucosa. Another work tried to evaluate the accuracy of computer-generated and conventional surgical guides using a randomized split-mouth design [17]. Each of the ten patients in this study were randomly selected for CAD/CAM-guided implant placement on their right or left side of the mouth. Conventional guides were used on the contralateral side. The authors concluded that implants placement using CAD/CAM surgical guides provided greater accuracy in a lateral direction than conventional guides. In addition, CAD/CAM guides showed less variability of deviation values, from implant planned locations, than conventional guides. Regarding implant optical navigation systems accuracy, in literature there are only few publications. A pilot study of Wittwer has tested one of these systems in 20 patients [18]. For each patient four implants were inserted in the intraforaminal region using a flapless optically guided procedure. Evaluating the CT of the patients before and after surgery, it was assessed the accuracy of the described system. The results suggest that this type of surgical procedure can be a viable and safe alternative in clinical cases with adequate amount of bone. However, in cases where there are irregularities in bone structures it can be less predictable.

Schneider and his group in 2009 published a systematic review of the literature available at time considering eight articles regarding accuracy [19]. All studies included in this review indicated a reasonable mean accuracy with however relatively high maximum deviations. This variability seemed to depend mainly by guided surgical technique chosen and especially by type of template stabilization. CAD/CAM surgical guides showed better degree of accuracy than conventional guides. Recent literature reviews have confirmed these observations regarding the precision of the various computer-guided surgery systems [20, 21]. These revisions have analysed 19 and 24 publications respectively involving different static image guidance systems, finding similar results. Meta-analysis of the accuracy revealed a mean error of about 1 mm at the entry point and of about 1.3 mm at the apex. However, even in these works, maximum deviation values are relevant. Significant differences for all deviation parameters were found for the number of templates used in favour of single template protocols. Less deviation values were also observed when more fixation pins were used.

From the data in the literature we can state that the computer-GIS has good accuracy levels, however because of the still significant deviations it is crucial the choice of the most appropriate surgical-guided protocol and its scrupulous execution. This allows on the one hand to avoid serious complications such as penetrating nerves or critical vases, on the other to be able to apply these protocols even in complex cases such as those with severe bone atrophy.

Computer-GIS is often associated with flapless implant insertion. Although in the literature there are no long-term studies that compare directly the success rate of conventional and flapless implant placement, many works seem to agree that the implant survival rates are comparable regardless of the type of implant protocol chosen. The two articles included in this review, despite the short period of follow-up, have highlighted a lack of statistically significant difference between the two clinical procedures about to the success rate of implant-prosthetic rehabilitations [13, 14]. Further confirmations of these observations were provided by Berdougo and co-workers in a study of 2010, which, evaluated retrospectively 552 implants placed in 169 patients. They founded no statistically significant differences in the cumulative survival rate after 1 to 4 years of follow-up [22] between implants inserted with flapless guided systems versus conventional open-flap implant surgery. Same conclusions were reached by a systematic review published in 2012 in which were included 28 studies on computer-guided implant placement with a total of 4032 analysed implants [23]. This systematic review indicated that guided placement had at least as good implant survival as conventional protocols showing also a significantly decrease pain and discomfort in the immediate postoperative period, but probably due to the use of flapless procedures themselves. In this review however, it was also suggested that this technique still requires a good preparation of operators to reduce as much as possible unexpected procedure-linked adverse events during guided implant placement.

Thanks to implants planning and placement in accordance with the prosthetic treatment plan, GIS may bring significant benefits to prosthetic rehabilitation procedures. Provisional prosthesis can be prepared before clinical phases so that, immediately after surgery, functional loading of the newly inserted implants can be easily achieved. It is also possible to use a single implant abutment both for the provisional and for the definitive rehabilitation, allowing time and costs reduction, but above all improving clinical outcomes especially in the esthetic zone [24, 25]. Many articles highlight how potential prosthetic benefits are greater, especially in the case of fully edentulous and immediate loading patients’ rehabilitations. In a paper published in 2007, Sanna described an immediately loaded CAD/CAM protocol on 30 consecutive patients, evaluating cumulative survival rate and marginal bone remodelling after 5 years [26]. Results seem to suggest that proposed treatment protocol allows a good survival rate of implant supported rehabilitations in fully edentulous patients. In another study of van Steenberghe and collaborators 27 patients with fully edentulous maxillae were recruited and treated with a digital guided protocol [27]. It was possible to transfer, with good accuracy, implant treatment planning to the surgical field allowing functional loading of implants immediately after their application. After a year, all implants and overlying prosthesis were considered successful.

However, prosthetic guided surgery advantages are today still largely theoretical and mostly linked to the opinion of some authors and not deriving from articles with high scientific evidence such as systematic reviews. In addition, many of these works highlight the important number of complications, especially with prostheses, that relieve these protocols [28]. Tahmaseb, in his review, reported intraoperative or prosthetic complications in 36.4% of the treated cases [21]. These reported complications included surgical complications like guide fractures or prosthetic complications like misfits with frameworks and prosthetic fractures. The rate of complications seemed to be closely related to the surgical technique learning curve.

The use of dedicated implant planning software and of guided surgery could sometimes easily avoid bone augmentation procedures. Many authors have published several works in which it was possible to insert implants with guided surgical protocols in atrophic areas. Fortin reported 98% implant survival rate after 4 years in partially edentulous cases with severely resorbed posterior maxilla avoiding sinus augmentation procedure [7]. Implants have been inserted with a CAD/CAM surgical template, based on digital planning, exploiting anterior or posterior wall or the septa of the sinus as well as the palatal curvature. During the 4-year observation period, no complications were recorded, no implants were lost, and there was no infection or inflammation.

In order to evaluate the benefits that guided surgery could provide they have to be assessed costs that these procedures imply. It must be considered an initial investment to buy the technology, but also the cost and the time for clinical team training. Finally, there will be a cost for digital workflow for each clinical case. We consider important that the clinician should be well prepared with regards to both new digital but also conventional procedures because they may need to be applied in case of any unforeseen event during guided surgery procedures. Even if the duration of the surgical intervention may be shorter with guided surgery compared to conventional techniques, it seems that much more time must be invested in the preoperative planning. If guided surgery can avoid bone grafting procedures, it can reduce the overall treatment cost. A significant treatment time reduction could as well reduce the overall costs and compensate some of the additional costs. Depending on the workflow an immediate reconstruction might as well lead to a reduced time amount, which is necessary for the completion of the final reconstruction. Unfortunately, in the literature cost-effectiveness report are not present also due to the multitude and diversity of the different protocols proposed.

Despite enthusiastic expectations are often associated with computer aided implant placement, this review revealed an important lack of high level scientific studies that could compare conventional implant protocols with digital workflows. Some RCTs investigations were retrieved but only two with at least 6 months of follow-up after implant placement could be included in this review [13, 14]. Most of minor evidence level studies are focussed on case series, technical notes or specific aspects of computer-GIS often without any comparison with conventional protocols. Furthermore, many clinical trials show results, but do not go to investigate how different protocol variables compete determining them. We believe that many factors are responsible for determining the effectiveness of GIS, from diagnostic and planning phases to surgical intervention. Every aspect should be analyzed more carefully to scientifically assess which GIS protocol could provide best performances in the specific clinical situation.

