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10 Use of Three-Dimensional Technology for Virtual Surgical Planning in Oral…
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203
Data
Collection
Virtual
Surgical
Planning
Merge Data
Into BSP
Design
Prosthesis
in BSP
Refine
Prosthesis
in MM
Clinical exam,
Cone beam CT,
fibula CT
Patient specific
data
Import and align
dental model and
fibula to CBCT
Postition implants
into fibula and
add teeth via
denture design
Export fibula and
prosthetic STL
Dental models or
optical intraoral
scan
Create implant
access holes and
finalize prosthesis
contours
3D Print
Prosthesis
Post
Processing
Fig. 10.8 Example of Jaw in A day workow (Reproduced with permission from Williams, Fayette
C et al. “Immediate Teeth in Fibulas: Planning and Digital Workow with Point-of-Care 3D
Printing.” Journal of oral and maxillofacial surgery: ofcial journal of the American Association
of Oral and Maxillofacial Surgeons vol. 78,8 (2020): 1320–1327. doi:10.1016/j.joms.2020.04.006)
Add model
support
Alcohol bath, cure
Add pink
composite
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S. A. D. Al Azri et al.
References
1. Allisy-Roberts P, Williams J.Farr’s physics for medical imaging. NewYork, NY: W.B.Saunders
Company; 2007.
2. Wippold FJ II.Head and neck imaging: the role of CT and MRI. J Magn Reson Imaging.
2007;25:453–65.
3. Pauwels R, Beinsberger J, Stamatakis H, etal. Com- parison of spatial and contrast resolution
for cone-beam computed tomography scanners. Oral Surg Oral Med Oral Pathol Oral Radiol.
2012;114(1):127–35.
4. Bartier S, Mazzaschi O, Benichou L, Sauvaget E. Computer-assisted versus traditional technique in bular free-ap mandibular reconstruction: a CT symmetry study.
Eur Ann Otorhinolaryngol Head Neck Dis. 2021;138(1):23–7. https://doi.org/10.1016/j.
anorl.2020.06.011; Epub 2020 Jun 30.
5. May MM, Howe BM, O'Byrne TJ, Alexander AE, Morris JM, Moore EJ, Kasperbauer JL,
Janus JR, Van Abel KM, Dickens HJ, Price DL. Short and long-term outcomes of threedimensional printed surgical guides and virtual surgical planning versus conventional methods
for bula free ap reconstruction of the mandible: decreased nonunion and complication rates.
Head Neck. 2021;43(8):2342–52. https://doi.org/10.1002/hed.26688; Epub 2021 Mar 31.
6. Jones JP, Amarista FJ, Jeske NA, Szalay D, Ellis E 3rd. Comparison of the accuracy of maxillary positioning with interim splints versus patient-specic guides and plates in executing
a virtual bimaxillary surgical plan. J Oral Maxillofac Surg. 2022;S0278-2391(22):00007–6.
https://doi.org/10.1016/j.joms.2022.01.006; Epub ahead of print.
7. Ying X, Tian K, Zhang K, Ma X, Guo H.Accuracy of virtual surgical planning in segmental
osteotomy in combination with bimaxillary orthognathic surgery with surgery rst approach.
BMC Oral Health. 2021;21(1):529. https://doi.org/10.1186/s12903- 021- 01892- 7. PMID:
34654418; PMCID: PMC8518167.
8. Rengarajoo J, Syed Husman SI, Hariri F.Three-dimensional surgical contouring of craniofacial brous dysplasia via patient-specic cutting guides and depth screws. Br J Oral Maxillofac
Surg. 2021;59(7):843–4. https://doi.org/10.1016/j.bjoms.2020.09.028; Epub 2020 Sep 28.
9. Day KM, Kelley PK, Harshbarger RJ, Dorafshar AH, Kumar AR, Steinbacher DM, Patel P,
Combs PD, Levine JP.Advanced three-dimensional technologies in craniofacial reconstruction.
Plast Reconstr Surg. 2021;148(1):94e–108e. https://doi.org/10.1097/PRS.0000000000008212.
