Dental Traumatology 2007; doi: 10.1111/j.1600-9657.2006.00509.x                                                     DENTAL...
Cohenca et al.                                                                 principles of nuclear magnetic resonance (N...
Digital imaging in dento-alveolar trauma                                                                                  ...
Cohenca et al.teeth. MRI was found to be somewhat superior to                          normally to cold and electric pulp ...
Digital imaging in dento-alveolar trauma                                                                          a       ...
Cohenca et al.a                                                 bc                                                  d     ...
Digital imaging in dento-alveolar trauma                                                                         right cen...
Cohenca et al.a                                       bc                             d                          e         ...
Digital imaging in dento-alveolar trauma    The application of computer-based systems and                              met...
Cohenca et al.      mandibular third molar anatomical relationships. J Calif               generation machine. Oral Surg O...
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Clinical indications for digital imaging in dento alveolar trauma. part 1 traumatic injuries

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  1. 1. Dental Traumatology 2007; doi: 10.1111/j.1600-9657.2006.00509.x DENTAL TRAUMATOLOGYClinical indications for digital imagingin dento-alveolar trauma. Part 1: traumaticinjuriesCohenca N, Simon JH, Roges R, Morag Y, Malfaz JM. Clinical Nestor Cohenca1, James H. Simon2,indications for digital imaging in dento-alveolar trauma. Part 1: Ramon Roges2, Yoav Morag3,traumatic injuries. Ó Blackwell Munksgaard, 2006. Jose Maria Malfaz2 1 Department of Endodontics, School of Dentistry, UniversityAbstract – Traumatized teeth present a clinical challenge with of Washington, Seattle, WA; 2Division of Surgical, Thera-regard to their diagnosis, treatment plan, and prognosis. Recent peutic and Bioengineering Sciences, University of Southern California School of Dentistry, Los Angeles, CA; 3Departmentdevelopments in imaging systems have enabled clinicians to 1 of Radiology, University of Michigan, Ann Arbor, MI, USAvisualize structural changes effectively. Computed tomography,magnetic resonance imaging and cone beam computed tomo- Key words: dental trauma; diagnosis; digitalgraphy are among the most commonly used systems for dental imaging; computed tomography; cone beam com-and maxillofacial surgery. The purpose of this review is to puted tomography; luxation injuries; root fracturedescribe the advantages and disadvantages of each technique and Nestor Cohenca, Department of Endodontics,the clinical application for dento-alveolar trauma. Three clinical University of Washington, POB 357448, Seattle, WAcases are described to illustrate the potential use of the NewTom 98195-7448, USA3G for diagnosis and treatment plan of dento-alveolar traumatic Tel.: +1 206 543 5044 Fax: +1 206 616 9085injuries. e-mail: cohenca@u.washington.edu Accepted 23 March, 2006The past decade has witnessed several changes in has been extensively reported in the literature (3, 5,the world of endodontics. New technologies, instru- 14–16). However, the potential use of 3-D imagingments and materials have resulted in a better for the diagnosis of dental trauma has not beendiagnosis and more predictable endodontic therapy. reported.Recent improvements in digital radiographic The incidence of dental trauma as a result of falls,imaging have introduced a new dimension with bicycle accidents, skateboarding and other sportsmany potential benefits for endodontic practice. activities is higher in children and adolescents, withDigital radiography (1), computed tomography (CT) the maxillary incisor teeth most commonly affected(2–4), magnetic resonance imaging (MRI) (5) and (17–19). The first clinical and radiographic exam-more recently cone beam computed tomography ination of the traumatized patient is crucial to(CBCT) (6–9) have become increasingly important determine the initial diagnosis, severity of the injury,in diagnosis and treatment planning. treatment plan and to create a baseline for follow The traditional projection (plain film) radiograph up. Common diagnostic aids for pulpal and peri-is a two-dimensional shadow of a three-dimensional apical conditions are percussion, palpation, tooth(3-D) object. Three-dimensional