The only evidence that was retrieved from the only two papers considered eligible for our review, is that clinical outcomes are similar for the image-guided implant placement and for the conventional procedure after a follow-up period of at least 6 months. Reduction of post-operative pain and surgical time are discussed. For Pozzi and co-workers, more pain was reported, 3 days after surgery, in the open flap control group despite of in flapless/miniflap computer-guided group more post-extractive implants, more complex cases and full edentulous maxillae were treated [14]. Vercruyssen and co-workers reported no significant differences in patient satisfaction, but this appears to be linked only with the questionnaire that is fulfil 1 year after restoration placement [13]. Another work published in 2010 by Arisan et al., regarding patient’s related outcomes, found similar evidences [11]. They showed statistically significant differences in favour of the group of patients treated with flapless guided surgery compared to those treated with conventional open-flap procedures, regarding the number of analgesics consumed, post-operative pain and haemorrhages. Also, Fortin and collaborators, in a controlled trial founded a significant difference in pain measurements, with higher scores on questionnaires in open-flap surgery group comparing with flapless guided surgery group [29]. In contrast, an RCTs published in 2010 show worse results in guided implant flapless groups in comparison to conventional open flap implant surgery [12].

Based on the results of the screened literature it is evident that the overall scientific evidence in the field of image guided implant placement is low. Only two RCTs with at least 6 months of follow-up could be identified. The only evidence that is retrieved is there are no statistically significant differences between conventional and computer-guided implant placement procedures, both for patient outcomes and implant survival rate. Reduction of post-operative pain and surgical time are discussed. Consequently, certain clinical recommendations cannot be given. However, indications for guided-implant surgery could be the need for minimally traumatic or flapless surgery, optimal implant positioning and immediate loading.

Further research should be designed as RCTs avoiding any possible sources of bias. These studies should take into consideration not only rehabilitation success and potential complications, but also patient-reported outcome measures (PROMs), and economic aspects. The purpose of these studies should therefore be to clarify clinical indications of guided implant surgery.

Computer-Aided Design/Computer-Aided Manufacturing

Computed tomography

Guided implant surgery

Randomized Controlled Trial

Not applicable.

This investigation was carried out without funding.

Availability of data and materials

All data generated or analysed during this study are included in this article. List of papers obtained from electronic search, list of excluded studies and reasons for exclusion are available from the authors upon request.

Authors’ contributions

All authors contributed to the work presented in this paper. MC wrote the entire manuscript. EM, MK, UH took part in study design and data analyse. TF designed and executed search strategy. CM coordinated the work and helped to draft the manuscript. All authors read and approved the final manuscript.

Authors’ information

Not applicable.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Authors’ Affiliations

Private Practitioner, Milan, Italy
Dental Science Department, University Vita Salute San Raphael, Milan, Italy
Oral Rehabilitation Department, School of Dental Medicine, Tel-Aviv University, Tel Aviv, Israel
Department of Oral Surgery and Implantology, Center for Dental, Oral and Maxillofacial Medicine (Carolinum), Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt am Main, Germany
Department of Surgical and Diagnostic Sciences (D.I.S.C.) Dental School, University of Genova, Genova, Italy
Oral Surgery, School of Dentistry, University of Lyon, Lyon, France
Private Practitioner, Via Tasso 45, 21052 Busto Arsizio, Italy

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  20. Van Assche N, Vercruyssen M, Coucke W, Teughels W, Jacobs R, Quirynen M. Accuracy of computer-aided implant placement. Clin Oral Implants Res. 2012;23(Suppl 6):112–23.PubMedView ArticleGoogle Scholar
  21. Tahmaseb A, Wismeijer D, Coucke W, Derksen W. Computer technology applications in surgical implant dentistry: a systematic review. Int J Oral Maxillofac Implants. 2014;29(Suppl):25–42.PubMedView ArticleGoogle Scholar
  22. Berdougo M, Fortin T, Blanchet E, Isidori M, Bosson JL. Flapless implant surgery using an image-guided system. A 1- to 4-year retrospective multicenter comparative clinical study. Clin Implant Dent Relat Res. 2010;12:142–52.PubMedView ArticleGoogle Scholar
  23. Hultin M, Svensson KG, Trulsson M. Clinical advantages of computer-guided implant placement: a systematic review. Clin Oral Implants Res. 2012;23(Suppl. 6):124–35.PubMedView ArticleGoogle Scholar
  24. Grandi T, Guazzi P, Samarani R, Maghaireh H, Grandi G. One abutment-one time versus a provisional abutment in immediately loaded post-extractive single implants: a 1-year follow-up of a multicentre randomised controlled trial. Eur J Oral Implantol. 2014;7(2):141–9.PubMedGoogle Scholar
  25. Canullo L, Bignozzi I, Cocchetto R, Cristalli MP, Iannello G. Immediate positioning of a definitive abutment versus repeated abutment replacements in post-extractive implants: 3-year follow-up of a randomised multicentre clinical trial. Eur J Oral Implantol. 2010;3(4):285–96.PubMedGoogle Scholar
  26. Sanna AM, Molly L, van Steenberghe D. Immediately loaded CAD-CAM manufactured fixed complete dentures using flapless implant placement procedures: a cohort study of consecutive patients. J Prosthet Dent. 2007;97(6):331–9.PubMedView ArticleGoogle Scholar
  27. van Steenberghe D, Glauser R, Blombäck U, Andersson M, Schutyser F, Pettersson A, Wendelhag I. A computed tomographic scan-derived customized surgical template and fixed prosthesis for flapless surgery and immediate loading of implants in fully edentulous maxillae: a prospective multicenter study. Clin Implant Dent Relat Res. 2005;7(Suppl 1):S111–20.PubMedView ArticleGoogle Scholar
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text:
(Closed) Tore between sparkle or lace

posted 4 years ago in Dress
  • poll: Sparkle or Lace?
    Dress 1 Sparkle : (53 votes)
    74 %
    Dress 2 Lace : (19 votes)
    26 %
  • Post # 2
    76 posts
    Worker bee

    I’ve seen dress 1 in person (it’s my sisters!) and it is STUNNING. The sample fit her like a glove, and when it’s hugging in the right spots it’s honestly breath taking.

    Post # 3
    2446 posts
    Buzzing bee
    • Wedding: May 2014

    I got married in a lace dress (Katie May’s Poipu), so I am partial to that. But I think both look great on you! Sorry that’s not much help

    Post # 4
    311 posts
    Helper bee
    • Wedding: October 2016

    Sparkle is calling to me! Definitely looks amazing!

    Post # 5
    252 posts
    Helper bee

    Overall I like the sparkle best on you.  The sparkle is perfect on the front.  I like the back of the lace dress on you better.

    Post # 6
    4040 posts
    Honey bee

    I vote Oh Wow!, to #1.