10. Palines PA, Ferrer JR, Yoo A, St Hilaire H, Stalder MW.Simplifying bony midface reconstruction with patient-specic titanium plates. Plast Reconstr Surg Glob Open. 2021;9(4):e3555.
https://doi.org/10.1097/GOX.0000000000003555. PMID: 33912374; PMCID: PMC8078310.
11. Rubio-Palau J, Ayats-Soler M, Albert-Cazalla A, Martìnez-Padilla I, Prieto-Gundin A, PrietoPeronnet N, Ramìrez-Fernández MP, Mareque-Bueno J.Accuracy of virtually planned maxillary distraction in cleft patients—an evaluative study. Ann Maxillofac Surg. 2021;11(1):49–57.
https://doi.org/10.4103/ams.ams_331_20; Epub 2021 Feb 18. PMID: 34522654; PMCID:
PMC8407633.
12. De Virgilio A, Iocca O, Di Maio P, Malvezzi L, Pellini R, Mercante G, Spriano G. Head
and neck soft tissue reconstruction with anterolateral thigh aps with various components:
development of an algorithm for ap selection in different clinical scenarios. Microsurgery.
2019;39(7):590–7.
13. Liu K, Zhang W, Wang Y, Xiang DW, Shi HB, Liu QL. Fibula osteal ap with proximal
peroneal perforator skin paddle for composite oromandibular reconstruction: a case report.
Medicine (Baltimore). 2020;99(50):e23590.
14. Pereira N, Valenzuela D, Mangelsdorff G, Kufeke M, Roa R.Detection of perforators for free
ap planning using smartphone thermal imaging: a concordance study with computed tomographic angiography in 120 perforators. Plast Reconstr Surg. 2018;141(3):787–92.
15. Rajati M, Pezeshki Rad M, Irani S, Khorsandi MT, Motasaddi ZM.Accuracy of high- resolution
computed tomography inlocating facial nerve injury sites in temporal bone trauma. Eur Arch
Otorhinolaryngol. 2014;271(8):2185–9.
10 Use of Three-Dimensional Technology for Virtual Surgical Planning in Oral…
https://t.me/medicina_free
16. Cheng K, Leinkram D, Howes D, Clark J.Incorporating ‘off-the-shelf’reconstruction plates
into the digital plan for mandible reconstruction. Int J Clin Oncol Cancer Ther. 2021;1(1):1–4.
17. Garrido-Martínez P, Quispe-López N, Montesdeoca-García N, Esparza-Gómez G, CebriánCarretero JL.Maxillary reconstruction with subperiosteal implants in a cancer patient: a oneyear follow-up. J Clin Exp Dent. 2022;14(3):e293.
18. Zhang N, Liu S, Hu Z, etal. Accuracy of virtual Sur- gical planning in two-jaw orthognathic
surgery: com- parison of planned and actual results. Oral Surg Oral Med Oral Pathol Oral
Radiol. 2016;122(2):143–51.
19. Resnick CM, Inverso G, Wrzosek M, etal. Is there a difference in cost between standard and virtual surgical planning for orthognathic surgery? J Oral Maxillofac Surg. 2016;74(9):1827–33.
20. Cheng H, Chen BP, Soleas IM, etal. Prolonged oper- ative duration increases risk of surgical
site infec- tions: a systematic review. Surg Infect (Larchmt). 2017;18(6):722–35.
21. Tondin GM, Leal MOCD, Costa ST, Grillo R, Jodas CRP, Teixeira RG.Evaluation of the
accuracy of virtual planning in bimaxillary orthognathic surgery: systematic review. Br J Oral
Maxillofac Surg. 2021;S0266-4356(21):00343. https://doi.org/10.1016/j.bjoms.2021.09.010;
Epub ahead of print. PMID: 35120785.
22. Chen Z, Mo S, Fan X, You Y, Ye G, Zhou N.A meta-analysis and systematic review comparing
the effectiveness of traditional and virtual surgical planning for orthognathic surgery: based
on randomized clinical trials. J Oral Maxillofac Surg. 2021;79(2):471.e1–471.e19. https://doi.
org/10.1016/j.joms.2020.09.005. Epub 2020 Sep 9. PMID: 33031773.