imaging overcomes mobility, coronal color changes, pulp sensitivitythis major limitation by allowing us to visualize the tests, and radiographs. When correctly performedthird dimension while at the same time eliminating and adequately interpreted these tests are reliable insuperimpositions. Previous studies reported the use diagnosing pulp necrosis (20).of CT and digital radiography for differential The purpose of this review is to discuss differentdiagnosis of periapical pathology (10, 11) and techniques of 3-D imaging and to illustrate thetreatment outcomes (12, 13). The use of 3-D clinical application of the CBCT for diagnosis andimaging systems in oral and maxillofacial surgery treatment plan of traumatic injuries.Dental Traumatology 2007; 23: 95–104 Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Munksgaard 95
  2. 2. Cohenca et al. principles of nuclear magnetic resonance (NMR), aComputed tomography spectroscopic technique used by scientists to obtainComputed tomography uses X-rays to portray a microscopic chemical and physical informationcross-sectional image of an object without super- about molecules (27). The technique was calledimpositions (21). The CT scanner makes multiple MRI rather than nuclear magnetic resonanceprojections of an object with a thin beam of X-rays. imaging (NMRI) because of the negative connota-Radiation detectors measure the object’s X-ray tions associated with the word nuclear in the lateattenuation at each of these projections and a 1970s. MRI started out as a tomographic imagingcomputer reconstructs the attenuation data to technique, in that it produced an image of the NMRproduce a cross-sectional image of the object (22). signal in a thin slice through the human body. The first clinical CT X-ray unit was developed in Felix Bloch and Edward Purcell, both of whom1972 by G.N. Hounsfield (23) in England and it were awarded the Nobel prize in 1952, discoveredrevolutionized clinical imaging by offering three the magnetic resonance phenomenon independentlymajor advantages – no superimpositions, the ability in 1946. In 1975 Richard Ernst proposed MRIto distinguish between objects of similar density using phase and frequency encoding, and Fourier(contrast resolution), and digitally acquired data, transformation. This technique is the basis oftherefore offering greater flexibility in processing, current MRI techniques. A few years later, inanalyzing, and storing of information. Improvement 1977, Raymond Damadian was the first to everin contrast and temporal resolution of early CT perform an MRI examination on a human beingscanning was achieved by the introduction of helical (28). In the same year, Peter Mansfield developedCT scanners and multi-detector computed tomo- the echo-planar imaging (EPI) technique. Thisgraphy (MDCT) (24). The slip ring technology of technique was developed in later years to producehelical CT scanners enabled continuous uninter- images at video rates (30 ms/image) (29).rupted acquisition of volumetric data with reduced Although the spatial resolution of MRI isscan times. The multiple rows of detectors in inferior to CT, the advent of the 3 Tesla MRIMDCT expanded the speed of scanning, thus may provide improved spatial resolution in addi-enabling breath hold imaging acquisition, resulting tion to the already superior contrast resolution ofin improvement in 3-D reconstructed images in the MRI. High-resolution T2-weighted imaging ofvirtually any plane. Sixteen-detector row MDCT a finger provided a voxel size of 0.19 · 0.19 ·can acquire substantial anatomic volumes with 0.42 mm (30).isotropic sub-millimeter spatial resolution and scan Imaging and analysis using magnetic resonancetimes of <10 s for 300 mm of coverage (25). brings exciting possibilities to medical and dental Computed tomography imaging is extremely specialties without concerns about radiation dose.important in maxillofacial trauma and has become However, MRI is less sensitive for osseous injurythe gold standard in imaging for these cases (26). and its application in the oro-facial field includeOther dental and maxillofacial indications for CT diagnosis of tumors of the oral cavity, pharynx,include the study of growth and development, oral larynx, paranasal sinuses, as well as diagnosis forpathology, salivary gland disease, and treatment temporomandibular joint and salivary gland dis-plan and placement of dental implants. The main eases (31). The main disadvantage of MRI falls intodisadvantages of CT are the high radiation dose the cost of the equipment and its interpretation.compared