    Post # 7
    1630 posts
    Bumble bee

    Are you getting married outside on the beach? The sparkle dress would definitely stand out with the sun and the water- the lace one, not as much

    Post # 8
    688 posts
    Busy bee

    The sparkle dress is breathtaking.. looks great on you

    Post # 9
    6142 posts
    Bee Keeper
    • Wedding: November 2009 - New York, NY

    The sparkly one!!!

    Post # 10
    667 posts
    Busy bee
    • Wedding: July 2015

    I think #1 looks spectacular on you! Though if you keep looking, I’m sure you’d be able to find a gown with sparkle AND lace if you can’t decide! 🙂

    Post # 11
    799 posts
    Busy bee
    • Wedding: June 2014

    Both are beautiful. I usually love lace, but dress #1 is amazing.

    Post # 12
    1080 posts
    Bumble bee
    • Wedding: September 2015

    Dress 1 looks exquisite on you. And side note- dat ass looks goooood

    Post # 13
    2273 posts
    Buzzing bee

    Sparkle Sparkle and a thousand times over SPARKLE – You look banging in that dress its one of my all time favorite wedding gowns 😀

    • This reply was modified 3 years, 8 months ago by  llussier.
    Post # 14
    23598 posts
    Honey Beekeeper
    • Wedding: September 2011

    Gosh, don’t make me choose, I love them both on you! 🙂

    Post # 15
    1868 posts
    Buzzing bee
    • Wedding: October 2017

    JK0487:  Both are beautiful I think the top on dress 2  is more flattering, but I like the bottom on the second. Not much help sorry!

    The topic ‘Tore between sparkle or lace’ is closed to new replies.

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text:
France, teenage son, travel
Comments 7

“France is a desperate party girl.”

I thought that yesterday, as we drove home from the local village with fresh bread. Autumn is really here: all the trees are red, gold, yellow, throwing their leaves onto the road in front of us. France has become a fraught, older ‘woman of the world’, throwing one last drunken ‘soirée’ before the lonely slam of Winter. She’s piling on her jewels, strings of rubies and gold chains, wrapping round and round her big bosom, as she leans forward into our space, spilling cheap champagne, desperate for us not to leave yet. She’s talking too loudly, her perfume’s too strong. She’s painted her toenails Tangerine, clinging to the last cotton dress of summer, her last green lace petticoat.

Tangerine GreenLace

She’s straining to throw bright sunsets, ignoring the bite of chill in the air, laughing hard at our more introspective moods, which lower on us as the darkness comes sooner.

France has a population of 60 million, and her visitors number 76 million a year. She’s busy, receiving them all, mostly from June-September 30. And now her season is over. Shops close, restaurants close, hotels close. You can’t hire a canoe, a horse, a caravan. It’s done. Shutters are being locked shut, signs brought in, tables outside wiped and stored away.

But part of France staggers on, wobbling in her high red suede heels. She wants more fun! She wants more people, more noise, more love! She throws her thin, fire-coloured confetti, and watches it whipped away by the wind. Her streamers are damp, hanging low between the lampposts, and the runs in her stockings are worse than ever.

But she wants to go on. She’s still beautiful, still tempting, yet the effort is almost too much. Her trees are such a perky red now, and the yellow is almost neon; every day the view seems brighter. But there’s an edge to it; greys, browns, even blacks are creeping in from the side, as last crops are gathered, and soils are turned and left bare for Winter.

We can feel the season changing, slinking lower. The sun isn’t warm till midday, then cooling again by 4 or 5. The fat ponies next to the supermarket carpark are hairier every day, while the last geese have flown past us to Africa (something so mournful about their sound):

A fortnight ago there were flocks every 30 minutes in the late afternoons, calling out their farewells; today was the first time we’d seen any for days. But no honking. They knew they’d left it late.

Tiny birds are flying in and out of the Barn eaves, searching for a sheltered nook. ‘Barry’ the resident bat hasn’t been around much- has he hitchhiked with the geese? Smart bat.

The old farmer down the lane has spent days gathering up his walnut crop; I watched his knotted hands struggling to transfer the small nuts to his basket. He’ll wash them and dry them on racks, then either press them for oil, or eat them during the coming months, like a squirrel. His neighbor further along has piled higher than his head the timber he’s gathered from the forest. In fields all around us, stacks of wood remind me that the temperature gets down below zero; while we two can survive for now, hugging up to the draughty fireplace, feet up on the concrete hearth, it’s not much fun. ‘15’ is beginning to rebel against the leaking bathroom, the weak shower you take sitting down in the cold metal bathtub, the hopeless toilet cistern. Hot water pipes bang, moan and knock; a poor soundtrack to the party the French slut is trying to coax out of us.

We’re sleeping a lot, under two quilts each; lights out by 10.30, cold noses tucking under the covers, not awake before 8.30 or 9. France wants to dance, but we’re beginning to hibernate. I can’t believe my Australian friends are swimming in the ocean! And neither can She. Clad in rusted velvet, rings of crimson, flashes of brass in her décolletage, France is desperate to celebrate one more time, with wine, cheese, and smoky kisses, trailing up to an unmade bed at dawn. But it’s almost over Honey, and there’s nothing you can do about it.

C’est la Vie.

  1. A beautiful piece, gg.

    This trip has helped your writing so much – not that it wasn’t already strong! but these last few posts have shone with a particularly elegant punch.

    Love, fan number 5,357.

  2. Marcia Smith says

    Darlings Made me shiver just reading Your b and S. Definitely time to pull the plug And come home where the sky is blue and sun shining, well most days. Tobes off yesterday to London and the rugby final and I roped myself into sorting Finca Teresa Beans that had slipped through the Panama net ! Mad! To B and j last night for dinner BBQ lamb. Lovely . Keep safe and hope to see you soon. Lots of love Mxx

    Sent from my iPhone

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text:
The Comfort Bear – Very Short Story

We sped onto the highway, me and my family, as we were eager to get home after a weekend at my grandmother’s. I don’t particularly remember what happened that weekend, but my parents told me I had fun. It wasn’t too young to remember either because I remembered vividly what happened next. It seemed like any other trip as we rode along the highway, me not paying attention to the outside and playing with my Game Boy I had got a year earlier.

I still have the thing as it can survive most anything…

Out of nowhere, a motorbike driver came into our lane and crashed on the front of our car. The windshield shattered and the motorbike driver flipped over the car and crashed behind us. Luckily he didn’t land in the other lane.

I was frozen in fear at the initial crash, what else could you do, especially as a child? But I believe that is how most people would react no matter their age – when you’re not in control. Indecently, my father had the wheel and he turned into the railing. I had never lost my breath so hard since that day – it was like all the air escaped my body and I gasped desperately to refill my lungs.

My parents had a similar reaction because it took them awhile to stumble out of the car and check on me. I remember the eyes of fear and blood trickling over my father’s face. He didn’t take note of his own injury and asked if I was all right. I answered weakly that I was. My mother lifted me from my seat and we leaned against the car while my father hurried to the motorbike driver.