23. Bernstein JM, Daly MJ, Chan H, Qiu J, Goldstein D, Muhanna N, de Almeida JR, Irish
JC.Accuracy and reproducibility of virtual cutting guides and 3D-navigation for osteotomies
of the mandible and maxilla. PloS One. 2017;12(3):e0173111.
24. Jenkins GW, Iqbal S, West N, Ellabban I, Kennedy MP, Adams JR.Dosimetry-guided virtual
surgical planning in the reconstruction of mandibular osteoradionecrosis. Br J Oral Maxillofac
Surg. 2021;59(8):947–51.
25. Lee IJ, Koom WS, Lee CG, Kim YB, Yoo SW, Keum KC, Kim GE, Choi EC, Cha IH.Risk factors and dose–effect relationship for mandibular osteoradionecrosis in oral and oropharyngeal
cancer patients. Int J Radiat Oncol Biol Phys. 2009;75(4):1084–91.
26. Gutwald R, Jaeger R, Lambers FM.Customized mandibular reconstruction plates improve
mechanical performance in a mandibular reconstruction model. Comput Methods Biomech
Biomed Engin. 2017;20(4):426–35.
27. Smith MH, Schrag CH, Chandarana SP, Cobb JG, Matthews TW, Mckenzie CD, Matthews
JL. Novel plate design to improve mandibular and maxillary reconstruction with the
Osteocutaneous bula ap. Plast Reconstr Surg Glob Open. 2019;7(1):e2094.
28. Anolik RA, Nelson JA, Rosen EB, Disa J, Matros E, Allen RJ Jr. Immediate dental implant
placement in the oncologic setting: a conceptual framework. Plast Reconstr Surg Glob Open.
2021;9(9):e3671.
29. Melville JC, Manis CS, Shum JW, Alsuwied D. Single-unit 3D-printed titanium reconstruction plate for maxillary reconstruction: the evolution of surgical reconstruction for
maxillary defects—a case report and review of current techniques. J Oral Maxillofac Surg.
2019;77(4):874–e1.
30. Gellrich NC, Zimmerer RM, Spalthoff S, Jehn P, Pott PC, Rana M, Rahlf B.A customised
digitally engineered solution for xed dental rehabilitation in severe bone deciency: a new
innovative line extension in implant dentistry. J Craniomaxillofac Surg. 2017;45(10):1632–8.
31. Spalthoff S, Borrmann M, Jehn P, Rahlf B, Gellrich NC, Korn P.Comparison of conventional
and digital workow for dental rehabilitation with a novel patient-specic framework implant
system: an experimental dataset evaluation. Int J Implant Dent. 2022;8(1):1–8.
32. Barry CP, MacDhabheid C, Tobin K, Stassen LF, Lennon P, Toner M, O’Regan E, Clark
JR. ‘Out of house’ virtual surgical planning for mandible reconstruction after cancer resection:
is it oncologically safe? Int J Oral Maxillofac Surg. 2021;50(8):999–1002.
33. Urken ML, Buchbinder D, Weinberg H, etal. Primary placement of osseointegrated implants
in microvascular mandibular reconstruction. Otolaryngol Head Neck Surg. 1989;101:56.
205
206
https://t.me/medicina_free
34. Rosen EB, Ahmed ZU, Habib AA, Huryn JM, Randazzo JD, Cracchiolo JR, Matros E, Nelson
J, Allen RJ Jr. Interim implant-supported resection prosthesis following bula free ap reconstruction of the arch with immediate implants: a novel approach for the oncologic patient. Int
J Periodontics Restorative Dent. 2020;40(6):861–7. https://doi.org/10.11607/prd.4675. PMID:
33151192; PMCID: PMC8383382.
35. Hutchison IL, Dawood A, Tanner S. Immediate implant supported bridgework simultaneous with jaw reconstruction for a patient with mandibular osteosarcoma. Br Dent
J. 2009;206(3):143–6. https://doi.org/10.1038/sj.bdj.2009.57. PMID: 19218947.
36. Patel A, Harrison P, Cheng A, Bray B, Bell RB.Fibular reconstruction of the maxilla and mandible with immediate implant-supported prosthetic rehabilitation: jaw in a day. Oral Maxillofac
Surg Clin North Am. 2019;31(3):369–86. https://doi.org/10.1016/j.coms.2019.03.002. Epub
2019 Jun 1. PMID: 31164268.
37. Williams FC, etal. Immediate teeth in bulas: planning and digital workow with point-ofcare 3D printing. J Oral Maxillofac Surg. 2020;78(8):1320–7.
