Surgical_Manuel

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					       VITANE
          International
         Maxicare Implant System
                France




    Surgical Manual



            Sole Distributor:
   Medical & Pharmaceutical Services
    Bashir Shakib Al Jabri & Co Ltd.
Tel: Jeddah: 6700430     Riyadh: 4643221
     Abha: 2260623       Khobar: 8985821
           GENERAL INFORMATION
                    ON
              SURGICAL PHASE
TREATMENT PLAN
•   Observation
•   Indication and contraindication
•   Primary clinical and final diagnostic evaluation
•   Actual treatment plan
•   Patient preparation for surgery
•   Actual implant surgery


OBSERVATION
•   Questionery
•   Patient selection
•   Clinical exam
•   Wishes and motivation
•   Aim and objective

INDICATION
Anyone missing teeth is a candidate for implant

CONTRA- INDICATION
 1- Absolute contraindications
•   Recent myocardial infarction
•   Valvular prosthesis
•   Severe renal disorder
•   Osteomalasia
•   Generalized secondary osteoporosis
•   Treatment resistant diabetes
•   Radiotherapy in progress
•   Chronic or sever alcoholism
•   Severe hormone deficiency
•   Drug addiction
•   Heavy smoking habit



                                  1
     2-Relative contraindications
•    Aids and seropositive cases
•    Prolonged use of corticosteroids
•    Disorders of phosphocalcic metabolism
•    Hematopoitic disorder
•    Buccopharyngeal tumors
•    Chemotherapy in progress
•    Mild renal disorder
•    Hepato-pancreatic disorder
•    Multiple indocrine disorder
•    Psychological disorder and psychosis
•    Unhealthy live style
•    Smoking habits (less than 20 cigarettes)
•    Lack of understanding and motivation
•    Unrealistic treatment plan

    PRIMARY CLINICAL AND FINAL DIAGNOSTIC
                 EVALUATION
1-ACTUAL TREATMENT PLAN
• Gingival treatment
• Occlusal
• Filling etc.
2-PATIENT PREPARATION FOR SURGERY
• Radiograph
• Cat scan
• MRI
• Lab tests
• Medication
3-ACTUAL IMPLANT SURGERY
• Antiseptic environment
• Anesthesia
• Incision
• Bone surgery
• Material
• Suture
• Temporary prosthesis
• Follow up
• Suture removal
• Final prosthesis



                                     2
Important landmark

• Mental foramen
• Inferior alveolar canal.
• Nasal cavity.
• Maxillary sinuses.




Pre-operation medication
• Anti inflammatory
• Antibiotic
• Oral sedation
• Infiltration Anesthesia
• Dexometazone



Incision
• Midcrestal
• Labial
• Lingual
• Longer than implant area
• Sharp incision through preiostium

Reflection
• Use sharp periosteal elevators
• Expose buccal-lingual borders of bone
• Remove any soft tissue on crestal bone of implant site

Implant Bone Preparation
• Determine the position and angulation of implant (use parallelism pins)
• Maxilla: drill to touch cortical floor of sinus
• Mandible: stay away 2mm from I.A.N. & 5mm from mental foramen
• Use internal irrigation with in and out motion
• Use sharp drill with correct speed)




                                      3
Implant selection
• Determine the thickness of the bone to chose the right diameter
• Determine the height of the bone to chose the right length
• Be sure, there is 1mm bone around the chosen implant to provide
vascularization & give support against mechanical forces

Top of implant position to the crest
• Dense crestal bone:
   1.even with crest
   2.slightly above crest
• Sponge or thin crestal bone:
   1.even with crest
   2.slightly below crest

Suturing
• Relaxed closure:
   1.Interrupted
   2.continuous
   3.combination

Post Operation
• Relative existing prosthesis over implant site:
  1.soft liner
  2.occlusion modified
• Medication:
  1.Antibiotic
  2.Anti-inflammatory
  3.analgesic
• Instructions




                                      4
                    Single Tooth Implant:
• Maxillary Central Incisors:
  Minimum length 12 mm, Diameter 3.6 mm
• Maxillary Posterior Teeth:
 12 mm 3.6 or 10 mm 4.3 or 4.6 mm Diameter