My father told, years later, that the helmet had saved the driver’s life and was the only thing that had held his brains together. I’m glad he didn’t share that detail with me at the time. There wasn’t much my father could do for the driver, however, but he remained by his side even though he was the cause of the accident. We heard later that, apparently, one of the bolts to the back wheel had been missing; a mechanic supposedly forgot to put it together and the wheel came loose on the road.

It took a while before I could express my fears as I was still in shock; but the tears eventually welled, out of nowhere and I bawled loudly in my mother’s arms. She let me cry as much as I wanted. She told me later that she wanted to cry too, but I cried for the both of us. The police came before the ambulance and they must’ve heard there was a family involved in the accident because one of them gave me a teddy bear, fresh out of the wrapper. It’s apparently common practice in Holland and still is.

It’s probably a good practice… It did comfort me a little.

I still have it somewhere in a trunk at my parents, along with all the other childhood items I kept. It took a long while before I relinquished that bear – longer than I care to admit. It invoked such strong feelings whenever I saw it – conflicting feels that I did not understand, at the time. But, whenever I did recall that horrible day, it never let the bear escape my embrace.

© Christopher Stamfors

I post Short Stories every week. Please check out my other fictions HERE.

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text:
The Sinister Silhouette

Title: The Sinister Silhouette
Author: Alex Grayson
Genre: Romance

Publication Date: May 25th, 2018

She whispers my name at night, filling my dreams with her haunting beauty.
Her tormented amber eyes beg me for something I don’t understand, and her agonizing pain becomes my own.
For years, she’s come to me, calling my name.
For years, I’ve never known who she was.
Until now…
Alex Grayson is the bestselling author of heart pounding, emotionally gripping contemporary romance including the Jaded Series, the Consumed Series, and two standalone novels. Her passion for books was reignited by a gift from her sister-in-law. After spending several years as a devoted reader and blogger, Alex decided to write and independently publish her first novel in 2014 (an endeavor that took a little longer than expected).

The rest, as they say, is history.
Originally a southern girl, Alex now lives in Ohio with her husband, two children, two cats and dog. She loves the color blue, homemade lasagna, casually browsing real estate, and interacting with her readers. Visit her website,, or find her on social media!

Author Links:
MY EYES FLICKER OPEN when I hear a thump. The first thing I see are my hands still laced together over my stomach. When I lift my head, a dull pain resonates in my neck from staying in the same position for so long. Closing my eyes, I tilt my head back and twist it from side to side, loosening the muscles.
When I scoot my ass back in the seat, I notice the nurse call remote has fallen to the floor. I pick it up, then stand to wind it around one of the rails to keep it from slipping off again.
My body locks in place and my jaw damn near falls to the floor when I look at Jules. She’s lying there with her eyes wide fucking open looking at the ceiling. The first thing I notice is the brilliant color of her eyes. Just like in my dreams, they’re a bright golden amber. She blinks slowly a couple times. She must not see me, because she keeps looking at the ceiling like it’s the most fascinating thing she’s ever seen.
I hold still, not wanting to startle her, but also desperately wanting her eyes directed at me.
Swallowing to wet my suddenly dry throat, I murmur softly, “Jules.”
Her lips part. She blinks a couple more times before her head slowly turns in my direction. The minute her eyes lock on mine, a rush of air leaves my lungs. Fuck, but they are striking.
I don’t get a chance to enjoy her eyes being on me before they fill with fear. I frown, confused at the stark terror forming on her face. I reach out a hand to her to try to quell the fear but drop it when her lips tremble. Her hands clutch the sides of her head as her mouth opens and she lets out a god-awful scream. I stumble back a step and knock into the chair, stunned at her hysterical behavior. She starts thrashing on the bed, her legs kicking the blanket off her as she presses herself as close to the railing as she can to get away from me. The whole time, her wide eyes stay connected with my astonished ones, like she’s accusing me of something.
A nurse rushes in, and I numbly step to the side to give her room. Another rushes in seconds later with a doctor following closely behind. They both go to the other side of the bed.
“NO!” Jules screams over and over again, clutching her head. “NONONO!”
The ache in my chest that’s always present in my dreams is back, except it’s ten times worse. The pain I feel seeing her suffer in the flesh makes the pain of seeing her suffer in my dreams feel like a fucking paper cut. It’s agonizing and all-consuming and takes my damn breath away.
I want nothing more than to go to her, to hold her against me, and make all her fears go away, but it’s me she fears, and that thought tears me apart.
“Mr. Hendrix, I’m going to have to ask you to leave.”
I ignore the nurse trying to usher me out of the room. I can’t take my eyes off Jules as she fights the doctor and nurses. They yell back and forth to each other as they try to calm her down. I grow angry when they hold her down and stick a needle into her IV. I force my legs to hold still, instead of rushing over and yanking them away. I know they’re professionals and only trying to help her, but I still don’t fucking like it.
“Mr. Hendrix.” The nurse tries again, grabbing my arm. “Theo!”
It’s the use of my brother’s name that has me ripping my eyes away from the distraught girl in the bed. I stare down at the nurse, and her eyes soften in sympathy. “Please, just wait outside until the doctor calms down your wife and assesses her. He’ll come talk to you as soon as he can.”
I don’t correct her on her mistake of thinking I’m my brother. I just give her a stiff nod before looking back at Jules one more time. She’s no longer screaming due to the medicine now running through her veins, but her eyes are still on me. Tears fall from them, soaking the pillow beneath her head, and it makes me want to fall to my knees and scream.
Instead, with one final look and my chest feeling hollow, I turn on my heel and leave the room.

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text:
How to meditate: a guide to self-discovery

Front Cover
Bantam Books, 1975 - Body, Mind & Spirit - 161 pages
1 Review

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LibraryThing Review

User Review  - CenterPointMN - LibraryThing

With his simple, straightforward approach, Lawrence LeShandemystifies meditation. No matter what you do or how busy you are, his brief, realistic guide lets you explore the many apths to meditation. His specific programs and exercises provide practical tools for you to begin your own journey. Read full review

LibraryThing Review

User Review  - kerowackie - LibraryThing

Great intro still in print since early 70s. Like everything else worth doing in this life, Meditation is often difficult, but rewards are limitless. Worth finding time for, like physical exercise which is often neglected in favor of more mundane, though necessary pursuits. Happy Destiny! Read full review

Why We Meditate
How a Meditation Feels
The Psychological Effects

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text:
MUSCLE MEMORY by Stylo Fantome Release Blitz with Review!!! @givemebooksblog @StyloFantome

Title: Muscle Memory
Author: Stylo Fantôme
Genre: Contemporary Romance
Release Date: August 28, 2017
Her lips, the way she feels, how she moves against me. Her
voice when she laughs, her eyes when she cries. Her soul connected to mine, for
better or for worse, for all eternity.
I don’t remember.

A blank face. Unrecognizable. The darkness and impenetrable fog, day after day
after day. Who am I? And for that matter, who is she?

I can’t remember.

Two sides to the same coin – one wants to remember, and the other wants to stay
forgotten. Which side will win? Can he trust his heart to bring him back to
her? Or will she stay lost in the fog forever?