S. A. D. Al Azri et al.
Chapter 11
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Advancing Immediate Dental
Rehabilitation inFree Tissue Transfer
Utilizing Point-of-Care Digital Workows
and3D Printing
DanielHammer, MarilynAndersen, JustinOdette, RaymondP.Shupak,
MichaelAndersen, FayetteC.Williams, andRoderickY.Kim
Introduction
Maxillofacial reconstructive surgery poses a unique set of challenges to the surgeon.
A defect in this region often results from pathology or trauma, and the resulting
defect affects both form and function with potential changes to speech, nutrition,
swallow function, and esthetics. Maxillofacial defects also have a signicant effect
on the patients’ psychosocial well-being. Therefore, oral and dental rehabilitation is
D. Hammer (*)
Department of Oral and Maxillofacial Surgery, Naval Medical Center San Diego,
San Diego, CA, USA
e-mail: daniel.a.hammer.mil@health.mil
M. Andersen
Department of Oral and Maxillofacial Surgery, Naval Hospital Twentynine Palms,
Twentynine Palms, CA, USA
e-mail: marilyn.a.andersen.mil@health.mil
J. Odette
Dental Department, USS Theodore Roosevelt (CVN 71), San Diego, CA, USA
e-mail: justin.r.odette.mil@health.mil
R. P. Shupak
Division of Oral and Maxillofacial Surgery, Geisinger Medical Center, Danville, PA, USA
e-mail: rshupak@geisinger.edu
M. Andersen
Department of Hospital Dentistry, Naval Medical Center San Diego, San Diego, CA, USA
e-mail: michael.r.andersen.mil@health.mil
F. C. Williams · R. Y. Kim
Department of Oral and Maxillofacial Surgery, John Peter Smith Hospital,
Fort Worth, TX, USA
e-mail: FWilliam@jpshealth.org; RKim01@jpshealth.org
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
J. C. Melville et al. (eds.), Advancements and Innovations in OMFS, ENT, and
Facial Plastic Surgery, https://doi.org/10.1007/978-3-031-32099-6_11
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imperative to fully restore the patient and should not be ignored and completed as
soon as predictably possible. Unfortunately, current data suggest that most patients
undergoing jaw reconstruction following pathologic resection do not receive immediate implants or an immediate prosthesis at the time of initial surgery [1].
The advantages of immediate dental rehabilitation (dental implants and temporary prosthesis at time of primary reconstruction) include a decrease in the number
of surgeries and expedited return to form and function. These advantages can
improve the patients’ psychosocial and overall well-being. Potential obstacles to
immediate dental rehabilitation include the learning curve to optimally virtual plan
the reconstruction, gaining familiarity with the complexities of 3D manufacturing,
nancial reimbursement, and nally, collaborating with a suitable restorative provider capable of delivering a nal restoration. Since comprehensive maxillofacial
reconstruction incorporates dental rehabilitation, strong consideration should be
given to immediate dental rehabilitation when feasible.
D. Hammer et al.
Immediate Dental Implant Placement inOsseous Free Flaps
Immediate dental implant placement into osseous free aps is well documented and
has a high success rate [2–4]. The accuracy and success rates have further increased
with the incorporation of virtual surgical planning (VSP) [5]. Some of the challenges previously faced by immediate implant placement and dental prosthesis
delivery can be simplied by computer-aided design and computer-aided manufacturing (CAD/CAM) technologies [6].
The implant positions should be determined at the time of planning the osseous
free ap. This allows for the fabrication of patient-specic cutting guides, which
incorporate additional features allowing for guided implant placement. Properly
positioned implants are imperative for dental rehabilitation, especially in the immediate setting. This minor shift in protocol greatly increases the likelihood of providing a sound foundation for delivery of an immediate prosthesis. With the use of this
protocol, the authors have maintained a high implant success rate in reconstructing
defects resultant to both benign and malignant disease and trauma. With the advent
and application of CAD/CAM technologies, immediate dental rehabilitation has
become predictable and safe.