• Single Molar:
2 implants if there is 16 mm Mesial- Distal space

Implant Placement in Edentulous Anterior Mandible

• Reflect soft tissue and find the mental foramen
• From the center of the foramen measure mesially on the top of the crest
7 mm and at that point make a reference mark on the crestal bone
• Do the same on the opposite side
• Implant should be placed 6 mm to 7 mm from center to center




      Implant placement in the Posterior Mandible

• Find mental foramen
• Measure from top of foramen to crest. Second pre-molar and first molar
region generally you can drill to this measure depth
• Take care not to perforate the lingual plate. Check undercut in the
sublingual fossa
• Do not give mandibular block-use infiltration anesthesia



                             Osteotomes
 Uses:
• Prepare Osteotomy in type 3&4 bone
• Start with pilot drill in 3 mm buccal-lingual crest width bone
• Expand bone for placement of a larger diameter implant
• Minimum reflection of preiostium
• If micro fracturing occurs, use cylindrical implant



                                     5
• Inferior Sinus Cortical Floor Elevation of 2 to 3 mm to place a long
implant.(i.e. :elevate floor so you can place a12 mm length implant
instead of a 10 mm)
• Prepare osteotomy to cortical floor and use larger round end of 3.25 or
3.8 mm diameter
• Mallet bone floor so that it just breaks cortical bone
• After in-fracture of floor, place a threaded or cylindrical implant


          Immediate Extraction Replacement

 Tooth replaced by at least 3mm
• No active pathology
• 3/4 existing socket has been prepare
• Graft material placed around neck of implant
• Primary soft tissue closure
• Primary fixation for the implant



                         Sinus Elevation

• Implant placed at same time of elevation if have 4 to 5 mm of existing
crestal bone
• Make incision on lingual aspect of the crest
• Reflect the flap on the buccal side
• Outline window carefully with#8 round bur to membrane
• Make sure lateral palate is free and you can gently move outline bone
• Prepare osteotomy just through existing sinus floor and place the
implants (Use a wide an implant as possible, 12-16 mm in length.)
• Replace sinus cavity and suture
• Post operative medication: same as other procedure except Amoxicilin
500 mg four times a day for one week is the antibiotic of choice. May
prescribe a decongestant (Sudafed)
• Instruct not to blow nose, and if they have to cough or sneeze, open
mouth




                                     6
     SURGICAL MANUEL
Introduction:

Dental implantology demands that the dentist possess profound
biological, biomechanical, surgical and restorative knowledge as well as a
broad spectrum related to patient treatment. Any dentist who wants to
experience long-term success with endosteal implants in his or her dental
practice must gather practical experience and extensive knowledge in the
areas of oral surgery, prosthodontics, periodontology, and preventive
dentistry.

Basic requirement of implant clinic:

    Adequate equipment, instruments, and personnel
    Asepsis and sterility conditions
    Systemic documentation using X-rays, photograph, recall, etc.

Setup for implant therapy:

The surgical implant operation must be performed in adherence with the
basic premises of asepsis and sterility. Special surgical drape kits must be
available for the dental practice in which implantology is performed.

Basic instrumentarium:
The surgical instrumentarium for an implant procedure is virtually
identical to that used for routine flap surgery. Several special instruments
for the placement of endosteal implants must also be on hand.

Surgical Motor:
Surgical motor used for dental implant operations must fulfill the
following requirements:
         - High torque
         - Limited RPM
         - Integrated cooling system
         - Provision of sufficient fluid volume
         - Speed-reduced contra-angle with internal cooling
         - Handpieces and contra-angles incorporating a speed
            reduction of 1:16, 1:64, and a maximum of 1:100 are
            appropriate.



                                     7
Guidelines for placing Endosteal dental implants:

The critical selection of patients and the critical application of endosteal
dental implants are the two most important prerequisites for the treatment
success:
    Evaluate risks and benefits
    Avoid overtreatment