I might never remember.
Warning: features adult themes

Purchase Links
99c for a very limited time!
Free in Kindle Unlimited
This book – just wow….
Muscle Memory will not leave my brain. I finished it a few days ago and I am still having trouble putting into words how I am feeling about this book. It sucked me in from the first sentence. Usually when I read a book about amnesia I really hope that the person gets their memory and life back. That wasn’t the case for me with Jay/Jon. While he was a fun guy before his accident, he was heading down a dark path that I believe would ultimately lead to death.
He and Delaney are amazing together but again, before the accident, the road they traveled was dark. They are heat and passion, but really, really bad for one another. Talk about the ultimate enablers – phew. These two are selfish, both in their need for each other and the drugs they crave.
Enter Kitty, post-accident Jay/Jon’s girlfriend. I wanted to like her. Really, I did. However, most if the time I wound up just wanting to punch her in the face. She was too needy, especially for a man that is going through something as traumatic as Jay/Jon.
Stylo writes my kind of books. I am never disappointed when I read them and Muscle Memory was no exception. She writes amazing, plot driven stories that keep you hanging on her every word and characters that jump off of the page and into your brain to become a part of you. I am dying to read what she has in store for us next!
Author Bio
Crazy woman
from a remote location in Alaska (where the need for a creative mind is a
necessity!), I have been writing since … forever? Yeah, that sounds about
right. I have been told that I remind people of Lucille Ball – I also see
shades of Jennifer Saunders, and Denis Leary. So basically, I laugh a lot, I’m
clumsy a lot, and I say the F-word A LOT.
I like dogs
more than I like most people, and I don’t trust anyone who doesn’t drink. No, I
do not live in an igloo, and no, the sun does not set for six months out of the
year, there’s your Alaska lesson for the day. I have mermaid hair – both a
curse and a blessing – and most of the time I talk so fast, even I can’t
understand me.
Yeah. I
think that about sums me up.
Author Links

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text:
Collections / Carioca Top Vinho
Carioca Top Vinho

Carioca Top Vinho

$ 40 Regular price

Part of BBB’s Street Style collection, this sexy cross lace top is inspired by the fun loving women of Rio de Janeiro. Dry fit spandex material, perfect for lounging or working out.

  • One size fits most
  • Silky smooth fabric
  • Made in Rio de Janeiro, Brazil

Product Care: Machine wash your gear in cold water and air dry. This will help extend the life of the material and keep the shape of your garment. (TIP: once in a while, put your BBB Leggings in the dryer on medium heat to tighten them back to their original shape)

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$ 40
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text:
My How Time Flies or What’s With the Art?

Okay, so it appears my last post was WHAT???? THREE MONTHS AGO?!?!?! WOW!!! Where has the time gone? Is it because I’m in my 40s now that time is going by so quickly? Or is it because as a mom of eight I usually don’t even know what time of day it is?! I just don’t know. So, for my few (very few – that’s okay) readers, I want to apologize if you’ve been holding your breath waiting for another blog post from me!

Whew, okay….now I got that out of the way. I thought maybe I’d tell you a little more about myself. (I originally sat down to write this on my computer on October 16 – the date is on the document) and now it’s November 14  November 19.  I’m glad I’m not doing this for a living!

My Creative Journey or What’s Up With All This Art Stuff?

Well here’s some background and history for you…

Anybody who knows me well or has known me for a very long time knows that my journey in creating visual art did not start with my introduction to Instagram at the end of 2015. Although any of my Facebook followers might think all my plethora of recent photos of art stuff might be a new thing for me, it is not.

Is Social Media a Downward Spiral?

For several years now, I’ve resisted “joining” IG – that’s Instagram – because I was already on Facebook and I just did not need any “more” social media in my life. In July of 2015, I was persuaded to open a Twitter account (to be able to watch Periscope back when it was directly linked to Twitter – a means to an end…) by my mom and brother. And then in December, an American friend and a South African friend here in Mozambique were extolling the virtues of Pinterest (which I’ve purposefully avoided for many years for several reasons). Well, I liked the idea of having a “visual” scrapbook of ideas as opposed to magazine clippings littering my life. And so, since I decided to join Pinterest, I thought, “What the hey… I guess since I’m on FB, Twitter, Periscope & Pinterest, it’s only a short jump to Instagram! So I joined.”

Well, I’m so incredibly grateful to the Lord for Instagram. Honestly…it has boosted my creativity to new heights.

Back to the Story…

My history goes back to probably when I was born to the Art Lady of Beaumont, Texas. If you’re reading this and grew up in Beaumont between 1980 and 2015, then you most likely know Mrs. Garrett, the Art Lady! Anyway, she’s the one who, when my best friend came over to spend the night when we were 7, let us walk through acrylic paint and walk all over big rolled out butcher paper in the garage. I did take some art classes at the Beaumont Art League when I was about 12 or 13. I specifically remember an oil painting I started of a horse’s head and never finished. Oil paints were far too high-maintenance for my lazy self! Then in 8th grade, I took art, which was fun. I didn’t take any art during high school due to the fact that I was already taking band and French, which I pursued all 4 years. And I don’t know what I did in College. I think I’ve blocked that time from my memory. Oh, Russian….I learned Russian. And I watched movies.

After I graduated from Texas A & M University with a bachelor’s degree in Russian, I spent almost one year in Far East Russia as a missionary on a team of people with the Navigators. Anyway, my spiritual mentor while in Blagoveshchensk was a sweet Jesus-lady from Florida who is very artistic. I’d learned basic calligraphy years before and had experimented with it. But she wrote beautiful encouraging scripture cards in calligraphy. So the artistic spark ignited the smoldering coals of creativity within me.

When I returned to the United States and lived with my parents for a year or so, I took a couple more art classes. One was a watercolor class by a well-known local artist in our area. He encouraged me to do some collage with old watercolor paintings and form them into a new painting. I tackled a huge full-size watercolor sheet of paper (which is like 4 feet by 4 feet or something) and worked from a photo of tobacco fields that I had taken while in France. All the old ladies in my class (why is it that all the “hobbies” I pursue are comprised of anywhere from 10-100 ladies with a median age of 65 while I’m the lone 25 year old?)…anyway, all the ladies in my class all exclaimed with excitement and awe: “Your work is so loose and free, etc. etc. etc.” I had no idea WHAT they were talking about!!!! That painting is still around (I think hanging on mommy’s fridge! – well- really the living room wall). Anyway, in those two or three years between Russia and getting married, I produced several paintings using different mediums. I also started doing calligraphy again, usually on the background of watercolor that I’d painted. The Art Lady and her best friend tried and tried to get me interested in 3-D work (sculpture and such), to which I looked at them and replied, “When y’all were 23, were y’all doing 3-D? No! Y’all were doing watercolor and calligraphy and acrylics and pastel!” “Well, yes, we sure were!” At that age, I just couldn’t see 3-D. Still have trouble with that!

So when I met and married the mechanic poet, and God started giving us encouraging words for the young single people around us, usually in the form of poetry, I would paint a background and then transcribe Brad’s poetic thoughts onto the painting in calligraphy. We did quite a few of these. And then came the beginning of the Artillery!