History of Immediate Dental Rehabilitation inOsseous
Free Flaps
Immediate dental rehabilitation with microvascular free tissue reconstruction was
rst completed by Dr. Iain Hutchison and Dr. Andrew Dawood in 2007 to reconstruct a mandibular continuity defect secondary to ballistic trauma. Previously,
11 Advancing Immediate Dental Rehabilitation in Free Tissue Transfer Utilizing…
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dental rehabilitation in free tissue transfer was completed in a staged manner either
by using prelaminated aps 6weeks after dental implant placement or by placing
the dental implants in the osseous free ap transorally after initial healing. Dr.
Hutchinson and Dr. Dawood’s surgery involved placement of dental implants into a
scapula with an immediate provisional prosthesis being delivered before leaving the
operating room [7, 8]. Since its inception, immediate dental rehabilitation in free
tissue transfer has gained popularity and predictability and has extended its application to a wide variety of clinical situations [9–13].
209
Expanded Applications ofImmediate Dental Rehabilitation in
Free Tissue Transfer
Initially, immediate dental rehabilitation was only recommended for secondary
trauma reconstruction or reconstruction of defects secondary to benign disease. It
was believed that these reconstructions in the setting of malignancy would lead to
increased complication rate, especially when the patient required adjuvant radiation
treatment. In the authors’ experience, postoperative radiation has not been associated with decreased rates of implant integration, further supported by emerging literature [10–13]. When implants are placed immediately during bula reconstruction,
adjuvant radiation therapy does not begin for another 4–6weeks. After radiation
begins, there are several more weeks before radiation doses reach signicant biologic levels. Since most of the implant integration is complete before the higher
doses of radiation accumulate, the integration rate of implants in bulas prior to
radiation is higher than implants placed after radiation [14, 15].
Furthermore, it is commonly believed that the reconstruction of a composite
defect with an osteocutaneous ap is a contraindication to immediate dental rehabilitation with concerns of an inability to achieve a watertight closure and possible
decreased skin paddle survival. Our experience has shown that skin paddles can be
successfully used with immediate rehabilitation when designed properly. In fact, to
perform a successful vestibular reconstruction, the skin paddle is integral. When
implants are placed at the suture line between the skin paddle and native mucosa, a
near watertight closure can be obtained. This results in a more favorable soft tissue
interface leading to less tissue mobility, resulting in improved implant health compared to native non-keratinized oral mucosa. The major disadvantage of utilizing a
skin paddle is the potential need for secondary debulking procedures.
Until recently, one of the major challenges to immediate dental rehabilitation of
a patient with a malignancy was the prolonged time needed to design and fabricate
the temporary dental prosthesis, which could be 6 or more weeks. It was simply not
acceptable to delay extirpation of the patient’s tumor to offer immediate dental rehabilitation. By leveraging emerging technologies, the temporary dental prosthesis
can now be fabricated and ready for delivery within 24h of the planning the free
ap reconstruction. This timeline is possible by utilizing open-source design
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software and in-house 3D printing (additive resin printing) or polymethylmethacrylate (PMMA) milling. Both technologies have revolutionized the ability to provide
a patient-customized rehabilitation within the time constraints of treating malignant
tumors [16].
Advantages of using 3D printing (additive resin printing) include rapid manufacturing time and low cost of equipment and consumable resins. The advantages of
milled pre-polymerized PMMA, such as polychromatic esthetics, exural strength,
and resistance to the accumulation of biolms, far surpass those of current
3D-printed resins. However, PMMA mills are more costly compared to resin
printers.
The in-house digital workow used to create the prosthesis provides a highquality prosthesis in signicantly less time and at less cost than using commercially
available dental labs [17].