Every therapeutic decision is a choice between benefit and risk,
especially when a relatively new form of therapy is being considered.
With implant-prosthodontic treatments, the most important considerations
are the surgical and prognostic risks versus the benefits in terms of
prosthetic function and esthetics.
The prosthodontist must decide whether, for each individual case,
implant-prosthetic or conventional treatment represents the superior
therapy.
The most basic rule is to use implants only when all of the prerequisites
for success are present and when the patient can be better served by
means of implant-prosthetic treatment than by conventional prosthetic
replacements.
The patient must also understand that, despite careful planning and good
initial conditions, dental implants are always associated with a certain
risk of failure, including loss of implants, osseous defects, and the
necessity to reconstruct the prosthesis.
Dentists must exercise extreme caution not to over-expand the spectrum
of dental implant indications in a cavalier manner simply because the
number of implant cases being treated in their practice seems not to be
increasing rapidly enough! In particular, they should not put at risk the
success in implantology that has been accrued over years of hard and
careful work. An excessively “proactive” approach in implantology
usually leads to more difficulties than benefits. The key elements for
success are caution, restraint, and a conservative attitude.
The dentist who is guided by the principles of medical ethics will choose
to place an implant only where it is truly necessary and reasonable.




                                     8
     Principle of Surgical Procedure


Preoperative Measures:

The implant surgical procedure can be performed using local infiltration
or nerve block anesthesia, with or without conscious sedation. Most
extensive surgical procedures can be performed under general anesthesia
if necessary, and if no contraindications exist.

Primary Incision:

The design and course of the incision must be such that the requirements
of good view in the surgical field as well as secure wound closure are
achieved. Broad exposure of the bone of the surgical field is necessary for
adequate access. In general, the larger the field of operation, the fewer
traumas there will be to the wound margins.
With all of the above in mind, the following criteria for the primary
incision are applicable:
- Assure sufficient blood supply for the flaps
- Do not endanger adjacent anatomical structures
- Provide adequate view of the surgical field
- Plan ahead for extension of the incision if this becomes necessary
   during the procedure
- Ensure complete coverage of the implants by the mucosal flaps




Drilling technique:

Surgical motors with internal or external cooling used for dental implant
placement are performed using standardized drills at relatively high speed
i.e., maximally 2000 rpm. To minimize trauma, only slight axial force is
applied, and the area is rinsed continuously with sterile saline. During the
drilling procedure, the drill should be moved up and down in the borehole
to ensure that the cooling solution reaches the cutting edge of the drill.
Copious rinsing during the drilling procedure is necessary to avoid over
heating the bone.



                                     9
                      Surgical Procedure
                     2.6 mm Vitane implants

Step 1
Drilling Procedure

1-By pilot drill
 The surgical preparation of the implant placement is to drill each of the
implant site to the appropriate depth reference line with the 2mm
diameter pilot drill with the suitable length. Ideally, the distance between
any two implants should be about as great as the implant diameter, i.e.,
about 2-4 mm.
The coronal portion of the implant is enlarged in the axial direction using
a pilot drill with same length of the chosen implant.
When placing more than one implant, place a parallelism gauge into the
completed pilot hole and proceed to the next implant site. Align the pilot
drill parallel to the previous pin when available bone permits and drill the
next hole.

2-By reamer
 Because of the preliminary preparation of the coronal aspect of the
implant site using the pilot drill, there should be no difficulty completing
the implant site to the proper depth and diameter using yellow 2.3 mm
reamer with 12 mm or 18mm length (depends on the length of the
implant) to enlarge the implant site.

3-By counterbore
 Using a 2.6 mm counterbore, a shoulder is created into the marginal
layer of compact bone at the entrance to the implant site. This creates a
conical support in the bone, which corresponds to the coronal portion of
the implant body. The procedure ensures sufficiently deep anchoring of
the implant in the bone, and also that the implant is seated to such a depth
that its cover screw is flush with the bone.
In case the base of the bone is broad then use 2.6 mm profile gauge. In
this condition there is no need to use counterbore.




                                     10
4-By tap
Use 2.5 mm bone tap for cutting threads on the internal aspect of the
implant site. The tap is rotated slowly into the hole, or you can use a
ratchet, stabilized by a bar handle. Copious rinsing with sterile saline is
constantly performed until the desired depth is achieved.
- If you are drilling in the maxilla no need to use bone tap.