If you’ve ever been a young mom, you probably know what happened to my creative process. It was pooped on, puked on & flushed down the potty!!!! Well, not entirely. I did actually start hand embroidery during this time, which was a lot less messy than painting.

Well, God led us to Cape Town for our first year in Africa (which is one of the main reasons we ALWAYS return to the Cape for births….it’s most definitely our home away from home). In Cape Town, I discovered the Cape Embroiderer’s Guild, which I joined and started to learn many new (actually old techniques) things. Once again, I was a twenty-something in a world of blue-haired old ladies. Of course, now, blue hair is pretty popular amongst the younger crowd too (I still have some blue left in my hair from last year in Texas!) I absolutely LOVED (still LOVE) hand embroidery. It’s much harder to find time to pursue this now with 8 children, but I digress. Once again, in 2003, all those older ladies were amazed at my refreshing choice of colors and my interpretation of ancient techniques. I can’t help it that I’m in love with lime green and turquoise and orange. I’m just not a traditionalist.

During that first eight months in Africa, we found ourselves serendipitously placed by the Lord in a duplex in Table View, a suburb just north of Cape Town. At that time, we weren’t doing anything in the way of “street ministry” or anything else. God was adjusting us to life overseas with small children and had us in a very unique place. Well, wouldn’t you know it, we noticed that the lady across the street from us was doing pottery in her garage. So I walked across the street to inquire about it. Well it turns out, she was not only doing pottery, but she was teaching it as well. Right there in her garage. Two kilns, two potters wheels. Right across the street. Brad said to me, “Jen there’s no question at all. You have to take a class from her. God dropped it on our doorstep!” Literally. So entered 3-D. I enjoyed it. I loved it! I loved the feeling of the clay in my hands. I liked throwing little bowls. I liked painting the greenware with glazes. I liked building things with my hands. It was a great time. I’ve kept a few of those things.

Others eventually broke or I ended up giving them away. And while I loved the whole aspect of working with clay, I somehow just decided it wasn’t for me for the long-term. Maybe I’ll do it again. But I’m not crazy enough about it to go out to the local river and try to find clay and build a kiln here. I know others who have done that. But all the physics and math and chemistry process that go into sculpting in clay is not for me. I love the “IDEA” of it. But not the daily practice of it. It’s just too much work.

I want instant art gratification.

So…let’s see….that was 2003. And why does it seem like 2004-2008 are a blur to me? We lived in 4 different countries, had 4 pregnancies, 1 miscarriage, 3 babies, moved into our village…into a house with no bathroom and no kitchen and no running water and….okay….now I know why it was a blur.

Enter Art Journaling magazine and Cloth, Paper, Scissors.

It was at this time during 2008 I think that I discovered the world of mixed-media art. I was so drawn to it. I devoured magazines that Mom sent me, longing for the “know-how” and the time to do it. I bought a few books. One of them was The Artistic Mother by Shona Cole, another mom of 6 children who has learned how to incorporate her art into her daily life. That inspired me greatly. But still, I didn’t know how to “do” art again. No time to stitch. No time to sketch. Definitely no time to paint. My art supplies were in storage in the States. There was an unquenchable longing to create. Now, I know some people who are amazingly creative and their medium is baking. One friend in South Africa who has a daughter that does the most amazing birthday cakes. That’s not me. That’s not my medium. Neither is cooking. I am a creative cook. And I cook all the time. But it’s not my art. It’s not where I am fulfilled expressing the creative spark from within me. I know that. I’m one of those people that is on a constant “self-discovery” journey.

We’ve been like that in missions as well. Someone once said, “You have to kiss a lot of frogs before you kiss the prince.” Well, in missions, we’ve done some work with orphans. We’ve done some work with food programs. We’ve done some other “humanitarian” stuff. And that’s not us. I am a wife and mommy who lives in a culture completely different from the one in which I was raised. THAT is my gifting. To support my husband and my family in difficult living circumstances. Our mission ministry is evangelism and church-planting. We’re so grateful that God has placed people here to feed orphans and such. It is a HUGE need. Well, we feed hungry people here….I’m not saying we turn away hungry mouths. But that’s not WHY we are here. Brad’s passionate about entering a village that’s never seen a white face and never heard the Name of Jesus. THAT is what we’re about…but I digress….I was talking about art…hold on, backing up out of the rabbit hole….

Finally Creating Art Again

What’s especially interesting is that I’ve been looking at those Art Magazines since about 2009. They are ones that my mom would buy to peruse and then send to me when she was done with them. Anyway…I’ve had a longing to make visual art again. And so at the beginning of 2015, Brad and I started trying to make it a daily habit of praying for each other right before bed. You’d think after 16 years of marriage (at that time) we would have already been in the habit of doing that. But if you know anyone who has children or if you have children yourself, especially more than 4, you know how your time is full of good intentions, but reality is often a different story. Well, as I’m writing this, we’ve slacked off a bit with this pray for each other thing. But for most of 2015 we prayed daily for each other. We shared 3 requests with each other and that’s what we brought to the Throne of God each night. One of my requests was that I would be able to actually pursue some mixed-media art journaling in practice and discover if that was one of the ways I could find a creative outlet. Well, several things happened through the year that brought me to where I am now in this journey.

In the past, I’ve gotten some supplies together to try to make a daily practice out of art, especially when we go to South Africa and have a baby and I want to save mementos and keep a visual journal (quasi-scrapbook) about our time. However, I haven’t been accustomed to making it part of my daily life. So in June of 2016, after having prayed for months about my explorations in art and after having discovered how many talented artist there are on Instagram (and Facebook as well, incidentally), I finally committed to doing the ICAD Challenge put on by DaisyArt. Basically, you do something visually creative on an index card for 61 days (all of June and July). It was a great jumpstart for me back into creating visual art and realizing, also, that I can just do some paint swatches or doodle with a pen or paint something that “feels” like art to me. Index Card Art is a great way to experiment with new techniques or different products without feeling like you are wasting supplies. I had a great time doing all those miniature artworks. And I was able to be more intentional about incorporating art into my daily life.

When August started, I was at a bit of a loss as to “what to do now.” But the embers had been reignited and I started approaching my daily life with some creativity in mind. Since then, I’ve had a real desire to paint whimsical faces. At least once or twice a week, I have been drawing, sketching or doodling or painting a lady’s face in some form. Enough that my two budding children artists have started doing faces as well. It’s really exciting to me to see how my interest in developing my own style and pursuing my art has trickled down to my children. Can’t wait to see how this progresses over the next few years!

Check out my Instagram feed by clicking on the IG icon in the right column to see some of my current artwork and projects.

Building, Construction, Process

Family Life Anecdote

I’m cleaning up the kitchen after breakfast with friends here – a family of 6 – and Gunnar, 13, comes in to wash oil-based paint off his hands. He uses some dishsoap liquid (Maq) and comments, “I don’t like this one as much as Sunlight.” I didn’t respond for a few minutes. Then he says, “This one doesn’t foam as nicely.” And I say, “Wait a minute….I’m still trying to process the first statement coming out of a 13 year old’s mouth! These are things that don’t come out of the average American 13 year old’s mouth! I’m so glad I have children that are above average!” (I chose those words “above average” so I didn’t put the moniker of “abnormal” or “weird” or “crazy fruitcake” into his impressionable 13 year old head. I’m really trying to watch what I say around them and speak life into them! He responds, “Well, the average American 13 year old wouldn’t have an opinion on dishsoap because he doesn’t do dishes, or if he does, he sticks them in the machine, then puts that little tablet of whatever it is in there, turns it on, then goes to play PSP. Except they probably don’t play PSP anymore, but whatever!”