with plain-film radiography and the highcost of the equipment. Image acquisition time has Cone beam computed tomographydecreased dramatically with the introduction ofMDCT (24) but this has come at the expense of Cone beam computed tomography, also calledreduced radiation dose efficiency. digital volume tomography (DVT), is a new tech- nique that produces 3-D digital imaging at reduced cost and less radiation for the patient than tradi-Magnetic resonance imaging tional CT scans (14). It also delivers a faster andMagnetic resonance imaging is a modern compu- easier image acquisition.terized method of scanning and creating images The NewTom 3G DVT 9000 (Quantitativeusing a strong magnetic field and radio waves. The Radiology s.r.l., Verona, Italy) was the first CBCThydrogen atoms in the patient’s body react with the introduced to the United States’ market in 2001.magnetic field and as a result of a radiofrequency Since then, several other systems have been com-pulse, emit their own radiofrequency signal which is mercialized, including CB MercuRay (Hitachi Med-analyzed by a computer to produce images. The ical Corp., Chiba-ken, Japan), 3D Accuitomo-XYZimages obtained help in detecting various abnor- Slice View Tomograph (J. Morita Manufacturing,malities in the tissues scanned. MRI is based on the Kyoto, Japan), and iCat (Xoran Technologies, Ann96 Dental Traumatology 2007; 23: 95–104 Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Munksgaard
  3. 3. Digital imaging in dento-alveolar trauma Multisequence multiplanar MRI Phillips Achieva 3.0TArbor, MI, USA/Imaging Sciences International, Radiofrequency antennae 0.7 · 0.8 · 2.0 mm† Varies/examinationHatfield, PA, USA). image acquisition *Effective dose as reported is provided from the manufacturer and is not truly comparable to other devices due to variable such as different size of imaging volumes and operational settings of the devices. Entire body The NewTom 3G acquires 360 images at 1° Supine 12 bit NA NA NA NA NA NA NAintervals in 36 s, with reconstructed image resolu-tion of 512 · 512 pixels and 12 bits per pixel (4096grayscale). The pixel size varies between 0.25 and0.42 mm depending on the user’s choices (large orsmall field and the sensor, 9 or 12 in). The axial slicethickness can be set up between 0.1 and 5 mm. multiple 360° rotations Dental applications of CBCT imaging have been Varies/examination Multi-DetectorCT state or gas Linear solidreported for oral and maxillofacial surgery (14, 32, Entire body Axial slice 110–140 Rotating 80–300 2.6–3.1 Supine 12 bit 0.31633), implantology (34, 35), and orthodontics (7, 36, Fan No37). Studies have suggested that CBCT providesaccurate and reliable linear measurements forreconstruction and imaging of dental and maxillo-facial structures (8, 38, 39). Panoramic type single Hitachi MercuRay intensifier CCD 360° rotations Not available Not reportedComparison between CBCT, CT, and MRI Maxillofacial Area image To 15 max 70–100 Seated Fixed Cone 8 bit CBCT, cone beam computed tomography; MDCT, multi-detector computed tomography; MRI, magnetic resonance imaging; NA, not applicable. 0.1 9.6Cone beam computed tomography results in afraction of the effective absorbed dose of radiation(E) compared with a traditional CT scan. Imaging ofa maxillomandibular volume with the NewTom 3Gresults in an E of 57 lS (6) while traditional medicalCTs result in an E of 1400 lSv for a maxillary CT silicon flat-panel detector Panoramic type single Area amorphousscan and 2100 lSv for a maxillomandibular exam- 360° rotations Direct current Not available Not reported Maxillofacial 40 or lessination (40). For purposes of comparison a pano- ISI/CAT Seated 12 bit Fixed Cone 120 1–3 0.4ramic radiograph results in an E of 6 lSv and a fullmouth series results in an E from 33 to 84 lSv (41)and 14 to 100 lSv (42) depending upon variablessuch as film speed, technique, kVp, and collimation. Hashimoto et al. (43) reported that CBCT (3DXmulti-image micro-CT) is more efficient than Panoramic type single 3DX AccuitomoMDCT for diagnosis and examination of hard intensifier CCD 360° rotations Direct current Maxillofacial Area imagetissues in the maxillofacial region. Image quality of 0.0074 Seated 60–80 0.125 Fixed 1–10 Cone 8 bit No 17the CBCT was deemed superior to MDCT forevaluation of right central incisor and left mandib-ular first molar cortical and cancelous bone, enamel, Variable voxel size numbers quoted are used in 2-D multislice imaging.dentin, pulp cavity, and periodontal ligament spacelamina dura in an anthropomorphic phantom. Table 1. Comparison