Step 2
Placing the implants
- The implant site is thoroughly rinsed with sterile saline, then permitted
   to fill with blood. Remove the 2.6 mm implant from the sterilized
   package using disposable implant inserter. Without contamination, the
   implant is transferred directly into the prepared site and temporarily
   screwed in by hand. The implant inserter is removed and the ratchet
   replaces the implant. The ratchet is correctly positioned, and with the
   help of holding bar the implant is rotated slowly into the final position.
- Finally, healing screw is inserted and screwed into place. The implant
   may not be placed below the level of the ridge because of the danger of
   osseous formation over the top of the implant during the healing phase.
- The field of operation is cleaned and rinsed. Single, interrupted sutures
   are used for closure of wound. It is important to assure precise
   adaptation of the mucosa flap around the implant neck. Any
   superfluous tissue should be surgically excised at this time


Step 3
4 to 6 months after implant insertion, exposure of the implant head by
  removing of the healing screw after small incision procedures or punch
  technique and put the healing abutment.




                                     11
                      Surgical Procedure
                     3.6 mm Vitane implants
Step 1
Drilling Procedure:

1-By pilot drill
 The surgical preparation of the implant placement is to drill each of the
implant site to the appropriate depth reference line with the 2mm
diameter pilot drill. Ideally, the distance between any two implants should
be about as great as the implant diameter, i.e., about 2-4 mm.
The coronal portion of the implant is enlarged in the axial direction using
a pilot drill (with same length of the chosen implant).
When placing more than one implant, place a parallelism gauge into the
completed pilot hole and proceed to the next implant site. Align the pilot
drill parallel to the previous pin when available bone permits and drill the
next hole.

2-By reamer
 Because of the preliminary preparation of the coronal aspect of the
implant site using the pilot drill, there should be no difficulty completing
the implant site to the proper depth and diameter using yellow 2.3 mm
and then green 3.0 mm reamer with 12 mm or 18mm length (depends on
the length of the implant) to enlarge the implant site.

3-By counterbore
 Using a 3.6 mm counterbore, a shoulder is created into the marginal
layer of compact bone at the entrance to the implant site. This creates a
conical support in the bone, which corresponds to the coronal portion of
the implant body. The procedure ensures sufficiently deep anchoring of
the implant in the bone, and also that the implant is seated to such a depth
that its cover screw is flush with the bone.
In case the base of the bone is broad then use 3.6 mm profile gauge. In
this condition there is no need to use counterbore.

4-By tap
  Use 3.5 mm bone tap for cutting threads on the internal aspect of the
implant site. The tap is rotated slowly into the hole, or you can use a
ratchet, stabilized by a bar handle. Copious rinsing with sterile saline is
constantly performed until the desired depth is achieved.
- If you are drilling in the maxilla no need to use bone tap.


                                     12
Step 2
Placing the implants
- The implant site is thoroughly rinsed with sterile saline, then permitted
   to fill with blood. Remove the 3.6 mm implant from the sterilized
   package using disposable implant inserter. Without contamination, the
   implant is transferred directly into the prepared site and temporarily
   screwed in by hand. The implant inserter is removed and the implant
   replaced by the ratchet. The ratchet is correctly positioned, and with
   the help of holding bar the implant is rotated slowly into the final
   position.
- Finally, healing screw is inserted and screwed into place. The implant
   may not be placed below the level of the ridge because of the danger of
   osseous formation over the top of the implant during the healing phase.
- The field of operation is cleaned and rinsed. Single, interrupted sutures
   are used for closure of wound. It is important to assure precise
   adaptation of the mucosa flap around the implant neck. Any
   superfluous tissue should be surgically excised at this time.

Step 3
 4 to 6 months after implant insertion, exposure of the implant head by
removing of the healing screw after small incision procedure or punch
technique and put the healing abutment.




                                    13
                     Surgical Procedure
                   4.3 mm Vitane implants
Step 1

Drilling Procedure:

1-By pilot drill
 The surgical preparation of the implant placement is to drill each of the
implant site to the appropriate depth reference line with the 2mm
diameter pilot drill. Ideally, the distance between any two implants should
be about as great as the implant diameter, i.e., about 2-4 mm.
The coronal portion of the implant is enlarged in the axial direction using
a pilot drill (with same length of the chosen implant).
When placing more than one implant, place a parallelism gauge into the
completed pilot hole and proceed to the next implant site. Align the pilot
drill parallel to the previous pin when available bone permits and drill the
next hole.

2-By reamer
 Because of the preliminary preparation of the coronal aspect of the
implant site using the pilot drill, there should be no difficulty completing
the implant site to the proper depth and diameter using yellow 2.3 mm
reamer and then green 3 mm and then white 3.3 mm and then red 3.9
mm with 12 mm or 18mm length (depends on the length of the implant)
to enlarge the implant site.