So for awhile we’ve been wanting to take in a shed that was attached to our pantry. In fact, before Christmas, Brad and the two older boys ripped the roof off of it, rendering it completely useless for the duration of rainy season (which lasted from December until April). That was a bit unfortunate because it’s where we store things that we don’t need in the house (think of it like a garage of sorts, but not big). We have no closets, so our warmer clothes and sleeping bags and camping stuff is packed away in foot lockers and stored in this shed). So we moved all the stuff to the Long Drop (that’s a latrine with a lid on the hole and a shed around it). The idea was that they’d start demolition and reconstruction, but then with the rains and a month and a half of sickness, the wind was knocked out of our sails. Then we also had the issue of floor plan. From my understanding, when married people are building any physical structure together this is always a source of disagreement, to put it mildly. He has in his mind one idea, from which he has no intention of deviating. And she has in her mind the way things really ought to be. And she’s right of course! Chill out, that’s a joke!!!! Well, for us, I wanted an extended room that would make my kitchen bigger (since it was originally tacked on to our walk-in pantry). Brad wanted more of a living room area, but had envisioned a very large one. We didn’t really have to compromise as such, because it took so many months to decide in the first place. When it all came down to it, we decided we want to have to lay a bigger foundation (for the time being) than the one we already had. We just wanted to enlarge the room. We both felt complete peace about that decision.

And so we got our contractor and discussed it with him. Now, you have to get out of your head the American idea of a contractor. I have friends who are contractors that are brilliant! That’s not the case here. The man who is our contractor is a local pastor who also works as a bricklayer (of mud bricks, mind you). He built our current houses (we have 2 separate structures – one for sleeping and one for eating that are joined by a veranda or porch). Quality control here is not a high priority like it is in our home culture. But this friend of ours can measure correctly and can mix cement (ratio-wise) that is fairly strong and reliable. That’s pretty much what is required. So they started what we projected to be maybe a 3 week job. Back home, it would have only taken about a week, tops. But more than likely about 3 days. Simple plan really…fill in a 3 foot high stairwell to take in as part of the new foundation, build a rectangular room with a corner half-bath. Install ceiling beams, tin, sand on top for insulation, then roofing beams and tin on top of that. Install front door and bathroom door. Brad installed the windows (which we haven’t sealed yet because he has to buy sealant in Pemba – 4 hours away). Well, as is not unusual here, the job has stretched into 2 months of sporadic labor, and the doorjambs were finally installed a few days ago by the workers (without the contractor here). Well, they installed them completely crooked. The bathroom door is narrower at the bottom than the top. And the front door is wonky-warped. It appears both will have to chiseled out and re-cemented.

And so we wait. We wait because the contractor is busy helping his son build an adobe hut. We wait because somebody’s brother’s cousin died and the workers have a funeral to attend. We wait because we need to learn patience. We wait because This Is Africa. We used to say, “TAB!” That’s Africa, Baby! Until we saw the movie Blood Diamond, in which the main character uses the acronym, “TIA – This is Africa.” And it’s true. It’s beautiful and rugged and right now it’s a huge dustbowl where we live, but it is Africa. It’s different than the city in which I grew up in Texas. It’s different than the United States. But for now, it’s home. It’s the only home my children have ever known. It’s how we roll. And one day, we’ll have a couch or sofa in the Alcove (that’s the name I’m contemplating for the new room, in which there will be no toys…and the adults, when we have guests over, will sit and drink tea and coffee) and it will be finished, complete with paintings by our British missionary friend hung on the wall. And the doors will fit and close snugly. But for now, it’s in process! The story of my life. Process.

If any of you might have seen my Facebook or Instagram post, we had an interesting incident with the very curious and adventurous toddler. I was making granola in the kitchen (the first window in the red house) when I heard Magnum exclaim, “Mom, Thunder is on the roof!” I literally was up to my elbows in mess and wasn’t exactly sure what he meant, so I told him to call Daddy. When I exited, I understood. Magnum was standing at the top of the ladder so Thunder wouldn’t fall. Thunder was up on top of the roof before they laid the roofing tin. He had climbed the ladder in the following picture (where the workers had left it) and was standing up on top of the edge of the roof with a somewhat surprised look on his face. Thank God that He always protects us! And oh that I had had my phone in my hand to take a picture, but I guess some situations call for wisdom. Like rescuing the toddler from a potentially lethal fall.

IMG_20160802_163053As I’m typing this, they have just ripped out the door jams and are re-cementing them in correctly. And I’m working on our newsletter and our new surprise…..a VLOG!!!!

If you’d like to subscribe to our newsletter, you can check out our Facebook page here. Or you can go to our website here. It is out of date, but that’s the other project I’m starting is updating the website.

Thanks for taking time out of your day to read. I’d love it if you replied with a comment or sent a message otherwise. It really means a lot when I hear from “the outside world!”

Until next time….

Re-Introduction – I’m Back!!!

So, I’ve decided to attempt to restart my blog. If any of you have visited here in the past, you have seen that even when I started I wasn’t an AVID blogger by any shake of the stick. But recently our communication lines have opened up such that I’ve discovered many new friends on Instagram and Periscope (mostly artists), and it occurred to me that I should at the very least update our 3 year old website and possibly even try to start blogging. Some obstacles I’ve faced as contemplating this are that there is such a culture out there of stay-at-home moms blogging as a way to make income for their family. I think that’s great! It’s wonderful! But it’s not for me. In fact, everytime I think about making money (however that happens) off of a blog, I get a sick feeling in my stomach. Literally! Another factor I’ve had to consider is that I feel like I have “nothing to offer.” Now, that’s not me being down on myself. It’s just that if you look at so many blogs out there, there’s lots of “tips” and “tricks” and “encouragements” and “teachings.” That’s not me! If somebody learns something from me, it’s just from me being me. It’s not because I’m a gifted encourager or teacher, because I’m not! I am who I am and I’m learning more and more everyday who that is and who that is not! So basically, I just want a little “corner” on the web where I can share my ramblings that give you a peek into our life. Life in the bush. The ups and downs and ins and outs of a Texan Christian missionary living in a village of mud huts in Africa. With 8 children. The only white family in our district (like a county). I hope you find this peek into my world encouraging in some way!