of different CBCT devices, MDCT, and MRI Panoramic type singleIn addition, the mean skin doses per examination intensifier CCD NewTom 9000 360° rotations 0.04–0.0515 Maxillofacial Smart scanwith the MDCT were 458 mSv examinations vs 10–15 max Area image 110 (fixed) 0.25–0.42 Supine 12 bit Fixed Cone1.19 mSv with the CBCT. Mah et al. (44) com- Yes 75pared the tissue-absorbed dose of CBCT and othercomputed tomographic imaging modalities. Theyconcluded that the effective dose for imaging ofmaxillomandibular volume with a NewTom 9000 issignificantly lower than that achieved with CT Effective dose* (max & mand) mSvimaging methods. A comparative table evaluatingtechnical characteristics and specifications of differ-ent CBCT devices, MDCT, and MRI is presented Auto exposure control(Table 1) (7). Imaging session (s) Image acquisition Magnetic resonance imaging has been Voxel size (mm3) Sensor detector Patient positioninfrequently used for dental evaluation despite the kVp range X-ray source X-ray beam Image area Parametersfact that it has the ability to demonstrate the neuro- Grayscale Anode mAvascular bundle within the mandibular canal, its rela-tion to the teeth and reveal the pulp chambers of the †Dental Traumatology 2007; 23: 95–104 Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Munksgaard 97
  4. 4. Cohenca et al.teeth. MRI was found to be somewhat superior to normally to cold and electric pulp tests. Radio-CT in imaging the mandibular canal prior to dental graphic examination showed a mid-root horizontalimplants (45) and comparable to CT in evaluation fracture on the maxillary left central incisor withof jaw bone length measurements (46). Gahleitner separation of the fragments and a radiolucent areaet al. (47) reported that patients with inflamed at the fracture line (Fig. 1b). No apical pathologydental pulp demonstrate bone marrow edema in could be observed. The NewTom 3G DVT 9000the periapical region which would not be apparent analysis at 0.2 mm cuts showed the horizontal rooton CT or CBCT. fracture from a cross-sectional view and demonstra- ted the oblique component of the fracture in the palatal aspect of the root (Fig. 2). Fracture of theCase 1 alveolar bone at the level of the root fracture wasA 15-year-old male patient presented to the Endo- also observed (Fig. 2c).dontic Graduate Clinic at the University of South- An initial diagnosis of pulp necrosis in theern California with a complaint of discomfort on his maxillary left central incisor was made and thefront upper teeth. His medical history was noncon- patient was scheduled for endodontic therapy oftributory. A review of the dental history revealed an the coronal fragment only. The treatment wasimpact injury to the face due to a fall that occurred uneventful and root canal filling was performedapproximately 4 months prior. The patient was using white mineral trioxide aggregate (Pro Root,initially treated by his general dentist who diagnosed Dentsply; Tulsa Dental, Johnson City, TN, USA)a root fracture on the maxillary left central incisor (Fig. 3).and applied a rigid splint with wire and compositeresins extending from the maxillary left canine to a bthe maxillary right canine (Fig. 1a). Four months later, the patient was referred forendodontic consultation. Visual examination re-vealed bacterial plaque retention due to the splintand poor oral hygiene. Upon clinical examination,the maxillary left central incisor did not respond toan electric pulp sensitivity test (Vitality Scanner;Analytic Technologies, Redmond, WA, USA) or toa cold sensitivity test at )50°C (Endo Frost; Roeko,Langenau, Germany). The tooth was mobile butwithout sensitivity to percussion or palpation. Theadjacent teeth were asymptomatic and responded c d a bFig. 1. (a) Periapical radiograph of the maxillary left central Fig. 2. (a) Frontal reconstruction with the NewTom demon-incisor following the initial diagnosis of a root fracture and strating an alveolar fracture of the buccal plate at the level ofapplication of a rigid splint using wire and composite resins the root fracture (see arrow). (b) Cross-sectional view confirmsextending from the maxillary left canine to the maxillary right the mid-root horizontal fracture. (c, d) At closer view, 0.2 mmcanine. Close reduction in the fragments is evident. (b) Four cuts show the horizontal root fracture with an obliquemonths later, the radiograph shows a mid-root horizontal component in the palatal aspect of the root and the fracturefracture with separation of the fragments and a radiolucent area of the alveolar bone in both buccal and palatal plates (seeat the fracture line. No apical pathology is observed. arrows).98 Dental Traumatology 2007; 23: 95–104 Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Munksgaard