3-By counterbore
 Using a 4.3 mm counterbore, a shoulder is created into the marginal
layer of compact bone at the entrance to the implant site. This creates a
conical support in the bone, which corresponds to the coronal portion of
the implant body. The procedure ensures sufficiently deep anchoring of
the implant in the bone, and also that the implant is seated to such a depth
that its cover screw is flush with the bone.
In case the base of the bone is broad then use 4.3 mm profile gauge. In
this condition there is no need to use counterbore.

4-By tap
  Use 4.2 mm bone tap for cutting threads on the internal aspect of the
implant site. The tap is rotated slowly into the hole, or you can use a
ratchet, stabilized by a bar handle. Copious rinsing with sterile saline is
constantly performed until the desired depth is achieved.
- If you are drilling on the maxilla no need to use bone tap.


                                     14
Step 2
Placing the implants
- The implant site is thoroughly rinsed with sterile saline, then permitted
   to fill with blood. Remove the 4.3 mm implant from the sterilized
   package using disposable implant inserter. Without contamination, the
   implant is transferred directly into the prepared site and temporarily
   screwed in by hand. The implant inserter is removed and the ratchet
   replaces the implant. The ratchet is correctly positioned, and with the
   help of holding bar the implant is rotated slowly into the final position.
- Finally, healing screw is inserted and screwed into place. The implant
   may not be placed below the level of the ridge because of the danger of
   osseous formation over the top of the implant during the healing phase.
- The field of operation is cleaned and rinsed. Single, interrupted sutures
   are used for closure of wound. It is important to assure precise
   adaptation of the mucosa flap around the implant neck. Any
   superfluous tissue should be surgically excised at this time.

Step 3
4 to 6 months after implant insertion, exposure of the implant head by
  removing of the healing screw after small incision procedures or punch
  technique and put the healing abutment.




                                     15
                     Surgical Procedure
                   4.6 mm Vitane implants
Step 1
Drilling Procedure:

1-By pilot drill
 The surgical preparation of the implant placement is to drill each of the
implant site to the appropriate depth reference line with the 2mm
diameter pilot drill. Ideally, the distance between any two implants should
be about as great as the implant diameter, i.e., about 2-4 mm.
The coronal portion of the implant is enlarged in the axial direction using
a pilot drill (with same length of the chosen implant).
When placing more than one implant, place a parallelism gauge into the
completed pilot hole and proceed to the next implant site. Align the pilot
drill parallel to the previous pin when available bone permits and drill the
next hole.

2-By reamer
 Because of the preliminary preparation of the coronal aspect of the
implant site using the pilot drill, there should be no difficulty completing
the implant site to the proper depth and diameter using yellow 2.3 mm
reamer and then green 3 mm and then white 3.3 mm and then red 3.9 mm
and then blue 4.2 mm with 12 mm or 18mm length (depends on the
length of the implant) to enlarge the implant site.

3-By counterbore
 Using a 4.6 mm counterbore, a shoulder is created into the marginal
layer of compact bone at the entrance to the implant site. This creates a
conical support in the bone, which corresponds to the coronal portion of
the implant body. The procedure ensures sufficiently deep anchoring of
the implant in the bone, and also that the implant is seated to such a depth
that its cover screw is flush with the bone.
In case the base of the bone is broad then use 4.6 mm profile gauge. In
this condition there is no need to use counterbore.
4-By tap
  Use 4.5 mm bone tap for cutting threads on the internal aspect of the
implant site. The tap is rotated slowly into the hole, or you can use a
ratchet, stabilized by a bar handle. Copious rinsing with sterile saline is
constantly performed until the desired depth is achieved.
- If you are drilling in the maxilla no need to use bone tap.