In the next few days, I hope to have a surprise to go along with our new newsletter, but it’s taking me a little time and brainwaves to organize it, neither of which I have in abundance at the moment! So, a little grace, if you will…

Back log on newsletters

How does one keep up with 7 children, a husband, newsletters, a website, & updating FB page? I have no idea?!?! I’ve visited a few blogs or websites maintained by moms of lots of children and I have no earthly idea how they do it! My brain has the capacity for it, but somewhere between making chips, popcorn & 3 meals a day and the computer, my brain becomes mush! All I want to do is sit still and listen to nothing! But since I’m trying to finalize the latest newsletter & the internet seems to be working & I’ve already ignored the children for breakfast and lunch and skipped my meals (basically) as well, I guess I should try to update the links to the latest newsletters. It seems as if maybe our last one was not put up on the blog either. Wow, but just the dashboard of this blog site scares me….it doesn’t seem to me quite as user-friendly as I originally thought. Also, I’d like to start posting a bit more, but most blogs are full of photos….and this one probably will not be, as the connection isn’t always reliable. We’ll see what I can manage.


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Early Childhood

man with toddlers

Early Childhood  Education Options

Brainerd Public Schools offers a variety of early childhood programming to meet the needs of our families.  These programs include:

Early Childhood Programs

  • Early Childhood Screening/Kindergarten Registration- The state of Minnesota requires that all children entering kindergarten complete an Early Childhood Screening and recommends this at age 3.  This appointment is a quick and simple check of how your child is learning and growing.

Early Childhood Special Education - early intervention and preschool special education to children birth to kindergarten, who show developmental delay in a variety of areas.  Students must complete an evaluation and meet qualifications to receive intervention services.

Kinderclub Early-Age Care & Pre-Kindergarten Program - KinderClub is an all-day childcare, enrichment and kindergarten readiness experience that serves our families during the school year and summer. Children must be four years old to attend.

Who to Contact
 Julie Domino
Early Childhood Special Education Director
 Jennifer Erickson
Early Childhood Special Education Secretary
 Tahnee Flowers photo
 Tahnee Flowers
Assistant Director of Community Education for Early Childhood Programs
 Jennifer Lindholm Photo
 Jennifer Lindholm
Early Childhood Programs Secretary
 Gina Thesing Photo
 Gina Thesing
Early Childhood Screening Secretary

Website by SchoolMessenger Presence. © 2018 West Corporation. All rights reserved.


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I have used many different training methodologies in my life, but the one I keep coming back to is rest pause training.
Get to know your vagus nerve. Create more joy. Be more energetic. All of this will optimize your fitness efforts and more.
Adaptation is the sole reason for working out, and recovery is one of the best ways to achieve it.
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Training is the easy part. What happens the other 22 hours of the day is where the battle will be won or lost.
When you plan your HIIT sessions, don't underestimate the importance of rest intervals. Here's what the research says.
Life can get in the way of a good night's sleep, but there are simple steps you can take to maximize the quality of your time on the pillow.
Proper nutrition, mobility, and recovery are clutch to stay healthy at any level of grappling.
It's easy to get caught up in the desire to make gains and forget about rest.
It's time to look at five additional tips to keep you on target for that better body without wasting your time on worthless pursuits.
A new study found significant overlap between these three factors and muscle growth.
Traditional hypertrophy programs often use short rest periods, but a new study suggests this might not be the best idea.
Place quality over quantity now so that you continue to make gains in strength, work capacity, mobility, and overall fitness.
What happens when your training schedule says it’s a big workout today, but you’re just not feeling it?
Want to get stronger, perform better, and increase your power? The answer lies in your recovery.
Whether you are a competitor or a recreational athlete, you can learn a lot about your body if you just listen.
To avoid the perils and pitfalls of overtraining, we need to understand it. This collection of seven articles and videos will help you keep overtraining at bay.


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Mauro Oliveira Decorated Chair

U.S, 21st c.

InquireShareprint SKU: LU835010266603 Category:

A wonderfully decorated chair by the noted Brazilian American artist Mauro Oliveira. The chair is a plastic chair that Mauro has magically transformed. It is signed on the back.. Please note that this chair cannot be used outdoors. Biography Best known for his geometric work done with automobile detailing vinyl tapes, Mauro Oliveira also creates three-dimensional wall artworks that resemble floating sculptures, creatively incorporating objects such as color pencils, pens, water color tablets, paper clips, rubber bands, wax, metals or other everyday materials. All his artworks are covered in an immaculate and glossy resin finish. A Brazilian born and mid child of seven siblings, growing up in extreme poverty, creativity started early at age 10: he took advantage of the free tin piggy banks given by all the banks back then and invited and encouraged other kids to paint them with him in order to sell at a weekend art fair in Sao Paulo: 1000s were sold. He made it to college and won a student exchange program Contest sponsored by the Federal University of Uberlândia, Brazil. He studied Journalism and the Arts and immigrated to the U.S. in 1990. Oliveira, lived half of his life in Brazil and the other half in the USA where he finally settled down in Los Angeles. He lived in three states in Brazil and in three states in America, having artworks exhibited in every city, including Sao Paulo, Rio de Janeiro, Miami, San Francisco, New York, San Diego, Palm Springs and Los Angeles. His greatest influences are Pablo Picasso and Joan Miro. Oliveira studied Journalism and Arts in Brazil and immigrated to the USA in 1990. Having a full circle in his life, he is now a full-time artist and couldn’t be happier. Inspired by nature, colors and geometry, he makes sure that every piece has a story to tell and touches everyone in one way or another. Oliveira likes to believe that he created his own eclectic style, using materials never used before for art. Mauro’s technique is eclectic to say the least. From early works with oil pastel, acrylic paint, pencils, water colors and a few other mediums, he discovered resin and a new whole art world opened up for him. For the past eight years, most of Oliveira works has a glossy resin finish. Because resin keeps everything together and cemented for life, his work with with automobile detailing tape got the assurance it needed to be used on arts. Early this year Oliveira started a series of Pop Icons such as Michael Jackson, Marilyn Monroe, Prince, Elizabeth Taylor and even President Barack Obama. All done with tapes, paint and covered with several layers of resin. Back in June, while walking back from almost daily hiking on Runyon Canyon, Mauro decided to walk by the star walk of fame. A homeless offered him a fake Oscar for a $1. That’s all he had on his package along with Id and a CC. Walking back home in Hollywood and not knowing what to do with the Oscar, a light build appeared on his head: that’s it, he was ready to work is technique on the most iconic and important award in the whole world. Each Oscar is one of a kind and has a special message with it: the golden oscar, the first of the series to be made, honors the academy with a ‘red carpet’ on the background and 10 shades of gold on the Oscar itself. The second one is the rainbow Oscar, honouring the GLBT Community (after all half of Hollywood is gay in his own words). The silver Oscar for example is a super hero The Super Silver Oscar to ‘compete’ with the eternal gold Oscar, you must have super powers Silver Oscar. Then there is the bloody Oscar, the police side of the Oscars, the lack of inclusion, the discrimination underneath, etc. Stay tuned because the Emmys and the Grammys will be next that, after all possible Oscar’s personalities and identities are explored.


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Uigean, Na h-Eileanan Siar

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Approximate Location Map

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Uigean is a hamlet in Na h-Eileanan Siar

Location and coordinates are for the approximate centre of Uigean within this administrative area. Geographic features and populated places may cross administrative borders.

Photos of Uigean

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