  5. 5. Digital imaging in dento-alveolar trauma a b c dFig. 3. Immediate postoperative periapical radiograph showingthe final obturation of the coronal fragment with mineraltrioxide aggregate. The patient was re-examined 10 months later.The maxillary left central incisor was asymptomaticand non-mobile. Follow-up radiographic examina- Fig. 4. (a, b) At 10-month follow up the periapical radiographtion was performed using plain periapical radio- shows evidence of root remodeling and a significant reductiongraphs and the NewTom 3G DVT 9000. Periapical of the fragments without interposition of granulation tissue. (c, d) NewTom images reveal only a slight reduction in theradiographs showed evidence of root remodeling space between the fragments with interposition of bone andand a significant reduction of the fragments without connective tissue. Lack of healing in the palatal surface of theinterposition of granulation tissue (Fig. 4a,b). Cross- root might be due to a double fracture of the root which can besectional view with the NewTom revealed only a seen in this cross-sectional proximal view (see arrow).slight reduction in the space between the fragmentswith interposition of bone and connective tissue(Fig. 4c,d). Lack of healing in the palatal surface of lucencies were diagnosed and associated with thethe root may have been due to a double fracture of traumatic displacement of the maxillary left incisorsthe root which can be seen in this cross-sectional (Fig. 6a–c). A radiopaque particle consistent with aproximal view (see arrow in Fig. 4d). tooth fragment was noted on the soft tissue radio- graph of the lower lip (Fig. 6d). Considering the severity of the trauma, theCase 2 patient was referred for digital imaging with theA 24-year-old male patient presented to the Center NewTom 3G DVT 9000. Images revealed a severefor Urgent Care, Trauma and Sports Dentistry at palatal displacement of the maxillary left centralthe University of Southern California with severe incisor with concomitant alveolar fracture and thetrauma to his maxillary left central and lateral lack of cortical bone buccal to the maxillary leftincisors after he fell down the stairs. His medical central and lateral incisors (Fig. 7). The toothhistory was unremarkable. fragment embedded on the lower lip was also Visual examination revealed a severe lateral detected (Fig. 7b). The emergency treatment proto-luxation of both maxillary left incisors (Fig. 5a–c). col included repositioning (Fig. 8) and stabilizationSoft tissue lacerations and localized swelling of the of the luxated teeth with acid-etched composite andlower and upper lips was also noted (Fig. 5c,d). The a flexible wire. The tooth fragment was surgicallyocclusion was altered and the patient was not able to removed from the lower lip and the patient givenbite in centric relation. Upon palpation of the amoxycillin 1500 mg daily for a week.buccal cortical plate, an alveolar fracture was Upon the patient’s request he was referred to hissuspected. Radiographically, periradicular radio- general dentist for the endodontic therapy of bothDental Traumatology 2007; 23: 95–104 Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Munksgaard 99
  6. 6. Cohenca et al.a bc d Fig. 5. (a) Preoperative clinical photo- graph immediately after admission at the emergency room. (b) Intraoral exam- ination showing a severe lateral luxation of both maxillary left incisors and injury of adjacent soft tissue. (c) Occlusal view of the displaced teeth. (d) Soft tissue lacer- ations and localized swelling of the lower lip is evident. a b a b c c d d e f g hFig. 6. (a, b) Periapical radiographs demonstrating periradicularradiolucencies associated with the traumatic displacement of the Fig. 7. (a) Frontal reconstruction with the NewTom showingmaxillary left incisors. (c) Occlusal radiograph of the pre-maxilla. the severity of the impact and subsequent trauma to the left pre-(d) A radiopaque particle consistent with a tooth fragment is maxilla. (b) The tooth fragment embedded on the lower lip wasapparent on the soft tissue radiograph of the lower lip. also detected in this axial view (see arrow). (c) A different axial cut reveals a severe palatal displacement of the maxillary leftmaxillary left incisors, removal of the splint and central incisor and alveolar fracture of the palatal bone. (d–h)follow up of the adjacent teeth. Recall of the patient Series of cross-sectional 0.2 mm cuts showing lateral luxation ofwas not possible due to lack of compliance. the teeth with concomitant alveolar fracture of the buccal cortical plate (see arrows).Case 3A 25-year-old male patient presented to the Center being elbowed during a basketball game. Thefor Urgent Care, Trauma and Sports Dentistry at patient reported that as a result of the injury, histhe University of Southern California 24 hours after maxillary left central incisor was ‘pushed back’ and100 Dental Traumatology 2007; 23: 95–104 Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Munksgaard