                                     16
Step 2
Placing the implants
- The implant site is thoroughly rinsed with sterile saline, then permitted
   to fill with blood. Remove the 4.6 mm implant from the sterilized
   package using disposable implant inserter. Without contamination, the
   implant is transferred directly into the prepared site and temporarily
   screwed in by hand. The implant inserter is removed and the ratchet
   replaces the implant. The ratchet is correctly positioned, and with the
   help of holding bar the implant is rotated slowly into the final position.
- Finally, healing screw is inserted and screwed into place. The implant
   may not be placed below the level of the ridge because of the danger of
   osseous formation over the top of the implant during the healing phase.
- The field of operation is cleaned and rinsed. Single, interrupted sutures
   are used for closure of wound. It is important to assure precise
   adaptation of the mucosa flap around the implant neck. Any
   superfluous tissue should be surgically excised at this time.

Step 3
 4 to 6 months after implant insertion, exposure of the implant head by
removing of the healing screw after small incision procedure or punch
technique and put the healing abutment.




                                     17
                   STEP BY STEP
   SURGICAL PROCEDURE FOR 2,6 mm VITANE IMPLANT

1 - First stage surgery
Procedure:

   1- Use a surgical guide to aid in proper location and angulation of the
      implant
   2- After anesthesia, make incision of appropriate design for elevation
      of a flap
   3- Drill the implant site to the appropriate depth by using the suitable
      length of the pilot
   4- Check the orientation of Osteotomy by using parallel pin
   5- Drill to the appropriate depth reference line with yellow 2.3 mm
      diameter by using the short reamer or long reamer as required
   6- Prepare the superior portion of the osteotomy for the neck of the
      implant with 2.6 mm threaded counterbore. Drill to the top edge of
      the counterbore flutes to enable placement of the implant even the
      crest of the ridge
   7- Place the tip of 2.6 mm bone tap into the drilled implant site
      Thread the osteotomy to the desired depth reference line. Apply
      firm pressure and begin rotating the thread former slowly (20 rpm
      maximum), or you can use a ratchet, stabilized by a ratchet
      extender, no need to use the bone tap in the maxilla.
   8- Remove the implant and the carrier from the sterile package and
      Screw it into the prepared site by the carrier. (Don’t touch the
      implant).
      REMARKS:
      a) If the implant can’t be placed to the desired depth with the
      carrier of the implant, remove the carrier and use implant screw
      driver 2.6 mm, also it is possible to use the ratchet and stabilizer
      with implant extender 2.6 mm, also it is possible to use implant
      extender 2.6 mm for motor insertion.
      b) If the implant doesn’t seat to the desired level, remove the
      implant and check the depth and superior portion to know what the
      reason is. And drill the depth or superior portion again, and then
      reinsert the implant into the osteotomy.
   9- Remove the healing screw from the carrier of the implant using hex
      driver and insert it inside the implant and screw it.
 10- Close and suture the tissue flap using desired technique.


                                    18
2 - Second stage surgery
Uncovering the implants:

When a two-stage implant procedure is used, the osseointegrated fixtures
may be surgically exposed after about 4 months (mandible) or 6 months
(maxilla). Special instruments are used for uncovering the implants. The
procedure is performed under local anesthesia by infiltration or block
anesthesia, if required.
Immediately after the implants are uncovered, they are checked for
osseointegration, and the quality of peri-implant tissue.

Technique for implant uncovering:

This usually consists of a mid-crestal incision to reach a metallic contact
with cover screws. Other incision patterns may be used according the
nature of the soft tissue and the experience of the surgeon in soft tissue
management. Once the cover screws are located, gingival tissues are
gently reclined to avoid tissue tear, which may compromise final esthetic
result

- Short or extended crestal incision through the middle of the
  keratinized mucosa, with buccal and lingual reflection of
  mucoperiosteal flaps.
- Crestal or paracrestal (palatal or lingual) mucosal incisions to expose
  the implants.
- A tissue “punch” (soft tissue trephine) can be used if sufficient
  attached gingiva is available.
- Monopolar electro surgical uncovering is occasionally used only in
  conjunction with broad expanse of attached gingiva. A direct contact
  with implant must not be made to avoided tissue necrosis by burning.




                                     19
Technique For Healing Abutment:

- Choose the healing abutment according to the diameter of uncovered
implant [2,6-3,6-4,3-4,6] mm; And 3 or 5mm high is according to the
thickness of tissue and space of occlusal.
- Use long or short hex driver to fit the healing abutment on the top of
uncovered implant.
- Suture the soft tissue around the healing abutment in case you
    uncovered the implant by incision technique.



 GOOD LUCK WITH VITANE IMPLANT System




                                   20

				
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