D. Hammer et al.
Preoperative Digital Workow: Data Gathering toTemporary
Prosthesis Design
The immediate dental rehabilitation digital workow can be performed in any ofce
or clinic setting with the appropriate hardware and software. Preoperative imaging
includes a maxillofacial CT or cone beam CT (CBCT) and CT angiography of the
bilateral lower extremities for evaluation of vessel presence and patency and implant
planning. The lower extremity imaging must have a slice thickness of 1mm or less,
and only patient-specic data should be used for virtual surgical planning (VSP). It
is important that in the maxillofacial CT or CBCT is obtained with the teeth slightly
apart in open occlusion to allow more accurate merging of the preoperative dentition with the CT data. Intraoral scans or stone models can be sent to an appropriate
surgical VSP engineer according to the preference of the surgeon.
During the VSP session, the resection and the bony reconstruction are planned as
dictated by the pathology and defect, followed by virtual placement of implants.
Virtual implant and abutment STL les are brought into the planning environment
and adjusted according to standard implant principles. We prefer to have implants
emerging from the anterior surface of the bula as it will position the skin paddle in
an orientation to reconstruct the vestibule. However, in cases where this is not possible, implants can also emerge from the posterior surface of the bula to allow for
appropriate ap geometry. The implant guide is digitally built with the bula osteotomy guide. It is important to note that the drill offset should be built into the guide
based on the fully guided implant system that is used (Figs.11.1 and 11.2).
When planning dental implant placement within the bula, there should be
approximately 15–18mm of restorative space from the platform of the implant to
the opposing occlusal surface. In our experience, the implants themselves should be
no less than 7mm apart from each other (external edge to external edge of adjacent
platform) to ensure cleansability of the prosthesis and at least 3mm from bular
Simulated Postoperative Anatomy
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211
Fig. 11.1 Finalized VSP of an immediate mandibular reconstruction. Note the restorative space
(15–18mm) needed for prosthesis restoration. Here the bula segments are shown at the inferior
border; however, the bula should be placed to allow for proper implant emergence. This often
positions the bula above the level of the inferior boarder
Reconstruction
VSP
Fibula Guide Detail - Dental Implants
Virtual Surgical Planning
Dental Implant cylinders
measure 3.8 mm x 13 mm.
Each dental implant shelf is 5 mm
thick and is offset 7 mm
from the top of the implant.
Total distance from top of
implant shelf to botom of
implant is 25 mm.
All measurements are
approximate.
12 mm
25 mm
Fig. 11.2 Fibula cut guide with merged guided implant sleeves. Note the implant guide sleeve
offset that corresponds to the offset on the guided implant drill length
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D. Hammer et al.
osteotomies to maintain the integrity of the bony junction. Implant depths should be
planned for the platforms to be 1–2mm subcrestal due to expected crestal bone loss.
Following the VSP session, STL les of the bula reconstruction with implants
are requested from the engineer. This ensures that the shells are accurately overlaid
(bula/implant/existing teeth) in the 3D work environment. This step is critical to
ensure that the planning session and implant positioning will align with the in-house
fabricated prosthesis. Then the digital in-house workow is followed, as previously
described [15]. The patient’s STL les are then imported to the 3D printer software
for temporary prosthesis fabrication.
For partial arch dental rehabilitation in a patient with existing dentition in the
region that will be removed, the temporary prosthesis design is cloned from the
patient’s existing dentition. The STL data is recorded from the intraoral scan and
modied within the software. A base is created with the close model feature. This
creates an identical copy of the patient’s dentition. After this step, a tooth-borne
guide is created digitally on teeth within the non-resected portion of the patient’s
contralateral dental arch. These two constructs are then combined with an interpositional connector. The prosthesis is further digitally smoothed and the digital
implant abutments are subtracted from the prosthesis using a Boolean difference
function to create holes in the prosthesis for intraoperative abutment pickup
(Figs. 11.3, 11.4, 11.5, and 11.6). The prosthesis is then manufactured through
either 3D resin printing or PMMA milling throughputs. In patients with no previous
existing dentition in the area being reconstructed, the dentition can be planned using
denture software using the same workow discussed above.
Fig. 11.3 Creating a tooth-borne oating prosthesis for partial dental arch reconstruction. This
portion of the guide will connect to the prosthesis and register to a printed model for pickup
in the leg
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