  7. 7. Digital imaging in dento-alveolar trauma right central incisor was not displaced as a result of the trauma (Fig. 10e). No splint was required as the teeth were stable and the patient was rescheduled for a follow-up examination. Ten days later the patient presented with marked crown discoloration on the maxillary left central incisor. Clinically, the tooth was asympto- matic and there was no sensitivity to percussion or palpation. Radiographic examination showed no evidence of pathology. Based on the available data, a conservative approach was recommended and the patient followed up clinically and radiograph- ically every 6 weeks. Four months later following a thorough clinical and radiographic examination,Fig. 8. Clinical photograph showing repositioning of the max- the maxillary left central incisor was diagnosedillary left central and lateral incisors. with pulp necrosis. The treatment plan included root canal therapy, intracoronal bleaching and coronal restoration of the maxillary left centralhe repositioned the tooth by himself. His medical incisor and follow up of the adjacent teeth. Thehistory was noncontributory. treatment was uneventful and the patient remained Extraoral examination revealed no significant asymptomatic.abnormality. Intraoral examination revealed soft Eleven months later a radiographic examina-tissue lacerations on the attached gingiva as well as tion (Fig. 11) showed evidence of apical boneon the upper lip (Fig. 9a). No occlusal interferences remodeling and new buccal cortical bone forma-were observed. Both maxillary left incisors were tion apical to the maxillary left central incisortender to percussion and with 1–2 mm mobility. (Fig. 11c).The maxillary left central incisor did not respond tovitality testing, although the adjacent teeth respon- Discussionded within normal limits. Radiographic examina-tion showed a slight displacement of the maxillary Most maxillofacial traumatic injuries involve theleft central incisor (Fig. 9b,c). Further examination dentition alone (50%), or both the dentition andwith the NewTom 3G DVT 9000 disclosed a more adjacent soft tissue (36%) (48). Maxillofacial frac-severe lateral luxation of the maxillary left central tures (13.6%) account for the remaining types ofincisor with subsequent alveolar fracture of the injury. Traumatized teeth present a clinical chal-buccal cortical bone (Fig. 10a–d). The maxillary lenge with regard to their diagnosis, treatment plan, a b cFig. 9. (a) Soft tissue lacerations on the attached gingiva and the upper lip. (b, c) Radiographs showing slight enlargement of theperiodontal ligament space on the mesial and apical aspects of the maxillary left central incisor due to the traumatic displacement ofthe tooth.Dental Traumatology 2007; 23: 95–104 Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Munksgaard 101
  8. 8. Cohenca et al.a bc d e Fig. 10. (a, b) Frontal reconstruction with the NewTom demonstrating luxation of the maxillary left central incisor with concomitant alveolar fracture. (c, d) Cross-sectional views showing lateral lux- ation of the maxillary left central incisor. (e) No evidence of traumatic displace- ment is noted on the maxillary right central incisor as result of the trauma. a b cFig. 11. Eleven-month follow-up. (a) The periapical radiograph shows evidence of apical bone remodeling. (b, c) Cross-sectionalimages demonstrate periradicular normalcy and new buccal cortical bone formation apical to the maxillary left central incisor.and prognosis. Unfortunately, film-based intraoral alveolar fractures (49). This limitation is due to theradiography provides poor sensitivity in the detec- projection geometry, superimposition of anatomiction of minimal tooth displacements, root, and structures, and processing errors.102 Dental Traumatology 2007; 23: 95–104 Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Munksgaard
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